Risk factors for Mallory-Weiss Tear during endoscopic submucosal dissection of superficial esophageal neoplasms

BACKGROUND

Adverse events during endoscopic submucosal dissection (ESD) of superficial esophageal neoplasms, such as perforation and bleeding, have been well-documented. However, the Mallory-Weiss Tear (MWT) during esophageal ESD remains under investigation.

AIM

To investigate the incidence and risk factors of the MWT during esophageal ESD.

METHODS

From June 2014 to July 2017, patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed. The clinicopathological characteristics of the patients were collected. Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD. The incidence of MWTs was determined, and the risk factors for MWT were then further explored.

RESULTS

A total of 337 patients with 373 lesions treated by ESD were analyzed. Twenty patients developed MWTs during ESD (5.4%). Multivariate analysis identified that female sex (OR = 5.36, 95%CI: 1.47-19.50, P = 0.011) and procedure time longer than 88.5 min (OR = 3.953, 95%CI: 1.497-10.417, P = 0.005) were independent risk factors for an MWT during ESD. The cutoff value of the procedure time for an MWT was 88.5 min (sensitivity, 65.0%; specificity, 70.8%). Seven of the MWT patients received endoscopic hemostasis. All patients recovered satisfactorily without surgery for the laceration.

CONCLUSION

The incidence of MWTs during esophageal ESD was much higher than expected. Although most cases have a benign course, fatal conditions may occur. We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.

[Etiology and pathogenesis of Mallory-Weiss syndrome]

Treatment results of 405 patients with Mallory-Weiss syndrome, X-ray gastric investigation in patients with severe bloating reflex were analyzed. Experimental part of the study involved rats and pigs, modeling esophageal and gastric rupture. Cardioesophageal and gastric cardial rupture happen in case of simultaneous sudden intragastric and intraabdominal hypertension, following the rule of Laplace.

Superior mesenteric artery blood flow in man measured with intra-arterial Doppler catheters: effect of octreotide

Changes in splanchnic blood flow are important in the pathogenesis of portal hypertension, but research in this area is hampered by the difficulty in measuring splanchnic arterial blood flow in man. We therefore investigated the use of intra-arterial Doppler catheters in measuring superior mesenteric artery blood flow in man and assessed the effect of intravenous octreotide on superior mesenteric artery blood flow in a placebo-controlled double-blind study. Nine experiments were performed in a flow model using vessels with internal diameters of 6.5, 4.5 and 3.0 mm, with flow rates ranging from 50 to 700 ml/min. In this model the catheters gave instantaneous, reproducible measurements of blood flow in vessels of 6.5 mm internal diameter with a mean error ranging from +5.3% to +36.4%, compared to electromagnetic flowmetry, but were less accurate in smaller vessels. When used in patients, the catheters provided stable, reproducible measurements of superior mesenteric blood flow, in 16 out of 20 patients studied. In a double-blind placebo-controlled study, including 12 subjects, superior mesenteric artery blood flow was significantly reduced in patients receiving octreotide. We suggest that measurement of splanchnic arterial blood flow using intra-arterial Doppler catheters may be a useful additional investigation in the assessment of splanchnic vascular pathophysiology and pharmacology in man.

Spontaneous intramural esophageal hematoma. Diagnosis by CT scanning

We describe a patient who suffered a spontaneous intramural esophageal hematoma while taking aspirin and dipyridamole. The diagnosis was initially made at endoscopy, with confirmation by computed tomography (CT). CT scanning was particularly valuable in both the diagnosis and in the follow-up of this lesion. As the prognosis for a spontaneous intramural esophageal hematoma is good with conservative management, its specific definition by computed tomography should facilitate proper management decisions.

Serendipitous detection of a Mallory-Weiss tear on hepatic imaging

A case of a bleeding Mallory-Weiss tear was detected by liver imaging and verified at endoscopy. Delayed imaging demonstrated small bowel visualization, confirming the impression of faint gastric activity observed on the initial routine scan.

Spontaneous submucosal dissection of the esophagus. A case report

A forty year-old Japanese woman complained of slight hematemesis and severe pain on swallowing. Fluoroscopic examination showed typical esophagograms of "double barreled esophagus" or "mucosal stripe". An esophageal ulceration, probably where the dissection re-entered the usual lumen, was endoscopically evident at the lower end of the mucosal bulging. A large, shallow ulcer of unknown cause was also identified in the just anal area from the esophago-gastric junction. She recovered with conservative treatment of fasting, cimetidine and sodium alginate.

A critical look at the accuracy of endoscopy and double-contrast radiography of the upper gastrointestinal (UGI) tract in patients with substantial UGI hemorrhage

Double-contrast radiography and endoscopy were compared in a prospective study of 100 patients with substantial hemorrhage of the upper gastrointestinal (UGI) tract. Endoscopy enabled detection of the primary bleeding site in 93% of the patients and correct diagnosis of 91% of all UGI lesions present. Double-contrast radiography detected 80% of primary bleeding sites and 76% of all UGI lesions present; whether the double-contrast examination was performed before or after endoscopy did not change its ability to detect lesions. Radiography demonstrated 68% (esophagitis) to 86% (duodenitis) of all superficial lesions. Endoscopy missed lesions in the duodenum and esophagus most frequently, while double-contrast radiography missed lesions in the esophagus most frequently. With the two modalities combined, the overall diagnostic accuracy for all lestions was 99%. Endoscopy and double-contrast radiography are complementary techniques for detecting acute bleeding sites of the UGI tract.

[Radiological aspects of Mallory-Weiss syndrome (author's transl)]

A case of Mallory-Weiss syndrome was diagnosed by joint baryum study and endoscopy. A survey of publications (15 references) shows that this affection is frequent and could be responsable of 5 to 10% of upper digestive hemorrhage of which some are grave. But conventional radiology only exceptionnally reveals these superficial lesions. Without endoscopy and according the ulceration be deep, the radiologist should be able to reveal the lesion a sa niche.

[Clinico-endoscopic classification of Mallory-Weiss syndrome]

Mallory--Weiss syndrome was diagnosed in 153 of 1373 patients subjected to endoscopy for acute gastroduodenal and esophageal bleeding. Besides, this syndrome was first diagnosed at operation in 10 cases, at roentgenoscopy in 8 cases and at autopsy--in 8 cases. A classification of Mallory--Weiss syndrome with regard to the localization of fissures of the organ mucous membrane, the depth of the injury to the organ wall, the degree of the acute blood loss, and to the forms of manifestations of the syndrome has been devised. The classification has a practical importance for it helps the surgeon to choose the method of the treatment of the patients with Mallory--Weiss syndrome.

Transcatheter embolization for treatment of Mallory-Weiss tears of the esophagogastric junction

Five patients with Mallory-Weiss tears of the esophagus and massive uncontrolled upper gastrointestinal bleeding were treated by Gelfoam embolization of the left gastric artery. Four of the five required no further therapy. In one case permanent hemostasis was not achieved due to extension of the tear to branches of the inferior phrenic artery. Since Mallory-Weiss tears are usually self-healing, embolization is potentially the primary treatment modality. Surgery can be reserved for treatment of transmural perforation or recurrent bleeding.

[The esophagogastral transitional region--localization of acute and chronic hemorrhages (author's transl)]

Various diseases which can be associated with hemorrhages are located in the esophagogastral transitional region. Emergency endoscopy can contribute significantly to the detection of an acute source of hemorrhage. Roentgenologic examination can make significant contributions toward the further clarification of acute and especially chronic hemorrhages, by assessment of the topographic, morphologic, functional and angiologic conditions. The relevant diseases in this respect are discussed with regard to clinical pattern and significance of the roentgenologic and endoscopic methods of examination, namely, reflux disease, hiatal hernia, cardial tumors, esophageal varices and Mallory-Weiss syndrome. Differential diagnostic problems are demonstrated by means of relevant cases. Brief reference is also made to "operated cardia" and the associated possibility of hemorrhage.

The roentgenographic demonstration of a gastric mucosal laceration (Mallory-Weiss Lesion)

The Mallory-Weiss lesion is responsible for many cases of upper gastrointestinal hemorrhage. Rapid diagnosis should be obtainable by endoscopic procedures. During active bleeding, angiography is the radiologic procedure of choice. The upper gastrointestinal series has been considered of little diagnostic use. Our case emphasizes that it may add valuable information when particular attention and careful technic are paid to the esophagogastric area.

The Mallory-Weiss syndrome

A policy of immediate investigation of patients with haematemesis or melaena or both led to the diagnosis of the Mallory-Weiss syndrome in 16 out of 121 patients admitted to a combined medical-surgical unit over three and a half years. A typical history suggestive of the diagnosis was obtainable in only nine of the 16 patients, though recent alcohol intake was high in another four. All patients survived the episode. Establishment of the diagnosis by oesophagogastroscopy was of special benefit when surgery was needed for control of continuing blood loss, but it also simplified the subsequent medical management of those patients in whom bleeding stopped spontaneously. The incidence of 13.2% in this series suggests that the Mallory-Weiss syndrome may be a relatively common cause of upper gastrointestinal bleeding.