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INTRODUCTION: Early neoplastic progression of Barretts esophagus (BE) is often treated with endoscopic therapy. Although effective, some patients are refractory to therapy or recur after apparent eradication of the BE. The goal of this study was to determine whether genomic alterations within the treated BE may be associated with persistent or recurrent disease. METHODS: We performed DNA sequencing on pre-treatment esophageal samples from 45 patients who were successfully treated by endoscopic therapy and did not recur as well as pre-treatment and post-treatment samples from 40 patients who had persistent neoplasia and 21 patients who had recurrent neoplasia. The genomic alterations were compared between groups. RESULTS: The genomic landscape was similar between all groups. Patients with persistent disease were more likely to have pre-treatment alterations involving the receptor tyrosine kinase pathway ( P = 0.01), amplifications of oncogenes ( P = 0.01), and deletions of tumor suppressor genes ( P = 0.02). These associations were no longer significant after adjusting for patient age and BE length. More than half of patients with persistent (52.5%) or recurrent (57.2%) disease showed pre-treatment and post-treatment samples that shared at least 50% of their driver mutations. DISCUSSION: Pre-treatment samples were genomically similar between those who responded to endoscopic therapy and those who had persistent or recurrent disease, suggesting there is not a strong genomic component to treatment response. Although it was expected to find shared driver mutations in pre-treatment and post-treatment samples in patients with persistent disease, the finding that an equal number of patients with recurrent disease also showed this relation suggests that many recurrences represent undetected minimal residual disease.

Background & aimsDiscerning whether laryngeal symptoms result from gastroesophageal reflux is clinically challenging and a reliable tool to stratify patients is needed. We aimed to develop and validate a model to predict the likelihood of gastroesophageal reflux disease (GERD) among patients with chronic laryngeal symptoms.MethodsThis multicenter international study collected data from adults with chronic laryngeal symptoms who underwent objective testing (upper gastrointestinal endoscopy and/or ambulatory reflux monitoring) between March 2018 and May 2023. The training phase identified a model with optimal receiver operating characteristic curves, and β coefficients informed a weighted model. The validation phase assessed performance characteristics of the weighted model.ResultsA total of 856 adults, 304 in the training cohort and 552 in the validation cohort, were included. In the training phase, the optimal predictive model (area under the curve, 0.68; 95% CI, 0.62-0.74), was the Cough, Overweight/obesity, Globus, Hiatal Hernia, Regurgitation, and male seX (COuGH RefluX) score, with a lower threshold of 2.5 and an upper threshold of 5.0 to predict proven GERD. In the validation phase, the COuGH RefluX score had an area under the curve of 0.67 (95% CI, 0.62-0.71), with 79% sensitivity and 81% specificity for proven GERD.ConclusionsThe externally validated COuGH RefluX score is a clinically practical model to predict the likelihood of proven GERD. The score classifies most patients with chronic laryngeal symptoms as low/high likelihood of proven GERD, with only 38% remaining as indeterminate. Thus, the COuGH RefluX score can guide diagnostic strategies and reduce inappropriate proton pump inhibitor use or testing for patients referred for evaluation of chronic laryngeal symptoms.

Introduction: The etiology of esophageal squamous papilloma (ESP) is largely unknown. Previous studies have shown a variable association with human papillomavirus (HPV) with conflicting data. The aim of this study was to further investigate the possible association of HPV in our ESP series using RNA in-situ hybridization (ISH) and compare study groups from the United States of America and China. Methods: Demographic and clinical data of patients with ESP were retrieved from the University of California Los Angeles (UCLA) (1/2016-3/2019) and Peking Union Medical College Hospital (PUMCH) (9/2014-3/2019) pathology databases. Hematoxylin and eosin slides were reexamined. Confirmed cases were examined by high- and low-risk HPV RNA ISH. Results: For the UCLA cohort, 13 429 upper endoscopies were performed and 78 biopsies from 72 patients were identified as ESP (F:M = 45:27, 66.7% > 45 years). Seventy-four (94.9%) biopsies were designated as polyps or nodules and 46.6% were located in the mid-esophagus. Other abnormal findings included gastroesophageal reflux disease (48.6%), hiatal hernia (38.9%), and esophagitis (36.1%). For the PUMCH cohort, 63 754 upper endoscopies were performed and 73 biopsies from 71 patients were identified as ESP (F:M = 48:23, 71.8% > 45 years). Sixty-four (87.7%) biopsies were designated as polyps or nodules and 57.5% were located in the mid-esophagus. Other abnormal findings included esophagitis (19.7%), and hiatal hernia (8.5%). No features of conventional cytologic dysplasia or viral cytopathic change were found. None of the cases was associated with squamous cell carcinoma, and none showed positive HPV RNA ISH results. Conclusions: No association was found between ESP and active HPV infection in our 2 cohorts. Other etiopathogenetic mechanisms, such as aging, might contribute to the development of these innocent lesions.

Background and Aim Methods Results Conclusions Gel immersion (GI) endoscopy provides a good visual field in endoscopic submucosal dissection (ESD); however, its clinical outcomes are poorly understood. This study aimed to compare the treatment outcomes between esophageal gel immersion endoscopic submucosal dissection (GI‐ESD) and conventional ESD (C‐ESD) to determine the safety and efficacy of GI‐ESD.The data of 71 consecutive patients who underwent esophageal ESD between April 2021 and March 2023 at a Japanese tertiary center were retrospectively reviewed. GI was achieved using an additional irrigation tube. The treatment outcomes between the GI‐ESD and C‐ESD groups were compared using inverse probability of treatment weighting (IPTW) to control for confounding factors.A total of 75 superficial esophageal epithelial neoplasms (41 in the C‐ESD and 34 in the GI‐ESD groups) were treated using ESD. The mean procedure time in the GI‐ESD group was significantly shorter than that in the C‐ESD group (59.2 ± 36.2 vs 85.3 ± 45.7 min, P = 0.008). After IPTW adjustment, the mean procedural times were 62.6 ± 36.6 and 82.9 ± 41.7 min in the GI‐ESD and C‐ESD groups, respectively (P = 0.037), and the incidence rate of muscle layer damage was 4.2% in the GI‐ESD group and 30.6% in the C‐ESD group (P = 0.001). In the multivariate analysis, specimen size ≥ 30 mm (odds ratio [OR]: 9.44, 95% confidence interval [CI]: 2.46–36.30, P = 0.001) was positively correlated with longer procedural time (≥ 90 min), whereas GI‐ESD (OR: 0.19, 95%CI: 0.05–0.68, P = 0.011) showed a negative association.Esophageal GI‐ESD may be useful in terms of safety and time efficiency. The GI technique could be an option for esophageal ESD. [ABSTRACT FROM AUTHOR]

Objectives: The endoscopic pressure study integrated system (EPSIS) represents an innovative approach for evaluating lower esophageal sphincter function by monitoring intragastric pressure using diagnostic gastroscopes. This study aimed to assess the feasibility and validity of employing ultrathin gastroscopes for EPSIS. Methods: A retrospective analysis was conducted on a database of consecutive patients who underwent EPSIS using both ultrathin and regular gastroscopes between September 2021 and October 2023. The study compared EPSIS parameters between the two gastroscope types to evaluate the correlation of key metrics. Results: Thirty patients underwent EPSIS with both ultrathin and regular gastroscopes. Significant positive correlations were observed in the pressure waveform: maximum intragastric pressure (mmHg) (ρ = 0.82, P < 0.001) and intragastric pressure gradient (mmHg/s) (ρ = 0.80, P < 0.001) when comparing the two gastroscopes. Maximum intragastric pressure (15.5 [5.3–20.3] vs. 18.5 [3.4–21.6], P < 0.001) and pressure gradient (0.16 [0.013–0.41] vs. 0.24 [0.0039–1.13], P < 0.001), (median [range]) were significantly lower with ultrathin gastroscopes. Conclusions: This study establishes that EPSIS parameters obtained with an ultrathin gastroscope exhibit a significant correlation with those obtained using a regular gastroscope, with each EPSIS parameter consistently lower. These findings support the viability of EPSIS for ultrathin gastroscopy and highlight its potential as a diagnostic tool for assessing lower esophageal sphincter function. [ABSTRACT FROM AUTHOR]

Background: Hiatal and paraesophageal hernia (HH/PEH) recurrence is the most common cause of failure after gastroesophageal anti-reflux surgery. Crural reinforcement with mesh has been suggested to address this issue, but its efficacy remains debated. In this study, we aimed to determine the impact of biosynthetic mesh reinforcement compared to suture cruroplasty on anatomic and symptomatic hernia recurrence. Method: Data of patients who underwent robotic HH/PEH repair with suture cruroplasty with or without biosynthetic mesh reinforcement between January 2012 and April 2024 were retrospectively reviewed. Gastroesophageal reflux disease symptoms and anatomic hernia recurrence were assessed at short-term (3 months to 1 year) and longer-term (≥ 1 year) follow-up. Symptomatic hernia recurrence was defined as having both anatomic recurrence and symptoms. Results: Out of the 503 patients in the study, 308 had undergone biosynthetic mesh repair, while 195 had suture-only repair. After the surgery, both groups demonstrated comparable improvements in symptoms. Short-term anatomic hernia recurrence rates were 11.8% and 15.6% for mesh and suture groups, respectively (p = 0.609), while longer-term rates were 24.7% and 44.9% (p = 0.015). The rates of symptomatic hernia recurrence in the same group were 8.8% and 14.6% in the short-term (p = 0.256), and 17.2% and 42.2% in longer-term follow-ups (p = 0.003). In the repair of medium and large-size hernias, mesh reinforcement resulted in a 50.0% relative risk reduction in anatomic hernia recurrences and a 59.2% reduction in symptomatic hernia recurrences at ≥ 1-year follow-up. Conclusion: After more than a year of follow-up, it has been found that using biosynthetic mesh for medium and large hiatal or paraesophageal hernia repair significantly reduces the likelihood of both anatomic and symptomatic recurrence compared to using only suture cruroplasty. These findings strongly support the use of biosynthetic mesh to manage larger hernias. However, further long-term multicenter randomized studies are needed to provide more conclusive evidence. [ABSTRACT FROM AUTHOR]

Background: Gastroesophageal reflux disease is a prevalent condition with significant clinical variability, complicating its evaluation and treatment. The gastroesophageal flap valve is a fundamental evaluation method, but have shown limitations in specificity and reliance on subjective endoscopists' experience. Recent insights suggest that gastroesophageal junction laxity may offer an objective and quantifiable measurement for the presence of gastroesophageal reflux disease. Methods: This retrospective study analyzed data from 401 patients who underwent comprehensive evaluations, including a symptom questionnaire, endoscopy, pH-impedance monitoring, high-resolution manometry, and treatment directions, between January 1, 2022 and October 31, 2023. Gastroesophageal junction laxity was assessed using a modified approach based on endoscopic image analysis, with the diameter of endoscope as reference to estimate the long diameter of the laxity ring. The independent association of gastroesophageal junction laxity with pathologic acid exposure, esophagitis, and hiatal hernia were assessed by adjusting with age and sex. Results: The mean age was 44.5 ± 5.5 years old, and 49.9% (200/401) were male. The most common symptoms (≥ 1 point) were acid regurgitation (333/401, 83.0%), heartburn (315/401, 78.6%), belching (278/401, 69.3%), bloating (241/401, 60.1%), and globus sensation (241/401, 60.1%). The gastroesophageal junction laxity was significantly associated with pathologic acid exposure, esophagitis, hiatal hernia, and lower esophageal sphincter resting pressure. Notably, with the increase in gastroesophageal junction laxity, the rates of pathologic acid exposure, esophagitis, and hiatal hernia increased gradually, the lower esophageal sphincter resting pressure decreased gradually. The gastroesophageal junction laxity was independent associated with pathologic acid exposure (OR = 2.33, 95%CI 1.77–3.07, p < 0.001), esophagitis (OR = 2.10, 95%CI 1.62–2.73, p < 0.001), and hiatal hernia (high-resolution manometry: OR = 3.39, 95%CI: 2.46–4.67, p < 0.001) (endoscopy: OR = 21.65, 95%CI 11.70–40.06, p < 0.001). Conclusion: The gastroesophageal junction laxity was significantly associated with the indicators of pathophysiology in gastroesophageal reflux disease. [ABSTRACT FROM AUTHOR]

L'actualité en oncologie radiothérapie est marquée par les résultats d'essais stratégiques particulièrement pour les cancers de l'œsophage et du rectum. Pour l'adénocarcinome de l'œsophage, en situation préopératoire, les résultats de l'étude ESOPEC ont montré un bénéfice de survie de la chimiothérapie périopératoire par 5-fluoro-uracile, leucovorine oxaliplatine, taxotère en comparaison à la chimioradiothérapie (irradiation de 41,4 Gy avec une chimiothérapie concomitante par carboplatine/paclitaxel). En situation exclusive, l'étude CONCORDE n'a pas montré de bénéfice de l'escalade de dose et la dose standard reste 50 Gy. Pour le cancer du pancréas opérable, l'étude NRG/RTOG0848 qui comparait la chimiothérapie adjuvante avec ou sans chimioradiothérapie complémentaire a retrouvé une augmentation significative de la probabilité de survie sans maladie à 5 ans dans le sous-groupe de patients sans atteinte ganglionnaire. Pour les cancers du rectum, l'actualisation à 7 ans des résultats de l'étude PRODIGE 23 a confirmé le bénéfice non seulement en termes de survie sans récidive mais également de survie globale d'une chimiothérapie néoadjuvante par 5-fluoro-uracile, acide folinique, irinotécan et oxalipalatine avant la chimioradiothérapie, alors que l'actualisation de l'étude RAPIDO a montré un taux de rechute locale inacceptable dans le bras expérimental. L'actualisation de l'étude OPRA a montré un taux de survie avec conservation d'organe à 5 ans significativement supérieur en faveur du bras chimioradiothérapie suivie de la chimiothérapie en comparaison à la chimiothérapie d'induction première suivie de chimioradiothérapie. Une étude de phase 2 incluant 41 patients atteints d'un cancer du rectum localement avancé avec défaillance du système de réparation de l'ADN, a montré qu'un traitement exclusif par immunothérapie anti-PDL1 (dostarlimab) pendant 6 mois permettait une réponse clinique complète sans recours à un traitement complémentaire (ni radiothérapie, ni chirurgie). Pour le carcinome épidermoïde du canal anal, la survie et les profils de toxicité des patients inclus dans la cohorte anabase traités pour une tumeur de petit stade (T1 ou T2) ont été comparés selon qu'ils aient reçu exclusivement de la radiothérapie ou de la chimioradiothérapie. L'ajout d'une chimiothérapie à la radiothérapie ne montrait pas de bénéfice mais augmentait la toxicité et le risque d'allongement du traitement en raison d'interruption. Current events in radiotherapy oncology are marked by the results of strategic trials, particularly for esophageal and rectal cancers. For resectable esophageal adenocarcinoma, results of the ESOPEC study showed a benefit in overall survival from the perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin and docetaxel compared to chemoradiotherapy (41.4 Gy radiotherapy and carboplatin/paclitaxel chemotherapy). In definitive setting, the CONCORDE study did not show any benefit from dose escalation and the standard dose remains 50 Gy. For resectable pancreatic cancer, the NRG/RTOG0848 study that compared adjuvant chemotherapy with or without chemoradiotherapy found a significant increase of the 5-year disease-free survival rate in the subgroup of node-negative patients. For rectal cancers, the 7-year update of PRODIGE 23 study confirmed the benefit in disease-free- and overall survival of neoadjuvant folinic acid, fluorouracil, irinotecan and oxaliplatin chemotherapy before chemoradiotherapy of T3, T4 or N+ adenocarcinoma, while the update of the RAPIDO study revealed an unacceptable local recurrence rate in the experimental arm. The update of the OPRA study shows a significantly higher 5-year organ preservation rate in favor of the chemoradiotherapy arm followed by consolidation chemotherapy compared to induction chemotherapy followed by CRT. A phase 2 study, including 41 patients with mismatch repair deficient, locally advanced rectal cancer reported that exclusive treatment with anti-PDL1 immunotherapy (dostarlimab) for 6 months resulted in complete clinical response without the need of additional treatment (neither radiotherapy nor surgery). For anal carcinoma, the analysis of survival and toxicity profiles of patients treated for a small stage T1 or T2 tumor were compared depending on whether they received exclusive radiotherapy or chemoradiotherapy. The addition of chemotherapy to radiotherapy did not show any survival benefit but significantly increased toxicity and the risk of radiotherapy disruption. [ABSTRACT FROM AUTHOR]

Forensic pathologists need to have comprehensive knowledge of a large variety of causes of sudden natural death. We describe a case of sudden and unexpected death in woman in her sixties due to rupture of a large paraesophageal hematoma. The post-mortem examination and differential diagnosis are discussed. The combined findings of whole-body post-mortem CT imaging (PMCT), targeted PMCT angiography, autopsy, and histology are most in keeping with 'esophageal apoplexy'; a rare cause of hemorrhage in the esophageal wall. A review of the literature indicates that most cases of esophageal apoplexy are self-limiting and that fatal complications are exceedingly rare. Our case demonstrates that esophageal apoplexy can present as sudden unexpected death. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion The impact of combining ablation index (AI)‐guided and very high‐power short‐duration (vHPSD) ablation on procedural factors at the posterior wall near the esophagus is unclear.Atrial fibrillation patients who underwent initial ablation using three‐dimensional mapping were enrolled. Patients were classified into two groups: those who underwent only AI‐guided pulmonary vein isolation (PVI) (AI group) and those who underwent vHPSD ablation at the posterior wall adjacent to the esophagus in addition to AI‐guided PVI (AI + vHPSD group). Differences in myocardial injury, inflammation, procedural characteristics, and pulmonary vein (PV) reconnection patterns were assessed between the two groups.This study included 167 patients (AI group, 83 patients; AI+vHPSD group, 84 patients). No significant differences in high‐sensitive troponin I or changes in inflammatory markers between pre‐ and Postablation were observed in either group. Total application time and total application energy were significantly lower in the AI+vHPSD group than in the AI group (p < 0.001 for both) despite no significant difference in the total number of applications between the groups. The incidence of esophagus temperature ≥40 degrees was significantly lower in the AI+vHPSD group than in the AI group (p = 0.036). However, the incidence of PV reconnections near the esophagus was significantly higher in the AI+vHPSD group than in the AI group (11.9% vs 3.6%, p = 0.046), despite no significant difference in the incidence of PV reconnections overall.The combination of AI‐guided PVI and vHPSD adjacent to the esophagus demonstrated reduced application energy requirements and maintained safety and effectiveness during the perioperative period. [ABSTRACT FROM AUTHOR]

AbstractObjectiveMaterial and methodsResultsConclusionsEosinophilic esophagitis (EoE) is a chronic immune-mediated disease. The budesonide orodispersible tablet (BOT) is recommended as second-line treatment according to the Danish guideline. This study aimed to compare potential treatment disparities before BOT initiation, follow-up practices, clinico-histologic remission rates during BOT treatment, and adherence to the national guideline between the highly specialized EoE-Cph cohort and the population-based DanEoE cohort.This cohort study compared 65 adult patients from the EoE-Cph cohort with 65 patients from the DanEoE cohort. All patients were diagnosed between 2015-2021. The diagnosis of EoE was defined according to the AGREE consensus. Data were extracted manually from medical records and registries.In the EoE-Cph cohort, 88% were prescribed proton pump inhibitors (PPIs) before started on BOT compared to 100% in the DanEoE cohort (p = 0.0035). Symptomatic follow-up occurred in 89% of EoE-Cph patients compared to 97% of DanEoE patients after BOT treatment (p = 0.0841). No difference was found between patients who underwent histologic follow-up after topical steroid treatment (83% versus 82%, p = 0.8162). Complete clinico-histologic remission was frequently observed, and no significant difference was observed between the two cohorts (67% versus 80%, p =0.1789). One out of four patients had conflicting symptomatic and histological responses.This study did not provide conclusive evidence favoring the treatment of EoE patients exclusively at highly specialized EoE centers. However, the authors acknowledge that further evidence is necessary before considering changes in clinical practice. Conflicting treatment responses, and discontinuation of treatment due to side effects remains a notable concern. [ABSTRACT FROM AUTHOR]

Summary: Background: Minimally invasive surgery is becoming the method of choice for the resection of esophageal cancer worldwide. Methods: Retrospective analysis of prospectively collected clinical data in a tertiary care center with a detailed description of the course of the program. Results: A total of 136 transthoracic esophageal resections were performed between 2010 and 2023. The study group included 116 operations, 69 of which were fully minimally invasive and 47 hybrid. 80.0% of the study group underwent surgery using a multimodality approach. The median operation time was 431 min (± 103). The R0 resection rate was 100%. Forty-two patients (36.2%) had no postoperative complications. The postoperative Clavien-Dindo > IIIb morbidity was 27%. The postoperative 90-d mortality rate was 1.7%. The average number of lymph nodes removed in the last quarter of cancer patients was 31. The anastomotic insufficiency rate for reoperation was 4% (Ivor-Lewis 4.2%, McKeown 5%). Conclusions: With extensive expertise in high-end minimally invasive abdominal and thoracic surgery, implementation of a minimally invasive esophageal resection program with a clinical and oncologic outcome within generally accepted limits is feasible. [ABSTRACT FROM AUTHOR]

Simple Summary: This study explores the microbiome of the upper digestive tract using a non-endoscopic capsule-sponge device, aiming to understand the differences in microbial communities among patients with varying risks for esophageal squamous cell carcinoma (ESCC). We compared microbiomes from the oral cavity, esophagus, and stomach across three groups: patients with esophageal squamous intraepithelial neoplasia, head and neck squamous cell cancer (HNSCC) survivors, and patients with functional dyspepsia. By analyzing microbial DNA using 16S rRNA gene sequencing, the study found distinct differences in microbiota diversity and composition between FD patients and HNSCC survivors, particularly in gastric and esophageal samples. However, differences between FD patients and those with esophageal neoplasia were minimal. These findings could help identify microbial patterns associated with ESCC risk and guide future research on the role of microbiome alterations in cancer development, potentially leading to new diagnostic or therapeutic approaches. Background: A non-endoscopic capsule-sponge device allows sampling the entire length of the esophagus. Here, we compared microbiomes of the oral cavity, esophagus, and gastric corpus collected by oral swab, capsule-sponge device, and endoscopic biopsy, respectively, in patients representing three distinct risk profiles for esophageal squamous cell carcinoma (ESCC). Methods: The study enrolled 11 patients with esophageal squamous intraepithelial neoplasia, 21 patients after curative treatment for head and neck squamous cell cancer (HNSCC) (HNSCC survivors), and 40 patients with functional dyspeptic (FD) symptoms. Microbial genomic DNA was analyzed using 16S rRNA gene amplicon sequencing. Results: The Shannon index of the capsule-sponge sample microbiota was significantly higher in FD group than in patients after treatment for HNSCC, and the Chao index of gastric samples differed between HNSCC survivors and FD patients. Analysis of the β-diversity of FD patients, HNSCC, and esophageal squamous intraepithelial neoplasia showed that different genera formed at each location. The abundance of 205, 116, and 9 genera differed between FD patients and HNSCC survivors in the gastric, capsule-sponge, and oral samples, respectively; 33 genera differed between the FD group and patients with esophageal squamous intraepithelial neoplasia in capsule-sponge samples. Conclusions: The bacterial communities of the upper digestive tract were clustered according to the anatomic site. Despite substantial differences in gastric and esophageal microbiota samples between FD patients and HNSCC survivors, the microbial members and diversity showed small differences between FD patients and those with esophageal squamous intraepithelial neoplasia. It remains unclear whether gastric and esophageal dysbiosis is associated with or is a consequence of treatment for HNSCC. [ABSTRACT FROM AUTHOR]

Simple Summary: Previous studies have demonstrated that the occurrence of immune-related adverse events (irAEs) is significantly associated with favorable efficacy and prognosis in patients with cancers treated with immune checkpoint inhibitors (ICIs), such as anti-programmed cell death protein 1 (PD-1) and anti-cytotoxic T lymphocyte-associated antigen. However, few studies have investigated this association in patients with esophageal squamous cell carcinoma (ESCC). Herein, we evaluated the relationship of irAEs with tumor response and survival in patients with unresectable advanced or recurrent ESCC treated with second- or later-line nivolumab, an anti-PD-1 antibody, monotherapy. We observed that the occurrence of mild (grade 1/2) irAEs during the entire period, as well as within 8 weeks of nivolumab initiation, was significantly associated with tumor response and survival following nivolumab monotherapy. Thus, mild irAEs may serve as predictive markers for the response and prognosis of patients with ESCC treated with ICIs. Background: Patients across various cancers who develop immune-related adverse events (irAEs) post-immune checkpoint inhibitor (ICI) treatment tend to experience better tumor response and survival than those who do not. However, studies regarding this association in patients with esophageal squamous cell carcinoma (ESCC) are limited. Methods: We assessed the relationship of irAEs with tumor response and survival in 82 consecutive patients with unresectable advanced or recurrent ESCC treated with second- or later-line nivolumab, an anti-PD-1 antibody, monotherapy. Results: We observed irAEs in 24 (29.3%) patients, with the overall response and disease control rates in the irAE-positive group being significantly better than those in the irAE-negative group (both p < 0.0001). During the entire period and within 8 weeks of nivolumab initiation, progression-free and overall survivals (PFS and OS, respectively) were significantly better in patients with grade1/2 irAEs than in those without. Univariate and multivariate analyses indicated grade1/2 irAEs during the entire period and within 8 weeks as independent covariates for PFS (entire period: hazard ratio [HR] 0.28, 95% confidence interval [CI] 0.16–0.49, p < 0.001; within 8 weeks: HR 0.46, 95% CI 0.23–0.93, p = 0.03) and OS (entire period: HR 0.24, 95% CI 0.13–0.44, p < 0.001; within 8 weeks: HR 0.41, 95% CI 0.18–0.92, p = 0.03). Conclusions: Grade1/2 irAEs during the entire treatment period and within 8 weeks of nivolumab initiation were significantly associated with improved tumor response and survival in patients with advanced ESCC treated with nivolumab monotherapy. Therefore, mild irAEs may be predictive markers for the response and prognosis of ESCC following ICI treatment. [ABSTRACT FROM AUTHOR]

Esophageal anastomotic fistula (AF) is a frequent and severe complication of an esophagectomy due to esophageal or eso-gastric junction cancer, regardless of the selected surgical technique. AF is usually treated by endoscopic stent placement. Objectives: This study aims to examine the efficacy of stents in the treatment of AF, analyzing the healing period and the factors that contribute to its delay. Methods: We collected data from 55 patients who underwent stent implantation for AF, and analyzed multiple variables related to patient healing time and surgical technique with two primary endpoints: post-stenting hospital stay and the time of stent usage until fistula closure. The patients were divided into three groups based on the anastomosis type (eso-gastric anastomosis, eso-gastric cervical anastomosis and eso-jejunal anastomosis) and they were compared using the primary endpoints. Results: Our findings show the differences between the three groups, with a longer hospital stay for eso-gastric anastomosis, and an extended time of fistula closure in the case of eso-gastric cervical anastomosis. We also found a significant correlation between the size of the fistula and the hospital stay (R = 0.4, p < 0.01). Regarding patients' risk factors, our results show an extended post-stenting hospital stay for those patients that underwent preoperative radiotherapy. Conclusions: Our results offer an extended view of the efficiency, hospitalization duration and healing time for esophageal anastomotic fistula, and reveal some of the factors that interfere with its resolution. [ABSTRACT FROM AUTHOR]

Diseases of the esophagus affect its function and often lead to replacement of long sections of the organ. Current healing methods involve the use of bioscaffolds processed from other animal models. Although the properties of these animal models are not exactly the same as those of the human esophagus, they nevertheless present a reasonable means of assessing the biomechanical properties of the esophageal tissue. Besides, sheep bear many similarities physiologically to humans and they also suffer from same diseases as humans. The morphology of their esophagus is also comparable to that of humans. Thus, in the study, an ovine esophagus was studied. Studies on the planar biaxial tests of the gross esophageal anatomy are limited. The composite nature of the gross anatomy of the esophagus makes the application of structure-based models such as Holzapfel-type models very difficult. In current studies the tissue is therefore often separated into specific layers with substantial collagen content. The effects of adipose tissue and other non-collagenous tissue often make the mechanical behavior of the esophagus widely diverse and unpredictable using deterministic structure-based models. Thus, it may be very difficult to predict its mechanical behavior. In the study, an NARX neural network was used to predict the stress–strain response of the gross anatomy of the ovine esophagus. The results show that the NARX model was able to achieve a correlation above 99.9% within a fitting error margin of 16%. Therefore, the use of artificial neural networks may provide a more accurate way of predicting the biaxial stress–strain response of the esophageal tissue, and lead to further improvements in the design and development of synthetic replacement materials for esophageal tissue. [ABSTRACT FROM AUTHOR]

Background: Accurate core temperature measurement in children is crucial; however, measuring esophageal temperature (TE) using a supraglottic airway device (SAD) can be challenging. Second-generation SADs, which have a gastric channel, can measure TE, and reduce gastric air volume. This study aimed to compare TE, measured using a probe inserted through the SAD gastric channel, with tympanic membrane (TTM) and forehead (TZHF) temperatures, measured using a zero-heat-flux cutaneous thermometer, with rectal temperature (TR). Methods: Temperature was recorded at 10-min intervals from 10 min after probe insertion until completion of surgery. We performed an equivalence test to evaluate whether the TE, TTM, and TZHF were equivalent to TR, with a margin of 0.3°C. Additionally, intraclass correlation coefficients (ICC) were calculated to assess the reliability of TE and TR at each time point. Results: We included 41 patients in the final analysis. In all patients, the esophageal probe was successfully inserted through the gastric channel of the SAD. When assessing agreement with TR as a reference, TE demonstrated equivalent results at all time points (P < 0.001 at 0, 10, 20, 30, and 40-min intervals and P = 0.018 at the 50-min interval), except at the completion of surgery (P = 0.697). TE also demonstrated good reliability with TR as a reference throughout the surgery (ICC > 0.75). Conclusions: In children with SAD insertion, TE can be accurately and feasibly measured through the SAD’s gastric channel, making it suitable for routine application. [ABSTRACT FROM AUTHOR]

Background/Aims Chicago classification version 4.0 enhances the diagnosis of esophageal motility disorders using position change and provocative tests such as multiple rapid swallows and a rapid drink challenge. This study investigates the diagnostic role of the rapid drink challenge based on Chicago classification 4.0 using a functional luminal imaging probe to estimate the cutoff value. Methods This study included 570 patients who underwent esophageal manometry with a rapid drink challenge between January 2019 and October 2022. The diagnostic flow was analyzed according to Chicago classification 4.0. Results Ninety-nine patients (38, achalasia; 11, esophagogastric junction outflow obstruction; 7, ineffective esophageal motility; 1, hypercontractile esophagus; and 42, normal esophageal function) failed the rapid drink challenge. Among the 453 participants, 50 and 86 were diagnosed with achalasia and esophagogastric junction outflow obstruction, respectively, using Chicago classification 4.0. In 249/453 (55.0%) patients initially diagnosed with esophagogastric junction outflow obstruction using Chicago classification 3.0, the diagnosis was changed to achalasia (n = 28), hypercontractile esophagus (n = 7), ineffective esophageal motility (n = 7), or normal esophageal function (n = 121) using Chicago classification 4.0. Rapid drink challenge-integrated relaxation pressure’s diagnostic cutoff value was 19 mmHg. Nine patients had diagnoses changed after the rapid drink challenge, including 3 with panesophageal pressurization. Conclusions Chicago classification 4.0 increased the diagnostic yield of the rapid drink challenge by 2.0% (9/453 patients). However, the rapid drink challenge had a failure rate of 17.9% (99/552 patients). Given the relatively low diagnostic yield and high failure rate of the rapid drink challenge, we recommend adopting an individualized approach to manometry [ABSTRACT FROM AUTHOR]

Background/Aims Pharyngeal pump, esophageal peristalsis, and phrenic ampulla emptying play important roles in the propulsion of bolus from the mouth to the stomach. There is limited information available on the mechanism of normal and abnormal phrenic ampulla emptying. The goal of our study is to describe the relationship between bolus flow and esophageal pressure profiles during the phrenic ampulla emptying in normal subjects and patient with phrenic ampulla dysfunction. Methods Pressure (using topography) and bolus flow (using changes in impedance) relationship through the esophagus and phrenic ampulla were determined in 15 normal subjects and 15 patients with retrograde escape of bolus from the phrenic ampulla into esophagus during primary peristalsis. Results During the phrenic ampulla phase, 2 high pressure peaks (proximal, related to lower esophageal sphincter and distal, related to crural diaphragm) were observed in normal subjects and patients during the phrenic ampulla emptying phase. The proximal was always higher than the distal one in normal subjects; in contrast, reverse was the case in patients with the retrograde escape of bolus from the phrenic ampulla into the esophagus. Conclusions We propose that a strong after-contraction of the lower esophageal sphincter plays an important role in the normal phrenic ampullary emptying. A defective lower esophageal after-contraction, along with high crural diaphragm pressure are responsible for the phrenic ampulla emptying dysfunction. [ABSTRACT FROM AUTHOR]

Although swallowing has been reviewed extensively, the coordination of the phases of swallowing have not. The phases are controlled by the brainstem, but peripheral factors help coordinate the phases. The occurrence, magnitude, and duration of esophageal phase depends upon peripheral feedback activated by the bolus. The esophageal phase does not occur without peripheral feedback from the esophagus. This feedback is mediated by esophageal slowly-adapting mucosal tension receptors through the recurrent and superior laryngeal nerves. A similar reflex mediated by the same peripheral pathway is the activation of swallowing by stimulation of the cervical esophagus. This reflex occurs primarily in human infants and animals, and this reflex may be important for protecting against aspiration after esophago-pharyngeal reflux. Not only are there inter-phase excitatory processes, but also inhibitory processes. A significant inhibitory process is deglutitive inhibition. When one swallows faster than peristalsis ends, peristalsis is inhibited by the new pharyngeal phase. This process prevents the ongoing esophageal peristaltic wave from blocking the bolus being pushed into the esophagus by the new wave. The esophageal phase returns during the last swallow of the sequence. This process is probably mediated by mucosal tension receptors through the superior laryngeal nerves. A similar reflex exists, the pharyngo-esophageal inhibitory reflex, but studies indicate that it is controlled by a different neural pathway. The pharyngo-esophageal inhibitory reflex is mediated by mucosal tension receptors through the glossopharyngeal nerve. In summary, there are significant peripheral processes that contribute to swallowing, whereby one phase of swallowing significantly affects the other. [ABSTRACT FROM AUTHOR]

Papillomaviruses (PVs) are oncogenic and infect the skin and mucosa of various host species. Considering the recent advances in research on PVs using rolling circle amplification (RCA) followed by high-throughput sequencing (HTS), in this study, we aimed to investigate the bovine papillomavirus (BPV) types associated with proliferative lesions in the upper alimentary tract of an affected bull and characterize the viral strains through complete genome sequencing using this strategy. We analyzed the PV strains associated with two hyperplastic esophageal lesions through PCR using degenerate primer pairs and RCA, followed by HTS. HTS of the libraries generated using RCA products provided the whole genome sequence of BPV4 present in squamous papilloma, whereas the complete genome sequence of BPV2 and subgenomic fragments of BPV4 were identified in carcinoma in situ (CIS). For the first time, we have sequenced BPV2 identified from the CIS of the bovine upper alimentary canal. Additionally, RCA followed by HTS allowed characterization of the mixed infection by BPV2 and BPV4 in this lesion. These data reveal that BPV4 is not the only BPV type present in CIS of the esophageal mucous membrane; moreover, a mixed infection caused by BPV2 and BPV4 at the tested anatomical site was demonstrated. [ABSTRACT FROM AUTHOR]

The application of artificial intelligence in esophageal tumor pathology highlights the ongoing and significant transformative impact AI has in medicine. This article provides a comprehensive overview of AI technologies' current use in diagnosing and treating esophageal squamous cell carcinoma (ESCC). Through our research, we identified and meticulously analyzed 33 relevant academic papers and studies that contribute to this field. These papers encompass a broad spectrum of AI applications related to the management of esophageal squamous cell carcinoma. AI integration and deployment in both the diagnosis process and therapeutic interventions for tumors offer highly promising prospects, for example, in endoscopic procedures AI algorithm can process endoscopic images in real-time to identify abnormalities that may be missed by the human eye, it can highlight subtle changes such as color variations, small growths or tissue anomalies, which might go unnoticed due to fatigue, distraction or human limitations in perceiving fine details. AI technologies enhance medical practice precision and effectiveness by significantly reducing the likelihood of human errors and offering practical, innovative solutions. Consequently, AI confluence with medical practice not only increases diagnosis accuracy but also improves the overall efficiency of treating esophageal squamous cell carcinoma. [ABSTRACT FROM AUTHOR]

Background: Despite recommendations to perform esophageal biopsies during esophagogastroduodenoscopy (EGD) for esophageal food impaction to evaluate for eosinophilic esophagitis (EoE), endoscopists often forgo biopsies. There are minimal data on the risks of biopsies in this setting. Aims: To determine the safety of performing biopsies during EGD for food impaction. Methods: We conducted a retrospective cohort study of patients who presented to University of North Carolina Hospitals from 2014 to 2021 with endoscopically confirmed food impaction. Data were abstracted from the medical records. Baseline clinical characteristics, procedural details, and adverse events were compared between patients who did and did not undergo biopsy. Adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extra-esophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Results: Of 188 patients who underwent EGD for food impaction, 73 (39%) had biopsies taken. Older and non-White patients were less likely to be biopsied. None of the Black patients had biopsies taken. Only 2 (2.7%) of the 73 biopsied patients had an adverse event, and neither was related to the biopsies. Patients who were biopsied were less likely to experience adverse events. There were no differences in re-admission, ICU admission, or 30-day mortality between patients who were and were not biopsied. Conclusions: Esophageal biopsies remain underperformed during EGD for food impaction, especially in certain patient populations. Esophageal biopsies at the time of food impaction are unlikely to cause adverse events. Safety concerns should not preclude biopsies, and biopsies should be performed in the absence of extenuating circumstances. [ABSTRACT FROM AUTHOR]

Objectives: Esophageal high-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, but it may be poorly tolerated and unsuccessful. We sought to evaluate a protocol for sedation and endoscopy-assisted (SEA) HRM in patients who previously failed standard HRM and assess patient perspectives towards it. Methods: Adult patients who previously failed HRM were prospectively enrolled. Under propofol sedation, an upper endoscopy was performed during which the HRM catheter was advanced under endoscopic visualization. If the catheter did not reach the stomach on its own, the endoscope itself or a snare was used to help it traverse the esophagogastric junction (EGJ). Results: Thirty patients participated (mean age 67.8, 70% female). The technical success of SEA-HRM was 100%. Twenty-two (73.3%) were diagnosed with a motility disorder including thirteen (43.3%) with achalasia. Eighteen (60%) had previously failed HRM due to discomfort/intolerance, while twelve (40%) failed due to catheter coiling in the esophagus. Subjects in the coiling group were more likely to need endoscopic assistance to traverse the EGJ (91.7% vs. 27.7%, p = 0.001) and have a motility disorder (100.0% vs. 55.6%, p = 0.010), including achalasia (75.0% vs. 22.2%, p = 0.004), compared to the discomfort/intolerance group. All patients preferred SEA-HRM and rated it higher than standard HRM (9.5 ± 1.3 vs. 1.9 ± 2.1, p = <0.001, on a scale of 1–10). Conclusions: SEA-HRM is a highly successful and well-tolerated option in patients who previously failed standard HRM. This should be the recommended approach in cases of failed HRM rather than secondary tests of esophageal motility. [ABSTRACT FROM AUTHOR]

Esophageal carcinoma is an aggressive cancer with a poor therapeutic response and a significant risk of recurrence after radical resection. It usually metastasizes to the lung, bones, or liver. Unusual spread can be found in other organs, but only nine cases of pancreatic metastases have been reported in the Medline database. In the present paper, a literature review of nine cases with esophageal squamous cell carcinoma and pancreatic metastasis was carried out. In addition to these cases, we present our case, the tenth case in the literature. It involved a patient who underwent surgery for esophageal squamous cell carcinoma and developed metachronous pancreatic metastasis 67 months after esophagectomy. Histopathological examination confirmed a squamous cell carcinoma metastasis. Conclusions: Pancreatic metastasis of esophageal squamous cell carcinoma is extremely rare. Pancreatic metastasis may develop several years after the treatment of the primary lesion. The diagnosis of metastasis is difficult, requiring histopathological and immunohistochemical examination. [ABSTRACT FROM AUTHOR]

Background: Narrow band imaging‐magnifying endoscopy (NBI‐ME) is used to identify changes in mucosal or vascular pattern observed on GI endoscopy in real time on the basis of optical image enhancement.It has a significant role in early detection of dysplasia, premalignant, and Malignant lesions along with its depth of invasion. Materials and methods: Upper and lower GI endoscopy performed in 1742 patients who presented with gastrointestinal symptoms at this tertiary center over 5 years out of which 1623 were evaluated with both NBI‐ME and histopathology. Real time endoscopic assessment was performed. Targeted biopsies were taken for comparative analysis. Results: Of the 1742 patients, 119 were excluded from the study. 807 underwent upper GI endoscopy and 816 underwent lower GI endoscopy. Mean age of presentation was 38 +/− 2.7 years. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of NBI‐ME for neoplastic esophageal lesions were 96.3%, 90.6%, 91.1%, 96.03%, respectively. For Barrett's esophagus it was 95.4%, 90.7%, 86.1%, and 90.7%; For gastric neoplastic lesions the values were 96.1%, 91.04%, 83.8%, and 97.9%. For colorectal it was 96.7%, 91.3%, 88.0%, and 97.7%. Overall sensitivity, specificity, PPV, and NPV of NBI‐ME for neoplastic lesions (both upper and lower GI) were 96.2%, 91.0%, 96.2%, and 97.2%. Of the 1623 patients, 951 received medical management with regular surveillance and 672 patients with high‐grade dysplasia, premalignant, and malignant conditions underwent interventions in form of either endoscopy or surgery. Conclusion: NBI‐ME has a greater role and can be considered as an effective tool in making early diagnosis and guiding optimum treatment. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Peroral endoscopic myotomy (POEM) may result in a distended distal esophagus, referred to as a blownout myotomy (BOM), the relevance of which is uncertain. The aim of this study was to investigate the prevalence, risk factors, and associated symptoms of BOM after achalasia treatment. METHODS: A data set of the locally treated patients in a randomized controlled trial comparing POEM with pneumatic dilation (PD) was analyzed. A BOM is defined as a >50% increase in esophageal diameter at its widest point in the distal esophagus between the lower esophageal sphincter and 5 cm above. RESULTS: Seventy-four patients were treated in our center, and 5-year follow-up data were available in 55 patients (32 patients [58%] randomized to POEM, 23 [42%] PD). In the group initially treated with POEM, the incidence of BOMincreased from 11.5%(4/38) at 3 months, to 21.1% (8/38) at 1 year, 27.8% (10/36) at 2 years, and 31.3%(10/32) at 5 years. None of the patients treated with PD alone developed a BOM. Patients who developed a BOM had a higher total Eckardt score and Eckardt regurgitation component compared with patients who underwent POEM without BOM development (3 [2.75-3.25] vs 2 [1.75-3], P 5 0.032, and 1 [0.75-1] vs 0 [0-1], P 5 0.041). POEM patients with a BOM more often report reflux symptoms (85% [11/13] vs 46% [2/16], P 50.023) and had a higher acid exposure time (24.5% [8-47] vs 6% [1.2-18.7], P 5 0.027). DISCUSSION: Thirty percent of the patients treated with POEM develop a BOM, which is associated with a higher acid exposure, more reflux symptoms, and symptoms of regurgitation. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) is a standard procedure for achalasia, an esophageal motility disorder, characterized by a thickened lower esophageal sphincter muscularis propria (LEMP). Visualization of this anatomical stratification has been made possible by the advent of endoscopic ultrasound (EUS). However, the effect of LEMP thickness on treatment outcomes remains unclear. The objective of this study was to investigate whether LEMP thickness affects treatment response post-POEM. Methods: This was a single-center, prospective cohort study of patients who underwent POEM between 2014 and 2021. Patients who underwent EUS to evaluate the LEMP before POEM were included in the study. We divided the patients into two groups according to muscle thickness measured by EUS (≥ 2.80 mm; group 1, < 2.80 mm; group 2). The pre- and post-procedural clinical parameters were compared between the two groups. Results: Among 278 patients, 189 were enrolled. There were no significant differences in the pre- and post-Eckardt scores, integrated relaxation pressure, and distensibility index between the two groups divided by muscle thickness. Furthermore, there was no statistically significant difference in symptom recurrence, as measured by an Eckardt score > 3, post-procedural complications, or post-POEM GERD symptoms. However, patients with thicker lower esophageal sphincter muscle showed a greater decrease in Eckardt scores (ΔES ≥ 3) which was statistically significant (P = 0.002). Conclusion: POEM is an effective and safe treatment method for achalasia, regardless of LES muscle thickness. There was a statistically significant difference in the decrease of Eckardt scores of 3 or greater (ΔES ≥ 3) after POEM in the thicker LEMP group suggesting greater alleviation of symptoms in POEM patients with thicker lower esophageal muscle. [ABSTRACT FROM AUTHOR]

Introduction: Dysphagia after anti-reflux surgery (ARS) is one of the most common indications for re-operative anti-reflux surgery and a leading cause of patient dissatisfaction. Unfortunately, the factors affecting its development are poorly understood. We investigated the correlation between pre-operative manometric and the intra-operative impedance planimetry (EndoFLIP™) measurements and development of post-operative dysphagia. Methods: A review of patients who underwent index robotic ARS in our institution. Patients who underwent pre-operative manometry and intra-operative EndoFLIP™ were included in our study. Dysphagia was assessed pre-operatively and at 3-month after surgery. Results: Fifty-five patients (26.9%) reported post-operative dysphagia, and 34 (16.6%) reported new or worsening dysphagia. On pre-operative manometry, patients with post-operative dysphagia had a lower distal contractile integral [868.7 (IQR 402.2–1447) mmHg s cm vs 1207 (IQR 612.1–2111) mmHg s cm, p = 0.006) and lower esophageal sphincter (LES) pressure [14.7 IQR (8.9–23.6) mmHg vs 20.7 IQR (10.2–32.6) mmHg, p = 0.01] compared to those without post-operative dysphagia. They were also found to have higher pre-operative cross-sectional surface area (CSA) [83 IQR (44.5–112) mm2 vs 66 IQR (42–93) mm2, p = 0.02], and distensibility index (DI) [4.2 IQR (2.2–5.5) mm2/mmHg vs 2.9 IQR (1.6–4.6) mm2/mmHg, p = 0.003] compared to patients without post-operative dysphagia. Additionally, the decrease in CSA [− 34 (− 18.5, − 74.5) mm2 vs − 26.5 (− 10.5, − 53.7) mm2, p = 0.03] and DI [− 2.3 (− 1.2, − 3.7) mm2/mmHg vs − 1.6 (− 0.7, − 3.3) mm2/mmHg, p = 0.03] measurements were greater in patients with post-operative dysphagia. Conclusion: Patients who developed dysphagia post-operatively had poorer pre-operative motility and a greater change in LES characteristics intra-operatively. This finding suggests the utility of pre-operative manometry and intra-operative EndoFLIP in identifying patients at risk of developing dysphagia post-operatively. [ABSTRACT FROM AUTHOR]

Objective: To describe the use of transoral robotic surgery (TORS) in conjunction with intraoperative localization techniques for removal of challenging upper aerodigestive tract (UADT) foreign bodies. Methods: Three cases were taken to the operating room for removal of UADT foreign bodies. Two of these cases had previously undergone failed surgery(s). TORS was performed in all 3 cases and intraoperative localization was used in 2 cases. Results: All foreign bodies were successfully removed. Conclusion: This case series is the largest-to-date on UADT foreign body removals using TORS. Additionally, the novel use of intraoperative localization techniques in conjunction with TORS is described. Such an approach can facilitate the identification of difficult-to-identify foreign bodies, as well as potentially decreasing operative time, number of operations, and associated morbidity. [ABSTRACT FROM AUTHOR]

High-resolution esophageal manometry [HRM] has become the gold standard for the evaluation of esophageal motility disorders. It is unclear whether there are HRM differences in diagnostic outcome based on regional or geographic distribution. The diagnostic outcome of HRM in a diverse geographical population of Mexico was compared and determined if there is variability in diagnostic results among referral centers. Consecutive patients referred for HRM during 2016–2020 were included. Four major referral centers in Mexico participated in the study: northeastern, southeastern, and central (Mexico City, two centers). All studies were interpreted by experienced investigators using Chicago Classification 3 and the same technology. A total of 2293 consecutive patients were included. More abnormal studies were found in the center (61.3%) versus south (45.8%) or north (45.2%) P  < 0.001. Higher prevalence of achalasia was noted in the south (21.5%) versus center (12.4%) versus north (9.5%) P  < 0.001. Hypercontractile disorders were more common in the north (11.0%) versus the south (5.2%) or the center (3.6%) P.001. A higher frequency of weak peristalsis occurred in the center (76.8%) versus the north (74.2%) or the south (69.2%) P  < 0.033. Gastroesophageal junction obstruction was diagnosed in (7.2%) in the center versus the (5.3%) in the north and (4.2%) in the south p.141 (ns). This is the first study to address the diagnostic outcome of HRM in diverse geographical regions of Mexico. We identified several significant diagnostic differences across geographical centers. Our study provides the basis for further analysis of the causes contributing to these differences. [ABSTRACT FROM AUTHOR]

SMARCA4-deficient undifferentiated tumors (SMARCA4-UT) are a newly described entity and are typically seen in the thoracic cavity. However, these tumors have been described in other body sites, including the esophagus. These tumors are rare, aggressive neoplasms, characterized by the loss of protein product of SMARCA4 (Brahma-related gene-1) and the preservation of INI1 (SMARCB1) expression. Here, we present two tumors of SMARCA4-UT of the esophagus with its microscopic appearance and immunohistochemical profile. We also include a literature review of SMARCA4-deficient tumors of the tubular gastrointestinal tract with their immunohistochemical and mismatch repair profiles for each specimen. Due to its non-specific histologic appearance and variable staining in expanded immunohistochemical panels, this tumor frequently overlaps with other tumor types, making the diagnosis of SMARCA4-UT challenging. These tumors are often associated with intestinal metaplasia of the esophagus and are thought to represent a high-grade undifferentiated transformation of a conventional esophageal adenocarcinoma. These tumors are typically associated with poor clinical outcomes and have poor response to conventional therapies. Currently, there are no standard guidelines for treatment of these tumors; however, palliative radiotherapy and systemic chemotherapy may provide benefit. More recently, immunotherapy and novel therapeutic targets have shown some promise for these patients. [ABSTRACT FROM AUTHOR]

The reconstruction of esophageal defects with restoring vocal functions is challenging. Major disadvantages of using a fasciocutaneous flap include the requirement for a long suture line for tubularization, the slow healing of mucosa‑skin anastomoses, and the necessity of using a voice prosthesis through a tracheoesophageal puncture. The transfer of the ileocolon flap is a totally autologous option for the simultaneous reconstruction of the esophagus and voice function. The ileocecal valve mechanism within the ileocolon flap obviates the need for the insertion of a voice prosthesis, and the terminal ileum acts as the voice tube which directs the air from the trachea to the neo‑esophagus. In this report, we describe in detail the surgical technique of the free ileocolon flap transfer for this indication, as well as modifications aimed at reducing complication rates. [ABSTRACT FROM AUTHOR]

Introduction: Current guidelines for double contrast barium esophagography studies (BAS) suggest that patients should be nil per os (NPO) prior to completing BAS for optimal esophageal coating, although the time required varies between practices and institutions. It is believed that consumption of food or water disrupts the ability for thick barium contrast to properly coat the esophageal mucosa. Exams that are rescheduled for this reason can lead to delays in care, without substantial evidence that NPO status truly affects esophageal mucosal coating for these exams with current barium mixtures. Objective: The study aims to identify the necessity, or lack thereof, of standard NPO protocol in patients undergoing BAS, in effort to prevent unnecessary procedural delay. Materials and methods: This study is an IRB-approved HIPAA-compliant study of 370 consecutive adult patients (115 male/255 female, mean age 55) who underwent BAS at our institution from January to June of 2022. Patients were divided into two groups: < 4 h NPO (n = 334), and ≥ 4 h NPO (n = 36). Four abdominal radiologists blinded to NPO interval independently reviewed a random sample of approximately 92 patients (91–94) and graded esophageal coating on a 4-point-scale with 1 being insufficient coating and 4 being optimal coating. Results: No significant statistical difference in mean esophageal coating score was found between the ≥ 4 h NPO cohort (3.04 ± SD 0.78) and the < 4 h NPO cohort (2.97 ± SD 0.70; P = 0.54). Subset analysis of patients who were NPO for < 2 h (n = 9) also showed no significant difference in mean esophageal coating score (3.11 ± SD 0.6; P = 0.92), compared to the standard ≥ 4 NPO status. Conclusion: Non-adherence to standard NPO protocol prior to BAS studies did not result in a significant difference in esophageal coating when compared to traditional preprocedural fasting of 4 or more hours. [ABSTRACT FROM AUTHOR]

Objective: Assessment of the effect of continuous cuff pressure control on airway injury in middle-aged and elderly patients undergoing endoscopic submucosal dissection (ESD). Method: A total of 104 eligible middle-aged and elderly patients requiring esophageal ESD from July 2022-September 2023 at the First Affiliated Hospital of Nanchang University were selected and randomly divided into two groups: the group undergoing general anesthesia tracheal intubation with continuous control of cuff pressure after intubation (Group A, n = 51) and the group undergoing general anesthesia tracheal intubation with continuous monitoring without control of cuff pressure (Group B, n = 53). After endotracheal intubation in Group A, under the guidance of an automatic cuff pressure controller, the air was used to inflate the tracheal cuff until the cuff pressure was 25–30cmH2O. The cuff pressure after intubation was recorded, and then the cuff pressure parameters were directly adjusted in the range of 25–30cmH2O until tracheal extubation after the operation. After endotracheal intubation, patients in Group B inflated the tracheal cuff with clinical experience, then monitored and recorded the cuff pressure with a handheld cuff manometer and instructed the cuff not to be loosened after being connected to the handheld cuff manometer—continuous monitoring until the tracheal extubation, but without any cuff pressure regulation. The patients of the two groups performed esophageal ESD. The left recumbent position was taken before the operation, and the cuff's pressure was recorded. Then, insert the gastrointestinal endoscope to find the lesion site and perform appropriate CO2 inflation to display the diseased esophageal wall for surgical operation fully. After determining the location, the cuff pressure of the two groups was recorded when the cuff pressure was stable. After the operation, the upper gastrointestinal endoscope was removed and the cuff pressure of the two groups was recorded. Postoperative airway injury assessment was performed in both groups, and the incidence of sore throat, hoarseness, cough, and blood in sputum was recorded. The incidence of postoperative airway mucosal injury was also observed and recorded in both groups: typical, episodic congestion spots and patchy local congestion. Result: The incidence of normal airway mucosa in Group A was higher than that in Group B (P < 0.05). In comparison, the incidence of occasional hyperemia and local plaque congestion in Group A was lower than in Group B (P < 0.05). Conclusion: Continuous cuff pressure control during operation can reduce airway injury in patients with esophageal ESD and accelerate their early recovery after the operation. [ABSTRACT FROM AUTHOR]

Purpose: Age-related changes to the swallowing mechanism, or presbyphagia, may put older adults at a higher risk for developing diseases and dysphagia. Maintaining swallowing functions could help prevent frailty and facilitate healthy ageing. This review summarises and appraises the effects of oropharyngeal exercises on the swallowing functions of healthy older adults without dysphagia. It is hypothesised that these exercises will strengthen and improve the structures and functions of the normal ageing swallow. Method: This review was reported according to the PRISMA 2020 guidelines. Five electronic databases (Medline, Embase, Cochrane Library, Web of Science, CINAHL) and Google Scholar were searched in June 2021. A rerun was done in January 2023. Study selection, data extraction, and quality assessment were done by two independent raters. Result: A total of 23 studies were reviewed. Meta-analysis was not conducted due to the heterogenous training protocols and outcomes. Majority (n = 21) had fair quality due to incomplete reporting. Exercises targeting oral structures were implemented the most (n = 15), followed by variations of the head lift (n = 4), and effortful swallow exercise (n = 1). Others implemented combined or multiapproach exercise studies (n = 3). Apart from surface electromyography findings, statistically significant improvements in oral and pharyngeal phase swallowing outcomes such as increased lingual isometric and swallowing pressures, bite force, muscle thickness, hyolaryngeal excursion, and upper oesophageal sphincter opening diameter were reported in 95% of the studies (n = 22). Conclusion: Collective evidence suggests that strength training for swallowing-related structures leads to increases in structural strength, endurance, and muscle mass. The effects of exercises on overall swallowing efficiency and safety remain unclear. Results should be interpreted with caution due to methodological limitations. Further research should examine the long-term effects of these exercises in preventing frailty and reducing the burden of dysphagia in older adults. [ABSTRACT FROM AUTHOR]

Background Purpose Dysphagia is one of the most common complaints that gastroenterologists encounter in the outpatient setting. To evaluate this common complaint, patients are often sent for a barium esophagram, a test that is widely available, inexpensive, and easy to perform. This simple test provides a reliable method to evaluate esophageal anatomy and structural abnormalities.This narrative reviews the history of the development and validation of the timed‐barium esophagram (TBE), along with its strengths and limitations, and discusses its use in the pre‐ and posttreatment assessment of patients with achalasia, esophagogastric junction outflow obstruction (EGJOO), and esophageal strictures. Providing excellent anatomic detail of the esophagus and an accurate assessment of esophageal emptying, over time, the TBE has become part of the standard workup in our Swallowing Center for patients with dysphagia. [ABSTRACT FROM AUTHOR]

Background: Pigeons (Columba livia) are mainly raised as a source of animal protein, racing, leisure and as an experimental animal. The present study investigated the morphology of the esophagus in the young and adult domestic pigeon, Columba livia domestica. Methods: Ten young and ten adult, normal, and healthy pigeons were collected from the local breeders. Samples from different parts of esophagus and crop were examined grossly, by stereomicroscopy, scanning and light microscopy. Results: The esophagus consisted of a long cervical part, a crop, and a short thoracic part. The crop was represented by a thin-walled outpouching with two lateral diverticula. The mucosa presented wavy fine folds in the cervical esophagus, irregular folds in the lateral diverticula giving it a corrugated appearance, and prominent longitudinal folds with several gland openings in the middle and lower parts of the crop, as well as in the thoracic esophagus. The density of gland openings was higher in adult pigeons than that in young pigeons. The mucosa of the esophagus was lined by non-keratinized stratified squamous epithelium. The shape, height, and branching of the mucosal folds differed between young and adult pigeons. Mucous-secreting alveoli were detected in the middle part of the crop as well as in the thoracic esophagus, but not in the cervical esophagus or lateral diverticula of the crop. Conclusion: The variations between the young and adult pigeons suggest a functional adaptation of adult pigeons to their diet compared to young pigeons. [ABSTRACT FROM AUTHOR]

Objectives Methods Results Conclusion The gastroesophageal junction (GEJ) consists of various anatomical components that together form a barrier to prevent reflux of gastric content. This study introduces a novel phase concept to dynamically evaluate the antireflux barrier (ARB) during endoscopy and analyzes its functionality.We reviewed previously the recorded endoscopic videos of subjects who underwent the endoscopic pressure study integrated system (EPSIS) from February to April 2024 for indications other than gastroesophageal reflux disease symptoms. This device was used as an auxiliary tool to measure intragastric pressure (IGP) during endoscopy with a retroflex view. The ARB dynamic was divided into three phases: Phase I (gastric phase), Phase II (lower esophageal sphincter phase), and Phase III (esophageal clearance phase). We evaluated the morphological changes in the ARB during insufflation using EPSIS.The median age of the 30 subjects was 58 years (interquartile range [IQR] 46.5–68.8), including 20 men and 10 women. Endoscopic findings and IGPs were recorded during the three phases. In Phase I, at low IGP (median 6.75 mmHg), the gastroesophageal flap valve and longitudinal folds were observed in 80% of cases. In Phase II, at moderate IGP (median 11.8 mmHg), the scope holding sign was observed in 86.7%. In Phase III, at high IGP (median 19 mmHg) inducing belching, peristalsis was observed in 80% of cases with median recovery time of 5 s.The phase concept provides a valuable framework for understanding the antireflux mechanism. Further research is needed to validate these findings in GEJ disorders and explore correlations with other modalities. [ABSTRACT FROM AUTHOR]

Background: Ingestion of corrosive substances represents a frequent and consequential medical scenario, significantly impacting both vital and functional prognoses through the emergence of acute complications or stenosis, which pose considerable therapeutic challenges. Currently, endoscopy remains the cornerstone modality for diagnostic assessment and management. Nevertheless, recent research highlights computed tomography (CT) as a promising alternative, avoiding the risks associated with endoscopy and reducing the unnecessary surgical interventions based on its findings. Methods: Our retrospective study, spanning three years, encompassed 28 patients who had ingested corrosive substances. Among them, 24 underwent both CT scanning and endoscopic evaluation using CT and endoscopic scores. Results: Employing Standardized CT scoring criteria alongside the Zargar's endoscopic classification, our findings revealed significant concordance between the two modalities, particularly in discerning trans-parietal necrosis within the esophagus and stomach. Notably, radiographic evidence of digestive tract injury was found to be predictive of complications in over 80% of cases, demonstrating high sensitivity and negative predictive value. Furthermore, CT scores indicating moderate to severe injury were significantly associated with stenosis, with slightly inferior performance compared to endoscopy. Of particular note, a CT score indicative of severe injury was found to be a good predictor of mortality, further underscoring the prognostic value of CT in these cases. Conclusion: While the utility of CT in this context is undeniable, its integration with endoscopic findings remains imperative. We advocate for a systematic approach incorporating CT scanning, with further prospective research warranted to explore the feasibility of CT as a standalone diagnostic tool, as suggested by some scholars. [ABSTRACT FROM AUTHOR]

Primary mucoepidermoid carcinoma of the esophagus is a rare condition characterized by a combination of squamous and mucin-secreting glandular malignant cells. Its clinical recognition is often challenging, pre-operative diagnosis is difficult, and there is a lack of standardized treatment protocols. Here, we present the clinicopathological characteristics of a previously underreported esophageal malignancy found in the distal esophagus of a 58-year-old woman. The initial endoscopic biopsy posed diagnostic challenges due to its small size and inadequate representation of glandular differentiation components making a final diagnosis of poorly differentiated squamous cell carcinoma. Recognizing the resectability of the tumor prompted surgical removal, revealing islands of squamous cells along with intermediate cells and mucin pools. Additionally, MECs in majority of the cases show MAML2 gene rearrangement; contrarily, the present case showed negative results. Enhanced clinicopathological awareness of esophageal MEC facilitated a definitive diagnosis and better patient management. It is imperative to increase awareness and globally document cases of esophageal MEC to enhance understanding, diagnosis, and management guidelines for this malignancy in this anatomical location. [ABSTRACT FROM AUTHOR]

Introduction. Barret’s esophagus (BE), is a common state, concerning roughly about 15% of GERD patients. The pathomechanism of BE is replacement of typical squamous-cell mucosa by a layer of intestinal-type glandular mucosa (intestinal metaplasia). In a number of cases the glands are prone to dysplasia which may lead to the occurrence of esophageal adenocarcinoma. The golden standard in diagnosis of BE is endoscopy combined with histopathological examination of biopsy material of the altered Z line. Unfortunately, many guidelines do not recommend endoscopic treatment in most cases of BE in favor of long-term screening, reserving the need for treatment for dysplastic BE. Material and methods. 53 patients suspected of BE (study group) and 45 patients without any macroscopic signs of BE (control group) underwent upper GI endoscopy during which several biopsies were taken from the elevated Z line. The study group was divided into 2 subgroups: I — without histopathological evidence of BE (n = 11); II — hi-stopathologically confirmed BE (n = 42). In addition to the standard histopathological examination, the material was screened for levels of CDX2 and p53 expression. Results. In the control group, none of the patients presented elevated CDX2 or p53 expression (0%). In the study group, 24 patients were CDX2 positive (45.28%) and 27 were p53 positive (50.94%). Both markers were positive in 21 cases (39.62%). Conclusions. Standard histopathological examination combined with immunohistochemical examination can prove to be a useful tool in confirming the diagnosis of BE, diagnosing early glandular displasia and, in some cases, eliminating false negative results. [ABSTRACT FROM AUTHOR]

Background: Achalasia cardia (AC) is an esophageal motility disorder which, if left untreated, may progress to end-stage sigmoid achalasia characterized by mega-esophagus. It occurs with equal frequency in men and women and there is no racial predilection. Peak incidence has been reported between 30 and 60 years of age. Case presentation: We herein report a case of a 48-year-old male with progressive dysphagia due to Sigmoid Achalasia, who was treated successfully with laparoscopy. Clinical significance: Several treatment options exist for the surgical management of a sigmoid esophagus with achalasia, but there is no clear gold standard. In our case, Heller's cardiomyotomy with Dorr's fundoplication provided favorable results. [ABSTRACT FROM AUTHOR]

Various diseases can affect the esophagus. Endoscopic ultrasound (EUS), which provides precise information about the layers of the esophageal wall, is the primary approach used to investigate esophageal diseases. However, CT is one of the most important imaging modalities for diagnosing esophageal diseases as it can elucidate mediastinal involvement, adjacent lymphadenopathy, and distant disease spread. These two modalities complement each other in the diagnosis of esophageal diseases. Although radiologists may be unfamiliar with EUS procedures and their interpretation, understanding them aids in the differential diagnosis of esophageal conditions. This pictorial essay illustrates the EUS and CT findings of various esophageal diseases originating in the esophageal wall. [ABSTRACT FROM AUTHOR]

Molten aluminum is among the most common causes of burns in the metal industry. However, only few reports are available on molten aluminum injuries. Herein, we report an unusual case of molten aluminum burn. The patient had burns not only on the body surface but also in the respiratory tract and esophagus, adding to the difficulty of treatment. Multidisciplinary consultation and cooperation led to the development of a treatment plan for the patient, which included tracheotomy, respiratory management, endoscopic therapy, infection control, and psychological support. To our knowledge, this is the first report of molten aluminum-induced burns involving the face, neck, respiratory tract, esophagus, and eyes. We also describe our experience with multidisciplinary treatment for the management of molten aluminum burns. [ABSTRACT FROM AUTHOR]

Background: Esophageal organoids from a variety of pathologies including cancer are grown in Advanced Dulbecco's Modified Eagle Medium-Nutrient Mixture F12 (hereafter ADF). However, the currently available ADF-based formulations are suboptimal for normal human esophageal organoids, limiting the ability to compare normal esophageal organoids with those representing a given disease state. Methods: We have utilized immortalized normal human esophageal epithelial cell (keratinocyte) lines EPC1 and EPC2 and endoscopic normal esophageal biopsies to generate three-dimensional (3D) organoids. To optimize the ADF-based medium, we evaluated the requirement of exogenous epidermal growth factor (EGF) and inhibition of transforming growth factor-(TGF)-β receptor-mediated signaling, both key regulators of the proliferation of human esophageal keratinocytes. We have modeled human esophageal epithelial pathology by stimulating esophageal 3D organoids with interleukin (IL)-13, an inflammatory cytokine, or UAB30, a novel pharmacological activator of retinoic acid signaling. Results: The formation of normal human esophageal 3D organoids was limited by excessive EGF and intrinsic TGFβ-receptor-mediated signaling. Optimized HOME0 improved normal human esophageal organoid formation. In the HOME0-grown organoids, IL-13 and UAB30 induced epithelial changes reminiscent of basal cell hyperplasia, a common histopathologic feature in broad esophageal disease conditions including eosinophilic esophagitis. Conclusions: HOME0 allows modeling of the homeostatic differentiation gradient and perturbation of the human esophageal epithelium while permitting a comparison of organoids from mice and other organs grown in ADF-based media. [ABSTRACT FROM AUTHOR]

Introduction: Esophageal inflammatory diseases are frequent diagnoses in clinical practice and have diverse etiologies, the most common being those associated with the exposure to gastric content, drugs and allergens. In diseases, the immunological component is well identified in endoscopic biopsies, which mainly contain the epithelium and the lamina propria; however, deeper layers are less studied. Moreover, the esophageal capacity of sensing luminal compounds is poorly understood. Methods: In transmural sections from proximal, middle and distal esophagus obtained from deceased patients, we performed a phenotypic analysis of the main immune cell populations and acid-sensing receptors by immunohistochemistry and immunofluorescence methods. Results: A total of nine donors were studied (absence of pathology, optimal tissue preservation and orientation). We found the following: (1) the vascular papillae and the lamina propria are the most infiltrated layers by the lymphoid lineage (T and B lymphocytes), followed by the epithelium, while the smooth muscular layers are mainly populated by the myeloid lineage (macrophages and mast cells); (2) intraepithelial macrophages are consistently found along the esophagus; and (3) eosinophils are absent in all the esophageal layers. The acid-sensing receptors ASIC-1, ASIC-2 and δENAC are expressed in the esophageal epithelium and in the lamina propria, yet only ASIC-2 is expressed in the muscularis mucosae. Conclusions: The human esophagus contains a differential distribution of immune cells and acid-sensing receptors across its layers. This study extends the esophageal histological knowledge previously described and reinforces its role as a defensive and sensing organ. [ABSTRACT FROM AUTHOR]

Esophageal mucoepidermoid carcinoma (EMEC) is a special subtype of esophageal malignancy, accounting for less than 1% of all cases of primary esophageal carcinoma. Pathologically, it consists of a mixture of adenocarcinoma and squamous cell carcinoma with mucin-secreting cells. Special staining for mucicarmine helps to diagnose EMEC. We present a rare case of EMEC successfully treated via endoscopic submucosal dissection (ESD). A 63-year-old man was referred to our tertiary hospital. On esophagogastroduodenoscopy, a 6-mm-sized subtle reddish depressed lesion was identified in the mid-esophagus. Diagnostic ESD was performed with a high suspicion of carcinoma. Histopathologic findings were consistent with EMEC which was confined to the lamina propria without lymphatic invasion. We plan to do a careful follow-up without administering adjuvant chemotherapy or radiotherapy. Due to the small volume of the lesion, establishing a diagnosis was difficult through forceps biopsy alone. However, by using ESD, we could confirm and successfully treat a rare case of early-stage EMEC. [ABSTRACT FROM AUTHOR]

Introduction Laryngopharyngeal reflux (LPR) is a syndrome caused by reflux of gastric contents into the pharynx or larynx which leads to symptoms of throat clearing, cough, pain, sensation of something stuck in the throat and change in voice. Evaluation of symptoms using the Reflux Symptom Index is considered to be the basic diagnostic procedure. LPR therapy is complex and requires modification of patient’s lifestyle and habits. LPR treatment and management is supposed to reduce the acidity or stomach contents and neutralize acidopeptidic activity in larynx, pharynx and oesophagus. High dosages of PPI (proton pump inhibitors) have shown the best effects in reducing reflux. Aims and objectives: The goal of the current study is 1. To determine the effects of gastric reflux on larynx and pharynx both clinically and endoscopically. 2. To evaluate the effect of proton pump inhibitors along with lifestyle modifications on laryngeal reflux symptom index and reflux finding score. LPR was treated with PPI, alkaline alginates and standard reflux precautions (avoidance of coffee, tea, chocolate, soda, greasy, fried, fatty, and spicy foods, alcohol and smoking). Results: The study constituted of 150 patients coming to ENT OPD with symptoms of laryngopharyngeal reflux and having RSI >13. All patients were examined by 70-degree video-laryngoscope and were treated with proton pump inhibitors, alginates and lifestyle modifications. 80 of them recovered after 2 weeks of lifestyle modification and treatment and 63 recovered after a month while 7 remained symptomatic after 3 months of treatment as well. Conclusion: Laryngopharyngeal reflux (LPR) is common in ENT practice but requires careful diagnosis due to its non-specific symptoms. Accurate diagnosis ensures appropriate management and avoids the pitfalls of overdiagnosis in LPR cases. [ABSTRACT FROM AUTHOR]

Background and Aims: Analysis of mean nocturnal baseline impedance (MNBI) and post‐reflux swallow‐induced peristaltic wave index (PSPWi) have been proposed to increase the diagnostic yield of pH‐impedance studies in reflux disease. However, routine use of these indices in clinical studies is yet to be established, particularly with PSPWi, which requires laborious manual analysis. Our study aimed to assess the utility of MNBI and PSPWi and their potential for future incorporation into clinical practice. Methods: pH‐impedance recordings from consecutive patients referred to the Motility Laboratory at Royal Adelaide Hospital for evaluation of gastro‐oesophageal reflux disease (GORD) were prospectively collected and manually analysed. Baseline demographic characteristics, symptoms, acid exposure time (AET), number of reflux episodes, and MNBI and PSPWi were collected. Results: Eighty‐nine patients were included in the study (age 50 ± 17 years, 35 males). MNBI and PSPWi inversely correlated with AET (R = −0.678, P < 0.0001 and R = −0.460, P < 0.0001 respectively) and with reflux episodes (R = −0.391, P = 0.0002 and R = −0.305, P = 0.0037 respectively). In patients with a negative pH study, but with typical reflux symptoms, 4/30 (13%) had pathologic MNBI and PSPWi. There was a positive correlation between MNBI and PSPWi values (R = 0.525, P < 0.0001). Performing analysis of PSPWi was substantially more laborious than MNBI. Conclusion: MNBI and PSPWi are both useful adjuncts in the diagnosis of reflux disease, although in our cohort MNBI showed stronger correlation with AET with less time to analyse. The role of these indices remains to be further explored, particularly in patients with inconclusive AET and in those with positive compared to negative symptom association. [ABSTRACT FROM AUTHOR]