ENDOSCOPIC STENTING IN THE TREATMENT OF RECURRENT EPIPHRENIC DIVERTICULUM AFTER LAPAROSCOPIC DIVERTICULECTOMY. CLINICAL CASE REPORT

Epiphrenic diverticulum, also known as a pulsion diverticulum, is a rare type of esophageal diverticulum occurring in the distal 10 centimeters of the esophagus. They are most commonly 4-10 cm above the gastric cardia representing 10% of all esophageal diverticula. Laparoscopic diverticulectomy has become the treatment of choice. This clinical case study is dedicated to minimally invasive treatment of recurrent epiphrenic diverticulum after laparoscopic diverticulectomy. A 74-year-old male patient was admitted to the hospital with complaints of dysphagia, regurgitation and halitosis. The examination revealed a 5 cm epiphrenic diverticulum with sings of inflammation. Laparoscopic transchiatal diverticulectomy, the Dor (anterior) fundoplication, cruroraphia and mediastinal drainage were performed. The patient was discharged on the 11-th postoperative day. The patient exhibited dysphagia relapse during a 3-month follow-up. Taking into account the previous surgical treatment and the habitus endoscopic esophageal stenting was chosen as the technique of choice for management. Under intravenous anesthesia a partially covered metal self-expandable stent 10 cm x 1.8 cm was inserted into the distal esophagus. Next day control fluoroscopy showed stable stent position and no evidence of leakage. The water-soluble contrast agent reached stomach freely. The patient was discharged on the 2nd post-operative day. Within 4 months after having a stent placed, the patient feels well and oral feeding is satisfactory. In terms of literature search we have not come across any reference to the post-epiphrenic diverticulectomy recurrence treatment, so the management was chosen individually based on the comorbid status of the patient. The installation of a partially covered metal self-expandable stent allowed to promptly eliminate dysphagia and design features enabled to achieve stent stable position. A partially covered metal self-expandable stent can be considered effective in the post-epiphrenic diverticulectomy recurrence treatment.

584 MULTIPLE OBSERVER DETERMINATION OF GASTRO-ESOPHAGEAL JUNCTION CHARACTERISTICS ON VIDEO-FLUOROSCOPY RELATING TO TROUBLESOME DYSPHAGIA POST-FUNDOPLICATION

Dysphagia is a common adverse effect of fundoplication and in some patients, there is no clear identifiable cause despite extensive investigation. Subtle anatomical features of anti-reflux surgery may relate to dysphagia. In this study multiple observers examine gastro-esophageal junction (GEJ) anatomy using objective measures of video-fluoroscopy swallow study (VFSS) to explore possible correlates with post-fundoplication dysphagia. Methods Thirty-one patients underwent structured VFSS 6–12 months after laparoscopic total (TotLF) or partial anterior (PAntLF) fundoplication recording: standing AP, 2x standing oblique (SOb), 2x prone oblique (POb), and prone oblique with continuous drinking (PObCont). Post-operative dysphagia was evaluated (Dakkak & Bennett Score: range 0–45; troublesome ≥12). Three observers (Obs1–3) independently measured: GEJ displacement anteriorly; degree of axis deviation of esophagus & GEJ (E-GEJ); posterior distal esophageal angle (PDEA); and GEJ opening diameter cf. maximal distal esophageal diameter (ME-GEJ). Correlations between measurements and dysphagia by operation type were assessed using linear regression analysis and linear mixed-effects models. Results Post-operatively, 5/18 TotLF and 4/13 PAntLF patients reported troublesome dysphagia. Three observers independently found: patients with troublesome dysphagia after TotLF had greater anterior displacement of the GEJ (SOb, range 0.61 cm–1.18 cm, Obs1 p = 0.04), and larger axis deviation of E-GEJ (POb, range 3.28°-13.07°, Obs2 p = 0.03) compared to patients with no/mild dysphagia. There was a trend for greater PDEA in patients with troublesome dysphagia after TotLF (POb, range 0.46°-2.12° and PObCont, range 3.37°-13.4°), but this trend did not reach statistical significance. Following PAntLF, all observers recorded a reduction in ME-GEJ for each unit of worsening dysphagia (PObCont, range 0.03 cm–0.04 cm, Obs1 p = 0.02, Obs2 p = 0.02). Conclusion Multiple observers concur that anterior GEJ displacement, the angle between the esophagus axis—GEJ axis, and posterior distal esophageal angulation are anatomical factors associated with troublesome dysphagia after total fundoplication. After partial anterior fundoplication, a small reduction in GEJ opening diameter relative to the distal esophagus related to worsening dysphagia. To reduce post-fundoplication dysphagia, attention to operative techniques affecting angulation and luminal diameter at the GEJ by fundoplication and hiatal repair is warranted.

195 RANDOMISED TRIAL OF LAPAROSCOPIC NISSEN VS. ANTERIOR 180 DEGREE PARTIAL FUNDOPLICATION—LATE CLINICAL OUTCOMES AT 15–20 YEARS

Laparoscopic Nissen fundoplication for gastro-oesophageal reflux is followed by troublesome side effects in some patients. Partial fundoplications are proposed for reflux control with less side effects. We reported earlier outcomes from a randomised control trial of Nissen vs. anterior 180° partial fundoplication, with a good outcome following anterior 180° partial fundoplication at up to 10 years follow-up. For this study we determined very late clinical outcomes at up to 20 years follow-up. Methods 107 patients were randomised to Nissen vs. anterior 180° partial fundoplication. 15–20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardised clinical questionnaire that included 0–10 analogue scores and yes/no questions to evaluate reflux symptoms, side-effects and overall satisfaction with surgery. Results Heartburn (mean score 3.2 vs 1.4, p = 0.001) and proton pump inhibitor use (41.7% vs 17.1%, p = 0.023) were higher, dysphagia for solids (mean score 1.8 vs 3.3, p = 0.015) was less, and ability to belch was better preserved (84.2% vs 65.9%, p = 0.030) after anterior fundoplication. Overall outcome measures were similar for both groups (mean satisfaction score 8.4 vs 8.0, p = 0.444; 86.8% vs 90.2% satisfied with outcome). Six patients underwent revision from anterior to Nissen fundoplication for reflux, and 5 from Nissen to partial fundoplication for dysphagia. Two further patients underwent revision following Nissen fundoplication for reflux and paraoesophageal hernia respectively. Conclusion At up to 20 years follow-up Nissen and anterior 180-degree partial fundoplication achieve similar rates over overall success, but with a demonstrable trade-off between better reflux symptom control vs. more side-effects after Nissen fundoplication.

Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia

Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary,it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.

Gastro-oesophageal fistula in an achalasia patient following myotomy as an unusual cause of heartburn

We report a case of delayed presentation of a gastro-oesophageal fistula following a Heller myotomy and anterior fundoplication for achalasia in a 28-year-old man. After a period of symptom resolution following initial operation, dysphagia and severe heartburn commenced temporarily, related to non-steroidal anti-inflammatory drug (NSAID) use. Endoscopy demonstrated a secondary opening in the lower oesophagus and a barium swallow showed an oesophageal fistula to the stomach. Currently, reasonable symptom control has been obtained on double dose pantoprazole. Barium study best demonstrated the abnormality. NSAIDs should possibly be avoided in cases of severe dysmotility of the oesophagus.

Perioperative manometric studies in laparoscopic Watson’s repair versus Nissen’s fundoplication

Background: Hiatus Hernia (HH) and GERD are common upper gastroesophageal disorders, The Nissen`s fundoplication is one of the most effective and commonly used surgical techniques in management of both GERD and hiatus hernia (HH). many surgeons are searching for alternative procedures due to the mechanical obstructive effects of Nissen's fundoplication, one of these procedures is partial anterior fundoplication (Watson’s repair).Methods: Eighty two patients, diagnosed to have GERD and/or HH, were scheduled for present study for laparoscopic anti-reflux surgery. They were randomized to either Watson’s repair (anterior partial fundoplication) (group I) or Nissen repair (group II) in the period between June 2012 and March 2017. Forty two patients for group I and forty patients were included in group II. Group I had partial anterior fundoplication and group II had Nissen's fundoplication. Follow up for all patients included in our study was scheduled at (2, 4weeks and 3, 6, 12months postoperatively) both subjectively - using a standardized scoring system for reflux symptoms (heartburn, regurgitation and dysphagia), gas bloating and objectively-using esophago-gastroscopy at 6ms and 12ms postoperatively, esophageal manometry, 24hours PH monitoring at 6ms and 12ms post operatively.Results: Three cases were excluded from the study because they were converted to open procedure, one of group I and two of group II. Mean operative time was significantly shorter in group I. As regarding to reflux symptoms (heartburn and regurgitation) Nissen was significantly higher in control of reflux symptoms at 3months but at 6, 12months Nissen still higher but without a clear significant difference. On the opposite side dysphagia was significantly higher in Nissen group than in Watson group at 3months and remained higher at 6,12months but with no significant difference, also gas related symptoms were higher in Nissen group than in Watson group all the time of follow up. Objectively, esophagitis improved to a similar extent in both groups. Watson was less effective in improving LES characters, and 24hours PH parameters in comparison to Nissen group but without any significant difference in both groups.Conclusions: Partial anterior fundoplication (Watson repair) can be safe, effective and simple alternative procedure for Nissen's fundoplication with less obstructive symptoms and complications.

Type IV Laryngotracheoesophageal Cleft Associated with Type III Esophageal Atresia in 1p36 Deletions Containing the RERE Gene: Is There a Causal Role for the Genetic Alteration?

The causes of embryological developmental anomalies leading to laryngotracheoesophageal clefts (LTECs) are not known, but are proposed to be multifactorial, including genetic and environmental factors. Haploinsufficiency of the RERE gene might contribute to different phenotypes seen in individuals with 1p36 deletions. We describe a neonate of an obese mother, diagnosed with type IV LTEC and type III esophageal atresia (EA), in which a 1p36 deletion including the RERE gene was detected. On the second day of life, a right thoracotomy and extrapleural esophagus atresia repair were attempted. One week later, a right cervical approach was performed to separate the cervical esophagus from the trachea. Three months later, a thoracic termino-terminal anastomosis of the esophagus was performed. An anterior fundoplication was required at 8 months of age due to severe gastroesophageal reflux and failure to thrive. A causal role of 1p36 deletions including the RERE gene in the malformation is proposed. Moreover, additional parental factors must be considered. Future studies are mandatory to elucidate genomic and epigenomic susceptibility factors that underlie these congenital malformations. A multiteam approach is a crucial factor in the successful management of affected patients.