CHARACTERIZATION OF UPPER THORACIC SPINAL NEURONS RESPONDING TO ESOPHAGEAL DISTENSION IN DIABETIC RATS

PubMed Central

Qin, Chao; Ghorbani, Marie L. M.; Wu, Mingyuan; Farber, Jay P.; Ma, Jianxin; Foreman, Robert D.

2009-01-01

The aim of this study was to examine spinal neuronal processing of innocuous and noxious mechanical inputs from the esophagus in diabetic rats. Streptozotocin (50 mg/kg, ip) was used to induce diabetes in 15 male Sprague-Dawley rats, and vehicle (10 mM citrate buffer) was injected into 15 rats as control. Four to eleven weeks after injections, extracellular potentials of single thoracic (T3) spinal neurons were recorded in pentobarbital anesthetized, paralyzed, and ventilated rats. Esophageal distensions (ED, 0.2, 0.4 ml, 20s) were produced by water inflation of a latex balloon in the thoracic esophagus. Noxious ED (0.4 ml, 20 s) altered activity of 44% (55/126) and 38% (50/132) of spinal neurons in diabetic and control rats, respectively. The short-lasting excitatory responses to ED were encountered more frequently in diabetic rats (27/42 vs 15/41, P<0.05). Spinal neurons with low threshold for excitatory responses to ED were more frequently encountered in diabetic rats (33/42 vs 23/41, P<0.05). However, mean excitatory responses and duration of responses to noxious ED were significantly reduced for high-threshold neurons in diabetic rats (7.4±1.1 vs 13.9±3.3 imp/s; 19.0±2.3 vs 31.2±5.5 s; P<0.05). In addition, more large size somatic receptive fields were found for spinal neurons with esophageal input in diabetic rats than in control rats (28/42 vs 19/45, P<0.05). These results suggested that diabetes influenced response characteristics of thoracic spinal neurons receiving mechanical esophageal input, which might indicate an altered spinal visceroceptive processing underlying diabetic esophageal neuropathy. PMID:19027368

Three-dimensional conformal radiation for esophageal squamous cell carcinoma with involved-field irradiation may deliver considerable doses of incidental nodal irradiation

PubMed Central

2012-01-01

Background To quantify the incidental irradiation dose to esophageal lymph node stations when irradiating T1-4N0M0 thoracic esophageal squamous cell carcinoma (ESCC) patients with a dose of 60 Gy/30f. Methods Thirty-nine patients with medically inoperable T1–4N0M0 thoracic ESCC were treated with three-dimensional conformal radiation (3DCRT) with involved-field radiation (IFI). The conformal clinical target volume (CTV) was re-created using a 3-cm margin in the proximal and distal direction beyond the barium esophagogram, endoscopic examination and CT scan defined the gross tumor volume (GTV) and a 0.5-cm margin in the lateral and anteroposterior directions of the CT scan-defined GTV. The PTV encompassed 1-cm proximal and distal margins and 0.5-cm radial margin based on the CTV. Nodal regions were delineated using the Japanese Society for Esophageal Diseases (JSED) guidelines and an EORTC-ROG expert opinion. The equivalent uniform dose (EUD) and other dosimetric parameters were calculated for each nodal station. Nodal regions with a metastasis rate greater than 5% were considered a high-risk lymph node subgroup. Results Under a 60 Gy dosage, the median Dmean and EUD was greater than 40 Gy in most high-risk nodal regions except for regions of 104, 106tb-R in upper-thoracic ESCC and 101, 104-R, 105, 106rec-L, 2, 3&7 in middle-thoracic ESCC and 107, 3&7 in lower-thoracic ESCC. In the regions with an EUD less than 40Gy, most incidental irradiation doses were significantly associated with esophageal tumor length and location. Conclusions Lymph node stations near ESCC receive considerable incidental irradiation doses with involved-field irradiation that may contribute to the elimination of subclinical lesions. PMID:23186308

Esophageal Lichen Planus: Clinical and Radiographic Findings in Eight Patients.

PubMed

Rauschecker, Andreas M; Levine, Marc S; Whitson, Matthew J; Tondon, Rashmi; Rubesin, Stephen E; Furth, Emma E; Metz, David C

2017-01-01

The purpose of this study is to present the clinical and radiographic findings of esophageal lichen planus. A search of computerized medical records identified 15 patients with pathologic findings of esophageal lichen planus on endoscopic biopsy specimens. Three other patients had presumed esophageal lichen planus, although no biopsy specimens were obtained. Twelve of these 18 patients (67%) had double-contrast esophagography performed at our institution; for eight of the 12 patients (67%), the studies revealed abnormalities in the esophagus. These eight patients constituted our study group. The barium esophagrams and medical records of these eight patients were reviewed to determine the clinical, radiographic, and endoscopic findings of esophageal lichen planus as well as the treatment and patient outcome. All eight patients were women (median age, 66.5 years), and all eight presented with dysphagia (mean duration, 3.2 years). Four patients had previous lichen planus that involved the skin (n = 1), the oral cavity (n = 2), or both (n = 1), and one patient later had lichen planus that involved the vagina. Five patients had a small-caliber esophagus with diffuse esophageal narrowing. The remaining three patients had segmental strictures in the cervical (n = 1), upper thoracic (n = 1), and distal thoracic (n = 1) esophagus. Esophageal lichen planus typically occurs in older women with longstanding dysphagia and often develops in the absence of extraesophageal disease. Barium esophagrams may reveal a small-caliber esophagus or, less commonly, segmental esophageal strictures. Greater awareness of the radiographic findings of esophageal lichen planus hopefully will lead to earlier diagnosis and better management of this condition.

Dosimetric effect of beam arrangement for intensity-modulated radiation therapy in the treatment of upper thoracic esophageal carcinoma.

PubMed

Fu, Yuchuan; Deng, Min; Zhou, Xiaojuan; Lin, Qiang; Du, Bin; Tian, Xue; Xu, Yong; Wang, Jin; Lu, You; Gong, Youling

2017-01-01

To evaluate the lung sparing in intensity-modulated radiation therapy (IMRT) for patients with upper thoracic esophageal tumors extending inferiorly to the thorax by different beam arrangement. Overall, 15 patient cases with cancer of upper thoracic esophagus were selected for a retrospective treatment-planning study. Intensity-modulated radiation therapy plans using 4, 5, and 7 beams (4B, 5B, and 7B) were developed for each patient by direct machine parameter optimization (DMPO). All plans were evaluated with respect to dose volumes to irradiated targets and normal structures, with statistical comparisons made between 4B with 5B and 7B intensity-modulated radiation therapy plans. Differences among plans were evaluated using a two-tailed Friedman test at a statistical significance of p < 0.05. The maximum dose, average dose, and the conformity index (CI) of planning target volume 1 (PTV1) were similar for 3 plans for each case. No significant difference of coverage for planning target volume 1 and maximum dose for spinal cords were observed among 3 plans in present study (p > 0.05). The average V 5 , V 13 , V 20 , mean lung dose, and generalized equivalent uniform dose (gEUD) for the total lung were significantly lower in 4B-plans than those data in 5B-plans and 7B-plans (p < 0.01). Although the average V 30 for the total lung were significantly higher in 4B-plans than those in 5B-plans and 7B-plans (p < 0.05). In addition, when comparing with the 4B-plans, the conformity/heterogeneity index of the 5B- and 7B-plans were significantly superior (p < 0.05). The 4B-intensity-modulated radiation therapy plan has advantage to address the specialized problem of lung sparing to low- and intermediate-dose exposure in the thorax when dealing with relative long tumors extended inferiorly to the thoracic esophagus for upper esophageal carcinoma with the cost for less conformity. Studies are needed to compare the superiority of volumetric modulated arc therapy with intensity-modulated radiation therapy technique. Copyright © 2017 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.

Radiobiological evaluation of simultaneously dose-escalated versus non-escalated intensity-modulated radiation therapy for patients with upper thoracic esophageal cancer.

PubMed

Huang, Bao-Tian; Wu, Li-Li; Guo, Long-Jia; Xu, Liang-Yu; Huang, Rui-Hong; Lin, Pei-Xian; Chen, Jian-Zhou; Li, De-Rui; Chen, Chuang-Zhen

2017-01-01

To compare the radiobiological response between simultaneously dose-escalated and non-escalated intensity-modulated radiation therapy (DE-IMRT and NE-IMRT) for patients with upper thoracic esophageal cancer (UTEC) using radiobiological evaluation. Computed tomography simulation data sets for 25 patients pathologically diagnosed with primary UTEC were used in this study. DE-IMRT plan with an escalated dose of 64.8 Gy/28 fractions to the gross tumor volume (GTV) and involved lymph nodes from 25 patients pathologically diagnosed with primary UTEC, was compared to an NE-IMRT plan of 50.4 Gy/28 fractions. Dose-volume metrics, tumor control probability (TCP), and normal tissue complication probability for the lung and spinal cord were compared. In addition, the risk of acute esophageal toxicity (AET) and late esophageal toxicity (LET) were also analyzed. Compared with NE-IMRT plan, we found the DE-IMRT plan resulted in a 14.6 Gy dose escalation to the GTV. The tumor control was predicted to increase by 31.8%, 39.1%, and 40.9% for three independent TCP models. The predicted incidence of radiation pneumonitis was similar (3.9% versus 3.6%), and the estimated risk of radiation-induced spinal cord injury was extremely low (<0.13%) in both groups. Regarding the esophageal toxicities, the estimated grade ≥2 and grade ≥3 AET predicted by the Kwint model were increased by 2.5% and 3.8%. Grade ≥2 AET predicted using the Wijsman model was increased by 14.9%. The predicted incidence of LET was low (<0.51%) in both groups. Radiobiological evaluation reveals that the DE-IMRT dosing strategy is feasible for patients with UTEC, with significant gains in tumor control and minor or clinically acceptable increases in radiation-induced toxicities.

Comparing Treatment Plan in All Locations of Esophageal Cancer

PubMed Central

Lin, Jang-Chun; Tsai, Jo-Ting; Chang, Chih-Chieh; Jen, Yee-Min; Li, Ming-Hsien; Liu, Wei-Hsiu

2015-01-01

Abstract The aim of this study was to compare treatment plans of volumetric modulated arc therapy (VMAT) with intensity-modulated radiotherapy (IMRT) for all esophageal cancer (EC) tumor locations. This retrospective study from July 2009 to June 2014 included 20 patients with EC who received definitive concurrent chemoradiotherapy with radiation doses >50.4 Gy. Version 9.2 of Pinnacle3 with SmartArc was used for treatment planning. Dosimetric quality was evaluated based on doses to several organs at risk, including the spinal cord, heart, and lung, over the same coverage of gross tumor volume. In upper thoracic EC, the IMRT treatment plan had a lower lung mean dose (P = 0.0126) and lung V5 (P = 0.0037) compared with VMAT; both techniques had similar coverage of the planning target volumes (PTVs) (P = 0.3575). In middle thoracic EC, a lower lung mean dose (P = 0.0010) and V5 (P = 0.0145), but higher lung V20 (P = 0.0034), spinal cord Dmax (P = 0.0262), and heart mean dose (P = 0.0054), were observed for IMRT compared with VMAT; IMRT provided better PTV coverage. Patients with lower thoracic ECs had a lower lung mean dose (P = 0.0469) and V5 (P = 0.0039), but higher spinal cord Dmax (P = 0.0301) and heart mean dose (P = 0.0020), with IMRT compared with VMAT. PTV coverage was similar (P = 0.0858) for the 2 techniques. IMRT provided a lower mean dose and lung V5 in upper thoracic EC compared with VMAT, but exhibited different advantages and disadvantages in patients with middle or lower thoracic ECs. Thus, choosing different techniques for different EC locations is warranted. PMID:25929910

Comparing treatment plan in all locations of esophageal cancer: volumetric modulated arc therapy versus intensity-modulated radiotherapy.

PubMed

Lin, Jang-Chun; Tsai, Jo-Ting; Chang, Chih-Chieh; Jen, Yee-Min; Li, Ming-Hsien; Liu, Wei-Hsiu

2015-05-01

The aim of this study was to compare treatment plans of volumetric modulated arc therapy (VMAT) with intensity-modulated radiotherapy (IMRT) for all esophageal cancer (EC) tumor locations.This retrospective study from July 2009 to June 2014 included 20 patients with EC who received definitive concurrent chemoradiotherapy with radiation doses >50.4 Gy. Version 9.2 of Pinnacle with SmartArc was used for treatment planning. Dosimetric quality was evaluated based on doses to several organs at risk, including the spinal cord, heart, and lung, over the same coverage of gross tumor volume.In upper thoracic EC, the IMRT treatment plan had a lower lung mean dose (P = 0.0126) and lung V5 (P = 0.0037) compared with VMAT; both techniques had similar coverage of the planning target volumes (PTVs) (P = 0.3575). In middle thoracic EC, a lower lung mean dose (P = 0.0010) and V5 (P = 0.0145), but higher lung V20 (P = 0.0034), spinal cord Dmax (P = 0.0262), and heart mean dose (P = 0.0054), were observed for IMRT compared with VMAT; IMRT provided better PTV coverage. Patients with lower thoracic ECs had a lower lung mean dose (P = 0.0469) and V5 (P = 0.0039), but higher spinal cord Dmax (P = 0.0301) and heart mean dose (P = 0.0020), with IMRT compared with VMAT. PTV coverage was similar (P = 0.0858) for the 2 techniques.IMRT provided a lower mean dose and lung V5 in upper thoracic EC compared with VMAT, but exhibited different advantages and disadvantages in patients with middle or lower thoracic ECs. Thus, choosing different techniques for different EC locations is warranted.

Treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement.

PubMed

Wu, Gang; Zhao, Yan Shi; Fang, Yi; Qi, Yu; Li, Xiangnan; Jiao, Dechao; Ren, Kewei; Han, Xinwei

2017-01-01

Spontaneous rupture of the esophagus is a rare but life-threatening thoracic emergency, with high rates of clinical misdiagnosis and mortality. This article summarizes our experience in the treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement. We retrospectively assessed the medical records of 19 patients with spontaneous esophageal rupture treated using our intervention protocol. Patients received local anesthesia and sedation prior to undergoing transnasal drainage catheter placement into the thoracic abscess cavity, followed by temporary esophageal stent and jejunal feeding tube placement. After the operation, abscess lavage, nutritional support, and anti-inflammatory treatment were given. The transnasal thoracic drainage catheter, esophageal stent, and feeding tube were removed after the healing of the abscess cavity. In all, 19 covered esophageal stents were placed in 19 patients with spontaneous esophageal rupture. All operations were technically successful. After an average of 84.06 days, the stents were successfully removed from 17 patients. No cases of massive hemorrhage, esophageal rupture, or other complications occurred during stent removal. An 82-year-old patient died of heart failure 2 months after the operation. One patient died of sudden massive hematemesis and hematochezia 55 days after the operation. In one patient, the esophageal injury failed to heal completely. Our treatment protocol is simple, minimally invasive, and efficacious and may be an alternative for patients who are not candidates for surgery, have a high risk of postoperative complications, or wish to undergo minimally invasive surgery. Therapeutic study, level V.

Use of Intercostal Flap for Conservative Surgical Management of Complex Lower Esophageal Fistula.

PubMed

du Pouget, L; Tuech, J J; Baste, J M

2015-01-01

Lower esophageal fistula is a rare complication after upper digestive tract surgery, but it is associated with high morbi-mortality. There is no consensus on therapeutic care, however when reoperation is necessary, a pedicled inter-costal flap from the thoracotomy can be easily harvested to patch a large defect or buttress a direct suture, saving -digestive reconstruction. This technique should be mastered by thoracic and general surgeons. We present here two cases of lower esophagus fistulas cured thanks to this intercostal flap, in which we avoided fistula recurrence with maintenance of digestive continuity. Copyright© Acta Chirurgica Belgica.

Traction esophageal diverticulum: a rare cause of gastro-intestinal bleeding.

PubMed

Ballehaninna, Umashankar K; Shaw, Jason P; Brichkov, Igor

2012-12-01

Esophageal diverticula are uncommon lesions that are usually classified according to their location (cervical, thoracic, or epiphrenic), or underlying pathogenesis (pulsion or traction), and their morphology (true or false).The majority of esophageal diverticula are acquired lesions that occur predominantly in elderly adults. Pulsion, or false, diverticula are the most commonly encountered type of esophageal diverticula noticed at the level of cricopharyngeus muscle, occur as a localized outpouchings that lacks a muscular coat, and as such their wall is formed entirely by mucosa and submucosa. True, or traction, esophageal diverticulum (TED) is seen in the middle one third of the thoracic esophagus in a peribronchial location, occurs secondary to mediastinal inflammatory lesions such as tuberculosis or histoplasmosis. The resultant desmoplastic reaction in the paraesophageal tissue causes full thickness pinching on the esophageal wall, producing a conical, broad-mouthed true diverticulum. They often project to the right side because subcarinal lymph nodes in this area are closely associated with the right anterior wall of the esophagus. TED usually presents with symptoms such as dysphagia, postural regurgitation, belching, retrosternal pain, heartburn, and epigastric pain. As in patients with pharyngoesophageal (Zenker's) diverticula, pulmonary symptoms are often present but underestimated in TED patients. These symptoms range from mild nocturnal cough to life-threatening massive aspiration. In this particular report we describe a rare case of TED presenting as a symptomatic upper gastrointestinal bleeding. Diagnostic evaluation of TED includes chest X-ray, barium esophagogram and manometry. A significant proportion of lower esophageal diverticula are associated with motility disorders. Management of TED include treating the underlying cause sometimes a surgical resection of diverticulum along with esophageal myotomy is necessitated in symptomatic patients.

Thoracoscopic enucleation of a large esophageal leiomyoma using a three thoracic ports technique.

PubMed

Akaraviputh, Thawatchai; Chinswangwatanakul, Vitoon; Swangsri, Jirawat; Lohsiriwat, Varut

2006-10-04

Video assisted thoracoscopic resection of an esophageal leiomyoma offers distinct advantages over an open approach. Many papers have described various techniques of thoracoscopic resection. We describe a 32-year old man who presented with intermittent dysphagia. Imaging studies showed a large esophageal leiomyoma. He underwent thoracoscopic enucleation using a three thoracic-ports technique. Thoracoscopic enucleation can be technically performed using a three thoracic-ports technique.

Thoracic Discitis as a Complication of Self-Expanding Metallic Stents in Esophageal Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

McQueen, A. S.; Eljabu, W.; Latimer, J., E-mail: joanne.latimer@nth.nhs.uk

2011-02-15

The role of metallic stents in the palliation of esophageal cancer is well established. Self-expanding metal stents (SEMSs) are frequently used, as they provide an effective and safe method of relieving malignant dysphagia. A number of complications are associated with the use of SEMSs, including esophageal perforation. We report a case of thoracic discitis occurring in a patient with advanced esophageal malignancy, treated with SEMSs. We propose that the likely etiology in this patient was esophageal perforation by a metallic stent.

[Experimental study on the lymph flow of the esophagus by injecting cuttlefish particles into the esophageal wall].

PubMed

Nakano, S

1994-04-01

Cuttlefish particles which have an affinity with lymphatic pathways are useful for investigating the lymph flow from the esophagus, because they can be distinguished from anthracosis in the thoracic lymph nodes by means of melanine breeching method. Four days after injecting the cuttlefish particles into the esophageal walls of 103 mongrel dogs, intrathoracic and abdominal lymph nodes were dissected and examined histologically to know how much of the injected particles have migrated into lymph nodes. In case of spreading of injected particles limited to the muscle layer, the staining rate per number of cases in the right uppermost mediastinal nodes was higher when the particles were injected into the upper and middle esophagus (75%) than into the lower esophagus (0%, p < 0.002). The rate of staining in the lymph nodes along the left gastric artery was higher when the particles were injected into the anal side (100%) than into the oral side of the canter of middle esophagus (14%, p < 0.001). If these situations were duplicated in humans, lymph node dissection for thoracic esophageal cancer should reasonably be considered from the findings on tumor location and depth of invasion by the tumor.

Management of an ingested fish bone in the lung using video-assist thoracic surgery: a case report.

PubMed

Tan, Sichuang; Tan, Sipin; Peng, Muyun; Yu, Fenglei

2015-06-01

We report a case of lung abscess caused by an ingested fish bone that was successfully treated by minimally invasive surgery. Although cases of ingested foreign body abscess are well reported, lung abscess caused by ingested fish bone is extremely rare. To date, less than 10 similar cases have been reported in the literature. To the best of our knowledge, the case presented in this case report is the first report of this kind that was successfully treated by video-assist thoracic surgery (VATS). A 47-year-old man was admitted to department of thoracic surgery with the complaint of continues dry cough and fever. The patient accidentally swallowed a long sharp-blade-shaped fish bone 20 days before, which perforated the upper thoracic esophagus on the right and embedded in the right upper lobe.The diagnosis was verified by computed tomography scan and a video-assist thoracic surgery procedure was successfully performed to treat the patient. The patient survived the esophageal perforation fortunately without involvement of great vessel injury and probable mediastinitis. This report may provide additional experience on lung abscess caused by ingested fish bones. However, it is also important to educate the public of the risks of trying to force an ingested object down into the stomach.

Impact of thoracic surgery on esophageal motor function—Evaluation by high resolution manometry

PubMed Central

Kandulski, Arne; Malfertheiner, Peter; Riedel, Sandra; Zardo, Patrick; Hachenberg, Thomas; Schreiber, Jens

2017-01-01

Background Alteration of esophageal function is a potential risk factor for postoperative complications in thoracic surgery. This prospective study investigates esophageal motility and function during and after thoracic procedures via high resolution manometry (HRM) and impedance technology with spatiotemporal representation of pressure data. Methods Twelve consecutive patients eligible for elective thoracic surgery underwent preoperative and postoperative (48 hours and 7 days) esophageal HRM. Swallowing acts were carried out with 5 mL of water, 10 mL of water and 1 cm3 bread in physiological posture to evaluate distal contraction integral (DCI). Length and location of contractile integrity breaks were measured by investigators blinded to the form of surgical intervention. The impact of surgical procedures on esophageal motility was quantified according to current Chicago Classification (CC) criteria. Pre-, intra- and postoperative 24-hour multi-channel impedance pH–metry (MII-pH) was performed to further analyze gastroesophageal reflux patterns. Results All patients were investigated 48 hours prior to and 7 days after thoracic procedures, with a total of n=675 swallowing acts being included in our study. Increased motility patterns of the tubular esophagus occurred temporally 48 hours postoperatively. DCI 48 hours after surgery increased significantly (5 mL, P=0.049; solid, P=0.014) and returned to baseline values after seven days (5 mL, P=0.039; solid, P=0.039). Break length was significantly reduced 48 hours postoperatively, especially in the proximal esophageal segment (transition zone). Follow-up measurements after another week were comparable to preoperative baseline findings. The perioperative MII-pH measurement showed numerous artifacts caused by intubation and ventilation during surgery also with increasing short and frequent acidic reflux episodes. Conclusions Thoracic procedures cause a transient modulation of esophageal peristalsis with postoperative increased contractility of the tubular esophagus, presumably without affecting intraesophageal reflex arcs. Although limited by the number of patients, we can conclude on our data that postoperative esophageal hypomotility is unlikely to promote secondary pulmonary complications. PMID:28740669

Impact of thoracic surgery on esophageal motor function-Evaluation by high resolution manometry.

PubMed

Wäsche, Anja; Kandulski, Arne; Malfertheiner, Peter; Riedel, Sandra; Zardo, Patrick; Hachenberg, Thomas; Schreiber, Jens

2017-06-01

Alteration of esophageal function is a potential risk factor for postoperative complications in thoracic surgery. This prospective study investigates esophageal motility and function during and after thoracic procedures via high resolution manometry (HRM) and impedance technology with spatiotemporal representation of pressure data. Twelve consecutive patients eligible for elective thoracic surgery underwent preoperative and postoperative (48 hours and 7 days) esophageal HRM. Swallowing acts were carried out with 5 mL of water, 10 mL of water and 1 cm 3 bread in physiological posture to evaluate distal contraction integral (DCI). Length and location of contractile integrity breaks were measured by investigators blinded to the form of surgical intervention. The impact of surgical procedures on esophageal motility was quantified according to current Chicago Classification (CC) criteria. Pre-, intra- and postoperative 24-hour multi-channel impedance pH-metry (MII-pH) was performed to further analyze gastroesophageal reflux patterns. All patients were investigated 48 hours prior to and 7 days after thoracic procedures, with a total of n=675 swallowing acts being included in our study. Increased motility patterns of the tubular esophagus occurred temporally 48 hours postoperatively. DCI 48 hours after surgery increased significantly (5 mL, P=0.049; solid, P=0.014) and returned to baseline values after seven days (5 mL, P=0.039; solid, P=0.039). Break length was significantly reduced 48 hours postoperatively, especially in the proximal esophageal segment (transition zone). Follow-up measurements after another week were comparable to preoperative baseline findings. The perioperative MII-pH measurement showed numerous artifacts caused by intubation and ventilation during surgery also with increasing short and frequent acidic reflux episodes. Thoracic procedures cause a transient modulation of esophageal peristalsis with postoperative increased contractility of the tubular esophagus, presumably without affecting intraesophageal reflex arcs. Although limited by the number of patients, we can conclude on our data that postoperative esophageal hypomotility is unlikely to promote secondary pulmonary complications.

Radiation therapy for gastric wall metastasis from esophageal carcinoma.

PubMed

Hashimoto, Naoko; Iwazawa, Jin; Abe, Hisashi; Mitani, Takashi; Kagawa, Kazufumi

2010-04-01

An 86-year-old man with dysphagia underwent gastrointestinal fiberscopy (GIF) and was found to have a circumferential type 3 advanced carcinoma in the upper thoracic esophagus and a type 2 tumor in the posterior wall of the gastric body. Microscopic examination of biopsy specimens of both tumors demonstrated moderately differentiated squamous cell carcinoma. He was diagnosed as having stage IVb (T3N0M1b) esophageal carcinoma with gastric wall metastasis. A total of 60 Gy in 30 fractions of three-dimensional conformal radiation therapy (3D-CRT) was first administered to the esophageal carcinoma, next to the gastric wall metastasis. Concurrent chemotherapy was not given because of the patient's refusal. No subjective morbidity was observed during the treatment. In the GIF study immediately after 3D-CRT, both esophageal and gastric wall tumors had attained a complete response. The dysphagia dissolved as the esophageal tumor shrunk. The patient has been doing well for 17 months after the start of 3D-CRT. No local recurrence was observed in either the esophagus or the stomach during follow-up GIF. Considering the dismal prognosis of esophageal carcinoma patients with intramural metastasis to the stomach, a watchful follow-up is needed.

Treatment of Traumatic Esophagopleural Fistula Using the Over-the-Scope-Clip System.

PubMed

Kim, Ji Hyoung; Park, Jong-Jae; Jung, Il Woo; Kim, Sang Hoon; Kim, Hee Dong; Choe, Jung Wan; Joo, Moon Kyung; Kim, Hyun Gu

2015-09-01

Esophagopleural fistula (EPF) is a rare condition that is usually accompanied by severe infection and life-threatening morbidity. Here, we report the successful treatment of an EPF by closing an esophageal orifice using the over-the-scope-clip (OTSC) system without postprocedural complications. A 41-year-old man had serious thoracic and abdominal trauma due to a traffic accident. Computed tomography revealed findings suggestive of esophageal rupture due to Boerhaave syndrome. An emergent explorative operation was performed for primary repair with the insertion of a vacuum-assisted closure device. A postoperative upper gastrointestinal series revealed an EPF tract connecting the left pleural space and distal esophagus. We performed an endoscopic procedure using the "traumatic-type"OTSC to seal the EPF, and the esophageal orifice was completely healed 2 weeks postoperatively. The OTSC system might represent a safe and feasible modality for the treatment of EPF.

Number and Location of Positive Nodes, Postoperative Radiotherapy, and Survival After Esophagectomy With Three-Field Lymph Node Dissection for Thoracic Esophageal Squamous Cell Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen Junqiang; Pan Jianji, E-mail: panjianji@126.com; Zheng Xiongwei

2012-01-01

Purpose: To analyze influences of the number and location of positive lymph nodes and postoperative radiotherapy on survival for patients with thoracic esophageal squamous cell carcinoma (TE-SCC) treated with radical esophagectomy with three-field lymphadenectomy. Methods and Materials: A total of 945 patients underwent radical esophagectomy plus three-field lymph node dissection for node-positive TE-SCC at Fujian Provincial Tumor Hospital between January 1993 and March 2007. Five hundred ninety patients received surgery only (S group), and 355 patients received surgery, followed 3 to 4 weeks later by postoperative radiotherapy (S+R group) to a median total dose of 50 Gy in 25 fractions.more » We assessed potential associations among patient-, tumor-, and treatment-related factors and overall survival. Results: Five-year overall survival rates were 32.8% for the entire group, 29.6% for the S group, and 38.0% for the S+R group (p = 0.001 for S vs. S+R). Treatment with postoperative radiotherapy was particularly beneficial for patients with {>=}3 positive nodes and for those with metastasis in the upper (supraclavicular and upper mediastinal) region or both the upper and lower (mediastinal and abdominal) regions (p < 0.05). Postoperative radiotherapy was also associated with lower recurrence rates in the supraclavicular and upper and middle mediastinal regions (p < 0.05). Sex, primary tumor length, number of positive nodes, pathological T category, and postoperative radiotherapy were all independent predictors of survival. Conclusions: Postoperative radiotherapy was associated with better survival for patients with node-positive TE-SCC, particularly those with three or more positive nodes and positive nodes in the supraclavicular and superior mediastinal regions.« less

Postoperative radiation in esophageal squamous cell carcinoma and target volume delineation

PubMed Central

Zhu, Yingming; Li, Minghuan; Kong, Li; Yu, Jinming

2016-01-01

Esophageal cancer is the sixth leading cause of cancer death worldwide, and patients who are treated with surgery alone, without neoadjuvant therapies, experience frequent relapses. Whether postoperative therapies could reduce the recurrence or improve overall survival is still controversial for these patients. The purpose of our review is to figure out the value of postoperative adjuvant therapy and address the disputes about target volume delineation according to published data. Based on the evidence of increased morbidity and disadvantages on patient survival caused by postoperative chemotherapy or radiotherapy (RT) alone provided by studies in the early 1990s, the use of postoperative adjuvant therapies in cases of esophageal squamous cell carcinoma has diminished substantially and has been replaced gradually by neoadjuvant chemoradiation. With advances in surgery and RT, accumulating evidence has recently rekindled interest in the delivery of postoperative RT or chemoradiotherapy in patients with stage T3/T4 or N1 (lymph node positive) carcinomas after radical surgery. However, due to complications with the standard radiation field, a nonconforming modified field has been adopted in most studies. Therefore, we analyze different field applications and provide suggestions on the optimization of the radiation field based on the major sites of relapse and the surgical non-clearance area. For upper and middle thoracic esophageal carcinomas, the bilateral supraclavicular and superior mediastinal areas remain common sites of recurrence and should be encompassed within the clinical target volume. In contrast, a consensus has yet to be reached regarding lower thoracic esophageal carcinomas; the “standard” clinical target volume is still recommended. Further studies of larger sample sizes should focus on different recurrence patterns, categorized by tumor locations, refined classifications, and differing molecular biology, to provide more information on the delineation of target volumes. PMID:27471393

Volumetric modulated arc therapy vs. c-IMRT for the treatment of upper thoracic esophageal cancer.

PubMed

Zhang, Wu-Zhe; Zhai, Tian-Tian; Lu, Jia-Yang; Chen, Jian-Zhou; Chen, Zhi-Jian; Li, De-Rui; Chen, Chuang-Zhen

2015-01-01

To compare plans using volumetric-modulated arc therapy (VMAT) with conventional sliding window intensity-modulated radiation therapy (c-IMRT) to treat upper thoracic esophageal cancer (EC). CT datasets of 11 patients with upper thoracic EC were identified. Four plans were generated for each patient: c-IMRT with 5 fields (5F) and VMAT with a single arc (1A), two arcs (2A), or three arcs (3A). The prescribed doses were 64 Gy/32 F for the primary tumor (PTV64). The dose-volume histogram data, the number of monitoring units (MUs) and the treatment time (TT) for the different plans were compared. All of the plans generated similar dose distributions for PTVs and organs at risk (OARs), except that the 2A- and 3A-VMAT plans yielded a significantly higher conformity index (CI) than the c-IMRT plan. The CI of the PTV64 was improved by increasing the number of arcs in the VMAT plans. The maximum spinal cord dose and the planning risk volume of the spinal cord dose for the two techniques were similar. The 2A- and 3A-VMAT plans yielded lower mean lung doses and heart V50 values than the c-IMRT. The V20 and V30 for the lungs in all of the VMAT plans were lower than those in the c-IMRT plan, at the expense of increasing V5, V10 and V13. The VMAT plan resulted in significant reductions in MUs and TT. The 2A-VMAT plan appeared to spare the lungs from moderate-dose irradiation most effectively of all plans, at the expense of increasing the low-dose irradiation volume, and also significantly reduced the number of required MUs and the TT. The CI of the PTVs and the OARs was improved by increasing the arc-number from 1 to 2; however, no significant improvement was observed using the 3A-VMAT, except for an increase in the TT.

Clinical outcome of definitive radiation therapy for superficial esophageal cancer.

PubMed

Koide, Yutaro; Kodaira, Takeshi; Tachibana, Hiroyuki; Tomita, Natsuo; Makita, Chiyoko; Itoh, Makoto; Abe, Tetsuya; Muro, Kei; Tajika, Masahiro; Niwa, Yasumasa; Itoh, Yoshiyuki; Naganawa, Shinji

2017-05-01

To analyze the clinical outcome of concurrent chemoradiotherapy in superficial esophageal cancer patients. We retrospectively analyzed data for 123 patients with superficial esophageal cancer who received external beam radiotherapy without intracavitary brachytherapy plus systemic chemotherapy during 1998-2015. Elective nodal irradiation was not performed. The dosage to planning treatment volume was 60 Gy in 30 fractions. The main outcome measure was overall survival. Patient characteristics were as follows: median age, 66 (41-83) years; male/female ratio, 106/17; squamous cell carcinoma/other, 122/1; cT1a/cT1b, 27/96; cervical esophagus/upper thoracic esophagus/middle thoracic esophagus/lower thoracic esophagus, 7/9/66/41 and concurrent chemoradiotherapy/radiotherapy alone, 100/23. Cisplatin and 5-fluorouracil were the most commonly used agents (85%). At the last follow-up (median 60.5 months), 91 (74%) patients were alive. Complete response was achieved in 116 (94.4%) patients. The 5-year overall survival, progression-free survival and local control rates were 77.0, 46.9 and 62.7%, respectively, similar to that in the elderly patients (P = 0.878, 0.754 and 0.648, respectively). There were 55 failures: 42 local, 10 regional and 3 distant failures. Nine local and seven regional failures developed out-of-field. Thirty-eight local failures (90%) were successfully salvaged, of which 30 (71%) were salvaged via endoscopic removal; only 2 regional failures (20%) were salvaged. Fifteen G3 acute toxicities occurred. One pneumonitis (G3), one pneumothorax (G3) and two pericardial effusion (G2) were the late toxicities observed. There were no G4 toxicities or treatment-related deaths. Concurrent chemoradiotherapy without intracavitary brachytherapy was effective and safe for superficial esophageal cancer, even in elderly patients. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Left colonic graft in esophageal reconstruction for caustic stricture: mortality and morbidity.

PubMed

Boukerrouche, A

2013-01-01

The adequacy of the blood supply to the left colon graft and its ability to transport food effectively from pharynx to stomach made it an esophageal substitute of choice, particularly in esophageal caustic stricture. From 1999 to 2009, 60 patients underwent colon interposition for esophageal caustic stricture (n= 57) and cancer (n= 3). An isoperistaltic colonic graft based on the left colonic artery could be used in all of these patients. The substernal route was used exclusively, and upper thoracic inlet was opened when necessary. The isoperistaltic left colonic graft interposed by substernal route represents the surgical procedure of choice in all operations performed for esophageal substitution during the study period. The operative mortality rate was 3.3%. A cervical fistula occurred in 10 patients (16.6%) and cervical anastomotic stricture in five patients (8.3%). Dilation was required in all the stricture of the esophageal colonic anastomosis with good response. The isoperistaltic left colic transplant supplied by the left colic pedicle is an excellent long-term replacement organ for the esophageal caustic stenosis. When performed by experienced surgeons, the left isoperistaltic esophagocoloplasty is a satisfactory surgical method for esophageal reconstruction with acceptable early morbidity and good long-term functional results. © 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

[Three cases of the malignant esophageal stenosis successfully treated with the Niti-S™ esophageal stent].

PubMed

Isohata, Noriyuki; Naritaka, Yoshihiko; Asaka, Shinichi; Shimakawa, Takeshi; Miyaki, Akira; Yamaguchi, Kentaro; Murayama, Minoru; Katsube, Takao; Ogawa, Kenji

2011-11-01

We herein report three cases of the malignant esophageal stenosis successfully treated with the Niti-S™ esophageal stent. CASE 1: The hilar lung cancer and its mediastinal lymph node metastasis pressed the esophagus extramurally and caused the marked stenosis. CASE 2: A metastatic lymph node along the left laryngeal nerve caused the stenosis of the trachea. A primary esophageal lesion located at the middle thoracic esophagus also caused the marked stenosis. At first, tracheal stent was placed because of dyspnea, and two weeks later, we placed an esophageal stent. Case 3: Esophageal cancer at lower thoracic esophagus after definitive radiation therapy caused the marked stenosis. Because of the stenosis of esophago-gastric junction( EGJ), we used an esophageal stent with a long cover in order to prevent a reflux into the esophagus. This new Niti-STM esophageal stent was easy to place at the stenosis without difficulty using a conventional device. The symptom was improved immediately for each case. We hope this new device will be used widely.

Atlas of the thoracic lymph nodal delineation and recommendations for lymph nodal CTV of esophageal squamous cell cancer in radiation therapy from China.

PubMed

Huang, Wei; Huang, Yong; Sun, Jujie; Liu, Xibin; Zhang, Jian; Zhou, Tao; Zhang, Baijiang; Li, Baosheng

2015-07-01

To construct an anatomical atlas of thoracic lymph node regions of esophageal cancer (EC) based on definitions from The Japan Esophageal Society (JES) and generate a consensus to delineate the nodal clinical target volume (CTVn) for elective nodal radiation (ENI) of esophageal squamous cell carcinoma (ESCC). An interdisciplinary group including two dedicated radiation oncologists, an experienced radiologist, a pathologist and two thoracic surgeons were gathered to generate a three-dimensional radiological description for the mediastinal lymph node regions of EC on axial CT scans. Then the radiological boundaries of lymph node regions were validated by a relatively large number of physicians in multiple institutions. An atlas of detailed anatomic boundaries of lymph node station No. 105-114 was defined on axial CT, along with illustrations. From the previous work, the study provided a guide of CTVn contouring for ENI of thoracic ESCC from a single center. It is feasible to use such an atlas of thoracic lymph node stations for radiotherapy planning. A phase III study based on the atlas is ongoing in China to measure quantitatively the ENI received by patients with ESCC. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Gastric-tube versus whole-stomach esophagectomy for esophageal cancer: A systematic review and meta-analysis.

PubMed

Zhang, Wenxiong; Yu, Dongliang; Peng, Jinhua; Xu, Jianjun; Wei, Yiping

2017-01-01

To conduct a systematic review and meta-analysis of studies comparing the gastric-tube vs. whole-stomach for esophageal cancer in order to determine the optimal surgical technique of esophagectomy. A comprehensive literature search was performed using PubMed, EMBASE, ScienceDirect, Ovid MEDLINE, Cochrane Library, Web of Science, Google Scholar, and Scopus. Clinical trials that compared the gastric-tube versus whole-stomach for esophageal cancer were selected. The clinical endpoints included anastomotic leakage, anastomotic stenosis, reflux esophagitis, pneumonia, delayed gastric emptying, and thoracic stomach syndrome. A total of 6 articles (1571 patients) were included. Compared to the whole-stomach approach, the gastric-tube approach was associated with a lower incidence of reflux esophagitis (95% confidence interval [CI]: 0.16 to 0.81, p = 0.01) and thoracic stomach syndrome (95% CI: 0.17 to 0.55, p < 0.0001). The rates of anastomotic leakage, anastomotic stenosis, pneumonia, and delayed gastric emptying did not significantly differ between the two groups. The gastric-tube esophagectomy is superior to the whole-stomach approach, as it is associated with a lower incidence of postoperative reflux esophagitis and thoracic stomach syndrome. Our findings must be validated in large-scale randomized controlled trials.

Severe esophageal toxicity after thoracic radiation therapy for lung cancer associated with the human immunodeficiency virus: a case report and review of the literature.

PubMed

Leigh, B R; Lau, D H

1998-10-01

This case report documents severe esophagitis and rapid esophageal stricture formation in a man infected with the human immunodeficiency virus (HIV) who was treated with standard thoracic irradiation for locally advanced non-small-cell lung cancer. Severe late esophageal toxicity is a rare complication of radiation therapy in patients who are HIV negative, but those who are HIV positive may be at increased risk. This article reviews the literature suggesting that HIV infection may lead to unusually severe radiation-induced mucosal injury. High-dose chest irradiation should be performed with caution in this group of patients.

(18)F-FDG uptake of the spinal cord was decreased after conventional dose radiotherapy in esophageal cancer patients.

PubMed

Harata, Naoki; Yoshida, Katsuya; Oota, Sayako; Fujii, Hayahiko; Isogai, Jun; Yoshimura, Ryoichi

2016-01-01

We retrospectively investigated changes of (18)F-fluorodeocyglucose ((18)F-FDG) uptake in the spinal cord, inside and outside the radiation fields, in patients with esophageal cancer before and after conventional dose radiotherapy. A total of 17 consecutive patients with esophageal cancer (16 males, one female; age 50-83 years, mean 67.0 years), who underwent conventional dose radiotherapy and (18)F-FDG PET/CT before and 5.1 months (range 1.6-8.6 months) after the radiotherapy, were retrospectively evaluated. Sixteen patients had esophageal cancer and one patient had esophageal metastasis from thyroid cancer. Mean standardized uptake values (SUVmean) of the cervical, thoracic (inside and outside the radiation fields) and lumbar spinal cord were measured. SUVmean of the thoracic spinal cord inside the radiation field was decreased significantly after radiotherapy compared to those before radiotherapy (p < 0.001). SUVmean of the cervical spinal cord showed the same trend but it was not statistically significant (p = 0.051). SUVmean of the thoracic spinal cord outside the radiation field and the lumbar spinal cord did not differ significantly before and after the radiotherapy (p = 0.146 and p = 0.701, respectively). The results suggest that glucose metabolism of the spinal cord is decreased in esophageal cancer patients after conventional dose radiotherapy.

Volumetric Modulated Arc Therapy vs. c-IMRT for the Treatment of Upper Thoracic Esophageal Cancer

PubMed Central

Lu, Jia-Yang; Chen, Jian-Zhou; Chen, Zhi-Jian; Li, De-Rui; Chen, Chuang-Zhen

2015-01-01

Objective To compare plans using volumetric-modulated arc therapy (VMAT) with conventional sliding window intensity-modulated radiation therapy (c-IMRT) to treat upper thoracic esophageal cancer (EC). Methods CT datasets of 11 patients with upper thoracic EC were identified. Four plans were generated for each patient: c-IMRT with 5 fields (5F) and VMAT with a single arc (1A), two arcs (2A), or three arcs (3A). The prescribed doses were 64 Gy/32 F for the primary tumor (PTV64). The dose-volume histogram data, the number of monitoring units (MUs) and the treatment time (TT) for the different plans were compared. Results All of the plans generated similar dose distributions for PTVs and organs at risk (OARs), except that the 2A- and 3A-VMAT plans yielded a significantly higher conformity index (CI) than the c-IMRT plan. The CI of the PTV64 was improved by increasing the number of arcs in the VMAT plans. The maximum spinal cord dose and the planning risk volume of the spinal cord dose for the two techniques were similar. The 2A- and 3A-VMAT plans yielded lower mean lung doses and heart V50 values than the c-IMRT. The V20 and V30 for the lungs in all of the VMAT plans were lower than those in the c-IMRT plan, at the expense of increasing V5, V10 and V13. The VMAT plan resulted in significant reductions in MUs and TT. Conclusion The 2A-VMAT plan appeared to spare the lungs from moderate-dose irradiation most effectively of all plans, at the expense of increasing the low-dose irradiation volume, and also significantly reduced the number of required MUs and the TT. The CI of the PTVs and the OARs was improved by increasing the arc-number from 1 to 2; however, no significant improvement was observed using the 3A-VMAT, except for an increase in the TT. PMID:25815477

SU-E-T-811: Volumetric Modulated Arc Therapy Vs. C-IMRT for the Treatment of Upper Thoracic Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zhang, W; Wu, L; Lu, J

2015-06-15

Purpose: To compare plans using volumetric-modulated arc therapy (VMAT) with conventional sliding window intensity-modulated radiation therapy (c-IMRT) to treat upper thoracic esophageal cancer (EC). Methods: CT datasets of 11 patients with upper thoracic EC were identified. Four plans were generated for each patient: c-IMRT with 5 fields (5F) and VMAT with a single arc (1A), two arcs (2A), or three arcs (3A). The prescribed doses were 64 Gy/32 F for the primary tumor (planning target volume 64, PTV64). The dose-volume histogram data, the number of monitoring units (MUs) and the treatment time (TT) for the different plans were compared. Results:more » All of the plans generated similar dose distributions for PTVs and organs at risk (OARs), except that the 2A- and 3A-VMAT plans yielded a significantly higher conformity index (CI) than the c-IMRT plan. The CI of the PTV64 was improved by increasing the number of arcs in the VMAT plans. The maximum spinal cord dose and the planning risk volume of the spinal cord dose for the two techniques were similar. The 2A- and 3A-VMAT plans yielded lower mean lung doses and heart V50 than the c-IMRT. The V20 and V30 for the lungs in all of the VMAT plans were lower than those in the c-IMRT plan, at the expense of increasing V5, V10 and V13. The VMAT plan resulted in significant reductions in MUs and TT. Conclusion: The 2A-VMAT plan appeared to spare the lungs from moderate-dose irradiation most effectively of all plans, at the expense of increasing the low-dose irradiation volume, and also significantly reduced the number of required MUs and the TT. The CI of the PTVs and the OARs was improved by increasing the arc-number from 1 to 2. however, no significant improvement was observed using the 3A-VMAT, except for an increase in the TT. This work was sponsored by Shantou University Medical College Clinical Research Enhancement Initiative(NO.201424)« less

Patterns of nodal metastases on 18F-FDG PET/CT in patients with esophageal squamous cell carcinoma are useful to guide treatment planning of radiotherapy.

PubMed

Liu, Chia-Ju; Cheng, Jason Chia-Hsien; Lee, Jang-Ming; Cheng, Mei-Fang; Tzen, Kai-Yuan; Yen, Ruoh-Fang

2015-05-01

The aim of the study was to examine the patterns of lymph node metastases from esophageal squamous cell carcinoma (ESCC) and compare the laterality of lymphatic metastasis in cervical, supraclavicular, and paratracheal areas using F-FDG PET/CT. The data of 75 patients who underwent F-FDG PET/CT for staging of ESCC between January 2011 and March 2012 were reviewed. Fourteen groups of lymph nodes from the neck to abdomen were defined. Lateralization of the upper thoracic lymph nodes was defined in reference to the midline of the trachea. Frequencies of positive lymph nodes were used to determine the pattern of lymphatic spread and compare the lateralization of metastases in the cervical and upper thoracic regions. The right paratracheal region was the most frequent site of metastasis among all patients. Left paratracheal and paragastric nodes were more frequent in upper and lower third ESCC, respectively. Upward and downward lymphatic spread was equal in mid third ESCC. In all patients, there was a trend toward more frequent lymph node metastasis on the right side than the left side for the supraclavicular and paratracheal regions. Further stratified analysis with tumor location found that right paratracheal node metastasis was significantly associated with mid third ESCC (P = 0.03). Remote nodal metastasis was found in 10.5% of patients with upper third ESCC and 13% of patients with lower third ESCC, respectively. Remote nodal metastasis was associated with higher SUV of the primary tumor (P = 0.02) and worse survival (P = 0.03). Receiver operating characteristic analysis showed a cutoff SUV of 14.8 for predicting remote lymph node metastases. PET/CT provides important information before radiotherapy planning. Mid and lower third ESCC tends to metastasize to the right paratracheal/supraclavicular lymph nodes. Remote nodal metastases on PET/CT correlated with higher primary tumor SUV and worse survival.

Thoracic multidisciplinary tumor board routinely impacts therapeutic plans in patients with lung and esophageal cancer: a prospective cohort study.

PubMed

Schmidt, Henner M; Roberts, John M; Bodnar, Artur M; Kunz, Sonia; Kirtland, Steven H; Koehler, Richard P; Hubka, Michal; Low, Donald E

2015-05-01

National and subspecialty guidelines for lung and esophageal cancers recommend treatment decisions to be made in a multidisciplinary tumor board (MTB). This study prospectively analyzes the actual impact of presentation at the thoracic tumor board on decision making in thoracic cancer cases. During the electronic submission process for presentation at MTB managing physicians documented their current treatment plan. The initial treatment plan was compared with the MTB final recommendation. Patient demographics, physician's proposed treatment plan, MTB recommendation, and documentation of application of MTB recommendations were prospectively recorded in an Institutional Review Board approved database. Between June 2010 and December 2012, 185 patients with esophageal and 294 patients with lung cancer were presented at the MTB. One hundred sixty-six patients were presented on more than 1 occasion, resulting in 724 assessments of 479 patients. In 48 esophageal cancer patients (26%) and 118 lung cancer patients (40%) MTB recommendations differed from the initial treatment plan. Overall, a differing MTB recommendation from the primary treatment plan occurred in 330 of 724 case presentations (46%). The MTB recommendations changed treatment plans in 40% and staging and assessment plans in 60% of patients. Follow-up in a cohort of 249 patients confirmed that MTB recommendations were followed in 97% of cases. This study validates the impact of the thoracic MTB. Recommendations will differ from the managing providers' initial plan in 26% to 40% of cases. However, MTB recommendations can be successfully initiated in the majority of patients. Complex thoracic cancer patients will benefit from multidisciplinary review and should ideally be presented at tumor board. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Comparative analysis of mechanical and manual cervical esophagogastric anastomosis following esophagectomy for esophageal cancer].

PubMed

Cayi, Ruijun; Li, Mei; Xiong, Gang; Cai, Kaican; Wang, Wujun

2012-06-01

To compare the complications associated with mechanical and manual cervical esophagogastric anastomosis following esophagectomy for esophageal cancer. From September, 2004 to June, 2007, 227 patients with middle and upper thoracic esophageal cancer underwent cervical esophagogastric anastomosis after esophagectomy. The patients were randomized into two groups and cervical esophagogastric anastomosis was performed using a stapler (n=102) or manually (n=125). The incidence of postoperative complications and operative time were compared between the two groups. In manual anastomosis group, anastomotic leak and anastomotic stricture occurred in 14.4% (18/125) and 8.8.% (11/125) of the patients, significantly higher than the incidences of 2.9% (3/102) and 3.9% (4/102) in the mechanical anastomosis group (P<0.01). Manual anastomosis required a significantly longer operative time than mechanical anastomosis (52∓12 vs 25∓5 min, P<0.01). The use of circular mechanical stapler in cervical esophagogastric anastomosis is associated with a lower rate of anastomotic leak and a shorter operative time, and is easy to learn and standardize to reduce the complications of the anastomosis.

Effect of Slip Time in Forming Neo-Esophageal Stenosis After Replacement of a Thoracic Esophagus With Nitinol Artificial Esophagus.

PubMed

Liang, Xian-Liang; Liang, Jian-Hui

2015-07-01

Attempts have been made to investigate the effect of slip time of nitinol artificial esophagus for forming neo-esophageal stenosis after replacement of a thoracic esophagus with nitinol artificial esophagus in 20 experimental pigs. The pigs whose slip time was less than 90 days postoperatively had severe dysphagia (Bown's III) immediately after they were fed, and the dysphagia aggravated gradually later on (Bown's III-IV). The pigs whose slip time was more than 90 days postoperatively had mild/moderate dysphagia (Bown's I-II) immediately after they were fed, and the dysphagia relieved gradually later on (Bown's II-I-0). The ratios between the diameter of neo-esophagus in different slip time and normal esophagus were 25% (at 2 months postoperatively), 58% (at 4 months postoperatively), and 93% (at 6 months postoperatively), respectively. The relationship between nitinol artificial esophagus slip time and neo-esophageal stenosis showed a positive correlation. After replacement of a thoracic esophagus with nitinol artificial esophagus, the artificial esophageal slip time not only affected the original diameter of the neo-esophagus immediately, but also affected the neo-esophageal scar stricture forming process later on. The narrowing of neo-esophagus is caused by overgrowth of scar tissue. But there is the positive correlation between artificial esophagus slip time and neo-esophageal stenosis, so this can be a way of overcoming neo-esophageal stenosis by delaying slip time of artificial esophagus. Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Dosimetric correlations of acute esophagitis in lung cancer patients treated with radiotherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Takeda, Ken; Nemoto, Kenji; Saito, Haruo

2005-07-01

Purpose: To evaluate the factors associated with acute esophagitis in lung cancer patients treated with thoracic radiotherapy. Methods and Materials: We examined 35 patients with non-small-cell lung cancer (n = 27, 77%) and small-cell lung cancer (n = 8, 23%) treated with thoracic radiotherapy between February 2003 and November 2004. The median patient age was 70 years (range, 50-83 years). The disease stage was Stage I in 2 patients (6%), Stage II in 1 (3%), Stage IIIa in 10 (28%), Stage IIIb in 9 (26%), and Stage IV in 9 (26%); 4 patients (11%) had recurrent disease after surgery. Amore » median dose of 60 Gy (range, 50-67 Gy) was given to the isocenter and delivered in single daily fractions of 1.8 or 2 Gy. With heterogeneity corrections, the median given dose to the isocenter was 60.3 Gy (range, 49.9-67.2 Gy). Of the 35 patients, 30 (86%) received concurrent chemotherapy consisting of a platinum agent, cisplatin or carboplatin, combined with paclitaxel in 18 patients (52%), irinotecan hydrochloride in 7 (20%), vincristine sulfate and etoposide in 2 (5%), vinorelbine ditartrate in 1 (3%), etoposide in 1 (3%), and docetaxel in 1 patient (3%). Three of these patients underwent induction therapy with cisplatin and irinotecan hydrochloride, administered before thoracic radiotherapy, and concurrent chemotherapy. Esophageal toxicity was graded according to the Radiation Therapy Oncology Group criteria. The following factors were analyzed with respect to their association with Grade 1 or worse esophagitis by univariate and multivariate analyses: age, gender, concurrent chemotherapy, chemotherapeutic agents, maximal esophageal dose, mean esophageal dose, and percentage of esophageal volume receiving >10 to >65 Gy in 5-Gy increments. Results: Of the 35 patients, 25 (71%) developed acute esophagitis, with Grade 1 in 20 (57%) and Grade 2 in 5 (14%). None of the patients had Grade 3 or worse toxicity. The most significant correlation was between esophagitis and percentage of esophageal volume receiving >35 Gy on univariate (p = 0.002) and multivariate (p = 0.018) analyses. Conclusion: The percentage of esophageal volume receiving >35 Gy was the most statistically significant factor associated with mild acute esophagitis.« less

Risk Factors for Esophageal Fistula Associated With Chemoradiotherapy for Locally Advanced Unresectable Esophageal Cancer

PubMed Central

Tsushima, Takahiro; Mizusawa, Junki; Sudo, Kazuki; Honma, Yoshitaka; Kato, Ken; Igaki, Hiroyasu; Tsubosa, Yasuhiro; Shinoda, Masayuki; Nakamura, Kenichi; Fukuda, Haruhiko; Kitagawa, Yuko

2016-01-01

Abstract Esophageal fistula is a critical adverse event in patients treated with chemoradiotherapy (CRT) for locally advanced esophageal cancer. However, risk factors associated with esophageal fistula formation in patients receiving CRT have not yet been elucidated. We retrospectively analyzed data obtained from 140 patients who were enrolled in a phase II/III trial comparing low-dose cisplatin with standard-dose cisplatin administered in combination with 5-flurouracil and concomitant radiotherapy. Inclusion criteria were performance status (PS) 0 to 2 and histologically proven thoracic esophageal cancer clinically diagnosed as T4 and/or unresectable lymph node metastasis for which definitive CRT was applicable. Risk factors for esophageal fistula were examined with univariate analysis using Fisher exact test and multivariate analysis using logistic regression models. Esophageal fistula was observed in 31 patients (22%). Of these, 6 patients developed fistula during CRT. Median time interval between the date of CRT initiation and that of fistula diagnosis was 100 days (inter quartile range, 45–171). Esophageal stenosis was the only significant risk factor for esophageal fistula formation both in univariate (P = 0.026) and in multivariate analyses (odds ratio, 2.59; 95% confidence interval, 1.13–5.92, P = 0.025). Other clinicopathological factors, namely treatment arm, age, sex, PS, primary tumor location, T stage, lymph node invasion to adjacent organs, blood cell count, albumin level, and body mass index, were not risk factors fistula formation. Esophageal stenosis was a significant risk factor for esophageal fistula formation in patients treated with CRT for unresectable locally advanced thoracic esophageal squamous cell carcinoma. PMID:27196482

Constrictive Pericarditis 5 Months after Radiation Therapy in a 62-Year-Old Woman with Esophageal Cancer.

PubMed

Yeneneh, Beeletsega T; Allen, Sorcha; Panse, Prasad; Mookadam, Farouk; Rule, William

2017-12-01

Most pericardial changes appear within a few weeks in patients who have undergone radiation therapy for thoracic neoplasms. Chronic pericardial constriction typically occurs decades later, consequent to fibrosis. Early constrictive pericarditis after chest irradiation is quite rare. We report the case of a 62-year-old woman who underwent radiation therapy for esophageal cancer and presented with constrictive pericarditis 5 months later. We searched the English-language medical literature from January 1986 through December 2015 for reports of early constrictive pericarditis after irradiation for thoracic malignancies. We defined "early" as a diagnosis within one year after radiation therapy. Five cases fit our criteria, and we summarize the findings here. To our knowledge, ours is the first definitive report of a patient with esophageal cancer to present with early radiation-induced constrictive pericarditis. We conclude that constrictive pericarditis can occur early after radiation for thoracic malignancies, albeit rarely. When planning care for cancer patients, awareness of this sequela is helpful.

SU-E-T-06: A Comparison of IMRT Treatment of Esophageal Carcinoma in Elekta-Precise and Varian23EX Linac

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bai, W; Fan, X; Qiu, R

2014-06-01

Purpose: To compare and analyze the characteristics of static intensity-modulated radiotherapy (IMRT) plans designed on Elekta and Varian Linac in different esophageal cancer(EC), exploring advantages and disadvantages of different vendor Linac, thus can be better serve for clinical. Methods: Twenty-four patients with EC were selected, including 6 cases located in the cervical, upper, middle and the lower thorax, respectively. Two IMRT plans were generated with the Oncentra planning system: in Elekta and Varian Linac, prescription dose of 60Gy in 30 fractions to the PTV. We examined the dose-volume histogram parameters of PTV and the organs at risk (OAR) such asmore » lungs, spinal cord and heart, and additional Monitor units(MU), treatment time, Homogeneity index(HI), Conformity index(CI) and Gamma index comparisons were performed. Results: All plans resulted in abundant dose coverage of PTV for EC of different locations. The doses to PTV, HI and OAR in Elekta plans were not statistically different in comparison with Varian plans, with the following exceptions: in cervical, upper and lower thoracic EC the PTV's CI, and in middle thorax EC PTV's D2, D50, V105 and PTV-average were better in Elekta plans than in Varian plans. In the cervical, upper and the middle thorax EC, treatment time were significantly decreased in Varian plans as against Elekta plans, while in the lower thoracic EC treatment time were no striking difference. MUs and gamma index were similar between the two Linac plans. Conclusion: For the the middle thorax EC Varian plans is better than Elekta plans, not only in treatment time but in the PTV dose; while for the lower thorax EC Elekta plans is the first choice for better CI; for the other part of the EC usually Elekta plans can increase the CI, while Varian plans can reduce treatment time, can be selected according to the actual situation of the patient treatment.« less

Elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for squamous cell carcinoma of the thoracic esophagus.

PubMed

Onozawa, Masakatsu; Nihei, Keiji; Ishikura, Satoshi; Minashi, Keiko; Yano, Tomonori; Muto, Manabu; Ohtsu, Atsushi; Ogino, Takashi

2009-08-01

There are some reports indicating that prophylactic three-field lymph node dissection for esophageal cancer can lead to improved survival. But the benefit of ENI in CRT for thoracic esophageal cancer remains controversial. The purpose of the present study is to retrospectively evaluate the efficacy of elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for thoracic esophageal cancer. Patients with squamous cell carcinoma (SCC) of the thoracic esophagus newly diagnosed between February 1999 and April 2001 in our institution was recruited from our database. Definitive chemoradiotherapy consisted of two cycles of cisplatin/5FU repeated every 5 weeks, with concurrent radiation therapy of 60 Gy in 30 fractions. Up to 40 Gy radiation therapy was delivered to the cervical, periesophageal, mediastinal and perigastric lymph nodes as ENI. One hundred two patients were included in this analysis, and their characteristics were as follows: median age, 65 years; male/female, 85/17; T1/T2/T3/T4, 16/11/61/14; N0/N1, 48/54; M0/M1, 84/18. The median follow-up period for the surviving patients was 41 months. Sixty patients achieved complete response (CR). After achieving CR, only one (1.0%; 95% CI, 0-5.3%) patient experienced elective nodal failure without any other site of recurrence. In CRT for esophageal SCC, ENI is effective for preventing regional nodal failure. Further evaluation of whether ENI leads to an improved overall survival is needed.

SU-E-T-125: Application of Jaw-Tracking Function in VMAT for Upper Thoracic Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zhang, W; Chen, J; Zhai, T

2015-06-15

Purpose: To explore the effect of the Jaw-tracking with RapidArc(JT-RapidArc) plans for upper thoracic esophageal cancer. Methods: Treatment planning was designed by using RapidArc and JT-RapidArc techniques for 11 consecutive patients. The dose-volume histogram parameters of PTV and the organs at risk(OAR), conformity index(CI), heterogeneity index(HI), low dose volume of normal tissue(B-P) and monitor units(MUs) were compared between the different techniques. Results: JT-RapidArc plans provided the better coverage of PTV1(64) D98 and HI(P<0.05), lower MLD, D2 of PTV1(64) and PTV2(54), but no statistically difference in CI(P>0.05), which comparison with RapidArc plans. Plans with JT- RapidArc had lower Lung of V5,more » V10, V13, V20, V30, MLD(P<0.05); heart of V20, MLD(P<0.05); and B-P of V5, V10, V15, V20, V30(P<0.05); but no significantly different in Spinal cord and SC-PRV as compared with RapidArc plans. JT-RapidArc plans increaseed the MUs by 1%(P>0.05) as compared with RapidArc plans. Conclusion: All of the plans had met the requirements of clinical dosimetry. JT-RapidArc plans as compared with RapidArc plans, showing better part of target coverage, part of OARS(lung and heart) and heart and B-P sparing, which MUs was slightly increased. This work was sponsored by Shantou University Medical College Clinical Research Enhancement Initiative(NO.201424)« less

Radiation dose to the lymph drainage area in esophageal cancer with involved-field irradiation.

PubMed

Shen, Wenbin; Gao, Hongmei; Zhu, Shuchai; Li, Youmei; Li, Juan; Liu, Zhikun; Su, Jinwei

2016-01-01

The aim of this study was to quantify the radiation dose to the corresponding lymph drainage area in esophageal cancer using three-dimensional conformal radiation therapy (3D-CRT) with involvED-field IRradiation (IFI) and to analyze associated factors. A retrospective analysis oF 81 patients with esophageal cancer was conducted. According to the location of the lesions, the lymph drainage area was delineated and the dosimetric parameters were calculated. The 1-, 3-, 5- and 8-year survival rates of the patients were 67.90, 33.33, 20.99 and 11.11%, respectively. Based on the dose-volume histogram in the treatment plan, we calculated the volume percentage of the planning target volume including clinically positive lymph nodes (PTV-N) receiving radiation doses of 30, 35, 40, 45 and 50 Gy (V PTV-N30-50 ). The median values of V PTV-N30-50 were 73, 70, 67, 64 and 58%, respectively. The prescribed dose size exhibited no correlation with V PTV-N30-35 , but did exhibit a significant correlation with V PTV-N40-50 ; the radiation field was not correlated with V PTV-N30-45 , but exhibited a significant correlation with V PTV-N50 ; The length of the lesion on esophageal barium meal X-ray and the PTV were significantly correlated with V PTV-N30-50 . The analysis of variance revealed that the V PTV-NX value in the upper thoracic segment was higher compared with that in the middle and lower thoracic segments; V PTV-N30-35 values differed significantly according to the different locations of the lesions, whereas V PTV-N40-50 values exhibited no significant differences. The value of V PTV-NX exerted no significant effect on long-term patient survival. Therefore, the corresponding lymph drainage area of esophageal cancer IS subjected to a certain Radiation dose when patients undergo 3D-CRT with IFI, which may play a role in the prevention of regional nodal metastasis. However, this hypothesis requires confirmation by further clinical studies.

Radiation dose to the lymph drainage area in esophageal cancer with involved-field irradiation

PubMed Central

SHEN, WENBIN; GAO, HONGMEI; ZHU, SHUCHAI; LI, YOUMEI; LI, JUAN; LIU, ZHIKUN; SU, JINWEI

2016-01-01

The aim of this study was to quantify the radiation dose to the corresponding lymph drainage area in esophageal cancer using three-dimensional conformal radiation therapy (3D-CRT) with involvED-field IRradiation (IFI) and to analyze associated factors. A retrospective analysis oF 81 patients with esophageal cancer was conducted. According to the location of the lesions, the lymph drainage area was delineated and the dosimetric parameters were calculated. The 1-, 3-, 5- and 8-year survival rates of the patients were 67.90, 33.33, 20.99 and 11.11%, respectively. Based on the dose-volume histogram in the treatment plan, we calculated the volume percentage of the planning target volume including clinically positive lymph nodes (PTV-N) receiving radiation doses of 30, 35, 40, 45 and 50 Gy (VPTV-N30-50). The median values of VPTV-N30-50 were 73, 70, 67, 64 and 58%, respectively. The prescribed dose size exhibited no correlation with VPTV-N30-35, but did exhibit a significant correlation with VPTV-N40-50; the radiation field was not correlated with VPTV-N30-45, but exhibited a significant correlation with VPTV-N50; The length of the lesion on esophageal barium meal X-ray and the PTV were significantly correlated with VPTV-N30–50. The analysis of variance revealed that the VPTV-NX value in the upper thoracic segment was higher compared with that in the middle and lower thoracic segments; VPTV-N30-35 values differed significantly according to the different locations of the lesions, whereas VPTV-N40-50 values exhibited no significant differences. The value of VPTV-NX exerted no significant effect on long-term patient survival. Therefore, the corresponding lymph drainage area of esophageal cancer IS subjected to a certain Radiation dose when patients undergo 3D-CRT with IFI, which may play a role in the prevention of regional nodal metastasis. However, this hypothesis requires confirmation by further clinical studies. PMID:26870295

Effects of treatment with oxytocin, xylazine butorphanol, guaifenesin, acepromazine, and detomidine on esophageal manometric pressure in conscious horses.

PubMed

Wooldridge, Anne A; Eades, Susan C; Hosgood, Giselle L; Moore, Rustin M

2002-12-01

To compare effects of oxytocin, acepromazine maleate, xylazine hydrochloride-butorphanol tartrate, guaifenesin, and detomidine hydrochloride on esophageal manometric pressure in horses. 8 healthy adult horses. A nasogastric tube, modified with 3 polyethylene tubes that exited at the postpharyngeal area, thoracic inlet, and distal portion of the esophagus, was fitted for each horse. Amplitude, duration, and rate of propagation of pressure waveforms induced by swallows were measured at 5, 10, 20, 30, and 40 minutes after administration of oxytocin, detomidine, acepromazine, xylazine-butorphanol, guaifenesin, or saline (0.9% NaCI) solution. Number of spontaneous swallows, spontaneous events (contractions that occurred in the absence of a swallow stimulus), and high-pressure events (sustained increases in baseline pressure of > 10 mm Hg) were compared before and after drug adminision. At 5 minutes after administration, detomidine increased waveform amplitude and decreased waveform duration at the thoracic inlet. At 10 minutes after administration, detomidine increased waveform duration at the thoracic inlet. Acepromazine administration increased the number of spontaneous events at the thoracic inlet and distal portion of the esophagus. Acepromazine and detomidine administration increased the number of high-pressure events at the thoracic inlet. Guaifenesin administration increased the number of spontaneous events at the thoracic inlet. Xylazine-butorphanol, detomidine, acepromazine, and guaifenesin administration decreased the number of spontaneous swallows. Detomidine, acepromazine, and a combination of xylazine butorphanol had the greatest effect on esophageal motility when evaluated manometrically. Reduction in spontaneous swallowing and changes in normal, coordinated peristaltic activity are the most clinically relevant effects.

Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome.

PubMed

Guntipalli, Prathima; Chason, Rebecca; Elliott, Alan; Rockey, Don C

2014-12-01

We have recognized a unique clinical syndrome in patients with upper gastrointestinal bleeding who are found to have severe esophagitis. We aimed to more clearly describe the clinical entity of upper gastrointestinal bleeding in patients with severe esophagitis. We conducted a retrospective matched case-control study designed to investigate clinical features in patients with carefully defined upper gastrointestinal bleeding and severe esophagitis. Patient data were captured prospectively via a Gastrointestinal Bleeding Healthcare Registry, which collects data on all patients admitted with gastrointestinal bleeding. Patients with endoscopically documented esophagitis (cases) were matched with randomly selected controls that had upper gastrointestinal bleeding caused by other lesions. Epidemiologic features in patients with esophagitis were similar to those with other causes of upper gastrointestinal bleeding. However, hematemesis was more common in patients with esophagitis 86% (102/119) than in controls 55% (196/357) (p < 0.0001), while melena was less common in patients with esophagitis 38% (45/119) than in controls 68% (244/357) (p < 0.0001). Additionally, the more severe the esophagitis, the more frequent was melena. Patients with esophagitis had less abnormal vital signs, lesser decreases in hematocrit, and lesser increases in BUN. Both pre- and postRockall scores were lower in patients with esophagitis compared with controls (p = 0.01, and p < 0.0001, respectively). Length of hospital stay (p = 0.002), rebleeding rate at 42 days (p = 0.0007), and mortality were less in patients with esophagitis than controls. Finally, analysis of patients with esophagitis and cirrhosis suggested that this group of patients had more severe bleeding than those without cirrhosis. We have described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. This syndrome is manifest by typical clinical features and is associated with favorable outcomes.

Multiple huge epiphrenic esophageal diverticula with motility disease treated with video-assisted thoracoscopic and hand-assisted laparoscopic esophagectomy: a case report.

PubMed

Taniguchi, Yoshiki; Takahashi, Tsuyoshi; Nakajima, Kiyokazu; Higashi, Shigeyoshi; Tanaka, Koji; Miyazaki, Yasuhiro; Makino, Tomoki; Kurokawa, Yukinori; Yamasaki, Makoto; Takiguchi, Shuji; Mori, Masaki; Doki, Yuichiro

2017-12-01

Epiphrenic esophageal diverticulum is a rare condition that is often associated with a concomitant esophageal motor disorder. Some patients have the chief complaints of swallowing difficulty and gastroesophageal reflux; traditionally, such diverticula have been resected via right thoracotomy. Here, we describe a case with huge multiple epiphrenic diverticula with motility disorder, which were successfully resected using a video-assisted thoracic and laparoscopic procedure. A 63-year-old man was admitted due to dysphagia, heartburn, and vomiting. An esophagogram demonstrated an S-shaped lower esophagus with multiple epiphrenic diverticula (75 × 55 mm and 30 × 30 mm) and obstruction by the lower esophageal sphincter (LES). Esophageal manometry showed normal peristaltic contractions in the esophageal body, whereas the LES pressure was high (98.6 mmHg). The pressure vector volume of LES was 23,972 mmHg 2  cm. Based on these findings, we diagnosed huge multiple epiphrenic diverticula with a hypertensive lower esophageal sphincter and judged that resection might be required. We performed lower esophagectomy with gastric conduit reconstruction using a video-assisted thoracic and hand-assisted laparoscopic procedure. The postoperative course was uneventful, and the esophagogram demonstrated good passage, with no leakage, stenosis, or diverticula. The most common causes of mid-esophageal and epiphrenic diverticula are motility disorders of the esophageal body; appropriate treatment should be considered based on the morphological and motility findings.

Accuracy of CT chest without oral contrast for ruling out esophageal perforation using fluoroscopic esophagography as reference standard: a retrospective study.

PubMed

Awais, Muhammad; Qamar, Saqib; Rehman, Abdul; Baloch, Noor Ul-Ain; Shafqat, Gulnaz

2018-02-26

Esophageal perforation has a high mortality rate. Fluoroscopic esophagography (FE) is the procedure of choice for diagnosing esophageal perforation. However, FE can be difficult to perform in seriously ill patients. We retrospectively reviewed charts and scans of all patients who had undergone thoracic CT (TCT) without oral contrast and FE for suspicion of esophageal perforation at our hospital between October, 2010 and December, 2015. Scans were interpreted by a single consultant radiologist having > 5 years of relevant experience. Statistical analysis was performed using SPSS version 20. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TCT were computed using FE as reference standard. Of 122 subjects, 106 (83%) were male and their median age was 42 [inter-quartile range (IQR) 29-53] years. Esophageal perforation was evident on FE in 15 (8%) cases. Sensitivity, specificity, PPV and NPV of TCT for detecting esophageal perforation were 100, 54.6, 23.4 and 100%, respectively. When TCT was negative (n = 107), an alternative diagnosis was evident in 65 cases. Thoracic computed tomography (TCT) had 100% sensitivity and negative predictive value for excluding esophageal perforation. FE may be omitted in patients who have no evidence of mediastinal collection, pneumomediastinum or esophageal wall defect on TCT. However, in the presence of any of these features, FE is still necessary to confirm or exclude the presence of an esophageal perforation.

SU-F-T-421: Dosimetry Change During Radiotherapy and Dosimetry Difference for Rigid and Deformed Registration in the Mid-Thoracic Esophageal Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tao, C; Liu, T; Chen, J

Purpose: This study aimed to analyze dosimetry changes during radiotherapy for the mid-thoracic esophageal carcinoma, and investigate dosimetry difference between rigid and deformed registration. Methods: Twelve patients with primary middle thoracic esophageal carcinoma were selected randomly. Based on first CT scanning of each patient, plans-o were generated by experience physicists. After 20 fractions treatment, the corresponding plans-re were created with second CT scanning. And then, these two CT images were rigid and deformed registration respectively, and the dose was accumulated plan-o with plan-re. The dosimetry variation of these plans (plan-o: with 30 fractions, plan-rig: the accumulated dose with rigid registrationmore » and plan-def: the accumulated dose with deformed registration) were evaluated by paired T-test. Results: The V20 value of total lung were 32.68%, 30.3% and 29.71% for plan-o, plan-rig and plan-def respectively. The mean dose of total lung was 17.19 Gy, 16.67 Gy and 16.51 Gy for plan-o plan-rig and plan-def respectively. There were significant differences between plan-o and plan-rig or plan-def for both V20 and mean dose of total lung (with p= 0.003, p= 0.000 for V20 and p=0.008, p= 0.000 for mean dose respectively). There was no significant difference between plan-rig and plan-def (with p=0.118 for V20 and p=0.384 for mean dose). The max dose of spinal-cord was 41.95 Gy, 41.48 Gy and 41.4 Gy for plan-o, plan-rig and plan-def respectively. There were no significant differences for the max dose of spinal-cord between these plans. Conclusion: The target volume changes and anatomic position displacement of mid-thoracic esophageal carcinoma should not be neglected in clinics. These changes would cause overdose in normal tissue. Therefore, it is necessary to have another CT scanning and re-plan during the mid-thoracic esophageal carcinoma radiotherapy. And the dosimetry difference between rigid and deformed fusions was not found in this study.« less

Dosimetric comparison between modulated arc therapy and static intensity modulated radiotherapy in thoracic esophageal cancer: a single institutional experience.

PubMed

Choi, Kyu Hye; Kim, Jina; Lee, Sea-Won; Kang, Young-Nam; Jang, HongSeok

2018-03-01

The objective of this study was to compare dosimetric characteristics of three-dimensional conformal radiotherapy (3D-CRT) and two types of intensity-modulated radiotherapy (IMRT) which are step-and-shoot intensity modulated radiotherapy (s-IMRT) and modulated arc therapy (mARC) for thoracic esophageal cancer and analyze whether IMRT could reduce organ-at-risk (OAR) dose. We performed 3D-CRT, s-IMRT, and mARC planning for ten patients with thoracic esophageal cancer. The dose-volume histogram for each plan was extracted and the mean dose and clinically significant parameters were analyzed. Analysis of target coverage showed that the conformity index (CI) and conformation number (CN) in mARC were superior to the other two plans (CI, p = 0.050; CN, p = 0.042). For the comparison of OAR, lung V 5 was lowest in s-IMRT, followed by 3D-CRT, and mARC (p = 0.033). s-IMRT and mARC had lower values than 3D-CRT for heart V 30 (p = 0.039), V 40 (p = 0.040), and V 50 (p = 0.032). Effective conservation of the lung and heart in thoracic esophageal cancer could be expected when using s-IMRT. The mARC was lower in lung V 10 , V 20 , and V 30 than in 3D-CRT, but could not be proven superior in lung V 5 . In conclusion, low-dose exposure to the lung and heart were expected to be lower in s-IMRT, reducing complications such as radiation pneumonitis or heart-related toxicities.

[A Case of Resected Gastric Cancer Invading the Esophagus with Esophageal Recurrence That Responded to Weekly Docetaxel／Cisplatin Chemotherapy].

PubMed

Maezawa, Yukio; Hayashi, Tsutomu; Yamamoto, Jun; Ohnishi, Hiroshi; Horii, Nobutoshi; Inoue, Hirohide; Kimura, Jun; Takagawa, Ryo; Makino, Hirochika; Suzuki, Yoshihiro; Ohshima, Takashi; Tsuburaya, Akira; Rino, Yasushi; Kunisaki, Chikara; Masuda, Munetaka

2015-10-01

A 77-year-old man underwent total gastrectomy with D1+ lymph node dissection after being diagnosed with cT4aN2M0, cStage ⅢB gastric cancer. Peritoneal dissemination was detected in the bursa omentalis. The pathological diagnosis after surgery was pT4aN3b (21/41) M1 (P1). He was treated with 6 courses of S-1 chemotherapy. Two years after surgery, upper gastrointestinal endoscopy revealed the presence of a tumor in the mid-thoracic esophagus. It was diagnosed to as metastatic esophageal cancer and treated with combination chemotherapy consisting of docetaxel (25 mg/m2, days 1, 8, 15) and cisplatin (25 mg/m2, days 1, 8, 15) in a 28-day cycle. A clinically complete response was observed after 5 courses of chemotherapy. Currently, the patient is alive with no signs of recurrence 12 months after the initial recurrence.

On the Quantitative Analysis of Liquid Flow in Physiological Tubes.

DTIC Science & Technology

1982-12-01

cri- copharyngeal sphincter which is aided by skeletal muscle (Vantrap- pen and hellemans, 1980) relaxes to accept the bolus and the gastro - esophageal ...lower ( gastro -) esophageal junction during peristalsis resulting from the interaction of gastric, esophageal and thoracic pressures. PIP is a pressure...higher than the downstream pressure and a flow velocity profile with no reflux (syn.: retropulsion). The 5 Pumping in Biological Tubes a. Peristaltic

[A new technic for esophago-enteral anastomosis with a mechanical stapler without purse-string sutures].

PubMed

Liboni, A; Mari, C; Zamboni, P; Uzzau, A; Noce, L; Bucoliero, F; Mele, M; Masala, C

1989-01-01

Staplers have improved the results of esophageal surgery, in our experience and in others experience, as esophago-enteric anastomoses have become safer and faster than when manual suturing is used. Probably one of the last problems in the stapler technique, especially in the thoracic area, is the performance of on adequate esophageal purse-string suture: an improper performance of this suture can cause a dangerous leak of the anastomosis. So, many surgeons, to reduce the risk of esophageal dehiscence connected with the esophageal purse-string, use either purse-string devices or alternative methods such as a second handsewn purse-string, U stitches of the esophagus, etc. We think that the risk of improper anastomoses after esophageal resection can be reduced if the need for the esophageal purse-string can be eliminated. This work shows our personal technique for performing esophagoenterostomy, especially in the thoracic area, using the new CEEA stapler (Autosuture) without esophageal purse-string sutures. According to the modified procedure the stapler anvil and the mini rod are introduced in the esophagectomy and a 2-0 thread is knotted around the CEEA mini rod. Then the esophageal mutilated part is closed by a linear stapler keeping a syringe needle, which contains the thread, through the linear suture. Then, using the thread as a pulling system, the surgeon makes the needle and the tip of the mini rod slide out of the esophageal suture. Now the surgeon can reassemble the CEEA and perform the anastomosis. There are many clinical reports that cite no leaks following circular stapled anastomoses across linear stapled closures.

[Self-expanding antireflux stents for malignant esophageal stenosis - a report of three cases].

PubMed

Kusano-Kitazume, Akiko; Ami, Katsunori; Nagahama, Takeshi; Kondo, Mayumi; Okamoto, Eiko; Tamura, Atsushi; Takagi, Kentaro; Hayasaka, Junnosuke; Watanabe, Ayako; Kawai, Yosuke; Fujiya, Keiichi; Amagasa, Hidetoshi; Ganno, Hideaki; Imai, Kenichiro; Fukuda, Akira; Ando, Masayuki; Arai, Kuniyoshi; Shibayama, Takao

2014-11-01

Use of a standard open stent or self-expanding metal stent for patients with malignant dysphagia is associated with a risk of gastroesophageal reflux especially when placed across the esophagogastric junction. We report 3 cases of malignant esophageal stenosis treated with a long cover-type Niti-STM stent with an antireflux mechanism. Case 1: A 87-year-old man presented with dysphagia due to esophageal cancer at the middle thoracic esophagus. Two months after surgery using a standard open stent, the dysphagia relapsed because of tissue overgrowth. Case 2: A 73-year-old woman presented with lung cancer and severe dysphagia due to enlarged mediastinal lymph nodes. Case 3: A 66-year-old man presented with dysphagia due to esophageal cancer at the lower thoracic esophagus. All 3 patients received an antireflux stent across the esophagogastric junction. In cases 1 and 2, dysphagia was relieved immediately without complications. In case 3, the patient experienced severe reflux and chest pain associated with stent placement and could not ingest any solid food. We conclude that the antireflux stent may be useful for palliation in patients with severe malignant esophageal obstruction; however, patients should be informed about the risk of failure to prevent reflux.

[Diagnostic image (113). A neonate blowing bubbles. Esophageal atresia with tracheoesophageal fistula, Hirschsprung disease and suspected Down's syndrome].

PubMed

Postema, R R; Meradji, M; Langemeijer, R A Th M

2002-11-09

In a male neonate 'blowing bubbles', three diagnoses were seen on a combined thoracic and abdominal X-ray: esophageal atresia with tracheoesophageal fistula, Hirschsprung's disease, and suspected Down's syndrome (because of the presence of II pairs of ribs).

Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia.

PubMed

Chaudhry, Naueen A; Zahid, Kamran; Keihanian, Sara; Dai, Yunfeng; Zhang, Qing

2017-11-28

To investigate the behavior of pulsatile pressure zones (PPZ's) as noted on high resolution esophageal impedance manometry (HREIM), and determine their association with dysphagia. Retrospective, single center case control design screening HREIM studies for cases (dysphagia) and controls (no dysphagia). Thoracic radiology studies were reviewed further in cases for (thoracic cardiovascular) thoracic cardiovascular (TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function (impedance). Among 317 screened patients, 56% cases and 64% controls had PPZ's. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ's in these 50 cases and 59 controls was similar (average 1.4 PPZ/patient). Controls (mean 31.2 ± SD 12 years) were a significantly younger population than cases (mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls (15.7 ± 10.0 mmHg) than cases (10.8 ± 9.7 mmHg). Although statistically significant ( P = 0.005), it was a weak predictor using logistic regression and ROC model (AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology (1 aberrant subclavian artery, 2 dilated left atrium). The posture (supine vs upright) with more prominent PPZ's impaired bolus clearance in 9 additional cases by > 20%. Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.

Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia

PubMed Central

Chaudhry, Naueen A; Zahid, Kamran; Keihanian, Sara; Dai, Yunfeng; Zhang, Qing

2017-01-01

AIM To investigate the behavior of pulsatile pressure zones (PPZ’s) as noted on high resolution esophageal impedance manometry (HREIM), and determine their association with dysphagia. METHODS Retrospective, single center case control design screening HREIM studies for cases (dysphagia) and controls (no dysphagia). Thoracic radiology studies were reviewed further in cases for (thoracic cardiovascular) thoracic cardiovascular (TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function (impedance). RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ’s. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ’s in these 50 cases and 59 controls was similar (average 1.4 PPZ/patient). Controls (mean 31.2 ± SD 12 years) were a significantly younger population than cases (mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls (15.7 ± 10.0 mmHg) than cases (10.8 ± 9.7 mmHg). Although statistically significant (P = 0.005), it was a weak predictor using logistic regression and ROC model (AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology (1 aberrant subclavian artery, 2 dilated left atrium). The posture (supine vs upright) with more prominent PPZ’s impaired bolus clearance in 9 additional cases by > 20%. CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel. PMID:29209125

Safe removal of upper esophageal coins by using Magill forceps: two centers' experience.

PubMed

Cetinkursun, Salih; Sayan, Ali; Demirbag, Suzi; Surer, Ilhami; Ozdemir, Tunc; Arikan, Ahmet

2006-01-01

Coin ingestion with subsequent esophageal coin impaction is common in children. Considerable debate surrounds the choice of technique for the removal of esophageal coins. This study demonstrates a minimally invasive technique for upper esophageal coin extraction. A retrospective review was conducted of 165 children who had upper esophageal coins extracted by using a Magill forceps. One hundred fifty-six coins (96.4%) were successfully removed without any complications. The average time taken to remove the coin was 33 seconds. Use of the Magill forceps technique minimizes instrumentation of the esophagus and is an easy, safe technique for removing coins from the upper end of the esophagus.

Radiation treatment for newly diagnosed esophageal cancer with prior radiation to the thoracic cavity

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sponseller, Patricia, E-mail: sponselp@uw.edu; Lenards, Nishele; Kusano, Aaron

2014-10-01

The purpose of this report is to communicate the use of single-positron emission computed tomography scan in planning radiation treatments for patients with a history of radiation to the thoracic cavity. A patient presented with obstructive esophageal cancer, having previously received chemotherapy and radiation therapy to the mediastinum for non-Hodgkin lymphoma 11 years earlier. Owing to a number of comorbidities, the patient was not a surgical candidate and was referred to the University of Washington Medical Center for radiation therapy. Prior dose to the spinal cord and lung were taken into account before designing the radiation treatment plan.

[Esophageal bronchogenic cyst: an uncommon cause of dysphagia in adults. Case report and literature review].

PubMed

Ceniceros-Cabrales, Ana P; Sánchez-Fernández, Patricio

2018-01-01

Bronchogenic cysts result from abnormal budding of the primitive tracheobronchial tube and are rare congenital cystic lesions. The location of the cyst depends on the embryological stage of abnormal budding. Although periesophageal bronchogenic cysts have been frequently reported, a completely intramural cyst is very rare. A 42-year-old female patient, a three-month course with retrosternal pain associated with food intake, accompanied by intermittent dysphagia to solids. Esophagogram, high resolution thoracic tomography and endoscopic ultrasound are performed, concluding a probable esophageal bronchogenic cyst. Resection is performed by video-assisted thoracic surgery, without complications. Patient presents with adequate evolution and complete remission of the symptomatology. Bronchogenic cysts of the esophageal wall are extremely uncommon lesions. Its surgical treatment is indicated to be symptomatic; video-assisted thoracoscopic surgery resection is of choice, with excellent long-term results and minimal morbidity. Copyright: © 2018 Permanyer.

Reoperations for esophageal achalasia.

PubMed

Omura, Nobuo; Kashiwagi, Hideyuki; Yano, Fumiaki; Tsuboi, Kazuto; Yanaga, Katsuhiko

2012-11-01

To define the factors predisposing to recurrence and evaluate the results of reoperations for achalasia. We reviewed the medical records of ten patients (4 men and 6 women; mean age, 51.5 ± 11.0 years), who underwent reoperations for achalasia between August 1994 and August 2010. The primary surgical procedures were Heller-Dor (HD) cardioplasty in nine patients and Heller myotomy in one patient. The factors contributing to failure of the primary operation included inadequate myotomy (n = 2), recurrent adhesion after myotomy (n = 2), reflux esophagitis (n = 2), difficulty in passage caused by tortuosity of the esophagus (n = 2), difficulty in passage through the thoracic esophagus (n = 1), and severe chest pain (n = 1). The reoperations included repeated HD procedures (n = 4), repair of an esophageal hiatal hernia (n = 2), thoracic esophageal myotomy (n = 2), straightening of the lower esophagus with gastropexy (n = 1), and subtotal esophagectomy (n = 1). The success rate of the reoperations for resolving symptoms was 90 % (9 patients). Selecting surgical procedures based on the causes and conditions of recurrence led to symptomatic improvement and acceptable outcomes.

Preoperative thoracic radiographic findings in dogs presenting for gastric dilatation-volvulus (2000-2010): 101 cases.

PubMed

Green, Jaime L; Cimino Brown, Dorothy; Agnello, Kimberly A

2012-10-01

To identify the incidence of clinically significant findings on preoperative thoracic radiographs in dogs with gastric dilatation-volvulus (GDV) and to determine if those findings are associated with survival. Retrospective study from 2000 to 2010. Urban university small animal teaching hospital. One hundred and one dogs diagnosed with GDV that had thoracic radiographs obtained preoperatively, and medical records available with the following information available: signalment, time of presentation, respiratory status, plasma lactate, presence of cardiac arrhythmias, reason for thoracic radiographs, radiographic findings, and outcome. None. Findings on preoperative thoracic radiographs included small vena cava (40%), esophageal dilation (39%), microcardia (34%), aspiration pneumonia (14%), cardiomegaly (5%), pulmonary nodule (4%), pulmonary edema (2%), sternal lymphadenopathy (1%), and pulmonary bullae (1%). Eighty-four percent of dogs (85 out of 101) survived to discharge. Dogs without cardiomegaly on presenting thoracic radiographs had a 10.2 greater odds of surviving to discharge. The most common findings on preoperative thoracic radiographs include esophageal dilation, microcardia, and a small vena cava while the incidence of pulmonary nodules was low. A negative association between survival and presence of cardiomegaly on preoperative thoracic radiographs in dogs with GDV supports the need to obtain these images for prognostic information in spite of the emergency surgical nature of the GDV. The main limitations of this study include the possibilities of type I and type II errors, the retrospective nature of the study, and the lack of well-defined criteria for obtaining thoracic radiographs. © Veterinary Emergency and Critical Care Society 2012.

Upper thoracic respiratory interneurons integrate noxious somatic and visceral information in rats.

PubMed

Qin, Chao; Chandler, Margaret J; Foreman, Robert D; Farber, Jay P

2002-11-01

The aim of this study was to determine if thoracic respiratory interneurons (TRINs) might receive peripheral noxious somatic and visceral inputs. Extracellular potentials of 78 respiration-related T(3) neurons, whose activity was driven by central respiratory output, were recorded from the intermediate zone in pentobarbital anesthetized, paralyzed, and ventilated male rats. These neurons were identified as interneurons by their locations and by the absence of antidromic activation from the cervical sympathetic trunk and cerebellum. Thoracic esophageal distension (ED) was produced by water inflation of a latex balloon (0.1-0.5 ml, 20 s). A catheter was placed in the pericardial sac to administer 0.2 ml bradykinin (10(-5) M) for noxious cardiac stimulation. Of 78 TRINs examined for ED, activity of 24 TRINs increased and activity of 8 TRINs decreased. Intrapericardial bradykinin increased activity in 26/65 TRINs tested and decreased activity in 5 TRINs. Seventy-four TRINs were tested for effects of brush, pressure, and pinch of the chest and upper back areas. No TRINs responded to brushing hair. Low-threshold responses to pressure were observed in 27 TRINs. Fourteen TRINs were wide dynamic range and 4 TRINs had high-threshold responses. Peripheral stimuli affected all types of TRINs, including inspiratory, expiratory, and biphasic neurons. Simultaneous phrenic recordings showed that effects of various somatic and visceral stimuli on TRINs were independent of central respiratory drive. Various somatovisceral and viscerovisceral patterns of input were observed in TRINs. The results suggested that TRINs participate in intraspinal processing and integration of nociceptive information from somatic fields and visceral organs.

Cure and prevention strategy for postoperative gastrointestinal fistula after esophageal and gastric cardiac cancer surgery.

PubMed

Han, Youkui; Zhao, Hui; Xu, HongRui; Liu, Shuzhong; Li, Li; Jiang, Chunyang; Yang, Bingjun

2014-01-01

Gastrointestinal fistula is the most serious complication of esophageal and gastric cardiac cancer surgery. According to occurrence of organ, gastrointestinal fistula can be divided into anastomotic fistula, gastric fistula; According to occurrence site, fistula can be divided into cervical fistula, thoracic fistula; According to time of occurrence, can be divided into early, middle and late fistula. There are special types of fistula including ‘thoracic cavity’-stomach-bronchial fistula, ‘thoracic cavity’-stomach-aortic fistula. Early diagnosis needs familiarity with various types of clinical gastrointestinal fistulas. However, Prevention of gastrointestinal fistula is better than cure, including perioperative nutritional support, respiratory tract management, and acid suppression, positive treatment of complications, antibiotic prophylaxis, and gastrointestinal decompression and eating timing. Prevention can effectively reduce the incidence of postoperative gastrointestinal fistula. Collectively, early diagnosis and treatment, nutritional supports are key to reducing mortality of gastrointestinal fistula.

Moderately hypofractionated conformal radiation treatment of thoracic esophageal carcinoma.

PubMed

Ma, Jin-Bo; Wei, Lin; Chen, Er-Cheng; Qin, Guang; Song, Yi-Peng; Chen, Xiang-Ming; Hao, Chuan-Guo

2012-01-01

To prospectively assess the efficacy and safety of moderately hypofractionated conformal radiotherapy in patients with thoracic esophageal cancer. From Sept. 2002 to Oct. 2005, 150 eligible patients with T2-4N0-1M0 stage thoracic esophageal squamous cell cancers were enrolled to receive either conventional fractionated radiation (CFR) or moderately hypofractionated radiation (MHR) with a three- dimensional conformal radiation technique. Of the total, 74 received moderately hypofractionated radiation with total dose of 54-60 Gy/18-20 fractions for 3.5-4 weeks in the MHR arm, and 76 received conventional radiation with total dose of 60 Gy/30 fractions for 6 weeks in the CFR arm. Concurrent chemotherapy comprised of paclitaxel and cisplatin. Safety was evaluated, and local control and overall survival rates were calculated. Statistically significant differences between the CFR versus MHR arms were observed in local/regional failure rate (47.3% v 27.0%, P=0.034) and the percentage of patients with persistent local disease (26.3% v 10.8%, P=0.012). But 3 and 5-year overall survival rates (43.2%, 38.8% v 38.2%, 28.0%, respectively) were not different between the two arms (P=0.268). There were no significant differences in the incidences of grade 3 or higher acute toxicities (66.3% v 50.0%) and late complications rates (27.0% v 22.4%) between the MHR and CFR arms. Moderately hypofractionated, three-dimensional radiation treatment could improve the local control rate of esophageal cancer and potentially increase patient survival.

Dosimetric comparison using different multileaf collimeters in intensity-modulated radiotherapy for upper thoracic esophageal cancer.

PubMed

Gong, Youling; Wang, Shichao; Zhou, Lin; Liu, Yongmei; Xu, Yong; Lu, You; Bai, Sen; Fu, Yuchuan; Xu, Qingfeng; Jiang, Qingfeng

2010-07-15

To study the impacts of multileaf collimators (MLC) width [standard MLC width of 10 mm (sMLC) and micro-MLC width of 4 mm (mMLC)] in the intensity-modulated radiotherapy (IMRT) planning for the upper thoracic esophageal cancer (UTEC). 10 patients with UTEC were retrospectively planned with the sMLC and the mMLC. The monitor unites (MUs) and dose volume histogram-based parameters [conformity index (CI) and homogeneous index (HI)] were compared between the IMRT plans with sMLC and with mMLC. The IMRT plans with the mMLC were more efficient (average MUs: 703.1 +/- 68.3) than plans with the sMLC (average MUs: 833.4 +/- 73.8) (p < 0.05). Also, compared to plans with the sMLC, the plans with the mMLC showed advantages in dose coverage of the planning gross tumor volume (Pgtv) (CI 0.706 +/- 0.056/HI 1.093 +/- 0.021) and the planning target volume (PTV) (CI 0.707 +/- 0.029/HI 1.315 +/- 0.013) (p < 0.05). In addition, the significant dose sparing in the D5 (3260.3 +/- 374.0 vs 3404.5 +/- 374.4)/gEUD (1815.1 +/- 281.7 vs 1849.2 +/- 297.6) of the spinal cord, the V10 (33.2 +/- 6.5 vs 34.0 +/- 6.7), V20 (16.0 +/- 4.6 vs 16.6 +/- 4.7), MLD (866.2 +/- 174.1 vs 887.9 +/- 172.1) and gEUD (938.6 +/- 175.2 vs 956.8 +/- 171.0) of the lungs were observed in the plans with the mMLC, respectively (p < 0.05). Comparing to the sMLC, the mMLC not only demonstrated higher efficiencies and more optimal target coverage, but also considerably improved the dose sparing of OARs in the IMRT planning for UTEC.

Inhaled Beta Agonist Bronchodilator Does Not Affect Trans-diaphragmatic Pressure Gradient but Decreases Lower Esophageal Sphincter Retention Pressure in Patients with Chronic Obstructive Pulmonary Disease (COPD) and Gastroesophageal Reflux Disease (GERD).

PubMed

Del Grande, Leonardo M; Herbella, Fernando A M; Bigatao, Amilcar M; Jardim, Jose R; Patti, Marco G

2016-10-01

Chronic obstructive pulmonary disease (COPD) patients have a high incidence of gastroesophageal reflux disease (GERD) whose pathophysiology seems to be linked to an increased trans-diaphragmatic pressure gradient and not to a defective esophagogastric barrier. Inhaled beta agonist bronchodilators are a common therapy used by patients with COPD. This drug knowingly not only leads to a decrease in the lower esophageal sphincter (LES) resting pressure, favoring GERD, but also may improve ventilatory parameters, therefore preventing GERD. This study aims to evaluate the effect of inhaled beta agonist bronchodilators on the trans-diaphragmatic pressure gradient and the esophagogastric barrier. We studied 21 patients (mean age 67 years, 57 % males) with COPD and GERD. All patients underwent high-resolution manometry and esophageal pH monitoring. Abdominal and thoracic pressure, trans-diaphragmatic pressure gradient (abdominal-thoracic pressure), and the LES retention pressure (LES basal pressure-transdiaphragmatic gradient) were measured before and 5 min after inhaling beta agonist bronchodilators. The administration of inhaled beta agonist bronchodilators leads to the following: (a) a simultaneous increase in abdominal and thoracic pressure not affecting the trans-diaphragmatic pressure gradient and (b) a decrease in the LES resting pressure with a reduction of the LES retention pressure. In conclusion, inhaled beta agonist bronchodilators not only increase the thoracic pressure but also lead to an increased abdominal pressure favoring GERD by affecting the esophagogastric barrier.

Doxepin Hydrochloride in Treating Esophageal Pain in Patients With Thoracic Cancer Receiving Radiation Therapy to the Thorax With or Without Chemotherapy

ClinicalTrials.gov

2017-11-30

Esophageal Carcinoma; Hypopharyngeal Carcinoma; Laryngeal Carcinoma; Lymphoma; Mesothelioma; Metastatic Malignant Neoplasm in the Lung; Metastatic Malignant Neoplasm in the Pleura; Metastatic Malignant Neoplasm in the Spinal Cord; Non-Small Cell Lung Carcinoma; Sarcoma; Small Cell Lung Carcinoma; Thymic Carcinoma; Thymoma; Thyroid Gland Carcinoma

Recurrent giant fibrovascular polyp of the esophagus

PubMed Central

Lee, Ser Yee; Chan, Weng Hoong; Sivanandan, Ranjiv; Lim, Dennis Teck Hock; Wong, Wai Keong

2009-01-01

Giant fibrovascular polyps of the esophagus and hypopharynx are rare benign esophageal tumors. They arise most commonly in the upper esophagus and may, rarely, originate in the hypopharynx. They can vary significantly in size. Even though they are benign, they may be lethal due to either bleeding or, rarely, asphyxiation if a large polyp is regurgitated. Patients commonly present with dysphagia or hematemesis. The polyps may not be well visualized on endoscopy and imaging plays a vital role in aiding diagnosis as well as providing important information for pre-operative planning, such as the location of the pedicle, the vascularity of the polyp and the tissue elements of the mass. They can also be recurrent in rare cases, especially if the resection margins of the base are involved. We review the recent literature and report a case of a 61-year-old man with a recurrent giant esophageal fibrovascular polyp with illustrative contrast barium swallow, CT and intra-operative images, who required several surgeries via a combination of endoscopic, trans-oral, trans-cervical, trans-thoracic and trans-abdominal approaches. PMID:19653354

Nondestructive measurement of esophageal biaxial mechanical properties utilizing sonometry

NASA Astrophysics Data System (ADS)

Aho, Johnathon M.; Qiang, Bo; Wigle, Dennis A.; Tschumperlin, Daniel J.; Urban, Matthew W.

2016-07-01

Malignant esophageal pathology typically requires resection of the esophagus and reconstruction to restore foregut continuity. Reconstruction options are limited and morbid. The esophagus represents a useful target for tissue engineering strategies based on relative simplicity in comparison to other organs. The ideal tissue engineered conduit would have sufficient and ideally matched mechanical tolerances to native esophageal tissue. Current methods for mechanical testing of esophageal tissues both in vivo and ex vivo are typically destructive, alter tissue conformation, ignore anisotropy, or are not able to be performed in fluid media. The aim of this study was to investigate biomechanical properties of swine esophageal tissues through nondestructive testing utilizing sonometry ex vivo. This method allows for biomechanical determination of tissue properties, particularly longitudinal and circumferential moduli and strain energy functions. The relative contribution of mucosal-submucosal layers and muscular layers are compared to composite esophagi. Swine thoracic esophageal tissues (n  =  15) were tested by pressure loading using a continuous pressure pump system to generate stress. Preconditioning of tissue was performed by pressure loading with the pump system and pre-straining the tissue to in vivo length before data was recorded. Sonometry using piezocrystals was utilized to determine longitudinal and circumferential strain on five composite esophagi. Similarly, five mucosa-submucosal and five muscular layers from thoracic esophagi were tested independently. This work on esophageal tissues is consistent with reported uniaxial and biaxial mechanical testing and reported results using strain energy theory and also provides high resolution displacements, preserves native architectural structure and allows assessment of biomechanical properties in fluid media. This method may be of use to characterize mechanical properties of tissue engineered esophageal constructs.

Leg raise increases pressure in lower and upper esophageal sphincter among patients with gastroesophageal reflux disease.

PubMed

Bitnar, P; Stovicek, J; Andel, R; Arlt, J; Arltova, M; Smejkal, M; Kolar, P; Kobesova, A

2016-07-01

The purpose of this study was to determine the relation between posturally increased intra-abdominal pressure and lower/upper esophageal sphincter pressure changes in patients with gastroesophageal reflux disease. We used high resolution manometry to measure pressure changes in lower and upper esophageal sphincter during bilateral leg rise. We also examined whether the rate of lower and upper esophageal sphincter pressure would increase during leg raise differentially in individuals with versus without normal resting pressure. Fifty eight patients with gastroesophageal reflux disease participated in the study. High resolution manometry was performed in relaxed supine position, then lower and upper esophageal sphincter pressure was measured. Finally, the subjects were instructed to keep their legs lifted while performing 90-degree flexion at the hips and knees and the pressure was measured again. Paired t-test and independent samples t-test were used. There was a significant increase in both lower (P < 0.001) and upper esophageal sphincter pressure (P = 0.034) during leg raise compared to the initial resting position. Individuals with initially higher pressure in lower esophageal sphincter (>10 mmHg) exhibited a greater pressure increase during leg raise than those with initially lower pressure (pressure ≤10 mmHg; P = 0.002). Similarly individuals with higher resting upper esophageal sphincter pressure (>44 mmHg) showed a greater pressure increase during leg raise than those with lower resting pressure (≤44 mmHg; P < 0.001). The results illustrate the influence of postural leg activities on intraesophageal pressure in patients with gastroesophageal reflux disease, indicating by means of high resolution manometry that diaphragmatic postural and sphincter function are likely interrelated in this population. Copyright © 2015 Elsevier Ltd. All rights reserved.

Black esophagus: Acute esophageal necrosis syndrome

PubMed Central

Gurvits, Grigoriy E

2010-01-01

Acute esophageal necrosis (AEN), commonly referred to as “black esophagus”, is a rare clinical entity arising from a combination of ischemic insult seen in hemodynamic compromise and low-flow states, corrosive injury from gastric contents in the setting of esophago-gastroparesis and gastric outlet obstruction, and decreased function of mucosal barrier systems and reparative mechanisms present in malnourished and debilitated physical states. AEN may arise in the setting of multiorgan dysfunction, hypoperfusion, vasculopathy, sepsis, diabetic ketoacidosis, alcohol intoxication, gastric volvulus, traumatic transection of the thoracic aorta, thromboembolic phenomena, and malignancy. Clinical presentation is remarkable for upper gastrointestinal bleeding. Notable symptoms may include epigastric/abdominal pain, vomiting, dysphagia, fever, nausea, and syncope. Associated laboratory findings may reflect anemia and leukocytosis. The hallmark of this syndrome is the development of diffuse circumferential black mucosal discoloration in the distal esophagus that may extend proximally to involve variable length of the organ. Classic “black esophagus” abruptly stops at the gastroesophageal junction. Biopsy is recommended but not required for the diagnosis. Histologically, necrotic debris, absence of viable squamous epithelium, and necrosis of esophageal mucosa, with possible involvement of submucosa and muscularis propria, are present. Classification of the disease spectrum is best described by a staging system. Treatment is directed at correcting coexisting clinical conditions, restoring hemodynamic stability, nil-per-os restriction, supportive red blood cell transfusion, and intravenous acid suppression with proton pump inhibitors. Complications include perforation with mediastinal infection/abscess, esophageal stricture and stenosis, superinfection, and death. A high mortality of 32% seen in the setting of AEN syndrome is usually related to the underlying medical co-morbidities and diseases. PMID:20614476

Radiation treatment for newly diagnosed esophageal cancer with prior radiation to the thoracic cavity.

PubMed

Sponseller, Patricia; Lenards, Nishele; Kusano, Aaron; Patel, Shilpen

2014-01-01

The purpose of this report is to communicate the use of single-positron emission computed tomography scan in planning radiation treatments for patients with a history of radiation to the thoracic cavity. A patient presented with obstructive esophageal cancer, having previously received chemotherapy and radiation therapy to the mediastinum for non-Hodgkin lymphoma 11 years earlier. Owing to a number of comorbidities, the patient was not a surgical candidate and was referred to the University of Washington Medical Center for radiation therapy. Prior dose to the spinal cord and lung were taken into account before designing the radiation treatment plan. Copyright © 2014 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.

Descending thoracic aorta dissection associated with esophageal carcinoma

PubMed Central

Saha, Kaushik; Saha, Debabrata; Bandyopadhyay, Ankan; Jash, Debraj

2013-01-01

The association of aortic dissection with a malignancy is a rare finding and previous reports are usually those of primary aortic sarcomas. A 45-year-old male presented to us with chest pain and dysphagia for 1 month with a background history of obstructive airway disease and uncontrolled hypertension. In this report we present a case of typical descending aorta dissection with associated esophageal carcinoma. PMID:24455548

A Contralateral Esophagus-Sparing Technique to Limit Severe Esophagitis Associated With Concurrent High-Dose Radiation and Chemotherapy in Patients With Thoracic Malignancies

DOE Office of Scientific and Technical Information (OSTI.GOV)

Al-Halabi, Hani; Paetzold, Peter; Sharp, Gregory C.

2015-07-15

Purpose: Severe (Radiation Therapy Oncology Group [RTOG] grade 3 or greater) esophagitis generally occurs in 15% to 25% of non–small cell lung cancer (NSCLC) patients undergoing concurrent chemotherapy and radiation therapy (CCRT), which may result in treatment breaks that compromise local tumor control and pose a barrier to dose escalation. Here, we report a novel contralateral esophagus-sparing technique (CEST) that uses intensity modulated radiation therapy (IMRT) to reduce the incidence of severe esophagitis. Methods and Materials: We reviewed consecutive patients with thoracic malignancies undergoing curative CCRT in whom CEST was used. The esophageal wall contralateral (CE) to the tumor wasmore » contoured as an avoidance structure, and IMRT was used to guide a rapid dose falloff gradient beyond the target volume in close proximity to the esophagus. Esophagitis was recorded based on the RTOG acute toxicity grading system. Results: We identified 20 consecutive patients treated with CCRT of at least 63 Gy in whom there was gross tumor within 1 cm of the esophagus. The median radiation dose was 70.2 Gy (range, 63-72.15 Gy). In all patients, ≥99% of the planning and internal target volumes was covered by ≥90% and 100% of prescription dose, respectively. Strikingly, no patient experienced grade ≥3 esophagitis (95% confidence limits, 0%-16%) despite the high total doses delivered. The median maximum dose, V45, and V55 of the CE were 60.7 Gy, 2.1 cc, and 0.4 cc, respectively, indicating effective esophagus cross-section sparing by CEST. Conclusion: We report a simple yet effective method to avoid exposing the entire esophagus cross-section to high doses. By using proposed CE dose constraints of V45 <2.5 cc and V55 <0.5 cc, CEST may improve the esophagus toxicity profile in thoracic cancer patients receiving CCRT even at doses above the standard 60- to 63-Gy levels. Prospective testing of CEST is warranted.« less

Risk factors for pericardial effusion after chemoradiotherapy for thoracic esophageal cancer—comparison of four-field technique and traditional two opposed fields technique

PubMed Central

Takata, Noriko; Kataoka, Masaaki; Hamamoto, Yasushi; Tsuruoka, Shintaro; Kanzaki, Hiromitsu; Uwatsu, Kotaro; Nagasaki, Kei; Mochizuki, Teruhito

2018-01-01

Abstract Pericardial effusion is an important late toxicity after concurrent chemoradiotherapy (CCRT) for locally advanced esophageal cancer. We investigated the clinical and dosimetric factors that were related to pericardial effusion among patients with thoracic esophageal cancer who were treated with definitive CCRT using the two opposed fields technique (TFT) or the four-field technique (FFT), as well as the effectiveness of FFT. During 2007–2015, 169 patients with middle and/or lower thoracic esophageal cancer received definitive CCRT, and 94 patients were evaluable (51 FFT cases and 43 TFT cases). Pericardial effusion was observed in 74 patients (79%) and appeared at 1–18.5 months (median: 5.25 months) after CCRT. The 1-year incidences of pericardial effusions were 73.2% and 76.7% in the FFT and TFT groups, respectively (P = 0.6395). The mean doses to the pericardium were 28.6 Gy and 31.8 Gy in the FFT and TFT groups, respectively (P = 0.0259), and the V40 Gy proportions were 33.5% and 48.2% in the FFT and TFT groups, respectively (P < 0.0001). Grade 3 pericardial effusion was not observed in patients with a pericardial V40 Gy of <40%, or in patients who were treated using the FFT. Although the mean pericardial dose and V40 Gy in the FFT group were smaller than those in the TFT group, the incidences of pericardial effusion after CCRT were similar in both groups. As symptomatic pericardial effusion was not observed in patients with a pericardial V40 Gy of <40% or in the FFT group, it appears that FFT with a V40 Gy of <40% could help minimize symptomatic pericardial effusion. PMID:29659940

Risk factors for pericardial effusion after chemoradiotherapy for thoracic esophageal cancer-comparison of four-field technique and traditional two opposed fields technique.

PubMed

Takata, Noriko; Kataoka, Masaaki; Hamamoto, Yasushi; Tsuruoka, Shintaro; Kanzaki, Hiromitsu; Uwatsu, Kotaro; Nagasaki, Kei; Mochizuki, Teruhito

2018-05-01

Pericardial effusion is an important late toxicity after concurrent chemoradiotherapy (CCRT) for locally advanced esophageal cancer. We investigated the clinical and dosimetric factors that were related to pericardial effusion among patients with thoracic esophageal cancer who were treated with definitive CCRT using the two opposed fields technique (TFT) or the four-field technique (FFT), as well as the effectiveness of FFT. During 2007-2015, 169 patients with middle and/or lower thoracic esophageal cancer received definitive CCRT, and 94 patients were evaluable (51 FFT cases and 43 TFT cases). Pericardial effusion was observed in 74 patients (79%) and appeared at 1-18.5 months (median: 5.25 months) after CCRT. The 1-year incidences of pericardial effusions were 73.2% and 76.7% in the FFT and TFT groups, respectively (P = 0.6395). The mean doses to the pericardium were 28.6 Gy and 31.8 Gy in the FFT and TFT groups, respectively (P = 0.0259), and the V40 Gy proportions were 33.5% and 48.2% in the FFT and TFT groups, respectively (P < 0.0001). Grade 3 pericardial effusion was not observed in patients with a pericardial V40 Gy of <40%, or in patients who were treated using the FFT. Although the mean pericardial dose and V40 Gy in the FFT group were smaller than those in the TFT group, the incidences of pericardial effusion after CCRT were similar in both groups. As symptomatic pericardial effusion was not observed in patients with a pericardial V40 Gy of <40% or in the FFT group, it appears that FFT with a V40 Gy of <40% could help minimize symptomatic pericardial effusion.

Diagnostic outcome of contrast videofluoroscopic swallowing studies in 216 dysphagic dogs.

PubMed

Pollard, Rachel E; Marks, Stanley L; Cheney, Diane M; Bonadio, Cecily M

2017-07-01

Determining the anatomic and functional origin for dysphagia is critical for development of an appropriate therapeutic plan and determination of the prognosis. The purpose of this retrospective study was to report the quantitative and qualitative outcome of contrast videofluoroscopic swallowing studies in a large cohort of dysphagic dogs presenting to a tertiary veterinary care hospital. The videofluoroscopic swallowing studies were reviewed to generate values for pharyngeal constriction ratio, timing of swallowing events (maximum pharyngeal contraction, opening of upper esophageal sphincter, closing of upper esophageal sphincter, and reopening of epiglottis), type of esophageal peristalsis generated, and esophageal transit time. One or more anatomic locations for origin of dysphagia were assigned (pharyngeal, cricopharyngeal, esophageal (primary motility disorder), other esophageal (stricture, vascular ring anomaly, mass), lower esophageal sphincter/hiatus. Sixty-one of 216 studies (28%) were deemed unremarkable. Twenty-seven of 216 dogs (13%) had pharyngeal dysphagia, 17/216 dogs (8%) had cricopharyngeal dysphagia, 98/216 dogs (45%) had dysphagia secondary to esophageal dysmotility, 19/216 dogs (9%) had dysphagia secondary to focal esophageal disorders, and 97/216 dogs (45%) had dysphagia of lower esophageal sphincter/hiatus origin. Multiple abnormalities were present in 82/216 (38%) dogs. Elevated pharyngeal constriction ratio was associated with pharyngeal, cricopharyngeal, and esophageal motility disorders, delayed upper esophageal sphincter opening was associated with cricopharyngeal disorders, a lower percentage of primary esophageal peristaltic waves was associated with cricopharyngeal, pharyngeal, or primary esophageal motility disorders. In conclusion, videofluoroscopic swallowing studies was pivotal in the diagnosis of dysphagia with 155/216 (72%) dogs receiving a final diagnosis. © 2017 American College of Veterinary Radiology.

Evaluation of esophageal motor function in clinical practice.

PubMed

Gyawali, C P; Bredenoord, A J; Conklin, J L; Fox, M; Pandolfino, J E; Peters, J H; Roman, S; Staiano, A; Vaezi, M F

2013-02-01

Esophageal motor function is highly coordinated between central and enteric nervous systems and the esophageal musculature, which consists of proximal skeletal and distal smooth muscle in three functional regions, the upper and lower esophageal sphincters, and the esophageal body. While upper endoscopy is useful in evaluating for structural disorders of the esophagus, barium esophagography, radionuclide transit studies, and esophageal intraluminal impedance evaluate esophageal transit and partially assess motor function. However, esophageal manometry is the test of choice for the evaluation of esophageal motor function. In recent years, high-resolution manometry (HRM) has streamlined the process of acquisition and display of esophageal pressure data, while uncovering hitherto unrecognized esophageal physiologic mechanisms and pathophysiologic patterns. New algorithms have been devised for analysis and reporting of esophageal pressure topography from HRM. The clinical value of HRM extends to the pediatric population, and complements preoperative evaluation prior to foregut surgery. Provocative maneuvers during HRM may add to the assessment of esophageal motor function. The addition of impedance to HRM provides bolus transit data, but impact on clinical management remains unclear. Emerging techniques such as 3-D HRM and impedance planimetry show promise in the assessment of esophageal sphincter function and esophageal biomechanics. © 2013 Blackwell Publishing Ltd.

Near-Infrared Lymphatic Mapping of the Recurrent Laryngeal Nerve Nodes in T1 Esophageal Cancer.

PubMed

Park, Seong Yong; Suh, Jee Won; Kim, Dae Joon; Park, Jun Chul; Kim, Eun Hye; Lee, Chang Young; Lee, Jin Gu; Paik, Hyo Chae; Chung, Kyoung Young

2018-06-01

It is still unclear that dissection of recurrent laryngeal nerve nodes is mandatory in patients with cT1 middle or lower thoracic esophageal squamous cell carcinoma when the nodes are negative in preoperative staging workup. We aimed to evaluate the feasibility of near-infrared image-guided lymphatic mapping of bilateral recurrent laryngeal nerve nodes. The day before operation, we injected indocyanine green (ICG) into the submucosal layer by endoscopy. At the time of upper mediastinal dissection, ICG-stained basins were identified along the bilateral recurrent laryngeal nerves and retrieved under guidance of the Firefly system. After the operation, remnant ICG-unstained basins were dissected from the specimen to assess the presence of metastasis. Of 29 patients enrolled, ICG-stained basins could be identified in 25 patients (86.2%), and 6 of them (24.0%) had nodal metastasis; 4 in the right recurrent laryngeal nerve chain, 1 in the left recurrent laryngeal nerve chain, and 1 in both recurrent laryngeal nerve chains. On pathologic examination of 345 recurrent laryngeal nerve nodes, two metastatic nodes were identified in ICG-unstained basins along the left recurrent laryngeal nerve in a patient who had lymph node metastases in ICG-stained basins along both recurrent laryngeal nerves. Negative predictive value in detection of nodal metastasis was 100% for the right recurrent laryngeal nerve chain and 98.2% for the left recurrent laryngeal nerve chain. Real-time assessment of recurrent laryngeal nerve nodes with near-infrared image was technically feasible, and we could detect lymphatic basins that most likely have nodal metastasis. Our technique might be useful in determining the optimal extent of lymphadenectomy. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Dosimetric benefits of IMRT and VMAT in the treatment of middle thoracic esophageal cancer: is the conformal radiotherapy still an alternative option?

PubMed

Wu, Zhiqin; Xie, Congying; Hu, Meilong; Han, Ce; Yi, Jinling; Zhou, Yongqiang; Yuan, Huawei; Jin, Xiance

2014-05-08

The purpose of this study is to investigate the dosimetric differences among conformal radiotherapy (CRT), intensity-modulated radiotherapy (IMRT), and volumetric-modulated radiotherapy (VMAT) in the treatment of middle thoracic esophageal cancer, and determine the most appropriate treatment modality. IMRT and one-arc VMAT plans were generated for eight middle thoracic esophageal cancer patients treated previous with CRT. The planning target volume (PTV) coverage and protections on organs at risk of three planning schemes were compared. All plans have sufficient PTV coverage and no significant differences were observed, except for the conformity and homogeneity. The lung V5, V10, and V13 in CRT were 47.9% ± 6.1%, 36.5% ± 4.6%, and 33.2% ± 4.2%, respectively, which were greatly increased to 78.2% ± 13.7% (p < 0.01), 80.8% ± 14.9% (p < 0.01), 48.4% ± 8.2% (p = 0.05) in IMRT and 58.6% ± 10.5% (p = 0.03), 67.7% ± 14.0% (p < 0.01), and 53.0% ± 10.1% (p < 0.01) in VMAT, respectively. The lung V20 (p = 0.03) in VMAT and the V30 (p = 0.04) in IMRT were lower than those in CRT. Both IMRT and VMAT achieved a better protection on heart. However, the volumes of the healthy tissue outside of PTV irradiated by a low dose were higher for IMRT and VMAT. IMRT and VMAT also had a higher MU, optimization time, and delivery time compared to CRT. In conclusion, all CRT, IMRT, and VMAT plans are able to meet the prescription and there is no clear distinction on PTV coverage. IMRT and VMAT can only decrease the volume of lung and heart receiving a high dose, but at a cost of delivering low dose to more volume of lung and normal tissues. CRT is still a feasible option for middle thoracic esophageal cancer radiotherapy, especially for the cost-effective consideration.

Intentional avoidance of the esophagus using intensity modulated radiation therapy to reduce dysphagia after palliative thoracic radiation.

PubMed

Granton, Patrick V; Palma, David A; Louie, Alexander V

2017-01-26

Palliative thoracic radiotherapy is an effective technique to alleviate symptoms of disease burden in advanced-stage lung cancer patients. Previous randomized controlled studies demonstrated a survival benefit in patients with good performance status at radiation doses of 35Gy 10 or greater but with an increased incidence of esophagitis. The objective of this planning study was to assess the potential impact of esophageal-sparing IMRT (ES-IMRT) compared to the current standard of care using parallel-opposed pair beams (POP). In this study, 15 patients with lung cancer treated to a dose of 30Gy in 10 fractions between August 2015 and January 2016 were identified. Radiation treatment plans were optimized using ES-IMRT by limiting the max esophagus point dose to 24Gy. Using published Lyman-Kutcher-Burman normal tissue complication probabilities (LKB-NTCP) models, both plans were evaluated for the likelihood of esophagitis (≥ grade 2) and pneumonitis (≥ grade 2). Using ES-IMRT, the median esophageal and lung mean doses reduced from 16 and 8Gy to 7 and 7Gy, respectively. Using the LKB models, the theoretical probability of symptomatic esophagitis and pneumonitis reduced from 13 to 2%, and from 5 to 3%, respectively. The median normalize total dose (NTD mean) accounting for fraction size for the GTV and PTV of the clinically approved POP plans compared to the ES-IMRT plans were similar. Advanced radiotherapy techniques such as ES-IMRT may have clinical utility in reducing treatment-related toxicity in advanced lung cancer patients. Our data suggests that the rate of esophagitis can be reduced without compromising local control.

[Malignant tumors of the esophagus in the Czech Republic].

PubMed

Duda, M; Adamcík, L; Dusek, L; Skrovina, M; Jínek, T

2012-03-01

Data analysis of the incidence, mortality and basic data regarding therapy of esophageal cancer in the Czech Republic and determining possible ways to improve the current situation. Analysis was performed using data obtained from the Czech National Cancer Registry and from the Registry of Thoracic Procedures from the Section of Thoracic Surgery of the Czech Surgical Society. Analysis of specialized literature provided generally accepted risk factors for the development of esophageal cancer. Esophageal cancer represents 0.7% of all solid malignant tumours in the Czech Republic (1.1% in males and 0.2% in females). During 1977 to 2008, the incidence increased from 2 to 5.4 cases per 100.000 inhabitants and mortality from 1.9 to 4.1 cases per 100.000 inhabitants. In absolute numbers, the incidence was 561 cases (5.4 per 100.000 inhabitants) in 2008. Absolute mortality rate was 452 deaths (4.3 per 100.000 inhabitants) and absolute prevalence (number of patients living with cancer or with its medical history) was 791 subjects(7.6 per 100.000 inhabitants). When compared to international data, the incidence in the Czech Republic is the 84th highest in the world and 17th highest in Europe (mortality rates are at the 85th place in the world and the 18th place in Europe). In the Czech Republic, the highest incidence is in the Moravian-Silesian and Zlin regions (6.1 per 100.000), the lowest in the Plzen (4.2) and Vysocina (4.1) regions. The average age at the time of diagnosis is 62 years in males and 68 years in females, the maximum incidence is between 55 and 69 years in males and between 58 and 79 years in females. Upon diagnosis, advanced stages of the disease predominate. In 2008, 28% of the detected esophageal cancer cases were stage I and II disorders, 60 % were stage III and IV disorders, and in 12% of the cases the stage was not determined. In the treated patient group, the five-year survival rate was 15.5% in total, based on an analysis of data from 2004 - 2007. The five-year survival was 30% in stage I and II diosease cases, 12% in stage III disorders and 2% in stage IV cases. When comparing the analysis of data from 2004 to 2007 with the analysis of data from 2000 to 2003, there is a 10% improvement in stages I and II and a 4% improvement in stage III disorders. According to the Thoracic Surgery Registry of Thoracic Procedures data covering the period 2007 to 2010, thoracic procedures are performed at 19 to 22 surgical departments, esophageal resections are performed at 13 to 14 surgical departments, but only in 8 to 9 of these departments is the frequency of such procedures more than 10 operations per year. At the authors' department, 53 esophageal resections have been performed in the past five years with a 3.8% postoperative mortality rate and a 23 % total postoperative morbidity rate. Forty-nine percent of the cases were adenocarcinomas. Based on its incidence in our population, esophageal cancer can be considered an unfrequent tumour. This analysis shows regions of the Czech Republic with higher incidence and the most at-risk age group in males. Significant risk factors for squamous cell cancer such as smoking and alcohol consumption have already been previously identified; in adenocarcinoma it is primarily Barrett's esophagus. Other risk groups include patients with achalasia and with strictures after corrosion injury to the esophagus. Acceptable treatment results may only be achieved in patients with less severe stages of the disease and it would therefore be appropriate to actively search for such patients in at-risk regions and among the risk groups as part of the preventive programs. To date, universally accepted guidelines for monitoring of such patients have not been defined. Surgical treatment is a highly specialized domain of thoracic surgeons focused on esophageal surgery and patients should be concentrated in specialized centres.

The effects of sleeve gastectomy on gastro-esophageal reflux and gastro-esophageal motility.

PubMed

Hayat, Jamal O; Wan, Andrew

2014-05-01

Sleeve gastrectomy is an increasingly performed bariatric procedure associated with low morbidity and good short to medium term effects on weight loss and comorbid conditions. Studies assessing the prevalence of post-operative gastro-esophageal reflux disease (GERD), show sleeve gastrectomy may provoke de novo GERD symptoms or worsening of pre-existing GERD. Pathophysiological mechanisms of GERD after sleeve gastrectomy include a hypotensive lower esophageal sphincter, increased gastro-esophageal pressure gradient and intra-thoracic migration of the remnant stomach. A reduction in the compliance of the gastric remnant may provoke an increase in transient lower esophageal sphincter relaxations. Time-resolved MRI suggests relative gastric stasis in the proximal remnant and increased emptying from the antrum. A lack of standardisation of technique, along with heterogeneity of studies assessing GERD may explain the wide variability in reported results. Simultaneous and careful repair of an associated hiatus hernia may result in a reduction in the prevalence of post-operative GERD.

Esophagitis and its causes: Who is “guilty” when acid is found “not guilty”?

PubMed Central

Grossi, Laurino; Ciccaglione, Antonio Francesco; Marzio, Leonardo

2017-01-01

Esophagitis is mainly a consequence of gastroesophageal reflux disease, one of the most common diseases affecting the upper digestive tract. However the esophageal mucosa can also be targeted by some infectious, systemic or chemical conditions. Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory disease, characterized by eosinophilic infiltration in the mucosa. Esophageal localization of Crohn’s disease is not very common, but it should always be considered in patients with inflammatory bowel disease complaining of upper digestive tract symptoms. There are also forms of infectious esophagitis (e.g., Herpes simplex virus or Candida albicans) occurring in patients with a compromised immune system, either because of specific diseases or immunosuppressive therapies. Another kind of damage to esophageal mucosa is due to drug use (including oncologic chemotherapeutic regimens and radiotherapy) or caustic ingestion, usually of alkaline liquids, with colliquative necrosis and destruction of mucosa within a few seconds. Dysphagia is a predominant symptom in EoE, while infectious, drug-induced and caustic damages usually cause chest pain and odynophagia. Endoscopy can be useful for diagnosing esophagitis, although no specific pattern can be identified. In conclusion when a patient refers upper gastrointestinal tract symptoms and the diagnosis of gastro-esophageal reflux disease is not convincing we should always carefully investigate the patient’s clinical history to consider possibilities other than the gastric refluxate. PMID:28533657

Esophageal perforation due to blunt chest trauma: Difficult diagnosis because of coexisting severe disturbance of consciousness.

PubMed

Mezuki, Satomi; Shono, Yuji; Akahoshi, Tomohiko; Hisanaga, Kana; Saeki, Hiroshi; Nakashima, Yuichiro; Momii, Kenta; Maki, Jun; Tokuda, Kentaro; Maehara, Yoshihiko

2017-11-01

Esophageal perforation due to blunt trauma is a rare clinical condition, and the diagnosis is often difficult because patients have few specific symptoms. Delayed diagnosis may result in a fatal clinical course due to mediastinitis and subsequent sepsis. In this article, we describe a 26-year-old man with esophageal perforation due to blunt chest trauma resulting from a motor vehicle accident. Because a severe disturbance of consciousness masked the patient's trauma-induced thoracic symptoms, we required 11h to diagnose the esophageal perforation. Therefore, the patient developed septic shock due to mediastinitis. However, his subsequent clinical course was good because of prompt combined therapy involving surgical repair and medical treatment after the diagnosis. Copyright © 2017 Elsevier Inc. All rights reserved.

Black esophagus syndrome associated with diabetic ketoacidosis

PubMed Central

Rigolon, Riccardo; Fossà, Irene; Rodella, Luca; Targher, Giovanni

2016-01-01

Acute esophageal necrosis, also known as “black esophagus syndrome”, is a rare acute esophageal disease that is often associated with vomiting and upper gastrointestinal haemorrhage. At present, little is known regarding the pathogenesis of this disease. We present the case of a 50-year-old white male patient with diabetic ketoacidosis suffering from acute esophageal necrosis with nausea and vomiting but without any clinical signs of upper gastrointestinal bleeding. PMID:26881192

Long-term esophageal motility changes after thyroidectomy: associations with aerodigestive disorders.

PubMed

Scerrino, G; Inviati, A; Di Giovanni, S; Paladino, N C; Di Giovanni, S; Paladino, N C; Di Paola, V; Raspanti, C; Melfa, G I; Cupido, F; Mazzola, S; Porrello, C; Bonventre, S; Gullotta, G

2017-01-01

Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months. The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again. After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p<0,001). Our study confirms that aerodigestive disorders after uncomplicated thyroidectomy, largely transient, are strictly connected with upper esophageal motility changes. In this viewpoint, the innervation of upper aerodigestive anatomical structures (larynx, pharynx, upper esophagus) and its variations should be focused.

Clinical innovations in Philippine thoracic surgery

PubMed Central

2016-01-01

Thoracic surgery in the Philippines followed the development of thoracic surgery in the United States and Europe. With better understanding of the physiology of the open chest and refinements in thoracic anesthetic and surgical approaches, Filipino surgeons began performing thoracoplasties, then lung resections for pulmonary tuberculosis and later for lung cancer in specialty hospitals dealing with pulmonary diseases—first at the Quezon Institute (QI) and presently at the Lung Center of the Philippines although some university and private hospitals made occasional forays into the chest. Esophageal surgery began its early attempts during the post-World War II era at the Philippine General Hospital (PGH), a university hospital affiliated with the University of the Philippines. With the introduction of minimally invasive thoracic surgical approaches, Filipino thoracic surgeons have managed to keep up with their Asian counterparts although the problems of financial reimbursement typical of a developing country remain. The need for creative innovative approaches of a focused multidisciplinary team will advance the boundaries of thoracic surgery in the Philippines. PMID:27651936

Upper Gastrointestinal Symptoms Predictive of Candida Esophagitis and Erosive Esophagitis in HIV and Non-HIV Patients

PubMed Central

Takahashi, Yuta; Nagata, Naoyoshi; Shimbo, Takuro; Nishijima, Takeshi; Watanabe, Koji; Aoki, Tomonori; Sekine, Katsunori; Okubo, Hidetaka; Watanabe, Kazuhiro; Sakurai, Toshiyuki; Yokoi, Chizu; Mimori, Akio; Oka, Shinichi; Uemura, Naomi; Akiyama, Junichi

2015-01-01

Abstract Upper gastrointestinal (GI) symptoms are common in both HIV and non-HIV-infected patients, but the difference of GI symptom severity between 2 groups remains unknown. Candida esophagitis and erosive esophagitis, 2 major types of esophagitis, are seen in both HIV and non-HIV-infected patients, but differences in GI symptoms that are predictive of esophagitis between 2 groups remain unknown. We aimed to determine whether GI symptoms differ between HIV-infected and non-HIV-infected patients, and identify specific symptoms of candida esophagitis and erosive esophagitis between 2 groups. We prospectively enrolled 6011 patients (HIV, 430; non-HIV, 5581) who underwent endoscopy and completed questionnaires. Nine upper GI symptoms (epigastric pain, heartburn, acid regurgitation, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia) were evaluated using a 7-point Likert scale. Associations between esophagitis and symptoms were analyzed by the multivariate logistic regression model adjusted for age, sex, and proton pump inhibitors. Endoscopy revealed GI-organic diseases in 33.4% (2010/6.011) of patients. The prevalence of candida esophagitis and erosive esophagitis was 11.2% and 12.1% in HIV-infected patients, respectively, whereas it was 2.9% and 10.7 % in non-HIV-infected patients, respectively. After excluding GI-organic diseases, HIV-infected patients had significantly (P < 0.05) higher symptom scores for heartburn, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia than non-HIV-infected patients. In HIV-infected patients, any symptom was not significantly associated with CD4 cell count. In multivariate analysis, none of the 9 GI symptoms were associated with candida esophagitis in HIV-infected patients, whereas dysphagia and odynophagia were independently (P < 0.05) associated with candida esophagitis in non-HIV-infected patients. However, heartburn and acid regurgitation were independently (P < 0.05) associated with erosive esophagitis in both patient groups. The internal consistency test using Cronbach's α revealed that the 9 symptom scores were reliable in both HIV (α, 0.86) and non-HIV-infected patients (α, 0.85). This large-scale endoscopy-based study showed that HIV-infected patients have greater GI symptom scores compared with non-HIV-infected patients even after excluding GI-organic diseases. None of the upper GI symptoms predict candida esophagitis in HIV-infected patients, but dysphagia and odynophagia predict candida esophagitis in non-HIV-infected patients. Heartburn and acid regurgitation predict erosive esophagitis in both patient groups. PMID:26632738

Upper Gastrointestinal Symptoms Predictive of Candida Esophagitis and Erosive Esophagitis in HIV and Non-HIV Patients: An Endoscopy-Based Cross-Sectional Study of 6011 Patients.

PubMed

Takahashi, Yuta; Nagata, Naoyoshi; Shimbo, Takuro; Nishijima, Takeshi; Watanabe, Koji; Aoki, Tomonori; Sekine, Katsunori; Okubo, Hidetaka; Watanabe, Kazuhiro; Sakurai, Toshiyuki; Yokoi, Chizu; Mimori, Akio; Oka, Shinichi; Uemura, Naomi; Akiyama, Junichi

2015-11-01

Upper gastrointestinal (GI) symptoms are common in both HIV and non-HIV-infected patients, but the difference of GI symptom severity between 2 groups remains unknown. Candida esophagitis and erosive esophagitis, 2 major types of esophagitis, are seen in both HIV and non-HIV-infected patients, but differences in GI symptoms that are predictive of esophagitis between 2 groups remain unknown. We aimed to determine whether GI symptoms differ between HIV-infected and non-HIV-infected patients, and identify specific symptoms of candida esophagitis and erosive esophagitis between 2 groups.We prospectively enrolled 6011 patients (HIV, 430; non-HIV, 5581) who underwent endoscopy and completed questionnaires. Nine upper GI symptoms (epigastric pain, heartburn, acid regurgitation, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia) were evaluated using a 7-point Likert scale. Associations between esophagitis and symptoms were analyzed by the multivariate logistic regression model adjusted for age, sex, and proton pump inhibitors.Endoscopy revealed GI-organic diseases in 33.4% (2010/6.011) of patients. The prevalence of candida esophagitis and erosive esophagitis was 11.2% and 12.1% in HIV-infected patients, respectively, whereas it was 2.9% and 10.7 % in non-HIV-infected patients, respectively. After excluding GI-organic diseases, HIV-infected patients had significantly (P < 0.05) higher symptom scores for heartburn, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia than non-HIV-infected patients. In HIV-infected patients, any symptom was not significantly associated with CD4 cell count. In multivariate analysis, none of the 9 GI symptoms were associated with candida esophagitis in HIV-infected patients, whereas dysphagia and odynophagia were independently (P < 0.05) associated with candida esophagitis in non-HIV-infected patients. However, heartburn and acid regurgitation were independently (P < 0.05) associated with erosive esophagitis in both patient groups. The internal consistency test using Cronbach's α revealed that the 9 symptom scores were reliable in both HIV (α, 0.86) and non-HIV-infected patients (α, 0.85).This large-scale endoscopy-based study showed that HIV-infected patients have greater GI symptom scores compared with non-HIV-infected patients even after excluding GI-organic diseases. None of the upper GI symptoms predict candida esophagitis in HIV-infected patients, but dysphagia and odynophagia predict candida esophagitis in non-HIV-infected patients. Heartburn and acid regurgitation predict erosive esophagitis in both patient groups.

Pink-color sign in esophageal squamous neoplasia, and speculation regarding the underlying mechanism

PubMed Central

Ishihara, Ryu; Kanzaki, Hiromitsu; Iishi, Hiroyasu; Nagai, Kengo; Matsui, Fumi; Yamashina, Takeshi; Matsuura, Noriko; Ito, Takashi; Fujii, Mototsugu; Yamamoto, Sachiko; Hanaoka, Noboru; Takeuchi, Yoji; Higashino, Koji; Uedo, Noriya; Tatsuta, Masaharu; Tomita, Yasuhiko; Ishiguro, Shingo

2013-01-01

AIM: To investigate the reasons for the occurrence of the pink-color sign of iodine-unstained lesions. METHODS: In chromoendoscopy, the pink-color sign of iodine-unstained lesions is recognized as useful for the diagnosis of esophageal squamous cell carcinoma. Patients with superficial esophageal neoplasms treated by endoscopic resection were included in the study. Areas of mucosa with and without the pink-color sign were evaluated histologically. The following histologic features that were possibly associated with the pink-color sign were evaluated. The keratinous layer and basal cell layer were classified as present or absent. Cellular atypia was classified as high grade, moderate grade or low grade, based on nuclear irregularity, mitotic figures, loss of polarity, chromatin pattern and nuclear/cytoplasmic ratio. Vascular change was assessed based on dilatation, tortuosity, caliber change and variability in shape. Vessels with these four findings were classified as positive for vascular change. Endoscopic images of the lesions were captured immediately after iodine staining, 2-3 min after iodine staining and after complete fading of iodine staining. Quantitative analysis of color changes after iodine staining was also performed. RESULTS: A total of 61 superficial esophageal neoplasms in 54 patients were included in the study. The lesions were located in the cervical esophagus in one case, the upper thoracic esophagus in 10 cases, the mid-thoracic esophagus in 33 cases, and the lower thoracic esophagus in 17 cases. The median diameter of the lesions was 20 mm (range: 2-74 mm). Of the 61 lesions, 28 were classified as pink-color sign positive and 33 as pink-color sign negative. The histologic diagnosis was high-grade intraepithelial neoplasia (HGIN) or cancer invading into the lamina propria in 26 of the 28 pink-color sign positive lesions. There was a significant association between pink-color sign positive epithelium and HGIN or invasive cancer (P = 0.0001). Univariate analyses found that absence of the keratinous layer and cellular atypia were significantly associated with the pink-color sign. After Bonferroni correction, there were no significant associations between the pink-color sign and presence of the basal membrane or vascular change. Multivariate analyses found that only absence of the keratinous layer was independently associated with the pink-color sign (OR = 58.8, 95%CI: 5.5-632). Quantitative analysis was performed on 10 superficial esophageal neoplasms with both pink-color sign positive and negative areas in 10 patients. Pink-color sign positive mucosa had a lower mean color value in the late phase (pinkish color) than in the early phase (yellowish color), and had similar mean color values in the late and final phases. These findings suggest that pink-color positive mucosa underwent color fading from the color of the iodine (yellow) to the color of the mucosa (pink) within 2-3 min after iodine staining. Pink-color sign negative mucosa had similar mean color values in the late and early phases (yellowish color), and had a lower mean color value in the final phase (pinkish color) than in the late phase. These findings suggest that pink-color sign negative mucosa did not undergo color fading during the 2-3 min after iodine staining, and underwent color fading only after spraying of sodium thiosulfate. CONCLUSION: The pink-color sign was associated with absence of the keratinous layer. This sign may be caused by early fading of iodine staining. PMID:23885140

Pancreaticoduodenectomy after esophageal and gastric surgery preserving right gastroepiploic vessels.

PubMed

Ikeda, Mami; Hasegawa, Kiyoshi; Akamatsu, Nobuhisa; Minagawa, Masami; Imamura, Hiroshi; Sugawara, Yasuhiko; Kokudo, Norihiro; Makuuchi, Masatoshi

2006-02-01

Secondary pancreaticoduodenectomy was performed in 2 patients, 1 who had undergone proximal gastrectomy for a gastric carcinoma and 1 who had undergone subtotal esophagectomy with stomach tube reconstruction for an inferior thoracic esophageal carcinoma. To prevent ischemia and congestion of the remnant stomach, the inflow and outflow pathways to the stomach, such as the right gastroepiploic artery and vein, were preserved. In this article, we describe the preservation procedures and discuss the problems of the secondary abdominal surgical procedure.

Starting a robotic program in general thoracic surgery: why, how, and lessons learned.

PubMed

Cerfolio, Robert J; Bryant, Ayesha S; Minnich, Douglas J

2011-06-01

We report our experience in starting a robotic program in thoracic surgery. We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive series of patients. Between February 2009 and September 2010, 150 patients underwent robotic operations. Types of procedures were lobectomy in 62, thymectomy in 30, and benign esophageal procedures in 6. No thymectomy or esophageal procedures required conversion. One conversion was needed for suspected bleeding for a mediastinal mass. Twelve patients were converted for lobectomy (none for bleeding, 1 in the last 24). Median operative time for robotic thymectomy was 119 minutes, and median length of stay was 1 day. The median time for robotic lobectomy was 185 minutes, and median length of stay was 2 days. There were no operative deaths. Morbidity occurred in 23 patients (15%). All patients with cancer had R0 resections and resection of all visible mediastinal and hilar lymph nodes. Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumors. Its advantage over thoracoscopy for pulmonary resection is unproven; however, we believe complete thoracic lymph node dissection and teaching is easier. Importantly, defined credentialing for surgeons and cost analysis studies are needed. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Impaired Upper Esophageal Sphincter Reflexes in Patients with Supra-Esophageal Reflux Disease

PubMed Central

Babaei, Arash; Venu, Mukund; Naini, Sohrab Rahimi; Gonzaga, Jason; Lang, Ivan; Massey, Benson; Jadcherla, Sudarshan; Shaker, Reza

2015-01-01

Background & Aims Normal responses of the upper esophageal sphincter (UES) and esophageal body to liquid reflux events prevent esophagopharyngeal reflux and its complications, but abnormal responses have not been characterized. We investigated whether patients with supra-esophageal reflux disease (SERD) have impaired UES and esophageal body responses to simulated reflux events. Methods We performed a prospective study of 25 patients with SERD (19–82 y old, 13 female) and complaints of regurgitation and supra-esophageal manifestations of reflux. We also included 10 patients with gastroesophageal reflux disease (GERD; 32–60 y old, 7 female) without troublesome regurgitation and supra-esophageal symptoms and 24 healthy asymptomatic individuals (controls; 19–49 y old, 13 female). UES and esophageal body pressure responses, along with luminal distribution of infusate during esophageal rapid and slow infusion of air or liquid, were monitored by concurrent high-resolution manometry and intraluminal impedance. Results A significantly smaller proportion of patients with SERD had UES contractile reflexes in response to slow esophageal infusion of acid than controls or patients with GERD. Only patients with SERD had abnormal UES relaxation responses to rapid distension with saline. Diminished esophageal peristaltic contractions resulted in esophageal stasis in patients with GERD or SERD. Conclusions Patients with SERD and complaints of regurgitation have impaired UES and esophageal responses to simulated liquid reflux events. These patterns could predispose them to esophagopharyngeal reflux. PMID:26188682

Baseline measure of health-related quality of life (Functional Assessment of Cancer Therapy-Esophagus) is associated with overall survival in patients with esophageal cancer.

PubMed

Kidane, Biniam; Sulman, Joanne; Xu, Wei; Kong, Qin Quinn; Wong, Rebecca; Knox, Jennifer J; Darling, Gail E

2016-06-01

Functional Assessment of Cancer Therapy-Esophagus is a health-related quality of life instrument validated in patients with esophageal cancer. It is composed of a general component and an esophageal cancer subscale. Our objective was to determine whether the baseline Functional Assessment of Cancer Therapy-Esophagus and esophageal cancer subscale scores are associated with survival in patients with stage II and III cancer of the gastroesophageal junction or thoracic esophagus. Data from 4 prospective studies in Canadian academic hospitals were combined. These included consecutive patients with stage II and III esophageal cancer who received neoadjuvant therapy followed by surgery or chemoradiation/radiation alone. All patients completed baseline Functional Assessment of Cancer Therapy-Esophagus. Functional Assessment of Cancer Therapy-Esophagus and esophageal cancer subscale scores were dichotomized on the basis of median scores. Cox regression analyses were performed. There were 207 patients treated between 1996 and 2014. Mean age was 61 ± 10.6 years. Approximately 69.6% of patients (n = 144) had adenocarcinoma. All patients had more than 9 months of follow-up. In patients with stage II and III, 93 deaths were observed. When treated as continuous variables, baseline Functional Assessment of Cancer Therapy-Esophagus and esophageal cancer subscale were associated with survival with hazard ratios of 0.89 (95% confidence interval [CI], 0.81-0.96; P = .005) and 0.68 (95% CI, 0.56-0.82; P < .001), respectively. When dichotomized, they were also associated with survival with a hazard ratio of 0.58 (95% CI, 0.38-0.89; P = .01) and 0.43 (95% CI, 0.28-0.67; P < .001), respectively. In patients with stage II and III esophageal cancer being considered for therapy, higher baseline Functional Assessment of Cancer Therapy-Esophagus and esophageal cancer subscale were independently associated with longer survival, even after adjusting for age, stage, histology, and therapy received. Further study is needed, but Functional Assessment of Cancer Therapy-Esophagus may be useful as a prognostic tool to inform patient decision-making and patient selection criteria for studies. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Bleeding after expandable nitinol stent placement in patients with esophageal and upper gastrointestinal obstruction: incidence, management, and predictors.

PubMed

Oh, Se Jin; Song, Ho-Young; Nam, Deok Ho; Ko, Heung Kyu; Park, Jung-Hoon; Na, Han Kyu; Lee, Jong Jin; Kang, Min Kyoung

2014-11-01

Placement of self-expandable nitinol stents is useful for the treatment of esophageal and upper gastrointestinal (GI) obstruction. However, complications such as stent migration, tumor overgrowth, and bleeding occur. Although stent migration and tumor overgrowth are well documented in previous studies, the occurrence of bleeding has not been fully evaluated. To evaluate the incidence, management strategies, and predictors of bleeding after placement of self-expandable nitinol stents in patients with esophageal and upper GI obstruction. We retrospectively reviewed the medical records and results of computed tomography and endoscopy of 1485 consecutive patients with esophageal and upper GI obstructions who underwent fluoroscopically guided stent placement. Bleeding occurred in 25 of 1485 (1.7%) patients 0 to 348 days after stent placement. Early stent-related bleeding occurred in 10 patients (40%) and angiographic embolization was used for 5/10. Late bleeding occurred in 15 patients (60%) and endoscopic hemostasis was used for 7/15. Twenty-two of 25 (88%) patients with bleeding had received prior radiotherapy and/or chemotherapy. Bleeding is a rare complication after placement of expandable nitinol stents in patients with esophageal and upper GI obstruction, but patients with early bleeding may require embolization for control. Care must be exercised on placing stents in patients who have received prior radiotherapy or chemotherapy. © The Foundation Acta Radiologica 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Laundry detergent pod ingestions: is there a need for endoscopy?

PubMed

Smith, Erika; Liebelt, Erica; Nogueira, Jan

2014-09-01

Laundry detergent pod (LDP) exposures in children have resulted in several referrals to the emergency department. Signs and symptoms can include gastrointestinal symptoms (vomiting, drooling), neurological symptoms (depressed sensorium), or metabolic changes (lactic acidosis). There is limited literature on esophageal injury following LDP ingestions. We reviewed three cases of pediatric LDP ingestions that underwent an upper endoscopy in a tertiary care pediatric hospital. All of our patients were younger than 3 years old. The upper endoscopies revealed superficial esophageal erosions in two patients and erythema in the other. None of the patients had oral burns. Two of them developed swallowing dysfunction. Follow-up upper GI studies were normal. Our three patients ingested laundry detergent pods and all of them developed some degree of esophageal injury despite the absence of oral erythema, ulcers, or swelling. A review of literature suggests LDP exposures are more severe than non-pod detergents. Reasons as to why this may be remain unclear, although investigation into the ingredients and mode of delivery may help us to better understand. In a literature review, no esophageal strictures have been reported after LDP ingestion. We reviewed esophageal injury classification systems in an attempt to predict who may be at greatest risk for stricture based on initial findings. Our case series demonstrates it is hard to predict esophageal injury based on signs and symptoms. Based on a literature review, long-term esophageal stricture is unlikely, but if gastrointestinal symptoms persist, it is reasonable to evaluate with an upper endoscopy. Larger studies are needed.

Characterization of primary pulmonary adenosquamous carcinoma-associated pleural effusion.

PubMed

Stewart, Jennifer; Holloway, Andrew; Rasotto, Roberta; Bowlt, Kelly

2016-03-01

A 10-year-old, female spayed Shih Tzu was presented due to weight loss, increased respiratory effort and lethargy, determined to be secondary to a congenital para-esophageal diaphragmatic defect with partial herniation of the stomach and spleen. Four days following reduction surgery of the displaced abdominal organs thoracic effusion developed. Thoracic fluid evaluation revealed a cell-rich, protein-poor modified transudate with neutrophils, reactive mesothelial cells, and atypical epitheloid cells which occasionally appeared to be keratinizing, consistent with neoplastic exfoliation. Thoracic effusion recurred 2 days later, with similar characteristics as the initial sample. Computed tomography (CT) indicated consolidation and displacement of the right middle and accessory lung lobes. Exploratory thoracic surgery demonstrated a thickened, hyperemic right middle lung lobe, and thickened pericardial diaphragmatic ligament. Histologic evaluation of these tissues identified a primary pulmonary adenosquamous carcinoma with intravascular and pleural invasion. Based on these cytologic, histologic, and clinical findings, we conclude that primary pulmonary carcinomas may involve superficial thoracic structures and exfoliate into a thoracic effusion. © 2016 American Society for Veterinary Clinical Pathology.

Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial.

PubMed

Dunning, James R; Cleland, Joshua A; Waldrop, Mark A; Arnot, Cathy F; Young, Ian A; Turner, Michael; Sigurdsson, Gisli

2012-01-01

Randomized clinical trial. To compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude (HVLA) thrust manipulation to nonthrust mobilization in patients with neck pain. Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain, no studies have directly compared the effects of both upper cervical and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain. Patients completed the Neck Disability Index, the numeric pain rating scale, the flexion-rotation test for measurement of C1-2 passive rotation range of motion, and the craniocervical flexion test for measurement of deep cervical flexor motor performance. Following the baseline evaluation, patients were randomized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical (C1-2) and upper thoracic (T1-2) spines. Patients were reexamined 48-hours after the initial examination and again completed the outcome measures. The effects of treatment on disability, pain, C1-2 passive rotation range of motion, and motor performance of the deep cervical flexors were examined with a 2-by-2 mixed-model analysis of variance (ANOVA). One hundred seven patients satisfied the eligibility criteria, agreed to participate, and were randomized into the HVLA thrust manipulation (n = 56) and nonthrust mobilization (n = 51) groups. The 2-by-2 ANOVA demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly (P<.001) greater reductions in disability (50.5%) and pain (58.5%) than those of the nonthrust mobilization group (12.8% and 12.6%, respectively) following treatment. In addition, the HVLA thrust manipulation group had significantly (P<.001) greater improvement in both passive C1-2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization. The number needed to treat to avoid an unsuccessful outcome was 1.8 and 2.3 at 48-hour follow-up, using the global rating of change and Neck Disability Index cut scores, respectively. The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain. Therapy, level 1b.

A Case of Ruptured Aneurysm of the Proper Esophageal Artery with Symptomatic Mediastinal Hematoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Liu, Jiajia; Sato, Yusuke, E-mail: yusuke@doc.med.akita-u.ac.jp; Takahashi, Satoshi

Mediastinal aneurysms are rare but potentially life-threatening. Among these, bronchial artery aneurysms are most frequently reported, whereas up to now aneurysms of the proper esophageal artery had never been reported. A 69-year-old woman was referred to our hospital for treatment of a massive mediastinal hematoma. Enhanced computed tomography and selective proper esophageal arteriography revealed a 5-mm aneurysm in the proper esophageal artery that arises from the thoracic aorta at the Th8 level and has an anastomotic branch with the bronchial artery peripherally. Transcatheter arterial embolization was successfully performed using a mixture of N-butyl cyanoacrylate and lipiodol (1:3 ratio, 0.3 ml). Post-embolizationmore » angiography showed no filling into the aneurysm. The patient recovered with no complications and was discharged on the 25th post-procedure day.« less

Surgical treatments for esophageal cancers

PubMed Central

Allum, William H.; Bonavina, Luigi; Cassivi, Stephen D.; Cuesta, Miguel A.; Dong, Zhao Ming; Felix, Valter Nilton; Figueredo, Edgar; Gatenby, Piers A.C.; Haverkamp, Leonie; Ibraev, Maksat A.; Krasna, Mark J.; Lambert, René; Langer, Rupert; Lewis, Michael P.N.; Nason, Katie S.; Parry, Kevin; Preston, Shaun R.; Ruurda, Jelle P.; Schaheen, Lara W.; Tatum, Roger P.; Turkin, Igor N.; van der Horst, Sylvia; van der Peet, Donald L.; van der Sluis, Peter C.; van Hillegersberg, Richard; Wormald, Justin C.R.; Wu, Peter C.; Zonderhuis, Barbara M.

2015-01-01

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy. PMID:25266029

Improving Outcomes for Esophageal Cancer using Proton Beam Therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chuong, Michael D.; Hallemeier, Christopher L.; Jabbour, Salma K.

Radiation therapy (RT) plays an essential role in the management of esophageal cancer. Because the esophagus is a centrally located thoracic structure there is a need to balance the delivery of appropriately high dose to the target while minimizing dose to nearby critical structures. Radiation dose received by these critical structures, especially the heart and lungs, may lead to clinically significant toxicities, including pneumonitis, pericarditis, and myocardial infarction. Although technological advancements in photon RT delivery like intensity modulated RT have decreased the risk of such toxicities, a growing body of evidence indicates that further risk reductions are achieved with protonmore » beam therapy (PBT). Herein we review the published dosimetric and clinical PBT literature for esophageal cancer, including motion management considerations, the potential for reirradiation, radiation dose escalation, and ongoing esophageal PBT clinical trials. We also consider the potential cost-effectiveness of PBT relative to photon RT.« less

Improving Outcomes for Esophageal Cancer using Proton Beam Therapy.

PubMed

Chuong, Michael D; Hallemeier, Christopher L; Jabbour, Salma K; Yu, Jen; Badiyan, Shahed; Merrell, Kenneth W; Mishra, Mark V; Li, Heng; Verma, Vivek; Lin, Steven H

2016-05-01

Radiation therapy (RT) plays an essential role in the management of esophageal cancer. Because the esophagus is a centrally located thoracic structure there is a need to balance the delivery of appropriately high dose to the target while minimizing dose to nearby critical structures. Radiation dose received by these critical structures, especially the heart and lungs, may lead to clinically significant toxicities, including pneumonitis, pericarditis, and myocardial infarction. Although technological advancements in photon RT delivery like intensity modulated RT have decreased the risk of such toxicities, a growing body of evidence indicates that further risk reductions are achieved with proton beam therapy (PBT). Herein we review the published dosimetric and clinical PBT literature for esophageal cancer, including motion management considerations, the potential for reirradiation, radiation dose escalation, and ongoing esophageal PBT clinical trials. We also consider the potential cost-effectiveness of PBT relative to photon RT. Copyright © 2016 Elsevier Inc. All rights reserved.

Preoperative computed tomography diagnosis of non-recurrent laryngeal nerve in patients with esophageal carcinoma.

PubMed

Niu, Zhong-Xi; Zhang, Hang; Chen, Long-Qi; Shi, Hui; Peng, Jun; Su, Li-Wei; Li, Wei; Xiao, Bo; He, Shu; Yue, Hong-Xu

2017-01-01

The non-recurrent laryngeal nerve (NRLN) is a rare but potentially serious anomaly that is commonly associated with the aberrant right subclavian artery (ARSA). It is easy to damage during surgical resection of esophageal cancer, leading to severe complications. Preoperative enhanced thoracic computed tomography (CT) scans of 2697 patients with esophageal carcinoma treated in our hospital between January 2010 and December 2013 were examined. We classified the positional relationship between the right subclavian artery and the membranous wall of the trachea into two types and used this method to predicate NRLN by identifying ARSA. Twenty-six patients (0.96%) were identified with ARSA, all of which were cases of NRLN by CT. NRLN was identified during surgery in the 26 patients, and a normal right recurrent laryngeal nerve was observed in 2671 patients. The ARSA was detected on the dorsal side of the membranous wall of the trachea in all 26 NRLN cases, while it was detected on the ventral side in all 2671 recurrent laryngeal nerve cases. Enhanced CT scanning is a reliable method for predicting NRLN by identifying ARSA. Preoperative recognition of this nerve anomaly allows surgeons to avoid damaging the nerve and abnormal vessels during esophagectomy. © 2016 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

Digestive toxicities after palliative three-dimensional conformal radiation therapy (3D-CRT) for cervico-thoracic spinal metastases.

PubMed

Peyraga, Guillaume; Caron, Delphine; Lizee, Thibaut; Metayer, Yann; Septans, Anne-Lise; Pointreau, Yoann; Denis, Fabrice; Ganem, Gerard; Lafond, Cedrik; Roche, Sophie; Dupuis, Olivier

2018-06-01

The palliative treatment for cervico-thoracic spinal metastases is based on a three-dimensional conformal radiation therapy (3D-CRT). Digestive toxicities are common and cause a clinical impact frequently underestimated in patients. We performed a retrospective study of digestive side effects occurring after palliative 3D-CRT for cervico-thoracic spinal metastases. All patients receiving palliative 3D-CRT at Jean Bernard Center from January 2013 to December 2014 for spinal metastases between the 5th cervical vertebra (C5) and the 12th thoracic vertebra (T12) were eligible. Three-dimensional conformal RT was delivered by a linear accelerator (CLINAC, Varian). Premedication to prevent digestive toxicities was not used. Adverse events ("esophagitis" and "nausea and/or vomiting") were evaluated according to the NCI-CTCae (version 4). From January 2013 to December 2014, 128 patients met the study criteria. The median age was 68.6 years [31.8; 88.6]. Most patients (84.4%) received 30 Gy in 10 fractions. The median overall time of treatment was 13 days [3-33]. Forty patients (31.3%) suffered from grade ≥ 2 of "esophagitis" (35 grade 2 (27.4%) and 5 grade 3 (3.9%)). Eight patients (6.3%) suffered from grade ≥ 2 of "nausea and/or vomiting" (6 grade 2 (4.7%), 1 grade 3 (0.8%), and 1 grade 4 (0.8%)). The high incidence of moderate to severe digestive toxicities after palliative 3D-CRT for cervico-thoracic spinal metastases led to consider static or dynamic intensity-modulated radiation therapy (IMRT) to reduce the dose to organ at risk (the esophagus and stomach). Dosimetric studies and implementation in the clinic should be the next steps.

Quantifying Contributions of the Cricopharyngeus to Upper Esophageal Sphincter Pressure Changes by Means of Intramuscular Electromyography and High-Resolution Manometry

PubMed Central

Jones, Corinne A.; Hammer, Michael J.; Hoffman, Matthew R.; McCulloch, Timothy M.

2014-01-01

Objectives We sought to determine whether the association between cricopharyngeus muscle activity and upper esophageal sphincter pressure may change in a task-dependent fashion. We hypothesized that more automated tasks related to swallow or airway protection would yield a stronger association than would more volitional tasks related to tidal breathing or voice production. Methods Six healthy adult subjects underwent simultaneous intramuscular electromyography of the cricopharyngeus muscle and high-resolution manometry of the upper esophageal sphincter. Correlation coefficients were calculated to characterize the association between the time-linked series. Results Cricopharyngeus muscle activity was most strongly associated with upper esophageal sphincter pressure during swallow and effortful exhalation tasks (r = 0.77 and 0.79, respectively; P < .01). The association was also less variable during swallow and effortful exhalation. Conclusions These findings suggest a greater coupling for the more automatic tasks, and may suggest less coupling and more flexibility for the more volitional, voice-related tasks. These findings support the important role of central patterning for respiratory- and swallow-related tasks. PMID:24633943

Thoracic trauma.

PubMed

Kagan, K G

1980-08-01

The physiologic equilibrium of chest injury patients is frequently precarious, and mild stress during examination and treatment may precipitate acute decompensation and death. This is particularly true with the respiratory system, where the normally large respiratory reserve capacity may be rapidly lost. Accurate assessment of the nature of the thoracic injury and the severity of that injury must be determined in order to formulate a therapeutic plan. Many thoracic injuries, such as pneumothorax, pulmonary contusions, or rib fractures, will be self-limiting. Other conditions must be recognized for their potentially lethal nature and dealt with aggressively, and these include cardiac tamponade, tension pneumothorax, and esophageal perforation. By performing a systematic evaluation of the patient and confirming or denying the presence of all possible types of thoracic injury, the veterinarian may avoid overtreatment of self-limiting lesions and recognize and aggressively treat those with potentially fatal outcomes.

Evaluation of the likelihood of reflux developing in patients with recurrent upper respiratory infections, recurrent sinusitis or recurrent otitis seen in ear-nose-throat outpatient clinics.

PubMed

Önal, Zerrin; Çullu-Çokuğraş, Fügen; Işıldak, Hüseyin; Kaytaz, Asım; Kutlu, Tufan; Erkan, Tülay; Doğusoy, Gülen

2015-01-01

Gastroesophageal reflux is considered a risk factor for recurrent or persistent upper and lower respiratory tract conditions including asthma, chronic cough, sinusitis, laryngitis, serous otitis and paroxysmal laryngospasm. Fifty-one subjects with recurrent (more than three) episodes of upper respiratory tract infection (URTI), serous otitis or sinusitis who had been admitted to an earnose- throat (ENT) outpatient clinic during the previous year were enrolled in the present study to evaluate the presence of laryngeal and/or esophageal reflux. The participants, who were randomly selected, were questioned about symptoms of reflux, including vomiting, abdominal pain, failure to thrive, halitosis, bitter taste in the mouth, chronic cough, heartburn, constipation and hoarseness. All subjects had an endoscopic examination, an otoscopic examination, a tympanogram and upper GI system endoscopy. Esophagitis was diagnosed endoscopically and histologically. The likelihood of occurrence of esophagitis was found to be higher only among subjects with postglottic edema/erythema as determined by pathological laryngeal examination. The reflux complaints reported did not predict the development of esophagitis, but the odds of esophagitis occurring were ninefold greater among subjects with recurrent otitis. Of the subjects, 45.1% were Helicobacter pylori-positive. However, no association was found between esophagitis and Helicobacter pylori positivity. The likelihood of the occurrence of esophagitis was found to be increased in the presence of recurrent otitis media and/or postglottic edema, irrespective of the presence of reflux symptoms. We concluded that, in contrast to the situation where adults are concerned, the boundaries for discriminating laryngopharyngeal reflux from gastroesophageal reflux are somewhat blurred in pediatric patients.

Esophageal motor dysfunction plays a key role in GERD with globus sensation--analysis of factors promoting resistance to PPI therapy.

PubMed

Tsutsui, Hideaki; Manabe, Noriaki; Uno, Masako; Imamura, Hiroshi; Kamada, Tomoari; Kusunoki, Hiroaki; Shiotani, Akiko; Hata, Jiro; Harada, Tamotsu; Haruma, Ken

2012-09-01

Patients with gastroesophageal reflux disease (GERD) also have various extra-esophageal symptoms. Laryngopharyngeal reflux disease (LPRD) is a subtype of GERD associated with globus sensation, but proton pump inhibitor (PPI) therapy achieves disappointing results. This study investigated esophageal motility in GERD patients with globus sensation who were resistant to PPI therapy. The subjects were 350 patients with globus sensation. All patients underwent both laryngoscopy and upper gastrointestinal endoscopy to exclude organic disease. After 4 weeks of treatment with rabeprazole sodium (20 mg daily), the patients were divided into PPI-responsive and PPI-resistant groups. Then we investigated esophageal motility in the PPI-resistant group by a multichannel intraluminal impedance and manometry study. A total of 119 patients (55.6%) were resistant to PPI therapy, among whom 57 patients (47.9%) had abnormal esophageal motility. They included 36 patients (66.4%) with ineffective esophageal motility, 9 patients (14.4%) with achalasia, 6 patients (9.6%) with diffuse esophageal spasm, 5 patients (8%) with nutcracker esophagus, and 1 patient (1.6%) with hypertensive lower esophageal sphincter. There were significant differences of upper esophageal sphincter pressure and esophageal body peristalsis between the patients with PPI-resistant LPRD and healthy controls matched for age and sex. Among patients with PPI-resistant LPRD, 47.9% had abnormal esophageal motility.

The peri-esophageal connective tissue layers and related compartments: visualization by histology and magnetic resonance imaging.

PubMed

Weijs, T J; Goense, L; van Rossum, P S N; Meijer, G J; van Lier, A L H M W; Wessels, F J; Braat, M N G; Lips, I M; Ruurda, J P; Cuesta, M A; van Hillegersberg, R; Bleys, R L A W

2017-02-01

An organized layer of connective tissue coursing from aorta to esophagus was recently discovered in the mediastinum. The relations with other peri-esophageal fascias have not been described and it is unclear whether this layer can be visualized by non-invasive imaging. This study aimed to provide a comprehensive description of the peri-esophageal fascias and determine whether the connective tissue layer between aorta and esophagus can be visualized by magnetic resonance imaging (MRI). First, T2-weighted MRI scanning of the thoracic region of a human cadaver was performed, followed by histological examination of transverse sections of the peri-esophageal tissue between the thyroid gland and the diaphragm. Secondly, pretreatment motion-triggered MRI scans were prospectively obtained from 34 patients with esophageal cancer and independently assessed by two radiologists for the presence and location of the connective tissue layer coursing from aorta to esophagus. A layer of connective tissue coursing from the anterior aspect of the descending aorta to the left lateral aspect of the esophagus, with a thin extension coursing to the right pleural reflection, was visualized ex vivo in the cadaver on MR images, macroscopic tissue sections, and after histologic staining, as well as on in vivo MR images. The layer connecting esophagus and aorta was named 'aorto-esophageal ligament' and the layer connecting aorta to the right pleural reflection 'aorto-pleural ligament'. These connective tissue layers divides the posterior mediastinum in an anterior compartment containing the esophagus, (carinal) lymph nodes and vagus nerve, and a posterior compartment, containing the azygos vein, thoracic duct and occasionally lymph nodes. The anterior compartment was named 'peri-esophageal compartment' and the posterior compartment 'para-aortic compartment'. The connective tissue layers superior to the aortic arch and at the diaphragm corresponded with the currently available anatomic descriptions. This study confirms the existence of the previously described connective tissue layer coursing from aorta to esophagus, challenging the long-standing paradigm that no such structure exists. A comprehensive, detailed description of the peri-esophageal fascias is provided and, furthermore, it is shown that the connective tissue layer coursing from aorta to esophagus can be visualized in vivo by MRI. © 2016 Anatomical Society.

Reflection of the State of Hunger in Impulse Activity of Nose Wing Muscles and Upper Esophageal Sphincter during Search behavior in Rabbits.

PubMed

Kromin, A A; Dvoenko, E E; Zenina, O Yu

2016-07-01

Reflection of the state of hunger in impulse activity of nose wing muscles and upper esophageal sphincter muscles was studied in chronic experiments on rabbits subjected to 24-h food deprivation in the absence of locomotion and during search behavior. In the absence of apparent behavioral activity, including sniffing, alai nasi muscles of hungry rabbits constantly generated bursts of action potentials synchronous with breathing, while upper esophageal sphincter muscles exhibited regular aperiodic low-amplitude impulse activity of tonic type. Latent form of food motivation was reflected in the structure of temporal organization of impulse activity of alai nasi muscles in the form of bimodal distribution of interpulse intervals and in temporal structure of impulse activity of upper esophageal sphincter muscles in the form of monomodal distribution. The latent form of food motivation was manifested in the structure of temporal organization of periods of the action potentials burst-like rhythm, generated by alai nasi muscles, in the form of monomodal distribution, characterized by a high degree of dispersion of respiratory cycle periods. In the absence of physical activity hungry animals sporadically exhibited sniffing activity, manifested in the change from the burst-like impulse activity of alai nasi muscles to the single-burst activity type with bimodal distribution of interpulse intervals and monomodal distribution of the burst-like action potentials rhythm periods, the maximum of which was shifted towards lower values, which was the cause of increased respiratory rate. At the same time, the monomodal temporal structure of impulse activity of the upper esophageal sphincter muscles was not changed. With increasing food motivation in the process of search behavior temporal structure of periods of the burst-like action potentials rhythm, generated by alai nasi muscles, became similar to that observed during sniffing, not accompanied by animal's locomotion, which is typical for the increased respiratory rhythm frequency. Increased hunger motivation was reflected in the temporal structure of impulse activity of upper esophageal sphincter muscles in the form of a shift to lower values of the maximum of monomodal distribution of interpulse intervals on the histogram, resulting in higher impulse activity frequency. The simultaneous increase in the frequency of action potentials bursts generation by alai nasi muscles and regular impulse activity of upper esophageal sphincter muscles is a reliable criterion for enhanced food motivation during search behavior in rabbits.

Esophageal motility pattern and gastro-esophageal reflux in chronic obstructive pulmonary disease.

PubMed

Gadel, Abil Ali; Mostafa, Mohamed; Younis, Ahmed; Haleem, Magdy

2012-01-01

The association of esophageal motility and gastroesophageal reflux symptoms with respiratory symptoms is not well established in patients with chronic obstructive pulmonary disease (COPD). The aim of this work is to study the abnormalities of esophageal function in COPD patients and study its relation to smoking index, body mass index and indices of hyperinflation. This study included 40 male COPD patients and 10 healthy controls. The patients and controls were subjected to spirometry, body plethysmography, esophageal manometry and 24hr pH-metry. Upper gastrointestinal symptoms were found in 55% of patients, hypotensive upper esophageal sphincter pressure in 65% of patients and hypotensive lower esophageal sphincter pressure in 52.5% of patients. Pathological acid reflux was found in 35% of patients. The severity of GERD increased with increased age, smoking index and body mass index, p<0.005. There was negative correlation between LESP and UESP compared with indices of hyperinflation, p<0.001. There was high prevalence of esophageal motility disorders in COPD patients, LESP and UESP were significantly negatively correlated to indices of hyperinflation. There was a high prevalence of GERD in COPD patents especially elderly, severe stage of COPD, high smoking index and high body mass index (BMI).

Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe.

PubMed

Carlson, Dustin A; Kahrilas, Peter J; Lin, Zhiyue; Hirano, Ikuo; Gonsalves, Nirmala; Listernick, Zoe; Ritter, Katherine; Tye, Michael; Ponds, Fraukje A; Wong, Ian; Pandolfino, John E

2016-12-01

Esophagogastric junction (EGJ) distensibility and distension-mediated peristalsis can be assessed with the functional lumen imaging probe (FLIP) during a sedated upper endoscopy. We aimed to describe esophageal motility assessment using FLIP topography in patients presenting with dysphagia. In all, 145 patients (aged 18-85 years, 54% female) with dysphagia that completed upper endoscopy with a 16-cm FLIP assembly and high-resolution manometry (HRM) were included. HRM was analyzed according to the Chicago Classification of esophageal motility disorders; major esophageal motility disorders were considered "abnormal". FLIP studies were analyzed using a customized program to calculate the EGJ-distensibility index (DI) and generate FLIP topography plots to identify esophageal contractility patterns. FLIP topography was considered "abnormal" if EGJ-DI was <2.8 mm 2 /mm Hg or contractility pattern demonstrated absent contractility or repetitive, retrograde contractions. HRM was abnormal in 111 (77%) patients: 70 achalasia (19 type I, 39 type II, and 12 type III), 38 EGJ outflow obstruction, and three jackhammer esophagus. FLIP topography was abnormal in 106 (95%) of these patients, including all 70 achalasia patients. HRM was "normal" in 34 (23%) patients: five ineffective esophageal motility and 29 normal motility. In all, 17 (50%) had abnormal FLIP topography including 13 (37%) with abnormal EGJ-DI. FLIP topography provides a well-tolerated method for esophageal motility assessment (especially to identify achalasia) at the time of upper endoscopy. FLIP topography findings that are discordant with HRM may indicate otherwise undetected abnormalities of esophageal function, thus FLIP provides an alternative and complementary method to HRM for evaluation of non-obstructive dysphagia.

Evaluation of esophageal motility utilizing the functional lumen imaging probe (FLIP)

PubMed Central

Carlson, Dustin A.; Kahrilas, Peter J.; Lin, Zhiyue; Hirano, Ikuo; Gonsalves, Nirmala; Listernick, Zoe; Ritter, Katherine; Tye, Michael; Ponds, Fraukje A.; Wong, Ian; Pandolfino, John E.

2016-01-01

Background Esophagogastric junction (EGJ) distensibility and distension-mediated peristalsis can be assessed with the functional lumen imaging probe (FLIP) during a sedated upper endoscopy. We aimed to describe esophageal motility assessment using FLIP topography in patients presenting with dysphagia. Methods 145 patients (ages 18 – 85, 54% female) with dysphagia that completed upper endoscopy with a 16-cm FLIP assembly and high-resolution manometry (HRM) were included. HRM was analyzed according to the Chicago Classification of esophageal motility disorders; major esophageal motility disorders were considered ‘abnormal’. FLIP studies were analyzed using a customized program to calculate the EGJ-distensibility index (DI) and generate FLIP topography plots to identify esophageal contractility patterns. FLIP topography was considered ‘abnormal’ if EGJ-DI was < 2.8 mm2/mmHg or contractility pattern demonstrated absent contractility or repetitive, retrograde contractions. Results HRM was abnormal in 111 (77%) patients: 70 achalasia (19 type I, 39 type II, 12 type III), 38 EGJ outflow obstruction, and three jackhammer esophagus. FLIP topography was abnormal in 106 (95%) of these patients, including all 70 achalasia patients. HRM was ‘normal’ in 34 (23%) patients: five ineffective esophageal motility and 29 normal motility. 17 (50%) had abnormal FLIP topography including 13 (37%) with abnormal EGJ-DI. Conclusions FLIP topography provides a well-tolerated method for esophageal motility assessment (especially to identify achalasia) at the time of upper endoscopy. FLIP topography findings that are discordant with HRM may indicate otherwise undetected abnormalities of esophageal function, thus FLIP provides an alternative and complementary method to HRM for evaluation of non-obstructive dysphagia. PMID:27725650

Architecture of Vagal Motor Units Controlling Striated Muscle of Esophagus: Peripheral Elements Patterning Peristalsis?

PubMed Central

Powley, Terry L.; Mittal, Ravinder K.; Baronowsky, Elizabeth A.; Hudson, Cherie N.; Martin, Felecia N.; McAdams, Jennifer L.; Mason, Jacqueline K.; Phillips, Robert J.

2013-01-01

Little is known about the architecture of the vagal motor units that control esophageal striated muscle, in spite of the fact that these units are necessary, and responsible, for peristalsis. The present experiment was designed to characterize the motor neuron projection fields and terminal arbors forming esophageal motor units. Nucleus ambiguus compact formation neurons of the rat were labeled by bilateral intracranial injections of the anterograde tracer dextran biotin. After tracer transport, thoracic and abdominal esophagi were removed and prepared as whole mounts of muscle wall without mucosa or submucosa. Labeled terminal arbors of individual vagal motor neurons (n = 78) in the esophageal wall were inventoried, digitized and analyzed morphometrically. The size of individual vagal motor units innervating striated muscle, throughout thoracic and abdominal esophagus, averaged 52 endplates per motor neuron, a value indicative of fine motor control. A majority (77%) of the motor terminal arbors also issued one or more collateral branches that contacted neurons, including nitric oxide synthase-positive neurons, of local myenteric ganglia. Individual motor neuron terminal arbors co-innervated, or supplied endplates in tandem to, both longitudinal and circular muscle fibers in roughly similar proportions (i.e., two endplates to longitudinal for every three endplates to circular fibers). Both the observation that vagal motor unit collaterals project to myenteric ganglia and the fact that individual motor units co-innervate longitudinal and circular muscle layers are consistent with the hypothesis that elements contributing to peristaltic programming inhere, or are “hardwired,” in the peripheral architecture of esophageal motor units. PMID:24044976

Prospective Comparison of Surgery Alone and Chemoradiotherapy With Selective Surgery in Resectable Squamous Cell Carcinoma of the Esophagus

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ariga, Hisanori; Nemoto, Kenji; Miyazaki, Shukichi

Purpose: Esophagectomy remains the mainstay treatment for esophageal cancer, although retrospective studies have suggested that chemoradiotherapy (CRT) is as effective as surgery. To determine whether CRT can substitute for surgery as the primary treatment modality, we performed a prospective direct comparison of outcomes after treatment in patients with resectable esophageal cancer who had received CRT and those who had undergone surgery. Methods and Materials: Eligible patients had resectable T1-3N0-1M0 thoracic esophageal cancer. After the surgeon explained the treatments in detail, the patients selected either CRT (CRT group) or surgery (OP group). The CRT course consisted of two cycles of cisplatinmore » and fluorouracil with split-course concurrent radiotherapy of 60Gy in 30 fractions. Patients with progressive disease during CRT and/or with persistent or recurrent disease after CRT underwent salvage resection. Results: Of 99 eligible patients with squamous cell carcinoma registered between January 2001 and December 2005, 51 selected CRT and 48 selected surgery. Of the patients in the CRT group, 13 (25.5%) underwent esophagectomy as salvage therapy. The 3- and 5-year survival rates were 78.3% and 75.7%, respectively, in the CRT group compared with 56.9% and 50.9%, respectively, in the OP group (p = 0.0169). Patients in the OP group had significantly more metastatic recurrence than those in the CRT group. Conclusions: Treatment outcomes among patients with resectable thoracic esophageal squamous cell carcinoma were comparable or superior after CRT (with salvage therapy if needed) to outcomes after surgery alone.« less

Comparison of carina-based versus bony anatomy-based registration for setup verification in esophageal cancer radiotherapy.

PubMed

Machiels, Mélanie; Jin, Peng; van Gurp, Christianne H; van Hooft, Jeanin E; Alderliesten, Tanja; Hulshof, Maarten C C M

2018-03-21

To investigate the feasibility and geometric accuracy of carina-based registration for CBCT-guided setup verification in esophageal cancer IGRT, compared with current practice bony anatomy-based registration. Included were 24 esophageal cancer patients with 65 implanted fiducial markers, visible on planning CTs and follow-up CBCTs. All available CBCT scans (n = 236) were rigidly registered to the planning CT with respect to the bony anatomy and the carina. Target coverage was visually inspected and marker position variation was quantified relative to both registration approaches; the variation of systematic (Σ) and random errors (σ) was estimated. Automatic carina-based registration was feasible in 94.9% of the CBCT scans, with an adequate target coverage in 91.1% compared to 100% after bony anatomy-based registration. Overall, Σ (σ) in the LR/CC/AP direction was 2.9(2.4)/4.1(2.4)/2.2(1.8) mm using the bony anatomy registration compared to 3.3(3.0)/3.6(2.6)/3.9(3.1) mm for the carina. Mid-thoracic placed markers showed a non-significant but smaller Σ in CC and AP direction when using the carina-based registration. Compared with a bony anatomy-based registration, carina-based registration for esophageal cancer IGRT results in inadequate target coverage in 8.9% of cases. Furthermore, large Σ and σ, requiring larger anisotropic margins, were seen after carina-based registration. Only for tumors entirely confined to the mid-thoracic region the carina-based registration might be slightly favorable.

Architecture of vagal motor units controlling striated muscle of esophagus: peripheral elements patterning peristalsis?

PubMed

Powley, Terry L; Mittal, Ravinder K; Baronowsky, Elizabeth A; Hudson, Cherie N; Martin, Felecia N; McAdams, Jennifer L; Mason, Jacqueline K; Phillips, Robert J

2013-12-01

Little is known about the architecture of the vagal motor units that control esophageal striated muscle, in spite of the fact that these units are necessary, and responsible, for peristalsis. The present experiment was designed to characterize the motor neuron projection fields and terminal arbors forming esophageal motor units. Nucleus ambiguus compact formation neurons of the rat were labeled by bilateral intracranial injections of the anterograde tracer dextran biotin. After tracer transport, thoracic and abdominal esophagi were removed and prepared as whole mounts of muscle wall without mucosa or submucosa. Labeled terminal arbors of individual vagal motor neurons (n=78) in the esophageal wall were inventoried, digitized and analyzed morphometrically. The size of individual vagal motor units innervating striated muscle, throughout thoracic and abdominal esophagus, averaged 52 endplates per motor neuron, a value indicative of fine motor control. A majority (77%) of the motor terminal arbors also issued one or more collateral branches that contacted neurons, including nitric oxide synthase-positive neurons, of local myenteric ganglia. Individual motor neuron terminal arbors co-innervated, or supplied endplates in tandem to, both longitudinal and circular muscle fibers in roughly similar proportions (i.e., two endplates to longitudinal for every three endplates to circular fibers). Both the observation that vagal motor unit collaterals project to myenteric ganglia and the fact that individual motor units co-innervate longitudinal and circular muscle layers are consistent with the hypothesis that elements contributing to peristaltic programming inhere, or are "hardwired," in the peripheral architecture of esophageal motor units. © 2013.

Candida esophagitis in an immunocompetent pregnant woman.

PubMed

Greenspoon, J S; Kivnick, S

1993-01-01

Nausea and vomiting are common during the first half of pregnancy and usually require only supportive measures. When symptoms are progressive and weight loss occurs, treatable causes should be sought by means of upper gastrointestinal endoscopy. We report a case of an immunocompetent gravida with invasive Candida albicans esophagitis. The immunocompetent primigravida developed progressive nausea, vomiting, epigastric pain, and a 4.1 kg weight loss during the second trimester of pregnancy. Treatment with metoclopramide and cimetidine for presumed gastroesophageal reflux was not effective. The patient had normal T-cell CD4 and CD8 subsets and was human immunodeficiency virus (HIV) antibody negative. Upper gastrointestinal endoscopy revealed C. albicans esophagitis which was treated with oral nystatin. The esophagitis had resolved completely when reassessed postpartum. The use of histamine(2) blockers is associated with an increased risk for fungal esophagitis and may have been a contributing cause in this case. Pregnant patients with persistent nausea, vomiting, and weight loss should be evaluated by endoscopy for fungal esophagitis.

Effects of Age, Gender, Bolus Condition, Viscosity, and Volume on Pharyngeal and Upper Esophageal Sphincter Pressure and Temporal Measurements during Swallowing

ERIC Educational Resources Information Center

Butler, Susan G.; Stuart, Andrew; Castell, Donald; Russell, Gregory B.; Koch, Kenneth; Kemp, Shannon

2009-01-01

Purpose: The purpose of this study was to determine the effects of trial (i.e., Trial 1 vs. Trial 2); viscosity (i.e., saliva, thin, nectar-thick, honey-thick, and pudding-thick water); volume (i.e., 5 mL vs. 10 mL); age (i.e., young vs. older adults); and gender on pharyngeal (i.e., upper and lower) and upper esophageal sphincter (UES) pressures,…

Risk of radiation pneumonitis in patients receiving taxane-based trimodality therapy for locally advanced esophageal cancer.

PubMed

Shaikh, Talha; Churilla, Thomas M; Monpara, Pooja; Scott, Walter J; Cohen, Steven J; Meyer, Joshua E

There are limited data regarding clinical and treatment factors associated with radiation pneumonitis (RP) in patients receiving taxane-based trimodality therapy for esophageal cancer. The purpose of this study was to identify predictors of RP in patients undergoing trimodality therapy. We retrospectively reviewed patients undergoing chemoradiation followed by esophagectomy between 2006 and 2011. The association between clinical and dosimetric factors with RP was assessed using χ 2 test and Mann-Whitney U test. Multivariable regression was used to assess the relationship between grade 2+ RP and clinical/dosimetric factors. Receiver operator curves were generated to identify threshold doses for RP. A total of 139 patients were included; 19 (13.7%) patients experienced grade 2+ RP. Patients with upper/middle thoracic tumors (P = .038) and receiving higher radiation doses (P = .038) were more likely to develop grade 2+ RP. There was no association between taxane-based therapy and grade 2+ RP (P = .728). The percent volume of lung receiving 5 Gy (V5; P < .001), 10 Gy (P < .001), 20 Gy (V20; P < .001), and 30 Gy (P < .001) was associated with an increased risk of grade 2+ RP. On multivariable regression, the lung V5 (odds ratio, 1.101; 95% confidence interval, 1.1014-1.195) and V20 (odds ratio, 1.149; 95% confidence interval, 1.1015-1.301) remained associated with grade 2+ RP. A V5 ≤65% and V20 ≤25% were identified as optimal thresholds for increased grade 2+ RP. Dosimetric parameters are strong predictors of symptomatic RP in patients undergoing trimodality therapy for esophageal cancer. Mitigating the risk of RP in these patients should be an important consideration during treatment planning. Copyright © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience.

PubMed

Goel, Ashish; Shah, Swati H; Selvakumar, Veda Padma Priya; Garg, Shubha; Kumar, Kapil

2018-02-01

Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3-9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks.

PubMed

Gelbmann, C M; Ratiu, N L; Rath, H C; Rogler, G; Lock, G; Schölmerich, J; Kullmann, F

2004-08-01

Extensive anastomotic leaks after esophageal resection and esophageal perforations are a therapeutic challenge. The aim of the present study was to assess the potential of the self-expandable Polyflex plastic stent for the treatment of these conditions. Between January 2002 and March 2003, nine patients were treated with a self-expandable Polyflex plastic stent for sealing of thoracic esophagoenteric anastomotic leaks following surgical resection (n = 5) or esophageal perforation (n = 4). In all patients the stents were inserted successfully without technical problems. In all but two patients complete sealing of the leak was achieved as demonstrated by radiography with water-soluble contrast media. The stent migration rate was 30 % and repositioning of the migrated stents was possible in all cases. Complete mucosal healing of the esophageal leaks and stent extraction was achieved in six patients. The stents were in situ for an average period of 135 +/- 78 days. Two critically ill patients with anastomotic leaks died in spite of stent insertion due to sepsis and one patient with esophageal perforation died due to the underlying malignant disease. Our preliminary experience with the self-expanding and removable Polyflex plastic stent for the sealing of anastomotic leaks and esophageal perforations suggests that this stent is a feasible treatment option, in particular, for more extensive esophageal defects, patients with co-morbid conditions, and critically ill patients.

Oroesophageal Fish Bone Foreign Body.

PubMed

Kim, Heung Up

2016-07-01

Fish bone foreign body (FFB) is the most frequent food-associated foreign body (FB) in adults, especially in Asia, versus meat in Western countries. The esophageal sphincter is the most common lodging site. Esophageal FB disease tends to occur more frequently in men than in women. The first diagnostic method is laryngoscopic examination. Because simple radiography of the neck has low sensitivity, if perforation or severe complications requiring surgery are expected, computed tomography should be used. The risk factors associated with poor prognosis are long time lapse after FB involvement, bone type, and longer FB (>3 cm). Bleeding and perforation are more common in FFB disease than in other FB diseases. Esophageal FB disease requires urgent treatment within 24 hours. However, FFB disease needs emergent treatment, preferably within 2 hours, and definitely within 6 hours. Esophageal FFB disease usually occurs at the physiological stricture of the esophagus. The aortic arch eminence is the second physiological stricture. If the FB penetrates the esophageal wall, a life-threatening aortoesophageal fistula can develop. Therefore, it is better to consult a thoracic surgeon prior to endoscopic removal.

Esophageal symptoms and their lack of association with high-resolution manometry in systemic sclerosis patients.

PubMed

Arana-Guajardo, Ana Cecilia; Barrera-Torres, Gustavo; Villarreal-Alarcón, Miguel Ángel; Vega-Morales, David; Esquivel-Valerio, Jorge Antonio

2017-12-16

The esophageal involvement in systemic sclerosis (SSc) causes impact in the morbidity and mortality. High resolution manometry assesses esophageal involvement. Our aim was to categorize esophageal motor disorder in patients with SSc by HRM. We carried out an observational, descriptive and cross-sectional study. All patients underwent HRM as well as semi-structured interviews to assess frequency and severity of upper GI symptoms. Patients also completed the gastroesophageal reflux questionnaire (Carlsson-Dent). We included 19 patients with SSc, 1 with morphea, and 1 with scleroderma sine scleroderma. Dysphagia and heartburn were the most frequent symptoms (61% each). We found an abnormal HRM in 15 (71.4%) patients. We found no statistically significant association between clinical or demographic variables and an abnormal HRM, or between any upper GI symptom and HRM findings. We observed a high prevalence of esophageal symptoms and of HRM abnormalities. However, there was no clear association between symptomatology and HRM findings. HRM does not seem to accurately predict upper GI symptomatology. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

Tracheobronchial lesions following esophagectomy: erosions, ulcers, and fistulae, and the predictive value of lymph node-related factors.

PubMed

Maruyama, Kiyotomi; Motoyama, Satoru; Sato, Yusuke; Hayashi, Kaori; Usami, Shuetu; Minamiya, Yoshihiro; Ogawa, Jun-ichi

2009-04-01

Following esophagectomy, tracheobronchial lesions (TBLs) can occur as a result of ischemia caused by extensive dissection around the tracheobronchus. In this study we assessed the causes and clinical features of these complications, paying particular attention to lymph node (LN)-related factors. Between January 2000 and March 2007, 305 consecutive patients underwent subtotal esophagectomy using a transthoracic approach with LN dissection for thoracic esophageal cancer. TBLs, including erosions, ulcers, and fistulae, without traumatic injury during the operation, were detected during bronchoscopic examinations performed twice daily after the operation. The correlation between TBLs and tumor or surgical factors were analyzed. TBLs were observed in 14 patients, accounting for an overall incidence of 5%; these included 6 fistulae, 5 ulcers, and 3 erosions. Cases with TBLs significantly more often involved three-field LN dissections (3FLD) than those without TBLs. Six (43%) patients with TBLs had more than four metastatic lymph nodes, while 9 (64%) had cervical and upper-mediastinal LN metastasis (p=0.034 and 0.041, respectively). More than 60 LNs were dissected from 10 (71%) patients with TBLs (p=0.021), and logistic regression analysis revealed that dissection of more than 60 lymph nodes and 3FLD were independent predictors of TBLs. Esophageal cancer patients requiring extensive LN dissection of more than 60 nodes and/or 3FLD have an increased risk of developing a TBL during their postoperative course.

Effects of alcohol consumption, cigarette smoking, and betel quid chewing on upper digestive diseases: a large cross-sectional study and meta-analysis.

PubMed

Chuang, Yun-Shiuan; Wu, Meng-Chieh; Yu, Fang-Jung; Wang, Yao-Kuang; Lu, Chien-Yu; Wu, Deng-Chyang; Kuo, Chie-Tong; Wu, Ming-Tsang; Wu, I-Chen

2017-09-29

Cigarette smoking is a well-known risk factor of upper digestive diseases. Findings on alcohol's effect on these diseases are inconsistent and with the exception of its association with esophageal cancer, little is known about betel quid chewing. This study investigated the association between use of these three substances and upper digestive diseases. We collected data from 9,275 patients receiving upper endoscopies between April 2008 and December 2013. Polynomial regressions were used to analyze the association between risk factors and diseases of the esophagus, stomach and duodenum. Meta-analysis for use of these substances and esophageal diseases was also performed. Participants who simultaneously consumed cigarettes, alcohol and betel quid had a 17.28-fold risk of esophageal cancer (95% CI = 7.59-39.33), 2.99-fold risk of Barrette's esophagus (95% CI = 2.40-4.39), 1.60-fold risk of grade A-B erosive esophagitis (95% CI = 1.29-2.00), 2.00-fold risk of gastric ulcer (95% CI = 1.52-2.63), 2.12-fold risk of duodenitis (95% CI = 1.55-2.89) and 1.29-fold risk of duodenal ulcer (95% CI = 1.01-1.65). Concurrent consumption of more substances was associated with significantly higher risk of developing these diseases. Meta-analysis also revealed use of the three substances came with a high risk of esophageal diseases. In conclusions, cigarette smoking, alcohol drinking and betel quid chewing were associated with upper digestive tract diseases.

Myxedema coma after esophagectomy.

PubMed

Yuan, Yong; Hu, Yang; Xie, Tianpeng; Zhao, Yongfan

2010-07-01

For most patients with esophageal cancer, esophagectomy is an effective therapy. Perioperative management is critical for clinical outcomes after the operation. Great efforts should be made to avoid postoperative complications. We report myxedema coma, an emergency condition caused by severe hypothyroidism, after a patient underwent esophagectomy for esophageal cancer. The patient was successfully treated with intravenous levothyroxine. We strongly recommend that physicians test the thyroid hormone levels in patients with risk factors. If myxedema coma occurs, immediate use of intravenous levothyroxine is effective for this lethal complication. Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

High-Resolution Manometry Evaluation of the Pharynx and Upper Esophageal Sphincter Motility in Patients with Achalasia.

PubMed

Menezes, Mariano A; Herbella, Fernando A M; Patti, Marco G

2015-10-01

The motility of the pharynx and upper esophageal sphincter (UES) is still poorly understood. It is also unclear if the motility of this area may be compromised in patients with achalasia. This study aims to evaluate the motility of the pharynx, UES, and proximal esophagus in patients with esophageal achalasia. Sixty patients with achalasia underwent high-resolution manometry (HRM) (52 % females, mean age 54 years). Esophageal dilatation was classified according to the radiologic diameter in Type I (<4 cm): 6 %; Type II (4-7 cm): 36 %; Type III (7-10 cm): 34 %; and Type IV (>10 cm): 24 %. HRM classified 43 % of the patients as Chicago Type I and 57 % as Type II. Manometric parameters were compared to normal values obtained from a previous study in volunteers. The motility of the velopharynx showed short, premature, and hypertonic contraction. The epiglottis also showed hypertonic contraction. The UES had increased residual pressure. Chicago classification Type II patients had higher UES residual pressure (p = 0.03). The degree of esophageal dilatation did not correlate with manometric parameters. Achalasia may affect the motility of the pharyngo-upper esophageal area. The changes observed may represent functional alterations to prevent aspiration, especially in patients with Chicago classification Type II achalasia.

Gastroesophageal junction of Anatolian shepherd dog; a study by topographic anatomy, scanning electron and light microscopy.

PubMed

Alsafy, M A M; El-Gendy, S A A

2012-03-01

The aim of this study was to cast a spotlight on the topography and to point out the clinical importance of the gastroesophageal junction (GEJ) in Anatolian Shepherd dogs. Nine Anatolian Shepherd dogs were used to study the morphology of the GEJ. The esophagus was appeared has a portion within the thoracic cavity while no portion of the esophagus presented within the abdominal cavity that documented the absence of the intra-abdominal portion in all studied dogs. The topographic anatomy, scanning electron and light microscopic examinations revealed that the gastroesophageal junction was located at the level of the phrenico-esophageal ligament (PEL) inside the esophageal hiatus. Our results were distinguished the morphology of the esophageal and gastric cardiac mucosa at the level of the gastroesophageal junction by the scanning electron micrographs. The light microscopical examination was explained the PEL attached to the esophageal side in one dog and to the gastric cardiac side in three dogs.

Esophageal rupture caused by explosion of an automobile tire tube: a case report.

PubMed

Yu, Yongkang; Ding, Sheng; Zheng, Yifeng; Li, Wei; Yang, Lie; Zheng, Xiushan; Liu, Xiaoyan; Jiang, Jianqing

2013-08-23

There have been no reports in the literature of esophageal rupture in adults resulting from an explosion of an automobile tire. We report the first case of just such an occurrence after an individual bit into a tire, causing it to explode in his mouth. A 47-year-old Han Chinese man presented with massive hemorrhage in his left eye after he accidentally bit an automobile tire tube which burst into his mouth. He was diagnosed with esophageal rupture based on a chest computed tomography scan and barium swallow examination. Drainage of empyema (right chest), removal of thoracic esophagus, exposure of cervical esophagus, cardiac ligation and gastrostomy were performed respectively. After that, esophagogastrostomy was performed. Successful anastomosis was obtained at the neck with no postoperative complications 3 months after the surgery. The patient was discharged with satisfactory outcomes. We present this case report to bring attention to esophageal rupture in adults during the explosion of an automobile tire tube in the mouth.

[Techniques for Preventing Postoperative Complication in Esophageal Salvage Surgery].

PubMed

Iwama, Mitsuru; Yasuda, Takushi; Shiraishi, Osamu; Kato, Hiroaki; Hiraki, Yoko; Tanaka, Yumiko; Yasuda, Atsushi; Shinkai, Masayuki; Imano, Motohiro; Kimura, Yutaka; Imamoto, Haruhiko

2017-07-01

Patients with esophageal cancer are often treated with definitive chemoradiotherapy (dCRT). Regardless of arrival at dCRT, the risk of local/regional recurrence during follow-up is significant. Many patient are faced with limited options for therapy once dCRT has failed. Salvage surgery is the only way for complete cure of patients with local/regional recurrent esophageal cancer after dCRT. However, salvage surgery has a significant high risk of fatal complications. We examine our preventive measures to reduce the incidence of postoperative complications after salvage surgery for thoracic esophageal cancer. The points of our preventive measures are them; I. the ingenuity of surgery, II. the securement of blood supply for the respiratory tract, III. standard lymphadenectomy, IV. countermeasures of anastomotic failure, V. countermeasures of dead space, VI. countermeasures of respiratory complications, VII. perioperative managements. Salvage surgery is a reasonable option to treat patients with local/regional recurrence after failed dCRT. Our preventive mesures are effective, therefore, we have to make the further technological developments and the safety of salvage surgery.

[Application of degree of portal systemic shunting in assessing upper gastrointestinal bleeding in patients with schistosomiasis cirrhosis].

PubMed

Shuai, Ju; Ying, Li; Chang-Xue, Ji; Biao, Zhang

2017-03-27

To discuss the application of the degree of portal systemic shunting in assessing the upper gastrointestinal bleeding in patients with hepatic schistosomiasis. Thirty-three patients with upper gastrointestinal bleeding caused by hepatic schistosomiasis (a bleeding group) and 29 schistosomiasis cirrhosis patients without bleeding (a non-bleeding group) were enrolled as investigation subjects in Jinshan Hospital. The subjects were scanned by the 128 abdominal slice spiral CT. The portal systemic shunting vessels were reconstructed by using thin slab maximum intensity projection (TSMIP) and multiplanar reconstruction (MPR). The degrees of the shunting vessels of the subjects were evaluated and compared, and the relationship between upper gastrointestinal bleeding and the degree of the shunting was analyzed. In the bleeding group, the occurrence rates of the shunting vessels were found as follows: 86.4% in left gastric varices, 68.2% in short gastric varices, 50.0% in esophageal varices, 50.0% in para-esophageal varices, 37.9% in gastric varices, 69.7% in gastric-renal varices, 51.5% in spleen-renal varices, 25.8% in abdominal wall varices, 15.2% in omentum varices, 63.6% in para-splenic varices, 34.8% in umbilical varices, 40.9% in retroperitoneal-paravertebral varices, and 36.4% in mesenteric varices. In the bleeding group, the occurrence rates and the degree of shunt were significantly higher than those in the non-bleeding group in esophageal varices, esophageal vein, left gastric vein and gastric varices (all P < 0.05). CT portal vein reconstruction can accurately display the location, degree and walking of all kinds of shunting vessels. Esophageal varices, esophageal vein, left gastric vein and gastric varices can accurately predict the risk of upper gastrointestinal bleeding in patients with hepatic schistosomiasis. The patents with higher degree of the shunting vessels have a higher risk of gastrointestinal bleeding.

Esophageal stenosis with sloughing esophagitis: A curious manifestation of graft-vs-host disease.

PubMed

Trabulo, Daniel; Ferreira, Sara; Lage, Pedro; Rego, Rafaela Lima; Teixeira, Gilda; Pereira, A Dias

2015-08-14

We report a case of a 56-year-old woman with a history of allogenic bone marrow transplantation for two years, complaining with dysphagia and weight loss. Upper endoscopy revealed esophageal stenosis and extensive mucosa sloughing. Biopsies confirmed the diagnosis of graft-vs-host disease (GVHD). Balloon dilation, corticosteroids and cyclosporin resulted in marked clinical improvement. Gastrointestinal tract is involved in the majority of patients with chronic GVHD. Esophageal manifestations are rare and include vesiculobullous disease, ulceration, esophageal webs, casts or strictures. Sloughing esophagitis along with severe stenosis requiring endoscopic dilation has never been reported in this context.

Assessment of esophageal involvement in systemic sclerosis and morphea (localized scleroderma) by clinical, endoscopic, manometric and pH metric features: a prospective comparative hospital based study.

PubMed

Arif, Tasleem; Masood, Qazi; Singh, Jaswinder; Hassan, Iffat

2015-02-15

Systemic sclerosis (SSc) is a generalized disorder of unknown etiology affecting the connective tissue of the body. It affects the skin and various internal organs. Gastrointestinal tract involvement is seen in almost 90% of the patients. Esophagus is the most frequently affected part of the gastrointestinal tract. Esophageal motility disturbance classically manifests as a reduced lower esophageal sphincter pressure (LESP) and loss of distal esophageal body peristalsis. Consequently, SSc patients may be complicated by erosive esophagitis and eventually by Barrett's esophagus and esophageal adenocarcinoma. Morphea, also known as localized scleroderma, is characterized by predominant skin involvement, with occasional involvement of subjacent muscles and usually sparing the internal organs. The involvement of esophagus in morphea has been studied very scarcely. The proposed study will investigate the esophageal involvement in the two forms of scleroderma (systemic and localized), compare the same and address any need of upper gastrointestinal evaluation in morphea (localized scleroderma) patients. 56 and 31 newly and already diagnosed cases of SSc and morphea respectively were taken up for the study. All the patients were inquired about the dyspeptic symptoms (heartburn and/or acid regurgitation and/or dysphagia). Upper gastrointestinal endoscopy, esophageal manometry and 24-hour pH monitoring were done in 52, 47 and 41 patients of SSc; and 28, 25 and 20 patients of morphea respectively. Esophageal symptoms were present in 39 cases (69.6%) of SSc which were mild in 22 (39.3%), moderate in 14 (25%), severe in three (5.3%); while only four cases (7.1%) of morphea had esophageal symptoms all of which were mild in severity. Reflux esophagitis was seen in 17 cases (32.7%) of SSc and only two cases (7.14%) of morphea. Manometric abnormalities were seen in 32 cases (68.1%) of SSc and none in morphea. Ambulatory 24-hour esophageal pH monitoring documented abnormal reflux in 33 cases (80.5%) of SSc and no such abnormality in morphea. While the esophageal involvement is frequent in SSc, no such motility disorder is seen in morphea. Meticulous upper gastrointestinal tract evaluation is justified only in SSc and not in morphea.

Evaluation of the reliability of clinical staging of T2 N0 esophageal cancer: a review of the Society of Thoracic Surgeons database.

PubMed

Crabtree, Traves D; Kosinski, Andrzej S; Puri, Varun; Burfeind, William; Bharat, Ankit; Patterson, G Alexander; Hofstetter, Wayne; Meyers, Bryan F

2013-08-01

Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tomography and endoscopic ultrasound imaging. Despite such progress, small single-center studies have questioned the reliability of clinical staging of T2 N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2 N0 disease using The Society of Thoracic Surgeons database. We retrospectively studied 810 clinical stage T2 N0 patients from 2002 to 2011, with 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was used to identify factors associated with upstaging at the time of surgical intervention. Among 752 clinical stage T2 N0 patients, 270 (35.9%) received induction therapy before the operation. Of 482 patients who went directly to surgical intervention, 132 (27.4%) were confirmed as pathologic T2 N0, 125 (25.9%) were downstaged (ie, T0-1 N0), and 225 (46.7%) were upstaged at the operation (T3-4 N0 or Tany N1-3). Exclusive tumor upstaging (ie, pathologic T3-4 N0) accounted for 41 patients (18.2%), whereas exclusive nodal upstaging (ie, pathological T1-2 N1-3) accounted for 100 (44.5%). Combined tumor and nodal upstaging (ie, pathological T3-4 N1-3) accounted for 84 patients (37.3%). Among patients who received induction therapy, 103 (38.1%) were upstaged vs 225 (46.7%) without induction therapy (p = 0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality (3.7% vs 3.7%, p > 0.99) and morbidity (46.3% vs 45%, p = 0.76) were similar. Despite advances in staging techniques, clinical staging of T2 N0 esophageal cancer remains unreliable. Recognizing T2 N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2 N0 disease with induction therapy, even though one-quarter of these patients will be pathologic T1 N0. Although this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the effect of upstaging on long-term survival. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Biomechanics of the lower thoracic spine after decompression and fusion: a cadaveric analysis.

PubMed

Lubelski, Daniel; Healy, Andrew T; Mageswaran, Prasath; Benzel, Edward C; Mroz, Thomas E

2014-09-01

Few studies have evaluated the extent of biomechanical destabilization of thoracic decompression on the upper and lower thoracic spine. The present study evaluates lower thoracic spinal stability after laminectomy, unilateral facetectomy, and unilateral costotransversectomy in thoracic spines with intact sternocostovertebral articulations. To assess the biomechanical impact of decompression and fixation procedures on lower thoracic spine stability. Biomechanical cadaveric study. Sequential surgical decompression (laminectomy, unilateral facetectomy, unilateral costotransversectomy) and dorsal fixation were performed on the lower thoracic spine (T8-T9) of human cadaveric spine specimens with intact rib cages (n=10). An industrial robot was used to apply pure moments to simulate flexion-extension (FE), lateral bending (LB), and axial rotation (AR) in the intact specimens and after decompression and fixation. Global range of motion (ROM) between T1-T12 and intrinsic ROM between T7-T11 were measured for each specimen. The decompression procedures caused no statistically significant change in either global or intrinsic ROM compared with the intact state. Instrumentation, however, reduced global motion for AR (45° vs. 30°, p=.0001), FE (24° vs. 19°, p=.02), and LB (47° vs. 36°, p=.0001) and for intrinsic motion for AR (17° vs. 4°, p=.0001), FE (8° vs. 1°, p=.0001), and LB (12° vs. 1°, p=.0001). No significant differences were identified between decompression of the upper versus lower thoracic spine, with trends toward significantly greater ROM for AR and lower ROM for LB in the lower thoracic spine. The lower thoracic spine was not destabilized by sequential unilateral decompression procedures. Addition of dorsal fixation increased segment rigidity at intrinsic levels and also reduced overall ROM of the lower thoracic spine to a greater extent than did fusing the upper thoracic spine (level of the true ribs). Despite the lack of true ribs, the lower thoracic spine was not significantly different compared with the upper thoracic spine in FE and LB after decompression, although there were trends toward significance for greater AR after decompression. In certain patients, instrumentation may not be needed after unilateral decompression of the lower thoracic spine; further validation and additional clinical studies are warranted. Copyright © 2014 Elsevier Inc. All rights reserved.

Dosimetric and efficiency comparison of high-dose radiotherapy for esophageal cancer: volumetric modulated arc therapy versus fixed-field intensity-modulated radiotherapy.

PubMed

Lin, C-Y; Huang, W-Y; Jen, Y-M; Chen, C-M; Su, Y-F; Chao, H-L; Lin, C-S

2014-08-01

The aim of this study was to compare high-dose volumetric modulated arc therapy (VMAT) and fixed-field intensity-modulated radiotherapy (ff-IMRT) plans for the treatment of patients with middle-thoracic esophageal cancer. Eight patients with cT2-3N0M0 middle-thoracic esophageal cancer were enrolled. The treatment planning system was the version 9 of the Pinnacle(3) with SmartArc (Philips Healthcare, Fitchburg, WI, USA). VMAT and ff-IMRT treatment plans were generated for each case, and both techniques were used to deliver 50 Gy to the planning target volume (PTV(50)) and then provided a 16-Gy boost (PTV(66)). The VMAT plans provided superior PTV(66) coverage compared with the ff-IMRT plans (P = 0.034), whereas the ff-IMRT plans provided more appropriate dose homogeneity to the PTV(50) (P = 0.017). In the lung, the V(5) and V(10) were lower for the ff-IMRT plans than for the VMAT plans, whereas the V(20) was lower for the VMAT plans. The delivery time was significantly shorter for the VMAT plans than for the ff-IMRT plans (P = 0.012). In addition, the VMAT plans delivered fewer monitor units. The VMAT technique required a shorter planning time than the ff-IMRT technique (3.8 ± 0.8 hours vs. 5.4 ± 0.6 hours, P = 0.011). The major advantages of VMAT plans are higher efficiency and an approximately 50% reduction in delivery time compared with the ff-IMRT plans, with comparable plan quality. Further clinical investigations to evaluate the use of high-dose VMAT for the treatment of esophageal cancer are warranted. © 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

[Complication related factors and efficacy with flexible endoscopy of 101 esophageal foreign bodies].

PubMed

Yan, Xiu-e; Zhou, Li-ya; Lin, San-ren; Wang, Ye; Cheng, Zhi-rong

2013-08-27

To analyze the related factors of complications and treatment efficacy with flexible endoscopy for esophageal foreign body (FB). In a retrospective study with consecutive data, 101 adults including 52 males and 49 females with esophageal FB impaction between January 2005 and December 2012 admitted into Department of Gastroenterology's Endoscopic Unit at Peking University Third Hospital were included, aged (49 ± 21) years. (1) FB impaction in upper and middle esophagus accounted for 87.1% (n = 88) of all esophageal FBs. No significant difference existed in interval time from impaction to removal of FB impacted between upper, middle and lower esophagus (P > 0.05) . (2) Patients with esophageal FB seeking hospital treatment accounted for 82.2% (n = 83) within 24 h and 99.0% (n = 100) within 48 h. Food lump, fish bone, chicken bone and fruit seeds accounted for 76.2% (n = 77). (3) Positive rates were 91.3% (21/23) and 24.1% (7/29) with upper gastrointestinal barium contrast and chest or abdominal plain film. The success rate was 94.1% (n = 95) with flexible endoscopy for removal of FB. (4) Denture was the most difficult FB for removal. Four patients in all 11 patients with denture impacted were not removed successfully with flexible endoscopy. (5) The complication (except for mild scratch) rate was 48.5% (n = 49) and the perforation rate 3.0% (n = 3) . Whether complications took place or not was independent of age, location of impaction, time from impaction to removal and size of FB (all P > 0.05) , but dependent on piercing into esophageal wall, concomitant with esophageal stricture and types of FB (all P < 0.01) . Whether perforation or not was independent of any above factor. Esophageal FB should be removed as soon as possible within 24 h especially for those with sharp edges and piercing into esophageal wall.

An L-Shaped Incision for an Extensive Thoracic Aortic Aneurysm and Coronary Artery Bypass Using the Left Internal Thoracic Artery.

PubMed

Abe, Tomonobu; Suenaga, Hiroto; Oshima, Hideki; Araki, Yoshimori; Mutsuga, Masato; Fujimoto, Kazuro; Usui, Akihiko

2015-04-01

An L-shaped incision combining an upper half mid-sternotomy and a left antero-lateral thoracotomy at the fourth intercostal space has been proposed by several authors for extensive aneurysms involving the aortic arch and the proximal thoracic descending aorta. This approach usually requires the division of the left internal thoracic artery at its mid position, thus making it unusable for coronary artery bypass. We herein report a modified surgical approach for simultaneous extensive arch and proximal thoracic descending aorta replacement and coronary artery bypass using the left internal thoracic artery combining a left antero-lateral thoracotomy at the sixth intercostal space and upper mid-sternotomy. The visualization of the whole diseased aorta down to the level below the hilum of the left lung was good, and the integrity of the left internal thoracic artery graft was preserved by early heparin administration before sternotomy.

Incidence and risk factors of acute kidney injury after esophageal cancer surgery: A nested case-control study.

PubMed

Wang, Wen; Wang, Tong; Feng, Xiaoshuang; Sun, Li

2017-03-01

Acute kidney injury (AKI) has been increasingly recognized as a common and serious postoperative complication. Although many studies have been conducted to investigate postoperative AKI after thoracic surgery, little is known about AKI after esophageal surgery. Thus, we conducted this study to determine the incidence and identify risk factors of postoperative AKI after esophageal cancer surgery. A retrospective nested case-control study of patients undergoing elective esophageal cancer surgery between July 2013 and July 2016 in a single tertiary specialized cancer hospital was performed. The primary outcome was development of AKI. Conditional logistic regression analysis was performed to identify independent risk factors for AKI. Of 2094 patients, 51 (2.4%) developed postoperative AKI after esophageal cancer surgery. In multivariate conditional logistic regression analysis, four risk factors for AKI after esophageal surgery for cancer were identified: preoperative serum creatinine level (OR 1.040; 95% CI 1.012-1.069), duration of surgery (OR 1.009; 95% CI 1.005-1.014), smoking history (OR 3.029; 95% CI 1.092-8.399) and hypertension (OR 6.422; 95% CI 2.736-15.070). Postoperative AKI occurred in 2.4% of patients after esophageal surgery for cancer. Preoperative serum creatinine level, duration of surgery, smoking history and hypertension were independent risk factors for postoperative AKI. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Clinicopathological Features of Cervical Esophageal Cancer: Retrospective Analysis of 63 Consecutive Patients Who Underwent Surgical Resection.

PubMed

Saeki, Hiroshi; Tsutsumi, Satoshi; Yukaya, Takafumi; Tajiri, Hirotada; Tsutsumi, Ryosuke; Nishimura, Sho; Nakaji, Yu; Kudou, Kensuke; Akiyama, Shingo; Kasagi, Yuta; Nakashima, Yuichiro; Sugiyama, Masahiko; Sonoda, Hideto; Ohgaki, Kippei; Oki, Eiji; Yasumatsu, Ryuji; Nakashima, Torahiko; Morita, Masaru; Maehara, Yoshihiko

2017-01-01

The objectives of this retrospective study were to elucidate the clinicopathological features and recent surgical results of cervical esophageal cancer. Cervical esophageal cancer has been reported to have a dismal prognosis. Accurate knowledge of the clinical characteristics of cervical esophageal cancer is warranted to establish appropriate therapeutic strategies. The clinicopathological features and treatment results of 63 consecutive patients with cervical esophageal cancer (Ce group) who underwent surgical resection from 1980 to 2013 were analyzed and compared with 977 patients with thoracic or abdominal esophageal cancer (T/A group) who underwent surgical resection during that time. Among the patients who received curative resection, the 5-year overall and disease-specific survival rates of the Ce patients were significantly better than those of the T/A patients (overall: 77.3% vs 46.5%, respectively, P = 0.0067; disease-specific: 81.9% vs 55.8%, respectively, P = 0.0135). Although total pharyngo-laryngo-esophagectomy procedures were less frequently performed in the recent period, the rate of curative surgical procedures was markedly higher in the recent period (2000-1013) than that in the early period (1980-1999) (44.4% vs 88.9%, P = 0.0001). The 5-year overall survival rate in the recent period (71.5%) was significantly better than that in the early period (40.7%, P = 0.0342). Curative resection for cervical esophageal cancer contributes to favorable outcomes compared with other esophageal cancers. Recent surgical results for cervical esophageal cancer have improved, and include an increased rate of curative resection and decreased rate of extensive surgery.

Temporary banding of the gastroesophageal junction in the critically ill neonate with esophageal atresia and tracheoesophageal fistula.

PubMed

Fagelman, K M; Boyarsky, A

1985-09-01

Patients with esophageal atresia and a distal tracheoesophageal fistula with associated conditions contributing to decreased pulmonary compliance present special problems in management. In the face of positive pressure ventilation, the fistula acts as a vent preventing adequate ventilatory effort from reaching the lungs. A thoracic approach to ligate or divide the fistula carries with it a high mortality rate. A technique is described whereby a silicone rubber band is applied to the gastroesophageal junction to effectively occlude the esophagus. It is designed so that is can be adjusted or removed, without operative intervention, according to the patient's clinical course and growth.

Upper esophageal sphincter (UES) metrics on high-resolution manometry (HRM) differentiate achalasia subtypes.

PubMed

Blais, P; Patel, A; Sayuk, G S; Gyawali, C P

2017-12-01

The upper esophageal sphincter (UES) reflexively responds to bolus presence within the esophageal lumen, therefore UES metrics can vary in achalasia. Within consecutive patients undergoing esophageal high-resolution manometry (HRM), 302 patients (58.2±1.0 year, 57% F) with esophageal outflow obstruction were identified, and compared to 16 asymptomatic controls (27.7±0.7 year, 56% F). Esophageal outflow obstruction was segregated into achalasia subtypes 1, 2, and 3, and esophagogastric junction outflow obstruction (EGJOO with intact peristalsis) using Chicago Classification v3.0. UES and lower esophageal sphincter (LES) metrics were compared between esophageal outflow obstruction and normal controls using univariate and multivariate analysis. Linear regression excluded multicollinearity of pressure metrics that demonstrated significant differences across individual subtype comparisons. LES integrated relaxation pressure (IRP) had utility in differentiating achalasia from controls (P<.0001), but no utility in segregating between subtypes (P=.27). In comparison to controls, patients collectively demonstrated univariate differences in UES mean basal pressure, relaxation time to nadir, recovery time, and residual pressure (UES-RP) (P≤.049). UES-RP was highest in type 2 achalasia (P<.0001 compared to other subtypes and controls). In multivariate analysis, only UES-RP retained significance in comparison between each of the subgroups (P≤.02 for each comparison). Intrabolus pressure was highest in type 3 achalasia; this demonstrated significant differences across some but not all subtype comparisons. Nadir UES-RP can differentiate achalasia subtypes within the esophageal outflow obstruction spectrum, with highest values in type 2 achalasia. This metric likely represents a surrogate marker for esophageal pressurization. © 2017 John Wiley & Sons Ltd.

Development of a Multidisciplinary Program to Expedite Care of Esophageal Emergencies.

PubMed

Ceppa, DuyKhanh P; Rosati, Carlo Maria; Chabtini, Lola; Stokes, Samantha M; Cook, Holly C; Rieger, Karen M; Birdas, Thomas J; Lappas, John C; Kessler, William R; DeWitt, John M; Maglinte, Dean D; Kesler, Kenneth A

2017-09-01

Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies. After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used. Eighty patients were referred and transported an average distance of 56 miles (range, 1-163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave's syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p < 0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p < 0.01). Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Esophageal leiomyoma in a dog causing esophageal distension and treated by transcardial placement of a self-expanding, covered, nitinol esophageal stent.

PubMed

Robin, Elisabeth M; Pey, Pascaline B; de Fornel-Thibaud, Pauline; Moissonnier, Pierre H M; Freiche, Valérie

2018-02-01

CASE DESCRIPTION A 10-year-old spayed female Rottweiler was referred for evaluation because of a 2-month history of regurgitation and weight loss, despite no apparent change in appetite. The dog had received antiemetic and antacid treatment, without improvement. CLINICAL FINDINGS Physical examination revealed a low body condition score (2/5), but other findings were unremarkable. Diffuse, global esophageal dilatation was noted on plain thoracic radiographs, and normal motility was confirmed through videofluoroscopic evaluation of swallowing. Transhepatic ultrasonographic and CT examination revealed a circumferential, intraparietal lesion in the distal portion of the esophagus causing distal esophageal or cardial subobstruction and no metastases. Incisional biopsy of the lesion was performed, and findings of histologic examination supported a diagnosis of esophageal leiomyoma. TREATMENT AND OUTCOME In view of numerous possible complications associated with esophageal surgery, the decision was made to palliatively treat the dog by transcardial placement of a self-expanding, covered, nitinol esophageal stent under endoscopic guidance. Two weeks after stent placement, radiography revealed complete migration of the stent into the gastric lumen. Gastrotomy was performed, and the stent was replaced and fixed in place. Twenty-four months after initial stent placement, the dog had a healthy body condition and remained free of previous clinical signs. CLINICAL RELEVANCE Diffuse benign muscular neoplasia should be considered as a differential diagnosis for acquired esophageal dilatation in adult and elderly dogs. In the dog of this report, transcardial stent placement resulted in resolution of the clinical signs, with no apparent adverse effect on digestive function. The described procedure could be beneficial for nonsurgical treatment of benign esophageal tumors in dogs.

Effect of Esophageal Cancer Surgeon Volume on Management and Mortality From Emergency Upper Gastrointestinal Conditions: Population-based Cohort Study.

PubMed

Markar, Sheraz R; Mackenzie, Hugh; Askari, Alan; Faiz, Omar; Hanna, George B

2017-11-01

To study the influence of esophageal cancer surgeon volume upon mortality from upper gastrointestinal emergencies. Volume-outcome relationships led to the centralization of esophageal cancer surgery. Hospital Episode Statistics data were used to identify patients admitted to hospitals within England (1997-2012). The influence of esophageal high-volume (HV) cancer surgeon status (≥5 resections per year) upon 30-day and 90-day mortality from esophageal perforation (EP), paraesophageal hernia causing obstruction or gangrene (PEH) and perforated peptic ulcer (PPU) was analyzed, independent of HV esophageal cancer center status and patient and disease-specific confounding factors. A total of 3707, 12,411, and 57,164 patients with EP, PEH, and PPU, respectively, were included. The observed 90-day mortality was 36.5%, 11.5%, and 29.0% for EP, PEH, and PPU, respectively.Management by HV cancer surgeon was independently associated with significant reductions in 30-day and 90-day mortality from EP (odds ratio, OR 0.51, 95% confidence interval, CI, 0.40-0.66), PEH (OR=0.70, 95% CI 0.53-0.91), and PPU (OR=0.85, 95% CI 0.7-0.95). Subset analysis of those patients receiving primary surgery as treatment showed no change in mortality when performed by HV cancer surgeons.However HV cancer surgeons performed surgery as primary treatment more commonly for EP (OR=2.38, 95% CI 1.87-3.04) and PEH (OR=2.12, 95% CI 1.79-2.51). Furthermore surgery was independently associated with reduced mortality for all 3 conditions. The complex elective workload of HV esophageal cancer surgeons appears to lower the threshold for surgical intervention in specific upper gastrointestinal emergencies such as EP and PEH, which in turn reduces mortality.

Epidural analgesia does not increase the rate of inpatient falls after major upper abdominal and thoracic surgery: a retrospective case-control study.

PubMed

Elsharydah, Ahmad; Williams, Tiffany M; Rosero, Eric B; Joshi, Girish P

2016-05-01

Postoperative epidural analgesia for major upper abdominal and thoracic surgery can provide significant benefits, including superior analgesia and reduced pulmonary dysfunction. Nevertheless, epidural analgesia may also be associated with decreased muscle strength, sympathetic tone, and proprioception that could possibly contribute to falls. The purpose of this retrospective case-control study was to search a large national database in order to investigate the possible relationship between postoperative epidural analgesia and the rate of inpatient falls. Data from the nationwide inpatient sample for 2007-2011 were queried for adult patients who underwent elective major upper abdominal and thoracic surgery. Multiple International Classification of Diseases, Ninth Revision, Clinical Modification codes for inpatient falls and accidents were combined into one binary variable. Univariate analyses were used for initial statistical analysis. Logistic regression analyses and McNemar's tests were subsequently used to investigate the association of epidural analgesia with inpatient falls in a 1:1 case-control propensity-matched sample after adjustment of patients' demographics, comorbidities, and hospital characteristics. Forty-two thousand six hundred fifty-eight thoracic and 54,974 upper abdominal surgical procedures were identified. The overall incidence of inpatient falls in the thoracic surgery group was 6.54% with an increasing trend over the study period from 4.95% in 2007 to 8.11% in 2011 (P < 0.001). Similarly, the overall incidence of inpatient falls in the upper abdominal surgery group was 5.30% with an increasing trend from 4.55% in 2007 to 6.07% in 2011 (P < 0.001). Postoperative epidural analgesia was not associated with an increased risk for postoperative inpatient falls in the thoracic surgery group (relative risk [RR], 1.18; 95% confidence interval [CI], 0.95 to 1.47; P = 0.144) and in the upper abdominal surgery group (RR, 0.84; 95% CI 0.64 to 1.09; P = 0.220). Inpatient falls compared with non-falls were associated with a longer median (interquartile range) length of hospital stay in both the thoracic surgery group (11 [7-17] days vs 9 [6-16] days, respectively; P < 0.001) and the upper abdominal surgery group (12 [7-20] days vs 10 [6-17] days, respectively; P < 0.001). Our study suggests that postoperative epidural analgesia for patients undergoing major upper abdominal and thoracic surgery is not associated with an increased risk of inpatient falls.

Response of the upper esophageal sphincter to esophageal distension is affected by posture, velocity, volume, and composition of the infusate.

PubMed

Babaei, Arash; Dua, Kulwinder; Naini, Sohrab Rahimi; Lee, Justin; Katib, Omar; Yan, Ke; Hoffmann, Raymond; Shaker, Reza

2012-04-01

Studies of the pressure response of the upper esophageal sphincter (UES) to simulated or spontaneous gastroesophageal reflux have shown conflicting results. These discrepancies could result from uncontrolled influence of variables such as posture, volume, and velocity of distension. We characterized in humans the effects of these variables on UES pressure response to esophageal distension. We studied 12 healthy volunteers (average, 27 ± 5 years old; 6 male) using concurrent esophageal infusion and high-resolution manometry to determine UES, lower esophageal sphincter, and intraesophageal pressure values. Reflux events were simulated by distal esophageal injections of room temperature air and water (5, 10, 20, and 50 mL) in individuals in 3 positions (upright, supine, and semisupine). Frequencies of various UES responses were compared using χ(2) analysis. Multinomial logistical regression analysis was used to identify factors that determine the UES response. UES contraction and relaxation were the overriding responses to esophageal water and air distension, respectively, in a volume-dependent fashion (P < .001). Water-induced UES contraction and air-induced UES relaxation were the predominant responses among individuals in supine and upright positions, respectively (P < .001). The prevalence of their respective predominant response significantly decreased in the opposite position. Proximal esophageal dp/dt significantly and independently differentiated the UES response to infusion with water or air. The UES response to esophageal distension is affected by combined effects of posture (spatial orientation of the esophagus), physical properties, and volume of refluxate, as well as the magnitude and rate of increase in intraesophageal pressure. The UES response to esophageal distension can be predicted using a model that incorporates these factors. Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.

Thoracoscopic Surgery in a Patient with Multiple Esophageal Carcinomas after Surgery for Esophageal Achalasia.

PubMed

Yamasaki, Yuki; Tsukada, Tomoya; Aoki, Tatsuya; Haba, Yusuke; Hirano, Katsuhisa; Watanabe, Toshifumi; Kaji, Masahide; Shimizu, Koichi

2017-01-01

We present a case in which we used a thoracoscopic approach for resection of multiple esophageal carcinomas diagnosed 33 years after surgery for esophageal achalasia. A 68-year-old Japanese man had been diagnosed with esophageal achalasia and underwent surgical treatment 33 years earlier. He was examined at our hospital for annual routine checkup in which upper gastrointestinal endoscopy showed a "0-IIb+IIa" lesion in the middle esophagus. Iodine staining revealed multiple irregularly shaped iodine-unstained areas, the diagnosis of which was esophageal carcinoma. Thoracoscopic subtotal esophagectomy was performed. Esophageal carcinoma may occur many years after surgery for esophageal achalasia, even if the passage symptoms have improved. So, long-term periodic follow-up is necessary for detection of carcinoma at an earlier stage.

Thoracoscopic Surgery in a Patient with Multiple Esophageal Carcinomas after Surgery for Esophageal Achalasia

PubMed Central

Tsukada, Tomoya; Aoki, Tatsuya; Haba, Yusuke; Hirano, Katsuhisa; Watanabe, Toshifumi; Kaji, Masahide; Shimizu, Koichi

2017-01-01

We present a case in which we used a thoracoscopic approach for resection of multiple esophageal carcinomas diagnosed 33 years after surgery for esophageal achalasia. A 68-year-old Japanese man had been diagnosed with esophageal achalasia and underwent surgical treatment 33 years earlier. He was examined at our hospital for annual routine checkup in which upper gastrointestinal endoscopy showed a “0-IIb+IIa” lesion in the middle esophagus. Iodine staining revealed multiple irregularly shaped iodine-unstained areas, the diagnosis of which was esophageal carcinoma. Thoracoscopic subtotal esophagectomy was performed. Esophageal carcinoma may occur many years after surgery for esophageal achalasia, even if the passage symptoms have improved. So, long-term periodic follow-up is necessary for detection of carcinoma at an earlier stage. PMID:28951795

Late onset Pott's paraplegia in patients with upper thoracic sharp kyphosis.

PubMed

Zhang, Zhengfeng

2012-02-01

The purpose of this study was to determine the clinical results of patients with late onset upper thoracic sharp Pott's kyphosis and to predict the prognosis for Pott's paraplegics. The study included five patients who developed late onset upper thoracic (T1-T4) sharp Pott's kyphosis/kyphoscoliosis within a period from 19 to 37 years after the active disease was healed. The kyphosis angle of the patients ranged from 95° to 105°. Among them, three patients suffered onset of paraplegia ranging from 26 to 31 years after spinal tuberculosis was healed. The duration of neurological deterioration before surgery ranged from four to five years. All patients underwent decompressive surgery with an attempt to correct the curve. Neurological status was evaluated using the ASIA impairment classification and the motor score. Postoperatively, kyphosis correction ranged from 20° to 30° for five patients. No neurological deficit occurred in two patients with normal neurological status. Two ASIA D paraplegics remained unchanged after surgery and no further improvement was found at one year follow-up. One ASIA C paralysis deteriorated neurologically to ASIA B after surgery and persisted to a deterioration of neurological status at one year follow-up. Upper thoracic sharp Pott's kyphosis and neurological deficits occur progressively. The neurological recovery or improvement of Pott's paraplegics with upper thoracic severe sharp kyphosis results in poor prognosis after decompressive surgery.

The effect of on-demand vs deep neuromuscular relaxation on rating of surgical and anaesthesiologic conditions in patients undergoing thoracolaparoscopic esophagectomy (DEPTH trial): study protocol for a randomized controlled trial.

PubMed

Veelo, Denise P; Gisbertz, Suzanne S; Hannivoort, Rebekka A; van Dieren, Susan; Geerts, Bart F; van Berge Henegouwen, Mark I; Hollmann, Markus W

2015-08-05

Deep muscle relaxation has been shown to facilitate operating conditions during laparoscopic surgery. Minimally invasive esophageal surgery is a high-risk procedure in which the use of deep neuromuscular block (NMB) may improve conditions in the thoracic phase as well. Neuromuscular antagonists can be given on demand or by continuous infusion (deep NMB). However, the positioning of the patient often hampers train-of-four (TOF) monitoring. A continuous infusion thus may result in a deep NMB at the end of surgery. The use of neostigmine not only is insufficient for reversing deep NMB but also may be contraindicated for this procedure because of its cholinergic effects. Sugammadex is an effective alternative but is rather expensive. This study aims to evaluate the use of deep versus on-demand NMB on operating, anaesthesiologic conditions, and costs in patients undergoing a two- or three-phase thoracolaparoscopic esophageal resection. We will conduct a single-center randomized controlled double-blinded intervention study. Sixty-six patients undergoing a thoracolaparoscopic esophageal resection will be included. Patients will receive either continuous infusion of rocuronium 0.6 mg/kg per hour (group 1) or continuous infusion of NaCl 0.9 % 0.06 ml/kg per hour (group 2). In both groups, on-demand boluses of rocuronium can be given (open-label design). The primary aim of this study is to compare the surgical rating scale (SRS) during the abdominal phase. Main secondary aims are to evaluate SRS during the thoracic phase, to evaluate anesthesiologic conditions, and to compare costs (in euros) associated with use of rocuronium, sugammadex, and duration of surgery. This study is the first to evaluate the benefits of deep neuromuscular relaxation on surgical and anaesthesiologic conditions during thoracolaparoscopic esophageal surgery. This surgical procedure is unique because it consists of both an abdominal phase and a thoracic phase taking place in different order depending on the subtype of surgery (a two- or three-stage transthoracic esophagectomy). In addition, possible benefits associated with deep NMB, such as decrease in operating time, will be weighed against costs. European Clinical Trials Database (EudraCT) number: 2014-002147-18 (obtained 19 May 2014) ClinicalTrials.gov: NCT02320734 (obtained 18 Dec. 2014).

Conservative treatment of esophageal perforation related to a peptic ulcer with pyloric stenosis.

PubMed

Tanaka, Ryo; Kosugi, Shin-Ichi; Sato, Daisuke; Hirukawa, Hiroshi; Tada, Tetsuya; Ichikawa, Hiroshi; Hanyu, Takaaki; Ishikawa, Takashi; Kobayashi, Takashi; Wakai, Toshifumi

2014-08-01

We report a case of esophageal perforation (Boerhaave syndrome) caused by vomiting related to a duodenal ulcer with pyloric stenosis. A 45-year-old male presented with left chest pain and dyspnea after forceful vomiting. Chest radiography and computed tomography (CT) revealed a massive left pleural effusion and left tension pneumothorax. Abdominal CT revealed pyloric stenosis with a remarkably dilated stomach. Tube thoracostomy and nasogastric suction were immediately performed and we selected conservative treatment based on the following factors-a stable general condition without sepsis, early diagnosis, and good drainage. Esophagogastroduodenoscopy on hospital day 9 demonstrated a healing ulcer in the lower esophagus and pyloric stenosis. We performed distal gastrectomy as elective surgery for pyloric stenosis due to a duodenal ulcer on hospital day 30. In summary, an esophageal perforation with contamination spreading to the thoracic cavity was successfully treated with conservative treatment.

Prognostic impact of postoperative radiation in patients undergoing radical esophagectomy for pathologic lymph node positive esophageal cancer.

PubMed

Xu, Yaping; Liu, Jinshi; Du, Xianghui; Sun, Xiaojiang; Zheng, Yuanda; Chen, Jianxiang; Li, Bo; Liu, Wei; Jiang, Hao; Mao, Weimin

2013-05-08

Though postoperative radiation for esophageal squamous cell carcinoma is offered in selected cases, there is conflicting evidence as to whether it improves overall survival (OS). A retrospective investigation was performed to analyze the prognostic impact of postoperative radiation therapy (PORT) in a large cohort of patients. From 2001 to 2009, 725 patients underwent radical esophagectomy (R0) with or without PORT were eligible for retrospective analysis. Patients were grouped into surgery alone (n = 467) and surgery plus PORT (n = 258). Median irradiation doses were 50 Gy (range: 40-56 Gy). Radiation fields encompassed the bilateral supraclavicular fossa, mediastinum, subcarinal area, and the tumor bed for the upper/middle-third disease; the bilateral supraclavicular fossa, mediastinum, the tumor bed, subcarinal area, and lower thoracic paraesophageal area for the lower-third disease. Kaplan-Meier and Cox regression analysis were used to compare OS. After median follow-up of 53 months, the median OS was 29 months in the PORT group and 23 months in the surgery alone group. The addition of PORT improved OS at 3 years from 36.6 to 43.6% compared with surgery alone. The use of PORT was associated with significantly improved OS (p = 0.018). For American Joint Committee on Cancer (AJCC) stage III esophageal cancer (T1-2N2M0, T3N1-2M0, T4N1-3M0), there was significant improvement in OS (p = 0.002) in the PORT group, not only for lymph-node metastatic ratio (LNMR) ≥0.25 (p = 0.001), but also for LNMR <0.25 (p = 0.043). However, for stage IIB disease (T1-2N1M0) there was no significant differences. The addition of POCT didn't prolong the OS significantly (Surgery alone group, p = 0.079; PORT group, p = 0.111). This large retrospective analysis supports the use of PORT for pathologic lymph node positive stage III esophageal squamous cell carcinoma. Given the retrospective nature of this study, the results should be confirmed by appropriately powered randomized trials. Further development of adjuvant therapy in EC is warranted.

Esophageal Achalasia: Pathophysiology, Clinical Presentation, and Diagnostic Evaluation.

PubMed

Schlottmann, Francisco; Neto, Rafael M L; Herbella, Fernando A M; Patti, Marco G

2018-04-01

Esophageal achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter to relax in response to swallowing. These abnormalities lead to impaired emptying of food from the esophagus into the stomach with resulting food stasis. Most patients experience severe dysphagia, and regurgitation can lead to aspiration and respiratory problems. Consequently, the quality of life of patients affected by achalasia is severely impacted. A thorough evaluation with upper endoscopy, barium swallow, and esophageal manometry is mandatory to establish the diagnosis and plan the optimal treatment. In selected patients, an ambulatory pH monitoring is recommended to distinguish between gastroesophageal reflux disease and achalasia.

Vertebral Uptake of Tc-99m Macroaggregated Albumin (MAA) with SPECT/CT Occurring in Superior Vena Cava Obstruction.

PubMed

Karls, Shawn; Hassoun, Hani; Derbekyan, Vilma

2016-09-01

A 67-year-old male presented with dyspnea for which lung scintigraphy was ordered to rule out pulmonary embolus. Planar images demonstrated abnormal midline uptake of Tc-99m macroaggregated albumin, which SPECT/CT localized to several thoracic vertebrae. Thoracic vertebral uptake on perfusion lung scintigraphy was previously described on planar imaging. Radionuclide venography and contrast-enhanced CT subsequently demonstrated superior vena cava (SVC) obstruction with collateralization through the azygous/hemiazygous system and vertebral venous plexus. SPECT/CT differentiated residual esophageal/tracheal ventilation activity, a clinically insignificant finding, from vertebral uptake indicative of SVC obstruction, a potentially life-threatening condition.

[Clinical value of para-recurrent laryngeal nerve lymphadenectomy for middle thoracic esophageal squamous cell carcinoma].

PubMed

Wang, Zhen; Liu, Shuoyan

2015-09-01

To analyze the pattern of lymphatic metastasis in middle thoracic esophageal squamous cell carcinoma (ESCC) with different T staging and to investigate the clinical value of para-recurrent laryngeal nerve lymphadenectomy. Clinicopathological data of 717 patients with middle thoracic ESCC undergoing Mckeown esophagectomy plus three-field lymph node dissection in Fujian Provincial Hospital from January 1999 to December 2007 were analyzed retrospectively. Lymph node metastatic rates of different T stages were calculated. Clinical value of each station lymphadenectomy, especially the para-recurrent laryngeal nerve lymphadenectomy, was evaluated by the efficacy index (EI, cross product of one station metastatic rate and 5-year survival of patient with positive lymph nodes of above station). Rates of lymph node metastasis were 29.0% (18/62), 61.1% (91/149) and 64.8% (328/506) in stage T1, T2 and T3 patients respectively. Despite T staging, metastatic rates of right para-recurrent laryngeal nerve lymph node (rRLN LN) were 21.0% (13/62), 28.9% (43/149) and 29.4% (149/506) in stage T1, T2 and T3 patients respectively, which was the most common among all lymph node stations. Metastatic rates of left para-recurrent laryngeal nerve lymph node (lRLN LN) were the second, with 8.1% (5/62), 17.4% (26/149) and 24.7% (125/506) in stage T1, T2, T3 patients respectively. Follow-up period lasted more than 5 years. The 5-year survival rates of positive rRLN LN were 53.8%, 39.5% and 32.2% in stage T1, T2 and T3 patients respectively, whose EI values were 11.3, 11.4 and 9.5 respectively. The 5-year survival rates of positive lRLN LN were 40.0%, 34.6% and 40.0% in stage T1, T2 and T3 patients respectively, whose EI values were 3.2, 6.0 and 9.9 respectively. Bilateral para-recurrent laryngeal nerve lymph nodes are the common sites of metastasis in middle thoracic esophageal squamous cell carcinoma. Right para-recurrent laryngeal nerve lymphadenectomy is of high clinical value despite the T staging. Left para-recurrent laryngeal nerve lymphadenectomy has better efficacy in stage T2 and T3 patients, but is limited in stage T1 patients.

Hydropneumothorax Due to Esophageal Rupture.

PubMed

Shiber, Joseph R; Fontane, Emily; Ra, Jin H; Kerwin, Andrew J

2017-06-01

A brief review of the historical aspects of esophageal rupture is presented along with a case and current recommendations for diagnostic evaluation and treatment. A 97-year-old woman complained of acute dyspnea without prior vomiting. Chest x-ray study showed a large right pneumothorax with associated effusion. A thoracostomy tube was placed with return of > 1 L turbid fluid with polymicrobial culture and elevated pleural fluid amylase level. Chest computed tomography (CT) scan demonstrated overt leakage of oral contrast into the right pleural space. She was treated with ongoing pleural evacuation, antibiotics, antifungals, and total parenteral nutrition. The patient and family declined surgical resection as well as endoscopic stent placement. In 1724, Boerhaave described spontaneous rupture of the esophagus postmortem; Boerhaave syndrome remains the name for complete disruption of the esophageal wall in the absence of pre-existing pathology typically occurring after vomiting. It most commonly occurs in the distal left posterolateral thoracic esophagus. Contrast esophagram is considered the "gold standard" for diagnosing esophageal rupture although CT esophagography also shows good diagnostic performance. Treatment includes nil per os status, broad-spectrum antibiotics, and drainage of the pleural space. Surgical repair of the esophageal perforation should be done early if the patient is deemed a good candidate, and esophageal stenting is also an option. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Esophageal perforation should be suspected in patients with new pleural effusion, often with overt pneumothorax, that is polymicrobial with elevated amylase. Copyright © 2017 Elsevier Inc. All rights reserved.

[Endoscopic bouginage of benign esophageal and cardial strictures].

PubMed

Wierzbicki, J; Błaszczuk, J; Czapla, L; Adamus, A

1997-01-01

Endoscopic bouginage of benign esophageal and cardial strictures was compared with surgical treatment. Bouginage was performed by Celestin or Eder-Puestow bougies. Results obtained suggest usefulness of bouginage in many patients with benign stenosis of the upper gastrointestinal tract.

Esophageal bypass operation prior to definitive chemoradiotherapy in advanced esophageal cancer with tracheobronchial invasion.

PubMed

Hihara, Jun; Hamai, Yoichi; Emi, Manabu; Aoki, Yoshiro; Taomoto, Junya; Miyata, Yoshihiro; Okada, Morihito

2014-01-01

In T4 esophageal cancer with tracheobronchial invasion, an esophagorespiratory fistula (ERF) often occurs during or after chemoradiotherapy. We have performed esophageal bypass operations prior to definitive chemoradiotherapy for these patients to increase the chemoradiotherapy completion rate by minimizing the potential effect of an ERF. The aim of this study was to examine the clinical outcome of esophageal bypass surgery prior to chemoradiotherapy. Between 1997 and 2010, 17 patients underwent esophageal bypass surgery followed by definitive chemoradiotherapy for esophageal cancer with tracheobronchial invasion (bypass group). Ten patients in the same circumstances were treated with chemoradiotherapy alone (control group). Overall survival, the clinical effect of chemoradiotherapy, the ERF incidence rate, and the safety of esophageal bypass surgery were assessed. The overall response rate to chemoradiotherapy was 64.7% in the bypass group and 90.0% in the control group. Except for 2 patients with ERF at initial diagnosis, 4 (26.7%) of the 15 patients developed ERF in the bypass group, and 3 (30.0%) of the 10 patients developed ERF in the control group during or after chemoradiotherapy. The 2-year and 3-year overall survival rates were 17.6% and 17.6% in the bypass group and 20.0% and 0% in the control group, respectively (p = 0.924); long-term survival of more than 3 years was seen only in the bypass group. Esophageal bypass surgery prior to definitive chemoradiotherapy could be performed safely, and this strategy contributed to long-term survival in the patients who achieved a good response to chemoradiotherapy but developed an ERF. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Utility of silicone esophageal bypass stents in the management of delayed complex esophageal disruptions.

PubMed

Kim, Anthony W; Liptay, Michael J; Snow, Norman; Donahue, Philip; Warren, William H

2008-06-01

The objective of this study was to review the clinical experience of temporarily placing an endoesophageal silicone salivary bypass stent and its value in managing patients with life-threatening esophageal disruptions. Clinical records of patients undergoing placement of silicone Montgomery salivary bypass stents from June 1998 to September 2007 were reviewed. Seventeen patients had a proven esophageal disruption in the absence of malignancy and with life-threatening sepsis refractory to conventional management. Underlying conditions were iatrogenic trauma from prior pulmonary surgery (4 patients), significant anastomotic leaks after an esophagogastrectomy (4 patients), delayed presentation (> 24 hours) of a perforated esophagus (4 patients), leak after esophageal surgery (3 patients), and esophagobronchial fistula secondary to inflammation and infection (2 patients). Stents were placed without securing, were sutured in place to the esophageal wall at the time of thoracotomy, or were secured by bringing holding sutures through the nostrils and tied over the bridge of the nose. In all cases, placement of the esophageal stent led to prompt improvement of the leak and, within a week, improvement of the sepsis. Supportive measures were continued after placement of the stent. Sixteen patients overcame the sepsis with ultimate healing of the esophageal disruption (13 patients) or maturation of the perforation into a chronic fistula (3 patients). Endoscopic stent removal was performed 2 to 16 weeks after placement. No patient had a stricture develop at the disruption site. One patient died of ruptured thoracic aorta. Silicone salivary bypass stents serve as an effective way of diverting and excluding the oral-alimentary stream, thereby providing optimal conditions for sepsis control. They are a useful adjunct in the management of complex esophageal conditions.

[Comparison of SIB-IMRT treatment plans for upper esophageal carcinoma].

PubMed

Fu, Wei-hua; Wang, Lv-hua; Zhou, Zong-mei; Dai, Jian-rong; Hu, Yi-min

2003-06-01

To implement simultaneous integrated boost intensity-modulated radiotherapy(SIB-IMRT) plans for upper esophageal carcinoma and investigate the dose profiles of tumor and electively treated region and the dose to organs at risk (OARs). SIB-IMRT plans were designed for two patients with upper esophageal carcinoma. Two target volumes were predefined: PTV1, the target volume of the primary lesion, which was given to 67.2 Gy, and PTV2, the target volume of electively treated region, which was given to 50.4 Gy. With the same dose-volume constraints, but different beams arrangements (3, 5, 7, or 9 equispaced coplanar beams), four plans were generated. Indices, including dose distribution, dose volume histogram (DVH) and conformity index, were used for comparison of these plans. The plan with three intensity-modulated beams could produce good dose distribution for the two target volumes. The dose conformity to targets and the dose to OARs were improved as the beam number increased. The dose distributions in targets changed little when the beam number increased from 7 to 9. Five to seven intensity-modulated beams can produce desirable dose distributions for simultaneous integrated boost (SIB) treatment for upper esophageal carcinoma. The primary tumor can get higher equivalent dose by SIB treatments. It is easier and more efficient to design plans with equispaced coplanar beams. The efficacy of SIB-IMRT remains to be determined by the clinical outcome.

Endoscopic vacuum therapy for various defects of the upper gastrointestinal tract.

PubMed

Kuehn, Florian; Loske, Gunnar; Schiffmann, Leif; Gock, Michael; Klar, Ernst

2017-09-01

Postoperative, iatrogenic or spontaneous upper gastrointestinal defects result in significant morbidity and mortality of the patients. In the last few years, endoscopic vacuum therapy (EVT) has been recognized as a new promising method for repairing upper gastrointestinal defects of different etiology. However, probably due to insufficient data and no commercially available system for EVT of the upper gastrointestinal tract, until the end of 2014, covering of esophageal defects with self-expanding metal stents (SEMS) were still the mainstay of endoscopic therapy. The aim of this article is to review the data available about EVT for various upper gastrointestinal defects. A selective literature search was conducted in Medline and PubMed (2007-2016), taking into account all the published case series and case reports reporting on the use of EVT in the management of upper gastrointestinal defects. EVT works through intracorporal application of negative pressure at the defect zone with an electronic controlled vacuum device along a polyurethane sponge drainage. This results in closure of the esophageal defect and internal drainage of the septic focus, simultaneously. Compared to stenting, EVT enables regular viewing of wound conditions with control of the septic focus and adjustment of therapy. Moreover, endoscopical negative pressure is applicable in all esophageal regions (cricopharygeal, tubular, gastroesophageal junction) and in anastomotic anatomic variants. EVT can be used solely as a definite treatment or as a complimentary therapy combined with operative revision. In total, there are published data of more than 200 patients with upper gastrointestinal defects treated with EVT, showing succes rates from 70-100%. The available data indicate that EVT is feasible, safe and effective with good short-term and long-term clinical outcomes in the damage control of upper GI-tract leaks. Still, a prospective multi-center study has to be conducted to proof the definite benefit of EVT for patients with esophageal defects.

Three-dimensional conformal radiation therapy for squamous cell carcinoma of the esophagus: a prospective phase I/II study.

PubMed

Wu, Kai-Liang; Chen, Guei-Yuan; Xu, Zhi-Yong; Fu, Xiao-Long; Qian, Hao; Jiang, Guo-Liang

2009-12-01

A prospective phase I-II study was conducted to determine the tolerance and local control rate of three-dimensional conformal radiotherapy (3-DCRT) for esophageal squamous cell carcinoma (SCC). Thirty patients underwent 3-DCRT for thoracic esophageal SCC. PTV1 composed of a 1.2-1.5 cm margin lateral around GTV and 3.0 cm margin superior/inferior of GTV. PTV2 encompassed GTV with a margin of 0.5-0.7 cm. The dose for PTV1 was 50 Gy in 2 Gy daily fractions; PTV2 received a boost of 16 Gy in 2 Gy daily fractions to a total dose of 66 Gy. Median follow-up time was 18 months. The most common acute toxicity was esophagitis in 63% of patients with RTOG grades 1-2, and in 3% with grade 3. RTOG grades 1-2 radiation pneumonitis developed in 27% of patients. One patient developed pulmonary fibrosis RTOG grade 2 and another patient experienced grade 3 pulmonary fibrosis. Two patients developed mild esophageal stricture requiring dilatation. Two-year overall survival, local disease progression-free rate, and distant metastasis-free rate were 69%, 36% and 56%, respectively. Although 3-DCRT to 66 Gy for esophageal SCC was well tolerated, the local control was disappointing. The result supports the use of chemoradiation as the standard care for esophageal SCC.

Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial.

PubMed

Dunning, James R; Butts, Raymond; Mourad, Firas; Young, Ian; Fernandez-de-Las Peñas, Cesar; Hagins, Marshall; Stanislawski, Thomas; Donley, Jonathan; Buck, Dustin; Hooks, Todd R; Cleland, Joshua A

2016-02-06

Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH. One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable. The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001). Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months. NCT01580280 April 16, 2012.

Inserting pedicle screws in the upper thoracic spine without the use of fluoroscopy or image guidance. Is it safe?

PubMed

Schizas, Constantin; Theumann, Nicolas; Kosmopoulos, Victor

2007-05-01

Several studies have looked at accuracy of thoracic pedicle screw placement using fluoroscopy, image guidance, and anatomical landmarks. To our knowledge the upper thoracic spine (T1-T6) has not been specifically studied in the context of screw insertion and placement accuracy without the use of either image guidance or fluoroscopy. Our objective was to study the accuracy of upper thoracic screw placement without the use of fluoroscopy or image guidance, and report on implant related complications. A single surgeon inserted 60 screws in 13 consecutive non-scoliotic spine patients. These were the first 60 screws placed in the high thoracic spine in our institution. The most common diagnosis in our patient population was trauma. All screws were inserted using a modified Roy-Camille technique. Post-operative axial computed tomography (CT) images were obtained for each patient and analyzed by an independent senior radiologist for placement accuracy. Implant related complications were prospectively noted. No pedicle screw misplacement was found in 61.5% of the patients. In the remaining 38.5% of patients some misplacements were noted. Fifty-three screws out of the total 60 implanted were placed correctly within all the pedicle margins. The overall pedicle screw placement accuracy was 88.3% using our modified Roy-Camille technique. Five medial and two lateral violations were noted in the seven misplaced screws. One of the seven misplaced screws was considered to be questionable in terms of pedicle perforation. No implant related complications were noted. We found that inserting pedicle screws in the upper thoracic spine based solely on anatomical landmarks was safe with an accuracy comparable to that of published studies using image-guided navigation at the thoracic level.

Cigarette smoking and hOGG1 Ser326Cys polymorphism are associated with 8-OHdG accumulation on mitochondrial DNA in thoracic esophageal squamous cell carcinoma.

PubMed

Lin, Chen-Sung; Wang, Liang-Shun; Chou, Teh-Ying; Hsu, Wen-Hu; Lin, Hui-Chen; Lee, Shu-Yu; Lee, Mau-Hua; Chang, Shi-Chuan; Wei, Yau-Huei

2013-12-01

We examined whether cigarette smoking affects the degrees of oxidative damage (8-hydroxyl-2'-deoxyguanosine [8-OHdG]) on mitochondrial DNA (mtDNA), whether the degree of 8-OHdG accumulation on mtDNA is related to the increased total mtDNA copy number, and whether human 8-oxoguanine DNA glycosylase 1 (hOGG1) Ser326Cys polymorphisms affect the degrees of 8-OHdG accumulation on mtDNA in thoracic esophageal squamous cell carcinoma (TESCC). DNA extracted from microdissected tissues of paired noncancerous esophageal muscles, noncancerous esophageal mucosa, and cancerous TESCC nests (n = 74) along with metastatic lymph nodes (n = 38) of 74 TESCC patients was analyzed. Both the mtDNA copy number and mtDNA integrity were analyzed by quantitative real-time polymerase chain reaction (PCR). The hOGG1 Ser326Cys polymorphisms were identified by restriction fragment length polymorphism PCR and PCR-based direct sequencing. Among noncancerous esophageal mucosa, cancerous TESCC nests, and metastatic lymph nodes, the mtDNA integrity decreased (95.2 to 47.9 to 18.6 %; P < 0.001) and the mtDNA copy number disproportionally increased (0.163 to 0.204 to 0.207; P = 0.026). In TESCC, higher indexes of cigarette smoking (0, 0-20, 20-40, and >40 pack-years) were related to an advanced pathologic N category (P = 0.038), elevated mtDNA copy number (P = 0.013), higher mtDNA copy ratio (P = 0.028), and increased mtDNA integrity (P = 0.069). The TESCC mtDNA integrity in patients with Ser/Ser, Ser/Cys, and Cys/Cys hOGG1 variants decreased stepwise from 65.2 to 52.1 to 41.3 % (P = 0.051). Elevated 8-OHdG accumulations on mtDNA in TESCC were observed. Such accumulations were associated with a compensatory increase in total mtDNA copy number, indexes of cigarette smoking, and hOGG1 Ser326Cys polymorphisms.

Acute Necrotizing Esophagitis Followed by Duodenal Necrosis

PubMed Central

del Hierro, Piedad Magdalena

2011-01-01

Acute Necrotizing Esophagitis is an uncommon pathology, characterized by endoscopic finding of diffuse black coloration in esophageal mucosa and histological presence of necrosis in patients with upper gastrointestinal bleeding. The first case of acute necrotizing esophagitis followed by duodenal necrosis, in 81 years old woman with a positive history of Type 2 Diabetes Mellitus, Hypertension, and usual intake of Nonsteroidal Anti-inflammatory drugs, is reported. Although its etiology remains unknown, the duodenal necrosis suggests that ischemia could be the main cause given that the branches off the celiac axis provide common blood supply to the distal esophageal and duodenal tissue. The massive gastroesophagic reflux and NSAID intake could be involved. PMID:27957030

Congenital hairy polyp of the oropharynx presenting as an esophageal mass in a neonate, a case report and literature review.

PubMed

Richter, Amy; Mysore, Krupa; Schady, Deb; Chandy, Binoy

2016-01-01

To review the literature of congenital hairy polyps and describe the clinical presentation, operative management, and histologic findings of a congenital hairy polyp arising from the palatopharyngeus muscle in a neonate with recurrent choking episodes. Chart review of a 2-month-old male referred to a tertiary care pediatric hospital. We present a case of a 2-month-old male who presented to the emergency room with recurrent episodes of choking and vomiting. The patient was previously healthy with no prior medical or neonatal history. The parents noted a small fleshy mass in the patient's oropharynx that he would chew on and swallow after several minutes. However, on physical exam, there was no evidence of oropharyngeal mass. The patient did not have respiratory distress. Imaging revealed a 22×7×11mm oblong, fatty mass in the lower cervical and upper thoracic esophagus with a thin stalk extending proximally to the upper collapsed esophagus. Intraoperative recorded laryngoscopy revealed a pedunculated soft palate mass attached to the right superior palatopharyngeus muscle. Histopathology revealed ectodermal and mesodermal elements in a polypoid structure lined by keratinizing squamous epithelium with adnexal structures and central mature adipose tissue, consistent with congenital hairy polyp resembling an accessory tragus of the ear and branchial anomaly. At 6-week follow up, the patient was doing well and gaining weight appropriately with no further choking episodes. There was no evidence of velopharyngeal dysfunction on follow up exam. The surgical site was completely healed and there was no evidence of recurrence. Congenital hairy polyps of the naso- and oropharynx are rare but may present as airway or esophageal masses, causing respiratory distress or choking episodes in a pediatric patient. The pathologic findings of keratinizing squamous epithelium, adnexal structures, adipose and cartilage tissues resemble congenital accessory tragus and may be considered a branchial arch anomaly. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Regional interdependence and manual therapy directed at the thoracic spine.

PubMed

McDevitt, Amy; Young, Jodi; Mintken, Paul; Cleland, Josh

2015-07-01

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.

Surgical Management of Hiatal Hernia in Children with Asplenia Syndrome.

PubMed

Miyake, Hiromu; Fukumoto, Koji; Yamoto, Masaya; Nouso, Hiroshi; Kaneshiro, Masakatsu; Koyama, Mariko; Urushihara, Naoto

2017-06-01

Purpose  Patients with asplenia syndrome (AS) are likely to have upper gastrointestinal tract malformations such as hiatal hernia. This report discusses the treatment of such conditions. Methods  Seventy-five patients with AS underwent initial palliation in our institution between 1997 and 2013. Of these, 10 patients had hiatal hernia. Of the patients with hiatal hernia, 6 had brachyesophagus and 7 had microgastria. Results  Of the 10 patients with hiatal hernia, 9 underwent surgery in infancy (7 before Glenn operation, 2 after Glenn operation). Two underwent typical Toupet fundoplication, and the other 7 underwent atypical repair including reduction of the stomach. Two patients with atypical repair showed recurrence of hernia and required reoperation. Three patients required reoperation due to duodenal obstruction. Duodenal obstruction occurred due to preduodenal portal vein or abnormal vessels compressing the duodenum. Obstructive symptoms were not seen in any cases preoperatively. Conclusions  In patients with hiatal hernia, typical fundoplication is often difficult because most have concomitant brachyesophagus, microgastria, and hypoplasia of the esophageal hiatus. However, we should at least reduce the stomach to the abdominal cavity as early as possible to increase thoracic cavity volume and allow good feeding. Increasing the volume of the thoracic cavity thus makes Glenn and Fontan circulations more stable. Duodenal obstruction secondary to vascular anomalies is also common, so the anatomy in the area near the duodenum should be evaluated pre- and intraoperatively. Georg Thieme Verlag KG Stuttgart · New York.

Treatments for esophageal cancer: a review.

PubMed

Kato, Hiroyuki; Nakajima, Masanobu

2013-06-01

Esophageal cancer is the eighth most common form of cancer worldwide. The treatments for esophageal cancer depend on its etiology. For mucosal cancer, endoscopic mucosal resection and endoscopic submucosal dissection are standard, while for locally advanced cancer, esophagectomy remains the mainstay. The three most common techniques for thoracic esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis). Surgery for carcinoma of the cervical esophagus requires an extensive procedure with laryngectomy in many cases. When the tumor is more advanced, neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is added. The theoretical advantages of adding chemotherapy to the treatment of esophageal cancer are potential tumor down-staging prior to surgery, as well as targeting micrometastases and, thus, decreasing the risk of distant metastasis. Cisplatin- and 5-fluorouracil-based regimes are used worldwide. Chemoradiotherapy is the standard for unresectable esophageal cancer and could also be considered as an option for resectable tumors. For patients who are medically or technically inoperable, concurrent chemoradiotherapy should be the standard of care. Although neoadjuvant chemoradiotherapy followed by surgery or salvage surgery after definitive chemoradiotherapy is a practical treatment; judicious patient selection is crucial. It is important to have a thorough understanding of these therapeutic modalities to assist in this endeavor.

Association of Esophageal Inflammation, Obesity and Gastroesophageal Reflux Disease: From FDG PET/CT Perspective

PubMed Central

Lee, Yi-Chia; Wang, Shan-Ying; Chiu, Han-Mo; Tu, Chia-Hung; Wang, Hsiu-Po; Lin, Jaw-Town; Wu, Ming-Shiang; Yang, Wei-Shiung

2014-01-01

Objective Gastroesophageal reflux disease (GERD) is associated with bothersome symptoms and neoplastic progression into Barrett's esophagus and esophageal adenocarcinoma. We aim to determine the correlation between GERD, esophageal inflammation and obesity with 18F-Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT). Methods We studied 458 subjects who underwent a comprehensive health check-up, which included an upper gastrointestinal endoscopy, FDG PET/CT and complete anthropometric measures. GERD symptoms were evaluated with Reflux Disease Questionnaire. Endoscopically erosive esophagitis was scored using the Los Angeles classification system. Inflammatory activity, represented by standardized uptake values (SUVmax) of FDG at pre-determined locations of esophagus, stomach and duodenum, were compared. Association between erosive esophagitis, FDG activity and anthropometric evaluation, including body mass index (BMI), waist circumference, visceral and subcutaneous adipose tissue volumes were analyzed. Results Subjects with erosive esophagitis (n = 178, 38.9%) had significantly higher SUVmax at middle esophagus (2.69±0.74 vs. 2.41±0.57, P<.001) and esophagogastric junction (3.10±0.89 vs. 2.38±0.57, P<.001), marginally higher at upper esophageal sphincter (2.29±0.42 vs. 2.21±0.48, P = .062), but not in stomach or duodenum. The severity of erosive esophagitis correlated with SUVmax and subjects with Barrett's esophagus had the highest SUVmax at middle esophagus and esophagogastric junction. Heartburn positively correlated with higher SUVmax at middle oesophagus (r = .262, P = .003). Using multivariate regression analyses, age (P = .027), total cholesterol level (P = .003), alcohol drinking (P = .03), subcutaneous adipose tissue (P<.001), BMI (P<.001) and waist circumference (P<.001) were independently associated with higher SUVmax at respective esophageal locations. Conclusions Esophageal inflammation demonstrated by FDG PET/CT correlates with endoscopic findings and symptomatology of GERD. Obesity markers, both visceral and general, are independent determinants of esophageal inflammation. PMID:24642729

Predictors of large esophageal varices in patients with cirrhosis.

PubMed

Chalasani, N; Imperiale, T F; Ismail, A; Sood, G; Carey, M; Wilcox, C M; Madichetty, H; Kwo, P Y; Boyer, T D

1999-11-01

Recent guidelines recommend that all cirrhotics undergo screening upper endoscopy to identify those patients at risk for bleeding from varices. However, this practice may not be cost effective as large esophageal varices are seen only in 9-36% of these patients. The aim of this study was to determine whether clinical variables were predictive of the presence of large esophageal varices. This is a retrospective analysis of cirrhotics who had a screening upper endoscopy during an evaluation for liver transplantation at three different centers and who had not previously bled from varices. A multivariate model was derived on the combined cohort using logistic regression. Three hundred forty-six patients were eligible for the study. The prevalence of large esophageal varices was 20%. On multivariate analysis, splenomegaly detected by computed tomographic scan (odds ratio: 4.3; 95% confidence interval: 1.6-11.5) or by physical examination (odds ratio: 2.0; 95% confidence interval: 1.1-3.8), and low platelet count were independent predictors of large esophageal varices. On the basis of these variables, cirrhotics were stratified into high- and low-risk groups for the presence of large esophageal varices. Patients with a platelet count of > or = 88,000/mm3 (median value) and no splenomegaly by physical examination had a risk of large esophageal varices of 7.2%. Those with splenomegaly or platelet count < 88,000/mm3 had a risk of large esophageal varices of 28% (p < 0.0001). Our data show that clinical predictors could be used to stratify cirrhotic patients for the risk of large esophageal varices and such stratification could be used to improve the cost effectiveness of screening endoscopy.

Prolonged monitoring of esophageal motor function in healthy children.

PubMed

Chitkara, Denesh K; Fortunato, Christine; Nurko, Samuel

2004-02-01

To describe diurnal variations of esophageal motor function in children using combined ambulatory 24-hour esophageal manometry and continuous intraluminal pH measurement (MP24). Medical records of all patients referred for the performance of MP24 from 1995 to 2002 at a tertiary care center were reviewed. Patients were selected retrospectively for this study using the following inclusion criteria: (1) no dysphagia, (2) normal upper gastrointestinal barium radiograph, (3) normal esophagogastroduodenoscopy and biopsies, (4) normal stationary esophageal manometry, (5) normal esophageal pH probe, and (6) no gastrointestinal pathology appearing after long-term follow-up. Data from the MP24 of these children were retrospectively analyzed for differences between meal, upright, and supine periods using nonparametric univariate analysis. One hundred twenty-three children had MP24 during the study period. Eleven met the criteria for normality and were included. Their mean age was 12.4 +/- 1.5 years. The number of contractions/minute in the upper, middle, and lower esophageal body differed significantly during meals and in the upright and supine periods (P < 0.01). A significant increase in motor activity occurred during meals (P < 0.01). There was less motor activity observed in the supine position than in the upright position (P < 0.01). There were significant differences in effective (P < 0.05) and total propagated peristalsis among the meal, upright, and supine periods (P < 0.01), with the largest percentage of propagated contractions observed during meals. This study provides the first information on prolonged esophageal motor activity in pediatric patients without esophageal disease. MP24 in children demonstrates significant diurnal variations in esophageal motor function that is similar to the findings in studies of healthy adults.

High resolution manometry findings in patients with esophageal epiphrenic diverticula.

PubMed

Vicentine, Fernando P P; Herbella, Fernando A M; Silva, Luciana C; Patti, Marco G

2011-12-01

The pathophysiology of esophageal epiphrenic diverticula is still uncertain even though a concomitant motility disorder is found in the majority of patients in different series. High resolution manometry may allow detection of motor abnormalities in a higher number of patients with esophageal epiphrenic diverticula compared with conventional manometry. This study aims to evaluate the high resolution manometry findings in patients with esophageal epiphrenic diverticula. Nine individuals (mean age 63 ± 10 years, 4 females) with esophageal epiphrenic diverticula underwent high resolution manometry. A single diverticulum was observed in eight patients and multiple diverticula in one. Visual analysis of conventional tracings and color pressure plots for identification of segmental abnormalities was performed by two researchers experienced in high resolution manometry. Upper esophageal sphincter was normal in all patients. Esophageal body was abnormal in eight patients; lower esophageal sphincter was abnormal in seven patients. Named esophageal motility disorders were found in seven patients: achalasia in six, diffuse esophageal spasm in one. In one patient, a segmental hypercontractile zone was noticed with pressure of 196 mm Hg. High resolution manometry demonstrated motor abnormalities in all patients with esophageal epiphrenic diverticula.

A novel laparoscopic approach for severe esophageal stenosis due to reflux esophagitis: how to do it.

PubMed

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Hoshino, Masato; Yamamoto, Se Ryung; Akimoto, Shunsuke; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2015-02-01

We herein report our technique for laparoscopic esophageal myotomy combined with Collis gastroplasty and Nissen fundoplication for severe esophageal stenosis. Our patient had experienced vomiting since childhood, and his dysphagia had gradually worsened. He was referred to our department for surgery because of resistance to pneumatic dilation. He was diagnosed with a short esophagus based on the findings of a preoperative upper gastrointestinal series and GI endoscopy. After exposing the abdominal esophagus, esophageal myotomy around the esophago-gastric junction (EGJ) was undertaken to introduce an esophageal bougie into the stomach. Then, stapled wedge gastroplasty was performed, and a short and loose Nissen fundoplication was performed. In addition, the bulging mucosa after myotomy was patched using the Dor method. The patient's postoperative course was uneventful. Most patients with esophageal stricture require subtotal esophagectomy. Laparoscopic surgery for patients with benign esophageal stricture refractory to repeated pneumatic dilation is challenging. However, our current procedure might abrogate the need for invasive esophagectomy for the surgical management of severe esophageal stenosis.

Non-variceal upper gastrointestinal bleeding in cirrhotic patients in Nile Delta.

PubMed

Gabr, Mamdouh Ahmed; Tawfik, Mohamed Abd El-Raouf; El-Sawy, Abd Allah Ahmed

2016-01-01

Acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients occurs mainly from esophageal and gastric varices; however, quite a large number of cirrhotic patients bleed from other sources as well. The aim of the present work is to determine the prevalence of non-variceal UGIB as well as its different causes among the cirrhotic portal hypertensive patients in Nile Delta. Emergency upper gastrointestinal (UGI) endoscopy for AUGIB was done in 650 patients. Out of these patients, 550 (84.6%) patients who were proved to have cirrhosis were the subject of the present study. From all cirrhotic portal hypertensive patients, 415 (75.5%) bled from variceal sources (esophageal and gastric) while 135 (24.5%) of them bled from non-variceal sources. Among variceal sources of bleeding, esophageal varices were much more common than gastric varices. Peptic ulcer was the most common non-variceal source of bleeding. Non-variceal bleeding in cirrhosis was not frequent, and sources included peptic ulcer, portal hypertensive gastropathy, and erosive disease of the stomach and duodenum.

Potential of Proton Therapy to Reduce Acute Hematologic Toxicity in Concurrent Chemoradiation Therapy for Esophageal Cancer.

PubMed

Warren, Samantha; Hurt, Christopher N; Crosby, Thomas; Partridge, Mike; Hawkins, Maria A

2017-11-01

Radiation therapy dose escalation using a simultaneous integrated boost (SIB) is predicted to improve local tumor control in esophageal cancer; however, any increase in acute hematologic toxicity (HT) could limit the predicted improvement in patient outcomes. Proton therapy has been shown to significantly reduce HT in lung cancer patients receiving concurrent chemotherapy. Therefore, we investigated the potential of bone marrow sparing with protons for esophageal tumors. Twenty-one patients with mid-esophageal cancer who had undergone conformal radiation therapy (3D50) were selected. Two surrogates for bone marrow were created by outlining the thoracic bones (bone) and only the body of the thoracic vertebrae (TV) in Eclipse. The percentage of overlap of the TV with the planning treatment volume was recorded for each patient. Additional plans were created retrospectively, including a volumetric modulated arc therapy (VMAT) plan with the same dose as for 3D50; a VMAT SIB plan with a dose prescription of 62.5 Gy to the high-risk subregion within the planning treatment volume; a reoptimized TV-sparing VMAT plan; and a proton therapy plan with the same SIB dose prescription. The bone and TV dose metrics were recorded and compared across all plans and variations with respect to PTV and percentage of overlap for each patient. The 3D50 plans showed the highest bone mean dose and TV percentage of volume receiving ≥30 Gy (V 30Gy ) for each patient. The VMAT plans irradiated a larger bone V 10Gy than did the 3D50 plans. The reoptimized VMAT62.5 VT plans showed improved sparing of the TV volume, but only the proton plans showed significant sparing for bone V 10Gy and bone mean dose, especially for patients with a larger PTV. The results of the present study have shown that proton therapy can reduced bone marrow toxicity. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Three-dimensional conformal radiotherapy with concurrent chemotherapy for postoperative recurrence of esophageal squamous cell carcinoma: clinical efficacy and failure pattern

PubMed Central

2013-01-01

Background To assess the therapeutic outcome and failure pattern of three-dimensional conformal radiotherapy (3D-CRT)-based concurrent chemoradiotherapy (CCRT) for recurrence of esophageal squamous cell carcinoma (SCC) after radical surgery. Methods Treatment outcome and failure pattern were retrospectively evaluated in 83 patients with localized cervical and thoracic recurrences after radical surgery for thoracic esophageal SCC. All patients were treated with 3DCRT-based CCRT (median radiation dose 60 Gy), in which 39 received concurrent cisplatin plus 5-fluorouracil (PF), and 44 received concurrent docetaxel plus cisplatin (TP). Treatment response was evaluated at 1–3 months after CCRT. Results With a median follow-up of 34 months (range, 2–116 months), the 3-year overall survival (OS) of all the patients was 51.8% and the median OS time was 43.0 months. The overall tumor response rate was 75.9% (63/83), with a complete remission (CR) rate of 44.6% (37/83). In univariate analysis, tumor response after CCRT (p = 0.000), recurrence site (p = 0.028) and concurrent chemotherapy (p = 0.090) showed a trend favoring better OS. Multivariate analysis revealed that tumor response after CCRT (p = 0.000) and concurrent chemotherapy (p = 0.010) were independent predictors of OS. Forty-seven patients had progressive diseases after CCRT, 27 had local failure (27/47, 57.4%), 18 had distant metastasis (18/47, 38.3%) and 2 had both local and distant failures (2/47, 4.3%). Conclusions 3DCRT-based CCRT is effective in postoperatively recurrent esophageal SCC. Patients that obtained complete remission after CCRT appeared to achieve long-term OS and might benefit from concurrent TP regimen. Local and distant failures remained high and prospective studies are needed to validate these factors. PMID:24139225

Three-dimensional conformal radiotherapy with concurrent chemotherapy for postoperative recurrence of esophageal squamous cell carcinoma: clinical efficacy and failure pattern.

PubMed

Bao, Yong; Liu, ShiLiang; Zhou, QiChao; Cai, PeiQiang; Anfossi, Simone; Li, QiaoQiao; Hu, YongHong; Liu, MengZhong; Fu, JianHua; Rong, TieHua; Li, Qun; Liu, Hui

2013-10-18

To assess the therapeutic outcome and failure pattern of three-dimensional conformal radiotherapy (3D-CRT)-based concurrent chemoradiotherapy (CCRT) for recurrence of esophageal squamous cell carcinoma (SCC) after radical surgery. Treatment outcome and failure pattern were retrospectively evaluated in 83 patients with localized cervical and thoracic recurrences after radical surgery for thoracic esophageal SCC. All patients were treated with 3DCRT-based CCRT (median radiation dose 60 Gy), in which 39 received concurrent cisplatin plus 5-fluorouracil (PF), and 44 received concurrent docetaxel plus cisplatin (TP). Treatment response was evaluated at 1-3 months after CCRT. With a median follow-up of 34 months (range, 2-116 months), the 3-year overall survival (OS) of all the patients was 51.8% and the median OS time was 43.0 months. The overall tumor response rate was 75.9% (63/83), with a complete remission (CR) rate of 44.6% (37/83). In univariate analysis, tumor response after CCRT (p = 0.000), recurrence site (p = 0.028) and concurrent chemotherapy (p = 0.090) showed a trend favoring better OS. Multivariate analysis revealed that tumor response after CCRT (p = 0.000) and concurrent chemotherapy (p = 0.010) were independent predictors of OS. Forty-seven patients had progressive diseases after CCRT, 27 had local failure (27/47, 57.4%), 18 had distant metastasis (18/47, 38.3%) and 2 had both local and distant failures (2/47, 4.3%). 3DCRT-based CCRT is effective in postoperatively recurrent esophageal SCC. Patients that obtained complete remission after CCRT appeared to achieve long-term OS and might benefit from concurrent TP regimen. Local and distant failures remained high and prospective studies are needed to validate these factors.

The cat vertebral column: stance configuration and range of motion

NASA Technical Reports Server (NTRS)

Macpherson, J. M.; Ye, Y.; Peterson, B. W. (Principal Investigator)

1998-01-01

This study examined the configuration of the vertebral column of the cat during independent stance and in various flexed positions. The range of motion in the sagittal plane is similar across most thoracic and lumbar joints, with the exception of a lesser range at the transition region from thoracic-type to lumbar-type vertebrae. The upper thoracic column exhibits most of its range in dorsiflexion and the lower thoracic and lumbar in ventroflexion. Lateral flexion is limited to less than 5 degrees at all segments. The range in torsion is almost 180 degrees and occurs primarily in the midthoracic region, T4-T11. Contrary to the depiction in most atlases, the standing cat exhibits several curvatures, including a mild dorsiflexion in the lower lumbar segments, a marked ventroflexion in the lower thoracic and upper lumbar segments, and a profound dorsiflexion in the upper thoracic (above T9) and cervical segments. The curvatures are not significantly changed by altering stance distance but are affected by head posture. During stance, the top of the scapula lies well above the spines of the thoracic vertebrae, and the glenohumeral joint is just below the bodies of vertebrae T3-T5. Using a simple static model of the vertebral column in the sagittal plane, it was estimated that the bending moment due to gravity is bimodal with a dorsiflexion moment in the lower thoracic and lumbar region and a ventroflexion moment in the upper thoracic and cervical region. Given the bending moments and the position of the scapula during stance, it is proposed that two groups of scapular muscles provide the major antigravity support for the head and anterior trunk. Levator scapulae and serratus ventralis form the lateral group, inserting on the lateral processes of cervical vertebrae and on the ribs. The major and minor rhomboids form the medial group, inserting on the spinous tips of vertebrae from C4 to T4. It is also proposed that the hypaxial muscles, psoas major, minor, and quadratus lumborum could support the lumbar trunk during stance.

Thoracic empyema and lung abscess resulting from gastropulmonary fistula as a complication of esophagectomy.

PubMed

Osaki, Toshihiro; Matsuura, Hiroshi

2008-06-01

A benign fistula between the gastric tube and the airway resulting from esophagectomy is a rare complication, but it is a potentially life-threatening status. We present a 59-year-old man with thoracic empyema and lung abscess resulting from a benign gastric tube-to-pulmonary fistula caused by a penetration of the peptic ulcer in the gastric tube four years after an esophagectomy for esophageal cancer. After a thorough conservative management of infection and nutrition, the fistula was successfully repaired surgically with direct closure. The postoperative course was uneventful. Two years and nine months later, the patient retains satisfactory oral feeding status and is in good general condition.

Preoperative chemotherapy for resectable thoracic esophageal cancer.

PubMed

Malthaner, R; Fenlon, D

2001-01-01

Carcinoma of the esophagus is a relatively uncommon but lethal cancer that continues to kill over 90% of its victims within 5 years. Surgery is the treatment of choice for most localized esophageal cancer patients. However, despite curative resection, the 5-year survival rate ranges from 15% to 39%. The failure of surgery to cure clinically localized esophageal cancer is because of the advanced state of the disease before symptoms occur, high frequency of lymph node involvement, and the common occurrence of submucosal spread and extension to surrounding structures. Preoperative chemotherapy has been used in an attempt to decrease tumour activity, increase resectability, and improve disease-free and overall survival. A number of studies have investigated whether preoperative chemotherapy followed by surgery leads to an improvement in cure rates, but the individual reports have not been encouraging. The role of preoperative chemotherapy in the treatment of resectable thoracic esophageal cancer remains undefined. The objective of this review is to determine the role of preoperative chemotherapy on overall survival and/or quality-of-life for patients with resectable thoracic esophageal carcinoma. Trials were identified by searching the Cochrane Controlled Trials Register (Issue 2 - 2000), MEDLINE (1966 - 2000), EMBASE (1988 - 2000) and CancerLit (1993 - 2000). The references of all identified studies, review articles, and standard textbooks were examined. Members of the Cochrane UGPD Group and experts in the oncology field were contacted and asked to supply details of any outstanding clinical trials and relevant unpublished materials. There were no language restrictions. The searches were updated in June 2000. The clinical trial registers of the National Cancer Institute and the Radiation Therapy Oncology Group were consulted for ongoing trials. Types of studies Studies (published or unpublished) that randomised patients with potentially resectable carcinoma of the esophagus (of any histologic type) to chemotherapy or no chemotherapy before surgery were included in this review. Studies were excluded if they were not truly randomised (phase I or II trials), earlier versions of updated trials, if other treatment modalities (e.g. radiotherapy, hyperthermia) were used, or if there was not a surgery alone control arm. Types of participants The participants consisted of patients with potentially resectable thoracic esophageal carcinoma (of any histologic type). Trials involving patients with carcinoma of the cervical esophagus were excluded. Types of interventions Trials that compared chemotherapy before surgery (esophagectomy) with surgical resection alone (esophagectomy). Types of outcome measures The primary outcome was death at yearly intervals. Morbidity (complications), and quality-of-life were secondary outcomes. Overall mortality at yearly intervals was determined by extracting the total number of patients randomised to the treatment and control groups and the number of deaths in each group. All analyses were carried out on intention-to-treat that is patients were analyzed according to their allocated treatment, irrespective of whether they received that treatment. Mortality at 1, 2, 3, 4 and 5 years were used as endpoints of clinical relevance. If survival numbers at the specified time intervals were not given, they were estimated from the published survival curves. The number of deaths in the treatment groups (preoperative chemotherapy plus surgery) was compared to the number of deaths in the control groups (surgery alone). Treatment modalities as well as patient demographics and characteristics and side-effects were also recorded. Trials meeting the inclusion criteria were evaluated by two independent reviewers using the Jadad method A total of 14 randomised controlled trials and 1 meta-analysis of preoperative chemotherapy versus surgery alone for esophageal carcinoma were identified to be potentially eligible for review. This review is based on 7 randomised trials and 1653 patients. At 1 year the Peto odds ratio based on the fixed-effects models showed no difference in mortality between preoperative chemotherapy and surgery alone (OR = 1.03). At 2 years there was a 20% significant decrease in mortality for preoperative chemotherapy (OR = 0.80; 95% C.I. 0.65 to 0.99) but the results were not robust. The results at 3, 4, and 5 years found odds ratios tending to favour preoperative chemotherapy, but wide confidence intervals that included 1. None of the published trials reported on quality-of-life outcomes. There appeared to be an increased risk of morbidity with chemotherapy. The results of this review suggest that there is no strong evidence to recommend preoperative chemotherapy in the treatment of surgically resectable carcinomas of the thoracic esophagus. (ABSTRACT TRUNCATED)

A case report of esophageal perforation: Complication of nasogastric tube placement

PubMed Central

Isik, Arda; Firat, Deniz; Peker, Kemal; Sayar, Ilyas; Idiz, Oguz; Soytürk, Mehmet

2014-01-01

Patient: Male, 70 Final Diagnosis: Esophageal perforation Symptoms: Abdominal pain • nausea • vomiting Medication: — Clinical Procedure: — Specialty: Surgery Objective: Unusual clinical course Background: Esophageal perforation is a well-defined and severe clinical condition. There are several etiologies of esophagus perforation. Case Report: We report the case of a 70-year-old Caucasian man who underwent an emergency cholecystectomy due to acute cholecystitis. Two days after surgery, his condition deteriorated. Thorax computerized tomography revealed an esophageal perforation. Conclusions: Esophageal perforation due to nasogastric application is relatively rare but the consequences are potentially serious. The anatomy of the upper gastrointestinal system should be understood by all healthcare professionals involved in the treatment. PMID:24803977

Efficacy of pectin solution for preventing gastro-esophageal reflux events in patients with percutaneous endoscopic gastrostomy.

PubMed

Adachi, Kyoichi; Furuta, Kenji; Aimi, Masahito; Fukazawa, Kousuke; Shimura, Shino; Ohara, Shunji; Nakata, Shuji; Inoue, Yukiko; Ryuko, Kanji; Ishine, Junichi; Katoh, Kyoko; Hirata, Toshiaki; Ohhata, Shuzo; Katoh, Setsushi; Moriyama, Mika; Sumikawa, Masuko; Sanpei, Mari; Kinoshita, Yoshikazu

2012-05-01

The aim of this study was to determine the efficacy of pectin solution, which increases the viscosity of liquid nutrient, for prevention of gastro-esophageal reflux in comparison with half-solid nutrient. The subjects were 10 elderly patients undergoing percutaneous endoscopic gastrostomy feeding. Twenty-four-hour esophageal multichannel intraluminal impedance and pH testing was performed during intake of half-solid nutrient and a combination of pectin solution and liquid nutrient. During 4 h after delivery, there was no significant difference in the total number of gastro-esophageal reflux events between the feeding of the half-solid nutrient and the combination of pectin solution and liquid nutrient (5.7 ± 1.2 vs 5.3 ± 1.0/4 h). Acidic reflux after delivery of the half-solid nutrient was significantly more frequent than that after delivery of the combination of pectin solution and liquid nutrient (80.7% vs 60.4%, p = 0.018). The incidence of gastro-esophageal reflux reaching the upper portion of the esophagus tended to be higher during delivery of the half-solid nutrient than during delivery of the combination of pectin solution and liquid nutrient (47.4% vs 34.0%, p = 0.153). In conclusion, the usage of pectin solution combined with liquid nutrient is effective for preventing acidic gastro-esophageal reflux and gastro-esophageal reflux reaching the upper portion of the esophagus.

Prognostic factors in clinical T1N0M0 thoracic esophageal squamous cell carcinoma invading the muscularis mucosa or submucosa.

PubMed

Uchinami, Yusuke; Myojin, Miyako; Takahashi, Hiroaki; Harada, Keiichi; Shimizu, Shinichi; Hosokawa, Masao

2016-06-21

Multimodality treatment is widely performed for clinical T1N0M0 (UICC-TNM classification, 7th edition) thoracic esophageal squamous cell carcinoma (ESCC), but available articles regarding treatment results are limited. This study assessed the outcomes of clinical T1N0M0 thoracic ESCC invading the muscularis mucosa (MM) or submucosa (SM) treated with radiotherapy (RT) or chemoradiotherapy (CRT). We retrospectively reviewed the medical charts of 90 patients with clinical T1N0M0 thoracic ESCC treated with RT or CRT in our hospital in 2004-2011. Of these 90 patients, we analyzed the cases of 71 patients who met our inclusion criteria. All 71 patients had MM or SM cancer. In the 47 patients treated with CRT, the chemotherapy regimen of 5-fluorouracil (5-FU) plus cisplatin (CDDP) was used for 46 patients and 5-FU and nedaplatin was used for one patient. Forty-five patients underwent endoscopic resection (ER) followed by RT or CRT as an additional treatment. Elective nodal irradiation (ENI) was used in 39 patients. For all analyses, statistical significance was defined as 0.05, and the Bonferroni correction was used for the multivariate analysis. The median age was 70 years (range 47-84). With a median follow-up of 43.6 months (range 1.5-124.2), the 5-year overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS) rates were 64.0, 72.8 and 50.0 %, respectively. The multivariate analysis showed that performance status (PS) was an independent prognostic factors for DSS and DFS (DSS, p < 0.001; DFS, p < 0.001). Chemotherapy in addition to RT showed a trend for better DSS (p = 0.032) but was not significant following Bonferroni correction. ER and ENI were not significant predictive factors for DSS and DFS. PS was an independent prognostic factor for DSS and DFS. ER and ENI had no significant relationship with DSS or DFS. The present results may be helpful in treatment decisions for clinical T1N0M0 thoracic ESCC.

Robotics in general thoracic surgery procedures.

PubMed

Latif, M Jawad; Park, Bernard J

2017-01-01

The use of robotic technology in general thoracic surgical practice continues to expand across various institutions and at this point many major common thoracic surgical procedures have been successfully performed by general thoracic surgeons using the robotic technology. These procedures include lung resections, excision of mediastinal masses, esophagectomy and reconstruction for malignant and benign esophageal pathologies. The success of robotic technology can be attributed to highly magnified 3-D visualization, dexterity afforded by 7 degrees of freedom that allow difficult dissections in narrow fields and the ease of reproducibility once the initial set up and instruments become familiar to the surgeon. As the application of robotic technology trickle downs from major academic centers to community hospitals, it becomes imperative that its role, limitations, learning curve and financial impact are understood by the novice robotic surgeon. In this article, we share our experience as it relates to the setup, common pitfalls and long term results for more commonly performed robotic assisted lung and thymic resections using the 4 arm da Vinci Xi robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) to help guide those who are interested in adopting this technology.

Slipping rib syndrome: a place for sonography in the diagnosis of a frequently overlooked cause of abdominal or low thoracic pain.

PubMed

Meuwly, Jean-Yves; Wicky, Stephan; Schnyder, Pierre; Lepori, Domenico

2002-03-01

To describe the sonographic appearance of a poorly recognized cause of low thoracic or upper abdominal pain. Three sonographic descriptions of slipping rib syndrome are presented. The 3 patients had abnormal mobility of a cartilaginous rib, which could slip over an adjacent rib during abdominal muscle contraction. Slipping rib syndrome should be considered in patients with histories of upper abdominal or low thoracic pain of unknown origin. We suggest that high-resolution sonography of the costal margin should be added to abdominal sonography in cases of nonspecific abdominal pain.

Use of the blue cotton screen method with endoscopy to detect occult esophageal foreign bodies

PubMed Central

Xia, Yan; Zhang, Fan; Xu, Weiran

2017-01-01

More than 20,000 cases of upper gastrointestinal foreign bodies (FBs) have been reported in the last 5 years in China. Early detection and treatment is vital in these patients. Differential diagnosis of esophageal injury and occult esophageal foreign bodies is challenging, particularly in the case of non-radio-opaque foreign bodies. A diagnostic technique with high accuracy and low risk is needed for clinical practice. We describe successful use of the “blue cotton screen method” to detect esophageal foreign bodies in 2 patients. The advantages and disadvantages of various diagnostic modalities in the management of patients with foreign body ingestion are presented. This technique is safer and more effective than traditional methods for foreign body impaction in the esophageal cavity. It could be applied for screening and in the differential diagnosis of esophageal injury and FBs in the esophageal lumen. PMID:29362659

Various upper endoscopic findings of acute esophageal thermal injury induced by diverse food: a case series.

PubMed

Lee, Yu Mi; Kim, Sun Moon; Kim, Ji Young; Song, Hyun Jung; Koo, Hoon Sup; Song, Kyung Ho; Kim, Yong Seok; Huh, Kyu Chan

2014-09-01

Esophageal thermal injury caused by food has been reported to occur mostly after drinking hot liquid food, and is known to produce alternating white and red linear mucosal bands. In addition, thermal injury caused by ingestion of hot solid foods is documented to be a cause of esophageal ulcers or pseudomembranes. From January 2006 to August 2012, five patients with suspected esophageal thermal injury underwent esophagogastroduodenoscopy with biopsy. A "candy-cane" appearance was observed in one case, pseudomembrane was observed in two cases, an esophageal ulcer was observed in one case, and a friable and edematous mucosa was noted in one case. We believe that the endoscopic findings of esophageal thermal injury depend on the following factors: causative materials, amount of food consumed, exposure period, and time to endoscopy after the incident. Therefore, physicians who encounter patients with suspected esophageal thermal injury should carefully take the patient's history considering these factors.

Reflux Hypersensitivity: A New Functional Esophageal Disorder.

PubMed

Yamasaki, Takahisa; Fass, Ronnie

2017-10-30

Reflux hypersensitivity, recently introduced by Rome IV as a new functional esophageal disorder, is currently considered as the presence of typical heartburn symptoms in patients with normal upper endoscopy and esophageal biopsies, normal esophageal pH test and with evidence of a close correlation between patients' heartburn and reflux events. Reflux hypersensitivity is very common and together with functional heartburn accounts for more than 90% of the heartburn patients who failed treatment with proton pump inhibitor twice daily. In addition, reflux hypersensitivity affects primarily young to middle aged women, commonly overlaps with another functional gastrointestinal disorders, and is often associated with some type of psychological comorbidity. Diagnosis is made by using endoscopy with esophageal biopsies, pH-impedance, and high-resolution esophageal manometry. Reflux hypersensitivity is primarily treated with esophageal neuromodulators, such as tricyclic anti-depressants and selective serotonin reuptake inhibitors among others. Surgical anti-reflux management may also play an important role in the treatment of reflux hypersensitivity.

Regional interdependence and manual therapy directed at the thoracic spine

PubMed Central

McDevitt, Amy; Young, Jodi; Mintken, Paul; Cleland, Josh

2015-01-01

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention. PMID:26309384

Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report

PubMed Central

2014-01-01

Background Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system. Case presentation A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion. Conclusions This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy. PMID:25319372

Three-Dimensional Photoacoustic Endoscopic Imaging of the Rabbit Esophagus

PubMed Central

Yao, Junjie; Chen, Ruimin; Zhou, Qifa; Shung, K. Kirk; Wang, Lihong V.

2015-01-01

We report photoacoustic and ultrasonic endoscopic images of two intact rabbit esophagi. To investigate the esophageal lumen structure and microvasculature, we performed in vivo and ex vivo imaging studies using a 3.8-mm diameter photoacoustic endoscope and correlated the images with histology. Several interesting anatomic structures were newly found in both the in vivo and ex vivo images, which demonstrates the potential clinical utility of this endoscopic imaging modality. In the ex vivo imaging experiment, we acquired high-resolution motion-artifact-free three-dimensional photoacoustic images of the vasculatures distributed in the walls of the esophagi and extending to the neighboring mediastinal regions. Blood vessels with apparent diameters as small as 190 μm were resolved. Moreover, by taking advantage of the dual-mode high-resolution photoacoustic and ultrasound endoscopy, we could better identify and characterize the anatomic structures of the esophageal lumen, such as the mucosal and submucosal layers in the esophageal wall, and an esophageal branch of the thoracic aorta. In this paper, we present the first photoacoustic images showing the vasculature of a vertebrate esophagus and discuss the potential clinical applications and future development of photoacoustic endoscopy. PMID:25874640

Three-dimensional photoacoustic endoscopic imaging of the rabbit esophagus.

PubMed

Yang, Joon Mo; Favazza, Christopher; Yao, Junjie; Chen, Ruimin; Zhou, Qifa; Shung, K Kirk; Wang, Lihong V

2015-01-01

We report photoacoustic and ultrasonic endoscopic images of two intact rabbit esophagi. To investigate the esophageal lumen structure and microvasculature, we performed in vivo and ex vivo imaging studies using a 3.8-mm diameter photoacoustic endoscope and correlated the images with histology. Several interesting anatomic structures were newly found in both the in vivo and ex vivo images, which demonstrates the potential clinical utility of this endoscopic imaging modality. In the ex vivo imaging experiment, we acquired high-resolution motion-artifact-free three-dimensional photoacoustic images of the vasculatures distributed in the walls of the esophagi and extending to the neighboring mediastinal regions. Blood vessels with apparent diameters as small as 190 μm were resolved. Moreover, by taking advantage of the dual-mode high-resolution photoacoustic and ultrasound endoscopy, we could better identify and characterize the anatomic structures of the esophageal lumen, such as the mucosal and submucosal layers in the esophageal wall, and an esophageal branch of the thoracic aorta. In this paper, we present the first photoacoustic images showing the vasculature of a vertebrate esophagus and discuss the potential clinical applications and future development of photoacoustic endoscopy.

Prevention of gastroduodenal content reflux and delayed gastric emptying after esophagectomy: gastric tube reconstruction with duodenal diversion plus Roux-en-Y anastomosis.

PubMed

Yano, M; Motoori, M; Tanaka, K; Kishi, K; Miyashiro, I; Shingai, T; Gotoh, K; Noura, S; Takahashi, H; Yamada, T; Ohue, M; Ohigashi, H; Ishikawa, O

2012-04-01

Reflux of gastroduodenal contents and delayed gastric emptying are the most common and serious problems after esophagectomy with gastric reconstruction. However, attempts to reduce the above symptoms, surgically as well as non-surgically, had no or limited effect. To address this issue, we performed retrosternal gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis (RY) in eight patients with thoracic esophageal cancer and compared the outcomes with control patients who underwent standard reconstruction. The procedure is simple, safe, and not associated with any postoperative complications. The pancreatic amylase concentrations in the gastric juice samples on postoperative day 2 were slightly lower in the non-RY group than in the RY group (1884 ± 2152 vs. 25,790 ± 23,542IU/mL, respectively, P= 0.07). Postoperative endoscopic examination showed neither reflux esophagitis nor residual gastric content in the RY group. Quality of life assessed by the Dysfunction After Upper Gastrointestinal Surgery-32 questionnaire postoperatively was significantly better in the RY group than in the non-RY group for 'decreased physical activity,''symptoms of reflux,''nausea and vomiting,' and 'pain.' The results of this pilot study suggest that gastric reconstruction with duodenal diversion plus RY seems effective in improving both the reflux and delayed gastric emptying. The benefits of this procedure need to be further assessed in a large-scale, randomized controlled trial. © 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Esophageal dysmotility in scleroderma: a prospective study of 183 cases.

PubMed

Lahcene, M; Oumnia, N; Matougui, N; Boudjella, M; Tebaibia, A; Touchene, B

2009-01-01

The goal of the study was to evaluate the prevalence and risk factors of esophageal motor disorders in systemic sclerosis. In 183 consecutive cases of scleroderma, as diagnosed by American College of Rheumatology criteria (1980). Patients' mean age was 40.6+/-13.3 years, the gender ratio was 0.13 and the average duration of disease was 6.8+/-7.5 years. A localized, cutaneous form was observed in 148 patients (81%) and a diffuse form in 35 (19%). All patients underwent upper gastrointestinal endoscopy and standard esophageal manometry. Esophageal symptoms and reflux esophagitis were found in 108 (59%) and 68 (37%) of patients, respectively. Esophageal motor disorders were present in 148 patients (81%), and were associated with a hypotensive lower esophageal sphincter in 114 (62%). The presence of these motor abnormalities was not related to age, gender, skin extension or duration of disease. Esophageal motor disorders were present in almost all patients with esophageal symptoms or esophagitis, and were also found in 48 (64%) of the asymptomatic patients. Esophageal motor disorders are frequently seen in scleroderma, especially in cases with clinical symptoms, but are not associated with a specific form of the disease.

Scintigraphic Evaluation of Esophageal Motility and Gastroesophageal Reflux in Patients Presenting with Upper Respiratory Tract Symptoms

PubMed Central

Amalachandran, Jaykanth; Simon, Shelley; Elangoven, Indirani; Jain, Avani; Sivathapandi, Thangalakshmi

2018-01-01

Purpose of Study: The purpose is to evaluate the findings and utility of esophageal transit scintigraphy (ETS) and gastroesophageal reflux scintigraphy (GES) in patients presenting with upper respiratory tract (URT) symptoms suspected to be due to gastroesophageal reflux (GER) disease. Materials and Methods: Thirty patients aged between 19 and 60 years underwent nasopharyngolaryngoscopy (NPL), ETS, and GES. Correlation between GER, esophageal motility, and NPL was evaluated. Inclusion criteria include patients with recurrent URT symptoms such as chronic dry cough/hoarseness of voice and itching/foreign body sensation in throat. Those with typical gastrointestinal (GI) symptoms of GER, URT symptoms relieved by antibiotics, surgical intervention in abdomen, cardiac/hepatobiliary diseases, etc. were excluded from the study. Results: Significant correlation was found between GER and NPL in 28/30 patients. More the grade of reflux, more severe was the NPL findings. Two patients with Grade II reflux had normal NPL suggesting structural inflammatory changes due to acidic pH of refluxate which have not yet manifested or symptoms could be due to nonacid refluxate. Incidence of esophageal motility disorder was statistically significant in patients with GER disease (GERD). Patients who had symptoms, but no demonstrable GER showed delayed ET in supine position suggesting the presence of esophageal motility disorder even before GERD. Conclusion: GES demonstrated GER in patients presenting with URT symptoms without typical GI symptoms. ETS showed coexistence of esophageal motility disorder in most patients presenting with URT symptoms even without an associated reflux disease. We hypothesize that primary abnormal esophageal motility leads to delayed esophageal clearance and consequently to URT symptoms. Addition of ETS to GES is easily feasible with no significant additional cost, time, or radiation burden. PMID:29430111

Clinico-Radiological Diagnosis of Isolated Congenital Esophageal Stenosis in a Preterm Neonate

PubMed Central

Sham, Minakshi

2013-01-01

A 2-day-old preterm female neonate weighing 1.6 kg and having excessive frothing from mouth was investigated for suspected esophageal atresia and tracheoesophageal fistula. X-ray findings of an unusually low-ending upper pouch (up to T8 level) and the absence of gas in abdomen lead to suspicion of an unusual variety of esophageal atresia. Hence unlike the usual management of pure esophageal atresia, in terms of esophagostomy and gastrostomy in neonatal period, right thoracotomy was performed allowing successful primary anastomosis. A high index of suspicion on the basis of radiological picture led to early diagnosis of a rare anomaly like congenital esophageal stenosis and successful management of this low birth weight baby. PMID:25755945

Radiation dose to the esophagus from breast cancer radiation therapy, 1943-1996: an international population-based study of 414 patients.

PubMed

Lamart, Stephanie; Stovall, Marilyn; Simon, Steven L; Smith, Susan A; Weathers, Rita E; Howell, Rebecca M; Curtis, Rochelle E; Aleman, Berthe M P; Travis, Lois; Kwon, Deukwoo; Morton, Lindsay M

2013-07-15

To provide dosimetric data for an epidemiologic study on the risk of second primary esophageal cancer among breast cancer survivors, by reconstructing the radiation dose incidentally delivered to the esophagus of 414 women treated with radiation therapy for breast cancer during 1943-1996 in North America and Europe. We abstracted the radiation therapy treatment parameters from each patient's radiation therapy record. Treatment fields included direct chest wall (37% of patients), medial and lateral tangentials (45%), supraclavicular (SCV, 64%), internal mammary (IM, 44%), SCV and IM together (16%), axillary (52%), and breast/chest wall boosts (7%). The beam types used were (60)Co (45% of fields), orthovoltage (33%), megavoltage photons (11%), and electrons (10%). The population median prescribed dose to the target volume ranged from 21 Gy to 40 Gy. We reconstructed the doses over the length of the esophagus using abstracted patient data, water phantom measurements, and a computational model of the human body. Fields that treated the SCV and/or IM lymph nodes were used for 85% of the patients and delivered the highest doses within 3 regions of the esophagus: cervical (population median 38 Gy), upper thoracic (32 Gy), and middle thoracic (25 Gy). Other fields (direct chest wall, tangential, and axillary) contributed substantially lower doses (approximately 2 Gy). The cervical to middle thoracic esophagus received the highest dose because of its close proximity to the SCV and IM fields and less overlying tissue in that part of the chest. The location of the SCV field border relative to the midline was one of the most important determinants of the dose to the esophagus. Breast cancer patients in this study received relatively high incidental radiation therapy doses to the esophagus when the SCV and/or IM lymph nodes were treated, whereas direct chest wall, tangentials, and axillary fields contributed lower doses. Published by Elsevier Inc.

Radiation Dose to the Esophagus From Breast Cancer Radiation Therapy, 1943-1996: An International Population-Based Study of 414 Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lamart, Stephanie, E-mail: stephanie.lamart@nih.gov; Stovall, Marilyn; Simon, Steven L.

2013-07-15

Purpose: To provide dosimetric data for an epidemiologic study on the risk of second primary esophageal cancer among breast cancer survivors, by reconstructing the radiation dose incidentally delivered to the esophagus of 414 women treated with radiation therapy for breast cancer during 1943-1996 in North America and Europe. Methods and Materials: We abstracted the radiation therapy treatment parameters from each patient’s radiation therapy record. Treatment fields included direct chest wall (37% of patients), medial and lateral tangentials (45%), supraclavicular (SCV, 64%), internal mammary (IM, 44%), SCV and IM together (16%), axillary (52%), and breast/chest wall boosts (7%). The beam typesmore » used were {sup 60}Co (45% of fields), orthovoltage (33%), megavoltage photons (11%), and electrons (10%). The population median prescribed dose to the target volume ranged from 21 Gy to 40 Gy. We reconstructed the doses over the length of the esophagus using abstracted patient data, water phantom measurements, and a computational model of the human body. Results: Fields that treated the SCV and/or IM lymph nodes were used for 85% of the patients and delivered the highest doses within 3 regions of the esophagus: cervical (population median 38 Gy), upper thoracic (32 Gy), and middle thoracic (25 Gy). Other fields (direct chest wall, tangential, and axillary) contributed substantially lower doses (approximately 2 Gy). The cervical to middle thoracic esophagus received the highest dose because of its close proximity to the SCV and IM fields and less overlying tissue in that part of the chest. The location of the SCV field border relative to the midline was one of the most important determinants of the dose to the esophagus. Conclusions: Breast cancer patients in this study received relatively high incidental radiation therapy doses to the esophagus when the SCV and/or IM lymph nodes were treated, whereas direct chest wall, tangentials, and axillary fields contributed lower doses.« less

Applying the technique of volume-modulated arc radiotherapy to upper esophageal carcinoma.

PubMed

Ma, Pan; Wang, Xiaozhen; Xu, Yingjie; Dai, Jianrong; Wang, Luhua

2014-05-08

This study aims to evaluate the possibility of using the technique of volume-modulated arc therapy (VMAT) to combine the advantages of simplified intensity-modulated radiation therapy (sIMRT) with that of regular intensity-modulated radiation therapy (IMRT) in upper esophageal cancer. Ten patients with upper esophageal carcinoma were randomly chosen in this retrospective study. sIMRT, IMRT, and VMAT plans were generated to deliver 60 Gy in 30 fractions to the planning target volume (PTV). For each patient, with the same clinical requirements (target dose prescription, and dose/dose-volume constraints to organs at risk (OARs)), three plans were designed for sIMRT (five equispaced coplanar beams), IMRT (seven equispaced coplanar beams), and VMAT (two complete arcs). Comparisons were performed for dosimetric parameters of PTV and of OARs (lungs, spinal cord PRV, heart and normal tissue (NT)). All the plans were delivered to a phantom to evaluate the treatment time. The Wilcoxon matched-pairs, signed-rank test was used for intragroup comparison. For all patients, compared to sIMRT plans, VMAT plans statistically provide: a) significant improvement in HI and CI for PTV; b) significant decrease in delivery time, lung V20, MLD, heart V30 and spinal cord PRV D1cc; c) significant increase in NT V5; and d) no significant reduction in lung V5, V10, and heart MD. For all patients, compared to IMRT plans, VMAT plans statistically provide: a) significant improvement in CI for PTV; b) significant decrease in delivery time, lung V20, MLD, NT and spinal cord PRV D1cc; c) significant increase in NT V5; and d) no significant reduction in HI for PTV, lung V5, V10, heart V30 and heart MD. For patients with upper esophageal carcinoma, using VMAT significantly reduces the delivery time and the dose to the lungs compared with IMRT, and consequently saves as much treatment time as sIMRT. Considering those significant advantages, compared to sIMRT and IMRT, VMAT is the first choice of radiotherapy techniques for upper esophageal carcinoma.

The association between incentive spirometry performance and pain in postoperative thoracic epidural analgesia.

PubMed

Harris, David J; Hilliard, Paul E; Jewell, Elizabeth S; Brummett, Chad M

2015-01-01

Effective use of postoperative incentive spirometry improves patient outcomes but is limited by pain after thoracic and upper abdominal surgery. Thoracic epidurals are frequently used to provide analgesia and attenuate postoperative pulmonary dysfunction. We hypothesized that, in patients with thoracic epidurals for thoracic and abdominal surgery, high pain scores would be associated with poorer incentive spirometry performance, even when accounting for other variables. Retrospective study of 468 patients who underwent upper abdominal or thoracic surgery using postoperative thoracic epidural analgesia between June 1, 2009, and August 31, 2013, at a single tertiary academic center. The association between incentive spirometry performance and pain was assessed as the primary outcome. Other independent predictors of incentive spirometry performance were also identified. Postoperative incentive spirometry performance was found to be inversely proportional to pain score, which correlated significantly stronger with deep breathing pain compared with pain at rest (-0.33 vs -0.14 on postoperative day 1; -0.23 vs -0.12 on postoperative day 2). Pain with deep breathing was independently associated with poorer incentive spirometry performance in the multivariable linear regression model (P < 0.0001), as was increasing age, female sex, thoracic surgery, and higher American Society of Anesthesiologists (ASA) physical status score. The present study suggests that pain with deep breathing is more indicative of thoracic epidural efficacy than is pain at rest. Furthermore, incentive spirometry performance could be used as another indicator of thoracic epidural efficacy. This may be particularly useful in patients reporting high pain scores postoperatively.

Value of two-phase dynamic multidetector computed tomography in differential diagnosis of post-inflammatory strictures from esophageal cancer

PubMed Central

Karmazanovsky, Grigory G; Buryakina, Svetlana A; Kondratiev, Evgeny V; Yang, Qin; Ruchkin, Dmitry V; Kalinin, Dmitry V

2015-01-01

AIM: To characterize the computed tomography (CT) findings in patients with post-inflammatory esophageal strictures (corrosive and peptic) and reveal the optimal scanning phase protocols for distinguishing post-inflammatory esophageal stricture and esophageal cancer. METHODS: Sixty-five patients with esophageal strictures of different etiology were included in this study: 24 patients with 27 histopathologically confirmed corrosive strictures, 10 patients with 12 peptic strictures and 31 patients with esophageal cancer were evaluated with a two-phase dynamic contrast-enhanced MDCT. Arterial and venous phases at 10 and 35 s after the attenuation of 200 HU were obtained at the descending aorta, with a delayed phase at 6-8 min after the start of injection of contrast media. For qualitative analysis, CT scans of benign strictures were reviewed for the presence/absence of the following features: “target sign”, luminal mass, homogeneity of contrast medium uptake, concentric wall thickening, conically shaped suprastenotic dilatation, smooth boundaries of stenosis and smooth mucous membrane at the transition to stenosis, which were compared with a control group of 31 patients who had esophageal cancer. The quantitative analysis included densitometric parameter acquisition using regions-of-interest measurement of the zone of stenosis and normal esophageal wall and the difference between those measurements (ΔCT) at all phases of bolus contrast enhancement. Esophageal wall thickening, length of esophageal wall thickening and size of the regional lymph nodes were also evaluated. RESULTS: The presence of a concentric esophageal wall, conically shaped suprastenotic dilatation, smooth upper and lower boundaries, “target sign” and smooth mucous membrane at the transition to stenosis were suggestive of a benign cause, with sensitivities of 92.31%, 87.17%, 94.87%, 76.92% and 82.05%, respectively, and specificities of 70.96%, 89.66%, 80.65%, 96.77% and 93.55%, respectively. The features that were most suggestive of a malignant cause were eccentric esophageal wall thickening, tuberous upper and lower boundaries of stenosis, absence of mucous membrane visualization, rupture of the mucous membrane at the upper boundary of stenosis, cup-shaped suprastenotic dilatation, luminal mass and enlarged regional lymph nodes with specificities of 92.31% 94.87%, 67.86%, 100%, 97.44%, 94.87% and 82.86%, respectively and sensitivities of 70.97%, 80.65%, 96.77%, 80.65%, 54.84%, 87.10% and 60%, respectively. The highest tumor attenuation occurred in the arterial phase (mean attenuation 74.13 ± 17.42 HU), and the mean attenuation difference between the tumor and the normal esophageal wall (mean ΔCT) in the arterial phase was 23.86 ± 19.31 HU. Here, 11.5 HU of ΔCT in the arterial phase was the cut-off value used to differentiate esophageal cancer from post-inflammatory stricture (P = 0.000). The highest attenuation of post-inflammatory strictures occurred in the delayed phase (mean attenuation 71.66 ± 14.28 HU), and the mean ΔCT in delayed phase was 34.03 ± 15.94 HU. Here, 18.5 HU of ΔCT in delayed phase was the cut-off value used to differentiate post-inflammatory stricture from esophageal cancer (P < 0.0001). CONCLUSION: The described imaging findings reveal high diagnostic significance in the differentiation of benign strictures from esophageal cancer. PMID:26269677

Characterization of swallow modulation in response to bolus volume in healthy subjects accounting for catheter diameter.

PubMed

Ferris, Lara; Schar, Mistyka; McCall, Lisa; Doeltgen, Sebastian; Scholten, Ingrid; Rommel, Nathalie; Cock, Charles; Omari, Taher

2018-06-01

Characterization of the pharyngeal swallow response to volume challenges is important for swallowing function assessment. The diameter of the pressure-impedance recording catheter may influence these results. In this study, we captured key physiological swallow measures in response to bolus volume utilizing recordings acquired by two catheters of different diameter. Ten healthy adults underwent repeat investigations with 8- and 10-Fr catheters. Liquid bolus swallows of volumes 2.5, 5, 10, 20, and 30 mL were recorded. Measures indicative of distension, contractility, and flow timing were assessed. Pressure-impedance recordings with pressure-flow analysis were used to capture key distension, contractility, and pressure-flow timing parameters. Larger bolus volumes increased upper esophageal sphincter distension diameter (P < .001) and distension pressures within the hypopharynx and upper esophageal sphincter (P < .05). Bolus flow timing measures were longer, particularly latency of bolus propulsion ahead of the pharyngeal stripping wave (P < .001). Use of a larger-diameter catheter produced higher occlusive pressures, namely upper esophageal sphincter basal pressure (P < .005) and upper esophageal sphincter postdeglutitive pressure peak (P < .001). The bolus volume swallowed changed measurements indicative of distension pressure, luminal diameter, and pressure-flow timing; this is physiologically consistent with swallow modulation to accommodate larger, faster-flowing boluses. Additionally, catheter diameter predominantly affects lumen occlusive pressures. Appropriate physiological interpretation of the pressure-impedance recordings of pharyngeal swallowing requires consideration of the effects of volume and catheter diameter. NA. Laryngoscope, 128:1328-1334, 2018. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Successful Recovery and Transplantation of 11 Organs Including Face, Bilateral Upper Extremities, and Thoracic and Abdominal Organs From a Single Deceased Organ Donor.

PubMed

Tullius, Stefan G; Pomahac, Bohdan; Kim, Heung Bae; Carty, Matthew J; Talbot, Simon G; Nelson, Helen M; Delmonico, Francis L

2016-10-01

We report on the to date largest recovery of 11 organs from a single deceased donor with the transplantation of face, bilateral upper extremities, heart, 1 lung, liver (split for 2 recipients), kidneys, pancreas, and intestine. Although logistically challenging, this case demonstrates the feasibility and safety of the recovery of multiple thoracic and abdominal organs with multiple vascular composite allotransplants and tissues. Our experience of 8 additional successful multiple vascular composite allotransplants, thoracic, and abdominal organ recoveries suggests that such procedures are readily accomplishable from the same deceased donor.

Report on First International Workshop on Robotic Surgery in Thoracic Oncology.

PubMed

Veronesi, Giulia; Cerfolio, Robert; Cingolani, Roberto; Rueckert, Jens C; Soler, Luc; Toker, Alper; Cariboni, Umberto; Bottoni, Edoardo; Fumagalli, Uberto; Melfi, Franca; Milli, Carlo; Novellis, Pierluigi; Voulaz, Emanuele; Alloisio, Marco

2016-01-01

A workshop of experts from France, Germany, Italy, and the United States took place at Humanitas Research Hospital Milan, Italy, on February 10 and 11, 2016, to examine techniques for and applications of robotic surgery to thoracic oncology. The main topics of presentation and discussion were robotic surgery for lung resection; robot-assisted thymectomy; minimally invasive surgery for esophageal cancer; new developments in computer-assisted surgery and medical applications of robots; the challenge of costs; and future clinical research in robotic thoracic surgery. The following article summarizes the main contributions to the workshop. The Workshop consensus was that since video-assisted thoracoscopic surgery (VATS) is becoming the mainstream approach to resectable lung cancer in North America and Europe, robotic surgery for thoracic oncology is likely to be embraced by an increasing numbers of thoracic surgeons, since it has technical advantages over VATS, including intuitive movements, tremor filtration, more degrees of manipulative freedom, motion scaling, and high-definition stereoscopic vision. These advantages may make robotic surgery more accessible than VATS to trainees and experienced surgeons and also lead to expanded indications. However, the high costs of robotic surgery and absence of tactile feedback remain obstacles to widespread dissemination. A prospective multicentric randomized trial (NCT02804893) to compare robotic and VATS approaches to stages I and II lung cancer will start shortly.

Clinical Implications and Pathogenesis of Esophageal Remodeling in Eosinophilic Esophagitis

PubMed Central

Hirano, Ikuo; Aceves, Seema S.

2014-01-01

In eosinophilic esophagitis (EoE), remodeling changes are manifest histologically in both the epithelium as well as in the subepithelium where lamina propria (LP) fibrosis, expansion of the muscularis propria and increased vascularity occur. The major clinical symptoms and complications of EoE are largely consequences of esophageal remodeling. Important mediators of the process include IL-5, IL-13, TGFβ1, mast cells, fibroblasts and eosinophils. Methods to detect remodeling effects include upper endoscopy, histopathology, barium esophagram, endoscopic ultrasonography, esophageal manometry, and functional luminal imaging. These modalities provide evidence of organ dysfunction that include focal and diffuse esophageal strictures, expansion of the mucosa and subepithelium, esophageal motor abnormalities and reduced esophageal distensibility. Complications of food impaction and perforations of the esophageal wall have been associated with reduction in esophageal caliber and increased esophageal mural stiffness. The therapeutic benefits of topical corticosteroids and elimination diet therapy in resolving mucosal eosinophilic inflammation of the esophagus are evident. Available therapies, however, have demonstrated variable ability to reverse existing remodeling changes of the esophagus. Systemic therapies that include novel, targeted biologic agents have the potential of addressing subepithelial remodeling. Esophageal dilation remains a useful, adjunctive therapeutic maneuver in symptomatic adults with esophageal stricture. As novel treatments emerge, it is essential that therapeutic endpoints account for the fundamental contributions of esophageal remodeling to overall disease activity. PMID:24813517

Detecting severe injuries of the upper body in multiple trauma patients.

PubMed

Horst, Klemens; Hildebrand, Frank; Kobbe, Philipp; Pfeifer, Roman; Lichte, Philipp; Andruszkow, Hagen; Lefering, Rolf; Pape, Hans Christoph

2015-12-01

The clavicle limits the upper thoracic cage and connects the body and upper extremities. The clavicle is easy to examine and is visible on standard emergency room radiographs. We hypothesized that clavicular fracture in polytrauma patients would indicate the presence of further injuries of the upper extremities, head, neck, and thorax. A population-based trauma registry was used. All patients were documented between 2002 and 2013. Inclusion criteria were age ≥16 y and injury severity score (ISS) ≥16. Patients were divided into two groups according to the presence or absence of a clavicular fracture (group C+ and group C-). Scoring was based on the abbreviated injury scale, ISS, and new injury severity score. Trauma mechanisms, demographics, and the posttraumatic clinical course were compared. In total, 4790 patients with clavicular fracture (C+) and 41,775 without (C-) were included; the mean ISS was 30 ± 11 (C+) versus 28 ± 12 (C-). Patients with clavicular fracture had a longer stay on the intensive care unit with 12 ± 14 versus 10 ± 13 d. Injuries to the thoracic wall, severe lung injuries as well as injuries to the cervical spine were significantly increased in C+ patients. Thoracic injuries as well as injuries of the shoulder girdle and/or arm showed an increased abbreviated injury scale in the C+ group. A clinically relevant coincidence of clavicular fractures with injuries of the chest and upper extremity was found. As clavicular fractures can be diagnosed easily, it might also help to reduce the incidence of missed injuries of the chest and upper extremity. Therefore, special attention should be paid on thoracic as well as upper extremity injures during the second and tertiary surveys in case of clavicular fractures. Copyright © 2015 Elsevier Inc. All rights reserved.

Robotic Approach in Benign and Malignant Esophageal Tumors; A Preliminary Seven Case Series.

PubMed

Tomulescu, Victor; Stanescu, Codrut; Blajut, Cristian; Barbulescu, Loredana; Droc, Gabriela; Herlea, Vlad; Popescu, Irinel

2018-01-01

Esophageal surgery has been recognized as very challenging for surgeons and risky for patients. Thoracoscopic approach have proved its benefit in esophageal surgery but has some drawbacks as tremor and limited degrees of freedom, contra-intuitive movements and fulcrum effect of the surgical tools. Robotic technology has been developed with the intent to overcome these limitations of the standard laparoscopy or thoracoscopy. These benefits of robotic procedure are most advantageous when operating in remote areas difficult to reach as in esophageal surgery. The aim of this paper is to present our small experience related with robotic approach in benign and malignant esophageal tumors and critically revise the evidence available about the use of the robotic technology for the treatment of these pathology. Methods: From January 2008 to September 2016 robotic surgery interventions related with benign or malignant esophageal tumors were performed in "Dan Setlacec" Center for General Surgery and Liver Transplantation of Fundeni Clinical Institute in seven patients. This consisted of dissection of the entire esophagus as part of an abdomino-thoracic-cervical procedure for esophageal cancer in 3 patients and the extirpation of an esophageal leiomyoma in 3 cases and a foregut esophageal cyst in one case. Results: All procedures except one were completed entirely using the da Vinci robotic system. The exception was the first case - a 3 cm leiomyoma of the inferior esophagus with ulceration of the superjacent esophageal mucosa. Pathology reports revealed three esophageal leiomyoma, one foregut cyst and three squamous cell carcinomas with free of tumor resection margins. The mean number of retrieved mediastinal nodes was 24 (22 - 27). The postoperative course was uneventful in four cases, in the other three a esophageal fistula occurred in the converted leiomyoma case (closed in the 14th postoperative day), a prolonged drainage in one esophageal cancer case and a temporary right recurrent nerve palsy in an other one. One patient with esophageal cancer and all patients with benign lesions are alive with no signs of recurrence and no symptomatology. Our experience is limited and we cannot conclude for the long term benefits of robotic surgery for esophageal tumors. In our experience the early outcomes were better then using classic open approach, but similar with the cases performed by thoracoscopic approach. We have noticed significant advantages of robotic surgery in relation of lymph node retrieval, leiomyoma dissection safe from esophageal mucosa and suturing. Ergonomics for the surgeon was incomparable better then with the thoracoscopic approach. Celsius.

Focal achalasia – case report and review of the literature

PubMed Central

TUTUIAN, RADU

2018-01-01

Esophageal achalasia is a primary smooth muscle motility disorder specified by aperistalsis of the tubular esophagus in combination with a poorly relaxing and occasionally hypertensive lower esophageal sphincter (LES). These changes occur secondary to the destruction of the neural network coordinating esophageal peristalsis and LES relaxation (plexus myentericus). There are limited data on segmental involvement of the esophagus in adults. We report on the case of a 54-year-old man who presented initially with complete aperistalsis limited to the distal esophagus. After a primary good response to BoTox-infiltration of the distal esophagus the patient relapsed two years later. The manometric recordings documented now a progression of the disease with a poorly relaxing hypertensive lower esophageal sphincter and complete aperistalsis of the tubular esophagus (type III achalasia according to the Chicago 3.0 classification system). This paper also reviews diagnostic findings (including high resolution manometry, CT scan, barium esophagram, upper endoscopy and upper endoscopic ultrasound data) in patients with achalasia and summarizes the therapeutic options (including pneumatic balloon dilatation, botulinum toxin injection, surgical or endoscopic myotomy). PMID:29440962

Dysphagia in Children with Esophageal Atresia: Current Diagnostic Options.

PubMed

Rayyan, Maissa; Allegaert, Karel; Omari, Taher; Rommel, Nathalie

2015-08-01

Dysphagia or swallowing disorder is very common (range, 15-52%) in patients with esophageal atresia. Children present with a wide range of symptoms. The most common diagnostic tools to evaluate esophageal dysphagia, such as upper barium study and manometry, aim to characterize anatomy and function of the esophageal body and the esophagogastric junction (EGJ). Using these technologies, a variety of pathological motor patterns have been identified in children with esophageal atresia. However, the most challenging part of diagnosing patients with esophageal dysphagia lies in the fact that these methods fail to link functional symptoms such as dysphagia with the esophageal motor disorders observed. A recent method, called pressure-flow analysis (PFA), uses simultaneously acquired impedance and manometry measurements, and applies an integrated analysis of these recordings to derive quantitative pressure-flow metrics. These pressure-flow metrics allow detection of the interplay between bolus flow, motor patterns, and symptomatology by combining data on bolus transit and bolus flow resistance. Based on a dichotomous categorization, flow resistance at the EGJ and ineffective esophageal bolus transit can be determined. This method has the potential to guide therapeutic decisions for esophageal dysmotility in pediatric patients with esophageal atresia. Georg Thieme Verlag KG Stuttgart · New York.

Dosimetric comparison of helical tomotherapy, RapidArc, and a novel IMRT & Arc technique for esophageal carcinoma.

PubMed

Martin, Spencer; Chen, Jeff Z; Rashid Dar, A; Yartsev, Slav

2011-12-01

To compare radiotherapy treatment plans for mid- and distal-esophageal cancer with primary involvement of the gastroesophageal (GE) junction using a novel IMRT & Arc technique (IMRT & Arc), helical tomotherapy (HT), and RapidArc (RA1 and RA2). Eight patients treated on HT for locally advanced esophageal cancer with radical intent were re-planned for RA and IMRT&Arc. RA plans employed single and double arcs (RA1 and RA2, respectively), while IMRT&Arc plans had four fixed-gantry IMRT fields and a conformal arc. Dose-volume histogram statistics, dose uniformity, and dose homogeneity were analyzed to compare treatment plans. RA2 plans showed significant improvement over RA1 plans in terms of OAR dose and PTV dose uniformity and homogeneity. HT plan provided best dose uniformity (p=0.001) and dose homogeneity (p=0.002) to planning target volume (PTV), while IMRT&Arc and RA2 plans gave lowest dose to lungs among four radiotherapy techniques with acceptable PTV dose coverage. Mean V(10) of the lungs was significantly reduced by the RA2 plans compared to IMRT&Arc (40.3%, p=0.001) and HT (66.2%, p<0.001) techniques. Mean V(15) of the lungs for the RA2 plans also showed significant improvement over the IMRT&Arc (25.2%, p=0.042) and HT (34.8%, p=0.027) techniques. These improvements came at the cost of higher doses to the heart volume compared to HT and IMRT&Arc techniques. Mean lung dose (MLD) for the IMRT&Arc technique (21.2 ± 5.0% of prescription dose) was significantly reduced compared to HT (26.3%, p=0.004), RA1 (23.3%, p=0.028), and RA2 (23.2%, p=0.017) techniques. The IMRT&Arc technique is a good option for treating esophageal cancer with thoracic involvement. It achieved optimal low dose to the lungs and heart with acceptable PTV coverage. HT is a good option for treating esophageal cancer with little thoracic involvement as it achieves superior dose conformality and uniformity. The RA2 technique provided for improved treatment plans using additional arcs with low doses to the lungs at the cost of increased heart dose. Plan quality could still be improved through the use of additional arcs. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Toxicosis associated with ingestion of quick-dissolve granulated chlorine in a dog.

PubMed

Hofmeister, Aaron S; Heseltine, Johanna C; Sharp, Claire R

2006-10-15

A dog was referred for treatment after ingestion of quick-dissolve chlorine granules intended for use in a swimming pool. At evaluation 18 hours after ingestion of the granules, the dog had tachypnea, signs of depression, approximately 5% dehydration, oral mucositis, and a productive cough. Increased respiratory tract sounds and wheezes were ausculted in all lung fields. Complete blood count revealed erythrocytosis and lymphopenia. Serum biochemical analyses revealed mildly high activities of hepatic enzymes and creatine kinase. Arterial blood gas concentrations were consistent with hypoxemia and hyperventilation. Thoracic radiography revealed widespread pulmonary alveolar infiltrates predominantly affecting the ventral portions of both lungs, consistent with noncardiogenic pulmonary edema secondary to aspiration of the granulated chlorine. Initial treatment included IV administration of an electrolyte solution with supplemental KCl, ranitidine, furosemide, cefotaxime, buprenorphine, and supplemental oxygen. Subsequent treatment included administration of meloxicam and an endoscopically placed percutaneous gastrostomy tube. Endoscopic examination revealed esophagitis and mild gastritis; therefore, metoclopramide and sucralfate were also administered. Fifteen days later, the gastrostomy tube was removed prior to discharge; endoscopic examination revealed grossly normal esophageal and gastric mucosa, and thoracic radiography revealed complete resolution of the lung lesions. Although ingestion of granulated chlorine is rare in veterinary patients, the resulting disease processes are common and can be treated successfully.

Spirocercosis in owned and stray dogs in Grenada.

PubMed

Chikweto, A; Bhaiyat, M I; Tiwari, K P; de Allie, C; Sharma, R N

2012-12-21

The aim of this retrospective study was to estimate the prevalence of Spirocerca lupi and its associated lesions in owned and stray dogs in Grenada. During 2001-2011 necropsies were carried out on 1022 owned and 450 stray dogs at the pathology diagnostic laboratory, School of Veterinary Medicine, St. George's University, Grenada. Lesions due to S. lupi characterized by focal to multifocal granulomatous esophagitis with aneurysms, mineralized plaques and nodules in the adjacent thoracic aorta were found in 90 (8.8%; 95% confidence interval, 7.1-10.5%) of owned dogs and 64 (14.2%; 95% CI, 11.2-17.6%) of stray dogs. Stray dogs were significantly more affected by spirocercosis than owned dogs (p=0.0022). Of the 90 owned dogs with spirocercosis, 3 dogs had aberrant migration to the thoracic vertebral column with resultant spondylitis; 1 dog each had aberrant migration involving the stomach and the lung. Two dogs had ruptured aorta with hemothorax. Among the 64 stray dogs with spirocercosis, one dog had an esophageal granuloma that transformed into a fibroblastic osteosarcoma; spondylitis due to aberrant migration of S. lupi and hypertrophic osteopathy. We report spirocercosis for the first time in the dogs from a tropical island of Grenada. Copyright © 2012 Elsevier B.V. All rights reserved.

Esophageal motility in children with suspected gastroesophageal reflux disease.

PubMed

Hoffman, Ilse; De Greef, Toon; Haesendonck, Nancy; Tack, Jan

2010-06-01

Motility abnormalities in adults with gastroesophageal reflux disease (GERD) include nontransmitted contractions, reduced distal esophageal contraction amplitude, and simultaneous contractions. Information on esophageal body motility in children with GERD is scarce. Our aim was to study esophageal motility patterns in children with GERD, taking into account the presence of anatomical abnormalities and neurological impairment, the effect of age on esophageal motility in GERD, and the relation between esophageal manometry and GERD severity parameters (acid exposure and presence of esophagitis). Consecutive children referred for severe GER(D) symptoms underwent a barium swallow, upper endoscopy, pH monitoring, and stationary water-perfused esophageal manometry. Mean lower esophageal sphincter (LES) pressure and velocity of propagation in the proximal and distal esophagus decreased with age in this group of children with GERD (all P < 0.01). Severely disturbed esophageal motility was found in children with previous esophageal atresia. Patients with psychomotor retardation had significantly lower occurrence of peristaltic waves (94% +/- 21% vs 79% +/- 38%; P = 0.001), distal propagation velocity (0.8 +/- 0.4 vs 0.6 +/- 0.5 cm/s; P = 0.05), and distal contraction duration (3.1 +/- 0.8 vs 3.4 +/- 1 seconds; P = 0.05). None of the manometric characteristics differed between patients with normal or abnormal esophageal pH monitoring or with or without erosive esophagitis. LES pressure and esophageal velocity decreased with increasing age. Esophageal manometry is severely impaired in children with esophageal atresia and psychomotor retardation. No specific esophageal motor abnormalities related to the presence of endoscopic esophagitis or abnormal pH monitoring were found.

Tolerance and dose-volume relationship of intrathoracic stomach irradiation after esophagectomy for patients with thoracic esophageal squamous cell carcinoma.

PubMed

Liu, Qi; Cai, Xu-Wei; Fu, Xiao-Long; Chen, Jun-Chao; Xiang, Jia-Qing

2015-10-13

To identify the tolerance of radiation with a high prescribed dose and predictors for the development of intrathoracic stomach toxicity in patients with thoracic esophageal squamous cell carcinoma (SCC) after esophagectomy followed by gastric conduit reconstruction. From 2011 to 2013, 105 patients after esophagectomy were treated with postoperative radiotherapy. The intrathoracic stomach was outlined with the calculation of a dose-volume histogram (DVH) for the initial intended treatment of 6020 cGy or 6300 cGy. The volume of the intrathoracic stomach receiving each dose was recorded at 10-Gy intervals between 10 and 40 Gy and at 5-Gy intervals between 40 and 60 Gy. The grade of toxicities was defined by the National Cancer Institute Common Toxicity Criteria version 4.0. The mean and maximum doses of the intrathoracic stomach were 2449 ± 986 cGy and 6519 ± 406 cGy, respectively. Sixteen (15.2%) and three (2.9%) experienced Common Toxicity Criteria Grade 2 and Grade 3 acute gastric toxicity. There were no Grade 4 toxicities. Fourteen patients (13.3%) exhibited late gastric complications possibly related to radiation. The volume percent of the intrathoracic stomach receiving at least 50 Gy (V50) was strongly associated with the degree of toxicity (p = 0.024, respectively). Multivariate analysis of patient and treatment-related factors revealed no other significant predictors of severe toxicities. The intrathoracic stomach is well tolerated with a high-dose irradiation for patients with esophageal SCC receiving radiotherapy after esophagectomy. A strong dose-volume relationship exists for the development of Grade 2 acute intrathoracic stomach toxicity in our study.

Tolerance and dose-volume relationship of intrathoracic stomach irradiation after esophagectomy for patients with thoracic esophageal squamous cell carcinoma

PubMed Central

Fu, Xiao-Long; Chen, Jun-Chao; Xiang, Jia-Qing

2015-01-01

Purpose To identify the tolerance of radiation with a high prescribed dose and predictors for the development of intrathoracic stomach toxicity in patients with thoracic esophageal squamous cell carcinoma (SCC) after esophagectomy followed by gastric conduit reconstruction. Methods and Materials From 2011 to 2013, 105 patients after esophagectomy were treated with postoperative radiotherapy. The intrathoracic stomach was outlined with the calculation of a dose-volume histogram (DVH) for the initial intended treatment of 6020 cGy or 6300 cGy. The volume of the intrathoracic stomach receiving each dose was recorded at 10-Gy intervals between 10 and 40 Gy and at 5-Gy intervals between 40 and 60 Gy. The grade of toxicities was defined by the National Cancer Institute Common Toxicity Criteria version 4.0. Results The mean and maximum doses of the intrathoracic stomach were 2449 ± 986 cGy and 6519 ± 406 cGy, respectively. Sixteen (15.2%) and three (2.9%) experienced Common Toxicity Criteria Grade 2 and Grade 3 acute gastric toxicity. There were no Grade 4 toxicities. Fourteen patients (13.3%) exhibited late gastric complications possibly related to radiation. The volume percent of the intrathoracic stomach receiving at least 50 Gy (V50) was strongly associated with the degree of toxicity (p = 0.024, respectively). Multivariate analysis of patient and treatment-related factors revealed no other significant predictors of severe toxicities. Conclusions The intrathoracic stomach is well tolerated with a high-dose irradiation for patients with esophageal SCC receiving radiotherapy after esophagectomy. A strong dose-volume relationship exists for the development of Grade 2 acute intrathoracic stomach toxicity in our study. PMID:26314958

Postoperative Radiation Therapy With or Without Concurrent Chemotherapy for Node-Positive Thoracic Esophageal Squamous Cell Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen, Junqiang; Pan, Jianji; Liu, Jian, E-mail: liujianfj@yahoo.com.cn

Purpose: To retrospectively compare the efficacy of radiation therapy (RT) and chemotherapy plus RT (CRT) for the postoperative treatment of node-positive thoracic esophageal squamous cell carcinoma (TESCC) and to determine the incidence and severity of toxic reactions. Methods and Materials: We retrospectively reviewed data from 304 patients who had undergone esophagectomy with 3-field lymph node dissection for TESCC and were determined by postoperative pathology to have lymph node metastasis without distant hematogenous metastasis. Of these patients, 164 underwent postoperative chemotherapy (cisplatin 80 mg/m{sup 2}, average days 1-3, plus paclitaxel 135 mg/m{sup 2}, day 1; 21-day cycle) plus RT (50 Gy),more » and 140 underwent postoperative RT alone. Results: The 5-year overall survival rates for the CRT and RT groups were 47.4% and 38.6%, respectively (P=.030). The distant metastasis rate, the mixed (regional lymph node and distant) metastasis rate, and the overall recurrence rate were significantly lower in the CRT group than in the RT group (P<.05). However, mild and severe early toxic reactions, including neutropenia, radiation esophagitis, and gastrointestinal reaction, were significantly more common in the CRT group than in the RT group (P<.05). No significant differences in incidence of late toxic reactions were found between the 2 groups. Conclusions: Our results show that in node-positive TESCC patients, postoperative CRT is significantly more effective than RT alone at increasing the overall survival and decreasing the rates of distant metastasis, mixed metastasis, and overall recurrence. Severe early toxic reactions were more common with CRT than with RT alone, but patients could tolerate CRT.« less

History and current status of mini-invasive thoracic surgery

PubMed Central

He, Jianxing

2011-01-01

Mini-invasive thoracic technique mainly refers to a technique involving the significant reduction of the chest wall access-related trauma. Notably, thoracoscope is the chief representative. The development of thoracoscope technique is characterized by: developing from direct peep to artificial lighting, then combination with image and video technique in equipments; technically developing from diagnostic to therapeutic approaches; developing from simpleness to complexity in application scope; and usually developing together with other techniques. At present, the widely used mini-invasive thoracic surgery refers to the mini-open thoracic surgery performed mainly by using some instruments to control target tissues and organs based on the vision associated with multi-limb coordination, which may be hand-assisted if necessary. The mini-invasive thoracic surgery consists of three approaches including video-assisted thoracic surgery (VATS), video-assisted Hybrid and hand-assisted VATS. So far the mini-invasive thoracic technique has achieved great advances due to the development in instruments of mini-invasive thoracic surgery which has the following features: instruments of mini-invasive thoracic surgery appear to be safe and practical, and have successive improvement and diversification in function; the specific instruments of open surgeries has been successively developed into dedicated instruments of endoscopic surgery; the application of endoscopic mechanical suture device generates faster fragmentation and reconstruction of organ tissues; the specific delicated instruments of endoscopic surgery have rapid development and application; and the simple instruments structurally similar to the conventional instruments are designed according to the mini-incison. In addition, the mini-invasive thoracic technique is widely used in five aspects including diseases of pleura membrane and chest wall, lung diseases, esophageal diseases, mediastinal diseases and heart diseases. However, there remain many problems in specifications and trainings, economic cost, conservation and innovation. Therefore, particular attention should be paid to these problems. Nevertheless, the promotion of thoracic surgery appears promising in the future. PMID:22263074

Cord blood-derived cytokine-induced killer cellular therapy plus radiation therapy for esophageal cancer: a case report.

PubMed

Wang, Liming; Huang, Shigao; Dang, Yazheng; Li, Ming; Bai, Wen; Zhong, Zhanqiang; Zhao, Hongliang; Li, Yang; Liu, Yongjun; Wu, Mingyuan

2014-12-01

Esophageal cancer is a serious malignancy with regards to mortality and prognosis. Current treatment options include multimodality therapy mainstays of current treatment including surgery, radiation, and chemotherapy. Cell therapy for esophageal cancer is an advancing area of research. We report a case of esophageal cancer following cord blood-derived cytokine-induced killer cell infusion and adjuvant radiotherapy. Initially, she presented with poor spirit, full liquid diets, and upper abdominal pain. Through cell therapy plus adjuvant radiotherapy, the patient remitted and was self-reliant. Recognition of this curative effect of sequent therapy for esophageal cancer is important to enable appropriate treatment. This case highlights cord blood-derived cytokine-induced killer cell therapy significantly alleviates the adverse reaction of radiation and improves the curative effect. Cell therapy plus adjuvant radiotherapy can be a safe and effective treatment for esophageal cancer.

Influence of experimental esophageal acidification on sleep bruxism: a randomized trial.

PubMed

Ohmure, H; Oikawa, K; Kanematsu, K; Saito, Y; Yamamoto, T; Nagahama, H; Tsubouchi, H; Miyawaki, S

2011-05-01

The aim of this cross-over, randomized, single-blinded trial was to examine whether intra-esophageal acidification induces sleep bruxism (SB). Polysomnography with electromyogram (EMG) of masseter muscle, audio-video recording, and esophageal pH monitoring were performed in a sleep laboratory. Twelve healthy adult males without SB participated. Intra-esophageal infusions of 5-mL acidic solution (0.1 N HCl) or saline were administered. The frequencies of EMG bursts, rhythmic masticatory muscle activity (RMMA) episodes, grinding noise, and the RMMA/microarousal ratio were significantly higher in the 20-minute period after acidic infusion than after saline infusion. RMMA episodes including SB were induced by esophageal acidification. This trial is registered with the UMIN Clinical Trials Registry, UMIN000002923. ASDA, American Sleep Disorders Association; EMG, electromyogram; GER, gastroesophageal reflux; LES, lower esophageal sphincter; NREM, non-rapid eye movement; REM, rapid eye movement; RMMA, rhythmic masticatory muscle activity; SB, sleep bruxism; SD, standard deviation; UES, upper esophageal sphincter.

Proton pump inhibitor resistance, the real challenge in gastro-esophageal reflux disease.

PubMed

Cicala, Michele; Emerenziani, Sara; Guarino, Michele Pier Luca; Ribolsi, Mentore

2013-10-21

Gastro-esophageal reflux disease (GERD) is one of the most prevalent chronic diseases. Although proton pump inhibitors (PPIs) represent the mainstay of treatment both for healing erosive esophagitis and for symptom relief, several studies have shown that up to 40% of GERD patients reported either partial or complete lack of response of their symptoms to a standard PPI dose once daily. Several mechanisms have been proposed as involved in PPIs resistance, including ineffective control of gastric acid secretion, esophageal hypersensitivity, ultrastructural and functional changes in the esophageal epithelium. The diagnostic evaluation of a refractory GERD patients should include an accurate clinical evaluation, upper endoscopy, esophageal manometry and ambulatory pH-impedance monitoring, which allows to discriminate non-erosive reflux disease patients from those presenting esophageal hypersensitivity or functional heartburn. Treatment has been primarily based on doubling the PPI dose or switching to another PPI. Patients with proven disease, not responding to PPI twice daily, are eligible for anti-reflux surgery.

Reflux Hypersensitivity: A New Functional Esophageal Disorder

PubMed Central

Yamasaki, Takahisa; Fass, Ronnie

2017-01-01

Reflux hypersensitivity, recently introduced by Rome IV as a new functional esophageal disorder, is currently considered as the presence of typical heartburn symptoms in patients with normal upper endoscopy and esophageal biopsies, normal esophageal pH test and with evidence of a close correlation between patients’ heartburn and reflux events. Reflux hypersensitivity is very common and together with functional heartburn accounts for more than 90% of the heartburn patients who failed treatment with proton pump inhibitor twice daily. In addition, reflux hypersensitivity affects primarily young to middle aged women, commonly overlaps with another functional gastrointestinal disorders, and is often associated with some type of psychological comorbidity. Diagnosis is made by using endoscopy with esophageal biopsies, pH-impedance, and high-resolution esophageal manometry. Reflux hypersensitivity is primarily treated with esophageal neuromodulators, such as tricyclic anti-depressants and selective serotonin reuptake inhibitors among others. Surgical anti-reflux management may also play an important role in the treatment of reflux hypersensitivity. PMID:28992673

[Esophageal motor function of gastroesophageal reflux disease].

PubMed

Wang, Hong; Tian, Yuan; Ding, Yan

2010-08-01

To study the relationship between esophageal motor functional disorder [decreased lower esophageal sphincter pressure (LESP)and ineffective motility (IEM)] and gastroesophageal reflux disease (GERD). Totally 89 patients with GERD were enrolled in this study. All of them underwent 24-hour pH monitoring with dual-channel probe and stationary esophageal manometry. In addition, 77 of these patients underwent upper endoscopy. IEM and LES, 10 mmHg were common disturbances in patients with GERD (54% and 48%, respectively). The number of the acid reflux events of distal esophagus and prevalence of moderate or severe erosive esophagitis (EE) were significantly higher in patients with low LESP and IEM than patients without low LESP ( P<0.05). The number of the acid reflux events in distal esophagus was significantly correlated with the severity of esophagitis, distal esophagus amplitude, and LESP, while no such correlation was found between IEM and degree of esophageal acid exposure or esophagitis. The pathophysiology of GERD is probably multifactorial. Lower LESP or IEM is not a independent pathophysiological factor for GERD. However,one single factor is insufficient to explain all the pathogenic mechanism of GERD.

Clinical and biological significance of stem-like CD133(+)CXCR4(+) cells in esophageal squamous cell carcinoma.

PubMed

Lu, Chunlai; Xu, Fengkai; Gu, Jie; Yuan, Yunfeng; Zhao, Guangyin; Yu, Xiaofang; Ge, Di

2015-08-01

Esophageal squamous cell carcinoma is one of the most frequent malignant tumors. Cancer stem cells are considered to be responsible for tumor growth, metastasis, and recurrence. Cluster of differentiation 133 (CD133) and C-X-C chemokine receptor type 4 (CXCR4) are frequently applied markers for the identification and isolation of cancer stem cells. However, few studies have investigated the coexpression of CD133 and CXCR4 in esophageal squamous cell carcinoma. This study aims to explore the clinical and biological role of stem-like CD133(+)CXCR4(+) cells in esophageal squamous cell carcinoma. Immunohistochemical staining was performed to detect the expression of CD133 and CXCR4 in esophageal squamous cell carcinoma tissues of patients. Flow cytometry and fluorescence-activated cell sorting were applied to analyze and isolate each subgroup in esophageal squamous cell carcinoma cell line TE-1. The characteristic differences between each subgroup were assayed in vitro. The association between CD133/CXCR4 expression and patients' prognosis was analyzed by Kaplan-Meier and Cox regression. Among 154 patient tissues, concomitant high CD133-CXCR4 expression accounts for 20.78% (32/154). In vitro, CXCR4(+) cells (CD133(+)CXCR4(+) and CD133(-)CXCR4(+)) showed high invasive potential and CD133(+)CXCR4(+) cells showed high proliferative capacity. Clinically, patients with concomitant high CD133-CXCR4 expression had decreased disease-free survival and overall survival (P < .01). Esophageal squamous cell carcinoma cells coexpressing CD133 and CXCR4 possess the characteristics of cancer stem cells. The concomitant high CD133-CXCR4 expression might be a novel marker for predicting the poor prognosis of patients with esophageal squamous cell carcinoma, and CD133 and CXCR4 may serve as potential therapeutic targets. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Laparogastroscopy and Esophageal Stenosis.

PubMed

Sabău, Alexandru-Dan; Hassan, Noor; Smarandache, Cătălin Gabriel; Miheţiu, Alin; Ţîţu, Ștefan; Sabău, Dan

2018-01-01

An original technique using laparoscopic instruments in a gastric endocavitary work chamber with potential for esophagus, stomach and D1 vizualisation. The main purpose of laparagastroscopy is to improve the quality of life of the patient disabling by the esophageal tumor. This method has several advantages: providing physiological feeding, harvesting materials for histopathological examination, solving eso-tracheal fistulas concurrently with the proposed operation and hemostatic role through compression, low energy and plastic consumption, rapid socio-economic reintegration, mental psychological care of the patient. Patients and Methods: The paper deals with 162 cases with different tumors of the esophagus, patients with different grades of esophageal stenosis, different stages of esophageal neoplasm. Both the patients with eso-tracheal fistulas and those with gastro- or jejunostoma were included. Results: From 162 cases, 33 cases (20%) with cervical esophageal neoplasm, 66 (41%) cases with thoracic esophageal neoplasm and 63 (39%) cases with abdominal esophageal neoplasm. The histopathological type is 37% adenocarcinomas and 63% squamous carcinomas. From total number of cases, 87 (54%) had no metastasis, and 75 (46%) had secondary determinations. The most frequent localization of metastasis was pulmonary, followed by liver (Fig. 1) and bone. The analysis of this intervention has shown that complications have been much lower both in terms of their numerical value and their severity, a longer survival time with a much higher satisfaction index is ensured. Esophageal endoprosthesis (EPE) through laparagastroscopic approach should be a a reserve procedure instead of a disabling gastrostomy or jejunostomy. EPE is an extremely effective procedure specially by keeping the physiology of food bowl. The approach is minimally invasive with minimal attack on the body with significant plastic and aesthetic reductions. This procedure allows the prosthesis to be viewed both during and after stenting to check its correct position. This method increases the survival time by keeping a relatively normal regimen. Celsius.

Lymphocytic Esophagitis: An emerging clinicopathologic disease associated with dysphagia

PubMed Central

Pasricha, Sarina; Gupta, Amit; Reed, Craig C.; Speck, Olga; Woosley, John T.; Dellon, Evan S.

2016-01-01

Background Lymphocytic Esophagitis (LyE) is a recently described clinicopathological condition, but little is known about its features and clinical associations. Aim To characterize patients with LyE, compare them to non-LyE controls, and identify risk factors. Methods We conducted a retrospective study of all patients ≥18 years old who underwent upper endoscopy with esophageal biopsy between January 1, 2000 and June 1, 2012. Archived pathology slides were re-reviewed and LyE was diagnosed if there was lymphocyte-predominant esophageal inflammation with no eosinophils or granulocytes. Three non-LyE controls groups were also defined: reflux, eosinophilic esophagitis (EoE), and normal. Clinical data were extracted from electronic medical records, and LyE cases were compared to non-LyE controls. Results 27 adults were diagnosed with LyE, and the majority were female (63%). The most common symptom was dysphagia (70%). 52% had a prior or current diagnosis of reflux. Endoscopic findings included strictures (37%), erosive esophagitis (33%), rings (26%), and hiatal hernia (26%); 33% of patients required dilation. After histology re-review, 78% of LyE patients were found to have more than 20 lymphs/hpf. In comparison to the normal, reflux and EoE controls, patients with LyE tended to be non-white (p<0.01), were more commonly tobacco users (p=0.02), and less likely to have seasonal allergies (p=0.02). Conclusion LyE commonly presents with dysphagia due to esophageal strictures which require dilation. Smoking was associated with LyE whereas atopy was not. LyE should be considered as a diagnostic possibility in patients with these characteristics undergoing upper endoscopy. PMID:27343035

Lymphocytic Esophagitis: An Emerging Clinicopathologic Disease Associated with Dysphagia.

PubMed

Pasricha, Sarina; Gupta, Amit; Reed, Craig C; Speck, Olga; Woosley, John T; Dellon, Evan S

2016-10-01

Lymphocytic esophagitis (LyE) is a recently described clinicopathological condition, but little is known about its features and clinical associations. The aim of this study was to characterize patients with LyE, compare them to non-LyE controls, and identify risk factors. We conducted a retrospective study of all patients ≥18 years old who underwent upper endoscopy with esophageal biopsy between January 1, 2000, and June 1, 2012. Archived pathology slides were re-reviewed, and LyE was diagnosed if there was lymphocyte-predominant esophageal inflammation with no eosinophils or granulocytes. Three non-LyE controls groups were also defined: reflux, eosinophilic esophagitis (EoE), and normal. Clinical data were extracted from electronic medical records, and LyE cases were compared to non-LyE controls. Twenty-seven adults were diagnosed with LyE, and the majority were female (63 %). The most common symptom was dysphagia (70 %). Fifty-two percentage had a prior or current diagnosis of reflux. Endoscopic findings included strictures (37 %), erosive esophagitis (33 %), rings (26 %), and hiatal hernia (26 %); 33 % of patients required dilation. After histology re-review, 78 % of LyE patients were found to have more than 20 lymphs/hpf. In comparison with the normal, reflux and EoE controls, patients with LyE tended to be nonwhite (p < 0.01), were more commonly tobacco users (p = 0.02) and less likely to have seasonal allergies (p = 0.02). LyE commonly presents with dysphagia due to esophageal strictures which require dilation. Smoking was associated with LyE, whereas atopy was not. LyE should be considered as a diagnostic possibility in patients with these characteristics undergoing upper endoscopy.

Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction: case report and literature review.

PubMed

Loudin, Michael; Anderson, Sharon; Schlansky, Barry

2016-10-24

Proximal or 'downhill' esophageal varices are a rare cause of upper gastrointestinal hemorrhage. Unlike the much more common distal esophageal varices, which are most commonly a result of portal hypertension, downhill esophageal varices result from vascular obstruction of the superior vena cava (SVC). While SVC obstruction is most commonly secondary to malignant causes, our review of the literature suggests that benign causes of SVC obstruction are the most common cause actual bleeding from downhill varices. Given the alternative pathophysiology of downhill varices, they require a unique approach to management. Variceal band ligation may be used to temporize acute variceal bleeding, and should be applied on the proximal end of the varix. Relief of the underlying SVC obstruction is the cornerstone of definitive treatment of downhill varices. A young woman with a benign superior vena cava stenosis due to a tunneled internal jugular vein dialysis catheter presented with hematemesis and melena. Urgent upper endoscopy revealed multiple 'downhill' esophageal varices with stigmata of recent hemorrhage. As there was no active bleeding, no endoscopic intervention was performed. CT angiography demonstrated stenosis of the SVC surrounding the distal tip of her indwelling hemodialysis catheter. The patient underwent balloon angioplasty of the stenotic SVC segment with resolution of her bleeding and clinical stabilization. Downhill esophageal varices are a distinct entity from the more common distal esophageal varices. Endoscopic therapies have a role in temporizing active variceal bleeding, but relief of the underlying SVC obstruction is the cornerstone of treatment and should be pursued as rapidly as possible. It is unknown why benign, as opposed to malignant, causes of SVC obstruction result in bleeding from downhill varices at such a high rate, despite being a less common etiology of SVC obstruction.

[Endoscopic contribution in the dilatation of caustic esophagus stenosis].

PubMed

Seydou, Togo; Abdoulaye, Ouattara Moussa; Xing, Li; Zi, Sanogo Zimogo; Sekou, Koumaré; Wen, Yang Shang; Ibrahim, Sankare; Sekou, Toure Cheik Ahmed; Boubacar, Maiga Ibrahim; Saye, Jacque; Jerome, Dakouo Dodino; Dantoumé, Toure Ousmane; Sadio, Yena

2016-01-01

The aim of this work was to present the contribution of the endoscopy in the management of esophageal dilatation for caustic esophageal stenosis (CES). This was a descriptive and prospective study in the thoracic surgery department at the Hospital of Mali. A total of 46 cases of CES is recorded and divided into 4 groups according to the topography of the esophageal lesions. For the different methods of dilatation the number of performed endoscopic support was determined to understand the contribution of endoscopic means in the success of dilatation for CES. The outcome, complications and mortality in the two methods were compared. Fibroscopy was used in 41.30% of patients with Savary Guillard dilators and in 47.82% of patients with Lerut dilators. Video laryngoscopy was used in 58.69% of patients who underwent dilatation with Lerut dilators. The passage of the guide wire was performed in 39.13% under video laryngoscopy and 58.68% under fibroscopy. In comparison of the two methods, there is a significant difference in the occurrence of complications (p=0.04075), general anesthesia (p=0.02287), accessibility (p=0.04805) and mortality (p=0.00402). The CES is a serious disease and under evaluated in Mali. The endoscopies contribute significantly to the success of esophageal dilatation for caustic stenosis in the different methods we used.

[Clinical research on the application of trans-esophageal echocardiography in monitoring Nuss surgery].

PubMed

Mou, Ling; Xu, Bing; Lan, Zhixun

2015-04-01

To investigate the validity and safety of trans-esophageal echocardiography (TEE) in monitoring of Nuss surgery. A total of 140 patients with pectus excavatum from Sichuan Provincial People's Hospital underwent Nuss surgery from August, 2011 to Aμgust, 2013. Among them, 72 patients received TEE monitoring while 68 patients didn't. The injury of heart and large vessels by the introducer and Nuss steel bar was observed by intraoperative TEE monitoring under middle-esophageal four chamber view and middle-esophageal aortic short axis view. The operation in all patients had been performed successfully without any severe complications. Satisfactory TEE images were obtained in all patients. The procedure of inserting the inducer and Nuss steel bar behind sternum and steel bar overturn could be seen clearly. No injury in heart and large vessels was detected. Local streak-like hemorrhage in 3 patients was observed under intra-operative TEE screen, but no further new bleeding was found in postoperative TEE examination. The blood was absorbed and couldn't see under trans-thoracic echocardiography in 1 month after the operation. The TEE is a non-invasive monitoring method. It is sensitive to detect the status of the heart and large vessels and can prevent the severe complications due to Nuss surgery.

Potential Role of the Microbiome in Barrett's Esophagus and Esophageal Adenocarcinoma.

PubMed

Snider, Erik J; Freedberg, Daniel E; Abrams, Julian A

2016-08-01

Esophageal adenocarcinoma and its precursor Barrett's esophagus have been rapidly increasing in incidence for half a century, for reasons not adequately explained by currently identified risk factors such as gastroesophageal reflux disease and obesity. The upper gastrointestinal microbiome may represent another potential cofactor. The distal esophagus has a distinct microbiome of predominantly oral-derived flora, which is altered in Barrett's esophagus and reflux esophagitis. Chronic low-grade inflammation or direct carcinogenesis from this altered microbiome may combine with known risk factors to promote Barrett's metaplasia and progression to adenocarcinoma.

Endoscopic findings in upper gastrointestinal bleeding patients at Lacor hospital, northern Uganda.

PubMed

Alema, O N; Martin, D O; Okello, T R

2012-12-01

Upper gastrointestinal bleeding (UGIB) is a common emergency medical condition that may require hospitalization and resuscitation, and results in high patient morbidity. Upper gastrointestinal endoscopy is the preferred investigative procedure for UGIB because of its accuracy, low rate of complication, and its potential for therapeutic interventions. To determine the endoscopic findings in patients presenting with UGIB and its frequency among these patients according to gender and age in Lacor hospital, northern Uganda. The study was carried out at Lacor hospital, located at northern part of Uganda. The record of 224 patients who underwent endoscopy for upper gastrointestinal bleeding over a period of 5 years between January 2006 and December 2010 were retrospectively analyzed. A total of 224 patients had endoscopy for UGIB which consisted of 113 (50.4%) males and 111 (49.6%) females, and the mean age was 42 years ± SD 15.88. The commonest cause of UGIB was esophagealvarices consisting of 40.6%, followed by esophagitis (14.7%), gastritis (12.6%) and peptic ulcer disease (duodenal and gastric ulcers) was 6.2%. The malignant conditions (gastric and esophageal cancers) contributed to 2.6%. Other less frequent causes of UGIB were hiatus hernia (1.8), duodenitis (0.9%), others-gastric polyp (0.4%). Normal endoscopic finding was 16.1% in patients who had UGIB. Esophageal varices are the commonest cause of upper gastrointestinal bleeding in this environment as compared to the west which is mainly peptic ulcer disease.

Physiology of Normal Esophageal Motility

PubMed Central

Goyal, Raj K; Chaudhury, Arun

2009-01-01

The esophagus consists of two different parts. In humans, the cervical esophagus is composed of striated muscles and the thoracic esophagus is composed of phasic smooth muscles. The striated muscle esophagus is innervated by the lower motor neurons and peristalsis in this segment is due to sequential activation of the motor neurons in the nucleus ambiguus. Both primary and secondary peristaltic contractions are centrally mediated. The smooth muscle of esophagus is phasic in nature and is innervated by intramural inhibitory (nitric oxide releasing) and excitatory (acetylcholine releasing) neurons that receive inputs from separate sets of preganglionic neurons located in the dorsal motor nucleus of vagus. The primary peristalsis in this segment involves both central and peripheral mechanisms. The primary peristalsis consist of inhibition (called deglutitive inhibition) followed by excitation. The secondary peristalsis is entirely due to peripheral mechanisms and also involves inhibition followed by excitation. The lower esophageal sphincter (LES) is characterized by tonic muscle that is different from the muscle of the esophageal body. The LES, like the esophageal body smooth muscle, is also innervated by the inhibitory and excitatory neurons. The LES maintains tonic closure due to its myogenic property. The LES tone is modulated by the inhibitory and the excitatory nerves. Inhibitory nerves mediate LES relaxation and the excitatory nerves mediate reflex contraction or rebound contraction of the LES. Clinical disorders of esophageal motility can be classified on the basis of disorders of the inhibitory and excitatory innervations and the smooth muscles. PMID:18364578

[Effect of cellular immune supportive treatment on immunity of esophageal carcinoma patients after modern two-field lymph node dissection].

PubMed

Wang, Jun-Ye; Ma, Guo-Wei; Dai, Shu-Qin; Rong, Tie-Hua; Wang, Xin; Lin, Peng; Ye, Wen-Feng; Zhang, Lan-Jun; Li, Xiao-Dong; Zhang, Xu; Yao, Guang-Yu

2007-07-01

Cellular immunity suppression is marked in patients with esophageal carcinoma, which may be resulted temporarily from surgical injury. This study was to evaluate the effect of cellular immune supportive treatment on cellular immunity of patients with esophageal carcinoma. A total of 60 patients with thoracic esophageal carcinoma, received two-field dissection, were randomized into control group and trial (immune supportive treatment) group. The patients in trial group were injected with Shenqi injection after operation; the patients in control group received no immune supportive treatment. Peripheral blood samples were obtained before operation, and 3 and 9 days after operation. AgNOR (argyrophilic nucleolar organizer regions) activity in peripheral blood T lymphocytes was measured by tumor immune microphotometry. T cell subsets were measured by flow cytometry. The proportions of CD3+CD4+ and CD4+/CD8+ cells were significantly higher in trial group than in control group at 3 days after operation (P < 0.05). The amount of AgNOR and proportions of CD3+, CD3+CD4+, CD4+/CD8+, and CD4+CD25+ cells were significantly higher in trial group than in control group at 9 days after operation (P < 0.05). There was no significant difference in 1-year survival rate between the 2 groups (P > 0.05). Shenqi injection could obviously improve cellular immunity of the esophageal carcinoma patients after modern two-field dissection.

Palliative Radiotherapy in the Local Management of Stage IVB Esophageal Cancer: Factors Affecting Swallowing and Survival.

PubMed

Suzuki, Gen; Yamazaki, Hideya; Aibe, Norihiro; Masui, Koji; Tatekawa, Kotoha; Sasaki, Naomi; Kimoto, Takuya; Nishimura, Takeshi; Nakashima, Akihiro; Takenaka, Tadashi; Fujiwara, Hitoshi; Ishikawa, Takeshi; Yamada, Kei

2017-06-01

To clarify the role of external-beam radiotherapy in the local management of state IVB esophageal cancer. We reviewed records of 31 patients with histopathologically-proven squamous cell carcinoma who underwent radiotherapy for their primary lesion. The change in dysphagia score from before to after treatment was assessed. Nutritional support-free survival (NSFS) was also evaluated. The median overall survival was 6 months. The overall rate of improvement in dysphagia score was 73% (23/31). The median NSFS was 5 months. Age at presentation <67 years, tumor location in the middle thoracic esophagus, and tumor length <7 cm were associated with significant improvement in swallowing scores. Responders to radiotherapy had significantly longer NSFS than non-responders (p=0.04). Palliative radiotherapy in the local management of stage IVB esophageal cancer is an effective treatment option for dysphagia. Factors highly associated with improvement of swallowing are age, tumor location, and tumor length. Response to radiotherapy is the most important factor in improving NSFS. Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.

A short-term increase of the postoperative naturally circulating dendritic cells subsets in flurbiprofen-treated patients with esophageal carcinoma undergoing thoracic surgery

PubMed Central

Chai, Xiao-qing; Shu, Shu-hua; Zhang, Xiao-lin; Xie, Yan-hu; Wei, Xin; Wu, Yu-jing; Wei, Wei

2016-01-01

The present study evaluated whether flurbiprofen increased the naturally circulating dendritic cells (DCs) subsets in patients with esophageal squamous cell carcinoma (ESCC) undergoing esophageal resection. Compared to healthy donors (n=20), the significantly depressed percentages of plasmacytoid DCs (pDCs), CD1c+ myeloid DCs (mDCs), and CD141+ mDCs among ESCC patients (n=60) were confirmed. Flurbiprofen was administered before skin incision and at the end of operation in group F (n=30), as well as placebo in group C (n=30). The postoperative suppressed percentages of pDCs, CD1c+ mDCs, and CD141+ mDCs increased significantly following the perioperative treatment with flurbiprofen. Flurbiprofen also significantly stimulated the postoperative IFN-f and IL-17 production, but inhibited the immunosuppressive IL-10 and TGF-β levels. Furthermore, flurbiprofen exerted a similar analgesic effect and brought a significantly less sufentanil consumption compared to group C. Taken together, flurbiprofen provided a short-term increase of postoperative naturally circulating DCs in ESCC patients. PMID:26959879

A short-term increase of the postoperative naturally circulating dendritic cells subsets in flurbiprofen-treated patients with esophageal carcinoma undergoing thoracic surgery.

PubMed

Wang, Di; Yang, Xin-lu; Chai, Xiao-qing; Shu, Shu-hua; Zhang, Xiao-lin; Xie, Yan-hu; Wei, Xin; Wu, Yu-jing; Wei, Wei

2016-04-05

The present study evaluated whether flurbiprofen increased the naturally circulating dendritic cells (DCs) subsets in patients with esophageal squamous cell carcinoma (ESCC) undergoing esophageal resection. Compared to healthy donors (n=20), the significantly depressed percentages of plasmacytoid DCs (pDCs), CD1c+ myeloid DCs (mDCs), and CD141+ mDCs among ESCC patients (n=60) were confirmed. Flurbiprofen was administered before skin incision and at the end of operation in group F (n=30), as well as placebo in group C (n=30). The postoperative suppressed percentages of pDCs, CD1c+ mDCs, and CD141+ mDCs increased significantly following the perioperative treatment with flurbiprofen. Flurbiprofen also significantly stimulated the postoperative IFN-f and IL-17 production, but inhibited the immunosuppressive IL-10 and TGF-β levels. Furthermore, flurbiprofen exerted a similar analgesic effect and brought a significantly less sufentanil consumption compared to group C. Taken together, flurbiprofen provided a short-term increase of postoperative naturally circulating DCs in ESCC patients.

Active self-correction of spinal posture in pain-free women in response to the command "straighten your back".

PubMed

Barczyk-Pawelec, Katarzyna; Sipko, Tomasz

2017-10-01

Evidence is limited regarding the regional changes in spinal posture after self-correction. The aim of the present study was to evaluate whether active self-correction improved standing and sitting spinal posture. Photogrammetry was used to assess regional spinal curvatures and vertical global spine orientation (GSO) in 42 asymptotic women aged 20-24 years. Upper thoracic spine angle and GSO increased in response to self-correction, while the thoracolumbar and lumbosacral angles decreased. Self-correction in the standing position resulted in decreased inclination of the upper thoracic and thoracolumbar spinal angles. Correction of sitting posture reduced the angle of the upper thoracic spine and GSO. The effects of active self-correction on spinal curvature and GSO were different for the standing versus sitting position; the greatest effects of active correction were noted in the thoracic spine. Balanced and lordotic postures were most prevalent in the habitual and actively self-corrected standing positions, whereas the kyphotic posture was most prevalent in the habitual sitting position, indicative that self-correction back posture in the standing position could be an important health-related daily activity, especially during prolonged sitting.

Improved Dysphagia After Decannulation of Tracheostomy in Patients With Brain Injuries

PubMed Central

Kim, Yong Kyun; Choi, Jung-Hwa; Yoon, Jeong-Gyu; Lee, Jang-Won

2015-01-01

Objective To investigate improved dysphagia after the decannulation of a tracheostomy in patients with brain injuries. Methods The subjects of this study are patients with brain injuries who were admitted to the Department of Rehabilitation Medicine in Myongji Hospital and who underwent a decannulation between 2012 and 2014. A video fluoroscopic swallowing study (VFSS) was performed in order to investigate whether the patients' dysphagia had improved. We measured the following 5 parameters: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal width, and semisolid aspiration. We analyzed the patients' results from VFSS performed one month before and one month after decannulation. All VFSS images were recorded using a camcorder running at 30 frames per second. An AutoCAD 2D screen was used to measure laryngeal elevation, post-swallow pharyngeal remnant, and upper esophageal width. Results In this study, a number of dysphagia symptoms improved after decannulation. Laryngeal elevation, pharyngeal transit time, and semisolid aspiration showed no statistically significant differences (p>0.05), however after decannulation, the post-swallow pharyngeal remnant (pre 37.41%±24.80%, post 21.02%±11.75%; p<0.001) and upper esophageal width (pre 3.57±1.93 mm, post 4.53±2.05 mm; p<0.001) showed statistically significant differences. Conclusion When decannulation is performed on patients with brain injuries who do not require a ventilator and who are able to independently excrete sputum, improved esophageal dysphagia can be expected. PMID:26605176

Improved Dysphagia After Decannulation of Tracheostomy in Patients With Brain Injuries.

PubMed

Kim, Yong Kyun; Choi, Jung-Hwa; Yoon, Jeong-Gyu; Lee, Jang-Won; Cho, Sung Sik

2015-10-01

To investigate improved dysphagia after the decannulation of a tracheostomy in patients with brain injuries. The subjects of this study are patients with brain injuries who were admitted to the Department of Rehabilitation Medicine in Myongji Hospital and who underwent a decannulation between 2012 and 2014. A video fluoroscopic swallowing study (VFSS) was performed in order to investigate whether the patients' dysphagia had improved. We measured the following 5 parameters: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal width, and semisolid aspiration. We analyzed the patients' results from VFSS performed one month before and one month after decannulation. All VFSS images were recorded using a camcorder running at 30 frames per second. An AutoCAD 2D screen was used to measure laryngeal elevation, post-swallow pharyngeal remnant, and upper esophageal width. In this study, a number of dysphagia symptoms improved after decannulation. Laryngeal elevation, pharyngeal transit time, and semisolid aspiration showed no statistically significant differences (p>0.05), however after decannulation, the post-swallow pharyngeal remnant (pre 37.41%±24.80%, post 21.02%±11.75%; p<0.001) and upper esophageal width (pre 3.57±1.93 mm, post 4.53±2.05 mm; p<0.001) showed statistically significant differences. When decannulation is performed on patients with brain injuries who do not require a ventilator and who are able to independently excrete sputum, improved esophageal dysphagia can be expected.

Esophageal adenocarcinoma and Barrett esophagus in a neurologically impaired teenager.

PubMed

Hwang, Jae-Yeon; Lee, Yeoun Joo; Chun, Peter; Shin, Dong Hoon; Park, Jae Hong

2016-11-01

Esophageal adenocarcinoma (EAC) accompanied by Barrett esophagus (BE) is rare in patients younger than 20 years old. EAC in the upper esophagus is also rare. We report a rare case of EAC with BE that developed in the upper esophagus after chronic, untreated gastroesophageal reflux disease in a neurologically impaired teenager. A 19-year-old neurologically impaired man underwent endoscopy for evaluation of dysphagia and vomiting, and was diagnosed with EAC with BE. He underwent transthoracic esophagectomy, extensive lymph node dissection, and cervical esophagogastric anastomosis, but the prognosis was poor. Pathology indicated poorly differentiated adenocarcinoma with BE. © 2016 Japan Pediatric Society.

Upper Gastrointestinal Conditions: Nonmalignant Conditions of the Esophagus.

PubMed

Estores, David S; Chang, Ku-Lang

2017-07-01

Eosinophilic esophagitis (EE) is an allergic disorder of the esophagus. This diagnosis requires the presence of specific symptoms and a significantly elevated number of eosinophils in the esophageal lining as determined by endoscopic biopsies. Symptoms tend to be nonspecific among patients younger than 15 years. Among adults, dysphagia is the most common symptom. Comanagement with a gastroenterology subspecialist is essential, particularly for EE patients with a stricture. EE is commonly misdiagnosed as gastroesophageal reflux disease (GERD). The diagnosis of GERD is established by symptom response (eg, postprandial heartburn, regurgitation) to acid suppression, such as administration of a once-daily proton pump inhibitor. Red flag signs and symptoms for esophageal cancer include dysphagia, weight loss, and unexplained anemia. Risk factors include tobacco use, obesity, a long history of heartburn, and a family history of esophageal cancer. Most experts agree that the presence of risk factor(s) signals the need for screening with an upper endoscopy. An abnormal or pathologic pH study result for a patient with negative endoscopy results indicates the presence of nonerosive reflux disease. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

Differential growth and development of the upper and lower human thorax.

PubMed

Bastir, Markus; García Martínez, Daniel; Recheis, Wolfgang; Barash, Alon; Coquerelle, Michael; Rios, Luis; Peña-Melián, Angel; García Río, Francisco; O'Higgins, Paul

2013-01-01

The difficulties in quantifying the 3D form and spatial relationships of the skeletal components of the ribcage present a barrier to studies of the growth of the thoracic skeleton. Thus, most studies to date have relied on traditional measurements such as distances and indices from single or few ribs. It is currently known that adult-like thoracic shape is achieved early, by the end of the second postnatal year, with the circular cross-section of the newborn thorax transforming into the ovoid shape of adults; and that the ribs become inclined such that their anterior borders come to lie inferior to their posterior. Here we present a study that revisits growth changes using geometric morphometrics applied to extensive landmark data taken from the ribcage. We digitized 402 (semi) landmarks on 3D reconstructions to assess growth changes in 27 computed tomography-scanned modern humans representing newborns to adults of both sexes. Our analyses show a curved ontogenetic trajectory, resulting from different ontogenetic growth allometries of upper and lower thoracic units. Adult thoracic morphology is achieved later than predicted, by diverse modifications in different anatomical regions during different ontogenetic stages. Besides a marked increase in antero-posterior dimensions, there is an increase in medio-lateral dimensions of the upper thorax, relative to the lower thorax. This transforms the pyramidal infant thorax into the barrel-shaped one of adults. Rib descent is produced by complex changes in 3D curvature. Developmental differences between upper and lower thoracic regions relate to differential timings and rates of maturation of the respiratory and digestive systems, the spine and the locomotor system. Our findings are relevant to understanding how changes in the relative rates of growth of these systems and structures impacted on the development and evolution of modern human body shape.

Differential Growth and Development of the Upper and Lower Human Thorax

PubMed Central

Bastir, Markus; García Martínez, Daniel; Recheis, Wolfgang; Barash, Alon; Coquerelle, Michael; Rios, Luis; Peña-Melián, Ángel; García Río, Francisco; O’Higgins, Paul

2013-01-01

The difficulties in quantifying the 3D form and spatial relationships of the skeletal components of the ribcage present a barrier to studies of the growth of the thoracic skeleton. Thus, most studies to date have relied on traditional measurements such as distances and indices from single or few ribs. It is currently known that adult-like thoracic shape is achieved early, by the end of the second postnatal year, with the circular cross-section of the newborn thorax transforming into the ovoid shape of adults; and that the ribs become inclined such that their anterior borders come to lie inferior to their posterior. Here we present a study that revisits growth changes using geometric morphometrics applied to extensive landmark data taken from the ribcage. We digitized 402 (semi) landmarks on 3D reconstructions to assess growth changes in 27 computed tomography-scanned modern humans representing newborns to adults of both sexes. Our analyses show a curved ontogenetic trajectory, resulting from different ontogenetic growth allometries of upper and lower thoracic units. Adult thoracic morphology is achieved later than predicted, by diverse modifications in different anatomical regions during different ontogenetic stages. Besides a marked increase in antero-posterior dimensions, there is an increase in medio-lateral dimensions of the upper thorax, relative to the lower thorax. This transforms the pyramidal infant thorax into the barrel-shaped one of adults. Rib descent is produced by complex changes in 3D curvature. Developmental differences between upper and lower thoracic regions relate to differential timings and rates of maturation of the respiratory and digestive systems, the spine and the locomotor system. Our findings are relevant to understanding how changes in the relative rates of growth of these systems and structures impacted on the development and evolution of modern human body shape. PMID:24073239

Melorheostosis involving the cervical and upper thoracic spine: radiographic, CT, and MR imaging findings.

PubMed

Motimaya, A M; Meyers, S P

2006-01-01

Melorheostosis, an uncommon mesenchymal dysplasia, rarely affects the axial skeleton. We describe the imaging findings of melorheostosis involving the cervical and upper thoracic spine. Radiographs and CT showed unilateral well-marginated undulating zones of cortical hyperostosis involving multiple vertebrae that were contiguous with a coalescent ossified right paravertebral mass. MR imaging showed zones of signal intensity void on all pulse sequences without contrast enhancement. Conservative management was elected because of lack of interval clinical and imaging changes for 8 years.

Logistic regression analysis of the risk factors of anastomotic fistula after radical resection of esophageal-cardiac cancer.

PubMed

Huang, Jinxi; Zhou, Yi; Wang, Chenghu; Yuan, Weiwei; Zhang, Zhandong; Chen, Beibei; Zhang, Xiefu

2017-11-01

This study was conducted to investigate the risk factors of anastomotic fistula after the radical resection of esophageal-cardiac cancer. Five hundred and forty-four esophageal-cardiac cancer patients who underwent surgery and had complete clinical data were included in the study. Fifty patients diagnosed with postoperative anastomotic fistula were considered the case group and the remaining 494 subjects who did not develop postoperative anastomotic fistula were considered the control. The potential risk factors for anastomotic fistula, such as age, gender, diabetes history, smoking history, were collected and compared between the groups. Statistically significant variables were substituted into logistic regression to further evaluate the independent risk factors for postoperative anastomotic fistulas in esophageal-cardiac cancer. The incidence of anastomotic fistulas was 9.2% (50/544). Logistic regression analysis revealed that female gender (P < 0.05), laparoscopic surgery (P < 0.05), decreased postoperative albumin (P < 0.05), and postoperative renal dysfunction (P < 0.05) were independent risk factors for anastomotic fistulas in patients who received surgery for esophageal-cardiac cancer. Of the 50 anastomotic fistulas, 16 cases were small fistulas, which were only discovered by conventional imaging examination and not presenting clinical symptoms. All of the anastomotic fistulas occurred within seven days after surgery. Five of the patients with anastomotic fistulas underwent a second surgery and three died. Female patients with esophageal-cardiac cancer treated with endoscopic surgery and suffering from postoperative hypoproteinemia and renal dysfunction were susceptible to postoperative anastomotic fistula. © 2017 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

[Cervical abscess by Streptococcus anginosus-milleri after foreign body ingestion and suspicion of esophageal perforation].

PubMed

Pino Rivero, V; Trinidad Ramos, G; González Palomino, A; Pantoja Hernández, C G; Mogollón Cano-Cortés, T; Carrasco Claver, F; Guerra Camacho, M; Blasco Huelva, A

2006-01-01

We report a case of cervical abscess after the ingestion of foreign body (chicken bone) secondary to probable esophageal perforation that it was sent to us with suspicion of mediastinal complication. The girl, 17 years-old, nothing else to arrive our hospitalary center required entrance in ICU due to her severe clinical process: High fever, intense neck-thoracic pain, laterocervical diffuse and progressive left inflammation and bad general state. The CT showed the presence of a well defined abscess and abundant aerial component that dissected the cervical muscles that made necessary to perform drainage verifying intraoperatively no mediastinal involvement. The culture of the purulent collection revealed Streptococcus anginosus/milleri resistant to clindamicine but sensible to penicilina and derivatives. We exposed a serie of considerations at respect of such microorganism and its clinical signification.

A phase I study of gefitinib with concurrent dose-escalated weekly docetaxel and conformal three-dimensional thoracic radiation followed by consolidative docetaxel and maintenance gefitinib for patients with stage III non-small cell lung cancer.

PubMed

Center, Brian; Petty, William Jeffrey; Ayala, Diandra; Hinson, William H; Lovato, James; Capellari, James; Oaks, Timothy; Miller, Antonius A; Blackstock, Arthur William

2010-01-01

Concurrent radiation and chemotherapy is the standard of care for good performance status patients with stage III non-small cell lung cancer. Locoregional control remains a significant factor relating to poor outcome. Preclinical and early clinical data suggest that docetaxel and gefitinib have radiosensitizing activity. This study sought to define the maximum tolerated dose of weekly docetaxel that could be given with daily gefitinib and concurrent thoracic radiation therapy. Patients with histologically confirmed, inoperable stage III non-small cell lung cancer and good performance status (Eastern Cooperative Oncology Group 0-1) were eligible for this study. Patients received three-dimensional conformal thoracic radiation to a dose of 70 Gy concurrently with oral gefitinib at a dose of 250 mg daily and intravenous, weekly docetaxel at escalating doses from 15 to 30 mg/m2 in cohorts of patients. Patients were given a 2-week rest period after the concurrent therapy, during which they received only gefitinib. After the 2-week rest period, patients received consolidation chemotherapy with docetaxel 75 mg/m2 given every 21 days for two cycles. Maintenance gefitinib was continued until disease progression or study completion. Sixteen patients were enrolled on the study between December 2003 and April 2007 with the following characteristics: median age, 64 years (range 43-79 years); M/F: 9/7; and performance status 0/1, 1/15. Dose-limiting pulmonary toxicity and esophagitis were encountered at a weekly docetaxel dose of 25 mg/m2, resulting in a maximum tolerated dose of 20 mg/m2/wk. Overall, grade 3/4 hematologic toxicity was observed in 27% of patients. Grade 3/4 esophageal and pulmonary toxicities were reported in 27% and 20% of patients, respectively. The overall response rate was 46%, and the median survival for all patients was 21 months. Concurrent thoracic radiation with weekly docetaxel and daily gefitinib is feasible but results in moderate toxicity. For further studies, the recommended weekly docetaxel dose for this chemoradiation regimen is 20 mg/m2.

A case study of chiropractic management of pregnancy-related heartburn with postulated fetal epigenome implications.

PubMed

Peterson, Caroline

2012-01-01

This case study reports on chiropractic care for pregnancy-related heartburn. The purpose of this article is to relate the benefit of chiropractic treatment for one individual, to contrast chiropractic management with the biomedical standard of care for pregnancy-related heartburn, and to point to potential epigenetic implications of the standard of care. A 32-year-old woman who was 24 weeks pregnant presented with persistent heartburn that she was treating with ranitidine (Zantac®) and calcium carbonate (Tums®) daily at the initiation of chiropractic care. Findings of the initial examination were thoracic intersegmental dysfunction and pain upon palpation of the diaphragm, with hypertonicity noted. Therapy localization was positive for reflexes associated with the esophagus and lower esophageal sphincter, suggesting spasms. Emotional components also were identified in association with the symptoms by the use of a mind-body therapy called NeuroEmotional Technique. The patient was treated by adjusting the thoracic spine, manually releasing the diaphragm spasms, and releasing the esophageal spasm with an activator (a small hand-held instrument that creates a percussive force). The patient was symptom-free and did not use medication after the fifth treatment. She was followed throughout the remainder of her pregnancy and was asymptomatic and required no further treatment. A larger study should investigate the effectiveness of chiropractic care for the treatment of pregnancy-related heartburn. Copyright © 2012 Elsevier Inc. All rights reserved.

Endotherapy for severe and complete pharyngo-esophageal post-radiation stenosis using wires, balloons and pharyngo-esophageal puncture (PEP) (with videos).

PubMed

Tang, Shou-jiang; Singh, Shailender; Truelson, John M

2010-01-01

Pharyngo-esophageal stenosis (PES) and upper esophageal stricture are common in patients who receive radiation therapy for laryngeal and hypopharyngeal cancers. In severe or complete stenosis, the patients generally have complete dysphagia with inability to swallow their saliva. Diagnostic and therapeutic esophagogastroduodenoscopy (EGD) plays an important role in investigating the dysphagia and in managing the underlying stenosis. We translate endoscopic retrograde cholangiopancreatography (ERCP) techniques and skills in approaching pancreaticobiliary obstruction in the management of severe and complete PES. We select and report three cases of severe or complete PES in which flexible endoscopic therapy was successfully provided by using fluoroscopy, ERCP wire guides, endoscopic balloons, and by performing pharyngo-esophageal puncture (PEP). We propose the term PEP in managing complete PES. We believe this approach can offer safety and efficiency with very high success rate.

Risk factors for reinsertion of urinary catheter after early removal in thoracic surgical patients.

PubMed

Young, John; Geraci, Travis; Milman, Steven; Maslow, Andrew; Jones, Richard N; Ng, Thomas

2018-03-08

To reduce the incidence of urinary tract infection, Surgical Care Improvement Project 9 mandates the removal of urinary catheters within 48 hours postoperatively. In patients with thoracic epidural anesthesia, we sought to determine the rate of catheter reinsertion, the complications of reinsertion, and the factors associated with reinsertion. We conducted a prospective observational study of consecutive patients undergoing major pulmonary or esophageal resection with thoracic epidural analgesia over a 2-year period. As per Surgical Care Improvement Project 9, all urinary catheters were removed within 48 hours postoperatively. Excluded were patients with chronic indwelling catheter, patients with urostomy, and patients requiring continued strict urine output monitoring. Multivariable logistic regression analysis was used to identify independent risk factors for urinary catheter reinsertion. Thirteen patients met exclusion criteria. Of the 275 patients evaluated, 60 (21.8%) required reinsertion of urinary catheter. There was no difference in the urinary tract infection rate between patients requiring reinsertion (1/60 [1.7%]) versus patients not requiring reinsertion (1/215 [0.5%], P = .389). Urethral trauma during reinsertion was seen in 1 of 60 patients (1.7%). After reinsertion, discharge with urinary catheter was required in 4 of 60 patients (6.7%). Multivariable logistic regression analysis found esophagectomy, lower body mass index, and benign prostatic hypertrophy to be independent risk factors associated with catheter reinsertion after early removal in the presence of thoracic epidural analgesia. When applying Surgical Care Improvement Project 9 to patients undergoing thoracic procedures with thoracic epidural analgesia, consideration to delayed removal of urinary catheter may be warranted in patients with multiple risk factors for reinsertion. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Effect of Gastrointestinal Malformations on the Outcomes of Patients With Congenital Heart Disease.

PubMed

Mery, Carlos M; De León, Luis E; Rodriguez, J Rubén; Nieto, R Michael; Zhang, Wei; Adachi, Iki; Heinle, Jeffrey S; Kane, Lauren C; McKenzie, E Dean; Fraser, Charles D

2017-11-01

The goal of this study was to assess the effect of associated gastrointestinal malformations (GI) on the outcomes of patients undergoing congenital heart operations. Neonates and infants with thoracic (esophageal atresia, tracheoesophageal fistula) and abdominal (duodenal stenosis/atresia, imperforate anus, Hirschsprung disease) GI malformations undergoing congenital heart operations between 1995 and 2015 were included. Two control groups were created, one for each group. Patients were matched by diagnosis, procedure, history of prematurity, presence of genetic syndrome, and a propensity score including weight and year of operation. The cohort included 383 patients: 52 (14%) with thoracic GI malformations and 98 (25%) thoracic GI controls, 80 (21%) with abdominal GI malformations and 153 (40%) abdominal GI controls. Median follow-up was 6 years (range, 16 days to 20 years). Patients with thoracic GI malformations had longer length of stay (p < 0.001), longer intubation times (p = 0.002), and higher perioperative death (p = 0.015) than controls. There was a tendency for worse overall survival than controls, mainly explained by the higher risk of early death (p = 0.06). No difference was found in outcomes between patients with abdominal GI malformations and controls. Patients with thoracic GI malformations have worse perioperative outcomes than controls, but their long-term survival does not seem to be significantly different. Abdominal GI malformations do not have a significant effect on outcomes. The presence of GI malformations should likely not preclude patients from undergoing congenital heart operations, but careful family counseling is necessary, especially for thoracic GI malformations. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Guide to thoracic imaging.

PubMed

Skinner, Sarah

2015-08-01

Thoracic imaging is commonly ordered in general practice. Guidelines exist for ordering thoracic imaging but few are specific for general practice. This article summarises current indications for imaging the thorax with chest X-ray and computed tomography. A simple frame-work for interpretation of the chest X-ray, suitable for trainees and practitioners providing primary care imaging in rural and remote locations, is presented. Interpretation of thoracic imaging is best done using a systematic approach. Radiological investigation is not warranted in un-complicated upper respiratory tract infections or asthma, minor trauma or acute-on-chronic chest pain.

The Role of Thoracic Medial Branch Blocks in Managing Chronic Mid and Upper Back Pain: A Randomized, Double-Blind, Active-Control Trial with a 2-Year Followup

PubMed Central

Manchikanti, Laxmaiah; Singh, Vijay; Falco, Frank J. E.; Cash, Kimberly A.; Pampati, Vidyasagar; Fellows, Bert

2012-01-01

Study Design. A randomized, double-blind, active-control trial. Objective. To determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain. Summary of Background Data. The prevalence of thoracic facet joint pain has been established as 34% to 42%. Multiple therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include medial branch blocks, radiofrequency neurotomy, and intraarticular injections. Methods. This randomized double-blind active controlled trial was performed in 100 patients with 50 patients in each group who received medial branch blocks with local anesthetic alone or local anesthetic and steroids. Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months. Results. Significant improvement with significant pain relief and functional status improvement of 50% or more were observed in 80% of the patients in Group I and 84% of the patients in Group II at 2-year followup. Conclusions. Therapeutic medial branch blocks of thoracic facets with or without steroids may provide a management option for chronic function-limiting thoracic pain of facet joint origin. PMID:22851967

Nonalcoholic Fatty Liver Disease Is Associated with Increased Risk of Reflux Esophagitis.

PubMed

Yang, Hyo-Joon; Chang, Yoosoo; Park, Soo-Kyung; Jung, Yoon Suk; Park, Jung Ho; Park, Dong Il; Cho, Yong Kyun; Ryu, Seungho; Sohn, Chong Il

2017-12-01

Reflux esophagitis is associated with obesity and metabolic syndrome; however, the relationship between nonalcoholic fatty liver disease (NAFLD) and reflux esophagitis is unclear. We examined the association between NAFLD and the development of reflux esophagitis. Our cohort consisted of 117,377 Korean adults without reflux esophagitis at baseline who underwent a health checkup program including upper endoscopy between 2002 and 2014 and were followed annually or biennially until December 2014. NAFLD was defined as hepatic steatosis on ultrasonography in the absence of excessive alcohol use or any other identifiable cause. Over 520,843.2 person-years of follow-up, 22,500 participants developed reflux esophagitis (incidence density, 43.2 per 1000 person-years). In models adjusted for age and sex, the adjusted hazard ratio (aHR) (95% confidence interval [CI]) for incident reflux esophagitis in subjects with NAFLD compared to those without was 1.16 (1.13-1.20). After further adjustment for confounders of center, year of visit, smoking status, alcohol intake, regular exercise, education level, and body mass index, the association between NAFLD and incident reflux esophagitis was attenuated, but remained significant (aHR 1.06; 95% CI 1.02-1.10). In this large cohort of Korean men and women, participants with NAFLD exhibited increased incidence of reflux esophagitis independent of possible confounders, suggesting that NAFLD contributes to the development of reflux esophagitis.

Esophageal lichen planus: An unusual cause of dysphagia in the elderly.

PubMed

Carbonari, Augusto Pinke Cruz; Imada, Regina Rie; Nakamura, Romeu; Araki, Osvaldo; Cristina, Kelly; Balancin, Marcelo Luiz; Ibrahim, Roberto El

2018-03-01

An 82-year-old man sought our service with dysphagia and was referred for upper endoscopy with biopsies, which evidenced multiple ulcers of the esophagus and oropharinx. Histopathology confirmed the unusual diagnosis of esophageal lichen planus. The correct clinical suspicion of this disease can facilitate the diagnosis and guide specific treatment, which can drastically change the natural course of the disease.

Unchanging pattern of prevalence of esophageal cancer, overall and by histological subtype, in the endoscopy service of the main referral hospital in the central region of Rio Grande do Sul State, in Southern Brazil.

PubMed

Fagundes, R B; de Carli, D; Xaubet, R V; Cantarelli, J C

2016-08-01

Squamous cell carcinoma (SCC) and adenocarcinoma (ADC) are the two main histological types of esophageal cancer. Southern Brazil has the highest rates of esophageal cancer in South America, and the most prevalent subtype of esophageal cancer has been SCC. This study assessed the trend changes in the histological types of esophageal cancer, in a 20-year period, in the central region of Rio Grande do Sul State, Brazil. We searched all cases of esophageal cancer from 1993 to 2012 by their histological diagnosis, grouping the patients in 4-year time periods to evaluate time trends. Among 18 441 upper gastrointestinal endoscopies we identified 686 cases of esophageal cancer. Histological study confirmed the diagnosis of SCC in 640 (93.3%) patients and ADC in 46 (6.7%). Overall, 522 men were diagnosed with esophageal carcinoma; from these, 489 (93.6%) presented SCC, and 33 (6.3%) ADC. Among women, 164 had the diagnosis of esophageal cancer, 151 (92%) SCC, and 13 (7.9%) ADC. The proportion found among men and women was 3.1:1, respectively. The prevalence rate of esophageal cancer, along a 20 year-period, remained stable, as well as the rates of SCC and ADC. SCC was the most common type of esophageal cancer, and ADC presented very low prevalence. © 2015 International Society for Diseases of the Esophagus.

New Combined Medical Treatment With Etilefrine and Octreotide for Chylothorax After Esophagectomy

PubMed Central

Ohkura, Yu; Ueno, Masaki; Iizuka, Toshiro; Haruta, Shusuke; Tanaka, Tsuyoshi; Udagawa, Harushi

2015-01-01

Abstract Postoperative chylothorax is a rare but well-known complication of general thoracic surgery. Medical treatment of chylothorax was reported in the past, but there is still considerable controversy on the appropriate management strategies. Two patients with esophageal cancer underwent esophagectomy, 2-field lymph node dissection, and resection of thoracic duct together with ileocolic reconstruction via the retrosternal route at our hospital. Chylothorax developed on the 32nd postoperative day (POD) in 1 patient and the 12th POD in the other, manifesting as a change in the character of thoracic drainage to turbid white. Both were immediately started on octreotide (300 μg/ day) and etilefrine (120 mg/day). When the amount of pleural effusion decreased to <50 mL/day, we performed pleurodesis with Picibanil (OK432). Thereafter, the patients gradually made satisfactory progress and resumed oral food intake, and the thoracotomy tubes were eventually removed. They have remained recurrence-free at the time of writing. In this report, we demonstrated the clinical efficacy of etilefrine for the management of postesophagectomy chylothorax. New medical treatment options for this condition are now broad and the usefulness of combined therapy consisting of a sclerosing agent, etilefrine, and octreotide is underscored, regardless of the status of the thoracic duct. PMID:26656358

New Combined Medical Treatment With Etilefrine and Octreotide for Chylothorax After Esophagectomy: A Case Report and Review of the Literature.

PubMed

Ohkura, Yu; Ueno, Masaki; Iizuka, Toshiro; Haruta, Shusuke; Tanaka, Tsuyoshi; Udagawa, Harushi

2015-12-01

Postoperative chylothorax is a rare but well-known complication of general thoracic surgery. Medical treatment of chylothorax was reported in the past, but there is still considerable controversy on the appropriate management strategies.Two patients with esophageal cancer underwent esophagectomy, 2-field lymph node dissection, and resection of thoracic duct together with ileocolic reconstruction via the retrosternal route at our hospital. Chylothorax developed on the 32nd postoperative day (POD) in 1 patient and the 12th POD in the other, manifesting as a change in the character of thoracic drainage to turbid white. Both were immediately started on octreotide (300 μg/ day) and etilefrine (120 mg/day). When the amount of pleural effusion decreased to <50 mL/day, we performed pleurodesis with Picibanil (OK432). Thereafter, the patients gradually made satisfactory progress and resumed oral food intake, and the thoracotomy tubes were eventually removed. They have remained recurrence-free at the time of writing.In this report, we demonstrated the clinical efficacy of etilefrine for the management of postesophagectomy chylothorax. New medical treatment options for this condition are now broad and the usefulness of combined therapy consisting of a sclerosing agent, etilefrine, and octreotide is underscored, regardless of the status of the thoracic duct.

Feasibility of tomotherapy to reduce normal lung and cardiac toxicity for distal esophageal cancer compared to three-dimensional radiotherapy.

PubMed

Nguyen, Nam P; Krafft, Shane P; Vinh-Hung, Vincent; Vos, Paul; Almeida, Fabio; Jang, Siyoung; Ceizyk, Misty; Desai, Anand; Davis, Rick; Hamilton, Russ; Modarresifar, Homayoun; Abraham, Dave; Smith-Raymond, Lexie

2011-12-01

To compare the effectiveness of tomotherapy and three-dimensional (3D) conformal radiotherapy to spare normal critical structures (spinal cord, lungs, and ventricles) from excessive radiation in patients with distal esophageal cancers. A retrospective dosimetric study of nine patients who had advanced gastro-esophageal (GE) junction cancer (7) or thoracic esophageal cancer (2) extending into the distal esophagus. Two plans were created for each of the patients. A three-dimensional plan was constructed with either three (anteroposterior, right posterior oblique, and left posterior oblique) or four (right anterior oblique, left anterior oblique, right posterior oblique, and left posterior oblique) fields. The second plan was for tomotherapy. Doses were 45 Gy to the PTV with an integrated boost of 5 Gy for tomotherapy. Mean lung dose was respectively 7.4 and 11.8 Gy (p=0.004) for tomotherapy and 3D plans. Corresponding values were 12.4 and 18.3 Gy (p=0.006) for cardiac ventricles. Maximum spinal cord dose was respectively 31.3 and 37.4 Gy (p < 0.007) for tomotherapy and 3D plans. Homogeneity index was two for both groups. Compared to 3D conformal radiotherapy, tomotherapy decreased significantly the amount of normal tissue irradiated and may reduce treatment toxicity for possible dose escalation in future prospective studies. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Influence of everyday bolus consistencies in different body positions on high-resolution esophageal pressure topography (HREPT) parameters.

PubMed

Hasan, Y; Go, J; Hashmi, S M; Valestin, J; Schey, R

2015-04-01

The standard protocol for esophageal manometry involves placing the patient in the supine position with head turned to left (supine head left [SHL]) while evaluating liquid bolus swallows. Routinely, semisolid or solid boluses are not evaluated. Currently, the daily American diet includes up to 40% solid or semisolid texture. Thus far, the data on the effect of different bolus on high-resolution esophageal pressure topography (HREPT) parameters are scarce. This study aims to evaluate the effect of every day bolus consistencies in different body positions on HREPT variables. HREPT was performed on healthy volunteers with a modified protocol including liquid swallows in the SHL position followed by applesauce (semisolid), cracker (solid), and marshmallow (soft solid) in three different positions (SHL, sitting, and standing). A total of 38 healthy adult subjects (22 males and 16 females, median age = 27, and mean body mass index = 25) were evaluated. The resting upper esophageal sphincter pressure was significantly different while subjects swallowed crackers, applesauce, and marshmallows in most positions compared with liquid SHL (P < 0.05). The lower esophageal sphincter, contractile front velocity, and distal contractile integral pressures did not differ in all different consistencies compared with SHL. The integrated relaxation period was significantly higher with solid bolus compared with liquid bolus only in SHL position. The intrabolus pressure was significantly different with solid and soft solid boluses in all postures compared to liquid SHL. The American diet consistency affects upper esophageal sphincter pressure and partially integrated relaxation period and intrabolus pressure in various positions. Semisolid bolus swallows do not cause substantial pressure changes and are safe for evaluation and maintaining adequate caloric intake in patients with dysphagia who cannot tolerate solids. © 2014 International Society for Diseases of the Esophagus.

Esophageal Carcinoma in African Americans: A Five-Decade Experience

PubMed Central

Nouri, Zahra; Nouraie, Mehdi; Razjouyan, Hadi; Lee, Edward E.; Dowlati, Ehsan; El-Seyed, El-Waleed; Laiyemo, Adeyinka; Brim, Hassan; Smoot, Duane T.

2012-01-01

Background Esophageal cancer accounts for a considerable proportion of carcinomas of the upper gastrointestinal tract in African Americans. Our aim was to describe the epidemiology of esophageal squamous cell cancer (ESCC) and esophageal adenocarcinoma (EA) among African Americans in the last five decades. Methods A total of 601 records of patients with documented esophageal cancer between 1959 and 2007 at Howard University Hospital were reviewed. Demographic characteristics, risk factors, clinical stage and histological findings were reviewed. The change in prevalence of the disease and the interaction between main risk factors with tumor stage of the patients were assessed over the years of this study. Result A total of 552 patients (91.8%) had ESCC while 49 patients (8.2%) had EA. The mean age at diagnosis was 60.1 and 60.6 years for ESCC and EA, respectively (P = 0.8). The peak incidence was in the 1980–1989 decade. Out of 136 ESCC patients with TNM staging information, 130 (95.6%) were diagnosed in stage 2 and above. The majority (73%) of the ESCC were in the mid- and upper third of the esophagus and associated with smoking and alcohol exposure. The majority (81%) of the EA were in the mid- and lower third. The most common presenting symptoms were dysphagia (77.7%), and weight loss (31.9%). Conclusion ESCC is the predominant esophageal cancer in African Americans and diagnosed in late stages, and its diagnosis in our institution has decreased since 1990. A combination of genetic factors, environmental influences (e.g., those related to diet), and the deleterious changes associated with smoking and alcohol consumption, and differences in tumor histology, are the obvious parameters that should be the focus of future studies, and early diagnosis at an earlier stage should be considered among blacks. PMID:21847566

[Hodgkin's disease with esophageal involvement].

PubMed

Njeh, M; Yengui, N; Tahri, N; Kchaou, M; Sellami, A; Jlidi, R; Krichen, M S

2000-10-01

Esophageal involvement in Hodgkin's disease, commonly known as a belated localization of the advanced forms, has been seldom reported (3 to 5% in post-mortem series and 0.7% in clinical series). We report the case of a 61-year-old man who had an esophagus localization revealing Hodgkin's disease stage IV EBb of Ann Arbor classification. The originality of this case was represented by: the revelation mode of the esophageal involvement such as dysphagia and upper gastrointestinal bleeding; the localization at the distal third of the esophagus with contiguous involvement of the gastric fundus; the absence of mediastinal nodes showing the primitive character of the esophageal injury. This observation incites us to consider Hodgkin's disease in the list of differential diagnoses of tumoral dysphagia, even if there was no ganglionic and/or visceral localization of the disease.

Upper GI tract findings in patients with heartburn in whom proton pump inhibitor treatment failed versus those not receiving antireflux treatment.

PubMed

Poh, Choo Hean; Gasiorowska, Anita; Navarro-Rodriguez, Tomas; Willis, Marcia R; Hargadon, Deborah; Noelck, North; Mohler, Jane; Wendel, Christopher S; Fass, Ronnie

2010-01-01

Failure of proton pump inhibitor (PPI) treatment in patients with heartburn is very common. Because endoscopy is easily accessible, it is commonly used as the first evaluative tool in these patients. To compare GERD-related endoscopic and histologic findings in patients with heartburn in whom once-daily PPI therapy failed versus those not receiving antireflux treatment. Cross-sectional study. A Veterans Affairs hospital. Heartburn patients from the GI outpatient clinic. Recording of endoscopic results. Endoscopic findings and association between PPI treatment failure and esophageal mucosal injury by using logistic regression models. A total of 105 subjects (mean age 54.7 +/- 15.7 years; 71 men, 34 women) were enrolled in the PPI treatment failure group and 91 (mean age 53.4 +/- 15.8 years; 68 men, 23 women) were enrolled in the no-treatment group (P = not significant). Anatomic findings during upper endoscopy were significantly more common in the no-treatment group compared with the PPI treatment failure group (55.2% vs 40.7%, respectively; P = .04). GERD-related findings were significantly more common in the no-treatment group compared with the PPI treatment failure group (erosive esophagitis: 30.8% vs 6.7%, respectively; P < .05). Eosinophilic esophagitis was found in only 0.9% of PPI treatment failure patients. PPI treatment failure was associated with a significantly decreased odds ratio of erosive esophagitis compared with no treatment, adjusted for age, sex, and body mass index (adjusted odds ratio 0.11; 95% CI, 0.04-0.30). Heartburn patients in whom once-daily PPI treatment failed demonstrated a paucity of GERD-related findings compared with those receiving no treatment. Eosinophilic esophagitis was uncommon in PPI therapy failure patients. Upper endoscopy seems to have a very low diagnostic yield in this patient population. 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

Balloon dilation of the esophago-gastric junction affects lower and upper esophageal sphincter function in achalasia.

PubMed

Wauters, L; Van Oudenhove, L; Selleslagh, M; Vanuytsel, T; Boeckxstaens, G; Tack, J; Omari, T; Rommel, N

2014-01-01

Pneumatic dilation of the lower esophageal sphincter (LES) in achalasia has an unappreciated effect on upper esophageal sphincter (UES) function. We studied UES pressure patterns at baseline and alterations in UES parameters resulting from therapy. High-resolution manometry (HRM) tracings from 50 achalasia patients, seen at a tertiary center between January 2009 and July 2011, were reviewed. Manometric parameters studied were (i) LES: resting pressure (restP), 4-second integrated relaxation pressure (IRP4); (ii) UES: resting pressure (restP), minimal relaxation pressure (MRP), peak pressure (PP), relaxation interval (RI), intrabolus pressure (IBP), and deglutitive sphincter resistance (DSR). Mixed models analyses with LES and UES parameters as dependent variables and treatment stage as within-subject independent variable of interest were used. Correlations between treatment-induced changes in LES, UES, and esophageal body (EB) parameters were performed. Pre- and posttreatment HRM tracings were available from 50 patients (mean age 52.7 ± 18.6 years, 29 men). Upper esophageal sphincter parameters MRP (17.9 ± 1.2 vs 15.2 ± 0.9 mmHg; p = 0.02) and IBP (31.5 ± 1.5 vs 27.4 ± 1.2 mmHg; p = 0.009) were significantly reduced after initial balloon dilation and this effect was significant in type II achalasia (p = 0.002 and p = 0.0006). Peak pressure, RI, and DSR were not. The therapeutic effect on LES IRP4 correlated significantly with the change in UES MRP, statistically mediated by the change in EB deglutitive pressure (p = 0.004 and p = 0.0002). We present the first HRM study demonstrating that pneumatic dilation of the LES affects intraesophageal and UES pressures in patients with achalasia. © 2013 John Wiley & Sons Ltd.

Effect of cervical vs. thoracic spinal manipulation on peripheral neural features and grip strength in subjects with chronic mechanical neck pain: a randomized controlled trial.

PubMed

Bautista-Aguirre, Francisco; Oliva-Pascual-Vaca, Ángel; Heredia-Rizo, Alberto M; Boscá-Gandía, Juan J; Ricard, François; Rodriguez-Blanco, Cleofás

2017-06-01

Cervical and thoracic spinal manipulative therapy has shown positive impact for relief of pain and improve function in non-specific mechanical neck pain. Several attempts have been made to compare their effectiveness although previous studies lacked a control group, assessed acute neck pain or combined thrust and non-thrust techniques. To compare the immediate effects of cervical and thoracic spinal thrust manipulations on mechanosensitivity of upper limb nerve trunks and grip strength in patients with chronic non-specific mechanical neck pain. Randomized, single-blinded, controlled clinical trial. Private physiotherapy clinical consultancy. Eighty-eight subjects (32.09±6.05 years; 72.7% females) suffering neck pain (grades I or II) of at least 12 weeks of duration. Participants were distributed into three groups: 1) cervical group (N.=28); 2) thoracic group (N.=30); and 3) control group (N.=30). One treatment session consisting of applying a high-velocity low-amplitude spinal thrust technique over the lower cervical spine (C7) or the upper thoracic spine (T3) was performed, while the control group received a sham-manual contact. Measurements were taken at baseline and after intervention of the pressure pain threshold over the median, ulnar and radial nerves. Secondary measures included assessing free-pain grip strength with a hydraulic dynamometer. No statistically significant differences were observed when comparing between-groups in any of the outcome measures (P>0.05). Those who received thrust techniques, regardless of the manipulated area, reported an immediate increase in mechanosensitivity over the radial (both sides) and left ulnar nerve trunks (P<0.05), and grip strength (P<0.001). For those in the control group, right hand grip strength and pain perception over the radial nerve also improved (P≤0.025). Low-cervical and upper-thoracic thrust manipulation is no more effective than placebo to induce immediate changes on mechanosensitivity of upper limb nerve trunks and grip strength in patients with chronic non-specific mechanical neck pain. A single treatment session using cervical or thoracic thrust techniques is not enough to achieve clinically relevant changes on neural mechanosensitivity and grip strength in chronic non-specific mechanical neck pain.

The History of Sympathetic Surgery.

PubMed

Hashmonai, Moshe

2016-11-01

At present, primary hyperhidrosis is the main indication for sympathectomy. For upper thoracic sympathetic ablation, excision of the second thoracic ganglion alone or with the first and/or third ganglia was the standard during the open surgery era. With the advent of thoracoscopy, modifications related to the level, extent, and type of ablation were proposed to attenuate compensatory hyperhidrosis. The ideal operation for sympathetic denervation of the face and upper limbs remain to be defined. Controlled double-blind studies with quantitave measurements of sweat production are required. Copyright © 2016 Elsevier Inc. All rights reserved.

Preclinical study of transcervical upper mediastinal dissection for esophageal malignancy by robot-assisted surgery.

PubMed

Mori, Kazuhiko; Yoshimura, Shuntaro; Yamagata, Yukinori; Aikou, Susumu; Seto, Yasuyuki

2017-06-01

Robotic surgical systems are potentially applicable to transcervical mediastinal lymph dissection for esophageal malignancy. Robot-assisted surgery was performed on a male fresh-frozen human cadaver. Devices for single-port laparoscopic surgery were deployed via one small incision in the left clavicular area. The task for the robot-assisted surgery was the upper mediastinal dissection to the level of the left main bronchus and en bloc harvest of the lymph nodes adherent to the left recurrent laryngeal nerve. An up-angled 30° scope in the 6 o'clock port and two robotic arms from the 3 and 9 o'clock ports worked effectively together. No collisions of the devices inside the cadaveric body or unexpected traumatic events occurred. The robotic surgical system can be used safely for the upper mediastinal dissection. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Sponge Sampling with Fluorescent In Situ Hybridization as a Screening Tool for the Early Detection of Esophageal Cancer.

PubMed

Haisley, Kelly R; Dolan, James P; Olson, Susan B; Toledo-Valdovinos, Sergio A; Hart, Kyle D; Bakis, Gene; Enestvedt, Brintha K; Hunter, John G

2017-02-01

Sponge cytology is a novel screening tool for esophageal cancer but has been unable to be validated for widespread use. Our aim was to apply fluorescent in situ hybridization to sponge cytology samples in order to evaluate the safety and efficacy of this modality in screening for esophageal cancer. At a single, multidisciplinary, NCI-designated cancer center, patients completed sponge cytology sampling prior to upper endoscopy. Samples were analyzed by p53 fluorescent in situ hybridization, and results were compared to the endoscopic diagnosis. Fifty patients were enrolled (96 % Caucasian, 68 % male, median age of 67). All patients successfully swallowed the capsule. No complications (string breakage, bleeding, mucosal injury) occurred. Endoscopy revealed that 38 % had normal esophageal mucosa and 62 % had an esophageal mucosal abnormality. In total, six samples demonstrated p53 loss (94 % specificity for any abnormality). The sensitivity of the p53 fluorescent in situ hybridization probe was13.3 % for any abnormality, 10 % for intestinal metaplasia, and 0 % for dysplasia or esophageal cancer. Esophageal sponge cytology is a promising, safe, and tolerable method for collecting esophageal cell samples. However, our data suggest that p53 fluorescent in situ hybridization does not improve the sensitivity for detecting cancer in these samples.

Manometric evaluation of the esophagus in patients with Behçet's disease.

PubMed

Bektas, Mehmet; Altan, Mehmet; Alkan, Murat; Ormeci, Necati; Soykan, Irfan

2007-01-01

Gastrointestinal (GI) involvement in Behçet's disease (BD) mainly appears in mucosa and affects 5-40% of patients, however the effects of the disease on lower esophageal sphincter (LES) pressure and esophageal contractions are not well known. The aims of this study were to evaluate esophageal motor function and to identify whether there was any specific motility pattern for patients with BD who had upper GI symptoms without endoscopic abnormality. 25 patients with BD, with a mean age of 43.1 (range 20-66) years, were admitted to our clinic whose main complaints were dyspeptic such as reflux, epigastric pain, vomiting and bloating. 25 healthy and age-matched individuals were also included in the study as controls. After one night fasting, LES pressure and esophageal contractions were measured. Esophageal motor abnormalities were detected in 16% (4/25) of these patients with manometric studies (non-specific esophageal motor disorder in 1, esophageal hypomotility in 2, and LES hypotension in 1 patient); 16% (4/25) of these patients had endoscopic findings and overall 32% (8/25) of the cases showed esophageal pathology. All cases with esophageal motor abnormalities were suffering from reflux and endoscopy showed grade B esophagitis in 2 of these cases. Median LES pressure and LES relaxation were significantly lower in patients with BD compared to the control group (16.8 +/- 10.5 vs. 20.4 +/- 6.1, p = 0.02, and 92.1 +/- 10.1 vs. 96.4 +/- 4.5, p = 0.03 respectively). Esophageal involvement in BD is significantly high. We propose manometric studies are necessary to evaluate esophageal manifestations in BD patients with esophageal symptoms even without endoscopic findings.

Evaluation of simulation training in cardiothoracic surgery: the Senior Tour perspective.

PubMed

Fann, James I; Feins, Richard H; Hicks, George L; Nesbitt, Jonathan C; Hammon, John W; Crawford, Fred A

2012-02-01

The study objective was to introduce senior surgeons, referred to as members of the "Senior Tour," to simulation-based learning and evaluate ongoing simulation efforts in cardiothoracic surgery. Thirteen senior cardiothoracic surgeons participated in a 2½-day Senior Tour Meeting. Of 12 simulators, each participant focused on 6 cardiac (small vessel anastomosis, aortic cannulation, cardiopulmonary bypass, aortic valve replacement, mitral valve repair, and aortic root replacement) or 6 thoracic surgical simulators (hilar dissection, esophageal anastomosis, rigid bronchoscopy, video-assisted thoracoscopic surgery lobectomy, tracheal resection, and sleeve resection). The participants provided critical feedback regarding the realism and utility of the simulators, which served as the basis for a composite assessment of the simulators. All participants acknowledged that simulation may not provide a wholly immersive experience. For small vessel anastomosis, the portable chest model is less realistic compared with the porcine model, but is valuable in teaching anastomosis mechanics. The aortic cannulation model allows multiple cannulations and can serve as a thoracic aortic surgery model. The cardiopulmonary bypass simulator provides crisis management experience. The porcine aortic valve replacement, mitral valve annuloplasty, and aortic root models are realistic and permit standardized training. The hilar dissection model is subject to variability of porcine anatomy and fragility of the vascular structures. The realistic esophageal anastomosis simulator presents various approaches to esophageal anastomosis. The exercise associated with the rigid bronchoscopy model is brief, and adding additional procedures should be considered. The tracheal resection, sleeve resection, and video-assisted thoracoscopic surgery lobectomy models are highly realistic and simulate advanced maneuvers. By providing the necessary tools, such as task trainers and assessment instruments, the Senior Tour may be one means to enhance simulation-based learning in cardiothoracic surgery. The Senior Tour members can provide regular programmatic evaluation and critical analyses to ensure that proposed simulators are of educational value. Published by Mosby, Inc.

Esophagogastric metaplasia relates to nodal metastases in adenocarcinoma of esophagus and cardia.

PubMed

Ruffato, Alberto; Mattioli, Sandro; Perrone, Ottorino; Lugaresi, Marialuisa; Di Simone, Massimo Pierluigi; D'Errico, Antonietta; Malvi, Deborah; Aprile, Maria Rosaria; Raulli, Giandomenico; Frassineti, Luca

2013-04-01

Immunohistochemical profiles of esophageal and cardia adenocarcinoma differ according to the presence or absence of Barrett's epithelium (BIM) and gastric intestinal metaplasia (GIM) in the fundus and antrum. Different lymphatic spreading has been demonstrated in esophageal adenocarcinoma. We investigated the correlation among the presence or absence of intestinal metaplasia in the esophagus and stomach and lymphatic metastases in patients who underwent radical surgery for esophageal and cardia adenocarcinoma. The mucosa surrounding the adenocarcinoma and the gastric mucosa were analyzed. The BIM+ patients underwent subtotal esophagectomy and gastric pull up, and the BIM- patients underwent esophagectomy at the azygos vein, total gastrectomy, and esophagojejunostomy. The radical thoracic (station numbers 2, 3, 4R, 7, 8, and 9) and abdominal (station numbers 15 through 20) lymphadenectomy was identical in both procedures except for the greater curvature. One hundred ninety-four consecutive patients were collected in three major groups: BIM+/GIM-, 52 patients (26.8%); BIM-/GIM-, 90 patients (46.4%); BIM-/GIM+, 50 patients (25.8%). Two patients (1%) were BIM+/GIM+. A total of 6,010 lymph nodes were resected: 1,515 were recovered in BIM+, 1,587 in BIM-/GIM+, and 2,908 in BIM-/GIM- patients. The percentage of patients with pN+ stations 8 and 9 was higher in BIM+ (p=0.001), and the percentage of patients with pN+ perigastric stations was higher in BIM- (p=0.001). The BIM-/GIM- patients had a number of abdominal metastatic lymph nodes higher than did the BIM-/GIM+ patients (p=0.0001). According to the presence or absence of BIM and GIM in the esophagus and cardia, adenocarcinoma correspond to three different patterns of lymphatic metastasization, which may reflect different biologic and carcinogenetic pathways. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Secure hemostasis in transhiatal esophagectomy for esophageal cancer with gauze packing.

PubMed

Hirahara, Noriyuki; Matsubara, Takeshi; Hari, Yoko; Fujii, Yusuke; Wake, Hitomi; Tajima, Yoshitsugu

2012-12-19

Transhiatal esophagectomy for esophageal cancer implies blind manipulation of the intrathoracic esophagus. We report a secure hemostatic method with gauze packing in transhiatal esophagectomy. The gauze-packing technique is utilized for hemostasis just after removal of the thoracic esophagus during transhiatal esophagectomy. After confirming cancer-free margins, the abdominal esophagus and cervical esophagus are transected. A vein stripper is inserted into the oral-side stump of the esophagus and led to exit from the abdominal-side stump of the esophagus. The vein stripper and the oral stump of the esophagus are affixed by silk thread. A polyester tape is then affixed to the vein stripper, as the polyester tape is left in the posterior mediastinum after removal of the esophagus toward the abdominal side. The polyester tape on the cervical side is ligated with gauze and the polyester tape is removed toward the abdominal side. The oral stump of gauze and new additional gauze are affixed. As the first gauze is pulled out from the abdominal side, the second gauze gets drawn from the cervical wound into the mediastinum. The posterior mediastinum is finally packed with gauze and possible bleeding at this site undergoes a complete astriction. The status of hemostasis with the gauze packing is checked by an observation of color and bloodstain on the gauze. Between January 2005 and February 2012, 13 consecutive patients with esophageal cancer underwent a transhiatal esophagectomy with the gauze-packing hemostatic technique. Hemostasis at the posterior mediastinum was performed successfully and quickly in all cases with this method, requiring up to four pieces of gauze for a complete hemostasis. Median required time for hemostasis was 1219 (range 1896 to 1293) seconds and estimated blood loss was 20.4 (range 15 to 25) ml during gauze packing. Our technique could minimize bleeding after the removal of the thoracic esophagus. The gauze-packing method is a simple and easy technique for secure hemostasis when performing a transhiatal esophagectomy.

Secure hemostasis in transhiatal esophagectomy for esophageal cancer with gauze packing

PubMed Central

2012-01-01

Background Transhiatal esophagectomy for esophageal cancer implies blind manipulation of the intrathoracic esophagus. We report a secure hemostatic method with gauze packing in transhiatal esophagectomy. Methods The gauze-packing technique is utilized for hemostasis just after removal of the thoracic esophagus during transhiatal esophagectomy. After confirming cancer-free margins, the abdominal esophagus and cervical esophagus are transected. A vein stripper is inserted into the oral-side stump of the esophagus and led to exit from the abdominal-side stump of the esophagus. The vein stripper and the oral stump of the esophagus are affixed by silk thread. A polyester tape is then affixed to the vein stripper, as the polyester tape is left in the posterior mediastinum after removal of the esophagus toward the abdominal side. The polyester tape on the cervical side is ligated with gauze and the polyester tape is removed toward the abdominal side. The oral stump of gauze and new additional gauze are affixed. As the first gauze is pulled out from the abdominal side, the second gauze gets drawn from the cervical wound into the mediastinum. The posterior mediastinum is finally packed with gauze and possible bleeding at this site undergoes a complete astriction. The status of hemostasis with the gauze packing is checked by an observation of color and bloodstain on the gauze. Results Between January 2005 and February 2012, 13 consecutive patients with esophageal cancer underwent a transhiatal esophagectomy with the gauze-packing hemostatic technique. Hemostasis at the posterior mediastinum was performed successfully and quickly in all cases with this method, requiring up to four pieces of gauze for a complete hemostasis. Median required time for hemostasis was 1219 (range 1896 to 1293) seconds and estimated blood loss was 20.4 (range 15 to 25) ml during gauze packing. Conclusions Our technique could minimize bleeding after the removal of the thoracic esophagus. The gauze-packing method is a simple and easy technique for secure hemostasis when performing a transhiatal esophagectomy. PMID:23253358

Phase I North Central Cancer Treatment Group Trial-N9923 of escalating doses of twice-daily thoracic radiation therapy with amifostine and with alternating chemotherapy in limited stage small-cell lung cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Garces, Yolanda I.; Okuno, Scott H.; Schild, Steven E.

Purpose: The primary goal was to identify the maximum tolerable dose (MTD) of thoracic radiation therapy (TRT) that can be given with chemotherapy and amifostine for patients with limited-stage small-cell lung cancer (LSCLC). Methods and Materials: Treatment began with two cycles of topotecan (1 mg/m{sup 2}) Days 1 to 5 and paclitaxel (175 mg/m{sup 2}) Day 5 (every 3 weeks) given before and after TRT. The TRT began at 6 weeks. The TRT was given in 120 cGy fractions b.i.d. and the dose escalation (from 4,800 cGy, dose level 1, to 6,600 cGy, dose level 4) followed the standard 'cohortsmore » of 3' design. The etoposide (E) (50 mg/day) and cisplatin (C) (3 mg/m{sup 2}) were given i.v. before the morning TRT and amifostine (500 mg/day) was given before the afternoon RT. This was followed by prophylactic cranial irradiation (PCI). The dose-limiting toxicities (DLTs) were defined as Grade {>=}4 hematologic, febrile neutropenia, esophagitis, or other nonhematologic toxicity, Grade {>=}3 dyspnea, or Grade {>=}2 pneumonitis. Results: Fifteen patients were evaluable for the Phase I portion of the trial. No DLTs were seen at dose levels 1 and 2. Two patients on dose level 4 experienced DLTs: 1 patient had a Grade 4 pneumonitis, dyspnea, fatigue, hypokalemia, and anorexia, and 1 patient had a Grade 5 hypoxia attributable to TRT. One of 6 patients on dose level 3 had a DLT, Grade 3 esophagitis. The Grade {>=}3 toxicities seen in at least 10% of patients during TRT were esophagitis (53%), leukopenia (33%), dehydration (20%), neutropenia (13%), and fatigue (13%). The median survival was 14.5 months. Conclusion: The MTD of b.i.d. TRT was 6000 cGy (120 cGy b.i.d.) with EP and amifostine.« less

Esophageal Baseline Impedance Reflects Mucosal Integrity and Predicts Symptomatic Outcome With Proton Pump Inhibitor Treatment.

PubMed

Xie, Chenxi; Sifrim, Daniel; Li, Yuwen; Chen, Minhu; Xiao, Yinglian

2018-01-30

Esophageal baseline impedance, which is decreased in gastroesophageal reflux disease (GERD) patients, is related to the severity of acid reflux and the integrity of the esophageal mucosa. The study aims to compare the baseline impedance and the dilated intercellular spaces (DIS) within patients with typical reflux symptoms and to evaluate the correlation of baseline impedance with DIS, esophageal acid exposure, as well as the efficacy of proton pump inhibitor (PPI) treatment. Ninety-two patients and 10 healthy controls were included in the study. Erosive esophagitis (EE) was defined by esophageal mucosal erosion under upper endoscopy. Patients without mucosa erosion were divided into groups with pathologic acid reflux (non-erosive reflux disease [NERD]) or with hypersensitive esophagus. The biopsies of esophageal mucosa were taken 2-4 cm above the gastroesophageal junction Z-line during upper endoscopy for DIS measurement. All the patients received esomeprazole 20 mg twice-daily treatment for 8 weeks. The efficacy of esomeprazole was evaluated among all patients. The intercellular spaces were dilated in both EE and NERD patients ( P < 0.05). The value 0.73 µm could be used as the cut-off DIS value to distinguish patients from controls (area under the curve [AUC] = 0.849, P < 0.01). One thousand seven hundred sixty-four ohms could be used as the cut-off impedance values to distinguish patients from controls (AUC = 0.794, P < 0.01). The baseline impedance was decreased in both EE patients and NERD patients, and negatively correlated to the acid exposure time ( r = -0.527, P < 0.05). There was a weak correlation between DIS and baseline impedance ( r = -0.230, P < 0.05). "Baseline impedance > 1764 Ω" was an independent predictor for PPI failure (OR, 11.9; 95% CI, 2.4-58.9; P < 0.01). The DIS and decreased baseline impedance was observed in patients with mucosa erosion or pathological acid reflux. The baseline impedance reflected the mucosal integrity, it was more sensitive to esophageal acid exposure. Patients with high impedance might not benefit from the PPI treatment.

Effects of Age on Esophageal Motility: Use of High-resolution Esophageal Impedance Manometry

PubMed Central

Shim, Young Kwang; Kim, Nayoung; Park, Yo Han; Lee, Jong-Chan; Sung, Jihee; Choi, Yoon Jin; Yoon, Hyuk; Shin, Cheol Min; Park, Young Soo; Lee, Dong Ho

2017-01-01

Background/Aims Disturbances of esophageal motility have been reported to be more frequent the aged population. However, the physiology of disturbances in esophageal motility during aging is unclear. The aim of this study was to evaluate the effects of age on esophageal motility using high-resolution esophageal impedance manometry (HRIM). Methods Esophageal motor function of 268 subjects were measured using HRIM in 3 age groups, < 40 years (Group A, n = 32), 40–65 years (Group B, n = 185), and > 65 years (Group C, n = 62). Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) pressures, integrated relaxation pressure, distal contractile integral, contractile front velocity, distal latency, and pressures and duration of contraction on 4 positions along the esophagus, and complete bolus transit were measured. Results Basal UES pressure was lower in Group C (P < 0.001) but there was no significant difference in the LES pressure among groups. Contractile duration on position 3 (10 cm from proximal LES high pressure zone) was longer in Group C (P = 0.001), and the contractile amplitude on position 4 (5 cm from proximal LES high pressure zone) was lower in Group C (P = 0.005). Distal contractile integral was lower in Group C (P = 0.037). Contractile front velocity (P = 0.015) and the onset velocity (P = 0.040) was lower in Group C. There was no significant difference in impedance values. Conclusions The decrease of UES pressure, distal esophageal motility, and peristaltic velocity might be related with esophageal symptoms in the aged population. PMID:28163259

Esophageal dysfunction in different stages of Parkinson's disease.

PubMed

Suttrup, I; Suttrup, J; Suntrup-Krueger, S; Siemer, M-L; Bauer, J; Hamacher, C; Oelenberg, S; Domagk, D; Dziewas, R; Warnecke, T

2017-01-01

Dysphagia is a clinically relevant symptom in patients with Parkinson's disease (PD) leading to pronounced reduction in quality of life and other severe complications. Parkinson's disease-related dysphagia may affect the oral and pharyngeal, as well as the esophageal phase of swallowing. To examine the nature and extend of esophageal dysphagia in different stages of PD and their relation to oropharyngeal dysfunction, we examined 65 PD patients (mean age 66.3±9.7 years, mean disease duration 7.9±5.8 years, mean Hoehn & Yahr [H&Y] stage 2.89±0.91) and divided into three groups (early [H&Y I+II; n=21], intermediate [H&Y III; n=25], and advanced stadium [H&Y IV+V; n=19]), using esophageal high-resolution manometry (HRM) to detect esophageal motor disorders. Oropharyngeal impairment was assessed using fiberoptic endoscopic evaluation of swallowing. Major esophageal motor disorders were detected in nearly one third of the PD patients. Minor impairment of the esophageal body was present in 95% of participants and throughout all disease stages with pathological findings especially in peristalsis and intrabolus pressure (IBP). The IBP was found to significantly increase in the advanced stadium. Although dysfunction of the upper and lower esophageal sphincters was observed in individual patients, alterations in these esophageal segments revealed no statistical significance compared with normative data. No clear association was found between the occurrence of oropharyngeal dysphagia and esophageal impairment. Esophageal body impairment in PD is a frequent phenomenon during all disease stages, which possibly reflects α-synucleinopathy in the enteric nervous system. © 2016 John Wiley & Sons Ltd.

Repeated measures of recent headache, neck and upper back pain in Australian adolescents.

PubMed

Grimmer, K; Nyland, L; Milanese, S

2006-07-01

The epidemiological and clinical literature identifies strong associations between adult headache, cervical and thoracic spine dysfunction and spinal posture. This paper reports on the prevalence and incidence of headache, neck and upper back pain which occurred in the previous week, in urban Australians aged 13-17 years. Commencing in 1999, we followed a cohort of South Australian students through 5 years of secondary schooling. Of our commencing cohort of students, 132 (30%) provided data on bodily pain every year. For both girls and boys, there was a significantly decreasing prevalence of headache over the study period, while neck pain and upper back pain increased. There was a significantly increasing trend over time for boys with upper back pain. Twenty percent of girls and boys consistently reported headache, neck pain or upper back pain over 5 years. The progression of early adolescent headaches to mid-adolescent neck and upper back pain potentially reflects the adolescents' biomechanical responses to intrinsic and extrinsic imposts. This requires further investigation to understand the causes of adolescent headache, neck and upper thoracic pain.

Reduced lung dose during radiotherapy for thoracic esophageal carcinoma: VMAT combined with active breathing control for moderate DIBH.

PubMed

Gong, Guanzhong; Wang, Ruozheng; Guo, Yujie; Zhai, Deyin; Liu, Tonghai; Lu, Jie; Chen, Jinhu; Liu, Chengxin; Yin, Yong

2013-12-20

Lung radiation injury is a critical complication of radiotherapy (RT) for thoracic esophageal carcinoma (EC). Therefore, the goal of this study was to investigate the feasibility and dosimetric effects of reducing the lung tissue irradiation dose during RT for thoracic EC by applying volumetric modulated arc radiotherapy (VMAT) combined with active breathing control (ABC) for moderate deep inspiration breath-hold (mDIBH). Fifteen patients with thoracic EC were randomly selected to undergo two series of computed tomography (CT) simulation scans with ABC used to achieve mDIBH (representing 80% of peak DIBH value) versus free breathing (FB). Gross tumor volumes were contoured on different CT images, and planning target volumes (PTVs) were obtained using different margins. For PTV-FB, intensity-modulated radiotherapy (IMRT) was designed with seven fields, and VMAT included two whole arcs. For PTV-DIBH, VMAT with three 135° arcs was applied, and the corresponding plans were named: IMRT-FB, VMAT-FB, and VMAT-DIBH, respectively. Dosimetric differences between the different plans were compared. The heart volumes decreased by 19.85%, while total lung volume increased by 52.54% in mDIBH, compared to FB (p < 0.05). The mean conformality index values and homogeneity index values for VMAT-DIBH (0.86, 1.07) were slightly worse than those for IMRT-FB (0.90, 1.05) and VMAT-FB (0.90, 1.06) (p > 0.05). Furthermore, compared to IMRT-FB and VMAT-FB, VMAT-DIBH reduced the mean total lung dose by 18.64% and 17.84%, respectively (p < 0.05); moreover, the V5, V10, V20, and V30 values for IMRT-FB and VMAT-FB were reduced by 10.84% and 10.65% (p > 0.05), 12.5% and 20% (p < 0.05), 30.77% and 33.33% (p < 0.05), and 50.33% and 49.15% (p < 0.05), respectively. However, the heart dose-volume indices were similar between VMAT-DIBH and VMAT-FB which were lower than IMRT-FB without being statistically significant (p > 0.05). The monitor units and treatment time of VMAT-DIBH were also the lowest (p < 0.05). VMAT combined with ABC to achieve mDIBH is a feasible approach for RT of thoracic EC. Furthermore, this method has the potential to effectively reduce lung dose in a shorter treatment time and with better targeting accuracy.

Feeding Problems and Their Underlying Mechanisms in the Esophageal Atresia–Tracheoesophageal Fistula Patient

PubMed Central

Mahoney, Lisa; Rosen, Rachel

2017-01-01

Feeding difficulties such as dysphagia, coughing, choking, or vomiting during meals, slow eating, oral aversion, food refusal, and stressful mealtimes are common in children with repaired esophageal atresia (EA) and the reasons for this are often multifactorial. The aim of this review is to describe the possible underlying mechanisms contributing to feeding difficulties in patients with EA and approaches to management. Underlying mechanisms for these feeding difficulties include esophageal dysphagia, oropharyngeal dysphagia and aspiration, and aversions related to prolonged gastrostomy tube feeding. The initial diagnostic evaluation for feeding difficulties in a patient with EA may involve an esophagram, videofluoroscopic imaging or fiberoptic endoscopic evaluation during swallowing, upper endoscopy with biopsies, pH-impedance testing, and/or esophageal motility studies. The main goal of management is to reduce the factors contributing to feeding difficulties and may include reducing esophageal stasis, maximizing reflux therapies, treating underlying lung disease, dilating strictures, and altering feeding methods, routes, or schedules. PMID:28620597

[Transient lower esophageal sphincter relaxation and the related esophageal motor activities].

PubMed

Han, Seung Hyo; Hong, Su Jin

2012-03-01

Transient lower esophageal sphincter (LES) relaxation (TLESR) is defined as LES relaxation without a swallow. TLESRs are observed in both of the normal individuals and the patients with gastroesophageal reflux disorder (GERD). However, TLESR is widely considered as the major mechanism of the GERD. The new equipments such as high resolution manometry and impedance pH study is helped to understand of TLESR and the related esophageal motor activities. The strong longitudinal muscle contraction was observed during development of TLESR. Most of TLESRs are terminated by TLESR related motor events such as primary peristalsis and secondary contractions. The majority of TLESRs are associated with gastroesophageal reflux. Upper esophageal sphincter (UES) contraction is mainly associated with liquid reflux during recumbent position and UES relaxation predominantly related with air reflux during upright position. The frequency of TLESR in GERD patients seems to be not different compared to normal individuals, but the refluxate of GERD patients tend to be more acidic during TLESR.

Esophageal motor function in Graves' disease.

PubMed

Meshkinpour, H; Afrasiabi, M A; Valenta, L J

1979-02-01

Esophageal motor function was studied in 10 patients with untreated Graves' disease and 15 healthy volunteers who served as controls. A noncompliant recording system with a triple-lumen assembly was used. Resting upper- and lower-esophageal-sphincter pressures, amplitude, duration, and velocity of peristaltic contractions in the body of the esophagus, and the number of repetitive and simultaneous contractions were measured. There was no significant difference in peristaltic amplitude and duration between the controls and the patients with Graves' disease. However, there was a significant increase in velocity of contractions in Graves' disease as compared with controls. On restudy of 5 patients who became euthyroid after treatment with 131I, all the measured parameters were unchanged except for velocity of the peristaltic contractions. The value for this measurement decreased essentially to the same as that found in the control subjects. It is concluded that: (1) thyrotoxicosis increases the propagation velocity of esophageal contraction, and (2) thyroid hormones may play a physiologic role in the control of esophageal motor function.

[A case-control study on the risk factors of esophageal cancer in Linzhou].

PubMed

Lu, J; Lian, S; Sun, X; Zhang, Z; Dai, D; Li, B; Cheng, L; Wei, J; Duan, W

2000-12-01

To explore the characteristics of prevalence and influencing factors on the genesis of esophageal cancer. A population-based 1:1 matched case-control study was conducted in Linzhou. A total number of 352 pairs of cases and controls matched on sex, age and neighborhoods. Data was analysed by SAS software to calculate the odds ratio of and to evaluate the relative risks. It was found that lower socio-economic status, environmental pollution around the residential areas, lampblack in room, lower body mass index (BMI), more pickled food intake, cigarette smoking, alcoholic drinking, vigor mental-trauma and depression were risk factors of esophageal cancer. It also showed that the subjects having had history of upper digestive tract operation, dysplasia of esophagus and family history of carcinoma markedly increased the risks of developing esophageal cancer. Esophageal cancer seemed to be resulted from the combination of genetic and environmental factor, hence called for of medical surveillance and comprehensive prevention.

Use of 3-dimensional computed tomography to detect a barium-masked fish bone causing esophageal perforation.

PubMed

Tsukiyama, Atsushi; Tagami, Takashi; Kim, Shiei; Yokota, Hiroyuki

2014-01-01

Computed tomography (CT) is useful for evaluating esophageal foreign bodies and detecting perforation. However, when evaluation is difficult owing to the previous use of barium as a contrast medium, 3-dimensional CT may facilitate accurate diagnosis. A 49-year-old man was transferred to our hospital with the diagnosis of esophageal perforation. Because barium had been used as a contrast medium for an esophagram performed at a previous hospital, horizontal CT and esophageal endoscopy could not be able to identify the foreign body or characterize the lesion. However, 3-dimensional CT clearly revealed an L-shaped foreign body and its anatomical relationships in the mediastinum. Accordingly, we removed the foreign body using an upper gastrointestinal endoscope. The foreign body was the premaxillary bone of a sea bream. The patient was discharged without complications.

Dosimetric benefits of automation in the treatment of lower thoracic esophageal cancer: Is manual planning still an alternative option?

PubMed

Li, Xiadong; Wang, Lu; Wang, Jiahao; Han, Xu; Xia, Bing; Wu, Shixiu; Hu, Weigang

2017-01-01

This study aimed to design automated volumetric-modulated arc therapy (VMAT) plans in Pinnacle auto-planning and compare it with manual plans for patients with lower thoracic esophageal cancer (EC). Thirty patients with lower thoracic EC were randomly selected for replanning VMAT plans using auto-planning in Pinnacle treatment planning system (TPS) version 9.10. Historical plans of these patients were then compared. Dose-volume histogram (DVH) statistics, dose uniformity, and dose homogeneity were analyzed to evaluate treatment plans. Auto-planning was superior in terms of conformity index (CI) and homogeneity index (HI) for planning target volume (PTV), significantly improving 8.2% (p = 0.013) and 25% (p = 0.007) compared with manual planning, respectively, and decreasing dose of heart and liver irradiated by 20 to 40 Gy and 5 to 30 Gy, respectively (p < 0.05). Meanwhile, auto-planning further reduced the maximum dose (D max ) of spinal cord by 6.9 Gy compared with manual planning (p = 0.000). Additionally, manual planning showed the significantly lower low-dose volume (V 5 ) for the lung (p = 0.005). For auto-planning, the V 5 of the lung was significantly associated with the relative volume index (the volume ratio of PTV to the lung), and the correlation coefficient (R) and p-value were 0.994 and 0.000. Pinnacle auto-planning achieved superior target conformity and homogeneity and similar target coverage compared with historical manual planning. Most of organs at risk (OARs) sparing was significantly improved by auto-planning except for the V 5 of the lung, and the low dose distribution was highly associated with PTV volume and lung volume in auto-planning. Copyright © 2017 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.

Eosinophilic esophagitis prevalence in an adult population undergoing upper endoscopy in southeastern Mexico.

PubMed

De la Cruz-Patiño, E; Ruíz Juárez, I; Meixueiro Daza, A; Grube Pagola, P; Roesch-Dietlen, F; Remes-Troche, J M

2015-01-01

Eosinophilic esophagitis (EoE) prevalence fluctuates according to the population studied and varies from 0.4% in an open population to 6.5% in subjects with esophageal symptoms. Even though this entity has been described in North American and European populations, it is still considered an 'unusual' condition in Latin America. The study aimed to determine EoE prevalence in patients undergoing elective endoscopy in a tertiary referral center in southeastern Mexico. Consecutive patients were evaluated that had been referred to the Medical and Biological Research Institute, Veracruz, Mexico, for upper endoscopy due to gastrointestinal symptoms. Demographic variables and symptoms were analyzed in all the cases. Eight mucosal biopsies of the esophagus (four proximal and four distal) were obtained and were reviewed by a blinded pathologist. Histological diagnosis was established when the mean eosinophil count at a large magnification was ≥15. A total of 235 subjects (137 women, 51.16 years) were evaluated, and EoE prevalence was 1.7% (4/235 95% confidence interval 0.2-3.6%). In all four cases, pH test were normal. Among patients with histological diagnosis of EoE, a greater number of patients with a past history of asthma (50% vs. 19.3%, P = 0.04) and a tendency for a greater frequency of dysphagia (50% vs. 25%, P = 0.10). There were no differences in the endoscopic findings (rings, grooves, plaques, or stricture) when compared with the patients presenting with erosive esophagitis. EoE prevalence among patients undergoing upper endoscopy from southeastern Mexico was 1.7%, which can be regarded as intermediate to low. © 2014 International Society for Diseases of the Esophagus.

Effect of heterogeneity correction on dosimetric parameters of radiotherapy planning for thoracic esophageal cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nakayama, Masao, E-mail: naka2008@med.kobe-u.ac.jp; Yoshida, Kenji; Nishimura, Hideki

2014-04-01

The present study aimed to investigate the effect of heterogeneity correction (HC) on dosimetric parameters in 3-dimensional conformal radiotherapy planning for patients with thoracic esophageal cancer. We retrospectively analyzed 20 patients. Two treatment plans were generated for each patient using a superposition algorithm on the Xio radiotherapy planning system. The first plan was calculated without HC. The second was a new plan calculated with HC, using identical beam geometries and maintaining the same number of monitor units as the first. With regard to the planning target volume (PTV), the overall mean differences in the prescription dose, maximum dose, mean dose,more » and dose that covers 95% of the PTV between the first and second plans were 1.10 Gy (1.8%), 1.35 Gy (2.2%), 1.10 Gy (1.9%), and 0.56 Gy (1.0%), respectively. With regard to parameters related to the organs at risk (OARs), the mean differences in the absolute percentages of lung volume receiving greater than 5, 10, 20, and 30 Gy (lung V{sub 5}, V{sub 10}, V{sub 20}, and V{sub 30}) between the first and second plans were 7.1%, 2.7%, 0.4%, and 0.5%, respectively. These results suggest that HC might have a more pronounced effect on the percentages of lung volume receiving lower doses (e.g., V{sub 5} and V{sub 10}) than on the dosimetric parameters related to the PTV and other OARs.« less

Activity of thoracic and lumbar epaxial extensors during postural responses in the cat

NASA Technical Reports Server (NTRS)

Macpherson, J. M.; Fung, J.; Peterson, B. W. (Principal Investigator)

1998-01-01

This study examined the role of trunk extensor muscles in the thoracic and lumbar regions during postural adjustments in the freely standing cat. The epaxial extensor muscles participate in the rapid postural responses evoked by horizontal translation of the support surface. The muscles segregate into two regional groups separated by a short transition zone, according to the spatial pattern of the electromyographic (EMG) responses. The upper thoracic muscles (T5-9) respond best to posteriorly directed translations, whereas the lumbar muscles (T13 to L7) respond best to anterior translations. The transition group muscles (T10-12) respond to almost all translations. Muscles group according to vertebral level rather than muscle species. The upper thoracic muscles change little in their response with changes in stance distance (fore-hindpaw separation) and may act to stabilize the intervertebral angles of the thoracic curvature. Activity in the lumbar muscles increases along with upward rotation of the pelvis (iliac crest) as stance distance decreases. Lumbar muscles appear to stabilize the pelvis with respect to the lumbar vertebrae (L7-sacral joint). The transition zone muscles display a change in spatial tuning with stance distance, responding to many directions of translation at short distances and focusing to respond best to contralateral translations at the long stance distance.

SU-E-J-248: Comparative Study of Two Image Registration for Image-Guided Radiation Therapy in Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Shang, K; Wang, J; Liu, D

2014-06-01

Purpose: Image-guided radiation therapy (IGRT) is one of the major treatment of esophageal cancer. Gray value registration and bone registration are two kinds of image registration, the purpose of this work is to compare which one is more suitable for esophageal cancer patients. Methods: Twenty three esophageal patients were treated by Elekta Synergy, CBCT images were acquired and automatically registered to planning kilovoltage CT scans according to gray value or bone registration. The setup errors were measured in the X, Y and Z axis, respectively. Two kinds of setup errors were analysed by matching T test statistical method. Results: Fourmore » hundred and five groups of CBCT images were available and the systematic and random setup errors (cm) in X, Y, Z directions were 0.35, 0.63, 0.29 and 0.31, 0.53, 0.21 with gray value registration, while 0.37, 0.64, 0.26 and 0.32, 0.55, 0.20 with bone registration, respectively. Compared with bone registration and gray value registration, the setup errors in X and Z axis have significant differences. In Y axis, both measurement comparison results of T value is 0.256 (P value > 0.05); In X axis, the T value is 5.287(P value < 0.05); In Z axis, the T value is −5.138 (P value < 0.05). Conclusion: Gray value registration is recommended in image-guided radiotherapy for esophageal cancer and the other thoracic tumors. Manual registration could be applied when it is necessary. Bone registration is more suitable for the head tumor and pelvic tumor department where composed of redundant interconnected and immobile bone tissue.« less

Effects of pacifier and taste on swallowing, esophageal motility, transit, and respiratory rhythm in human neonates.

PubMed

Shubert, T R; Sitaram, S; Jadcherla, S R

2016-04-01

Pacifier use is widely prevalent globally despite hygienic concerns and uncertain mechanistic effects on swallowing or airway safety. The effects of pacifier and taste interventions on pharyngo-esophageal motility, bolus transit, and respiratory rhythms were investigated by determining the upper esophageal sphincter (UES), esophageal body, esophagogastric junction (EGJ) motor patterns and deglutition apnea, respiratory rhythm disturbances, and esophageal bolus clearance. Fifteen infants (six males; median gestation 31 weeks and birth weight 1.4 kg) underwent high-resolution impedance manometry at 43 (41-44) weeks postmenstrual age. Manometric, respiratory, and impedance characteristics of spontaneous swallows, pacifier-associated dry swallowing and taste (pacifier dipped in 3% sucrose)-associated swallowing were analyzed. Linear mixed and generalized estimating equation models were used. Data are presented as mean ± SEM, %, or median (IQR). Pharyngo-esophageal motility, respiratory, and impedance characteristics of 209 swallows were analyzed (85 spontaneous swallows, 63 pacifier- swallows, 61 taste- swallows). Basal UES and EGJ pressures decreased upon pacifier (p < 0.05) and taste interventions (p < 0.05); however, esophageal motility, respiratory rhythm, and impedance transit characteristics were similar with both interventions. Oral stimulus with pacifier or taste interventions decreases UES and EGJ basal pressure, but has no effects on pharyngo-esophageal motility, airway interactions, or esophageal bolus transit. A decrease in central parasympathetic-cholinergic excitatory drive is likely responsible for the basal effects. © 2016 John Wiley & Sons Ltd.

Incidence of Esophageal Carcinomas After Surgery for Achalasia: Usefulness of Long-Term and Periodic Follow-up.

PubMed

Ota, Masaho; Narumiya, Kosuke; Kudo, Kenji; Yagawa, Yohsuke; Maeda, Shinsuke; Osugi, Harushi; Yamamoto, Masakazu

2016-11-14

BACKGROUND Patients with esophageal achalasia are considered to be a high-risk group for esophageal carcinoma, and it has been reported that this cancer often arises at a long interval after surgery for achalasia. However, it is unclear whether esophageal carcinoma is frequent when achalasia has been treated successfully and the patient is without dysphagia. In this study, we reviewed patients with esophageal carcinoma who were detected by regular follow-up after surgical treatment of achalasia.   CASE REPORT Esophageal cancer was detected by periodic upper GI endoscopy in 6 patients. Most of them had early cancers that were treated by endoscopic resection. All 6 patients had undergone surgery for achalasia and the outcome had been rated as excellent or good. Annual follow-up endoscopy was done and the average duration of follow-up until cancer was seen after surgery was 14.3 years (range: 5 to 40 years). Five patients had early cancer. Four cases had multiple lesions.   CONCLUSIONS In conclusion, surgery for achalasia usually improves passage symptoms, but esophageal cancer still arises in some cases and the number of tumors occurring many years later is not negligible. Accordingly, long-term endoscopic follow-up is needed for detection of malignancy at an early stage.

Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry.

PubMed

Roman, S; Holloway, R; Keller, J; Herbella, F; Zerbib, F; Xiao, Y; Bernard, L; Bredenoord, A J; Bruley des Varannes, S; Chen, M; Fox, M; Kahrilas, P J; Mittal, R K; Penagini, R; Savarino, E; Sifrim, D; Wu, J; Decullier, E; Pandolfino, J E; Mion, F

2017-02-01

Criteria for transient lower esophageal sphincter relaxations (TLESRs) are well-defined for Dentsleeve manometry. As high-resolution manometry (HRM) is now the gold standard to assess esophageal motility, our aim was to propose a consensus definition of TLESRs using HRM. Postprandial esophageal HRM combined with impedance was performed in 10 patients with gastroesophageal reflux disease. Transient lower esophageal sphincter relaxations identification was performed by 17 experts using a Delphi process. Four investigators then characterized TLESR candidates that achieved 100% agreement (TLESR events) and those that achieved less than 25% agreement (non-events) after the third round. Logistic regression and decision tree analysis were used to define optimal diagnostic criteria. All diagnostic criteria were more frequently encountered in the 57 TLESR events than in the 52 non-events. Crural diaphragm (CD) inhibition and LES relaxation duration >10 seconds had the highest predictive value to identify TLESR. Based on decision tree analysis, reflux on impedance, esophageal shortening, common cavity, upper esophageal sphincter relaxation without swallow and secondary peristalsis were alternate diagnostic criteria. Using HRM, TLESR might be defined as LES relaxation occurring in absence of swallowing, lasting more than 10 seconds and associated with CD inhibition. © 2016 John Wiley & Sons Ltd.

Navigating the pathway to robotic competency in general thoracic surgery.

PubMed

Seder, Christopher W; Cassivi, Stephen D; Wigle, Dennis A

2013-01-01

Although robotic technology has addressed many of the limitations of traditional videoscopic surgery, robotic surgery has not gained widespread acceptance in the general thoracic community. We report our initial robotic surgery experience and propose a structured, competency-based pathway for the development of robotic skills. Between December 2008 and February 2012, a total of 79 robot-assisted pulmonary, mediastinal, benign esophageal, or diaphragmatic procedures were performed. Data on patient characteristics and perioperative outcomes were retrospectively collected and analyzed. During the study period, one surgeon and three residents participated in a triphasic, competency-based pathway designed to teach robotic skills. The pathway consisted of individual preclinical learning followed by mentored preclinical exercises and progressive clinical responsibility. The robot-assisted procedures performed included lung resection (n = 38), mediastinal mass resection (n = 19), hiatal or paraesophageal hernia repair (n = 12), and Heller myotomy (n = 7), among others (n = 3). There were no perioperative mortalities, with a 20% complication rate and a 3% readmission rate. Conversion to a thoracoscopic or open approach was required in eight pulmonary resections to facilitate dissection (six) or to control hemorrhage (two). Fewer major perioperative complications were observed in the later half of the experience. All residents who participated in the thoracic surgery robotic pathway perform robot-assisted procedures as part of their clinical practice. Robot-assisted thoracic surgery can be safely learned when skill acquisition is guided by a structured, competency-based pathway.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yang, J; Wang, X; Zhao, Z

Purpose: Acute esophageal toxicity is a common side effect in spine stereotactic body radiotherapy (SBRT). The respiratory motion may alter esophageal position from the planning scan resulting in excessive esophageal dose. Here we assessed the dosimetric impact resulting from the esophageal motion using 4DCT. Methods: Nine patients treated to their thoracic spines in one fraction of 24 Gy were identified for this study. The original plan on a free breathing CT was copied to each phase image of a 4DCT scan, recalculated, scaled, and accumulated to the free breathing CT using deformable image registration. A segment of esophagus was contouredmore » in the vicinity of treatment target. Esophagus dose volume histogram (DVH) was generated for both the original planned dose and the accumulated 4D dose for comparison. In parallel, we performed a chained deformable registration of 4DCT phase images to estimate the motion magnitude of the esophagus in a breathing cycle. We examined the correlation between the motion magnitude and the dosimetric deviation. Results: The esophageal motion mostly exhibited in the superior-inferior direction. The cross-sectional motion was small. Esophagus motion at T1 vertebra level (0.7 mm) is much smaller than that at T11 vertebra level (6.5 mm). The difference of Dmax between the original and 4D dose distributions ranged from 9.1 cGy (esophagus motion: 5.6 mm) to 231.1 cGy (esophagus motion: 3.1 mm). The difference of D(5cc) ranged from 5 cGy (esophagus motion: 3.1 mm) to 85 cGy (esophagus motion: 3.3 mm). There was no correlation between the dosimetric deviation and the motion magnitude. The V(11.9Gy)<5cc constraint was met for each patient when examining the DVH calculated from the 4D dose. Conclusion: Respiratory motion did not result in substantial dose increase to esophagus in spine SBRT. 4DCT simulation may not be necessary with regards to esophageal dose assessment.« less

Effect of sodium meclofenamate on radiation-induced esophagitis and cystitis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ambrus, J.L.; Ambrus, C.M.; Lillie, D.B.

Stumptailed monkeys (Macaca arctoides) received 2000 rad irradiation to the upper half of the esophagus and to the bladder by a 6-MeV linear accelerator. Endoscopy and biopsy was obtained from these organs weekly for 3 weeks. At the end of this period, the animals were autopsied and histopathologic examination undertaken. Sodium meclofenamate in doses of 5-20 mg/kg/day p.os was found effective in reducing or preventing radiation-induced esophagitis and cystitis.

Acute Esophageal Necrosis: An Update

PubMed Central

Inayat, Faisal; Hurairah, Abu; Virk, Hafeez Ul Hassan

2016-01-01

Acute esophageal necrosis (AEN) or “black esophagus” is a rare clinical entity with an unclear etiology. It is diagnosed at upper gastrointestinal endoscopy with the presence of strikingly black necrotic esophagus. The treatment is primarily medical, but the prognosis is generally poor due to advanced age and comorbid illnesses in patients who develop AEN. Herein, we discussed the implications of poor glycemic control in regards with AEN and undertook a literature review of this rare diagnosis. PMID:27583242

Effort Thrombosis Presenting as Pulmonary Embolism in a Professional Baseball Pitcher

PubMed Central

Bushnell, Brandon D.; Anz, Adam W.; Dugger, Keith; Sakryd, Gary A.; Noonan, Thomas J.

2009-01-01

Context: Effort thrombosis, or Paget-Schroetter’s syndrome, is a rare subset of thoracic outlet syndrome in which deep venous thrombosis of the upper extremity occurs as the result of repetitive overhead motion. It is occasionally associated with pulmonary embolism. This case of effort thrombosis and pulmonary embolus was in a 25-year-old major league professional baseball pitcher, in which the only presenting complaints involved dizziness and shortness of breath without complaints involving the upper extremity—usually, a hallmark of most cases of this condition. The patient successfully returned to play for 5 subsequent seasons at the major league level after multimodal treatment that included surgery for thoracic outlet syndrome. Objective: Though rare, effort thrombosis should be included in the differential diagnosis of throwing athletes with traditional extremity-focused symptoms and in cases involving pulmonary or thoracic complaints. Rapid diagnosis is a critical component of successful treatment. PMID:23015912

Zn concentration in esophageal tissue in patients with and without upper gastrointestinal disease

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wong, R.K.H.; Kadakia, S.C.; Maydonovitch, C.

1986-03-05

Measurements of tissue Zn in humans with upper gastrointestinal disease could provide information about underlying pathophysiology but these data have never been obtained. With recent endoscopic methods they obtained 2-6 mg pinch mucosal biopsies of epithelium and lamina propria from proximal (P), middle (M) and distal (D) areas of esophagus under direct vision through a flexible 1 cm endoscope in 35 subjects without gastrointestinal disease (N) and in 35 patients with the following endoscopically proven gastrointestinal pathology: 12 with esophagitis (E), 14 with duodenal ulcer disease (DU) and 9 with gastritis (G). Samples were dried, weighed, digested with HNO/sub 3/,more » dried, resuspended in 3% HNO/sub 3/ and Zn estimated by flame atomic absorption spectrophotometry. Esophageal Zn in N decreased progressively as biopsies extended from P to D (P, 108 +/- 29 ..mu..g/g dry weight, Mean +/- SEM; M, 158 +/- 23; D, 134 +/- 16) but this pattern was generally reversed in patients, with D consistently demonstrating Zn elevated 50-120% above normal. The greatest increase was in G in whom Zn in D was more than twice normal (DU, 290 +/- 76, p < 0.01). These are the first Zn levels obtained from esophagus in living human subjects and indicate (1) a specific pattern of Zn distribution in normal esophagus and (2) a significantly altered pattern in D in several diseases of the upper gastrointestinal tract.« less

3D printing-assisted preoperative plan of pedicle screw placement for middle-upper thoracic trauma: a cohort study.

PubMed

Xu, Wei; Zhang, Xuming; Ke, Tie; Cai, Hongru; Gao, Xiang

2017-08-11

This study aimed to evaluate the application of 3D printing in assisting preoperative plan of pedicle screw placement for treating middle-upper thoracic trauma. A preoperative plan was implemented in seven patients suffering from middle-upper thoracic (T3-T7) trauma between March 2013 and February 2016. In the 3D printing models, entry points of 56 pedicle screws (Magerl method) and 4 important parameters of the pedicle screws were measured, including optimal diameter (ϕ, mm), length (L, mm), inclined angle (α), head-tilting angle (+β), and tail-tilting angle (-β). In the surgery, bare-hands fixation of pedicle screws was performed using 3D printing models and the measured parameters as guidance. A total of seven patients were enrolled, including five men and two women, with the age of 21-62 years (mean age of 37.7 years). The position of the pedicle screw was evaluated postoperatively using a computerized tomography scan. Totally, 56 pedicle screws were placed, including 33 pieces of level 0, 18 pieces of level 1, 4 pieces of level 2 (pierced lateral wall), and 1 piece of level 3 (pierced lateral wall, no adverse consequences), with a fine rate of 91.0%. 3D printing technique is an intuitive and effective assistive technology to pedicle screw fixation for treating middle-upper thoracic vertebrae, which improve the accuracy of bare-hands screw placement and reduce empirical errors. The trial was approved by the Ethics Committee of the Fujian Provincial Hospital. It was registered on March 1st, 2013, and the registration number was K2013-03-001.

Preoperative noninvasive EUS evaluation in patients with esophageal cancer considered for esophagectomy.

PubMed

Gheorghe, Cristian; Stanescu, Codrut; Gheorghe, Liana; Bancila, Ion; Herlea, Vlad; Becheanu, Gabriel; Voinea, Daniela; Iacob, Razvan; Lupescu, Ioana; Anghel, Rodica; Croitoru, Adina; Popescu, Irinel

2006-06-01

Worldwide, esophageal cancer ranks fifth in the mortality rate regarding tumor locations. EUS is an essential tool in the evaluation of these patients allowing accurate staging and permitting stratified treatment options. AIM. We have studied prospectively the impact of EUS in the evaluation and decision for therapy of patients with esophageal cancer diagnosed in our center. From March 2001 through March 2006, 220 patients were hospitalized at the Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, with the diagnosis of esophageal cancer. Out of the 220 patients, 41 patients, with no major comorbidities contraindicating esophagectomy already having been screened by abdominal and thoracic CT to disclose distant metastases, had EUS with the definite purpose of staging esophageal carcinoma and selecting adequate therapy. Assuming that without preoperative staging by EUS, all 41 patients in the study group would have been offered surgical treatment, we evaluated the number of patients and the modality in which EUS resulted in changes to the therapeutic plan. Depth of invasion was recorded for the 41 patients as follows: T1 in 2 patients (4.9%), T2 in 6 patients (14.6%), T3 in 24 patients (58.5%), and T4 in 10 patients (22%). Regional lymph node (N) status as determined by EUS criteria was as follows: N0 in 7 patients (17%) and N1 in 34 patients (83%). Assessment of distant metastases (M) was recorded showing 4 patients with celiac axis lymph nodes metastases (M1). Preoperative EUS staging changed the decision for surgery in 18 of 41 patients (44%) (p<0.0001) and allowed primary esophagectomy in only 6 patients (15%) (p<0.0001). Compared to histopathology, the overall accuracy of EUS staging for pT1 and pT2 was 80% for staging pT3 and pT4 77% and for lymph node evaluation was approximately 75%. Esophageal EUS offers useful information to clinicians caring for patients with esophageal cancer, impacts clinical decision making, and should be used in appropriate settings to plan patients' care.

Diagnostic Imaging and Newer Modalities for Thoracic Diseases: PET/Computed Tomographic Imaging and Endobronchial Ultrasound for Staging and Its Implication for Lung Cancer.

PubMed

Counts, Sarah J; Kim, Anthony W

2017-08-01

Modalities to detect and characterize lung cancer are generally divided into those that are invasive [endobronchial ultrasound (EBUS), esophageal ultrasound (EUS), and electromagnetic navigational bronchoscopy (ENMB)] versus noninvasive [chest radiography (CXR), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI)]. This chapter describes these modalities, the literature supporting their use, and delineates what tests to use to best evaluate the patient with lung cancer. Copyright © 2017 Elsevier Inc. All rights reserved.

An Unusual Cause of Acute Upper Gastrointestinal Bleeding: Acute Esophageal Necrosis

PubMed Central

Tokala, Madhusudhan R.; Dhillon, Sonu; Pisoh, Watcoun-Nchinda; Walayat, Saqib; Vanar, Vishwas; Puli, Srinivas R.

2016-01-01

Acute esophageal necrosis (AEN), also called “black esophagus,” is a condition characterized by circumferential necrosis of the esophagus with universal distal involvement and variable proximal extension with clear demarcation at the gastroesophageal junction. It is an unusual cause of upper gastrointestinal bleeding and is recognized with distinct and striking mucosal findings on endoscopy. The patients are usually older and are critically ill with shared comorbidities, which include atherosclerotic cardiovascular disease, diabetes mellitus, hypertension, chronic renal insufficiency, and malnutrition. Alcoholism and substance abuse could be seen in younger patients. Patients usually have systemic hypotension along with upper abdominal pain in the background of clinical presentation of hematemesis and melena. The endoscopic findings confirm the diagnosis and biopsy is not always necessary unless clinically indicated in atypical presentations. Herein we present two cases with distinct clinical presentation and discuss the endoscopic findings along with a review of the published literature on the management of AEN. PMID:27642529

Photodynamic therapy--1994: treatment of benign and malignant upper aerodigestive tract disease

NASA Astrophysics Data System (ADS)

Schweitzer, Vanessa G.

1995-03-01

From 1983 to 1994 Phase II and III clinical studies at Henry Ford Hospital demonstrated complete or partial responses in 46 of 47 patients treated with hematoporphyrin-derivative photodynamic therapy (HPD-PDT) for a variety of benign and malignant upper aerodigestive tract disease: (1) superficial `condemned mucosa' or `field cancerization' of the oral cavity; (2) stage III/IV head and neck cancer; (3) mucocutaneous AIDS-related Kaposi's sarcoma of the upper aerodigestive tract; (4) recurrent laryngotracheal papillomatosis; (5) severe dysplasia/adenocarcinoma in situ in Barrett's esophagus; (6) partial or completely obstructing terminal esophageal cancer. HPD-PDT produced complete responses in 19 patients (follow up 6 months to 8 years) with `field cancerization' (CIS, T1) of the oral cavity and larynx (6), adenocarcinoma in situ in Barrett's esophagus (2), mucocutaneous Kaposi's sarcoma (9), obstructing esophageal carcinoma (1), and stage IV squamous cell carcinoma of the nasopharynx (1). PDT treatment protocols, results, complications, and application as adjunct or primary oncologic therapy for head and neck disease are reviewed.

Use of thoracic spine thrust manipulation for neck pain and headache in a patient following multiple-level anterior cervical discectomy and fusion: a case report.

PubMed

Salvatori, Renata; Rowe, Robert H; Osborne, Raine; Beneciuk, Jason M

2014-06-01

Case report. Thoracic spine thrust manipulation has been shown to be an effective intervention for individuals experiencing mechanical neck pain. The patient was a 46-year-old woman referred to outpatient physical therapy 2 months following multiple-level anterior cervical discectomy and fusion. At initial evaluation, primary symptoms consisted of frequent headaches, neck pain, intermittent referred right elbow pain, and muscle fatigue localized to the right cervical and upper thoracic spine regions. Initial examination findings included decreased passive joint mobility of the thoracic spine, limited cervical range of motion, and limited right shoulder strength. Outcome measures consisted of the numeric pain rating scale, the Neck Disability Index, and the global rating of change scale. Treatment consisted of a combination of manual therapy techniques aimed at the thoracic spine, therapeutic exercises for the upper quarter, and patient education, including a home exercise program, over a 6-week episode of care. Immediate reductions in cervical-region pain (mean ± SD, 2.0 ± 1.1) and headache (2.0 ± 1.3) intensity were reported every treatment session immediately following thoracic spine thrust manipulation. At discharge, the patient reported 0/10 cervical pain and headache symptoms during all work-related activities. From initial assessment to discharge, Neck Disability Index scores improved from 46% to 16%, with an associated global rating of change scale score of +7 ("a very great deal better"). This case report describes the immediate and short-term clinical outcomes for a patient presenting with symptoms of neck pain and headache following anterior cervical discectomy and fusion surgical intervention. Clinical rationale and patient preference aided the decision to incorporate thoracic spine thrust manipulation as a treatment for this patient. Level of Evidence Therapy, level 4.

Photodynamic therapy for cancer

MedlinePlus

... Photoradiation therapy; Cancer of the esophagus - photodynamic; Esophageal cancer - photodynamic; Lung cancer - photodynamic ... the light at the cancer cells. PDT treats cancer in the: Lungs, using a bronchoscope Esophagus, using upper endoscopy Doctors ...

[A Case of Removable Self-Expandable Metallic Stent(SEMS)Placement for Gastric Tube Stenosis after Esophageal Cancer Resection].

PubMed

Yoshikawa, Yukihiro; Yoshikawa, Masato; Kawabata, Ryohei; Yoshida, Yuta; Kawada, Masahiro; Yasuyama, Akinobu; Watase, Chikashi; Koga, Chikato; Hitora, Toshiki; Murakami, Masahiro; Hirota, Masaki; Ikenaga, Masakazu; Shimizu, Junzo; Hasegawa, Junichi

2015-11-01

A 68-year-old man underwent esophagectomy for early esophageal cancer. Postoperative upper gastrointestinal series and esophagogastroduodenoscopy showed gastric tube stenosis. To improve passage, a removable self-expandable metallic stent (SEMS) was placed across the stenotic lesion. Two weeks later, the stent was removed, and passage through the gastric tube improved. The patient has no symptoms of stenosis. A removable SEMS could be an option for the treatment of gastric tube stenosis after esophagectomy.

Prevalence of eosinophilic esophagitis in patients with gastroesophageal reflux symptoms: A cross-sectional study from a tertiary care hospital in North India.

PubMed

Baruah, Bhaskarjyoti; Kumar, Tarun; Das, Prasenjit; Thakur, Bhaskar; Sreenivas, Vishnubatla; Ahuja, Vineet; Gupta, Siddhartha Datta; Makharia, Govind K

2017-09-01

Eosinophilic esophagitis (EoE) is being recognized increasingly all over the globe; Indian data is however sparse. We screened patients with symptoms of gastroesophageal reflux disease (GERD) for presence of EoE in them. Consecutive patients with symptoms suggestive of GERD underwent gastroduodenoscopy and esophageal biopsies, obtained from both the upper esophagus (5 cm below the upper esophageal sphincter) and lower esophagus (5 cm above gastroesophageal junction), as well as from any other endoscopically visible abnormal mucosa. Demographic and clinical characteristics, endoscopic findings, peripheral blood eosinophilic count, and history of use of proton-pump inhibitors (PPIs) were analyzed. Stool examination was done to rule out parasitoids. EoE was diagnosed if number of mucosal eosinophil infiltrate was >20 per high-power field. In the latter, Warthin-Starry stain was performed to rule out presence of H elicobacter pylori. Of 190 consecutive patients with symptoms of GERD screened, esophageal biopsies were available in 185 cases. Of them, 6 had EoE, suggesting a prevalence of 3.2% among patients with GERD. On univariate analysis, history of allergy, non-response to PPI, and absolute eosinophil counts and on multivariable analysis, history of allergy and no response to PPIs were significant predictors of EoE. Presence of EOE did not correlate with severity of reflux symptoms. In this hospital-based study from northern part of India, prevalence of EoE in patients with GERD was 3.2%. EoE should be considered as a diagnostic possibility, especially in those with history of allergy, no-response to PPI, and absolute eosinophil count of ≥250/cumm.

Preoperative endoscopic titanium clip placement facilitates intraoperative localization of early-stage esophageal cancer or severe dysplasia.

PubMed

Tan, Lei; Feng, Juan; Zhao, Qin; Chen, Ping; Yang, Guotao

2017-08-02

Accurate intraoperative localization of esophageal lesions is essential for successful surgical resection. We tested whether preoperative endoscopic placement of titanium clips could facilitate intraoperative localization of early-stage esophageal cancer or severe dysplasia. A prospective randomized clinical trial was performed between May 2012 and July 2014. All enrolled patients received preoperative endoscopy and esophageal endoscopic ultrasound, as well as pathological study on the biopsy specimen, to confirm early stage esophageal cancer or severe dysplasia. One day before the surgical operation, patients in the experimental group received the preoperative endoscopic titanium labeling of esophageal lesions. Then, during the surgical operation, palpitation of titanium clips was used to localize the lesions in these patients. In patients in the control group, palpitation of nodules or esophageal wall mucosal thickening, together with the consideration of the results from preoperative endoscopic and ultrasound studies, was applied to estimate the location of the esophageal lesions. Study outcomes included the proportions of patients having successful intraoperative pre-resection lesion localization, post-esophagectomy lesion visualization, negative upper surgical margin, change of surgical approaches, and positive postoperative pathological diagnosis. A total of 27 patients were enrolled into the study, with 14 in the experimental group and 13 in the control group. Compared to the patients in the control group, a higher proportion of patients in the experimental group had statistically significant successful intraoperative esophageal lesion localization (100 versus 15.3% in the experimental versus control group). Preoperative endoscopic titanium clip placement could facilitate intraoperative localization of early-stage esophageal cancer or severe dysplasia. Current study was registered in Chinese Clinical Trial Registry and World Health Organization International Clinical Trials Registry Platform, ChiCTR-INR-17010949 . Registered 22 March 2017, retrospectively registered.

Esophageal and anorectal involvement in systemic sclerosis: a systematic assessment with high resolution manometry.

PubMed

Luciano, Laure; Granel, Brigitte; Bernit, Emmanuelle; Harle, Jean-Robert; Baumstarck, Karine; Grimaud, Jean-Charles; Bouvier, Michel; Vitton, Véronique

2016-01-01

In systemic sclerosis (SSc), esophageal and anorectal involvements are frequent and often associated with each other. In clinical practice, esophageal explorations are often prescribed, while anorectal explorations are rarely proposed and therefore, under-recognised. However, it is well documented in the literature that early detection of anorectal dysfunction could delay and/or prevent the onset of symptoms such as fecal incontinence (FI). The main objective was the systematic evaluation and detection of esophageal and anorectal involvements in SSc patients. In this monocentric retrospective study, all patients with SSc addressed in the Department of Functional Digestive Explorations, North Hospital, Marseille for esophageal and anorectal explorations were included. Self-Questionnaires, evaluating the symptoms and quality of life, were filled by patients during their visit. Explorations were performed on the same day: high resolution esophageal manometry (EHRM), 3 Dimensional high resolution anorectal manometry (3DHRARM) and endo anal sonography (EUS). 44 patients (41 women), mean age 59.8±12 years, were included. With regard to the symptoms, 45.5% of patients had gastro-esophageal reflux disease (GERD), 66.9% dysphagia, 65.9% constipation and 77.3% FI. The incidence of esophageal dismotility was 65.9%, anorectal and both upper and lower dysfunction were 43.2%. More than 89% patients with abnormal explorations (EHRM, 3DHRARM or both) were symptomatic. Duration of SSc and altered quality of life was correlated with the severity of digestive involvement. Anorectal dysfunction appears to be closely linked to esophageal involvement in SSc. Their routine screening is undoubtedly essential to limit the occurrence of severe symptoms such as FI.

A functional study of the esophagus in patients with non-cardiac chest pain and dysphagia.

PubMed

Gullo, Roberto; Inviati, Angela; Almasio, Piero Luigi; Di Paola, Valentina; Di Giovanni, Silvia; Scerrino, Gregorio; Gulotta, Gaspare; Bonventre, Sebastiano

2015-03-01

Nutcracker esophagus and non-specific motility disorders are the main causes of non-cardiac chest pain (NCCP), with gastroesophageal reflux in 60% of cases. Achalasia and diffuse esophageal spasm are the most frequent anomalies described in patients with dysphagia. The goal of this study was to evaluate the occurrence of esophageal body and lower esophageal sphincter motor abnormalities in patients with dysphagia, NCCP, or both. This study is a retrospective analysis of 716 patients with NCCP and/or dysphagia tested between January 1994 and December 2010. 1023 functional studies were performed, 707 of which were esophageal manometries, 225 esophageal pH-meters, and 44 bilimetries. We divided the patients into three groups: group 1 was composed of patients affected with dysphagia, group 2 with NCCP and group 3 with NCCP and dysphagia. Manometric anomalies were detected in 84.4% of cases (p<0.001). The most frequent esophageal motility alteration was achalasia (36%). The lower esophageal sphincter was normal in 45.9% of patients (p<0.001). In all 3 groups, 80.9%, 98.8%, and 93.8, respectively, of patients showed normal upper esophageal sphincter (p=0.005). Our data differs from those of other studies because they were collected from and analyzed by a single tertiary level referral center by a single examiner. This could have eliminated the variability found in different hands and different experiences. The high percentage of symptomatic patients with non-pathologic esophageal motility pattern suggests an unclear origin of the disease, with possible neuromuscular involvement. As a result, these patients may need more-detailed diagnostic studies.

Photodynamic therapy in thoracic oncology: a single institution experience

NASA Astrophysics Data System (ADS)

Luketich, James D.; Fernando, Hiran C.; Christie, Neil A.; Litle, Virginia R.; Ferson, Peter F.; Buenaventura, Percival O.

2001-04-01

We have performed 800 photodynamic therapy (PDT) treatments in over 300 patients at the University of Pittsburgh since 1996. Over 150 patients have undergone PDT for palliation of dysphagia for esophageal cancer. Of the first 77 dysphagia improved in 90.8% with a mean dysphagia-free interval of 80 days. An expandable metal stent was required for extrinsic compression in 19 patients. We have treated 14 high-risk patients with early esophageal cancer or Barrett's high-grade dysplasia for curative intent. At a median follow-up of 12.8 months eight remain free of cancer. Over 100 patients have undergone PDT for lung cancer. Sixty-two patients received 77 courses for palliation. Thirty-five patients were treated for non-massive hemoptysis with resolution in 90%. Forty-four patients were treated for dyspnea with improvement in 59%. A subset of seven high-risk patients with early lung cancer were treated with curative intent. A complete response was seen in 7/10 lesions at a mean follow-up of 30 months. PDT offers good palliation for both advanced esophageal and lung cancer. The role of PDT for curative intent needs further investigation in protocol settings. In our preliminary experience we have treated a small number of non-surgical, high-risk patients with a reasonable success rate.

Specific movement of esophagus during transient lower esophageal sphincter relaxation in gastroesophageal reflux disease.

PubMed

Kim, Hoon Il; Hong, Su Jin; Han, Jae Pil; Seo, Jung Yeon; Hwang, Kyoung Hwa; Maeng, Hyo Jin; Lee, Tae Hee; Lee, Joon Seong

2013-07-01

Transient lower esophageal sphincter relaxation (TLESR) is the main mechanism of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the characteristics of transient lower esophageal sphincter movement in patients with or without gastroesophageal reflux by high-resolution manometry (HRM). From June 2010 to July 2010, we enrolled 9 patients with GERD (GERD group) and 9 subjects without GERD (control group), prospectively. The manometry test was performed in a semi-recumbent position for 120 minutes following ingestion of a standardized, mixed liquid and solid meal. HRM was used to identify the frequency and duration of TLESR, esophageal shortening length from incomplete TLESR, upper esophageal sphincter (UES) response, and the related esophageal motor responses during TLESR. TLESR occurred in 33 in the GERD group and 34 in the control group after 120 minutes following food ingestion. Duration of TLESR and length of esophageal shortening did not differ between 2 groups. UES pressure increase during TLESR was mostly detected in patients with GERD, and UES relaxation was observed frequently in the control group during TLESR. TLESR-related motor responses terminating in TLESR were predominantly observed in the control group. Increased UES pressure was noted frequently in the GERD group, suggesting a mechanism for preventing harmful reflux, which may be composed mainly of fluid on the larynx or pharynx. However, patients with GERD lacked the related motor responses terminating in TLESR to promote esophageal emptying of refluxate.

Influence of esophagectomy on the gastroesophageal reflux in patients with esophageal cancer.

PubMed

Kim, D; Min, Y W; Park, J G; Lee, H; Min, B-H; Lee, J H; Rhee, P-L; Kim, J J; Zo, J I

2017-12-01

This study aims to assess the influence of esophagectomy with gastric transposition on the gastroesophageal reflux (GER) and gastric acidity in patients with esophageal cancer. Data on 53 esophageal cancer patients who underwent 24-hour impedance-pH monitoring after esophagectomy were retrospectively analyzed. We used a solid-state esophageal pH probe in which the esophageal pH sensor is placed 1.5 cm distal to the upper esophageal sphincter and the gastric pH sensor is located 15 cm distal to the esophageal pH channel. 24-hour impedance-pH monitoring data and other clinical data including anastomosis site stricture and incidence of pneumonia were collected. We defined pathologic reflux with reference to known normative data. Stricture was defined when an intervention such as bougienage or balloon dilatation was required to relieve dysphagia. The esophageal and gastric mean pH were 5.47 ± 1.51 and 3.33 ± 1.64, respectively. The percent time of acidic pH (<4) was 6.66 ± 12.49% in the esophagus and 70.53 ± 32.19% in the stomach. Esophageal pathologic acid reflux was noticed in 32.1%, 20.8%, and 35.8% during total, upright, and recumbent time, respectively. Esophageal pathologic bolus reflux was noted in 83.0%, 77.4%, and 64.2% during total, upright, and recumbent time, respectively. Gastric acidity increased with time after esophagectomy. Esophageal acid exposure time correlated with intragastric pH. However, esophageal pathologic acid reflux was not associated with anastomosis site stricture or pneumonia. In conclusion, GER frequently occurs after esophagectomy. Thus, strict lifestyle modifications and acid suppression would be necessary in patients following esophagectomy. © The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Esophageal sensation in premature human neonates: temporal relationships and implications of aerodigestive reflexes and electrocortical arousals

PubMed Central

Parks, Vanessa N.; Peng, Juan; Dzodzomenyo, Samuel; Fernandez, Soledad; Shaker, Reza; Splaingard, Mark

2012-01-01

Electrocortical arousal (ECA) as an effect of visceral provocation or of its temporal relationships with aerodigestive reflexes in premature neonates is not known. We tested the hypothesis that esophageal provocation results in both esophageal reflex responses and ECAs during sleep and that ECAs are dependent on the frequency characteristics of esophageal neuromotor responses. We defined the spatiotemporal relationship of ECAs in relation to 1) spontaneous pharyngoesophageal swallow sequences and gastroesophageal reflux (GER) events and 2) sensory-motor characteristics of esophageal reflexes. Sixteen healthy premature neonates born at 27.9 ± 3.4 wk were tested at 36.8 ± 1.9 wk postmenstrual age. Ninety-five midesophageal and 31 sham stimuli were given in sleep during concurrent manometry and videopolysomnography. With stimulus onset as reference point, we scored the response latency, frequency occurrence and duration of arousals, peristaltic reflex, and upper esophageal sphincter contractile reflex (UESCR). Changes in polysomnography-respiratory patterns and esophageal sensory-motor parameters were scored by blinded observers. Significantly (for each characteristic listed, P < 0.05), swallow sequences were associated with arousals and sleep state changes, and arousals were associated with incomplete peristalsis, response delays to lower esophageal sphincter relaxation, and prolonged esophageal clearance. GER events (73.5%) provoked arousals, and arousals were associated with response delays to peristaltic reflexes or clearance, sleep state modification, and prolonged respiratory arousal. Midesophageal stimuli (54%) provoked arousals and were associated with increased frequency, prolonged latency, prolonged response duration of peristaltic reflexes and UESCR, and increased frequency of sleep state changes and respiratory arousals. In human neonates, ECAs are provoked upon esophageal stimulation; the sensory-motor characteristics of esophageal reflexes are distinct when accompanied by arousals. Aerodigestive homeostasis is defended by multiple tiers of aerodigestive safety mechanisms, and when esophageal reflexes are delayed, cortical hypervigilance (ECAs) occurs. PMID:21852361

The Effects of Aspiration Status, Liquid Type, and Bolus Volume on Pharyngeal Peak Pressure in Healthy Older Adults

PubMed Central

Stuart, Andrew; Wilhelm, Erika; Rees, Catherine; Williamson, Jeff; Kritchevsky, Stephen

2015-01-01

The reasons for aspiration in healthy adults remain unknown. Given that the pharyngeal phase of swallowing is a key component of the safe swallow, it was hypothesized that healthy older adults who aspirate are likely to generate less pharyngeal peak pressures when swallowing. Accordingly, pharyngeal and upper esophageal sphincter pressures were examined as a function of aspiration status (i.e., nonaspirator vs. aspirator), sensor location (upper vs. lower pharynx), liquid type (i.e., water vs. milk), and volume (i.e., 5 vs. 10 ml) in healthy older adults. Manometric measurements were acquired with a 2.1-mm catheter during flexible endoscopic evaluation. Participants (N = 19, mean age = 79.2 years) contributed 28 swallows; during 8 swallows, simultaneous manometric measurements of upper and lower pharyngeal and upper esophageal pressures were obtained. Pharyngeal manometric peak pressure was significantly less for aspirators (mean = 82, SD = 31 mmHg) than for nonaspirators (mean = 112, SD = 20 mmHg), and upper pharyngeal pressures (mean = 85, SD = 32 mmHg) generated less pressure than lower pharyngeal pressures (mean = 116, SD = 38 mmHg). Manometric measurements vary with respect to aspiration status and sensor location. Lower pharyngeal pressures in healthy older adults may predispose them to aspiration. PMID:20623303

Is histologic esophagitis associated with dental erosion: a cross-sectional observational study?

PubMed

Friesen, Lynn Roosa; Bohaty, Brenda; Onikul, Robin; Walker, Mary P; Abraham, Caren; Williams, Karen B; Cocjin, Jose T; Cocjin, Eileen L; Friesen, Craig A

2017-08-10

Gastroesophageal reflux disease (GERD) affects 15-25% of children and adolescents in the United States. The diagnosis of GERD in children is complex as reported symptoms or symptom profiles have been found to be unreliable. Frequently, the diagnosis must be confirmed by objective tests such as pH monitoring or histological evidence of esophagitis on an esophageal biopsy. Dental erosion has been shown to be associated with GERD as an atypical complication and has the potential to be a marker of GERD. The purposes of this study were to compare the frequency and patterns of dental erosion in children and adolescents with and without histologic esophagitis. Twenty-five subjects were recruited from patients scheduled for an upper gastrointestinal endoscopy. Information regarding potential GERD symptoms, food habits, and dental hygiene habits were obtained. Intra-oral photographs were taken, and a dental exam for erosion was performed. The results of a standard biopsy taken from the lower third of the esophagus during an endoscopy were used to divide subjects into either the control group or the GERD group (i.e. those with histologic esophagitis). Twenty-two subjects yielded 586 evaluable teeth. No significant difference was found between frequency or erosion patterns of those with and without histologic esophagitis. Dental erosions were more frequent in primary teeth. Dental erosions do not appear to be associated with histologic esophagitis indicative of GERD.

Risk Factors for Helicobacter pylori Infection and Endoscopic Reflux Esophagitis in Healthy Young Japanese Volunteers.

PubMed

Tanaka, Yuichiro; Sakata, Yasuhisa; Hara, Megumi; Kawakubo, Hiroharu; Tsuruoka, Nanae; Yamamoto, Koji; Itoh, Yoichiro; Hidaka, Hidenori; Shimoda, Ryo; Iwakiri, Ryuichi; Fujimoto, Kazuma

2017-11-15

Objective The aim of this study was to determine the prevalence and risk factors of reflux esophagitis and Helicobacter pylori (H.pylori) infection and their interrelationship in healthy young Japanese volunteers. Methods Between 2010 and 2016, 550 fifth-year medical students at Saga Medical School, aged 22 to 30 years, underwent upper gastrointestinal endoscopy and completed a questionnaire (frequency scale for symptoms of gastroesophageal reflux disease). H. pylori infection was determined by detecting urinary immunoglobulin G antibodies. Results H. pylori antibodies were detected in 45 of the 550 subjects (8.2%). Endoscopic reflux esophagitis was detected in 38 out of 550 (6.9%): grade A in 37 subjects (97.3%) and grade B in 1. Most subjects with reflux esophagitis were H. pylori-negative (35/37). Nodular gastritis was observed in 33.3% (15/45) of H. pylori-positive subjects. The risk factors for H. pylori infection were drinking well water in childhood, nodular gastritis, and duodenal ulcer scars. The risk factors for endoscopic reflux esophagitis were male gender and obesity (body mass index ≥25). Conclusion This study describes the risk factors for H. pylori infection and reflux esophagitis in healthy young Japanese subjects. The prevalence of reflux esophagitis was relatively high, and the infection rate of H. pylori was low compared with the aged Japanese population.

Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders

PubMed Central

Kang, Hyoun Woo

2015-01-01

Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum. PMID:26064817

Anesthetic management of the SRS™ Endoscopic Stapling System for gastro-esophageal reflux disease.

PubMed

Topuz, Ufuk; Umutoglu, Tarik; Bakan, Mefkur; Ozturk, Erdogan

2013-01-14

The SRS(TM) Endoscopic Stapling System (Medigus, Tel Aviv, Israel) is a new tool capable of creating a totally endoscopic fundoplication, combined with an endoscope, endoscopic ultrasound and a surgical stapler. SRS(TM) endoscopic stapling for gastro-esophageal reflux disease is a minimally invasive, outpatient procedure, which requires general anesthesia with positive-pressure ventilation. Keeping the patient on positive end-expiratory pressure (PEEP) may minimize the pressure gradient between the esophagus and the mediastinum, as well as help to prevent air from leaking around the screws and causing pneumomediastinum. In addition, in patients with hiatal hernia, higher PEEP levels may be required to increase intra-thoracic pressure and to force the stomach to slide into the abdomen for ease of endoscopy. We advise smoother emergence from anesthesia, taking precautions for retching, postoperative nausea and vomiting (PONV), while coughing and gagging during extubation and PONV may affect the success of the procedure. Total intravenous anesthesia with propofol and remifentanil seems to be a good choice for these reasons.

Sagittal range of motion of the thoracic spine using inertial tracking device and effect of measurement errors on model predictions.

PubMed

Hajibozorgi, M; Arjmand, N

2016-04-11

Range of motion (ROM) of the thoracic spine has implications in patient discrimination for diagnostic purposes and in biomechanical models for predictions of spinal loads. Few previous studies have reported quite different thoracic ROMs. Total (T1-T12), lower (T5-T12) and upper (T1-T5) thoracic, lumbar (T12-S1), pelvis, and entire trunk (T1) ROMs were measured using an inertial tracking device as asymptomatic subjects flexed forward from their neutral upright position to full forward flexion. Correlations between body height and the ROMs were conducted. An effect of measurement errors of the trunk flexion (T1) on the model-predicted spinal loads was investigated. Mean of peak voluntary total flexion of trunk (T1) was 118.4 ± 13.9°, of which 20.5 ± 6.5° was generated by flexion of the T1 to T12 (thoracic ROM), and the remaining by flexion of the T12 to S1 (lumbar ROM) (50.2 ± 7.0°) and pelvis (47.8 ± 6.9°). Lower thoracic ROM was significantly larger than upper thoracic ROM (14.8 ± 5.4° versus 5.8 ± 3.1°). There were non-significant weak correlations between body height and the ROMs. Contribution of the pelvis to generate the total trunk flexion increased from ~20% to 40% and that of the lumbar decreased from ~60% to 42% as subjects flexed forward from upright to maximal flexion while that of the thoracic spine remained almost constant (~16% to 20%) during the entire movement. Small uncertainties (±5°) in the measurement of trunk flexion angle resulted in considerable errors (~27%) in the model-predicted spinal loads only in activities involving small trunk flexion. Copyright © 2015 Elsevier Ltd. All rights reserved.

Movement coordination and differential kinematics of the cervical and thoracic spines in people with chronic neck pain.

PubMed

Tsang, Sharon M H; Szeto, Grace P Y; Lee, Raymond Y W

2013-07-01

Research on the kinematics and inter-regional coordination of movements between the cervical and thoracic spines in motion adds to our understanding of the performance and interplay of these spinal regions. The purpose of this study was to examine the effects of chronic neck pain on the three-dimensional kinematics and coordination of the cervical and thoracic spines during active movements of the neck. Three-dimensional spinal kinematics and movement coordination between the cervical, upper thoracic, and lower thoracic spines were examined by electromagnetic motion sensors in thirty-four individuals with chronic neck pain and thirty-four age- and gender-matched asymptomatic subjects. All subjects performed a set of free active neck movements in three anatomical planes in sitting position and at their own pace. Spinal kinematic variables (angular displacement, velocity, and acceleration) of the three defined regions, and movement coordination between regions were determined and compared between the two groups. Subjects with chronic neck pain exhibited significantly decreased cervical angular velocity and acceleration of neck movement. Cross-correlation analysis revealed consistently lower degrees of coordination between the cervical and upper thoracic spines in the neck pain group. The loss of coordination was most apparent in angular velocity and acceleration of the spine. Assessment of the range of motion of the neck is not sufficient to reveal movement dysfunctions in chronic neck pain subjects. Evaluation of angular velocity and acceleration and movement coordination should be included to help develop clinical intervention strategies to promote restoration of differential kinematics and movement coordination. Copyright © 2013 Elsevier Ltd. All rights reserved.

Prevalence of Helicobacter pylori prevalence and upper gastrointestinal endoscopy in HIV/AIDS patients with gastrointestinal symptoms in the University Teaching Hospitals in Cameroon.

PubMed

Andoulo, F A; Kowo, M; Ngatcha, G; Ndam, A N; Awouoyiegnigni, B; Sida, M B; Tzeuton, C; Ndjitoyap Ndam, E C

2016-08-01

To determine the prevalence of Helicobacter pylori (H. pylori) infection and of various upper gastrointestinal (GI) lesions in HIV + patients with GI symptoms and the relation of H. pylori infection to CD4 cell counts. In all, 56 HIV + patients and 56 age- and sex-matched HIV - controls, all with upper GI symptoms, were evaluated by an upper endoscopy examination and gastric biopsy. H. pylori status was assessed with a urease test and histology. HIV was diagnosed with the rapid test and enzyme-linked immunosorbent assay (ELISA). The prevalence of H. pylori was 50% (28/56 [95%CI 36.3-63.7]) in HIV + subjects and 55% (31/56 [95%CI 41.5-68.7]) in HIV - controls (p = 0.57). H. pylori infection rates did not differ significantly in HIV + patients between those with a CD4 count ≥200/mm 3 (52%) and those with a CD4 count <200/mm 3 (42%) (p = 0.62). The prevalence on endoscopy of specific lesions in HIV + patients and controls were compared: esophageal candidiasis (61%, 34/56 vs. 7%; p<0.0001), esophageal ulcers (18%, 10/56 vs 2%; p = 0.01), corpus gastritis (41%; 23/56 vs 5%; p<0.0001), and duodenitis (20%, 11/56, vs 0%; p = 0.001). The prevalence rate of H. pylori did not differ significantly between HIV + and HIV - subjects. Prevalence of H. pylori was also lower, although not significantly, among HIV + patients with CD4 T-cell counts below 200/mm 3 . On endoscopy, esophageal candidiasis was the most common finding in HIV + patients, discovered by dysphagia.

[Hospital mortality associated with upper gastrointestinal hemorrhage due to ruptured esophageal varices at the Lomé Campus Hospital in Togo].

PubMed

Bouglouga, O; Bagny, A; Lawson-Ananissoh, L; Djibril, M

2014-01-01

To study hospital mortality associated with upper gastrointestinal hemorrhages due to variceal bleeding in the department of hepatology and gastroenterology at the Lome Campus University Hospital. This retrospective cross-sectional and analytic study examined the 55 patients admitted for variceal bleeding on upper endoscopies during the 3-year period from January 1, 2008, through December 31, 2010. These patients accounted for 4.1% of all hospitalizations during the study period in the department. Their average age was 35 years, and their sex-ratio 4. A history of chronic liver disease was found in 65.5%. Liver cirrhosis was the principal cause of the esophageal varices, complicated by hepatocellular carcinoma in 30.9% of them. The mortality rate was 25.5% and was not related to the cause of portal hypertension. All the patients with a recurrence of bleeding died. Mortality was associated with jaundice. Blood transfusion did not significantly improve the prognosis. the mortality rate among patients with upper gastrointestinal hemorrhage linked to variceal bleeding is high in our unit. The prevention of hepatitis virus B is important because it is the main cause of chronic liver disease causing portal hypertension in our department.

Effect of heterogeneity correction on dosimetric parameters of radiotherapy planning for thoracic esophageal cancer.

PubMed

Nakayama, Masao; Yoshida, Kenji; Nishimura, Hideki; Miyawaki, Daisuke; Uehara, Kazuyuki; Okamoto, Yoshiaki; Okayama, Takanobu; Sasaki, Ryohei

2014-01-01

The present study aimed to investigate the effect of heterogeneity correction (HC) on dosimetric parameters in 3-dimensional conformal radiotherapy planning for patients with thoracic esophageal cancer. We retrospectively analyzed 20 patients. Two treatment plans were generated for each patient using a superposition algorithm on the Xio radiotherapy planning system. The first plan was calculated without HC. The second was a new plan calculated with HC, using identical beam geometries and maintaining the same number of monitor units as the first. With regard to the planning target volume (PTV), the overall mean differences in the prescription dose, maximum dose, mean dose, and dose that covers 95% of the PTV between the first and second plans were 1.10Gy (1.8%), 1.35Gy (2.2%), 1.10Gy (1.9%), and 0.56Gy (1.0%), respectively. With regard to parameters related to the organs at risk (OARs), the mean differences in the absolute percentages of lung volume receiving greater than 5, 10, 20, and 30Gy (lung V5, V10, V20, and V30) between the first and second plans were 7.1%, 2.7%, 0.4%, and 0.5%, respectively. These results suggest that HC might have a more pronounced effect on the percentages of lung volume receiving lower doses (e.g., V5 and V10) than on the dosimetric parameters related to the PTV and other OARs. © 2013 Published by American Association of Medical Dosimetrists on behalf of American Association of Medical Dosimetrists.

Effects of preemptive analgesia with flurbiprofen ester on lymphocytes and natural killer cells in patients undergoing esophagectomy: A randomized controlled pilot study.

PubMed

Zhou, Yi; Huang, Jinxi; Bai, Yu; Li, Changsheng; Lu, Xihua

2017-11-01

Tumors may induce systemic immune dysfunction, which can be aggravated by surgery and anesthesia/analgesia. Data on the effect of flurbiprofen preemptive analgesia on immune dysfunction is limited. The aim of this study was to investigate the effect of flurbiprofen preemptive analgesia on lymphocytes and natural killer (NK) cells in patients undergoing thoracotomy and thoracoscopy radical esophagectomy, and to explore the analgesic methods suitable for tumor patients. This was a randomized controlled pilot study of 89 patients with esophageal cancer treated with surgery at the Henan Cancer Hospital between January 1, 2015 and December 31, 2016. The patients were divided into three groups: group 1, thoracotomy; group 2, thoracoscopy and laparoscopic surgery; and group 3, flurbiprofen, thoracoscopy, and laparoscopic surgery. CD3+, CD19+, NK, CD4+, and CD8+ cells in whole blood were measured by flow cytometry 30 minutes before surgery (T0), at the end of the thoracic section of the procedure (T1), and at the end of the operation (T2). There were no significant differences in CD3+, CD19+, CD8+, NK, and CD4+ cells between the three groups or regarding the time points during the procedure (all P > 0.05). Thoracotomy and thoracoscopy surgery resulted in similar immunological outcomes. Flurbiprofen ester preemptive analgesia did not suppress the immune function in patients and could be a safe analgesic method for patients with esophageal cancer undergoing surgery. © 2017 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

Treatment of esophageal cancer with radiation therapy -a pan-Chinese survey of radiation oncologists.

PubMed

Zhang, Yun; Liu, Jing; Zhang, Wencheng; Deng, Weiye; Yue, Jinbo

2017-05-23

Lots of controversies were found about the treatment in relation to radiation therapy (RT) for esophageal squamous cell carcinoma (ESCC). We designed a questionnaire of these controversies to do a pan-Chinese survey of radiation oncologists (ROs). For operable ESCC, 53% ROs chose surgery plus postoperative chemoradiotherapy (CRT), while 40% chose preoperative CRT plus surgery. For target volume of postoperative RT, most ROs (92%) would delineate tumor bed plus involved lymph nodes region before surgery. For definitive RT, most ROs (81%) would give patients higher RT dose to 60-65Gy. For radiation target volume, most ROs would give patients prophylactic irradiation of the bilateral superclavicular-lymph nodes region for cervical ESCC (93%), and the left gastric lymph nodes region for lower thoracic ESCC (72%). For the treatment of mediastinal lymph nodes, 72% ROs preferred elective nodal irradiation, while 28% did the involved nodal irradiation. For concurrent chemotherapy regimen, PF (5-Fu + cisplatin) and TP (cisplatin + paclitaxel) were used widely (49% and 46%, respectively). During simulation, four-dimensional computer tomography (4D CT) was not widely used (48%), even for cervical or lower thoracic ESCC (52%). For daily RT delivery, only 66% ROs would perform imaging guidance RT daily. In summary, more controversies existed in the treatment of ESCC with RT in China, including treatment strategy, radiation dose and target contour. Future goals include standardization of treatment strategy, radiation dose, and target contour, and application of 4D CT and daily imaging guidance, and pursuit of randomized trials in Chinese population.

Upper gastrointestinal alterations in kidney transplant candidates.

PubMed

Homse Netto, João Pedro; Pinheiro, João Pedro Sant'Anna; Ferrari, Mariana Lopes; Soares, Mirella Tizziani; Silveira, Rogério Augusto Gomes; Maioli, Mariana Espiga; Delfino, Vinicius Daher Alvares

2018-05-14

The incidence of gastrointestinal disorders among patients with chronic kidney disease (CKD) is high, despite the lack of a good correlation between endoscopic findings and symptoms. Many services thus perform upper gastrointestinal (UGI) endoscopy on kidney transplant candidates. This study aims to describe the alterations seen on the upper endoscopies of 96 kidney-transplant candidates seen from 2014 to 2015. Ninety-six CKD patients underwent upper endoscopic examination as part of the preparation to receive kidney grafts. The data collected from the patients' medical records were charted on Microsoft Office Excel 2016 and presented descriptively. Mean values, medians, interquartile ranges and 95% confidence intervals of the clinic and epidemiological variables were calculated. Possible associations between endoscopic findings and infection by H. pylori were studied. Males accounted for 54.17% of the 96 patients included in the study. Median age and time on dialysis were 50 years and 50 months, respectively. The most frequent upper endoscopy finding was enanthematous pangastritis (57.30%), followed by erosive esophagitis (30.20%). Gastric intestinal metaplasia and peptic ulcer were found in 8.33% and 7.30% of the patients, respectively. H. pylori tests were positive in 49 patients, and H. pylori infection was correlated only with non-erosive esophagitis (P = 0.046). Abnormal upper endoscopy findings were detected in all studied patients. This study suggested that upper endoscopy is a valid procedure for kidney transplant candidates. However, prospective studies are needed to shed more light on this matter.

Effect of nasal noninvasive respiratory support methods on pharyngeal provocation-induced aerodigestive reflexes in infants.

PubMed

Jadcherla, Sudarshan R; Hasenstab, Kathryn A; Sitaram, Swetha; Clouse, Brian J; Slaughter, Jonathan L; Shaker, Reza

2016-06-01

The pharynx is a locus of provocation among infants with aerodigestive morbidities manifesting as dysphagia, life-threatening events, aspiration-pneumonia, atelectasis, and reflux, and such infants often receive nasal respiratory support. We determined the impact of different oxygen delivery methods on pharyngeal stimulation-induced aerodigestive reflexes [room air (RA), nasal cannula (NC), and nasal continuous positive airway pressure (nCPAP)] while hypothesizing that the sensory motor characteristics of putative reflexes are distinct. Thirty eight infants (28.0 ± 0.7 wk gestation) underwent pharyngoesophageal manometry and respiratory inductance plethysmography to determine the effects of graded pharyngeal stimuli (n = 271) on upper and lower esophageal sphincters (UES, LES), swallowing, and deglutition-apnea. Comparisons were made between NC (n = 19), nCPAP (n = 9), and RA (n = 10) groups. Importantly, NC or nCPAP (vs. RA) had: 1) delayed feeding milestones (P < 0.05), 2) increased pharyngeal waveform recruitment and duration, greater UES nadir pressure, decreased esophageal contraction duration, decreased distal esophageal contraction amplitude, and decreased completely propagated esophageal peristalsis (all P < 0.05), and 3) similarly developed UES contractile and LES relaxation reflexes (P > 0.05). We conclude that aerodigestive reflexes were similarly developed in infants using noninvasive respiratory support with adequate upper and lower aerodigestive protection. Increased concern for GERD is unfounded in this population. These infants may benefit from targeted oromotor feeding therapies and safe pharyngeal bolus transit to accelerate feeding milestones. Copyright © 2016 the American Physiological Society.

Effect of nasal noninvasive respiratory support methods on pharyngeal provocation-induced aerodigestive reflexes in infants

PubMed Central

Hasenstab, Kathryn A.; Sitaram, Swetha; Clouse, Brian J.; Slaughter, Jonathan L.; Shaker, Reza

2016-01-01

The pharynx is a locus of provocation among infants with aerodigestive morbidities manifesting as dysphagia, life-threatening events, aspiration-pneumonia, atelectasis, and reflux, and such infants often receive nasal respiratory support. We determined the impact of different oxygen delivery methods on pharyngeal stimulation-induced aerodigestive reflexes [room air (RA), nasal cannula (NC), and nasal continuous positive airway pressure (nCPAP)] while hypothesizing that the sensory motor characteristics of putative reflexes are distinct. Thirty eight infants (28.0 ± 0.7 wk gestation) underwent pharyngoesophageal manometry and respiratory inductance plethysmography to determine the effects of graded pharyngeal stimuli (n = 271) on upper and lower esophageal sphincters (UES, LES), swallowing, and deglutition-apnea. Comparisons were made between NC (n = 19), nCPAP (n = 9), and RA (n = 10) groups. Importantly, NC or nCPAP (vs. RA) had: 1) delayed feeding milestones (P < 0.05), 2) increased pharyngeal waveform recruitment and duration, greater UES nadir pressure, decreased esophageal contraction duration, decreased distal esophageal contraction amplitude, and decreased completely propagated esophageal peristalsis (all P < 0.05), and 3) similarly developed UES contractile and LES relaxation reflexes (P > 0.05). We conclude that aerodigestive reflexes were similarly developed in infants using noninvasive respiratory support with adequate upper and lower aerodigestive protection. Increased concern for GERD is unfounded in this population. These infants may benefit from targeted oromotor feeding therapies and safe pharyngeal bolus transit to accelerate feeding milestones. PMID:27012774

Biomechanical Quantification of Mendelsohn Maneuver and Effortful Swallowing on Pharyngoesophageal Function.

PubMed

Doeltgen, Sebastian Heinrich; Ong, Ellisa; Scholten, Ingrid; Cock, Charles; Omari, Taher

2017-11-01

Objective To quantify the effects of 2 swallowing maneuvers used in dysphagia rehabilitation-the Mendelsohn maneuver and effortful swallowing-on pharyngoesophageal function with novel, objective pressure-flow analysis. Study Design Evaluation of intervention effects in a healthy control cohort. Setting A pharyngoesophageal motility research laboratory in a tertiary education facility. Subjects Twelve young healthy subjects (9 women, 28.6 ± 7.9 years) from the general public, without swallowing impairment, volunteered to participate in this study. Methods Surface electromyography from the floor-of-mouth musculature and high-resolution impedance manometry-based pressure flow analysis were used to assess floor-of-mouth activation and pharyngoesophageal motility, respectively. Subjects each performed 10 noneffortful control swallows, Mendelsohn maneuver swallows, and effortful swallows, with a 5-mL viscous bolus. Repeated measures analyses of variance was used to compare outcome measures across conditions. Results Effortful and Mendelsohn swallows generated greater floor-of-mouth contraction ( P = .001) and pharyngeal pressure ( P < .0001) when compared with control swallows. There were no changes at the level of the upper esophageal sphincter, except for a faster opening to maximal diameter during maneuver swallows ( P = .01). The proximal esophageal contractile integral was reduced during Mendelsohn swallows ( P = .001). Conclusion Effortful and Mendelsohn maneuver swallows significantly alter the pharyngoesophageal pressure profile. Faster opening of the upper esophageal sphincter may facilitate bolus transfer during maneuver swallows; however, reduced proximal esophageal contractility during Mendelsohn maneuver swallows may impair bolus flow and aggravate dysphagic symptoms.

Confusing or Ambiguous Upper Gut Symptoms

MedlinePlus

... esophageal sphincter. This is called gastroesophageal reflux – the fundamental abnormality underlying GERD. Unlike vomiting, the regurgitated material ... Belching Bloating and Distension Chronic Pain Medications Self-management Other Management Techniques 8-step Approach to Chronic ...

Globus

MedlinePlus

... the contraction of the muscles of the upper esophageal sphincter have garnered inconsistent results, and no related anatomical abnormalities have been observed in the throat and larynx. Nevertheless, a troubled patient may be greatly ... Globus Sphincter of Oddi Dysfunction Lower ...

Biliary metal stents for proximal esophageal or hypopharyngeal strictures.

PubMed

Bechtler, Matthias; Wagner, Florian; Fuchs, Erik-Sebastian; Jakobs, Ralf

2015-11-01

Endoscopic dilation is the standard of care for stenoses of the cervical esophagus, but refractory strictures require some form of stenting. Most endoscopists avoid the placement of metal stents near the upper esophageal sphincter as they can cause major problems like severe cervical pain and globus sensation. We report our results with the use of biliary SEMS in the upper esophagus, which have a smaller diameter than regular esophageal stents and therefore exert less expansive force. We retrospectively reviewed all patients in our center between July 2011 and June 2014 who received a biliary metal stent because of a refractory stricture in the cervical esophagus. We implanted biliary SEMS (Wallflex, Boston Scientific) with a diameter of 1 cm and length of 6-8 cm. Technical and clinical success, adverse events and duration of stenting were evaluated. Ten patients were treated with biliary SEMS in the upper esophagus. Strictures were located between 10 and 19 cm from incisor teeth. Stent placement was successful in all (10/10) patients. One stent had to be extracted because of pain and globus sensation. Apart from that stent tolerability was good. All remaining patients (9/9) reported improvement of dysphagia with a decrease in mean dysphagia score from 3.2 to 1.78. Mean duration of stenting was 68 days. Because of a high clinical success rate and good tolerability, biliary metal stents are a reasonable alternative for difficult strictures in the cervical esophagus, especially in the palliative setting.

[Initial results of robotic esophagectomy for esophageal cancer].

PubMed

Trugeda Carrera, M Soledad; Fernández-Díaz, M José; Rodríguez-Sanjuán, Juan Carlos; Manuel-Palazuelos, José Carlos; de Diego García, Ernesto Matias; Gómez-Fleitas, Manuel

2015-01-01

There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards. Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Concordance of clinical diagnosis of T classification among physicians for locally advanced unresectable thoracic esophageal cancer.

PubMed

Yokota, Tomoya; Yasuda, Takushi; Kato, Hiroyuki; Nozaki, Isao; Sato, Hiroshi; Miyata, Yoshinori; Kuroki, Yoshifumi; Kato, Ken; Hamamoto, Yasuo; Tsubosa, Yasuhiro; Ogawa, Hirofumi; Ito, Yoshinori; Kitagawa, Yuko

2018-02-01

We conducted a multicenter phase II trial assessing chemoselection with docetaxel plus 5-fluorouracil and cisplatin induction chemotherapy and subsequent conversion surgery for locally advanced, unresectable esophageal cancer. The aim of this study was to validate the concordance of clinical T diagnosis among physicians in the cases of this trial. Computed tomography scans and esophagoscopic images of 48 patients taken at baseline were centrally reviewed by 6 senior physicians with experience in esophageal oncology. Individual reviewers voted for definitive T4, relative T4, relative T3, or definitive T3. Discordant diagnoses between reviewers were resolved by the majority opinion. The reviewers were blinded to patient clinical outcome data and to the vote of the other reviewers. Ninety percent of cases were diagnosed as clinical T4 by investigators, while 33.3-75.0% (median 70.8%) of cases were judged to be T4 by 6 reviewers. Discordant diagnosis between investigators and reviewers occurred in 33% (16/48) of all cases (Cohen's kappa coefficient 0.0519), including 12 cases where curative resection was considered possible (48%, n = 25) and 4 cases where curative resection was considered impossible (17%, n = 23). Critical discordance (one reviewer voted for definitive T3 but the other voted for definitive T4, and vice versa) between reviewers occurred in 0-12.5% of cases (median 2.1%). There were inter-observer variations in clinical diagnosis of the T category of locally advanced, unresectable esophageal cancer. Accurate clinical diagnosis of T classification is required for determining the optimum treatment for each patient.

Dose-Response Relationship between Radiation Dose and Loco-regional Control in Patients with Stage II-III Esophageal Cancer Treated with Definitive Chemoradiotherapy.

PubMed

Kim, Hyun Ju; Suh, Yang-Gun; Lee, Yong Chan; Lee, Sang Kil; Shin, Sung Kwan; Cho, Byung Chul; Lee, Chang Geol

2017-07-01

The correlation between radiation dose and loco-regional control (LRC) was evaluated in patients with stage II-III esophageal cancer treated with definitive concurrent chemoradiotherapy (CRT). Medical records of 236 stage II-III esophageal cancer patients treated with definitive CRT at Yonsei Cancer Center between 1994 and 2013 were retrospectively reviewed. Among these, 120 received a radiation dose of < 60 Gy (standard-dose group), while 116 received ≥ 60 Gy (high-dose group). The median doses of radiation in the standard- and high-dose groups were 50.4 and 63 Gy, respectively. Concurrent 5-fluorouracil/cisplatin chemotherapy was administered to most patients. There were no differences in patient characteristics between the two groups except for high Karnofsky performance status and lower-thoracic lesions being more prevalent in the standard-dose group. The median progression-free survival (PFS) and overall survival (OS) times were 13.2 months and 26.2 months, respectively. Patients in the high-dose group had significantly better 2-year LRC (69.1% vs. 50.3%, p=0.002), median PFS (16.7 months vs. 11.7 months, p=0.029), and median OS (35.1 months vs. 22.3 months, p=0.043). Additionally, LRC exhibited a dose-response relationship and the complete response rate was significantly higher in the high-dose group (p=0.006). There were no significant differences in treatment-related toxicities between the groups. A higher radiation dose (> 60 Gy) is associated with increased LRC, PFS, and OS in patients with stage II-III esophageal cancer treated with definitive CRT.

Preliminary treatment results of proton beam therapy with chemoradiotherapy for stage I-III esophageal cancer.

PubMed

Takada, Akinori; Nakamura, Tatsuya; Takayama, Kanako; Makita, Chiyoko; Suzuki, Motohisa; Azami, Yusuke; Kato, Takahiro; Tsukiyama, Iwao; Hareyama, Masato; Kikuchi, Yasuhiro; Daimon, Takashi; Toyomasu, Yutaka; Ii, Noriko; Nomoto, Yoshihito; Sakuma, Hajime; Fuwa, Nobukazu

2016-03-01

The effect of proton beam therapy (PBT) on various cancers is controversial. We aimed to evaluate the efficacy and safety of PBT with alternating chemoradiotherapy (ACRT) for patients with stage I-III esophageal cancer. Two cycles of systemic chemotherapy with a continuous infusion of 5-fluorouracil (5-FU) on days 1-5 and a 5h infusion of nedaplatin (NDP) on day 6 were accompanied by thoracic irradiation using X-ray therapy and PBT. During the first half of the treatment, X-rays were delivered to the prophylactic area. During the second half of the treatment, proton beams were used to irradiate the involved field. To reduce the dose of cardiac irradiation, proton beams were delivered with posterior and posterior oblique angles. Between January 2009 and December 2012, 47 patients were enrolled in this study. The median follow-up duration was 29 months for all patients and 40 months for survivors. The 3 year overall survival rate, progression-free survival rate, and local control rate were 59.2%, 56.3%, and 69.8%, respectively. With respect to grade 3-4 late toxicities, there were no pleural or pericardial effusions, but two patients (4.3%) had esophageal stenosis, one patient (2.1%) had fistula, and two patients (4.3%) developed radiation pneumonitis. PBT with ACRT might have the potential to reduce the risk of cardiac damage and might become one of the primary methods of esophageal cancer treatment. © 2016 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

Use of a specially designed partially covered self-expandable metal stent (PSEMS) with a 40-mm diameter for the treatment of upper gastrointestinal suture or staple line leaks in 11 cases.

PubMed

Fischer, Andreas; Bausch, Dirk; Richter-Schrag, Hans-Juergen

2013-02-01

The use of self-expandable stents to treat postoperative leaks and fistula in the upper gastrointestinal (GI) tract is an established treatment for leaks of the upper GI tract. However, lumen-to-stent size discrepancies (i.e., after sleeve gastrectomy or esophageal resection) may lead to insufficient sealing of the leaks requiring further surgical intervention. This is mainly due to the relatively small diameter (≤30 mm) of commonly used commercial stents. To overcome this problem, we developed a novel partially covered stent with a shaft diameter of 36 mm and a flare diameter of 40 mm. From September 2008 to September 2010, 11 consecutive patients with postoperative leaks were treated with the novel large diameter stent (gastrectomy, n = 5; sleeve gastrectomy, n = 2; fundoplication after esophageal perforation, n = 2; Roux-en-Y gastric bypass, n = 1; esophageal resection, n = 1). Treatment with commercially available stents (shaft/flare: 23/28 mm and 24/30 mm) had been unsuccessful in three patients before treatment with the large diameter stent. Due to dislocation, the large diameter stent was anchored in four patients (2× intraoperatively with transmural sutures, 2× endoscopically with transnasally externalized threads). Treatment was successful in 11 of 11 patients. Stent placement and removal was easy and safe. The median residence time of the stent was 24 (range, 18-41) days. Stent dislocation occurred in four cases (36 %). It was treated by anchoring the stent. Mean follow-up was 25 (range, 14-40) months. No severe complication occurred during or after intervention and no patient was dysphagic. Using the novel large diameter, partially covered stent to seal leaks in the upper GI tract is safe and effective. The large diameter of the stent does not seem to injure the wall of the upper GI tract. However, stent dislocation sometimes requires anchoring of the stent with sutures or transnasally externalized threads.

Incentive spirometry does not enhance recovery after thoracic surgery.

PubMed

Gosselink, R; Schrever, K; Cops, P; Witvrouwen, H; De Leyn, P; Troosters, T; Lerut, A; Deneffe, G; Decramer, M

2000-03-01

To investigate the additional effect of incentive spirometry to chest physiotherapy to prevent postoperative pulmonary complications after thoracic surgery for lung and esophageal resections. Randomized controlled trial. University hospital, intensive care unit, and surgical department. Sixty-seven patients (age, 59 +/- 13 yrs; forced expiratory volume in 1 sec, 93% +/- 22% predicted) undergoing elective thoracic surgery for lung (n = 40) or esophagus (n = 27) resection. Physiotherapy (breathing exercises, huffing, and coughing) (PT) plus incentive spirometry (IS) was compared with PT alone. Lung function, body temperature, chest radiograph, white blood cell count, and number of hospital and intensive care unit days were all measured. Pulmonary function was significantly reduced after surgery (55% of the initial value) and improved significantly in the postoperative period in both groups. However, no differences were observed in the recovery of pulmonary function between the groups. The overall score of the chest radiograph, based on the presence of atelectasis, was similar in both treatment groups. Eight patients (12%) (three patients with lobectomy and five with esophagus resection) developed a pulmonary complication (abnormal chest radiograph, elevated body temperature and white blood cell count), four in each treatment group. Adding IS to regular PT did not reduce hospital or intensive care unit stay. Pulmonary complications after lung and esophagus surgery were relatively low. The addition of IS to PT did not further reduce pulmonary complications or hospital stay. Although we cannot rule out beneficial effects in a subgroup of high-risk patients, routine use of IS after thoracic surgery seems to be ineffective.

The prevalence of gastro-esophageal reflux disease and esophageal dysmotility in Chinese patients with idiopathic pulmonary fibrosis.

PubMed

Gao, Feng; Hobson, Anthony Robert; Shang, Zhan Min; Pei, Yan Xiang; Gao, Yan; Wang, Jian Xin; Huang, Wan Nong

2015-02-19

The cause of idiopathic pulmonary fibrosis (IPF) remains unknown, yet gastro-esophageal reflux disease (GERD) is highly prevalent in this population. GERD prevalence was studied, and esophageal function tests (EFT) were assessed in Chinese IPF patients. We prospectively studied 69 IPF patients who undertook both stationary High Resolution esophageal Manometry/Impedance (HRiM) and 24-hour esophageal Multi-Channel Intraluminal Impedance with pH Recordings (MII/pH). Patients were divided into GERD+ and GERD- groups according to pH results. Controls were HRiM treated healthy volunteers, and patients without IPF received HRiM and MII/pH diagnosed with GERD. 69 IPF patients, 62 healthy volunteers, and 88 IPF negative GERD patients were selected. GERD prevalence in IPF was 43/69 (62.3%), and 58.1% of patients presented with at least one typical symptom. Symptoms had a sensitivity of 58.1%, a specificity of 61.6%, a positive predictive value of 71.4% and a negative predictive of 47.1%. Compared with healthy volunteers, IPF patients had significantly decreased lower esophageal sphincter pressure (LESP), upper esophageal sphincter pressure (UESP) and complete bolus transit rate (CBTR). By contrast, IPF patients had increased total bolus transit time and prevalence of weak peristalsis. MII/pH showed that one third of IPF patients had abnormal distal and proximal reflux, especially non-acid reflux. Compared with GERD patients without IPF, GERD patients with IPF had significantly decreased CBTR and UESP with increased bolus exposure time. GERD prevalence in IPF was high, but symptoms alone were an unreliable predictor of reflux. IPF patients had lower LESP and UESP, impaired esophageal peristalsis and bolus clearance function with more proximal reflux events.

Hypersensitivity to acid is associated with impaired esophageal mucosal integrity in patients with gastroesophageal reflux disease with and without esophagitis.

PubMed

Weijenborg, Pim W; Smout, André J P M; Verseijden, Caroline; van Veen, Henk A; Verheij, Joanne; de Jonge, Wouter J; Bredenoord, Albert J

2014-08-01

Increased esophageal sensitivity and impaired mucosal integrity have both been described in patients with gastroesophageal reflux disease, but the relationship between hypersensitivity and mucosal integrity is unclear. The aim of the present study was to investigate acid sensitivity in patients with erosive and nonerosive reflux disease and control subjects to determine the relation with functional esophageal mucosal integrity changes as well as to investigate cellular mechanisms of impaired mucosal integrity in these patients. In this prospective experimental study, 12 patients with nonerosive reflux disease, 12 patients with esophagitis grade A or B, and 11 healthy control subjects underwent an acid perfusion test and upper endoscopy. Mucosal integrity was measured during endoscopy by electrical tissue impedance spectroscopy and biopsy specimens were analyzed in Ussing chambers for transepithelial electrical resistance, transepithelial permeability and gene expression of tight junction proteins and filaggrin. Patients with nonerosive reflux disease and esophagitis were more sensitive to acid perfusion compared with control subjects, having a shorter time to perception of heartburn and higher perceived intensity of heartburn. In reflux patients, enhanced acid sensitivity was associated with impairment of in vivo and vitro esophageal mucosal integrity. Mucosal integrity was significantly impaired in patients with esophagitis, displaying higher transepithelial permeability and lower extracellular impedance. Although no significant differences in the expression of tight junction proteins were found in biopsies among patient groups, mucosal integrity parameters in reflux patients correlated negatively with the expression of filaggrin. In conclusion, sensitivity to acid is enhanced in patients with gastroesophageal reflux disease, irrespective of the presence of erosions, and is associated with impaired esophageal mucosal integrity. Mucosal integrity of the esophagus is associated with the expression of filaggrin. Copyright © 2014 the American Physiological Society.

Predictive factors of silent reflux in subjects with erosive esophagitis.

PubMed

Lei, Wei-Yi; Yu, Hao-Chun; Wen, Shu-Hui; Liu, Tso-Tsai; Yi, Chih-Hsun; Wang, Chia-Chi; Hsu, Ching-Sheng; Chen, Chien-Hwa; Chen, Chien-Lin; Pace, Fabio

2015-01-01

Asymptomatic erosive esophagitis by definition is a condition lacking any reflux symptom. We aimed to investigate the prevalence of asymptomatic erosive esophagitis in a general population undergoing periodic health checkup. Consecutive subjects undergoing a medical checkup were enrolled for evaluation of reflux disease with upper endoscopy and a validated reflux questionnaire. The presence and severity of erosive esophagitis were evaluated. In all subjects, demographic characteristics and biochemical data were recorded, and sleep and psychological characteristics were assessed by means of self-administered Pittsburgh Sleep Quality Index score, Taiwanese Depression Questionnaire score, and State-Trait Anxiety Inventory score. Of 2568 subjects eligible for this study, erosive esophagitis was found in 676 subjects (26.3%), in whom the proportions of asymptomatic and symptomatic erosive esophagitis were 59.2% (400 subjects) and 40.8% (276 subjects) respectively. At a univariate analysis, it was found that asymptomatic erosive esophagitis subjects were more frequently of female gender, of older age, with a lower level of education. They also showed less alcohol and tea consumption, less depression, less anxiety, lower serum level of triglyceride, and lower prevalence of metabolic syndrome. Multivariate analysis revealed that female sex (OR = 1.645, p = 0.0146) was a positive predictive factor for asymptomatic erosive esophagitis, whereas higher level of education (OR = 0.564, p = 0.044), higher Taiwanese Depression Questionnaire score (OR = 0.922, p < 0.001), and the presence of metabolic syndrome (OR = 0.625, p = 0.0379) were negative predictive factors. Asymptomatic erosive esophagitis is a common feature in otherwise healthy subjects and is independently associated with female gender, lower education level, less depression, and lower prevalence of metabolic syndrome. Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

[Analyses of the characteristics of esophageal motility in patients with pharyngeal paraesthesia who visit the Department of gastroenterology].

PubMed

Wang, Zhenjiang; Chen, Yuping; Guo, Tingting

2015-07-01

To investigate the influence of the local sensory abnormality in throat while the change of motility in the upper esophageal sphincter (UES) and lower esophageal sphincter (LES), as well as the change of esophageal body in pharyngeal paraesthesia. From January 2014 to January 2015 there were sixty-four patients who had pharyngeal susceptible syndrome (PSS) but without confirmed organic disease were enrolled as the PSS group, forty healthy volunteers as the control group. High resolution manometry (HRM) was utilized to distinguish esophageal motility patterns of PSS, including the muscular tension of LES and UES, the integrity, adaptability, amplitude, speed and duration of esophageal peristalsis at 10 swallows. The resting LES and UES pressures and the distal contractile integral (DCI) of esophagus in PSS group were lower than that in control group (P < 0.05). The esophageal peristalsis was decelerated and shortened in duration, and amplitude of contraction notably lower in PSS group compared with its counterpart (P < 0.05). The integrity of esophageal peristalsis was impaired in PSS with remarkable changes in motility patterns, involving ratio of major and minor interrupts, and synchronous contraction rate (P < 0.05). As for the time course from relaxation to the lowest pressure point of UES and time for restoration, no definite difference was noticed between the two groups (P > 0.05). The average peak pressure was similar in two groups (P > 0.05). Muscle tension around the UES has no obvious change when pharyngeal paraesthesia occurred, but the reduction of esophageal motor function, clearance ability, anti-reflux gastroesophageal junction, causing the abnormal reflux which hurt the pharyngeal surface mucosa maybe one of the most important reasons leading to pharyngeal paresthesia.

Non-alcoholic fatty liver disease and the development of reflux esophagitis: A cohort study.

PubMed

Min, Yang Won; Kim, Youngha; Gwak, Geum-Youn; Gu, Seonhye; Kang, Danbee; Cho, Soo Jin; Guallar, Eliseo; Cho, Juhee; Sinn, Dong Hyun

2018-05-01

Non-alcoholic fatty liver disease (NAFLD), a hepatic manifestation of the metabolic syndrome, is associated with gastroesophageal reflux disease in cross-sectional studies, but a prospective association has not been evaluated. The current study aimed to determine whether NAFLD increases the risk of incident reflux esophagitis in a large cohort study. We conducted a cohort study of 34 063 men and women without reflux esophagitis or other upper gastrointestinal disease at baseline who underwent health checkup examinations between January 2003 and December 2013. Fatty liver was diagnosed by ultrasound based on standard criteria. Reflux esophagitis was defined by the presence of at least grade A mucosal break on esophagogastroduodenoscopy. The prevalence of NAFLD at baseline was 33.2%. During 153 520.2 person-years of follow-up, the cumulative incidences of reflux esophagitis for participants without and with NAFLD were 9.6% and 13.8%, respectively (P < 0.001). The age-adjusted and sex-adjusted hazard ratio for the risk of reflux esophagitis development in participants with NAFLD compared with those without NAFLD was 1.15 (95% confidence interval 1.07-1.23; P < 0.001). However, this association disappeared after adjusting for body mass index and other metabolic factors (hazard ratio 1.01, 95% confidence interval 0.94-1.09; P = 0.79). Similarly, in multivariable-adjusted models, there was no significant association between NAFLD severity and the risk of developing reflux esophagitis. Non-alcoholic fatty liver disease is not independently associated with the risk of the development of reflux esophagitis, but rather, reflux esophagitis is primarily the consequence of increased body mass index commonly associated with NAFLD. © 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Fluorescent marker for the detection of crop and upper gastrointestinal leakage in poultry processing plants.

PubMed

Byrd, J A; Hargis, B M; Corrier, D E; Brewer, R L; Caldwell, D J; Bailey, R H; McReynolds, J L; Herron, K L; Stanker, L H

2002-01-01

Previous published research has identified the crop as a source of Salmonella and Campylobacter contamination for broiler carcasses and reported that broiler crops are 86 times more likely to rupture than ceca during commercial processing. Presently, we evaluated leakage of crop and upper gastrointestinal contents from broilers using a fluorescent marker at commercial processing plants. Broilers were orally gavaged with a fluorescent marker paste (corn meal-fluorescein dye-agar) within 30 min of live hang. Carcasses were collected at several points during processing and were examined for upper gastrointestinal leakage using long-wavelength black light. This survey indicated that 67% of the total broiler carcasses were positive for the marker at the rehang station following head and shank removal. Crops were mechanically removed from 61% of the carcasses prior to the cropper, and visual online examination indicated leakage of crop contents following crop removal by the pack puller. Examination of the carcasses prior to the cropper detected the marker in the following regions: neck (50.5% positive), thoracic inlet (69.7% positive), thoracic cavity (35.4% positive), and abdominal cavity (34.3% positive). Immediately prior to chill immersion, 53.2% of the carcasses contained some degree of visually identifiable marker contamination, as follows: neck (41.5% positive), thoracic inlet (45.2% positive), thoracic cavity (26.2% positive), and abdominal cavity (30.2% positive). These results suggest that this fluorescent marker technique may serve as a useful tool for rapid identification of potential changes, which could reduce the incidence of crop rupture and contamination of carcasses at processing.

Preventive effects of 125I seeds on benign restenosis following esophageal stent implantation in a dog model

PubMed Central

GAN, ZHEN; JING, JIAN; ZHU, GUANGYU; QIN, YONGLIN; TENG, GAOJUN; GUO, JINHE

2015-01-01

The present study aimed to evaluate the effects of iodine-125 (125I) seeds on the proliferation of primary esophageal fibroblasts in dogs, and to assess the safety and preventive efficacy of 125I seed-pre-loaded esophageal stents in benign restenosis following implantation. Primary fibroblasts were cultured with various 125I seed activities, which were then evaluated using cell proliferation and apoptosis assays as well as cell cycle analysis using Annexin V/propidium iodide (PI) double staining and PI staining. Prior to sacrification, animals were submitted to esophageal radiography under digital subtraction angiography. Esophageal tissues were collected and examined for macroscopic, microscopic and pathological alterations. The results demonstrated a significant and dose-dependent inhibition of fibroblast proliferation and increased apoptosis following exposure to 125I seeds. G0/G1 fibroblast populations increased in a dose-dependent manner following treatment with 125I seeds, in contrast to cells in S phase. Four weeks following implantation, α-smooth muscle actin and proliferating cell nuclear antigen expression levels in the experimental group were significantly lower compared with those in the control group; in addition, eight weeks following implantation, esophageal inner diameters were increased in the experimental group. 125I seeds inhibited proliferation of dog esophageal fibroblasts via cell cycle arrest and apoptosis. In conclusion, 125I seed-pre-loaded esophageal stents inhibited benign hyperplasia in the upper edge of the stent to a certain extent, which relieved benign restenosis following implantation with a good safety profile. PMID:25543838

Acute Esophageal Necrosis Presenting With Henoch-Schönlein Purpura

PubMed Central

Bernstein, Gregory R.; Malik, Zubair; Schey, Ron

2015-01-01

A 63-year-old woman with abdominal pain and melena developed a palpable, purpuric rash and acute kidney injury. Skin and kidney biopsy confirmed Henoch-Schönlein purpura. Upper endoscopy revealed diffuse, circumferential, black-appearing mucosa of the esophagus consistent with acute esophageal necrosis (AEN), also known as black esophagus. AEN is a very rare cause of gastrointestinal hemorrhage with a high mortality risk. To our knowledge, there have been no prior reports of AEN associated with Henoch-Schonlein purpura or other vasculitis. PMID:26504868

Esophageal tuberculosis with coexisting opportunistic infections in a renal allograft transplant recipient.

PubMed

Kumar, Sunil; Minz, Mukut; Sinha, Saroj K; Vaiphei, Kim; Sharma, Ashish; Singh, Sarbpreet; Kenwar, Deepesh B

2017-02-01

We report a renal allograft transplant recipient with esophageal tuberculosis (TB) coinfected with herpes simplex virus (HSV) and Candida. The patient presented with oropharyngeal candidiasis and was started on fluconazole. Upper gastrointestinal endoscopy showed whitish patches with mucosal ulcers in the esophagus. Histopathological examination confirmed TB and HSV infection. The patient recovered after antiviral, antifungal, and anti-tubercular therapy with reduction in immunosuppression. In a TB-endemic zone, TB can coexist with opportunistic infections in an immunocompromised host. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Upper Gastrointestinal Tract Motility Disorders in Women, Gastroparesis, and Gastroesophageal Reflux Disease.

PubMed

Zia, Jasmine K; Heitkemper, Margaret M

2016-06-01

This article reviews the sex differences in upper gastrointestinal (GI) motility for both healthy and common dysmotility conditions. It focuses on gastroesophageal reflux disease and other esophageal motor disorders for the esophagus and on gastroparesis and accelerated gastric emptying for the stomach. It also describes differences in upper GI motility signs and symptoms during each female hormonal stage (ie, menstrual cycle, pregnancy, perimenopause, menopause) for both healthy participants and those suffering from one of the aforementioned upper GI dysmotility conditions. More research still needs to be conducted to better understand sex differences in upper GI motility. Copyright © 2016 Elsevier Inc. All rights reserved.

Unstable upper and middle thoracic fractures. Preliminary experience with a posterior transpedicular correction-fixation technique.

PubMed

Payer, M

2005-06-01

A number of conservative and operative approaches have been described for the treatment of unstable traumatic upper and middle thoracic fractures. The advantage of surgical correction and fixation/fusion lies in its potential to restore sagittal and coronal alignment, thereby indirectly decompressing the spinal cord. A consecutive series of 8 patients with unstable traumatic upper and middle thoracic fractures is reviewed. In all patients, polyaxial pedicle screws were inserted bilaterally into the two levels above and below the fracture. Rods that were less contoured ("undercontoured") than the regional hyperkyphosis at the injured level, were anchored to the caudal four screws. The cranial four screws, with the vertebrae to which they were inserted, were then progressively pulled posteriorly onto the undercontoured rods with rod reducers, thus correcting the hyperkyphosis and anterolisthesis. The mean follow-up was 15 months. The mean regional kyphosis was 23 degrees preoperatively, 17 degrees postoperatively and 18 degrees at follow-up. The mean anterolisthesis was 8 mm preoperatively, 1 mm postoperatively and 1 mm at follow-up. No hardware failure occurred. Five patients with complete spinal cord injury at presentation made no neurological recovery, two patients with incomplete spinal cord injury initially (ASIA B), recovered substantially (to ASIA D), and the patients who were neurologically intact at presentation remained so.

Etiological and Endoscopic Profile of Middle Aged and Elderly Patients with Upper Gastrointestinal Bleeding in a Tertiary Care Hospital in North India: A Retrospective Analysis.

PubMed

Mahajan, Pranav; Chandail, Vijant Singh

2017-01-01

Upper gastrointestinal (GI) bleeding is a common medical emergency associated with significant morbidity and mortality. The clinical presentation depends on the amount and location of hemorrhage and the endoscopic profile varies according to different etiology. At present, there are limited epidemiological data on upper GI bleed and associated mortality from India, especially in the middle and elderly age group, which has a higher incidence and mortality from this disease. This study aims to study the clinical and endoscopic profile of middle aged and elderly patients suffering from upper GI bleed to know the etiology of the disease and outcome of the intervention. Out of a total of 1790 patients who presented to the hospital from May 2015 to August 2017 with upper GI bleed, and underwent upper GI endoscopy, data of 1270 patients, aged 40 years and above, was compiled and analyzed retrospectively. All the patients included in the study were above 40 years of age. Majority of the patients were males, with a male to female ratio of 1.6:1. The most common causes of upper GI bleed in these patients were portal hypertension-related (esophageal, gastric and duodenal varices, portal hypertensive gastropathy, and gastric antral vascular ectasia GAVE), seen in 53.62% of patients, followed by peptic ulcer disease (gastric and duodenal ulcers) seen in 17.56% of patients. Gastric erosions/gastritis accounted for 15.20%, and duodenal erosions were seen in 5.8% of upper GI bleeds. The in-hospital mortality rate in our study population was 5.83%. The present study reported portal hypertension as the most common cause of upper GI bleeding, while the most common endoscopic lesions reported were esophageal varices, followed by gastric erosion/gastritis, and duodenal ulcer.

Prospective Study of Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors Concurrent With Individualized Radiotherapy for Patients With Locally Advanced or Metastatic Non-Small-Cell Lung Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wang Jing; Xia Tingyi, E-mail: xiatingyi1959@21cn.com; Wang Yingjie

Purpose: To establish the safety profile and efficacy of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) concurrent with individualized radiotherapy (RT) in patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC). Patients and Methods: Between June 2007 and January 2010, 26 patients with Stage III/IV NSCLC were enrolled in this prospective study. These patients were treated with EGFR-TKIs (gefitinib 250 mg or erlotinib 150 mg, oral daily) concurrent with individualized RT with curative intent. The thoracic RT plans were individually designed on the basis of tumor size and normal tissue volume constraints. All patients were assessed for toxicity,more » and 25 patients were available for efficacy. The primary endpoints were acute toxicity, overall survival, and median survival time. The secondary endpoints included local control rate, time to tumor progression, and progression-free survival (PFS). Results: Median gross tumor volume, mean lung dose, and lung V20 were 56 cm{sup 3}, 8.6 Gy, and 14%, respectively. Median thoracic radiation dose was 70 Gy at a margin of gross tumor volume (range, 42-82 Gy), and median biological equivalent dose was 105 Gy (range, 60-119 Gy). Acute skin, hematologic, esophageal, and pulmonary toxicities were acceptable and manageable. Severe adverse events included neutropenia (Grade 4, 4%) and thrombocytopenia (Grade 4, 8%), esophagitis (Grade 3, 4%), and pneumonitis (Grade 3, 4%). With a median follow-up of 10.2 months, a local control rate of 96% was achieved for thoracic tumor. Median time to progression, median PFS, and median survival time were 6.3, 10.2, and 21.8 months, respectively. The 1- and 2-year PFS rates were both 42%, and 1-, 2-, and 3-year overall survival rates were 57%, 45%, and 30%, respectively. Conclusion: Concurrent EGFR-TKIs with individualized RT shows a favorable safety profile and promising outcome, therefore serving as a therapeutic option for patients with locally advanced or metastatic NSCLC.« less

Development of upper tract stones in patients with congenital neurogenic bladder.

PubMed

Stephany, Heidi A; Clayton, Douglass B; Tanaka, Stacy T; Thomas, John C; Pope, John C; Brock, John W; Adams, Mark C

2014-02-01

Patients with neurogenic bladder are at increased risk of developing upper tract stones. We hypothesized that patients with lower urinary tract stone disease are at greater risk of developing upper tract stones. We performed a 10-year retrospective case-control study of patients with neurogenic bladder to determine the association between bladder and upper tract stones. Independent risk factors for upper tract stones were assessed. Cases and controls were matched 1:1. Univariable analysis was performed by Fisher's exact test and the Mann-Whitney U test. Multivariable logistic regression was performed. 52 cases and controls were identified. Cases were significantly more likely to be non-ambulatory, have bowel-urinary tract interposition, thoracic level dysraphism, and history of bladder stones. On multivariable analysis, independent predictors of stone formation were male sex (OR 2.82; p = 0.02), dysraphism involving the thoracic spine (OR 3.37; p = 0.014) bowel-urinary tract interposition (OR 2.611; p = 0.038), and a history of bladder stones (OR 3.57; p = 0.015). Patients with neurogenic bladder are at increased risk for upper tract stones. The presence of bladder stones may herald the development of upper tract stones. The predictors of stone disease identified should guide prospective studies to better understand the natural history of upper tract stone development in this population. Copyright © 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Do large hiatal hernias affect esophageal peristalsis?

PubMed Central

Roman, Sabine; Kahrilas, Peter J; Kia, Leila; Luger, Daniel; Soper, Nathaniel; Pandolfino, John E

2013-01-01

Background & Aim Large hiatal hernias can be associated with a shortened or tortuous esophagus. We hypothesized that these anatomic changes may alter esophageal pressure topography (EPT) measurements made during high-resolution manometry (HRM). Our aim was to compare EPT measures of esophageal motility in patients with large hiatal hernias to those of patients without hernia. Methods Among 2000 consecutive clinical EPT, we identified 90 patients with large (>5 cm) hiatal hernias on endoscopy and at least 7 evaluable swallows on EPT. Within the same database a control group without hernia was selected. EPT was analyzed for lower esophageal sphincter (LES) pressure, Distal Contractile Integral (DCI), contraction amplitude, Contractile Front Velocity (CFV) and Distal Latency time (DL). Esophageal length was measured on EPT from the distal border of upper esophageal sphincter to the proximal border of the LES. EPT diagnosis was based on the Chicago Classification. Results The manometry catheter was coiled in the hernia and did not traverse the crural diaphragm in 44 patients (49%) with large hernia. Patients with large hernias had lower average LES pressures, lower DCI, slower CFV and shorter DL than patients without hernia. They also exhibited a shorter mean esophageal length. However, the distribution of peristaltic abnormalities was not different in patients with and without large hernia. Conclusions Patients with large hernias had an alteration of EPT measurements as a consequence of the associated shortened esophagus. However, the distribution of peristaltic disorders was unaffected by the presence of hernia. PMID:22508779

An animal model of photodynamic-therapy-induced esophageal stricture: preliminary report

NASA Astrophysics Data System (ADS)

Perry, Yaron; Epperly, Michael W.; Finkelstein, Sydney; Klein, Edwin; Greenberger, Joel; Luketich, James

2003-06-01

Photodynamic Therapy (PDT) using Photofrin has been recently approved by the FDA for the treatment of esophageal cancer and Barrett's esophagus. A major limitation of PDT for Barrett's esophagus is the development of esophageal stricture in up to 53% of patients. Mechanisms of PDT stricture formation have not been elucidated. The major difficulty is the lack of an animal model for PDT-induced stricture. We have used a pig model in which the esophagus is very similar to that of the human esophagus. Two (Scrofa) domestic pigs were injected with Photofrin at dosage of 2 mg/kg 48 hours prior to photoactivation with 630 nm light. Following anesthesia, a laser probe (2.5 cm in length) was passed through the oral cavity to approximately the mid-point of the esophagus via an endoscope. Light energy (400 Joules (J)/cm) was delivered as a single dose in one pig or repeated at 72 hours in the second pig. In this pig model, upper endoscopy, Barium swallow and pathological studies confirmed stricture formation following esophageal PDT exposure of 400 J as one or two fractions. We believe that this is the first animal model created to study esophageal strictures resulting from PDT.

Endoscopic ultrasonography predicts early esophageal variceal bleeding in liver cirrhosis: A case report.

PubMed

Men, Changjun; Zhang, Guoliang

2017-04-01

Bleeding esophageal and gastric varices constitute a serious complication in liver cirrhosis. Previous studies have shown that endoscopic ultrasonography (EUS) can be used to predict early esophageal variceal bleeding in liver cirrhosis. We report a case of a 46-year-old man with hepatitis B liver cirrhosis (CTP score, 5; Child-Pugh class, A) who was admitted to our hospital due to a decreased appetite lasting 1 week. He was initially diagnosed with decompensated hepatitis B cirrhosis; an abdominal computed tomography (CT) scan indicated a diagnosis of liver cirrhosis and portal hypertension (PHT). Common endoscopic examination showed no evidence of gastroesophageal varices; EUS revealed distinct varices of the esophageal and gastric veins. Six months after discharge, the patient was rehospitalized because of upper gastrointestinal bleeding. Endoscopic ligation was implemented as well as esophageal varices loop ligature (EVL). Six months later, EUS showed obvious collateral and perforator veins. We should strongly recommend that patients with liver cirrhosis undergo EUS in addition to a routine endoscopic examination. EUS can play an important role in evaluating the risk for bleeding in PHT and can be used to assess the efficacy of EVL.

Endoscopic therapy in early adenocarcinomas (Barrett's cancer) of the esophagus.

PubMed

Knabe, Mate; May, Andrea; Ell, Christian

2015-07-01

The incidence of early esophageal adenocarcinoma has been increasing significantly in recent decades. Prognosis depends greatly on the choice of treatment. Early cancers can be treated by endoscopic resection, whereas advanced carcinomas have to be sent for surgery. Esophageal resection is associated with high perioperative mortality (1-5%) even in specialized centers. Early diagnosis enables curative endoscopic treatment option. Patients with gastrointestinal symptoms and a familial risk for esophageal cancer should undergo upper gastrointestinal endoscopy. High-definition endoscopes have been developed with technical add-on that helps endoscopists to find fine irregularities in the esophageal mucosa, but interpreting the findings remains challenging. In this review we discussed novel and old diagnostic procedures and their values, as well as our own recommendations and those of the authors discussed for the diagnosis and treatment of early Barrett's carcinoma. Endoscopic resection is the therapy of choice in early esophageal adenocarcinoma. It is mandatory to perform a subsequent ablation of all residual Barrett's mucosa to avoid metachronous lesions. © 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.

[Pathological gastroesophageal reflux in patients with severe, morbid and hyper obesity].

PubMed

Csendes, A; Burdiles, P; Rojas, J; Burgos, A; Henríquez, A

2001-09-01

Overweight can be a risk factor for pathological gastroesophageal reflux or hiatal hernia. To study the prevalence of gastroesophageal reflux in patients with severe obesity. Sixty seven patients, 51 female, aged 17 to 56 years old with a body mass index over 35 kg/m2, were studied. An upper gastrointestinal endoscopy was performed in all, esophageal manometry was done in 32 and 24 h pH monitoring was done in 32 patients. Seventy nine percent of patients complained of heartburn and 66% of regurgitation. In 16 patients, endoscopy was normal. An erosive esophagitis was found in 33 patients, a short columnar epithelium in 12 and a Barret esophagus with intestinal metaplasia in six. Normal endoscopic findings and erosive esophagitis were present with a higher frequency in women. No association between the degree of obesity and esophageal lesions was observed. Lower esophageal sphincter pressure and abdominal length were significantly higher in subjects with a body mass index over 50 compared to those with a body mass index between 35 and 39.9 kg/m2. No differences were observed in 24 h pH monitoring. A high proportion of severely obese patients had symptoms and endoscopical findings of pathological gastroesophageal reflux.

Polymorphisms Near TBX5 and GDF7 Are Associated With Increased Risk for Barrett’s Esophagus

PubMed Central

Palles, Claire; Chegwidden, Laura; Li, Xinzhong; Findlay, John M.; Farnham, Garry; Castro Giner, Francesc; Peppelenbosch, Maikel P.; Kovac, Michal; Adams, Claire L.; Prenen, Hans; Briggs, Sarah; Harrison, Rebecca; Sanders, Scott; MacDonald, David; Haigh, Chris; Tucker, Art; Love, Sharon; Nanji, Manoj; deCaestecker, John; Ferry, David; Rathbone, Barrie; Hapeshi, Julie; Barr, Hugh; Moayyedi, Paul; Watson, Peter; Zietek, Barbara; Maroo, Neera; Gay, Laura; Underwood, Tim; Boulter, Lisa; McMurtry, Hugh; Monk, David; Patel, Praful; Ragunath, Krish; Al Dulaimi, David; Murray, Iain; Koss, Konrad; Veitch, Andrew; Trudgill, Nigel; Nwokolo, Chuka; Rembacken, Bjorn; Atherfold, Paul; Green, Elaine; Ang, Yeng; Kuipers, Ernst J.; Chow, Wu; Paterson, Stuart; Kadri, Sudarshan; Beales, Ian; Grimley, Charles; Mullins, Paul; Beckett, Conrad; Farrant, Mark; Dixon, Andrew; Kelly, Sean; Johnson, Matthew; Wajed, Shahjehan; Dhar, Anjan; Sawyer, Elinor; Roylance, Rebecca; Onstad, Lynn; Gammon, Marilie D.; Corley, Douglas A.; Shaheen, Nicholas J.; Bird, Nigel C.; Hardie, Laura J.; Reid, Brian J.; Ye, Weimin; Liu, Geoffrey; Romero, Yvonne; Bernstein, Leslie; Wu, Anna H.; Casson, Alan G.; Fitzgerald, Rebecca; Whiteman, David C.; Risch, Harvey A.; Levine, David M.; Vaughan, Tom L.; Verhaar, Auke P.; van den Brande, Jan; Toxopeus, Eelke L.; Spaander, Manon C.; Wijnhoven, Bas P.L.; van der Laan, Luc J.W.; Krishnadath, Kausilia; Wijmenga, Cisca; Trynka, Gosia; McManus, Ross; Reynolds, John V.; O’Sullivan, Jacintha; MacMathuna, Padraic; McGarrigle, Sarah A.; Kelleher, Dermot; Vermeire, Severine; Cleynen, Isabelle; Bisschops, Raf; Tomlinson, Ian; Jankowski, Janusz

2015-01-01

Background & Aims Barrett's esophagus (BE) increases the risk of esophageal adenocarcinoma (EAC). We found the risk to be BE has been associated with single nucleotide polymorphisms (SNPs) on chromosome 6p21 (within the HLA region) and on 16q23, where the closest protein-coding gene is FOXF1. Subsequently, the Barrett's and Esophageal Adenocarcinoma Consortium (BEACON) identified risk loci for BE and esophageal adenocarcinoma near CRTC1 and BARX1, and within 100 kb of FOXP1. We aimed to identify further SNPs that increased BE risk and to validate previously reported associations. Methods We performed a genome-wide association study (GWAS) to identify variants associated with BE and further analyzed promising variants identified by BEACON by genotyping 10,158 patients with BE and 21,062 controls. Results We identified 2 SNPs not previously associated with BE: rs3072 (2p24.1; odds ratio [OR] = 1.14; 95% CI: 1.09–1.18; P = 1.8 × 10−11) and rs2701108 (12q24.21; OR = 0.90; 95% CI: 0.86–0.93; P = 7.5 × 10−9). The closest protein-coding genes were respectively GDF7 (rs3072), which encodes a ligand in the bone morphogenetic protein pathway, and TBX5 (rs2701108), which encodes a transcription factor that regulates esophageal and cardiac development. Our data also supported in BE cases 3 risk SNPs identified by BEACON (rs2687201, rs11789015, and rs10423674). Meta-analysis of all data identified another SNP associated with BE and esophageal adenocarcinoma: rs3784262, within ALDH1A2 (OR = 0.90; 95% CI: 0.87–0.93; P = 3.72 × 10−9). Conclusions We identified 2 loci associated with risk of BE and provided data to support a further locus. The genes we found to be associated with risk for BE encode transcription factors involved in thoracic, diaphragmatic, and esophageal development or proteins involved in the inflammatory response. PMID:25447851

The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial

PubMed Central

Krauss, John; Creighton, Doug; Ely, Jonathan D.; Podlewska-Ely, Joanna

2008-01-01

This study examined the effect of translatoric spinal manipulation (TSM) on cervical pain and cervical active motion restriction when applied to upper thoracic (T1-T4) segments. Active cervical rotation range of motion was measured re- and post-intervention with a cervical inclinometer (CROM), and cervical pain status was monitored before and after manipulation with a Faces Pain Scale. Study participants included a sample of convenience that included 32 patients referred to physical therapy with complaints of pain in the mid-cervical region and restricted active cervical rotation. Twenty-two patients were randomly assigned to the experimental group and ten were assigned to the control group. Pre- and post-intervention cervical range of motion and pain scale measurements were taken by a physical therapist assistant who was blinded to group assignment. The experimental group received TSM to hypomobile upper thoracic segments. The control group received no intervention. Paired t-tests were used to analyze within-group changes in cervical rotation and pain, and a 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. Significance was accepted at p = 0.05. Significant changes that exceeded the MDC95 were detected for cervical rotation both within group and between groups with the TSM group demonstrating increased mean (SD) in right rotation of 8.23° (7.41°) and left rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cervical rotation showed significant improvement during right rotation for patients experiencing pain during bilateral rotation only (p=.05). This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation. PMID:19119394

Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation.

PubMed

Veenstra, Benjamin R; Goldberg, Ross F; Bowers, Steven P; Thomas, Mathew; Hinder, Ronald A; Smith, C Daniel

2016-05-01

Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation. We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture. A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10). Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for relief of dysphagia with reoperative intervention.

Comparative effectiveness of upfront esophagectomy versus induction chemoradiation in clinical stage T2N0 esophageal cancer: A decision analysis.

PubMed

Semenkovich, Tara R; Panni, Roheena Z; Hudson, Jessica L; Thomas, Theodore; Elmore, Leisha C; Chang, Su-Hsin; Meyers, Bryan F; Kozower, Benjamin D; Puri, Varun

2018-05-01

We compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 (cT2N0) esophageal cancer. We also assessed the influence of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation. We created a decision analysis model representing 2 treatment strategies for cT2N0 esophageal cancer: upfront esophagectomy that may be followed by adjuvant therapy for upstaged patients and induction chemoradiation for all patients with cT2N0 esophageal cancer followed by esophagectomy. Parameter values within the model were obtained from published data, and median survival for pathologic subgroups was derived from the National Cancer Database. In sensitivity analyses, staging uncertainty of endoscopic ultrasound was introduced by varying the probability of pathologic upstaging. The baseline model showed comparable median survival for both strategies: 48.3 months for upfront esophagectomy versus 45.9 months for induction chemoradiation and surgery. The sensitivity analysis demonstrated induction chemoradiation was beneficial, with probability of upstaging > 48.1%, which is within the published range of 32% to 65% probability of pathologic upstaging after cT2N0 diagnosis. The presence of any of 3 key variables (size larger than 3 cm, high grade, or lymphovascular invasion) was associated with > 48.1% risk of upstaging, thus conferring a survival advantage to induction chemoradiation. The optimal treatment strategy for cT2N0 esophageal cancer depends on the accuracy of endoscopic ultrasound staging. High-risk features that confer increased probability of upstaging can inform clinical decision making to recommend induction chemoradiation for select cT2N0 patients. Copyright © 2018 The American Association for Thoracic Surgery. All rights reserved.

Pretreatment Dysphagia in Esophageal Cancer Patients May Eliminate the Need for Staging by Endoscopic Ultrasonography.

PubMed

Ripley, R Taylor; Sarkaria, Inderpal S; Grosser, Rachel; Sima, Camelia S; Bains, Manjit S; Jones, David R; Adusumilli, Prasad S; Huang, James; Finley, David J; Rusch, Valerie W; Rizk, Nabil P

2016-01-01

Neoadjuvant therapy is commonly administered to patients with localized disease who have T3-4 esophageal disease as staged by endoscopic ultrasound (EUS). Previously, we noted that patients who present with dysphagia have a higher EUS T stage. We hypothesized that the presence of dysphagia is predictive of EUS T3-4 disease and that staging EUS could be forgone for esophageal cancer patients with dysphagia. We performed a prospective, intent-to-treat, single-cohort study in which patients with potentially resectable esophageal cancer completed a standardized four-tier dysphagia score survey. EUS was performed as part of our standard evaluation. To determine whether the presence of dysphagia predicted EUS T3-4 disease, the dysphagia score was compared with EUS T stage. The study enrolled 114 consecutive patients between August 2012 and February 2014: 77% (88 of 114) received neoadjuvant therapy, 18% (20 of 114) did not, and 5% (6 of 114) pursued treatment elsewhere. In total, 70% (80 of 114) underwent esophagectomy; of these, 54% (61 of 114) had dysphagia and 46% (53 of 114) did not. Dysphagia scores were 66% (40 of 61) grade 1, 25% (15 of 61) grade 2, and 10% (6 of 61) grade 3 to 4. Among patients with dysphagia, 89% (54 of 61) had T3-4 disease by EUS; among those without dysphagia, only 53% (28 of 53) had T3-4 disease by EUS (p < 0.001). The presence of dysphagia in patients with esophageal cancer was highly predictive of T3-4 disease by EUS. On the basis of this finding, approximately 50% of patients currently undergoing staging EUS at our institution could potentially forgo EUS before neoadjuvant therapy. Patients without dysphagia, however, should still undergo EUS. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Dosimetric rationale and early experience at UFPTI of thoracic proton therapy and chemotherapy in limited-stage small cell lung cancer.

PubMed

Colaco, Rovel J; Huh, Soon; Nichols, Romaine C; Morris, Christopher G; D'Agostino, Harry; Flampouri, Stella; Li, Zuofeng; Pham, Dat C; Bajwa, Abubakr A; Hoppe, Bradford S

2013-04-01

Concurrent chemoradiotherapy (CRT) is the standard of care in patients with limited-stage small cell lung cancer (SCLC). Treatment with conventional x-ray therapy (XRT) is associated with high toxicity rates, particularly acute grade 3+ esophagitis and pneumonitis. We present outcomes for the first known series of limited-stage SCLC patients treated with proton therapy and a dosimetric comparison of lung and esophageal doses with intensity-modulated radiation therapy (IMRT). Six patients were treated: five concurrently and one sequentially. Five patients received 60-66 CGE in 30-34 fractions once daily and one patient received 45 CGE in 30 fractions twice daily. All six patients received prophylactic cranial irradiation. Common Terminology Criteria for Adverse Events, v3.0, was used to grade toxicity. IMRT plans were also generated and compared with proton plans. The median follow-up was 12.0 months. The one-year overall and progression-free survival rates were 83% and 66%, respectively. There were no cases of acute grade 3+ esophagitis or acute grade 2+ pneumonitis, and no other acute grade 3+ non-hematological toxicities were seen. One patient with a history of pulmonary fibrosis and atrial fibrillation developed worsening symptoms four months after treatment requiring oxygen. Three patients died: two of progressive disease and one after a fall; the latter patient was disease-free at 36 months after treatment. Another patient recurred and is alive, while two patients remain disease-free at 12 months of follow-up. Proton therapy proved superior to IMRT across all esophageal and lung dose volume points. In this small series of SCLC patients treated with proton therapy with radical intent, treatment was well tolerated with no cases of acute grade 3+ esophagitis or acute grade 2+ pneumonitis. Dosimetric comparison showed better sparing of lung and esophagus with proton therapy. Proton therapy merits further investigation as a method of reducing the toxicity of CRT.

A Prospective Study of Proton Beam Reirradiation for Esophageal Cancer.

PubMed

Fernandes, Annemarie; Berman, Abigail T; Mick, Rosemarie; Both, Stefan; Lelionis, Kristi; Lukens, John N; Ben-Josef, Edgar; Metz, James M; Plastaras, John P

2016-05-01

Reirradiation to the esophagus carries a significant risk of complications. Proton therapy may offer an advantage in the reirradiation setting due to the lack of exit dose and potential sparing of previously radiated normal tissues. Between June 2010 and February 2014, 14 patients with a history of thoracic radiation and newly diagnosed or locally recurrent esophageal cancer began proton beam reirradiation on a prospective trial. Primary endpoints were feasibility and acute toxicity. Toxicity was graded according Common Toxicity Criteria version 4.0. The median follow-up was 10 months (2-25 months) from the start of reirradiation. Eleven patients received concurrent chemotherapy. The median interval between radiation courses was 32 months (10-307 months). The median reirradiation prescription dose was 54.0 Gy (relative biological effectiveness [RBE]) (50.4-61.2 Gy[RBE]), and the median cumulative prescription dose was 109.8 Gy (76-129.4 Gy). Of the 10 patients who presented with symptomatic disease, 4 patients had complete resolution of symptoms, and 4 had diminished or stable symptoms. Two patients had progressive symptoms. The median time to symptom recurrence was 10 months. Maximum acute nonhematologic toxicity attributable to radiation was grade 2 (64%, N=9), 3 (29%, N=4), 4 (0%), and 5 (7%, N=1). The acute grade 5 toxicity was an esophagopleural fistula more likely related to tumor progression than radiation. Grade 3 nonhematologic acute toxicities included dysphagia, dehydration, and pneumonia. There was 1 late grade 5 esophageal ulcer more likely related to tumor progression than radiation. There were 4 late grade 3 toxicities: heart failure, esophageal stenosis requiring dilation, esophageal ulceration from tumor, and percutaneous endoscopic gastrostomy tube dependence. The median time to local failure was 10 months, and the median overall survival was 14 months. Our data demonstrate that proton reirradiation is feasible, with an encouraging symptom control rate, modest radiation-related toxicity, and favorable survival in this high-risk population. Copyright © 2016 Elsevier Inc. All rights reserved.

Cerebral Arterial Gas Embolism During Upper Endoscopy.

PubMed

Eoh, Eun J; Derrick, Bruce; Moon, Richard

2015-09-15

Arterial gas embolism can be caused by direct entry of gas into systemic arteries or indirectly by venous-to-arterial shunting. Although arterial gas embolism is rare, most documented cases are iatrogenic, resulting from the entry of gas during procedures that involve direct vascular cannulation or intracavitary air insufflation. Of the 18 identified case reports of air embolism during endoscopy, 11 cases describe findings of cerebral arterial gas embolism during upper endoscopy. Only 1 of these occurred during endoscopic balloon dilation of an esophageal stricture. We report a rare case of cerebral arterial gas embolism in a 64-year-old woman, which occurred during endoscopic dilation of an esophageal stricture and was subsequently treated with hyperbaric oxygen therapy. In this case report, we explore the possible etiologies, clinical workup, and therapeutic management of cerebral artery gas embolisms. Hyperbaric oxygen therapy is the treatment of choice for cerebral arterial gas embolism, with earlier treatments resulting in better outcomes.

Diagnosis and endoscopic treatment of esophago-bronchial fistula due to gastric heterotopy.

PubMed

Katsanos, Konstantinos H; Christodoulou, Dimitrios K; Kamina, Sevasti; Maria, Kosmidou; Lambri, Evangelia; Theodorou, Stavroula; Tsampoulas, Konstantinos; Vasiliki, Mitsi; Tsianos, Epameinondas V

2010-04-16

Heterotopic gastric mucosa patches are congenital gastrointestinal abnormalities and have been reported to occur anywhere along the gastrointestinal tract from mouth to anus. Complications of heterotopic gastric mucosa include dysphagia, upper gastrointestinal bleeding, upper esophageal ring stricture, adenocarcinoma and fistula formation. In this case report we describe the diagnosis and treatment of the first case of esophago-bronchial fistula due to heterotopic gastric mucosa in mid esophagus. A 40-year old former professional soccer player was referred to our department for treatment of an esophago-bronchial fistula. Microscopic examination of the biopsies taken from the esophageal fistula revealed the presence of gastric heterotopic mucosa. We decided to do a non-surgical therapeutic endoscopic procedure. A sclerotherapy catheter was inserted through which 1 mL of ready to use synthetic surgical glue was applied in the fistula and it closed the fistula opening with excellent results.

[Association between acid reflux and esophageal dysmotility in patients with gastroesophageal reflux disease].

PubMed

Yi, Zhi-hui; Feng, Li; Wen, Mao-yao; Liu, Jian-rong; Yang, Li

2014-05-01

To investigate the association between esophageal motility and acid reflux in patients with gastroesophageal reflux disease (GERD). A total of 94 patients with typical reflux symptoms such as heartburn, regurgitation and chest pain, whose score (Sc) of reflux diagnostic questionnaire (RDQ) was greater than or equal to 12 were enrolled in the study. Each participant was evaluated by upper gastrointestinal endoscopy, high resolution manometry (HRM) of esophagus and 24 h esophageal pH monitoring. The participants were divided into groups of reflux esophagitis (RE) and non-erosive reflux disease (NERD) on the basis of endoscopy findings. The 24 h esophageal pH monitoring categorized participants into physiologic reflux (pH) and pathologic reflux (pH+). The characteristics of esophageal motility and acid reflux were compared between the two groups of participants. Lower but non-significant differences (P > 0.05) were found in pressure of lower esophageal sphincter (LESP), length of lower esophageal sphincter (LESL), esophageal contraction amplitude (CA), distal contractile integral (DCI) and effective peristalsis proportion (EPP) in the participants in the RE group compared with those in the NERD group. Participants in the RE group had significantly higher prevalence of reduced LESP (63.0% vs. 31.7%, P < 0.01) and hiatus hernia (HH) (37.0% vs. 14.3%, P < 0.05) than those in the NERD group, pH+ was more prevalent in the RE group than in the NERD group (63.0% vs. 17.5%, P < 0.01). Indicators of 24 h esophageal pH monitoring were significantly higher in participants in the RE group compared with those in the NERD group (P < 0.05). Participants with pH+ had significantly lower LESP, CA and higher HH and prevalence of reduced LESP compared with those with pH (P < 0.05). LESL, DCI and EPP were lower in those with pH+ compared with those with pH-, but without statistical significance (P > 0.05). RE is closely associated with acid reflux and hiatus hernia. Esophageal dysmotility is more likely to appear in patients with pH+. The interaction of acid reflux and esophageal dysmotility may play a role in GERD.

Changes in shoulder pain and disability after thrust manipulation in subjects presenting with second and third rib syndrome.

PubMed

Dunning, James; Mourad, Firas; Giovannico, Giuseppe; Maselli, Filippo; Perreault, Thomas; Fernández-de-Las-Peñas, César

2015-01-01

The purpose of this preliminary study was to investigate changes in shoulder pain, disability, and perceived level of recovery after 2 sessions of upper thoracic and upper rib high-velocity low-amplitude (HVLA) thrust manipulation in patients with shoulder pain secondary to second and third rib syndrome. This exploratory study evaluated 10 consecutive individuals with shoulder pain, with or without brachial pain, and a negative Neer impingement test, who completed the Shoulder Pain and Disability Index (SPADI), the numeric pain rating scale (NPRS), and the global rating of change. Patients received 2 sessions of HVLA thrust manipulation targeting the upper thoracic spine bilaterally and the second and third ribs on the symptomatic side. Outcome measures were completed after the first treatment session, at 48 hours, 1 month, and 3 months. Patients showed a significant decrease in SPADI (F = 59.997; P = .001) and significant decrease in resting shoulder NPRS (F = 63.439; P = .001). For both NPRS and SPADI, there were significant differences between the pretreatment scores and each of the postintervention scores through 3-month follow-up (P < .05). Large within-group effect sizes (Cohen's d ≥ 0.8) were found between preintervention data and all postintervention assessments in both outcomes. Mean global rating of change scores (+6.8 at 3 months) indicated "a very great deal better" outcome at long-term follow-up. This group of patients with shoulder pain secondary to second and third rib syndrome who received upper thoracic and upper rib HVLA thrust manipulations showed significant reductions in pain and disability and improvement in perceived level of recovery. Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.

Intraoperative assessment of microperfusion with visible light spectroscopy in oesophageal and colorectal anastomosis

NASA Astrophysics Data System (ADS)

Karliczek, Anne; Benaron, David A.; Baas, Peter; van der Stoel, Anne; Wiggers, Theo; Plukker, John; van Dam, Gooitzen M.

2007-07-01

In gastrointestinal surgery, leakage of anastomoses in general is a challenging problem because of the related mortality and morbidity1,2. The highest incidence of anastomotic leakage is found at the most proximal and most distal parts of the digestive tract, i.e. esophageal and colorectal anastomoses. Increased strain and limited vascular supply at the anastomoses are the two main reasons of leakage, especially in the absence of a serosal layer at these sites2,3,4. Apart from these local risk factors, several general risk factors attributed to the occurrence of anastomotic failure, of which smoking, cardiovascular disease, gender, age and malnutrition are the most important2,5-8. Most of these factors suggest local ischemia as an important cause of anastomotic dehiscence. In esophageal resection the blood supply to the remaining esophageal end is compromised due to ligation of arteries and resection of surrounding mediastinal tissue. Furthermore, the gastric conduit, usually only based on the right gastroepiploic artery, is transposed from its anatomical abdominal position into the thoracic cavity and cervical region. Apart from co-existing morbidities such as sepsis, cardiovascular and several systemic diseases, the altered vascular supply frequently compromises the microcirculation at both ends of the anastomosis, and is as such responsible for the higher rate of leakage compared to small and other large bowel anastomoses9,10.

Esophageal capsule endoscopy is not the optimal technique to determine the need for primary prophylaxis in patients with cirrhosis

PubMed Central

Krok, Karen L.; Wagennar, Rebecca Rankin; Kantsevoy, Sergey V.

2016-01-01

Introduction Capsule endoscopy has been suggested as a potential alternative to endoscopy for detection of esophagogastric varices and severe portal hypertensive gastropathy (PHG). The aim of the study was to determine whether PillCam esophageal capsule endoscopy could replace endoscopy for screening purposes. Material and methods Sixty-two patients with cirrhosis with no previous variceal bleeding had PillCam capsule endoscopy and video endoscopy performed on the same day. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of capsule endoscopy were compared to endoscopy for the presence and severity of esophageal and gastric varices, PHG and the need for primary prophylaxis. Patients’ preference was assessed by a questionnaire. Results Four (6%) patients were unable to swallow the capsule. Sensitivity, specificity, PPV and NPV of capsule endoscopy for detecting any esophageal varices (92%, 50%, 92%, 50%), large varices (55%, 91%, 75%, 80%), variceal red signs (58%, 87%, 69%, 80%), PHG (95%, 50%, 95%, 50%), and the need for primary prophylaxis (91%, 57%, 78%, 80%) were not optimal, with only moderate agreement (κ) between capsule and upper GI endoscopy. Had only a capsule endoscopy been performed, 12 (21.4%) patients would have received inappropriate treatment. Capsule endoscopy also failed to detect (0/13) gastric varices. The majority of patients ranked capsule endoscopy as more convenient (69%) and their preferred (61%) method. Conclusions Despite the preference expressed by patients for capsule endoscopy, we believe that upper GI endoscopy should remain the preferred screening method for primary prophylaxis. PMID:27186182

Influence of Ionizing Radiation on Stromal-Epithelial Communication in Esophageal Carcinogenesis

NASA Astrophysics Data System (ADS)

Huff, Janice; Patel, Zarana; Grugan, Katharine; Rustgi, Anil; Cucinotta, Francis A.

Esophageal cancer is the 6th leading cause of cancer death worldwide and is associated with a variety of risk factors including tobacco use, heavy alcohol consumption, human papilloma virus infection, and certain dietary factors such as trace mineral and vitamin deficiencies. A connection with ionizing radiation exposure is revealed by the high excess relative risk for esophageal squamous cell carcinoma observed in the survivors of the atomic bomb detonations in Japan. Esophageal carcinomas are also seen as secondary malignancies in patients who received radiotherapy for breast and thoracic cancers; additionally, patients with head/neck and oral squamous cell cancers are at increased risk for metachronous esophageal squamous cell cancers. This malignancy is rapidly fatal, mainly because it remains asymptomatic until late, advanced stages when the disease is rarely responsive to treatment. In normal epithelium, the stromal microenvironment is essential for the maintenance and modulation of cell growth and differentiation. Cross talk between the epithelial and stromal compartments can influence many aspects of malignant progression, including tumor cell proliferation, migration, invasion and recruitment of new blood vessels. To test the hypothesis that radiation exposure plays a role in esophageal carcinogenesis via non-targeted mechanisms involving stromal-epithelial cell communication, we are studying radiation effects on hTERT-immortalized human esophageal epithelial cells and genetic variants grown in co-culture with human esophageal stromal fibrob-lasts (Okawa et al., Genes Dev. 2007. 21: 2788-2803). We examined how irradiation of stromal fibroblasts affected epithelial migration and invasion, behaviors associated with cancer promotion and progression. These assays were conducted in modified Boyden chambers using conditioned media from irradiated fibroblasts. Our results using low LET gamma radiation showed a dose-dependent increase in migration of epithelial cells when exposed to conditioned media from irradiated vs. non-irradiated fibroblasts. We also observed enhanced invasion through a basement membrane matrix in similarly treated cells. Candidate factors that me-diate these effects were identified using antibody capture arrays, and their increased secretion in irradiated fibroblasts was confirmed using ELISAs. We are currently analyzing the effect of these individual factors on epithelial migration and invasion, as well as their influence on cell survival and DNA repair. Our current studies using high-LET radiation will elucidate radiation quality effects on these processes. These results should further our understanding of the mechanisms by which radiation impacts the tissue microenvironment and how it influences cancer development processes.

Laparoscopic Transhiatal Treatment of Large Epiphrenic Esophageal Diverticulum

PubMed Central

Casella, Giovanni; Recchia, Carlo Luigi; Bianchi, Ermanno; Lomartire, Nazzareno

2008-01-01

Background: Epiphrenic diverticulum is an uncommon disorder of the distal third of the esophagus. We report the case of a 73-year-old woman with a large symptomatic esophageal epiphrenic diverticulum, diffuse nonspecific esophageal dysmotility, and a hiatal hernia. Methods: Surgery was indicated by the patient's symptoms, the size of the diverticulum (maximum diameter 10 cm), and the associated esophageal motor disorder. Preoperative study included barium swallow, upper gastrointestinal endoscopy, and esophageal manometry. A laparoscopic transhiatal diverticulectomy associated with a Heller myotomy, hiatoplasty, and a Dor's fundoplication was carried out. The overall operative time was 230 minutes. Results: No intraoperative complications occurred. Gastrografin swallow performed on postoperative day 4 did not show any signs of leakage from the staple line. The postoperative hospital stay was 5 days. The patient was readmitted 10 days after discharge complaining of fever and chest pain. A new Gastrografin swallow demonstrated a small leak from the staple line successfully treated with 3 weeks of total enteral nutrition. Conclusion: The laparoscopic approach to epiphrenic diverticulum is feasible. Postoperative Gastrografin swallow is not 100% sensitive in detecting small suture-line leaks if a preexisting esophageal motility disorder is present. In case of late postoperative fever and pleural effusion, a suture-line leak should be suspected. Conservative management of the small suture-line leak should be considered as an effective therapeutic option. PMID:18402751

Esophageal acid sensitivity and mucosal integrity in patients with functional heartburn.

PubMed

Weijenborg, P W; Smout, A J P M; Bredenoord, A J

2016-11-01

Patients with functional heartburn (FH) experience troublesome heartburn that is not related to gastroesophageal reflux. The etiology of the heartburn sensation in FH patients is unknown. In patients with reflux disease, esophageal hypersensitivity seems associated with impaired mucosal integrity. We aimed to determine esophageal sensitivity and mucosal integrity in FH and non-erosive reflux disease (NERD) patients. In this prospective experimental study, we performed an acid perfusion test and upper endoscopy with biopsies in 12 patients with NERD and nine patients with FH. Mucosal integrity was measured during endoscopy using electrical tissue impedance spectroscopy and biopsy specimens were analyzed in Ussing chambers for transepithelial electrical resistance and transepithelial permeability. Lag time to heartburn perception was significantly longer in FH patients (median 12 min) than in NERD patients (median 3 min). Once perceived, intensity of heartburn was scored equal with median visual analog scale 6.5 and 7.1 respectively. Esophageal mucosal integrity was also comparable between FH and NERD patients, both in vivo extracellular impedance and ex vivo transepithelial resistance and permeability were similar. Patients with FH did not show acid hypersensitivity as seen in patients with NERD. However, once perceived, intensity of heartburn is similar. Esophageal mucosal integrity is similar between NERD and FH patients, and is therefore unlikely to be the underlying cause of the observed difference in esophageal acid perception. © 2016 John Wiley & Sons Ltd.

The Esophageal Anastomotic Stricture Index (EASI) for the management of esophageal atresia.

PubMed

Sun, Linda Yi-Chan; Laberge, Jean-Martin; Yousef, Yasmine; Baird, Robert

2015-01-01

Anastomotic stricture is the most common complication following repair of esophageal atresia. An Esophageal Anastomotic Stricture Index (EASI) based on the postoperative esophagram may identify patients at high risk of stricture formation. Digital images of early postoperative esophagrams of patients undergoing EA repair from 2005 to 2013 were assessed. Demographics and outcomes including dilations were prospectively collected. Upper (U-EASI) and lower (L-EASI) pouch ratios were generated using stricture diameter divided by maximal respective pouch diameter. Score performances were evaluated with area under the receiver operator curves (AUC) and the Fisher's exact test for single and multiple (>3) dilatations. Interrater agreement was evaluated using the intraclass correlation coefficient (ICC). Forty-five patients had esophagrams analyzed; 28 (62%) required dilatation and 19 received >3 (42%). U-EASI and L-EASI ratios ranged from 0.17 to 0.70, with L-EASI outperforming the U-EASI as follows: L-EASI AUC: 0.66 for a single dilatation, 0.65 for >3 dilatations; U-EASI AUC: 0.56 for a single dilatation, 0.67 for >3 dilatations. All patients with an L-EASI ratio of ≤0.30 (n=8) required multiple esophageal dilatations, p=0.0006. The interrater ICC was 0.87. The EASI is a simple, reproducible tool to predict the development and severity of anastomotic stricture after esophageal atresia repair and can direct postoperative surveillance. Copyright © 2015 Elsevier Inc. All rights reserved.

Elevated Temperature and 6-7 Year Outcome of Neonatal Encephalopathy

PubMed Central

Laptook, Abbot R.; McDonald, Scott A.; Shankaran, Seetha; Stephens, Bonnie E.; Vohr, Betty R.; Guillet, Ronnie; Higgins, Rosemary D.; Das, Abhik

2013-01-01

OBJECTIVE Determine if higher temperature after hypoxia-ischemia is associated with death or IQ < 70 at 6-7 yr among infants treated with intensive care without hypothermia. DESIGN/METHODS Control infants (non-cooled, n=106) of the NICHD Neonatal Research Network hypothermia trial had serial esophageal and skin temperatures over 72hrs. Each infant's temperature was ranked to derive an average of the upper and lower quartile, and median of each site. Temperatures were used in logistic regressions to determine adjusted associations with death or IQ < 70 at 6-7yrs. Secondary outcomes were death, IQ < 70, and moderate/severe CP. IQ and motor function were assessed with Wechsler Scales for Children and Gross Motor Function Classification System. Results are odds ratio (OR, per °C increment within the quartile or median) and 95% confidence interval (CI). RESULTS Primary outcome was available for 89 infants. At 6-7yrs death or IQ < 70 occurred in 54 infants (37 deaths, 17 survivors with IQ < 70) and moderate/severe CP in 15 infants. Death or IQ < 70 was associated with the upper quartile average of esophageal (OR 7.3, 95% CI 2.0-26.3) and skin temperature (OR 3.5, 95% 1.2-10.4). CP was associated with the upper quartile average of esophageal (OR 12.5, 95% CI 1.02-155) and skin temperature (OR 10.3, 95% 1.3-80.2). CONCLUSIONS Among non-cooled infants of a randomized trial, elevated temperatures during the first post-natal days are associated with increase odds of a worse outcome at 6-7yrs. PMID:23595408

Poland syndrome with bilateral features: case description with review of the literature.

PubMed

Baban, Anwar; Torre, Michele; Bianca, Sebastiano; Buluggiu, Anna; Rossello, Mario Igor; Calevo, Maria Grazia; Valle, Maura; Ravazzolo, Roberto; Jasonni, Vincenzo; Lerone, Margherita

2009-07-01

Poland syndrome (PS) has been described as unilateral pectoral muscle deficiency variably associated with ipsilateral thoracic and upper limb anomalies. Bilateral hypoplasia/aplasia of the pectoralis muscle and upper limb defects in association with variable thoracic muscles, chest wall deformities and lower limb defects have been infrequently reported in the literature. We report on a 3(1/2)-year-old girl with clinical features consisting in bilateral asymmetric pectoral muscle defects (complete agenesis on the left side and agenesis of the sternocostal head on the right side), nipple hypoplasia, left rib defect, and right hand symbrachydactyly. In this study, we reviewed the bilateral features present in our patient and those described in the literature. Hypotheses explaining bilateral features in PS are reviewed.

[Poland'syndrome and hand's malformations: about a clinic series of 37 patients].

PubMed

Foucras, L; Grolleau, J L; Chavoin, J P

2005-04-01

Poland's syndrome is a rare malformation which associates thoracic anomalies and anomalies of homolateral upper end. We wish to know the frequency of hand's malformations in this syndrome in our clinical experience. We have revised 37 patients who were seen initially for a thoracomammary anomaly. This clinical series from plastic surgery service of Toulouse has been revised to know the importance of hand's malformations. Hand's malformations in Poland's syndrome are rare in your study, they touch only 12% patients. We find only 4 malformations in 33 patients, four were lost. They were only females, we find three brachymesophalangies and a major form. Hand's malformations in Poland's syndrome are less frequent than classically. There is no parallelism between gravity of thoracic malformation and that one of upper end. In this series, we find only one case with syndactyly; originally, Poland's syndrome was named < Poland's syndactyly >. Finally, we think that we can talk about Poland's syndrome without anomaly of homolateral upper end, the major element is musculary agenesia of sternocostal pectoralis major. The search of homolateral upper end has to be systematic in front of suspicious of Poland's syndrome.

Swallowing and pharyngo-esophageal manometry in obstructive sleep apnea.

PubMed

Oliveira, Luciana Almeida Moreira da Paz; Fontes, Luiz Henrique de Souza; Cahali, Michel Burihan

2015-01-01

Upper airway nerve and muscle damage associated with obstructive sleep apnea may impair the strength and dynamics of pharyngeal and esophageal contractions during swallowing. To evaluate the presence of alterations in pharyngoesophageal manometry in patients with obstructive sleep apnea with and without oropharyngeal dysphagia. This study prospectively evaluated 22 patients with obstructive sleep apnea without spontaneous complaints of dysphagia, using a questionnaire, fiberoptic endoscopic evaluation of swallowing, and pharyngoesophageal manometry, including measurement of the upper and lower esophageal sphincter pressures and mean pharyngeal pressures at three levels during swallowing. The dysphagia group consisted of 17 patients (77.3%) in whom swallowing abnormalities were detected on fiberoptic endoscopic evaluation of swallowing (n=15; 68.2%) and/or in the questionnaire (n=7; 31.8%). The five remaining cases comprised a control group without oropharyngeal dysphagia. In all cases of abnormalities on fiberoptic endoscopic evaluation of swallowing, there was premature bolus leakage into the pharynx. There was no statistically significant difference between the groups regarding any of the pharyngoesophageal manometry measurements, age, or severity of obstructive sleep apnea. Pharyngoesophageal manometry detected no statistically significant difference between the groups with and without oropharyngeal dysphagia. Copyright © 2015 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Heating and Cooling Rates With an Esophageal Heat Exchange System.

PubMed

Kalasbail, Prathima; Makarova, Natalya; Garrett, Frank; Sessler, Daniel I

2018-04-01

The Esophageal Cooling Device circulates warm or cool water through an esophageal heat exchanger, but warming and cooling efficacy in patients remains unknown. We therefore determined heat exchange rates during warming and cooling. Nineteen patients completed the trial. All had general endotracheal anesthesia for nonthoracic surgery. Intraoperative heat transfer was measured during cooling (exchanger fluid at 7°C) and warming (fluid at 42°C). Each was evaluated for 30 minutes, with the initial condition determined randomly, starting at least 40 minutes after induction of anesthesia. Heat transfer rate was estimated from fluid flow through the esophageal heat exchanger and inflow and outflow temperatures. Core temperature was estimated from a zero-heat-flux thermometer positioned on the forehead. Mean heat transfer rate during warming was 18 (95% confidence interval, 16-20) W, which increased core temperature at a rate of 0.5°C/h ± 0.6°C/h (mean ± standard deviation). During cooling, mean heat transfer rate was -53 (-59 to -48) W, which decreased core temperature at a rate of 0.9°C/h ± 0.9°C/h. Esophageal warming transferred 18 W which is considerably less than the 80 W reported with lower or upper body forced-air covers. However, esophageal warming can be used to supplement surface warming or provide warming in cases not amenable to surface warming. Esophageal cooling transferred more than twice as much heat as warming, consequent to the much larger difference between core and circulating fluid temperature with cooling (29°C) than warming (6°C). Esophageal cooling extracts less heat than endovascular catheters but can be used to supplement catheter-based cooling or possibly replace them in appropriate patients.

Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus.

PubMed

Passaretti, Sandro; Mazzoleni, Giorgia; Vailati, Cristian; Testoni, Pier Alberto

2016-10-28

To investigate the relationship between pathological oropharyngeal (OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes. In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease (GERD). We enrolled only patients with a reflux symptom index (RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal high-resolution manometry (HRM). Patients were divided into two groups on the basis of a normal or pathological pH-metric finding (Ryan Score) and all manometric characteristics of the two groups were compared. We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure (median 71 mmHg vs 126 mmHg, P = 0.004) and the median proximal contractile integral (median 215.5 cm•mmHg•s vs 313.5 cm•mmHg•s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mmHg isobaric contour (38.7% vs 15.38%, P < 0.0001). In patients with suspected GERD-related extra-esophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.

Changing Epidemiology of Upper Gastrointestinal Hemorrhage in the Last Decade: A Nationwide Analysis.

PubMed

Wuerth, Brandon A; Rockey, Don C

2018-05-01

Upper gastrointestinal hemorrhage (UGIH) is common and carries substantial mortality requiring frequent hospitalizations. To investigate trends in etiology and outcome of UGIH in hospitalized patients in the USA. Retrospective, observational cohort study of the Nationwide Inpatient Sample from 2002 to 2012 was carried out. UGIH was identified in hospitalizations with a principle ICD-9-CM diagnosis of UGIH or secondary diagnosis of UGIH with a principal diagnosis of hematemesis, blood in stool, or gastrointestinal bleeding. Age 18 years or older was required for inclusion, and elective admissions and transferred patients were excluded. The hospitalization rate of UGIH in the USA decreased by 21% from 2002 to 2012, from 81 to 67 cases per 100,000 population (p < 0.01). The greatest declines occurred for gastritis and PUD, which decreased by 55 and 30%, respectively (p < 0.01). There were increases in neoplasm, Dieulafoy lesions, angiodysplasia, and esophagitis, which increased by 50, 33, 32 and 20%, respectively (p < 0.01). The all-cause inpatient mortality rate of UGIH decreased 28% from 2.6 per 100 cases in 2002 to 1.9 in 2012 (p < 0.01). The greatest decline occurred for esophagitis, Mallory-Weiss tear, and neoplasm, which decreased by 39% (p < 0.01), 36% (p = 0.02), and 36% (p < 0.01), respectively. The rate of hospitalization for bleeding caused by esophageal varices remained constant and low (approximately 2%) throughout the study period; the mortality for esophageal varices also remained constant at 6-7%. The epidemiology of UGIH hemorrhage appears to be shifting, with a decline in PUD and gastritis; an increase in hospitalization rate for neoplasm, Dieulafoy lesions, angiodysplasia, and esophagitis; and a reduction in overall mortality. The decreasing hospitalization rate and mortality rate of UGIH suggest population trends in use of treatments for PUD, improved hemostatic techniques, and overall care.

Esophagram findings in cervical esophageal stenosis: A case-controlled quantitative analysis.

PubMed

West, Jacob; Kim, Cherine H; Reichert, Zachary; Krishna, Priya; Crawley, Brianna K; Inman, Jared C

2018-01-04

Cervical esophageal stenosis is often diagnosed with a qualitative evaluation of a barium esophagram. Although the esophagram is frequently the initial screening exam for dysphagia, a clear objective standard for stenosis has not been defined. In this study, we measured esophagram diameters in order to establish a quantitative standard for defining cervical esophageal stenosis that requires surgical intervention. Single institution case-control study. Patients with clinically significant cervical esophageal stenosis defined by moderate symptoms of dysphagia (Functional Outcome Swallowing Scale > 2 and Functional Oral Intake Scale < 6) persisting for 6 months and responding to dilation treatment were matched with age, sex, and height controls. Both qualitative and quantitative barium esophagram measurements for the upper, mid-, and lower vertebral bodies of C5 through T1 were analyzed in lateral, oblique, and anterior-posterior views. Stenotic patients versus nonstenotic controls showed no significant differences in age, sex, height, body mass index, or ethnicity. Stenosis was most commonly at the sixth cervical vertebra (C 6) lower border and C7 upper border. The mean intraesophageal minimum/maximum ratios of controls and stenotic groups in the lateral view were 0.63 ± 0.08 and 0.36 ± 0.12, respectively (P < 0.0001). Receiver operating characteristic analysis of the minimum/maximum ratios, with a <0.50 ratio delineating stenosis, demonstrated that lateral view measurements had the best diagnostic ability. The sensitivity of the radiologists' qualitative interpretation was 56%. With application of lateral intraesophageal minimum/maximum ratios, we observed improved sensitivity to 94% of the esophagram, detecting clinically significant stenosis. Applying quantitative determinants in esophagram analysis may improve the sensitivity of detecting cervical esophageal stenosis in dysphagic patients who may benefit from surgical therapy. IIIb. Laryngoscope, 2018. © 2018 The American Laryngological, Rhinological and Otological Society, Inc.

Definitive chemoradiotherapy versus neoadjuvant chemoradiotherapy followed by surgery for stage II to III esophageal squamous cell carcinoma.

PubMed

Barbetta, Arianna; Hsu, Meier; Tan, Kay See; Stefanova, Dessislava; Herman, Koby; Adusumilli, Prasad S; Bains, Manjit S; Bott, Matthew J; Isbell, James M; Janjigian, Yelena Y; Ku, Geoffrey Y; Park, Bernard J; Wu, Abraham J; Jones, David R; Molena, Daniela

2018-06-01

Definitive chemoradiotherapy (CRT) remains the most commonly used treatment for locally advanced esophageal squamous cell carcinoma (SCC), because of perceptions that esophagectomy offers an unclear survival advantage. We compare recurrence, overall survival (OS), and disease-free survival (DFS) in patients treated with definitive CRT or neoadjuvant CRT followed by surgery (trimodality). This was a retrospective cohort study of patients with stage II and III SCC of the middle and distal esophagus in patients who completed CRT. Treatment groups were matched (1:1) on covariates using a propensity score-matching approach. The effect of trimodality treatment, compared with definitive CRT, on OS, DFS, and site-specific recurrence was evaluated as a time-dependent variable and analyzed using Cox regression with a gamma frailty term for matched units. We included 232 patients treated between 2000 and 2016: 124 (53%) with definitive CRT and 108 (47%) with trimodality. Trimodality was used less frequently over time (61% before 2009 and 29% after 2009; P < .0001). After matching, each group contained 56 patients. Median OS and DFS were 3.1 and 1.8 years for trimodality versus 2.3 and 1.0 years for CRT. Surgery was independently associated with improved OS (hazard ratio, 0.57; 95% confidence interval, 0.34-0.97; P = .039) and DFS (hazard ratio, 0.51; 95% confidence interval, 0.32-0.83; P = .007). CRT followed by surgery might decrease local recurrence and increase DFS and OS in patients with esophageal SCC. Until better tools to select patients with pathological complete response are available, surgery should remain an integral component of the treatment of locally advanced esophageal SCC. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Stenting of the Upper Gastrointestinal Tract: Current Status

DOE Office of Scientific and Technical Information (OSTI.GOV)

Katsanos, Konstantinos; Sabharwal, Tarun, E-mail: tarun.sabharwal@gstt.nhs.uk; Adam, Andreas

2010-08-15

Minimally invasive image-guided insertion of self-expanding metal stents in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastroduodenal outlet obstructions. A concise review is presented of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contraindications for treatment are analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology. Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.

The thoracic paraspinal shadow: normal appearances.

PubMed

Lien, H H; Kolbenstvedt, A

1982-01-01

The width of the right and left thoracic paraspinal shadows were measured at all levels in 200 presumably normal individuals. The paraspinal shadow could be identified in nearly all cases on the left side and in approximately one-third on the right. The range of variation was greater on the left side than one the right. The left paraspinal shadow was wider at the upper levels and in individuals above 40 years of age.

T-helper 2 cytokines, transforming growth factor β1, and eosinophil products induce fibrogenesis and alter muscle motility in patients with eosinophilic esophagitis.

PubMed

Rieder, Florian; Nonevski, Ilche; Ma, Jie; Ouyang, Zhufeng; West, Gail; Protheroe, Cheryl; DePetris, Giovanni; Schirbel, Anja; Lapinski, James; Goldblum, John; Bonfield, Tracey; Lopez, Rocio; Harnett, Karen; Lee, James; Hirano, Ikuo; Falk, Gary; Biancani, Piero; Fiocchi, Claudio

2014-05-01

Patients with eosinophilic esophagitis (EoE) often become dysphagic from the combination of organ fibrosis and motor abnormalities. We investigated mechanisms of dysphagia, assessing the response of human esophageal fibroblasts (HEFs), human esophageal muscle cells (HEMCs), and esophageal muscle strips to eosinophil-derived products. Biopsy specimens were collected via endoscopy from the upper, middle, and lower thirds of the esophagus of 18 patients with EoE and 21 individuals undergoing endoscopy for other reasons (controls). Primary cultures of esophageal fibroblasts and muscle cells were derived from 12 freshly resected human esophagectomy specimens. Eosinophil distribution was investigated by histologic analyses of full-thickness esophageal tissue. Active secretion of EoE-related mediators was assessed from medium underlying mucosal biopsy cultures. We quantified production of fibronectin and collagen I by HEF and HEMC in response to eosinophil products. We also measured the expression of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 by, and adhesion of human eosinophils to, HEFs and HEMCs. Eosinophil products were tested in an esophageal muscle contraction assay. Activated eosinophils were present in all esophageal layers. Significantly higher concentrations of eosinophil-related mediators were secreted spontaneously in mucosal biopsy specimens from patients with EoE than controls. Exposure of HEFs and HEMCs to increasing concentrations of eosinophil products or co-culture with eosinophils caused HEFs and HEMCs to increase secretion of fibronectin and collagen I; this was inhibited by blocking transforming growth factor β1 and p38 mitogen-activated protein kinase signaling. Eosinophil binding to HEFs and HEMCs increased after incubation of mesenchymal cells with eosinophil-derived products, and decreased after blockade of transforming growth factor β1 and p38 mitogen-activated protein kinase blockade. Eosinophil products reduced electrical field-induced contraction of esophageal muscle strips, but not acetylcholine-induced contraction. In an analysis of tissues samples from patients with EoE, we linked the presence and activation state of eosinophils in EoE with altered fibrogenesis and motility of esophageal fibroblasts and muscle cells. This process might contribute to the development of dysphagia. Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.

Esophageal motility and 24-h pH profiles of patients with heterotopic gastric mucosa in the cervical esophagus.

PubMed

Korkut, Esin; Bektaş, Mehmet; Alkan, Murat; Ustün, Yusuf; Meco, Cem; Ozden, Ali; Soykan, Irfan

2010-02-01

Heterotopic gastric mucosa occurs as a flat island of red mucosa in the proximal third of the esophagus where it gives rise to the cervical inlet patch. The aims of this study were to investigate the esophageal motility pattern and 24-h pH profiles of patients with cervical inlet patch. Thirty patients (16 women, mean age: 44.9 years, range: 23-72) diagnosed as having heterotopic gastric mucosa in the cervical esophagus with upper gastrointestinal symptoms had undergone esophageal motility testing and 24-h pH monitorisation with a double-channel pH probe. Manometric investigation was abnormal in 7 patients (non-specific esophageal motor disorder in 4 patients, esophageal hypomotility in 1 patient, and hypotensive LES in 2 patients). Pathological acid reflux (pH<4) was found in 9 (30%) of 30 heterotopic gastric mucosa patients during pH monitorisation from the distal probe. Pathological acid reflux in the proximal esophagus (percentage of total time of pH<4) was seen in four of these nine patients. Only four of the 30 patients (13.3%) presented with "acid independent episodes" during the 24-h esophageal pH monitorisation. Manometric investigation and 24-h pH monitorisation revealed that some of the patients with HGM have signs of esophageal motor dysfunction and "acid independent episodes" from the patches. These abnormalities may be responsible for some of the symptoms of HGM patients. Copyright 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Mechanism of UES relaxation initiated by gastric air distension

PubMed Central

Medda, Bidyut K.; Shaker, Reza

2014-01-01

The aim of this study was to determine the mechanism of initiation of transient upper esophageal sphincter relaxation (TUESR) caused by gastric air distension. Cats (n = 31) were decerebrated, EMG electrodes were placed on the cricopharyngeus, a gastric fistula was formed, and a strain gauge was sewn on the lower esophageal sphincter (n = 8). Injection of air (114 ± 13 ml) in the stomach caused TUESR (n = 18) and transient lower esophageal sphincter relaxation (TLESR, n = 6), and this effect was not significantly (P > 0.05) affected by thoracotomy. Free air or bagged air (n = 6) activated TLESR, but only free air activated TUESR. Closure of the gastroesophageal junction blocked TUESR (9/9), but not TLESR (4/4), caused by air inflation of the stomach. Venting air from distal esophagus during air inflation of the stomach prevented TUESR (n = 12) but did not prevent air escape from the stomach to the esophagus (n = 4). Rapid injection of air on the esophageal mucosa always caused TUESR (9/9) but did not always (7/9) cause an increase in esophageal pressure. The time delay between the TUESR and the rapid air pulse was significantly more variable (P < 0.05) than the time delay between the rapid air pulse and the rise in esophageal pressure. We concluded that the TUESR caused by gastric air distension is dependent on air escape from the stomach, which stimulates receptors in the esophagus, but is not dependent on distension of the stomach or esophagus, or the TLESR. Therefore, the TUESR caused by gastric air distension is initiated by stimulation of receptors in the esophageal mucosa. PMID:24970778

APIO-EE-9 is a novel Aurora A and B antagonist that suppresses esophageal cancer growth in a PDX mouse model

PubMed Central

Liu, Kangdong; Liu, Fangfang; Chen, Hanyong; Gorja, Dhilli Rao; Reddy, Kanamata; Bode, Ann M.; Dong, Ziming; Dong, Zigang

2017-01-01

Esophageal cancer (EC) is one of the most aggressive malignancies of the upper aerodigestive tract. Over the past three decades, with advances in surgical techniques and treatment, the prognosis of esophageal cancer has only slowly improved. Thus identifying novel molecular targets and developing therapeutic agents are critical. Aurora kinases play a crucial role in mitosis and selective inhibitors might provide an effective therapeutic treatment for cancer. However, the role of Aurora kinases in EC is still inadequately studied. Here, we identified a novel compound, referred to as APIO-EE-9, which inhibits growth and colony formation and induces apoptosis of esophageal cancer cells. Using computer modeling, we found that APIO-EE-9 interacted with both Aurora A and B in the ATP-binding pocket. APIO-EE-9 inhibited both Aurora A and B kinase activities in a dose-dependent manner. Treatment with APIO-EE-9 substantially reduced the downstream Aurora kinase phosphorylation of histone H3 (Ser10), resulting in formation of multiple nuclei and centrosomes. Additionally, esophageal cancer cells expressing shAurora A or shAurora B kinase exhibited a dramatic reduction in proliferation and colony formation. Injection of these cells as xenografts in mice reduced tumor formation compared to wildtype cells. Importantly, APIO-EE-9 significantly decreased the size of esophageal patient-derived xenograft (PDX) tumors implanted in SCID mice. These results demonstrated that APIO-EE-9 is a specific Aurora kinase inhibitor that could be developed as a therapeutic agent against esophageal cancer. PMID:28881819

APIO-EE-9 is a novel Aurora A and B antagonist that suppresses esophageal cancer growth in a PDX mouse model.

PubMed

Jin, Guoguo; Yao, Ke; Guo, Zhiping; Zhao, Zhenjiang; Liu, Kangdong; Liu, Fangfang; Chen, Hanyong; Gorja, Dhilli Rao; Reddy, Kanamata; Bode, Ann M; Dong, Ziming; Dong, Zigang

2017-08-08

Esophageal cancer (EC) is one of the most aggressive malignancies of the upper aerodigestive tract. Over the past three decades, with advances in surgical techniques and treatment, the prognosis of esophageal cancer has only slowly improved. Thus identifying novel molecular targets and developing therapeutic agents are critical. Aurora kinases play a crucial role in mitosis and selective inhibitors might provide an effective therapeutic treatment for cancer. However, the role of Aurora kinases in EC is still inadequately studied. Here, we identified a novel compound, referred to as APIO-EE-9, which inhibits growth and colony formation and induces apoptosis of esophageal cancer cells. Using computer modeling, we found that APIO-EE-9 interacted with both Aurora A and B in the ATP-binding pocket. APIO-EE-9 inhibited both Aurora A and B kinase activities in a dose-dependent manner. Treatment with APIO-EE-9 substantially reduced the downstream Aurora kinase phosphorylation of histone H3 (Ser10), resulting in formation of multiple nuclei and centrosomes. Additionally, esophageal cancer cells expressing shAurora A or shAurora B kinase exhibited a dramatic reduction in proliferation and colony formation. Injection of these cells as xenografts in mice reduced tumor formation compared to wildtype cells. Importantly, APIO-EE-9 significantly decreased the size of esophageal patient-derived xenograft (PDX) tumors implanted in SCID mice. These results demonstrated that APIO-EE-9 is a specific Aurora kinase inhibitor that could be developed as a therapeutic agent against esophageal cancer.

The Benefits of Combination Therapy with Esomeprazole and Rebamipide in Symptom Improvement in Reflux Esophagitis: An International Multicenter Study.

PubMed

Hong, Su Jin; Park, Soo-Heon; Moon, Jeong Seop; Shin, Woon Geon; Kim, Jae Gyu; Lee, Yong Chan; Lee, Dong Ho; Jang, Jae Young; Kim, Jae J; Lee, Hang-Lak; Lee, Sang Woo; Hwangbo, Young; Xu, Jianming; Wang, Bangmao; Xue, Zhanxiong; Liu, Fei; Yuan, Yaozong; Leelakusolvong, Somchai; Dy, Frederick

2016-11-15

To investigate the effects of esomeprazole and rebamipide combination therapy on symptomatic improvement in patients with reflux esophagitis. A total of 501 patients with reflux esophagitis were randomized into one of the following two treatment regimens: 40 mg esomeprazole plus 300 mg rebamipide daily (combination therapy group) or 40 mg esomeprazole daily (monotherapy group). We used a symptom questionnaire that evaluated heartburn, acid regurgitation, and four upper gastrointestinal symptoms. The primary efficacy end point was the mean decrease in the total symptom score. The mean decreases in the total symptom score at 4 weeks were estimated to be -18.1±13.8 in the combination therapy group and -15.1±11.9 in the monotherapy group (p=0.011). Changes in reflux symptoms from baseline after 4 weeks of treatment were -8.4±6.6 in the combination therapy group and -6.8±5.9 in the monotherapy group (p=0.009). Over a 4-week treatment course, esomeprazole and rebamipide combination therapy was more effective in decreasing the symptoms of reflux esophagitis than esomeprazole monotherapy.

Laparoscopic Heller myotomy and fundoplication in patients with Chagas' disease achalasia and massively dilated esophagus.

PubMed

Pantanali, Carlos A R; Herbella, Fernando A M; Henry, Maria A; Mattos Farah, Jose Francisco; Patti, Marco G

2013-01-01

Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still controversial. This multicenter and retrospective study aims to evaluate the outcome of laparoscopic Heller myotomy in patients with a massively dilated esophagus. Eleven patients (mean age, 56 years; 6 men) with massively dilated esophagus (esophageal diameter greater than 10 cm) underwent a laparoscopic Heller myotomy and anterior fundoplication between 2000 and 2009 at three different institutions. Preoperative workup included upper endoscopy, esophagram, and esophageal manometry in all patients. Average follow-up was 31.5 months (range, 3 to 60 months). Two patients (18%) had severe dysphagia, four patients (36%) had mild and occasional dysphagia to solid food, and five patients (45%) were asymptomatic. All patients gained or kept body weight, except for the two patients with severe dysphagia. Of the two patients with severe dysphagia, one underwent esophageal dilatation and the other a laparoscopic esophagectomy. They are both doing well. Heller myotomy relieves dysphagia in the majority of patients even when the esophagus is massively dilated.

Repair of an aberrant subclavian arterioesophageal fistula following esophageal stent placement

PubMed Central

Hosn, Maen Aboul; Haddad, Fady; El-Merhi, Fadi; Safadi, Bassem; Hallal, Ali

2014-01-01

A fistula formation between the esophagus and an aberrant right subclavian artery is a rare but fatal complication that has been mostly described in the setting of prolonged nasogastric intubation and foreign body erosion. We report a case of a young morbidly obese patient who underwent sleeve gastrectomy that was complicated by a postoperative leak at the level of the gastroesophageal junction. A covered esophageal stent was placed endoscopically to treat the leak. The patient developed massive upper gastrointestinal bleeding secondary to the erosion of the stent into an aberrant retroesophageal right subclavian artery twelve days after stent placement. She was ultimately treated by endovascular stenting of the aberrant right subclavian artery followed by thoracotomy and esophageal repair over a T-tube. This case report highlights the multidisciplinary approach needed to diagnose and manage such a devastating complication. It also emphasizes the need for imaging studies prior to stent deployment to delineate the vascular anatomy and rule out the possibility of such an anomaly in view of the growing popularity of esophageal stents, especially in the setting of a leak. PMID:24976906

A rare case of skin blistering and esophageal stenosis in the course of epidermolysis bullosa - case report and literature review.

PubMed

Michalak, Agata; Cichoż-Lach, Halina; Prozorow-Król, Beata; Buk, Leszek; Dzida, Monika

2018-04-13

Epidermolysis bullosa (EB) constitutes a heterogenous group of rare multisystem genetically transmitted disorders comprising several blistering muco-cutaneous diseases with a monogenic basis and either autosomal dominant or autosomal recessive mode of inheritance. EB manifestation is not only limited to the skin. Systemic signs might involve the nose, ear, eye, genitourinary tract and upper gastrointestinal tract. The presence of particular symptoms is directly determined by a type of altered skin protein. Gastrointestinal manifestation of EB is most commonly reflected by esophageal stenosis due to recurrent esophageal blistering, followed by consequent scarring. Here we present a case of a man with dystrophic EB and dysphagia, skin blistering, joints contractures and missing nails. To our knowledge, the presented man is the oldest one diagnosed with EB living in Poland. Management of an esophageal stricture in such circumstances is based on endoscopic dilatation. However, in most severe cases, placement of a gastrostomy tube is required. Despite great advances in medicine, a targeted therapy in the course of EB has not been established yet.

Esophageal cancer diagnosed by high-resolution manometry of the esophagus: A case report

PubMed Central

LIU, RONGBEI; CHU, HUA; XU, FEI; CHEN, SHUJIE

2016-01-01

A 48-year-old female who presented with a history of dysphagia for 5 months and regurgitation for 1 week was referred to the Sir Run Run Shaw Hospital (Hangzhou, China) for further evaluation, since the gastroscopy and endoscopic ultrasound performed in local hospitals did not reveal the presence of cancer. High-resolution manometry (HRM) of the esophagus was performed to determine the patient's condition, and revealed an abnormal high-pressure zone that was located 33 cm from the incisor and did not relax upon swallowing. Synchronous waves were observed, and the pressure of the esophageal lumen was found to increase with secondary synchronous peristaltic waves. The lower esophageal sphincter was 39 cm from the incisor and relaxed upon swallowing. The abnormal high-pressure zone could have been caused by an obstruction, and therefore an upper gastrointestinal series (barium swallow) test and gastroscopy were recommended to further pinpoint the cause. Following the two examinations, mid-esophageal cancer was considered as a possible diagnosis. A biopsy was performed and the final diagnosis was that of basaloid squamous cell carcinoma. The findings of the present study suggest that, for patients with evident symptoms of esophageal motor dysfunction without significant gastroscopy findings, HRM is recommended. PMID:27123076

Alpha-fetoprotein-producing esophageal adenocarcinoma: a mimicker of hepatocellular carcinoma.

PubMed

Wang, Jeremy; Liu, Wendy; Parikh, Keyur; Post, Anthony Benjamin

2017-02-01

Alpha-fetoprotein (AFP)-producing esophageal adenocarcinoma (EAC) is a rare occurrence. Elevation of serum AFP is commonly associated with hepatocellular carcinoma and yolk sac tumors, but rarely with esophageal carcinoma. Here, we report a rare case of AFP-producing EAC. A 51-year-old man presented with two weeks of acid reflux and a 35-lb weight loss. Laboratory data were notable for transaminitis and AFP was 2524 ng/mL. Computed tomography of the abdomen revealed abnormal thickening of the esophagus and multiple metastatic masses throughout the liver. Biopsy of one of the masses revealed adenocarcinoma of gastrointestinal origin. Subsequent upper endoscopy revealed an esophageal mass with biopsy notable for ulcerated dysplastic glandular mucosa with likely underlying malignancy. The patient underwent palliative esophageal stent placement but died two months later. Elevated AFP levels are an unusual occurrence in EAC. Prognosis is poor given its advanced presenting stage and high metastatic potential. Most cases are unsuccessfully treated with surgery and chemotherapy. Serial measurement of serum AFP may be useful for monitoring clinical status and treatment response. Clinicians should consider AFP-producing EAC in their differential diagnosis in the work-up of a liver mass in the setting of elevated AFP or liver function impairment, especially in the absence of chronic liver disease.

Effects of age, gender, bolus condition, viscosity, and volume on pharyngeal and upper esophageal sphincter pressure and temporal measurements during swallowing.

PubMed

Butler, Susan G; Stuart, Andrew; Castell, Donald; Russell, Gregory B; Koch, Kenneth; Kemp, Shannon

2009-02-01

The purpose of this study was to determine the effects of trial (i.e., Trial 1 vs. Trial 2); viscosity (i.e., saliva, thin, nectar-thick, honey-thick, and pudding-thick water); volume (i.e., 5 mL vs. 10 mL); age (i.e., young vs. older adults); and gender on pharyngeal (i.e., upper and lower) and upper esophageal sphincter (UES) pressures, durations, and onsets (i.e., onset of upper pharyngeal pressures relative to onsets of UES relaxations and onset of lower relative to upper pharyngeal pressures). Twenty-three young adults (M=30 years) and 21 older healthy adults (M=75 years) participated. Measurements were acquired with a 2.1-mm catheter during simultaneous manometric and endoscopic swallowing assessment. Participants contributed 18 swallows, affording a study total of 792 swallows for analyses. There was no significant effect of trial on any measurement of pressure, duration, and onset (ps=.63, .39, and .71, respectively). It was found that viscosity, volume, age, and gender affected pressure, duration, and onset measurements (e.g., onset of upper pharyngeal pressures relative to onsets of UES relaxations) but in varying degrees relative to the location in the pharynx or UES and the type of measurement (e.g., pressure, onset). Manometric measurements vary with respect to age, gender, and bolus variables and interactions of each. Consideration of these variables is paramount in understanding normal and pathological swallowing if manometry is to develop as a quantitative adjunct to videofluoroscopic and endoscopic swallowing tools.

High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry.

PubMed

Choi, Won Seok; Kim, Tae Wan; Kim, Ja Hyun; Lee, Sang Hyuk; Hur, Woon Je; Choe, Young Gil; Lee, Sang Hyuk; Park, Jung Ho; Sohn, Chong Il

2013-10-01

Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus. Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls. There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001). HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation.

High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry

PubMed Central

Choi, Won Seok; Kim, Tae Wan; Kim, Ja Hyun; Lee, Sang Hyuk; Hur, Woon Je; Choe, Young Gil; Lee, Sang Hyuk; Park, Jung Ho

2013-01-01

Background/Aims Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus. Methods Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls. Results There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001). Conclusions HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation. PMID:24199007

Axillary Temperature, as Recorded by the iThermonitor WT701, Well Represents Core Temperature in Adults Having Noncardiac Surgery.

PubMed

Pei, Lijian; Huang, Yuguang; Mao, Guangmei; Sessler, Daniel I

2018-03-01

Core temperature can be accurately measured from the esophagus or nasopharynx during general anesthesia, but neither site is suitable for neuraxial anesthesia. We therefore determined the precision and accuracy of a novel wireless axillary thermometer, the iThermonitor, to determine its suitability for use during neuraxial anesthesia and in other patients who are not intubated. We enrolled 80 adults having upper abdominal surgery with endotracheal intubation. Intraoperative core temperature was measured in distal esophagus and was estimated at the axilla with a wireless iThermonitor WT701 (Raiing Medical, Boston MA) at 5-minute intervals. Pairs of axillary and reference distal esophageal temperatures were compared and summarized using linear regression and repeated-measured Bland-Altman methods. We a priori determined that the iThermonitor would have clinically acceptable accuracy if most estimates were within ±0.5°C of the esophageal reference, and suitable precision if the limits of agreement were within ±0.5°C. There were 3339 sets of paired temperatures. Axillary and esophageal temperatures were similar, with a mean difference (esophageal minus axillary) of only 0.14°C ± 0.26°C (standard deviation). The Bland-Altman 95% limits of agreement were reasonably narrow, with the estimated upper limit at 0.66°C and the lower limit at -0.38°C, thus ±0.52°C, indicating good agreement across the range of mean temperatures from 34.9°C to 38.1°C. The absolute difference was within 0.5°C in 91% of the measurements (95% confidence interval, 88%-93%). Axillary temperature, as recorded by the iThermonitor WT701, well represents core temperature in adults having noncardiac surgery and thus appears suitable for clinical use.

The Nonsteroidal Anti-inflammatory Drug Diclofenac Reduces Acid-Induced Heartburn Symptoms in Healthy Volunteers.

PubMed

Kondo, Takashi; Oshima, Tadayuki; Tomita, Toshihiko; Fukui, Hirokazu; Okada, Hiroki; Watari, Jiro; Miwa, Hiroto

2015-07-01

We investigated the effects of diclofenac, a nonsteroidal anti-inflammatory drug that inhibits prostaglandin production, on induction of esophageal sensation by acid perfusion in healthy men. We performed a prospective, double-blind, placebo-controlled, 2-period, cross-over study over 3 visits in 12 healthy men. Diclofenac was given 6 hours and 2 hours before an acid perfusion test. During the test, hydrochloric acid (0.15 mol/L) was perfused into the lower esophagus for 30 minutes; we evaluated upper gastrointestinal symptoms using a validated categoric rating scale. Then, we calculated and assessed the acid perfusion sensitivity score (APSS). Biopsy specimens were collected by endoscopy of the distal esophagus before and after acid perfusion; levels of prostaglandin E2 (PGE2) (pg/mg) were measured in the samples using an enzyme-linked immunosorbent assay. Compared with placebo, diclofenac significantly reduced the APSS for heartburn (82.2 ± 12.2 for placebo and 47.5 ± 8.9 for diclofenac; P < .01). Of the upper gastrointestinal symptoms, only the APSS for heartburn was reduced significantly by diclofenac. Compared with placebo, diclofenac reduced the overproduction of PGE2 by esophageal tissues after acid perfusion (23.3 ± 5.2 for placebo and 11.4 ± 3.5 for diclofenac; P < .05). APSS correlated with the development of heartburn and esophageal levels of PGE2 (r = 0.53; P < .05 for heartburn vs PGE2). Diclofenac attenuated acid-induced heartburn by inhibiting PGE2 overproduction in the esophagus. Esophageal PGE2 might be involved in producing heartburn symptoms. Clinical Trials Registry no: UMIN000014595. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ito, Hisao; Yamada, Takayuki; Ishibashi, Tadashi

A 65-year-old man underwent a thromboexclusionoperation for management of chronic Stanford type B dissecting aneurysmin 1991. However, long-term follow-up CT scans after the operation revealed that the ascending aorta gradually enlarged and was eventually complicated by recurrent aortic dissection. The patient complained of frequent bloody sputum, whereas chest roentogenography showed no pulmonary abnormalities. Subsequent swallow esophagogram demonstrated that the upper esophagus was deviated to the right and the middle esophagus was greatly compressed by the aortic clamp. Esophageal endoscopy showed a bloody inner surface and marked swelling of the middle esophagus. The patient eventually died of massive hematemesis in 2001.more » We describe the imaging features of unanticipated complications such as recurrent dissecting aneurysm or impending esophageal rupture.Furthermore, we discuss the cause of hematemesis and document that the aortic clamp migrated and resulted in development of a recurrent aneurysmal dissection, which in turn resulted in esophageal rupture with aneurysmal disruption.« less

Repair of esophageal atresia with proximal fistula using endoscopic magnetic compression anastomosis (magnamosis) after staged lengthening.

PubMed

Dorman, Robert M; Vali, Kaveh; Harmon, Carroll M; Zaritzky, Mario; Bass, Kathryn D

2016-05-01

We describe the treatment of a patient with long-gap esophageal atresia with an upper pouch fistula, mircogastria and minimal distal esophageal remnant. After 4.5 months of feeding via gastrostomy, a proximal fistula was identified by bronchoscopy and a thoracoscopic modified Foker procedure was performed reducing the gap from approximately 7-5 cm over 2 weeks of traction. A second stage to ligate the fistula and suture approximate the proximal and distal esophagus resulted in a gap of 1.5 cm. IRB and FDA approval was then obtained for endoscopic placement of 10-French catheter mounted magnets in the proximal and distal pouches promoting a magnetic compression anastomosis (magnamosis). Magnetic coupling occurred at 4 days and after magnet removal at 13 days an esophagram demonstrated a 10 French channel without leak. Serial endoscopic balloon dilation has allowed drainage of swallowed secretions as the baby learns bottling behavior at home.

Sporadic ganglioneuromatosis of esophagogastric junction in a patient with gastro-esophageal reflux disorder and intestinal metaplasia.

PubMed

Siderits, Richard; Hanna, Iman; Baig, Zahid; Godyn, Janusz-J

2006-12-28

A 58-year-old female with a recurrent history of upper abdominal pain and intermittent dysphagia underwent endoscopic evaluation that demonstrated an irregular and nodular esophago-gastric (EG) junction and grade I erosive esophagitis. Biopsies showed prominent intestinal metaplasia of Barrett's type without dysplasia, chronic inflammation and multiple aggregates of large cells within the mucosal lamina propria, some with spindle shaped nuclei. Immunohistochemistry stains for keratins AE-1/AE-3 were negative, while S-100 and NSE were positive. This, together with routine stains, was diagnostic for mucosal ganglioneuromatosis. The background of chronic inflammation with intestinal type metaplasia was consistent with long-term reflux esophagitis. No evidence of achalasia was seen. Biopsies of gastric antrum and fundus were unremarkable, without ganglioneural proliferation. Colonoscopy was unremarkable. No genetic syndromes were identified in the patient including familial adenomatous polyposis and multiple endocrine neoplasia type IIb (MEN IIb). Iansoprazole (Prevacid) was started by oral administration each day with partial relief of symptoms. Subsequent esophagogastroscopy repeated at 4 mo showed normal appearing EG junction. Esophageal manometry revealed a mild non-specific lower esophageal motility disorder. Mild motor dysfunction is seen with gastro-esophageal reflux disease (GERD) and we feel that the demonstration of localized ganglioneuromatosis was not likely related etiologically. In the absence of findings that might suggest neural hypertrophy, such as achalasia, the nodular mucosal irregularity seen with this instance of ganglioneuromatosis may, however, have exacerbated the patient's reflux.

Dysphagia among adult patients who underwent surgery for esophageal atresia at birth.

PubMed

Huynh Trudeau, Valérie; Maynard, Stéphanie; Terzic, Tatjana; Soucy, Geneviève; Bouin, Mickeal

2015-03-01

Clinical experiences of adults who underwent surgery for esophageal atresia at birth is limited. There is some evidence that suggests considerable long-term morbidity, partly because of dysphagia, which has been reported in up to 85% of adult patients who undergo surgery for esophageal atresia. The authors hypothesized that dysphagia in this population is caused by dysmotility and⁄or anatomical anomalies. To determine the motor and anatomical causes of dysphagia. A total of 41 adults, followed at the Esophageal Atresia Clinic at Hôpital Saint-Luc (Montreal, Quebec), were approached to particpate in the present prospective study. Evaluation was completed using upper endoscopy, manometry and barium swallow for the participants who consented. The medical charts of respondents were systematically reviewed from the neonatal period to 18 years of age to assess medical and surgical history. All 41 patients followed at the clinic consented and were included in the study. Dysphagia was present in 73% of patients. Esophagogastroduodenoscopy was performed in 32 patients: hiatal hernia was present in 62% (n=20); esophageal diverticulum in 13% (n=4); macroscopic Barrett esophagus in 31% (n=10); and esophagitis in 19% (n=6). Histological esophagitis was present in 20% and intestinal metaplasia in 10%. There were no cases of dysplagia or adenocarcinoma. Esophageal manometry was performed on 56% of the patients (n=23). Manometry revealed hypomotility in 100% of patients and included an insufficient number of peristaltic waves in 96%, nonpropagating peristalsis in 78% and low-wave amplitude in 95%. Complete aperistalsis was present in 78%. The lower esophageal sphincter was abnormal in 12 (52%) patients, with incomplete relaxation the most common anomaly. Of the 41 patients, 29 (71%) consented to a barium swallow, which was abnormal in 13 (45%). The anomalies found were short esophageal dilation in 28%, delay in esophageal emptying in 14%, diverticula in 14% and stenosis in 7% of patients. There was more than one anomaly in 14% of patients. Dysphagia was a highly prevalent symptom in adults who underwent surgery for esophageal atresia. The present study is the first to demonstrate that motor and anatomical abnormalities may be implicated in causes of dysphagia in this population. Furthermore, these anomalies may be demonstrated with simple investigations such as endoscopy, manometry and barium swallow.

Dysphagia among adult patients who underwent surgery for esophageal atresia at birth

PubMed Central

Huynh-Trudeau, Valérie; Maynard, Stéphanie; Terzic, Tatjana; Soucy, Geneviève; Bouin, Mickael

2015-01-01

BACKGROUND: Clinical experiences of adults who underwent surgery for esophageal atresia at birth is limited. There is some evidence that suggests considerable long-term morbidity, partly because of dysphagia, which has been reported in up to 85% of adult patients who undergo surgery for esophageal atresia. The authors hypothesized that dysphagia in this population is caused by dysmotility and/or anatomical anomalies. OBJECTIVE: To determine the motor and anatomical causes of dysphagia. METHODS: A total of 41 adults, followed at the Esophageal Atresia Clinic at Hôpital Saint-Luc (Montreal, Quebec), were approached to particpate in the present prospective study. Evaluation was completed using upper endoscopy, manometry and barium swallow for the participants who consented. The medical charts of respondents were systematically reviewed from the neonatal period to 18 years of age to assess medical and surgical history. RESULTS: All 41 patients followed at the clinic consented and were included in the study. Dysphagia was present in 73% of patients. Esophagogastroduodenoscopy was performed in 32 patients: hiatal hernia was present in 62% (n=20); esophageal diverticulum in 13% (n=4); macroscopic Barrett esophagus in 31% (n=10); and esophagitis in 19% (n=6). Histological esophagitis was present in 20% and intestinal metaplasia in 10%. There were no cases of dysplagia or adenocarcinoma. Esophageal manometry was performed on 56% of the patients (n=23). Manometry revealed hypomotility in 100% of patients and included an insufficient number of peristaltic waves in 96%, non-propagating peristalsis in 78% and low-wave amplitude in 95%. Complete aperistalsis was present in 78%. The lower esophageal sphincter was abnormal in 12 (52%) patients, with incomplete relaxation the most common anomaly. Of the 41 patients, 29 (71%) consented to a barium swallow, which was abnormal in 13 (45%). The anomalies found were short esophageal dilation in 28%, delay in esophageal emptying in 14%, diverticula in 14% and stenosis in 7% of patients. There was more than one anomaly in 14% of patients. CONCLUSION: Dysphagia was a highly prevalent symptom in adults who underwent surgery for esophageal atresia. The present study is the first to demonstrate that motor and anatomical abnormalities may be implicated in causes of dysphagia in this population. Furthermore, these anomalies may be demonstrated with simple investigations such as endoscopy, manometry and barium swallow. PMID:25803019

Upper esophageal sphincter abnormalities: frequent finding on high-resolution esophageal manometry and associated with poorer treatment response in achalasia.

PubMed

Chavez, Yamile H; Ciarleglio, Maria M; Clarke, John O; Nandwani, Monica; Stein, Ellen; Roland, Bani C

2015-01-01

Abnormalities of the upper esophageal sphincter (UES) on high-resolution esophageal manometry (HREM) have been observed in both symptomatic and asymptomatic individuals and are often interpreted as incidental findings of unclear clinical significance. Our primary aims were: (1) to assess the frequency of UES abnormalities in consecutive patients referred for HREM studies; and (2) to characterize the demographics, clinical symptoms, and manometric profiles associated with UES abnormalities as compared with those with normal UES function. We performed a retrospective study of 200 consecutive patients referred for HREM. Patients were divided into those with normal and abnormal UES function, including impaired relaxation (residual pressure >12 mm Hg), hypertensive (>104 mm Hg), and hypotensive (<34 mm Hg) resting pressure. Clinical and manometric profiles were compared. A total of 32.5% of patients had UES abnormalities, the majority of which were hypertensive (55.4%). Patients with achalasia were significantly more likely to have UES abnormalities as compared with normal UES function (57.2% vs. 42.9%, P=0.04), with the most frequent abnormality being a hypertensive UES (50%). In addition, patients with impaired lower esophageal sphincter (LES) relaxation (esophagogastric junction outflow obstruction or achalasia) were more likely to have an UES abnormality present as compared with those with normal LES relaxation (53.1% vs. 28.6%, P=0.01). When we assessed for treatment response among patients with achalasia, we found that subjects with evidence of UES dysfunction had significantly worse treatment outcomes as compared with those without UES abnormalities present (20% improved vs. 100%, P=0.015). This remained true even after adjusting for type of treatment received (surgical myotomy, per-oral endoscopic mytotomy, botulinum toxin injection, pneumatic dilatation, medical therapy, P=0.67) and achalasia subtype (P=1.00). UES abnormalities are a frequent finding on HREM studies, especially in patients with impaired LES relaxation, including both achalasia and esophagogastric junction outflow obstruction. Interestingly, the most common UES abnormality associated with achalasia was a hypertensive resting UES, despite the fact that achalasia is thought to spare striated muscle. Among patients with achalasia, we found a significant association between the lack of treatment response and the presence of UES dysfunction. The routine evaluation of UES function in patients referred for manometry may enhance our understanding of esophageal motility disorders and may yield important prognostic information, particularly in subjects with achalasia. Future prospective studies are needed to further delineate the underlying mechanism between UES dysfunction with achalasia and other esophageal motility disorders to predict treatment response and guide therapeutic treatment modalities.

T-helper 2 Cytokines, Transforming Growth Factor β1, and Eosinophil Products Induce Fibrogenesis and Alter Muscle Motility in Patients with Eosinophilic Esophagitis

PubMed Central

Rieder, Florian; Nonevski, Ilche; Ma, Jie; Ouyang, Zhufeng; West, Gail; Protheroe, Cheryl; DePetris, Giovanni; Schirbel, Anja; Lapinski, James; Goldblum, John; Bonfield, Tracey; Lopez, Rocio; Harnett, Karen; Lee, James; Hirano, Ikuo; Falk, Gary; Biancani, Piero; Fiocchi, Claudio

2014-01-01

BACKGROUND & AIMS Patients with eosinophilic esophagitis (EoE) often become dysphagic from the combination of organ fibrosis and motor abnormalities. We investigated mechanisms of dysphagia, assessing the response of human esophageal fibroblasts (HEF), muscle cells (HEMC), and esophageal muscle strips to eosinophil-derived products. METHODS Biopsies were collected via endoscopy from the upper, middle and lower thirds of the esophagus of 18 patients with EoE and 21 individuals undergoing endoscopy for other reasons (controls). Primary cultures of esophageal fibroblasts and muscle cells were derived from 12 freshly resected human esophagectomy specimens. Eosinophil distribution was investigated by histologic analyses of full-thickness esophageal tissue. Active secretion of EoE-related mediators was assessed from medium underlying mucosal biopsy cultures. We quantified production of fibronectin and collagen I by HEF and HEMC in response to eosinophil products. We also measured expression of ICAM1 and VCAM1 by, and adhesion of human eosinophils to, HEF and HEMC. Eosinophil products were tested in an esophageal muscle contraction assay. RESULTS Activated eosinophils were present in all esophageal layers. Significantly higher concentrations of eosinophil-related mediators were spontaneously secreted in mucosal biopsies from patients with EoE than controls. Exposure of HEF and HEMC to increasing concentrations of eosinophil products or co-culture with eosinophils caused HEF and HEMC to increase secretion of fibronectin and collagen I; this was inhibited by blocking transforming growth factor (TGF)β1 and p38 mitogen-activated protein kinase (MAKP) signaling. Eosinophil binding to HEF and HEMC increased following incubation of mesenchymal cells with eosinophil-derived products, and decreased following blockade of TGFβ1 and p38MAPK blockade. Eosinophil products reduced electrical field-induced contraction of esophageal muscle strips, but not acetylcholine-induced contraction. CONCLUSION In an analysis of tissues samples from patients with EoE, we linked the presence and activation state of eosinophils in EoE with altered fibrogenesis and motility of esophageal fibroblasts and muscle cells. This process might contribute to the development of dysphagia. PMID:24486052

Mechanisms of repetitive retrograde contractions in response to sustained esophageal distension: a study evaluating patients with postfundoplication dysphagia.

PubMed

Carlson, Dustin A; Kahrilas, Peter J; Ritter, Katherine; Lin, Zhiyue; Pandolfino, John E

2018-03-01

Repetitive retrograde contractions (RRCs) in response to sustained esophageal distension are a distinct contractility pattern observed with functional luminal imaging probe (FLIP) panometry that are common in type III (spastic) achalasia. RRCs are hypothesized to be indicative of either impaired inhibitory innervation or esophageal outflow obstruction. We aimed to apply FLIP panometry to patients with postfundoplication dysphagia (a model of esophageal obstruction) to explore mechanisms behind RRCs. Adult patients with dysphagia after Nissen fundoplication ( n = 32) or type III achalasia ( n = 25) were evaluated with high-resolution manometry (HRM) and upper endoscopy with FLIP. HRM studies were assessed for outflow obstruction and spastic features: premature contractility, hypercontractility, and impaired deglutitive inhibition during multiple-rapid swallows. FLIP studies were analyzed to determine the esophagogastric junction (EGJ)-distensibility index and contractility pattern, including RRCs. Barium esophagram was evaluated when available. RRCs were present in 8/32 (25%) fundoplication and 19/25 (76%) achalasia patients ( P < 0.001). EGJ outflow obstruction was detected in 21 (67%) fundoplication patients by HRM, FLIP, or esophagram [6 (29%) had RRCs]. On HRM, none of the fundoplication patients had premature contractility, whereas 3/4 with defective inhibition on multiple-rapid swallows and 2/4 with hypercontractility had RRCs. Regression analysis demonstrated HRM with spastic features, but not esophageal outflow obstruction, as a predictor for RRCs. RRCs in response to sustained esophageal distension appear to be a manifestation of spastic esophageal motility. Although future study to further clarify the significance of RRCs is needed, RRCs on FLIP panometry should prompt evaluation for a major motor disorder. NEW & NOTEWORTHY Repetitive retrograde contractions (RRCs) are a common response to sustained esophageal distension among spastic achalasia patients when evaluated with the functional luminal imaging probe. We evaluated patients with postfundoplication dysphagia, i.e., patients with suspected mechanical obstruction, and found that RRCs occasionally occurred among postfundoplication patients, but often in association with manometric features of esophageal neuromuscular imbalance. Thus, RRCs appear to be a manifestation of spastic esophageal dysmotility, likely from neural imbalance resulting in excess excitation.

External validation of the Society of Thoracic Surgeons General Thoracic Surgery Database.

PubMed

Magee, Mitchell J; Wright, Cameron D; McDonald, Donna; Fernandez, Felix G; Kozower, Benjamin D

2013-11-01

The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) reports outstanding results for lung and esophageal cancer resection. However, a major weakness of the GTSD has been the lack of validation of this voluntary registry. The purpose of this study was to perform an external, independent audit to assess the accuracy of the data collection process and the quality of the database. An independent firm was contracted to audit 5% of sites randomly selected from the GTDB in 2011. Audits were performed remotely to maximize the number of audits performed and reduce cost. Auditors compared lobectomy cases submitted to the GTSD with the hospital operative logs to evaluate completeness of the data. In addition, 20 lobectomy records from each site were audited in detail. Agreement rates were calculated for 32 individual data elements, 7 data categories pertaining to patient status or care delivery, and an overall agreement rate for each site. Six process variables were also evaluated to assess best practice for data collection and submission. Ten sites were audited from the 222 participants. Comparison of the 559 submitted lobectomy cases with operative logs from each site identified 28 omissions, a 94.6% agreement rate (discrepancies/site range, 2 to 27). Importantly, cases not submitted had no mortality or major morbidity, indicating a lack of purposeful omission. The aggregate agreement rates for all categories were greater than 90%. The overall data accuracy was 94.9%. External audits of the GTSD validate the accuracy and completeness of the data. Careful examination of unreported cases demonstrated no purposeful omission or gaming. Although these preliminary results are quite good, it is imperative that the audit process is refined and continues to expand along with the GTSD to insure reliability of the database. The audit results are currently being incorporated into educational and quality improvement processes to add further value. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Balloon dilatation in esophageal strictures in epidermolysis bullosa and the role of anesthesia.

PubMed

Gollu, Gulnur; Ergun, Ergun; Ates, Ufuk; Can, Ozlem S; Dindar, Huseyin

2017-02-01

Esophageal involvement, which causes stricture, is a complication in epidermolysis bullosa. This causes dysphagia and malnutrition and leads to deterioration of skin lesions in these patients. The charts of 11 patients with epidermolysis bullosa and esophageal stricture who were included into dilatation program between 2003 and 2015 were retrospectively reviewed. Seven of the patients were female and four were male. The median age was 14 (2-32) years. The mean body weight of patients was 27.8 (9-51) kg. The location and number of strictured parts of the esophagus were previously evaluated with upper gastrointestinal contrast study and after that flexible endoscopy was used for dilatation. Eight patients had middle esophageal, three patients had proximal esophageal and one of them had both proximal and middle esophageal strictures. The strictures were dilated 56 times in total (mean 5 times). One patient underwent gastrostomy and was medically followed-up after a perforation occurrence during the dilatation procedure. In a 32-year-old female patient, colon interposition was performed after four dilatations since optimal nutritional and developmental status could not be achieved. The dilatation program of nine patients is still in progress. Seven of them can easily swallow solid food but two of them have some difficulties in swallowing between dilatations. One patient rejected the program and quitted, while one patient refused colon interposition and died because of complications related to amyloidosis during the dilatation program. After resolution of the swallowing problem, skin lesions were observed to heal quickly. Epidermolysis bullosa is a rare cause of dysphagia. Esophageal balloon dilatation with flexible endoscopy is a safe and efficient method in patients with this condition. © 2016 International Society for Diseases of the Esophagus.

Impact of deep brain stimulation on pharyngo-esophageal motility: a randomized cross-over study.

PubMed

Derrey, S; Chastan, N; Maltete, D; Verin, E; Dechelotte, P; Lefaucheur, R; Proust, F; Freger, P; Leroi, A M; Weber, J; Gourcerol, G

2015-09-01

Bilateral subthalamic nucleus (STN) stimulation is used to alleviate Parkinson's disease (PD) motor symptoms. Recently, it has been shown that this therapeutic also increased gut cholinergic contractions. We therefore investigated the effect of STN stimulation on esophageal motility in an interventional randomized study. Sixteen humans PD patients (4 women, 12 men; age: 62.4 ± 9.3-years old) who underwent STN stimulation for at least 6 months were randomly evaluated with either stimulator turned OFF then ON, or inversely. Esophageal high resolution manometry was performed at the end of each ON and OFF period, with a 5 min resting period followed by ten swallows of 5 mL. During the ON, an increase in the distal contractility index was found (OFF: 1750 ± 629 vs ON: 2171 ± 755 mmHg/cm/s; p = 0.03), with no difference in the distal front velocity. A decrease in the integrative relaxation pressure of the lower esophageal sphincter (LES) was noted (OFF: 11.1 ± 1.8 mmHg vs ON: 7.2 ± 1.8 mmHg; p < 0.05) in ON. The LES resting pressure remained unchanged during the two periods. This resulted in a decrease in the intrabolus pressure (p = 0.03). No difference was observed for the upper esophageal sphincter, nor the pharyngeal contraction amplitude and velocity. In conclusion, STN stimulation in PD patients increased esophageal body contractions and enhanced the LES opening. This suggests that the nigrostriatal-striatonigral loop is involved in the control of esophageal motility. © 2015 John Wiley & Sons Ltd.

Mechanism of UES relaxation initiated by gastric air distension.

PubMed

Lang, Ivan M; Medda, Bidyut K; Shaker, Reza

2014-08-15

The aim of this study was to determine the mechanism of initiation of transient upper esophageal sphincter relaxation (TUESR) caused by gastric air distension. Cats (n = 31) were decerebrated, EMG electrodes were placed on the cricopharyngeus, a gastric fistula was formed, and a strain gauge was sewn on the lower esophageal sphincter (n = 8). Injection of air (114 ± 13 ml) in the stomach caused TUESR (n = 18) and transient lower esophageal sphincter relaxation (TLESR, n = 6), and this effect was not significantly (P > 0.05) affected by thoracotomy. Free air or bagged air (n = 6) activated TLESR, but only free air activated TUESR. Closure of the gastroesophageal junction blocked TUESR (9/9), but not TLESR (4/4), caused by air inflation of the stomach. Venting air from distal esophagus during air inflation of the stomach prevented TUESR (n = 12) but did not prevent air escape from the stomach to the esophagus (n = 4). Rapid injection of air on the esophageal mucosa always caused TUESR (9/9) but did not always (7/9) cause an increase in esophageal pressure. The time delay between the TUESR and the rapid air pulse was significantly more variable (P < 0.05) than the time delay between the rapid air pulse and the rise in esophageal pressure. We concluded that the TUESR caused by gastric air distension is dependent on air escape from the stomach, which stimulates receptors in the esophagus, but is not dependent on distension of the stomach or esophagus, or the TLESR. Therefore, the TUESR caused by gastric air distension is initiated by stimulation of receptors in the esophageal mucosa. Copyright © 2014 the American Physiological Society.

Expert Consensus Contouring Guidelines for Intensity Modulated Radiation Therapy in Esophageal and Gastroesophageal Junction Cancer.

PubMed

Wu, Abraham J; Bosch, Walter R; Chang, Daniel T; Hong, Theodore S; Jabbour, Salma K; Kleinberg, Lawrence R; Mamon, Harvey J; Thomas, Charles R; Goodman, Karyn A

2015-07-15

Current guidelines for esophageal cancer contouring are derived from traditional 2-dimensional fields based on bony landmarks, and they do not provide sufficient anatomic detail to ensure consistent contouring for more conformal radiation therapy techniques such as intensity modulated radiation therapy (IMRT). Therefore, we convened an expert panel with the specific aim to derive contouring guidelines and generate an atlas for the clinical target volume (CTV) in esophageal or gastroesophageal junction (GEJ) cancer. Eight expert academically based gastrointestinal radiation oncologists participated. Three sample cases were chosen: a GEJ cancer, a distal esophageal cancer, and a mid-upper esophageal cancer. Uniform computed tomographic (CT) simulation datasets and accompanying diagnostic positron emission tomographic/CT images were distributed to each expert, and the expert was instructed to generate gross tumor volume (GTV) and CTV contours for each case. All contours were aggregated and subjected to quantitative analysis to assess the degree of concordance between experts and to generate draft consensus contours. The panel then refined these contours to generate the contouring atlas. The κ statistics indicated substantial agreement between panelists for each of the 3 test cases. A consensus CTV atlas was generated for the 3 test cases, each representing common anatomic presentations of esophageal cancer. The panel agreed on guidelines and principles to facilitate the generalizability of the atlas to individual cases. This expert panel successfully reached agreement on contouring guidelines for esophageal and GEJ IMRT and generated a reference CTV atlas. This atlas will serve as a reference for IMRT contours for clinical practice and prospective trial design. Subsequent patterns of failure analyses of clinical datasets using these guidelines may require modification in the future. Copyright © 2015 Elsevier Inc. All rights reserved.

Expert consensus contouring guidelines for IMRT in esophageal and gastroesophageal junction cancer

PubMed Central

Wu, Abraham J.; Bosch, Walter R.; Chang, Daniel T.; Hong, Theodore S.; Jabbour, Salma K.; Kleinberg, Lawrence R.; Mamon, Harvey J.; Thomas, Charles R.; Goodman, Karyn A.

2015-01-01

Purpose/Objective(s) Current guidelines for esophageal cancer contouring are derived from traditional two-dimensional fields based on bony landmarks, and do not provide sufficient anatomical detail to ensure consistent contouring for more conformal radiotherapy techniques such as intensity-modulated radiation therapy (IMRT). Therefore, we convened an expert panel with the specific aim to derive contouring guidelines and generate an atlas for the clinical target volume (CTV) in esophageal or gastroesophageal junction (GEJ) cancer. Methods and Materials Eight expert academically-based gastrointestinal radiation oncologists participated. Three sample cases were chosen: a GEJ cancer, a distal esophageal cancer, and a mid-upper esophageal cancer. Uniform CT simulation datasets and an accompanying diagnostic PET-CT were distributed to each expert, and he/she was instructed to generate gross tumor volume (GTV) and CTV contours for each case. All contours were aggregated and subjected to quantitative analysis to assess the degree of concordance between experts and generate draft consensus contours. The panel then refined these contours to generate the contouring atlas. Results Kappa statistics indicated substantial agreement between panelists for each of the three test cases. A consensus CTV atlas was generated for the three test cases, each representing common anatomic presentations of esophageal cancer. The panel agreed on guidelines and principles to facilitate the generalizability of the atlas to individual cases. Conclusions This expert panel successfully reached agreement on contouring guidelines for esophageal and GEJ IMRT and generated a reference CTV atlas. This atlas will serve as a reference for IMRT contours for clinical practice and prospective trial design. Subsequent patterns of failure analyses of clinical datasets utilizing these guidelines may require modification in the future. PMID:26104943

Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: a prospective randomized controlled trial.

PubMed

Hsu, Hsao-Hsun; Chen, Jin-Shing; Huang, Pei-Ming; Lee, Jang-Ming; Lee, Yung-Chie

2004-06-01

The use of a circular stapler in cervical esophagogastric anastomosis remains controversial. This study was to compare the postoperative and long-term results of manual and mechanical techniques for cervical esophagogastric anastomosis after resection for squamous cell carcinoma. A prospective randomized controlled trial was undertaken in 63 patients with curatively resectable squamous cell cancer of the thoracic esophagus between 1996 and 1999. Patients were randomized to receive either a hand-sewn (32 patients) or circular stapled (31 patients) cervical esophagogastric anastomosis. The mean operating time was longer when the hand-sewn method was used (524 vs. 447 min, P < 0.001). Anastomotic leakage was noted in seven patients (22%) in the hand-sewn group and eight patients (26%) in the stapler group (P = NS). Hospital mortality occurred in four patients (13%) of the hand-sewn group and in three patients (10%) of the stapler group (P = NS). After the operation, four patients (14%) in the hand-sewn group and five patients (18%) in the stapler group developed a benign esophageal stricture (P = NS). The mean follow-up time was 24 months, and the rates of freedom from benign stricture and survival were comparable in each group. Performing cervical esophagogastric anastomoses using a circular mechanical stapler had a shorter operating time and a comparable outcome to the hand-sewn method. The circular mechanical stapler could be used as an alternative for cervical esophagogastric anastomosis after resection for esophageal squamous cell cancer.

Adjuvant sunitinib following chemoradiotherapy and surgery for locally advanced esophageal cancer: a phase II trial.

PubMed

Horgan, A M; Darling, G; Wong, R; Guindi, M; Liu, G; Jonker, D J; Lister, J; Xu, W; MacKay, H M; Dinniwell, R; Kim, J; Pierre, A; Shargall, Y; Asmis, T R; Agboola, O; Seely, A J; Ringash, J; Wells, J; Marginean, E C; Haider, M; Knox, J J

2016-11-01

The prognosis for locally advanced esophageal cancer is poor despite the use of trimodality therapy. In this phase II study, we report the feasibility, tolerability and efficacy of adjuvant sunitinib. Included were patients with stage IIa, IIB or III cancer of the thoracic esophagus or gastroesophageal junction. Neoadjuvant therapy involved Irinotecan (65 mg/m 2 ) + Cisplatin (30 mg/m 2 ) on weeks 1 and 2, 4 and 5, 7 and 8 with concurrent radiation (50Gy/25 fractions) on weeks 4-8. Sunitinib was commenced 4-13 weeks after surgery and continued for one year. Sixty-one patients were included in the final analysis, 36 patients commenced adjuvant sunitinib. Fourteen patients discontinued sunitinib due to disease recurrence (39%) within the 12-month period, 12 (33%) discontinued due to toxicity, and 3 (8%) requested cessation of therapy. In the overall population, median survival was 26 months with a 2 and 3-year survival rate of 52% and 35%, respectively. The median survival for the 36 patients treated with sunitinib was 35 months and 2-year survival probability of 68%. In a historical control, a prior phase II study with the same trimodality therapy (n = 43), median survival was 36 months, with a 2-year survival of 67%. Initiation of adjuvant sunitinib is feasible, but poorly tolerated, with no signal of additional benefit over trimodality therapy for locally advanced esophageal cancer. © 2015 International Society for Diseases of the Esophagus.

Jasmine tea consumption and upper gastrointestinal cancer in China.

PubMed

Gao, Ying; Hu, Nan; Han, XiaoYou; Giffen, Carol; Ding, Ti; Goldstein, Alisa M; Taylor, Philip R

2009-12-01

Epidemiological data on green/jasmine tea and esophageal as well as gastric cancer are limited and inconclusive. In order to study the effect of jasmine tea in upper gastrointestinal (UGI) cancers, we evaluated 600 esophageal squamous cell carcinoma (ESCC), 598 gastric cardia cancer (GCA), and 316 gastric non-cardia cancer (GNCA) cases and 1,514 age-, gender-, and neighborhood-matched controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated from logistic regression adjusted for matching factors and potential confounders. Among controls, 35% of males and 8% of females reported consumption of jasmine tea; other tea consumption was rare. Consumption of jasmine tea (ever vs. never) was not associated with risk of ESCC (OR = 1.15, 95% CI 0.92–1.44), GCA (OR = 1.14, 95% CI 0.88–1.37), or GNCA (OR = 0.85, 95% CI 0.64–1.15) in males and females combined. Among males, cumulative lifetime consumption showed a significant positive dose–response relation with ESCC risk, but not for GCA and GNCA. In exploratory analyses, occupation affected the relation between tea and ESCC such that consumption in males was associated with increased risk only in non-office workers. Overall, we found no evidence for a protective effect of tea in esophageal or gastric cancer. Further studies of the potential effects of thermal damage, tea quality, and water quality on UGI cancers are suggested.

Upper esophageal sphincter motility in gastroesophageal reflux disease in the light of the high-resolution manometry.

PubMed

Nadaleto, B F; Herbella, F A M; Pinna, B R; Patti, M G

2017-04-01

This study aims to evaluate the upper esophageal sphincter (UES) motility in patients with gastroesophageal reflux disease (GERD) as compared to healthy volunteers. We retrospectively studied the HRM tests of 44 patients (median age: 61 years, 54% females) under evaluation for GERD. The manometric UES parameters of these patients were compared to 40 healthy volunteers (median age: 27 years, 50% females). Almost half of the patients had a short and hypotonic UES. Patients with extraesophageal symptoms had a higher proportion of hypotonic UES as compared to patients with esophageal symptoms. Reflux pattern did not influence manometric parameters. Proximal reflux (any number of episodes) was present in 37(84%) patients (median number of proximal episodes = 6). Manometric parameters are similar in the presence or absence of proximal reflux. There is not a correlation between the UES length and UES basal pressure. In conclusion, our results show that: (1) the manometric profile of the UES in patients with GERD is characterized by a short and hypotonic UES in half of the patients; (2) this profile is more pronounced in patients with extraesophageal symptoms; and (3) neither the presence of proximal reflux nor reflux pattern bring a different manometric profile. © The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Radiological manifestations of radiation-induced injury to the normal upper gastrointestinal tract

DOE Office of Scientific and Technical Information (OSTI.GOV)

Goldstein, H.M.; Rogers, L.F.; Fletcher, G.H.

1975-10-01

Radiation-induced injury to the normal esophagus, stomach, and duodenum in patients with advanced cervical carcinoma who received high para-aortic lymph- node irradiation to an average tumor dose of 5,000 rads is discussed. Radiation esophagitis is usually the result of mediastinal irradiation for bronchogenic carcinoma. The most consistent radiological finding is abnormal motility, with esophageal stricture and/or ulceration occurring less frequently. Radiation gastritis is usually present as pyloric ulceration or irregular contractions of the antrum, simulating gastric carcinoma. Postbulbar duodenal mucosal thickening, ulceration, and strictures may occur. Pertinent clinical features, pathogenesis, and pathological correlations are discussed. (auth)

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of non-lymph node thoracic lesions

PubMed Central

Yang, Huizhen; Zhao, Heng; Garfield, David H.; Teng, Jiajun; Han, Baohui; Sun, Jiayuan

2013-01-01

AIMS: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has shown excellent diagnostic capabilities for mediastinal and hilar lymphadenopathy. However, its value in thoracic non-lymph node lesions is less clear. This study was designed to assess the value of EBUS-TBNA in distinguishing malignant from benign thoracic non-lymph node lesions. METHODS: From October 2009 to August 2011, 552 patients underwent EBUS-TBNA under local anesthesia and with conscious sedation. We retrospectively reviewed 81 of these patients who had tracheobronchial wall-adjacent intrapulmonary or isolated mediastinal non-lymph node lesions. On-site cytological evaluation was not used. Immunohistochemistry (IHC) was performed to distinguish the origin or type of malignancy when necessary. RESULTS: EBUS-TBNA was performed in 68 tracheobronchial wall-adjacent intrapulmonary and 13 isolated mediastinal non-lymph node lesions. Of the 81 patients, 77 (95.1%, 60 malignancies and 17 benignancies) were diagnosed through EBUS-TBNA, including 57 primary lung cancers, 2 mediastinal tumors, 1 pulmonary metastatic adenocarcinoma, 7 inflammation, 5 tuberculosis, 3 mediastinal cysts, 1 esophageal schwannoma, and 1 focal fibrosis. There were four false-negative cases (4.9%). Of the 60 malignancies, there were 9 (15.0%) which originally had no definite histologic origin or type. Thus, IHC was performed, with 7 (77.8%) being subsequently confirmed. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EBUS-TBNA in distinguishing malignant from benign lesions were 93.4% (60/64), 100% (17/17), 100% (60/60), 81.0% (17/21), and 95.1% (77/81), respectively. CONCLUSION: EBUS-TBNA is a safe procedure with a high sensitivity for distinguishing malignant from benign thoracic non-lymph node lesions within the reach of EBUS-TBNA, with IHC usually providing a more definitive diagnosis. PMID:23439919

Human thoracic duct in vitro: diameter-tension properties, spontaneous and evoked contractile activity.

PubMed

Telinius, Niklas; Drewsen, Nanna; Pilegaard, Hans; Kold-Petersen, Henrik; de Leval, Marc; Aalkjaer, Christian; Hjortdal, Vibeke; Boedtkjer, Donna Briggs

2010-09-01

The current study characterizes the mechanical properties of the human thoracic duct and demonstrates a role for adrenoceptors, thromboxane, and endothelin receptors in human lymph vessel function. With ethical permission and informed consent, portions of the thoracic duct (2-5 cm) were resected and retrieved at T(7)-T(9) during esophageal and cardia cancer surgery. Ring segments (2 mm long) were mounted in a myograph for isometric tension (N/m) measurement. The diameter-tension relationship was established using ducts from 10 individuals. Peak active tension of 6.24 +/- 0.75 N/m was observed with a corresponding passive tension of 3.11 +/- 0.67 N/m and average internal diameter of 2.21 mm. The equivalent active and passive transmural pressures by LaPlace's law were 47.3 +/- 4.7 and 20.6 +/- 3.2 mmHg, respectively. Subsequently, pharmacology was performed on rings from 15 ducts that were normalized by stretching them until an equivalent pressure of 21 mmHg was calculable from the wall tension. At low concentrations, norepinephrine, endothelin-1, and the thromboxane-A(2) analog U-46619 evoked phasic contractions (analogous to lymphatic pumping), whereas at higher contractions they induced tonic activity (maximum tension values of 4.46 +/- 0.63, 5.90 +/- 1.4, and 6.78 +/- 1.4 N/m, respectively). Spontaneous activity was observed in 44% of ducts while 51% of all the segments produced phasic contractions after agonist application. Acetylcholine and bradykinin relaxed norepinephrine preconstrictions by approximately 20% and approximately 40%, respectively. These results demonstrate that the human thoracic duct can develop wall tensions that permit contractility to be maintained across a wide range of transmural pressures and that isolated ducts contract in response to important vasoactive agents.

Resident training in a new robotic thoracic surgery program.

PubMed

White, Yasmine N; Dedhia, Priya; Bergeron, Edward J; Lin, Jules; Chang, Andrew A; Reddy, Rishindra M

2016-03-01

The volume of robot-assisted operations has drastically increased over the past decade. New programs have focused on training surgeons, whereas resident training has lagged behind. The objective of this study was to evaluate our institutional experience with resident participation in thoracic robotic surgery cases since the initiation of our program. The first 100 robotic thoracic surgery cases at our institution were retrospectively reviewed and categorized into three sequential cohorts. Procedure type, patient and operative characteristics, level of resident participation (primary surgeon [PS] or assistant), and postoperative variables were evaluated. Of the first 100 cases, 38% were lung resections, 23% were esophageal operations, and 20% were sympathectomies. The distribution of cases changed over time with the proportion of pulmonary resections significantly increasing. Patient age (P < 0.05), body mass index (P = not significant [NS]), and comorbidities (P = NS) increased over time. Resident participation as PS increased from 33%-59% between the early and late cohorts (P < 0.05). A subset analysis of the 20 lobectomies (7 attending PS, 13 residents) showed similar patient characteristics (P = NS): age (67 versus 69), body mass index (29.5 versus 26.1), and American Society of Anesthesiologists category (2.8 versus 2.8). Operative and postoperative characteristics were also similar (P = NS) regardless of PS: operative time (260 versus 249 min), estimated blood loss (187 versus 203 mL), and length of stay (4.8 versus 4.7 d). Residents can participate as the PS in a variety of thoracic operations during the implementation of a robotics program. Operative time, estimated blood loss, and length of stay were similar regardless of level of resident participation. Copyright © 2016 Elsevier Inc. All rights reserved.

Sagittal and transversal plane deformity in thoracic scoliosis.

PubMed

Kotwicki, Tomasz

2002-01-01

The aim of the study was to assess the sagittal and transversal plane deformity of the spine in thoracic scoliosis by the mean of 3-D radiographic analysis. 46 patients admitted for surgery for thoracic idiopathic scoliosis underwent preoperative radiographic assessment. All patients presented the same pattern of the coronal plane deformity: single right thoracic curve (Lenke 1, King 3). Neither lumbar nor proximal thoracic structural curve were present. The Cobb angle varied from 41gamma to 77 gamma (mean 55,4 gamma +/- 8,6 gamma). Long cassette standing antero-posterior and lateral radiographs were analysed. Three-dimensional reconstruction with Rachis 91TM software was performed for each pair of radiographs. The following parameters were assessed: sagittal thoracic Cobb angle (Th4-Th12), upper thoracic kyphosis angle (Th5-Th8), lower thoracic kyphosis angle (Th9-Th12), superior and inferior hemi-curve sagittal angles, lumbar lordosis, sacral slope, sacral incidence, vertebral plate index, segmental vertebral axial rotation throughout the thoracic and lumbar spine. Results showed great variability of parameters assessed. The non-harmonious distribution of kyphosis was demonstrated in the thoracic spine. Local Th9-Th12 hypokyphosis and adjacent local Th5-Th8 hyperkyphosis constitute the most typical sagittal pathologies. So called normokyphotic curves were composed of one hyperkyphotic and one hypokyphotic zone. Th1-Th4 segment revealed two patterns of segmental rotation distribution: a purely compensatory curve with no vertebral axial rotation or a rotated curve presenting the morphology intermediate between Lenke 1 and Lenke 2 types (or King 3 and King 5). curves presenting the same coronal plane deformity differ in their morphology assessed in the two other planes; global thoracic kyphosis angle is a misleading parameter because it covers hypo- and hyperkyphotic zones; local distal thoracic (Th9-Th12) hypokyphosis is present in idiopathic thoracic scoliosis.

Endoscopic outcome beyond esophageal variceal eradication in children with extrahepatic portal venous obstruction.

PubMed

Itha, Srivenu; Yachha, Surender Kumar

2006-02-01

To find out the recurrence of esophageal varices, evolution of gastric varices, portal hypertensive gastropathy (PHG) and risk of rebleeding following esophageal variceal eradication. Between 1992 and 2002, children with extrahepatic portal venous obstruction (EHPVO) and bleeding from esophageal varices received endoscopic injection sclerotherapy until eradication. Surveillance endoscopy was performed initially at 3 months and subsequently at intervals of 6 months to one year to detect esophageal and gastric varices, and PHG. Gastric varices were classified as gastroesophageal (GOV) or isolated gastric varices (IGV). Gastroesophageal varices included types GOV1 and GOV2 that extend along lesser and greater curvatures respectively. Patients who had recurrence of bleeding were evaluated by emergency upper gastrointestinal endoscopy. 163 of 183 children who achieved esophageal variceal eradication were evaluated. Esophageal varices recurred in 40% cases. Primary gastric varices (before sclerotherapy) were seen in 61% cases [GOV 98% (83% GOV1, 15% GOV2) and IGV 2%] and secondary (after sclerotherapy) in 28% [GOV 71% (47% GOV1, 24% GOV2) and IGV 29%]. Secondary gastric varices were distributed as 20% GOV1, 42% GOV2 and 87% IGV. Frequency of gastric varices before sclerotherapy and at the last follow up showed decrease in GOV1 from 82 to 56 (P = 0.02), increase in GOV2 from 15 to 23 and increase in IGV from 2 to 15 (P < 0.001). PHG increased in frequency from 12% to 41% (P < 0.001) and severity from one patient to 12 (P < 0.001). Eleven cases had rebleeding from gastric varices (5 GOV1, 4 GOV2 and 2 IGV). Following esophageal variceal eradication in children with EHPVO a significant decrease in GOV1, increase in IGV and increased frequency and severity of PHG takes place. Small rebleeding risk persists from gastric varices irrespective of the type.

Influence of exercise testing in gastroesophageal reflux in patients with gastroesophageal reflux disease.

PubMed

Mendes-Filho, Antonio Moreira; Moraes-Filho, Joaquim Prado Pinto; Nasi, Ary; Eisig, Jaime Natan; Rodrigues, Tomas Navarro; Barbutti, Ricardo Correa; Campos, Josemberg Marins; Chinzon, Decio

2014-01-01

Gastroesophageal reflux disease is a worldwide prevalent condition that exhibits a large variety of signs and symptoms of esophageal or extra-esophageal nature and can be related to the esophagic adenocarcinoma. In the last few years, greater importance has been given to the influence of physical exercises on it. Some recent investigations, though showing conflicting results, point to an exacerbation of gastroesophageal reflux during physical exercises. To evaluate the influence of physical activities in patients presenting with erosive and non erosive disease by ergometric stress testing and influence of the lower esophageal sphincter tonus and body mass index during this situation. Twenty-nine patients with erosive disease (group I) and 10 patients with non-erosive disease (group II) were prospectively evaluated. All the patients were submitted to clinical evaluation, followed by upper digestive endoscopy, manometry and 24 h esophageal pH monitoring. An ergometric testing was performed 1 h before removing the esophageal pH probe. During the ergometric stress testing, the following variables were analyzed: test efficacy, maximum oxygen uptake, acid reflux duration, gastroesophageal reflux symptoms, influence of the lower esophageal sphincter tonus and influence of body mass index in the occurrence of gastroesophageal reflux during these physical stress. Maximum oxigen consumption or VO 2 max, showed significant correlation when it was 70% or higher only in the erosive disease group, evaluating the patients with or without acid reflux during the ergometric testing (p=0,032). The other considered variables didn't show significant correlations between gastroesophageal reflux and physical activity (p>0,05). 1) Highly intensive physical activity can predispose the occurrence of gastroesophageal reflux episodes in gastroesophageal reflux disease patients with erosive disease; 2) light or short sessions of physical activity have no influence on reflux, regardless of body mass index; 3) the lower esophageal sphincter tonus does not influence the occurrence of reflux disease episodes during exercise testing.

[Clinical analysis of diagnosis and treatment on retro-esophageal space abscess].

PubMed

Chen, Ze; Zhong, Zhaotang; Liang, Minzhi

2014-12-01

To explore the clinical manifestations and treatments of retro-esophageal space abscess. The clinical data of 27 cases with retro-esophageal space abscess were analyzed retrospectively. Twenty-one cases (77. 78%) were secondary to acute injury of esophageal meatus caused by foreign bodies. 2 cases (7. 41%)were secondary to old foreign body infection in retro-esophageal space, 3 cases (11. 11%) after secondary to pharyngeal abscess, and 1 case (3. 70%) was unknown to etiology. All patients were confirmed by sectional medicalimageology. Six cases(Conservation group, C group) were treated conservatively and 6 cases (Oropharyngeal incision group, OI group) were performed with oropharyngeal incision drainage. 15 cases(Extra-neck incision group, ENI group)were performed with extra-neck incision and vacuum sealing drainage. In C group, 6 cases were cured with conservative therapy and the average hospital stay was 15. 6 days. In OI group, 5 cases were healed with oropharyngeal drainage but aspiration pneumonia complicated with septic shock occurred in 2 cases, and 1 case dead from septic shock secondary to mediastinum and lung abscess. The average hospital stay was 18. 8 days. In ENI group, 15 patients were cured with extra-neck drainage without complication and the average hospital stay was 9. 5 days. The main causes of retro-esophageal space abscess are foreign body injury of upper esophagus and remnant of retro-esophageal space. Sectional medicalimageology can be of important value of diagnosis and treatment for displaying the retro-esophageal space abscess and other deep cervical fascia space sufficiently. Incision and vacuum sealing drainage via extra-neck is an effective therapy while oropharyngeal drainage is less effective and is not advocated as a primary treatment because of aspiration pneumonia complication . Conservative cure is a choice for patients without dyspnoea and background diseases, and it is necessary to recognize and treat severe complications early.

INFLUENCE OF EXERCISE TESTING IN GASTROESOPHAGEAL REFLUX IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE

PubMed Central

MENDES-FILHO, Antonio Moreira; MORAES-FILHO, Joaquim Prado Pinto; NASI, Ary; EISIG, Jaime Natan; RODRIGUES, Tomas Navarro; BARBUTTI, Ricardo Correa; CAMPOS, Josemberg Marins; CHINZON, Décio

2014-01-01

Background Gastroesophageal reflux disease is a worldwide prevalent condition that exhibits a large variety of signs and symptoms of esophageal or extra-esophageal nature and can be related to the esophagic adenocarcinoma. In the last few years, greater importance has been given to the influence of physical exercises on it. Some recent investigations, though showing conflicting results, point to an exacerbation of gastroesophageal reflux during physical exercises. Aim To evaluate the influence of physical activities in patients presenting with erosive and non erosive disease by ergometric stress testing and influence of the lower esophageal sphincter tonus and body mass index during this situation. Methods Twenty-nine patients with erosive disease (group I) and 10 patients with non-erosive disease (group II) were prospectively evaluated. All the patients were submitted to clinical evaluation, followed by upper digestive endoscopy, manometry and 24 h esophageal pH monitoring. An ergometric testing was performed 1 h before removing the esophageal pH probe. During the ergometric stress testing, the following variables were analyzed: test efficacy, maximum oxygen uptake, acid reflux duration, gastroesophageal reflux symptoms, influence of the lower esophageal sphincter tonus and influence of body mass index in the occurrence of gastroesophageal reflux during these physical stress. Results Maximum oxigen consumption or VO 2 max, showed significant correlation when it was 70% or higher only in the erosive disease group, evaluating the patients with or without acid reflux during the ergometric testing (p=0,032). The other considered variables didn't show significant correlations between gastroesophageal reflux and physical activity (p>0,05). Conclusions 1) Highly intensive physical activity can predispose the occurrence of gastroesophageal reflux episodes in gastroesophageal reflux disease patients with erosive disease; 2) light or short sessions of physical activity have no influence on reflux, regardless of body mass index; 3) the lower esophageal sphincter tonus does not influence the occurrence of reflux disease episodes during exercise testing. PMID:24676289

Mobilisation of the thoracic spine in the management of spondylolisthesis.

PubMed

Mohanty, P P; Pattnaik, Monalisa

2016-07-01

Segmental instability due to lumbar spondylolisthesis is a potential cause of chronic low back pain. Hypomobility of the spine results in compensatory segmental hypermobility of the segment above or below restricted segments. Therefore, the aim of the study is to determine the effects of mobilisation of the hypomobile upper thoracic spine along with conventional flexion exercises and stretching of short hip flexors on the degree of slippage and the functions of the persons with lumbar spondylolisthesis. All patients with spondylolisthesis were randomly assigned into two groups: Group I - Experimental group, treated with mobilisation of the thoracic spine along with the conventional physiotherapy and Group II - Conventional group, treated with conventional stretching, strengthening, and lumbar flexion exercise programme. The experimental group treated with mobilisation of the thoracic spine shows a significant reduction in the percentage of vertebral slip from pre-treatment to post-treatment measurements. Low back pain due to spondylolisthesis may be benefited by mobilisation of the thoracic spine along with stretching of short hip flexors, piriformis, lumbar flexion range of motion exercises, core strengthening exercises, etc. Copyright © 2016 Elsevier Ltd. All rights reserved.

A Prospective Study of Proton Beam Reirradiation for Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fernandes, Annemarie, E-mail: Annemarie.fernandes@gmail.com; Berman, Abigail T.; Mick, Rosemarie

Purpose: Reirradiation to the esophagus carries a significant risk of complications. Proton therapy may offer an advantage in the reirradiation setting due to the lack of exit dose and potential sparing of previously radiated normal tissues. Methods and Materials: Between June 2010 and February 2014, 14 patients with a history of thoracic radiation and newly diagnosed or locally recurrent esophageal cancer began proton beam reirradiation on a prospective trial. Primary endpoints were feasibility and acute toxicity. Toxicity was graded according Common Toxicity Criteria version 4.0. Results: The median follow-up was 10 months (2-25 months) from the start of reirradiation. Eleven patients receivedmore » concurrent chemotherapy. The median interval between radiation courses was 32 months (10-307 months). The median reirradiation prescription dose was 54.0 Gy (relative biological effectiveness [RBE]) (50.4-61.2 Gy[RBE]), and the median cumulative prescription dose was 109.8 Gy (76-129.4 Gy). Of the 10 patients who presented with symptomatic disease, 4 patients had complete resolution of symptoms, and 4 had diminished or stable symptoms. Two patients had progressive symptoms. The median time to symptom recurrence was 10 months. Maximum acute nonhematologic toxicity attributable to radiation was grade 2 (64%, N=9), 3 (29%, N=4), 4 (0%), and 5 (7%, N=1). The acute grade 5 toxicity was an esophagopleural fistula more likely related to tumor progression than radiation. Grade 3 nonhematologic acute toxicities included dysphagia, dehydration, and pneumonia. There was 1 late grade 5 esophageal ulcer more likely related to tumor progression than radiation. There were 4 late grade 3 toxicities: heart failure, esophageal stenosis requiring dilation, esophageal ulceration from tumor, and percutaneous endoscopic gastrostomy tube dependence. The median time to local failure was 10 months, and the median overall survival was 14 months. Conclusions: Our data demonstrate that proton reirradiation is feasible, with an encouraging symptom control rate, modest radiation-related toxicity, and favorable survival in this high-risk population.« less

Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia.

PubMed

Mattioli, Sandro; Ruffato, Alberto; Lugaresi, Marialuisa; Pilotti, Vladimiro; Aramini, Beatrice; D'Ovidio, Frank

2010-11-01

Quality of outcome of the Heller-Dor operation is sometimes different between studies, likely because of technical reasons. We analyze the details of myotomy and fundoplication in relation to the results achieved over a 30-year single center's experience. From 1979-2008, a long esophagogastric myotomy and a partial anterior fundoplication to protect the surface of the myotomy was routinely performed with intraoperative manometry in 202 patients (97 men; median age, 55.5 years; interquartile range, 43.7-71 years) through a laparotomy and in 60 patients (24 men; median age, 46 years; interquartile range, 36.2-63 years) through a laparoscopy. The follow-up consisted of periodical interview, endoscopy, and barium swallow, and a semiquantitative scale was used to grade results. Mortality was 1 of 202 in the laparotomy group and 0 of 60 in the laparoscopy group. Median follow-up was 96 months (interquartile range, 48-190.5 months) in the laparotomy group and 48 months (interquartile range, 27-69.5 months) in the laparoscopy group. At intraoperative manometry, complete abolition of the high-pressure zone was obtained in 100%. The Dor-related high-pressure zone length and mean pressure were 4.5 ± 0.4 cm and 13.3 ± 2.2 mm Hg in the laparotomy group and 4.5 ± 0.5 cm and 13.2 ± 2.2 mm Hg in the laparoscopy group (P = .75). In the laparotomy group poor results (19/201 [9.5%]) were secondary to esophagitis in 15 (7.5%) of 201 patients (in 2 patients after 184 and 252 months, respectively) and to recurrent dysphagia in 4 (2%) of 201 patients, all with end-stage sigmoid achalasia. In the laparoscopy group 2 (3.3%) of 60 had esophagitis. A long esophagogastric myotomy protected by means of Dor fundoplication cures or substantially reduces dysphagia in the great majority of patients affected by esophageal achalasia and effectively controls postoperative esophagitis. Intraoperative manometry is likely the key factor for achieving the reported results. Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Proton Beam Therapy and Concurrent Chemotherapy for Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lin, Steven H., E-mail: shlin@mdanderson.org; Komaki, Ritsuko; Liao Zhongxing

2012-07-01

Purpose: Proton beam therapy (PBT) is a promising modality for the management of thoracic malignancies. We report our preliminary experience of treating esophageal cancer patients with concurrent chemotherapy (CChT) and PBT (CChT/PBT) at MD Anderson Cancer Center. Methods and Materials: This is an analysis of 62 esophageal cancer patients enrolled on a prospective study evaluating normal tissue toxicity from CChT/PBT from 2006 to 2010. Patients were treated with passive scattering PBT with two- or three-field beam arrangement using 180 to 250 MV protons. We used the Kaplan-Meier method to assess time-to-event outcomes and compared the distributions between groups using themore » log-rank test. Results: The median follow-up time was 20.1 months for survivors. The median age was 68 years (range, 38-86). Most patients were males (82%) who had adenocarcinomas (76%) and Stage II-III disease (84%). The median radiation dose was 50.4 Gy (RBE [relative biologic equivalence]) (range, 36-57.6). The most common grade 2 to 3 acute toxicities from CChT/PBT were esophagitis (46.8%), fatigue (43.6%), nausea (33.9%), anorexia (30.1%), and radiation dermatitis (16.1%). There were two cases of grade 2 and 3 radiation pneumonitis and two cases of grade 5 toxicities. A total of 29 patients (46.8%) received preoperative CChT/PBT, with one postoperative death. The pathologic complete response (pCR) rate for the surgical cohort was 28%, and the pCR and near CR rates (0%-1% residual cells) were 50%. While there were significantly fewer local-regional recurrences in the preoperative group (3/29) than in the definitive CChT/PBT group (16/33) (log-rank test, p = 0.005), there were no differences in distant metastatic (DM)-free interval or overall survival (OS) between the two groups. Conclusions: This is the first report of patients treated with PBT/CChT for esophageal cancer. Our data suggest that this modality is associated with a few severe toxicities, but the pathologic response and clinical outcomes are encouraging. Prospective comparison with more traditional approach is warranted.« less

Proton Beam Therapy and concurrent chemotherapy for esophageal cancer

PubMed Central

Lin, Steven H.; Komaki, Ritsuko; Liao, Zhongxing; Wei, Caimiao; Myles, Bevan; Guo, Xiaomao; Palmer, Matthew; Mohan, Radhe; Swisher, Stephen G.; Hofstetter, Wayne L.; Ajani, Jaffer A.; Cox, James D.

2014-01-01

Purpose/Objective Proton beam therapy (PBT) is a promising modality for the management of thoracic malignancies. We report our preliminary experience of treating esophageal cancer patients with concurrent chemotherapy (CChT) and PBT at MD Anderson Cancer Center. Materials/Methods This is an analysis of 62 esophageal cancer patients enrolled on a prospective study evaluating normal tissue toxicity from CChT/PBT from 2006 to 2010. Patients were treated with Passive Scattering PBT with 2 or 3 field beam arrangement using 180–250 MV protons. We used the method of Kaplan and Meier to assess time to event outcomes and compared the distributions between groups using the log-rank test. Results The median follow-up time was 20.1 months for survivors. The median age was 68 years (range 38–86). Most were males (82%), had adenocarcinomas (76%) and had stage II-III disease (84%). The median radiation dose was 50.4 Gray-Equivalence (Gy(RBE)) (range 36–57.6). The most common grade 2–3 acute toxicities from CChT/PBT were esophagitis (46.8%), fatigue (43.6%), nausea (33.9%), anorexia (30.1%), and radiation dermatitis (16.1%). There were two cases of grade 2 and 3 radiation pneumonitis and two grade 5 toxicities. A total of 29 patients (46.8%) received preoperative CChT/PBT with one postoperative death. The pathologic complete response (pCR) rate for the surgical cohort was 28%, and the pCR and near CR rate (0–1% residual cells) was 50%. While there were significantly fewer local-regional recurrences in the preoperative group (3/29) as compared to the definitive CChT/PBT group (16/33) (log-rank test p=0.005), there were no differences in DM free interval or OS between the two groups. Conclusions This is the first report of patients treated with PBT/CChT for esophageal cancer. Our data suggest that this modality is associated with a few severe toxicities but the pathologic response and clinical outcomes are encouraging. Prospective comparison with more traditional approach is warranted. PMID:22417808

Proton beam therapy and concurrent chemotherapy for esophageal cancer.

PubMed

Lin, Steven H; Komaki, Ritsuko; Liao, Zhongxing; Wei, Caimiao; Myles, Bevan; Guo, Xiaomao; Palmer, Matthew; Mohan, Radhe; Swisher, Stephen G; Hofstetter, Wayne L; Ajani, Jaffer A; Cox, James D

2012-07-01

Proton beam therapy (PBT) is a promising modality for the management of thoracic malignancies. We report our preliminary experience of treating esophageal cancer patients with concurrent chemotherapy (CChT) and PBT (CChT/PBT) at MD Anderson Cancer Center. This is an analysis of 62 esophageal cancer patients enrolled on a prospective study evaluating normal tissue toxicity from CChT/PBT from 2006 to 2010. Patients were treated with passive scattering PBT with two- or three-field beam arrangement using 180 to 250 MV protons. We used the Kaplan-Meier method to assess time-to-event outcomes and compared the distributions between groups using the log-rank test. The median follow-up time was 20.1 months for survivors. The median age was 68 years (range, 38-86). Most patients were males (82%) who had adenocarcinomas (76%) and Stage II-III disease (84%). The median radiation dose was 50.4 Gy (RBE [relative biologic equivalence]) (range, 36-57.6). The most common grade 2 to 3 acute toxicities from CChT/PBT were esophagitis (46.8%), fatigue (43.6%), nausea (33.9%), anorexia (30.1%), and radiation dermatitis (16.1%). There were two cases of grade 2 and 3 radiation pneumonitis and two cases of grade 5 toxicities. A total of 29 patients (46.8%) received preoperative CChT/PBT, with one postoperative death. The pathologic complete response (pCR) rate for the surgical cohort was 28%, and the pCR and near CR rates (0%-1% residual cells) were 50%. While there were significantly fewer local-regional recurrences in the preoperative group (3/29) than in the definitive CChT/PBT group (16/33) (log-rank test, p = 0.005), there were no differences in distant metastatic (DM)-free interval or overall survival (OS) between the two groups. This is the first report of patients treated with PBT/CChT for esophageal cancer. Our data suggest that this modality is associated with a few severe toxicities, but the pathologic response and clinical outcomes are encouraging. Prospective comparison with more traditional approach is warranted. Copyright © 2012 Elsevier Inc. All rights reserved.

Fungal colonization of the esophagus in alcoholic liver disease.

PubMed

Péter, Z; Zala, J; Szabó, O; Telegdy, L; Horváth, Z; Makara, M; Schuller, J

2000-10-01

Little is known about the fungal colonization of the esophagus. Since alcoholic liver disease (ALD) patients are prone to fungal esophagitis, we have investigated the esophageal fungal colonization of this patient group. One hundred consecutive ALD patients were enrolled in this prospective study. 22 patients with dyspeptic symptoms acted as controls. After taking an oropharyngeal swab, patients underwent an upper gastrointestinal endoscopy and surface material was obtained from the esophagus for direct smears and culture. In the ALD group pseudohyphae were found in 21.5% and yeast forms in 6.4% of the direct smears. The culture was positive in 40.8% of the ALD patients, the isolated strains were: 30 C. albicans, 2 C. kefyr, 2 C. krusei, 1 C. zeylanoides and in 3 cases the species could not be identified. 41.9% of ALD patients and 13.6% of control patients (p = 0.013) had fungi in their esophagus. Significantly more ALD patients had fungal esophagitis than in the control group (19.3% vs. 0%, p = 0.021), the rate of fungal colonization was also higher, but the difference was not significant (22.5% vs. 13.6%). A significantly higher rate of fungal esophagitis and esophageal colonization was found in patients with fungi in their oropharyngeal swabs (p = 0.00001). Fungal colonization of the esophagus is frequent in ALD patients. Its presence might have clinical significance in the case of liver transplantation.

Differential role of microRNAs in the pathogenesis and treatment of Esophageal cancer.

PubMed

Hemmatzadeh, Maryam; Mohammadi, Hamed; Karimi, Mohammad; Musavishenas, Mohammad Hossein; Baradaran, Behzad

2016-08-01

Esophageal cancer (EC) is the most invasive disease associated with inclusive poor prognosis. EC usually is found as either adenocarcinoma (EAC) or squamous cell carcinomas (ESCC). ESCC forms in squamous cells and highly occurs in the upper third of the esophagus. EAC appears in glandular cells and ordinarily develops in the lower one third of the esophagus near the stomach. Barrett's esophagus (BE) is a metaplastic precursor of EAC. There is a persistent need for improving our understanding of the molecular basis of this disease. MicroRNAs (miRNAs) demonstrate an uncovered class of small, non-coding RNAs that can negatively regulate the protein coding gene, and are associated with approximately all known physiological and pathological processes, especially cancer. MiRNAs can affect cancer pathogenesis, playing a crucial role as either oncogenes or tumor suppressors. The recent emergence of observations on the role of miRNAs in cancer and their functions has induced many investigations to examine their relevance to esophageal cancer. In esophageal cancer, miRNA dysregulation plays a crucial role in cancer prognosis and in patients' responsiveness to neo-adjuvant and adjuvant therapies. In this review, the oncogenic, tumor suppressive, and drug resistance related roles of miRNAs, and their involvement in the pathogenesis and treatment of esophageal cancer were summarized. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

High-resolution manometry findings in patients with achalasia and massive dilated megaesophagus.

PubMed

Menezes, M A; Andolfi, C; Herbella, F A M; Patti, M G

2017-05-01

Achalasia may present in a non-advanced or an advanced (end stage) stage based on the degree of esophageal dilatation. Manometric parameters and esophageal caliber may be prognostic for the outcome of treatment. The correlation between manometry and disease stage has not been yet fully studied. This study aims to describe high-resolution manometry findings in patients with achalasia and massive dilated megaesophagus. Eighteen patients (mean age 61 years, 55% females) with achalasia and massive dilated megaesophagus, as defined by a maximum esophageal dilatation >10 cm at the barium esophagram, were studied. Achalasia was considered secondary to Chagas' disease in 14 (78%) of the patients and idiopathic in the remaining. All patients underwent high-resolution manometry. Upper esophageal sphincter was hypotonic and had impaired relaxation in the majority of patients. Aperistalsis was seen in all patients with an equal distribution of Chicago type I and type II. No type III was noticed. Lower esophageal sphincter did not have a characteristic manometric pattern. In 50% of the cases, the manometry catheter was not able to reach the stomach. Our results did not show a manometric pattern in patients with achalasia and massive dilated esophagus. © The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

What is the best way to manage GERD symptoms in the elderly?

PubMed

Bacak, Brian S; Patel, Mihir; Tweed, Elizabeth; Danis, Peter

2006-03-01

No evidence supports one method over another in managing uncomplicated gastroesophageal reflux disease (GERD) for patients aged >65 years. For those with endoscopically documented esophagitis, proton pump inhibitors (PPIs) relieve symptoms faster than histamine H2 receptor antagonists (H2RAs) (strength of recommendation [SOR]: B, extrapolation from randomized controlled trials [RCTs]). Treating elderly patients with pantoprazole (Protonix) after resolution of acute esophagitis results in fewer relapses than with placebo (SOR: B, double-blind RCT). Limited evidence suggests that such maintenance therapy for prior esophagitis with either H2RAs or PPIs, at half- and full-dose strength, decreases the frequency of relapse (SOR: B, extrapolation from uncontrolled clinical trial). Laparoscopic antireflux surgery for treating symptomatic GERD among elderly patients without paraesophageal hernia reduces esophageal acidity, with no apparent increase in postoperative morbidity or mortality compared with younger patients (SOR: C, nonequivalent before-after study). Upper endoscopy is recommended for elderly patients with alarm symptoms, new-onset GERD, or longstanding disease (SOR: C, expert consensus). Elderly patients are at risk for more severe complications from GERD, and their relative discomfort from the disease process is often less than from comparable pathology for younger patients (SOR: C, expert consensus). Based on safety profiles and success in the general patient population, PPIs as a class are considered first-line treatment for GERD and esophagitis for the elderly (SOR: C, expert consensus).

Volumetric-modulated arc therapy for the treatment of a large planning target volume in thoracic esophageal cancer.

PubMed

Abbas, Ahmar S; Moseley, Douglas; Kassam, Zahra; Kim, Sun Mo; Cho, Charles

2013-05-06

Recently, volumetric-modulated arc therapy (VMAT) has demonstrated the ability to deliver radiation dose precisely and accurately with a shorter delivery time compared to conventional intensity-modulated fixed-field treatment (IMRT). We applied the hypothesis of VMAT technique for the treatment of thoracic esophageal carcinoma to determine superior or equivalent conformal dose coverage for a large thoracic esophageal planning target volume (PTV) with superior or equivalent sparing of organs-at-risk (OARs) doses, and reduce delivery time and monitor units (MUs), in comparison with conventional fixed-field IMRT plans. We also analyzed and compared some other important metrics of treatment planning and treatment delivery for both IMRT and VMAT techniques. These metrics include: 1) the integral dose and the volume receiving intermediate dose levels between IMRT and VMATI plans; 2) the use of 4D CT to determine the internal motion margin; and 3) evaluating the dosimetry of every plan through patient-specific QA. These factors may impact the overall treatment plan quality and outcomes from the individual planning technique used. In this study, we also examined the significance of using two arcs vs. a single-arc VMAT technique for PTV coverage, OARs doses, monitor units and delivery time. Thirteen patients, stage T2-T3 N0-N1 (TNM AJCC 7th edn.), PTV volume median 395 cc (range 281-601 cc), median age 69 years (range 53 to 85), were treated from July 2010 to June 2011 with a four-field (n = 4) or five-field (n = 9) step-and-shoot IMRT technique using a 6 MV beam to a prescribed dose of 50 Gy in 20 to 25 F. These patients were retrospectively replanned using single arc (VMATI, 91 control points) and two arcs (VMATII, 182 control points). All treatment plans of the 13 study cases were evaluated using various dose-volume metrics. These included PTV D99, PTV D95, PTV V9547.5Gy(95%), PTV mean dose, Dmax, PTV dose conformity (Van't Riet conformation number (CN)), mean lung dose, lung V20 and V5, liver V30, and Dmax to the spinal canal prv3mm. Also examined were the total plan monitor units (MUs) and the beam delivery time. Equivalent target coverage was observed with both VMAT single and two-arc plans. The comparison of VMATI with fixed-field IMRT demonstrated equivalent target coverage; statistically no significant difference were found in PTV D99 (p = 0.47), PTV mean (p = 0.12), PTV D95 and PTV V9547.5Gy (95%) (p = 0.38). However, Dmax in VMATI plans was significantly lower compared to IMRT (p = 0.02). The Van't Riet dose conformation number (CN) was also statistically in favor of VMATI plans (p = 0.04). VMATI achieved lower lung V20 (p = 0.05), whereas lung V5 (p = 0.35) and mean lung dose (p = 0.62) were not significantly different. The other OARs, including spinal canal, liver, heart, and kidneys showed no statistically significant differences between the two techniques. Treatment time delivery for VMATI plans was reduced by up to 55% (p = 5.8E-10) and MUs reduced by up to 16% (p = 0.001). Integral dose was not statistically different between the two planning techniques (p = 0.99). There were no statistically significant differences found in dose distribution of the two VMAT techniques (VMATI vs. VMATII) Dose statistics for both VMAT techniques were: PTV D99 (p = 0.76), PTV D95 (p = 0.95), mean PTV dose (p = 0.78), conformation number (CN) (p = 0.26), and MUs (p = 0.1). However, the treatment delivery time for VMATII increased significantly by two-fold (p = 3.0E-11) compared to VMATI. VMAT-based treatment planning is safe and deliverable for patients with thoracic esophageal cancer with similar planning goals, when compared to standard IMRT. The key benefit for VMATI was the reduction in treatment delivery time and MUs, and improvement in dose conformality. In our study, we found no significant difference in VMATII over single-arc VMATI for PTV coverage or OARs doses. However, we observed significant increase in delivery time for VMATII compared to VMATI.

[Epidemiology of upper gastrointestinal bleeding in Gabon].

PubMed

Gaudong Mbethe, G L; Mounguengui, D; Ondounda, M; Magne, C; Bignoumbra, R; Ntsoumou, S; Moussavou Kombila, J-B; Nzenze, J R

2014-01-01

The department of internal medicine of the military hospital of Gabon managed 92 cases of upper gastrointestinal bleeding from April 2009 to November 2011. The frequency of these hemorrhages in the department was 8.2%; they occurred most often in adults aged 30-40 years and 50-60 years, and mainly men (74%). Erosive-ulcerative lesions (65.2%) were the leading causes of hemorrhage, followed by esophageal varices (15.2%). These results underline the importance of preventive measures for the control of this bleeding.

The Benefits of Combination Therapy with Esomeprazole and Rebamipide in Symptom Improvement in Reflux Esophagitis: An International Multicenter Study

PubMed Central

Hong, Su Jin; Park, Soo-Heon; Moon, Jeong Seop; Shin, Woon Geon; Kim, Jae Gyu; Lee, Yong Chan; Lee, Dong Ho; Jang, Jae Young; Kim, Jae J.; Lee, Hang-Lak; Lee, Sang Woo; Hwangbo, Young; Xu, Jianming; Wang, Bangmao; Xue, Zhanxiong; Liu, Fei; Yuan, Yaozong; Leelakusolvong, Somchai; Dy, Frederick

2016-01-01

Background/Aims To investigate the effects of esomeprazole and rebamipide combination therapy on symptomatic improvement in patients with reflux esophagitis. Methods A total of 501 patients with reflux esophagitis were randomized into one of the following two treatment regimens: 40 mg esomeprazole plus 300 mg rebamipide daily (combination therapy group) or 40 mg esomeprazole daily (monotherapy group). We used a symptom questionnaire that evaluated heartburn, acid regurgitation, and four upper gastrointestinal symptoms. The primary efficacy end point was the mean decrease in the total symptom score. Results The mean decreases in the total symptom score at 4 weeks were estimated to be −18.1±13.8 in the combination therapy group and −15.1±11.9 in the monotherapy group (p=0.011). Changes in reflux symptoms from baseline after 4 weeks of treatment were −8.4±6.6 in the combination therapy group and −6.8±5.9 in the monotherapy group (p=0.009). Conclusions Over a 4-week treatment course, esomeprazole and rebamipide combination therapy was more effective in decreasing the symptoms of reflux esophagitis than esomeprazole monotherapy. PMID:27282265

Hypnotherapy for Esophageal Disorders.

PubMed

Riehl, Megan E; Keefer, Laurie

2015-07-01

Hypnotherapy is an evidence based intervention for the treatment of functional bowel disorders, particularly irritable bowel syndrome. While similar in pathophysiology, less is known about the utility of hypnotherapy in the upper gastrointestinal tract. Esophageal disorders, most of which are functional in nature, cause painful and uncomfortable symptoms that impact patient quality of life and are difficult to treat from a medical perspective. After a thorough medical workup and a failed trial of proton pump inhibitor therapy, options for treatment are significantly limited. While the pathophysiology is likely multifactorial, two critical factors are believed to drive esophageal symptoms--visceral hypersensitivity and symptom hypervigilance. The goal of esophageal directed hypnotherapy is to promote a deep state of relaxation with focused attention allowing the patient to learn to modulate physiological sensations and symptoms that are not easily addressed with conventional medical intervention. Currently, the use of hypnosis is suitable for dysphagia, globus, functional chest pain/non-cardiac chest pain, dyspepsia, and functional heartburn. In this article the authors will provide a rationale for the use of hypnosis in these disorders, presenting the science whenever available, describing their approach with these patients, and sharing a case study representing a successful outcome.

Hypnotherapy for Esophageal Disorders

PubMed Central

Riehl, Megan E.; Keefer, Laurie

2015-01-01

Hypnotherapy is an evidence based intervention for the treatment of functional bowel disorders, particularly irritable bowel syndrome. While similar in pathophysiology, less is known about the utility of hypnotherapy in the upper gastrointestinal tract. Esophageal disorders, most of which are functional in nature, cause painful and uncomfortable symptoms that impact patient quality of life and are difficult to treat from a medical perspective. After a thorough medical workup and a failed trial of proton pump inhibitor therapy, options for treatment are significantly limited. While the pathophysiology is likely multifactorial, two critical factors are believed to drive esophageal symptoms—visceral hypersensitivity and symptom hypervigilance. The goal of esophageal directed hypnotherapy is to promote a deep state of relaxation with focused attention allowing the patient to learn to modulate physiological sensations and symptoms that are not easily addressed with conventional medical intervention. Currently, the use of hypnosis is suitable for dysphagia, globus, functional chest pain/non-cardiac chest pain, dyspepsia, and functional heartburn. In this article the authors will provide a rationale for the use of hypnosis in these disorders, presenting the science whenever available, describing their approach with these patients, and sharing a case study representing a successful outcome. PMID:26046715

[Conservative treatment improved corrosive esophagitis and pneumomediastinum in a patient who ingested bleaching agent containing sodium hypochlorite and sodium hydroxide].

PubMed

Nakano, Hiroshi; Iseki, Ken; Ozawa, Akiko; Tominaga, Aya; Sadahiro, Ryoichi; Otani, Koichi

2014-03-01

A 69-year-old man was admitted to the emergency department 3 hours after ingestion of a bleaching agent containing hypochlorous acid and sodium hydroxide in a suicide attempt. Enhanced chest computed tomography scans taken on admission indicated an edematous esophagus and air bubbles in the mediastinum. He underwent endotracheal intubation and mechanical ventilation until day 9 because of laryngeal edema. On day 10, his endoscopy indicated diffuse reddish mucosal hyperemia, erosions, and lacerated mucosal lesions in the esophagus that were indicative of grade 2b corrosive esophagitis. Treatment with a proton pump inhibitor was initiated, with which the condition of the esophagus improved, and on day 44, a slight stricture of the upper part of the esophagus was observed. He was discharged on day 64 without any complaints. The ingestion of sodium hypochlorite induces corrosive esophagitis and acute phase of gastritis. Ingestion of any corrosive agent is known as a risk factor for esophagus cancer in the long-term. In such cases with esophageal stricture, esophagectomy is recommended for preventing esophagus cancer. Considering the age of the patient, however, he did not undergo esophagectomy.

Role of a health psychologist in the management of functional esophageal complaints.

PubMed

Riehl, M E; Kinsinger, S; Kahrilas, P J; Pandolfino, J E; Keefer, L

2015-07-01

Upper gastrointestinal complaints are common among patients in a gastrointestinal clinic. Outside of typical gastroesophageal reflux disease symptoms that are treated with medication, the symptom presentations of esophageal patients, particularly those with functional conditions, are often difficult to treat and account for high health-care utilization. This manuscript describes the role of a health psychologist in the treatment of esophageal disorders using behavioral medicine interventions. Observations over the course of a 1-year period indicate that the sample presents with a relatively low level of psychological distress but reports negative effects of their symptoms on health-related quality of life. Five case examples of commonly treated disorders (globus, non-cardiac chest pain, functional dysphagia, rumination syndrome, supragastric belching) are described to highlight how behavioral treatment can improve patients' symptoms, decrease health-care utilization, and improve overall quality of life in a timely and relatively simple manner. Successful treatment outcomes are associated with a collaborative working alliance between patient, health psychologist, and gastroenterologist. Results indicate the benefit of referring appropriate esophageal patients to a health psychologist with specialization in gastroenterology. © 2014 International Society for Diseases of the Esophagus.

Thoracic stomach-right main bronchus fistula treated with dual Y-shaped covered airway stents.

PubMed

Li, Z-M; Lu, H-B; Ren, K-W; Han, X-W; Wu, G; Jiao, D-C

2017-06-01

To determine the efficacy of dual Y-shaped covered airway stents to treat thoracic stomach-right main bronchus fistulae. Fifteen patients who developed thoracic stomach-right main bronchus fistula after oesophageal cancer resection and postoperative irradiation were retrospectively analysed. All fistulae were close to the right upper lobe bronchus. Two Y-shaped covered airway stents were designed for each patient. Under radiographic guidance, one stent was placed from the right main bronchus into the bifurcation of upper lobe and intermediate bronchus, the other was placed from the trachea into both main bronchi. All fistulae were closed immediately after stenting. All patients could eat a semi-solid diet. The symptom of coughing while lying down resolved in all patients, and no complications, such as airway bleeding or pneumothorax, occurred. The average survival time was 26.65 months (range 2-40 months, 11 patients were still alive at the study end). Two patients died of tumour recurrence. Another two patients died of pulmonary infections. In one of these patients, there was a long delay between symptom onset and stenting. In the other patient, a small rupture occurred in the silicone membrane covering the stent, which allowed the leakage of gastric contents into the lung. Dual Y-shaped covered airway stent placement is feasible and safe to treat thoracic stomach-right main bronchus fistulae. Improvements to the material covering the stents is required. Copyright © 2017. Published by Elsevier Ltd.

Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults.

PubMed

Nativ-Zeltzer, N; Logemann, J A; Zecker, S G; Kahrilas, P J

2016-05-01

We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined. Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter. Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus. Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies. © 2016 John Wiley & Sons Ltd.

Association Between Nocturnal Acid Reflux and Sleep Disturbance in Patients With Gastroesophageal Reflux Disease.

PubMed

Hung, Jui-Sheng; Lei, Wei-Yi; Yi, Chih-Hsun; Liu, Tso-Tsai; Chen, Chien-Lin

2016-08-01

This study was conducted to investigate whether there is a direct association between subjective sleep quality and esophageal acid reflux in patients with gastroesophageal reflux disease. We enrolled patients with classic reflux symptoms for endoscopy and ambulatory pH monitoring. The severity of esophageal mucosal injury was assessed by upper endoscopy. Distal esophageal acid exposure was determined by ambulatory 24-hour pH monitoring. Sleep disturbance was assessed by using the Pittsburgh Sleep Quality Index. In total, 103 patients (53 patients without sleep dysfunction and 50 patients with sleep dysfunction) were studied. Erosive esophagitis was found more in patients with sleep disturbance than in those without sleep disturbance (45% versus 31%, P = 0.04). Abnormal esophageal pH was found more in patients with dysfunction (22%) than in patients without sleep dysfunction (5.7%, P = 0.03). Recumbent acid contact time (%) was greater in patients with sleep disturbance than in those without sleep disturbance (3.7 ± 2.4 versus 1.9 ± 0.9, P = 0.04). Sleep quality score positively correlated with acid contact time (r = 0.32, P = 0.02), prolonged reflux events (r = 0.45, P = 0.008) and longer reflux event (r = 0.28, P = 0.03) during recumbent period. Patients with gastroesophageal reflux disease along with sleep dysfunction are characterized with greater nocturnal acid reflux and more erosive esophagitis. Our study suggests that increased nocturnal acid reflux may play a role in inducing sleep disturbance in patients with gastroesophageal reflux disease. Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.

[Multivariate ordinal logistic regression analysis on the association between consumption of fried food and both esophageal cancer and precancerous lesions].

PubMed

Guo, L W; Liu, S Z; Zhang, M; Chen, Q; Zhang, S K; Sun, X B

2017-12-10

Objective: To investigate the effect of fried food intake on the pathogenesis of esophageal cancer and precancerous lesions. Methods: From 2005 to 2013, all the residents aged 40-69 years from 11 counties (cities) where cancer screening of upper gastrointestinal cancer had been conducted in rural areas of Henan province, were recruited as the subjects of study. Information on demography and lifestyle was collected. The residents under study were screened with iodine staining endoscopic examination and biopsy samples were diagnosed pathologically, under standardized criteria. Subjects with high risk were divided into the groups based on their different pathological degrees. Multivariate ordinal logistic regression analysis was used to analyze the relationship between the frequency of fried food intake and esophageal cancer and precancerous lesions. Results: A total number of 8 792 cases with normal esophagus, 3 680 with mild hyperplasia, 972 with moderate hyperplasia, 413 with severe hyperplasia carcinoma in situ, and 336 cases of esophageal cancer were recruited. Results from multivariate logistic regression analysis showed that, when compared with those who did not eat fried food, the intake of fried food (<2 times/week: OR =1.60, 95% CI : 1.40-1.83; ≥2 times/week: OR =2.58, 95% CI : 1.98-3.37) appeared a risk factor for both esophageal cancer or precancerous lesions after adjustment for age, sex, marital status, educational level, body mass index, smoking and alcohol intake. Conclusion: The intake of fried food appeared a risk factor for both esophageal cancer and precancerous lesions.

Clinical feasibility of a new through-the-scope fully covered esophageal self-expandable metallic stent: an in vivo animal study.

PubMed

Cheon, Young Koog; Lee, Tae Yoon; Sung, In Kyung; Shim, Chan Sup

2014-01-01

Most delivery devices used for esophageal stents for obstructing esophageal cancer have a diameter of 5-8 mm, a size that is too large to pass through the endoscopic working channel. The conventional esophageal stent requires multiple endoscopic procedures for implantation. The purpose of the present study was to evaluate the clinical feasibility of a newly developed fully covered, self-expanding, through-the-scope (TTS) esophageal stent in a porcine model. Eight mini pigs were used. Each animal underwent placement of a fully covered TTS stent (Hanarostent® Esophagus TTS) and the upper part of the stent was fixed by suturing with nylon. Fluoroscopy was carried out every week to assess migration of the stent. Follow-up endoscopy was done every month for 3 months to evaluate the status of the membrane, stent mesh, grade of tissue hyperplasia, and mucosal changes at both ends of the stent. All stents were successfully and easily deployed, and were placed without any distortion in the stent or without rupture of the membrane. In two cases, stent migration was observed after 8 weeks. No case of membrane disruption, stent mesh disruption or tissue hyperplasia at either end of the stent was found at the completion of the study. Our findings indicate that the new fully covered self-expanding TTS esophageal stent is easy and simple to implant, and no significant distortion of mesh or disruption of membrane was observed. © 2013 The Authors. Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society.

The Spectrum of Surgical Remediation of Transoral Incisionless Fundoplication-Related Failures.

PubMed

Puri, Ruchir; Smith, C Daniel; Bowers, Steven P

2018-05-16

To evaluate outcomes of surgical remediation for symptomatic or anatomic failure after a transoral incisionless fundoplication (TIF). This retrospective study was performed on 11 patients who underwent a remedial operation following TIF failure between June 2011 and September 2016 at the Mayo Clinic in Florida for persistent foregut symptoms. Upper gastrointestinal workup characterized 1 patient as having normal post-TIF anatomy and 10 as having anatomic failure. Ambulatory pH testing was performed in 7 patients and was abnormal in all. All patients underwent a laparoscopic takedown of the prior endoscopic fundoplication and removal of all accessible polypropylene T-fasteners. All patients had esophageal salvage and have not required a reoperation. Anatomical findings included hiatal hernia (7), esophageal diverticulum (2), hiatal mesh erosion of esophagus (1), long-segment esophageal stricture (1), and normal anatomy (1). Remedial operations included laparoscopic explant of fasteners in all patients with conversion to fundoplication (7), resection/imbrication of esophageal diverticulum (2), Heller myotomy (1), and mesh explant and complex esophageal repair (1). Mean operative time was 177 minutes and median length of stay 3 days (range 2-13 days). At mean follow-up of 10.7 months (range 1-42 months), 7 patients had persistent complaints. Esophagogastroduodenoscopy was repeated in these 7 patients and was normal (n = 3), mild stenosis requiring dilation (n = 2), Los Angeles grade B esophagitis (n = 1), and Barrett's esophagus (n = 1). Anatomic distortion of the distal esophagus after TIF can be significant, making subsequent operations complex. After remedial surgery, few patients will continue to have troublesome symptoms such as dysphagia.

Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gelfond, M.; Rozen, P.; Gilat, T.

1982-11-01

The effects of sublingual isosorbide dinitrate (5 mg) and nifedipine (20 mg) were compared in 15 patients with achalasia. The parameters examined included the manometric measurement of the lower esophageal sphincter pressure, the radionuclide assessment of esophageal emptying and the clinical response. The mean basal lower esophageal sphincter pressure fell significantly after both drugs (p less than 0.01), with a maximum fall of 63.5% 10 min after receiving isosorbide dinitrate, but by only 46.7% 30 min after nifedipine. The esophageal radionuclide test meal retention was significantly less (p less than 0.01) only after receiving isosorbide dinitrate. The drug improved initialmore » esophageal emptying by its effect on the lower esophageal sphincter and by relieving the test meal hold-up noted to occur at the junction of the upper and midesophagus. Eight patients cleared their test meal within 10 min after isosorbide dinitrate administration while only two did so after nifedipine. Subjectively, 13 patients had their dysphagia relieved by isosorbide dinitrate and 8 by nifedipine. However, this relief was not confirmed in 4 patients by the radionuclide study and they, as well as the other 3 patients who did not respond to therapy, were referred to pneumatic dilatation. Side effects were more prominent after nitrates. Three of the patients are currently receiving nifedipine and 5 patients received isosorbide dinitrate therapy for 8-14 mo. The radionuclide test meal is currently the best way of objectively evaluating drug therapy in patients with achalasia. Isosorbide dinitrate is more effective than nifedipine in relieving their symptoms.« less

Alterations in hyolaryngeal elevation after esophageal anastomosis: A possible mechanism for airway aspiration.

PubMed

Demir, Numan; Arslan, Selen Serel; Yalcin, Sule; Karaduman, Ayşe; Tanyel, Feridun Cahit; Soyer, Tutku

2017-10-01

A prospective study was performed to evaluate anatomical alterations and hyolaryngeal elevation (HE) by videofluoroscopic swallowing study (VFSS) in patients with esophageal atresia-tracheoesophageal fistula (EA-TEF). Patients operated for EA-TEF were evaluated for age, sex, type of atresia and time to esophageal anastomosis. All patients were evaluated by videofluoroscopic swallowing study (VFSS). Penetration-Aspiration scale (PAS≥7 is considered as aspiration), distance between upper esophageal sphincter and 2nd cervical vertebrae (UES-C2) and hyolaryngeal elevation (HE) were evaluated by the same deglutitionist who was blind to the study. The results of EA-TEF patients were compared with healthy children. Eighteen patients with EA-TEF and 10 healthy controls were included. The median age was 16months (12-36m) in EA-TEF and 18months (13-51m) in controls. Male-to-female ratio was 5:4 and 4:1 respectively. 12 of cases were isolated-EA, 1 of them was EA-proximal TEF and 5 of the cases were EA-distal TEF. Half of the cases had primary EAN and others underwent delayed esophageal repair. Early oral feeding was also started in 9 patients (50%) whereas others had delayed oral feeding. VFSS showed aspiration in 27.7 (n=5) of cases (PAS≥7) in EA group. The median distance between UES-C2 was 3.04cm (min: 2.17-max: 3.94) in EA and 4.17cm (min: 3.45-max: 6.24cm) in controls. Median distance for HE was 0.37cm (min: 0.18-max: 1.1cm) in EA and 1.15 (min: 0.61-max: 1.06cm) in controls. The distance between UES-C2 was significantly lower than controls (p<0.05) and HE was decreased in EA-TEF without any statistical significance. Children with EA-TEF had shortened distance between airway and upper esophagus. HE may be inefficient to protect airway during deglutition. Anatomical alterations after EAN suggest that airway problems may be related with decreased HE in children with EATEF. Level II (Development of diagnostic criteria in a consecutive series of patients and a universally applied "gold standard"). Copyright © 2017 Elsevier Inc. All rights reserved.

Breast size, thoracic kyphosis & thoracic spine pain - association & relevance of bra fitting in post-menopausal women: a correlational study.

PubMed

Spencer, Linda; Briffa, Kathy

2013-07-01

Menopause would seem to exist as a period of accelerated changes for women and their upper torso mechanics. Whether these anthropometric changes reflect changes in pain states remains unclear. Plausible mechanisms of pain exist for the independent and combined effect of increasing breast size and thoracic kyphosis. Bra fit has the potential to change when the anthropometric measures (chest circumference and bust circumference) used to determine bra size change, such as postmenopausally.Identifying an association between breast size, thoracic kyphosis and thoracic spine pain in postmenopausal women and identifying the relevance of bra fit to this association may be of importance to the future management and education of post-menopausal women presenting clinically with thoracic spine pain. A cross-sectional study design. Fifty-one postmenopausal bra-wearing women were recruited. Measures included breast size (Triumph International), thoracic kyphosis (flexible curve), bra fitted (Y/N) and pain (Short Form McGill Pain Questionnaire) and tenderness on palpation (posteroanterior pressure testing). These measures were collected in one session at a physiotherapy clinic. The majority of the women in this study were overweight or obese and wearing an incorrect sized bra. Pain was significantly related to breast size, body weight and BMI at mid thoracic levels (T7-8). In contrast self-reported thoracic pain was not correlated with age or index of kyphosis (thoracic kyphosis). Women with thoracic pain were no more likely to have their bra professionally fitted whereas women with a higher BMI and larger breasts were more likely to have their bra professionally fitted. The findings of this study show that larger breasts and increased BMI are associated with thoracic pain in postmenopausal women. This is unrelated to thoracic kyphosis. Increasing breast size and how a bra is worn may have biomechanical implications for the loaded thoracic spine and surrounding musculature. Post-menopause women present with a spectrum of anthropometrical changes that have the potential to contribute to altered biomechanics and affect pain states in the thoracic spine.

Genetics Home Reference: familial thoracic aortic aneurysm and dissection

MedlinePlus

... and dissection ( familial TAAD ) involves problems with the aorta , which is the large blood vessel that distributes ... Familial TAAD affects the upper part of the aorta, near the heart. This part of the aorta ...

Portal hypertension associated with sickle cell disease.

PubMed

Kumar, Sunil; Joshi, R; Jain, A P

2007-01-01

We report a 12-year-old girl with sickle cell disease who presented with pain in abdomen, fever, joint pain and hematemesis. On examination she had mild jaundice and splenomegaly. Upper GI endoscopy showed esophageal varices. She was treated with variceal band ligation and is well on folic acid supplements and propranolol.

[Successful treatment of locally advanced squamous cell carcinoma of the esophagus by combination chemotherapy with 5-fluorouracil plus nedaplatin following tracheal stent tube placement-a case report].

PubMed

Nishimura, Junya; Kubo, Naoshi; Lee, Tomohiro; Shinto, Osamu; Sakurai, Katsunobu; Toyokawa, Takahiro; Tanaka, Hiroaki; Muguruma, Kazuya; Shibutani, Masatsune; Yamazoe, Sadaaki; Nagahara, Hisashi; Kimura, Kenjiro; Amano, Ryosuke; Ohtani, Hiroshi; Yashiro, Masakazu; Maeda, Kiyoshi; Ohira, Masaichi; Hirakawa, Kosei

2013-11-01

The patient was a 68-year-old man who complained of hoarseness and dyspnea. Upper gastrointestinal endoscopy revealed a type 3 tumor located in the middle thoracic esophagus at 30 cm from the incisor tooth that involved one-fourth of the circumference of the esophagus. Histopathological examination revealed moderately differentiated squamous cell carcinoma. Chest computed tomography( CT) revealed severe tracheal stenosis due to compression by a metastatic lymph node along the left recurrent laryngeal nerve. The patient was diagnosed as having cT4( 106recL-trachea), N2( 101L, 106recL, 106recR), M0, Stage IVa unresectable esophageal carcinoma. After insertion of a tracheal stent tube( spiral Z stent: diameter, 18 mm; length, 80 mm) to improve dyspnea, combination chemotherapy with 5-fluorouracil( 5-FU) plus nedaplatin was administered. Subsequent CT and endoscopy showed that the main tumor and the metastatic lymph node had significantly reduced in size and that complete response (CR) had been achieved. Thirty months after the initial treatment, the patient showed no sign of disease recurrence, after completion of 19 cycles of chemotherapy. The patient did not experience any severe adverse events. We report a case of a patient with locally advanced squamous cell carcinoma of the esophagus successfully treated with 5-FU/nedaplatin combination chemotherapy following tracheal stent tube placement.

[Late complications of liver cirrhosis - management of gastrointestinal bleeding in the presence of portal hypertension].

PubMed

Hejda, Václav

Cirrhosis is the end stage of progressive development of different liver diseases and is associated with significant morbidity and mortality rates. Cirrhosis is associated with a number of potential complications, in particular with development of portal hypertension. Portal hypertension with the production of ascites, hepatic and gastric varices bleeding in the upper part of the gastrointestinal tract, presents the breakpoint in the natural course of cirrhosis, and it is associated with a considerably worse prognosis of patients, with a dramatically increased risk of mortality. A major progress was reached during the past 10-20 years in diagnosing liver cirrhosis (including non-invasive methods), in primary prevention of the initial episode of upper gastrointestinal bleeding and in the therapy of acute bleeding due to modern pharmacotherapy, with regard to expanding possibilities of therapeutic endoscopy and relatively new options for management of acute bleeding (esophageal stents, TIPS and suchlike). However acute upper gastrointestinal bleeding associated with portal hypertension still presents a considerable risk of premature death (15-20 %). Early diagnosing and causal treatment of numerous liver diseases may lead to slowing or regression of fibrosis and cirrhosis and possibly even of the degree of portal hypertension and thereby also the risk of bleeding.Key words: cirrhosis - esophageal varices - treatment of bleeding - portal hypertension.

Conflicts in wound classification of neonatal operations.

PubMed

Vu, Lan T; Nobuhara, Kerilyn K; Lee, Hanmin; Farmer, Diana L

2009-06-01

This study sought to determine the reliability of wound classification guidelines when applied to neonatal operations. This study is a cross-sectional web-based survey of pediatric surgeons. From a random sample of 22 neonatal operations, participants classified each operation as "clean," "clean-contaminated," "contaminated," or "dirty or infected," and specified duration of perioperative antibiotics as "none," "single preoperative," "24 hours," or ">24 hours." Unweighted kappa score was calculated to estimate interrater reliability. Overall interrater reliability for wound classification was poor (kappa = 0.30). The following operations were classified as clean: pyloromyotomy, resection of sequestration, resection of sacrococcygeal teratoma, oophorectomy, and immediate repair of omphalocele; as clean-contaminated: Ladd procedure, bowel resection for midgut volvulus and meconium peritonitis, fistula ligation of tracheoesophageal fistula, primary esophageal anastomosis of esophageal atresia, thoracic lobectomy, staged closure of gastroschisis, delayed repair and primary closure of omphalocele, perineal anoplasty and diverting colostomy for imperforate anus, anal pull-through for Hirschsprung disease, and colostomy closure; and as dirty: perforated necrotizing enterocolitis. There is poor consensus on how neonatal operations are classified based on contamination. An improved classification system will provide more accurate risk assessment for development of surgical site infections and identify neonates who would benefit from antibiotic prophylaxis.

Video-Assisted Thoracic Sympathectomy for Hyperhidrosis.

PubMed

Milanez de Campos, Jose Ribas; Kauffman, Paulo; Gomes, Oswaldo; Wolosker, Nelson

2016-08-01

By the 1980s, endoscopy was in use by some groups in sympathetic denervation of the upper limbs with vascular indications. Low morbidity, cosmetic results, reduction in the incidence of Horner syndrome, and the shortened time in hospital made video-assisted thoracic sympathectomy (VATS) better accepted by those undergoing treatment for hyperhidrosis. Over the last 25 years, this surgical procedure has become routine in the treatment of hyperhidrosis, leading to a significant increase in the number of papers on the subject in the literature. Copyright © 2016 Elsevier Inc. All rights reserved.

[Emergency radiology in acute traumatic rupture of the thoracic aorta. Detection of atypical forms. Apropos of 52 cases].

PubMed

Pinet, F; Vuilliez, J G; Gourdol, Y; Celard, P; Villard, J; Cognet, J B

1983-10-27

Fifty-two traumatic ruptures of the thoracic aorta were hospitalized between 1972 and 1982, with 46 angiographies. The most significant clinical sign of aortic rupture is the difference in blood pressure between the upper and lower limbs. The frequency of chest film findings is discussed. The aortography by arterial route must be performed at the sligh test suspicion, sometimes without radiographic signs, to establish diagnostics and detect associated lesions (dissection) and unusual types (low localization, multiple localization, localized rupture of the intima.

Congenital pseudarthrosis of the clavicle causing thoracic outlet syndrome

PubMed Central

Watson, Hannah Isabella; Hopper, Graeme Philip; Kovacs, Peter

2013-01-01

A 7-year-old girl presented with an asymptomatic right supraclavicular swelling. Radiographs were interpreted as showing a non-union of her clavicle. No treatment was given at this time. However, she represented 12 years later with right upper limb pain and altered sensation. Examination revealed a positive Allen's test on the right. Repeat radiographs demonstrated a pseudarthrosis of the clavicle, associated with a secondary complication of thoracic outlet syndrome with vascular and neurological complications present. Non-operative management failed to relieve her symptoms. Operative intervention successfully treated her symptoms. PMID:23975919

Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis.

PubMed

Markar, Sheraz R; Arya, Shobhit; Karthikesalingam, Alan; Hanna, George B

2013-12-01

Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity. Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor. No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61-13.9; P = 0.005). A tailored surgical approach to the patient's physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.

[Indications, diagnoses and quality markers in upper and lower endoscopies in 2010 and 2011 at the 1st Department of Medicine, Semmelweis University, Budapest].

PubMed

Gönczi, Lóránt; Kürti, Zsuzsanna; Golovics, Petra; Végh, Zsuzsanna; Lovász, Barbara; Dorkó, Andrea; Seres, Anna; Sümegi, Liza; Menyhárt, Orsolya; Kiss, Lajos; Papp, János; Gecse, Krisztina; Lakatos, Péter László

2016-12-01

The aim was to assess the incidence of endoscopic findings based on the indication of the procedures in upper/lower endoscopies, and measuring quality indicators of colonoscopies at the 1st Department of Medicine, Semmelweis University, Budapest. Data of 2987 patients (male/female:1361/1626, mean age: 60.7 years(y), SD: 16.7y) between 01.01.2010 and 31.12.2011 were analyzed. Both inpatient and outpatient records were collected. Incidence of peptic ulcer disease, esophageal varices, gastric polyps and gastric cancer were 10.8%, 4.5%, 6.1%, 2.9% in upper endoscopies, respectively. In colonoscopies colorectal polyps, diverticulosis, colorectal cancer and IBD were found in 29.9%, 22.4%, 6.9%, 9.7%, respectively. In patients having upper endoscopy with GI bleeding indication, older age (p<0.001), male gender (p<0.001, OR: 1.64), acenocoumarol/heparin use (p<0,001, peptic ulcers and esophageal varices were more frequent (p<0.001, OR: 2.83 and p<0.001, OR: 2.79), while in colonoscopies colorectal cancer had higher incidence (p<0.001, OR:3.27). 81% of colonoscopies were complete. Causes of incomplete procedures were ineffective bowel preparation (38.2%), technical difficulties (25.1%) and strictures (20.5%). The endoscopic findings and quality indicators (adenoma detection rate, coecal intubation rate) were in line with that reported in published series. Orv. Hetil., 2016, 157(52), 2074-2081.

Update on Functional Heartburn

PubMed Central

Yamasaki, Takahisa; O’Neil, Jessica

2017-01-01

The definition of functional heartburn has been refined over the years. It is currently described, based upon Rome IV criteria, as typical heartburn symptoms in the presence of normal upper endoscopy findings (including normal biopsies), normal esophageal pH testing, and a negative association between symptoms and reflux events. Functional heartburn is very common, affecting women more than men, and with reflux hypersensitivity makes up the majority of heartburn patients who fail twice-daily proton pump inhibitor therapy. These disorders overlap with other functional gastrointestinal disorders and are often accompanied by psychological comorbidities. Diagnosis is made by using endoscopy with esophageal biopsies, wireless pH capsule, pH-impedance monitoring, and high-resolution esophageal manometry. Additional diagnostic tools that may be of value include magnification endoscopy, chromoendoscopy, narrow-band imaging, autofluorescence imaging, mucosal impedance, impedance baseline values, and histopathology scores. Functional heartburn is primarily treated with neuromodulators. Psychological intervention and complementary and alternative medicine may also play important roles in the treatment of these patients. PMID:29339948

Identifying Minimal Changes in Nonerosive Reflux Disease: Is the Pay Worth the Labor?

PubMed

Gabbard, Scott L; Fass, Ronnie; Maradey-Romero, Carla; Gingold Belfer, Rachel; Dickman, Ram

2016-01-01

Gastroesophageal reflux disease has a variable presentation on upper endoscopy. Gastroesophageal reflux disease can be divided into 3 endoscopic categories: Barrett's esophagus, erosive esophagitis, and normal mucosa/nonerosive reflux disease (NERD). Each of these phenotypes behave in a distinct manner, in regards to symptom response to treatment, and risk of development of complications such as esophageal adenocarcinoma. Recently, it has been proposed to further differentiate NERD into 2 categories: those with and those without "minimal changes." These minimal changes include endoscopic abnormalities, such as villous mucosal surface, mucosal islands, microerosions, and increased vascularity at the squamocolumnar junction. Although some studies have shown that patients with minimal changes may have higher rates of esophageal acid exposure compared with those without minimal changes, it is currently unclear if these patients behave differently than those currently categorized as having NERD. The clinical utility of identifying these lesions should be weighed against the cost of the requisite equipment and the additional time required for diagnosis, compared with conventional white light endoscopy.

Phase II Study of Chemoradiotherapy With 5-Fluorouracil and Cisplatin for Stage II-III Esophageal Squamous Cell Carcinoma: JCOG Trial (JCOG 9906)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kato, Ken, E-mail: kenkato@ncc.go.jp; Muro, Kei; Department of Clinical Oncology, Aichi Cancer Center Hospital, Nagoya, Aichi

Purpose: In this Phase II study, we evaluated the efficacy and toxicity of chemoradiotherapy (CRT) with cisplatin (CDDP) and 5-fluorouracil (5-FU) for Stage II-III esophageal squamous cell carcinoma (ESCC). Patients and Methods: Patients with clinical Stage II-III (T1N1M0 or T2-3N0-1M0) thoracic ESCC were enrolled between April 2000 and March 2002. Chemotherapy comprised two courses of protracted infusion of 5-FU (400 mg/m{sup 2}/day) on Days 1-5 and 8-12, and 2-h infusion of CDDP (40 mg/m{sup 2}) on Days 1 and 8; this regimen was repeated every 5 weeks. Concurrent radiotherapy involved 60-Gy irradiation (30 fractions) for 8 weeks with a 2-weekmore » break. Responders received two courses of 5-FU (800 mg/m{sup 2}/day) on Days 1-5 and CDDP (80 mg/m{sup 2}) on Day 1. Final analysis was conducted in March 2007. Survival and late toxicities were monitored for 5 years. Results: The characteristics of the 76 patients enrolled were as follows: median age, 61 years; male/female, 68/8; performance status 0/1, 59/17 patients; Stage IIA/IIB/III, 26/12/38 patients. Of the 74 eligible patients, 46 (62.2%) achieved complete response. Median survival time was 29 months, with 3- and 5-year survival rates of 44.7% and 36.8%, respectively. Acute toxicities included Grade 3/4 esophagitis (17%), nausea (17%), hyponatremia (16%), and infection without neutropenia (12%). Late toxicities comprised Grade 3/4 esophagitis (13%), pericardial (16%) and pleural (9%) effusion, and radiation pneumonitis (4%), causing 4 deaths. Conclusions: CRT is effective for Stage II-III ESCC with manageable acute toxicities and can provide a nonsurgical treatment option. However, further improvement is required for reduction in late toxicity.« less

Role of Adjuvant Treatment in Esophageal Cancer With Incidental Pathologic Node Positivity.

PubMed

Gao, Sarah J; Park, Henry S; Corso, Christopher D; Rutter, Charles E; Kim, Anthony W; Johung, Kimberly L

2017-07-01

The optimal adjuvant treatment for cT1-2 N0 esophageal cancer patients found to have pathologic nodal involvement after an upfront operation is unclear. This study investigated the effects of postoperative chemotherapy and chemoradiation therapy on overall survival in cT1-2 N0 patients with incidental pN + disease stratified by margin status. We identified cT1-2 N0 M0 esophageal carcinoma patients from 2004 to 2012 from the National Cancer Data Base. Patients were categorized as having received surgical resection alone, surgical resection followed by chemotherapy (S+CT), and surgical resection followed by concurrent chemoradiation therapy (S+CRT). Subset analyses were conducted on margin-negative and margin-positive patients. Overall survival was compared by Kaplan-Meier estimation, the log-rank test, and multivariable Cox regression analysis. Among 443 patients, 52.6% received surgical resection alone, 18.7% received S+CT, and 28.6% received S+CRT. Significantly more adenocarcinoma patients received adjuvant treatment (50.8%) than squamous cell carcinoma patients (27.7%, p = 0.001). On multivariable analysis, S+CT (hazard ratio, 0.64; 95% confidence interval, 0.45 to 0.91; p = 0.014) and S+CRT (hazard ratio, 0.73; 95% confidence interval,. 0.55 to 0.98; p = 0.038) both were associated with significantly increased overall survival. These findings persisted among margin-negative patients. However, in margin-positive patients, S+CRT (hazard ratio, 0.29; p = 0.002) was the only treatment arm that was associated with significantly improved survival compared with surgical resection alone. Among cT1-2 N0 pN + esophageal cancer patients, adjuvant chemotherapy may be sufficient for margin-negative patients, whereas adjuvant chemoradiation therapy appears necessary for margin-positive patients. Further prospective studies are needed to confirm the results. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Upper gastrointestinal bleeding following transcatheter aortic valve replacement: A retrospective analysis.

PubMed

Stanger, Dylan E; Abdulla, Alym H; Wong, Frank T; Alipour, Sina; Bressler, Brian L; Wood, David A; Webb, John G

2017-08-01

The aim of this study was to identify the incidence of upper gastrointestinal bleeding (UGIB) in the postprocedural period following transcatheter aortic valve replacement (TAVR). As TAVR moves into intermediate- and low-risk patients, it has become increasingly important to understand its extracardiac complications. The patient population undergoing TAVR have clinical and demographic characteristics that place them at significant risk of UGIB. Practical aspects of TAVR, including use of antithrombotic therapy, further increase risk of UGIB. A retrospective single-center evaluation of 841 patients who underwent TAVR between January 2005 and August 2014 was performed in conjunction with analysis of referral patterns to the gastroenterology service for UGIB at the same site. The overall risk of UGIB following TAVR was found to be 2.0% (n = 17/841). Additionally, the risk of UGIB in patients receiving triple antithrombotic therapy was found to be 10-fold greater than patients not receiving triple antithrombotic therapy (11.8% vs 1.0%). Endoscopy findings demonstrated five high-risk esophageal lesions including erosive esophageal ulcers, visible vessels at the GE junction, erosions at distal esophagus, and an actively bleeding esophageal ring that had been intubated through by the transesophageal echocardiography (TEE) probe. This large cohort study demonstrates that TAVR is associated with a moderate risk of severe UGIB. The results of this study suggest that patients on triple antithrombotic therapy are at highest risk for severe UGIB. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

The effect of short-term upper thoracic self-mobilization using a Kaltenborn wedge on pain and cervical dysfunction in patients with neck pain.

PubMed

Oh, Hyung-Taek; Hwangbo, Gak

2018-04-01

[Purpose] The aim of this study was to determine the effect of short-term self-joint mobilization of the upper spine using a Kaltenborn wedge on the pain and cervical dysfunction of patients with neck pain. [Subjects and Methods] Twenty-seven patients with neck pain were divided into two groups; the self-mobilization group (SMG, n=13) and the self-stretching group (SSG, n=14). The SMG performed upper thoracic self-mobilization and the SSG performed self-stretching exercises as a short-term intervention for a week. To assess the degree of neck pain, the visual analog scale (VAS) was utilized, and to measure the joint range of motion at the flexion-extension, it was compared and analyzed by using the goniometer. [Results] Both SMG and SSG show a significant decrease in the visual analog scale and a significant increase in joint range of motion within the group. In the comparison of groups, there was no significant difference, but it indicated effects on improving the range of motion of extension in SMG. [Conclusion] Self-mobilization of the upper spine, using a Kaltenborn wedge, was useful in alleviating pain in and dysfunction of the cervical spine, and in particular, in improving cervical spine extension in this study.

Intraoperative recurrent laryngeal nerve monitoring: a useful method for patients with esophageal cancer.

PubMed

Zhong, D; Zhou, Y; Li, Y; Wang, Y; Zhou, W; Cheng, Q; Chen, L; Zhao, J; Li, X; Yan, X

2014-07-01

It is well accepted that recurrent laryngeal nerve paralysis is a severe complication of esophagectomy or lymphadenectomy performed adjacent to the recurrent laryngeal nerves. Herein, determination of the effectiveness of implementing continuous recurrent laryngeal nerve monitoring to reduce the incidence of recurrent laryngeal nerve paralysis after esophagectomy was sought. A total of 115 patients diagnosed with esophageal cancer were enrolled in the thoracic section of the Tangdu Hospital of the Fourth Military Medical University from April 2008 to April 2009. Clinical parameters of patients, the morbidity, and the mortality following esophageal resection were recorded and compared. After the surgery, a 2-year follow up was completed. It was found that recurrent laryngeal nerve paralysis and postoperative pneumonia were more frequently diagnosed in the patients that did not receive continuous recurrent laryngeal nerve monitoring (6/61 vs. 0/54). Furthermore, positive mediastinal lymph nodes (P = 0.015), total mediastinal lymph nodes (P < 0.001), positive total lymph nodes (P = 0.027), and total lymph nodes (P < 0.001) were more often surgically removed in the patients with continuous recurrent laryngeal nerve monitoring. These patients also had a higher 2-year survival rate (P = 0.038) after surgery. It was concluded that continuous intraoperative recurrent laryngeal nerve monitoring is technically safe and effectively identifies the recurrent laryngeal nerves. This may be a helpful method for decreasing the incidence of recurrent laryngeal nerve paralysis and postoperative pneumonia, and for improving the efficiency of lymphadenectomy. © 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Spinal fusion limits upper body range of motion during gait without inducing compensatory mechanisms in adolescent idiopathic scoliosis patients.

PubMed

Holewijn, R M; Kingma, I; de Kleuver, M; Schimmel, J J P; Keijsers, N L W

2017-09-01

Previous studies show a limited alteration of gait at normal walking speed after spinal fusion surgery for adolescent idiopathic scoliosis (AIS), despite the presumed essential role of spinal mobility during gait. This study analyses how spinal fusion affects gait at more challenging walking speeds. More specifically, we investigated whether thoracic-pelvic rotations are reduced to a larger extent at higher gait speeds and whether compensatory mechanisms above and below the stiffened spine are present. 18 AIS patients underwent gait analysis at increasing walking speeds (0.45 to 2.22m/s) before and after spinal fusion. The range of motion (ROM) of the upper (thorax, thoracic-pelvic and pelvis) and lower body (hip, knee and ankle) was determined in all three planes. Spatiotemporal parameters of interest were stride length and cadence. Spinal fusion diminished transverse plane thoracic-pelvic ROM and this difference was more explicit at higher walking speeds. Transversal pelvis ROM was also decreased but this effect was not affected by speed. Lower body ROM, step length and cadence remained unaffected. Despite the reduction of upper body ROM after spine surgery during high speed gait, no altered spatiotemporal parameters or increased compensatory ROM above or below the fusion (i.e. in the shoulder girdle or lower extremities) was identified. Thus, it remains unclear how patients can cope so well with such major surgery. Future studies should focus on analyzing the kinematics of individual spinal levels above and below the fusion during gait to investigate possible compensatory mechanisms within the spine. Copyright © 2017 Elsevier B.V. All rights reserved.

A Safe and Reproducible Anastomotic Technique for Minimally Invasive Ivor Lewis Esophagectomy: The Circular Stapled Anastomosis with the Transoral Anvil

PubMed Central

Campos, Guilherme M; Jablons, David; Brown, Lisa M; Ramirez, René M; Rabl, Charlotte; Theodore, Pierre

2010-01-01

Objectives In expert hands, the intra-thoracic esophago-gastric anastamosis usually provides a low rate of strictures and leaks. However, anastomoses can be technically challenging and time consuming when minimally invasive techniques are used. We present our preliminary results of a standardized 25mm/4.8mm circular stapled anastomosis using a trans-orally placed anvil. Materials and Methods We evaluated a prospective cohort of 37 consecutive patients offered minimally invasive Ivor Lewis Esophagectomy at a tertiary referral center. The esophagogastric anastomosis was created using a 25mm anvil (Orvil, Autosuture, Norwalk, CT) passed trans-orally, in a tilted position, and connected to a 90cm long PVC delivery tube through an opening in the esophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (EEA XL 25mm with 4.8mm Staples, Autosuture, Norwalk, CT) inserted into the gastric conduit. Primary outcomes were leak and stricture rates. Results Thirty-seven patients (mean age 65 yrs) with distal esophageal adenocarcinoma (n=29), squamous cell cancer (n=5), or high-grade dysplasia in Barrett's Esophagus (n=3) underwent an Ivor Lewis Esophagectomy between October 2007 and August 2009. The abdominal portion of the operation was completed laparoscopically in 30 patients (81.1%). The thoracic portion was done using a muscle sparing mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 patients (37.8%). There were no intra-operative technical failures of the anastomosis or deaths. Five patients had strictures (13.5%) and all were successfully treated with endoscopic dilations. One patient had an anastomotic leak (2.7%) that was successfully treated by re-operation and endoscopic stenting of the anastomosis. Discussion The circular stapled anastomosis with the transoral anvil allows for an efficient, safe and reproducible anastomosis. This straightforward technique is particularly suited to the completely minimally invasive Ivor Lewis Esophagectomy. PMID:20153660

Poster — Thur Eve — 36: Implementation of constant dose rate and gantry speed arc therapy(CDR-CAS-IMAT) for thoracic esophageal carcinoma on Varian 23EX

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zhang, Ruohui; Department of Medical Physics, Medical Faculty Mannheim, Heidelberg University; Fan, Xiaomei

2014-08-15

Objective: The purpose of this study is to propose an alternative planning approach for VMAT using constant dose rate and gantry speed arc therapy(CDR-CAS-IMAT) implementation on conventional Linac Varian 23EX and used IMRT as a benchmark to evaluate the performance. Methods and materials: Eighteen patients with thoracic esophageal carcinoma who were previously treated with IMRT on Varian 23EX were retrospectively planned for CDR-CAS-IMAT plans. Dose prescription was set to 60 Gy to PTVs in 30 fractions. The planning objectives for PTVs and OAR were corresponding with the IMRT plans. Dose to the PTVs and OAR were compared to IMRT withmore » respect to plan quality, MU, treatment time and delivery accuracy. Results: CDR-CAS-IMAT plans led to equivalent or superior plan quality as compared to IMRT, PTV's CI relative increased 16.2%, while small deviations were observed on minimum dose for PTV. Volumes in the cord receiving 40Gy were increased from 3.6% with IMRT to 7.0%. Treatment times were reduced significantly with CDR-CAS-IMAT(mean 85.7s vs. 232.1s, p < .05), however, MU increased by a factor of 1.3 and lung V10/5/3.5/aver were relative increase 6.7%,12%,17.9%,4.2%, respectively. And increased the E-P low dose area volume decreased the hight dose area. There were no significant difference in Delta4 measurements results between both planning techniques. Conclusion: CDR-CAS-IMAT plans can be implemented smoothly and quickly into a busy cancer center, which improved PTV CI and reduces treatment time but increased the MU and low dose irradiated area. An evaluation of weight loss must be performed during treatment for CDR-CAS-IMAT patients.« less

Low Prevalence of Biopsy-Proven Eosinophilic Esophagitis in Patients with Esophageal Food Impaction in Mexican Population.

PubMed

García-Compeán, Diego; González-González, José A; Duran-Castro, José J; Herrera-Quiñones, Gilberto; Borjas-Almaguer, Omar D; Maldonado-Garza, Héctor J

2018-06-01

Eosinophilic esophagitis (EoE) is the most common cause of dysphagia and esophageal food impaction (EFI) in the USA, Western Europe, and Australia. In Mexico, the uncomplicated form of this disease is infrequent, and prevalence in patients with EFI is unknown. To determine the prevalence and causes of EFI, endoscopic and therapeutic aspects, and establish the prevalence of biopsy-proven EoE in patients with EFI. Diagnostic upper gastrointestinal endoscopy reports from January 2011 to December 2016 were retrospectively reviewed. Patients with therapeutic procedures, gastrointestinal hemorrhage, or non-food foreign body impaction were excluded. The number of patients with EFI was determined. Additionally, patients with esophageal biopsy were retained for EoE prevalence calculation. The diagnosis of EoE was defined with the presence of eosinophil infiltration count ≥ 15/high-power field with or without typical endoscopic abnormalities. A total of 4700 reports of the same number of patients were selected; 2209 were males (47%) with a mean age of 57.6 ± 12.3 years (range 14-93). We identified 36 patients with EFI (0.76, 95% CI 0.51-1.01), 16 males (44.4%) with a mean age of 54.9 ± 19.7 (range 22-92). Esophageal biopsies were obtained in 17/36 (47.2%) cases. The diagnosis of EoE was confirmed in 2 patients (11.7%). Peptic stenosis was the most frequent cause of EFI. EoE is an infrequent cause of EFI in the Mexican population (11.7%). EoE had the lowest prevalence compared to that reported in Caucasian populations. The prevalence of EFI was also low.