Approach to esophageal absent contractility: can we do better?

Absent contractility (AC), a motility disorder characterized by the absence of esophageal contractions while maintaining normal lower esophageal sphincter relaxation, is recognized as a distinctive major disorder of peristalsis on esophageal high-resolution manometry that warrants comprehensive understanding. This unique motility disorder often co-occurs with connective tissue, rheumatologic or autoimmune diseases, with scleroderma being the classic example. Symptoms of gastroesophageal reflux are common. AC can profoundly impact patients' lives and result in a spectrum of complications, including erosive esophagitis, esophageal candidiasis, Barrett's esophagus, and malnutrition. To address the intricate complexities of AC and its multifaceted complications, a multidisciplinary approach is paramount. This approach considers the distinct clinical presentation and underlying rheumatologic conditions of the individual patient, recognizing the inherent diversity within this disorder. While medical management of gastroesophageal reflux remains the cornerstone of AC treatment, emerging surgical and endoscopic interventions offer additional therapeutic options for those grappling with this challenging condition. This comprehensive review provides an in-depth evaluation of recent advances in our understanding of AC and its management. It endeavors to offer valuable insights into therapeutic strategies for AC and its associated issues.

Comprehensive Assessment of Esophageal Disorders Associated with Hiatus Hernia: Insights from Big Data Analysis.

Hiatus hernia (HH) is a prevalent endoscopic finding in clinical practice, frequently co-occurring with esophageal disorders, yet the prevalence and degree of association remain uncertain. We aim to investigate HH's frequency and its suspected association with esophageal disorders. We reviewed endoscopic reports of over 75,000 consecutive patients who underwent gastroscopy over 12 years in two referral centers. HH was endoscopically diagnosed. We derived data on clinical presentation and a comprehensive assessment of benign and malignant esophageal pathologies. We performed multiple regression models to identify esophageal sequela associated with HH. The overall frequency of HH was (16.8%); the majority (89.5%) had small HHs (<3 cm). Female predominance was documented in HH patients, who were significantly older than controls (61.1±16.5 vs. 52.7±20.0; P < 0.001). The outcome analysis of esophageal pathology revealed an independent association between HH, regardless of its size, and erosive reflux esophagitis (25.7% vs. 6.2%; OR = 3.8; P < 0.001) and Barrett's esophagus (3.8% vs. 0.7%; OR = 4.7, P < 0.001). Furthermore, following rigorous age and sex matching, in conjunction with additional multivariable analyses, large HHs were associated with higher rates of benign esophageal strictures (3.6% vs. 0.3%; P < 0.001), Mallory Weiss syndrome (3.6% vs. 2.1%; P = 0.01), and incidents of food impactions (0.9% vs. 0.2%; P = 0.014). In contrast, a lower rate of achalasia was noted among this cohort (0.55% vs. 0%; P = 0.046). Besides reflux-related esophageal disorders, we outlined an association with multiple benign esophageal disorders, particularly in patients with large HHs.

Gas Embolism After a Patient's Ninth ERCP Procedure.

Gas embolism is a rare and potentially fatal complication of endoscopic retrograde cholangiopancreatography (ERCP). We present a 66-year-old man who developed gas embolism after undergoing therapeutic ERCP for cholangitis. Some risk factors of gas embolism in this patient included stones in the common bile duct with cholangitis and a history of multiple ERCP procedures. Early diagnosis and rapid treatment of this potentially fatal complication resulted in our patient's full recovery.

The impact of overweight on diverticular disease: a cross-sectional multicenter study.

INTRODUCTION: The prevalence of colonic diverticulosis and diverticulitis has significantly increased in recent years. Obesity is a well­known risk factor for diverticulitis, but far less is known about the association between diverticulitis and overweight. OBJECTIVE: We aimed to examine the association between overweight and diverticulitis and to study the potential relationship between body mass index (BMI) and disease severity. PATIENTS AND METHODS: We conducted a retrospective, multicenter study. Patients diagnosed with diverticulosis confirmed by colonoscopy were included. The diagnosis of diverticulitis was confirmed by computed tomography. Weight status was defined as normal in the case of BMI in the range of 18.5- 24.9 kg/m2, overweight when BMI was 25-29.9 kg/m2, and obesity with BMI equal or above 30 kg/m2. RESULTS: The study included 592 patients. Among them, 157 (26.5%) had normal BMI, 191 (32.3%) were overweight, and 244 (41.2%) were obese. Patients with BMI above the normal range, overweight and obese were at higher odds of acute diverticulitis as compared with those with normal BMI. This was evidenced by the values of odds ratio (OR) 3.10 (95% CI, 2.00-4.73; P <0.001) for weight above the normal range, OR 1.85 (95% CI, 1.14-3.00; P = 0.01) for overweight, and OR 4.50 (95% CI, 2.84-7.12; P <0.001) for obese patients. CONCLUSIONS: Overweight was associated with an increased risk of diverticulitis among patients with diverticulosis. Since overweight is a modifiable factor, this observation has preventive importance.

Achalasia in the Elderly: Diagnostic Approach and a Proposed Treatment Algorithm Based on a Comprehensive Literature Review.

Achalasia is not uncommonly diagnosed in elderly patients and its incidence and prevalence are growing in this population. However, a scarcity of studies has assessed the typical pathophysiological and clinical features of the disease as well as the effectiveness and safety of the various therapeutic options in elderly populations. Botulinum toxin injection has been used for achalasia treatment since 1994 and is traditionally considered the preferred treatment for fragile elder patients. However, recently more evidence has become available regarding the safety and effectiveness of pneumatic balloon dilation (BD), laparoscopic Heller myotomy (LHM) and per-oral endoscopic myotomy (POEM) in elderly patients with achalasia. In the current review we present the current literature on this topic with a focus on the clinical presentation of achalasia in the elderly and manometric features thereof, as well as summarize the effectiveness and safety of the various therapeutic options. Furthermore, we propose a practical management algorithm as a means to guide the treatment of future cases. We recommend that a conservative/BTI approach should be adopted in the fragile unfit patient. In the elderly fit patient, the treatment decision should be based on the achalasia type, patient preference and the available expertise, similar to the approach adopted for the non-elderly population.

Impact of Pneumoperitoneum on the Development of Acute Kidney Injury: Comparison Between Normal and Diabetic Rats.

BACKGROUND: Minimally invasive surgery is considered the gold-standard approach for many surgical procedures. However, it requires CO2 insufflation and elevated intra-abdominal pressure (IAP), which may result in adverse pulmonary, cardiovascular, gastrointestinal, and renal changes. The kidneys are highly sensitive to pressure changes, where risk factors such as severe infection, dehydration, older age, and chronic kidney disease may aggravate the likelihood for the development of acute kidney injury (AKI). Unfortunately, the impact of diabetes mellitus on the deleterious effects of elevated IAP-induced AKI was not fully studied so far. The present study was designed to examine the effect of pneumoperitoneum on renal function and the development of AKI in diabetic rats. MATERIALS AND METHODS: Sprague Dawley rats were divided into 2 groups: control (nondiabetic) rats (n=7) and diabetic rats (n=10). A Veress needle was introduced through the supravesical incision where inflating CO2 allowing the IAP to be increased to the desired pressures 7, 10, and 14 mm Hg for 45 minutes each and at the end of the experiment, the pressure was deflated to zero. During each pressure point, hemodynamic parameters were recorded and urine and blood samples were collected for analysis. RESULTS: The baseline values of renal hemodynamic were significantly lower in diabetic rats. There were no major statistically significant changes from baseline in urinary flow, urinary sodium excretion (UNaV), glomerular filtration rate, and renal plasma flow during 7 mm Hg pressure in both groups. When the IAP was further elevated, a significant deterioration of these parameters was recorded. This trend was more pronounced among diabetic rats. When examining urinary neutrophil gelatinase-associated lipocalin, a linear correlation was observed between the IAP and the biomarker level. This correlation was more significant in the diabetic group. CONCLUSION: The present study demonstrated a direct correlation between IAP elevation and the development of AKI. Diabetic rats were more sensitive to the deleterious effect of pneumoperitoneum, where urinary neutrophil gelatinase-associated lipocalin levels may be used as a future biomarker to predict postoperative AKI, especially in patients with diabetes.

Frozen section examination may facilitate reconstructive surgery for mid and low rectal cancer.

BACKGROUND: Distal margin >1 cm provides an oncologic safety in low-lying rectal cancers. We evaluated the accuracy of frozen section (FS) examination in estimating distal margins, and its impact on intraoperative decision making regarding restorative proctectomy. METHODS: Retrospective study of patients who underwent surgery for adenocarcinoma of the mid or lower rectum during 2001-2010 and for whom a distal margin specimen was examined intraoperatively by FS, to confirm microscopically free margins. Intraoperative findings, and frozen and final paraffin section findings were retrieved from patient charts. A distal margin of ≤1 cm was compared with >1 cm, for free margins at final pathology and local recurrence (LR). The impact of a distal margin ≤5 mm was also assessed. The impact of FS on intraoperative decision making, in patients who did and did not receive preoperative chemoradiotherapy, was assessed. RESULTS: The mean age of the 63 patients studied was 66.4 ± 11.8 years, and median tumor distance from the anal verge 6 cm (range 1-10 cm). Seven patients underwent abdominoperineal resection, 54 anterior resection, and two Hartman procedures. FS sensitivity and specificity were 83% and 98%, respectively. Accuracy of FS was high for the 41 patients treated with preoperative chemoradiotherapy, and the 22 who were not. Distal margin >5 mm at FS examination ensured a free margin at final pathology. LR rate was comparable between patients with distal margin >10 mm and ≤10 mm, 8% vs 11%, P = 0.65. CONCLUSIONS: FS examination may help determine free distal margin and consequently, in selected cases, may facilitate a restorative procedure in patients with low rectal cancer.

Benign cystic mesothelioma of the peritoneum: a rare case and review of the literature.

A 19-year-old male presented with right lower quadrant pain. Imaging studies revealed a cystic peritoneal mass. At surgery, a large peritoneal mass was excised. The pathology report revealed a benign cystic mesothelioma, and a right hemicolectomy with cytoreductive surgery was completed.