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Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.

Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.

Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms. We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation. Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. Thirteen (ten females) patients (mean age 45.2 ± 5.1 years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p

Several surgical options exist for refractory gastroparesis (Gp) including gastric electric stimulation (GES) and pyloric surgery (PS) such as pyloromyotomy or pyloroplasty. Few studies exist comparing the outcomes of these surgeries. Compare the clinical outcomes of GES, PS, and simultaneous GES+PS for refractory Gp. Patients undergoing surgical intervention at our medical center from January 2016 to April 2019 were given pre- and post-surgery questionnaires to assess their response to intervention: Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM) grading symptoms and Clinical Patient Grading Assessment Scale (CPGAS) grading response to treatment. Results are expressed as mean ± SE. One hundred thirty-two patients underwent surgical intervention; 12 were excluded. Mean CPGAS improvement overall was 2.8 ± 0.2 (p 0.05). Mean improvement in Gastroparesis Cardinal Symptom Index (GCSI) total score was 1.0 ± 0.1 (p 0.05). GES and GES + PS, but not PS only, significantly improved symptoms of nausea and vomiting (p

Gastroesophageal reflux disease (GERD) is quite prevalent worldwide, especially in the western hemisphere. The pathophysiology of GERD is complex, involving an incompetent esophagogastric junction (EGJ) as an anti-reflux barrier, as well as other co-morbid conditions such as gastroparesis, hiatal herniation or hyper acid secretion. Esophageal dysmotility is also frequently encountered in GERD, further contributing to the disease in the form of fragmented peristalsis, ineffective esophageal motility (IEM) or the more severe aperistalsis. The latter is quite common in systemic connective tissue disorders such as scleroderma. The main stay treatment of GERD is pharmacologic with proton pump inhibitors (PPI), with surgical fundoplication offered to patients who are not responsive to medications or would like to discontinue them for medical or other reasons. The presence of esophageal dysmotility that can worsen or create dysphagia can potentially influence the choice of fundoplication (partial or complete), or whether it is even possible. Most of the existing literature demonstrates that fundoplication may be safe in the setting of ineffective or weak peristalsis, and that post-operative dysphagia cannot be reliably predicted by pre-operative manometry parameters. In cases of complete aperistalsis (scleroderma-like esophagus), partial fundoplication can be offered in select patients who exhibit prominent reflux symptoms after a comprehensive multidisciplinary evaluation. Roux-en-Y gastric bypass is an alternative to fundoplication in patients with this extreme form of esophageal dysmotility, after careful consideration of the nutritional status.

The prevalence of insulinomas is 13 cases per million population per year of which 414% tumor is malignant. Weight gain is one of the symptoms of the disease, often resulting in morbid obesity with indications for surgical treatment. The presented clinical case demonstrates the successful treatment of malignant insulinoma with the manifestation of hypoglycemic syndrome after carrying out biliopancreatic bypass with longitudinal gastrectomy for morbid obesity.

The incidence of gastroesophageal reflux disease (GERD) remains on the rise. Pathophysiology of GERD is multifactorial, revolving around an incompetent esophagogastric junction as an antireflux barrier, with other comorbid conditions contributing to the disease. Proton pump inhibitors remain the most common treatment of GERD. Endoscopic therapy has gained popularity as a less invasive option. The presence of esophageal dysmotility complicates the choice of surgical fundoplication. Most literature demonstrates that fundoplication is safe in the setting of ineffective or weak peristalsis and that postoperative dysphagia cannot be predicted by preoperative manometry parameters. More data are needed on the merits of endoluminal approaches to GERD.

SUMMARYThe optimal treatment of esophageal cancer in octogenarians is controversial. While the safety of esophagectomy has been demonstrated in elderly patients, surgery and multimodality therapy are still offered to a select group. Additionally, the long-term outcomes in octogenarians have not been thoroughly compared to those in younger patients. We sought to compare the outcomes of esophageal cancer treatment between octogenarians and non-octogenarians in the National Cancer Database (2004–2014). The major endpoints were early postoperative mortality and long-term survival. A total of 107,921 patients were identified [octogenarian—16,388 (15.2%)]. Compared to non-octogenarians, octogenarians were more likely to be female, of higher socioeconomic status, and had more Charlson comorbidities (p < 0.001 for all). Octogenarians were significantly less likely to undergo esophagectomy (11.5% vs. 33.3%; p < 0.001) and multimodality therapy (2.0% vs. 18.5%; p < 0.001), a trend that persisted following stratification by tumor stage and Charlson comorbidities. Both 30-day and 90-day mortality were higher in the octogenarian group, even after multivariable adjustment (p ≤ 0.001 for both). Octogenarians who underwent multimodality therapy had worse long-term survival when compared to younger patients, except for those with stage III tumors and no comorbidities (HR: 1.29; p = 0.153). Within the octogenarian group, postoperative mortality was lower in academic centers, and the long-term survival was similar between multimodality treatment and surgery alone (HR: 0.96; p = 0.62). In conclusion, octogenarians are less likely to be offered treatment irrespective of tumor stage or comorbidities. Although octogenarians have higher early mortality and poorer overall survival compared to younger patients, outcomes may be improved when treatment is performed at academic centers. Multimodality treatment did not seem to confer a survival advantage compared to surgery alone in octogenarians, and more prospective studies are necessary to better elucidate the optimal treatment in this patient population.

BACKGROUND Gastroparesis (GP) is characterized by delayed gastric emptying with symptoms of nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. Various surgical options exist to treat GP not responding to medical treatments (refractory GP), including gastric electric stimulation (GES), gastrectomy (GTx), and pyloric interventions (PI), whereas the outcomes of these procedures have been published; few comparison studies exist. METHODS PubMed literature review for articles from September 1988 to October 2017 was performed for prospective and retrospective analyses reporting >5 patients. Unweighted (per study) and weighted (per patient) overall improvement and improvement in symptoms of nausea, vomiting, and abdominal pain were calculated and compared for the different procedures. RESULTS Of 325 studies satisfying search criteria, 38 met the study criteria and were included for analysis. Total response to intervention, both weighted and unweighted, was greater with PIs compared to GES (P

s / Pancreatology 14 (2014) S1eS129 S92 preoperative counseling, no fasting and bowel preparation, no preanaesthetic medication, intraoperative fluids restriction (5ml/kg/h), pain control through subfascial wound catheter, immediate naso-gastric-tube removal, early clear fluids resumption, mobilization and urinary-catheter (UC) removal. Results: 68 patients (M:F1⁄436:32; mean age: 67) undergoing pancreaticoduodenectomy (69%), distal pancreatectomy (26%) and other procedures (5%) were included. Proportions of patients achieving key protocol targets were: 100% was given preoperative counseling; no patient was given bowel preparation or fasted; 51% didn’t receive preanaesthetic medication; fluid restriction was achieved in 25%. Subfascial wound catheter was placed in 97%, NGT was removed by POD 1 in 72%; on POD 181% of patients resumed clear fluids per os and 94% achieved early mobilization. UC was removed by POD 3 in 70%. Median post-operative stay was 10 with a 30-day readmission rate of 7%. Mortality rate was 1% while morbidity rate was 39% (pancreatic fistula incurred in 35%). Conclusion: ERAS protocol is safe and feasible. A multidisciplinary team (surgeon, anesthetist, nurse, physiotherapist) is vital to its correct application; more experience is necessary to improve the rate of adhesion to the single key targets.