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Devices originally designed for closure of cardiac septal defects have also been proposed for the treatment of acquired tracheo-oesophageal fistula (TOF). Choosing the right occluder device to match TOF size and shape is essential for a tailored treatment. We report the successful endoscopic closure of a post-radiotherapy TOF using preprocedural CT scan with holographic three-dimensional reconstruction and an Amplatzer atrial septal device. Complete TOF sealing was achieved with resolution of respiratory symptoms, and the patient was maintaining his ability to eat at 4-month follow-up.

Summary Background The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force. Methods An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence. Results Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia. Conclusion A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.

Some experiments were performed to determine the effect on the friction coefficient of a little temperature increase caused by a small electrical resistance inserted in different ways in a ski or a ski-like device. It appears that at a low speed, this warming is able to reduce significantly the friction coefficient. The conditions of the experiments cover only reduced speed and temperature intervals. A possible interpretation of this phenomenon is based on the modification of the quasi-liquid layer existing on the surface of snow at temperatures higher than −30°C. A wider set of parameter conditions should be analyzed to confirm this interpretation.

Gastroesophageal reflux disease is diagnosed at an alarming rate after laparoscopic sleeve gastrectomy. Revisional surgery with conversion to Roux-en-Y gastric bypass does not guarantee reflux control and is associated with morbidity. There is a need to optimize the objective foregut patient pathway prior to bariatric surgery and to perform concurrent hiatal repair in individuals with a defective esophago-gastric junction and abnormal esophageal acid exposure. The role of adjunctive surgical procedures (hiatal reinforcement, fundoplication, magnetic sphincter augmentation) is still controversial due to lack of follow-up and standardized reporting, and current recommendations are based on expert opinion or case series.

Diagnosis of esophageal disorders is well ahead of available treatment options. With HRM, for example, one can identify numerous conditions and their variants, which may lose meaning if the clinical and therapeutic implications of these subclassifications are limited. We report an exemplary case of a patient with hiatal hernia complaining of reflux, dysphagia, and chest pain refractory to medical treatment. Jackhammer esophagus was diagnosed and a hybrid approach consisting of POEM and concomitant crural repair and Dor fundoplication is proposed.

The straight leg raise (SLR) maneuver during high-resolution manometry (HRM) can assess esophagogastric junction (EGJ) barrier function by measuring changes in intraesophageal pressure (IEP) when intra-abdominal pressure is increased. We aimed to determine whether increased esophageal pressure during SLR predicts pathologic esophageal acid exposure time (AET).Adult patients with persistent gastroesophageal reflux disease (GERD) symptoms undergoing HRM and pH-impedance or wireless pH study off proton pump inhibitor were prospectively studied between July 2021 and March 2022. After the HRM Chicago 4.0 protocol, patients were requested to elevate 1 leg at 45º for 5 seconds while supine. The SLR maneuver was considered effective when intra-abdominal pressure increased by 50%. IEPs were recorded 5 cm above the lower esophageal sphincter at baseline and during SLR. GERD was defined as AET greater than 6%.The SLR was effective in 295 patients (81%), 115 (39%) of whom had an AET greater than 6%. Hiatal hernia (EGJ type 2 or 3) was seen in 135 (46%) patients. Compared with patients with an AET less than 6%, peak IEP during SLR was significantly higher in the GERD group (29.7 vs 13.9 mm Hg; P.001). Using receiver operating characteristic analysis, an increase of 11 mm Hg of peak IEP from baseline during SLR was the optimal cut-off value to predict an AET greater than 6% (area under the receiver operating characteristic curve, 0.84; sensitivity, 79%; and specificity, 85%), regardless of the presence of hiatal hernia. On multivariable analysis, an IEP pressure increase during the SLR maneuver, EGJ contractile integral, EGJ subtype 2, and EGJ subtype 3, were found to be significant predictors of AET greater than 6% CONCLUSIONS: The SLR maneuver can predict abnormal an AET, thereby increasing the diagnostic value of HRM when GERD is suspected.gov ID: NCT04813029.

With the advent of high-resolution esophageal manometry, it is recognized that the antireflux barrier receives a contribution from both the lower esophageal sphincter (intrinsic sphincter) and the muscle of the crural diaphragm (extrinsic sphincter). Further, an increased intra-abdominal pressure is a major force responsible for an adaptive response of a competent sphincter or the disruption of the esophagogastric junction resulting in gastroesophageal reflux, especially in the presence of a hiatal hernia. This review describes how the pressure dynamics in the lower esophageal sphincter were discovered and measured over time and how this has influenced the development of antireflux surgery.

OBJECTIVE Normative values for high-resolution manometry (HRM) have been obtained with the patient lying supine. The aim of the study was to compare supine, semirecumbent and sitting positions during HRM in terms of variation in normative metrics, diagnostic yield, and patient's comfort. METHODS A prospective, single-center feasibility study was planned in consecutive patients referred to the esophageal function laboratory. In each of the three positions, 10 consecutive 5 ml water swallows and three 10 ml multiple rapid swallows were administered. Validated reflux questionnaires were administered prior to the test, and a visual analogue scale (VAS) assessing the patient's comfort after the test. RESULTS Twenty patients presenting with gastroesophageal reflux symptoms completed the study protocol. The intra-abdominal segment of the lower esophageal sphincter was significantly longer in the sitting position (P = 0.013), and the multiple rapid swallow distal contractile integral was lowest in the supine position (P = 0.012). The VAS comfort score did not significantly differ in the three body positions (P = 0.295). The concordance in the final diagnosis was 80% for semirecumbent vs. sitting (kappa = 0.15; P = 0.001), 70% for supine vs. sitting and 65.0% for semirecumbent vs. supine. CONCLUSION Compared to the supine position, both the semirecumbent and sitting position seems to provide similar advantages. HRM metrics and the final manometric diagnosis may be affected by body position, but complementary maneuvers, such are the rapid drink challenge, can resolve diagnostic discrepancies and improve the overall accuracy of the test.

Background Esophageal lipomatous tumors, also reported as fibrovascular polyp, fibrolipoma, angiolipoma, and liposarcoma, account for less than 1% of all benign mesenchymal submucosal tumors of the esophagus. Clinical presentation and therapy may differ based on location, size, and morphology. A comprehensive and updated systematic review of the literature is lacking. Methods A systematic review of the literature was performed according to PRISMA guidelines. Pubmed, Embase, Cochrane, and Medline databases were consulted using MESH keywords. Non-English written articles and abstracts were excluded. Sex, age, symptoms at presentation, diagnosis, tumor location and size, surgical approach and technique of excision, pathology, and morphology were extracted and recorded in an electronic database. Results Sixty-seven studies for a total of 239 patients with esophageal lipoma or liposarcoma were included in the qualitative analysis. Among 176 patients with benign lipoma, the median age was 55. The main symptoms were dysphagia (64.2%), transoral polyp regurgitation (32.4%), and globus sensation (22.7%). The majority of lipomas (85.7%) were intraluminal polyps, with a stalk originating from the upper esophagus. Overall, 165 patients underwent excision of the mass through open surgery (65.5%), endoscopy (27.9%), or laparoscopy/thoracoscopy (3.6%). Only 5 (3%) of patients required esophagectomy. Of the 11 untreated patients with an intraluminal polyp, 7 died from asphyxia. Overall, liposarcoma was diagnosed in 63 patients, and 12 (19%) underwent esophagectomy. Conclusion Esophageal lipomatous tumors are rare but potentially lethal when are intraluminal and originate from the cervical esophagus. Modern radiological imaging has improved diagnostic accuracy. Minimally invasive transoral and laparoscopic/thoracoscopic techniques represent the therapeutic approach of choice.

Despite the evolution of the endoscopic techniques for the treatment of symptomatic Zenker diverticulum, comparative studies are lacking. Aim of this observational study was to compare safety, efficacy, and outcomes of endoscopic stapling (ES) versus Laser (EL). A prospectively collected database of patients who underwent treatment for Zenker diverticulum at a single institution was reviewed. Consecutive patients treated by ES or EL were included in the study. Demographic data, presenting symptoms, diverticulum characteristics, and intra- and postoperative data were analyzed. The Functional Outcome Swallowing Scale (FOSS) and MD Anderson Dysphagia Inventory (MDADI) questionnaires were administered to assess severity of dysphagia and quality of life before and after treatment. Between March 2017 and September 2018, 36 patients underwent ES or EL. In the TL group (n = 19), the diverticulum size was smaller compared to the EL group (n = 17) (p = 0.002). Two perforations occurred in the EL group, one treated conservatively and the other requiring drainage of a mediastinal abscess. At a median follow-up of 16 months, symptoms improved in both groups but the number of patients with a postoperative FOSS score ≥ 2 significantly decreased only after EL (p

The magnetic sphincter augmentation (MSA) device has been proven safe and effective in controlling typical reflux symptoms and esophageal acid exposure for up to 6-year follow-up. Longer term outcomes have not been reported yet. A prospectively maintained database was reviewed to assess long-term safety and efficacy of the laparoscopic MSA procedure at a single referral center. Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), use of proton-pump inhibitors (PPI), and esophageal acid exposure were compared to baseline. Favorable outcomes were defined as ≥ 50% improvement of GERD-HRQL total score and PPI discontinuation. Between March 2007 and March 2020, 335 patients met the study inclusion criteria, and 124 of them were followed from 6 to 12 years after surgery (median 9 years, IQR 2). Mean total GERD-HRQL score significantly improved from 19.9 to 4.01 (p p 15 (OR 4.09). We confirm long-term safety and efficacy of MSA in terms of symptom improvement, decreased drug dependency, and reduced esophageal acid exposure.

Background/Aims According to the Chicago classification version 3.0, high-resolution manometry (HRM) should be performed in the supine position. However, with the patient in the upright/sitting position, the test could more closely simulate real-life behavior and may be better tolerated. We performed a systematic review of the literature to search whether the manometric variables and the final diagnosis are affected by positional changes. Methods A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies published in English that compared HRM results in different body positions were included. Moreover, the change in diagnosis of esophageal motility disorders according to the shift of body position was investigated. Results Seventeen studies including 1714 patients and healthy volunteers met the inclusion criteria. Six studies showed a significant increase in lower esophageal sphincter basal pressure in the supine position. Integrated relaxation pressure was significantly higher in the supine position in 10 of 13 studies. Distal contractile index was higher in the supine position in 9 out of 10 studies. One hundred and fifty-one patients (16.4%) out of 922 with normal HRM in the supine position were diagnosed with ineffective esophageal motility (IEM) when the test was performed in the upright position (P < 0.001). Conclusions Performing HRM in the upright position affects some variables and may change the final manometric diagnosis. Further studies to determine the normal values in the sitting position are needed. (J Neurogastroenterol Motil 2020;26:335-343)

Heartburn, regurgitation, pulmonary aspiration, and remnant esophagitis represent common sequelae of esophagectomy and gastric conduit reconstruction. Proton pump inhibitors are the mainstay of treatment. The aim of the study was to focus on the efficacy of combination therapy with mucosal surface protection. Patients undergoing esophagectomy were followed up to 1 year. Patients in group A received 60 mg/day lansoprazole and those in group B received combination therapy. During follow-up, the dosage of lansoprazole was reduced to 30 mg/day in asymptomatic patients with or without grade A–B esophagitis. The Gastro-Esophageal Reflux Disease – Health-Related Quality of Life (GERD-HRQL) and the Short-Form 36 (SF-36) were used to assess postoperative quality of life, and the foregut symptom questionnaire to assess the prevalence of regurgitation, respiratory symptoms, and sleep disorders. Between August 2017 and August 2018, 56 patients were enrolled in the study. Over follow-up, the incidence of refractory symptoms and/or esophagitis grade C–D was 35.7% in group A and 21.4% in group B (p = 0.024). At 1 year, 18 (64.2%) patients in group A and 22 (78.5%) in group B remained symptom free and without severe esophagitis under treatment with 30 mg of lansoprazole (p = 0.076). The GERD-HRQL score was similar at 3 and 6 months (p = 0.790 and p = 0.812, respectively); at 12 months, patients in group B had a lower score although the difference was not significant (p = 0.216). There were no statistically significant differences in terms of SF-36 scores at 1‑year follow-up. Concerning the foregut symptom questionnaire, group B experienced less respiratory symptoms (p = 0.045) and sleep disorders (p = 0.039). At 1‑year after esophagectomy, combination therapy with 30 mg lansoprazole and Esoxx® appears to be an effective antireflux strategy.

The contact angle is one of the most sensitive experimental values describing a junction between three phases, being influenced by the composition and properties of contacting media as well as the structure and composition of interfaces involved. The origins and importance of the contact angle in analysis of three-phase systems date back to the famous works on cohesion and adhesion of fluids published by Thomas Young in 1805 and later by Athanase Dupré in 1869. Since then, the contact angle has remained one of the most important values measured experimentally during characterization of solids and their wetting characteristics. Such measurements, however, involve solid surfaces that deviate from the idealized ones used in thermodynamic and mechanical modeling of three-phase junctions by Young, Dupré and others, and there is typically more than one value of contact angle measured on such surfaces. As a result, the attention of scientists and researchers in the past two centuries has been on development of methods for accurate contact angle measurements, interpretation of experimental values and understanding of the causes of contact angle value variation and contact angle hysteresis. This paper reviews advancements made in interpretation of experimental contact angles and their use in characterization of solid surfaces.

Introduction: Outcomes of laparoscopic procedures for gastroesophageal reflux disease (GERD) are variable depending on surgical expertise and/or patient-related factors. Some procedures may be inadequate in patients with severe disease. Effectiveness of laparoscopic magnetic sphincter augmentation (MSA) has not been extensively tested in patients with severe disease.Methods: A prospectively collected database was analyzed to identify patients who underwent MSA at a single institution. Individuals who had previous esophago-gastric surgery were excluded. Severe GERD was defined as lower esophageal sphincter pressure 50. Clinical characteristics and outcomes of patients with severe GERD were compared with those of patients with mild to moderate GERD who served as control group.Results: Over the study period, a total of 336 patients met the inclusion criteria, and 102 (30.4%) had severe GERD. The median follow-up was 24 months (IQR = 75) in severe GERD patients and 32 months (IQR = 84) in those with non-severe GERD. Patients with severe GERD had a higher rate of dysphagia and higher GERD-HRQL scores. After the MSA procedure, symptoms, health-related quality of life scores, and proton-pump inhibitors consumption significantly decreased in both groups (p < 0.05). No difference between groups was found in the prevalence of severe post-operative dysphagia, the need for endoscopic dilation or device removal, and the DeMeester score.Conclusion: Laparoscopic MSA is safe and effective in reducing symptoms, PPI use, and esophageal acid exposure also in patients with severe GERD.

Summary Background Acute strangulated ventral hernia is associated with operative morbidity and mortality. General anesthesia may increase the operative risk, especially in morbidly obese and COVID-19-positive individuals. Methods A 67-year-old woman with body mass index (BMI) 51 kg/m2, hospitalized for SARS-CoV-2-related interstitial pneumonia and renal failure, presented with acute abdominal pain, nausea, vomiting, and abdominal tenderness secondary to giant ventral hernia strangulation. Results Due to the suspicion of vascular bowel compromise at contrast-enhanced CT scan, urgent open surgical repair surgery was performed under spinal anesthesia and Venturi mask support. There was no need for an intensive care unit (ICU) stay. Postoperative course was uneventful, and the patient was transferred to a rehabilitation center on postoperative day 10. Conclusion Although some anesthetists and surgeons may be reluctant to use regional anesthesia for both emergent and elective ventral hernia repair, this may represent an excellent option in obese patients with a high respiratory risk.

Purpose Symptom recurrence after initial surgical management of esophageal achalasia occurs in 10–25% of patients. The aim of this study was to analyze safety and efficacy of revisional therapy after failed Heller myotomy (HM). Methods A retrospective review of a prospective database was performed searching for patients with recurrent symptoms after primary surgical therapy for achalasia. Patients with previously failed HM were considered for the final analysis. The Foregut questionnaire, and the Atkinson and Eckardt scales were used to assess severity of symptoms. Objective investigations routinely included upper gastrointestinal endoscopy and barium swallow study. Redo treatments consisted of endoscopic pneumatic dilation (PD), laparoscopic HM, hybrid Ivor Lewis esophagectomy, or stapled cardioplasty. A yearly clinical and endoscopic follow-up was scheduled in all patients. Results Over a 20-year period, 26 patients with a median age of 66 years (IQR 19.5) underwent revisional therapy after failed HM for achalasia at a tertiary-care university hospital. The median time after index procedure was 10 years (IQR 21). Revisional therapy consisted of endoscopic pneumatic dilation (n=13), laparoscopic HM and fundoplication (n=10), esophagectomy (n=2), and stapled cardioplasty and fundoplication (n=1). Nine (34.6%) of these patients required further endoscopic or surgical treatments. There was no mortality, and the overall complication rate was 7.7%. At a median follow-up of 42 months (range 10–149), a significant decrease of dysphagia, regurgitation, chest pain, respiratory symptoms, and median Eckardt score (p Conclusion In specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.

Minimally invasive enucleation is the treatment of choice in symptomatic patients with esophageal leiomyoma. Comprehensive long-term follow-up data are lacking. Aim of this study was to review the clinical outcomes of three procedures for enucleation of leiomyoma of the esophagus and esophagogastric junction. A single institution retrospective review was performed using a prospectively collected research database and individual medical records. Demographics, presenting symptoms, use of proton-pump inhibitors (PPI), tumor location and size, treatment modalities, and subjective and objective clinical outcomes were recorded. Barium swallow and upper gastrointestinal endoscopy were routinely performed during the follow-up. Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and Short-Form 36 questionnaires were used to compare quality of life before and after treatment. Between 2002 and 2017, 35 patients underwent minimally invasive leiomyoma enucleation through thoracoscopy (n = 15), laparoscopy (n = 15), and endoscopy (n = 5). The overall morbidity rate was 14.3% and there was no mortality. All patients had a minimum of 1-year follow-up. The median follow-up was 49 (IQR 54) months, and there were no recurrences of leiomyoma. At the latest follow-up, the SF-36 scores were unchanged compared to baseline. However, there was a higher incidence of reflux symptoms (p

The role of splenectomy in proximal gastric cancer is still debated. The objective of the present meta-analysis was to provide more-robust evidence about the effect of spleen-preserving total gastrectomy on postoperative infectious complications, overall morbidity, and 5-year overall survival (os). PubMed, embase, and the Web of Science were consulted. Pooled effect measures were calculated using an inverse-variance weighted or Mantel&ndash, Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I2 index and Cochran Q-test. Three randomized controlled trials published between 2000 and 2018 were included. Overall, 451 patients (50.1%) underwent open total gastrectomy with spleen preservation and 448 (49.9%) underwent open total gastrectomy with splenectomy. The patients ranged in age from 24 to 78 years. No differences were found in the number of harvested lymph nodes (p = 0.317), the reoperation rate (p = 0.871), or hospital length of stay (p = 0.347). The estimated pooled risk ratios for infectious complications, overall morbidity, and mortality were 1.53 [95% confidence interval (ci): 1.09 to 2.14, p = 0.016], 1.51 (95% ci: 1.11 to 2.05, p = 0.008), and 1.23 (95% ci: 0.40 to 3.71, p = 0.719) respectively. The estimated pooled hazard ratio for 5-year os was 1.06 (95% ci: 0.78 to 1.45, p = 0.707). Spleen-preserving total gastrectomy should be considered in patients with curable gastric cancer because it is significantly associated with decreased postoperative infectious complications and overall morbidity, with no difference in the 5-year os. Those observations appear worthwhile for establishing better evidence-based treatment for gastric cancer.

Background Magnetic sphincter augmentation (MSA) is an innovative antireflux procedure that can improve lower esophageal sphincter (LES) competency and reduce symptoms of gastroesophageal reflux disease (GERD). Some patients report postoperative dysphagia. To date, no studies have described reference high‐resolution manometry (HRM) values after MSA implantation. Methods High‐resolution manometry was performed in patients free of dysphagia after MSA with or without concurrent crura repair. Reference values for all parameters of the Chicago Classification were defined as those between the 5th and 95th percentiles. The contribution of concurrent crura repair to LES competency and to reference values was also analyzed. Key Results Eighty‐four patients met the study inclusion criteria. The upper limit of normality for integrated relaxation pressure (IRP) and intrabolus pressure (IBP) was 20.2 mmHg and 30.3 mmHg, respectively. Both variables were higher after MSA compared to normative Chicago Classification v3.0 values. The Distal Contractile Integral upper limit was in the range of normality. Patients undergoing crura repair had a significantly higher IRP (p = 0.0378) and lower GERDQ‐A scores (p = 0.0374) and Reflux Symptom Index (p = 0.0030) compared to those who underwent MSA device implantation alone. Conclusion & Inferences This study provides HRM reference values for patients undergoing successful MSA implantation. Crural repair appears to be a key component of LES augmentation and is associated with improved clinical outcomes., Upper limit of normality for IRP and intrabolus pressure was higher after magnetic sphincter augmentation compared to normative Chicago v3.0 values. Patients in whom crura repair was part of the surgical procedure had a significantly higher IRP and better control of reflux symptoms.

Significant technical changes and a shift toward a transoral approach have occurred in the management of Zenker’s diverticulum over the past three decades. Transoral stapling is already an established and commonly performed procedure. Zenker peroral endoscopic myotomy (Z-POEM) and Zenker peroral endoscopy septotomy (Z-POES) are innovative techniques that are rapidly spreading and replacing more traditional therapeutic options. This review provides an overview of the current status of minimally invasive transoral management to assess whether a tailored approach is feasible and safe and may improve quality of life and reduce recurrence rates.

Esophageal lipoma is a rare neoplasm with heterogeneous and sometimes life-threatening clinical presentation. We report the case of two patients, a 77-year-old man and a 69-year-old woman presenting with heartburn and dysphagia, and with recurrent vomiting and asphyxia, respectively. Upper gastrointestinal endoscopy and computed tomography were highly suggestive of the diagnosis of esophageal lipoma and identified an intramural and an intraluminal pedunculated mass originating, respectively, from the distal and the cervical esophagus. The first patient was treated by laparoscopic transhiatal enucleation and the second by transoral endoscopic resection under general anesthesia. Both had an uneventful postoperative course and were discharged home on postoperative day 2. Minimally invasive excision of esophageal lipoma is feasible and effective. It may be life-saving in patients with pedunculated tumors who suffer from intermittent regurgitation of a bulky polypoid mass in the mouth causing asphyxia.

Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction.The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected.Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P0.011). Surgical therapy was required in 4 patients (6.1%).Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.

The presence of a capping agent (CTAB) on Pd nanoparticles produces a strong static disorder in the surface region. This results in a surface softening, which contributes to an overall increase in the Debye–Waller coefficient measured by X-ray powder diffraction. Molecular dynamics and density functional theory simulations show that the adsorption-induced surface disorder is strong enough to overcome the effects of nanoparticle size and shape.

Models of perceived affective quality of soundscapes have been recently included into standards to guide the measurement and improvement of urban soundscapes. Such models have been developed in outdoor contexts and their validity in indoor built environments is unclear. A laboratory listening test was performed in a mock-up living room with a window sight, in order to develop an indoor soundscape model for residential buildings. During the test, 35 participants were asked to rate 20 different scenarios each. Scenarios were defined by combining four indoor sound sources and five urban environments, filtered through a window ajar, on 97 attribute scales. By applying principal component analysis, Comfort, Content, and Familiarity, were extracted as the main perceptual dimensions explaining respectively 58%, 25% and 7% of the total variance. Relationships between the principal component scores, acoustic parameters and indoor and outdoor sound categories were investigated. Comfort, Content, and Familiarity were found to be better predicted respectively by loudness N10, level variability LA10-LA90 and sharpness S. The magnitude of linear-mixed-effect model predictions sensibly improved by accounting for sound categories, thus pointing at the importance of semantic meaning of sounds in indoor soundscape assessment. A measurement system is proposed, based on a 2-D space defined by two orthogonal axes, Comfort and Content, and two additional axes, Engagement and Privacy – Control, rotated 45° on the same plane. The model indicates the perceptual constructs to be measured (e.g. in post-occupancy evaluations), the attribute scales to be employed and actions to improve indoor soundscape quality, thus providing a reference for both research and practice.

Background Transthyretin (TTR) has been described as a predictor for outcomes in medical and surgical patients. However, the association of TTR on admission and over time on outcomes has not yet been prospectively assessed in trauma patients. Methods This is a prospective observational study including trauma patients admitted to the intensive care unit (ICU) of a large Level I trauma center 05/2014–05/2015. TTR levels at ICU admission and all subsequent values over time were recorded. Patients were observed for 28 days or until hospital discharge. The association of outcomes and TTR levels at admission and over time was assessed using multivariable regression and generalized estimating equation (GEE) analysis, respectively. Results A total of 237 patients with TTR obtained at admission were included, 69 of whom had repeated TTR measurements. Median age was 40.0 years and median ISS 16.0; 83.1% were male. Below-normal TTR levels at admission (41.8%) were independently associated with higher in-hospital mortality (p = 0.042), more infectious complications (p = 0.032), longer total hospital length of stay (LOS) (p = 0.013), and ICU LOS (p = 0.041). Higher TTR levels over time were independently associated with lower in-hospital mortality (p = 0.015), fewer infections complications (p = 0.028), shorter total hospital and ICU LOS (both p

Aim The aim of this study was to evaluate esophageal motility before and after Magnetic Sphincter Augmentation (MSA) for medically refractory Gastro-Esophageal Reflux Disease (GERD). Background and Methods MSA (LINX® Reflux Management System) is intended for patients with chronic GERD with incomplete symptom relief from proton-pump inhibitors (PPI) and abnormal acid exposure. A prospectively collected database of patients who underwent MSA between 2007 and 2019 was queried. All patients who completed pre- and post-operative high-resolution manometry (HRM) were included in the study. Additional investigations included Health-Related Quality of Life (GERD-HRQL) questionnaire, Functional Outcome Swallowing Scale (FOSS), upper gastrointestinal endoscopy, barium swallow, and 24-96 hours pH-study. Data were analyzed using Wilcoxon signed rank test and McNemar test. Results Forty-five patients met the inclusion criteria. The median follow-up was 10 months (IQR 6). Compared to baseline, there was a statistically significant reduction in PPI use (p=0.000), rate of heartburn (p=0.000), regurgitation (p=0.008), and extra-esophageal symptoms (p=0.000). Only three (6.7%) patients required dietary changes. The GERD-HRQL score significantly improved (p=0.000). There was a significant increase in the Lower Esophageal Sphincter (LES) competency, including LES length (p=0.004) and Esophago-gastric Contractile Integral ((EGJ-CI) (p=0.000). A significant increase in integrated relaxation pressure (IRP) (p=0.000), mean Distal Contractile Integral (DCI) (p=0.008) and intrabolus pressure (p=0.000) was also found. Thirteen (28.9%) patients presented pre-operative Ineffective Esophageal Motility (IEM) and five of them resolved postoperatively. Two patients (4.4%) developed IEM after surgery: both had IRP and DCI values within normal limits, and one of them complained of dysphagia. However, the GERD-HRQL score recovered in both patients. Conclusion MSA was clinically effective in relieving both typical and atypical GERD symptoms. LES competency increased after MSA. EGJ outflow obstruction was uncommon and not associated with symptoms. Finally, ineffective esophageal motility may reverse to normal after MSA.

BACKGROUND Magnetic sphincter augmentation with the Linx® system is a novel laparoscopic procedure for the treatment of gastro-esophageal reflux disease (GERD). Only few data are available regarding the impact of Linx on high-resolution manometry (HRM) variables. METHODS The prospectively collected database of patients who underwent Linx procedure at a single institution was queried. All patients who completed pre- and postoperative HRM, GERD health-related quality of life (GERD-HRQL) questionnaire, and functional outcome swallowing scale (FOSS) questionnaire were included in the study. KEY RESULTS Forty-five out of 304 patients were included. At a median follow-up of 12 months (IQR 10) after surgery, a statistically significant increase of lower esophageal sphincter (LES) total length (P = .002), intra-abdominal length (P = .001), integrated relaxation pressure (IRP), intrabolus pressure (IBP), and esophagogastric contractile integral (EGJ-CI) was noted (P

Background Persistent or de novo gastroesophageal reflux disease (GERD) may be a significant clinical issue after gastric/bariatric surgical procedures. We investigated the effect of magnetic sphincter augmentation (MSA) in the treatment of GERD after previous gastric/bariatric surgery. Database We conducted a systematic review according to the Preferred Reporting Items For Systematic Reviews and Meta-analyses statement. We searched multiple databases (PubMed, Cochrane, Embase, Scopus) up to May 2019. We also queried the prospectively collected database of patients who underwent MSA at our tertiary-care hospital and compared postsurgical to naive patients operated during the same time period. Results Seven studies (3 case series and 4 case reports), for a total of 35 patients, met the inclusion criteria in the systematic review. The most common index operation was a bariatric procedure, either sleeve gastrectomy or Roux-en-Y gastric bypass. After MSA implant, the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) score significantly improved compared to baseline (P = .005). Two patients (5.7%) required laparoscopic device removal. In the local institutional cohort series of 67 patients treated by MSA, the prevalence of preoperative grade B esophagitis, operative time, size of MSA, and length of stay were greater in patients with prior gastric surgery compared to naive patients. Conclusions MSA is a safe, simple, and standardized antireflux procedure. It is also feasible in patients with refractory GERD following gastric/bariatric surgery. Further prospective and comparative studies are needed to validate the preliminary clinical experience in this subset of patients.

Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy,” and “esophageal resection.” Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.

Mechanical obstruction secondary to colonic impact of a gallstone resulting from a direct cholecystocolonic fistula is a rare event. Although spontaneous resolution has been described, surgical or endoscopic procedures may be required to relieve the obstruction. The overall complication rate related to surgical treatment is relevant because of the acute presentation in elderly patients with multiple comorbidities and high operative risk. An extensive literature search over the last two decades (1997–2017) was conducted. MEDLINE, Embase, and Cochrane databases were consulted. All the articles, case reports, and case series that described the management of colonic gallstone obstruction were included in this narrative review. In all, 41 cases of colonic gallstone ileus were included. The majority of the patients were successfully managed with an open (78%), endoscopic (14.6%), or laparoscopic approach (4.9%). Spontaneous resolution of the mechanical obstruction was described in one case (2.5%). The overall morbidity and mortality rates of the surgical-related procedures were 31% and 9.4%, respectively. In the endoscopic groups, there was no procedure-related morbidity and mortality. An endoscopic approach may be a better therapeutic option in selected patients with colonic gallstone obstruction unfit for surgery.

Open esophagectomy is a high-risk procedure in patients with liver cirrhosis. With the advent of minimally invasive surgical techniques, the overall morbidity and mortality rates of esophagectomy have decreased. The aim of this study was to describe short-term outcomes of minimally invasive esophagectomy in patients with proven liver cirrhosis.Retrospective observational cohort study. Demographics, preoperative clinical characteristics, and outcomes of patients undergoing minimally invasive esophagectomy for carcinoma were analyzed. Patients with concomitant liver cirrhosis were compared to patients without liver cirrhosis undergoing similar surgical procedures. In addition, variables possibly associated with postoperative morbidity and mortality in patients with cirrhosis were investigated.Out of 443 patients undergoing minimally invasive esophagectomy, 18 (4.1%) had concomitant liver cirrhosis. Demographics and preoperative clinical variables were similar in the 2 patient groups. While the overall morbidity rate was similar, the 90-day mortality rate was significantly higher in patients with liver cirrhosis (P = .023). There was a significantly higher rate of sepsis and anastomotic, respiratory, and hemorrhagic complications in patients with liver cirrhosis who died in the postoperative period.Minimally invasive esophagectomy is feasible in patients with liver cirrhosis. Future strategies should focus on total minimally invasive procedures and early recognition of surgical complications.

Much interest has recently been focused on contact angles, wetting and non-wettable surfaces as is evidenced by the rapid pace and sheer number of papers published in recent years. However, in many cases there exist misconceptions and misuses of terminology, leading to misinterpretation of experimental contact angles, measurements of which deceptively appear to be simple. Terms describing contact angles, wettability, superhydrophobicity and similar other terminology are loosely used. In this contribution, key terms used in relation to contact angles are defined precisely based on the accumulative knowledge from the surface chemistry community over the last decades. The definitions provided are scientifically rigorous to avoid any ambiguity and confusion. The theoretical considerations underlying these definitions are only briefly mentioned, with references to the relevant papers. Interpretation and meaning of the measured contact angles can be made simpler if the basic concepts are clearly understood and theory-based indications are applied. The clarity of definitions should make data interpretation and comparison easier for future contributions to journals, including this journal.

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

An intriguing simple toy, commonly known as the Notched Stick, is discussed as an example of a “vibrot”, a device designed and built to yield conversion of mechanical vibrations into a rotational motion. The toy, that can be briefly described as a propeller fixed on a stick by means of a nail and free to rotate around it, is investigated from both an experimental and a numerical point of view, under various conditions and settings, to investigate the basic working principles of the device. The conversion efficiency from vibration to rotational motion turns out to be very small, or even not detectable at all, whenever the propeller is tightly connected to the stick nail and perfectly axisymmetrical with respect to the nail axis; the small effects possibly observed can be ascribed to friction forces. In contrast, the device succeeds in converting vibrations into rotations when the propeller center of mass is not aligned with the nail axis, a condition occurring when either the nail-propeller coupling is not tight or the propeller is not completely axisymmetrical relative to the nail axis. The propeller rotation may be induced by a process of parametric resonance for purely vertical oscillations of the nail, by ordinary resonance if the nail only oscillates horizontally or, finally, by a combination of both processes when nail oscillations take place in an intermediate direction. Parametric resonance explains the onset of rotations also when the weight of the propeller is negligible. In contrast with what is commonly claimed in the literature, the possible elliptical motion of the nail, due to a composition of two harmonic motions of the same frequency imposed along orthogonal directions, seems unnecessary to determine the propeller rotation.

Metastasis to the esophagus is a rare event that can occur by direct infiltration of malignancies from nearby organs or, more infrequently, via lymphatic or hematogenous spread. We reviewed the hospital charts of a patient presenting with dysphagia in whom a distant metastasis to the esophagus from a primary lung adenocarcinoma was documented. A review of the pertinent literature was performed. A 74 year-old man with previous history of lung cancer and transoral septum stapling for Zenker’s diverticulum presented with subtotal dysphagia and chest pain. On upper gastrointestinal endoscopy, a vegetating mass of the middle esophagus, covered by fragile and bleeding mucosa, was found. Esophageal biopsies demonstrated metastasis from a poorly differentiated lung adenocarcinoma with evidence of thyroid transcription factor (TTF) positive neoplastic cells. A computed tomography scan revealed a radiopaque mass in the upper right lung. Combination chemotherapy was initiated and a partially covered stent was placed endoscopically. A distant metastatic tumor to the esophagus with mucosal infiltration is an exceptional event. In our patient, immunohistochemistry was useful to confirm the diagnosis of primary lung carcinoma.

The EROI is one of the most important indices to evaluate the net energy output of a source of primary energy (there is a lively debate on the usability of this kind of parameter, but here we will use it under the hypothesis that it is a good way to establish if an oil company has a level of efficiency close to other energetic sources). It is generally defined as the ratio between the energy extracted by a given resource and the energy costs sustained to extract that energy. We tried to set up an alternative method for the calculation of the EROI, taking (1) as a proxy of the energy costs the available data about the CO2 emissions of the oil companies, as reported in the sustainability reports (SRs), recommended by the international organisms such as IPCC and WBCSD, although not mandatory, and (2) as a proxy of the energy extracted the CO2 emissions estimate obtained by a stoichiometric conversion of the oil/gas production declared by the oil companies. Both proxies have been also corrected to take into account the different CO2 emission rate per unit energy of oil and gas. The resulting estimates of EROI are rather homogeneous and not too different from the values reported in the literature. The method could be suitable for year-by-year comparison of the time evolution of this important energy quality parameter for the individual energy-producing and energy-delivering companies.

Prehospital endotracheal intubation (ETI) for traumatic brain injury (TBI) is a controversial issue. The aim of this study was to investigate the effect of prehospital ETI in patients with TBI. Cohort-matched study using the US National Trauma Data Bank (NTDB) 2008–2012. Patients with isolated severe blunt TBI (AIS head ≥3, AIS chest/abdomen