INTERNATIONAL SOCIETY FOR DISEASES OF THE ESOPHAGUS
The October-November issue of Diseases of the Esophagus contains the first three articles dedicated to the analysis of the data gathered by the Worldwide Esophageal Cancer Collaboration (WECC) lead by Prof. Thomas Rice, that will form the basis for the new (8th) edition of the UICC- AJC TNM classification.
Data from more than 22,000 patients with staged esophageal cancer from 33 institutions in six continents were analyzed. Each institution submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all causes mortalities from the first management decision. Clinical data, pathological data, and pathological data in patients that received neoadjuvant chemo or chemoradiotherapy were separately addressed. One of the most relevant finding of this analysis is the need for a separate classification for pathological stage in patients operated with or without neoadjuvant therapy.
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Traditionally we used to measure the LES generated pressure, either during resting or at swallowing, by means of water perfused catheter or solid state sensors. With modern High Resolution Manometry, the LES generated pressures are measured in several points few mm apart. The function of LES is inferred by calculating its pressure and the length on whom this pressure is exerted and how it alters after swallowing.
Two articles in the current issue of Diseases of the Esophagus deal with a new tool (Endoflip) that allows to calculate the force needed to open the LES (LES distensibility). In the first, A. Ilczyszyn, K. Hamaoui, J. Cartwright and A. Botha, discuss the clinical utility of these measurements to optimize the myotomy in achalasia patients (Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome, pages 455–462) and in the second, C. Lottrup, B. P. McMahon, P. Ejstrud, M. A. Ostapiuk, P. Funch-Jensen and A. M. Drewes present their finding on LES distensibility in a group of Hiatus hernia, Barretts and control patients. (Esophagogastric junction distensibility in hiatus hernia, pages 463–471) .
ISDE is proud to announce that the society's journal Diseases of the Esophagus has reached the highest Impact Factor in its history, 2.146, placing it 52 out ot 78 titles in Gastroenterology and Hepatology category of the Journal Citation Reports®.
Thank you to all the contributors, the associate editors and reviewers for their great job!
Massive Para-esophageal hernias
Giant para-esophageal hernias constitute a relevant challenge for gastroenterologist and surgeons with many unanswered questions. Should the presence of a giant para-esophageal hernia prompt to surgical repair even in asymptomatic or mild symptomatic patients? Given the high recurrence rate reported after primary repair, should we modify the surgical technique by using mesh or by elongating the esophagus with a Collis gastroplasty?
Should we routinely add a fundoplication to prevent (or cure) reflux? Giant para-esophageal hernia is a frequent conditions in elderly patients: what is the best treatment for octagenarians and nonageanrians with this condition?
Andre Duranceau, a former editor of Diseases of the Esophagus and Professor of Thoracic Surgery at the University of Montreal, reviews the literature and combine it with his vast experience on this disease in the article “Massive Para-esophageal hernias” in the June issue of the Journal.
Safety and efficacy of endoscopic spray cryotherapy for Barrett’s dysplasia: results of the National Cryospray Registry
S. Ghorbani et al.
Active treatment rather than simple surveillance in case of High-grade Dysplasia in Barrett epihelium (BE) is recommended by current AGA and BSG guidelines and the possibility of expanding active treatment even in selected patients with Low-grade Dysplasia is suggested. Currently, the most common modality of BE ablation is by using thermal energy with Radio Frequency that has been proven effective in eradicating dysplastic lesion and BE, with acceptable rates of post-treatment stricture, post-treatment pain and persistence or recurrence of BE. The main drawback of RFA is the relative high cost of each treatment. In the present issue of Diseases of the Esophagus, Ghorbani and co-workers present the results of the National Cryospray Registry, suggesting that, at the other end of the spectrum of thermal ablation, a similar rate of success in eradicating Dysplasia and BE may be achieved by freezing the tissue. In their consecutive series of 96 patients enrolled in the registry (321 cryotherapy sessions) with 21 months of follow up, complete ablation of HGD was achieved in 91% of patients and BE eradication was achieved in 68% of patients. One stricture (non requiring dilatation) and one bleeding (treated endoscopically) were observed. Only one patient experienced severe pain whereas mild to moderate chest pain and dysphagia were reported in 38% of the patients and after 23% of the procedures. Cryotherapy resulted particularly effective in treating Short Segment of BE (100% of success). Based on these results, cryotherapy is suggested as a safe and effective treatment to ablate dysplastic BE.
Performance of different imaging modalities in assessment of response to neo-adjuvant therapy in primary esophageal cancer C.Yip et al. Dis Esophagus February 2016
Although neo-adjuvant therapies (NT) are widely employed in the treatment of esophageal cancer, a substantial benefit in survival is evident only for those patients with an objective clinical and/or pathological response. The accurate assessment of response is therefore a paramount to optimize the treatment of such patients. The diagnostic tools to assess the response following neo-adjuvant therapy are far by optimal, however, and no single imaging modality has a sufficient diagnostic accuracy.
In their excellent review (C. Yip and coworkers examine the currently available imaging modalities: endoscopic ultrasound (EUS), computed tomography (CT), positron emission tomography associated to CT scan (PET-CT scan) and functional MRI. Each of the first three imaging modality have shown relevant limitations in assessing response to NT. The authors suggest that functional MRI with gadolinium is the single imaging modality that provides excellent soft tissue delineation and functional information regarding tumor angiogenesis, having the potential to be a useful response-assessment tool (if confirmed by further studies). In addition its combination with PET (PET/functional MRI) could be the way forward in the response assessment after NT in esophageal cancer.
“Refractory GERD: a complicated puzzle”
The persistence of symptoms in GERD patients despite adequate PPI therapy is a rather common and sometimes frustrating problem. Two articles in this January issue of Diseases of the Esophagus deal with this topic, offering some insight on the mechanisms underlying the condition.
In the first article by Mandalyia et al (Survey of findings in patients having persistent heartburn on PPI therapy), 100 patients with GERD symptoms refractory to PPI were assessed by means of combined impedance-pH study and the Symptom Sensitivity Index (SSI). Patients were then divided into 4 groups on the basis of these findings, i.e. cases with acid reflux, those with non-acid reflux, those with a positive SSI and those with normal reflux parameters; the Authors suggested that the normal treatment strategy of increasing the PPI dose when patients remain symptomatic might only be appropriate for some patients.
In the second study by DeBortoli et al. (Lower pH value of weakly acidic refluxes as determinants of heartburn perception in GERD patients with normal esophageal acid exposure), the Authors focused on patients with a positive Symptom Association Probability (SAP) index and Symptom Index for weakly acidic reflux, finding that a lower nadir pH (in the range of pH 4 to 5.5) during non-acid reflux was associated with symptom perception, suggesting that a higher concentrations of hydrogen ions may be an important symptom trigger, even for “non-acid” reflux in this complex condition.
Inter-observer agreement for diagnostic classification of esophageal motility disorders defined in high-resolution manometry
by Mark Fox et al.
High resolution manometry is widely accepted in the clinical practice and is now considered the “golden standard” to diagnose esophageal motor disorders. The inter-observer agreement of this test was not yet validated, however. In this article Mark Fox and colleagues asked 18 pratictioners from 13 institutions to analyze individual water swallows and 36 practitioners from 28 institutions to assess 40 diagnostic studies. Consensus agreement was found in most of normal peristalsis and in achalasia, but not for cases of peristaltic dysmotility. In clinical studies the agreement among the assessors was substantial for achalasia type I/II, but fair to moderate for any diagnosis. The Authors suggest that in clinical practice diagnostic performance should be based not only on pattern recognition of HRM images, but also on quantitative metrics of contractile and intrabolus pressures that provide an obiective diagnosis of esophageal motor abnormalities.
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Diseases of the Esophagus
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Neoadjuvant therapies for advanced esophageal cancer are widespreading: nearly 45% of the patients undergoing esophagectomy received neoadjuvant therapy in 2010 in the USA, doubling the number from 2005. The use of induction therapy prior to surgery is supported by several studies that have shown an effective improvement in the disease-free and overall-survival rate, without compromising the morbidity and mortality of the operation, at least in the setting of the high-volume specialized centers involved in the randomized trials. Not much is known if neoadjuvant therapy has a detrimental effect on esophagectomy when “all” centers involved in the surgical management of these patients are considered. Even less is known on the effect of induction therapy on the postoperative quality of life. Two articles in this issue of Diseases of the Esophagus deal with these topics.
In the first article1 the authors report their findings on 1939 patients who underwent esophagectomy between 2005 and 2010, using the American College of Surgeons National Quality Improvement Program database: neoadjuvant therapy did not increase the 30 days mortality nor the major morbidity after esophagectomy, and only an increase of the incidence of venous thromboembolism was observed.
In the second article2 , the Quality of Life (QoL) was assessed in 84 patients whithout induction therapy and in 47 with neoadjuvant therapy, before the treatment and at 3, 6, 12 and 24 months after surgery: QoL values were extremely reduced immediately after surgery but recovered slowly during the postoperative period to almost preoperative levels in many scores, with no significant differences related to the neoadjuvant therapy.
(Mungo B, Molena D, Stem D, Yang SC et al. Does neoadjuvant therapy for esophageal cancer increase postoperative morbidity or mortality Dis. Esoph. 2015; Hauser C, Patett C, von Schoenfels W et al Does neoadjuvant treatment before oncolgic esophgectomy affect the postoperative quality of life? a prospective, longitudinal outcome study. Dis Esoph. 2015;…)
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© International Society for Diseases of the Esophagus 2016