The AFS Textbook of Foregut Disease

Preface
Contents
Part I: Basic Considerations
1: History of AFS
Part II: GERD and Eosinoplhilic Esophagitis
2: GERD Pathophysiology: The Role of the Sphincter and Crural Diaphragm
Gastroesophageal Reflux Mechanisms
Bibliography
3: Gastroesophageal Reflux Disorders: Diagnostic Approach
Symptomatology
Clinical Questionnaires
Empiric Acid Suppression Trial
Upper Endoscopy
Ambulatory Reflux Monitoring
Catheter-Based Impedance-pH Monitoring
On Versus Off-Therapy Testing
Wireless pH Monitoring
High-Resolution Esophageal Manometry
Barium Esophagram
Endoscopic Functional Luminal Imaging Probe
Gastric Emptying Study
Bibliography
4: Medical Therapy for GERD
Introduction
Goals of Treatment
Lifestyle and Diet Changes
Diet and Weight
Sleep
Antacids and Alginates
H2 Receptor Antagonists (H2RAs)
Proton Pump Inhibitors
Other Pharmacologic Options
Future Medications
Long-Term Management
Refractory Disease
Conclusions/Summary Points
Bibliography
5: Phenotypes of Gastroesophageal Reflux Disease and Personalized Management
Introduction
Concept of Personalization in GERD Management
GERD Phenotypes (Table 5.1)
Erosive Esophagitis
Nonerosive Reflux Disease
Functional Reflux Syndromes
Barrett’s Esophagus
Reflux Chest Pain Syndrome
Regurgitation-Dominant Reflux Disease
Extra-Esophageal Syndromes
Assessing GERD Phenotype (Fig. 5.1)
Clinical Presentation
Endoscopic Evaluation
Ambulatory Reflux Monitoring
Esophageal Motility and Esophageal Function Evaluation
Personalized Approach to GERD Therapy (Table 5.3)
Role of Acid Suppression in GERD Therapy
Role of Endoscopic and Surgical Therapy
Lifestyle Modifications
Alternative Therapies
Conclusions
Bibliography
6: Laryngopharyngeal Reflux and Pulmonary Manifestations
Introduction
Pathophysiology
Laryngopharyngeal and Pulmonary Symptoms
The Challenge of Establishing the Diagnosis
Ambulatory pH Monitoring
Novel Biomarkers
Medical Therapy of Patients with LPR
Explanations for Limited Effect of Medical Treatment
Surgical Therapy for LPR
Results of Surgery for LPR and Pulmonary Symptoms
Factor Influencing the Outcome of Surgery in Patients with LPR
Explanations for Suboptimal Outcome of Surgery
Other Surgical Options
Conclusion
Bibliography
7: The Spectrum of Eosinophilic Esophagitis
Definition, Epidemiology, and Incidence/Prevalence
Pathophysiology/Mechanism
Diagnosis
Treatment
Anti-Inflammatory Treatment and Technical Considerations
PPIs
Swallowed Topical Steroids
Diet Elimination
Dupilumab
Dilation and Technical Considerations
Future Directions
Bibliography
8: Esophageal Hypersensitivity and Functional Dyspepsia
Esophageal Hypersensitivity
Introduction
Epidemiology
Pathophysiology
Peripheral Sensitization
Central Sensitization
Viscero-Visceral Hyperalgesia
Stress and Esophageal Hypersensitivity
Clinical Evaluation
Functional Chest Pain
Functional Heartburn and Reflux Hypersensitivity
Globus
Functional Dysphagia
Management
Functional Chest Pain
Functional Heartburn
Reflux Hypersensitivity
Globus
Functional Dysphagia
Conclusion
Functional Dyspepsia
Introduction
Epidemiology
Pathophysiology
Diagnosis
Management
Helicobacter pylori Eradication
Acid Suppression
Antidepressants
Prokinetic Agents
5-Hydroxytryptamine (5-HT)1A Receptor Agonist
Phytotherapy
Psychological Therapy
Dietary Modification
Conclusion
References
9: Endoscopic GERD Therapies
Introduction
Pre-Procedure Evaluation
Transoral Incisionless Fundoplication
TIF Mechanism of Action
TIF Patient Selection
TIF Technical Considerations
TIF Outcomes
Concomitant Laparoscopic Hernia Repair and TIF (cTIF)
Emerging Applications for TIF
TIF Summary
Endoscopic Anti-Reflux Gastroesophageal Junction Augmentation
Mechanism of Action
Patient Selection
Anti-Reflux Mucosectomy (ARMS)
Anti-Reflux Mucosal Ablation (ARMA) and Cardia Ligation Endoscopic Anti-Reflux (CLEAR) Procedure
Novel Applications of Endoscopic GEJ Augmentation
GEJ Augmentation Summary
Conclusion
Suggested Readings
Tif
EGJ Augmentation
10: Understanding the Optimal Gastroesophageal Flap Valve: The Omega Flap Valve
Introduction
Collaboration of Gastroenterology and GI Surgery
Concomitant Transoral Incisionless Fundoplication (cTIF)
The Optimal Antireflux Valve
Understanding the Omega Gastroesophageal Flap Valve
Understanding the Outcome and Geometric Limitations of the Surgical Fundoplication Techniques
Proposal of the Omega Fundoplication
Conclusion
References
11: Laparoscopic Fundoplication
Introduction
Indications and Workup
Physiology of Surgical Fundoplication: How Does it Work?
Brief History of Fundoplication
Technique
Patient’s Position
Port Placement
Esophageal Mobilization
Cruroplasty
Division of Short Gastrics
Geometry of the Fundoplication
Fixation
Other Technical Considerations
Tailoring the Fundoplication
Complications
Postoperative Care
Outcomes: What Can we Expect?
Comparison to Other Antireflux Procedures
Conclusions
References
12: Comprehensive Review of the Anti-Reflux Mechanism and Fundoplication
Introduction
Principles of the Anti-Reflux Mechanism
Lower Esophageal Sphincter
Gastric Sling Fibers
Angle of His
Gastroesophageal Flap Valve
Crural Diaphragm
Phrenoesophageal Ligament
Mechanism of the Fundoplication
Lower Esophageal Sphincter Augmentation/Fundoplication
Intra-Abdominal Esophageal Length
GEJ Flap Valve and Recreation of the Angle of his
Crural Repair
Creation of the Fundoplication
Nissen Fundoplication
Nissen-Rossetti Fundoplication
Toupet Fundoplication
Dor Fundoplication
Watson Fundoplication
Belsey-Mark IV Fundoplication
Lind Fundoplication
Transoral Incisionless Fundoplication (TIF)
Fundoplication Outcomes
Watson Fundoplication
Dor Fundoplication
Toupet Fundoplication
Belsey Mark IV Fundoplication
Lind Fundoplication
Transoral Incisionless Fundoplication
Conclusion
References
13: Laparoscopic Magnetic Sphincter Augmentation
Introduction
Device and Mechanism
Concept Development and Early Trials
Indications and Patient Selection
Preoperative Evaluation
Technical Considerations
Surgical Technique
Device Sizing and Implantation
Postoperative Management
Complications
Intra- and Perioperative Complications
Postoperative Dysphagia
Explantation and Migration
Erosion
Outcomes
Prospective Single-Arm Studies
Comparison with Proton Pump Inhibitors
Comparison with Fundoplication
MSA in Patients with Hiatal Hernias Greater than 3 Cm
Obesity
Motility Disorders
Barrett’s Esophagus
Post Bariatric Surgery
Conclusion
References
14: Diagnosis and Management of Paraesophageal Hiatal Hernia
Introduction, Definition, Incidence, and Prevalence
History of Paraesophageal Hernia
Classification
Indications for Surgery
Surgical Anatomy
Technical Considerations
Open Vs Laparoscopic Vs Robotic
Dissection of the Hiatus
Excision of the Hernia Sac
Esophageal Mobilization
Repairing the Hiatus
Mesh Vs No Mesh
Mesh Complications
Fundoplication
Gastropexy
Postoperative Consideration
Healthcare Costs
Bibliography
15: Reoperative Anti-Reflux Surgery
Introduction
Preoperative Evaluation and Workup
Operative Approaches
Redo Hiatal Hernia Repair and Fundoplication
Roux-en-Y Reconstruction
Multiple Previous Fundoplications
Short Esophagus
Esophageal Dysmotility
Damaged Gastroesophageal Junction or Fundus
Delayed Gastric Emptying
Non-tissue Redo ARS
Conclusion
Bibliography
Part III: Barrett’s Esophagus and Esophageal Neoplasm
16: Screening for Barrett’s Esophagus
Introduction
Why Screen for BE?
Whom to Screen?
Risk Factors for BE
BE Risk Assessment Tools
Special Populations
When to Stop Screening?
How to Screen?
Endoscopic Screening
Conventional Esophagogastroduodenoscopy (cEGD)
Unsedated Transnasal Endoscopy
Swallowable Imaging Capsules
Video Capsule Endomicroscopy
Swallowable Cell Sampling Devices Combined with Biomarkers
Biomarkers Used for BE Detection in Combination with Swallowable Esophageal Sampling Devices
Trefoil Factor 3
Methylated DNA Markers
MicroRNAs
Volatile Organic Compounds [52]
Alterations in Esophageal Microbiome [52]
Challenges with BE Screening
References
17: Understanding the Histopathology of GERD and Barrett’s Esophagus
Introduction
Present Understanding of the Histopathology of GERD
Nonerosive and Erosive Reflux Esophagitis
Barrett’s Esophagus
Esophageal Adenocarcinoma (Fig. 17.1)
Present Understanding of the Normal State
A New Understanding of the Normal State
A New Understanding of the Histopathology of GERD
Normal → Early GERD with No Visible CLE at Endoscopy
Progression of GERD with No Visible CLE at Endoscopy
The Pathological Anatomy of Early GERD: The Dilated Distal Esophagus
Pathophysiology of the Dilated Distal Esophagus (Lower Esophageal Sphincter Damage)
Late (Severe) GERD with Visible CLE
The Second Metaplasia: IM in Cardiac Mucosa (Barrett’s Esophagus)
The Third Histological Change: Neoplastic Mutations in Barrett’s Esophagus (Fig. 17.1)
Progression of GERD Defined by Abdominal LES Damage and Correlative Histology
Conclusion
References
18: Management of Nondysplastic Barrett’s Esophagus
Defining Barrett’s Esophagus
Risks Associated with Barrett’s Esophagus
Minimizing Risk of Dysplastic Progression: Medical Therapy
Minimizing Risk of Dysplastic Progression: Anatomic Intervention
The Rationale for Endoscopic Surveillance of Nondysplastic Barrett’s Esophagus
Assessment for Dysplasia within Barrett’s Mucosa
Evaluating a Nondysplastic Barrett’s Segment for Risk of Progression to Dysplasia
The Argument for Endoscopic Eradication Therapy to Treat Nondysplastic Barrett’s Esophagus
Conclusion
References
19: Management of Dysplastic Barrett’s Esophagus
Introduction
Epidemiology
Definitions and Terminology
Identification of Dysplasia
Management
Indications for EET
Endoscopic Resection
Endoscopic Mucosal Resection (EMR)
Endoscopic Submucosal Dissection (ESD)
Ablation
Radiofrequency Ablation (RFA)
Cryoablation (CA)
Argon Plasma Coagulation (APC)
Photodynamic Therapy (PDT)
Conclusion
Bibliography
20: Management of Early Esophageal Cancer
Introduction
Current Status of Endotherapy in the United States
Owning a Hammer Does Not Make you a Contractor
Patient Selection and Pretreatment Evaluation
T1b Cancer
Endotherapy Techniques
Endoscopic Resection
Endoscopic Ablation
Staging
Surveillance Post-Endotherapy
Endotherapy Failure
Post-Endotherapy Reflux Management
Conclusion
References
21: Cancer of the Esophagus: Epidemiology and Genetics
Introduction
Epidemiology
Incidence
Survival
Etiology
Squamous Cell Carcinoma
Nonmodifiable Risk Factors
Modifiable Risk Factors
Adenocarcinoma
Nonmodifiable Risk Factors
Modifiable Risk Factors
Genetics
Conclusions
Bibliography
22: Screening Technologies for Barrett’s Esophagus and Esophageal Adenocarcinoma
Introduction
Rationale for Screening for Barrett’s Esophagus
Risk Factors for Barrett’s Esophagus and Who to Screen
Conventional (Video-Based) Screening Techniques
Esophagogastroduodenoscopy
Transnasal Endoscopy
Emerging Screening Techniques
Swallowable Tissue Sampling Devices
Trefoil Factor 3
Methylated DNA Biomarkers
MicroRNA
Tethered Capsule Endomicroscopy
Exhaled Volatile Organic Compounds
Cost-Effectiveness of Screening
Conclusions and Future Directions
References
23: Staging Endoscopic Ultrasound
Introduction
Esophageal Cancer
Epidemiology and Risk Factors
Classification
Pretreatment Evaluation
Pretreatment Staging
EUS in Staging
EUS Examination Technique
T-Staging
N-Staging
M-Staging
Comparison Among Different Modalities for Staging Esophageal Cancer
EUS in Restaging After Therapy
Special Considerations
Stenotic Lesions
Outcomes
Impact on Patient Management and Survival
Cost-Effectiveness and Economic Impact
Gastric Cancer
Epidemiology and Risk Factors
Classification
Pretreatment Evaluation
Pretreatment Staging
EUS in Staging
EUS Examination Technique
T-Stage
N-Staging
M-Staging
EUS Accuracy
Early Gastric Cancer (EGC)
M-Staging
Comparison with Other Modalities
EUS After Neoadjuvant Chemotherapy
Special Considerations
Linitis Plastica
Limitations of Staging EUS
Conclusion
References
Further Reading
24: Minimally Invasive Esophagectomy
Introduction
Indications
Preoperative Evaluation
Operative Technique
Laparoscopic Phase
Positioning
Port Placement
Diagnostic Laparoscopy
Hiatal Dissection and Lymph Node Dissection
Gastric Mobilization
Conduit Creation
Pyloric Drainage Procedure
Placement of Feeding Jejunostomy Tube
Mediastinal Dissection
Conclusion of Laparoscopic Component
Thoracoscopic Phase
Positioning and Port Placement
Esophageal Dissection
Thoracic Anastomosis
Variations of Minimally Invasive Esophagectomy
Minimally Invasive Ivor Lewis Esophagectomy
Minimally Invasive Three-Field McKeown Esophagectomy
Minimally Invasive Transhiatal Esophagectomy
Two-Stage Procedures
Special Considerations
Postoperative Management
Complications
Outcomes
Conclusions
References
25: Endoscopic Management of Anastomotic Leaks
Introduction
Indications
Patient Selection and Preoperative Evaluation
General Principles
Specific Techniques and Outcomes
Endoscopic Dilation
Endoscopic Stents
Endoluminal Vacuum Therapy (EVAC)
Endoscopic Clips and Suturing
Postoperative Considerations
Conclusions
Bibliography
26: Palliative Therapy in Esophageal Cancer
Introduction
Disease Staging
Endoscopic Mechanical Interventions
Stenting
Dilation
Endoscopic Ablation Therapy for Esophageal Cancer
Photodynamic Therapy (PDT)
Cryoablation
Argon Plasma Coagulation (APC)
Endoscopic Laser Ablation
Endoscopic Oncological Therapies
External Beam Radiation Therapy (EBRT)
Endoluminal Brachytherapy
Endoscopic Chemotherapy
Endoscopic Chemical Administration
Nonendoscopic Palliation and Palliation of Nondysphagia Symptoms
Systemic Chemotherapy and Chemoradiation
Management of Bleeding: Hemostatic Powder, Argon Plasma Coagulation, Angiography
Malnutrition
Perforation
Surgical Approaches
Conclusions
Bibliography
Part IV: Esophageal Motility Disorders, Esophageal Injury, and Benign Disease of the Esophagus
27: Pathophysiology of Esophageal Motility Disorders
Pathophysiology of Esophageal Motility Disorders
Disorders of Esophagogastric Junction Outflow
Achalasia
Esophagogastric Junction Outflow Obstruction
Disorders of Peristalsis
Absent Contractility
Ineffective Esophageal Motility (IEM)
Distal Esophageal Spasm (DES)
Hypercontractile Esophagus
Summary
References
28: Diagnostic Testing for Esophageal Motility Disorders: Barium Radiography, High-Resolution Manometry, and the Functional Lumen Imaging Probe (FLIP)
Introduction
Barium Radiography
Introduction
Indications and Patient Selection
Protocol and Technical Considerations
Outcomes and Interpretation
Healthcare Costs
Esophageal High-Resolution Manometry (HRM)
Introduction
Indications and Patient Selection
Equipment and Patient Preparation
Protocol and Technical Considerations
Outcomes and Interpretation
Healthcare Costs
Functional Lumen Imaging Probe (FLIP)
Introduction
Indications and Patient Selection
Equipment
Protocol and Technical Considerations
Outcomes and Interpretation
Healthcare Costs
Conclusions
Bibliography
29: The Chicago Classification of Esophageal Motor Disorders
Introduction
The First Chicago Classification—Version 1.0
Updates in the Chicago Classification—Versions 2.0 and 3.0
The Current Chicago Classification—Version 4.0 (Fig. 29.2)
Standardized HRM Protocol (Fig. 29.3)
Chicago Classification Version 4.0 of Esophageal Motility Disorders
Disorders of EGJ Outflow (Table 29.2)
Achalasia (Fig. 29.4)
EGJ Outflow Obstruction
Disorders of Peristalsis (Table 29.3)
Absent Contractility (Fig. 29.5a)
Distal Esophageal Spasm (Fig. 29.6a)
Hypercontractile Esophagus (Fig. 29.6b–d)
Ineffective Esophageal Motility (Fig. 29.5)
EGJ Barrier Metrics
Conclusion
Bibliography
30: Cricopharyngeal Disorders, Endoscopic, Stapled, and Open Cricomyotomy and Adjuncts for Zenker’s Diverticulum
Introduction
Background
Relevant Anatomy
Pathophysiology
Clinical Presentation
Evaluation
Treatment Considerations
Treatment Modalities and Technical Considerations
Botulinum Toxin
Dilation
Myotomy
Open Approach
Rigid Endoscopy
Flexible Endoscopy
Outcomes
Cricopharyngeal Achalasia
Open Surgery
Open vs. Endoscopic Surgery
Comparison of Endoscopic Techniques
Conclusions
References
31: Minimally Invasive Management of Epiphrenic Diverticulum
Introduction
Epidemiology/Pathophysiology
Clinical Presentation
Diagnostic Evaluation
Management Strategies
Non-Operative Management
Endoscopic Therapy
Surgical Therapy
Thoracotomy
Minimally Invasive Approaches
Trans-Hiatal Minimally Invasive Approach
Preoperative Considerations
Minimally Invasive Trans-Hiatal Operative Technique
Surgical Pearls/Pitfalls
Postoperative Care
Per-Oral Endoscopic Myotomy (POEM)
Surgical Outcomes and Complications
Conclusions
References
32: Disorders of Esophagogastric Junction Outflow and Peristalsis
Disorders of Esophagogastric Junction Outflow
Achalasia
EGJ Outflow Obstruction
Epidemiology
Pathophysiology
Clinical Features
Diagnosis
Manometric Testing
Imaging
Endoscopy
FLIP
Disorders of Peristalsis
Absent Contractility
Distal Esophageal Spasm
Introduction
Epidemiology
Pathophysiology
Clinical Features
Diagnosis
Manometric Testing
Imaging
Endoscopy
FLIP
Hypercontractile Esophagus
Introduction
Epidemiology
Pathophysiology
Clinical Features and Presentation
Diagnosis
Manometric Testing
Endoscopy
FLIP
Esophagogastric Junction Outflow Obstruction
Introduction
Epidemiology
Pathophysiology
Clinical Features and Presentation
Diagnosis
Manometric Testing
Imaging
Endoscopy
FLIP
Ineffective Esophageal Motility
Introduction
Epidemiology
Pathophysiology
Clinical Presentation
Diagnosis
Manometric Testing
FLIP
References
33: Therapies for Spastic Esophageal Motor Disorders
Introduction
Approach to Management
Pharmacologic Therapy
Calcium Channel Blockers
Nitrates and Phosphodiesterase (PDE-5) Inhibitors
Peppermint Oil
Proton Pump Inhibitors
Neuromodulators
Endoscopic Therapy for Spastic Esophageal Motility Disorders
Dilation
Botulinum Toxin Injection
Surgical/Endosurgical Therapy for Spastic Esophageal Motility Disorders
Patient Selection for Surgical/Endosurgical Management
Procedures: Laparoscopic Heller’s Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM)
Risks and Considerations
Outcomes
Cost Considerations
Concerns
Conclusion: Surgical/Endosurgical Therapy for Spastic Esophageal Motility Disorders
Conclusions
Bibliography
34: Pneumatic Dilation for the Treatment of Achalasia
Introduction
Definition, Incidence/Prevalence, Epidemiology, Pathophysiology/Mechanism
Indications
Patient Selection
Preoperative Evaluation
Technique
Outcomes
Healthcare Costs
References
35: Minimally Invasive Heller Myotomy
Introduction
Common Indications for Myotomy
Achalasia
Esophagogastric Junction Outflow Obstruction (EGJOO)
Epiphrenic Diverticulum
Preoperative Evaluation
Specific Considerations
Patient Preparation
Laparoscopic Heller Myotomy with Partial Fundoplication
Technical Procedure
Myotomy
Partial Fundoplication
Robot-Assisted Heller Myotomy
Benefit Compared to Laparoscopic Approach
Technical Procedure
Intraoperative Functional Assessment
Postoperative Care
Complications
Outcomes
Conclusions
References
36: Per-Oral Endoscopic Myotomy (POEM)
Introduction, Background of POEM Procedure
Current Indications and Outcomes for POEM
Achalasia (Types 1, 2, 3) and Spastic Esophageal Disorders
Clinical Outcomes—Relief of Dysphagia
Outcomes by Achalasia Subtypes
Outcomes of Other Spastic Esophageal Disorders (Jackhammer, DES, EGJOO)
Long-Term Outcomes
Post-POEM GERD
POEM vs LHM: Clinical Outcomes
Indications for LHM vs POEM
Failed Prior Interventions (Heller, Botox, Pneumatic Dilation, POEM)
Pre-procedure Evaluation
Technical Considerations (Fig. 36.3)
Anterior vs Posterior Approach
Vertical vs Horizontal Mucosal Incision
Extent of Tunnel/Myotomy
Full Thickness vs Circular Myotomy
Managing Esophageal Diverticulum
Reflux Prevention Strategies
Post-procedural Complications
Conclusions
References
37: Scleroderma
Introduction
Pathophysiology
Clinical Manifestations
Oropharyngeal Cavity
Esophagus
Stomach
Diagnostic Evaluation
Esophagus
Stomach
Treatment Considerations
Esophagus
Stomach
Conclusion
Bibliography
38: Benign Lesions of the Esophagus
Introduction
Epithelial Lesions
Glycogenic Acanthosis
Inlet Patch (Heterotopic Gastric Mucosa)
Squamous Papilloma
Hyperplastic (Inflammatory) Polyp
Fibrovascular Polyp
Inflammatory Fibroid Polyp
Hamartoma
Polypoid Bacillary Angiomatosis
Pyogenic Granuloma
Ectopic Sebaceous Glands
Esophagitis Dissecans Superficialis
Schatzki Ring
Subepithelial Lesions
Duplication Cyst
Pancreatic Rest
Xanthoma
Lipoma
Leiomyoma
Granular Cell Tumor
Schwannoma
Lymphangioma
Glomus Tumor
Gastrointestinal Stromal Tumor
References
39: Management of Caustic Injury and Esophageal Stricture
Caustic Injury
Clinical Features
Epidemiology
Pathophysiology and Mechanism of Injury
Classification of Injury
Initial Management
Evaluation
Treatment
Subsequent Management and Long-Term Sequelae
Medical Management
Reconstructive Surgery
Management of Esophageal Strictures
Clinical Features
Etiology
Stricture Characterization
Management of Benign Esophageal Strictures
Endoscopic Dilation
Endoscopic Dilation with Steroid or Mitomycin C Injection
Endoscopic Incisional Therapy
Esophageal Stents
Self-Dilation
Management of Malignant Esophageal Strictures
Esophageal Stents
Debulking Endoscopic Therapy
Bibliography
40: Management of Esophageal Perforation
Introduction
Etiology
Presentation
Diagnosis
Guiding Principles for Management
Principle #1) Resuscitation and Control of Sepsis
Principle #2) Diversion of the Salivary Stream
Principle #3) Nutritional Support
Management of Esophageal Perforations
Conservative Management
Interventional Radiology Management
Flexible Endoscopic Management
Surgical Management of Esophageal Perforations
Boerhaave’s Syndrome
Conclusion
References
Part V: Gastric Disorders
41: Pathophysiology of Gastric Neuromuscular Disorders
Introduction
Epidemiology and Clinical Presentation
Epidemiology
Disease Prevalence and Patient Characteristics
Healthcare Burden
Etiologies
Pathophysiology of Delayed Gastric Emptying
Normal Gastric Motor Function
Pathophysiology of Gastroparesis
Antral Hypomotility
Pyloric Dysfunction
Duodenal Dysmotility
Autonomic Dysfunction
Visceral Hypersensitivity
Immune Dysregulation in Delayed Gastric Emptying
Pathophysiology of Gastroparesis Syndromes with Non-delayed Gastric Emptying
Introduction
Further Descriptions of the Concept of GPS
Other Aspects of Gastroparetic Syndromes
Specific Areas of Gastroparetic Syndromes (GPS)
Enteric Aspects of GPS
Neuropathic Factors in GPS
Inflammatory Aspects in GPS
Immune/Genetic Aspects of GPS
Serosal/Hormonal Aspects of GPS
Additional Factors Involving GPS
Gastro-Pyloric Dysfunction
Gastroesophageal Dysfunction
The Role of Diet
Pathophysiology Based on Symptoms
Conclusion
References
42: Diagnostic Testing and Pharmacotherapy in Gastroparesis
Introduction
Diagnostic Testing
Gastric Emptying Evaluation
Small Bowel Radiography
Antroduodenal Manometry
Electrogastrography
Gastric Magnetic Resonance Imaging (MRI)
Ultrasound
Pharmacotherapy
Prokinetic Agents
Anti-nausea
Neuromodulation
Conclusion
References
43: Endoscopic Pyloric Therapies for Gastroparesis
Introduction
Botulinum Toxin Injection into the Pylorus
Endoscopic Dilation of the Pylorus
Transpyloric Stenting for the Management of Gastroparesis
Indications and Patient Selection
Technical Aspects
Post-procedure Care
Outcomes
Gastric Peroral Endoscopic Myotomy (G-POEM)
Indications and Patient Selection
Technical Aspects
Post-procedure Care
Outcomes
Conclusion
Bibliography
44: Surgical Treatment of Gastroparesis
Introduction, Definition, Incidence/Prevalence: Gastroparesis (GP)
Gastric Electrical Stimulation (GES) System
Indications for GES
Mechanism of Action
Patient Selection
Preoperative Evaluation
Technical Considerations
Outcomes
GES System-Related Complications
Postoperative Considerations
Healthcare Costs
Specific Considerations
Surgical Pyloroplasty
Indications for Pyloroplasty
Operative Technique
Complications
Outcomes
Simultaneous Pyloroplasty with Gastric Electrical Stimulation
Conclusions
Further Reading
45: Cyclic Vomiting Syndrome, Dumping, and Marijuana-Induced Hyperemesis Syndrome
Cyclic Vomiting Syndrome
Introduction
Etiology
Diagnosis
Clinical Features
Comorbid Conditions and Impact of CVS
Management
Conclusion
Dumping Syndrome
Features of Dumping Syndrome
Rapid Gastric Emptying in Cyclic Vomiting Syndrome
Epidemiology of Rapid Gastric Emptying
Pathogenic Role of Rapid Gastric Emptying
Contrast of Gastric Emptying Abnormalities in Cyclic Vomiting Syndrome vs. Cannabinoid Hyperemesis
Cannabinoid Hyperemesis Syndrome
Introduction
Pathophysiology
Role of Cannabinoids in CHS and CVS
Is CHS a Distinct Disorder?
Management
Conclusion
References
Part VI: Gastric Cancer and Other Gastroesophageal Disorders
46: Gastric Cancer Epidemiology, Genetics, and Screening
Introduction
Epidemiology of Sporadic Gastric Cancer
Variations in Incidence and Mortality of Gastric Cancer
Familial Gastric Cancer
Hereditary Diffuse Gastric Cancer
Gastric Adenocarcinoma and Proximal Polyposis of the Stomach
Familial Intestinal Gastric Cancer
Gastric Cancer Genetics
Molecular Classification Systems
Precision Oncology
Screening Recommendations
Summary
Bibliography
47: Diagnosis and Management of Gastric Intestinal Metaplasia
Introduction
Epidemiology
Pathophysiology
Histologic Features
Diagnosis and Management of GIM
Endoscopic Diagnosis
Risk Stratification
Staging Systems
Management
Eradication of H. pylori
Short-Interval Endoscopic Evaluation
Endoscopic Surveillance
Healthcare Cost Considerations
Conclusion
Bibliography
48: Endoscopic Staging and Resection for Early Gastric Cancer
Case Presentation
Introduction
Endoscopic Evaluation of EGC
Assessment of Margins
Staging: Depth of Invasion and Lymph Node Involvement
Indications for Resection of EGC
Absolute, Expanded, and Relative Criteria for Endoscopic Resection
Absolute Indications for EMR or ESD
Absolute Indications for ESD
Expanded Indications for ESD
Relative Indications
Submucosal Invasion
Undifferentiated Adenocarcinoma
Techniques for Resection
Endoscopic Mucosal Resection
Endoscopic Submucosal Dissection
Technique
Surveillance Post-treatment
Curative Resection
Noncurative Resection
Helicobacter pylori (H. pylori) Infection
Case Conclusion
References
49: Laparoscopic Total and Subtotal Gastrectomy
Introduction
Definitions and Indications
Gastric Adenocarcinoma
Preoperative Evaluation
Laparoscopic Approach
Lymphadenectomy
Surgical Technique
Patient Positioning and Preoperative Considerations
Port Placement and Diagnostic Laparoscopy
Omentectomy and Division of the Gastrocolic Ligament
Division of the Hepatogastric Ligament
Division of the Right Gastroepiploic Pedicle and Gastric Resection
Modified D2 Lymphadenectomy
Reconstruction
Postoperative Considerations
Postoperative Management
Perioperative Morbidity and Anastomotic Complications
Conclusions
Bibliography
50: Laparoscopic Resection of Gastric and Esophageal Submucosal Tumors
Introduction
Epidemiology
Diagnosis/Pre-op Evaluation
Indications/Patient Selection
Contraindications for Minimally Invasive Management
Technical Consideration
Esophagus
Room Step-Up and Port Placement
Proximal and Mid-esophageal Tumors
Distal Esophageal Tumors
Stomach
Room Step-Up and Port Placement
Gastric Fundus and Greater Curvature Tumors
Lesser Gastric Curve and Pre-pyloric Tumors
Gastric Cardia-Exophytic GEJ Tumors
Gastric Cardia-Endophytic GEJ Tumors Without Esophageal Extension
Esophageal Outcomes
Gastric Outcomes
Postoperative Considerations
Conclusion
Bibliography
51: Peptic Ulcer Disease
Introduction
Epidemiology
Pathophysiology
H. pylori
NSAIDs
Non-H. pylori/Non-NSAID Causes of PUD
Clinical Manifestations
Complications of Peptic Ulcer Disease
Hemorrhage
Perforation
Gastric Outlet Obstruction
Penetrating/Fistulizing PUD
Diagnostic Testing
Endoscopic Evaluation of Ulcers
Diagnostic Tests for H. pylori Infection
Treatment of H. pylori Infection
Screen for and Stop NSAIDs in Patients with PUD
Acid Suppressive Therapy
Other Suggestions to Promote Ulcer Healing
Evaluation for Suspected Zollinger-Ellison Syndrome
Stress Ulcers
Endoscopic, Interventional Radiology, and Surgical Treatments for Complicated PUD
Management of Hemorrhage Due to PUD
Management of Other Complications of PUD
Conclusion
Bibliography
52: Primary Gastric Lymphoma
Introduction
Gastric MALT
Gastric Diffuse Large B-Cell Lymphoma
Clinical Presentation
Diagnosis
Staging
Treatment
Chemotherapy
First-Line Chemotherapy for Advanced Stage Disease
Second and Subsequent Lines of Chemotherapy
Treatment Options for Elderly or Infirm Patients
Histologically Transformed or High-Grade Lymphoma
Radiation Therapy
References
Part VII: Obesity and Metabolic Disease
53: Laparoscopic and Robotic Sleeve Gastrectomy
Introduction, Definition, Incidence/Prevalence
Epidemiology, Pathophysiology/Mechanism
Indications and Patient Selection
Preoperative Evaluation
Technical Considerations
Laparoscopic Technique
Robotic
Concomitant Hiatal Hernia Repair
Conversion to Sleeve Gastrectomy
Outcomes
Postoperative Considerations
Healthcare Costs
Specific Considerations
Conclusions
Bibliography
54: Laparoscopic and Robot-Assisted Roux-en-Y Gastric Bypass
Introduction
Epidemiology
Pathophysiology
Indications and Patient Selection
Indications
Patient Selection
Contraindications
Preoperative Evaluation
Multidisciplinary Evaluation and Education
Psychiatric Evaluation
Medically Supervised Weight Loss
Upper Endoscopy
Patient Education
Technical Consideration
Laparoscopic Roux-en-Y Gastric Bypass
Patient Positioning
Trocar Placement
Biliopancreatic Limb
Alimentary Limb
Jejunojejunostomy
Gastric Pouch Creation
Gastrojejunostomy
Robot-Assisted Roux-en-Y Gastric Bypass
Example Video of Laparoscopic Roux-en-Y Gastric Bypass
Postoperative Care
Outcomes
Healthcare Costs and Considerations
Conclusion
References
55: Endoscopic Gastric Remodeling for Weight Loss
Introduction
Bariatric Endoscopy
Candidates for ESG and POSE
Preoperative Evaluation
Intraprocedural and Postoperative Protocol
Endoscopic Sleeve Gastroplasty
Technical Aspects and Procedural Considerations
Outcomes
Safety
Primary Obesity Surgery Endoluminal (POSE) Procedure
Technical Aspects and Procedural Considerations
Outcomes
Safety
ESG Versus POSE
Endoscopic Revision After Bariatric Surgery
Argon Plasma Coagulation
Transoral Outlet Reduction Endoscopy (TORe)
Restorative Obesity Surgery Endoluminal (ROSE)
Revisional Endoscopic Sleeve Gastroplasty of Laparoscopic Sleeve Gastrectomy
Training and Program Development
Cost of Endobariatric Therapies
Conclusion and Future Directions
References
56: Strategies in Management of GERD in the Severely Obese Undergoing Bariatric Surgery
Current Surgical Options in the Management GERD and Severe Obesity
Pathophysiology of GERD Associated with Bariatric Surgery
Innovative Strategies in the Management of Patients with GERD and Obesity
Staged Procedures: Antireflux Surgery Followed by Bariatric Surgery
Single Stage Procedure: Flap Valve Preserving Bariatric Surgery
Conclusions
References
57: Endoscopic Management of Bariatric Complications
Introduction
Leaks (RYGB and SG)
Overall Clinical Management
Diversion/Exclusion Technique
SEMS
Internal Drainage Techniques
Double Pigtail Stents (DPS)
Endoscopic Vacuum Therapy (EVT)
Septotomy
Closure Techniques
Clipping
Sealants
Biomaterial Plug
Endoscopic Suturing
Septal Occluder
Gastrojejunal Anastomosis (GJA) Stricture
Marginal Ulcers (RYGB)
Isolated Sleeve Gastrectomy Stricture
Silastic Ring and Band-Related Complications (Fobi-Capella Procedure)
References
58: Bariatric Surgery Complications and Management
Introduction
Complications of Sleeve Gastrectomy
Staple Line Leaks
Stenosis/Stricture
Bleeding After Laparoscopic Sleeve Gastrectomy
Complications of Gastric Bypass
Leaks After Gastric Bypass
Strictures After Gastric Bypass
Marginal Ulceration and Gastrogastric Fistula After Gastric Bypass
Obstruction
Roux-en-O Bypass
Complications After Biliopancreatic Diversion with Duodenal Switch
Complications of Laparoscopic Adjustable Gastric Band
Conclusions
References
59: Post-bariatric Surgery GERD
Normal Anti-reflux Mechanism
Lower Esophageal Sphincter
Crural Diaphragm
Mechanisms of Reflux
Obesity and GERD
Bariatric Surgical Interventions
Laparoscopic Sleeve Gastrectomy (LSG)
Roux-en-Y Gastric Bypass
GERD After Sleeve
Clinical Presentation of GERD After RYGB
Progression of GERD to Barrett’s Esophagus After Bariatric Surgery
Approach to Management of Post-bariatric Surgery GERD
Endoscopic Approaches
Radiofrequency Ablation
Anti-reflux Mucosectomy (ARMS)
Surgical Approaches
Magnetic Sphincter Augmentation (MSA): LINX
Conversion to RYGB
Concurrent or Subsequent Treatments of GERD in the Setting of Bariatric Surgery Currently Available
Hiatal Hernia Repair
Concurrent Fundoplication
Concurrent Magnetic Sphincter Augmentation (MSA)
References
60: Gastroesophageal Reflux Disease and Metabolic Surgery
Introduction
Epidemiology
Pathophysiology
Presentation
Workup/Diagnosis
GERD Around Metabolic Surgery
Management
Non-procedural Management
Procedural Management
Hiatal Hernia
Conclusion
References
Part VIII: Specific Considerations
61: Health Advocacy
Introduction
Legislative Advocacy
Payer Advocacy
Physicians as Effective Advocates
Conclusion
References
62: Robotic Foregut Surgery
Robotic Heller Myotomy
Introduction
Robotic Heller Myotomy
Surgical Technique
Robotic Antireflux Surgery
Introduction
Robotic Fundoplication
Surgical Technique for Robotic Fundoplication
Robotic Paraesophageal Hernia
Introduction
Robotic Paraesophageal Hernia Repair
Surgical Technique for Robotic Paraesophageal Hernia Repair
Robotic Revisional Foregut Surgery
Introduction
Indications and Pre-operative Preparation for Re-operative Foregut Surgery
Surgical Technique of Redo Foregut Surgery
Outcomes
Conclusion
Bibliography
Index