The Relevance of Ineffective Esophageal Motility to Surgical Practice

Foregut surgery is often complicated by postoperative dysphagia. Preoperative esophageal manometry has been used to counsel patients and to guide choice of operation to minimize dysphagia outcomes. Uncertainty surrounds the optimal surgical management of patients with disordered motility. While treatment protocols are generally accepted for the disorders of esophagogastric junction outflow, surgery choice in the presence of disorders of peristalsis, particularly ineffective esophageal motility (IEM), is less clear. With the diagnosis of IEM, provocation testing is being utilized to predict postoperative dysphagia and to guide management, though evidence is not yet sufficient to allow for strong recommendations.

Biopsy forceps disruption paired with bougie dilation of esophageal strictures lengthens time to repeat intervention

Summary Esophageal strictures commonly cause dysphagia and require treatment with endoscopic dilation using balloons or bougies. We aimed to determine whether biopsy forceps disruption of strictures at time of dilation increases time to repeat intervention or duration of intervention-free follow-up. We performed a retrospective analysis of 289 adults (age 61.0 ± 0.8 years, 66.4% female) who underwent dilation of an esophageal stricture at our tertiary care center between 2014 and 2016. Exclusions consisted of endoscopic intervention within the preceding 6 months, prior foregut neoplasia, achalasia, radiofrequency ablation, endoscopic mucosal resection, endoscopic submucosal dissection, or foregut surgery. Demographics, clinical presentation, dilation technique, and follow-up were abstracted from electronic medical records. We compared time to repeat dilation and duration of intervention-free follow-up between treatment subgroups. Balloon dilation was performed more often than bougie dilation (76.8 vs. 17.6%); biopsy forceps disruption was performed in 23.2%. Over a median follow-up of 52.9 months, 135 patients (46.7%) underwent repeat dilation. Age, body mass index, gender, and use of antisecretory medications did not influence need for repeat dilation (P = ns for each). Bougie dilation with biopsy forceps disruption prolonged time to repeat dilation in all patients (P ≤ 0.02), particularly in those with gastroesophageal reflux disease (P ≤ 0.03), compared with bougie dilation alone and balloon dilation with or without disruption. On Kaplan–Meier analysis, bougie dilation with biopsy forceps resulted in longer intervention-free follow-up compared with dilation alone (P = 0.03). We conclude that stricture disruption with biopsy forceps increases time to repeat intervention with bougie but not balloon dilation.

504 THE USE OF ENDOSCOPIC VACUUM THERAPY (EVT) AS COMPARED TO ENDOSCOPIC STENTING (ES) FOR LEAKAGES AFTER FOREGUT SURGERY

Anastomotic leakage after foregut surgeries are often difficult to manage. The conventional way of endoscopic treatment is ES. However, it carries a risk of stent migration and erosion. EVT is a novel way of treating these leaks. Methods This was a retrospective cohort study including all patients with anastomotic leak after foregut surgery and were treated with ES or EVT between July 2008 and July 2019. Patients’ demographics, type of surgery, size of anastomotic defect, success rate, complications, number of procedures were recorded and compared. Results There were 17 patients treated with ES and 7 patients treated with EVT. The success rate of both therapies are similar. (11/17(64.7%) in the ES group vs 5/7(71.4%) in the EVT group; p = 0.751). However, there was a trend to less complications in the EVT group (9/17 (52.9%) in ES group vs. 1/7(14.2%) in EVT group; p = 0.135). On the other hand, the EVT group has a trend to requiring more endoscopic procedures (median (range) 3 (7) procedures in the ES group vs 6(11) in the EVT group; p 0.435). Conclusion The use of EVT is feasible and safe in treating anastomotic leaks after foregut surgeries. Although more procedures are required, it achieved similar success rate while having a trend to less complications.