Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with other parameters are needed.
BackgroundPatients who undergo trans-catheter aortic valve replacement (TAVR) may have concomitant aortic aneurysms. We sought to clarify the incidence of aortic aneurysms and its impact on clinical outcomes among patients undergoing TAVR.MethodsWe performed a retrospective analysis of patients with severe symptomatic aortic stenosis who underwent TAVR from January 2012 to June 2016. Multi-detector computer tomography (MDCT) was performed on all patients and images were reviewed to identify thoracic and abdominal aortic aneurysms (TAA and AAA). The incidence of vascular complications (VARC-2 definition), and in-hospital and 6-month major adverse cardiac events (MACE) defined as a composite of all-cause mortality, cardiac arrest, myocardial infarction, and stroke were recorded.ResultsAmong 232 patients included in the analysis, 22 patients (9.5%) had aortic aneurysms (11 had AAA, 8 had TAA, and 3 had both). Patients with aortic aneurysms had a higher, albeit statistically insignificant, rate of smoking history (63.6% vs. 42.9%, p = 0.062). Both groups of patient predominantly underwent TAVR via trans-femoral access (72.7% vs. 71.4%, p = 0.90). The incidence of vascular complications was similar between the two groups (9.1% vs. 10.5%, p = 1.0). Patients with aortic aneurysms had a similar in-hospital MACE (4.5% vs. 6.2%, p = 1.0) and 6-month MACE (9.1% vs. 9.0%, p = 1.0) compared to those without aneurysms.ConclusionsIn our patient cohort, 9.5% of patients who underwent TAVR had concomitant aortic aneurysms. Patients with aortic aneurysms had similar incidence of vascular complications as well as in-hospital and 6-month MACE compared to those without.
As antireflux surgery has been used increasingly for gastroesophageal reflux disease (GERD), a need has arisen for an accurate method to assess esophageal length. There are a number of preoperative tests that can help surgeons to establish the presence of a short esophagus, but intraoperative assessment after esophageal mobilization is the standard method. In this era of laparoscopic surgery, the surgeon mobilizes the esophagus extensively from the abdomen and then determines if mobilization is sufficient. We report an intraoperative technique that combines laparoscopic with endoscopic methods to determine the position of the gastroesophageal junction. Because two physicians are required, there is additional operating room time, resulting in increased costs. However, these costs are offset by the assurance that the complications of the short esophagus can be avoided. With experience, modifications were made, resulting in the technique described herein.
Background: Clinical history remains an important part of the medical evaluation of patients with gastroesophageal reflux disease (GERD). Heartburn, regurgitation, and dysphagia are considered typical symptoms of GERD. Priority rankings of these symptoms can be determined with a standardized questionnaire. Objective: To determine whether symptom priority ranking and symptom severity grading can provide useful information in the evaluation of patients with GERD. Methods: From 1,850 patients that were analyzed retrospectively, patients with dysphagia unrelated to GERD were excluded. A standardized questionnaire was applied before each patient underwent any esophageal diagnostic study. Priority of symptoms was determined to be primary, secondary, tertiary, or none based on the patient response to the questionnaire. Presence of a stricture was determined either by endoscopy, esophagraphy, or both studies. Stationary esophageal manometry and 24-hour pH monitoring were performed on all patients. Through bivariate and multivariate analysis, the relationships among typical GERD symptoms, esophageal reflux-related stenosis, lower esophageal sphincter pressure, and composite score were established. Results: High priority ranking of the symptom dysphagia is predictive of the presence of an esophageal stricture, but has a negative association with abnormal manometric and pH studies. In contrast, high priority ranking of the symptom heartburn and regurgitation are positively associated with abnormal manometric and pH results. Conclusions: Priority ranking can be a valuable adjunct to objective testing in the evaluation of GERD. In certain clinical situations it can obviate the need for 24-hour pH monitoring.
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