The Role of High-Resolution Manometry Prior to and Following Antireflux Surgery: The Padova Consensus

BACKGROUND

In the last two decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiologic information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision making.

METHOD

A multi-disciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre- and post- ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM prior to ARS and the role of HRM following ARS.

CONCLUSION

This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre- and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.

10-year follow-up results of the European Achalasia Trial: a multicentre randomised controlled trial comparing pneumatic dilation with laparoscopic Heller myotomy

OBJECTIVE

As achalasia is a chronic disorder, long-term follow-up data comparing different treatments are essential to select optimal clinical management. Here, we report on the 10-year follow-up of the European Achalasia Trial comparing endoscopic pneumodilation (PD) with laparoscopic Heller myotomy (LHM).

DESIGN

A total of 201 newly diagnosed patients with achalasia were randomised to either a series of PDs (n=96) or LHM (n=105). Patients completed symptom (Eckardt score) and quality-of-life questionnaires, underwent functional tests and upper endoscopy. Primary outcome was therapeutic success defined as Eckardt score <3 at yearly follow-up. Secondary outcomes were the need for retreatment, lower oesophageal sphincter pressure, oesophageal emptying, gastro-oesophageal reflux and the rate of complications.

RESULTS

After 10 years of follow-up, LHM (n=40) and PD (n=36) were equally effective in both the full analysis set (74% vs 74%, p=0.84) and the per protocol set (74% vs 86%, respectively, p=0.07). Subgroup analysis revealed that PD was superior to LHM for type 2 achalasia (p=0.03) while there was a trend, although not significant (p=0.05), that LHM performed better for type 3 achalasia. Barium column height after 5 min at timed barium oesophagram was significantly higher for patients treated with PD compared with LHM, while other parameters, including gastro-oesophageal reflux, were not different.

CONCLUSIONS

PD and LHM are equally effective even after 10 years of follow-up with limited risk to develop gastro-oesophageal reflux. Based on these data, we conclude that PD and LHM can both be proposed as initial treatment of achalasia.

Manometric identikit of a functioning and effective fundoplication for gastroesophageal reflux disease in the high-resolution manometry ERA

BACKGROUND

The pathophysiological and clinical value of performing High-Resolution Manometry (HRM) after laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD) is still unclear and debated.

OBJECTIVE

We sought to establish the HRM parameters indicative of functioning fundoplications, and whether HRM could distinguish them from tight or defective ones.

METHODS

The study involved patients with GERD who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication between 2010 and 2022. HRM and 24-h pH monitoring were performed before and 6 months after surgery. The study population was divided into 5 groups: LN and LT patients with normal 24h-pH findings (LNpH- and LTpH-, respectively); LN and LT patients with pathological 24h-pH findings (LNpH+ and LTpH + groups, respectively); and patients with a postoperative dysphagia intensity score >2 (Dysphagia group). The novel Hiatal Morphology (HM) classification was applied, envisaging 3 different subtypes: HM1 (normal), HM2 (intrathoracic fundoplication), and HM3 (slipped fundoplication).

RESULTS

Among the 132 patients recruited during the study period, 46 were in the LNpH- group, 51 in the LTpH- group, 15 in the LNpH + group, 7 in the LTpH + group, and 5 in the Dysphagia group. In multivariate analysis, postoperative abdominal lower esophageal sphincter length (p = 0.001) and HM2 (p < 0.001) were both independently associated with surgical failure. Integrated relaxation pressure was significantly higher in the Dysphagia group than in the LNpH- group.

CONCLUSION

This study generated reference HRM values for an effective LF, and confirms that using HRM to assess the neo-sphincter and HM improves the clinical assessment in cases of symptom recurrence.

Laparoscopic Heller-Dor Is a Persistently Effective Treatment for Achalasia Even in Pediatric Patients: A 25-Year Experience at a Single Tertiary Center

BACKGROUND

 Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller-Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital.

MATERIALS AND METHODS

 We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure.

RESULTS

 During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11-15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5-13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux.

CONCLUSION

 LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.

The International Network on Oesophageal Atresia (INoEA) consensus guidelines on the transition of patients with oesophageal atresia-tracheoesophageal fistula

Oesophageal atresia-tracheoesophageal fistula (EA-TEF) is a common congenital digestive disease. Patients with EA-TEF face gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life issues in childhood, adolescence and adulthood. Although consensus guidelines exist for the management of gastrointestinal, nutritional, surgical and respiratory problems in childhood, a systematic approach to the care of these patients in adolescence, during transition to adulthood and in adulthood is currently lacking. The Transition Working Group of the International Network on Oesophageal Atresia (INoEA) was charged with the task of developing uniform evidence-based guidelines for the management of complications through the transition from adolescence into adulthood. Forty-two questions addressing the diagnosis, treatment and prognosis of gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life complications that patients with EA-TEF face during adolescence and after the transition to adulthood were formulated. A systematic literature search was performed based on which recommendations were made. All recommendations were discussed and finalized during consensus meetings, and the group members voted on each recommendation. Expert opinion was used when no randomized controlled trials were available to support the recommendation. The list of the 42 statements, all based on expert opinion, was voted on and agreed upon.

Trends and perioperative mortality in gastric cancer surgery: a nationwide population‑based cohort study

This study aimed to investigate changes and perioperative mortality over a 6-year period within the Italian Hospital Information System among patients with gastric cancer (GC) who underwent gastrectomies and to identify risk factors associated with 90-day mortality. Additionally, nationwide differences between high and low-volume hospitals were evaluated. A nationwide retrospective study was conducted using patient hospital discharge records (HDRs) based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) classification. The HDRs were linked to the National Tax Registry records using deterministic record linkage. The data were obtained from the Italian National Outcomes Evaluation Programme (PNE). Multivariate logistic regression was used to examine risk factors for 90-day mortality among patients with GC who underwent partial or total gastrectomies over the period from 2018 to 2020 with adjustment for comorbidities. Overall, the number of patients with GC who underwent total or partial gastrectomies steadily decreased in Italy from 5765 in 2015 to 4291 in 2020 (p < 0.001). The use of the laparoscopic approach more than doubled from 2015 (10.8%) to 2020 (26.3%), with a concomitant conversion rate from laparoscopy to open surgery decreasing from 7.7 to 5.8%. The 30 and 90-day mortality rates remained stable over time (p > 0.05). Low-volume hospitals had higher inpatient, early, and late mortality compared to high-volume hospitals (5.9% vs 3.8%, 6.3% vs 3.8%, and 11.8% vs 7.9%, respectively; p < 0.001). Multivariate logistic regression analysis showed that an advanced age (adjusted odds ratio: 3.72; 95% [CI]: 3.15-4.39; p < 0.001), an open approach (adjusted-OR: 1.69, 95% CI: 1.43-1.99, p < 0.001) and a total gastrectomy (adjusted-OR: 1.44, 95% CI: 1.27-1.64, p < 0.001) were independent risk factors for 90-day mortality. Additionally, patients with GC who referred to high-volume hospitals were 26% less likely to die within 90 days after a gastrectomy than those who underwent surgery in low-volume hospitals. During the 6-year period, surgeons implemented a minimally invasive approach to reduce the conversion over time. Centralisation was associated with better outcomes while advanced age, an open approach, and total gastrectomy were identified as risk factors for 90-day mortality.

Transoral septotomy with septum traction is an effective treatment for recurrent Zenker diverticulum

Symptoms of Zenker diverticulum can recur whatever the type of primary treatment administered. A modified transoral stapler-assisted septotomy (TS) was introduced in clinical practice a few years ago to improve the results of this mini-invasive technique. The aim of this prospective, controlled study was to assess the outcome of TS in patients with recurrent Zenker diverticulum (RZD), as compared with patients with treatment-naïve Zenker diverticulum (NZD). Patients diagnosed with NZD or RZD, and treated with TS between 2015 and 2021 were compared. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow and endoscopy were performed before and after the TS procedure. In sum, 89 patients were enrolled during the study period: 68 had NZD and 21 had RZD. The patients' demographic and clinical data were similar in the two groups. Three mucosal lesions were detected intra-operatively, and one came to light at post-operative radiological assessment in the NZD group. No mucosal lesions were detected in the RZD group. The median follow-up was 36 months (interquartile range 23-60). The treatment was successful in 97% NZD patients and 95% of RZD patients (P = 0.56). This is the first comparative study based on prospectively collected data to assess the outcome of TS in patients with RZD. Traction on the septum during the procedure proved effective in the treatment of RZD, achieving a success rate that was excellent, and comparable with the outcome in treating NZD.

Laparoscopic Heller-Dor is an effective long-term treatment for end-stage achalasia

BACKGROUND

The end-stage achalasia is a difficult condition to treat, for the esophageal diameter and conformation of the gullet, that may progress to a sigmoid shape. The aim of this study was to examine the outcome of Laparoscopic Heller-Dor in patients with end-stage achalasia, comparing them with patients who had mega-esophagus without a sigmoid shape.

METHODS

From 1992 to 2020, patients with a diagnosis of sigmoid esophagus, or radiological stage IV achalasia (the SE group), and patients with a straight esophagus larger than 6 cm in diameter, or radiological stage III achalasia (the NSE group), were all treated with LHD. The two groups were compared in terms of patients' symptoms, based on the Eckardt score, and on barium swallow, endoscopy and manometry performed before and after the treatment. The failure of the treatment was defined as an Eckardt score > 3, or the need for further treatment.

RESULTS

The study involved 164 patients: 73 in the SE group and 91 in the NSE group. No intra- or postoperative mortality was recorded. The median follow-up was 51 months (IQR 25-107). The outcome was satisfactory in 71.2% of patients in the SE group, and in 89% of those in the NSE group (p = 0.005).

CONCLUSIONS

SE is certainly the worst condition of the disease and the final outcome of LHD, in term of symptom control, is inferior compared to NSE. Despite this, almost 3/4 of the SE patients experienced a significant relieve in symptoms after LHD, which may therefore still be the first surgical option to offer to these patients, before considering esophagectomy.

Fetlock Joint Angle Pattern and Range of Motion Quantification Using Two Synchronized Wearable Inertial Sensors per Limb in Sound Horses and Horses with Single Limb Naturally Occurring Lameness

Fetlock joint angle (FJA) pattern is a sensitive indicator of lameness. The first aim of this study is to describe a network of inertial measurement units system (IMUs) for quantifying FJA simultaneously in all limbs. The second aim is to evaluate the accuracy of IMUs for quantifying the sagittal plane FJA overground in comparison to bi-dimensional (2-D) optical motion capture (OMC). 14 horses (7 free from lameness and 7 lame) were enrolled and analyzed with both systems at walk and trot on a firm surface. All enrolled horses were instrumented with 8 IMUs (a pair for each limb) positioned at the dorsal aspect of the metacarpal/metatarsal bone and pastern and acquiring data at 200 Hz. Passive markers were glued on the center of rotation of carpus/tarsus, fetlock, and distal interphalangeal joint, and video footages were captured at 60 Hz and digitalized for OMC acquisition. The IMU system accuracy was reported as Root Mean Square Error (RMSE) and Pearson Correlation Coefficient (PCC). The Granger Causality Test (GCT) and the Bland−Altman analysis were computed between the IMUs and OMC patterns to determine the agreement between the two systems. The proposed IMU system was able to provide FJAs in all limbs using a patented method for sensor calibration and related algorithms. Fetlock joint range of motion (FJROM) variability of three consecutive strides was analyzed in the population through 3-way ANOVA. FJA patterns quantified by IMUs demonstrated high accuracy at the walk (RMSE 8.23° ± 3.74°; PCC 0.95 ± 0.03) and trot (RMSE 9.44° ± 3.96°; PCC 0.96 ± 0.02) on both sound (RMSE 7.91° ± 3.19°; PCC 0.97 ± 0.03) and lame horses (RMSE 9.78° ± 4.33°; PCC 0.95 ± 0.03). The two systems’ measurements agreed (mean bias around 0) and produced patterns that were in temporal agreement in 97.33% of the cases (p < 0.01). The main source of variability between left and right FJROM in the population was the presence of lameness (p < 0.0001) and accounted for 28.46% of this total variation. IMUs system accurately quantified sagittal plane FJA at walk and trot in both sound and lame horses.

Esophageal Achalasia: Diagnostic Evaluation

A precise diagnosis is key to the successful treatment of achalasia. Barium swallow, upper endoscopy and high-resolution manometry provide the necessary information about a patient's anatomy, absence of other diseases, and type of achalasia (I, II, III). High-resolution manometry also has prognostic value, the best results of treatment being obtained in type II achalasia according to the Chicago classification. Abdominal CT scanning and endoscopic ultrasound might be warranted if an underlying malignancy is suspected.

Pharyngo-Esophageal Perforation Following Anterior Cervical Spine Surgery: A Single Center Experience and a Systematic Review of the Literature

STUDY DESIGN

Case series and systematic review of the Literature.

OBJECTIVES

Pharyngo-esophageal perforation (PEP) is a rare, life-threatening complication of anterior cervical spine surgery (ACSS). Best management of these patients remains poorly defined. The aim of this study is to present our experience with this entity and to perform a systematic Literature review to better clarify the appropriate treatment of these patients.

METHODS

Patients referred to our center for PEP following ACSS (January 2002-December 2018) were identified from our database. Moreover, an extensive review of the English Literature was conducted according to the 2009 PRISMA guidelines.

RESULTS

Twelve patients were referred to our Institution for PEP following ACSS. Indications for ACSS were trauma (n = 10), vertebral metastases (n = 1) and disc herniation (n = 1). All patients underwent hardware placement at the time of ACSS. There were 6 early and 6 delayed PEP. Surgical treatment was performed in 11 patients with total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement, anatomical suture of the fistula and suture line reinforcement with myoplasty. Complete resolution of PEP was observed in 6 patients. Five patients experienced PEP persistence, requiring further surgical management in 2 cases. At a median follow-up of 18.8 months, all patients exhibited permanent resolution of the perforation.

CONCLUSIONS

PEP following ACSS is a rare but dreadful complication. Partial or total removal of the fixation devices, direct suture of the esophageal defect and coverage with tissue flaps seems to be an effective surgical approach in these patients.

From dynamic self-organization to avalanching instabilities in soft-granular threads

We study the dynamics of threads of monodisperse droplets, including droplet chains and multi-chains, in which the droplets are interconnected by capillary bridges of another immiscible liquid phase. This system represents wet soft-granular matter - a class of granular materials in which the grains are soft and wetted by thin fluid films-with other examples including wet granular hydrogels or foams. In contrast to wet granular matter with rigid grains (e.g., wet sand), studied previously, the deformability of the grains raises the number of available metastable states and facilitates rearrangements which allow for reorganization and self-assembly of the system under external drive, e.g., applied via viscous forces. We use a co-flow configuration to generate a variety of unique low-dimensional regular granular patterns, intermediate between 1D and 2D, ranging from linear chains and chains with periodically occurring folds to multi-chains and segmented structures including chains of finite length. In particular, we observe that the partially folded chains self-organize via limit cycle of displacements and rearrangements occurring at a frequency self-adapted to the rate of build-up of compressive strain in the chain induced by the viscous forces. Upon weakening of the capillary arrest of the droplets, we observe spontaneous fluidization of the quasi-solid structures and avalanches of rearrangements. We identify two types of fluidization-induced instabilities and rationalize them in terms of a competition between advection and propagation. While we use aqueous droplets as the grains we demonstrate that the reported mechanisms of adaptive self-assembly apply to other types of soft granular systems including foams and microgels. We discuss possible application of the reported quasi-1D compartmentalized structures in tissue engineering, bioprinting and materials science.

Multimodal treatment of radiation-induced esophageal cancer: Results of a case-matched comparative study from a single center

PURPOSE

Radiation-induced esophageal cancer (RIEC) is a rare but severe late consequence of radiotherapy. The literature regarding this topic is predominately limited in describing the risk of this disease. Tumor behavior, treatment strategies, and prognosis of this cancer remain poorly defined.

PATIENTS AND METHODS

We collected data of patients who were referred to our unit between 2000 and 2020 for RIEC. After tumor board discussion, upfront surgery or neoadjuvant therapy and surgery were indicated as the main treatment. Preoperative characteristics, long-term and short-term postoperative outcomes of RIEC patients were compared with a 1:1 clustering-matched cohort of patients affected by primary esophageal cancer (PEC).

RESULTS

At pre-matching, 54 RIEC and 936 PEC patients were enrolled. The median time between primary irradiation and diagnosis of RIEC was 13.5 years, and the median primary radiation dose was 60 Gy. Compared to the unmatched cohort of PECs, RIEC patients were more frequently female (p = 0.0007), had earlier detection of disease (p = 0.03) and presented more frequently with upper esophageal cancers (p < 0.0001). Neoadjuvant treatment was used less frequently in RIEC patients (p < 0.0001). After matching, the 51 RIEC and 50 PEC patients showed comparable results in terms of exposure to neoadjuvant treatment, surgical radicality and survival outcomes. RIEC patients had more severe postoperative complications (p = 0.04) and a higher proportion of pulmonary complications (p = 0.04).

CONCLUSIONS

Curative treatments are feasible for RIEC. Neoadjuvant chemotherapy or chemoradiation can be used in this subgroup, treatment response and long-term outcomes are comparable to those of PEC. The risk of postoperative complications is probably related to the detrimental effect of primary irradiation on lung function.

Could the Pittsburgh Severity Score guide the treatment of esophageal perforation? Experience of a single referral center

BACKGROUND

Esophageal perforation (EP) is characterized by high morbidity and mortality. The Pittsburgh Severity Score (PSS) is a scoring system based on clinical factors at the time of EP presentation, intended to guide treatment. The aim of the study is to verify PSS usefulness in stratifying EP severity and in guiding clinical decisions.

METHODS

All patients referred to our unit for EP between January 2005 and January 2020 were enrolled. Patients were stratified according to their PSS into three groups (PSS ≤ 2, 3-5, and >5): the postoperative outcomes were compared. The predictive value of the PSS was evaluated by simple linear and logistic regression for the following outcomes: need for surgery, complications, in-hospital mortality, intensive care unit (ICU) and hospital stay, time to refeeding, and need for reintervention.

RESULTS

Seventy-three patients were referred for EP (male/female, 46/27). Perforations were more frequently iatrogenic (41.1%) or spontaneous (38.3%). The median PSS was 4 (interquartile range, 2-6). Surgery was required in 60.3% of cases. Pittsburgh Severity Score was associated with ICU admission, hospital stay, need for surgery and reintervention, postperforation complications and mortality. After regression analysis, PSS was significantly predictive of postperforation complications (p < 0.01), in-hospital mortality (p = 0.01), ICU admission (p < 0.01), need for surgical treatment (p < 0.01), and need for reintervention (p = 0.02).

CONCLUSION

Pittsburgh Severity Score is useful in stratifying patients in risk groups with different morbidity and mortality. It is also useful in guiding the therapeutic conduct, selecting patients for nonoperative management. Prospective studies are needed to confirm the role of the PSS in the treatment of esophageal perforation.

LEVEL OF EVIDENCE

Management, Therapeutic/Care; level IV.

Optimal Treatment of cT2N0 Esophageal Carcinoma: Is Upfront Surgery Really the Way?

BACKGROUND

Staging is inaccurate for cT2N0 esophageal cancer, and patients often are clinically mis-staged. This study aimed to evaluate the outcome after upfront surgery or neoadjuvant therapy, considering the impact of clinical "mis-staging."

METHODS

This study reviewed patients with squamous cell carcinoma (SCC) or adenocarcinoma (ADK) of the esophagus who underwent upfront surgery (S group) or neoadjuvant treatment (chemoradiotherapy [CRT] group) for cT2N0 cancer. Overall survival (OS), disease-free survival (DFS), morbidity, and mortality were evaluated. Correctly staged (cTNM = pTNM), understaged (cTNM < pTNM), and overstaged (cTNM > pTNM) patients in the S group and the CRT group were analyzed. Risk factors for unexpected lymph-node involvement were identified in the S group and for cancer-related death in the whole study cohort.

RESULTS

The study enrolled 229 patients with cT2N0 esophageal cancer. The 5-year OS rate was 34.2% in the S group versus 55.7% in the CRT group (p = 0.0088). The DFS also was significantly higher (p = 0.01). The morbidity and mortality rates were similar. In the S group, the cTNM was correctly staged for 21.4% and understaged for 63.4% of the patients, with 48.7% of the patients showing unexpected nodal involvement. A tumor length of 3 cm or more was an independent predictor of nodal metastases in SCC (p = 0.03), as was lymphovascular invasion (LVI) in ADK (p < 0.01). Cancer-related mortality was independently associated with lymph-node metastases (p = 0.03) and treatment by upfront surgery (p = 0.01).

CONCLUSION

Given the high rate of understaged patients in this study (63.4%), the authors advocate for combining the induction therapy with surgery in cT2N0, achieving better survival with similar morbidity and mortality.

Manometric pattern progression in esophageal achalasia in the era of high-resolution manometry

Esophageal manometry represents the gold standard technique for the diagnosis of esophageal achalasia because it can detect both the lack of lower esophageal sphincter (LES) relaxation and abnormal peristalsis. From the manometric standpoint, cases of achalasia can be segregated on the grounds of three clinically relevant patterns according to the Chicago Classification v3.0. It is currently unclear whether they represent distinct entities or are part of a disease continuum with the possibility of transition from a pattern to another one. The four cases described in the present report could provide further insights on this topic because the manometric pattern changed from type III to type II in all patients—without any invasive treatment. The cases described here support the hypothesis that the different manometric patterns of achalasia represent different stages in the evolution of the same disease, type III being the early stage, type II an intermediate stage, and type I probably the end stage of achalasia.

Comparison of in situ sediment remediation amendments: Risk perspectives from species sensitivity distribution

Contaminated sediment is a major issue for aquatic environments, but attention must be kept even during remediation activities that can negatively affect resident biota especially when applied in situ. For the first time, the species sensitivity distribution (SSD) approach was applied to amendments used for in situ sediment remediation considering 39 papers including both freshwater (F) and saltwater (S) effect data (i.e. n = 17 only F, n = 19 only S, and n = 3 both F and S). Toxicity data related to the application of activated carbon (AC), nano-Zero-Valent-Iron (nZVI), apatite (A), organoclay (OC) and zeolite (Z) were collected and analyzed. SSD curves were constructed by lognormal model providing comprehensive comparisons of the sensitivities of different species to the relative testing methods. Results indicated that Bacteria were the most sensitive group of testing organisms, while Crustaceans were the less sensitive. The hazardous concentration for 5% of the affected species (HC5) were derived to determine the concentration protecting 95% of the species. OC, A and Z presented both acute and chronic toxicity. The HC5 values in descending order are: AC (4.79 g/L) > nZVI (0.02 g/L) > OC, A and Z (1.77E-04 g/L). AC and nZVI can be considered safer than OC, A and Z in sediment remediation activities, even if in situ long-term effects remained still underexplored.

Laparoscopic Revisional Surgery After Failed Heller Myotomy for Esophageal Achalasia: Long-Term Outcome at a Single Tertiary Center

BACKGROUND

Laparoscopic Heller myotomy (HM) has gained acceptance as the gold standard of treatment for achalasia. However, 10-20% of the patients will experience symptom recurrence, thus requiring further treatment including pneumodilations (PD) or revisional surgery. The aim of our study was to assess the long-term outcome of laparoscopic redo HM.

METHODS

Patients who underwent redo HM at our center between 2000 and 2019 were enrolled. Postoperative outcomes of redo HM patients (redo group) were compared with that of patients who underwent primary laparoscopic HM in the same time span (control group). For the control group, we randomly selected patients matched for age, sex, FU time, Eckardt score (ES), previous PD, and radiological stage. Failure was defined as an Eckardt score > 3 or the need for re-treatment.

RESULTS

Forty-nine patients underwent laparoscopic redo HM after failed primary HM. A new myotomy on the right lateral wall of the EGJ was the procedure of choice in the majority of patients (83.7%). In 36 patients (73.5%) an anti-reflux procedure was deemed necessary. Postoperative outcomes were somewhat less satisfactory, albeit comparable to the control group; the incidence of postoperative GERD was higher in the redo group (p < 0.01). At a median 5-year FU time, a good outcome was obtained in 71.4% of patients in the redo group; further 5 patients (10.2%) obtained a long-term symptom control after complementary PD, thus bringing the overall success rate to 81.6%. Stage IV disease at presentation was independently associated with a poor outcome of revisional LHD (p = 0.003).

CONCLUSIONS

This study reports the largest case series of laparoscopic redo HM to date. The procedure, albeit difficult, is safe and effective in relieving symptoms in this group of patients with a highly refractory disease. The failure rate, albeit not significantly, and the post-operative reflux are higher than after primary HM. Patients with stage IV disease are at high risk of esophagectomy.

Laparoscopic Heller-Dor Is an Effective Treatment for Esophageal-Gastric Junction Outflow Obstruction

BACKGROUND

The treatment of esophagogastric junction outflow obstruction (EGJOO) currently mirrors that of achalasia, but this is based on only a few studies on small case series. The aim of this prospective, controlled study was to assess the outcome of laparoscopic Heller-Dor (LHD) in patients with EGJOO, as compared with patients with esophageal achalasia.

MATERIALS AND METHODS

Between 2016 and 2019, patients with manometric diagnosis of idiopathic EGJOO and patients with radiological stage I achalasia, both treated with LHD, were compared. The achalasia group was further analyzed by subgrouping the patients based on the manometric pattern. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3 or the need for retreatment.

RESULTS

During the study period, 150 patients were enrolled: 25 patients had EGJOO and 125 had radiological stage I achalasia (25 pattern I, 74 pattern II, and 26 pattern III). The median follow-up was 24 months (IQR: 34-16). Treatment was successful in 96% of patients in the EGJOO group and in 96% of achalasia patients with pattern I, 98.7% in those with pattern II, and 96.2% of those with pattern III (p=0.50). High-resolution manometry showed a reduction in the LES resting pressure and integrated relaxation pressure for all patients in all 4 groups (p<0.001).

CONCLUSION

This is the first comparative study based on prospective data collection to assess the outcome of LHD in patients with EGJOO. LHD emerged as an effective treatment for EGJOO, with an excellent success rate, comparable with the procedure's efficacy in treating early-stage achalasia.

Development and preliminary evaluation of a communication skills training programme for hospital physicians by a specialized palliative care service: the 'Teach to Talk' programme

BACKGROUND

There is widespread agreement about the importance of communication skills training (CST) for healthcare professionals caring for cancer patients. Communication can be effectively learned and improved through specific CST. Existing CSTs have some limitations with regard to transferring the learning to the workplace. The aim of the study is developing, piloting, and preliminarily assessing a CST programme for hospital physicians caring for advanced cancer patients to improve communication competences.

METHODS

This is a Phase 0-I study that follows the Medical Research Council framework; this paper describes the following sections: a literature review on CST, the development of the Teach to Talk training programme (TtT), the development of a procedure for assessing the quality of the implementation process and assessing the feasibility of the implementation process, and the pilot programme. The study was performed at a 900-bed public hospital. The programme was implemented by the Specialized Palliative Care Service. The programme was proposed to 19 physicians from 2 departments.

RESULTS

The different components of the training course were identified, and a set of quality indicators was developed. The TtT programme was implemented; all the physicians attended the lesson, videos, and role-playing sessions. Only 25% of the physicians participated in the bedside training. It was more challenging to involve Haematology physicians in the programme.

CONCLUSIONS

The programme was completed as established for one of the two departments in which it was piloted. Thus, in spite of the good feedback from the trainees, a re-piloting of a different training program will be developed, considering in particular the bed side component. The program should be tailored on specific communication attitude and believes, probably different between different specialties.

Preventing action slows down performance in perceptual judgment

Action and vision are known to be tightly coupled with each other. In a previous study, we found that repeatedly grasping an object without any visual feedback might result in a perceptual aftereffect when the object was visually presented in the context of a perceptual judgement task. In this study, we explored whether and how such an effect could be modulated by presenting the object behind a transparent barrier. Our conjecture was that if perceptual judgment relies, in part at least, on the same processes and representations as those involved in action, then one should expect to find a slowdown in judgment performance when the target object looks to be out of reach. And this was what we actually found. This indicates that not only acting upon an object but also being prevented from acting upon it can affect how the object is perceptually judged.

A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring

Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.

International guidelines and recommendations for surgery during Covid-19 pandemic: A Systematic Review

BACKGROUND

During the COVID-19 pandemic, surgical departments were forced to re-schedule their activity giving priority to urgent procedures and non-deferrable oncological cases. There is a lack of evidence-based literature providing clinical and organizational guidelines for the management of a general surgery department. Aim of our study was to review the available recommendations published by general Surgery Societies and Health Institutions and evaluate the underlying Literature.

MATERIALS AND METHODS

A review of the English Literature was conducted according to the AMSTAR and to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

After eligibility assessment, a total of 22 papers and statements were analyzed. Surgical societies have established criteria for triage and prioritization in order to identify procedures that can be postponed after the pandemic and those that should not. Prioritization among oncologic cases represents a difficult task: clinicians have to balance a possible delay in cancer diagnosis or treatment against the risk for a potential COVID-19 exposure. There is broad agreement among guidelines that indication to proceed with surgery should be discussed in virtual Tumor Boards taking into consideration alternative therapeutic approaches. Several guidelines deal with the role of laparoscopic surgery during the pandemic: a tailored approach is currently suggested, with a case-by-case evaluation provided that appropriate personal protective equipment is available in order to minimize the potential risk of transmission. Finally, there is a considerable agreement in the published Literature concerning the management of the personnel during the peri- and intraoperative phase and on the technical advices regarding the induction, operative and recover maneuvers in COVID-19 cases.

CONCLUSIONS

During COVID-19 pandemic, it is of paramount importance to face the emergency in the most effective and efficient manner, retrieving resources from non-essential settings and, at the same time, providing care to high priority non-COVID-19 related diseases.