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We report a case of a patient with esophageal squamous cell carcinoma who presented with obstruction of the esophagus. On endoscopy, a central ulcerating lesion was found spreading to the anterior wall of the middle esophagus. Four courses of chemoradiation therapy successfully produced a complete response for 3 years. A recurrence occurred which consisted of a morphologically flat lesion that occupied the entire circumference of the esophagus. Endoscopic submucosal dissection removed all lesions en bloc. To prevent a post-procedure mucosal defect of the circumference of the esophagus, biodegradable poly-l-lactic acid monofilaments esophageal stents were placed on the same day. One month later, the patient reported a feeling of obstruction. An endoscopic examination revealed food stuck in the stents, this was removed, and balloon dilatation provided good passage which has been maintained for 7 months.

Introduction: Transoral incisionless fundoplication (TIF) with the EsophyX(™) device is reported to be effective for creating a continent gastroesophageal valve and for good functional results, as measured by pH impedance in patients with gastroesophageal reflux disease (GERD). The aim of this study is to assess the long-term effect of TIF in patients with symptomatic GERD., Patients and Methods: TIF 2.0 fundoplication was done in 42 consecutive patients. All were studied with GERD-HRQL and GERD-QUAL questionnaires, upper gastrointestinal (GI) endoscopy, esophageal manometry, and 24 h pH impedance before and at 6, 12, and 24 months after TIF., Results: In all, 35 patients completed 6-month follow-up; 21 (60.0%) completely stopped proton pump inhibitor (PPI) therapy, 6 (17.1%) more than halved it, and 8 (22.9%) continued with the same dose as before the procedure. There were 26 patients with complete 24-month follow-up; 11 (42.3%) completely stopped PPI therapy, 7 (26.9%) more than halved it, and 8 (30.8%) were taking the same dose as before the procedure. Hiatal hernia and ineffective esophageal motility seemed to raise the risk of recurrence of symptoms (p = 0.02 and p < 0.001, respectively). The number of fasteners deployed during TIF was the only factor predictive of successful outcome (p = 0.018)., Conclusions: TIF using the EsophyX device allowed withdrawal or reduction of PPI in about 77% of patients at 6-month follow-up and about 69% at 24 months. Larger number of fasteners deployed during TIF was predictive of positive outcome; pre-TIF ineffective esophageal motility and hiatal hernia raised the risk of recurrence of GERD symptoms, but were not significant from a prospective point of view.

Background: Increased esophagogastric junction distensibility occurs with esophageal reflux. The EndoFLIP(®) is now available as a clinical tool to measure this. Control data for patients without reflux has to date only been available for a handful of patients evaluated under sedation during endoscopy. This study explores the baseline data for patients who undergo laparoscopy using general anesthesia with pneumoperitoneum., Methods: Patients who require surgery in the absence of a history of esophageal reflux underwent EndoFLIP(®) evaluation of pressure, cross-sectional area, and distensibility with bag fills of 30 and 40 ml. This was performed after induction of anesthesia, during pneumoperitoneum, and just before extubation., Results: Baseline levels were established and were noted to be significantly affected by the impact of pneumoperitoneum, with negligible effects from general anesthesia, patient gender, age, body mass index, or muscle relaxation., Conclusions: These data provide a guide for more accurate intraoperative EndoFLIP(®) calibration of crural hiatal repair during surgery.

Objectives: The ingestion of a foreign body is one of the most common endoscopic emergencies. Foreign bodies in the upper gastrointestinal tract should be extracted as soon as possible to avoid serious complications such as perforation o bleeding. However, removals of foreign bodies with sharp edges are very difficult and can develop complications during their removal. Various devices have therefore been developed to prevent mucosal injury from the sharp edges during endoscopic extraction., Materials and Methods: We report a new technique for the successful foreign body extraction of upper digestive tract using the cap from six shooter variceal banding reused., Results: We present 17 cases (9 males and 8 females). The types of foreign bodies removed were: chicken bones (n:7), fish bones (n:3), denture prosthesis (n:2), food bolus (n:2), long pin (n:1), golden thumb tack (n: 1) and press-through package (n:1). There were no complications., Conclusions: This new technique is safe and effective. Highlights its advantages: enhanced sight pharyngo esophageal junction, foreign bodies disimpact at that level, food bolus suck, avoid sharp object damage mucosal or scope and decrease time removal.

Magnification endoscopy enables in vivo evaluation of gastrointestinal mucosa. Furthermore, endocytoscopy (ECS) with ultra-high magnification enables in vivo observation of cellular atypia during routine endoscopic examination. The purpose of this study is to clarify the efficacy of ECS and endocytoscopic atypia (ECA) classification in various types of benign and malignant pathology in the esophagus. Consecutive 110 patients, who underwent ECS in our institution from March 2003 to December 2009, were included in this study. One hundred and forty-six esophageal lesions were classified according to ECA classification, and these endocytoscopic images were compared with histological images. We categorized endocytoscopic images into five categories according to size and uniformity of nuclei, number of cells and regularity of cellular arrangement. Eighty-one out of 89 ECA-1 to ECA-3 lesions (91.0%) corresponded to Vienna categories 1 to 3. Seventy-one out of 84 ECA-4 or ECA-5 lesions (91.2%) corresponded to Vienna category 4 or 5. Overall accuracy of ECS was 91.3%, providing images similar to conventional hematoxylin and eosin staining. In addition, with ECS, we can take an 'optical biopsy' even in patients with cardiovascular disease without interrupting anticoagulant therapy. A newly designed single charge-coupled device endocytoscope allows observation of target tissue noninvasibly from regular magnification to ultra-high magnification. The development of ECS has opened the door to in vivo cellular imaging, enabling endoscopic diagnosis of tissue cytological atypia during routine endoscopic examination., (© 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Background: Endoscopic antireflux techniques have emerged as alternative therapies for gastroesophageal reflux disease (GERD). Endoscopic plication receives continuing interest as an effective and safe procedure. This treatment option has not been the subject of comparison with well-established operative therapies to date. The present study aimed at comparatively evaluating the effectiveness of endoscopic plication and laparoscopic fundoplication in terms of quality of life and symptom control., Methods: Between October 2006 and April 2010, 60 patients with documented GERD were randomly assigned to undergo either endoscopic plication or laparoscopic fundoplication. Quality-of-life scores and symptom grading were recorded before treatment and at 3- and 12-month follow-up. Outcomes were compared with the statistical significance set at a p value of 0.05., Results: Twenty-nine patients from the endoscopic group and 27 patients from the operative group were available at follow-up. Quality-of-life scores showed a substantial and similar increase for both groups after treatment. Symptoms of heartburn (p < 0.02), regurgitation (p < 0.004), and asthma (p = 0.03) were significantly improved in the endoscopic group, whereas laparoscopic fundoplication was more effective in controlling symptoms of heartburn (p < 0.01) and regurgitation (p < 0.05) compared to the endoscopic procedure., Conclusions: Endoscopic plication and laparoscopic fundoplication resulted in significant symptom improvement with similar quality-of-life scores in a selected patient population with GERD, whereas operative treatment was more effective in the relief of heartburn and regurgitation at the expense of higher short-term dysphagia rates.

Background: There are limited studies that evaluate the efficacy of endoscopic fundoplication (EF) for gastroesophageal reflux disease (GERD) with the EsophyX™ device, especially with the most recent procedural iteration (TIF-2). This study was a prospective evaluation of our early experience with this device and procedure., Methods: Data were collected prospectively on 23 consecutive patients undergoing EF (March 2009 to August 2010). All patients completed a symptom questionnaire assessing frequency and severity of gastrointestinal and respiratory symptoms, 24-h pH, and manometry studies preoperatively and were encouraged to repeat these at 6 months., Results: All patients had abnormal pH studies and were on proton-pump inhibitor (PPI) therapy prior to EF. Median age was 47 years (19-62 years), and six (23%) were male. Nine (41%) patients had Body Mass Index (BMI) ≥ 30 kg/m(2), and three (14%) had a small hiatal hernia (≤ 2 cm). The procedure was aborted in two patients for retained food. Three patients underwent subsequent laparoscopic Nissen fundoplication for persistent or recurrent symptoms. Median hospitalization was 1 day, and there were no major perioperative complications. At 6 month follow-up, 19 (86%) patients completed a symptom questionnaire, and 14 (64%) and 11 (50%) patients underwent pH and manometry studies, respectively. There was a significant reduction in heartburn (P = 0.02), total percentage acid contact time (P = 0.002), DeMeester score (P = 0.002), and PPI use (P = 0.003). Overall, 8 out of 14 (57%) patients had abnormal pH studies and 11 out of 19 (58%) remained on PPI therapy at 6 months., Conclusion: EF with EsophyX™ is associated with significant reduction in heartburn and abnormal acid exposure at 6 months, although the majority of patients did not experience normalization of their pH studies and remained on PPI therapy. The procedure has an acceptable safety profile, but the question remains as to whether it is effective enough to warrant a place in the armamentarium for the treatment of GERD.

Background: Historical ambulatory pH monitoring systems for the evaluation of gastroesophageal reflux disease have been catheter based and uncomfortable for patients, commonly limiting both their diet and activities. Catheter-based studies have also been reported to underestimate the amount of reflux a patient may have in a normal, routine day. Compared with conventional catheter-based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patient's routine lifestyle, given the effects of sedation. Few studies have evaluated the merits of 24 versus 48-hour wireless pH monitoring., Aims: The aims of this study were (1) to identify differences in reflux parameters between 24 versus 48-hour testing as measured by wireless pH monitoring and (2) to assess the effect of 48-hour studies on the number of reflux episodes and symptom correlation as compared with 24-hour studies., Methods: A retrospective chart review of 124 consecutive patients who underwent 48-hour wireless esophageal pH monitoring studies was prepared. All patients underwent esophagogastroduodenoscopy using intravenous conscious sedation before wireless capsule placement. Acid reflux variables (including total reflux time, number of reflux episodes, and total percent time of pH<4) and symptom-association probability (SAP) scores were compared for day 1 versus day 2 versus total., Results: Forty-eight-hour SAP scores were significantly higher when compared with the first 24 hours for all reported primary symptoms. SAP scores were calculated at 24 and 48 hours, respectively for heartburn (56 vs. 65, P<0.0001), regurgitation (65 vs. 80, P<0.0001), chest pain (59 vs. 78, P=0.0009), and cough (55 vs. 64, P=0.0027). In addition, the percentage of SAP scores >95 was significantly higher for both heartburn and regurgitation (34% vs. 48%, P=0.003 and 38% vs. 62%, P=0.005). As expected, 48-hour testing also captured a significantly higher number of reflux episodes as compared with day 1 results alone (97 vs. 47, P<0.0001). There were no statistical differences noted between the 2 days for total percent time of pH <4., Conclusions: Forty-eight-hour wireless (Bravo) pH monitoring strengthens symptom correlation as compared with 24-hour results alone and yields a greater percentage of SAP scores >95 for typical symptoms of gastroesophageal reflux disease. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48-hour studies for total percent time pH <4, 48-hour studies captured significantly more reflux episodes as compared with 24 hours of monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48-hour studies performed as a standard of practice.

Background: Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs., Methods: Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected, Results: A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause., Conclusions: Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

A novel disposable transnasal esophagoscope, the E.G. Scan (IntroMedic Co. Ltd., Seoul, Korea), was developed for the evaluation of esophageal diseases while eliminating the inconvenience associated with sterilization, portability, patient monitoring, complications, and the economic burden of sedation. The feasibility, safety, and tolerability of the first version of the E.G. Scan was evaluated in this pilot study. Nasal esophagoscopy was performed successfully in 46 patients with known or suspected esophageal diseases. At least 50% of the Z-line was visualized by the E.G. Scan in 38 (82.6%) of 46 patients. Abnormalities were identified in 27 patients: erosive esophagitis (n=18), Barrett's esophagus (n=1), esophageal varices (n=7), and esophageal candidiasis (n=1). Nasal pain was absent or mild in most patients, and adverse events were not observed. Further technical improvement of the E.G. Scan would increase the diagnostic usefulness in future clinical practice., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (SEMS). This study aimed to determine the potential preventive effect of proximal fixation on the mucosa by clips for patients treated with fully covered SEMS., Methods: In this study, 44 patients (25 males, 57%) were treated with fully covered SEMS including 22 patients with esophageal stricture (4 malignant obstructions, 6 anastomotic strictures, and 12 peptic strictures) and 22 patients with fistulas or perforations (10 anastomotic leaks, 4 perforations, and 8 postbariatric surgery fistulas). The Hanarostent (n = 25), Bonastent (n = 5), Niti-S (n = 12), and HV-stent (n = 2) with diameters of 18 to 22 mm and lengths of 80 to 170 mm were used. Two to four clips (mean, 2.35 ± 0.75 clips) were used consecutively in 23 patients to fix the upper flared end of the stent with the esophageal mucosal layer. Stent migration and its consequences were collected in the follow-up assessment with statistical analysis to compare the patients with and without clip placement., Results: No complication with clip placement was observed, and the retrieval of the stent was not unsettled by the persistence of at least one clip (12 cases). Stent migration was noted in 15 patients (34%) but in only in 3 of the 23 patients with clips (13%). The number of patients treated to prevent one stent migration was 2.23. The predictive positive value of nonmigration after placement of the clip was 87%. In the multivariate analysis, the fixation with clips was the unique independent factor for the prevention of stent migration (odds ratio, 2.3; 95% confidence interval, 0.10-0.01; p = 0.03)., Conclusions: Anchoring of the upper flare of the fully covered SEMS with the endoscopic clip is feasible and significantly reduces stent migration.

Barogenic esophageal injury or Boerhaave syndrome is an esophageal perforation entailing very high mortality and morbidity. Endoscopic techniques have been introduced in the treatment of various types of esophageal perforation. This report describes the first patient who underwent a successful endoscopic clipping involving sealing of a transpleural esophageal rupture within 24 hours of the onset of symptoms.

History and Admission Findings: A 38-year-old man was referred to a gastroenterologist because of thoracic pain and dysphagia of uncertain cause., Investigations: Endoscopy revealed a centrally depressed, coarse submucosal tumor, 1.0 cm in diameter, in the anterior wall of the esophagus at about 35 cm from the teeth. Button-hole biopsy revealed histologically and immunohistochemically a granular cell tumor (Abrikossoff's tumor), positive for S-100 protein. CT-staging was unremarkable, except for a thickening of the distal esophageal wall., Treatment and Course: Minimally invasive submucosal resection was undertaken using the videoscopic/endoscopic rendezvous technique. Histological examination confirmed complete resection of the tumor. The clinical course was uneventful and endoscopy 6 and 12 weeks after the operation showed complete resection of the tumor., Conclusion: An exact preoperative diagnosis beyond a mere description of site and morphology, but also providing the histopathological data creates favorable conditions for planning and performing a minimally invasive resection. Submucosal resection with the videoscopic/endoscopic in rendezvous technique offers the possibility of complete resection, which can often not be achieved in a submucosal tumor by only endoscopic resection., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Intrathoracic esophageal anastomotic leaks and perforations are very morbid and challenging problems. Esophageal stents are increasingly playing an integral role in the management of these patients. Our objective was to report our experience with esophageal stent placement for anastomotic leaks and perforations and to provide a treatment algorithm., Methods: We performed a review of patients with stent placement for esophagogastric anastomotic leaks or esophageal perforation from March 2005 to August 2009. A prospective database was used to collect data. Success was defined as endoscopic defect closure, negative esophagram, and resumption of oral intake. Failure was defined as no change in leak size or clinical signs of ongoing infection. We collected and analyzed patient demographics, diagnosis, clinical history, and poststent outcomes using descriptive statistics., Results: Thirty-seven patients underwent esophageal stent placement for anastomotic leaks (n = 22) and perforations (n = 15). The median time from original procedure to diagnosis of leak or perforation was 6 days (0-420 days). Nineteen patients (51%) had 21 associated procedures for source control. We placed 94 stents (mean = 2.7 stents/patient); 16 patients (43%) required more than 1 stenting procedure (mean = 1.8 procedures/patient). The median time to restoration of esophageal integrity was 33 days (7-120 days). There were 22 successes (59%); 2 failures were secondary to undrained abscess. Only 2 failures occurred in the last 15 patients (88% success). Strictures did not develop in any patients. Serious complications occurred in 3 patients (stent erosion, leak enlargement, fatal gastroaortic fistula)., Conclusions: Esophageal stents can potentially play an integral role in the management of anastomotic leaks and perforations. Success depends on appropriate procedures for source control and surgeon experience., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Endoscopic submucosal dissection (ESD) increases en bloc and histologically complete resection rate of neoplastic mucosal tumors but is technically more demanding than EMR. Limited data are available comparing the efficacy and safety of a new ESD designed to overcome these limitations and conventional ESD (C-ESD) techniques., Objective: To compare the safety, efficacy, and operation time of the new HybridKnife ESD (HK-ESD) with C-ESD in the esophagus., Design: Prospective, randomized, controlled study., Setting: Animal research laboratory., Subjects: Seventeen anesthetized Yorkshire pigs., Interventions: Removal of a 4-cm length of half-circumference esophageal mucosa by C-ESD with Hook knife or Flexknife versus HK-ESD., Main Outcome Measurements: Procedure time, en bloc and complete resection rate, and complications (bleeding and perforation)., Results: All resections were completed en bloc. Procedure time was shorter in C-ESD. However, it was similar after 12 procedures. Significantly more bleeding occurred during C-ESD (28 vs 12, P = .0007). Histological muscularis propria injuries occurred with equal frequency (16 vs 17) and were mostly seen during the first 11 procedures. There were 3 perforations (2 endoscopic, 1 histological), all with C-ESD., Limitations: Nonsurvival study, use of 2 conventional knives, no training period for a new procedure., Conclusions: The HK-ESD technique was equally effective as the C-ESD technique for successful en bloc resection and was safer with less bleeding and perforation. Although procedure time was longer in HK-ESD, the difference became nonsignificant after 12 procedures., (Copyright © 2011. Published by Mosby, Inc.)

Zenker's diverticulum occurs as a result of impaired relaxation of the cricopharyngeal muscle primarily causing dysphagia. Affected are elderly patients with several comorbidities. By means of endoscopic intervention the septum is divided between the diverticulum and esophagus which allows unobstructed passage of food and liquids to the diverticulum into the esophagus. Advantages of this technique are manifold: usually general anesthesia is not required, the intervention can be performed in an outpatient setting or if necessary, hospital stay is short and the complication rate is low. Therefore, it is a suitable option for multimorbid patients. In approximately 90% of interventions symptoms of dysphagia are improved after the first treatment resulting in excellent effective medium term results in most cases.

Stenting of esophageal leaks, ie, anastomotic leaks or perforations, might be a minimally invasive alternative to surgery in most clinical situations. However, it must be emphasized that surgery should be considered if stent treatment in combination with drainage and antibiotics does not improve the clinical condition of the patient. Stent insertion should be performed as soon as possible after diagnosis of the leak., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Undernutrition has been shown to be predictive of 30-day mortality in patients undergoing self-expanding metal stent (SEMS) insertion for inoperable oesophageal cancer. The aim of this study was to assess the relationship between nutritional factors and 30-day mortality in patients undergoing SEMS insertion for palliation of oesophageal cancer., Methods: A retrospective cohort study was conducted from April 2007 to June 2009. BMI, swallowing ability, calorific intake and nature of nutritional support were recorded. ICD-10 causes of death were obtained from the Department of Health and Social Services., Results: Fifty-six stents were inserted into 53 patients (mean age 70 years, male n=35). Median (interquartile range) BMI was 21.0 kg/m (18.7-24.0). Median pre-SEMS swallowing grade was 3. Median calorific intake as a percentage of estimated daily requirements was 94.0% (75.6-100.0%). Thirty (56.6%) patients tolerated an oral diet enhanced with supplement drinks whereas 23 (43.4%) patients required more invasive forms of enteral and parenteral support. The 30-day mortality rate was 11.3% (n=6) and cumulative median survival was 84 (interquartile range 38-156) days. BMI, calorific intake and swallowing capacity were not predictors of survival. Although there was a nonsignificant trend for reduced survival in those patients who did (n=23) receive invasive nutritional support compared with those who did not (n=30) (83.9 vs. 151.3 days, P=0.053), invasive nutritional support itself was not predictive of 30-day mortality (P=0.74)., Conclusion: The requirement for invasive nutritional support before SEMS insertion is associated with a poor prognosis and possibly represents more aggressive tumour pathology. Further prospective assessment of prognostic factors, including nutritional parameters, to facilitate reliable selection of appropriate palliative modalities in oesophageal cancer is required.

In case of Zenker's diverticulum, treatment is indicated as soon as the diagnosis is established. Therapy should aim at the elimination of dysphagia and the symptoms of food retention and should reliably prevent recurrence. Currently, three different therapeutic approaches are applied: the classical option is open transcervical myotomy and diverticulectomy/diverticulopexy and alternatively stapled diverticulostomy with a linear stapler or flexible endoscopic diverticulostomy is propagated. As compared to the surgical (open) approach, rigid or flexible endotherapy is less invasive. However, endotherapy is not always feasible for all types of Zenker's diverticulum and the recurrence rate is high. Accordingly, open diverticulectomy is recommended in patients with an adequate life expectancy and good general operability.

Monitoring of esophageal pH is a major component of the evaluation of gastroesophageal reflux disease. A recent innovation has led to the replacement of the intraluminal probe by a wireless capsule. This capsule is attached to the esophageal wall and transmits the appropriate data to a patient-worn receiver. After a short period of time the capsule detaches itself from the wall and is eliminated. We recently encountered a patient in which the capsule did not detach in a timely manner. It was imaged during a preoperative esophagogram.

Introduction: Perforation of the oesophagus into the thoracic cavity is a potentially life-threatening condition. The causes are numerous. Treatment for oesophageal perforation targets mediastinal and pleural contamination. Present knowledge about the causes of perforation and the types of treatment is poor., Material and Methods: A retrospective review was made between 1997 and 2005 based on extracts from the National Patient Registry., Results: A total of 286 patients were diagnosed with perforation of the oesophagus (131 women and 155 men). Their average age was 60 years. A wide spectrum of causes was reported, e.g. instrumentation of the oesophagus 136 (47.6%), spontaneous rupture 89 (31.1%) or procedures otherwise related to surgical intervention 9 (3.1%). One third of the patients started conservative treatment 91 (31.9%). The majority of the patients were transferred to a thoracic surgery department for further treatment: about 25% of patients underwent surgery. The average hospitalization time was 18 days. The mortality rate was 21%., Conclusion: Oesophageal perforation remains a diagnostic and therapeutic challenge and the condition requires aggressive treatment. Recent consensus in early treatment with thoracotomy, debridement, irrigation and subsequent parenteral nutrition has improved survival. In this material, most perforations were iatrogenic in nature. In the 2002-2005 period, the study showed that 29% of the iatrogenic perforations were caused by the use of a rigid endoscope which is risky and whose use should therefore be restricted. It is advisable to set up national guidelines for treatment of oesophageal perforation and to centralise treatment.

Objective: Esophageal anastomotic leaks, perforations, and fistulae are associated with considerable morbidity and mortality. The aim of the present study was to assess the efficacy of self-expanding plastic stents in the treatment of esophageal leaks., Methods: From 2001 to 2009, 41 patients with postoperative anastomotic leaks (n = 30), esophageal perforations (n = 6), or fistulae (n = 5) were treated by endoscopic insertion of self-expanding plastic stents. The clinical outcome of the patients was analyzed, including leak healing, morbidity, and mortality., Results: Self-expanding plastic stents were successfully inserted in all 41 patients without procedure-related complications. Non-ventilated patients received oral feeding an average of 3.9 days after stent placement. Complete leak healing was obtained in 27 of 30 patients (90%) with anastomotic leaks and 5 patients (83%) with perforation. Sealing of fistulae by the stents was achieved in all 5 patients, and closure of the fistula was observed in 2 patients (40%). The mean healing time was 30 days for anastomotic leaks, 15 days for esophageal perforations, and 16 days for fistulae. Stent migration occurred in 14 cases, but endoscopic reintervention and new stent placement were successful in all cases. In-hospital mortality after treatment of esophageal leaks with stents was 10%., Conclusions: In combination with effective interventional or surgical drainage, stenting is a viable option for the treatment of esophageal anastomotic leaks and perforations, but the success in tracheoesophageal fistula is limited., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction: Laparoscopic Nissen fundoplication has been shown to have many benefits for patients including shorter hospital stay and fewer operative complications. The traditional laparoscopic Nissen fundoplication has been performed by the use of 5 incisions. With the inception of single incision procedures, surgeons have been examining other procedures that may benefit from adoption of an even less invasive technique., Materials: A 36-year-old female underwent a single incision laparoscopic Nissen fundoplication using 3 trocars. The patient's body mass index was 29 kg/m., Results: The operative time was 52 minutes. There were no intraoperative or postoperative complications within the 30 days. The patient was discharged home on the first postoperative day on a full liquid diet., Conclusions: Single incision laparoscopic Nissen fundoplication is feasible with comparable outcomes with the traditional 5 incision laparoscopic technique.

Objectives/hypothesis: Narrow band imaging combined with magnifying endoscopy (NBI-ME) is useful for the detection of superficial cancer in the oropharynx, hypopharynx, and esophagus. We used NBI-ME to evaluate the frequency of superficial cancer spread (SCS) contiguous with advanced oropharyngeal and hypopharyngeal cancers and esophageal cancers., Study Design: Retrospective., Methods: We retrospectively studied 45 patients with oropharyngeal and hypopharyngeal cancer and 44 with esophageal cancer who underwent NBI-ME from October 2006 through April 2009. The following variables were evaluated: 1) the frequency of SCS contiguous with advanced oropharyngeal and hypopharyngeal cancer and esophageal cancer, and 2) the influence of SCS contiguous with advanced oropharyngeal and hypopharyngeal cancer on clinical T category and clinical stage., Results: SCS contiguous with the primary tumor was found in 49% (22/45) of the patients with advanced oropharyngeal and hypopharyngeal cancer and in 52% (23/44) of those with advanced esophageal cancer. When SCS contiguous with the primary tumor was included in the evaluation of tumor size in advanced oropharyngeal and hypopharyngeal cancer, the clinical T category and clinical stage were revised in 20% (9/45) and 4% (2/45) of patients, respectively; SCS was ≤ 2 cm in 64% of cases (14/22) and between >2 cm and ≤ 4 cm in 36% (8/22)., Conclusions: NBI-ME should be included in the pretreatment diagnostic work-up to evaluate lesion extent and decide optimal surgical margins and radiation fields in patients with advanced oropharyngeal and hypopharyngeal cancer., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Most surgeons believe that cruroplasty (hiatoplasty) is an essential part of antireflux operations. One of the main causes of failure after antireflux operation is gastric (wrap) herniation through the hiatus that may be attributed to breakdown of the hiatal closure or a faulty repair. Surgeons are at present faced with the dilemma of choosing between a risk of recurrence and the fear of complications of prosthetic hiatal reinforcement. We reviewed the literature to evaluate the current status of hiatal mesh repair (HMR). Indication, technique, complications, and results are shown. Available data show a small number of mesh-related complications compared with the number of patients submitted to the procedure, and better results of HMR compared with simple hiatal closure. We support the use of HMR when performed by skilled foregut surgeons, as complications described occurred more frequently in the earliest cases of the series. In addition, HMR should be probably used selectively. However, studies to identify the patients at risk of hernia recurrence or mesh-related complications are still elusive. The ideal type of mesh and the ideal technique for mesh implantation are yet to be established.

Introduction: Multiband mucosectomy (MBM) is a relatively new technique for endoscopic resection in Barrett's esophagus. This ligate-cut technique uses a modified variceal band ligator allowing for six consecutive resections without prior submucosal lifting. The aim was to evaluate the safety of MBM and its efficacy for complete endoscopic removal of delineated target areas in Barrett's esophagus., Methods: Prospective registration of all MBM procedures in Barrett's esophagus was carried out between November 2004 and October 2009 in two hospitals. Prior to MBM, the target area was delineated with coagulation markings, followed by endoscopic resection until the delineated area was completely resected. Primary end points were acute (during procedure) plus early complications (<30 days) and the rate of complete endoscopic resection of the delineated target area., Results: A total of 243 MBM procedures, with 1060 resections, were performed in 170 patients. MBM was performed for focal lesions (n=113), for Barrett's esophagus removal as part of a (stepwise) radical endoscopic resection protocol (n=117), and as escape treatment after radiofrequency ablation (n=13). The only acute complication was bleeding (in 3%, endoscopically managed); no perforations occurred despite absence of submucosal lifting. Early complications consisted of delayed bleeding (in 2%, endoscopically managed) and stenosis, which occurred in 48% of patients treated in a (stepwise) radical resection protocol; patients treated for focal lesions or in escape treatment showed no stenosis. Complete endoscopic resection was achieved in 91% of the focal lesions, in 86% of cases treated under the (stepwise) radical endoscopic resection protocol, and 100% for escape treatment after radiofrequency ablation., Conclusion: MBM is a safe and effective technique for the removal of delineated target areas in Barrett's esophagus., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Barrett's mucosa resection techniques are time consuming, often difficult to perform, and used with varying success. This report describes the authors' results with a new device and technique for strip endoscopic mucosal resection (SEMR) using a cold excision blade., Methods: A retrospective review of ex vivo and in vivo animal and human esophagi experiments was conducted to develop the essential design characteristics of a transoral strip mucosal excision device. Depth, size, shape, and technique of excision were serially evaluated., Results: The SEMR device allows precise capsule positioning with satisfactory excision size and depth in ex vivo and in vivo experiments. A total of 10 excisions were performed on five normal ex vivo cadaveric human esophagi. The specimens ranged in size from 3×2.5 to 2.5×2.2 cm. The average specimen thickness was 0.297 mm. For 147 (99.8%) of 150 fields of examination, muscularis mucosa was included. Six additional in vivo experiments demonstrated device safety and feasibility., Conclusion: Satisfactory excision depth was reproducible. Further animal survival experiments and clinical trials will define the role of the SEMR device for patients with Barrett's esophagus.

Objective: The aim of this study is to assess the efficacy and safety of laparoscopic antireflux surgery (LARS) after failed endoscopic treatments for gastroesophageal reflux disease., Materials and Methods: The perioperative results of 9 patients, who had received endoscopic antireflux intervention before being subjected to LARS between March 2004 and November 2009, were analyzed retrospectively on a prospective database., Results: Endoscopically, while 6 patients had received radiofrequency ablation (Stretta; Curon Medical, Fremont, CA), 2 patients had been subjected to biopolymer injection (Enteryx; Boston Scientific, Natick, MA) and 1 patient to endoluminal plication (NDO plicator; NDO Surgical, Mansfield, MA). The mean age of the patients was 40 years while the mean values for their body mass index, symptom duration, and follow-up length were 25.6, 38 months, and 35 months, respectively. Mean operation length and mean discharge time were 56 minutes and 1 day, respectively. None of the patients who were subjected to NDO plicator and Stretta showed difficulty in dissection or perioperative complication. In contrast, the patients who had been subjected to Enteryx presented serious problems during LARS, and because of severe difficulty in dissection total fundoplication could not be performed. In both of those cases, LARS did not succeed., Conclusions: In patients who received Stretta and NDO plicator procedures and failed to respond, LARS does not present any difficulty or problem. However, performing LARS among patients who received Enteryx shows problems and fails to produce a successful result.

Background: Several small series have suggested an increased risk of complications associated with esophageal dilation in patients with eosinophilic esophagitis (EoE)., Objective: To quantitate the risk and identify risk factors for esophageal complications in dilation in EoE patients., Design: Retrospective, uncontrolled, single-center study., Setting: Tertiary referral hospital., Patients: A total of 161 EoE patients (mean ± standard deviation age 44.3 ± 15.3 years, 112 men, 49 women, 150 white patients, 10 unknown, 1 Asian)., Interventions: Through-the-scope balloon or Savary dilation of EoE., Main Outcome Measurements: The rate of complications defined as deep mucosal tear, major bleeding, or perforation, and determination of risk factors for complications., Results: A total of 293 dilations were performed in 161 patients. Complications reported were deep mucosal tear in 9.2% (n = 27), major bleeding in 0.3% (n = 1), and immediate perforation in 1.0% (n = 3). All patients with perforations were successfully treated medically without surgery (mean ± standard deviation hospital stay 5.3 ± 3.2 days). Factors associated with an increased risk of complications were luminal narrowing in the upper (odds ratio [OR], 5.62; 95% CI, 2.07-15.26; P < .001) and middle third of the esophagus (OR, 4.93; 95% CI, 1.64-14.83; P < .005) compared with lower third, luminal stricture unable to be traversed with a standard upper endoscope (OR, 2.48; 95% CI, 1.06-5.83; P = .037), and use of Savary dilator (OR, 2.63; 95% CI, 1.18-5.83; P = .018)., Limitations: Retrospective design, uncontrolled study., Conclusions: Deep mucosal tears are common after dilation (9%), but the risk of immediate transluminal perforation with EoE is approximately 1%. The risk of severe complications is increased in patients with more proximal stricture and strictures that initially prevent endoscope passage., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

The aim of this study is to assess patients treated for esophageal foreign bodies. The charts of patients (n=177), between January 1994 and April 2009, were investigated retrospectively. Patients' age and gender, locations and types of foreign bodies (FBs) and interventions were taken into consideration. Fifty-seven percent of the patients were male. The youngest patient was 6 months, whereas the oldest was 83 years old. The median age was 9 years. Half of the patients were in their first decade. Treatment took place 11 h (ranging from 1 to 120 h) after impaction of the FB. One hundred fifty-two FBs were removed in 177 patients. Our negative esophagoscopy (n=25) rate was 14%. The FBs were radiopaque in 75% (n=114) and were commonly (71%; n=109) located in the cervical esophagus. Metallic coins (n=81-53%) were the most commonly observed inorganic FB while bones and/or meat impaction (n=54-35%) were the most frequent organic FB. A total of 182 endoscopic interventions were performed on these patients. One hundred eleven of them were esophagoscopy and the remaining 71 were direct laryngoscopy. The FB was pushed into the stomach in 11 patients. Our morbidity rate was 1.6% (n=3). Iatrogenic perforation occurred in two patients. There was no mortality. Esophageal FBs may vary in type: sharp or round objects, metallic, plastic or organic material. FBs are commonly found at pharyngoesophageal junction and usually removed by McGill forceps. Rigid esophagoscopy is used for children and adults because of its large working channel. Rigid instruments are considered reliable and safe for extracting foreign bodies., (© 2010 Copyright the Authors. Journal compilation © 2010, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Context: Gastroesophageal reflux disease is one of the most common digestive diseases and an important cause of distress to patients. Diagnosis of this condition can require ambulatory pH monitoring., Objectives: To determine the diagnostic yield of a wireless ambulatory pH monitoring system of 48-hours, recording to diagnose daily variability of abnormal esophageal acid exposure and its symptom association., Methods: A total of 100 consecutive patients with persistent reflux symptoms underwent wireless pH capsule placement from 2004 to 2009. The wireless pH capsule was deployed 5 cm proximal to the squamocolumnar junction after lower esophageal sphincter was manometrically determined. The pH recordings over 48-h were obtained after uploading data to a computer from the receiver that recorded pH signals from the wireless pH capsule. The following parameters were analyzed: (1) percentual time of distal esophageal acid exposure; (2) symptom association probability related to acid reflux. The results between the first and the second day were compared, and the diagnostic yield reached when the second day monitoring was included., Results: Successful pH data over 48-h was obtained in 95% of patients. Nearly one quarter of patients experienced symptoms ranging from a foreign body sensation to chest pain. Forty-eight hours pH data analysis was statistically significant when compared to isolated analysis of day 1 and day 2. Study on day 2 identified seven patients (30.4%) that would be missed if only day 1 was analyzed. Three patients (18.7%) out of 16 patients with normal esophageal acid exposure on both days, showed positive symptom association probability, which generated an increase in diagnostic yield of 43.4%., Conclusion: Esophageal pH monitoring with wireless capsule is safe, well tolerated, does not require sedation. The extended 48-h period of study poses an increased yield to diagnose gastroesophageal reflux disease patients.

Aim: to investigate the side effects and survival of endoscopic variceal ligation by using Indonesian Endoscopic Ligator versus Endoscopic Variceal Sclerotherapy., Methods: we studied the medical records and endoscopy reports of patients who underwent endoscopic variceal ligation (EVL) or endoscopic sclerotherapy (EST) from January 2003 until December 2006. EST was done using ethoxysclerol injection; and ligation was done using a home-made Indonesian endoscopic ligating device. Patient characteristics, side effects of EVL and EST, as well as survival and length of stay were collected. Data of side effects was analyzed by chi-square test., Results: there were no statistically significant differences of patients characteristics among both groups. The side effects in EVL group (29.2%) were less frequent than the EST group (60.9%) (p = 0.009). The death side effect in the EVL group (1.0%) was less frequent than in the EST group (21.7%) (p<0.001). The four-year survival in patients who had EVL and EST were 91.7% and 16.7%, respectively (p<0.001)., Conclusion: EVL had fewer side effects than EST in the treatment of esophageal varices bleeding. Death in the EVL group was lower than in the EST group.

Aim: To evaluate the efficacy of self expandable metallic stents (SEMS) in patients with malignant esophageal obstruction and fistulas., Methods: SEMS were implanted in the presence of fluoroscopic guidance in patients suffering from advanced and non-resectable esophageal, cardiac and invasive lung cancer between 2002 and 2009. All procedures were performed under conscious sedation. All patients had esophagus obstruction and/or fistula. In all patients who required reintervention, recurrence of dysphagia, hemorrhage, and fistula formation were indications for further endoscopy. Patients' files were scanned retrospectively and the obtained data were analyzed using SPSS 13.0 for Windows. The χ(2) test was used for categorical data and was analysis of variance for non-categorical data. Patients' long-term survival was assessed using the Kaplan-Meier method., Results: Stents were successfully implanted in 90 patients using fluoroscopic guidance. Reasons for stent implantation in these patients were esophageal stricture (77/90, 85.5%), external pressure (8/90, 8.8%) and tracheo-esophageal fistula (5/90, 5.5%). Dysphagia scores (mean ± SD) were 3.37 ± 0.52 before and 0.90 ± 0.43 after stent implantation (P = 0.002). Intermittent, non-massive hemorrhage due to the erosion caused by the distal end of the stent in the stomach occurred in only one patient who received implementation at cardio-esophageal junction. Mean survival following stenting was 134.14 d (95% confidence interval: 94.06-174.21)., Conclusion: SEMS placement is safe and effective in the palliation of dysphagia in selected patients with malignant esophageal strictures.