Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation, whose incidence is rising. It significantly affects patients’ quality of life and, if left untreated, results in fibrotic complications. Although broad consensus has been achieved on first-line therapy, a subset of patients remains non-responder to standard therapy. The pathogenesis of EoE is multifactorial and results from the complex, still mostly undefined, interaction between genetics and intrinsic factors, environment, and antigenic stimuli. A deep understanding of the pathophysiology of this disease is pivotal for the development of new therapies. This review provides a comprehensive description of the pathophysiology of EoE, starting from major pathogenic mechanisms (genetics, type 2 inflammation, epithelial barrier dysfunction, gastroesophageal reflux, allergens, infections and microbiota) and subsequently focusing on the single protagonists of type 2 inflammation (involved cells, cytokines, soluble effectors, surface proteins and transcription factors) that could represent present and future therapeutic targets, while summarizing previous therapeutic approaches in literature.

A redo myotomy should be considered in patients who underwent myotomy for achalasia and presenting with recurrent dysphagia. Preliminary results using POEM indicate that the technique can be safely used in patients who have undergone previous surgical myotomy.

Achalasia is a neurodegenerative motility disorder of the esophagus; dysphagia, weight loss, chest pain, and regurgitation are its main symptoms. Surgical myotomy (HM) is considered the gold standard treatment. However, peroral endoscopic myotomy (POEM) seems to be a safe and effective alternative option. The aim of this study is to compare the safety and efficacy of these techniques. From March 2012 to June 2015, 74 patients with symptomatic primary achalasia underwent myotomy. The two groups were compared in terms of intraoperative and postoperative outcomes and Eckardt score at last follow-up. A morphofunctional comparison was also performed. Thirty-two myotomies were performed endoscopically (POEM group) and 42 were performed laparoscopically with a 180° anterior fundoplication (surgical myotomy [SM] group). Operative time was significantly shorter for the POEM group (63 [range: 32-114] vs. 76 minutes [54-152]; P = 0.0005). Myotomy was significantly longer for the POEM group (12 [range: 10-15] vs. 9 cm [range: 7-10]; P = 0.0001). Postoperative morbidity occurred in two patients (4.7%) in the SM group; no complications (P = not significant) were recorded for the POEM group. The median Eckardt score at last follow-up decreased for each group from 6 to 1 (P < 0.001). Morphological evaluation was performed for 20 patients and functional evaluation was performed in 18 patients of each group. Lower esophageal sphincter resting and relaxation pressures were significantly reduced in both groups (P < 0.001). Eight patients in the POEM group (40%) had esophagitis at endoscopy: 4 (20%) with Los Angeles (LA) grade A, 3 (15%) with LA grade B, and 1 patient with LA grade D (5%). Five patients in POEM group (28%) had a pathologic DeMeester score. In the SM group, one patient (5%) had esophagitis (P = 0.04; 95% CI) and 4 patients (22%) presented a pathological DeMeester score. Perioperative results for POEM and SM are similar. The absence of an antireflux wrap leads to an increased risk of reflux with consequent esophagitis. SM with an antireflux wrap could be a preferred choice when a long standing gastroesophageal reflux could potentially lead to a damage as, for example, in young patients.

Purpose To evaluate the post-coronavirus disease-19 (COVID-19) outcome of thyroid function in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related thyrotoxicosis. Methods This was a single-center prospective study involving 29 patients (11 females, 18 males; median age 64 years, range: 43-85) with thyrotoxicosis diagnosed after hospitalization for COVID-19 and then followed-up for a median period of 90 days (range: 30-120) after hospital discharge. At follow-up, patients were evaluated for serum thyrotropin (TSH), freethyroxine (FT4), free-triiodiothyronine (FT3), TSH receptor antibodies (TRAb), thyroglobulin antibodies (TgAb), thyroperoxidase antibodies (TPOAb) and ultrasonographic thyroid structure. Results After recovery of COVID-19, serum TSH values significantly increased (P < 0.001) and FT4 values significantly decreased (P = 0.001), without significant change in serum FT3 (P = 0.572). At follow-up, 28 subjects (96.6%) became euthyroid whereas overt hypothyroidism developed in one case. At the ultrasound evaluation of thyroid gland, hypoecogenicity was found in 10 patients (34.5%) and in these cases serum TSH values tended to be higher than those without thyroid hypoecogenity (P = 0.066). All subjects resulted to be negative for TgAb, TPOAb and TRAb. Conclusion In a short-term follow-up, thyroid function spontaneously normalized in most subjects with SARS-CoV-2-related thyrotoxicosis. However, thyroid hypoecogenicity was found in a remarkable number of them and future longer-term studies are needed to clarify whether this ultrasonographic alteration may predispose to develop late-onset thyroid dysfunction.

Background: The long-term outcomes of esophageal peroral endoscopic myotomy (POEM) are still unknown. Methods: We searched electronic databases (Medline/Pubmed, EMBASE, Scopus) for studies assessing outcomes after POEM for esophageal achalasia, with a minimum median follow-up duration of 36 months. Pooled rates of clinical success and post-operative reflux were calculated and compared with the same values at 12/24/36 months when available. Sub-group analyses were also performed to explore the inter-study heterogeneity. Results: From 1528 initial records, 11 studies (2017-2021) satisfied all the eligibility criteria for inclusion. A total of 2342 (48.1 ± 6.8 years; 50.1% males) patients were analyzed with a median follow-up of 48 (IQR, 45-60) months. Pooled clinical success rate was 87.3% (95% CI, 86.3%-91.0%; I2= 73.1%). Symptomatic reflux pooled rate was 22.0% (95% CI, 14.4%-29.5%, I2= 92.7%). Three cases of peptic strictures and one Barrett’s esophagus were reported. Pooled rate of severe adverse events was 1.5% (95% CI, 0.5%–2.5%, I2= 52.8%). Conclusions: Long-term clinical efficacy of POEM persists in nearly 87% of patients with achalasia. Post-POEM symptomatic reflux seems to remain stable over time. Risk for Barrett’s esophagus and peptic strictures appears minimal.