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Pharyngoesophageal injury has high morbidity and mortality despite advances in diagnostics and surgical therapy. It is essential to rapidly identify patients injury to avoid severe sequelae. In this review, the common etiologies of penetrating esophageal injury will be reviewed as well as the initial evaluation and diagnostic techniques. Management of pharyngoesophageal injuries will be discussed including indications for observation, endoscopic management, or open surgical repair.

Background High-power, short-duration ablation for pulmonary vein isolation (PVI) in the treatment of atrial fibrillation (AF) facilitates the procedure and improve effectiveness; however, esophageal injury remains a safety concern. Objective The purpose of this study was to investigate the role of luminal esophageal temperature (LET) monitoring during high-power ablation for PVI in terms of endoscopic esophageal lesion. Methods Patients with symptomatic AF underwent ablation index–guided high-power (AI-HP) PVI (50 W; AI anterior wall/posterior wall: 550/400). In the first consecutive set of patients, an insulated esophageal temperature probe was used for LET monitoring (cutoff LET >39°C) (group A). In the second consecutive set of patients, the probe was not used (group B). All patients were scheduled to undergo esophageal endoscopy 1–3 days after ablation. Results A total of 120 patients (60 group A; 60 group B) were included in the study (mean age 67.8 years; 64% male). Baseline characteristics and procedural outcomes were similar between the 2 groups. Procedural PVI was achieved in all patients. First-pass PVI rate was 96.6%. Mean procedural radiofrequency (RF) time was 11.5 minutes, mean procedural time was 55.5 minutes, and fluoroscopic time was 5.6 minutes. Mean contact force at the LA posterior wall was 23 g, and mean RF ablation time at the LA posterior wall was 3.2 minutes. Two patients in group A and 1 patient in group B had endoscopic small esophageal lesions (P = .99). No serious procedural adverse events were observed. Conclusion Among patients undergoing AI-HP (50 W) PVI, the incidences of ablation-related endoscopic esophageal lesion in patients with and those without use of a temperature probe for LET monitoring (cutoff 39°C) were comparably low.

Background Increased peak luminal esophageal temperature (LET) is associated with increased risk of esophageal injury after left atrial posterior wall (LAPW) ablation. The magnitude, distribution, and risk factors of LET increase with high-power short-duration (HPSD) LAPW ablation are not well understood. Objective The purpose of this study was to describe the spatial and temporal characteristics of LET changes associated with HPSD LAPW radiofrequency (RF) ablation. Methods LET was sampled at 20 Hz using a 12-point esophageal temperature monitor (CIRCA S-CATH; Circa Scientific, Inc) in 16 patients undergoing LAPW ablation. Esophageal temperature sensor position and lesion locations were recorded using an electroanatomic mapping system with fluoroscopic integration (CARTO 3, CARTOUNIVU; Biosense Webster, Inc). Point-by-point LAPW ablation was performed at 50 W for 6 seconds. The first 20 LAPW lesions were individually analyzed in each patient. Results LET increase ≥4°C (8 lesions: max LET 5.8°C), 2°–4°C (34 lesions), and 1°–2°C (58 lesions) occurred at 9 ± 2 mm, 8 ± 2 mm, and 13 ± 2 mm from sensors, respectively. Lesions placed >20 mm from a temperature sensor did not result in an LET increase ≥2°C. Temperature resolution to within 1°C of baseline occurred ∼60 seconds after cessation of RF application. Consecutive lesions resulting in additive heating of at least 1°C occurred in 17 lesion pairs with an interlesion distance of 9 ± 4 mm and interlesion time of 21 ± 4 seconds. Conclusion HPSD LAPW ablation can result in severe esophageal temperature increases. Significant LET increase will be undetected when lesions are >20 mm away from a temperature sensor. Additive LET increase was observed with consecutive lesions placed

New strategies recently proposed to mitigate injury caused by lithium coin cell batteries lodged in the esophagus include prehospital administration of honey to coat the battery and prevent local hydroxide generation and in-hospital administration of sucralfate suspension (or honey). This study was undertaken to define the safe interval for administering coating agents by identifying the timing of onset of esophageal perforations.A retrospective study of 290 fatal or severe battery ingestions with esophageal lodgment was undertaken to identify cases with esophageal perforations.Esophageal perforations were identified in 189 cases (53 fatal, 136 severe; 95.2% in children ≤4 years). Implicated batteries were predominantly lithium (91.0%) and 92.0% were ≥20 mm diameter. Only 2% of perforations occurred in24 h following ingestion, including 3 severe cases with perforations evident at 11-17 h, 12 h, and 18 h. Another 7.4% of perforations (11 cases) became evident 24 to 47 h post ingestion and 10.1% of perforations (15 cases) became evident 48 to 71 h post ingestion. By 3 days post ingestion, 26.8% of perforations were evident, 36.9% by 4 days, 46.3% by 5 days, and 66.4% by 9 days.Esophageal perforation is unlikely in the 12 h after battery ingestion, therefore the administration of honey or sucralfate carries a low risk of extravasation from the esophagus. This first 12 h includes the period of peak electrolysis activity and battery damage, thus the risk of honey or sucralfate is low while the benefit is likely high.

Background Currently, little is known about the onset, natural progression, and management of esophageal injuries after atrial fibrillation (AF) ablation. Objectives We sought to provide a systematic review on esophageal injury after AF ablation and identify temporal relationships between various types of esophageal lesions, their progression, and clinical outcomes. Methods A comprehensive search of PubMed and Web of Science was conducted until September 21, 2017. All AF ablation patients who underwent upper gastrointestinal endoscopy within 1 week of the procedure were included. Patients with esophageal lesions were classified into 3 types by using our novel Kansas City classification: type 1: erythema; type 2a: superficial ulcers; type 2b: deep ulcers; type 3a: perforation without communication with the atria; and type 3b: perforation with atrioesophageal fistula. Results Thirty studies met our inclusion criteria. Of the 4473 patients, 3921 underwent upper gastrointestinal evaluation. The overall incidence of esophageal injuries was 15% (570). There were 206 type 1 lesions (36%), 222 type 2a lesions (39%), and 142 type 2b lesions (25%). Six of 142 type 2b lesions (4.2%) progressed further to type 3, of which, 5 were type 3a and 1 was type 3b. All type 1 and type 2a and most type 2b lesions resolved with conservative management. One type 3a and 1 type 3b lesions were fatal. Conclusion Based on our classification, all type 1 and most type 2 lesions resolved with conservative management. A small percentage (4.2% [6 of 142]) of type 2b lesions progressed to perforation and/or fistula formation, and these patients need to be followed closely.

Objectives This study retrospectively evaluated the feasibility and esophageal thermal injury (ETI) patterns of high-power short-duration (HPSD) radiofrequency atrial fibrillation (AF) ablation. Background ETI following AF ablation can lead to serious complications. Little consensus exists on the optimal radiofrequency power setting or on the optimal strategy to assess ETI. Methods A total of 687 patients undergoing first-time AF ablation with either HPSD ablation (50 W for 5 s, n = 574) or low-power long-duration ablation (LPLD, ≤35 W for 10 to 30 s, n = 113) were analyzed. ETI was assessed by late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) within 24 h post-ablation. Patients with moderate or severe esophageal LGE had a follow-up MRI within 24 h to 1 week, and esophagogastroduodenoscopies were performed when significant gastrointestinal symptoms or persistent LGE on repeat MRI was present. AF recurrence adjusted for potential confounders was analyzed. Results The average age was 69.0 ± 11.8 years in the group undergoing HPSD ablation versus 68.3 ± 11.6 years in the LPLD group (p = 0.554), with 67.1% versus 59.3% male (p = 0.111). Esophageal LGE patterns were similar (64.8% vs. 57.5% none, 21.0% vs. 28.3% mild, 11.5% vs. 11.5% moderate, 2.8% vs. 2.7% severe for HPSD vs. LPLD, respectively; p = 0.370) with no atrioesophageal fistulas. Mean procedure length was significantly shorter in the HPSD group (149 ± 65 min vs. 251 ± 101 min; p Conclusions HPSD ablation results in similar ETI patterns, as assessed by same-day LGE MRI, compared with the LPLD setting but with significantly shorter procedure times. Recurrence rates at 2.5-year follow-up are similar.

Background We illustrate the case of an unstable fracture of the cervical spine in ankylosing spondylitis with associated esophageal injury after minor trauma. Case Description A 66-year-old man fell backwards from the first rung of a ladder, sustaining a transverse fracture of the C6 vertebral body and a new diagnosis of ankylosing spondylitis. He was taken for surgical fixation; however, his esophagus was discovered entrapped within the fracture at the time of surgery. Despite the severity of the injury, with surgical reduction, fixation, and esophageal exclusion this patient made a full recovery. Conclusion This case demonstrates the severity of injury after minor trauma in the context of ankylosing spondylitis, the capacity for full recovery in esophageal perforations in spinal trauma, and that clinical suspicion of such injuries allows early diagnosis, treatment, and reduced complications.

Esophagitis results from diverse causes, including gastroesophageal reflux, immune-mediated or allergic reactions, therapeutic complications, and infections. The appropriate clinical management differs in each of these situations and is often guided by pathologic interpretation of endoscopic mucosal biopsy specimens. This review summarizes the diagnostic features of unusual forms of esophagitis, including eosinophilic esophagitis, lymphocytic esophagitis, esophagitis dissecans superficialis, drug-induced esophageal injury, and bullous disorders. Differential diagnoses and distinguishing features are emphasized.

Traumatic esophageal injuries occur less than 10% of the time in the setting of blunt or penetrating trauma. The purpose of this literature review is to provide an update on the most recent changes involving the diagnosis and treatment of esophageal injuries. A literature search was conducted using PubMed, to identify articles written in English language with the terms "non- iatrogenic", "esophageal", "trauma", "diagnosis", "management", and "prognosis". Case reports and articles involving non-traumatic esophageal perforations were excluded. Fifty pertinent articles in English language from 1947 to 2015 were selected for review. Based on the review of all articles, we designed a diagnostic and therapeutic algorithm to facilitate the diagnosis and management of the traumatic esophageal injury.

A 37-year-old incarcerated male ingested a complex “X-shaped” foreign body that resulted in a penetrating aorto-esophageal injury. A primary esophagotomy with retrieval of the foreign body and muscle flap closure was performed simultaneously with thoracic endovascular aortic repair. This multidisciplinary surgical approach controls for both immediate exsanguination and postoperative complications to improve patient outcome.

Injuries related to button battery ingestion have become increasingly common in children. Recognition of battery ingestion is often delayed and thus leads to serious esophageal injury. Resultant distal acquired tracheoesophageal fistulas are difficult to safely access and repair. Herein, we report the multidisciplinary repair of a distal tracheoesophageal injury, secondary to battery ingestion, via an innovative trans-cervical surgical approach.

INTRODUCTIONBlunt esophageal injuries secondary to external air compression of anterior chest and abdomen complicated with esophageal perforation are uncommon events associated with worse outcomes.PRESENTATION OF CASEWe reported a rare case of esophageal perforation following an external air-compression injury along with the relevant review of literatures. The patient presented with chest pain and shortness of breath and was managed with tube thoracostomy, followed by thoracotomy and eventually with temporary endoscopic stenting.DISCUSSIONIn such trauma case, the external pressurized air forms a shock wave which usually directed to the hollow viscus. Patients with external air-compression injury presented with chest pain and pneumothorax should be suspected for esophageal perforation.CONCLUSIONHigh index of suspicion is needed for early diagnosis of esophageal perforation after blunt trauma. Appropriate drainage, antibiotic and temporary endoscopic esophageal stenting may be an optimal approach in selected patients, especially with delayed diagnosis.

SummaryAimsEsophageal-left atrial (LA) fistula during atrial fibrillation (AF) ablation is a fatal event. We explored the relation of the esophagus-to-ablated point distance and esophageal temperature rise.MethodsConsecutive patients (n=106) underwent complex fractionated atrial electrogram-guided AF ablation using CartoMerge; the pulmonary veins were isolated in 23 patients. Maximum radiofrequency (RF) power near the esophagus was 15W. Ablated points with esophageal temperature rise (monitored with a probe) to ≥38.0°C were tagged; if ≥39.0°C, RF was discontinued.ResultsOf 1647 ablated points near the esophagus, 274 were associated with a temperature rise to 38.0–38.9°C and 241 points to ≥39.0°C. Distances (mm) from points to esophagus were 5.1±0.6 (no rise), 4.2±3.1 (38.0–38.9°C), 2.9±2.5 (≥39.0°C). Altogether, 15.5% of points in the upper LA posterior wall, 41.5% in the middle, and 30.2% in the lower caused rises to ≥38.0°C; 8.7%, 24.6%, and 11.0% caused rises to ≥39.0°C. The middle wall was most affected (p5.0mm distance was 2.28 (p=0.004). The longest distance for ≥38.0°C rise was 18.5mm.ConclusionDistance is an important predictor of esophageal temperature rise. The middle LA posterior wall is most vulnerable. A dose of 15W is too high for ablation, especially 20.0mm away are relatively safe.

To assess the posterior left atrial–esophageal relationship throughout the cryoablation of atrial fibrillation, avoiding esophageal injury and even more severe complication of post procedure atrial esophageal fistula. From July 2016 to September 2016, 36 consecutive atrial fibrillation patients

Esophageal injury is a rare complication of atrial fibrillation ablation procedures. Undiagnosed, it can progress to ulceration, perforation and, rarely atrioesophageal fistula (AEF) formation. A 60 year old man with history of atrial fibrillation, mechanical aortic valve and warfarin intolerance

Esophageal injury related lesions post atrial fibrillation (AF) ablation range from superficial erythema to a full blown atrio-esophageal fistula (AEF). Very little is known about the natural progression of these lesions. We performed a systematic review of the literature to identify temporal

Intraoperative transesophageal echocardiography (TEE) is an invaluable tool for the management of cardiac surgical procedures. It allows evaluation of myocardial function, valvular pathology, atheromatous disease, dissection of the aorta, and estimation of pulmonary artery pressure. Despite its relative safety, TEE has a reported estimated risk of 0.18%. Esophageal injury is the major risk associated with TEE placement. This is a case report of a patient who sustained a contained esophageal dissection during insertion of a TEE probe prior to minimally invasive mitral valve repair. It is also a demonstration of use of the multi-imaging modalities used to evaluate and manage patients until full recovery.

A range of tests is available to the physician pursuing the diagnosis of gastroesophageal reflux disease (GERD). Many times, these studies are unnecessary because the history is sufficiently revealing to identify the presence of troubling reflux disease. 1 However, this may not be the case and the clinician must decide which tests to choose to arrive at a diagnosis in a reliable, timely, and cost-effective manner (Table 1). Furthermore, the various esophageal tests need to be selected carefully depending upon the information desired. For example, identifying the presence of gastroesophageal reflux disease is different from proving that the patient's symptoms are caused by reflux episodes. Additionally, defining that acid reflux exists may not be enough. To tailor appropriate medical or surgical therapy requires knowing whether complications of GERD are present as well as possible mechanisms by which abnormal GER occurs. A thorough and well-devised investigation strategy requires knowledge of testing procedures ranging from radiology and pathology to physiology and endoscopy. An informed background in these areas allows the clinician and investigator to address not only the presence of reflux and its correlation to patient symptoms but also the severity of esophageal injury and even the mechanisms by which the damage is done. By using the available tests judiciously, one can increase the opportunity of making a correct diagnosis of GERD and simultaneously limit the potential inconveniences or cost to the patient.

We present a useful technique for the surgical management of long-segment cervical esophageal tears using a sternocleidomastoid flap with overlying skin patch. The flap is easily accessible, customizable, and offers the ability to repair long segments of cervical and upper thoracic esophageal injuries.

Background: Rapid and significant rise in esophageal temperature (ET) during radiofrequency ablation (RFA) for atrial fibrillation (AF) can be an indicator of an esophageal injury and limits our ability to achieve pulmonary vein isolation(PVI) by incomplete left atrial posterior wall (PW)ablation.

Survival after blunt neck trauma resulting in combined tracheal and esophageal injury is uncommon. We present the case of a young boy who sustained complete transection of the trachea and subtotal transection of the esophagus after a clothes line type injury.

The esophageal wall can only respond to injury in a limited fashion. This article explores some of the protective mechanisms involved as well as current approaches to diagnosis and management of chemical- and radiation-induced esophageal injury.

BACKGROUND Catheter ablation of the left atrium ( LA) is associated with potential collateral injury to surrounding structures, especially the esophagus and the right phrenic nerve (PN). OBJECTIVES The purpose of this study was to evaluate the efficacy and feasibility of intrapericardial balloon placement (IPBP) for the protection of collateral structures adjacent to the LA. METHODS Electroanatomic mapping was performed in porcine hearts using a transseptal endocardial approach in eight swine weighing 40-50 kg. An intrapericardial balloon was inflated in the oblique sinus, via percutaneous epicardial access, to displace the esophagus. Similarly, with the balloon positioned in the transverse sinus, IPBP was used to displace the right PN. Esophageal temperature was monitored while endocardial radiofrequency (RF) energy was delivered to the distal inferior PV. RESULTS In all cases, balloon placement was successful with no significant effects on hemodynamic function. Balloon inflation increased the distance between the esophagus and posterior LA by 12.3 +/- 4.0 mm. IPBP significantly attenuated increases in luminal esophageal temperature during endocardial RF application (6.1 +/- 2.4 degrees C vs. 1.2 +/- 1.1 degrees C; P

The predictive value of initial clinical evaluation in the management of alkaline corrosive ingestion remains unclear. This multicenter study was designed to determine if specific clinical signs and symptoms following ingestion of alkaline corrosives could predict significant esophageal injury. Alkaline corrosives were defined by a pH greater than or equal to 12. Signs and symptoms previously suggested as predictive of significant esophageal injury were documented on a standardized data form. Esophagoscopy reports were reviewed blinded to initial symptoms. Three hundred thirty-six alkaline-corrosive ingestions were analyzed. The mean number of symptoms reported in patients who did not have esophagoscopy was 1.2, in patients who had esophagoscopy was 3.0, and in patients that had visualized second or third degree esophageal burns was 4.8. Of 88 patients who had esophagoscopy, 63 (72%) had both the esophagoscopy report and initial symptom assessment available. Esophagoscopy was positive, defined as second or third degree esophageal burns, in 18 of 63 cases (29%). All patients with significant burns were symptomatic. No single or group of initially reported signs and symptoms could identify all patients with potentially serious esophageal burns.

We report four cases of esophageal injury associated with the ingestion of commonly prescribed tablets or capsules. History and clinical characteristics of these cases suggest that the medications failed to transit the esophagus and acted locally to produce esophagitis. A search of English- and foreign-language medical journals documented 221 similar cases due to 26 different types of medication. While most of these esophageal injuries are self-limited and produce no morbidity beyond transient retrosternal pain, odynophagia, and dysphagia, major complications have occurred, such as mediastinal penetration, hemorrhage, and death. Patients should be counseled to take pills in an upright posture with liberal amounts of fluid well before retiring for the night.

modalities were included in this analysis. Patients who stopped EET and started surveillance prior to CE-IM were excluded. Complete eradication of intestinal metaplasia (CE-IM) was defined as having an endoscopy with no visible columnar lined epithelium in the tubular esophagus and biopsies of the neo-squamous mucosa showing no intestinal metaplasia. Patients were considered to have achieved CE-IM if they had done so with 2cm were less likely to achieve CE-IM compared to those with C extents ≤2cm (64.3% vs. 73.5%, p=0.027). Patients with M extents of > 3cm were less likely to achieve CE-IM compared to those with M extents ≤3cm (61.2% vs. 88.4%, p

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has been used in the operating room with increasing frequency since the early 1980s, and its safety has been reported across many centers. The diagnosis of esophageal injury is rare but should be considered in the postoperative setting after cardiac surgery using TEE, with an incidence of one in 1,000 major injuries.1 A case of delayed presentation of esophageal njury in a patient after cardiac surgery is described. The ocation and shape of the tear suggested the cause to be comression of the esophagus against a thoracic vertebral osteohyte.

Percutaneous endoscopic gastrostomy (PEG) has advantages over open gastrostomy, and is an accepted technique for children. However, a number of technical problems may be encountered during insertion. This report identifies those problems and proposes precautions that can be taken to reduce their likelihood. Recognized major complications include esophageal injury, colonic perforation, wound infection, gastric erosion by the gastrostomy tube, and later symptomatic gastroesophageal reflux requiring correction by fundoplication.

BACKGROUNDA while patients with GERD (E+ and E-/pH+ groups) had significantly (p

Esophageal foreign bodies are frequently encountered in the pediatric population, and a high degree of suspicion should be maintained in the setting of postprandial dysphagia. We report the case of a 14-year-old boy with a penetrating esophageal injury after the accidental ingestion of a wire bristle from a grill brush.

G A A b st ra ct s NSAID use and erosive esophagitis and/or esophageal strictures. Most studies were published 10 years ago and significant heterogeneity was seen between studies. Limited data suggest that use of NSAIDs was not significantly increased in patients with esophageal injury compared with controls, with a magnitude of effect size smaller than that reported with gastroduodenal ulcers. More evidence is required to have a clearer picture of esophageal injury caused by NSAIDs.