Safe and Timely Removal of a Fractured Tracheostomy Tube with the Use of a Controlled Radial Expansion Balloon.

Controlled radial expansion (CRE) balloon dilators are traditionally used to dilate esophageal strictures during an esophagogastroduodenoscopy (EGD). EndoFLIP is a diagnostic tool used during an EGD to measure important parameters of the gastrointestinal lumen, capable of assessing treatment before and after dilation. EsoFLIP is a related device that combines a balloon dilator with high-resolution impedance planimetry to provide some of the luminal parameters in real time during dilation. We sought to compare procedure time, fluoroscopy time, and safety profile of esophageal dilation using either CRE balloon dilation combined with EndoFLIP (E + CRE) versus EsoFLIP alone. A single-center retrospective review was performed to identify patients ≤ 21years of age who underwent an EGD with biopsy and esophageal stricture dilation using E + CRE or EsoFLIP between October 2017 and May 2022. Twenty-nine EGDs with esophageal stricture dilation were performed in 23 patients (19 E + CRE and 10 EsoFLIP). The two groups did not differ in age, gender, race, chief complaint, type of esophageal stricture, or history of prior gastrointestinal procedures (all p > 0.05). The most common medical history in the E + CRE and EsoFLIP groups were eosinophilic esophagitis and epidermolysis bullosa, respectively. Median procedures times were shorter in the EsoFLIP cohort compared to E + CRE balloon dilation (40.5min [IQR 23-57min] for the EsoFLIP group; 64min [IQR 51-77min] for the E + CRE group; p < 0.01). Median fluoroscopy times were also shorter for patients who underwent EsoFLIP (0.16min [IQR 0-0.30min] for EsoFLIP dilation; 0.30min [IQR 0.23-0.55] for the E + CRE group; p = 0.003). There were no complications or unplanned hospitalizations in either group. EsoFLIP dilation of esophageal strictures was faster and required less fluoroscopy than CRE balloon dilation combined with EndoFLIP in children, while being equally as safe. Prospective studies are needed to further compare the two modalities.

Patient: Female, 19-year-old Final Diagnosis: Fractured tracheostomy tube Symptoms: Airway obstruction Medication:— Clinical Procedure: — Specialty: Otolaryngology Objective: Unusual clinical course Background:A wide variety of emergency scenarios associated with tracheostomy tubes have been reported in patients with complex airway disease. Fracture of a tracheostomy tube is a rare complication with a potential for catastrophic outcome. The aim of this case report is to present clinical features and management of airway compromise due to a fractured tracheostomy tube in a patient with subglottic and tracheal stenosis.Case Report:A 19-year-old woman with a history of chronic lung disease, developmental delay, subglottic stenosis, and tracheal stenosis presented to the Emergency Department after her mother noticed that the tracheostomy tube was broken at the junction of the cannula and neck plate. Upon arrival, the patient was stable and the stoma site had a pinpoint-size opening. A chest X-ray revealed a dislodged tracheostomy tube with the shaft’s convexity ventrally oriented in the trachea. The stoma was dilated to allow passage of a 2.5-mm flexible laryngo-scope into the trachea. The fractured tracheostomy tube lodged in the trachea distal to the stoma and proximal to the carina. The fractured tracheostomy tube migrated to the suprastomal site at the time of repeat tracheoscopy under general anesthesia. The fractured tracheostomy tube was removed transorally through the tracheal and subglottic stenosis with the use of optical forceps and rigid bronchoscope.Conclusions:Prompt recognition and management of a fractured tracheostomy tube is critical to prevent morbidity and mortality. Caregivers and healthcare providers must be prudent about proper tracheostomy tube care, potential manufacturing defects, and monitoring the condition of tracheostomy tubes.

Background: Central airway obstruction can arise from both benign and malignant conditions, as well as from congenital or acquired causes. One common cause of acquired central airway obstruction is post-intubation subglottic and tracheal stenosis. Presentations can vary widely, from asymptomatic cases to symptoms such as difficulty clearing secretions and dyspnea on exertion due to airway narrowing. Critical tracheal or subglottic stenosis may present with stridor. Bronchoscopy is the primary diagnostic tool for assessing the type and severity of stenosis in the subglottic and tracheal regions. Controlled radial expansion (CRE) balloon bronchoplasty is a cost-effective procedure that can be performed either under sedation in a bronchoscopy suite or under general anesthesia in an operating room. This technique provides temporary relief and can be repeated, allowing time for more definitive or complex treatments. Materials and Methods: This case series study was conducted in the Department of Pulmonary Medicine in collaboration with the Department of Ear, Nose, and Throat at SCB Medical College and Hospital, Cuttack, Odisha, India, from January 2018 to July 2021. Six patients with subglottic and tracheal stenosis confirmed via fiber-optic bronchoscopy, all of whom had previously undergone tracheostomy, were included. Balloon bronchoplasty was performed using rigid laryngoscopy under general anesthesia with a CRE balloon (Boston Scientific), an Alliance-II integrated inflation device, a guide wire, and an Alliance inflation syringe. A follow-up fiber-optic bronchoscopy was conducted 1 month later. If an optimal tracheal diameter of 8–10 mm was not achieved, the patient underwent an additional CRE balloon bronchoplasty session. Results: This case series evaluated six patients with subglottic or tracheal stenosis. CRE balloon bronchoplasty was completed in three patients, with no recurrence of stenosis. However, the remaining three patients did not achieve an optimal tracheal lumen with CRE balloon bronchoplasty and were referred for tracheal reconstruction surgery. Discussion: CRE balloon bronchoplasty is an effective treatment for restoring optimal tracheal lumen in simple benign subglottic or tracheal stenosis cases. Patients with more complex stenosis should be considered for earlier referral to tracheal reconstruction surgery. Conclusion: CRE balloon bronchoplasty is a safe, straightforward, efficient, and repeatable procedure for relieving central airway obstruction due to benign subglottic and tracheal stenosis. It can serve as either a standalone treatment or an adjunct to other therapies for managing benign subglottic and tracheal stenosis.

The purpose of this study was to investigate the safety and clinical effectiveness of a controlled radial expansion (CRE) balloon catheter in dilating benign esophageal strictures, and to assess factors influencing the effectiveness of this procedure. From February 2000 to June 2002, 25 patients with documented benign esophageal strictures at our hospital were enrolled and treated with CRE balloon dilation. There were 17 men and eight women, with ages ranging from 30 to 82 years. The average age of the enrolled patients was 56.1 years. All of the strictures were dilated using CRE dilators under direct visualization, without fluoroscopic monitoring. The dilation diameters were planned in series up to 15 mm using a "rule of three". If dysphagia and esophageal strictures recurred during the clinical follow-up after completion of a series of dilations, additional dilation was carried out until symptomatic relief was achieved. Effective treatment was defined as the ability of patients with or without repeated dilations to maintain a solid or semisolid diet for more than 12 months. Depending on the effectiveness and duration of treatment, the patients were divided into three groups: group A, the successful group in which the initial series of dilations was effective without the need for any additional dilation for recurrent strictures or dysphagia; group B, the relapse group, in which the initial series of dilations was effective, but additional dilations were needed due to recurrent strictures or dysphagia; and group C, the group in which the initial series of dilations failed or consecutive dilations could not be carried out due to intolerance. The 25 patients received a total of 95 sessions of dilation (3.8 +/- 1.2 sessions per patient). There were 11 patients in group A, 11 patients in group B, and three patients in group C. The median follow-up period was 16.5 months (range 12 - 32 months). The number of initial dilations required to achieve symptomatic relief showed a negative correlation with the pre-dilation diameter of the strictures ( r = - 0.92, P < 0.01). Thinner strictures required more dilations before symptomatic relief was achieved. In addition, the stricture length in group B (5.4 +/- 3.4 cm) was significantly longer than that in group A (2.6 +/- 1.1 cm) ( P = 0.009). The overall success rate was 88 % (22 of 25), including 100 % in the 21 patients with a stricture length of less than 8 cm and 25 % in the four patients with a stricture length more than 8 cm ( P = 0.02). CRE balloon dilation without fluoroscopy is an effective treatment for esophageal strictures less than 8 cm in length. Pre-dilation diameter and stricture length are factors that influence the numbers of dilations required and the need for additional dilations.

To assess the efficacy and safety of dilatation of the papilla of Vater with large balloons for the treatment of choledocolithiasis in patients with difficult or risky extraction due to stone characteristics or peripapillary anatomy. Prospective. This study includes 93 patients in whom large-balloon dilation was performed between June 2005 and January 2008. Patients had multiple large stones, tapered distal CBD (common bile duct), peri-/intra-diverticular papilla, and previous sphincterotomy or Billroth-II surgery. A controlled radial expansion (CRE) balloon with a diameter range of 12-20 mm was used. Stone removal was achieved in a single session in all patients (100 %). Most procedures (86%) did not require an extended exploration time. Mechanical lithotripsy was needed in 3.2 % of cases. There were two mild complications (2.1%). Hyperamilasemia was detected in 16% of patients. Papillary dilation with a large balloon is an effective, safe, and easy technique for the retrieval of difficult common bile-duct stones. The procedure neither adds time to the exploration, nor increases complications, and obviates the need for mechanical lithotripsy in a majority of patients.

IntroductionExtraction of large (>1 cm) CBD stones at ERCP is often difficult despite adequate sphincterotomy. Failure of extraction of stones warrants repeat ERCPs and also referral to advanced techniques such...

INTRODUCTION: Plummer-Vinson syndrome (PVS) is a rare disease that presents with iron deficiency anemia, dysphagia, and esophageal webs. It usually occurs in middle aged women of Caucasian ethnicity and increases the risk for esophageal cancer. Prevalence of PVS has decreased due to early detection of iron deficiency and repletion of iron stores. While PVS has also been commonly described in children and adolescents, it is seldom reported in the elderly population. CASE DESCRIPTION/METHODS: An 88-year-old female with a history of mild cognitive impairment, allergic rhinitis, and GERD presented with dysphagia to solid foods along with a decreased appetite and a ten pound weight loss during the past one year. Physical exam showed bilateral mild erythema of the angle of the mouth. Routine lab work revealed a normal WBC count, platelet count, basic metabolic profile but did have iron deficiency anemia (Hb 11.9 g/dL, iron saturation 11% and ferritin of 8 ng/ml). She was prescribed 324 mg daily dose of ferrous gluconate. Three months later, she presented to the ER with food impaction and underwent EGD to remove a food bolus in the cervical esophagus. Localized erythematous mucosa with erosions was noted in the esophagus at the site of food impaction. Normal oropharyngeal function was found during speech pathology evaluation while a video fluoroscopic barium swallow showed localized narrowing in the cervical esophagus along with transient pill retention (Image 1). New labs indicated good response to iron replacement (hemoglobin 14 g/dL, iron saturation 23%, and ferritin of 26 ng/ml). An EGD was repeated three weeks later which demonstrated normal appearance of pharynx and upper esophageal sphincter. Upon careful inspection, an upper esophageal web, 18 cm from the incisors, was noted and dilated using controlled radial expansion (CRE) balloon (Image 2). Biopsy was taken from the upper and lower esophagus which revealed normal mucosa. On follow up, patient reported resolution of difficulty swallowing. DISCUSSION: Dysphagia is reported in up to 10% of the elderly population. It commonly causes malnutrition, and is associated with increased mortality. The usual etiologies include cognitive dysfunction, neurological diseases and/or esophageal disorders. To our knowledge, this is the third case of PVS related dysphagia reported in an octogenarian in the literature. Iron replacement can help resolve dysphagia in PVS but, occasionally, dilation of esophageal webs may be required.Image 1.: Video fluoroscopic barium swallow shows cervical esophagus narrowing (arrow).Image 2.: Esophageal web located 18 cm from the incisors (A). CRE balloon dilation of esophageal web (B) resulting in mucosal tear and disruption on the web (C &D).

Comparison of Transgastric Access Techniques for Natural Orifice Translumenal Endoscopic Surgery (NOTES)

A 14-month-old male presented to the emergency department with a 4-day history of vomiting after the intake of liquids or solids. During the admission, imaging studies revealed an esophageal web, a form of congenital esophageal stenosis. He was treated with a combination of Endoluminal Functional Lumen Imaging Probe (EndoFLIP) and controlled radial expansion (CRE) balloon dilation, followed by EndoFLIP and EsoFLIP dilation 1 month later. The patient’s vomiting resolved after treatment, and he was able to gain weight. This report describes one of the first cases of applying EndoFLIP and EsoFLIP to treat an esophageal web in a pediatric patient.

Endoscopic Balloon Dilatation Should Be the Initial Therapy of Choice in Benign Ulcer Related Gastric Outlet Obstruction

Acute Variceal Bleeding (AVB) is a life-threatening complication of portal hypertension that necessitates prompt and effective intervention. Endoscopic Variceal Ligation (EVL) is the primary treatment modality; however, anatomical variations, such as oesophageal webs, can impede the procedure. The present report describes a 40-year-old female patient presenting with haematemesis and melena. Endoscopy confirmed active variceal bleeding, but the advancement of an endoscope equipped with a band ligator was obstructed by a cricopharyngeal web, rendering EVL unfeasible. Haemostasis was initially achieved using sclerotherapy with sodium tetradecyl sulfate. Subsequent endoscopic dilation of the web with a Controlled Radial Expansion (CRE) balloon facilitated successful band ligation. The present case underscores the importance of early recognition of anatomical anomalies and highlights the need for adaptable strategies in the management of AVB, particularly in emergent settings where time is critical. The clinical implications are significant, as the case highlights a previously unreported barrier to EVL in the form of a cricopharyngeal web. It emphasises the necessity for endoscopists to consider anatomical variations when standard procedures fail. The present report contributes to the literature by documenting an unusual clinical scenario that required modification of the standard therapeutic approach to achieve haemostasis in a life-threatening situation.

A duodenal hematoma secondary to blunt -abdominal trauma is a relatively rare condition and is usually managed conservatively. We report a case of a post-traumatic duodenal hematoma after a road traffic accident in a 10-year-old boy, who presented with progressive vomiting 3 weeks after the accident. The case was managed using serial esophagogastroduodenoscopy (EGD) with dilatation. Controlled radial expansion (CRE) balloon dilatation was performed 4 times over a period of 11 weeks. The patient recovered uneventfully and remained asymptomatic at the 3-month follow-up after the last endoscopic dilatation. This case highlights the applicability of EGD with CRE balloon dilatation as an alternative to surgical treatment in patients with symptomatic post-traumatic duodenal hematomas.

P349 Risk of lymphoma in patients with inflammatory bowel disease: A Korean single-center study

The transgastric approach is currently being studied as a potentially less invasive alternative to conventional laparoscopy for intra-abdominal surgery. A major obstacle to overcome is the closure of the transgastric incision in a rapid, reproducible, and safe manner. The effectiveness of various techniques for gastrotomy closure were compared by assessing leak pressures in an ex vivo porcine stomach model. Whole stomachs from adult white pigs were suspended in a Plexiglas box to facilitate endoscopic technique. Standard gastrotomies were made by needle knife incision and dilation with a controlled radial expansion (CRE) balloon. The first arm used standard QuickClips; the second, a prototype device developed by LSI Solutions; the third, hand-sewn by a senior surgeon; the final, a control with open gastrotomy. Five stomachs were tested per study arm. After closure, each stomach was inflated by an automated pressure gauge. The pressures to achieve air leakage and liquid leakage were recorded. The unclosed controls demonstrated air leakage at a median pressure of 15 mmHg, representing baseline system resistance. The QuickClip closures leaked air at a median pressure of 33 mmHg. The prototype gastrotomy device yielded the highest median air leak pressure of 85 mmHg while dramatically diminishing time for incision and gastrotomy closure to approximately 5 min. The hand-sewn closures leaked air at a median pressure of 47 mmHg. Using Kruskal-Wallis statistical analysis, the comparisons were significant (p = 0.0019). Post hoc paired comparisons using MULTTEST procedure with both Bonferroni and bootstrap adjustments revealed that the difference between prototype and clips was significant; prototype versus hand-sewn was not. Liquid-leak pressures produced similar results. The prototype device decreases procedure time and yields leak-resistant gastrotomy closures that are superior to clips and rival hand-sewn interrupted stitches.

Dilatation of Small Bowel Strictures By Double Balloon Enteroscopy: Further Results from the UK