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Background: Dysphagia is a potential complication following anti-gastroesophageal reflux surgery (ARS), with challenging management. Endoscopic balloon dilation is recommended for patients with significant dysphagia from tight wraps or strictures. We aim to evaluate factors associated with the need for post-ARS dilation and the outcomes of balloon dilation. Additionally, we assessed the predictors of sustained clinical failure after dilation., Methods: A retrospective analysis was conducted on patients who underwent robotic or laparoscopic ARS between January 2012 and April 2023. Patients were divided based on whether they received balloon dilation using a through-the-scope wire-guided dilator. Excluded were those with pre-existing achalasia, other dilation devices, or inadequate follow-up., Results: Of 1002 patients, 69 underwent 94 postoperative dilations, and the remainder were controls. The dilation cohort was older (63.78 vs. 56.14 years, P = 0.032) and had more magnetic sphincter augmentations (MSA) (P = 0.004), a prior history of ARS (P = 0.039), and a higher rate of laparoscopic surgery (P = 0.009) compared to controls. Of all dilations, 54 (57.5%) patients reported immediate dysphagia improvement, and 39 (41.5%) had sustained improvement. Sixteen (23.2%) patients required reoperation, primarily for hiatal hernia recurrence or slipped wrap. Multivariable logistic regression showed that MSA (OR 0.04, 95% CI 0.01-0.46, P = 0.031) and requiring multiple dilations (OR 0.16, CI 0.03-0.68) predicted sustained dilation failure., Conclusions: Factors including older age, history of prior ARS, and MSA are correlated with higher post-ARS dilation rates. Although dilation improves symptoms in approximately half of patients initially, one-fourth may eventually require reoperation, mostly due to a slipped wrap or hernia recurrence. Thus, in cases of persistent dysphagia, consideration for surgical failure is important, and further imaging and workup are warranted. Patients who undergo MSA and those who have more than one dilation are more likely to experience dilation failure., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Dysphagia after anti-reflux surgery (ARS) is one of the most common indications for re-operative anti-reflux surgery and a leading cause of patient dissatisfaction. Unfortunately, the factors affecting its development are poorly understood. We investigated the correlation between pre-operative manometric and the intra-operative impedance planimetry (EndoFLIP™) measurements and development of post-operative dysphagia., Methods: A review of patients who underwent index robotic ARS in our institution. Patients who underwent pre-operative manometry and intra-operative EndoFLIP™ were included in our study. Dysphagia was assessed pre-operatively and at 3-month after surgery., Results: Fifty-five patients (26.9%) reported post-operative dysphagia, and 34 (16.6%) reported new or worsening dysphagia. On pre-operative manometry, patients with post-operative dysphagia had a lower distal contractile integral [868.7 (IQR 402.2-1447) mmHg s cm vs 1207 (IQR 612.1-2111) mmHg s cm, p = 0.006) and lower esophageal sphincter (LES) pressure [14.7 IQR (8.9-23.6) mmHg vs 20.7 IQR (10.2-32.6) mmHg, p = 0.01] compared to those without post-operative dysphagia. They were also found to have higher pre-operative cross-sectional surface area (CSA) [83 IQR (44.5-112) mm 2 vs 66 IQR (42-93) mm 2 , p = 0.02], and distensibility index (DI) [4.2 IQR (2.2-5.5) mm 2 /mmHg vs 2.9 IQR (1.6-4.6) mm 2 /mmHg, p = 0.003] compared to patients without post-operative dysphagia. Additionally, the decrease in CSA [- 34 (- 18.5, - 74.5) mm 2 vs - 26.5 (- 10.5, - 53.7) mm 2 , p = 0.03] and DI [- 2.3 (- 1.2, - 3.7) mm 2 /mmHg vs - 1.6 (- 0.7, - 3.3) mm 2 /mmHg, p = 0.03] measurements were greater in patients with post-operative dysphagia., Conclusion: Patients who developed dysphagia post-operatively had poorer pre-operative motility and a greater change in LES characteristics intra-operatively. This finding suggests the utility of pre-operative manometry and intra-operative EndoFLIP in identifying patients at risk of developing dysphagia post-operatively., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Numerous studies comment on quality of life outcomes comparing complete and partial fundoplication with or without a bougie. Society guidelines are moving toward recommending partial fundoplication over complete fundoplication due to improved side effect profile with similar outcomes. Retrospective studies and randomized trials have elucidated that use of a bougie during Nissen fundoplication does impact long-term dysphagia. To date there are no retrospective or prospective data that guide practice for partial fundoplications., Objective: The purpose of this project is to investigate the clinical implications of using a bougie for Toupet fundoplication with regard to short-term and long-term dysphagia and need for further therapeutic interventions., Methods: A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic, pre-operative quality of life outcomes data, perioperative, and post-operative quality of life outcomes data of 373 patients from 2011 to 2022 undergoing Toupet fundoplication without bougie or with a traditional Savary 56Fr or 58Fr bougie were reviewed. The two groups were compared using student's t-test to identify statically significant differences between the groups., Results: Between 2011 and 2022, 373 patients underwent Toupet fundoplication (276 with traditional bougie, 97 without). Median follow-up in the bougie group was 19 months, versus 9 months in the non bougie group. There was no difference between early (3 weeks) and late dysphagia scores (6 months). In the bougie group there were two mucosal perforations due to the bougie. There were no statistically significant differences in GERD-HRQL, gas bloat, and dysphagia scores between groups at one year., Conclusion: There is no difference observed in early or late dysphagia scores, GERD-HRQL, gas bloat or need for dilation in patients undergoing Toupet fundoplication with or without a traditional bougie. It is reasonable to discontinue the use of a traditional bougie during Toupet fundoplication, especially due to risk of esophageal perforation., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia., Methods: One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis., Results: At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years., Conclusions: LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Endoluminal functional lumen imaging probe (EndoFLIP) provides a real-time assessment of gastroesophageal junction (GEJ) compliance during fundoplication. Given the limited data on EndoFLIP measurements during the Hill procedure, we investigated the impact of the Hill procedure on GEJ compliance compared to Toupet fundoplication., Methods: Patients who underwent robotic Hill or Toupet fundoplication with intraoperative EndoFLIP between 2017 and 2022 were included. EndoFLIP measurements of the GEJ included cross sectional surface area (CSA), intra-balloon pressure, high pressure zone length (HPZ), distensibility index (DI), and compliance. Subjective reflux symptoms, gastroesophageal reflux disease-health related quality of life (GERD-HRQL) score, and dysphagia score were assessed pre-operatively as well as at short- and longer-term follow-up., Results: One-hundred and fifty-four patients (71.9%) had a Toupet fundoplication while sixty (28%) patients underwent the Hill procedure. The CSA [27.7 ± 10.9 mm 2 vs 42.2 ± 17.8 mm 2 , p < 0.0001], pressure [29.5 ± 6.2 mmHg vs 33.9 ± 8.5 mmHg, p = 0.0009], DI [0.9 ± 0.4 mm 2 /mmHg vs 1.3 ± 0.6 mm 2 /mmHg, p = 0.001], and compliance [25.9 ± 12.8 mm 3 /mmHg vs 35.4 ± 13.4 mm 3 /mmHg, p = 0.01] were lower after the Hill procedure compared to Toupet. However, there was no difference in post-fundoplication HPZ between procedures [Hill: 2.9 ± 0.4 cm, Toupet: 3.1 ± 0.6 cm, p = 0.15]. Follow-up showed no significant differences in GERD-HRQL scores, overall dysphagia scores or atypical symptoms between groups (p > 0.05)., Conclusion: The Hill procedure is as effective to the Toupet fundoplication in surgically treating gastroesophageal reflux disease (GERD) despite the lower CSA, DI, and compliance after the Hill procedure. Both procedures led to DI < 2 mm 2 /mmHg with no significant differences in dysphagia reporting (12-24) months after the procedure. Further studies to elucidate a cutoff value for DI for postoperative dysphagia development are still warranted., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Zenker's diverticulum (ZD) is a false pulsion diverticulum of the cervical esophagus. It is typically found in older adults and manifests with dysphagia. The purpose of this study is to describe our experience with Per-oral endoscopic myotomy for Zenker's (Z-POEM) and intraoperative impedance planimetry (FLIP)., Methods: We performed a single institution retrospective review of patients undergoing Z-POEM in a prospective database between 2014 and 2022. Upper esophageal sphincter (UES) distensibility index (DI, mm 2 /mmHg) was measured by FLIP before and after myotomy. The primary outcome was clinical success. Secondary outcomes included technical failure, adverse events, and quality of life as assessed by the gastroesophageal health-related quality of life (GERD-HRQL), reflux severity index (RSI), and dysphagia score. A statistical analysis of DI was done with the paired t-test (p < 0.05)., Results: Fifty-four patients underwent Z-POEM, with FLIP measurements available in 30 cases. We achieved technical success and clinical success in 54/54 (100%) patients and 46/54 patients (85%), respectively. Three patients (6%) experienced contained leaks. Three patients were readmitted: one for aforementioned contained leak, one for dysphagia, and one post-operative pneumonia. Three patients with residual dysphagia underwent additional endoscopic procedures, all of whom had diverticula > 4 cm. Following myotomy, mean DI increased by 2.0 ± 1.7 mm 2 /mmHg (p < 0.001). In those with good clinical success, change in DI averaged + 1.6 ± 1.1 mm 2 /mmHg. Significant improvement was found in RSI and GERD-HRQL scores, but not dysphagia score., Conclusion: Z-POEM is a safe and feasible for treatment of ZD. We saw zero cases of intraoperative abandonment. We propose that large diverticula (> 4 cm) are a risk factor for poor outcomes and may require additional endoscopic procedures. An improvement in DI is expected after myotomy, however, the ideal range is still not known., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Study Aims: Esophageal mucosal bridge (EMB) may be diagnosed at the anastomotic site in children operated on for esophageal atresia (EA) but so far only a few cases (n = 4) have been reported. This study aimed to characterize EMB in children with EA, risk factors, and treatment., Patients and Methods: This retrospective multicenter study recorded patient's characteristics, EMB diagnosis circumstances, endoscopic management, follow-up, and EMB recurrence in children with EA aged less than 18 years, compared with paired EA patients without EMB., Results: Thirty patients were included (60% male, 90% EA/tracheoesophageal fistula, 43% associated malformations). Compared to 44 paired controls, EMB was associated with a history of nasogastric tube feeding (31% vs. 9.1%, p = 0.02) and severe gastroesophageal reflux disease (history of fundoplication: 41.4% vs. 13.6%, p < 0.01). 77% had symptoms (food impaction and/or dysphagia). Endoscopic management was performed in 53% of patients (83% electrocoagulation) with no technical difficulties or complications. 80% of the symptomatic patients with EMB improved after endoscopic treatment, independently of anastomotic stricture dilatation or not., Conclusion: EMB endoscopic management by electrocoagulation is safe and often leads to symptom improvement., (© 2023. The Author(s).)

Introduction: Failure of the cricopharyngeus to relax results in oropharyngeal dysphagia, which over time results in hypertrophy and increased risk for aspiration. Open myotomy is one definitive treatment option, however there are several drawbacks attributable to the long neck incision, ± drain placement, and invasiveness of the procedure. We aim to share our experience using the DaVinci robotic platform to perform a minimally invasive cricopharyngeal myotomy, which has never been described before in the literature., Methods: All robotic cricopharyngeal myotomies performed in adult patients by a single surgeon from 2021 to 2022 were retrospectively reviewed. No patients were excluded. Outcomes of interest included length of procedure, time to diet resumption, hospital length of stay, complications, symptom improvement at follow-up, and symptom recurrence., Results: Eight robotic cricopharyngeal myotomies were performed. The median age was 65 years old (62-91) and mostly female (n = 5, 56%) with a median BMI of 28.9 kg/m 2 (21.7-39.5). The median procedure length was 113 min (94-141) and there were no intraoperative complications. All patients underwent a post-procedural esophagram with no leaks were identified. All patients were started on clear liquids in recovery and transitioned to full liquids prior to discharge. All but one patient was subsequently discharged home on the same day as procedure. All patients had routine 2-week post-operative follow-up in addition to phone follow-up at a later date (6-11 months post-operative). All patients reported resolution of symptoms. There were no complications or readmissions. No instances of recurrence were reported. On cost analysis, the minimally invasive robotic approach allows for an outpatient procedure with similar cost to an open approach with a one-night stay., Conclusion: Our experience with the novel technique of minimally invasive robotic cricopharyngeal myotomy for cricopharyngeal bars with cervical dysphagia is safe, efficacious, less invasive, and cost saving, with excellent patient outcomes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Mesh reinforced cruroplasty during laparoscopic paraesophageal hernia repair remains controversial due to wide variation in surgical technique and mesh composition. This study aims to review outcomes and rates of recurrence following laparoscopic paraesophageal hernia repair (LPEHR) with mesh reinforced cruroplasty utilizing absorbable mesh at a single institution., Methods: A retrospective review of all patients who underwent LPEHR with mesh was performed. Medical records were reviewed for patient reported, radiographic or endoscopic evidence of recurrence, defined as > 2 cm of vertical intrathoracic stomach. If no studies were available for review, patients were considered to have no recurrence. Outcomes and mesh-related complications were also reviewed., Results: Between 10/2008 and 9/2021, 473 patients underwent LPEHR with absorbable mesh; 1.3% type 2 hernias, 86.0% type 3 hernias, 12.7% type 4 hernias. Three types of mesh were used: initially biologic mesh (n = 83), then heavyweight synthetic bioabsorbable mesh (n = 261), and finally lightweight synthetic bioabsorbable mesh (n = 111). There were no significant differences in age, ASA, BMI, gender, smoking status, chronic steroid use, preoperative acid suppression, hernia type, or recurrent hernia between groups. There were no significant differences in 30-day postoperative outcomes. Reflux Symptom Index, GERD-HRQL, and Dysphagia Scores at 1- and 2-year postoperative timepoints were not significantly different. The overall recurrence rate was 16.7%, with no significant differences in recurrence rates between biologic, heavyweight or lightweight biosynthetic absorbable mesh through 2 years after surgery. A shorter median time to recurrence (10 months, p = 0.016) was seen in the lightweight group., Conclusion: LPEHR with absorbable mesh reinforced cruroplasty is feasible and safe, with equivalent patient-reported outcomes, including dysphagia, up to 2-years postop regardless of mesh choice. No significant differences in recurrence rates between biologic, heavyweight, or lightweight synthetic bioabsorbable mesh were seen up to 2 years after LPEHR., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although obesity is an established risk factor for adverse outcomes after paraesophageal hernia repair (PEHR), many obese patients nonetheless receive PEHR. The purpose of this study was to explore risk factors for adverse outcomes of PEHR among this high-risk cohort. We hypothesized that obese patients may have other risk factors for adverse outcomes following PEHR., Methods: A retrospective study of adult obese patients who underwent minimally invasive PEHR from 2017 to 2019 was performed. Patients were excluded for BMI < 30 or if they had concomitant bariatric surgery at time of PEHR. The primary outcome of interest was a composite adverse outcome (CAO) defined as having any of the four following outcomes after PEHR: persistent GERD > 30 d, persistent dysphagia > 30 d, recurrence, or reoperation. Chi-square and t-test analysis was used to compare demographic and clinical characteristics. Multivariable logistic regression analysis was used to evaluate independent predictors of CAO., Results: In total, 139 patients met inclusion criteria with a median follow-up of 19.7 months (IQR 8.8-81). Among them, 51/139 (36.7%) patients had a CAO: 31/139 (22.4%) had persistent GERD, 20/139 (14.4%) had persistent dysphagia, 24/139 (17.3%) had recurrence, and 6/139 (4.3%) required reoperation. On unadjusted analysis, patients with a CAO were more likely to have a history of prior abdominal surgery (86.3% vs 70.5%, p = 0.04) and were less likely to have undergone a preoperative CT scan (27.5% vs 45.5%, p = 0.04). On multivariable analysis, previous abdominal surgery was independently associated with an increased likelihood of CAO whereas age and preoperative CT scan had a decreased likelihood of CAO., Conclusions: Although there were adverse outcomes among obese patients, minimally invasive PEHR may be feasible in a subset of patients at specialized centers. These findings may help guide the appropriate selection of obese patients for PEHR., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Dysphagia is the most common complaint after magnetic sphincter augmentation (MSA), with nearly one-third of patients requiring at least one dilation following MSA. A subset of patients require frequent dilations, but there is a paucity of data on the characteristics of this population. This study aimed to identify predictors of the need for frequent dilations within the first year after implant and to assess these patients' outcomes., Methods: This is a retrospective review of prospectively collected data of patients who underwent MSA over an 8-year period. Frequent dilations were defined as 2 or more dilations within 1 year of surgery. Patients completed baseline and 1-year postoperative GERD-HRQL questionnaires and objective physiology testing. Baseline demographic, clinical characteristics, and objective testing data were compared between patients who did and did not require frequent dilations., Results: A total of 697 (62.7% female) patients underwent MSA, with 62 (8.9%) patients requiring frequent dilation. At a mean (SD) of 12.3 (3.4) months follow-up, the frequent dilation group had higher median GERD-HRQL total scores (21.0 vs. 5.0, p < 0.001), PPI use (20.8% vs.10.1%, p = 0.023), dissatisfaction (46.7% vs. 11.6%, p < 0.001), and device removal (25.8% vs. 2.2%, p < 0.001) rates. Acid normalization was comparable (p = 0.997). Independent predictors of frequent dilation included preoperative odynophagia (OR 2.85; p = 0.001), IRP > 15 mmHg (OR 2.88; p = 0.006), and > 30% incomplete bolus clearance (OR 1.94; p = 0.004). At a mean (SD) of 15.7 (10.7) months, 28 (45.1%) patients underwent device removal after frequent dilation. Independent predictors of device removal after frequent dilation within 5 years of surgery were preoperative odynophagia (OR 7.18; p = 0.042), LES resting pressure > 45 mmHg (OR 28.5; p = 0.005), and ≥ 10% failed swallows (OR 23.5; p < 0.001)., Conclusions: The need for frequent dilations after MSA is a marker for poor symptom control, dissatisfaction, and device removal. Patients with preoperative odynophagia, high LES pressures, and poor esophageal motility should be counseled of their risk for these poor outcomes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In the surgical management of GERD, the traditional procedure is laparoscopic total (Nissen) fundoplication. However, partial fundoplication has been advocated as providing similar reflux control while potentially minimizing dysphagia. The comparative outcomes of different approaches to fundoplication are a topic of ongoing debate and long-term outcomes remain uncertain. This study aims to compare long-term gastroesophageal reflux disease (GERD) related outcomes following different fundoplication procedures., Methods: MEDLINE, EMBASE, PubMed, and CENTRAL databases were searched up to November 2022 to identify randomized controlled trials (RCTs) comparing different types of fundoplications reporting long-term (> 5 years) outcomes. The primary outcome was incidence of dysphagia. Secondary outcomes included incidence of heartburn/reflux, regurgitation, inability to belch, abdominal bloating, reoperation, and patient satisfaction. DataParty, which uses Python 3.8.10 was used to perform the network meta-analysis. We evaluated the overall certainty of evidence with the GRADE framework., Results: 13 RCTs were included, with 2063 patients across Nissen (360°), Dor (anterior 180°-200°), and Toupet (posterior 270°) fundoplications. Network estimates demonstrated that Toupet had lower incidence of dysphagia compared to Nissen (OR 0.285; 95% CrI 0.06-0.958). There were no differences in dysphagia between Toupet and Dor (OR 0.473, 95% CrI 0.072-2.835) or between Dor and Nissen (OR 1.689, 95% CrI 0.403-7.699). The three fundoplication types were comparable in all other outcomes., Conclusions: All three approaches of fundoplication share similar long-term outcomes, with the Toupet fundoplication likely providing the best long-term durability with lowest odds of developing postoperative dysphagia., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Esophageal squamous cell cancer (ESCC) is mostly diagnosed in its later stages, when patients present with dysphagia and weight loss. Esophageal dilation with percutaneous endoscopic gastrostomy (PEG) is a common surgical procedure in patients with locally advanced ESCC because of tumor obstruction and enteral nutrition support during neoadjuvant or definitive concurrent chemoradiotherapy (CCRT). Esophageal dilation with PEG is widely performed under general anesthesia (GA) with endotracheal intubation., Aim of the Study: To determine the overall success rate of completing this procedure using intravenous (IV) sedation with dexmedetomidine (DEX) relative to GA and to compare its perioperative conditions, including procedure times, pain scores (visual analog scale), adverse events, and costs., Settings: Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Thailand., Patients and Methods: Prospective randomized controlled trial (RCT) of locally advanced ESCC patients who had dysphagia and needed esophageal dilation with PEG between January 2020 and December 2021. Esophageal dilation (using a Savary-Gilliard dilator) and PEG were performed using the pull technique., Results: Seventy patients were randomly assigned to either the DEX group (n = 34) or the GA group (n = 36). All patients in both groups underwent successful surgery. The DEX group had a significantly shorter procedure time, lower procedure cost, and lower total hospital cost than the GA group. However, there were no significant between-group differences in pain scores or length of hospital stay. There were no serious adverse events in either group; however, the GA group had some incidences of sore throat, transient hoarseness, and atelectasis., Conclusion: This study found that IV sedation with DEX during esophageal dilation with PEG was as effective and safe as using GA., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy., Methods: We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3., Results: 103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72 min, p < 0.01) as was mean length of stay (1.56 vs 0.3 days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD., Conclusion: Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The aim was to evaluate the clinical significance of multiple rapid swallows (MRS) during high-resolution manometry (HRM) prior to fundoplication. Despite pre-operative HRM, up to 38% of patients report post-fundoplication dysphagia. Suggestion that MRS improves prediction of dysphagia after fundoplication has not been investigated when using a tailored approach. We hypothesize response to MRS is predictive of dysphagia after tailored fundoplication., Methods: A retrospective cohort study was performed on patients undergoing HRM with MRS provocation 5/2019-7/2021 at a single institution. Patients who underwent subsequent index laparoscopic fundoplication, without peptic stricture or achalasia, were included. After performing standard 10-swallow HRM, MRS provocation was performed. Patient-reported dysphagia frequency scores were collected at initial consultation and post-operative follow-up. At least weekly symptoms were considered clinically significant. Normal MRS response was defined as adequate deglutitive inhibition and MRS contractile response. Fundoplications were tailored based on standard HRM values., Results: HRM was performed in 1201 patients, 220 met inclusion criteria. Clinically significant pre-operative dysphagia was reported by 85 (38.6%). Patients undergoing partial fundoplication (n = 123, 55.9%) had lower mean distal contractile integer, distal esophageal contraction amplitude, and percent peristalsis (p < 0.005). Post-operatively, 120 (54.5%) were without dysphagia, 59 (26.8%) had improved dysphagia, 26 (11.8%) had unchanged dysphagia, and 15 (6.8%) reported new dysphagia. There was no statistical difference in early or late dysphagia outcome between tailored fundoplication groups (p = 0.69). On univariate and multivariate analysis, neither MRS response, nor standard HRM metrics were significantly associated with post-operative dysphagia. Younger age (OR 0.96, 95% CI 0.94-0.986, p = 0.042) and the presence of pre-operative dysphagia (OR 2.54, 95% CI 1.17-5.65, p = 0.015) were significant predictors of post-operative dysphagia., Conclusion: The risk of clinically significant dysphagia post-fundoplication is low when using a tailored approach based on standard HRM metrics. Additional data provided by MRS does not add to surgical decision-making using the investigated approach., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Magnetic sphincter augmentation (MSA) erosion, disruption or displacement clearly requires device removal. However, up to 5.5% of patients without anatomical failure require removal for dysphagia or recurrent GERD symptoms. Studies characterizing these patients or their management are limited. We aimed to characterize these patients, compare their outcomes, and determine the necessity for further reflux surgery., Methods: This is a retrospective review of 777 patients who underwent MSA at our institution between 2013 and 2021. Patients who underwent device removal for persistent dysphagia or recurrent GERD symptoms were included. Demographic, clinical, objective testing, and quality of life data obtained preoperatively, after implantation and following removal were compared between removal for dysphagia and GERD groups. Sub-analyses were performed comparing outcomes with and without an anti-reflux surgery (ARS) at the time of removal., Results: A total of 40 (5.1%) patients underwent device removal, 31 (77.5%) for dysphagia and 9 (22.5%) for GERD. After implantation, dysphagia patients had less heartburn (12.9-vs-77.7%, p = 0.0005) less regurgitation (16.1-vs-55.5%, p = 0.0286), and more pH-normalization (91.7-vs-33.3%, p = 0.0158). Removal without ARS was performed in 5 (55.6%) GERD and 22 (71.0%) dysphagia patients. Removal for dysphagia patients had more complete symptom resolution (63.6-vs-0.0%, p = 0.0159), freedom from PPIs (81.8-vs-0.0%, p = 0.0016) and pH-normalization (77.8-vs-0.0%, p = 0.0455). Patients who underwent removal for dysphagia had comparable symptom resolution (p = 0.6770, freedom from PPI (p = 0.3841) and pH-normalization (p = 0.2534) with or without ARS. Those who refused ARS with removal for GERD had more heartburn (100.0%-vs-25.0%, p = 0.0476), regurgitation (80.0%-vs-0.0%, p = 0.0476) and PPI use (75.0%-vs-0.0%, p = 0.0476)., Conclusions: MSA removal outcomes are dependent on the indication for removal. Removal for dysphagia yields excellent outcomes regardless of anti-reflux surgery. Patients with persistent GERD had worse outcomes on all measures without ARS. We propose a tailored approach to MSA removal-based indication for removal., (© 2023. The Author(s).)

Background: Surgical treatment options of gastroesophageal reflux disease have changed significantly in the last 50 years. Magnetic Sphincter Augmentation (MSA) and Anti-reflux Mucosectomy (ARMs) are gaining traction but there is a paucity of literature comparing these novel options to Toupet fundoplication and gold standard Nissen fundoplication., Methods: This is a retrospective review of a prospectively maintained database, evaluating patients undergoing Nissen, Toupet, MSA, and ARMs. Pre-operative, intra-operative, and post-operative variables including Reflux symptom index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire (GERD-HRQL), and Dysphagia scores were compared between groups., Results: During the study period, 649 patients underwent anti-reflux surgery. Patients who underwent Nissen or Toupet were younger than those undergoing MSA or ARMs (65 ± 12 and 67 ± 14 years vs 56 ± 14 and 56 ± 18 years, P < 0.01). Average operative time for Nissen was 127 ± 40 min which was similar to a Toupet at 122 ± 32 min. These durations were significantly longer than for MSA, averaging 79 ± 29, and ARMs, at a mean 35 ± 3 min (all P < 0.001). Length of stay was significantly different among all four groups with Nissen, Toupet, MSA, and ARMs patients staying a median of 31, 24, 7, and 3 h post operatively, respectively (all P < 0.001). Complications and re-admissions were similarly low among all groups. Despite minor differences in RSI and GERD-HRQL scores at isolated follow-up time points, quality of life scores seems to be similar overall at up to 5 years follow-up. Gas bloat and dysphagia did not differ among groups at any time point., Conclusions: Novel anti-reflux surgery options provide similar GERD-related quality of life compared to traditional full or partial fundoplications with the added benefit of shorter operative time and faster recovery., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In recent years, flexible endoscopic therapy of Zenker's diverticulum seems to become the standard approach. The aim of this study was to assess the safety, efficacy and short-term outcome of flexible endoscopic diverticulotomy of Zenker's diverticulum with a pulsed Holmium laser (PHL)., Patients and Methods: All patients treated with endoscopic laser-diverticulotomy using a PHL between February 2013 and November 2021 at the University Hospital Salzburg were extracted from our prospectively maintained endoscopic database. Demographic data, size of Zenker's diverticulum, procedure duration, complications, short-term outcome and rate of recurrence were evaluated., Results: In the study period, 45 procedures in 36 patients were performed. Mean depth of the Zenker diverticulum was 21 mm (10-60 mm), mean procedure time was 31 min (15-60 min), intraprocedural adverse events occurred in 2 out of 45 patients (5%) which were both managed endoscopically, post-procedural stenosis occurred in 1 patient (2%). In the follow-up examinations (mean follow-up after 6.4 months), 27 out of 36 patients (75%) were symptom-free, 6 patients (17%) reported an improvement of dysphagia. 3 patients (9%) suffered from persistent dysphagia. After initial symptom relief, a recurrent diverticulum occurred in 5 patients. Endoscopic re-intervention with PHL was done in these cases., Conclusions: Flexible endoscopic treatment of primary and recurrent Zenker's diverticulum using a PHL is a promising, safe and effective treatment with, in our opinion, technical advantages in comparison to the CO 2 laser. Further controlled prospective trials are needed., (© 2022. The Author(s).)

Background: This systematic review aimed to analyse the use of the SX-ELLA biodegradable stent (BDS) for benign oesophageal strictures through the assessment of clinical and technical success, differences in pre- and post-BDS insertion dysphagia scores, rates of stent migration, and safety., Methods: A systematic review was reported according to PRISMA guidelines, with a prospectively registered protocol. The databases PubMed, Embase, SCOPUS, and ClinicalTrials.gov were searched up to March 2022. Studies assessing the use of the SX-ELLA BDS in adults with benign oesophageal strictures were included. A pooled data analysis was conducted to analyse the clinical and technical success associated with BDS use, rate of stent migration, and safety., Results: Of the 1509 articles identified, 16 studies treating 246 patients were eligible for inclusion. BDS was clinically successful in 41.9% of cases (95% CI = 35.7 - 48.1%), defined as those who experienced complete symptom resolution following BDS insertion. Technical success was achieved in 97.2% of patients (95% CI = 95.1 - 99.3%). A pooled analysis concluded a decrease in mean dysphagia score of 1.8 points (95% CI = 1.68 - 1.91) following BDS insertion. Re-intervention was required in 89 patients (36.2%, 95% CI = 30.2 - 42.2%), whilst stent migration occurred in 6.5% of patients (95% CI = 3.4 - 9.6%). A total of 37 major clinical complications related to BDS insertion were reported (15.0%, 95% CI = 10.5 - 19.5%)., Conclusion: The pooled data analysis demonstrates the high technical and moderate clinical success of the SX-ELLA biodegradable stent, supporting its use for benign oesophageal strictures in adults. However, greater evidence is required for more robust conclusions to be made in terms of success when compared to alternative methods of intervention, such as endoscopic dilation., (© 2022. Crown.)

Background: Cervical anastomotic strictures after esophagectomy cause significant disease burden. We aimed to study the technical feasibility and safety of intensive endoscopic therapy., Methods: In this pilot study, we included 15 patients with an untreated benign cervical anastomotic stricture after esophagectomy. Intensive endoscopic therapy comprised three endoscopic modalities: in- and excision using a needle-knife, intralesional steroid injections and bougie dilation. In two endoscopic procedures, the stricture was dilated up to a luminal diameter of 18 mm. Patients were followed up to 6 months., Results: A luminal diameter of 18 mm was achieved in 13 of 15 patients (87%) after two endoscopic procedures. No major adverse events related to the investigational treatment occurred. Median dysphagia scores significantly improved from 2 (IQR, interquartile range, 2-3) at baseline to 0 (IQR 0-1) after 14 days (p < 0.001). Eleven (73%) patients developed recurrent symptoms of dysphagia requiring a median of 1 (IQR 0-3) additional endoscopic dilation procedure., Conclusions: Achieving a luminal diameter of 18 mm in two procedures with intensive endoscopic therapy was technically feasible and effective in reducing dysphagia rapidly in patients with a cervical anastomotic stricture after esophagectomy. No major adverse events related to the investigational treatment were observed., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Symptomatic Zenker's diverticulum (ZD) occurs mostly in the elderly, who often have significant comorbidities, and poor neck hyperextension, putting them at high risk for surgical management while also increasing the potential of technical failure. Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) offers a safe approach to this problem with high technical and clinical success rates. There are limited data on its use following a failed surgical approach or in patients unfit for a surgical approach. The aim of this study was to assess clinical and technical outcomes of FEIT-Z in patients who were non-operative candidates or refused or failed surgical management., Methods: Patients who underwent FEIT-Z from January 2015 to February 2019 at a tertiary referral center were included. Patient demographics, prior ZD surgical history, procedural data, dysphagia scores, clinical success, and adverse events (AE) were collected. Univariable analysis was performed to assess differences between pre- and post-FEIT-Z dysphagia scores., Results: 30 patients undergoing FEIT-Z were included. Seven had a prior failed ZD surgical approach, 6 refused surgical management, and 17 were deemed to be non-operative candidates based on medical comorbidities. Mean age was 78.4 (± 12.1) and 36.7% were male. Technical success of FEIT-Z was 96.7%. There was a significant improvement in dysphagia scores after FEIT-Z: 2.3 (± 0.64) vs. before, 0.4 (± 0.76) (p < 0.001). Long-term clinical success was achieved in 73.3% of patients. Adverse events were seen in 23.3% of patients; however, these were graded as mild in 85.7% of patients. One microperforation was managed with antibiotics., Conclusion: FEIT-Z is a safe procedure with low adverse events and a high rate of technical and clinical success. FEIT-Z can be done in patients who fail previous surgical treatment, refuse a surgical approach, or are not surgical candidates due to medical comorbidity or other factors., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Enteral access is required for a variety of reasons from neuromuscular disorders to dysphagia. Gastrostomy tubes (GTs) can be placed endoscopically, surgically, or radiographically and complications include infection, bleeding, leakage and unintentional removal. Routine post-procedural follow-up is limited by inconsistent guidelines and management by different specialty teams. We established a dedicated GT clinic to provide continuity of care and prophylactic GT exchange. We hypothesized that patients followed in the GT clinic would have reduced Emergency Department (ED) utilization., Methods: A retrospective review of patients who underwent GT placement from January 2010 to January 2020 was conducted. Baseline demographics, indications for GT placement, number and reason for ED visits and utilization of a multidisciplinary GT clinic were studied., Results: A total of 97 patients were included. The most common indication for placement was dysphagia (88, 91%) and the most common primary diagnosis was head and neck malignancy (51, 51%). The GT clinic is a multidisciplinary clinic staffed by surgeons and residents, dieticians, and wound care specialists and cared for 16 patients in this study. Three patients (19%) in the GT clinic group required ED visits compared to 44 (54%) in the standard of care (SOC) group (p < 0.05). There was an average of 0.9 ED visits per patient (range 0-7) in the GT clinic group vs 1.6 ED visits per patient (range 0-20) in the SOC group (p = 0.34). Feeding tubes were prophylactically exchanged an average of 7 times per patient in the GT clinic group vs 3 times per patient in the SOC group (p < 0.05)., Conclusion: A multidisciplinary clinic dedicated to GT care limits ED visits for associated complications by more than 50%. Follow-up in a dedicated clinic with prophylactic tube exchange decreases ED visits and should be considered at facilities that care for patients with GTs., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Laparoscopic magnetic sphincter augmentation (MSA) has emerged as an alternative to laparoscopic Nissen fundoplication (LNF) for the management of symptomatic gastroesophageal reflux disease (GERD). While short-term outcomes of MSA compare favorably to those of LNF, direct comparisons of long-term outcomes are lacking. We hypothesized that the long-term patient-reported outcomes of MSA would be similar to those achieved with LNF., Methods: We tested this hypothesis in a retrospective cohort undergoing primary LNF or MSA between March 2013 and July 2015. The primary outcome was GERD-Health Related Quality of Life (GERD-HRQL) score at long-term follow-up relative to baseline. Secondary outcomes included dysphagia and bloating scores, proton-pump inhibitor (PPI) cessation, reoperations, and overall satisfaction with surgery., Results: 70 patients (25 MSA, 45 LNF) met criteria for study inclusion. MSA patients had lower baseline BMI (median: 27.1 [IQR: 22.7-29.9] versus 30.4 [26.4-32.8], p = 0.02), lower total GERD-HRQL (26 [19-32] versus 34 [25-40], p = 0.02), and dysphagia (2 [0-3] versus 3 [1-4], p = 0.02) scores. Median follow-up interval exceeded 5 years (MSA: 68 [65-74]; LNF: 65 months [62-69]). Total GERD-HRQL improved from 26 to 9 after MSA (p < 0.001) and from 34 to 7.5 after LNF (p < 0.01); these scores did not differ between groups (p = 0.68). Dysphagia (MSA: 1 [0-2]; LNF: 0 [0-2], p = 0.96) and bloating (MSA: 1.5 [0.5-3.0]; LNF: 3.0 [1.0-4.0], p = 0.08) scores did not show any statistically significant differences. Device removal was performed in 4 (16%) MSA patients and reoperation in 3 (7%) LNF patients. Eighty-nine percent of LNF patients reported satisfaction with the procedure, compared to 70% of MSA patients (p = 0.09)., Conclusions: MSA appears to offer similar long-term improvement in disease-specific quality of life as LNF. For MSA, there was a trend toward reduced long-term bloating compared to LNF, but need for reoperation and device removal may be associated with patient dissatisfaction., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Success rate of endoscopic dilation (ED) of complex benign esophageal strictures (CBES) can be as low as 65%. Since EDs are usually performed at 2-4-week intervals, the aim of this study was to evaluate the clinical outcomes of EDs done initially at weekly intervals., Methods: A cohort of patients with CBES (luminal diameter < 10 mm) underwent ED at weekly intervals and subsequent dilation intervals adjusted based on response. Weekly EDs were also re-initiated in those requiring additional interventions (electro-cautery/stents). Group A patients: Failed prior EDs done at ≥ 2-week intervals. Group B: CBES with no prior dilations. Success was defined as achieving and maintaining a luminal diameter of ≥ 14 mm and patient remaining dysphagia-free with minimal re-interventions., Results: 488 EDs were performed on a cohort of 57 consecutive patients with CBES. Median follow-up was 4 years. Group A: 21 patients (mean age 65 ± 13 years; mean interval between prior failed dilations 17 ± 9 days). 57% of these patients achieved long-term success with weekly dilations (mean 8 ± 4.7 dilations/patient). Group B: 36 patients (mean age 61 ± 13 years, mean 6.5 ± 5.5 dilations/patient). Long-term success was 83.3% (P = 0.033). Despite weekly dilations, unable to achieve a diameter of 14 mm in 5 patients. AE: perforation 1 (0.2%), bleeding 1 (0.2%)., Conclusion: Significant proportion of patients with CBES who failed prior dilations done at ≥ 2-week intervals achieved dysphagia-free status by initiating weekly dilations. Hence, before considering other options (electro-cautery/stents), one can consider using this approach. This approach can also be used upfront in patients with newly diagnosed CBES., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Anti-reflux surgery (ARS) has known long-term complications, including dysphagia, bloat, and flatulence, among others. The factors affecting the development of post-operative dysphagia are poorly understood. We investigated the correlation of intra-operative esophagogastric junction (EGJ) characteristics and procedure type with post-operative dysphagia following ARS., Methods: Robotic ARS was performed on 197 consecutive patients with pathologic reflux utilizing EndoFLIP™ technology. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and high-pressure zone (HPZ) length were collected. Dysphagia was assessed pre-operatively and at 3 months post-operatively., Results: The median pre-operative DI for all procedures was 2.6 (IQR 1.6-4.5) mm 2 /mmHg. There was no difference in post-operative DI between procedures [Hill: 0.9 (IQR 0.7-1.1) mm 2 /mmHg, Nissen: 1.0 (IQR 0.7-1.4) mm 2 /mmHg, Toupet: 1.2 (IQR 0.8-1.5) mm 2 /mmHg, Linx: 1.0 (IQR 0.7-1.2) mm 2 /mmHg, p = 0.24], whereas post-operative HPZ length differed by augmentation type [Hill: 3 (IQR 2.8-3) cm, Nissen: 3.5 (IQR 3-3.5) cm, Toupet: 3 (IQR 2.5-3.5) cm, Linx: 2.5 (IQR 2.5-3) cm, p = 0.032]. Eighty-nine patients (45.2%) had pre-operative dysphagia. Thirty-two patients (27.6%) reported any dysphagia at their 3-month post-operative visit and 12 (10.3%) developed new or worsening post-operative dysphagia [Hill: 2/18 (11.1%), Nissen: 2/35 (5.7%), Toupet: 4/54 (7.4%), Linx: 4/9 (44.4%), p = 0.006]. The median pre-operative and post-operative DI of patients who developed new or worsening dysphagia was 2.0 (IQR 0.9-3.8) mm 2 /mmHg and 1.2 (IQR 1.0-1.8) mm 2 /mmHg, respectively, and that of those who did not was 2.5 (IQR 1.6-4.0) mm 2 /mmHg and 1.0 (IQR 0.7-1.4) mm 2 /mmHg (p = 0.21 and 0.16, respectively)., Conclusions: Post-operative DI was similar between procedures, and there was no correlation with new or worsening post-operative dysphagia. Linx placement was associated with higher rates of new or worsening post-operative dysphagia despite a shorter post-procedure HPZ length and similar post-operative DI when compared to other methods of LES augmentation., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Endoluminal functional lumen imaging probe (EndoFLIP) provides an objective measure of the distensibility index (DI) during different parts of hiatal hernia repair. However, the absolute DI measure above a cut-off after creating a barrier alone has not shown a relationship to dysphagia after surgery. We wanted to determine if the change in DI with volume change is associated with dysphagia., Methods: We included patients who had hiatal hernia repair with EndoFLIP values, including two values taken at the end of the surgical case with different volumes of fluid in the balloon (30 mL and 40 mL). We compared the absolute and change in DI during hiatal hernia repair and performed an analysis to determine if there was a correlation with short-term clinical outcomes., Results: A total of 103 patients met the inclusion and exclusion criteria. Most of the patients underwent Toupet fundoplication (n = 56, 54%), followed by magnetic sphincter augmentation (LINX, n = 28, 27%) and Nissen fundoplication (n = 19, 18%). There was a significant reduction in the DI from the initial DI taken after mobilization of the hiatus (3 mm 2 /mmHg) and after the creation of the barrier (1.4 mm 2 /mmHg, p < 0.001). A minority of patients had a decrease or no change in the DI with an increase in balloon volume increased from 30 to 40 mL (n = 37, 36%). Overall, after 1 month, there was a significant decrease in the GERD-HRQL score from 23 to 4 (p < 0.001) and bloat score from 3 to 2 (p = 0.003) with a non-significant decrease in the dysphagia score from 1 to 0 (p = 0.11). Patients who had a decreased or unchanged DI with an increase in the balloon volume from 30 to 40 mL had a significant decrease in their dysphagia score by 2 points (p = 0.04)., Conclusion: The decreased or unchanged DI with an increase in the balloon volume on EndoFLIP is associated with a significant reduction in dysphagia after surgery. The decrease in DI denotes the esophagus's ability to create higher pressure relative to the change in the cross-sectional area with a larger bolus across the gastroesophageal junction. This measure may be a new marker that can predict short-term outcomes in patients undergoing hiatal hernia repair., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Anti-reflux mucosectomy (ARMS) is a novel endoscopic treatment for refractory gastroesophageal reflux disease (rGERD). Several studies have validated its safety and effectiveness, but postoperative dysphagia remains in concern. Since the influence of different resection ranges on efficacy and complications of ARMS has rarely been studied, this study aimed to compare outcomes of 180°ARMS and 270°ARMS in treatment of rGERD., Methods: This study was conducted from August 2017 to September 2020. 39 eligible patients underwent either 180° ARMS or 270° ARMS and followed up at 6 months postoperation. Primary outcome measure was assessed by Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Secondary outcomes included quality of life, PPI use, gastroesophageal flap valve grade, presence of reflux esophagitis, acid exposure time (AET), distal contractile integral (DCI), and integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) and complication rate. Per-protocol analysis was performed., Results: Among 39 patients, 18 underwent 180° ARMS, while 21 underwent 270° ARMS. At postoperative 6 months follow-up period, primary outcome showed no significant difference between two groups (p = 0.34). Similarly, no significant difference was demonstrated between groups regarding most secondary outcomes except for fewer complaints of newly dysphagia in 180° ARMS group. No other serious complications were observed in both groups., Conclusion: Although 180° ARMS and 270° ARMS could be equally effective for treatment of rGERD, 180° ARMS might be more recommended due to lower incidence of newly post-procedural dysphagia., (© 2021. The Author(s).)

Background: Symptomatic Zenker's diverticulum management has evolved from an open intervention to an endoscopic management. At our center, both an otolaryngologist and a gastroenterologist are present in the operating room when treating these lesions. An intra-procedural consensus is reached to undergo either rigid endoscopy or flexible endoscopic diverticulotomy with ENT guidance. We evaluated the real-world efficacy with a cooperative gastroenterology-otolaryngology approach., Methods: Single-center retrospective study of patients who underwent a cooperative endoscopic diverticulotomy by a gastroenterologist and otolaryngologist at Cleveland Clinic Florida between 2012 and 2019. Demographic and clinical data, intra-procedural findings/complications, post-procedural symptoms, recurrence rate, and reintervention variables were extracted. Patients included in the study were > 17 years old, with symptomatic confirmed typical single Zenker's diverticulum., Results: 63 subjects were identified. Patients were predominantly males (63.5%) and white (84.1%), with mean age 73.5 years (53-95). Most subjects presented dysphagia (98.4%), mostly to solids (79.4%). Other demographic and clinical data are described in Table 1. The diverticula had a mean size of 36.3 mm. In 30.1% of the cases food debris was found during the procedure. The mean procedure length was 38.4 minutes. All cases were performed as outpatient. Technical success was achieved in all cases. Patients were followed for a mean of 3.24 months post-procedure. Clinical success was achieved in 92% subjects. One intra-procedural perforation was treated with endoclip. Table 1 Pre-procedural demographic and clinical variables in patients undergoing Zenker's diverticulum cooperative approach Variable Value (n = 63) Sex, n (%)  Male  Female 40 (63.5) 23 (36.5) Ethnicity/Race, n (%)  Non-Hispanic White  Hispanic  Black 53 (84.1) 7 (11.1) 3 (4.8) Smoking status, n (%)  Never  Former  Active 29 (46.0) 26 (41.3) 8 (10.7) Previous intervention for Zenker's diverticulum, n (%) 12 (19.1) Dysphagia, n (%)  Only to solids  Only to liquids  Both solids and liquids 50 (79.4) 0 (0) 12 (19.0) Regurgitation of food, n (%)  Chronic cough, n (%) 13 (20.6)  Halitosis, n (%) 9 (14.3) CONCLUSION: A cooperative endoscopic approach by gastroenterology and otolaryngology for symptomatic Zenker's diverticulum management offered excellent technical and clinical success. This approach proved to be safe and effective., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD., Methods: We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results., Results: Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction., Conclusion: The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Various technical modifications of Nissen fundoplication (NF) that aim to improve patients' outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF., Methods: 283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed., Results: Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively., Conclusion: Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF., (© 2021. The Author(s).)

Background and Aims: The management of patients with hypopharyngeal or cervical esophageal refractory benign strictures (RBS) after surgery and radiotherapy ± chemotherapy for laryngeal cancer is challenging. We aimed to assess the long-term efficacy and safety of a new designed fully covered SEMS in these patients., Methods: We reviewed the results of a prospectively collected database of 40 consecutive patients with dysphagia due to RBS of the cervical esophagus or hypopharynx after surgery and radiotherapy with or without chemotherapy for laryngeal cancer, unfit for surgery, referred in two tertiary-care endoscopic centers from June 2005 to December 2018. All of them were treated with placement of a Niti-S Conio cervical stent., Results: After placement of the first stent, dysphagia improved in all patients. The total number of adverse events was 35 out of a total of 299 procedures (11.7%): 25 (8.4%) stent migrations, 6 (2%) tumor overgrowth, 3 severe pain and 1 pharyngo-cutaneous fistula. Stents were periodically changed. In only one patient with a cervical esophageal stricture the stent was definitively removed after 7 sessions of stent placement because of stricture resolution. Patients were followed-up for a median of 11.6 months and a significant improvement in dysphagia was reported in all patients (p < 0.001)., Conclusions: The use of this conformable, small caliber new designed Niti-S stent, exchanged periodically, appeared safe and permitted durable oral intake in patients with difficult-to-treat hypopharyngeal or cervical esophagus strictures, avoiding the need for periodic dilations., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA., Materials and Methods: A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients., Results: Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m 2 . 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12-14 beads) versus a larger MSA implant (15-17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026)., Conclusion: Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia., Methods: We prospectively collected data on PF patients referred to Esophageal Clinic over 18 months. EGJO diagnosis was made by (a) endoscopist's description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8 mm 2 /mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20 mm, 30 mm, or 35 mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score., Results: Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3 cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20 mm balloon and 7 with ≥ 30 mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7-82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1-88.4%, p = 0.0001)., Conclusions and Inferences: Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.

Introduction: Ineffective esophageal motility (IEM) is a physiologic diagnosis and is a component of the Chicago Classification. It has a strong association with gastroesophageal reflux and may be found during work-up for anti-reflux surgery. IEM implies a higher risk of post-op dysphagia if a total fundoplication is done. We hypothesized that IEM is not predictive of dysphagia following fundoplication and that it is safe to perform total fundoplication in appropriately selected patients., Methods: Retrospective chart review of patients who underwent total fundoplication between September 2012 and December 2018 in a single foregut surgery center and who had IEM on preoperative manometry. We excluded patients who had partial fundoplication, previous foregut surgery, other causes of dysphagia or an esophageal lengthening procedure. Dysphagia was assessed using standardized Dakkak score ≤ 40 and GERD-HRQL question 7 ≥ 3., Results: Two hundred patients were diagnosed with IEM and 31 met the inclusion criteria. Median follow-up: 706 days (IQR 278-1348 days). No preoperative factors, including subjective dysphagia, transit on barium swallow, or individual components of manometry showed statistical correlation with postoperative dysphagia. Of 9 patients with preoperative dysphagia, 2 (22%) had persistent postoperative dysphagia and 7 had resolution. Of 22 patients without preoperative dysphagia, 3 (14%) developed postoperative dysphagia; for a combined rate of 16%. No patient needed re-intervention beyond early recovery or required reoperation for dysphagia during the follow-up period., Conclusion: In appropriately selected patients, when total fundoplication is performed in the presence of preoperative IEM, the rate of long-term postoperative dysphagia is similar to the reported rate of dysphagia without IEM. With appropriate patient selection, total fundoplication may be performed in patients with IEM without a disproportionate increase in postoperative dysphagia. The presence of preoperative IEM should not be rigidly applied as a contraindication to a total fundoplication.

Background: In peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the mucosal incision and muscular interruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach., Methods: All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system., Results: Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group (p = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients (p = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group (p ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients (p = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group (p = 0.094)., Conclusions: MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.

Background: Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia., Methods: We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively., Results: From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment "success" RR 1.71, 95% CI 1.34-2.17; 126 patients) and in observational studies (Eckardt score MD - 0.43, 95% CI - 0.71 to - 0.16; 5 studies; I 2 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08-0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6-12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02-7.00; I 2 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events., Conclusions: POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.

Background: There has been an increase in sleeve gastrectomy (SG) procedures being performed worldwide, and a paralleled rise in prevalence of gastric sleeve stenosis (GSS). Symptoms include dysphagia, reflux, and obstructive symptoms. Upper gastrointestinal series (UGIS) is commonly performed in the diagnostic algorithm prior to referral for endoscopic dilation; however, little is known about its utility in making a diagnosis. Our aim was to evaluate positive predictive value (PPV) and negative predictive value (NPV) of UGIS in detection of GSS., Methods: We performed a retrospective analysis of a prospectively collected database at a tertiary center for patients referred with nausea/vomiting or obstructive symptoms following SG between 2017 and 2019. All patients underwent upper endoscopy (EGD) for evaluation of GSS. Serial balloon dilations were performed for GSS with increasing balloon size and/or filling pressure until symptom resolution or referral for surgical revision. Primary outcomes were PPV and NPV for UGIS in predicting GSS. Secondary outcomes included EGD findings and symptom response to dilation., Results: Thirty consecutive patients were included in the analyses. The most common presenting symptoms were nausea (66.7%), vomiting (60.0%) reflux (66.7%), and abdominal pain (54.8%). Twenty-two (73.3%) patients underwent UGIS prior to EGD. On diagnostic EGD, 27 (87.1%) patients were diagnosed with GSS. The sensitivity and NPV of UGIS to detect GSS was 30.0%, and 12.5%, respectively. All 6 patients with GSS on UGIS also had GSS on endoscopic evaluation (specificity = 100%, PPV = 100%). Twenty-six (86.6%) patients had resolution of symptoms with a mean 1.97 ± 1.13 dilations., Conclusion: UGIS following SG has low NPV to evaluate for GSS. Independent of the UGIS findings, majority of patients found to have GSS on EGD had symptom improvement with dilations. The utility of UGIS is limited for diagnosing GSS and when suspicion for GSS is high, patients should be referred directly for EGD.

Background: Cameron lesions (CL) are common complications of large hiatal hernia (HH) disease and are known to result in chronic blood loss with resultant microcytic anemia. There is support in the literature that repair of HH may lead to resolution of CL and restore normal hemoglobin levels. This study aimed to determine the impact of elective HH repair on resolution of anemia and the quality of life (QOL) in patients with CL., Method: A single-institution, retrospective review analyzed all patients with history of CL or anemia (hemoglobin < 12.0 gm/dl in women, < 13.5 gm/dl in men) who underwent HH repair from January 2012 to May 2019. Four validated surveys were used to assess QOL: Reflux Symptom Index (RSI), gastroesophageal reflux disease health-related QOL (GERD-HRQL), laryngopharyngeal reflux health-related QOL (LPR-HRQL), and QOL and swallowing disorders (SWAL) survey. History of iron supplements and perioperative hemoglobin were also noted., Result: Ninety-six patients were included in this study. The mean age was 67.4 ± 10.8 years and 79% of patients were female. CL were endoscopically identified in 61.5% of patients preoperatively, and the rest of the patients experienced anemia of undiagnosed origin but had a high suspicion for CL. Mean follow-up after HH repair was 17.3 months (range, 1 month-5 years). Mean preoperative hemoglobin was 11.01 ± 2.9 gm/dl and 13.23 ± 1.6 gm/dl postoperatively (p < 0.01). Forty-two (73.7%) patients had resolution of anemia during follow-up and 94.5% stopped supplemental oral iron. Finally, QOL scores significantly improved after surgical intervention: RSI (63%), GERD-HRQL (77%), LPR-HRQOL (72%), and SWAL (13%)., Conclusion: Elective HH repair in patients with chronic anemia secondary to CL may potentially resolve CL and anemia and contribute to significant QOL improvements. Future studies will prospectively assess the resolution of CL with biochemical and endoscopic follow-up to confirm the preliminary findings of our analysis.

Background: Approximately 3-6% of patients undergoing anti-reflux surgery require "redo" surgery for persistent gastroesophageal reflux disease (GERD). Further surgery for patients with two failed prior anti-reflux operations is controversial due to the morbidity of reoperation and poor outcomes. We examined our experience with surgical revision of patients with at least two failed anti-reflux operations., Methods: Adults undergoing at least a second-time revision anti-reflux surgery between 1999 and 2017 were eligible. The primary outcomes were general and disease-specific quality-of-life (QoL) scores determined by Short-Form-36 (SF36) and GERD-Health-Related QoL (GERD-HRQL) instruments, respectively. Secondary outcomes included perioperative morbidity and mortality., Results: Eighteen patients undergoing redo-redo surgery (13 with 2 prior operations, 5 with 3 prior operations) were followed for a median of 6 years [IQR 3, 12]. Sixteen patients (89%) underwent open revisions (14 thoracoabdominal, 2 laparotomy) and two patients had laparoscopic revisions. Indications for surgery included reflux (10 patients), regurgitation (5 patients), and dysphagia (3 patients). Intraoperative findings were mediastinal wrap herniation (9 patients), misplaced wrap (2 patients), mesh erosion (1 patient), or scarring/stricture (6 patients). Procedures performed included Collis gastroplasty + fundoplication (6 patients), redo fundoplication (5 patients), esophagogastrectomy (4 patients), and primary hiatal closure (3 patients). There were no deaths and 13/18 patients (72%) had no postoperative complications. Ten patients completed QoL surveys; 8 reported resolution of reflux, 6 reported resolution of regurgitation, while 4 remained on proton-pump inhibitors (PPI). Mean SF36 scores (± standard deviation) in the study cohort in the eight QoL domains were as follows: physical functioning (79.5 [± 19.9]), physical role limitations (52.5 [± 46.3]), emotional role limitations (83.3 [± 36.1]), vitality (60.0 [± 22.7]), emotional well-being (88.4 [± 8.7]), social functioning (75.2 [± 31.0]), pain (66.2 [± 30.9]), and general health (55.0 [± 39.0])., Conclusion: An open thoracoabdominal approach in appropriately selected patients needing third-time anti-reflux surgery carries low morbidity and provides excellent results as reflected in QoL scores.

Background and Aims: Epinephric diverticula are frequently associated with esophageal motility disorder. Their management implies surgery, with 15% morbidity and 3% mortality rates. Flexible endoscopy could be an effective and safer approach for treating esophageal diverticulum with motility disorder. We report our experience of seven consecutive cases treated with per-oral endoscopic submucosal septotomy and myotomy (D-POEM)., Methods: Seven consecutive patients were referred for symptomatic non-zenker's esophageal diverticulum. The steps of the procedure were as follows: (i) analysis of the esophageal anatomy; (ii) vertical mucosal incision just above the upper edge of the diverticulum; (iii) submucosal tunneling by submucosal dissection, alongside the submucosal window of the diverticulum and the downstream septum; (iv) identification of the septum and the diverticular area; (v) diverticular septotomy followed by antegrade esocardial myotomy up to 2 cm below the cardia; and (vi) closure of the mucosal incision., Results: Three men and four women aged from 62 to 90 years were treated. Four patients had a diet with adapted texture before the treatment and five patients had weight loss (4 kg to 24 kg). At preoperative evaluation, all had an esophageal motility disorder at high-resolution manometry. The procedures were successfully performed in all the patients without per-operative complications. During the 30 postoperative days, no significant adverse events occurred. Three months after treatment, six patients (85%) had clinical improvement with complete or partial regression of dysphagia. All the patients stabilized or gained weight after the treatment., Conclusion: The D-POEM technique is a mini-invasive effective and safe technique to treat symptoms due to both esophageal motility disorder and distal esophageal diverticula. It could be a very interesting solution for non-surgical patients in the first time that could be extended to other patients after favorable larger series.

Introduction: Magnetic sphincter augmentation (MSA) is a promising antireflux surgical treatment. The cost associated with the device may be perceived as a drawback by payers, which may limit the adoption of this technique. There are limited data regarding the cost of MSA in the management of reflux disease. The aims of the study were to report the clinical outcome and quality of life measures in patients after MSA and to compare the pharmaceutical and procedure payer costs and the disease-related and overall expense of MSA compared to laparoscopic Nissen fundoplication (LNF) from a payer perspective., Methods and Procedures: This prospective observational study was performed in conjunction with the region's largest health insurance company. Data were collected on patients who underwent MSA over a 2-year period beginning in September 2015 at the study network hospitals. The LNF comparison group was procured from members' claims data of the payer. Inclusion was predicated by patients having continuous coverage during study period. The total procedural reimbursement and the disease-related and overall medical claims submitted up to 12 months prior to surgery and up to 12 months following surgery were obtained. The payer reimbursement data are presented as allowed cost per member per month (PMPM). These values were then compared between groups., Results: There were 195 patients who underwent MSA and 1131 that had LNF. MSA results in comparable symptom control, PPI elimination rate, and quality of life measures compared to values reported for LNF in the literature. The median (IQR) reimbursement of surgery was $13,522 (13,195-14,439) for those who underwent MSA and $13,388 (9951-16,261) for patients with LNF, p = 0.02. In patients who underwent MSA, the median reimbursement related to the upper gastrointestinal disease was $ 305 PMPM, at 12 months prior to surgery and $ 104 at 12 months after surgery, representing 66% decrease in cost. These values were $ 233 PMPM and $126 PMPM for patients who underwent LNF, representing a 46% decrease (p = 0.0001). At 12 months following surgery, the reimbursement for overall medical expenses had decreased by 10.7% in the MSA group and 1.4% in the LNF group when compared to the preoperative baseline reimbursement. The reimbursement for PPI use after surgery showed a 95% decrease in the MSA group and 90% among LNF group when compared to the preoperative baseline (p = 0.10)., Conclusion: When compared with LNF, MSA results in a reduction of disease-related expenses for the payer in the year following surgery. While MSA is associated with a higher procedural payer cost compared to LNF, payer costs may offset due to reduction in the expenses after surgery.

Background: Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period., Methods: Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome., Results: Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes., Conclusions: POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.

Purpose: The aim of the present paper is to report the results of a single institution series of hiatal hernia repair (HHR) with augmented mesh hiatoplasty focusing on safety and efficacy profile of Bio-A absorbable synthetic mesh., Materials and Methods: A retrospective evaluation of prospectively maintained database showed 120 consecutive patients submitted to HHR reinforced with bio-absorbable synthetic mesh. The study populations included two groups: (A) 92 obese patients-reinforced hiatoplasty concurrent with bariatric procedure; (B) 28 non-obese patients-reinforced hiatoplasty concurrent with antireflux surgery. Symptoms assessment was made with GERD-HRQL and Rome III. The X-ray with barium swallow, the CT scan, in selected cases, and the endoscopy were used as recurrence evaluation and as endoscopic complications assessment. Only patients with a mean follow-up of 12 months were included in this study. A Cox hazard was made to evaluate factors affecting the recurrence., Results: No case of intra-peri and post-operative (mean follow-up of 41 months) complications mesh related were registered. The dysphagia-rate was 8.7% for Group A and 11% for Group B. 74% of Group A and 61% of Group B patients are actually PPIs free with median GERD-HRQL score of 4 (from 16) and 6 (from 23), respectively (difference pre-post-operative < 0.05). Recurrence rate was 5.4% in Group A and 7.1% in Group B. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR = 8; p < 0.05)., Conclusions: This is, in our knowledge, the largest report (120 consecutive patients) with mid-term follow-up (41 months of mean FU) on bio-absorbable mesh on the hiatus in obese and non-obese patients. These results supports the use of absorbable mesh for HHR (safe profile-0% of complications rate), showing excellent recurrence rate results and good GERD symptoms control.

Background: Although around 30% of patients with gastroesophageal reflux disease (GERD) are insufficiently treated with medical therapy, only 1% opt for surgical therapy. One of the reasons behind this multifactorial phenomenon is the described adverse effect of long-term dysphagia or gastric bloating syndrome after surgical treatment. Aim of this study was to evaluate the most common side effects associated with anti-reflux surgery, as well as long-term outcomes in a large cohort of highly surgically standardized patients after laparoscopic Nissen fundoplication (LNF)., Methods: Out of a prospective patients' database including all patients that underwent anti-reflux surgery between 01/2003 and 01/2017 at our institution, 350 consecutive patients after highly standardized LNF were included in this study. A standardized interview was performed by one physician assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD-Health-Related-Quality-of-Life (GERD-HRQL), Alimentary Satisfaction (AS), and patients' overall satisfaction., Results: After a median follow-up of 4 years, persistent dysphagia (PD) after LNF was observed in 8 (2%) patients, while postoperative gas-bloat syndrome in 45 (12.7%) cases. Endoscopic dilatation was needed in 7 (2%) patients due to dysphagia, and 19 (5%) patients underwent revision surgery due to recurrence of GERD. The postoperative GERD-HRQL total score was significantly reduced (2 (IQR 0-4.3) vs. 19 (IQR 17-32); p < 0.000) and the median AS was 9/10. Heartburn relief was achieved in 83% of patients. Eighty-three percent of patients were free of PPI intake after follow-up, whereas 13% and 4% of the patients reported daily and irregular PPI use, respectively., Conclusion: LNF is a safe and effective surgical procedure with low postoperative morbidity rates and efficient GERD-related symptom relief. PD does not represent a relevant clinical issue when LNF is performed in a surgical standardized way. These results should be the benchmark to which long-term outcomes of new surgical anti-reflux procedures are compared.

Background and Study Aim: Complete esophageal obstruction after (chemo)radiation for head and neck cancers is rare. However, inability to swallow one's own saliva strongly inflicts upon quality of life. Techniques for endoscopic recanalization in complete obstruction are not well established. We assessed the efficacy and safety of rendezvous recanalization., Patients and Methods: We performed a retrospective review of all patients who underwent endoscopic recanalization of complete proximal esophageal obstruction after radiotherapy between January 2009 and June 2016. Technical success was defined as an ability to pass an endoscope across the recanalized lumen, clinical success by changes in the dysphagia score. Adverse events were recorded prospectively., Results: 19 patients with complete obstruction (dysphagia IV°), all of whom had failed at least one trial of conventional dilatation, underwent recanalization by endoscopic rendezvous, a combined approach through a gastrostomy and perorally under fluoroscopic control. Conscious sedation was used in all patients. In 18/19 patients (94.7%), recanalization was technically successful. In 14/18 patients (77.8%), the post-intervention dysphagia score changed to ≤ II. Three patients had their PEG removed. Factors negatively associated with success were obstruction length of 50 mm; and tumor recurrence for long-term success. No severe complications were recorded., Conclusions: Rendezvous recanalization for complete esophageal obstruction is a reliable and safe method to re-establish luminal patency. Differences between technical and clinical success rates highlight the importance of additional functional factors associated with dysphagia. Given the lack of therapeutic alternatives, rendezvous recanalization is a valid option to improve dysphagia.

Background: We have previously reported short-term outcomes after hiatal hernia repair (HHR) at the time of magnetic sphincter augmentation (MSA) for gastroesophageal reflux disease (GERD). Here we report intermediate-term outcomes and hernia recurrence rate after concomitant MSA and HHR., Methods: This is a retrospective cohort study of patients who underwent repair of a hiatal hernia 3 cm or larger at the time of MSA implantation between May 2009 and December 2015. The primary endpoint was hiatal hernia recurrence identified by routine postoperative videoesophagography or endoscopy. Recurrence was defined by a 2 cm or greater upward displacement of the stomach through the diaphragmatic esophageal hiatus. Secondary endpoints included cessation of proton-pump inhibitor (PPI), persistent dysphagia requiring intervention, and GERD health-related quality-of-life (HRQL) scores 1 year from surgery., Results: During the study period, 47 of 53 (89%) patients underwent concomitant MSA with HHR and complied with surveillance. Hiatal hernias ranged from 3 to 7 cm (mean 4 ± 1). Mean clinical follow-up time was 19 months (range 1-39). GERD-HRQL score decreased from 20.3 to 3.1 (p < .001), 89% of patients remained off PPIs, and 97% of patients reported improvement or resolution of symptoms. Two recurrent hiatal hernias were identified on surveillance imaging for a recurrence rate of 4.3% at a mean 18 (± 10) months after initial operation. Persistent dysphagia occurred in 13% (6/47) over the first year, which resolved after a single balloon dilation in 67% (4/6). Two patients elected for device removal due to dilation-refractory dysphagia and persistent reflux symptoms., Conclusion: Concomitant magnetic sphincter augmentation and hiatal hernia repair in patients with gastroesophageal reflux disease and a moderate-sized hiatal hernia demonstrates durable subjective reflux control and an acceptable hiatal hernia recurrence rate at 1- to 2-year follow-up.

Background: Dysphagia is a common complication in stroke patients, which severely affects quality of life. This study aimed to evaluate the effectiveness and safety of temperature-controlled plasma radiofrequency (coblation)-assisted endoscopic cricopharyngeal myotomy (CAECPM) for the treatment sustained (>6 months) dysphagia in stroke patients., Methods: This retrospective case-control study included a total of 24 stroke patients with sustained dysphagia, who were either treated with transcervical cricopharyngeal myotomy (CPM) (n = 16) or CAECPM (n = 12). The patients' swallowing function was evaluated by the Chinese version of the swallow quality-of-life questionnaire (CSWAL-QOL), and dysphagia and aspiration was evaluated using the videofluoroscopic swallowing study (VFSS) swallowing (VFSS-SWAL) score and VSSF aspiration (VFSS-ASPI) score. In each patient, esophageal pressure and complications were also recorded., Results: The CSWAL-QOL score was increased and the VFSS-SWAL and VFSS-ASPI scores were reduced after CAECPM treatment. The upper esophageal sphincter pressure was significantly reduced after CAECPM. Only 1 of 12 (8.3%) patients had subcutaneous and mediastinal emphysema, and 2 patients had gastric regurgitation., Conclusion: This exploratory study demonstrates that CAECPM is worth further investigation for dysphagia after stroke. CAECPM may be an effective and safe treatment for sustained dysphagia in stroke patients. Larges and prospective studies are required to validate these results.

Introduction: Stent migration is a significant clinical problem in palliation of malignant strictures in the esophagus and gastro-esophageal junction (GEJ). We have compared a newer design of a fully-covered stent to a widely used semi-covered stent using migration >20 mm as the primary outcome variable. Effects on dysphagia, quality of life (QoL) and re-intervention frequency were also investigated., Methods: Patients with dysphagia due to non-curable esophagus/GEJ cancer were randomized to receive either a more recent design of a fully-covered stent (n = 48) or a conventional semi-covered stent (n = 47). Chest x-ray, dysphagia and QoL were studied at baseline, one week, four weeks and three months thereafter., Results: There were no significant differences either in stent migration distance or in the migration frequency. Stent migration during the total study period occurred in 37.2 % in the semi-covered group compared to 20.0 % for the fully-covered group. Dysphagia was measured with Watson and Ogilvie scores and with the dysphagia module in the QoL scale (QLQ-OG25). On average, there was a tendency to better dysphagia relief for the fully-covered design as scored with the two latter dysphagia instruments (p= 0.081 and p= 0.067) at three months and towards more re-interventions in the semi-covered group (p= 0.083)., Conclusion: In spite of its somewhat lower intrinsic radial force, the fully-covered stent was comparable to the conventional semi-covered stent with regard to stent migration. The data further suggest a potential benefit of the fully-covered stent in improving dysphagia in patients with longer life expectancy.

Background: Self-expanding metal stents (SEMSs) are the palliative treatment of choice for rapid symptomatic relief in patients with malignant dysphagia. Increasingly endoscopically guided insertion is performed as a day case and without the need for fluoroscopic guidance. This consecutive case series reports 11-year experience of endoscopically guided SEMS insertion in a large UK specialist oesophagogastric unit., Methods: Patients undergoing stent insertion for malignant dysphagia between 2003 and 2014 were identified from a prospectively maintained database. Data on patient demographics, tumour characteristics, indications, technique of insertion, complications, and need for re-intervention were abstracted and then corroborated by retrospective review of electronic case records., Results: A total of 362 patients with a median age of 76 years underwent primary SEMS insertion under endoscopic guidance. Repeat endoscopic intervention was required in 26 patients within 30 days and 59 patients within 90 days of primary insertion, giving Kaplan-Meier estimated re-intervention rates of 7.7 % and 20.3 %, respectively. Higher tumours were associated with need for repeat intervention (p = 0.014). The most frequent repeat intervention was insertion of a new stent, most commonly for stent migration or tumour overgrowth. Out of 252, 222 (88.1 %) patients referred through a rapid access pathway were stented as day cases, and the 30-day readmission rate in this cohort did not differ significantly from patients stented as inpatients (p = 0.774). Three (0.8 %) patients suffered a perforation, and there was a single procedure-related death., Conclusions: This large consecutive case series demonstrates that endoscopically guided SEMS insertion in malignant dysphagia can be performed efficiently as a day case with low complication, readmission, and re-intervention rates.

Background: Endoscopic placement of fully covered self-expanding metal stents (FCSEMS) to treat malignant dysphagia in patients with esophageal cancer significantly improves dysphagia; however, these stents have a high migration rate., Aim: To determine whether FCSEMS fixation using an endoscopic suturing device treated malignant dysphagia and prevented stent migration in patients with locally advanced esophageal cancer receiving neoadjuvant therapy when compared to patients with FCSEMS placement alone., Method: A review of patients with locally advanced esophageal cancer who underwent FCSEMS placement at 3 centers was performed. Patients were divided into two groups: Group A (n = 26) was composed of patients who underwent FCSEMS placement with suture placement, and Group B (n = 67) was composed of patients with FCSEMS placement alone., Results: There were no significant differences between Groups A and B in demographics, and tumor characteristics. The technical success rate for stent placement was 100 %. There was no difference between Groups A and B in the median stent diameter and stent lengths. Mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively, p < 0.001). Patients had a median follow-up of 4 months. Immediate adverse events were mild chest discomfort in 4 patients in Group A and 2 patients in Group B (p = 0.05), and significant acid reflux in 3 patient in Group A compared to 2 patients in Group B (p = 0.1). The stent migration rate was significantly lower in Group A compared to compared to Group B (7.7 vs 26.9 %, respectively, p = 0.004). There was a delayed perforation in 1 patient and 1 death due to aspiration pneumonia in Group B., Conclusion: Fixation of esophageal FCSEMSs by using an endoscopic suturing device in patients receiving neoadjuvant therapy was shown to be feasible, safe, and relatively effective at preventing stent migration compared to those who had stent placed alone.