Flexible versus rigid endoscopy in the management of esophageal foreign body impaction: systematic review and meta-analysis

Background

Foreign body (FB) impaction accounts for 4% of emergency endoscopies in clinical practice. Flexible endoscopy (FE) is recommended as the first-line therapeutic option because it can be performed under sedation, is cost-effective, and is well tolerated. Rigid endoscopy (RE) under general anesthesia is less used but may be advantageous in some circumstances. The aim of the study was to compare the efficacy and safety of FE and RE in esophageal FB removal.

Methods

PubMed, MEDLINE, Embase, and Cochrane databases were consulted matching the terms "Rigid endoscopy AND Flexible endoscopy AND foreign bod*". Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I2 index and Cochrane Q test.

Results

Five observational cohort studies, published between 1993 and 2015, matched the inclusion criteria. One thousand four hundred and two patients were included; FE was performed in 736 patients and RE in 666. Overall, 101 (7.2%) complications occurred. The most frequent complications were mucosal erosion (26.7%), mucosal edema (18.8%), and iatrogenic esophageal perforations (10.9%). Compared to FE, the estimated RE pooled success OR was 1.00 (95% CI 0.48-2.06; p = 1.00). The pooled OR of iatrogenic perforation, other complications, and overall complications were 2.87 (95% CI 0.96-8.61; p = 0.06), 1.09 (95% CI 0.38-3.18; p = 0.87), and 1.50 (95% CI 0.53-4.25; p = 0.44), respectively. There was no mortality.

Conclusions

FE and RE are equally safe and effective for the removal of esophageal FB. To provide a tailored or crossover approach, patients should be managed in multidisciplinary centers where expertise in RE is also available. Formal training and certification in RE should probably be re-evaluated.

Regulating migration of esophageal stents - management using a Sengstaken-Blakemore tube: A case report and review of literature

Stent migration, which causes issues in stent therapy for esophageal perforations, can counteract the therapeutic effects and lead to complications. Therefore, techniques to regulate stent migration are important and lead to effective stent therapy. Here, in these cases, we placed a removable fully covered self-expandable metallic stent (FSEMS) in a 52-year-old man with suture failure after surgery to treat Boerhaave syndrome, and in a 53-year-old man with a perforation in the lower esophagus due to acute esophageal necrosis. At the same time, we nasally inserted a Sengstaken-Blakemore tube (SBT), passing it through the stent lumen. By inflating a gastric balloon, the lower end of the stent was supported. When the stent migration was confirmed, the gastric balloon was lifted slightly toward the oral side to correct the stent migration. In this manner, the therapy was completed for these two patients. Using a FSEMS and SBT is a therapeutic method for correcting stent migration and regulating the complete migration of the stent into the stomach without the patient undergoing endoscopic rearrangement of the stent. It was effective for positioning a stent crossing the esophagogastric junction.

Trans-Balloon Visualisation During Dilatation (TBVD) of Oesophageal Strictures: a Novel Innovation

BACKGROUND

Hydrostatic balloon dilatation of upper gastrointestinal strictures is associated with a risk of perforation that varies with the underlying pathology and with the technique employed. We present a technique of trans-balloon visualisation of the stricture during dilatation (TBVD) that allows direct 'real-time' observation of the effect of dilatation on the stricture, facilitating early recognition of mucosal abruption, thereby reducing the perforation rate.

PATIENTS AND METHODS

We retrospectively analysed 100 consecutive patients, undergoing balloon dilatation of oesophageal strictures between 1st of January 2011 and 1st of July 2014.

RESULTS

One hundred patients underwent 186 dilatations, with 34 having multiple procedures (mean 1.86). All had oesophageal strictures (mean diameter 8.49 mm, range 5-11 mm) and most underwent dilatation up to a maximum of 17 mm (mean 14.7 mm). Fifty-six percent were male and the average age was 62.5 years (17-89 years). Only one patient (0.5% of all procedures) had a full-thickness perforation requiring intervention while just one further patient had a deep mucosal tear that did not require intervention.

CONCLUSIONS

TBVD is a safe technique with a short learning curve and is one of the important factors that allow potentially difficult dilatations to be performed safely with an exceptionally low rate of adverse events of less than 1%.

[Treatment of benign esophageal stricture]

The article presents an analysis of long-term experience of treatment of 128 patients with benign esophagus and esophageal anastomosis strictures in Kirov Military Medical Academy. This significant data included all possible variations of scarry esophageal strictures according their etiology, localization and the extension. The wide range of methods, which involved the different variants of bouginage, balloon dilation, stenting, electrosurgical dissection and resection of the stomach, were applied in treatment of the patients. The analysis of immediate and long-term results allowed detecting the criteria of choice and indication for use of the methods or their combination. Practical recommendations reflect the strategy of each variant of treatment and have the specific character. Possible complications and negative results of irrational application of different methods were presented. The immediate and long-term results gave evidence of the successful treatment of the patients with scarry esophagus and esophageal anastomosis strictures.

[Complications of endoscopy in children]

Endoscopic examination is a valuable procedure both in the diagnostics and in the treatment of alimentary tract diseases. It is usually safe, however, it is invasive and therefore burdened by complications risk, particularly when it is performed as a therapeutic procedure. Taking into consideration the causative agent, complications of endoscopy can be divided into these occurring already before examination being the result of preparation to the examination and directly connected with the procedure of examination. The occurrence of complication may require other, additional diagnostic procedures, treatment including surgical, moreover it can be a cause of patient death. The prevention of complications of endoscopy includes proper qualification to the examination, detailed history of concomitant diseases, proper preparation for the examinations, experienced staff conducting the examination and proper technical setting.

Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture

Stellate ganglion block is utilized in the diagnosis and management of various vascular disorders and sympathetically mediated pain in the upper extremity, head and neck. The cervical sympathetic chain is composed of superior, middle, intermediate, and inferior cervical ganglia. However, in approximately 80% of the population, the inferior cervical ganglion is fused with the first thoracic ganglion, forming the stellate ganglion also known as cervicothoracic ganglion. The stellate ganglion lies medial to the scalene muscles, lateral to the longus coli muscle, esophagus and trachea along with the recurrent laryngeal nerve, anterior to the transverse processes and prevertebral fascia, superior to the subclavian artery and the posterior aspect of the plura, and posterior to the vertebral vessels at C7 level. Consequently, inadvertent placement of the needle into the vertebral artery, thyroid, neural tissues, or esophagus can occur with the fluoroscopic or blind approach. While fluoroscopy is a reliable method for identifying boney structures, ultrasound may identify the vertebral vessels, thyroid gland and vessels, longus coli muscles, nerve roots and the esophagus. Thus, ultrasound may prevent inadvertent placement of the needle into these structures as might happen with either the blind technique or fluoroscopic technique. A patient with complex regional pain syndrome type I of the left upper extremity was scheduled for left stellate ganglion block with the anterior paratracheal approach under fluoroscopy. Real-time ultrasound imaging prevented inadvertent injury to the esophagus as well as the thyroid gland and vessels. Ultrasound-guided block may improve patient safety by avoiding the soft tissue structures in the needle path that can't be readily seen by fluoroscopy. This may be particularly useful in the patient with asymptomatic pharyngoesophageal diverticulum (Zenker diverticulum).

[Incidence and prevention methods of complications of gastrointestinal endoscopy procedures]

Endoscopic procedures are considered to be a standard element of diagnosing establishing as well as curative measure undertaken in many illnesses of digestive tract. Common use of such potent tool means higher incidence of complications associated with such procedures. In order to qualify a patient to a proper procedure it is essential to reconsider the probability of complications and possibilities of its prevention. To evaluate the risk of the procedure the character of the possible complication and its frequency should be taken into account. Author presents the general complications which are independent of endoscopic procedure and the group of complications typical for a various kind of endoscopic procedures, which are closely related to the procedure. General complications are associated with preparation for the procedure, infections revealing as a result of the procedure and sedation. Specific complications, which are not related to the scale of the procedure, include perforations and bleedings. They are relatively common and might be dangerous, but unfortunately those complications result from improper qualification and preparation the patient to the procedure. Acute pancreatitis is one of the specific complications connected to ERCP. Because of the fact that the risk of this complication is very high the proper qualification of the patient to the procedure is crucial. Nowadays ERCP procedure is being used only in approved therapeutic procedure. This paper focus on basic enoscopic complications and their occurrence conditions. Special interest is placed upon prevention of various types of complications, especially those that incidence is higher in every day clinical practice.

Riesgo de perforación en la mucosectomía esofágica con banda: estudio experimental con dos modelos de ligadores

OBJECTIVE

endoscopic mucosal resection with ligation (EMRL) is considered an efficient, safe method for the treatment of some esophageal, gastric and colorectal tumors. We conducted this study using a porcine model in order to compare the safety of esophageal EMRL with two multiband ligation systems, since many centers only use these ligator models in EMRL (commercialized for varix ligation).

METHODS

eight pigs were used, which were submitted to 23 esophageal resections without previous injection. Ten resections were conducted using the Six Shooter Saeed model, and 13 resections used the Speedband Superview Super 7 model. The technique was also compared by making random cuts either above or below the band.

RESULTS

five perforations occurred, all of them using the Speedband model. This represents 38.5% of total in the Speedband model group. No perforation occurred when using the Six Shooter model (p = 0.046). On the contrary, no significant differences were found regarding frequency of perforation when cutting above or below the band.

CONCLUSIONS

esophageal EMRL using the Speedband model without previous injection leads to perforation in a high percentage of cases in an experimental animal model. Further studies are required to find out whether a previous injection may increase the safety of this technique with this ligator model.

Successful Sealing of Benign Esophageal Leaks after Temporary Placement of a Self-Expanding Plastic Stent without Fluoroscopic Guidance

INTRODUCTION

We report on our experience with the temporary use of a self-expanding plastic stent (SEPS) in the treatment of non-malignant esophageal leaks.

MATERIAL AND METHODS

Between November 2001 and May 2005 ten patients with iatrogenic esophageal perforations (n = 4), post-surgical leaks (n = 5) and esophago-mediastinal fistulas after caustic injury (n = 1) were treated by temporary SEPS placement. In eight out of ten patients SEPS placement was done without fluoroscopy due to the emergency setting. Stent removal was performed with a rat-toothed forceps.

RESULTS

Leaks were located in the proximal (n = 1), middle (n = 6) and distal (n = 3) parts of the esophagus. The mean leakage size was 2 cm. Stent placement without fluoroscopy was always successful. The median duration of stent therapy was 55.5 days (range 15,438). In 7/10 cases the SEPS was readily removed, showing complete healing of the former leak. Four patients died during the follow-up. However, their deaths were not related to the stent therapy.

DISCUSSION

The temporary use of the SEPS represents a safe method for sealing benign esophageal leaks. In the emergency-setting SEPS placement without fluoroscopy is feasible and the stent can be easily removed. In contained perforations without severe mediastinitis of the mid esophagus the SEPS should be discussed as a gentle first-line therapy.

Removal of press-through-packs impacted in the upper esophagus using an overtube

Foreign bodies in the upper esophagus should be removed as soon as possible to avoid serious complications. However, removals of foreign bodies in the upper esophagus are very difficult, especially if they have sharp edges, such as press-through-packs (PTPs). We experienced four cases of the impacted PTPs in the upper esophagus which was successfully extracted endoscopically with the overtube. Because two edges of PTPs were so firmly impacted in the esophageal wall in all cases, the PTPs were not movable in the upper esophagus. However, after insertion of the overtube, PTPs became movable and were successfully extracted and no serious complications occurred after extraction of PTPs. In one case, insertion of the overtube rapidly expanded the upper esophagus and PTP progressed to the gastric cavity and it could be extracted with the endoscopic protector hood. The endoscopic removal with the overtube was a simple, safe and effective technique for the removal of the impacted PTPs in upper esophagus.

Mechanical Esophageal Deflection During Ablation of Atrial Fibrillation

To prevent esophageal damage during ablation of atrial fibrillation, we developed a technique to move the esophagus away from a desired ablation site too close to the esophagus. Under fluoroscopy, a transesophageal echocardiography probe was used to deflect the barium-opacified esophagus from the ablation site. This technique was successfully employed in three patients where critical sites of the posterior left atrial wall were very close to the esophagus.

Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy

BACKGROUND

Laparoscopic Heller myotomy has emerged as the treatment of choice for achalasia. However, intraoperative esophageal perforation remains a significant complication. Computer-enhanced operative techniques have the potential to improve outcomes for certain operative procedures. Robotic, computer-enhanced laparoscopic telemanipulators using 3-dimensional magnified imaging and motion scaling are designed uniquely to facilitate certain operations requiring fine-tissue manipulation. We hypothesized that computer-enhanced robotic Heller myotomy would reduce intraoperative complications compared with laparoscopic techniques.

METHODS

All patients undergoing an operation for achalasia at 3 institutions with a robotic surgery system (DaVinci; Intuitive Surgical Corporation, Sunnyvale, Calif) were followed-up prospectively. Demographics, perioperative course, complications, and hospital stay were recorded. Follow-up evaluation was obtained via a standardized symptom survey, office visits, and medical records. Data were compared with preoperative symptoms using a Mann-Whitney U test, and operating times were compared using the ANOVA test.

RESULTS

Between August 2000 and August 2004 there were 104 patients who underwent a robotic Heller myotomy with partial fundoplicaton. There were 53 women and 51 men. All patients were symptomatic. The operative time was 140.55 minutes overall, but improved from 162.63 minutes to 113.50 minutes from 2000-2002 to 2003-2004 (P = .0001). There were no esophageal perforations. There were 8 minor complications and 1 patient required conversion to an open operation. Sixty-six (62.3%) patients were discharged on the first postoperative day and the average hospital stay was 1.5 days. A symptom survey was completed in 79 of 104 patients (76%) at follow-up evaluation. Symptoms improved in all patients with an average follow-up symptom score of 0.48 compared with 5.0 before the operation (P = .0001). Forty-three of the 79 patients from whom follow-up data were collected had a minimum follow-up period of 1 year. The follow-up period averaged 16 months. No patients required reoperation.

CONCLUSIONS

Computer-enhanced robotic laparoscopic techniques provide a clear advantage over standard laparoscopy for the operative treatment of achalasia. We have shown in this large series that Heller myotomy can be completed using this technology without esophageal perforation. The application of computer-enhanced operative techniques appears to provide superior outcomes in selected procedures.

Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent

BACKGROUND

Esophageal anastomotic leaks can lead to prolonged hospitalization. In this article we present our experience with the placement of the Polyflex self-expanding plastic stent (Willy Ruesch GMBH, Kernen, Germany) for leak occlusion.

METHODS

Between April 2000 and November 2003, 24 patients were included into this prospective study and underwent Polyflex stent placement for postoperative esophageal anastomotic leaks. The primary operation was esophagectomy in 13 patients, gastrectomy in 7, cardia resection in 2, and other procedures in 2 patients. The median interval between operation and stent placement was 19 days (range, 4 to 65). The effectiveness of leak occlusion was evaluated by water-soluble contrast swallow and the clinical course.

RESULTS

In 2 patients stent misplacement produced an enlarged anastomotic dehiscence that necessitated reoperation. Radiologic evaluation was impossible in 4 patients because of their generally restricted condition. Among 18 evaluable patients, leak occlusion was successful with a single stent in 16 patients (89%) based on radiologic evaluation. Immediate oral feeding was well tolerated by these patients. After a median follow-up of 220 days (range, 7 to 1221), 9 cases of late stent dislocation were observed. Stent removal in patients after esophagectomy with gastric pull-up led to dysphagia from anastomotic strictures in 2 patients. Symptomatic strictures did not develop in the 5 evaluable postgastrectomy patients after stent removal.

CONCLUSIONS

The placement of self-expanding plastic stents is a highly effective treatment for esophageal anastomotic leaks. Because clinically-relevant anastomotic strictures can be expected, we do not recommend stent removal after esophagectomy with gastric pull-up reconstruction.

Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation

Topography of the esophagus in atrial fibrillation ablation.

INTRODUCTION

The close anatomic relationship of the posterior wall of the left atrium (LA) and the thermosensitive esophagus creates a potential hazard in catheter ablation procedures.

METHODS AND RESULTS

In 30 patients (pts) with atrial fibrillation (AF) undergoing catheter ablation, we prospectively studied the course and contact of the esophagus in relation to LA and the topographic proximity to ablation lines encircling the right-sided and left-sided pulmonary veins (PV) as well as to the posterior line connecting the encircling lines using the electromagnetic mapping system for reconstruction of LA and for tagging of the esophagus. This new technique of anatomic tagging of the esophagus was validated against the CT scan as a standard imaging procedure. The esophageal course was highly variable, extending from courses in direct vicinity to the left- or right-sided PV as well as in the midportion of the posterior LA. In order to avoid energy application in direct proximity to the esophagus, adjustments of the left and right PV encircling lines were necessary in 14/30 pts (47%) and 3/30 (10%). In 30 pts (100%), the mid- to inferior areas of the posterior LA revealed contact with the esophagus. Therefore, posterior and inferior linear ablation lines were abandoned and shifted to superior in 29 pts (97%).

CONCLUSIONS

Anatomic tagging of esophagus revealed a highly variable proximity to different areas of the posterior LA suggesting individual adjustment of encircling and linear ablation lines in AF ablation procedures to avoid the life threatening complication of esophagus perforation.

Study on endoscopic esophageal mucosal resection with ligating device. II--Experimental study

BACKGROUND/AIMS

This study reports on animal experiments regarding the safety of endoscopic esophageal mucosal resection with a ligating device (EEMRL), as well as the amount of mucosa which can be removed by this technique, the depth of resection and the feasibility of piecemeal resection.

METHODOLOGY

Three experiments were performed in six mongrel dogs under general anesthesia.

RESULTS

When EEMRL was done without submucosal injection of saline, resection reached the muscular layer and caused esophageal perforation. The average dimensions of the mucosal pieces resected using 8-, 10-, and 12-mm devices was 13 x 10 mm, 18 x 15 mm, and 22 x 18 mm, respectively. Resection reached the mid-plane of the submucosa and the depth was almost uniform. After piecemeal resection, there was no macroscopically visible mucosa at the resection site and each mucosal piece was resected along the mid-plane of the submucosa.

CONCLUSIONS

The experimental study indicated that submucosal injection of saline is essential to prevent esophageal perforation. It also showed that EEMRL allows resection up to the mid-plane of the submucosa, that the 12-mm device allows en bloc resection of lesions < or = 15 mm in diameter and that EEMRL is suitable for piecemeal resection.

Endoscopic mucosal resection for the entire gastrointestinal mucosal lesions

In general, mucosal cancer of the gastrointestinal tract has the lowest risk of lymph node metastasis, and is curatively managed by the EMR procedure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

BACKGROUND AND STUDY AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

[Severe complication in endoscopic ligation of esophageal varices]

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

[Acute erosion of the esophagus, stomach and duodenum]

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complications of endoscopic injection sclerotherapy: a review

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

Intraluminal pressures generated during esophageal bougienage

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