Finding relief for the self-conscious esophagus: laparoscopic anti-reflux surgery and the esophageal hypersensitivity and anxiety scale.

INTRODUCTION: Measures of mood and effective coping strategies have notable correlations with quality of life and treatment responses. There is evidence that patients with previously diagnosed anxiety disorders have less improvement in patient-reported outcome measures (PROMs) after laparoscopic anti-reflux surgery (LARS) and that objective pathology does not correlate well with symptom severity. We were interested in investigating whether anxiety and hypervigilance, as measured preoperatively with the esophageal hypervigilance anxiety scale (EHAS), is associated with the improvement in GERD-specific PROMs and EHAS scores 6 months after LARS. METHODS: We performed a retrospective cohort study of 102 adult patients (31% men, average age 64) who underwent LARS. In the preoperative evaluation, baseline gastroesophageal reflux disease-health-related quality of life (GERD-HRQL), laryngopharyngeal reflux symptom index (LPR-RSI) and EHAS scores were collected in addition to the standard reflux workup, including endoscopy, manometry, barium swallow, and pH study. For all three surveys, a higher score represents worse symptom severity. At 6 months postoperatively, 70 patients completed repeat GERD-HRQL, LPR-RSI, and EHAS surveys. We then analyzed for surgical and patient-related factors associated with improvement in the 6-month postoperative GERD-HRQL and LPR-RSI scores. RESULTS: There was a statistically significant decrease in the GERD-HRQL (25 vs. 2, p < 0.001), LPR-RSI (17 vs. 3, p < 0.001) and EHAS (34 vs. 15, p < 0.001) 6 months after LARS. On multivariable linear regression, a higher baseline EHAS score was independently associated with a greater improvement in GERD-HRQL (ß 0.35, p < 0.001) and LPR-RSI (ß 0.19, p = 0.03) 6-months after LARS. Additionally, the degree of improvement in EHAS, GERD-HRQL, and LPR-RSI was not influenced by the type of LARS performed or by the severity of disease. CONCLUSION: These findings are consistent with literature suggesting that measures of psychoemotional health correlate better with symptom intensity than objective pathology. We found that patients with a higher EHAS score have greater symptom severity and lower quality of life at baseline. Novel findings to this study are that patients with a higher preoperative EHAS, a measure of psychoemotional health, actually benefitted more from surgery and not less, which has been the traditional view in the literature. Future studies are warranted to establish directionality and explore the role of preoperative cognitive behavioral therapy with LARS for patients with significant symptoms of hypervigilance and anxiety.

Psychoemotional factors and their influence on the quality of life in patients with GERD.

Patient-reported outcomes (PROs) are integral to determining the success of foregut surgical interventions and psychoemotional factors have been hypothesized to impact the quality of life of patients. This study evaluates the correlation between PROs-specifically the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) and the Laryngopharangeal Reflux Symptom Index (LPR-RSI)-and the recently validated Esophageal Hypervigilance Anxiety Scale (EHAS). We hypothesize that patients with higher EHAS scores have significantly elevated GERD-HRQL LPR-RSI compared to those with normal scores. EHAS has been developed and validated in chronic esophageal disorders, but clinical impact is unknown. In this retrospective study, 197 patients (38% men, average age 56 ± 16) completed the following surveys:(1) EHAS, (2) GERD-HRQL, and (3) LPR-RSI. All patients referred for surgical evaluation of GERD completed the surveys as part of their pre-operative workup and post-operative follow-up In bivariate analysis, EHAS correlated with both GERD-HRQL (r 0.53, P = <0.001) and LPR-RSI (r 0.36, P = 0.009). Accounting for potential confounding with sex and age in multivariable linear regression models, a higher GERD-HRQL score (ß 0.38; 95% CI 0.29 to 0.48; P = <0.001; Semipartial R2 0.20) and a higher LPR-RSI score (ß 0.21; 95% CI 0.13 to 0.29; P = <0.001; Semipartial R2 0.08) were independently associated with higher EHAS. The observed relationship between mental health and GERD symptom intensity is consistent with the biopsychosocial paradigm of illness. Future studies focused on post-surgical outcomes following the incorporation of EHAS into perioperative care is needed to evaluate its effectiveness as a clinical decision support tool in ARS.

Surgical and endoscopic management options for patients with GERD based on proton pump inhibitor symptom response: recommendations from an expert U.S. panel.

BACKGROUND AND AIMS: The objective of this study was to examine expert opinion and agreement on the treatment of distinct GERD profiles from surgical and therapeutic endoscopy perspectives. METHODS: We used the RAND/University of California, Los Angeles Appropriateness Method over 6 months (July 2018 to January 2019) to assess the appropriateness of antireflux interventions among foregut surgeons and therapeutic gastroenterologists. Patients with primary atypical or extraesophageal symptoms were not considered. Patient scenarios were grouped according to their symptom response to proton pump inhibitor (PPI) therapy. The primary outcome was appropriateness of an intervention. RESULTS: Antireflux surgery with laparoscopic fundoplication (LF) and magnetic sphincter augmentation (MSA) were ranked as appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. Radiofrequency energy was not ranked as appropriate for complete or partial responders. There was lack of agreement between surgery and interventional gastroenterology groups on the appropriateness of LF and MSA for PPI nonresponders. Rankings for PPI nonresponders were similar when results from impedance-pH testing on PPI therapy were available, except that LF and MSA were not ranked as appropriate for PPI nonresponders if the impedance-pH study was negative. CONCLUSIONS: This work highlights areas of agreement for invasive therapeutic approaches for GERD and provides impetus for further interdisciplinary collaboration and trials to compare and generate novel and effective treatment approaches and care pathways, including the role of impedance-pH testing in PPI nonresponders.

Worldwide Experience with Erosion of the Magnetic Sphincter Augmentation Device.

BACKGROUND: The magnetic sphincter augmentation device continues to become a more common antireflux surgical option with low complication rates. Erosion into the esophagus is an important complication to recognize and is reported to occur at very low incidences (0.1-0.15%). Characterization of this complication remains limited. We aim to describe the worldwide experience with erosion of the magnetic sphincter augmentation device including presentation, techniques for removal, and possible risk factors. MATERIALS AND METHODS: We reviewed data obtained from the device manufacturer Torax Medical, Inc., as well as the Manufacturer and User Facility Device Experience (MAUDE) database. The study period was from February 2007 through July 2017 and included all devices placed worldwide. RESULTS: In total, 9453 devices were placed and there were 29 reported cases of erosions. The median time to presentation of an erosion was 26 months with most occurring between 1 and 4 years after placement. The risk of erosion was 0.3% at 4 years after device implantation. Most patients experienced new-onset dysphagia prompting evaluation. Devices were successfully removed in all patients most commonly via an endoscopic removal of the eroded portion followed by a delayed laparoscopic removal of the remaining beads. At a median follow-up of 58 days post-removal, there were no complications and 24 patients have returned to baseline. Four patients reported ongoing mild dysphagia. CONCLUSIONS: Erosion of the LINX device is an important but rare complication to recognize that has been safely managed via minimally invasive approaches without long-term consequences.

Favorable results from a prospective evaluation of 200 patients with large hiatal hernias undergoing LINX magnetic sphincter augmentation.

INTRODUCTION: Magnetic sphincter augmentation (MSA) of the lower esophageal sphincter restores the antireflux barrier in patients with hiatal hernias ≤3 cm. We performed a prospective study in patients undergoing MSA with the LINX device during repair of paraesophageal and hernias over 3 cm axial component. METHODS AND PROCEDURES: Multicenter, prospective study of consecutive patients treated with MSA at the time of repair of hiatal hernias >3 cm. RESULTS: 200 patients (110 female) were treated between March 2014 and February 2017 via laparoscopic hernia repair and MSA. Mean age was 59.5 years, mean BMI 29.4. 40% had esophagitis, 20% intestinal metaplasia, 72 of 77 tested had abnormal pH studies. Preoperative PPI use was reported by 87%. Eighteen patients had prior hiatal hernia/fundoplication. All had normal function. 78% of patients had axial hiatal hernia ≥5 cm or large paraesophageal component. Mean operative time was 81 min (38-193), EBL was 10 cc. Non-permanent mesh reinforcement of hiatal repair was performed in 83% of the patients. There were two readmissions for dehydration; 2 patients with pulmonary embolism, and 1 patient with cardiac ischemia. Nineteen patients required dilation. 156 pts were followed at a median of 8.6 months. GERD-HRQL scores improved from 26 preoperatively to 2 postoperatively. Complete PPI independence was achieved in 94% (147/156). Videoesophagram in 51 patients at median 11 months found 3 asymptomatic hernias <3 cm. One symptomatic patient underwent successful repair of the hernia without MSA manipulation. There have been no device explants, erosions, or migrations to date. CONCLUSIONS: This prospective study of 200 patients with >3 cm hernias undergoing MSA with hiatoplasty resulted in favorable outcomes with median of 9 months follow-up. Comparing this to published reports of MSA in patients with <3 cm hernias, the safety and clinical efficacy of MSA are independent of initial hernia size.

Influencing factors for port-site hernias after single-incision laparoscopy.

PURPOSE: Single-incision laparoscopic surgery (SILS) has been demonstrated to be a feasible alternative to multiport laparoscopy, but concerns over port-site incisional hernias have not been well addressed. A retrospective study was performed to determine the rate of port-site hernias as well as influencing risk factors for developing this complication. METHODS: A review of all consecutive patients who underwent SILS over 4 years was conducted using electronic medical records in a multi-specialty integrated healthcare system. Statistical evaluation included descriptive analysis of demographics in addition to bivariate and multivariate analyses of potential risk factors, which were age, gender, BMI, procedure, existing insertion-site hernia, wound infection, tobacco use, steroid use, and diabetes. RESULTS: 787 patients who underwent SILS without conversion to open were reviewed. There were 454 cholecystectomies, 189 appendectomies, 72 colectomies, 21 fundoplications, 15 transabdominal inguinal herniorrhaphies, and 36 other surgeries. Cases included 532 (67.6 %) women, and among all patients mean age was 44.65 (±19.05) years and mean BMI of 28.04 (±6). Of these, 50 (6.35 %) patients were documented as developing port-site incisional hernias by a health care provider or by incidental imaging. Of the risk factors analyzed, insertion-site hernia, age, and BMI were significant. Multivariate analysis indicated that both preexisting hernia and BMI were significant risk factors (p value = 0.00212; p value = 0.0307). Morbidly obese patients had the highest incidence of incisional hernias at 18.18 % (p value = 0.02). CONCLUSIONS: When selecting patients for SILS, surgeons should consider the presence of an umbilical hernia, increased age and obesity as risk factors for developing a port-site hernia.

Clinical analgesic equivalence for morphine and hydromorphone with prolonged PCA.

A morphine to hydromorphone equivalence ratio of 7:1 has become the accepted standard, but evidence supporting it comes from single dose studies performed before the advent of patient controlled analgesia (PCA). We compared morphine and hydromorphone use with PCA in bone marrow transplantation patients who required opioids for the control of severe oral mucositis over several days or weeks. An exploratory analysis of clinical records from 102 patients (981 patient days) who used PCA opioids for varying periods of up to 50 days suggested a morphine to hydromorphone use ratio of 3:1. To clarify this observation, we studied a subset of patients under matched conditions. During a 7 day window in which mean oral mucositis severity did not vary across drug use groups and pain scores did not vary over time, patients in both groups gave equal pain relief satisfaction scores. Thirty-six patients who used morphine and 21 who used hydromorphone contributed data on pain, satisfaction with pain control, and drug consumption. We observed an average morphine/hydromorphone ratio of 3:1. This differs markedly from historical single dose studies used in published dose equivalency recommendations implying that other equivalency ratios in clinical use may be inappropriate.

Endoscopic fluorescence detection of high-grade dysplasia in Barrett's esophagus.

BACKGROUND & AIMS: Early detection and treatment of esophageal cancer in Barrett's esophagus may improve patient survival if dysplasia is effectively detected at endoscopy. Typically, four-quadrant pinch biopsy specimens are taken at 2-cm intervals. This study was conducted to determine whether laser-induced fluorescence spectroscopy could be used to detect high-grade dysplasia in patients with Barrett's esophagus. METHODS: Four hundred ten-naonometer laser light was used to induce autofluorescence of Barrett's mucosa in 36 patients. The spectra were analyzed using the differential normalized fluorescence (DNF) index technique to differentiate high-grade dysplasia from either low-grade or nondysplastic mucosa. Each spectrum was classified as either premalignant or benign using two different DNF indices. RESULTS: Analysis of the fluorescence spectra from all patients collectively using the DNF intensity at 480 nm (DNF480) index showed that 96% of nondysplastic Barrett's esophagus samples were classified as benign, all low-grade dysplasia samples as benign, 90% of high-grade dysplasia samples as premalignant, and 28% of low-grade with focal high-grade dysplasia samples as premalignant. Using the two DNF indices concurrently, all patients with any high-grade dysplasia were classified correctly. CONCLUSIONS: Laser-induced fluorescence spectroscopy has great potential to detect high-grade dysplasia in Barrett's esophagus when using the DNF technique.

In vivo cancer diagnosis of the esophagus using differential normalized fluorescence (DNF) indices.

BACKGROUND AND OBJECTIVE: We report the use of new diagnostic parameters based on the differential normalized fluorescence (DNF) signals for malignant tumor diagnosis. STUDY DESIGN/MATERIALS AND METHODS: Over 200 measurements of endogenous fluorescence from normal and malignant esophageal tissues were performed during routine endoscopy in 48 patients. A pulsed nitrogen-pumped dye laser was used to provide in situ excitation at 410 nm. Direct collection of the fluorescence signal emitted by the tissue was achieved using an intensified photodiode array detector equipped with a fiberoptic probe. RESULTS: The fluorescence signals were normalized with respect to the total fluorescence signal area. The cancer diagnosis indices were defined by the difference between the normalized fluorescence signal of a tumor and the mean value of a reference set of normal tissues. The results of the DNF approach were compared with endoscopic examinations and histopathology interpretations of the biopsy samples. Excellent correlation in the classification of normal and malignant tumors for the samples was found. CONCLUSION: The data indicated that the DNF approach has a significant potential to provide a direct, real-time, and in-situ technique for cancer diagnosis of the esophagus without requiring biopsy of the tumors and time-consuming histopathology tests.

Acid and alkaline solutions of local anesthetics: duration of nerve block and tissue pH.

The effect of solution pH on the duration of rat infraorbital nerve blocks produced by 1% lidocaine or 0.25% bupivacaine at pH 5.0 and 7.4, with and without epinephrine was investigated in a double-blind study. The time course of tissue pH changes subsequent to infections into the infraorbital area or abdominal musculature of rats was measured with a tissue pH microelectrode. Injectable pH had little or no effect upon the duration of block. Tissue pH was minimally changed by the injection of solutions at pH 7.4, but decreased appreciably with injections of solutions at pH 5.0, or if the injectate contained epinephrine.

Anaesthesia in the morbidly obese. A comparison of anaesthetic and analgesic regimens for upper abdominal surgery.

Seventy morbidly obese patients presented for upper abdominal surgery; 17% had pre-existing cardiovascular disease and 23% pre-existing respiratory disease. Twenty-eight patients received general anaesthesia, plus narcotic analgesia postoperatively, and 42 general anaesthesia plus thoracic epidural analgesia intra- and postoperatively. Aspects of anaesthetic management are discussed and compared with previous similar reports. Doses of local anaesthetic for induction of epidural analgesia were less than those for the non-obese but doses of local anaesthetic for maintenance of epidural analgesia were similar to those in non-obese patients. Patients who had thoracic epidural analgesia required less volatile anaesthesia than the group who had general anaesthesia and narcotic analgesics. Postoperative respiratory complications were more common in patients with pre-existing cardiovascular and respiratory disease, and occurred less frequently in patients who had thoracic epidural analgesia.

Postoperative glucose tolerance during extradural analgesia.

Thirteen patients undergoing lower abdominal gynaecological surgery were allocated to general anaesthesia (halothane and nitrous oxide) or general anaesthesia plus extradural analgesia (T8-S5). I.v. glucose tolerance tests were performed on the day before surgery and 8 h after skin incision. All patients having extradural analgesia (T8) were pain-free following surgery. Extradural analgesia blocked the hyperglycaemic response to surgery but not the late postoperative cortisol response, although values were significantly less than in the group receiving general anaesthesia alone. Impairment of glucose tolerance and of insulin response to the glucose load in the period after operation were not influenced by extradural analgesia and this may have resulted from insufficient inhibition of the stress-induced release of catecholamines or cortisol, or both, or from blockade of stimulatory efferent sympathetic pathways to pancreatic islets.

Duration of action of nerve blocks produced by mixtures of local anesthetics and low molecular weight dextran: studies in rat infraorbital nerve blocks.

The duration of rat infraorbital nerve block by 1% lidocaine or 0.25% bupivacaine, and its modification by low molecular weight dextran, was investigated in a randomized, observer-blind study. The addition of low molecular weight dextran did not prolong the duration of the blocks. No evidence of slow releasing or local anesthetic binding properties attributed to low molecular weight dextran was found.

Propranolol in thyrotoxicosis. Cardiovascular changes during thyroidectomy in patients pre-treated with propranolol.

The cardiovascular changes during anaesthesia and thyroidectomy have been studied in seven thyrotoxic patients prepared with propranolol. The heart rate and cardiac rhythm remained very stable throughout surgery. A 20% increase in mean arterial pressure occurred during surgical stimulation. A decrease in cardiac output, due to decreased stroke volume, occurred during surgical stimulation. A decrease in cardiac output, due to decreased stroke volume, occurred during surgery, reaching a maximum of 21% during ligation of the thyroid vessels and returning to pre-operative values by the end of surgery. The fall in cardiac output was accompanied by raised central venous pressure and raised total peripheral resistance.

Effects of adrenaline and the concentration of solution on extradural block with etidocaine.

Forty patients allocated to four groups received extradural injections of etidocaine for the performance of lower abdominal surgery. Twenty millilitre of the 1% or 1.5% solutions with or without adrenaline (1:200 000) was given in a double-blind manner. The addition of adrenaline to etidocaine did not significantly prolong the duration of analgesia, but it produced significant more motor block. Etidocaine 1.5% caused significantly longer durations of analgesia and more motor block than the 1% solution. The spread of sensory analgesia was similar with all four solutions of local anaesthetic agent.

Circulatory effects of labetalol during halothane anaesthesia.

Labetalol is a drug possessing both alpha and beta adrenergic receptor blocking properties. Its possible use in induced hypotension during halothane anaesthesia has been investigated. It causes a satisfactory decrease in arterial pressure unaccompanied by tachycardia. The circulatory effects of the drug during halothane anaesthesia, both with spontaneous and controlled respiration, have been measured and compared with those of halothane alone. In patients anaesthetised with 1% halothane, labetalol, with both spontaneous and controlled ventilation, was associated with a reduction in MAP from 71.5 mmHg to 54.0 mmHg (P less than 0.001) and 66.8 mmHg to 50.4 mmHg (P less than 0.001) respectively. This reduction was associated with decreases in Qt of 18% and 12% respectively. In the presence of labetalol, with 3% halothane and spontaneous respiration, the depressant effects of the anaesthetic on the heart became rapidly apparent: Qt was reduced by a further 28%. In patients not receiving labetalol, the depressant effects of 3% halothane were frequently countered by the positive inotropic effects of hypercarbia.

Observed and predicted accumulation of local anaesthetic agents during continuous extradural analgesia.

After lumbar extradural injections of ligocaine or etidocaine for surgical anaesthesia further accumulation in the plasma was minimal following top-up injections for pain relief after operation. The dose regimens were: 20 ml of 2% plain lignocaine HCl solution for surgical anaesthesia followed by 10 ml every 1 h until 4 h, and 20 ml of 1% plain etidocaine HCl solution for surgical anaesthesia followed by 10 ml every 2 h until 8 h. Plasma drug concentrations measured after initial doses were used to predict those following successive doses. Agreement between predicted and experimental values was good and further projections were made concerning the local accumulation of etidocaine.

Cardiovascular effects of labetalol during halothane anaesthesia.

1 The circulatory effects of labetalol 25 mg intravenously in six patients during 1% halothane anaesthesia were studied. 2Labetalol caused a marked decrease in arterial pressure and a consistent but modest (20%) decrease in cardiac output. Heart rate was slowed and stroke volume did not change significantly. Central venous pressure increased and peripheral resistance decreased. 3 Increasing the halothane concentration of 3% led to marked myocardial depression as evidenced by reduced cardiac output and increased central venous pressure with increasing arterial hypotension. 4 Labetalol may be a suitable drug for controlling induced hypotension under general anaesthesia, although high concentrations of halothane should be used with care.