Society: SSAT

Background and aims: Several small studies reported high risk of progression to high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in Barrett’s esophagus (BE) patients who undergo solid organ transplantation (SOT). However, the major shortcoming of these reports is the lack of a control population. Therefore, we aim to determine the rates of neoplastic progression in SOT patients with BE compared to controls and also the risk factors associated with progression.
Methods: A retrospective case-control study of all patients with a confirmed diagnosis of BE (age ≥18 years) seen between Jan 2000 and Dec 2021 was conducted. Cases were all BE patients who had SOT; controls were all BE patients with no SOT and no immunosuppressant use. Demographics, endoscopic and histological findings, duration of follow-up (in years), history of fundoplication and immunosuppressant use were abstracted. Patients with ≥1 surveillance endoscopies were included to calculate incidence rates of HGD/EAC. Multivariate logistic regression was done to identify the risk factors associated with progression of BE patients to HGD/EAC.
Results: There were 118 cases with SOT (lung =35, liver=35, kidney=35, heart=14, pancreas=2) and 756 controls with no prior history of SOT or immunosuppressant use. Patients with SOT were predominantly younger (p=0.022); male, had lower body mass index (BMI) and active smokers (p<0.001 for all) (table 1). On multivariate analysis, older age, male gender, BE segment length, higher BMI and hiatal hernia were more likely to be associated with progression of BE to HGD/EAC (table 2). BE patients with immunosuppressant medication use were twice more likely to progress to HGD/EAC (p<0.001) (table 2).
Conclusion: Immunosuppressant use increases the risk of neoplastic progression in patients with BE. Therefore, these patients may need more aggressive surveillance. This study has important clinical implications for surveillance in BE patients with SOT.

<b>Table 1</b>: Baseline Characteristics

Table 1: Baseline Characteristics

<b>Table 2: Multivariable Model for Prevalent or Incident HGD/EAC</b>

Table 2: Multivariable Model for Prevalent or Incident HGD/EAC

INTRODUCTION
Screening colonoscopy (SC) is widely accepted and has been shown to decrease the rate of colorectal cancer death. Guidelines and acceptance of screening for Barrett’s esophagus (BE) are less established despite the fact that esophageal adenocarcinoma (EA) remains the fastest increasing cancer in the United States. The aim of this study was to assess the frequency of SC in patients ultimately found to have EA, and to evaluate the presence of symptoms that might have prompted an esophagogastroduodenoscopy (EGD) and potentially earlier diagnosis of the EA.
METHODS
A retrospective chart review was performed to identify all patients who were referred to a single center with esophageal cancer between July 2016 and November 2022. Patients with any histology other than adenocarcinoma were excluded.
RESULTS
There were 221 patients referred with EA. Of these, a SC had been done prior to the diagnosis of EA in 108 patients (49%), 96 men and 12 women. The median age was 66.4 years. A total of 203 SC had been done (range 1-7 per patient). The median interval from SC to the diagnosis of EA was 2.88 years. The highest stage lesion found on SC was colorectal carcinoma in 2 patients and tubulovillous adenoma in 3 patients. There were 36 patients (33.3%) with no findings on SC. At the time of SC, gastroesophageal reflux disease (GERD) symptoms or regular acid suppression medication use was documented in 48.1% of patients (Table). In those with GERD symptoms, the symptoms had been present either life-long or for many years in 69% of patients. Only 19 patients (17.6%) that had a SC had an EGD at any time prior to the diagnosis of EA. In 8 patients, the EGD that found EA was done at the time of SC for anemia, regurgitation symptoms or new-onset dysphagia. A T1 lesion was found in 25% of these patients compared to only 7% of patients that had an EGD separate from the SC (p=0.059). Dysphagia was present at the time of SC in 9 patients, and in 3 patients a SC without an EGD was performed a median of 3 months prior to the EGD that showed EA.
CONCLUSIONS
Nearly one-half of patients ultimately diagnosed with EA had GERD symptoms for many years or were using acid suppression medications regularly at the time of SC, but did not undergo EGD. In 40% of the patients the SC was done within 2 years of the diagnosis of EA. The addition of an EGD at the time of SC in these patients may have allowed early detection of BE or EA.

Background
Transthoracic esophagectomy has historically been characterized as an operation with substantial postoperative morbidity. The application of the robotic surgical platform to enable robotic-assisted minimally invasive esophagectomy (RAMIE) has been prospectively shown to reduce postoperative complications when compared to open resection with thoracotomy. However, RAMIE requires significant institutional investment to fully realize postoperative benefits of minimally invasive resection. We sought to describe improvements in postoperative outcomes over time in our high-volume single-center experience of over 500 RAMIEs.

Methods
Patients undergoing robotic-assisted transthoracic two-field esophagectomy were identified from a prospectively-maintained institutional database (2010-2021). Patients were included if the abdominal portion of the operation was performed open or minimally invasive; all thoracic portions were performed robotically. Primary postoperative outcomes of interest included length of stay (LOS), 30-day pulmonary complication, and 30-day cardiac complication. Cases were separated into cumulative volume quintile (CVQ) by surgical date. Associations between outcomes and CVQ were assessed using regression analysis, as appropriate, with adjustment for clinical factors (age, sex, receipt of neoadjuvant therapy), tumor factors (site, histology, clinical stage), and open vs minimally invasive abdominal portion.

Results
In all, there were 504 RAMIEs identified for study. Median patient age was 66 years (IQR 58-72) and the majority were male (81.9%), were performed for adenocarcinoma (88.1%), and received neoadjuvant therapy (83.9%). Median operative time was 415 minutes, which did not vary by CVQ (p=0.24). Median operative blood loss decreased with increasing CVQ, but not after adjustment for other factors (p=0.79).
The rate of 30-day respiratory complication was lowest (7.0%) in the highest CVQ (cases 404-504), compared to CVQ1 27.7%, CVQ2 16.8%, CVQ3 27.7%, and CVQ4 17.8%, (p=0.001). The association between higher CVQ and reduced rate of respiratory complication remained significant after adjustment for other factors (OR 0.71, p<0.001). Exploratory analysis revealed LOS decreased steadily with cumulative volume (Figure). Median LOS was 10, 10, 9, 9, and 7 days by increasing CVQ (p<0.001) which remained significant in multivariable adjustment (mean -1.2 days per CVQ, p<0.001). No significant association between rate of 30-day cardiac complication and CVQ was observed (CVQ1 28.7%, CVQ2 24.8%, CVQ3 38.6%, CVQ4 27.7, CVQ5 25.0%, p=0.20).

Conclusions
LOS and postoperative respiratory complication decreased significantly over our experience with 500 RAMIEs. The well-established benefits of minimally invasive resection are likely maximized when performed in a high-volume center with experience in optimization of postoperative care.

Introduction
Complex operations have become increasingly centralized at HVCs, which are believed to deliver improved outcomes. While readmission rates have been used administratively to measure surgical performance, surgical volume, as it relates to readmission rates, has not been studied using a population-based database. This study aimed to compare outcomes between HVCs and LVCs in the performance of PEHR.

Methods
The Nationwide Readmissions Database was queried for all patients undergoing PEHR from 2016 to 2018. Patients were excluded if they were <18 years old or had an emergent operation, concurrent bariatric procedure, or a diagnosis of gastrointestinal malignancy. Centers were stratified into percentiles based on elective procedure volume by year. HVCs were defined as in the top 5th percentile (>42 procedures/year), and LVCs were defined as 50th percentile or less (£ 5 procedures/year). Patient characteristics and outcomes were compared with standard statistical methods.

Results
During the 3-year period, 36,484 PEHR patients were identified. Of these, 11,355 (31.1%) underwent PEHR at a HVC and 4,904 (13.4%) at a LVC. Patients were similar in age (65 [55, 72] vs 65 [54, 72] years, p=0.621) and sex (71.8% vs 72.9% female, p=0.145). HVC patients were more concentrated in metropolitan teaching (95.4% vs 48.8%) and large (82.7% vs 33.5%) hospitals (p<0.001). Hospital charges were higher at HVCs ($54,190 [$36,396, $86,599] vs $50,054 [$31,596, $81,821], p<0.001). HVCs performed a higher proportion of laparoscopic (73.3% vs 69.6%, p<0.001), similar proportion of robotic (16.2% vs 15.9%, p=0.661), and lower proportion of open (9.9% vs 13.5%, p<0.001) procedures. HVC patients had less perioperative mortality (0.2% vs 0.5%, p<0.001), major bleeding (0.2% vs 0.4%, p=0.040), pneumonia (0.8% vs 2.3%, p<0.001), respiratory failure (2.2% vs 4.4%, p<0.001), acute renal failure (1.6% vs 2.6%, p<0.001), and sepsis (0.6% vs 1.5%, p<0.001) and shorter length of stay (LOS) (3.0 ± 3.9 vs 3.4 ± 4.6 days, p=0.003). HVCs had lower 30-day (6.6% vs 8.2%, p<0.001), 90-day (9.5% vs 11.1%, p=0.003), and 180-day (11.5% vs 13.0%, p=0.010) readmission rates and readmissions requiring reoperation (0.4% vs 0.9%, p=0.002). In regression analysis, HVCs were protective for 30-day (OR=0.781 [0.642-0.950]) and 90-day readmission (OR=0.837 [0.707-0.990]), mortality (OR=0.247 [0.112-0.544]), and complications (OR=0.764 [0.641-0.910]).

Conclusions
HVCs performed more laparoscopic and fewer open PEHR than LVCs. HVCs had a shorter LOS, lower readmission rates at 30- and 90-days, a reduced rate of readmissions requiring reoperation, fewer complications, and lower mortality rates. Procedure volume was independently predictive of improved outcomes in PEHR. These results support centralization of PEHR to HVCs.

BACKGROUND: Surgical anti-reflux procedures remain the definitive treatment for chronic, medically refractory gastroesophageal reflux disease (GERD), according to consensus guidelines. Patients with GERD frequently present with extra-esophageal manifestations, such as laryngopharyngeal reflux. It may be difficult to discern GERD as the cause of the patient’s condition, and multiple specialist consultations may occur to rule out other etiologies. The choice of initial referral, the timing of referral from diagnosis, and the patient’s comorbidity burden may impact timing of the definitive management—fundoplication. This study aims to examine referral patterns and co-morbidity status to identify factors that influence duration of time between GERD diagnosis and anti-reflux surgery.

METHODS: A retrospective, 10-year review was performed examining patients ages 18-64 with GERD who underwent Nissen fundoplication between January 1, 2010 and January 1, 2020 at a single tertiary referral center. Patients with peptic stricture, esophageal adenocarcinoma, or Barrett’s esophagus with high grade dysplasia were excluded. Patient demographics and clinical variables were collected. Kaplan Meier estimates and linear regression analyses were performed to analyze the association between initial referral type and time to surgery, number of co-morbidities and time to surgery, PCP type and time to general surgery and/or GI referral, and number of co-morbidities and time to general surgery and/or GI referral.

RESULTS: A total of 426 patients were identified with 37 excluded. Analyses were performed of referrals to otolaryngology (ENT), gastroenterology (GI), or general surgery for ICD codes associated with GERD. Referral to ENT delayed time to surgical treatment by 1.3 years compared to those who were initially referred to GI or general surgery (3.4 vs 2.1 years) (p<0.05). A greater co-morbidity burden strongly delayed anti-reflux surgery from initial GERD diagnosis (p < 0.001). Linear regression analysis found that for each individual co-morbidity, the predicted time from GERD diagnosis to fundoplasty increased by 146 days (Fig. 1 and 2). This relationship was maintained when controlling for the association between number of comorbidities and time to either general surgery or GI referral (p < 0.001). There was no association found between type of PCP (MD, nurse practitioner, or physician assistant) and time to referral (p = 0.72).

CONCLUSION: Our results emphasize the importance of deliberate referral practices for patients with GERD to minimize duration of reflux and mitigate potential complications. A large portion of ENT referrals are made for reflux symptoms, yet our data may indicate a need for a change to local referral patterns, as it suggests that initial referral to gastroenterology and/or general surgery may shorten the time to definitive treatment.

Kaplan Meier estimates showing time in days from GERD diagnosis to fundoplication (x-axis) and probability of having undergone fundoplication (y-axis) and influence of comorbidity burden.

Kaplan Meier estimates showing time in days from GERD diagnosis to fundoplication (x-axis) and probability of having undergone fundoplication (y-axis) and influence of comorbidity burden.

Lowess smoother plot showing a strongly positive correlation between co-morbidity burden (x-axis) and time in days between GERD diagnosis and fundoplication (y-axis).

Lowess smoother plot showing a strongly positive correlation between co-morbidity burden (x-axis) and time in days between GERD diagnosis and fundoplication (y-axis).

Introduction:
Peroral Endoscopic Myotomy (POEM) has revolutionized the treatment of achalasia. A myotomy performed endoscopically can extend more proximally than conventional laparoscopic approaches. As a result, the POEM technique is a useful method to treat spastic esophageal motility disorders. However, the ideal myotomy length is still unknown. The purpose of this study is to describe the clinical outcomes of patients with spastic esophageal motility disorders undergoing a standard (≤10 cm) or long (>10 cm) endoscopic myotomy.

Methods and Procedures:
We performed a single institution retrospective review of a prospective quality database. All patients with type III Achalasia, Distal Esophageal Spasm (DES) and Jackhammer Esophagus (JE) undergoing POEM were included. Manometry confirmed the diagnosis of hypercontractile esophageal dysmotility. Patients underwent either a standard myotomy (≤10 cm) or long myotomy (>10 cm) at the discretion of the operating surgeon. The primary outcome was Eckardt score at follow up, with clinical success defined as Eckardt score less than three. Secondary outcomes included operative time, procedural complications, resolution of symptoms, post-operative pH assessment, reflux severity index (RSI) and GERD health-related quality of life (GERD-HRQL) questionnaire scores. Comparisons were made using chi-square and Wilcoxon rank-sum tests.

Results:
From 2012 to 2022, 53 patients with hypercontractile esophageal motility disorders (n=37 type III achalasia, n=14 DES, n=2 JE) underwent POEM, 15 (28.3%) of which were standard myotomies. The procedure was performed by two foregut surgeons at a single institution. The average length of standard and long myotomies were 8.9 ± 1.9 cm and 19.3 ± 4.7 cm (p<0.001), respectively. There were no differences in operative time (102 ± 58 minutes and 104 ± 44 minutes, p=0.323), intraoperative complication rate (6.7% and 2.6%, p=0.489) or 30-day complication rate (6.7% and 10.5%, p=0.825). Clinical success was comparable between groups at first follow up visit (78.6% and 77.3%, p=0.686) and persisted for both groups up to the fourth follow-up at a median of 17 months post-op (Table 1). At one year, differences in RSI (11.5 ± 12.3 and 14.1 ± 13.9, p=0.872), GERD-HRQL (5.6 ± 5.3 and 9.5 ± 10.9, p=0.560) and dysphagia scores (1.0 ± 0.0 and 1.4 ± 0.9, p=0.198) were unremarkable. When comparing myotomy lengths in type III achalasia patients alone, again there was no change.

Conclusion:
In the endoscopic treatment of spastic esopahgeal motility disorders, standard myotomy is non-inferior to long myotomy.

Introduction: Clinical experience has shown that a subset of patients with initial complete resolution of reflux symptoms after magnetic sphincter augmentation (MSA) return with delayed symptom recurrence, concerning for failure of MSA. However, these patients may have no objective evidence of reflux and respond to endoscopic dilation. This group of patients are not well studied. The aim of this study was to characterize patients who present with delayed recurrence of reflux symptoms after MSA and assess the impact of dilation on their outcome.

Methods: This was a retrospective review of 775 patients who underwent MSA between 2013 and 2021 at our institution. Patients with complete resolution of reflux symptoms who had late recurrence of their symptoms were selected. They underwent endoscopy with dilation, pH-monitoring and manometry, at the time of recurrence. Patients were divided into two groups based on whether their delayed recurrent symptoms resolved after dilation. Demographic, clinical and objective testing data were compared between groups, preoperatively, at the time of recurrence and yearly after dilation.

Results: There were 43 (5.5%) patients who were symptom free for at least 18 months after MSA but presented with delayed recurrent reflux symptoms at a mean (SD) of 33.2 (13.0) months. Of these patients, 28 (65.1%) had recurrent symptom resolution after dilation that was durable at a mean (SD) of 17.3 (7.7) months. These patients were younger [52.0 (38-59) vs. 59.8 (53-66), p=0.020], but sex (p=0.185) and BMI (p=0.593) were similar between groups.
Preoperatively, patients who failed to respond to dilation had more frequent severe esophagitis (LA C or D) (26.6% vs. 3.5%, p=0.042), hiatal hernia (93.3% vs. 60.7%, p=0.032) and lower median (IQR) distal contractile integral (DCI) [1155(809-1910) vs. 2236 (1418-3793), p=0.032].
At the time of recurrence, patients who failed to respond to dilation had more recurrent hiatal hernia (33.3% vs. 3.5%, p=0.014), esophagitis (60% vs. 7.1%, p=0.001) and abnormal DeMeester score (>14.7) (66.6% vs. 22.2%, p=0.007). The manometry of those who did respond to dilation showed higher LES resting pressure [35.6(25-42) vs. 22.1(19-28), p=0.037], integrated relaxation pressure (IRP) [14.7(11-24) vs. 11.3(10-13), p=0.048] and DCI [1921(1567-3502) vs. 1083(798-1245), p=0.008].
After dilation, freedom from PPI was significantly higher in the resolution group (82.1% vs. 13.3%, p<0.001). No patients who responded to dilation underwent device removal, compared to 40% of those who failed to respond (p=0.001).

Conclusion: Recurrent reflux symptoms following resolution for minimum of 18 months occur in 5.5% of patients. Those without anatomical failure or objective evidence of reflux can be effectively managed with dilation alone. Patients who fail to respond to dilation have a more severe reflux disease prior to implant.

Background: Despite the availability of prosthetic material to repair recurrent and large complex paraesophageal hernias, recurrences and complications remain unacceptably high. We have recently reported on the use of the patient’s own posterior rectus fascia as a well vascularized onlay graft following as standard cruroplasty. Here we report the early results of a limited series of fifteen patients and offer refinements in the technique using robotic surgery.

Methods: A group of fifteen patients were selected who either presented with large attenuated hiatal hernia defects (n=10) or recurrent hiatal hernias (n=5). Using a robotic technique, the hernia is reduced in the usual fashion. A well vascularized portion of right posterior rectus fascia (approximately 5x7 cm) is then harvested by preserving the vascular pedicle of the round ligament. To alleviate any tension, the flap is passed under the left lobe of the liver, cut to encircle the esophagus, and laid over the cruroplasty. The flap is sutured posteriorly and anteriorly to the diaphragm using interrupted or running sutures (see figure). Postoperative clinical metrics included length of stay, 30-day readmissions, clinical complications, and six month esophagram.

Results: Our series included 12 women and 3 men with mean age of 73 years (62-80), BMI of 27 (22-37) and 9 month follow up. Later in the series, additional time to harvest the flap was approximately 30 minutes. All patients recovered similar to our historical non-flap patients with no alterations in postoperative pain or length of stay. When symptoms regarding any right abdominal pain were specifically solicited, no symptoms were noted. One patient experienced right sided abdominal wall bruising that resolved spontaneously. All patients were satisfied with their repairs at an average follow up of 9 months (0-22 months). To date, no clinical recurrences have been noted based on elicited symptoms, and on available imaging (UGI, CT scan) only one small recurrence (2.7cm) was identified without evidence of clinical symptoms.

Conclusions: The use of posterior rectus fascia for hiatal reconstruction provides many advantages of using durable, autologous, vascularized tissue with a peritoneal lining to buttress the crural repair and is technically feasible with a minimal impact on operative time or post-operative recovery as seen in this 15 patient series. In patents with a difficult to repair hernia, a reinforced repair with the strength of autologous fascia appears to have the appropriate risk-benefit profile over use of mesh. Although in this current series short-term recurrence rates were low, larger sample sizes and long-term outcomes are needed to determine the efficacy of this repair and its selection criteria.

Introduction:
Diaphragmatic reconstruction is a key component of hiatal hernia repair. Results are optimized by minimizing axial tension along the esophagus and radial tension across the diaphragmatic opening. Clinically relevant radial tension is difficult to assess intraoperatively. The shape of the hiatal opening appears to influence tension across the hiatus during closure and could be used intraoperatively to inform operative decision making. We categorized hiatal defects into 4 shapes as a surrogate of radial tension to determine their impact on operative interventions and outcomes.

Methods:
We retrospectively reviewed elective primary hiatal hernias (>3 cm in axial length) repaired at a single center from 2010-2020. Patients with intra-operative unrepaired hiatal photos with at least one year of follow up were included. The hiatal openings were classified into shapes: slit, inverted teardrop, “D”, and oval, with two-person agreement. Shapes were ordered in this manner to represent progression or increasing complexity based on our center’s experience. Recurrence was defined as any anatomical recurrence identified endoscopically or radiographically.

Results:
There were 239 patients studied, of which 111 (46%) recurred. The median follow up was 3.0 years (IQR: 1.8-5.4 years). There were 49 slits, 63 inverted teardrops, 93 “D”s, and 34 ovals. Demographics, comorbidities, and operative characteristics are described in Table 1.

As shape progressed from slit to inverted teardrop to “D” to oval we saw an increase in age (p<0.001), higher percentage of paraesophageal hernias (p<0.001), longer hernia axial length (p<0.001), and increase in hiatal width (p<0.001). Mesh, Collis gastroplasty, and relaxing incisions were more commonly employed in “D” and ovals (p=0.003, p=0.06, p<0.001, respectively).

Radiographic recurrence rates were not statically different amongst the hiatal shapes, but recurrences occurred sooner as shape progressed (p=0.017).

Recurrence free survival analysis with Kaplan Meier curve showed that “D” and oval have a lower recurrence free survival trend compared to slits and inverted teardrops. At 5 years, recurrence free survival trended inversely with increased shape (67% survival, 59%, 51%, and 45%).

Conclusion:
Four different hiatal shapes can be described during hiatal hernia surgery. They provide insight into their chronicity but also a spectrum of complexity with “D” and oval shapes being more complex. While more complex shapes predispose to earlier recurrence; their overall recurrence rates can be equated to less complex shapes with the use of adjunctive measures to reduce hiatal tension. Shape can serve as an intra-operative tool to inform surgeons of the need for adjunctive measures.

Table 1. Patient Characteristics, Hernia Characteristics, Operative Interventions, and Outcomes

Table 1. Patient Characteristics, Hernia Characteristics, Operative Interventions, and Outcomes

Table 2. Recurrence Free Survival by Shape

Table 2. Recurrence Free Survival by Shape

Background: Spinal deformities such as kyphosis, lordosis, and scoliosis can distort the diaphragm. Older studies have demonstrated a possible association between these deformities, especially kyphosis, and hiatal hernia occurrence and size. Nevertheless, there is a paucity of information on the effects of such spinal deformities on the preoperative presentation and postoperative recurrence of hiatal hernia. Our hypothesis is that the presence of spinal deformities will increase the risk of hiatal hernia recurrence after repair.

Methods: The medical records of patients undergoing hiatal hernia repair from 2009 to 2021, were reviewed for the following information: age (yrs.), sex (male/female), body mass index, co-morbidities, date of hiatal hernia repair, preoperative GERD symptoms, presence and type of spinal deformity (kyphosis, lordosis, scoliosis, multiple), Cobb angle (degrees), type of hiatal hernia and size (cm), type of hiatal hernia repair, recurrence and size (cm), time to recurrence (months), reoperation, type of reoperation, and time to reoperation (months). Statistical analysis was done with chi-squared test for categorical data, Students’ t-test for normal-distributed continuous data, and Mann-Whitney U-test for non-normal-distributed continuous data.

Results: Of the 449 patients undergoing hiatal hernia repair, 68 (17.8%) had some type of spinal deformity. The distribution of spinal deformity types were kyphosis 16 (23.5%), lordosis 1 (1.5%), scoliosis 41 (60.3%), and multiple 10 (14.7%). Those patients with spinal deformities were more likely to be female compared to those without deformities (83.8% vs 70.9%, p=0.03) and to be of older age (63.5+13.1 vs 58.5+14.5, p=0.009). Although not reaching statistical significance, spinal deformity patients had a preoperative GERD symptom rate of 97.1% compared to 90.8% for patients without spinal deformities (p=0.08). There was no significant difference in the distribution of sliding vs paraesophageal hernias (63.6% vs 56.1%, p= 0.3). Patients with spinal deformities had significantly larger hernias (6.4+2.6 vs 4.6+2.1, p=0.00001), higher recurrence rates (45.6% vs 28.1%, p=0.004) shorter time to recurrence (median [IQR] 13.8 [5.6-24.5] vs 21 [12.5-51.8], p=0.02), and fewer reoperations (58.1% vs 75.7%, p=0.05). There was no significant difference in recurrent hernia size (p=0.9).

Conclusions: Patients with spinal deformities were significantly more likely to have larger hiatal hernias. This group is at higher risk of hiatal hernia recurrence after repair with shorter times to recurrence. They were less likely to have their recurrences repaired despite having similar size recurrences. This is a group that requires special attention with additional preoperative counseling and possibly use of surgical adjuncts in repair.

Introduction:
Restoration of lower esophageal sphincter (LES) competency by antireflux surgery affects esophageal body and esophagogastric junction function. The advent of high-resolution manometry (HRM) has increased the fidelity and detail with which these effects can be evaluated. However, in standard HRM interpretation, most characteristics used in surgical practice were developed with conventional manometry. To best utilize the potential of HRM technology, novel manometric characteristics must be evaluated. The aim of this study was to assess the impact of Nissen fundoplication on novel and standard HRM characteristics.

Methods:
Pre and postoperative HRM files for patients who underwent primary Nissen fundoplication at our institution from 2013 to 2021 were reanalyzed by a single investigator. Standard HRM characteristics included LES characteristics, integral relaxation pressure (IRP), distal contractile integral (DCI), mean wave amplitude (MWA), and contractile front velocity (CFV). Novel HRM characteristics included upper esophageal sphincter (UES) resting and residual pressures, distal latency (DL), transition point length between skeletal and smooth muscle contraction and bolus clearance. DL was defined as time between swallow initiation and contractile deceleration point and late latency (LL) as time between swallow initiation and the intersection of the distal esophageal contraction and LES. The length and duration between the UES at swallow initiation and the beginning of the smooth muscle contraction was also evaluated.

Results:
The study population included 81 patients with a median (IQR) age of 60.8 (51-69). Manometry was repeated at a median (IQR) of 13.3 (11-28) months after surgery.
Nissen fundoplication increased mean (SD) LES total length [2.7 (0.8) to 3.1 (0.7), p<0.001], abdominal length [0.2 (0.6) to 1.4 (0.9), p<0.001], and resting pressure [21.4 (13.5) to 26.0 (12.7), p=0.009]. IRP increased from 8.2 (6.7) to 11.4 (6.4) (p=0.0001). DCI (p=0.084), percent intact (p=0.085), MWA (p=0.224), and CFV (p=0.085) were unchanged.
Among novel characteristics, fundoplication increased DL [7 (1.2) to 8.2 (5.9), p<0.0001], LL [9.8 (2.5) to 10.1 (2.2), p=0.023], transition point length [2.5 (2.2) to 3.1 (2.4), p=0.008], and esophageal body length [21.9 (3.7) to 23.5 (2.4), p<0.0001]. Bolus clearance decreased from 68% (36) to 59% (36) after surgery (p=0.042). UES resting (p=0.068) and residual (p=0.105) pressures and smooth muscle contraction length (p=0.348) and duration (0.067) were similar before and after surgery.

Conclusions:
Nissen fundoplication increases LES characteristics and IRP, but has minimal impact on standard esophageal body characteristics. However, novel high resolution manometry characteristics suggest that fundoplication increases the esophageal body length and duration of propagation of esophageal peristalsis.

Esophageal adenocarcinoma is a cancer that arises through a series of metaplastic changes to the esophageal mucosa and typically carries a poor prognosis. Esophageal adenocarcinoma is a growing cause for concern throughout the world, with incidence rising sharply over the last three decades. In Western countries the rise in esophageal adenocarcinoma has been particularly dramatic, with incidence surpassing that of esophageal squamous cell carcinoma. Many physiologic risk factors have been described for esophageal adenocarcinoma including gastroesophageal reflux disease (GERD), Barrett’s esophagus, obesity, and tobacco smoking. The molecular pathophysiology of esophageal adenocarcinoma has yet to be fully characterized and could provide valuable insight into the diagnosis and treatment of this disease.

Gene expression is regulated by a variety of regulatory molecules including microRNAs (miRNAs). miRNAs are small, conserved ribonucleic acid molecules that regulate cellular processes. When dysregulated, miRNAs may contribute to oncogenesis and have been described to influence the progression of many human cancers. The exact profile of miRNAs associated with the pathogenesis of esophageal adenocarcinoma is unknown, though some candidate miRNAs have been reported in the literature. To identify the unique miRNA profile associated with esophageal adenocarcinoma, we compared esophageal adenocarcinoma tissue to adjacent healthy tissues through bulk RNA sequencing analysis and validated our findings using real-time polymerase chain reaction. We then conducted Ingenuity Pathway Analysis (IPA) to identify miRNA-gene relationships. We further utilized Causal Network Analysis and Upstream Regulator Analysis to identify miRNA-gene relationships that are not readily observed using traditional methods of sequencing analysis.

Our analysis identified 37 aberrantly expressed miRNAs in esophageal adenocarcinoma compared to control tissue, including 34 miRNAs that have not been previously reported in EAC. Seven miRNAs were found to be associated with activated networks in esophageal adenocarcinoma tissues and 30 miRNAs were associated with inhibited networks.

The miRNA-gene relationships that we identified provide novel insights into potentially oncogenic molecular pathways associated with the development of esophageal adenocarcinoma and may be used as future biomarkers for treatment strategies.

miRNA-Gene Network 1 of 4: microRNAs identified in activated networks through Causal Network analysis (esophageal adenocarcinoma vs. healthy adjacent tissue). Red circles: upregulated genes, green circles: downregulated genes, blue squares: microRNA’s, dotted line: predicted gene-gene interaction, solid line: predicted miRNA interaction with gene.

miRNA-Gene Network 1 of 4: microRNAs identified in activated networks through Causal Network analysis (esophageal adenocarcinoma vs. healthy adjacent tissue). Red circles: upregulated genes, green circles: downregulated genes, blue squares: microRNA’s, dotted line: predicted gene-gene interaction, solid line: predicted miRNA interaction with gene.

Objective: to assess the feasibility and outcomes of Same-day Surgery (SDS) in primary and reoperative laparoscopic hiatal hernia repairs. Methods: Retrospective review. SDS was planned in elective procedures/ASA II-III. Opioid-Based Anesthesia Protocol (OBAP) was replaced by Opioid-Free Anesthesia Protocol (OFAP). Outcomes: length of stay, transition from SDS to observation (OBS)/inpatient (INP)/postoperative ER visits/readmissions. Values are median (IQR). Results: From 04/13/2017 to 09/29/2022 there were 525 hiatal hernia repairs in 498 patients, primary: 428/525 (81.5%), reoperative: 97/525 (25 had > 1 operation). Primary procedures were laparoscopic. Reoperative group, laparoscopic: 90/97 (92.8%), open Roux-En-Y: 7/97 (7.2%). Primary group, planned as SDS: 314/428 (73.4%), planned and performed as SDS: 246/314 (78.3%) vs. planned and not performed as SDS: 68/314 (21.7%). There was no difference in age/sex/BMI/ASA/type of hernia between 2 groups. Hernia size: 5.0 cm (4.0-6.0) vs. 6.0 (4.0-8.5), p=0.002. Operative time: 99.0 min (83.0-116.0) vs. 106.0 (89.0-122.0), p=0.020. The most common cause of transition from SDS to OBS/INP: patient preference in 30/68 (44.1%). Reoperative laparoscopic group, planned as SDS: 51/90 (56.7%), planned and performed as SDS: 27/51 (52.9%) vs. planned and not performed as SDS: 24/51 (47.1%). There was no difference in age, sex, BMI, ASA, hernia size and type, and operative time between 2 groups. The most common cause of transition from SDS to OBS/INP: patient preference in 16/24 (66.7%). Primary planned and performed as SDS with OBAP: 77/314 (24.5%) vs. planned and performed as SDS with OFAP: 169/314 (53.8%), p< 0.001. Reoperative planned and performed as SDS with OBAP: 2/51 (3.9%) vs. planned and performed as SDS with OFAP: 25/51 (49.0%), p< 0.001. Primary planned and performed as SDS with Toupet: 89/314 (28.3%) vs. planned and performed as SDS with fundopexy: 140/314 (44.6%), p< 0.001. Reoperative planned and performed as SDS with Toupet: 2/51 (3.9%) vs. planned and performed as SDS with fundopexy: 24/51 (47.1%), p< 0.001. Primary, ER visit after SDS: 39/246 (15.9%), readmissions after SDS: 26/246 (10.6%). Reoperative, ER visit after SDS: 3/27 (11.1%), readmissions after SDS: 3/27 (11.1%). Multivariable regression analysis: OFAP was the positive predictor of SDS as compared to OBAP (OR 7.4 [95%CI: 2.9, 18.8]). Negative predictors of SDS: type II/III hiatal hernia compared to I (OR 0.28 [95% CI: 0.14, 0.58]), ASA III compared to II (OR 0.47 [95% CI: 0.25, 0.88]), and duration of operation (OR 0.98 [0.97, 0.99]). Conclusion: Laparoscopic hiatal hernia repair can be performed as SDS in the majority of primary and reoperative procedures with good outcomes and low postoperative ER visits and readmissions. OFAP increases the feasibility of SDS hiatal hernia repair.

Introduction Mapping the lymphatic flow from a tumor, including lymph nodes (LNs) and lymphatic vessels, using near-infrared imaging with indocyanine green, has been used for the intraoperative prediction of lymph node metastasis in esophageal cancer. However, we found a decline in the diagnostic accuracy of this technique in patients undergoing neoadjuvant chemotherapy (NAC). Fibrosis in metastatic LNs after NAC has been considered a reason for the alteration of the lymphatic flow. Nonetheless, the mechanism for chemotherapy-induced fibrosis in metastatic LNs has not been elucidated. We focused on the accumulation of macrophages in the necrotic tumor cells. This study explores the role of macrophages contributing to fibrosis in metastatic LNs in esophageal cancer patients who received NAC.
Methods We enrolled 21 patients who underwent curative esophagectomy for esophageal squamous cell carcinoma (ESCC) at our institution between 2017 and 2022. One or two LNs diagnosed with pathologically N-positive by permanent histological diagnosis or with clinically N-positive by CT scans performed before NAC were selected arbitrarily from each patient’s specimen. We conducted the immunohistochemistry for obtained LNs, targeting human macrophage marker (CD68) and TGF-β1. The ratio of the number of CD68-positive cells in the tumor or fibrosis area to those in the surrounding subcapsular sinus area was used as a degree of macrophage accumulation (AM score). Moreover, we defined the intensity/population (IP) score (0-15), which was the product of scored staining intensity (0-3) and scored stained cell frequency (1-5), as an expression index for TGF-β1. We classified LNs into four groups according to their response to NAC as follows: LNs obtained from patients who had not received NAC (nLN), LNs with poor response (pLN), with good response (gLN), and with complete response (cLN), obtained from patients who had received NAC. Good response was defined as a decrease of ≥ 50 % in areas of viable tumor cells.
Results A total of 30 LNs obtained from enrolled patients, including seven categorized as nLN, five as pLN, eight as gLN, and ten as cLN were analyzed. AM scores of gLN and cLN were higher than those of nLN and pLN (nLN 0.75, pLN 0.46, gLN 1.79, and cLN 2.56). Furthermore, gLN had a higher IP score than other groups (nLN 1.0, pLN 1.0, gLN 7.5, and cLN 1.0) (Fig.1). The double immunofluorescence staining for LNs categorized as gLN showed the co-expression of CD68 and TGF-β1 (Fig.2).
Conclusions Macrophages accumulating in LNs with necrotic tumor cells and their TGF-β1 secretion may induce fibrosis in metastatic LNs in ESCC patients who received NAC. Blocking TGF-β1 activity may prevent fibrosis and lymphatic flow alteration and allow the intraoperative prediction of nodal involvement using near-infrared imaging, even for ESCC patients who received NAC.

Introduction: The left thoracoabdominal (LTA) incision offers excellent exposure for bulky Siewert II/III tumors of the esophagogastric junction. We explore how either esophagogastrostomy or esophagojejunostomy performed during LTA esophagogastrectomy effect postoperative outcomes and quality of life (QoL).

Methods: From 01/07-01/22 all patients undergoing LTA were identified from a single center’s prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy an esophagogastrostomy (GAS) or Roux-En-Y esophagojejunostomy (R-Y) was fashioned. Patients were stratified according to the method of reconstruction and postoperative outcomes compared including complications and clinical/endoscopic reflux. If available, the Functional Assessment of Cancer Therapy – Esophagus (FACT-E) questionnaire was used to compare QoL at various timepoints through the patient journey.

Results: LTA was performed in 147 patients of whom 135 (92%) were included. There were 97 GAS (72%) and 38 R-Y patients (28%). Most were male (110/135,81%) aged 66 years (range 27-90). The most common pathology was adenocarcinoma (115/135, 85%), with an equal incidence of ypT3/4 lesions between GAS and R-Y patients (64/97 vs 30/38 NS) whilst ypN+ was higher in the latter (31/38 vs 57/97 p=0.012). Clavien Dindo grade 3-4 complications and reoperation were similar between the groups (26/97, 27% vs 9/38, 24% and 8/97, 8% vs 3/38, 8% NS). Anastomotic leak and 30-day readmission were significantly higher among GAS patients (14/97, 14% vs 1/38, 3% p=0.040 and 16/97, 16% vs 1/38, 3% p = 0.029). Following LTA, 90/147 patients had QoL data available including 68/97 (70%) GAS and 22/38 (58%) R-Y patients. FACT-E scores were available for 80/21/24/18/23/24 patients at diagnosis, preoperatively and postoperatively at 1, 3-6 months, 1-3 and 3+ years respectively. At each time interval, there was no difference in the scores when comparing GAS with R-Y (79/91/72/84/89/114 vs 79/107/71/73/80/100 NS). As a whole, FACT-E improved between baseline and preoperatively (79, 34-124 vs 102, 81-123, p = 0.027) with baseline scores only being exceeded at 3+ years after surgery (79, 34-124 vs 102, 62-124 p=0.001). Similarly, preoperative FACT-E scores significantly higher than scores for the first 3 years. Only at 3+ years were the FACT-E scores equivalent to preoperative values (102, 62-124, p = NS). Clinical reflux and endoscopic esophagitis was significantly higher >6 months postoperatively among GAS compared with R-Y patients (15/28, 54% versus 0/5, 0.0% , p = <0.001 and 15/27 47.8% versus 0/7, 0.0%, p = 0.008).

Conclusion: The type of reconstruction did not affect QoL however it did affect the postoperative course. It took 3+ years for QoL scores to equal or exceed preoperative values. Clinicians and patients should be aware of these outcomes when planning operative intervention.

Introduction:
Magnetic sphincter augmentation (MSA) is an effective alternative to fundoplication with reduced rates of gas-bloat and preserved ability to belch. This suggests a comparatively modest impact on gastric physiology. However, there is paucity of objective gastric physiology data after MSA. The current study aims to assess the impact of MSA on gastric emptying.
Methods:
This was a retrospective review of prospectively collected data from patients with no history of pyloroplasty who underwent gastric emptying scintigraphy (GES) before and after MSA between 2016 and 2021. Delayed gastric emptying (DGE) was defined as 4-hour percent retention >10%. Rapid gastric emptying was defined as 1-hour percent retention <30%. Patients completed the GERD-HRQL questionnaire and pH-monitoring preoperatively and at 12 months postoperatively. Normalization of esophageal acid exposure was defined as DeMeester score <14.7.
Results:
The final study population consisted of 55 patients (74.6% female) with a mean (SD) age of 51.6 (13.1) and BMI of 29.6 (5.0). At a mean (SD) follow up of 13.7 (3.8) months, median (IQR) GERD-HRQL score decreased from 39 (25-53) to 14 (5-26) (p<0.001), 90.2% of patients were free from use of proton pump inhibitors (PPI) and 71.1% had normalization of esophageal acid exposure. Median (IQR) 4-hour retention on GES was similar before and after MSA [1.0 (0.0-3.0) to 1.0 (0.0-6.0), p=0.702]. There were 5 (9.1%) patients with preoperative DGE, of which all normalized after MSA. However, of the 50 (90.9%) patients with normal preoperative GES, 6 (12.0%) patients developed de novo postoperative DGE. There was no significant change in the prevalence of DGE (p=0.782). There was no correlation between pre- and postoperative 4-hour retention (p=0.788).
Median (IQR) 1-hour retention significantly decreased after MSA [68.0 (56.0-83.0) to 56.8 (40.0-72.0), p=0.001]. There was a significant increase in the number of patients with rapid gastric emptying from 0 (0%) to 6 (10.9%), p=0.008. Figure 1 shows a direct correlation between pre- and postoperative 1-hour retention [R: 0.366 95%CI (0.11-0.58), p=0.006].
Patients with preoperative DGE had similar postoperative GERD-HRQL scores (p=0.097), PPI use (p=1.000), and pH normalization (0.308) compared to those without DGE. Patients with postoperative normal, de novo rapid, and de novo delayed gastric emptying had similar GERD-HRQL scores (p=0.122), PPI use (p=0.489) and pH normalization (0.168).
Conclusion:
Magnetic sphincter augmentation resulted in resolution of preoperative delayed gastric emptying in all patients. However, due to de novo postoperative DGE, there is no net effect on the prevalence of DGE. Early gastric emptying was enhanced with 10.9% developing de novo rapid gastric emptying. Antireflux outcomes at 1-year after MSA were unaffected by preoperative gastric emptying status.

Introduction: Esophagectomy is the gold-standard treatment for locally advanced esophageal cancer but has high morbimortality rates. Sarcopenia is a common comorbidity in esophageal cancer patients. The association of esophagectomy and preoperative sarcopenia may relate to poor prognosis. However, the exact burden of sarcopenia in esophagectomy remains unclear. Therefore, this systematic review and meta-analysis aimed to establish the impact of sarcopenia on postoperative outcomes of esophagectomy for cancer.
Methods: An electronic search was conducted by two reviewers on Embase, PubMed, Cochrane, and LILACS, alongside a manual search of the references. The inclusion criteria were cohorts, case series, and clinical trials; adult patients; studies evaluating patients with sarcopenia undergoing esophagectomy or gastroesophagectomy for cancer; and studies that analyze relevant outcomes. The exclusion criteria were letters, editorials, congress abstracts, case reports, reviews, cross-sectional studies, patients undergoing surgery for benign conditions, and animal studies. Forest plots were used for synthesis and expressed by the risk difference (RD) or mean difference (MD). Statistical heterogeneity was evaluated with I². Random effect models were applied. All studies underwent the risk of bias assessment by the ROBINS-I tool and quality of evidence analysis by GRADE. This study was written following PRISMA statement recommendations.
Results: 38 studies were included in the meta-analysis. Patients with preoperative sarcopenia had a higher risk for postoperative complications (RD: 0.08; 95% CI: 0.02 to 0.14; I²: 67.7%), severe postoperative complications (RD: 0.11; 95% CI: 0.04 to 0.19; I²: 68.9%), pneumonia (RD: 0.13; 95% CI: 0.09 to 0.18; I²: 63.7%), and longer hospital stay (MD: 3.54 days; 95% CI: 0.41 to 6.66 days; I²: 94.8%) than patients with no preoperative sarcopenia. No significant difference was found for postoperative mortality (RD: 0.01; 95% CI: -0.03 to 0.05; I²: 93.3%) and anastomotic leak (RD: 0.01; 95% CI: -0.01 to 0.02; I²: 0). The 3-year overall survival was lower in patients with sarcopenia (RD: -0.16; 95% CI: -0.23 to -0.10; I²: 70.3%; Figure 1). The major risk of bias concern was related to the risk of selection, and certainty was very low to moderate.
Conclusion: Preoperative sarcopenia impacts postoperative early and long-term outcomes in esophagogastric resection for cancer.
Registration number: CRD42021270332.

Figure 1. The 3-year overall survival. Patients with sarcopenia had a lower probability of survival at a 3-year follow-up than those without.

Figure 1. The 3-year overall survival. Patients with sarcopenia had a lower probability of survival at a 3-year follow-up than those without.

Francisco Tustumi

USP

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