The tissue effect of argon plasma coagulation on esophageal and gastric mucosa

BACKGROUND

Argon plasma coagulation is a diathermy-based non-contact therapeutic endoscopic modality that may have a lower risk of perforation than other tissue ablation techniques.

METHODS

Its effect was studied on three fresh esophageal and three fresh gastric resection specimens using power settings from 40 to 99 Watts at 90 degrees, with 1 mm separation using pulse durations of 1 and 3 seconds. A scoring system for depth of tissue damage was created and samples were analyzed blindly by a gastrointestinal histopathologist.

RESULTS

There was significantly greater damage to gastric tissue using a 3-second (compared with 1-second) pulse (p = 0.003) and marginally significantly greater damage to esophageal tissue using the 3-second pulse (p = 0.053). Tissue damage was related to power setting for gastric (p = 0.031) but not for esophageal tissue (p = 0. 065). Only 1 of 42 esophageal samples and 2 of 42 gastric samples examined showed damage extending into the muscularis propria.

CONCLUSIONS

Deep tissue damage that could lead to perforation was rare with argon plasma coagulation. The depth of gastric mucosal damage increased with increased pulse duration and increasing power settings, and, although the depth of esophageal mucosal damage was marginally related to pulse duration, it was not related to the power setting. (Gastrointest Endosc 2000;52:342-5).

The spectrum of spontaneous and iatrogenic esophageal injury: perforations, Mallory-Weiss tears, and hematomas

Esophageal perforations, Mallory-Weiss tears, and esophageal hematoma involve traumatic injury to the esophagus. These can be iatrogenic, in particular due to esophageal instrumentation, but can also occur spontaneously. The remarkable increase in diagnostic and therapeutic endoscopy as well as esophageal surgery has made instrumentation the most common cause of esophageal perforation. In many instances, spontaneous perforations are associated with retching and vomiting, which causes a sudden increase in intraesophageal pressure. A high index of suspicion leading to rapid diagnosis and appropriate therapy are needed to optimize clinical outcomes. This article focuses on esophageal perforations, Mallory-Weiss tears, and esophageal hematomas, with emphasis on etiology, pathogenesis, clinical presentation, diagnosis, management, and prevention.

Endoscopic mucosal resection using a cap: techniques for use and preventing perforation

Endoscopic mucosal resection (EMR) is one of several local treatments that provide a specimen for histopathological analysis. The authors developed a technique of EMR using a transparent plastic cap (EMRC) in 1992. By using the EMRC procedure, any part of the gastrointestinal tract mucosa can be easily accessed. The technical details of EMRC are described. The authors have performed EMR in 380 cases of gastrointestinal lesions. The most serious complication may be perforation. Two perforations (one in the esophagus and one in the colon) have occurred. By evaluating recorded videotapes, it was determined that the lack of submucosal saline injection was the major cause. Therefore, large volume injection, which creates a large bleb and potentially reduces the risk of perforation, is recommended. Furthermore, target mucosa should be strangulated at the middle part of the created bleb (never strangulated at the base). Particularly in the colon, injecting a sufficient volume of saline and controlling the power of suction are extremely important, because the cap on the colonoscope is relatively large in size.

Preoperative staging of esophageal carcinoma: miniprobe sonography versus conventional endoscopic ultrasound in a prospective histopathologically verified study

BACKGROUND AND STUDY AIMS

Endosonographic staging of esophageal carcinoma may be limited by non-traversable tumor stenoses. Dilation of malignant esophageal strictures carries a significant risk of esophageal perforation. We therefore evaluated the use of ultrasonic miniprobes in the staging of stenotic esophageal carcinoma compared with conventional endoscopic ultrasound.

PATIENTS AND METHODS

In a blinded, prospective study, which included histopathological evaluation, 53 consecutive patients (43 male, 10 female, mean age 61 years) with stenosing esophageal carcinomas were examined preoperatively. Endosonography was done using the optical GF-UM3 echo endoscope. If tumor strictures were not traversable with this instrument, a blind esophagoprobe, the MH-908 was used for endosonography. Miniprobe sonography (MPS) was done during esophagoscopy in all patients. The various imaging modalities were assessed in terms of complete tumor traversability and correct tumor staging. Every patient underwent surgical tumor resection.

RESULTS

MPS of the esophagus and proximal parts of the stomach was possible in all 53 patients without prior dilation of tumor stenoses. Endosonography with the GF-UM3 instrument was precluded in 23 patients (43.4%) while in 20 of the latter patients the MH 908 esophagoprobe could be passed through tumor stenoses. The overall accuracy rates for depth of tumor infiltration (T) staging were: 62% (31/50) for endosonography (GF-UM3 plus esophagoprobe) and 86.8% (46/53) for MPS. The accuracy rates for T staging in tumors traversable both with the GF-UM3 echo endoscope and with miniprobes were 56.7% (17/30) for GF-UM3 and 80% (24/30) for MPS. The accuracy rates for T staging in tumors traversable only with the MH-908 esophagoprobe and with miniprobes were 70% (14/20) for the MH-908 and 95% (19/20) for MPS. With regard to the presence or absence of peri-esophageal metastatic lymph nodes (N staging), the accuracy rates were 83% (25/30) for MPS and 70% (21/30) for the GF-UM3, and 80% (16/20) for MPS and 70% (14/20) for the MH-908.

CONCLUSION

Compared with conventional endosonography using 7.5-MHz large diameter instruments, MPS enables: a) safe passage through high-grade malignant esophageal strictures, achieving b) higher accuracy rates for T staging, and c) similar rates for N staging. The use of MPS can also represent an improvement in the comfort and safety of patients. Moreover, miniprobe sonography is highly cost-effective compared with conventional endosonography. Thus, MPS appears to be a valuable addition to the armamentarium for staging esophageal carcinoma.

Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery

BACKGROUND

This study retrospectively assesses the mechanisms of 13 esophageal or gastric injuries resulting from dilator or nasogastric tube placement during laparoscopic foregut surgery and is intended to assist in determining methods of prevention.

METHODS

Information regarding esophageal or gastric injury during laparoscopic foregut surgery was obtained from six experienced laparoscopic surgeons. The specific mechanisms of injury were determined by discussion with the operating surgeon and review of the operative reports.

RESULTS

Eleven cases of esophageal or gastric perforation occurred during bougie insertion and two perforations occurred secondary to nasogastric tube placement during Nissen fundoplication or Heller myotomy. Five perforations required conversion to open operation for repair including two delayed thoracotomies. The 13 injuries occurred during the performance of 1,620 laparoscopic foregut operations for an overall incidence of 0.8%.

CONCLUSION

Foregut injury resulting from esophagogastric intubation during laparoscopic surgery is more common than expected. Risk factors include esophageal anatomy, intrinsic pathologic changes of the esophagus, and inexperience. Prevention must focus on close communication between the surgeon and anesthesiologist and safe techniques of dilator insertion.

How to avoid esophageal perforation while performing laparoscopic dissection of the hiatus

An increasing number of surgeons attempt advanced laparoscopic procedures, involving the distal esophagus such as Nissen fundoplication, truncal vagotomy, and Heller's myotomy. At this time, there are probably as many techniques as there are surgeons. The authors have tried to provide a "ready to use" universal strategy that details how to approach the distal esophagus while avoiding the dangerous pitfalls of surgery in that area.

[Severe complication in endoscopic ligation of esophageal varices]

The case of an esophageal perforation of a 47 year old patient with cirrhosis of the liver is described as a complication of endoscopic band ligation of esophageal varices. It is discussed how to avoid this complication.

[Acute erosion of the esophagus, stomach and duodenum]

Acute burns of the oesophago-gastro-duodenal tract require an immediate diagnostic and therapeutic approach. Early endoscopy has been shown to assist greatly in determining the further treatment of corrosive injury. The main task of radiology is to detect perforations. While first degree burns cause hardly any therapeutic problems, second and third degree burns require intensive care right from the start. Later, possible stricture formation warrants chief attention. Early corticosteroid treatment seems to be effective in preventing stricture development in second degree burns.

A new protector device for safe endoscopic removal of sharp gastroesophageal foreign bodies in infants

The accidental ingestion of sharp foreign bodies into the upper-gastrointestinal tract is not uncommon in children. Endoscopic extraction of these objects poses technical difficulties, and a number of dangerous complications can occur. We present two cases of successful retrieval of large, sharp gastroesophageal foreign bodies in small children using a new, commercially available endoscopic end protector hood that prevents exposure of the esophageal and pharyngeal wall to injuries and laceration by the foreign body. This device is simple to use, versatile, and effective and advances the safe endoscopic removal of a variety of gastroesophageal foreign bodies in pediatric patients.

Diagnostic rigid and flexible oesophagoscopy in carcinoma of the oesophagus: a comparison

BACKGROUND

Flexible oesophagoscopy is regarded as superior to rigid oesophagoscopy on the basis of perforation rates as an end point. This advantage may be more apparent than real because no comparison has been made in a diagnostic setting in patients with carcinoma of the oesophagus with both perforation rate and diagnostic efficacy as indices.

METHODS

A retrospective analysis was carried out on data on 336 diagnostic oesophagoscopies in patients with carcinoma of the oesophagus, comparing rigid with flexible oesophagoscopy.

RESULTS

Both rigid and flexible oesophagoscopies were performed without perforation when they were used for diagnosis only. Rigid biopsy achieved a diagnostic success rate of 99.3%, compared with 80.5% for flexible oesophagoscopy.

CONCLUSIONS

Diagnostic oesophagoscopy can be achieved without perforation with either instrument, but the chance of diagnosing carcinoma was significantly greater with the rigid instrument.

Complications of endoscopic injection sclerotherapy: a review

As endoscopic injection sclerotherapy becomes more widely applied to the treatment of bleeding esophageal varices, an increasing number of complications are being reported. Dysphagia, chest pain, and fever are usually transient and incosequential but may herald more serious life-threatening sequelae. Mortality commonly results from the major complications of recurrent bleeding, perforation, sepsis, and respiratory disorders. We carried out a review of sclerotherapy complications to understand their basis and to determine what measures can be taken to prevent or manage them.

Intraluminal pressures generated during esophageal bougienage

Although esophageal bougienage is a widely used palliative procedure for both benign and malignant esophageal strictures, little is known about the pressure generated or applied to the esophageal wall during this procedure. Accordingly, water-perfused catheters were radially implanted into Maloney dilators to monitor esophageal wall pressure in 13 patients undergoing bougienage for reflux-induced lower esophageal strictures. Maximal pressure generated in this group ranged from a low of 25 to a high of 830 mmHg and was generally higher in individuals with newly dilated strictures and with use of larger bougies. In a control group of 11 patients, resting esophageal wall pressure during dilation was 5 mmHg, a value similar to that measured in stricture patients. Maximal pressure occurred in the area of the lower esophageal sphincter and was not statistically higher than sphincter pressure measured with standard rapid pull-through technique. These studies help to define esophageal wall response to bougienage and the pressures generated at the time of esophageal dilation.