Objective: This American Foregut Society consensus utilized existing literature and international expert opinion to provide a better definition and clinical approach to nonerosive reflux disease (NERD) that harmonizes with modern published concepts and consensus processes. Methods: A core expert group (14 gastroenterologists and foregut surgeons) developed the initial statements supported by a systematic literature review using a modified Delphi process. The statements were reviewed and voted upon by a separate voting group (17 expert gastroenterologists and foregut surgeons). Multiple iterations of the statements were created with anonymous voting and virtual discussions to develop consensus. Consensus agreement required ≥80% of voting group rating statements 7 to 9 on a 9-point Likert scale. Results: The core group proposed 41 statements, with the most in the treatment and prognosis category (n = 12) and the fewest in the definition category (n = 4). After round one, there was a consensus of agreement on 25 statements (61%). In round two, a virtual discussion was held, and the 16 remaining statements underwent language modification for repeat voting. In round three, consensus was reached on 11 of the 16 statements. Therefore, agreement was reached on 36 of the original 41 proposed statements (87.8%). The final statements with consensus agreement ranged from definition of NERD (n = 4), epidemiology and natural course (n = 8), pathophysiology (n = 6), diagnosis (n = 6), to treatment and prognosis (n = 12). Conclusions: Evidence-based statements provide a clinical description of NERD and a standardized framework for future collaborative research.
Zenker’s diverticulum (ZD) is a rare pulsion-type hypopharyngeal pseudodiverticulum caused by cricopharyngeal motor dysfunction that presents with dysphagia, regurgitation, cough, and aspiration in older adults. Diagnosis is established with contrast esophagram and endoscopy. Transoral stapled cricopharyngeal myotomy is performed using a rigid Weerda scope followed by mechanical stapler division of the common septum. Large contemporary series demonstrate excellent symptom relief, low perioperative morbidity, and staple-line leak rates of less than 1%. Conversion to open repair is required in 5% to 13% of patients because of unfavorable anatomy, while recurrence requiring reintervention occurs in 5% to 10%. Careful patient selection and meticulous operative technique are essential for optimal outcomes.
Background: Endoscopic surveillance of Barrett’s esophagus (BE) aims to detect dysplasia early, but the risk of neoplastic progression in BE is highly variable. Histology, the current gold standard for risk stratification, has limitations that may contribute to the modest impact of surveillance on esophageal adenocarcinoma (EAC) mortality. The Tissue Systems Pathology-9 (TSP-9) test provides personalized prognostic data on progression to high grade dysplasia (HGD) or EAC within 5 years and may improve risk stratification. Methods: The American Foregut Society convened a panel of 10 gastroenterologists and 4 foregut surgeons with BE expertise. The RAND/UCLA Appropriateness Method was used to evaluate the role of TSP-9 across clinical scenarios and BE phenotypes (nondysplastic [NDBE], indefinite for dysplasia [IND], and low-grade dysplasia [LGD]). A literature review informed the scientific basis, rationale and clinical integration of TSP-9. Results: Consensus was reached on 15 statements; 5 did not reach agreement. The panel supported TSP-9 for risk assessment in NDBE, IND, and LGD independent of histology. In NDBE/IND, low-risk scores support guideline-based surveillance. Intermediate risk scores warrant consideration of closer surveillance or endoscopic eradication therapy (EET), while high-risk scores favor closer surveillance or EET. For LGD EET was supported for intermediate or high-risk scores, but no consensus was reached for low-risk scores. TSP-9 was considered useful for identifying prevalent dysplasia and high-risk patients for early intervention. Uncertainty remained regarding performance in erosive esophagitis and relative to expert pathology in IND/LGD. Conclusions: These consensus-based recommendations support the use of TSP-9 to enhance BE risk stratification and guide management.
Background: Esophagectomy is associated with an extended clinical course and a challenging, prolonged recovery. Prehabilitation programs aim to improve postoperative outcomes, particularly in complex surgeries like esophagectomy. This study evaluates the implementation and feasibility of the Thoracic Surgery Optimization Program (TOP), for esophagectomy patients. Methods: A retrospective study was performed of all patients that underwent esophagectomy from 2022 to 2024. Patients were divided into two groups: the “No TOP” group (before TOP, 01/2022-10/2023) and the “TOP” group (after TOP, 11/2023-06/2024). Variables analyzed included compliance with program components, G8 Frailty scores, and postoperative outcomes such as LOS, ICU LOS, complications, and time to adjuvant therapy. Results: There were 71 esophagectomies included, mean age 69 years old with 39 (54.9%) in the No TOP group and 32 (45.1%) in the TOP group. After the implementation of TOP, frailty assessments identified 71.9% of patients as frail with a median frailty score 11. TOP participants demonstrated good compliance with the prehabilitation program components with % compliance with physical therapy, 87.5% compliance with nutrition, and 62.5% compliance with the overall program. There were no significant differences in complication or readmission rates between groups. 62.5% of the TOP group ambulated on POD1. Patients in the TOP group had shorter ICU LOS (1.9 vs 5.7 days, P = .003), however, no significant differences were observed in total hospital length of stay, postoperative complications, or readmissions. Conclusion: Implementation of the TOP was feasible with good participation in multidisciplinary prehabilitation among patients undergoing esophagectomy, including those identified as frail. Although shorter ICU stays and more frequent POD1 ambulation were observed after implementation, the retrospective before-and-after design and potential for temporal and care-process confounding prevent attribution of these differences to TOP. A substantial effect on overall postoperative recovery was not established.
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by esophageal dysfunction and progression to fibrostenotic remodeling. Advances in understanding the underlying type 2 inflammatory pathways have led to the development of targeted biologic therapies, with dupilumab representing the first approved agent for this condition. This chapter reviews the pathophysiology of EoE and rationale for targeted therapies including mechanisms of action, key clinical trial data, and emerging therapies under investigation. As therapeutic options expand, important questions remain regarding patient selection and personalization of therapy, optimal treatment positioning, and the long-term safety and effectiveness of biologic therapy.
