Evaluation of Antireflux Mucosectomy for Severe Gastroesophageal Reflux Disease: Medium-Term Results of a Pilot Study.

BACKGROUND: Antireflux mucosectomy, a new endoscopic treatment for gastroesophageal reflux disease, consists of endoscopic mucosal resection at the esophagogastric junction. This study aim was to evaluate the medium-term efficacy of the antireflux mucosectomy technique for patients with severe gastroesophageal reflux disease symptoms (proton pump inhibitor treatment-dependent or proton pump inhibitor treatment-resistant gastroesophageal reflux disease). METHODS: Between January 2017 and June 2018, 13 patients with severe gastroesophageal reflux disease without hiatal hernia, with positive pH reflux, were included in this monocentric prospective pilot study. The primary outcome was clinical success, defined by improvement evaluated by the Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire at 24 months. Secondary outcomes were technical success, decreased use of proton pump inhibitors, patient satisfaction, and adverse events. RESULTS: Thirteen patients [females = 8 (62%)], mean age 59 (range, 54-68), were included. The antireflux mucosectomy procedure had technical success in all patients. At 24 months, for 11 patients, gastroesophageal reflux disease symptoms were significantly improved, and mean gastroesophageal reflux disease score decreased from 33 (range, 26-42) to 3 (range, 0-7) (p = 0.001). Ninety-one percent (n = 10) of patients had a lower proton pump inhibitor intake at 24 months. One patient had 3 endoscopic balloon dilatations for EGJ stenosis, two patients had melena ten days after procedure, and seven patients had thoracic or abdominal pain. Patient's satisfaction at 24 months was 81%. CONCLUSIONS: In patients with severe gastroesophageal reflux disease, despite occurrence of several short-term adverse events, antireflux mucosectomy seemed effective in improving gastroesophageal reflux disease symptoms at 24 months. This trial is registered with ClinicalTrials: NCT03357809.

Stent placement in the management of oesophageal leaks.

OBJECTIVE: To examine retrospectively the patients of our department who had a self-expandable totally covered metal stent placed for oesophageal leak. METHODS: Patients hospitalised in our department for oesophageal cancer and/or oesophageal perforation between 2004 and 2006. All medical records were retrospectively reviewed. Seventy-two patients underwent oesophageal resection for oesophageal cancer and 16 were managed for oesophageal perforations. RESULTS: Eight out of 72 patients submitted to resection for oesophageal cancer had postoperative leaks, while one patient developed tracheo-oesophageal fistula (TEF) due to prolonged mechanical ventilation. Six of them had stent placement in first intention, whereas two received the procedure after an unsuccessful repeat operation. The mean stent placement time was 18.4 days (SD=15.2 days), whereas the median was 14 days. The leak was managed efficiently by the stent in seven patients, whereas two patients needed repeat operations (one with TEF). The mean stent removal time was 56.8 days (SD=30.5 days) and the median was 40 days. None developed anastomotic stricture. On the other hand, three out of 16 patients with perforation had a stent, two of them for Boerhaave syndrome and one for iatrogenic rupture after bariatric surgery. One of them required the stent 17 days after surgical repair with excellent results, while the other two patients had the stent placed immediately, but still needed thoracotomy to control the leak. CONCLUSIONS: Stent placement can prove very useful in the management of post-oesophagectomy anastomotic leaks, but its contribution needs to be evaluated with caution in cases of oesophageal perforations or TEF. Larger series and prospective comparative clinical trials could eventually clarify the role of stents in clinical practice of surgical patients.

Long-term observation and functional state of the esophagus after primary repair of spontaneous esophageal rupture.

BACKGROUND: Long-term outcome of patients treated for a spontaneous esophageal rupture (Boerhaave's syndrome) is seldom reported. METHODS: From 1989 to 2004, 62 esophageal perforations were treated in a single institution. Eighteen patients presented with a spontaneous esophageal rupture. Among them, 15 could be treated with a transthoracic primary repair and constituted the material of the present study. A chart review was performed with special attention to survival, residual symptoms, and anatomic and motility disorders. RESULTS: Three patients died postoperatively (20%). At last follow-up, 10 patients were alive and 2 had died from unrelated causes. At a median delay of 13 months (3 to 74), 7 patients accepted to undergo complementary investigations. None of them had any anatomic abnormality as checked by barium swallow. Six patients complained of mild symptoms from gastroesophageal reflux. Six patients (85%) presented with esophageal motility disorders on manometry and 4 (54%) had nocturne chronic reflux disease on pH monitoring. Two patients underwent endoscopic ultrasonography, of which one presented with a focal absence of one layer of the esophageal wall within the area of the suture. With time, no patient experienced recurrence, but one developed a cancer in the cervical esophagus. CONCLUSIONS: These results suggest that esophageal functional disorders are the rule after primary repair of a Boerhaave's syndrome. Whether or not these findings are causal, coincidental, or related to the surgical treatment remains unclear. However, performance of routine postoperative explorations is strongly encouraged for a better understanding of this challenging condition.