Navigating reflux disease after achalasia treatments:Balancing risks and benefits

The peroral endoscopic myotomy(POEM)procedure has revolutionized the management of achalasia in many centres around the world as it offers patients a minimally invasive endoscopic solution to their dysphagia caused by achalasia.Alongside its success in alleviating dysphagia,concerns regarding postoperative gastroesophageal reflux disease have emerged as a pertinent issue which are not fully resolved.In this study,Nabi et al have comprehensively reviewed the topic of the prediction,prevention and management of gastroesophageal reflux after POEM.POEM is a purely endoscopic procedure which is usually performed without any anti-reflux procedure.Certain patients may be better served by a laparoscopic Heller’s myotomy and fundoplication and it is important that gastroenterologists and surgeons provide comprehensive risks and benefits of each achalasia treatment option so that patients can decide what treatment is best for them.This article by Nabi et al provides a comprehensive review of the current status of this issue to allow these discussions to occur.

Conduit necrosis following esophagectomy: An up-to-date literature review

Esophageal conduit ischaemia and necrosis is an uncommon but devastating complication of esophagectomy and remains one of the most challenging issues in surgical practice. The incidence, time interval to develop symptoms, and clinical presentation are highly variable with no predictable pattern. Evidence comes from case reports and case series rather than randomized controlled trials.We describe the issues surrounding conduit necrosis affecting the stomach,jejunum and colon as an esophageal replacement and the advantages,disadvantages and challenges of each type of reconstruction. Diagnosis is challenging for the most experienced surgeon. Upper gastrointestinal endoscopy and computed tomography thorax with both oral and intravenous contrast is the gold standard. Management, either conservative or interventional is also a difficult decision. Management options include conservative treatment and more aggressive treatments such as stent insertion, surgical debridement and repair of the esophagus using jejunum, colon or a musculocutaneous flap. In spite of recent advances in surgical techniques, there is no reliable strategy to manage esophageal conduit necrosis. Our review covers the pathophysiology and clinical significance of esophageal necrosis while highlighting current techniques of prevention, diagnosis and treatment of this life-threatening condition.

Vascular calcification does not predict anastomotic leak or conduit necrosis following oesophagectomy

BACKGROUND Anastomotic leaks(AL)and gastric conduit necrosis(CN)are serious complications following oesophagectomy.Some studies have suggested that vascular calcification may be associated with an increased AL rate,but this has not been validated in a United Kingdom population.AIM To investigate whether vascular calcification identified on the pre-operative computed tomography(CT)scan is predictive of AL or CN.METHODS Routine pre-operative CT scans of 414 patients who underwent oesophagectomy for malignancy with oesophagogastric anastomosis at the Queen Elizabeth Hospital Birmingham between 2006 and 2018 were retrospectively analysed.Calcification of the proximal aorta,distal aorta,coeliac trunk and branches of the coeliac trunk was scored by two reviewers.The relationship between these calcification scores and occurrence of AL and CN was then analysed.The Esophagectomy Complications Consensus Group definition of AL and CN was used.RESULTS Complication data were available in n=411 patients,of whom 16.7%developed either AL(15.8%)or CN(3.4%).Rates of AL were significantly higher in female patients,at 23.0%,compared to 13.9%in males(P=0.047).CN was significantly more common in females,(8.0%vs 2.2%,P=0.014),patients with diabetes(10.6%vs 2.5%,P=0.014),a history of smoking(10.3%vs 2.3%,P=0.008),and a higher American Society of Anaesthesiologists grade(P=0.024).Out of the 14 conduit necroses,only 4 occurred without a concomitant AL.No statistically significant association was found between calcification of any of the vessels studied and either of these outcomes.Multivariable analyses were then performed to identify whether a combination of the calcification scores could be identified that would be significantly predictive of any of the outcomes.However,the stepwise approach did not select any factors for inclusion in the final models.The analysis was repeated for composite outcomes of those patients with either AL or CN(n=69,16.7%)and for those with both AL and CN(n=10,2.4%)and again,no significant associations were detected.In the subset of patients that developed these outcomes,no significant associations were detected between calcification and the severity of the complication.CONCLUSION Calcification scoring was not significantly associated with Anastomotic Leak or CN in our study,therefore should not be used to identify patients who are high risk for these complications.