Esophageal Diagnosis Research Articles

Dual-Stage U-Shape Convolutional Network for Esophageal Tissue Segmentation in OCT Images

Automatic segmentation is the crucial step for esophageal optical coherence tomography (OCT) image processing, which is able to highlight diagnosis-related tissue layers and provide characteristics such as shape and thickness for esophageal disease diagnosis. This study proposes a dual-stage framework using a specifically designed encoder-decoder network configuration for accurate and reliable esophageal layer segmentation, which is named as the dual-stage U-shape convolutional network (D-UCN). The proposed approach utilized one UCN to locate the target tissue region, which is followed by another UCN with similar architecture to achieve the final segmentation. In this way, the proposed strategy effectively solves the problems encountered in our previous studies, such as disturbance from neighboring diagnostically unrelated tissues, probe protection sheaths from the imaging equipment and the inevitable speckle noise. Experimental results on esophageal OCT B-scans from C57BL mice demonstrated that the proposed dual-stage framework achieved performance comparable to manual segmentation. The effectiveness and advantages of the dual-stage strategy are also confirmed in comparison with graph theory dynamic program (GTDP) and U-Net.

Diagnosis and Outcome of Oesophageal Crohn's Disease.

Crohn's disease [CD] can involve any part of the gastrointestinal tract. We aimed to characterize the clinical, endoscopic and histological features and treatment outcomes of CD patients with oesophageal involvement. We collected cases through a retrospective multicentre European Crohn's and Colitis Organisation CONFER [COllaborative Network For Exceptionally Rare case reports] project. Clinical data were recorded in a standardized case report form. A total of 40 patients were reported (22 males, mean [±SD, range] age at oesophageal CD diagnosis: 25 [±13.3, 10-71] years and mean time of follow-up: 67 [±68.1, 3-240] months). Oesophageal involvement was established at CD diagnosis in 26 patients [65%] and during follow-up in 14. CD was exclusively located in the oesophagus in two patients. Thirteen patients [32.2%] were asymptomatic at oesophageal disease diagnosis. Oesophageal strictures were present in five patients and fistulizing oesophageal disease in one. Eight patients exhibited granulomas on biopsies. Proton-pump inhibitors [PPIs] were administered in 37 patients [92.5%]. Three patients underwent endoscopic dilatation for symptomatic strictures but none underwent oesophageal-related surgery. Diagnosis in pre-established CD resulted in treatment modifications in 9/14 patients. Clinical remission of oesophageal disease was seen in 33/40 patients [82.5%] after a mean time of 7 [±5.6, 1-18] months. Follow-up endoscopy was performed in 29/40 patients and 26/29 [89.7%] achieved mucosal healing. In this case series the endoscopic and histological characteristics of isolated oesophageal CD were similar to those reported in other sites of involvement. Treatment was primarily conservative, with PPIs administered in the majority of patients and modifications in pre-existing inflammatory bowel disease-related therapy occurring in two-thirds of them. Clinical and endoscopic remission was achieved in more than 80% of the patients.

416 Esophageal Body Dysfunction in Patients With Esophagogastric Junction Outflow Obstruction: A Potential Flaw in the Chicago Classification

INTRODUCTION: High-resolution manometry using the Chicago Classification is standard in the evaluation of esophageal motility. When the relaxation of the esophagogastric junction is impaired and achalasia excluded, esophagogastric junction outflow obstruction (EGJ-OO) is diagnosed and the esophageal body is essentially ignored. We sought to characterize the function of the esophageal body in consecutive patients with EGJ-OO. METHODS: Retrospective review of the esophageal manometry findings in consecutive patients where there was computer recognition of EGJ-OO collected over a 2-month period. In each case, the esophageal body was reviewed manually and results reported independent of the suggested computer diagnosis. RESULTS: 116 patients underwent manometry over a 2-month period and 30 (26%) were identified as having EGJ-OO. The indications for testing included chronic cough (n = 5), GERD (n = 8), dysphagia (n = 9) and esophageal evaluation associated with severe lung disease or transplantation (n = 8). The mean IRP was 20.8 (range 16-33.6) and did not vary depending on indication (P = 0.381). Computer interpretation was EGJ-OO in all patients without mention of the esophageal body. After review, 11 (37%) had an additional esophageal diagnosis. In effective esophageal motility (IEM) was the most prevalent among them (IEM-8, achalasia-2, jackhammer esophagus-1; P = 0.020). The frequency of an additional esophageal diagnosis was significantly different between GERD (0%) and dysphagia (66%; P = 0.004), but not between other groups (i.e. 40% in cough and 37.5% in transplant group). An esophageal body diagnosis was significantly more likely in patients with IRP > 25 (80%) compared with those with IRP < 25 (28%; P = 0.028). CONCLUSION: 1-EGJ-OO is common in patients referred for esophageal manometry. 2-An additional esophageal body diagnosis is common in those with EGJ-OO.3-Esophageal diagnoses are more common in patients with dysphagia and in those with a very high IRP. The body of the esophagus is important in cases of EGJ-OO and should be reported independent of the computer-generated interpretation of the Chicago Classification.

Esophageal Perforation after Anterior Cervical Spine Surgery

Study DesignRetrospective case analyses.PurposeTo investigate the causes, diagnosis, and management of esophageal perforation, depending on the time of diagnosis.Overview of LiteratureTo date, few studies have addressed these issues.MethodsA total of seven patients were included in this study. The patients were classified into three groups based on esophageal perforation diagnosis time: intraoperative (diagnosed during surgery), perioperative (diagnosed within 30 days postoperatively), and delayed (diagnosed >30 days postoperatively) groups.ResultsIn the intraoperative group (N=2), infectious spondylitis was the main cause of esophageal perforation. Anterior plate and screw removal, followed by posterior instrumentation, was performed. The injured esophagus was managed by omentum flap repair in one patient and primary repair in one patient. In the perioperative group (N=2), revision surgery for infection and metal failure were the main causes of esophageal perforation. In both cases, food residue was drained on the third postoperative day. The injured esophagus was managed conservatively. In the delayed group (N=3), chronic irritation caused by metal failure was the main cause of esophageal perforation. In all patients, there was no associated infection. The anterior instrumentation was removed, and the two patients were treated by primary repair, and one patient was treated using sternocleidomastoid muscle flap. One patient in intraoperative group died of sepsis.Conclusions The main cause of intraoperative esophageal perforation was esophageal adhesions because of infectious spondylitis. However, perioperative and delayed esophageal perforations were caused by chronic irritation because of metal failure. Anterior plate and screw removal was necessary, and posterior instrumentation and fusion may be considered, depending on the fusion status.

External validation of a model to determine risk of progression of Barrett's oesophagus to neoplasia.

A risk prediction model containing sex, smoking history, Barrett's oesophagus length and presence of low-grade dysplasia was found to identify individuals at a higher risk of progression to oesophageal adenocarcinoma or high-grade dysplasia. To externally validate the model predicting risk of progression from Barrett's oesophagus to neoplasia and assess the predictive utility of additional factors. We conducted a retrospective cohort study among individuals from the population-based Northern Ireland Barrett's register with a histologically confirmed diagnosis of Barrett's oesophagus (with intestinal metaplasia) between 1993 and 2005. The association between a points based model and risk of progression to high-grade dysplasia or oesophageal adenocarcinoma until 2010 was assessed using Cox Proportional Hazards model. Model performance was assessed using area under the receiver operating characteristics curves (AUROC), sensitivity and specificity. We identified 1198 individuals with Barrett's oesophagus of whom 54 progressed. The model discriminated reasonably well between progressors and nonprogressors, with an AUROC of 0.70 (95% CI 0.63-0.78). When categorised into low, intermediate and high risk groups, the AUROC was 0.68 (95% CI 0.61-0.74). Compared to using data on dysplasia and segment length for risk stratification, the model resulted in a net reclassification improvement of 20.9%. This external validation provides further evidence that a model based on sex, smoking, Barrett's segment length and baseline low-grade dysplasia may help to risk stratify patients after an initial diagnosis of Barrett's oesophagus. The model also performed better than the use of low-grade dysplasia status alone for risk-stratification.

Methylation Biomarker Panel Performance in EsophaCap Cytology Samples for Diagnosing Barrett's Esophagus: A Prospective Validation Study.

Barrett's esophagus is the only known precursor of esophageal adenocarcinoma (EAC). Although endoscopy and biopsy are standard methods for Barrett's esophagus diagnosis, their high cost and risk limit their use as a screening modality. Here, we sought to develop a Barrett's esophagus detection method based on methylation status in cytology samples captured by EsophaCap using a streamlined sensitive technique, methylation on beads (MOB). We conducted a prospective cohort study on 80 patients (52 in the training set; 28 in the test set). We used MOB to extract and bisulfite-convert DNA, followed by quantitative methylation-specific PCR to assess methylation levels of 8 previously selected candidate markers. Lasso regression was applied to establish a prediction model in the training set, which was then tested on the independent test set. In the training set, five of eight candidate methylation biomarkers (p16, HPP1, NELL1, TAC1, and AKAP12) were significantly higher in Barrett's esophagus patients than in controls. We built a four-biomarker-plus-age lasso regression model for Barrett's esophagus diagnosis. The AUC was 0.894, with sensitivity 94.4% [95% confidence interval (CI), 71%-99%] and specificity 62.2% (95% CI, 44.6%-77.3%) in the training set. This model also performed with high accuracy for Barrett's esophagus diagnosis in an independent test set: AUC = 0.929 (P < 0.001; 95% CI, 0.810%-1%), with sensitivity=78.6% (95% CI, 48.8%-94.3%) and specificity = 92.8% (95% CI, 64.1%-99.6%). EsophaCap, in combination with an epigenetic biomarker panel and the MOB method, is a promising, well-tolerated, low-cost esophageal sampling strategy for Barrett's esophagus diagnosis. This approach merits further prospective studies in larger populations.

Learning visual representations with optimum-path forest and its applications to Barrett’s esophagus and adenocarcinoma diagnosis

In this work, we introduce the unsupervised Optimum-Path Forest (OPF) classifier for learning visual dictionaries in the context of Barrett's esophagus (BE) and automatic adenocarcinoma diagnosis. The proposed approach was validated in two datasets (MICCAI 2015 and Augsburg) using three different feature extractors (SIFT, SURF, and the not yet applied to the BE context A-KAZE), as well as five supervised classifiers, including two variants of the OPF, Support Vector Machines with Radial Basis Function and Linear kernels, and a Bayesian classifier. Concerning MICCAI 2015 dataset, the best results were obtained using unsupervised OPF for dictionary generation using supervised OPF for classification purposes and using SURF feature extractor with accuracy nearly to 78% for distinguishing BE patients from adenocarcinoma ones. Regarding the Augsburg dataset, the most accurate results were also obtained using both OPF classifiers but with A-KAZE as the feature extractor with accuracy close to 73%. The combination of feature extraction and bag-of-visual-words techniques showed results that outperformed others obtained recently in the literature, as well as we highlight new advances in the related research area. Reinforcing the significance of this work, to the best of our knowledge, this is the first one that aimed at addressing computer-aided BE identification using bag-of-visual-words and OPF classifiers, being this application of unsupervised technique in the BE feature calculation the major contribution of this work. It is also proposed a new BE and adenocarcinoma description using the A-KAZE features, not yet applied in the literature.

Postoperative Esophageal Leaks in Malignant Pathology - Optimal Management: A Systematic Review

Postoperative esophageal leaks are one of the major causes of postoperative mortality and morbidity. The purpose of this study was to review current knowledge of current methods of diagnosis and management of postoperative esophageal leaks. Methods: A systematic literature search was performed in the PubMed/Medline database using the terms "postoperative esophageal leaks" and "postesophagectomy complications" to identify articles relevant to the current diagnostic and prophylactic and curative treatment of post-oesophagectomy anastomotic fistulas. Results: Several papers have shown that the incidence of fistulas varies and is dependent on several factors: the location of the anastomosis, the type of suture used, the biological condition of the patient. Due to the severity of the mediastinal anastomotic fistula, great importance is being given to the methods of preventing its occurrence by intraoperative testing or improving the gastric tube vascularity. The most recent articles present endoscopic methods of treating this complication by using coated esophageal stents and endoluminal vacuum therapy. In patients with mediastinal postoperative esophageal fistulas, diagnosis and management represent a real challenge for the surgeon-endoscopist-therapist team. The early diagnosis and the establishment of an optimal therapy to address the parietal defect and the biological status of the patient are mandatory conditions for resolving this postoperative complication.

Obesity Associated With Higher Risk of Barrett’s Esophagus but Indolent Disease Progression: A Nationwide Analysis

Introduction: Obesity has been associated with worse outcomes in patients with Barrett’s esophagus (BE) and linked to increased odds of metaplasia. Latest studies are now relatively old, small or with limited number of outcome measures. The aim of our study was to explore the association between BMI categories and BE occurrence and associated mortality and resource utilization using a national database. Methods: This case-control study utilized the 2014 National Inpatient Sample. All patients with BE were included using ICD9CM codes. None were excluded. The cohort was stratified into four categories: malnourished, normal/overweight, obese and morbidly obese using ICD9CM codes and compared to non-BE controls. The primary outcome was the odds of BE across cohorts. Secondary outcomes included top admission reasons, length of hospital stay (LOS), total hospitalization charges and costs. Multivariate regression adjusted for age, sex, income in patient zip code, Charlson Comorbidity Index (CCI), hospital region, location, size and teaching status. An interaction term allowed odds comparison between cohorts. Propensity matching yielded a 1:1 matching population for gender, age and CCI. Results: 113,355 patients with BE were propensity matched to controls including 4,450 malnourished, 92,095 normal/overweight, 9,240 obese and 7,570 morbidly obese. All cohorts had higher odds of BE, with the obese cohort featuring the highest odds at 1.34 (p<0.01) compared to controls. After adjusting for confounders, malnourished patients had increased mortality odds (aOR:2.48,p<0.01), and obese patients had decreased mortality odds (aOR:0.60,p=0.05), though results did not differ clinically from non-BE populations. Table 1 and 2 display all outcomes and top admission reasons. Cohorts did not differ in total costs or hospitalization charges compared to controls. Malnourished and morbidly obese BE patients had shorter LOS compared to non-BE controls (p=0.03). Conclusion: The malnourished, obese and morbidly obese cohorts had higher adjusted odds of BE. Subgroups with the highest unadjusted mortality were the malnourished, normal/overweight, morbidly obese and obese, though differences were not statistically significant on multivariate analysis when comparing BE and non-BE patients. No clinically significant differences in LOS, total costs or charges were noted between BE and non-BE cohorts. This suggests that the slow disease progression does not significantly impact clinical outcomes in inpatients.368_A Figure 1. Means and Adjusted odds ratios for the evaluated parameters in malnourished, obese and morbidly obese patients when compared to normal/overweight controls, stratified by the presence or absence of Barrett’s esophagus diagnosis.368_B Figure 2. Top five admission diagnoses in patients with Barrett’s esophagus.

Acid suppression medications reduce risk of oesophageal adenocarcinoma in Barrett's oesophagus: a nested case‐control study in US male veterans

Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) may reduce the risk of oesophageal adenocarcinoma (OAC) in Barrett's oesophagus; however, current epidemiologic studies are inconclusive. To evaluate the independent effects of PPIs and H2RAs on risk of OAC in patients with Barrett's oesophagus. We conducted a nested case-control study of male veterans diagnosed with Barrett's oesophagus. Cases with incident OAC were matched by incidence density sampling on birth year and Barrett's diagnosis date to controls with Barrett's oesophagus who did not develop OAC. We identified prescription medication usage 1 year prior to Barrett's oesophagus diagnosis to 3 months prior to the OAC diagnosis. Odds ratios (OR) and 95% CI were estimated using conditional logistic regression. Compared with 798 controls, the 300 cases were less likely to use PPIs (90.0% vs 94.5%, P = 0.01) and H2RAs (19.7% vs 25.7%, P = 0.04). In the multivariable model including the use of statins, H2RAs, aspirin and nonsteroidal anti-inflammatory drugs, PPI use was associated with 41% lower risk of OAC (OR 0.59, 95% CI 0.35-0.99). While risk reduction of OAC was stronger for high-dose PPIs (omeprazole daily dose >40 mg, adjusted OR 0.11, 95% 0.04-0.36), we did not find a dose-response relationship with PPI duration (P trend = 0.45). Likewise, H2RA use was independently associated with 30% lower risk of OAC (OR 0.70, 95% CI 0.50-0.99). Use of PPIs and H2RAs among patients with Barrett's oesophagus are associated with lower risk of OAC. Further clinical trials are needed to confirm this possible chemopreventive effect.

Incidence, morbidity and mortality of patients with achalasia in England: findings from a study of nationwide hospital and primary care data.

Achalasia is an uncommon condition characterised by failed lower oesophageal sphincter relaxation. Data regarding its incidence, prevalence, disease associations and long-term outcomes are very limited. Hospital Episode Statistics (HES) include demographic and diagnostic data for all English hospital attendances. The Health Improvement Network (THIN) includes the primary care records of 4.5 million UK subjects, representative of national demographics. Both were searched for incident cases between 2006 and 2016 and THIN for prevalent cases. Subjects with achalasia in THIN were compared with age, sex, deprivation tand smoking status matched controls for important comorbidities and mortality. There were 10 509 and 711 new achalasia diagnoses identified in HES and THIN, respectively. The mean incidence per 100 000 people in HES was 1.99 (95% CI 1.87 to 2.11) and 1.53 (1.42 to 1.64) per 100 000 person-years in THIN. The prevalence in THIN was 27.1 (25.4 to 28.9) per 100 000 population. Incidence rate ratios (IRRs) were significantly higher in subjects with achalasia (n=2369) compared with controls (n=3865) for: oesophageal cancer (IRR 5.22 (95% CI: 1.88 to 14.45), p<0.001), aspiration pneumonia (13.38 (1.66 to 107.79), p=0.015), lower respiratory tract infection (1.33 (1.05 to 1.70), p=0.02) and mortality (1.33 (1.17 to 1.51), p<0.001). The median time from achalasia diagnosis to oesophageal cancer diagnosis was 15.5 (IQR 20.4) years. The incidence of achalasia is 1.99 per 100 000 population in secondary care data and 1.53 per 100 000 person-years in primary care data. Subjects with achalasia have an increased incidence of oesophageal cancer, aspiration pneumonia, lower respiratory tract infections and higher mortality. Clinicians treating patients with achalasia should be made aware of these associated morbidities and its increased mortality.

Symptom association probability does not reliably distinguish functional heartburn from reflux hypersensitivity.

Symptom association probability (SAP) is thought to distinguish reflux hypersensitivity from functional disorders. A diagnosis of hypersensitive oesophagus (SAP-positive) indicates that gastro-oesophageal reflux disease (GERD) is the cause of continued symptoms. To conduct an analysis of pH and symptom criteria that lead to a diagnosis of SAP-positivity METHODS: We calculated SAP for 205 patients with GERD symptoms refractory to proton pump inhibitor (PPI) therapy who underwent endoscopy with wireless pH monitoring from 2007 to 2014. Patients were divided into three groups: pH-negative with no oesophagitis (n = 45), pH-positive with no oesophagitis (n = 130), and patients with oesophagitis (n = 30). We constructed a 2 × 2 table of symptom and reflux event association and quantified the number of 2-minute intervals for each of the 2 × 2 variables that distinguished SAP-positive from SAP-negative. In a separate cohort of 58 patients who had undergone anti-reflux surgery, we evaluated the effects of pre-surgery SAP. The difference in symptom association parameters that led to a diagnosis of an SAP-positive was small (2.98% in oesophagitis-positive; 1.56% in oesophagitis-negative/pH-positive; 0.48% in oesophagitis-negative/pH-negative). In the pH-negative/oesophagitis-negative group, a difference of 0.48% led to a diagnosis of hypersensitivity. There was significant variability in SAP values between day 1 and day 2 of pH testing in all groups, with the greatest in the oesophagitis-positive group, despite objective evidence for reflux (27% in oesophagitis-positive, 19% pH-positive/oesophagitis-negative, and 7% in pH-negative/oesophagitis-negative). Pre-surgery SAP was not associated with response to anti-reflux surgery. In PPI-refractory GERD, SAP cannot accurately distinguish reflux hypersensitivity from functional oesophageal symptoms.

Endoscopic diagnosis of hiatus hernia under deep inspiration is not consistent with esophageal manometric diagnosis

To investigate the relationship between endoscopic and esophageal manometric hiatus hernia (HH). Forty-six gastroesophageal reflux disease patients with endoscopic HH under maintenance therapy were recruited. Endoscopy was performed on all patients in a fully conscious state. Endoscopic HH was defined as apparent separation greater than 1cm of the lower margin of the esophageal palisade vessels and the diaphragm hiatus on endoscopy under deep inspiration. Esophageal manometry was conducted using high-resolution manometry (HRM). The length between the lower margin of the lower esophageal sphincter and pulmonary inversion point was measured 10 times. The mean and maximum of the length was then calculated. The mean HH length on HRM was 0cm (0-0) [median (25th to 75th percentile)], 0cm (0-0), 0.5cm (0-1.1), and 2.2cm (1.3-2.5) in the groups with endoscopic HH lengths of 1-2, 2-3, 3-4, and 4-5cm, respectively. The maximum HH length on HRM was 0cm (0-0), 0cm (0-0), 0.8cm (0-1.4), and 2.4cm (1.5-2.9) in the 1-2, 2-3, 3-4, and 4-5cm endoscopic HH groups, respectively. The mean and maximum HH lengths increased significantly in the group with an endoscopic HH length of 4-5cm compared with the other groups, but did not differ significantly among the 1-2, 2-3, and 3-4cm groups. Of patients with endoscopic HH less than 3cm, few had esophageal manometric HH greater than 2cm. Endoscopic diagnosis of HH under deep inspiration is not consistent with esophageal manometric diagnosis, leading to overdiagnosis.

WATS 3D Brush Biopsy Variability Compared to Traditional Forceps Biopsy in the Identification of Barrettʼs Esophagus and Dysplasia Diagnosis

Introduction: Barrett's esophagus (BE) is a premalignant condition that requires surveillance to monitor for progression to dysplasia and esophageal adenocarcinoma. Wats 3D transepithelial biopsy (Wats3D) has been developed to augment traditional biopsy and with the intent to better detect dysplasia and esophageal adenocarcinoma. The aim of this study was to compare the variability of detection of Barrett's esophagus, degree of dysplasia and adenocarcinoma of Wats 3D brush biopsy to traditional forceps biopsy. Methods: 27 patients who have a clinical history of GERD and who had an EGD had both traditional forceps biopsies utilizing Seattle protocol and Wats 3D biopsy were identified. Any patient who had traditional biopsy but not Wats or vice versa were excluded. The results of identification of Barrett's esophagus, degree of dysplasia, or adenocarcinoma were compared between the two biopsy types using a Kappa coefficient Results: Kappa coefficient was calculated at 0.49 indicating moderate agreement between the two biopsy types (P=0.01, 95% confidence interval). Of the 27 patient's in the study 6 patients had Wats biopsy and forceps biopsies that did not agree. Of these six patient's, four patients (14.8%) had forceps biopsies that had more advanced pathology (low grade dysplasia vs barrett's in two cases, and barrett's vs no barrett's in two), while two patients (7.4%) had more advanced pathologic diagnosis with Wats 3D vs forceps biopsies. One of these patients had esophageal adenocarcinoma on Wats 3D but only Barrett's with high grade dysplasia on forceps biopsies Conclusion: Esophageal adenocarcinoma has a high mortality rate and a poor prognosis. As such screening for and surveillance of BE are critical in preventing progression. Wats transepithelial biopsy allows an endoscopist to obtain a wide area, full thickness biopsy and then a computer assisted 3D analysis is made in which the 200 of the most suspect cells and cell clusters are analyzed by a pathologist. By taking a wider biopsy with Wats technology, it stands to reason that the rate of detection of Barrett's esophagus and adenocarcinoma may be higher, or can at the very least be used to augment traditional biopsy for better detection rates. We found that there was a moderate amount of agreement between the two biopsy types. The data shows that while Wats 3D biopsy cannot replace traditional biopsies, the two can be combined to increase sensitivity when diagnosing Barrett's. It is our practice to treat the biopsy with the highest degree of severity in accordance with ACG guidelines. Overall, Wats should be considered an adjunct to traditional forceps biopsy in the screening and surveillance of patient's with Barret's.

Esophageal Acclimation to Catheter Placement During High-Resolution Manometry: A Case Series

Introduction: While many labs allow patients to acclimate to catheter placement prior to undergoing measurement, there is no agreement about the ideal timing of measurement. Our experience at a military tertiary care center suggests that a standardized period of acclimation should be employed to minimize pressure artifact and obtain the correct diagnosis. Six cases are presented where a 10 minute acclimation period resulted in 6 different diagnoses versus obtaining a measurement immediately following catheter placement.Table. DemographicsTable: Table. IRP4, DCI and Diagnosis Before and After AcclimationMethods: Topical anesthesia (Lidocaine) was given as a gargle and trans-nasally. A unidirectional MMS-catheter was positioned such that measurements of the UES, LES and gastric pressures could be obtained. Immediately following catheter placement, the patient underwent five 5 ml swallows. This was followed by a 10 minute acclimation period when the patient's history was obtained. Ten 5 ml swallows were then performed. Swallow vigor, integrity and IRP4 were obtained for each phase of swallows and appropriate Chicago Classification V3 diagnoses were applied. Results: The mean age of our patients (3 M, 3F, mean age: 41.5±9.4 yrs.) with varying symptoms (see chart). Mean IRP4 decreased in all patients (15.42 vs. 12.92 mmHg, mean %change -13.89%±0.5935, P=0.4) except for one patient with achalasia type II whose IRP increased during the 2nd measurement. DCI decreased markedly between the 1st and 2nd measurement (1888 vs. 757 mmHg, mean change=-1131±626 mm Hg, P=0.1056). Most significantly, the diagnosis changed in all six patients between the first and second measurement. Conclusion: (1) A significant change in esophageal motility findings occurs if patients are allowed to acclimate and relax prior to HRM testing. (2) Following a period of acclimation, esophageal body (DCI) and LESp decrease. (3) These motility changes may result in different esophageal motility diagnosis. (4) More stable HRM results occurs by waiting a 10 minutes prior to performing in the procedure. We hypothesize that fluid build-up, anxiety and esophageal spasm or relaxation triggered by catheter placement could contribute to false measurements, though more controlled research and larger trials are needed to confirm our suspicions.

Benign esophageal schwannoma: a brief overview and our experience with this rare tumor

BackgroundBenign esophageal tumors are uncommon, comprising approximately 2% of esophageal tumors. Esophageal schwannomas constitute an even rarer entity, with few cases reported in the literature.Case presentationWe present a 66-year-old male who was referred for dysphagia. A computed tomography scan showed a well-demarcated, enhancing, and homogenous esophageal tumor measuring 50 mm. The tumor was hypermetabolic on positron emission tomography, and an endoscopic ultrasound-guided fine needle aspiration demonstrated the presence of benign spindle cells. We performed an uncomplicated, simple, tumor enucleation through a cervical approach. Histology revealed spindle-shaped cells in a fasciculated, disarrayed pattern. Immunohistochemistry demonstrated positive staining for S-100 protein and negative staining for KIT, CD34, desmin, and α-smooth muscle actin. These findings were consistent with a benign esophageal schwannoma.ConclusionsWe report our experience with esophageal schwannoma, a rare but benign diagnosis of the esophagus.

Difference of achalasia subtypes based on clinical symptoms, radiographic findings, and stasis scores

IntroductionThree subtypes of achalasia have been defined through high-resolution esophageal manometry: subtype i shows no pressurization with swallows, subtype ii has increased isobaric panesophageal pressure, and subtype iii has distal esophageal spastic non-isobaric contractions. Studies describing the subtypes based on radiographic findings, clinical symptoms, and stasis scores are limited. AimTo determine the differences in clinical symptoms, radiographic findings, and stasis scores for the 3 achalasia subtypes. MethodsPatients undergoing high-resolution esophageal manometry received a questionnaire about current symptoms and previous treatments. The questions included the presence of symptoms and their severity. Barium swallow tests were performed before the high-resolution esophageal manometry study to evaluate the maximum esophageal diameter. Stasis scores were calculated using the transit patterns on high-resolution esophageal manometry. ResultsOne hundred and eight patients with high-resolution esophageal manometry diagnosis of achalasia (n=8, subtype i; n=84, subtype ii; n=16, subtype iii) within the time frame of 1/2012-6/2015 were included in the study. Sex distribution was similar between the subtypes. Patient age was younger for subtype i (38±16 years), compared with subtypes ii (55±17 years) and iii (63±17 years) (P=.03). Esophageal symptoms did not differ between subtypes regarding the severity of nausea, chest pain, coughing, and heartburn, except for increased vomiting severity in subtype i (2.8±1.4 vs. 1.4±1.4 vs. 1.2±1.2, P<.01). A significant radiographic difference in esophageal dilation was seen between subtypes ii and iii (35.1±14.4 vs. 24.0±7.2mm, P=.023). Stasis scores did not significantly differ between the subtypes. ConclusionsAchalasia subtypes had similar clinical symptoms, except for increased vomiting severity in subtype i. The maximum esophageal diameter in subtype ii was significantly greater than in subtype iii. Esophageal stasis scores were similar. Thus, high-resolution esophageal manometry remains essential in assessing achalasia subtypes.

High-resolution esophageal manometry: interpretation in clinical practice.

Esophageal high-resolution manometry (HRM) is the current state-of-the-art diagnostic tool to evaluate esophageal motility patterns and, as such, is widely adopted in clinical practice. This article will review the interpretation of esophageal HRM in clinical practice. HRM uses a high-resolution catheter to transmit intraluminal pressure data that are subsequently converted into dynamic esophageal pressure topography (EPT) plots. Metric data from EPT plots are synthesized to yield an esophageal motility diagnosis according to the Chicago Classification, a formal analytic scheme for esophageal motility disorders, which is currently in version 3.0. The standard HRM protocol consists of a baseline phase and a series of 10 wet swallows in the supine or reclined position. In addition, data from swallows in the seated position and provocative HRM maneuvers provide useful information about motility properties. Combined high-resolution impedance technology is also clinically available and enables concurrent assessment of bolus transit and postprandial responses. Finally, there is ongoing interest to optimize the training and competency assessment for interpretation of HRM in clinical practice. Esophageal HRM is a valuable and sophisticated clinical tool to evaluate esophageal motility patterns. Emerging clinical applications of esophageal HRM include combined impedance technology, provocative maneuvers, and postprandial evaluation.

1002 Impact of Receipt of Serial Endoscopic Procedures Prior to Esophageal Adenocarcinoma Diagnosis on Stage and Survival

1002 Impact of Receipt of Serial Endoscopic Procedures Prior to Esophageal Adenocarcinoma Diagnosis on Stage and Survival

Identification of molecular targets for esophageal carcinoma diagnosis using miRNA-seq and RNA-seq data from The Cancer Genome Atlas: a study of 187 cases.

Esophageal carcinoma (ESCA) is one of the most common malignancies worldwide, and its pathogenesis is complex. In this study, we identified differentially expressed miRNAs (DEMs) and genes (DEGs) of ESCA from The Cancer Genome Atlas (TCGA) database. The diagnostic values of DEMs were determined by receiver operating characteristic (ROC) analyses and validated based on data from Gene Expression Omnibus (GEO). The top five DEMs with the best diagnostic values were selected, and their potential targets were predicted by various in silico methods. These target genes were then identified among the DEGs from TCGA. Furthermore, the overlapping genes were subjected to protein-protein interaction (PPI) analysis, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. The miRNA-transcription factor (TF) regulatory relations were determined using CircuitsDB and TransmiR. Finally, the regulatory networks of miRNA-TF and miRNA-gene were constructed and analyzed. A total of 136 DEMs and 3541 DEGs were identified in ESCA. The top five DEMs with the highest area under the receiver operating characteristic curve (AUC) values were miRNA-93 (0.953), miRNA-21 (0.928), miRNA-4746 (0.915), miRNA-196a-1 (0.906) and miRNA-196a-2 (0.906). The combined AUC of these five DEMs was 0.985. The KEGG analysis with 349 overlapping genes showed that the calcium signaling pathway and the neuroactive ligand-receptor interaction were the most relevant pathways. The regulatory networks of miRNA-TF and miRNA-gene, including 38 miRNA-TF and 560 miRNA-gene pairs, were successfully established. Our findings may provide new insights into the molecular mechanisms of ESCA pathogenesis. Future research will aim to explore the role of novel miRNAs in the pathogenesis and improve the early diagnosis of ESCA.