Eosinophilic Esophagitis: Review and Update

Background: Eosinophilic esophagitis (EoE) was first described in the 1990s, showing an increasing incidence and prevalence since then, being the leading cause of food impaction and the major cause of dysphagia. Probably, in a few years, EoE may no longer be considered a rare disease. Methods: This article discusses new aspects of the pathogenesis, symptoms, diagnosis, and treatment of EoE according to the last published guidelines. Results: The epidemiological studies indicate a multifactorial origin for EoE, where environmental and genetic factors take part. EoE affects both children and adults and it is frequently associated with atopic disease and IgE-mediated food allergies. In patients undergoing oral immunotherapy for desensitization from IgE-mediated food allergy the risk of developing EoE is 2.72%. Barrier dysfunction and T-helper 2 inflammation is considered to be pathogenetically important factors. There are different patterns of clinical presentation varying with age and can be masked by adaptation habits. Besides, symptoms do not usually correlate with histologic disease activity. The diagnostic criteria for EoE has evolved but mainly requires symptoms of esophageal dysfunction with histologic evidence of a peak value of at least 15 eosinophils per high-power field. Endoscopies have to be repeated in order to diagnose, monitor, and treat EoE. Treatment of EoE can be started either by drugs (PPIs and topical corticosteroids) or elimination diets. The multistage step-up elimination diet management approach of EoE is promising. Endoscopic dilation is used for patients with severe dysphagia/food impaction with inadequate response to anti-inflammatory treatment. Conclusions: Research in recent years has contributed to a better understanding of EoE's pathogenesis, genetic background, natural history, allergy workup, standardization in assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. However, several unmet needs are to be solved urgently, as finding a non-invasive disease-monitoring methods and biomarkers for routine practice, the development or new therapies, novel food allergy testing to detect triggering foods, drug, and doses required for initial therapy and safety issues with long-term maintenance therapy, amongst others. Besides, multidisciplinary management units of EoE, involving gastroenterologists, pediatricians, allergists, pathologists, dietitians, and ENT specialists are needed.

Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response

Achalasia is a motor disorder characterized by esophageal aperistalsis and failure of lower esophageal sphincter relaxation. The cardinal symptoms are dysphagia, food regurgitation and weight loss. The most effective treatments are pneumatic dilation (PD) of the cardia and Heller esophageal myotomy with partial fundoplication. There is still controversy regarding which treatments should be initially done. The aims of this study were to evaluate clinical response and the variables related to good results in both treatments. Ninety-two patients with achalasia diagnosed by esophageal manometry were randomized to receive either PD or laparoscopic Heller myotomy with partial fundoplication. After the procedure, patients were followed up clinically and submitted to esophageal manometry and pH monitoring. Three months after treatment, 73% of the patients from PD group and 84% of the surgery group had good results (P = 0.19). After 2 years of follow-up, 54% of the PD group and 60% of the surgery group (P = not significant) were symptom free. Variables related to a good response to PD were a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment. Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment when compared with PD. The reflux rate was significantly higher in the PD group (27.7%) compared with the surgery group (4.7%), P = 0.003. We concluded that surgical treatment and PD for achalasia are equally effective even after 2 years of follow-up. The choice of treatment for achalasia should be based on the following parameters: treatment availability, rate of good results, complication rates, variables related to good responses and also the patient's wish.

Esophageal foreign bodies in adults with different durations of time from ingestion to effective treatment

Objective

This study was performed to identify the differences in clinical characteristics, operative methods, complications, and postoperative hospitalization stays for adults with esophageal foreign bodies with different durations of time from ingestion to effective treatment.

Methods

We retrospectively reviewed the medical records of 221 patients with a diagnosis of a foreign body in the esophagus, confirmed by rigid esophagoscopy, flexible esophagoscopy, or surgery. The differences between the two groups (Group A, ≤24 hours from ingestion to effective treatment; Group B, >24 hours from ingestion to effective treatment) were analyzed.

Results

Sharp foreign bodies comprised the majority of objects in the two groups, including jujube pits, bones (excluding fish bones), fish bones, dentures, and seafood shells. Foreign bodies located in the upper esophagus were more commonly observed in Group A than B. Significant differences were observed in the complication rate and length of postoperative hospitalization stays. Adults with esophageal foreign bodies had a high complication rate.

Conclusions

Rigid esophagoscopy can be used to remove sharp and bulky foreign bodies if more effective methods are unavailable. Effective treatment within 24 hours resulted in fewer complications and shorter postoperative hospitalization stays.

Evaluation of 968 children with corrosive substance ingestion

Background and Aims:

The aim of the study was to evaluate the etiology, treatment, and prognosis in children who had presented at our clinic with corrosive substance ingestion and comparison of our results with the literature.

Materials and Methods:

The patients were put on nil by mouth and broad-spectrum antibiotics were administered. Oral fluids were started for patients whose intraoral lesions resolved and who could swallow their saliva. Steroids were not given, a nasogastric catheter was not placed, and early endoscopy was not used.

Results:

A total of 968 children presented at our clinic for corrosive substance ingestion during the 22-year period. The stricture development rate was 13.5%. Alkali substance ingestion caused a stricture development rate of 23%. A total of 54 patients required 1–52 sessions (mean 15 ±12) of dilatation.

Conclusion:

We do not perform early endoscopy, administer steroids, or place a nasogastric catheter at our clinic for patients who had ingested a corrosive substance. This approach has provided results similar to other series. We feel that determining the burn with early esophagoscopy when factors that prevent or decrease the development of corrosive strictures will be very important.

Diagnosis of Pediatric Foreign Body Ingestion: Clinical Presentation, Physical Examination, and Radiologic Findings

OBJECTIVES

(1) To describe clinical and radiologic findings in patients with esophageal foreign bodies. (2) To examine the sensitivity and specificity of history, physical examination, and radiologic studies in children with suspected foreign body ingestion.

METHODS

A retrospective cohort study was performed evaluating all children who underwent esophagoscopy for suspected foreign body ingestion at our institution from 2006 to 2013.

RESULTS

Five hundred forty-three patients were included (54% male). Average age was 4.7 years (SD = 4.1 years). Foreign bodies were identified on esophagoscopy in 497 cases (92%). Ingestion was witnessed in 23% of cases. Most common presenting symptoms were choking/gagging (49%), vomiting (47%), and dysphagia/odynophagia (42%). Most patients with foreign bodies had a normal exam (76%). Most foreign bodies were radiopaque (83%). In 59% of patients with normal chest radiographs, a foreign body was present. Sensitivity and specificity of 1 or more findings on history, physical examination, and imaging were 99% and 0%, 21% and 76%, and 83% and 100%, respectively.

CONCLUSIONS

Most patients with esophageal foreign bodies are symptomatic. Although many patients will have a normal physical examination, an abnormal exam should increase suspicion for a foreign body. Most esophageal foreign bodies are radiopaque, but a normal chest radiograph cannot rule out a foreign body.

Bronchoscopy, laryngoscopy, and esophagoscopy during the COVID-19 pandemic

Background

The United States now has the highest death toll due to COVID‐19. Many otolaryngology procedures, including laryngoscopy, bronchoscopy, and esophagoscopy, place otolaryngologists at increased risk of coronavirus transmission due to close contact with respiratory droplets and aerosolization from the procedure. The aim of this study is to provide an overview of guidelines on how to perform these procedures during the coronavirus pandemic.

Methods

Literature review was performed. Articles citing laryngoscopy, bronchoscopy, esophagoscopy use with regard to COVID‐19 were included.

Results

Laryngoscopy, bronchoscopy, and esophagoscopy are all used in both emergent and elective situations. Understanding the risk stratification of cases and the varied necessity of personal protective equipment is important in protecting patients and health care workers.

Conclusions

Summary guidelines based on the literature available at this time are presented in order to decrease transmission of the virus and protect those involved.

The management of oesophageal soft food bolus obstruction: a systematic review

INTRODUCTION

Oesophageal soft food bolus obstruction (OSFBO) is a surgical emergency. However, no national guidelines exist regarding its management. This paper systematically reviews the literature with respect to the management of OSFBO.

METHODS

Relevant studies included were identified from the the Cochrane Library, the National Center for Biotechnology Information and the US National Library of Medicine resources. A systematic review was performed on 8 November 2010.

RESULTS

This systematic review of the management of OSFBO shows no evidence that any medical intervention is more effective than a 'watch and wait' policy in enabling spontaneous disimpaction. Furthermore, the use of hyoscine butylbromide for OSFBO probably stems from a misquoted textbook. Surgical removal of an OSFBO is effective but not without potential risk. There is some evidence to support surgical intervention within 24 hours to prevent complications deriving from the initial obstruction.

CONCLUSIONS

There is a need for large double-blind, randomised, placebo controlled trials of drugs used in the medical management of OSFBO. Until the results from such trials are available, the treatment of OSFBO will remain based on inconsistent clinical judgement.

The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions

Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.

Screening for oesophageal cancer

BACKGROUND

Oesophageal cancer is a global heath problem. The prognosis for advanced oesophageal cancer is generally unfavourable, but early-stage asymptomatic oesophageal cancer is basically curable and could achieve better survival rates. The two most commonly used tests are cytologic examination and endoscopy with mucosal iodine staining. The efficacy of the screening tests is controversial, and the true benefit and efficacy of screening remains uncertain because of the potential lead-time and length-time biases. This review was conducted to examine the evidence for the efficacy of screening for oesophageal cancer (squamous cell carcinoma and adenocarcinoma).

OBJECTIVES

To determine the efficacy of early screening, using endoscopy with iodine staining or cytologic examination, in reducing mortality from oesophageal cancer in asymptomatic individuals from high-risk and general populations.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 8), The Cochrane Library (2012, Issue 8), MEDLINE (1950 to August 2012), EMBASE (1980 to August 2012), Allied and Complementary Medicine (AMED) (1985 to August 2012), Chinese Biomedical Database (CBM) (January 1975 to August 2012), VIP Database (January 1989 to August 2012), China National Knowledge Infrastructure (CNKI) (January 1979 to August 2012), and the Internet. We also searched reference lists, conference proceedings, and databases of ongoing trials. There was no restriction on language or publication status in the search for trials.

SELECTION CRITERIA

We included only randomised controlled trials (RCT) of screening versus no screening for oesophageal cancer. Randomisation of groups or clusters of individuals was acceptable.

DATA COLLECTION AND ANALYSIS

Two review authors independently scanned the titles and abstracts from the initial search for potential trials for inclusion. We did not find any trials that met the inclusion criteria.

MAIN RESULTS

The electronic search identified 3482 studies. Two authors independently reviewed the references. The reports of 18 studies were retrieved for further investigation. None met the eligibility criteria for a RCT investigation of the effects of screening versus no screening for oesophageal cancer.

AUTHORS' CONCLUSIONS

There were no RCTs that determined the efficacy of screening for oesophageal cancer. Non-RCTs showed a high incidence and the reported better survival after screening could be caused by selection bias, lead-time and length-time biases. RCTs are needed to determine the efficacy of screening for oesophageal cancer.

The role of aerodigestive tract endoscopy in penetrating neck trauma

OBJECTIVE/HYPOTHESIS

To determine the role of aerodigestive tract endoscopy in the management of penetrating neck trauma.

STUDY DESIGN

Retrospective case series.

METHODS

A search of the hospital's trauma database was performed for patients who presented with penetrating neck trauma between July 1989 and June 2008. The mechanism and site of injury, airway status and manipulation, physical findings, diagnostic and therapeutic steps taken, and outcomes were all recorded.

RESULTS

One hundred sixty-three patients were identified. There were 144 males and 19 females. The mean age was 28 years (range, 13 to 65 years). There were 105 gunshot wounds, 9 shotgun injuries, and 48 stab wounds. Seventy-three patients (45%) underwent emergent neck exploration, of which 15 had upper aerodigestive tract injuries; intraoperative endoscopy was performed on 13 and was used to guide the repair. Ninety patients (55%) did not meet the criteria for emergent neck exploration. Endoscopy in this group was performed in symptomatic patients, which revealed two cases of unilateral true vocal fold motion impairment, one mucosal laceration of the right mainstem bronchus, one questionable area of injury at the apical segment of the right upper lobe bronchus, and one mucosal laceration of the proximal esophagus.

CONCLUSIONS

Aerodigestive tract endoscopy is critical in assessing and guiding surgical repair of injuries noted on surgical exploration. In stable patients with a low clinical suspicion of aerodigestive tract injury, it was of low yield. We propose a new algorithm for assessing aerodigestive tract injuries that includes multidetector computed tomography, in which only symptomatic patients who fail to meet the criteria for emergent neck exploration undergo endoscopy.

LEVEL OF EVIDENCE

4.

Microflora composition in the gastrointestinal tract in patients with Barrett's esophagus

Background

The incidence of esophageal adenocarcinoma (EAC) has been increasing over the last 40 years. While Barrett's esophagus is a known risk factor for the development of EAC, the role of the microflora in the development of EAC is still largely unknown and is being investigated further by multiple centers. Our goal was to identify trends in microflora composition along various aspects of the upper gastrointestinal tract in patients with Barrett's esophagus.

Methods

After obtaining institutional review board approval, 12 patients agreed to participate in the study. While endoscopy was performed for surveillance Barrett's monitoring, additional biopsies of esophageal mucosa were taken from the (I) proximal esophagus, (II) mid-esophagus, (III) distal esophagus, and (IV) Barrett's esophagus. Additional swabs were also taken from the uvula and the endoscope used during the procedure. The swabs from the uvula and endoscope were obtained prior to the endoscope entering the stomach, to prevent exposing the endoscope to the acidic environment of the stomach. The most common bacterial elements were identified by amplifying sample DNA using a panel of 5 "universal" fusion primer pairs. The 400-500 base pair fragments created an overlap which covered 95% of the bacterial 16s gene.

Results

Throughout the esophagus, 34 bacterial genera were found which had a relative abundance of >1.0. Streptococcal genera were prevalent in all aspects of the esophagus, ranging from 16% to 70% of the bacterial community. Haemophilus genera were uniquely abundant in the Barrett's esophageal tissue but relatively absent elsewhere in the upper gastrointestinal tract. Overall, the percentage of Gram-positive organisms was much higher in the proximal than distal esophagus. The microflora pattern obtained from the uvula and endoscopic swabs did not correlate with any of the tissue biopsies along any aspect of the esophagus.

Conclusions

In patients with Barrett's esophagus, Streptococcal genera are widespread throughout the esophagus. Gram-positive genera tend to decrease as a percentage of overall flora distally. Obtaining a simple swab of the oropharynx or endoscope itself appears to be a poor substitute for tissue biopsy of esophageal mucosa when evaluating microflora patterns.

The role of the otolaryngologist in the evaluation and diagnosis of eosinophilic esophagitis

OBJECTIVE

To describe the clinical presentation and role of the otolaryngologist in the evaluation of eosinophilic esophagitis (EoE) at a tertiary pediatric hospital.

STUDY DESIGN

Retrospective review.

METHODS

Records from pediatric patients with a diagnosis of EoE from 2003 to 2015 were reviewed. Study variables were analyzed to compare patients presenting to different specialties.

RESULTS

Two hundred and fifty-one patients with EoE were evaluated. The median age at diagnosis was 9.0 years (range 0.8-19.0); 73% were male. Sixty-seven percent of patients initially presented to gastroenterology and 18% to otolaryngology. Time from initial presentation to diagnosis did not differ between the patients presenting to the two specialties (median 2.3 vs. 2.0 months, P = 0.510). Overall, 26% presented with airway symptoms (stridor, chronic cough, croup, or dysphonia). Patients diagnosed by the otolaryngology service were younger (3.4 vs. 10.4 years, P < 0.0001), had a higher incidence of airway symptoms (68% vs. 15%, P < 0.001), and demonstrated fewer gastrointestinal symptoms (86% vs. 100%, P < 0.001).

CONCLUSION

Patients with EoE frequently present to otolaryngology undiagnosed in the first 5 years of life, making esophagoscopy with biopsy an important adjunct to airway endoscopy in children with refractory aerodigestive symptoms. Otolaryngologists are uniquely poised to facilitate early diagnosis and initiation of therapy for these children, potentially reducing long-term sequelae.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1459-1464, 2017.

Patient Reported Outcomes and Objective Swallowing Assessments in a Multidisciplinary Dysphagia Clinic

OBJECTIVES/HYPOTHESIS

Dysphagia encompasses a complex compilation of symptoms which often differ from findings of objective swallowing evaluations. The purpose of this investigation was to compare the results of subjective dysphagia measures to objective measures of swallowing in patients evaluated in a multidisciplinary dysphagia clinic.

STUDY DESIGN

Prospective cohort study.

METHODS

The study cohort included all patients evaluated in the multidisciplinary dysphagia clinic over 24 months. Participants were evaluated by a multidisciplinary team including a laryngologist, gastroenterologist, and speech-language pathologist. Evaluation included a videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), and transnasal esophagoscopy (TNE). Data collected included diet (FOIS), Eating Assessment Tool (EAT-10) score, Reflux symptom index (RSI) score, and the findings of the VFSS exam.

RESULTS

A total of 75 patients were included in the analysis. The average EAT-10 score was 16.3 ± 2.1, RSI was 21.4 ± 0.6, and FOIS score was 6.0 ± 1.33. VFSS revealed impairments in the oral phase in 40% of the cohort, pharyngeal in 59%, and esophageal in 49%. Abnormalities were noted in one phase for 32%, in 2 phases in 32%, and three phases in 18%. Patients with abnormal pharyngeal findings on VFSS had significantly higher EAT-10 scores (P = .04). Patients with abnormal oral findings on VFSS were noted to have significantly lower FOIS scores (P = .03).

CONCLUSIONS

Data presented here demonstrate a relationship between patient reported symptoms and objective VFSS findings in a cohort of patients referred for multidisciplinary swallowing assessment suggesting such surveys are helpful screening tools but inadequate to fully characterize swallowing impairment.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1088-1094, 2021.

Intraoperative esophagoscopy provides accuracy and safety in video-assisted thoracoscopic enucleation of benign esophageal submucosal tumors

Benign esophageal tumors are rare; complete surgical resection is essential for the management of the submucosal tumors. Larger, symptomatic, or non-diagnostic lesions should be resected for both diagnostic and therapeutic indications. Video-assisted thoracic surgery has become a popular treatment in the field of thoracic surgery; however, thoracoscopic esophageal surgery may lead to an increase in operative complications. The effect and safety of thoracoscopic surgery for esophageal submucosal lesions were evaluated. A retrospective study evaluated patients undergoing thoracoscopic treatment of benign submucosal tumors. Between March 2011 and December 2013, 17 patients underwent thoracoscopic resection of benign submucocal tumors. Intraoperative esophagoscopy was performed for tumor localization by transillumination and confirmation of mucosal integrity after enucleation in every patient. Median patient age was 47 years (range 30-65). The median surgery time was 170 minutes (range 80-429). The median tumor size was 3.8 cm (range 1.3-9). The median hospital stay was 4 days (range 2-12). There were 16 leiomyoma and 1 neurogenic tumor. There was one case of conversion to thoracotomy because of residual tumor after enucleation. Mucosal injuries occurred in three patients, two accidentally and one intentionally; each patient was treated with primary repair and confirmed integrity with flexible esophagoscopy at operating room. The small sized tumor with intraoperative esophagoscopy could be localized. Esophagoscopic assistance was necessary in eight patients to have better idea where to make myotomy. There were no major morbidities such as postoperative leakage or mortality. Esophageal submucosal tumors can be treated safely with thoracoscopic surgery. However, intraoperative esophagoscopy allows accurate tumor localization, direction of esophageal access incision, and decreases complications during VATS enucleation of esophageal submucosal tumors.

Retrospective evaluation of factors associated with degree of esophagitis, treatment, and outcomes in dogs presenting with esophageal foreign bodies (2004-2014): 114 cases

OBJECTIVE

To characterize a population of dogs presenting for esophageal foreign body removal and evaluate factors associated with degree of esophagitis and minor and major complications.

DESIGN

Retrospective evaluation of dogs who presented for esophageal foreign body removal between January 2004 and December 2014.

SETTING

University veterinary teaching hospital.

ANIMALS

Data collected from 114 dogs included signalment, history, clinical signs, physical examination findings, duration and location of foreign body, degree of esophagitis, foreign body removal success, feeding tube placement, and clinical outcomes. Owners were contacted for outcome data not available in the medical record. Data were analyzed for breed predispositions, whether duration or type of foreign body was associated with degree of esophagitis or complications, and factors associated with feeding tube placement.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The overall success rate for foreign body removal via esophagoscopy was 95% with a complication rate of 22%. Small breed dogs were overrepresented. Dogs with a foreign body present for >24 h were significantly more likely to have severe esophagitis (P < 0.001) and major complications (P = 0.0044). Foreign body type did not predict degree of esophagitis or complications, though fishhooks were more likely to require surgical removal (P = 0.033). Feeding tubes (15 gastrostomy, 1 nasoesophageal) were placed in 14% of dogs and were more likely to be placed if the foreign body had been present for >24 h (P < 0.001).

CONCLUSIONS

Consistent with previous studies, esophageal foreign bodies, appropriately identified and endoscopically removed, carry a good prognosis, particularly if they have been present for ≤24 h.

Rapid and safe removal of foreign bodies in the upper esophagus in children using an optimized Miller size 3 video laryngoscope blade

BACKGROUND

Foreign bodies lodged in the upper esophagus in children may result in life-threatening complications, especially with button batteries. Rapid removal is essential to prevent complications. Experts report that extraction with a suitable laryngoscope and a forceps is feasible under general anesthesia, but no further data had been available so far.

AIMS

To study foreign body visualization and removal from the upper esophagus in children using a new optimized Miller size 3 blade video laryngoscope.

METHODS

This prospective observational study was performed in three pediatric hospitals. The clinical observations were reported anonymously on an electronic spreadsheet after obtaining the informed consent from the parents or guardians. During the observational period from January 2019 to October 2020, all children with a foreign body lodged into the upper esophagus were eligible for participation and 22 cases were included. Main outcome measures were rates of successful removal and complications as well as duration of the procedure. Secondary outcome was subjective assessment regarding the quality of the visualization and the feasibility of the procedure.

RESULTS

Success rate was 100% with no complications. Mean intervention and anesthesia times were 5 ± 4 minutes and 26 ± 25 minutes. Quality of visualization of the foreign body was judged as 'excellent' or 'good' in all cases and the feasibility of the procedure as 'without' or 'with little' effort in 95% of all cases.

CONCLUSION

The new Miller size 3 video laryngoscope enables rapid, easy, and reliable extraction of foreign bodies when they are located in the upper part of the esophagus. As early removal of esophageal foreign bodies, especially with button batteries, prevents life-threatening complications, we suggest this technique as the first choice of treatment.

Comparison of different anesthesia techniques during esophagogastroduedenoscopy in children: a randomized trial

BACKGROUND

Esophagogastroduedenoscopy (EGD) in children is usually performed under general anesthesia. Anesthetic goals include minimization of airway complications while maximizing operating room (OR) efficiency. Currently, there is no consensus on which anesthetic technique best meets these goals. We performed a prospective randomized study comparing three different anesthetic techniques.

AIMS

To evaluate the incidence of respiratory complications (primary aim) and institutional efficiency (secondary aim) among three different anesthetic techniques in children undergoing EGD.

METHODS

Subjects received a standardized inhalation induction of anesthesia followed by randomization to one of the three groups: Group intubated, sevoflurane (IS), Group intubated, propofol (IP), and Group native airway, nonintubated, propofol (NA). Respiratory complications included minor desaturation (SpO2 between 94% and 85%), severe desaturation (SpO2 < 85%), apnea, airway obstruction/laryngospasm, aspiration, and/or inadequate anesthesia during the endoscopy. Evaluation of institutional efficiency was determined by examining the time spent during the different phases of care (anesthesia preparation, procedure, OR stay, recovery, and total perioperative care).

RESULTS

One hundred and seventy-nine children aged 1-12 years (median 7 years; 4.0, 10.0) were enrolled (Group IS N = 60, Group IP N = 59, Group NA N = 61). The incidence of respiratory complications was higher in the Group NA (0.459) vs Group IS (0.033) or Group IP (0.086) (P < 0.0001). The most commonly observed complications were desaturation, inadequate anesthesia, and apnea. There were no differences in institutional efficiency among the three groups.

CONCLUSION

Respiratory complications were more common in Group NA. The use of native airway with propofol maintenance during EGD does not offer advantages with respect to respiratory complications or institutional efficiency.

Value of Transnasal Esophagoscopy in the Workup of Laryngo-Pharyngeal Reflux

Background: Laryngopharyngeal reflux (LPR) can display a variety of symptoms, and upper endoscopy is occasionally used for its investigation. The aim of the present study was to determine the value of transnasal esophagoscopy (TNE) in the workup of LPR. Methods: In 200 consecutive patients with suspected LPR, reflux symptom index (RSI), reflux finding score (RFS), oropharyngeal pH-monitoring (PHM) and transnasal esophagoscopy (TNE) were carried out and rated according to the Horvath Score. Results: In the investigation of LPR, TNE showed a sensitivity, specificity and accuracy of 96%, 85% and 95%, respectively. The most common pathologic TNE findings in LPR patients were an insufficient cardia, hiatal hernia, lymphoid follicles and visible reflux. Conclusions: TNE is a supportive method in the workup of LPR, which can display the underlying pathology and directly affect therapeutic decisions.

Current Indications for Transnasal Esophagoscopy: An American Broncho-Esophagological Association Survey

INTRODUCTION:

The aim of this study was to evaluate the current indications for and clinical factors influencing the use of transnasal esophagoscopy (TNE).

METHODS:

An online survey was sent to American Broncho-Esophagological Association members, including questions on demographics, indications, and factors influencing the use of TNE.

RESULTS:

Sixty of 251 members (24%) completed the survey. Ninety-three percent of respondents reported academic practices, while 98% practice in medium to large urban settings. Thirty-five (58%) completed laryngology fellowships. Mean monthly TNE procedure count was 7.15 (range, <1-35). The most common indications were dysphagia (82%), biopsy (50%), and laryngopharyngeal reflux (47%). Chronic cough, head and neck cancer screening, gastroesophageal reflux (GER), and tracheoesophageal puncture were also commonly reported indications (44% each). For laryngopharyngeal reflux and GER, most respondents perform TNE for recalcitrant disease following a medical trial of at least 3 months. Long-standing GER symptoms, documentation of GER on pH and impedance testing, and abnormal findings on previous esophagoscopy lead to greater TNE use. Specific dysphagia indications included abnormal esophagographic findings (70%), history or examination localizing to the esophagus (60%), solid dysphagia only (53%), and solid and/or liquid dysphagia (40%). The primary sites most likely to prompt TNE use for head and neck cancer surveillance were the esophagus (92.3%) and hypopharynx (84.6%). Balloon dilation was the most common indication for which respondents do not currently perform TNE but would like to (n = 8).

CONCLUSIONS:

TNE indications have not been well established. According to respondents from the American Broncho-Esophagological Association, TNE is most commonly used for dysphagia and laryngopharyngeal reflux and slightly less so for GER and head and neck cancer screening and surveillance. Several clinical indicators were identified that influence the decision to perform TNE.

Comparison of Outcomes in Medical Therapy vs Surgical Intervention of Esophageal Foreign Bodies

Objectives (1) Compare efficacy of primary medical therapy vs primary surgical intervention in patients with esophageal foreign bodies (EFBs). (2) Investigate variables that may predict successful outcomes in patients treated for EFBs. Study Design Case series with chart review. Setting Single-institution academic tertiary care medical center. Subjects and Methods Adult patients (older than 18 years) seen at the University of Michigan Emergency Department (ED) over an 8-year period with the diagnosis of EFBs (January 1, 2003, to December 31, 2011; N = 250). Decision was made by ED physicians whether to treat patients with first-line medical therapy vs surgical intervention. Pertinent clinical and demographic data were extracted from medical records and summarized by descriptive statistics. Results First-line treatment with surgical intervention (flexible or rigid esophagoscopy with foreign body removal) was much more likely to lead to resolution of symptoms than medical therapy (glucagon alone or in combination with other medical therapy) (98% vs 28%, P < .0001). When delivered within 12 hours of symptom onset, medical therapy was more likely to be successful (34% resolution vs 12% resolution, P < .01). There was no difference in complication rates for primary medical therapy vs surgical intervention (8% vs 8%). Conclusions Patients with EFBs are a commonly encountered consultation for both otolaryngologists and gastroenterologists. In these patients, first-line surgical intervention is superior to medical therapy and should not be avoided for a trial of medical therapy or concern for higher morbidity. Implementation of these findings has the ability to positively affect treatment patterns, outcomes, and patient quality of life.

Medical management of esophageal perforation secondary to esophageal foreign bodies in 5 dogs

OBJECTIVE

To describe 5 cases of conservative management of substantial esophageal perforation in dogs.

SERIES SUMMARY

Five dogs presented with an esophageal foreign body (EFB) and resultant esophageal perforation. Clinical signs at presentation included tachycardia, tachypnea, and increased respiratory effort. Thoracic radiography was performed in all cases, and in each case, pleural and mediastinal effusion was present, suggesting esophageal perforation prior to endoscope-guided removal. A full thickness esophageal defect was visualized after foreign body removal in 4/5 cases. Treatment included IV crystalloid fluid therapy, IV antimicrobials, analgesia, and proton pump inhibitors in all cases. Two dogs had a percutaneous endoscopically placed gastrostomy feeding tube placed and 1 dog received prednisolone sodium succinate IV because of marked pharyngeal inflammation. Complications after EFB removal included pneumothorax (n = 2) and pneumomediastinum (n = 4). Four of the 5 dogs survived to discharge and did not have complications 2-4 weeks following discharge. One dog was euthanized as result of aspiration pneumonia following EFB removal.

NEW OR UNIQUE INFORMATION PROVIDED

Traditionally, surgical management of esophageal perforations has been recommended. This can be a costly and invasive procedure and requires a high degree of surgical skill. In this report, conservative management of substantial esophageal perforation in 5 dogs is described; medical management may be a viable treatment option in dogs with perforation of the esophagus due to EFB.

Analysis of the management and risk factors for complications of esophageal foreign body impaction of jujube pits in adults

Introduction

Foreign body impaction is a common emergency in the field of otolaryngology. The prevalence of a jujube pit as an esophageal foreign body has increased in the Jiaodong Peninsula. However, reports on this are scarce.

Aim

To investigate the methods for diagnosing and treating esophageal foreign body impaction of a jujube pit and to determine the risk factors for complications.

Material and methods

We conducted a retrospective review of the medical records of patients who were diagnosed with esophageal impaction of a jujube pit. Demographic, clinical, radiological, and endoscopic data were collected and analyzed.

Results

Neither plain radiography nor esophagogram provided enough information on the surrounding issues and complications. The rate of secondary radiological examination was 51.61% for the patients who did not undergo prior computed tomography. The success rate of rigid esophagoscopy was 95.45%; 18 of these patients (27.27%) had previously undergone flexible esophagoscopy without foreign body removal. Logistic regression showed that the time from ingestion to presentation and the jujube pit size were independent risk factors for complications.

Conclusions

Computed tomography without contrast material is the preferred diagnostic method for adults with esophageal jujube pit impaction, and rigid esophagoscopy can be used for therapy even though the first flexible esophagoscopy failed. Large diameter of the jujube pit constituting the esophageal foreign body (≥ 25 mm) and long duration between pit ingestion and presentation (> 12 h) were associated with increased complications in the patients in this study.

Presumptive non-cirrhotic bleeding esophageal varices in a dog

An 8‐year‐old male American Staffordshire terrier was admitted for evaluation of chronic episodes of ptyalism and hematemesis after exercise. Abnormalities were not detected on routine clinicopathological tests, thoracic radiography, and abdominal ultrasonography. Endoscopic examination revealed a labyrinthine network of severely distended, hemorrhagic esophageal blood vessels. Computed tomography angiography demonstrated a network of para‐esophageal vessels that communicated with the celiac artery caudally and the brachiocephalic trunk cranially, consistent with a diagnosis of non‐cirrhotic esophageal varices. This is a report of exercise, ptyalism, and hematemesis secondary to presumptive, non‐cirrhotic, bleeding esophageal varices in a dog.

[Diagnostic and treatment of foreign bodies of the upper digestive tract]

OBJECTIVE

To evaluate the results of diagnosis and treatment of foreign bodies of the upper gastrointestinal tract.

MATERIAL AND METHODS

There were 1187 patients aged 15-99 years with suspected foreign body of the upper gastrointestinal tract. In 536 patients (266 men, 270 women), foreign bodies were detected. Ingestion of a foreign body was more common in patients aged 46-65 years. In 516 patients, foreign bodies were detected in the esophagus (pharyngo-esophageal junction - 25, upper third of the esophagus - 426, middle third of the esophagus - 34, lower third of the esophagus - 21, esophageal-gastric junction - 10). Four patients admitted with esophageal wall perforation. In 3 cases, foreign bodies were localized in the throat, 15 patients - in the stomach, 2 patients - in the duodenum.

RESULTS

In most cases, foreign bodies were organic (n=506). Removal was successful in 530 cases. In 4 patients with esophageal wall perforation and mediastinitis, removal was performed intraoperatively. Flexible endoscope was used in 500 cases. In 86 patients, foreign bode was displaced in the stomach using flexible endoscopy. Foreign body removing wasn't successful in 4 cases. In 2 patients, extraction was followed by esophageal wall damage. In 4 patients, esophagotomy was applied to extract foreign body. Suturing the esophageal wall defect was carried out in 2 cases. Abrasion and erosive esophagitis were the most common injuries of esophageal mucosa. Esophageal diseases were detected in 75 cases after foreign body removal (67 cases - benign esophageal diseases). One patient died from bedsore of innominate artery complicated by acute hemorrhage.

CONCLUSION

Foreign bodies of the upper gastrointestinal tract are observed in 45% of patients at admission. Neck and chest X-ray examination is obligatory before endoscopy. Flexible endoscopy is a gold standard for diagnosis and extraction of foreign bodies. Repeated endoscopy after foreign body extraction should be mandatory. It is necessary to visualize complications associated with foreign body and identify esophageal diseases.

Transnasal Esophagoscopy-Our Experience

Introduction  Transnasal esophagoscopy (TNE) is a widely used tool both in the diagnosis and treatment of patients presenting complaints within the head and the neck. This is because this investigative adjunct examination provides the advantage of visualizing above the level of the cricopharyngeus muscle when compared to the more widely used esophagogastroduodenoscopy (EGD).

Objectives  We have assessed if the implementation of TNE within a district general hospital (DGH) was feasible, and investigated if the resources of our patients could be better directed away from other investigations such as barium swallow and EGD in favor of this novel technique. The TNE technique has been largely applied in central teaching hospitals within the United Kingdom, but there are still no published reports of a DGH investigating its applicability in this smaller-sized clinical environment.

Method  We have analyzed our theater database to find all the patients who had undergone TNE, and recorded their reason for presenting, the preceding investigations, and the procedural findings.

Results  In most cases, the TNE was conducted without technical issues, and we were able to identify positive findings in 43% of the patients who underwent Esophagogastroduodenoscopy (EGD). We were able to treat patients successfully during the investigation when a cricopharyngeal stricture or narrowing was found. A normal EGD did not preclude further investigations with TNE. All but one of our patients were treated as day-case procedures.

Conclusion  Transnasal esophagoscopy can be successfully delivered within a DGH. A previous EGD does not mean that the TNE will not reveal positive findings due to its superior visualization of the pharynx and the upper esophagus.