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[EN] Objective To model the evolution of peak temperature and volume of damaged esophagus during and after radiofrequency (RF) ablation using low power-moderate duration (LPMD) versus high power-short duration (HPSD) or very high power-very short duration (VHPVSD) settings. Methods An in silico simulation model of RF ablation accounting for left atrial wall thickness, nearby organs and tissues, as well as catheter contact force. The model used the Arrhenius equation to derive a thermal damage model and estimate the volume of esophageal damage over time during and after RF application under conditions of LPMD (30 W, 20 s), HPSD (50 W, 6 s), and VHPVSD (90 W, 4 s). Results There was a close correlation between maximum peak temperature after RF application and volume of esophageal damage, with highest correlation (R-2 = 0.97) and highest volume of esophageal injury in the LPMD group. A greater increase in peak temperature and greater relative increase in esophageal injury volume in the HPSD (240%) and VHPSD (270%) simulations occurred after RF termination. Increased endocardial to esophageal thickness was associated with a longer time to maximum peak temperature (R-2 > 0.92), especially in the HPSD/VHPVSD simulations, and no esophageal injury was seen when the distances were >4.5 mm for LPMD or >3.5 mm for HPSD. Conclusion LPMD is associated with a larger total volume of esophageal damage due to the greater total RF energy delivery. HPSD and VHPVSD shows significant thermal latency (resulting from conductive tissue heating after RF termination), suggesting a requirement for fewer esophageal temperature cutoffs during ablation., Ministerio de Ciencia, Innovación y Universidades, Grant/Award Number: RTI2018-094357-B-C21

Background Esophageal injury (EI) remains a concern when performing pulmonary vein isolation (PVI) using the high-power short-duration (HPSD) technique. Objective We aim to indicate that high esophageal temperature during HPSD PVI does not correlate with positive esophageal endoscopy (EGD) findings. Methods A retrospective observational study was performed on 43 patients undergoing PVI using HPSD (50 W for 6–7 seconds per lesion) at Tulane Medical Center from July 2020 to January 2021. Esophageal temperature was monitored throughout the procedure using a temperature probe and patients underwent EGD the following day. Small ulcers, nonbleeding erosions, erythema, and/or esophagitis were considered positive EGD findings. Results Mean age was 64.9 years; 46.5% of the patients were female. Eleven patients had positive EGD findings (group 1) and 32 patients had normal EGD (group 2). There was no statistical difference in mean esophageal peak temperature between group 1 and group 2 (43.9°C ± 2.9°C and 42.5°C ± 2.3°C, respectively, P = .17). There was no association between positive EGD results and esophageal temperature during PVI. Mean baseline esophageal temperature was similar in both groups (36.1°C, P = .78). Average contact force (P = .53), ablation time (P = .67), age (P = .3096), sex (P = .4), body mass index (P = .14), and other comorbidities did not correlate with positive endoscopy results. We found positive correlation between the distance of the left atrium (LA) to esophagus and positive EGD (P = .0001). Conclusion EI during HPSD PVI does not correlate to esophageal temperature changes during ablation. However, esophageal injury does correlate to a shorter proximity of the esophagus to the LA.

Background Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade. Case presentation A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries. Conclusions The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.

Study Design: Case series and systematic review of the Literature. Objectives: Pharyngo-esophageal perforation (PEP) is a rare, life-threatening complication of anterior cervical spine surgery (ACSS). Best management of these patients remains poorly defined. The aim of this study is to present our experience with this entity and to perform a systematic Literature review to better clarify the appropriate treatment of these patients. Methods: Patients referred to our center for PEP following ACSS (January 2002-December 2018) were identified from our database. Moreover, an extensive review of the English Literature was conducted according to the 2009 PRISMA guidelines. Results: Twelve patients were referred to our Institution for PEP following ACSS. Indications for ACSS were trauma (n = 10), vertebral metastases (n = 1) and disc herniation (n = 1). All patients underwent hardware placement at the time of ACSS. There were 6 early and 6 delayed PEP. Surgical treatment was performed in 11 patients with total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement, anatomical suture of the fistula and suture line reinforcement with myoplasty. Complete resolution of PEP was observed in 6 patients. Five patients experienced PEP persistence, requiring further surgical management in 2 cases. At a median follow-up of 18.8 months, all patients exhibited permanent resolution of the perforation. Conclusions: PEP following ACSS is a rare but dreadful complication. Partial or total removal of the fixation devices, direct suture of the esophageal defect and coverage with tissue flaps seems to be an effective surgical approach in these patients

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.

INTRODUCTION : The ingestion of corrosive agents is still an important public health issue in our country. The GIT injuries caused by caustic agents can range from minor to fatal, or can lead to chronic disease with poor quality of life. Corrosive agents with a pH level less than two or more than twelve can rapidly penetrate the layers of the oesophagus and result in necrosis and scar formation in the mucosa. Acidic agents produce coagulation necrosis and eschar formation that may limit tissue penetration and may even spare the oesophagus when the transit is rapid. On the other hand, Alkaline agents when ingested produce liquefaction necrosis and can cause serious oesophageal injury by penetrating to deep muscle layers. The basic histopathologic reaction of tissue subjected to caustic burn is the synthesis, deposition and remodelling of collagen. Following full-thickness injuries to the oesophageal wall, the normal oesophagus is replaced by dense connective tissue. Collagen overproduction has been estimated to cause stenosis in half of the patients suffering severe burns. Consequently, when treating caustic burn injuries, it is necessary to prevent stenosis by inhibiting collagen synthesis or changing the properties of the deposited collagen. The optimal management protocol in the treatment of severe caustic injury remains controversial. The main goal of medical treatment is to inhibit inflammatory reaction or stricture formation secondary to oesophageal burning. Stricture formation is thought to be overcome by suppressing fibroplasia and scarring. Many agents directed at wound healing and stricture prevention have been used in several experimental studies in past. Results of such treatment protocols including steroids, antibiotics, heparin, indomethacin, sucralfate, vitamin E, as well as total parenteral nutrition are all controversial in treatment of corrosive burns. Randomised control trials on the role of proton pump inhibitors in caustic injuries of GIT are lacking. A few experimental studies have investigated the relationship between proton pump inhibitors and corrosive burns and has shown that proton pump inhibitors can reduce inflammation in early phase of caustic injury. Proton pump inhibitors, by decreasing gastric acid secretion and thereby GER can prevent worsening of corrosive injury. In addition proton pump inhibitors has also been shown to have anti-inflammatory and antioxidant properties. A prospective study from turkey on 13 patients have showed that omeprazole can be used effectively in treatment of acute corrosive injury of esophagus. There are no studies from India which have attempted to assess the usefulness of proton pump inhibitors in treatment of acute corrosive injury of esophagus. This prompted us to study the usefulness of pantoprazole in the treatment of patients presenting with acute corrosive injury of the oesophagus. AIM OF THE STUDY : To study the efficacy of high dose pantoprazole in causing mucosal healing after acute corrosive injury of esophagus. CONCLUSION : Treatment of corrosive injury is controversial and there are no definitive protocols. Intravenous proton pump inhibitors are widely used in treatment of corrosive injuries despite lack of evidence. Our study has demonstrated that effective mucosal healing can be achieved by intravenous proton pump inhibitor infusion. Though majority of patients in our study had minor grade of injury, 27% of the patients included in the study had 2b and 3a injury. When analysis is confined to these patients, 53% showed improvement by 1 grade, 33.3% showed improvement by 2 grades and 13.3% did not show improvement. Therefore it is evident from above that high dose pantoprazole is also beneficial in patients with higher grade of injury and may prevent late complications in these patients. A larger randomised placebo controlled trial in patients with higher grade of oesophageal injury is needed to determine if high dose pantoprazole should form standard of care in treatment of patients with acute corrosive injury of oesophagus.

Deviation of the esophagus during atrial fibrillation (AF) ablation can reduce esophageal injury. This study reports upon a novel esophageal retractor that utilizes vacuum suction and mechanical deflection to deviate the esophagus. The device was used in seven patients undergoing cryoballoon AF ablation. The esophagus was deviated 31.9 ± 4.4 mm to the right and 28.2 ± 5.9 mm to the left. Endoscopy at 4.4 ± 1.5 days postablation showed no esophageal injury. This study demonstrates the safe and effective deviation of the esophagus without a trailing edge with an esophageal retractor utilizing vacuum suction and mechanical deflection.

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.

Catheter ablation has emerged as an effective treatment for atrial fibrillation (AF). Atrial esophageal fistula (AEF) is a rare, but feared complication. With increasing utilization of ablation therapy for AF, the understanding of the relationship between AEF and ablation has been improved in recent years. Efforts to reduce the risk of AEF have focused on decreasing the risk of severe esophageal injury (EI) and the presumed subsequent progression from EI to AEF, including esophageal temperature monitoring, esophageal cooling systems, esophageal deviation devices, and decreasing and/or curtailing ablation energy delivery. Periprocedural assessment may help identify higher risk patients and detect early esophageal lesions. This review systematically summarizes and evaluates the current strategies and techniques utilized to reduce the risk of AEF in the clinical workflow for AF ablation. We expect that this review will help clinicians to better understand the principles, advantages, and disadvantages of these methods, and to find suitable strategies using current available tools.

Highlights • Most common mechanism of esophageal perforation is iatrogenic. • High index of suspicion in penetrating chest trauma followed by relevant investigations may reduce delay. • Early primary repair is sufficient for select cases of traumatic esophageal perforation. • Associated injuries are more likely in such cases to lead to increased morbidity., Introduction Mortality after esophageal perforation is high irrespective of the treatment modality. The rarity of traumatic esophageal perforations has made it difficult to conduct comprehensive studies that can answer pertinent questions with regard to management. Presentation of case We report a case of through and through thoracic esophageal injury caused by an assailant’s arrow in a young physically active male adult. Diagnosis was made on-table. He successfully underwent primary repair of the esophageal injury 16 h post injury via a left thoracotomy. Recurrent lung collapse and pleural effusion was managed with tube thoracostomy and chest physiotherapy. Discussion Esophageal perforations occur infrequently and may produce vague symptoms leading to diagnostic and therapeutic delays. High index of suspicion particularly in penetrating chest trauma followed by relevant investigations may reduce delay. Principles of management include treatment of contamination, wide local drainage, source control and nutritional support. Source control is achieved surgically or through endoluminal placement of stents. Surgical options include primary repair, creation of a controlled fistula by T-tube or esophageal exclusion. Conclusion Primary repair of traumatic injury to a healthy esophagus is feasible for cases diagnosed early and without significant mediastinal contamination as in our case. Associated injuries are more likely in such cases to lead to increased morbidity and prolonged hospital stay and must be handled carefully.

Although gastroesophageal damage is commonly induced by accidental drinking of a strong acid or alkali, damage due to the consumption of a vinegar beverage is not well known. We report a case of corrosive esophageal ulcer found in an adolescent consuming a vinegar drink daily. A 15-year-old male visited the emergency room presenting with hematemesis and severe epigastric pain. Multiple longitudinal ulcers, concurrent mucosal hemorrhage, and denuded mucosa were noted in the whole of the esophagus via an endoscopic examination. He had been drinking a vinegar beverage daily without sufficient dilution. The patient was treated with corticosteroid, antibiotic therapy, and mucosa protecting alginate medication and was asked to fast for a week. The follow-up endoscopy showed improvements of the esophageal injuries. Overall, continuous consumption of a vinegar beverage can result in acidic burns and destruction of the surface of the upper gastrointestinal tract. Therefore, vinegar beverages should be considered as corrosive agents.

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

Medications can cause several complications in the esophagus and lead to medication-induced esophageal injury. This study was carried out among patients diagnosed as medication-induced esophageal injury from June 2015 to October, 2018 in the Department of Gastroenterology, Enam Medical College and Hospital, Savar, Dhaka to investigate clinical and endoscopic characteristics of medication-induced esophageal injury as well as outcome of these patients with treatment. Patients diagnosed as malignancy, viral or fungal esophagitis, esophageal varix, corrosive and sclerotherapy induced ulcer and GERD were excluded. Clinical and endoscopic characteristics of patients diagnosed as medication-induced injury were analyzed. After given treatment, clinical improvements as well as mucosal healing of oesophageal injury were noted. Thirty seven patients were diagnosed as medication-induced esophageal injury. Their median age was 40; 17 were males and 20 were females. Common symptoms were chest pain (94.6 %), odynophagia (78.4 %) and dysphagia (62.2 %). Symptoms appeared between 3 hours to 15 hours after ingestion of medication. Predisposing factors for 75.67% of the patients were related to taking the medicine with insufficient water or in recumbent position, or both. The main causative agents were antibiotics, Non-steroidal anti-inflammatory drugs (NSAIDs) and Alendronate sodium. Common diseases that required treatment with these drugs were various urinary system diseases, osteoporosis and migraine. During endoscopy, 25 had only ulcer, 7 had only erosion and 5 had both ulcer and erosion. Most of the ulcers and erosions were located at the middle third of the oesophagus with a rate of 70%, and 58.3% respectively. Appearance of the ulcer was oval, circular, kissing and geographical shaped and their sizes vary between 6 mm to 18 mm and single or multiple in numbers. All the patients were treated with proton pump inhibitors (PPIs) or sucralfate, and the causative drugs were discontinued. Symptoms resolution occurred within 5 to 12 days after treatment and mucosal healing were detected in all patients after 4 weeks who were performed endoscopy. Almost every kind of medication, particularly doxycycline, NSAIDs can cause oesophageal ulcer and erosion. It can be successfully treated with PPIs and discontinuation of the causative medication and prevented by warning patients about drinking water sufficiently and sitting up while taking the pill. Faridpur Med. Coll. J. Jan 2019;14(1): 2-7

Objectives Despite the efforts to reduce the exposure to corrosive household products, caustic ingestion in children is currently a significant medical problem. The aims of the present study were to evaluate the clinical consequences of caustic ingestion and to identify prognostic factors that could concur in driving both diagnostic and therapeutic management. Methods All consecutive children referred for ingestion of a caustic substance from June 2017 to June 2018 were enrolled. Medical records, laboratory and endoscopic findings were reviewed and analyzed. Results We enrolled 44 children with caustic ingestion. Alkaline agents were ingested by 26 of 44 (59.1%) patients, whereas acid agents were ingested by 18 of 44 patients (40.9%). Alkaline rather than acid agents were associated with a worse endoscopic score (r: 0.45) and a higher probability of early esophageal stricture occurrence (r: 0.38). The specific risk of the presence of severe esophageal lesions rose progressively with increasing number of symptoms whereas no esophageal injury was found in asymptomatic patients. Conclusions Our data suggest that endoscopic evaluation is mandatory in symptomatic patients to direct therapeutic management, but it could be avoided in asymptomatic patients after accidental ingestion, particularly if the ingestion is only suspected and patients have no oropharyngeal burns.

La ulceración esofágica por ingestión de doxiciclina es una de las causas más frecuentes de lesión esofágica. Ha sido subdiagnosticada y escasamente reconocida en dermatología. El dolor retroesternal, la odinofagia de aparición brusca y el antecedente de ingesta de doxiciclina u otros fármacos son características que facilitan su diagnóstico. Puede presentar complicaciones serias, como hemorragias, estenosis y mediastinitis.

Atrioesophageal fistula (AEF) is one of the most dreaded complications of atrial fibrillation (AFib) catheter ablation (CA) associated with high morbidity and mortality. In this review, we provide the latest evidence on the factors associated with esophageal thermal injury associated with CA, including discussion of strategies used in mitigating the risk of progression to AEF. We also discuss future directions and advances in ablation technologies that promise to further reduce the risk of this deadly complication. Radiofrequency point-by-point ablation guided by electroanatomic mapping is the most common CA technique. Conventional CA using low-power long-duration lesions is now being replaced by high-power short-duration (HPSD) ablation that is proven to create more durable lesions with less incidence of esophageal thermal injury. Luminal esophageal temperature (LET) monitoring using the novel multi-sensor probe (MSP) offers a better thermodynamic profile when compared to single sensor probe (SSP). Furthermore there has been a leap in the innovation of multimodality imaging which is now incorporated as a screening tool post ablation for prognostication and early preventative measures for AEF. Finally, new emerging ablation techniques including pulsed field electroporation and “one-shot” ablation are under clinical trials and may show promising results. The integration of multiple strategies at different stages of AFib CA may help mitigate the risk of AEF in the future. These strategies include the use of HPSD ablation and MSP for LET monitoring as well as the integration of imaging as a screening tool post ablation.

Cervical injuries are common and have high morbimortality. The cervical region is highly susceptible due to the structures present. Lesions in this area requires attention with the respiratory tract and continuous discussions over that intra-surgery management for the purpose defining protocols and techniques to provide better prognosis. Surgical exploration is mandatory for unstable patients, which requires experienced professionals to avoid catastrophic results. This report presents a case of a male patient victim of a car accident that resulted in penetrating cervical trauma by iron wire that culminated in tracheal transection and esophageal lesion, that as a result of early diagnosis and treatment and with multidisciplinary monitoring in the therapy it obtained a good evolution.

Background The incidence of endoscopically detected esophageal lesions after pulmonary vein isolation (PVI) is as high as 18%. Intraesophageal temperature rise (ITR) during ablation is a predictor of esophageal injury. Objective The purpose of this study was to describe an ablation strategy aiming to enclose the pulmonary veins with contiguous, stable, and optimized radiofrequency applications (referred to as CLOSE-PVI). We evaluated esophageal and periesophageal injury with endoscopy in patients revealing ITR during CLOSE-PVI. Methods Eighty-five patients with ITR during CLOSE-PVI underwent endoscopy of the esophagus (with ultrasound in 38 patients). PVI consisted of contact force (CF)-guided encircling of the veins using 35-W applications, respecting strict criteria of intertag distance (≤6 mm) and ablation index (AI; 550 arbitrary unit [au] anterior wall, 400 au posterior wall, 300 au if ITR >38.5°C). Results Endoscopy was performed 9 ± 4 days after PVI. At the posterior wall, median power was 35 W [interquartile range (IQR) 35–35], application time 18 ± 5 seconds, CF 13 ± 6g, and AI 403 ± 38 au. A median of 5 applications [IQR 4–7] per patient over a length of 21.8 ± 6.8 mm resulted in ITR >38.5°C (median 39.9°C, IQR 39.2°C–41.2°C, range 38.6°C–50.0°C). For these applications, median power was 35 W [IQR 30–35], application time 14 ± 3 seconds, CF 12 ± 5g, and AI 351 ± 38 au. The incidence of esophageal erythema/erosion on endoscopy was 1 of 85 (1.2%) and of ulceration was 0 of 85 (0%). The incidence of mediastinal or esophageal injury on ultrasound was 0 of 38 (0%). Conclusion The occurrence of esophageal or periesophageal injury after CLOSE-PVI is markedly low (1.2%). Absence of esophageal ulceration in patients with ITR suggests that this strategy of delivering contiguous, relatively high-power, and short-duration radiofrequency applications at the posterior wall is safe.

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.

Caffeine is one of the most frequently used stimulants worldwide. It is, therefore, subject to frequent intentional and unintentional misuse. However, severe erosive esophagitis due to acute caffeine overdose is extremely rare. We report the case of a 43-year-old male with a past medical history of paranoid schizophrenia admitted to our hospital with esophageal symptoms (throat pain, retrosternal chest pain, dysphagia/odynophagia, nausea, and vomiting) two days after ingesting a bottle of caffeine pills containing about 30 g of caffeine in a suicide attempt. He was found to have rhabdomyolysis and acute renal failure warranting hemodialysis. Esophagogastroduodenoscopy done due to persistent retrosternal chest pain, dysphagia, odynophagia, and nausea despite being on oral famotidine 20 mg daily revealed severe erosive esophagitis. This case highlights the risk of concurrent renal and gastrointestinal injuries after acute ingestion of an excessive amount of caffeine tablets. Our experience suggests that in patients of caffeine overdose with persistent esophageal symptoms such as odynophagia, dysphagia, and retrosternal chest pain, endoscopic evaluation is advisable to rule out drug-induced esophagitis.

OBJECTIVES Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs? METHODS Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS-2. RESULTS Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA. CONCLUSION CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury.

Esophageal emergencies such as rupture or postoperative leak are uncommon but may be life threatening when they occur. Delay in their diagnosis and treatment may significantly increase morbidity and mortality. Causes of esophageal injury include iatrogenic (including esophagogastroduodenoscopy and stent placement), foreign body ingestion, blunt or penetrating trauma to the chest or abdomen, and forceful retching, also called Boerhaave syndrome. Although fluoroscopic esophagography remains the imaging study of choice according the American College of Radiology appropriateness criteria, CT esophagography has been shown to be at least equal to if not superior to fluoroscopic evaluation for esophageal injury. In addition, CT esophagography allows diagnosis of extraesophageal abnormalities, both as the cause of the patient's symptoms as well as incidental findings. CT esophagography also allows rapid diagnosis since the examination can be readily performed in most clinical settings and requires no direct radiologist supervision, requiring only properly trained technologists and a CT scanner. Multiple prior studies have shown the limited utility of fluoroscopic esophagography after a negative chest CT scan and the increase in accuracy after adding oral contrast agent to CT examinations, although there is considerable variability of CT esophagography protocols among institutions. Development of a CT esophagography program, utilizing a well-defined protocol with input from staff from the radiology, gastroenterology, emergency, and general surgery departments, can facilitate more rapid diagnosis and patient care, especially in overnight and emergency settings. The purpose of this article is to familiarize radiologists with CT esophagography techniques and imaging findings of emergent esophageal conditions.

Was to investigate in detail the case of a combination of esophageal injury and aortic aneurysm from the standpoint of the perspective of medical care. It was established that the circumstances of the improper provision of medical care in this case were the subjective nature in the form of insufficient and incorrect provision of it. It is shown that continuous training of doctors and mid-level medical workers within the continuing medical education is a gurantee of proper medical care.Детальное изучение казуистического случая сочетания ранения пищевода и аневризмы аорты с позиций качества оказания медицинской помощи. Установлено, что обстоятельства ненадлежащего оказания медицинской помощи в данном случае были субъективного порядка в виде недостаточного и неправильного ее оказания. Показано, что постоянное повышение квалификации врачей и медицинских работников среднего звена в рамках непрерывного медицинского образования — залог надлежащего оказания медицинской помощи.

Esophageal injury is a rare but potentially life-threatening condition. Endoscopic or surgical procedures are the most common causes of esophageal perforation which may lead to mediastinitis. Esophageal emergencies may initially present nonspecific clinical manifestations but characteristic imaging features which are crucial for ensuring an accurate diagnosis. In this chapter, the pathophysiology and characteristic imaging findings of traumatic and non-traumatic esophageal emergencies including esophageal perforation, Boerhaave’s syndrome, esophageal intramural dissection, esophageal hernia, acute phlegmonous esophagitis, and aortoesophageal fistula are discussed.

Operative complications are an inherent risk in all surgical approaches. With the advancement of technology comes a departure from technical comfort zones, and frequently a steep learning curve as new practices are adopted. To successfully execute safe surgeries, the importance of a team approach cannot be overemphasized. All team members must be trained and comfortable with robotic surgery and able to navigate technical dilemmas as they arise in the operating room. In this chapter, we present common complications across the field of robotic surgery, and review recommendations for their prevention and treatment.

Purpose Thermal damage to the esophagus is a risk from radiofrequency (RF) ablation of the left atrium for the treatment of atrial fibrillation (AF). The most extreme type of thermal injury results in atrio-esophageal fistula (AEF) and a correspondingly high mortality rate. Various strategies for reducing esophageal injury have been developed, including power reduction, esophageal deviation, and esophageal cooling. One method of esophageal cooling involves the direct instillation of cold water or saline into the esophagus during RF ablation. Although this method provides limited heat-extraction capacity, studies of it have suggested potential benefit. We sought to perform a meta-analysis of published studies evaluating the use of esophageal cooling via direct liquid instillation for the reduction of thermal injury during RF ablation. Methods We searched PubMed for studies that used esophageal cooling to protect the esophagus from thermal injury during RF ablation. We then performed a meta-analysis using a random effects model to calculate estimated effect size with 95% confidence intervals, with an outcome of esophageal lesions stratified by severity, as determined by post-procedure endoscopy. Results A total of 9 studies were identified and reviewed. After excluding preclinical and mathematical model studies, 3 were included in the meta-analysis, totaling 494 patients. Esophageal cooling showed a tendency to shift lesion severity downward, such that total lesions did not show a statistically significant change (OR 0.6, 95% CI 0.15 to 2.38). For high-grade lesions, a significant OR of 0.39 (95% CI 0.17 to 0.89) in favor of esophageal cooling was found, suggesting that esophageal cooling, even with a low-capacity thermal extraction technique, reduces the severity of lesions resulting from RF ablation. Conclusions Esophageal cooling reduces the severity of the lesions that may result from RF ablation, even when relatively low heat extraction methods are used, such as the direct instillation of small volumes of cold liquid. Further investigation of this approach is warranted, particularly with higher heat extraction capacity techniques.

Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.

Children represent up to 80% of the population globally who are exposed to caustic ingestion injury. Caustic injury to the esophagus may be caused by alkalis and acids, both producing very different injury patterns. Initial management should prioritize respiratory and cardiovascular stability. Upper gastrointestinal endoscopy and endoscopic grading of esophageal injury remains the mainstay of diagnosis and may aid management decisions. Further studies are necessary as there continues to be minimal evidence for the use of adjuvant medical therapy including antacids, antibiotics, and steroid use. Sequelae such as esophageal strictures may be managed initially with esophageal dilation, with surgical management reserved for failure of dilations. Long-term endoscopic screening is necessary for the development of esophageal cancer, which may occur decades later from the injury.

Background: The mechanism of esophageal thermal injury (ETI; esophageal mucosal injury and periesophageal nerve injury leading to gastric hypomotility) remains unknown when using a high-power short-duration (HP-SD) setting. This study sought to evaluate the characteristics of esophageal injuries in atrial fibrillation ablation using a HP-SD setting. Methods: After exclusion of 5 patients with their esophagus at the right portion of left atrium and 21 patients with additional ablations such as box isolation and low voltage area ablation in left atrium posterior wall, 271 consecutive patients (62±10 years, 56 women) who underwent pulmonary vein isolation by radiofrequency catheter ablation were analyzed. In the 101 patients, a HP-SD setting at 45 to 50 W with an Ablation Index module was used (HP-SD group). In the remaining 170 patients before introduction of the HP-SD setting, a conventional power setting of 20 to 30 W with contact force monitoring was used (conventional group). We performed esophagogastroduodenoscopy after pulmonary vein isolation in all patients and investigated the incidence and characteristics of ETI. Results: Although the incidence of ETI was significantly higher in the HP-SD group compared with the conventional group (37% versus 22%, P =0.011), the prevalence of esophageal lesions did not differ between the groups (7% versus 8%). Multivariate logistic regression analysis revealed that the use of the HP-SD setting (odds ratio, 6.09, P Conclusions: Although the use of the HP-SD setting was a strong predictor of ETI, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.

This letter to the editor concerns the article: 'Innovative tools for atrial fibrillation ablation' by Rottner et al., published in the journal on 13th of May 2020. We read the article with great interest and congratulate the authors on an impressively detailed summary of the current tools and technological advances in atrial fibrillation ablation. Improving the safety of this procedure is very important due to widespread clinical practice and the increasing demand for this procedure. We would like to share further discussion with the authors and the journal's readership on current advances in improving the safety of this procedure - esophageal cooling. The results of a large randomized trial was recently presented, the IMPACT study (NCT03819946), which showed that a simple, standardized method of esophageal cooling with the ensoETM® device can significantly reduce esophageal thermal injury by 83.4%. Esophageal protection is important as esophageal injury has a high mortality rate to those that sustain this injury although the overall incidence is low. Rottner et al. discuss a much smaller study on esophageal cooling and the limitations of this study are also discussed.

Atrial fibrillation ablation is an increasingly common procedure adapted by electrophysiologists across the world. Any procedure naturally comes with inherent risks of complications. The goal of this review is to elaborate latest techniques and strategies to avoid complications of ablation. There is increased focus on new tools for avoiding esophageal injury as well as minimizing phrenic nerve injury in addition to utilization of newer ablation technologies to address safer and effective ablation. A combination of improved patient selection and better treatment protocols combined with methods for early detection of complications will significantly reduce the incidence of complications. Newer innovative technologies like esophageal temperature monitoring, mechanical deviation, and integration of ablation parameters are helping to avoid or minimize collateral damage.

INTRODUCTION Few studies have examined heat transfer and thermal injury on the epiesophageal surface during radiofrequency application, or compared the risk of esophageal thermal injury between standard and high-power, short-duration (HPSD) ablation. We studied the thermodynamics of HPSD and standard ablation at different tissue interfaces between the left atrium and esophagus, focusing on epiesophageal temperature changes and thermal injury. METHODS AND RESULTS Fresh porcine heart and esophageal sections were secured to a custom holder and submerged in a temperature-controlled, circulating water bath. During ablation, thermistors recorded temperatures at the catheter tip-atrial interface, epiesophageal-atrial interface, and esophageal lumen. Samples were ablated in triplicate with the following parameters: contact force (15/25g), power (10/20/30 W standard; 40/45/50 W HPSD), and duration (10/20/30 s standard; 5/10/15 s HPSD). Epiesophageal and endoluminal temperature rises were greater in HPSD than in standard ablation (epiesophageal: 5.9 ± 5.6 vs. 2.2 ± 2.0°C, p

Funding Acknowledgements None Introduction Convergent procedure is a minimally invasive surgical approach for treatment of atrial fibrillation (AF) combining epicardial and endocardial radiofrequency (RF) ablation. However, there is conflicting data regarding the rate of major complications after convergent treatment of AF. Apart from common complications the esophageal injury incidence after convergent procedure is not well documented. Purpose Our aim was to assess major complication occurrence after convergent procedure with additional emphasis on the incidence of esophageal injury. Methods One hundred forty-seven consecutive patients (113 male, mean age 59 ± 9 years, BMI 29 ± 5 kg/m2) with persistent (122, 83%) and paroxysmal (25, 17%) AF were treated with convergent procedure that included epicardial RF ablation with coagulation devices (12 lesions, each for 90 s, with 30 W power), combined with endocardial RF catheter ablation for pulmonary vein isolation. The approach for epicardial ablation was diaphragmatic pericardial window through subxiphoid incision. Infusion of cooled saline into the pericardial space during epicardial ablations and monitoring of esophageal temperature with temperature probe were additional precautions to avoid esophageal overheating. All patients had endoscopy of the esophagus at least 2 days after the procedure to assess for presence of esophageal injury. Adverse events resulting in additional intervention or causing long-term disability were defined as major complication. Results During short-term follow-up (minimum of 5 months) major complication rate was 6.1%. Three patients had cardiac tamponade, 4 had abdominal bleeding, 1 had ischemic stroke and 1 had arterial pseudoaneurysm. Esophageal mucosal lesions were observed in 11 patients (7.5%) that did not result in major complication. All lesions were followed with additional endoscopies and resolved without any intervention. Conclusions Complication rate after minimally invasive convergent procedure for treatment of AF in our patient cohort is low. Prevention of esophageal overheating resulted in absence of major esophageal injury.

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

Objective: The objective of the study is to test whether the use of edible oil might be an early treatment strategy for reducing button battery-induced esophageal injury.Methods: A button battery was inserted into esophageal segments collected from pigs. The esophageal segments were randomly allotted to one of the following six treatments: (1) untreated (nothing injected), (2) lemon juice, (3) orange juice, (4) colza oil, (5) peanut oil, and (6) olive oil. Every hour, the battery discharge and the pH value were measured in the esophageal tissue. After treatment for 6 h, the residual voltage of the battery was measured and the esophageal tissue was processed with H&E staining.Results: In esophageal segments of the untreated group, a large area of the mucous membrane was severely eroded. Partial erosion was observed in esophageal tissues treated with either lemon juice or orange juice. Furthermore, the esophageal tissues were basically intact, had little damage when treated with oils. The highest extra-esophageal discharge voltage was recorded in the untreated group, a medium amount of discharge voltage was recorded in the lemon juice and orange juice groups, and the lowest discharge voltage was recorded in all the edible oils groups.Conclusions: Edible oils immersed the battery, reduced the surrounding electrolysis, and thus attenuated battery discharge. As a result, treatment with edible oils attenuated the pH alkalization and tissue damage in button battery injury of pig esophageal segments. These results indicate that edible oils might be used in the treatment of button battery ingestion.