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Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr 2011; 23:1115-27; quiz 1220-1. [PMID: 20864313 DOI: 10.1016/j.echo.2010.08.013] [Citation(s) in RCA: 333] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Indexed: 01/09/2023]
Abstract
Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.
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Review |
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333 |
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Enns R, Eloubeidi MA, Mergener K, Jowell PS, Branch MS, Pappas TM, Baillie J. ERCP-related perforations: risk factors and management. Endoscopy 2002; 34:293-8. [PMID: 11932784 DOI: 10.1055/s-2002-23650] [Citation(s) in RCA: 179] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND STUDY AIMS Perforations during endoscopic retrograde cholangiopancreatography (ERCP) are rare, and the management of these perforations is variable, with some patients requiring immediate surgery and others only conservative management. We reviewed all ERCP-related perforations at our institution to determine: a) their incidence; b) clinical outcomes; c) which management approaches gave the best results; and d) which factors predict a perforation. PATIENTS AND METHODS All patients who underwent ERCP and suffered perforation were reviewed. To compare the length of hospital stay of the perforation group with that of patients suffering a different complication, patients who developed post-ERCP pancreatitis were also reviewed. To evaluate predictors of ERCP-related perforations, three groups were compared: group 1 (n = 49), normal ERCP/no complications; group 2 (n = 52), ERCP complicated by pancreatitis; and group 3 (n = 33), ERCP with perforation. RESULTS Of 33 patients with confirmed ERCP-related perforations, only seven patients required surgical intervention. The overall length of hospital stay (6.5 +/- 3.5 days) was significantly longer (P = 0.003) than that of a random group of patients with the complication of post-ERCP pancreatitis (4.7 +/- 2.6 days). According to univariate analysis, risk factors included: sphincterotomy (odds ratio [OR] 9.0, 95 % confidence interval [CI] 3.2 - 28.1); sphincter of Oddi dysfunction (OR 3.8, 95 % CI 1.4 - 11.0); and dilated common bile duct (OR 4.07, 95 % CI 1.63 - 10.18, P = 0.003). In the multivariate logistic regression analysis, additional predictive factors included the duration of procedure (OR 1.021, 95 % CI 1.006 - 1.036), and biliary stricture dilation (OR 7.2, 95 % CI 1.84 - 28.11). CONCLUSIONS (i) The incidence of ERCP-related perforations is very low (0.35 %). (ii) Esophageal, gastric and duodenal perforations usually require surgery, but sphincterotomy- and guide wire-related perforations rarely do so. (iii) Factors which carry increased risk of an ERCP-related perforation include suspected sphincter of Oddi dysfunction, greater age, a dilated bile duct, sphincterotomy, and longer duration of the procedure.
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Comparative Study |
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Straumann A, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008; 6:598-600. [PMID: 18407800 DOI: 10.1016/j.cgh.2008.02.003] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis is a rapidly emerging, chronic inflammatory disorder. Prolonged inflammation evokes structural alterations and a fragile esophageal wall prone to perforation/rupture and food impaction. This report assesses the risk of spontaneously arising and procedure-induced complications and proposes practical recommendations. METHODS The Swiss Esophageal Esophagitis Database documented 251 confirmed cases. A chart review identified which patients had required endoscopic bolus removal and/or experienced transmural esophageal perforation/rupture. In addition, a MEDLINE search for "eosinophilic esophagitis" with "esophageal perforation" or "esophageal rupture" was undertaken. RESULTS During an 18-year period, 87 patients (34.7%) experienced 134 food impactions requiring flexible (124, 92.5%) or rigid (10, 7.5%) endoscopic bolus removal. Transmural perforation occurred in 20% (2/10) of rigid procedures, and 1 esophageal rupture (Boerhaave's syndrome) was observed. CONCLUSIONS Bolus removal by rigid endoscopy is a high-risk procedure and should be avoided in eosinophilic esophagitis patients who require a gentler approach. Whether food impaction and esophageal wall remodeling can be prevented with anti-inflammatory medication is still undetermined. All Boerhaave's syndrome cases should be evaluated for underlying eosinophilic esophagitis.
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163 |
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Gaudinez RF, English GM, Gebhard JS, Brugman JL, Donaldson DH, Brown CW. Esophageal perforations after anterior cervical surgery. JOURNAL OF SPINAL DISORDERS 2000; 13:77-84. [PMID: 10710155 DOI: 10.1097/00002517-200002000-00015] [Citation(s) in RCA: 144] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An esophageal perforation after anterior cervical surgery is an uncommon but well recognized complication. During the past 25 years, 44 patients have presented to Craig Hospital (Rocky Mountain Regional Spinal Injury Center) with esophageal perforations; this is the largest series reported to date. There were 34 patients whose esophageal injury was related to the operations performed for cervical fractures, of which 28 patients had plate and screw fixation. The most frequently occurring clinical symptoms were that of neck and throat pain, odynophagia, dysphagia, hoarseness, and aspiration. The most common clinical findings were an elevated temperature, localized induration and neck tenderness, crepitus or subcutaneous air in the neck and anterior chest wall, an unexplained tachycardia, and blood in the nasogastric tube. Imaging studies indicated an esophageal injury in only 32 (72.7%) patients. Twenty-two patients experienced cervical osteomyelitis or an abscess of the neck. Nonoperative treatment is fraught with a high mortality, and 42 patients required surgical repair of their esophageal injury. The length of hospital stay averaged 253 days. Successful management of esophageal perforations depends on the physicians' awareness of the causes, prompt recognition of the symptoms and clinical findings, and immediate institution of treatment.
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Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP, Lang RM. Clinical Features of Complications From Transesophageal Echocardiography: A Single-Center Case Series of 10,000 Consecutive Examinations. J Am Soc Echocardiogr 2005; 18:925-9. [PMID: 16153515 DOI: 10.1016/j.echo.2005.01.034] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is an essential diagnostic tool that has gained widespread use in clinical cardiology. It is considered reasonably noninvasive and safe; however, insertion and operation of the TEE probe may cause hypopharyngeal, esophageal, or gastric trauma. The current study reports a single-center experience of esophagogastric trauma in 10,000 consecutive TEE examinations. METHODS TEE examinations were performed by 9 attending physicians who were trained in endoscopic procedures and had been performing TEE studies for at least 1 year. RESULTS One case of hypopharyngeal perforation (0.01%), 2 cases of cervical esophageal perforation (0.02%), and no cases of gastric perforation (0%) occurred after TEE examination. No fatalities (0%) occurred. We describe the clinical characteristics of individuals who experienced esophageal perforation during this 10-year period. CONCLUSIONS This single-center study demonstrates that TEE examinations are associated with a very low risk of esophagogastric trauma when performed in a safe setting by experienced operators.
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141 |
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Xie F, Yun H, Bernatsky S, Curtis JR. Brief Report: Risk of Gastrointestinal Perforation Among Rheumatoid Arthritis Patients Receiving Tofacitinib, Tocilizumab, or Other Biologic Treatments. Arthritis Rheumatol 2016; 68:2612-2617. [PMID: 27213279 PMCID: PMC5538140 DOI: 10.1002/art.39761] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/17/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate gastrointestinal (GI) perforation in rheumatoid arthritis (RA) patients receiving tofacitinib, tocilizumab, or other biologic agents. METHODS Using health plan data from 2006 through 2014, RA patients without prior GI perforation were identified. Those in whom treatment with tofacitinib or a biologic agent was being initiated were followed up for incident GI perforation with hospitalization. Crude incidence rates were calculated by exposure. Adjusted Cox proportional hazards models were used to evaluate the association between GI perforation and exposures. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated. RESULTS A cohort of 167,113 RA patients was analyzed. Among them, 4,755 began treatment with tofacitinib, 11,705 with tocilizumab, 115,047 with a tumor necrosis factor inhibitor (TNFi), 31,214 with abatacept, and 4,392 with rituximab. Compared to TNFi recipients, abatacept recipients were older, tofacitinib and rituximab recipients were younger, and tocilizumab recipients were similar in age. Patients beginning treatment with a non-TNFi agent were more likely to have previously received biologic agents than patients beginning treatment with a TNFi. The incidence of GI perforation per 1,000 patient-years was 0.86 (tofacitinib), 1.55 (tocilizumab), 1.07 (abatacept), 0.73 (rituximab), and 0.83 (TNFi). Most perforations occurred in the lower GI tract: the incidence of lower GI tract perforation per 1,000 patient-years was 0.86 (tofacitinib), 1.26 (tocilizumab), 0.76 (abatacept), 0.48 (rituximab), and 0.46 (TNFi). Lower GI tract perforation risk was significantly elevated with tocilizumab treatment, and numerically elevated with tofacitinib treatment, versus treatment with TNFi. Adjusted HRs were 2.51 (95% CI 1.31-4.80) for tocilizumab and 1.94 (95% CI 0.49-7.65) for tofacitinib. Older age (HR 1.16 per 5 years [95% CI 1.10-1.22]), diverticulitis/other GI conditions (HR 3.25 [95% CI 1.62-6.50]), and prednisone use at >7.5 mg/day (HR 2.29 [95% CI 1.39-3.78]) were associated with lower GI tract perforation. The incidence of upper GI tract perforation was similar among all drug exposures. CONCLUSION The risk of lower GI tract perforation associated with tocilizumab treatment, and possibly tofacitinib treatment, is elevated compared to that associated with TNF blockade.
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Research Support, N.I.H., Extramural |
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133 |
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Newhouse KE, Lindsey RW, Clark CR, Lieponis J, Murphy MJ. Esophageal perforation following anterior cervical spine surgery. Spine (Phila Pa 1976) 1989; 14:1051-3. [PMID: 2588052 DOI: 10.1097/00007632-198910000-00004] [Citation(s) in RCA: 126] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The authors surveyed the Cervical Spine Research Society to compile a series of esophageal perforations following anterior cervical spine surgery. Twenty-two cases were assembled. Six occurred at the time of surgery, 6 in the postoperative period, and 10 weeks to months later. Eight surgeries were because of fracture. Hardware was implicated in 25% of cases occurring after surgery. Diagnosis was confirmed most often by direct vision at reexploration or esophography. Treatment usually consisted of drainage, repair, and parenteral antibiotics; 2 cases were successfully treated by enteral feeding and antibiotics alone. There was one fatality, and all patients required prolonged hospitalization. Cervical fracture and the use of hardware may be associated with this complication. Clinical suspicion and esophography are important diagnostic tools. Drainage and parenteral antibiotics are recommended treatment.
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126 |
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Hernandez LV, Jacobson JW, Harris MS, Hernandez LJ. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc 2000; 51:460-2. [PMID: 10744819 DOI: 10.1016/s0016-5107(00)70448-2] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traditionally, mercury-filled rubber bougies are used for dilation of simple or mild-to-moderate esophageal strictures, whereas through-the-scope balloon dilators and wire-guided polyvinyl bougies have become standard for more complex strictures. Because few comparative trials are available, the choice of dilator and technique is largely based on the training and experience of the operator. METHODS We reviewed 348 esophageal dilation procedures performed on a total of 142 patients over a 4-year period (January 1, 1993, to January 1, 1997). The location and cause of stricture, the maximum diameter of the instrument used per session, the rate of perforation, and the rate of fluoroscopy use were recorded. RESULTS Maloney, balloon (hydrostatic and pneumatic type), and Savary dilations were performed in 102, 156, and 90 sessions, respectively. Perforations occurred in 4 patients. All of these perforations occurred when Maloney dilators were passed blindly into complex strictures (Fisher's exact test, p = 0.011, two-tailed). Three of these four patients had undergone endoscopy with conscious sedation immediately before the dilation. The immediate outcome of surgery was good in all 4 patients with no deaths. CONCLUSION Perforation was most commonly associated with the blind passage of Maloney bougies into complex strictures.
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Comparative Study |
25 |
119 |
9
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Kaplan M, Mutlu EA, Jakate S, Bruninga K, Losurdo J, Losurdo J, Keshavarzian A. Endoscopy in eosinophilic esophagitis: "feline" esophagus and perforation risk. Clin Gastroenterol Hepatol 2003; 1:433-7. [PMID: 15017642 DOI: 10.1016/s1542-3565(03)00222-2] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Idiopathic eosinophilic esophagitis is an underdiagnosed disease with typical endoscopic findings, which have not been well described. METHODS Charts and pathology reports at two tertiary care centers from June 1993 to April 2002 were reviewed to describe the endoscopic findings of this disease and to correlate them with clinical characteristics. Eight patients were identified as having eosinophilic esophagitis based on clinical symptoms and pathology reports. RESULTS Soft and subtle ring(s) in the esophagus were found in 7 of 8 patients. In 3 of 8 patients, the esophagus appeared rigid. Mucosal rents occurred with simple passage of the endoscope in 5 of 8 patients. One patient developed a perforation after simple passage of the endoscope. Endoscopic findings can be normal or very subtle in these patients, and the findings can easily be missed during endoscopy. Tearing of the esophagus can occur with simple passage of the endoscope or biopsy even in the absence of overt rings. A minimum of 8 weeks of medical therapy (proton pump inhibitor, histamine antagonists, immunosuppressants) should be undertaken before considering dilation because of the high risk involved with the procedure and the good response to medical therapy. CONCLUSIONS We recommend considering dilation only in patients with eosinophilic esophagitis who do not respond to medical therapy and have rings that appear to be obstructing the lumen.
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Multicenter Study |
22 |
114 |
10
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Quine MA, Bell GD, McCloy RF, Matthews HR. Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England. Br J Surg 1995; 82:530-3. [PMID: 7613903 DOI: 10.1002/bjs.1800820430] [Citation(s) in RCA: 111] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
After cardiopulmonary complications, perforation is the second most important cause of complications following flexible upper gastrointestinal endoscopy. A recent audit of 14,149 procedures detected a perforation rate of 0.05 per cent (overall mortality rate 0.008 per cent) during diagnostic endoscopy, and a perforation rate of 2.6 per cent (overall mortality rate 1.0 per cent) following oesophageal intubation or dilatation. The incidence of perforation following both diagnostic and therapeutic upper gastrointestinal endoscopy has not changed over the past 10 years. The risk factors are numerous but this audit demonstrated that inexperience increases the likelihood of perforation.
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30 |
111 |
11
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Patel K, Abbassi-Ghadi N, Markar S, Kumar S, Jethwa P, Zaninotto G. Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Dis Esophagus 2016; 29:807-819. [PMID: 26175119 DOI: 10.1111/dote.12387] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy for the treatment of achalasia. This review aims to assess subjective and objective metrics of achalasia treatment efficacy, perioperative adverse events and the incidence of postoperative gastroesophageal reflux disease in patients treated with POEM. Secondary aims include a pooled analysis comparison of the clinical outcomes and procedural safety of POEM versus laparoscopic Heller's myotomy (LHM). A systematic review of the literature, up to and including January 15, 2015, was conducted for studies reporting POEM outcomes. Studies comparing POEM to LHM were also included for the purpose of pooled analysis. Outcomes from 1122 POEM patients, from 22 studies, are reported in this systematic review. Minor operative adverse events included capno/pneumo-peritoneum (30.6%), capno/pneumo-thorax (11.0%) and subcutaneous emphysema (31.6%). Major operative adverse events included mediastinal leak (0.3%), postoperative bleeding (1.1%) and a single mortality (0.09%). There was an improvement in lower esophageal sphincter pressure and timed barium esophagram column height of 66% and 80% post-POEM, respectively. Symptom improvement was demonstrated with a pre- and post-POEM Eckardt score ± standard deviation of 6.8 ± 1.0 and 1.2 ± 0.6, respectively. Pre- and post-POEM endoscopy showed esophagitis in 0% and 19% of patients, respectively. The median (interquartile range) points scored for study quality was 15 (14-16) out of total of 32. Pooled analysis of three comparative studies between LHM and POEM showed similar results for adverse events, perforation rate, operative time and a nonsignificant trend toward a reduced length of hospital stay in the POEM group. In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality for achalasia.
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Review |
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12
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Cotton PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointest Endosc 2006; 63:378-82; quiz 464. [PMID: 16500382 DOI: 10.1016/j.gie.2005.06.046] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Accepted: 06/09/2005] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study reports the analysis of a personal series of 59 cases in which ERCP malpractice was alleged. METHODS Half of the cases involved pancreatitis; 16 suffered perforation after sphincterotomy (8 of which involved pre-cutting), and 10 had severe biliary infection. There were 2 esophageal perforations. Fifteen of the patients died. The most common allegation (54% of cases) was that the ERCP, or the therapeutic procedure, was not indicated. Most of these patients had pain only, usually after cholecystectomy. Negligent performance was alleged in 19 cases, with corroborating evidence in 8. Inadequate postprocedure care was alleged in 5 cases, including 3 with a delayed diagnosis of perforation. Disputes about the extent of the education and consent process were common. RESULTS The final outcome was available in 40 cases. Sixteen were withdrawn, and 14 were settled. Of the 10 that came to trial, half were defense verdicts. CONCLUSIONS The lessons are clear. ERCP should be done for good indications, by trained endoscopists with standard techniques, with good documented patient informed consent and communication before and after the procedure. Speculative ERCP, sphincterotomy, and pre-cuts are high-risk for patients and for practitioners.
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13
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Abstract
BACKGROUND EUS is considered to be as safe a procedure as EGD. However, the longer, rigid tip of the echoendoscopes raises concern about cervical esophageal perforation during intubation. Our aim was to determine the rate of this complication. METHODS Members of the American Endosonography Club were surveyed by questionnaire to determine the number of EUS examinations performed and the number of cervical esophageal perforations encountered up to June 1999. Each questionnaire was coded to avoid duplicate reporting. RESULTS Questionnaires were mailed to 203 members; 86 (42.4%) responded. Cervical esophageal perforation occurred in 16 of 43,852 reported upper EUS procedures at a frequency of 0.03%. Fifteen (94%) patients were elderly. A history of difficult intubation with prior endoscopic procedures was present in 7 (44%) patients. Three patients had large cervical osteophytes. In 9 (56%) patients, the procedure was done by an endosonographer with less than 1 year of experience. Two patients required surgery. One patient died as a result of the perforation and the other 13 (81%) patients were managed successfully with conservative treatment. CONCLUSIONS The incidence of cervical perforation during upper EUS may be higher than during EGD. Advanced patient age, difficult intubation during prior upper endoscopy, operator inexperience, and the presence of large cervical osteophytes may contribute to cervical perforation during upper EUS examination.
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14
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Takahashi H, Arimura Y, Okahara S, Uchida S, Ishigaki S, Tsukagoshi H, Shinomura Y, Hosokawa M. Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma. Endoscopy 2011; 43:184-9. [PMID: 21234854 DOI: 10.1055/s-0030-1256109] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND STUDY AIMS Growing evidence suggests that esophageal stricture frequently develops after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in early esophageal cancer patients, with an incidence proportional to the greater extent of mucosal defects resulting from improved EMR/ESD techniques. There seems to be a potential risk of perforation during bougienage in such patients. PATIENTS AND METHODS 648 stricture dilations for 78 lesions in 76 patients were consecutively included. The outcomes after combined use of Maloney and Savary wire-guided bougienage for esophageal strictures after EMR/ESD were analyzed in a single-institute retrospective case series study. The perforation rate was determined and risk factors for perforation were identified. RESULTS Patients underwent a median of 5.0 dilation procedures performed over a median 3.0 months for post-EMR/ESD strictures. Initial dilation was done a median 14 days following endoscopic resection. Perforations developed in seven patients (7/648 dilation procedures, 1.1%), all in the lower esophagus, and bleeding occurred in one patient (0.1% dilations). Two independent risk factors for development of perforation during dilation therapy for post-EMR/ESD stricture were identified: multiple dilations (odds ratio [OR] 1.2; P=0.012), and lower site of stricture (OR 12.8; P=0.043). Dysphagia was ameliorated by the dilations, and no patient required surgery. CONCLUSIONS A specific emerging risk of perforation in dilation therapy for post-EMR/ESD strictures was identified. Carefully planned treatment is necessary in patients with severe post-EMR/ESD strictures especially strictures requiring multiple dilations or located in the lower esophagus.
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Yang D, Zou F, Xiong S, Forde JJ, Wang Y, Draganov PV. Endoscopic submucosal dissection for early Barrett's neoplasia: a meta-analysis. Gastrointest Endosc 2018; 87:1383-1393. [PMID: 28993137 DOI: 10.1016/j.gie.2017.09.038] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The role of endoscopic submucosal dissection (ESD) in Barrett's esophagus (BE) is not well established. This meta-analysis aimed to evaluate the safety and efficacy of ESD for the management of early BE neoplasia. METHODS Three online databases were searched. The Cochran Q test and I2 were used to test for heterogeneity. Pooling was conducted using either fixed- or random-effects models depending on heterogeneity across studies. For the main outcomes, potential sources of heterogeneity were evaluated via linear regression analysis. RESULTS Eleven studies (501 patients, 524 lesions) were included. Mean lesion size was 27 mm (95% confidence interval [CI], 20.9-33.1). Pooled estimate for en bloc resection was 92.9% (95% CI, 90.3%-95.2%). The pooled R0 (complete) and curative resection rates were 74.5% (95% CI, 66.3%-81.9%) and 64.9% (95% CI, 55.7%-73.6%), respectively. There was no association between R0 or curative resection rates and study setting (Asia vs West), length of BE, lesion characteristics, procedural time, or length of follow-up. The pooled estimates for perforation and bleeding were 1.5% (95% CI, .4%-3.0%) and 1.7% (95% CI, .6%-3.4%), respectively. Esophageal stricture rate was 11.6% (95% CI, .9%-29.6%). Incidence of recurrence after curative resection was .17% (95% CI, 0%-.3%) at a mean follow-up 22.9 months (95% CI, 17.5-28.3). CONCLUSIONS ESD for early BE neoplasia is associated with a high en bloc resection rate, acceptable safety profile, and low recurrence after curative resection. ESD should be considered as part of the armamentarium for the management of BE neoplasia.
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Meta-Analysis |
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Nair LA, Reynolds JC, Parkman HP, Ouyang A, Strom BL, Rosato EF, Cohen S. Complications during pneumatic dilation for achalasia or diffuse esophageal spasm. Analysis of risk factors, early clinical characteristics, and outcome. Dig Dis Sci 1993; 38:1893-904. [PMID: 8404411 DOI: 10.1007/bf01296115] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
UNLABELLED A retrospective cohort study was performed to assess risk factors, early clinical characteristics, and outcome of complications in patients undergoing pneumatic dilation. Of 178 patients with achalasia or diffuse esophageal spasm who underwent 236 dilations with a Browne-McHardy dilator, 16 patients experienced a complication (9.0%). Nine major complications developed: perforations (4), hematemesis (2), fever (2), and angina (1). A prior pneumatic dilation and use of inflation pressure > or = 11 PSI were independent risk factors by multivariate analysis for developing a complication. An esophagram immediately following the dilation identified three of the four perforations. Three postdilation findings were identified as indicators of patients with an increased risk of having developed a perforation: blood on the dilator, tachycardia, and prolonged chest pain lasting > 4 hr after dilation. In all patients incurring a major complication, one of the three indicators, or the complication itself was recognized within 5 hr of dilation. All patients with complications, including the four with perforation who received prompt surgical repair and esophagomyotomy, recovered uneventfully. The symptomatic relief of dysphagia in patients with perforation undergoing emergent surgical repair and esophagomyotomy was similar to patients undergoing elective esophagomyotomy. CONCLUSIONS (1) Pneumatic dilation is a safe treatment of achalasia, with a 1.7% risk of perforation. (2) The risk of developing a complication is increased by having had a previous pneumatic dilation or by use of inflation pressures > or = 11 psi. (3) All patients with a major complication were identified within 5 hr after dilation. (4) Complications following pneumatic dilation, if recognized and treated promptly, were not associated with adverse, long-term sequelae.
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Comparative Study |
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75 |
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Dougherty M, Runge TM, Eluri S, Dellon ES. Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86:581-591.e3. [PMID: 28461094 PMCID: PMC5601027 DOI: 10.1016/j.gie.2017.04.028] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/19/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Esophageal dilation is a now recognized to be an important therapeutic modality in eosinophilic esophagitis (EoE). We aimed to evaluate the safety of esophageal dilation in EoE, especially regarding perforation risk, and to examine perforation risk by dilator type. METHODS We conducted a systematic review of the published literature from January 1, 1950 to June 30, 2016 using PubMed, EMBASE, and Web of Science. Studies were included if they described patients with EoE who underwent elective esophageal dilation and also reported the presence or absence of at least 1 adverse event (eg, perforation, bleeding, pain, or hospitalization). We used random-effects meta-analysis to estimate the frequency of each adverse event. RESULTS Of 923 identified articles, 37 met inclusion criteria and represented 2034 dilations in 977 patients. On meta-analysis, postprocedure hospitalization occurred in .689% of dilations (95% confidence interval [CI], 0%-1.42%), clinically significant GI hemorrhage in .028% (95% CI, 0%-.217%), and clinically significant chest pain in 3.64% (95% CI, 1.73%-5.55%). Nine perforations were documented, at a rate of .033% (95% CI, 0%-.226%) per procedure after meta-analysis. None of the perforations resulted in surgical intervention or mortality. Most (5/9) were reported before 2009 (rate, .41% [95% CI, 0%-2.75%]); from 2009 forward the rate was .030% (95% CI, 0%-.225%). Dilation method was described in 30 studies (1957 dilations), in which 4 perforations were detected. The estimated perforation rate for bougies was .022% (95% CI, 0%-.347%) and for balloons was .059% (95% CI, 0%-.374%). CONCLUSIONS Perforation from esophageal dilation in EoE is rare, and there is no evidence of a significant difference in perforation risk related to dilator type. Esophageal dilation should be considered a safe procedure in EoE.
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Morino M, Rebecchi F, Festa V, Garrone C. Preoperative pneumatic dilatation represents a risk factor for laparoscopic Heller myotomy. Surg Endosc 1997; 11:359-61. [PMID: 9094277 DOI: 10.1007/s004649900363] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The development of minimally invasive surgery has renewed interest in the surgical therapy of achalasia. METHODS 21 patients with esophageal achalasia underwent Heller's laparoscopic myotomy with anterior fundoplication between August 1991 and March 1996. RESULTS There were two intraoperative perforations of the mucosa sutured laparoscopically with no postoperative sequelae; both complications occurred in patients previously treated with pneumatic dilatation; no perforations occurred in the 14 patients who had not been submitted to pneumatic dilatation (28% vs 0%). There were no surgical mortalities and no postoperative morbidities. Complete relief of dysphagia and modifications of radiological and manometric patterns were achieved in all patients. All patients remain asymptomatic at follow-ups ranging from 3 to 55 months after surgery. CONCLUSIONS Laparoscopic Heller's myotomy is as effective as traditional surgery in treating symptoms and has all the advantages of pneumatic dilatation in terms of short hospital stay, quick recovery, and low cost; preoperative pneumatic dilatation is a risk factor for intraoperative mucosal perforation.
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Wang N, Razzouk AJ, Safavi A, Gan K, Van Arsdell GS, Burton PM, Fandrich BL, Wood MJ, Hill AC, Vyhmeister EE, Miranda R, Ahn C, Gundry SR. Delayed primary repair of intrathoracic esophageal perforation: is it safe? J Thorac Cardiovasc Surg 1996; 111:114-21; discussion 121-2. [PMID: 8551755 DOI: 10.1016/s0022-5223(96)70407-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The management of intrathoracic esophageal perforation with delayed diagnosis is a subject of controversy. Because of the obvious advantages of primary repair as a simple single-stage operation, this technique was preferentially used to treat 18 of 22 consecutive patients with esophageal perforation. These patients were stratified into three groups according to the time interval between perforation and repair: group A, less than 6 hours, five patients (28%); group B, 6 to 24 hours, six patients (33%); and group C, more than 24 hours, seven patients (39%). Group A patients were older (p < 0.05) and group B had fewer iatrogenic perforations (B, 17%; A, 80%; C, 57%, p < 0.1). Additional tissue was used to buttress the repair site in all three groups (A, 3/5 patients, 60%; B, 4/6 patients, 67%; C, 6/7 patients, 86%; p = not significant). In seven patients (39%), a fundic wrap was used to reinforce the site of primary repair. The outcomes of the three groups were analyzed. Group A had the lowest proportion of postoperative leaks (A, 0/4 patients, 0%; B, 4/6 patients, 67%; C, 5/6 patients, 83%; p < 0.05) and postoperative morbidity (A, 2/5 patients, 40%; B, 6/6 patients, 100%; C, 6/7 patients, 86%; p < 0.1). However the increased incidence of leak and morbidity did not lead to an increase in mortality. One death occurred in each group, with an overall mortality of 17% (A, 1/5 patients, 20%; B, 1/6 patients, 17%; C, 1/7 patients, 14%; p = not significant). We conclude that in the era of advanced intensive care capabilities, primary repair of intrathoracic esophageal perforation can be safely accomplished in most patients regardless of the time interval between perforation and operation. Leakage at the suture site is common unless primary repair is carried out without delay. Postoperative leakage, however, is usually inconsequential and does not necessarily result in an adverse outcome.
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Schmitz RJ, Sharma P, Badr AS, Qamar MT, Weston AP. Incidence and management of esophageal stricture formation, ulcer bleeding, perforation, and massive hematoma formation from sclerotherapy versus band ligation. Am J Gastroenterol 2001; 96:437-41. [PMID: 11232687 DOI: 10.1111/j.1572-0241.2001.03460.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of this study was to compare the incidence and endoscopic management of esophageal stricture formation, significant ulcer bleeding, massive esophageal hematoma, and perforation resulting from endoscopic band ligation or sclerotherapy of esophageal varices. METHODS Consecutive esophagogastroduodenoscopies in which band ligation or sclerotherapy was performed for acute or obliterative therapy were entered into a computerized endoscopy database during a 7-yr period. Patients were excluded if they died within 72 h of treatment session from complications unrelated to the procedure. Sclerotherapy was performed using a 25-gauge needle with 1.5% sodium tetradecyl sulfate and banding was primarily performed with a Wilson-Cook 6 or 10 shooter. Complications were assessed at scheduled endoscopy and outpatient clinic visits, review of quality assurance data tallied on a monthly basis, and patient records. RESULTS Two hundred twenty-one cases of sclerotherapy were performed in 59 patients compared to 110 cases of band ligation in 52 patients. Five patients were excluded because of death within 72 h of the procedure. The incidence of complications from sclerotherapy:banding on a per patient basis included: esophageal stricture formation 25.6%:1.9%, ulcer bleed 25.4%:5.7%, esophageal perforation 2.2%:0%, and massive esophageal hematoma 1.6%:0%. A significant difference in complications between sclerotherapy and band ligation was noted for both stricture formation (p < 0.0005) and ulcer bleeding (p < 0.0001). The majority of ulcer bleeds required no therapeutic intervention, whereas stricture formation required multiple dilation sessions. CONCLUSIONS Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. The majority of complications can be managed with endoscopic interventions.
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Vrouenraets BC, Been HD, Brouwer-Mladin R, Bruno M, van Lanschot JJB. Esophageal perforation associated with cervical spine surgery: report of two cases and review of the literature. Dig Surg 2004; 21:246-9. [PMID: 15237259 DOI: 10.1159/000079495] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Esophageal perforation after anterior cervical spine surgery is a rare complication with various clinical presentations and treatments. METHODS Two cases of esophageal perforation after anterior cervical spine surgery are described, one occurring in the immediate postoperative period and one several years after plate stabilization of the cervical spine. RESULTS Primary suturing of the acute perforation and diversion of the salivary flow by means of T-tube placement after delayed presentation allowed successful healing of the esophageal defects. CONCLUSION When encountering acute dysphagia after cervical spine surgery, one should think of an esophageal perforation and install immediate further diagnostics and therapy. Treatment depends on the time of detection and size of the perforation. In early stages, with vital tissues, primary suturing is the treatment of choice. If presentation is late, it seems advisable to limit the procedure to simple drainage after removal of foreign bodies.
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Case Reports |
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Kim IO, Yeon KM, Kim WS, Park KW, Kim JH, Han MC. Perforation complicating balloon dilation of esophageal strictures in infants and children. Radiology 1993; 189:741-4. [PMID: 8234699 DOI: 10.1148/radiology.189.3.8234699] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE The authors retrospectively reviewed their experience with balloon dilation of esophageal strictures in infants and children to determine the prevalence of esophageal perforation during this procedure. MATERIALS AND METHODS Balloon dilation was performed in 32 patients with esophageal stricture due to either congenital or postoperative stenosis. The total number of procedures was 141; each patient underwent one to 12 procedures. RESULTS Four cases of esophageal perforation occurred during balloon dilation and were detected immediately after the procedure. Perforation in three of these patients was treated nonoperatively with parenteral fluid and antibiotics, and one patient was treated surgically with resection and creation of an anastomosis. The clinical course after treatment was favorable in all cases. CONCLUSION Although esophageal perforation during balloon dilation of benign strictures has been reported as a rare complication, four perforations were observed in 32 patients. Esophageal perforation can occur in infants and children more frequently than previously reported.
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Case Reports |
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Vestergaard P, Schwartz K, Pinholt EM, Rejnmark L, Mosekilde L. Gastric and esophagus events before and during treatment of osteoporosis. Calcif Tissue Int 2010; 86:110-5. [PMID: 19957165 DOI: 10.1007/s00223-009-9323-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 11/04/2009] [Indexed: 11/27/2022]
Abstract
Prior studies have indicated an excess risk of gastroduodenal ulcers and esophagus perforations with the use of bisphosphonates. However, little is known about the contribution of comorbid conditions and concomitant drug use on this risk. We studied the risk of esophagus and gastric events in patients on a wide range of drugs against osteoporosis both before and after initiation of these drugs. We studied a nationwide register-based cohort from Denmark with all users of drugs against osteoporosis between 1996 and 2006 (n = 103,562) as cases and three age- and sex-matched controls from the general population (n = 310,683). In a crude analysis, most drugs were already associated with an increased risk of esophagitis, esophageal ulcerations, or esophageal perforations or gastroduodenal ulcers before initiation of the drugs. Upon adjustment, this excess risk disappeared for most drugs except parathyroid hormone and its analogues, etidronate and clodronate. Only for etidronate, alendronate, and raloxifene were sufficient data present for events after initiation of the drugs, and for these, an increased risk was present for all events except gastroduodenal ulcers with raloxifene. Several drugs against osteoporosis are associated with an increased risk of esophagitis, esophageal ulcers, esophageal perforation, and gastroduodenal ulcers. However, the increase was already present before initiation of the drug for several types of drugs against osteoporosis. This points at an effect of the underlying condition being treated or comorbid conditions and drugs being provided in patients with osteoporosis, such as nonsteroidal anti-inflammatory drugs and corticosteroids.
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Augoustides JGT, Hosalkar HH, Milas BL, Acker M, Savino JS. Upper Gastrointestinal Injuries Related to Perioperative Transesophageal Echocardiography: Index Case, Literature Review, Classification Proposal, and Call for a Registry. J Cardiothorac Vasc Anesth 2006; 20:379-84. [PMID: 16750740 DOI: 10.1053/j.jvca.2005.10.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Indexed: 11/11/2022]
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Wang Y, Liu ZQ, Xu MD, Chen SY, Zhong YS, Zhang YQ, Chen WF, Qin WZ, Hu JW, Cai MY, Yao LQ, Zhou PH, Li QL. Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy. Gastrointest Endosc 2019; 89:769-778. [PMID: 30218646 DOI: 10.1016/j.gie.2018.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI. METHODS A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment. RESULTS POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042). CONCLUSIONS MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.
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