Background: Achalasia is a rare esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and aperistalsis, with multiple diagnostic and therapeutic options. ChatGPT, an artificial intelligence (AI)-powered large language model, has demonstrated utility as a patient resource across multiple medical and surgical domains. This study evaluated the accuracy, comprehensiveness, and readability of ChatGPT-generated responses to frequently asked patient questions about achalasia. Methods: Fifty-nine frequently asked achalasia questions were compiled from institutional patient education websites and the achalasia patient community. Each question was entered into ChatGPT (GPT-4; OpenAI) in April 2025 in a separate session, generating an initial response that was then simplified at a lower reading level. Responses were independently rated by two fellowship-trained foregut surgeons, with adjudication by a gastroenterologist with advanced training in esophagology. Initial responses were rated as comprehensive, correct but inadequate, mixed, or completely incorrect. Simplified responses were rated as less, equally, or more accurate and comprehensive than the originals. Readability was assessed using seven validated formulas. Results: Of 59 initial responses, 55 (93%) were rated as comprehensive. Simplified responses were equally accurate in 93% (n = 55) and equally comprehensive in 90% (n = 53) of cases. Initial responses corresponded to a college-to-graduate reading level, whereas simplified responses improved significantly to an eighth- to twelfth-grade reading level ( P < .001). Conclusion: ChatGPT-4 generated accurate and comprehensive responses to patient questions about achalasia and reliably simplified them while preserving content fidelity. ChatGPT may serve as a useful adjunct to physician-led patient information, though appropriate prompting strategies and clinical oversight remain necessary for responsible implementation.
Introduction: African Americans (AA) have a decreased prevalence of Barrett’s esophagus (BE) compared to non-Hispanic Whites (nHw). However, the difference in long-segment (LSBE) or short-segment BE (SSBE) prevalence between AA and nHw has not been determined to date. The study aim was to estimate the odds ratios for histologic LSBE or SSBE between nHw and AA across the available studies. Methods: Publication search in the Medline and Embase databases from 1999 to 2025 was performed. Included studies had histologically confirmed BE and classified it as LSBE or SSBE. Each study was weighted according to its inverse variance. Effect distribution measures were examined using visual and tabular displays as well as tests of homogeneity to reveal risk estimate variation of histologic BE occurrence between AA and nHw using a DerSimonian-Laird random-effects method. Odds ratio was calculated along with 95% confidence intervals. Forest plots were conducted, and a summary odds ratio with 95% CI of histologic BE was reported. Heterogeneity was quantified using the I 2 statistic. A sensitivity analysis was performed comparing results with and without case-control studies. Results: Three eligible studies reported histologic confirmation of LSBE and SSBE in AA and nHw. When pooled, the odds of developing LSBE were 0.095 (95% CI, 0.05-0.15) and 0.31 (95% CI, 0.27-0.34) for SSBE in AA compared to nHw. Conclusions: AA patients have lower odds of developing LSBE and SSBE compared to nHw. Further studies are required to determine the clinical implications and progression to EAC.
Background: Efforts to reduce adverse side-effects of the classic Nissen 360° fundoplication have largely focused on reducing wrap circumference to a partial fundoplication described as anterior or posterior (with the point of reference being the anterior of the body), while the role of fundoplication symmetry has not been examined. This opinion piece from the American Foregut Society (AFS) Anti-Reflux Barrier (ARB) Collaborative evaluates the evolving concept of fundoplication symmetry in the context of ARB function and its surgical restoration. Methods: The AFS Anti-Reflux Barrier Collaborative met monthly (2024-2026) to evaluate commonly performed fundoplications with respect to anterior–posterior symmetry, using the angle of His as a reference point. Expert consensus and relevant historical literature were reviewed. Results: Fundoplications are traditionally classified as anterior, posterior, complete, or partial based on wrap location and circumference. However, when assessed by the degree of anterior versus posterior fundic contact with the esophagus, substantial variability exists. These technical distinctions are rarely detailed in outcome reports. Examples include symmetric fundoplications such as Nissen Anterior-Posterior, Belsey Mark IV, combined transoral incisionless, and Lind 300°, and asymmetric fundoplications such as the Nissen-Rosetti, Toupet, and partial anterior. Transition to minimally invasive surgery has shifted the construction from complete to partial wraps and reduced anterior–posterior symmetry. The ARB Collaborative suggests that restoring symmetric stabilization of the gastroesophageal flap valve with a 90° bare area of esophagus on the lesser curve side most closely resembles the native valve and may optimize outcomes. The proposed AFS Omega configuration described herein reflects this approach. Conclusions: Partial, symmetric valve reconstruction combined with hernia repair may reduce fundoplication side effects without compromising efficacy. The Omega configuration represents a conceptual shift from conventional practice. Fundoplication symmetry—beyond the anterior vs posterior partial distinction—should be systematically reported. Intraoperative endoscopic assessment of valve symmetry may further refine surgical technique and guide future innovation.
The Tissue Systems Pathology-9 (TSP-9) test aids in Barrett’s esophagus (BE) risk stratification by estimating the 5-year probability of progression (PoP) to high-grade dysplasia or esophageal adenocarcinoma. The influence of a personal history of non-esophageal cancer on TSP-9 PoP is unknown. In this analysis, we found that a history of non-esophageal cancer was not associated with elevated PoP at ≥6% threshold. TSP-9 may reflect local BE biology rather than systemic oncological history, but this remains to be elucidated.
The RefluxStop procedure reconstructs the antireflux barrier (ARB) while avoiding sequelae of encircling/compressing the distal esophagus. It has become the primary antireflux procedure at our institutions with few side effects and improved treatment effect based on our experience, including in ineffective esophageal motility (IEM) and large hernia sufferers. Key steps include extensive esophageal dissection superiorly and posterior dissection of the fundus to create a floppy fundus, looser crural repair, 90° to 120° left-sided esophagogastric plication between the vagal trunks, and loose device fundal pouch invagination 5 cm above the angle of His, to stabilize the ARB and gastroesophageal junction.
Esophageal cancer (EC), a highly lethal malignancy with over 445 000 deaths globally in 2022, ranks among the leading causes of cancer mortality globally. As survival improves in EC, cancer therapy-related cardiac dysfunction (CTRCD) has emerged as an important cause of morbidity and mortality. Contemporary treatment strategies involving surgery, fluoropyrimidine-based chemotherapy, immune checkpoint inhibitors, and thoracic radiotherapy expose patients to distinct and overlapping mechanisms of cardiovascular injury. The increasing use of perioperative regimens such as fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) and immunochemotherapy (d-FLOT) approaches further underscores the importance of cardiovascular surveillance. Current evidence suggests that whole-heart dosimetric parameters alone may inadequately predict cardiovascular risk, whereas cardiac substructure-specific assessment and multimodal surveillance may facilitate earlier detection of subclinical injury and more individualized management. However, existing evidence remains largely retrospective, and standardized thresholds for biomarkers, imaging parameters, and surveillance intervals are lacking. Cardio-oncology has become essential in mitigating these risks through early detection and preventive strategies. In this review, we summarize current evidence on the mechanisms, incidence, and predictors of CTRCD in EC. By integrating biochemical, imaging, dosimetric, and predictive modeling approaches, clinicians may better balance oncologic efficacy with cardiovascular safety, reduce long-term cardiac morbidity, and improve overall outcomes in patients undergoing contemporary multimodality treatment for esophageal cancer.
A growing body of literature is beginning to elucidate the role of the microbiome in esophageal cancer. Oral health factors such as tooth loss and periodontal disease are associated with both esophageal microbiome changes and esophageal cancer risk. In esophageal squamous cell cancer, the periodontal pathogens Fusobacterium nucleatum and Porphyromonas gingivalis have been shown to have pro-neoplastic effects and are associated with worse clinical outcomes. Although distinct shifts in esophageal microbiome composition have been described, the role of bacteria in the pathogenesis of esophageal adenocarcinoma remains comparatively understudied. Bacteria represent potential prognostic and therapeutic biomarkers, as well as modifiable targets in esophageal neoplasia.
Resection for refractory peptic strictures at the gastroesophageal junction is often the option of last resort. While resection can be straightforward, the reconstruction options may vary depending on location of the stricture, surgeon experience, and other patient factors. We discuss 4 distinct reconstruction options, including gastric pull up to the upper chest or neck, roux-n-y esophagojejunostomy, colonic interposition, and jejunal interposition graft to the thoracic inlet or higher. Each has different considerations and potential complications. We recommend jejunostomy feeding tubes regardless of reconstruction planned.
Background: Patients with malignant dysphagia and protein-calorie malnutrition from locally advanced esophageal cancer often require enteric nutritional support. Percutaneous endoscopic gastrostomy (PEG) tubes are commonly used in cancer patients. However, the impact of tumor seeding along the gastrostomy tract and its influence on recurrence and survival has not been described. Methods: We performed a retrospective study of patients who underwent esophagectomy for locally advanced esophageal carcinoma by a single surgeon from December 1, 2014 through July 31, 2024. We ascertained risk ratios and 95% confidence intervals to examine the association between implant seeding and recurrence. Kaplan-Meier curves were used to assess survival. Results: Of the 172 patients who underwent esophagectomy over the study period, 14 had PEG tubes placed prior to referral for esophagectomy. Of these, 4 (29%) had tumor seeding at the PEG site. Those who had tumor seeding were 2.5 times (95% CI: 0.83-7.53) ( P = 0.25) more likely to recur and had a lower median survival (22.8 months; range, 13.2-30.7), as compared with those who did not (median, 33.6 months; range, 7.1-69.7) ( P = 0.11), although neither result reached statistical significance. Conclusions: We noted that pre-treatment PEG tubes in patients with locally advanced esophageal carcinoma are associated with a high risk of tumor seeding, which has a negative impact on recurrence and survival rates. For those patients being treated for cure and in need of enteric nutritional support, we recommend alternative feeding access, such as a jejunostomy.
Anti-Obesity Medications (AOM) include multiple classes of medications that can be used for the treatment of obesity which can be categorized as first generation, second generation and third generation AOM. First and Second generation AOM’s were used in a limited number of patients in clinical practice, but the introduction of the third generation of AOMs—semaglutide and tirzepatide, glucagon-like peptide-1 receptor agonist (GLP1-RA) and dual GLP-1/glucose-dependent insulinotropic polypeptide receptor agonist (GIP-RA), respectively, has led to significantly higher obesity treatment with AOMs. These medications are significantly more effective than first and second generation AOMs, however, they also have significant effects on gastrointestinal motility. This has led to a broader discussion on the use of these medications in patients undergoing anesthesia for surgical or endoscopic procedures. In this review we discuss the full-spectrum of anti-obesity medications, their impact on gastric motility, data on clinical outcomes in patients undergoing endoscopic procedures on GLP-1 RA and the current landscape of medical society guidelines for patients on GLP-1 RA undergoing endoscopic procedures.
There are multiple potential complications of eosinophilic esophagitis (EoE). These range from symptom-specific to disease-progression related, which result in fibrostenosis. Clinical manifestations of strictures and narrowing are further complicated by esophageal food impaction (EFI) and esophageal perforation, which can be spontaneous or iatrogenic. This life-threatening complication of EoE is rare and risk can be minimized with careful endoscopic technique during procedures to remove food impactions and during esophageal dilation. Complications of progression can be mitigated with effective EoE treatment and structured patient follow-up and monitoring. This paper reviews this spectrum of EoE complications and discusses assessment, management and prevention.
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal disease increasingly encountered by surgeons across foregut practice, presenting as dysphagia, food bolus impaction, and fibro stenotic strictures. Although medical and dietary therapies are first-line, surgeons play a critical role in perioperative recognition, obtaining diagnostic biopsies at the index endoscopy, and endoscopic management. This clinically focused review highlights clinical cues for EoE, best practices for endoscopy and biopsies, pathophysiology, and operative planning considerations, and evolving treatment paradigms. Durable outcomes require multidisciplinary coordination to optimize inflammation, prevent recurrent fibro stenosis, and avoid inappropriate operations or reoperations.
Background: Gastroparesis is a common complication after lung transplantation, characterized by delayed gastric emptying that causes nausea, vomiting, and abdominal distension. It is often severe, refractory to medical therapy, and may require surgical intervention. This condition can lead to respiratory complications such as microaspiration and obliterative bronchiolitis. Gastric per-oral endoscopic myotomy (G-POEM) has emerged as a promising treatment for refractory cases.Methods: This multicenter retrospective study included post-lung transplant patients who underwent G-POEM for medically refractory gastroparesis at four U.S. tertiary centers. The primary outcome was clinical response, defined as a >= 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI).Results: Fifty-eight patients (mean age 53.8 +/- 12.0 years; 32 female) underwent G-POEM at a median of 12.5 months post-transplant. Gastroparesis was diagnosed at a median of 4.8 months post-transplant, with severe to very severe delayed gastric emptying in 47 of 52 patients based on gastric emptying studies. Fourteen patients (24.1%) were dependent on a gastrojejunostomy tube at baseline. On follow-up, 9 of 13 patients with available data were able to discontinue tube feeds and tolerate a regular diet. All procedures were technically successful. Clinical success was achieved in 73% of patients, with no intraprocedural or postprocedural complications. Follow-up gastric emptying studies were available in 36 patients, of whom 29 showed improvement or normalization.Conclusions: This study demonstrates that G-POEM is a safe and effective treatment for refractory gastroparesis in lung transplant recipients and represents a viable option for this complex patient population, warranting further studies to confirm long-term outcomes.
