No abstract

No abstract

While abnormal EGJ and esophageal body metrics are collectively associated with elevated esophageal reflux burden, increasing proportions of failed swallows are better predictors of reflux burden and outcome compared to the current IEM definition.

Background Association between proportions of hypomotile swallows on esophageal high‐resolution manometry (HRM) and esophageal reflux burden remains incompletely understood. We investigated relationships between hypomotility, acid exposure time (AET), and mean nocturnal baseline impedance (MNBI) on ambulatory reflux monitoring. Methods Clinical data, HRM, and ambulatory pH‐impedance studies (performed off acid suppression) from patients with persisting reflux symptoms were reviewed from five international centers. AET (abnormal > 6%) and MNBI (abnormal < 2292 ohms) were extracted from pH‐impedance studies. Distal contractile integral (DCI) designated esophageal peristalsis into normal (DCI > 450 mmHg.cm.s), fragmented (DCI > 450 mmHg.cm.s with breaks > 5 cm), weak (DCI 100‐450 mmHg.cm.s), and failed (DCI < 100 mm mmHg.cm.s) sequences. Univariate and multivariate analyses were performed to identify motor associations of abnormal reflux burden. Key Results Of 351 patients (52.1 ± 0.8 years, 67%F), 29.3% had AET > 6% and 61.8% had MNBI < 2292 ohms. On univariate analysis, both fragmented peristalsis and IEM associated with abnormal AET (P ≤ .01) and MNBI (P ≤ .03); reflux burden was more profound with >70% fragmented as well as ineffective sequences compared to ≤70% for each (P < .05 for each comparison). When weak and failed sequences within IEM were separately analyzed, ≥50% failed sequences predicted abnormal AET (P ≤ .009), and ≥50% weak sequences did not (P = .14). On multivariate regression, ≥50% failed sequences predicted abnormal AET (P = .02), and >70% ineffective sequences trended strongly (P = .069); >70% ineffective sequences predicted abnormal MNBI (P = .046), and >70% fragmented sequences trended strongly (P = .076). Conclusions and Inferences Breaks in esophageal peristaltic integrity seen with fragmented and failed sequences are more relevant to abnormal esophageal acid burden than weak sequences.

Evidence suggests that preoperative IABP may have a beneficial effect on mortality and morbidity in specific high risk patient groups undergoing coronary artery bypass grafting, however there are many problems with the quality, validity and generalisability of the trials. However, the available evidence is not robust enough to extend the use of IABP to truly elective, high risk patients. Defining more precisely which patient groups may benefit would be the challenge for the future.

The aim of this study was to evaluate the effect of preoperative delay on the efficacy of video-assisted thoracoscopic surgery (VATS) for post-pneumonic pleural empyema (PPE). This was a prospective study of 39 consecutive patients with PPE who were treated by VATS with curative intent over a 4-year period. Failure to obtain full lung re-expansion resulted in conversion to thoracotomy. Pre- and post-operative variables were correlated with surgical outcome. VATS debridement was successful in 16 (41%) patients while conversion to open decortication was needed in 23 patients (21 immediate, two delayed), There was no difference in the age/sex distribution of the two groups. In the failed VATS group the delay from hospital admission to operation was longer: 24 (2.1) vs. 16.6 (2.7) days (P = 0.03, 95% CI 0.53-14.3 days); operating time was longer: 128.2 (7.9) vs. 86.2 (10.4) min (P = 0.003, 95% CI 15.2-68.5 min) and post-operative stay was longer: 8.4 (0.8) vs. 5.2 (0.6) days (P = 0.03, 95% CI 1.1-5.3 days). VATS can be used successfully to treat PPE with a faster post-operative recovery when successful than open surgery. Delayed surgical intervention decreases the success of VATS thus earlier referral for surgical intervention in PPE (ideally within 21 days) is advocated to gain its full benefits.

No abstract

Background Mean nocturnal baseline impedance (MNBI) augments the diagnostic yield of multichannel intraluminal impedance‐pH (MII‐pH) monitoring. While acid exposure time (AET) correlates with MNBI, it remains unclear whether esophageal motility affects MNBI values. The present study was aimed at evaluating the respective roles of esophageal motor function and AET on MNBI. Methods High‐resolution manometry (HRM) studies and ambulatory 24‐hour MII‐pH monitoring tracings were retrospectively analyzed from consecutive endoscopy‐negative GERD patients with typical symptoms responsive to previous acid‐suppressive therapy from three tertiary care centers. Univariate and multivariate analyses were performed to determine predictors of pathologic MNBI values at 3 cm and 5 cm above the lower esophageal sphincter (LES). Key Results Patients with pathological AET displayed lower MNBI values at 3 cm and 5 cm (P < .01) compared to patients with non‐pathological AET. Similarly, significantly lower MNBI values were also noted at both sites with type 3 EGJ compared to type 1 EGJ (P ≤ .02 for each comparison), and with absent contractility compared to normal peristalsis (P ≤ .02 for each comparison). On multivariate analysis, the presence of type 2 or 3 EGJ and absent contractility were associated with a significantly higher probability of pathological MNBI values at 3 cm and 5 cm above the LES. Conclusions and Inferences Disruption of the EGJ and absent contractility on HRM are both associated with lower MNBI values. HRM findings complement reflux testing using MII‐pH monitoring.