Anterior Esophagus Research Articles

400. CONSTRUCTION OF A MODULAR SYSTEM OF ‘INFLATABLE SINGLE-INCISION MEDIASTINOSCOPY ESOPHAGECTOMY’ BASED ON FASCIA ANATOMY

Abstract Background We improved Inflatable Single-Incision Mediastinoscopy esophagectomy to implement the simultaneous laparoscopic esophagectomy with inflatablesingle-Incision mediastinoscope and lymphadenectomy along bilateral recurrent laryngeal nerves under mediastinoscopy through a single left-neck incision and formed the concept of modular treatment of inflatable mediastinoscopic esophagectomy based on fascial anatomy which we can achieve standardized add programmed esophageal dissociation, greatly shorten the learning curve, make it easier to popularize and promote, and help us to control the operation time and complications. Methods According to anatomy of the periesophageal fascia we summarized six surgical modules, respectively is: To make the neck incision, dissociate posterior and left esophagus, dissociate anterior and right esophagus, lymphadenectomy along left recurrent laryngeal nerves, lymphadenectomy along right recurrent laryngeal nerves, dissect the Subcarinal lymph nodes. The clinical data of patients undergoing esophagectomy with inflatable single-pore mediastinoscope from February 2020 to February 2021 in our hospital were summarized and analyzed, and compared with the data of minimally invasive thoracic esophagectomy, in order to verify the clinical application effect of this modular system. Results In the validation study of modularization in this subject, no perioperative death was found in the 44 patients and the R0 resection rate was 100% confirmed by postoperative pathology. The average operation time was 204.9 ± 45.4 minutes, mean intraoperative blood loss was 64.6 ± 45.5 mL, average number of lymph nodes removed was 19.5 ± 9.1, average length of hospital stay was 27.0 ± 18.17 days, postoperative anastomotic fistula (2.27%), anastomotic stenosis (13.64%), chylous leakage (0%), pleural effusion (4.55%), and pulmonary infection (9.09%), better than the control group. The incidence of postoperative hoarseness (18.19%) which needed to be improved. Conclusion This standardized and modular surgical procedure description based on fascia anatomy is proposed for the first time for the esophagectomy under inflatable mediastinoscope, and is an exploration of the construction of a modular system for this surgical procedure. This modular system enables us to achieve standardized, programmed and rapid esophageal dissociation, which has good clinical application value.

P-EGS25 Boerhaave’s Syndrome Secondary to Symptomatic COVID-19 Infection

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has infected over 140 million people worldwide (1). COVID-19 symptoms primarily involve the respiratory system. However, recent data suggests that gastrointestinal symptoms occur in 11-61% of cases (2, 3).Boerhaave’s syndrome is a rare and dangerous disorder of the gastrointestinal tract, associated with a mortality rate of up to 50% (4). It most commonly occurs due to a lack of coordination between upper and lower oesophageal sphincters during forceful emesis, leading to an abrupt rise in intra-oesophageal pressures which leads to a transmural tear (5). Less commonly, a tear can be secondary to prolonged coughing (6). The majority of tears occur in the distal posterolateral third of the oesophagus and have an average length of 2.2 cm (7). Risk factors include males, excess alcohol or food consumption (6). We present a case of Boerhaave’s syndrome secondary to prolonged coughing, from COVID-19 infection. The tear was 8 cm in length in the mid anterior oesophagus. The patient survived a major operation and prolonged intensive care stay. Meloy et al. (8) published one case of oesophageal rupture in symptomatic COVID-19 – unfortunately the patient passed away before intervention.MethodsA 75-year-old Caucasian female was day seven of COVID-19 infection and had been coping in the community with a continuous dry cough and mild shortness of breath. She presented to Accident and Emergency in the late afternoon when her cough developed into unremitting retching, vomiting, a global headache and epigastric pain disproportionate to presentation. No associated haematemesis or change in bowel habit. Past medical history was significant for hypertension, hypothyroidism, depression and anxiety. Previous surgical history included an open appendicectomy, cholecystectomy and resection of a melanoma. She was previously independent, consumed alcohol socially, a non-smoker and compliant with her regular medications.A CT chest with contrast demonstrated distal oesophageal rupture transversely with pneumomediastinum and extensive surgical emphysema in the neck and secondary bilateral pleural effusions, consistent with Boerhaave’s syndrome. The patient was taken to theatre the next morning for an oesophago-gastro-duodenoscopy (OGD), right posterolateral thoracotomy and primary repair of the oesophageal perforation.On endoscopy, an 8cm defect in the anterior oesophagus starting at the T4 vertebral level was identified and was repaired using tunnelled permanent mesh. During the surgery, mediastinitis was noted and washed out. The antimicrobial therapy was altered post-operatively to intravenous tazocin and fluconazole. ResultsThe management of this patient was a huge multidisciplinary team achievement. She spent forty-six days recovering in ICU, intubated, ventilated and sedated with noradrenaline vasopressor support. The patient developed a severe acute kidney injury, requiring haemofiltration. The mediastinal fluid culture grew Enterococcus faecalis, sensitive to vancomycin and antibiotic therapy was adjusted accordingly. The patient’s recovery was burdened by seizures, whilst being weaned off sedation, and episodes of bradycardia and asystole, most of which were self-resolving except one requiring thirty seconds of cardio-pulmonary resuscitation. After chest drain removal, the patient redeveloped a right sided loculated pleural effusion so a further drain was inserted.A gastrografin contrast swallow study performed thirty-five days post-operatively demonstrated no evidence of contrast leak although some tracheobronchial aspiration. She was later stepped down to the ward and recovered very well. However, a component of post-ICU delirium and low mood was persistent. The patient had a repeat water-soluble contrast study on day 77 which demonstrated a contained anastomotic leak, managed conservatively. She was deemed medically ready for discharge at day 110. She was readmitted due to dysphagia secondary to a stricture at the site of mesh repair. OGD was performed and a stent was inserted.ConclusionsCOVID-19 infection may lead to an abnormal presentation of Boerhaave’s syndrome, with oesophageal tears being secondary to coughing, longer and more proximal.Peri-operative morbidity in COVID patients is elevated and clinicians should consider the short and long term implications of this to provide a holistic approach to care. Clinicians should maintain an awareness of the diversity of COVID-associated complications whilst ensuring that they do not succumb to the diagnostic overshadowing that becomes commonplace during a pandemic.

Ablation Index-Guided High-Power Radiofrequency Application Shortens the Procedure Time With Similar Outcomes to Conventional Power Application in Atrial Fibrillation Ablation.

Background: The impact of high-power radiofrequency (RF) application in ablation index (AI)-guided atrial fibrillation (AF) ablation has not been elucidated.Methods and Results: We investigated 1,333 patients undergoing first AF ablation (median age 68 years; interquartile range [IQR] 61–73 years). The first 301 patients underwent AI-guided conventional power RF application (CP group), whereas the following 1,032 patients underwent high-power RF application (HP group). The minimum AI target values were 400, 360, and 260 at the left atrial anterior wall, posterior wall, and esophagus, respectively. RF power in the CP group was 30–40, 20–25, and 20 W at the anterior wall, posterior wall, and esophagus, respectively, compared with 50, 40, and 25, respectively, in the HP group. Procedure time was shorter in the HP than CP group (median 153 [IQR 129–190] vs. 180 (IQR 152–229) min; P<0.0001). The percentage of first-pass pulmonary vein isolation (69% vs. 73%; P=0.07) and all procedure-related complications (2.0% vs. 3.4%; P=0.19) was similar. Kaplan-Meier analysis showed similar recurrence-free survival (RFS) for all AF types. Respective 1-year RFS in the CP and HP groups was 82% and 87% in paroxysmal AF, 78% and 82% in persistent AF, and 59% and 58% in long-standing persistent AF.Conclusions: In AI-guided AF ablation, high-power RF application shortens the procedure time without increasing complications and with similar outcomes.

Digestive Tract and the Muscular Pharynx/Esophagus in Wild Leptocephalus Larvae of European Eel (Anguilla anguilla)

Several aspects of the biology of European eel (Anguilla anguilla) larvae are still unknown; particularly, information about their functional development and feeding is sparse. In the present study, we histologically characterize the digestive system of wild caught specimens of European eel leptocephalus larvae. The aim was to provide more understanding about how food may be ingested and mechanically processed in the leptocephalus larvae, and to discuss this in the context of its hypothesized feeding strategy. Larvae were caught in the Sargasso Sea during the “Danish Eel Expedition 2014” with the Danish research vessel Dana. The larval sizes ranged from 7.0 to 23.3 mm standard length (SL) at catch. We found that the mouth/pharynx, especially the anterior esophagus, was surrounded by a multi-layered striated muscle tissue and that the epithelium in the mouth/pharynx had a rough filamentous surface, followed by epithelial columnar cells with multiple cilia in the anterior esophagus. This suggests an expandable pharynx/esophagus, well-suited for the transportation of ingested food and likely with a food-crushing or grinding function. The digestive tract of the larvae consisted of a straight esophagus and intestine ventrally aligned within the larval body, and its length was linearly correlated to the larval length (SL). The length of the intestinal part constituted up to 63% of the total length of the digestive tract. The intestinal epithelium had a typical absorptive epithelium structure, with a brush border and a well-developed villi structure. Some cilia were observed in the intestine, but any surrounding muscularis was not observed. The liver was observed along the posterior part of the esophagus, and pancreatic tissue was located anterior to the intestine. Our findings support the hypothesis that the eel leptocephalus may ingest easily digestible gelatinous plankton and/or marine snow aggregates. The muscular esophagus and the ciliated epithelium appear sufficient to ensure nutrient transport and absorption of the ingested food through the digestive tract.

Phenome-wide analyses establish a specific association between aortic valve PALMD expression and calcific aortic valve stenosis

Calcific aortic valve stenosis (CAVS) is a frequent heart disease with significant morbidity and mortality. Recent genomic studies have identified a locus near the gene PALMD (palmdelphin) strongly associated with CAVS. Here, we show that genetically-determined expression of PALMD in the aortic valve is inversely associated with CAVS, with a stronger effect in women, in a meta-analysis of two large cohorts totaling 2359 cases and 350,060 controls. We further demonstrate the specificity of this relationship by showing the absence of other significant association between the genetically-determined expression of PALMD in 9 tissues and 852 phenotypes. Using genome-wide association studies meta-analyses of cardiovascular traits, we identify a significant colocalized positive association between genetically-determined expression of PALMD in four non-cardiac tissues (brain anterior cingulate cortex, esophagus muscularis, tibial nerve and subcutaneous adipose tissue) and atrial fibrillation. The present work further establishes PALMD as a promising molecular target for CAVS.

Light and Scanning Electron Microscopic Observations on Grillotia erinaceus (Cestoda: Trypanorhyncha)

In the present study, the plerocercoids of Grillotia erinaceus were obtained from the wall of the anterior oesophagus, stomach, pyloric caeca and liver of teleost Black Sea whiting Merlangius merlangus and adults were collected from the intestine of elasmobranch thornback rays Raja clavata caught by commercial fishing vessels off Sinop, Turkey. Standard parasitological investigation methods were applied and morphological diagnostic features of the whole parasite, bothria, scolex, tentacular armatures and tentacles were studied in detail using a light and Scanning Electron Microscope (SEM). The plerocercoids of this parasite had a total length of 5.96 mm on average and this was 21.6 mm on average in adults. The measurement data of all morphological diagnostics are provided and photomicrographs of each part of the parasite are presented. This study also provides the detailed morphological features of both plerocercoids and adults of G. erinaceus in M. merlangus and R. clavata for the first time in the Turkish coasts of the Black Sea.&nbsp;&nbsp;

Sa1315 EFFECTIVENESS AND SAFETY OF PER ORAL ENDOSCOPIC MYOTOMY IN ACALASIA COMPARING ANTERIOR AND POSTERIOR APPROACH IN A REFERENCE CENTER

Achalasia is an esophageal primary motor disorder, characterized manometrically by the incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. Heller's myotomy is the gold standard therapie, but per oral endoscopic myotomy (POEM), with similar clinical and manometric success, is considered a safe alternative, the submucosal wall approach possible anterior or posterior esophagus depending on operator experience. As gastroesophageal reflux disease (GERD) is its main complication, there is few evidence about wich approach is safer and more effective. To describe in patients with achalasia who undergo POEM the manometric characteristics, pre and post procedure clinics with 6-month follow-up and compare the effectiveness and complications in anterior and posterior approach. We include patients with a diagnosis of achalasia virgins to treatment, candidates for POEM with anterior or posterior approach at the Hospital 1ero de Octubre ISSSTE in Mexico City from 2016 to 2018. We exclude patients with previous endoscopic and surgical treatment and other esophageal motor disorders. At the 6-month follow-up, we evaluated clinical response (Eckardt <3), manometric (integral relaxation pressure IRP <15 mmHg), endoscopy esophagitis (Los Angeles Classification), questionnaire of symptoms of gastroesophageal reflux (GERD Q> 8 points) and 24-hour pH-metry (Demeester> 14.7). Descriptive statistics were used; For difference of proportions between the 2 techniques in non-parametric variables X2and for parametric variables t of student; The statistical package SPSS V.22 was used and a p value of less than 0.05 was considered statistically significant. 51 patients were included, 21 with type II achalasia (41.2%); Average age of 59.3 years (25-88 years), 32 women (62.7%). Baseline Eckardt score of 9, baseline IRP of 35.7 mm Hg. Anterior approach in 29 cases (56.9%). The average procedure time was 62.3 minutes (range 34-118), the anterior technique with 60.3 minutes (p=0.348). In the follow-up clinical and manometric response of 90.2% in both groups, without significant differences between them. The most frequent adverse event was subcutaneous emphysema in 11 cases (21.6%), with a greater tendency in posterior approach 31.8% (p=0.114); In 4 patients perforations without difference between approaches (p=0.417) resolved with endoscopic management. Esophagitis was diagnosed in 15 cases (29.4%), positive pH-metry by Demeester in 33.3% of cases without significant differences. POEM is a safe procedure in both approaches (anterior or posterior), with no differences in procedure time and adverse events. We obtained a clinical and manometric success in the similar follow-up between groups, without finding significant differences in the presence of GERD by clinic, endoscopy and 24-hour pH-metry.

Current Status of Esophageal Protection.

Catheter ablation of atrial fibrillation necessitates ablation on the posterior left atrium. The anterior esophagus touches the posterior left atrium, although its course is highly variable. The proximity of the left atrium to the esophagus confers risk of injury with radiofrequency and cryoablation owing to the heat transfer that occurs with thermal ablation. Early detection of esophageal temperature changes with probes may decrease the extent of damage to the esophagus, but evidence is mixed. Avoiding ablation on the esophagus with esophageal deviation and modifying ablation approaches may decrease the risk of injury.

Homology conundrum among foreguts of caenogastropod molluscs: A view from comparative patterns of development

AbstractEvolution of two novel feeding strategies among caenogastropod molluscs, suspension feeding in calyptraeids such as Crepidula fornicata and predatory feeding with a pleurembolic proboscis among neogastropods, may have both involved elongation of the anterior esophagus. Emergence of predatory feeding with a proboscis is particularly significant because it correlates with the rapid adaptive radiation of buccinoidean and muricoidean neogastropods during the Cretaceous. However, the notion that this important evolutionary transition involved elongation of the anterior esophagus to extend down a long proboscis has been disputed by evidence that it may have been the wall of the buccal cavity that elongated. We undertook a comparative study on foregut morphogenesis during larval and metamorphic development in C. fornicata and in three species of neogastropods with a pleurembolic proboscis to examine the hypothesis that the same region of foregut has elongated in all. We approached this by identifying a conserved marker for the boundary between buccal cavity and anterior esophagus, which was recognizable before the developing foregut showed regional differences in length. A survey of four species of littorinimorph caenogastropods suggested that the site of neurogenic placodes for the buccal ganglia could serve as this marker. Results showed that foregut lengthening in C. fornicata involved elongation posterior to neurogenic placodes for buccal ganglia, an area that corresponded to the anterior esophagus in the other littorinimorphs. However, foregut elongation occurred anterior to neurogenic placodes for buccal ganglia in two buccinoidean and one muricoidean neogastropod. The elongated foregut within the pleurembolic proboscis of these neogastropods qualifies as anterior esophagus only if the definition of the anterior esophagus is expanded to include the dorsal folds that run down the roof of the buccal cavity. Regardless of how the anterior esophagus is defined, comparative developmental data do not support the hypothesis of homology between the elongated adult foregut regions in C. fornicata and in neogastropods with a pleurembolic proboscis.

Morphological and histochemical characterisation of the mucosa of the digestive tract in matrinxã Brycon amazonicus (Teleostei: Characiformes).

This study describes anatomical, histological and histochemical features of the digestive tract mucosal layer of the matrinxã Brycon amazonicus, an omnivorous freshwater fish endemic from the Amazon basin. This species presents short thick oesophagus with longitudinal folds, that allow the passage of large food items. The mucosa is lined with a stratified secretory epithelium rich in goblet cells that secrete neutral and acid mucins. The two mucin types provide different viscosity in anterior and posterior oesophagus related to the protective and lubricant functions, respectively. The stomach is a highly distensible Y-shaped saccular organ. Here, it is proposed that this anatomical shape plays an essential role in food storage when food availability is abundant. The stomach mucosa is composed of epithelial cells with intense neutral mucin secretion to protects against gastric juice. The intestine is slightly coiled and presents internally a complex pattern of transversal folds that increases the absorption surface and the retention time of food. Goblet cells in the intestine secrete acid and neutral mucins that lubricate the epithelium and aid in the digestive processes. In the rectum, an increase in goblet cells population occurs that may be related to better lubrication.

Anatomical and histological adaptations of digestive tract in relation to food and feeding habits of lizardfish, Synodus variegatus (Lacepède, 1803)

The adaptations in anatomical and histological structures of the digestive tract of fish are correlated with their food and feeding habits. An understanding of these habits is essential to emphasize the related functional mechanisms of fish digestive physiology. Little is known about the adaptations of the alimentary tract of coral reef fish to food and feeding strategies in the Egyptian Red Sea. The present study investigated the anatomical and histological structure of the digestive tract of the lizardfish, Synodus variegatus. The results indicated that the oesophagus in S. variegatus is a short, narrow and distensible muscular tube, that is adapted to conduction of food. The mucosa is composed of a thin stratum of simple columnar epithelium opens to the lumen and a thick layer of mucous tubular glands located at the base in both the anterior and posterior oesophagus. The muscular layer is formed of one circular layer. The stomach has a great distensibility with a bag-like shape to enable the fish to swallow relatively huge preys. Further, it has numerous gastric glands in the cardiac portion for food digestion. As for the pyloric portion, it is a very dense layer of muscularis, which contributes in regulating the passage of digested food to the intestine. The relative length of gut ranges from 0.67 to 0.73 cm with an average of 0.7 ± 0.02 cm. The intestine is a short uncomplicated tube. The mucosal folds in the anterior intestine are very long, numerous and with round tips. Such structures are shorter and fewer in number towards the mid intestine, and much thicker and blunt in the posterior intestine. The epithelial lining of the intestine consists of columnar cells for absorption, and numerous large goblet cells for the lubrication of feces. Finally, based on the findings of the anatomical and histological investigations, it may be concluded that there is a correlation between the adaptations in the digestive tract structure of the lizardfish, S. variegatus, and their feeding habits.

Left pulmonary artery sling with tracheal stenosis

We present the case of a 4-year-old girl, bronchofiberscopy (scope diameter 2.8mm): one third below oftrachea, which was divided into two orifices. The orifice on the right side was larger and divided into twosuborifices. The left orifice was stenosis and could not pass the bronchoscope. Whole trachea mucosa was redand edema, and could not observe the cartilage ring of trachea. Chest X-ray: infiltration of right lower lobe.Chest CT multiple probes with contrast injection confirmed that: At the sixth to seventh thoracic vertebral level,the left pulmonary artery was arisen from the right pulmonary artery then passed in between the behindtrachea and anterior oesophagus to reach the left lung hilar. And at the fourth to fifth thoracic vertebral level,the right upper bronchus was arisen from trachea and then the trachea was shrunk diameter to reach the leftlung hilar, at the end, the trachea divided 2 bronchi: left main bronchus and “bridging bronchus”. Thatbronchus from left lung hilar returned to the right lung.This patient was diagnosed birth defect: Left pulmonary artery sling with trachea stenosis, type IIA.

PS01.084: BOERHAAVE SYNDROME: CONTINUING CHALLENGE TO TREATMENT

Abstract Background Boerhaave syndrome produces an extremely severe clinical profile due to extravasation of digestive secretions and food into the mediastinum and pleural space. Diagnosis is often delayed, since it is a rare disease and is usually confused with other equally serious pathologies. These factors contribute to its high mortality rate. We present a case which was previously treated in three different institutions and finally referred to our department. Methods 81 year old gentleman was diagnosed as Boerhaave syndrome on 23rd Jan 2017. He had treatment in three different institutions: right ICD in first center: feeding jejunostomy and venting gastrostomy in second center: over the scope clipping and hemoclip in third center. As he continued to have persistent leak of enteral contents and purulent discharge in ICD, he was referred to our department for further management, two months after the intial insult. Results Patient was optimised for surgery and transhiatal esophagectomy with esophago gastric anastomosis was done in our department. Operative findings: Abdomen entered through midline incision, hiatal peritoneum incised, gastro esophageal junction encircled and esophagus mobilised. It revealed purulent discharge from right hemithorax and a 4cm esophageal perforation along right lateral aspect of esophagus above GE junction.About 120ml of foul smelling pus drained. Considering unhealthy esophageal tissue, long rent and failed endotherapy it was decided to do transhiatal esophagectomy. Previous gastrostomy site closed in 2 layers with 3–0 PDS. Through left anterior sternomastoid incision cervical esophagus mobilised and transected at low neck level and the specimen was removed through the hiatus. A gastric tube was made with linear staples and brought into neck through posterior mediastenum by camera sheath technique. Esophago-gastric anastamosis completed with posterior stapled and anterior hand sewn technique. Post op period was uneventful. Conclusion Early diagnosis and appropriate therapeutic strategies can reduce the mortality rate of Boerhaave's syndrome. Early intervention reduces the morbidity and mortality. The mortality increases with increasing time post insult. our patient who had undergone multiple theraputic modalities in three different centers was succesfully managed with trans hiatal esophagectomy in our department. Disclosure All authors have declared no conflicts of interest.

Anatomical , histological and histochemical studies of digestive tract of fish Mastacembelus mastacembelus

The present study involves anatomical comparsion, histological and histochemical structures of digestive tract ofMastacembelusmastacembelus (carnivore) at the level of light microscope hematoxylin and eosin , mallory's triple , periodic acid schiff (PAS) , and alician blue stains (PH1and PH2) were use . The anatomical Results revealed cylindrical muscular tube esophagus connecting pharynx , directly to cardic stomach of M. mastacembelus .The stomach shape is cystoid with cardic, fundic and pyloric portions . Pyloric caeci absent in M. Mstacembelus.intestine is shortest, relative length (RGL) is (0.58) , (S) letter shape and not coiled . Histologically the esophagus of M. Mstacembelus composed of two parts, anterior and posterior parts .The stomach has cardic , fundic and pyloric portions while intestine divided into four parts, proximal , middle, distal and anus .The arrangement and number of strata forming digestive wall from esophagus up to anus is similar in studied fish , involving four basic layers (mucosa , submucosa , mascularis and serosa) . Tunica muscularis along the digestive canal consist of two smooth muscle layers inner (circuler) and outer (longitudinal) expectesophagus which included stratified muscle layers . Many mucosal folds were lining digestive tract. These folds become crowded, very long and branched along all intestinal divisions and then become very short in anus . Tunica mucosa consist of simple columnar epithelium lining G.I from esophagus to anus . Goblet cells present among esophageal, intestinal and anal mucosal epithelium . They are numerous along esophagus and posterior intestine . Lamina propria directly under mucosal epithelium consists of thick layer of Connective tissue present in anterior esophagus, stomach and intestine . Lamina propria contain great amount of gastric glands consist of oval or spherical secretory unit lined by one type of pyramedial cell. Posterior stomach mucosal surface contains great amount of gastric pit. muscularis mucosa absent in M. mastacembelus. Tunica submucosa along digestive canal of studied fish consist of thin areolar connective tissue and collection of lymphatic cells similar to lymphatic follicle seen in anterior intestine . G.I serosa layer consist of connective tissue covered bymesotheliur. This study showed the presence of different amounts and types of mucous material in different G.I regions . positive tissue reaction with PAS, AB1, AB2 ensure presence of mucous material . Tissue reaction with PAS was very strong in esophagus and intestine while it was strong in stomach while tissue reaction withAB2 was moderate in esophagus, stomach and intestine .

Pure single-port laparoscopic proximal gastrectomy using a novel double-flap technique

We developed a novel double-flap technique as an anti-reflux procedure following sin-gle-port laparoscopic proximal gastrectomy. After performing laparoscopic proximal gas-trectomy, an H-shaped seromuscular flap is created on the anterior wall of the gastric remnant and then reconstruction procedure is started. First, the posterior esophageal wall is fixed to the stomach at the cranial edge of the submucosal window. Second, the posterior wall of the esophagus and the gastric mucosa are sutured and layer-to-layer suturing is then performed between the anterior esophagus and stomach to complete the esophagogas-trostomy. Finally, the anastomotic site and distal esophagus are covered with the sero-muscular flap. All steps were performed using continuous barbed sutures to facilitate anastomotic procedures. The above mentioned procedure is safe and feasible for the treatment of gastric cancer with acceptable short- and mid-term results. Thus, this pro-cedure may be an attractive surgical option as a minimally invasive surgery.

Pure single-port laparoscopic proximal gastrectomy using a novel double-flap technique

We developed a novel double-flap technique as an anti-reflux procedure following sin-gle-port laparoscopic proximal gastrectomy. After performing laparoscopic proximal gas-trectomy, an H-shaped seromuscular flap is created on the anterior wall of the gastric remnant and then reconstruction procedure is started. First, the posterior esophageal wall is fixed to the stomach at the cranial edge of the submucosal window. Second, the posterior wall of the esophagus and the gastric mucosa are sutured and layer-to-layer suturing is then performed between the anterior esophagus and stomach to complete the esophagogas-trostomy. Finally, the anastomotic site and distal esophagus are covered with the sero-muscular flap. All steps were performed using continuous barbed sutures to facilitate anastomotic procedures. The above mentioned procedure is safe and feasible for the treatment of gastric cancer with acceptable short- and mid-term results. Thus, this pro-cedure may be an attractive surgical option as a minimally invasive surgery.

The Use of “Through-the-Scope” Fully Covered Self-expanding Metal Stent to Stop Refractory Variceal Bleeding in a Patient With Hemorrhagic Shock

Introduction: A Sengstaken-Blakemore tube is often utilized in cases of severe variceal bleeding. Limitations for this treatment included a high rate of bleeding recurrence upon removal, and increased rate of esophageal perforation with placement. Esophageal fully covered self-expanding metal stents (FCSEMS) have been proposed as a possible treatment option for severe variceal bleeding in place of a Sengstaken-Blakemore tube. Case: Mr. S a 49 year old male with history of cirrhosis from alcohol and hepatitis C who presented with bright red blood per rectum. Two weeks prior, anesophagogastroduodenoscopy (EGD) demonstrated grade 2 esophageal varices for which he underwent banding. Hematemesis resolved and Hgb stabilized and he was discharged home. Vital signs including orthostatic vitals were unremarkable. His mucous membranes were moist without pallor and abdomen was soft/nontender with minimal fluid wave. Laboratory data demonstrated Hgb 10.8 mg/dL, platelets 98 u/L, INR 1.9 and total bilirubin 1.9 mg/dL. Liver enzymes were within normal limits. Proton pump inhibitor and octreotide drips were initiated for treatment. EGD identified a new varix closely associated with an ulceration from previous banding. An attempt was made to band this new varix, but with reinsertion of the endoscope the varix ruptured. Exsanguination ensued and banding nor sclerotherapy could be performed secondary to inability to visualize the bleeding vessel. He progressed to hemorrhagic shock and then pulseless electrical activity. Cardiac resuscitation was performed. A Sengstaken-Blakemore tube was unsuccessful secondary to inability to pass the tube. An 18mm x 120 mm “through the scope” (TTS) FCSEMS (Taewoong Medical Co.) was advanced into the gastric lumen under direct endoscopy and withdrawn into the esophagus. Exsanguination ceased after stent deployment. A 3 cm laceration was noted in the anterior esophagus from the Sengstaken-Blakemore tube placement attempt and a second FCSEMS was placed. His pulse returned after cessation of bleeding and rapid transfusion of red blood cells. However, he sustained severe anoxic brain injury and after several days care was withdrawn. Discussion: Patients with exsanguination from ruptured varices may benefit from placement of TTS esophageal FCSEMS instead of a Sengstaken-Blakemore tube. TTS esophageal FCSEMS allow for direct endoscopic placement, limited risk of perforation, and longer treatment time to stabilize patients for a more definitive treatment, such as TIPS.Figure 1Figure 2Figure 3

Morphological and histological identification of Paramphistomum cervi (Trematoda: Paramiphistoma) in the rumen of infected sheep

Aim:This study was undertaken to identify Paramphistomum cervi on the basis of its morphology and histology to be the common cause of paramphistomosis in infected sheep and its differentiation from other similar Paramphistomes in Gujarat.Materials and Methods:Adult rumen flukes were recovered from the rumen of naturally infected sheep slaughtered in various abattoirs in Gujarat. Some adult flukes were flattened and stained in Borax carmine, and some were sectioned in the median sagittal plane and histological slides of the flukes were prepared for detailed morphological and histological studies.Result:Microscopic pictures of the parasite used in identification define the similarity in the morphology and histology of the anterior sucker, pharynx, esophagus, genital atrium, posterior sucker (acetabulum) and testes to the P. cervi.Conclusion:It can be concluded that the most common species found in sheep infected with Paramphistomosis is P. cervi on the basis of its histo-morphological appearance in Gujarat.

The anterior esophageal region of Schistosoma japonicum is a secretory organ.

BackgroundThe esophagus of blood-feeding schistosomes has been largely neglected although its posterior portion was designated as a gland decades ago. However, we recently showed it plays a pivotal role in blood processing. It is clearly demarcated into anterior and posterior compartments, both surrounded by a mass of cell bodies. Feeding movies revealed that erythrocytes accumulate in the anterior compartment before entering the posterior, indicating that a distinct process is executed there. We therefore investigated ultrastructural aspects and possible functions of the anterior region.MethodsThe heads of adult Schistosoma japonicum were detached and prepared for both transmission and scanning electron microscopy to define the detailed ultrastructure of the anterior esophagus. Cryosections of heads were also prepared for immunocytochemistry and confocal microscopy to define the pattern of intrinsic host antibody binding in the anterior esophageal lining.ResultsThe anterior syncytial lining of the esophagus is highly extended by long, thin corrugations of cytoplasm projecting towards the lumen. Strikingly in the male worm, the tips of the corrugations are further expanded by numerous threads of cytoplasm, producing a spaghetti-like appearance in the central lumen. Flattened, pitted cytoplasmic plates are interspersed in the tangled mass of threads. Abundant, morphologically distinct light vesicles of varied size and contents are manufactured in the cell bodies, from where they traffic through cytoplasmic connections to the corrugations and out to the tips. Clusters of vesicles accumulate in expanded tips in males, together with occasional mitochondria whilst females have more mitochondria but fewer vesicles. The membranous contents of light vesicles are secreted mainly from the tips, but also from the sides of the corrugations. They coat the surfaces and then form organised self-adherent membrane figures when shed into the lumen. Host antibody binds strongly in a characteristic pattern to the anterior esophageal lining indicating that the secretions are highly immunogenic.ConclusionsWe suggest that the anterior esophageal region is an independent secretory organ. The contents of light vesicles are released into the esophageal lumen via the tips of corrugation to interact with incoming blood. Our immediate task is to establish their composition and role in blood processing.

Calcium Detection and Other Cellular Studies in the Esophagus and Crop of the Marine SlugAglaja tricolorata(Euopisthobranchia, Cephalaspidea)

To obtain more data about the digestive system of cephalaspideans, the esophagus and crop of Aglaja tricolorata were investigated using light and electron microscopy. In this cephalaspidean, the low epithelial cells of the anterior esophagus have a border of microvilli covered by a cuticle formed by acid polysaccharides. The esophageal pouches at the hind region of the anterior esophagus contain subepithelial secretory cells filled with electron-dense vesicles rich in neutral polysaccharides and proteins. A ciliated epithelium covers the base of the esophageal pouches. In the crop, the tall columnar epithelium is covered by a cuticle and forms many deep invaginations. The cuticle on the surface of the epithelium contains acid polysaccharides, but the material filling the lumen of the epithelial invaginations consists of neutral polysaccharides and proteins. Epithelial cells of the crop have a border of short microvilli and many mitochondria; lysosome-like bodies and some lipid droplets are present in the apical region. The elongated nucleus, numerous deep cell membrane invaginations and several hemidesmosomes are located at the basal region. Secretory cells are absent in the crop. Numerous large vacuolar cells are present in the connective tissue of the crop. With the pyroantimonate method, calcium was detected in the peripheral vesicles and central vacuole of these cells. WDS X-ray Intensity maps obtained by EPMA (Electron microprobe) confirmed the presence of calcium. This result supports the relationship between the vacuolar cells of aglajids and the calcium cells of pulmonate gastropods. In the posterior esophagus, epithelial cells are similar to the epithelial cells of the crop and secretory cells are also absent.