Complaints Of Dysphagia Research Articles

S2265 A Rare Case of Esophageal Carcinoma After Tracheoesophageal Fistula Repair

Introduction: Tracheoesophageal fistula (TEF) constitutes one of the commonest congenital anomalies with an incidence of roughly 1 in 3500 births with treatment consisting of surgical correction in very early life. Chronic complications can include esophageal stricture, dysphagia, gastroesophageal reflux disease (GERD), Barrett’s esophagus, and esophageal cancer. While rare, these patients do have an increased risk of esophageal carcinoma attributable to chronic GERD leading to ongoing mucosal disruption. Sparce data on esophageal cancer after TEF repair appears to show an increased risk of this event occurring after 40 years of age. Case Description/Methods: The patient is a 32-year-old man with a past medical history of Cystic Fibrosis, GERD, osteoporosis, and tobacco use, and a past surgical history significant for Tracheoesophageal fistula repair. The patient presented to a primary care physician with complaints of dysphagia. He reported dysphagia only to liquids that started 2 months before presentation. The dysphagia was gradually progressed to solids. He was referred to gastroenterology, and an EGD was performed showing a single traversable mass measuring 5 cm in the esophagus (20 cms. from incisors) covering one-quarter of the circumference, and cold forceps biopsy was performed. The EGD also revealed signs of the previous tracheoesophageal fistula repair and mild generalized atrophic mucosa. Biopsies taken from the esophagus and stomach were sent for pathology. Pathology from the esophageal biopsy came back positive for moderately differentiated Squamous cell carcinoma and gastric biopsy revealed chronic gastritis with complete intestinal metaplasia. The patient was referred to oncology and underwent a PET scan which revealed the esophageal malignancy and bilateral pulmonary nodules. The patient was started on chemoradiation therapy and follows up with oncology regularly (Figure). Discussion: This case describes the importance of continuity of care during the transition from pediatrics to adult care in the field of gastroenterology in patients with a history of TEF repair, given the patient’s young age. While it appears esophageal cancer after TEF repair is rare, there should be an investigation into guidelines for adequate screening in this disease process.Figure 1.: Histopathology and endoscopic images.

S2434 A Rare Case of Epiphrenic Diverticulum as a Complication of Esophageal Motility Disorders

Introduction: Esophageal diverticula are a rare finding with an estimated incidence of 1:500 000 per year and a prevalence of 0.015–2%. It is usually associated with esophageal motility disorders, particularly Achalasia. The suspected mechanism is secondary to increased intraluminal pressure from the primary esophageal motility disorder, which leads to herniation of the mucosa and submucosa through the muscular layer. It is usually asymptomatic but can present with dysphagia, regurgitation, nausea, vomiting, aspiration, heartburn, weight loss, and retrosternal pain. Here we offer a case of a large esophageal diverticulum in a 52-year-old male who has been having symptoms for years. Given the symptomatic nature of his diverticulum, he underwent surgical repair. Case Description/Methods: A 52-year-old patient with no significant past medical history presented with complaints of dysphagia that was worsening over several years, associated with halitosis and food regurgitation. The patient was having a routine screening colonoscopy when he had an episode of coffee-ground emesis. He subsequently underwent an esophagogastroduodenoscopy which revealed a large epiphrenic esophageal diverticulum. He then had an esophagogram and Computer Tomography (CT) of chest and abdomen, which confirmed the presence of the diverticulum and significant narrowing of the GE junction. Esophageal manometry was not pursued, given the difficulty of placing the probe and the risk of perforation. He subsequently underwent left thoracotomy with resection of the large esophageal diverticulum, long myotomy (11 cm), and Besley fundoplication. Esophagram following surgery was negative for any leak (Figure). He was started on a clear liquid diet that was later advanced to full liquid, with the patient tolerating it well. He was subsequently discharged home. Discussion: Esophageal diverticula are rare findings with an estimated incidence of 1:500 000 per year and a prevalence of 0.015–2%. Most esophageal diverticula are acquired and present in older adults. Surgical repair is associated with mortality of 0 to 9% and morbidity of 20%. This case serves as a reminder to keep a broad differential diagnosis when approaching a patient with symptoms of a motility disorder. Early detection can provide timely management and prevent further complications.Figure 1.: Esophagram after surgical repair of epiphrenic esophageal diverticulum.

S2400 Granular Cell Tumor: A Rare Disease of Esophagus

Introduction: Granular cell tumors (GCTs) are rare, often benign tumors of neurogenic origin. GCTs are usually found incidentally but can present with dysphagia in symptomatic patients. They are diagnosed via biopsy and histology following an esophagogastroduodenoscopy( EGD). We present a case of a 46-year-old female who presented with dysphagia, GERD, and weight loss diagnosed with esophageal granular cell tumor following an EGD. Case Description/Methods: A 46 years old female with a past medical history of H. pylori gastritis presents with complaints of dysphagia for 3 months and GERD associated with weight loss. EGD reviewed a single 4 mm nodule found in the lower third of the esophagus with the appearance of a lipoma (Figure). Biopsy of esophagus nodule resulted in esophageal squamous epithelium with focal granular cell tumor; Immunohistochemistry tumor cells are positive for S100, CD56, CD68, negative for calretinin and AE1/3 supporting rare esophageal granular cell tumor. EUS demonstrated a 4.7 mm x 2.6 mm intramural (subepithelial) lesion appeared to originate from within the superficial mucosa (Layer 1), Patient underwent repeat EGD with en-bloc cap and band-assisted endoscopic mucosal resection (EMR) followed by 3 hemoclips placed for hemostasis. The patient was discharged home on a proton pump inhibitor. The patient reports clinical improvement on follow-up after 4 weeks. Discussion: GCTs are thought to originate from Schwann cells; the prevalence of GCTs is challenging to determine as there have been roughly 300 documented cases of GCTs discussed in the literature. Conversely, patients with larger diameter lesions typically present with indolent dysphagia and other less common symptoms such as gastro-esophageal reflux disease, dyspepsia, chest pain, cough, or nausea. GCTs on EGD appear sessile, yellow-white in color, and firm, with a negative pillow sign. After performing EGD, an endoscopic ultrasound (EUS) is diagnostically utilized to ascertain tumor invasion and provide a biopsy through fine needle aspiration (FNA). Histopathological diagnosis, including immunohistological staining, is essential for confirmation of GCT. Immunohistological staining is positive for S-100, PAS (Periodic Acid Schiff), neuron-specific enolase, nestin, and vimentin. Patients whose neoplasms are less than 1 cm in diameter are treated conservatively with endoscopic follow-up, with tumors greater than 1 cm in diameter, or having clinical symptoms that need endoscopic or surgical resection.Figure 1.: A: EUS showing 4.7 mm x 2.6 mm hypoechoic intramural (subepithelial) lesion was found in the lower third of the esophagus. It appeared to originate from within the superficial mucosa (Layer 1). A tissue diagnosis was obtained prior to this exam. B: EGD significant for sessile, yellow white in color, and firm mass followed by EMR. C: Histopathology with H&E showing clusters of polygonal cells with granular eosinophilic cytoplasm (top) and S100 stain (below).

P268 Laryngeal Mucormycosis: does mucor take the voice away?

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjectiveThis case aims to highlight a unique presentation of Mucormycosis.Methods and ResultsA 57-year-old retired office supervisor, presented to the ENT department with complaints of hoarseness of voice ending with almost complete dysphonia over 6 months. There were no complaints of stridor, dyspnea or dysphagia. He had no history of prior surgery or tracheal intubation. On examination, a lesion over his right vocal cord was noted (Fig. 1) and underwent surgical excision of the lesion.HPE of the lesion (Fig. 2) showed hyperplastic stratified squamous epithelium which was partly ulcerated and covered by thick bands of necro-inflammatory material. Within the necrotic material were seen broad aseptate fungal hyphae. Beneath the necrotic material was inflamed granulation tissue with fibrosis. No tissue or vascular invasion was noted as per the report, however there was a recurrence of the lesion after 15 days.ID team opinion was sought in view of need for antifungals. Owing to financial constraints, CT chest could not be done, but his chest X-ray was normal. His HbA1c was 7.5%, which was suggestive of newly detected diabetes mellitus (DM).In this case, even though no angioinvasion or tissue invasion was reported, the presence of hyphae in the area of necrosis, the presence of inflammatory local tissue reaction, coupled with newly detected DM, prompted the ID team to advise treatment with amphotericin B followed by suspension posaconazole (GR was not available at the that time). The patient was not willing for treatment at the time. However, local recurrence of the lesion occurred 2 weeks later. Surgical resection along with posaconazole, TDM and close follow-up was advised. However, the patient was lost to follow-up, possibly due to loss of confidence in us?ConclusionThe importance of sending every surgically excised tissue for histopathology and culture has been highlighted by this case. Early ID opinion and AF therapy could have averted recurrence and loss of patient confidence. Chronic Granulomatous form of mucormycosis though rare, needs timely diagnosis and treatment in the form of surgical resection as well as systemic antifungal therapy.

Dysphagia Presentation, Airway Invasion, and Gender Differences in a Clinically Based Sample of People with Parkinson's Disease.

Dysphagia in People with Parkinson's Disease (PWPD) is expected to occur in most individuals. The manifestation of dysphagia and its salient swallow dysfunction characteristics leading to decreased airway safety are not well understood. The aim of this study was to quantify dysphagia presentation and severity, examine contributors to airway invasion, and explore gender differences in dysphagia manifestation in PWPD. 60 PWPD in clinical, healthcare settings underwent a Videofluoroscopic Swallow Study (VFSS) after referral for complaints of dysphagia. VFSS records and videos were analyzed to obtain dysphagia diagnosis, Videofluoroscopic Dysphagia Scale (VDS) scores, laryngeal vestibule kinematic timings, and Penetration-Aspiration Scale scores. Frequencies of VDS component and PAS scores were examined. MANOVA and logistic regression analyses were used to identify predictors of penetration and aspiration. Pharyngeal stage dysphagia was prevalent throughout PWPD and presented more frequently than oral stage dysphagia. Pharyngeal residue was a significant predictor for aspiration events. Laryngeal vestibule closure reaction time (LVCrt) and duration time (LVCd) were significant predictors of airway invasion, as were bolus consistency and volume. LVCrt, LVCd, and pharyngeal stage VDS scores were significantly altered in men compared to women in PWPD. A broad clinical sample of PWPD displayed atypical frequencies of airway invasion and frequent atypical scores of oral and pharyngeal stage physiologies. Thicker and smaller bolus consistencies significantly reduced the odds of airway invasion. Men and women presented with significantly different swallow physiology including prolonged LVCrt, LVCd, and more frequent atypical scores of pharyngeal residue and laryngeal elevation.Journal instruction requires a country for affiliations; however, these are missing in affiliation [1, 2]. Please verify if the provided country are correct and amend if necessary.Yes, USA is correct as the provided country.

Impact of Surgical Intervention on Nonobstructive Dysphagia: A Retrospective Study Based on High-Resolution Impedance Manometry in a Taiwanese Population at a Single Institution.

Esophageal motility disorders account for a large proportion of nonobstructive dysphagia cases, which constitute a heterogeneous group of diagnoses that commonly result in peristaltic derangement and impaired relaxation of the lower esophageal sphincter. We performed a single-institution retrospective study enrolling consecutive patients with chief complaints of dysphagia who underwent HRIM from December 2014 to December 2019, and analyzed demographic, clinical, and manometric data using descriptive statistics. In total, 277 identified patients were included in the final analysis. Ineffective esophageal motility (n = 152, 24.5%) was the most common diagnosis by HRIM, followed by absent contractility, EGJ outflow obstruction, type II achalasia, and type I achalasia. Furthermore, surgery including exploratory, laparoscopic, and robotic myotomy, as well as POEM, is considered the most effective treatment for patients with non-spastic achalasia and EGJOO, due to its effective symptom palliation and prevention of disease progression; surgery also contributes to an obvious improvement of dysphagia compared with slightly less efficacy for other related symptoms. Our study aimed to elaborate the clinical characteristics of patients with nonobstructive dysphagia based on HRIM in a Taiwanese population, and to analyze the therapeutic outcomes of such patients who ultimately underwent surgical interventions.

Esophageal Cancer Requiring Multiple Biopsies in a Lung Transplant Recipient with Previously Normal Objective Studies

<h3>Introduction</h3> Esophageal cancer is a relatively rare malignancy in lung transplant (LT) recipients. <h3>Case Report</h3> We report the case of a 61-year-old man with a history of bilateral LT (08/2017) for COPD who presented 4 years after transplant with a 1-month complaint of dysphagia to solids (mainly large pills) only. He had no history of reflux disease; routine, prior esophagram, EGD, and gastric emptying studies were grossly normal; no evidence of Barrett's esophagus. We performed an EGD that found a 2-cm long focal stricture in the proximal/mid-esophagus. A biopsy from the region confirmed atypical squamous epithelium but not dysplasia or malignancy. A chest CT showed scattered, bilateral solid and ground-glass sub-centimeter pulmonary nodules and circumferential thickening of the proximal/mid-esophagus. At this time, the primary concern was esophageal stricture possibly related to gastroduodenal aspiration. Meanwhile, surveillance bronchoscopies showed no evidence of ACR, granulomatous inflammation, or malignancy. We performed a second EGD with limited ultrasound assessment for esophageal stent placement at the stricture. Unfortunately, biopsy at this time revealed moderately differentiated, keratinizing, invasive squamous cell carcinoma. Given this finding, we performed robotic bronchoscopy with EBUS-guided FNA of the right upper lobe and right lower lobe pulmonary nodules; pathology was non-diagnostic. An abdomen/pelvis CT showed no intraabdominal or intrapelvic malignancy concerns. A follow-up PET/CT showed increased metabolic activity in the proximal esophagus surrounding the esophageal stent and in the distal esophagus. There was no focal uptake involving the previously identified pulmonary nodules. The patient was informed and shared the decision to start definitive chemoradiotherapy with weekly carboplatin and paclitaxel. <h3>Summary</h3> Suspicion for this malignancy was particularly low given no previous history of reflux disease, grossly normal objective studies to date, and a first biopsy not diagnostic for dysplasia or malignancy. Nonetheless, esophageal stricturing with complaint of dysphagia to solids only should raise concern for malignancy.

Autoavaliação da qualidade de vida, risco para disfagia e alteração de deglutição em pacientes internados com COVID-19

ABSTRACT Purpose: to identify the impact of swallowing changes and dysphagia complaints on quality-of-life and eating self-assessments of COVID-19 inpatients. Methods: the study comprised 54 COVID-19 inpatients above 18 years old, whose swallowing was clinically assessed by a speech-language-hearing therapist. They were classified regarding food intake (with the FOIS scale) and degree of dysphagia. They also filled out a sample characterization questionnaire and the SWAL-QOL and EAT-10 protocols. Results: the respiratory condition led to worse quality-of-life self-assessment Fatigue results, oral food intake and dysphagia severity classifications. Females had worse quality-of-life self-assessment Burden and Food selection scores. Swallowing complaints were associated with worse eating self-assessments. Patients at risk of dysphagia had worse quality-of-life self-assessments in five out of the 11 domains, worse oral food intake levels, and worse dysphagia severity. Conclusion: COVID-19 inpatients commonly have swallowing complaints and are at risk of dysphagia, with worse quality-of-life self-assessment, lower oral food intake classification, and worse dysphagia severity rating.

A Submucosal Tumor Developing 15 Years After Endoscopic Resection With Additional Chemoradiotherapy for Esophageal Cancer

Question: A 80-year-old man with a complaint of dysphagia was referred to our hospital. He had the past history of early esophageal cancer of the lower esophagus 15 years prior and underwent endoscopic submucosal dissection (ESD). The pathological evaluation revealed squamous cell carcinoma, pT1b-SM2, negative lymphovascular invasion, and negative horizontal and vertical margins for which additional chemoradiation therapy (radiation, 66 Gy/33 Fr; chemotherapy, 5-flourouracil and cisplatin) was performed.

Challenging Airway Management in Patients With Zenker’s Diverticulum

The acquired hypopharyngeal diverticulum (Zenker’s) is characterized by a posterior wall outpouching of the pharyngeal mucosa and submucosa through the vulnerable points of the pharyngoesophageal junction. We describe the case of a 67-year-old male who was recently diagnosed with Zenker's diverticulum and had complaints of dysphagia and halitosis. An endoscopic treatment (diverticulotomy) was performed without difficulties. The anesthetic management included rapid sequence induction, avoiding succinylcholine, and intraoperative infusion of dexmedetomidine. The neuromuscular blockade was reversed using sugammadex, decreasing the risk of failed extubation and possible airway re-intervention. The patient was discharged home the following day without complications.

Native oesophageal mucocoele: A rare complication of double exclusion of oesophagus.

Introduction and importanceNative oesophageal mucocoele usually follows bipolar exclusion of oesophagus for various reasons and is very rare in literature. Though mostly asymptomatic, its symptoms can be divided into 3 groups – Compressive, Infective and fistulizing symptoms. The management options described in the literature are percutaneous drainage, chemical ablation, esophagectomy and internal drainage using Roux-en-Y reconstruction.Case reportA 40 year old female, presented with complaints of dysphagia, weight loss and chest pain for 6 month. She had history of retrosternal gastric pull-up for oesophageal stricture following corrosive injury. On evaluation with CT chest, there was a well-defined fluid attenuated tubular elongated lesion in the mediastinum in the region of oesophagus which was non-opacified with oral contrast and a diagnosis of giant oesophageal mucocoele was made. She underwent internal drainage of mucocoele by roux-en-Y esophagojejunostomy with placement of transanastomotic drain and discharged with an uneventful recovery with the trans-anastomotic drain in situ, which was removed on outpatient basis. Now she is asymptomatic in the subsequent follow up.Clinical discussion and conclusionThough rare, mucocoele of oesophagus can lead to life threatening complication like respiratory distress, sepsis. Its diagnosis requires high index of suspicion and CT chest is helpful. Management options depend upon nutritional status of the patient and associated co-morbidities. Esophagectomy is the definitive form of treatment but not always possible and other options can be internal or percutaneous drainage.

S2084 Acquiring the Diagnosis of an Acquired Tracheoesophageal Fistula

Introduction: Tracheoesophageal fistulas (TEFs) can be congenital or acquired. Congenital causes are rare and accompanied by tracheal atresia or stenosis. More recently, greater than 50% of acquired TEFs have been caused by malignancies in the mediastinum. We present a unique case in which an acquired TEF was diagnosed in an unconventional way. Case Description/Methods: A 57-year-old male with history of hypertension, alcohol misuse & ongoing tobacco use (40 pack years) presented to primary care with complaints of progressive dysphagia, initially to solids then later to liquids as well, over the course of 2.5 years. He also had a sensation of a “lump” in his throat but denied reflux symptoms. Vitals, physical exam, & blood work at the time did not reveal anything concerning. He was thought to have oropharyngeal dysphagia. Laryngoscopy showed normal pharynx & significant erythema in the arytenoid and esophageal inlet without any mass. He was lost to follow-up due to the SARS-CoV2 pandemic. Several months later, he came to the Emergency Department with complaints of vomiting, productive cough, 20-pound weight loss and fatigue. CT imaging revealed irregular thickness of the upper thoracic esophagus with enlarged subcarinal lymph nodes, and a 1.5-cm pulmonary nodule in the middle lobe. Due to suspicion for esophageal cancer he underwent esophagoscopy with ultrasonography. Patient was found to have a hypoechoic mass with irregular borders in the middle third of the esophagus, involving 100% of the lumen circumference, measuring up to 15 mm in thickness. Evaluation was limited due to obstruction. Biopsies were obtained. The proximal portion of the esophageal mass was noted to be invading adventitia, making it at least T3 lesion. During the procedure minimal CO2 was used for insufflation, but when attempts were made to traverse the obstruction, capnography revealed an end-tidal CO2 estimating 90 mmHg – indicating a high likelihood of TEF. Cardiothoracic surgery recommended esophageal stenting with gastrostomy tube placement. Pathology revealed squamous cell carcinoma. The patient followed up with Oncology for staging and treatment. Discussion: Identification of TEFs can be challenging. Esophagoscopy, the gold standard for diagnosis, may miss small or subtle TEFs even with fluoroscopy. Recent studies have shown potential of using capnography as a novel method in diagnosing TEFs with the benefit of reducing the need for radiation. Our unique case highlights application of such diagnostic modality to identify a TEF.

S2034 Wrong Tube: A Mysterious Case of Dysphagia in a Patient with Tracheostomy

Introduction: Dysphagia simply means difficulty swallowing. It occurs in 11% to 93% of patients following tracheostomy and is therefore one of the most common side effects seen after the procedure [1]. We present a case of dysphagia following tracheostomy with unusual endoscopic findings. Case Description/Methods: An 83-year-old male with a past medical history of laryngeal cancer treated with partial laryngectomy followed by complete laryngectomy and permanent tracheostomy. Complete laryngectomy and tracheostomy were performed 15 years prior to his presentation. He presented with a chief complaint of dysphagia. Patient had dysphagia to both solids and liquids associated with weight loss for 6 months’ duration. Patient was in no acute distress. A diagnostic upper endoscopy was done which showed a trachea-esophageal fistula through which the tracheostomy tube was seen penetrating the esophageal wall. Patient was subsequently referred to ENT for possible removal of tracheostomy and consideration of esophageal stenting in an attempt to heal the trachea-esophageal fistula. Discussion: Some of the proposed hypotheses for dysphagia after tracheostomy include loss of hypomandibular muscle group function and a delayed trigger in the swallowing response [1-2]. More commonly it is seen with esophageal compression which can sometimes cause excessive pressure on the posterior wall of the esophagus leading to tracheoesophageal fistula as well [3]. In our case, the tracheostomy tube was seen penetrating the wall of the esophagus. We propose this likely occurred due to excessive pressure by the tracheostomy tube eventually causing necrosis, tissue breakdown and fistula formation through which the tube slowly migrated into the esophagus, presenting with symptoms of dysphagia. Fortunately the patient was stable from a respiratory perspective with adequate gas exchange thought to be secondary to the fenestrated tracheostomy which allowed for air ventilation despite misplaced position. To our knowledge this is one of the first reported cases of such a complication which makes this a unique case. It gives us ground for early endoscopy to rule out any structural defects similar to this in a patient with a tracheostomy presenting with dysphagia.Figure 1.: Tracheostomy penetrating esophageal wall visualized during endoscopy.

Sistemik Skleroz’da Özofagus Tutulumu ve Gastroözofageal Reflü Hastalığı: Üçüncü Basamak Deneyimi

Aim: Esophagus is the most frequently involved gastrointestinal segment in systemic sclerosis (SS). Gastroesophageal reflux, which occurs with the motility disorder caused by esophageal involvement, has an important place in the course of the disease due to many local and systemic complications. In this study, we investigated the demographic features, endoscopic, manometric, and 24-hour pH monitoring findings of patients with SS.&#x0D; Materials and Methods: Twenty-six patients with SS who presented with dysphagia or heartburn complaints were identified. Patients' files, endoscopic, manometric, and 24-hour ph monitoring findings of the esophagus were examined.&#x0D; Results: All of the patients were symptomatic, 96.1% were women. 46.1% of them applied with the complaint of heartburn and 53.9% with the complaint of dysphagia. The frequency of esophagitis was found to be significantly higher (p = 0.005). Pathological reflux was detected in 90% of the patients who underwent 24-hour pH monitoring and it was significantly higher (p = 0.013).&#x0D; Conclusion: Esophageal involvement is a hallmark manifestation of SS and typically occurs secondary to heartburn and dysphagia.In our society, the incidence of GERD and GERD-related complications is high in SS patients with esophageal symptoms. It is important to refer these patients to experienced gastroenterology centers to be evaluated primarily by endoscopic and then other diagnostic methods.

337 MESH REINFORCEMENT OF THE HIATOPLASTY. PROTECTING THE ACHILLES' HEEL

Abstract Disruption of hiatoplasty is one of the main causes of anti reflux surgeries failure. There are some conditions that are associated with higher risks of disruption, leading to hernia recurrence. Bioabsorbable meshes have a safer profile compared to the permanent ones and we show in this video its use aiming to prevent early and possibly, late recurrence. Methods We present a video about different indications for reinforcement of hiatal closure with bioabsorbable mesh. With the security of bioabsorbable materials and previous experiences with these kind of meshes used in an U configuration, we are suggesting that it can be used as an inverted C over the posterior and anterior sutures placed to close the hiatal defect. The mesh is cut during the surgery to better accommodate as an onlay protection. It can be fixed to the diaphragm in different ways, but we used fibrin glue in this series. Results Sixteen patients were operated with this technique. The long term results are not available at this point, but short term results are very encouraging. We have noticed a slightly higher complaint of dysphagia among these patient compared to what we use to observe in our non-mesh patients, but dilatation was not necessary in any patient. Conclusion The use of bioabsorbable mesh in the hiatus is safe and can be used with more frequently to prevent hiatal recurrences in specific groups of patients. Video https://www.dropbox.com/s/jsblif0pfjcuicu/BIOMESH.mov?dl=0.

Heterotopia of gastric mucosa and long segmental Barrett’ oesophagus complicated by cicatricial stricture of the upper third of the oesophagus

A 26-year-old patient with no symptoms of gastroesophageal reflux disease developed complaints of dysphagia. Endoscopic examination revealed a short grade 3 cicatricial stricture in the upper third of the oesophagus, and in the lower parts of the oesophagus mucosa was represented by a columnar epithelium for 16 cm. Histological examination verified the long segmental Barrett’ oesophagus. Above the stricture large areas of heterotopia of the gastric mucosa were determined among the regular oesophageal squamous epithelium. While taking proton pump inhibitors, the patient underwent a long course of endoscopic bougienage with intramural dexamethasone injections, which made it possible to stabilize the lumen in the stricture zone at a level of 12 mm. A precise examination of all parts of the oesophagus with the use of modern clarifying imaging techniques allows to correctly interpret the endoscopic picture and determine the further tactics of treatment and follow-up, taking into account the possible risks of neoplasia in the heterotoped area of the mucosa of the upper third of the oesophagus.

ENDOSCOPIC STENTING IN THE TREATMENT OF RECURRENT EPIPHRENIC DIVERTICULUM AFTER LAPAROSCOPIC DIVERTICULECTOMY. CLINICAL CASE REPORT

Epiphrenic diverticulum, also known as a pulsion diverticulum, is a rare type of esophageal diverticulum occurring in the distal 10 centimeters of the esophagus. They are most commonly 4-10 cm above the gastric cardia representing 10% of all esophageal diverticula. Laparoscopic diverticulectomy has become the treatment of choice. This clinical case study is dedicated to minimally invasive treatment of recurrent epiphrenic diverticulum after laparoscopic diverticulectomy. A 74-year-old male patient was admitted to the hospital with complaints of dysphagia, regurgitation and halitosis. The examination revealed a 5 cm epiphrenic diverticulum with sings of inflammation. Laparoscopic transchiatal diverticulectomy, the Dor (anterior) fundoplication, cruroraphia and mediastinal drainage were performed. The patient was discharged on the 11-th postoperative day. The patient exhibited dysphagia relapse during a 3-month follow-up. Taking into account the previous surgical treatment and the habitus endoscopic esophageal stenting was chosen as the technique of choice for management. Under intravenous anesthesia a partially covered metal self-expandable stent 10 cm x 1.8 cm was inserted into the distal esophagus. Next day control fluoroscopy showed stable stent position and no evidence of leakage. The water-soluble contrast agent reached stomach freely. The patient was discharged on the 2nd post-operative day. Within 4 months after having a stent placed, the patient feels well and oral feeding is satisfactory. In terms of literature search we have not come across any reference to the post-epiphrenic diverticulectomy recurrence treatment, so the management was chosen individually based on the comorbid status of the patient. The installation of a partially covered metal self-expandable stent allowed to promptly eliminate dysphagia and design features enabled to achieve stent stable position. A partially covered metal self-expandable stent can be considered effective in the post-epiphrenic diverticulectomy recurrence treatment.

Esophageal tuberculosis with Esophagopulmonary fistula: A case report

Esophageal tuberculosis (TB) is a rare manifestation of tuberculosis with secondary involvement being more common. The most common presentation is with dysphagia and a high index of suspicion for a tubercular etiology should be kept in mind, especially in a TB endemic region like India. Early diagnosis is essential to prevent complications such as bleeding, perforation, or stricture and also because the disease is curable with antitubercular therapy. We present a case report of a young female who presented to our hospital with complaints of cough and dysphagia and was subsequently diagnosed with esophageal tuberculosis complicated by an esophagopulmonary fistula.

Tongue and Lip Comparisons between Healthy and Nondysphagic Poststroke Individuals

Background: The lips and tongue play a substantial role in efficient clearance of food from the mouth and pharynx into the esophagus. No study has compared oral pressures between healthy individuals and poststoke individuals who report functional swallow abilities. Aim: The current study aimed to investigate the presence of differences in oral pressures between healthy individuals and poststroke individuals who report functional swallowing abilities. Design: This is a controlled matched pair study. Population: Eighteen control participants (CG) and 18 nondysphagic poststroke participants (NDSG) were enrolled into this study. Methods: The Iowa Oral Performance Instrument (IOPI) was used to measure and compare tongue strength, endurance, and functional lingual and labial pressures between sex and age-matched pairs. Results: Six paired, two-tailed t tests revealed that tongue and lip pressures were different between the 2 groups. Maximum anterior tongue pressures and posterior tongue pressures were also different, i.e., t(17) = –2.89 (p = 0.010) and t(17) = –2.85 (p = 0.011), with the CG presenting higher pressures. Right lip pressures were significantly lower in the NDSG compared to the CG, i.e., t(17) = 2.45 (p = 0.0001). Left lip pressures were significantly lower in the NDSG compared to the CG, i.e., t(17) = –5.43 (p = 0.0001). Tongue endurance, i.e., t(17) = 0.092 (p = 0.928) and saliva swallow pressures, i.e., t(17) = –0.490 (p = 0.63) were not different. Conclusion: Although poststroke participants reported functional swallowing abilities, there were differences in tongue and lip pressures but not in endurance or saliva swallow pressures. Clinical Rehabilitation Impact: Poststroke individuals without complaints of dysphagia who are not assessed may experience subclinical dysphagia that could negatively impact their nutrition and quality of life.

P-MN006. Warning sign to diagnose amyotrophic lateral sclerosis (ALS) – rare case

Introduction . A progressive and devastating Amyotrophic Lateral Sclerosis (ALS) disorder locations are upper and lower motor neurons at the spinal or bulbar level. ALS is a fascinating case because it is rare, with an unclear aetiology and many problems in choosing the right management strategy. In the data obtained at the General Hospital in Malang Indonesia, there were 3 cases of ALS and 2 cases of death in the last 4 years. Results . We report 2 serial cases of suspected ALS patients with tetraparesis UMN type and parese N. XII LMN type (atrophy and fasciculation). The first case, accompanied with complaints of dysphagia, dysphonia, and parese N. IX, X, with an Electromyography (EMG) result severe axonal demyelinating motoric sensoric polyneuropathy. And for the second case, accompanied with complaints of dysartria, parese N. VII D UMN type, with an Electromyography (EMG) result severe motor neuron disease lower brain stem dd severe motoric neuropathy. In first case it is not an ALS because there were a sensory polyneuropathy and second case there were clinically definite diagnosis criteria of ALS by showing the presence of UMN and LMN symptoms in three regions with a result of an electrophysiology. In first case patient died after 1 year of diagnosis and in second cases the patient was still alive with limited physical activity. Conclusion . ALS is difficult to diagnose because it has similar symptoms to some other neurological diseases. From this rare series of cases, a clinician should be able to assess a symptom that leads to ALS diagnosis such as the presence of upper and lower motor neuron symptoms strongly suggests the presence of the disease. Keywords: Amyotrophic Lateral Sclerosis (ALS), Electromyography (EMG), Neuron Motoric Disease, Rare Case.