Laparoscopic hand-sewn cardioplasty: an alternative procedure for end-stage achalasia

Background Primary achalasia is a rare oesophageal motor disorder characterized by the absence of swallow-induced relaxation of the lower oesophageal sphincter and diminished or absent oesophageal body peristalsis. Around 5% of these patients will develop end-stage achalasia, where oesophagectomy may be advocated. We present the laparoscopic hand-sewn cardioplasty as an alternative ‘oesophagus-preserving’ procedure in patients with end-stage achalasia. Methods We present a retrospective review of four patients who underwent laparoscopic hand-sewn cardioplasty. Data collected included pre-operative demographic information and investigations; and post-operative outcomes. Patients were scored pre- and post-operatively using Reflux Symptom Index, Eating Assessment Tool-10 and Voice Handicap Index-10 questionnaires. Results Four patients underwent laparoscopic hand-sewn cardioplasty during the study period. In one patient, it was performed as a rescue procedure during attempted myotomy following multiple perforations of friable mucosa. In the other three patients, laparoscopic hand-sewn cardioplasty was performed for end-stage achalasia. None of the patients had post-operative complications and all patients were discharged on the second post-operative day. All patients experienced improvement in swallowing symptoms (EAT-10; p = 0.03) but developed post-operative gastroesophageal reflux. Conclusion To our knowledge, this is the first published case series of laparoscopic hand-sewn cardioplasty for end-stage achalasia. It appears to be a safe and effective procedure for the treatment of end-stage achalasia, offering an alternative minimally invasive procedure to oesophagectomy. Laparoscopic hand-sewn cardioplasty can also be used as a ‘rescue’ procedure during myotomy in patients who have poor-quality mucosa which perforates intra-operatively or is at high risk of perforation/leaking post-operatively.

Usefulness of The Reflux Symptom Index in the Management of Laryngopharyngeal Reflux

Introduction Laryngopharyngeal Reflux (LPR) is highly prevalent in the general population and its impact on health systems is growing dramatically by the day. The contents of the stomach flowing back into the oesophagus, pharynx and larynx because of a transient relaxation of the lower oesophageal sphincter leads to a spectrum of symptoms diagnosed as LPR and Gastroesophageal Reflux Disease (GERD). The aim was to study in detail the symptoms of LPR and to ascertain if and how they hamper the routine of an individual by using the Reflux Symptom Index (RSI). Materials and Methods The Reflux Symptom Index (RSI) is a self-administered nine-item outcomes instrument for LPR. Ninety-one patients with clinically diagnosed LPR were taken up for this study and were issued the RSI (translated into the local language for better results) before and after treatment. Data was assessed at the end of 3 months and 6 months. Results The tabulated data showed significant improvement in the symptomatic index after treatment. Conclusion It can thus be concluded that RSI is still highly valid in the follow-up for patients with LPR because it can be easily administered and gives accurate results with excellent validation.

A Bitter Pill to Swallow: Pseudoachalasia Secondary to Oesophageal Deviation Resulting from Mediastinal Shift and Left Atrial Enlargement after Left Lower Lobectomy

Pseudoachalasia, also known as secondary achalasia, is a rare clinical condition mimicking idiopathic achalasia but unrelated to primary loss of nitrergic innervation. It has mostly been attributed to malignancy infiltrating the oesophageal wall, but several other benign underlying pathologies have been reported. Because of similar manometric appearance, high-resolution manometry (HRM) of the oesophagus alone cannot distinguish between idiopathic achalasia and pseudoachalasia. Misdiagnosis can result in ineffective treatment by dilatation or even more invasive therapy. This is the first case-report of pseudoachalasia secondary to oesophageal deviation resulting from mediastinal shift and left atrial enlargement following prior left lower lobectomy. HRM, the gold standard for the diagnosis of achalasia, confirmed the incomplete relaxation of the lower oesophageal sphincter (LES) in absence of normal oesophageal peristalsis. However, additional workup with CAT scan and cardiac ultrasound identified an anatomical shift by the extrinsic mass effect resulting from the atrial enlargement, but without contrast retention at the LES.

Achalasia Cardia: A Comprehensive Review

Achalasia cardia is the best characterised oesophageal motility disorder. It is characterised by progressive ganglion cell degeneration in the oesophageal myenteric plexus, which results in impaired lower oesophageal sphincter (LES) relaxation upon swallowing and aperistalsis in the distal smooth muscle segment of the oesophagus. The usual presenting features are dysphagia to both liquids and solids from onset, regurgitation of undigested food, retrosternal pain, heartburn, and weight loss. Initial investigations include upper gastrointestinal (GI) endoscopy and timed barium oesophagogram, whereas high resolution manometry is diagnostic. Therapy in achalasia cardia is directed towards biochemical or mechanical reduction in LES pressures. If candidates are fit for surgery, pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller’s myotomy are the mainstays of therapy that act by mechanical disruption of LES. On the other hand, botulinum toxin and pharmacotherapy (nitrates and calcium channel blockers) act by biochemical reduction of LES and are reserved for surgically unfit patients with limited life expectancy because of their short-lived efficacy. Oesophagectomy is reserved for treating refractory longstanding cases, who have previously failed multiple therapies.

Tethered capsule en face optical coherence tomography for imaging Barrett’s oesophagus in unsedated patients

ObjectiveBarrett’s oesophagus (BE) screening outside the endoscopy suite can identify patients for surveillance and reduce mortality. Tethered capsule optical coherence tomography (OCT) can volumetrically image oesophageal mucosa in unsedated patients and detect features of BE. We investigated ultrahigh-speed tethered capsule swept-source OCT (SS-OCT), improved device design, developed procedural techniques and measured capsule contact, longitudinal pullback non-uniformity and patient toleration.DesignOCT was performed in 16 patients prior to endoscopic surveillance/treatment. Unsedated patients swallowed the capsule with sips of water and the tether was pulled back to image the oesophagus. SS-OCT at 1 000 000 A-scans/s enabled imaging 10 cm oesophageal lengths in 10 s with 30 µm transverse and 8 µm axial resolution. Capsule contact, longitudinal image coverage and patient toleration were assessed.ResultsNine patients had non-dysplastic BE, three had ablative treatment-naïve neoplasia and four had prior ablation for dysplasia. Dry swallows facilitated capsule transit through the lower oesophageal sphincter (LES), and waiting 10 s before pullback reduced swallow induced LES relaxation. Slow nasal inhalation facilitated capsule retrieval and minimised gag reflex. The procedure was well tolerated. Ultrahigh-speed SS-OCT generated cross-sectional and subsurface en face images showing BE features, while subsurface en face images were required to assess the gastro-oesophageal junction. Candidate features of dysplasia were also identified which could inform follow-up endoscopy/biopsy. BE features were seen in all patients with histologically confirmed BE. Mean capsule contact over BE was 75%±27% for all patients and better in short segment BE. Mean longitudinal image coverage over BE was 59%±34% and better for long segment BE.ConclusionsUltrahigh-speed tethered capsule SS-OCT can image en face and cross-sectional mucosal features over wide areas. Device and procedure optimisation improved performance. BE features could be identified in all patients, but limited capsule contact and longitudinal coverage could cause sampling errors for focal pathologies.

Taking the ‘sauer’ out of sauerkraut: a rapid update on the pathophysiology and treatment of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD), in layman’s terms known as heartburn, is a condition characterised by frequent oesophageal contact with gastric acid. Contrary to what is generally accepted, GERD is not caused by excessive quantities of gastric acid. Rather, symptoms result from any combination of a number of contributing factors, including decreased lower oesophageal sphincter pressure, hiatus hernia (where the stomach protrudes through the diaphragm), reduced oesophageal and gastric clearance and compromised oesophageal mucosa barrier integrity. Although most patients are able to manage GERD symptoms by means of lifestyle changes, chronic and recurrent episodes of reflux may result in erosive oesophagitis, nasal inflammation, dysphagia, i.e. difficulty in swallowing, and even pulmonary complications, e.g. asthma.