Esophageal Route Research Articles

Development of Test Programs for the Biorelevant Characterization of Esophageal-Applied Dosage Forms.

In the local treatment of the esophageal mucosa, the retention time of the different dosage forms, such as tablets, films or liquids, is of high relevance for the effective treatment of diseases. Unfortunately, there are only few in vitro models describing the esophageal route of administration. To predict the behaviour of an esophageal-applied dosage form, it is necessary to simulate the site of application in a biorelevant way. The aim of this work was to develop two test setups for an esophageal peristalsis model which was described in a previous study. Different parameters such as flow rate, peristalsis, angle of inclination or mucous membrane were varied or introduced into the model. A stimulated and unstimulated modus were developed and tested with two different dosage forms. The time until the dosage form was cleared from the in vitro model was shorter with the stimulated than with the unstimulated modus. Also, esophageal-applied films had a prolonged transit time compared to a viscous syrup. The modification of the simulated esophageal surface made it possible to estimate the retention time of the dosage forms. It could be demonstrated that the residence time of a dosage form depends on different parameters affecting each other.

Imaging Modality to Guide Left Atrial Appendage Closure: Current Status and Future Perspectives.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults. The left atrial appendage (LAA) is the most likely source of thrombus formation in patients with non-valvular atrial fibrillation (NVAF). Left atrial appendage closure (LAAC) represents an effective alternative to NOAC in patients with NVAF. Expert consensus documents recommend intraprocedural imaging by means of either transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in addition to standard fluoroscopy to guide LAAC. TEE-guided LAAC usually requires general anesthesia. The ICE technique is a "minimalist approach", without general anesthesia, but ICE imaging techniques are not yet simplified and standardize, and the ICE may result in inferior image quality compared with that of TEE. Another "minimalist approach" can be the use of ICE via the esophageal route (ICE-TEE), that jet is validated to identify the presence of LAA thrombi in patients and to perform other procedures. In our cath laboratory ICE-TEE to guide LAAC is used in some complex patients. Indeed, our single center experience suggests that ICE-TEE could be a good alternative imaging technique to guide LAAC procedure without general anesthesia.

OUTSPREADING THE BORDERS OF INTERVENTIONAL PULMONOLOGY: THE EVER-GROWING APPLICATIONS OF COMBINED EBUS/EUS-B

TYPE: Late Breaking Abstract TOPIC: Procedures INTRODUCTION: Interventional pulmonary disposes of echoendoscopic techniques that can be used in a tracheal or esophageal route, with great impact on the diagnosis and staging of lung cancer. Other diagnostic potentialities are also possible, although there are still few reports described in the literature. CASE PRESENTATION: A 62-year-old female smoker presented a spiculated nodule in the posterior segment of the left upper lobe and another adjacent to the anterior wall of the gastric body. She was scheduled to perform endoscopic examination under general anaesthesia. No endobronchial abnormalities were detected through conventional bronchoscopy. The pulmonary nodule was accessed by radial endobronchial ultrasound (EBUS) and transbronchial biopsy was performed. The heterogeneous abdominal nodule was approached via esophageal EBUS (EUS-B) needle aspiration. A structured EUS assessment of six landmarks was also performed. No complications were recorded. The pathology report described coexistence of lung adenocarcinoma and gastrointestinal stromal tumour. DISCUSSION: This case highlights the success of radial EBUS in peripheral pulmonary nodules without endobronchial involvement and the added benefit of the endobronchial bronchoscope that can also be passed into the esophagus and stomach, thereby allowing adjacent structures to be sampled. The combination of these techniques allowed the prompt diagnosis of an uncommon event of two synchronous tumours. CONCLUSIONS: EUS-B is complementary to EBUS and is well suited in the hands of a trained pulmonologist. These techniques have shown that most of the previous limitations can be overcome in a single session, by one operator and with a high diagnostic yield, thereby decreasing healthcare cost, time delays and patient discomfort. DISCLOSURE: No significant relationships. KEYWORD: Diagnosis; Combined endoscopic-endobronchial ultrasound-guided transbronchial needle aspiration

Anatomical insights into posterior wall isolation in patients with atrial fibrillation: A hypothesis to protect the esophagus.

Left atrial posterior wall (LAPW) isolation may be performed as an additional atrial fibrillation (AF) ablation strategy based on pulmonary vein isolation. A modified posterior-inferior line (MPL) was proposed for reducing esophageal injury. The aim of this study was to evaluate the anatomical characteristics of the MPL, compared with the conventional posterior line (CPL). Multidetector computed tomography was performed in 102 consecutive AF patients (male/female = 60/42) preoperative, and the parameters were evaluated as follows: the distance from MPL and CPL to the esophagus, fat pad presence and thickness in the course of MPL and CPL, and the esophageal route below CPL. The average distance from the MPL to the esophagus was longer than from CPL to the esophagus (3.7 ± 1.5 vs. 1.7 ± 0.4 mm, p < .001). Proportion of fat pad was higher in the course of MPL than CPL. The myocardium tissue and fat pad under MPL was thicker than under CPL (2.9 ± 1.1 vs. 1.6 ± 0.3 mm, p < .001; 1.4 ± 0.6 vs. 0.9 ± 0.2 mm, p < .001), respectively. In patients whose esophagus was unconfined in a triangular space at the left inferior pulmonary vein level, the average distance from MPL to esophagus was longer than the confined patients (4.0 ± 1.7 vs. 3.2 ± 1.0 mm, p = .001). The MPL was far away from the esophagus with thicker myocardium tissue and more fat pad than the CPL; thus, MPL could serve as a favorable alternative in linear ablation for LAPW isolation.

EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial.

Endobronchial Ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard of care modality for the evaluation of mediastinal lymphadenopathy. Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-B-FNA), wherein one introduces the EBUS bronchoscope through the esophageal route, is also a safe and efficacious diagnostic modality for sampling the mediastinal lymph nodes. The objective of this study was to compare the diagnostic yield and patient comfort with these two available approaches. We randomized subjects with predominant subcarinal or lower left paratracheal mediastinal lymph node enlargement to either EBUS-TBNA or EUS-B-FNA (50 to each group). Co-Primary objectives were the comparison of adequate and diagnostic aspirates between groups. Key secondary objectives were a comparison of Operator rated cough and Operator rated procedural comfort on Visual Analog scale (VAS), procedure duration and complications between the groups. Baseline characteristics were comparable between the groups. The proportion of adequate (EBUS-TBNA 46/50; 92% and EUS-B-FNA 48/50;96%, P=0.4) and diagnostic aspirates (EBUS-TBNA 38/50; 76% and EUS-B-FNA 36/50;74%, P=0.4) were similar between the two groups. Operator rated cough was significantly less, and Operator rated patient comfort significantly higher with the EUS-B-FNA approach. Procedure duration was significantly shorter with EUS-B-FNA [18.1(14.4) minutes versus 16.4 (49.6) minutes, P<0.001]. Minor complications occurred in one patient in the EBUS-TBNA group and none in the EUS-B-FNA group. During the endosonographic evaluation for undiagnosed mediastinal lymphadenopathy located at predominantly the subcarinal or lower left paratracheal stations, EUS-B-FNA as compared with EBUS-TBNA provides greater patient comfort with a similar diagnostic yield.

Caulim e óxido crômico sob diferentes formas de administração em estudo de consumo e digestibilidade

Animal nutrition needs simple methodologies to be applied under field conditions, providing valid estimates of consumption and digestibility that can be used by both farmers and animal input industry. Thus, the search for new substances, provided in a practical way, quantified by simple and low-cost analytical methodologies, replacing external indicators (chromic oxide used as reference) would be well accepted by the scientific community. In this context, the aim of this study was to assess the supply of chorionic oxide by esophageal route or mixed in the diet and the use of kaolin as an indicator, under the same forms of administration, to estimate fecal production and digestibility using four castrated male Holstein cattle. The experimental design was a 4 × 4 Latin square design, with four experimental periods of 12 days and six-day intervals between periods. Treatments consisted of supplying chromic oxide by esophageal route (COer), kaolin by esophageal route (Kaoer), chromic oxide mixed to the diet (COdiet), and kaolin mixed to the diet (Kaodiet). The treatment Kaodiet allowed obtaining estimates of fecal production similar to the treatment COer. The treatment COdiet did not differ from the treatment COer (p &gt; 0.05) considering all the assessed parameters, evidencing that the indicator chromic oxide can be supplied mixed directly in the diet without damaging the estimates of fecal production and digestibility. Under the studied conditions, kaolin was not an effective indicator to obtain accurate estimates of fecal production and further studies are needed to adjust the analytical techniques of aluminum extraction as well as to resolve some doubts regarding its digestion process.

Transoral Extraction of a Laparoscopically Resected Large Gastric GIST

Although natural orifice specimen extraction is now widely performed, there have been no reports of transoral extraction following laparoscopic gastric resection. This report describes the first transoral specimen extraction in a patient with a gastrointestinal stromal tumor (GIST) of the lesser curvature of the stomach. The clinical data of a patient with a large gastric GIST were reviewed. Totally laparoscopic resection of the gastric lesser curvature was performed using four trocars. The specimen, put in a retrieval bag, was withdrawn via the transgastric and esophageal route. Reconstruction of the stomach was performed using the intracorporeal technique. The procedure was successfully accomplished without intraoperative and postoperative complications. In conclusion, transoral specimen extraction after laparoscopic gastric resection is a safe and feasible operative procedure for selected patients with a large benign gastric tumor.

Induction of therapeutic hypothermia via the esophagus: a proof of concept study.

Induction of hypothermia (a 4 °C decrease from baseline) improves outcomes in adult cardiac arrest and neonatal hypoxic ischemic encephalopathy, and may benefit other conditions as well. Methods used to implement or prevent hypothermia typically require skin contact with blankets or pads or intravascular access with catheter devices. The study was to evaluate the potential to induce mild therapeutic hypothermia via an esophageal route in a porcine model. Single-animal proof-of-concept study of a prototype esophageal device in a 70 kg Yorkshire swine. We measured the rate of temperature change after placement of a prototype device to induce hypothermia via the esophagus, and compared this rate to known temperature changes that occur under similar laboratory conditions without a hypothermic device. Swine temperature decreased from a starting temperature of 37.8 °C to 33.8 °C (achieving the goal of a 4 °C decrease) in 175 minutes, resulting in a cooling rate of 1.37 °C/h. Histopathology of the esophagus showed normal tissue without evidence of injury. A prototype of an esophageal cooling device induced hypothermia effectively in a large single-swine model.

Therapeutic hypothermia induction via an esophageal route—a computer simulation

ObjectivesMild therapeutic hypothermia has been shown to improve outcomes after adult cardiac arrest but remains underused. Development of easier methods than currently exist to induce therapeutic hypothermia may help increase use of this treatment. We developed a mathematical model to evaluate the potential to induce mild therapeutic hypothermia through the esophagus. MethodsUsing a finite element mathematical modeling software package incorporating Pennes Bioheat equation, we predicted the changes in body temperature that would occur with placement of an esophageal cooling device containing recirculating chilled water at 10°C. ResultsPatient temperature under the simulated conditions decreased from 37°C to 33°C in approximately 40 minutes. Distribution of body temperature was not uniform in our model, with the skin surface and extremities showing a greater temperature decrease than in the patient's core. ConclusionsOur computer simulations suggest that inducing mild therapeutic hypothermia via an esophageal route is feasible.

346: Computer Simulation of the Induction of Hypothermia Via an Esophageal Route

346: Computer Simulation of the Induction of Hypothermia Via an Esophageal Route

Esophageal reconstruction for hypopharyngoesophageal strictures after corrosive injury.

To evaluate the surgical outcome of patients with caustic stricture of the hypopharyngoesophagus. During a 25-year period, we performed esophageal reconstruction in 152 patients with diffuse or multiple caustic esophageal stricture. Of them, esophageal substitute was pulled up and anastomosed to the hypopharynx in 50 (33%) patients, and anastomosed to the cervical esophagus in the other 102 (67%) patients. Patients whose esophageal substitute anastomosed to the hypopharynx were enrolled to the present study. Among these 50 study patients, 13 underwent ablation of damaged organs and feeding jejunostomy in acute stage of corrosive injury, and the remaining 37 patients were initially organ preserved with or without feeding gastrostomy or jejunostomy. Six patients had respiratory distress caused by laryngotracheal stricture. The ileocolon (28/50) was commonly used as an esophageal substitute in reconstruction and most substitutes (43/50) went through the substernal route. There was one operative death. Eight (16%) patients had major early postoperative complications. Six patients underwent revision for late stenosis of hypopharyngeal anastomosis, and one redoing reconstruction using the jejunum because of failure of the transplanted ileocolon. Postoperatively, swallow function and maintaining body weight were considered good in 42 patients (84%) after an average of 8 months follow-up. Five of six patients who underwent concomitant tracheostomy or laryngosurgery for laryngotracheal stricture got unsatisfactory result. The surgical outcome of the study patients was worse than that in patients with esophageal substitute anastomosed to a healthy cervical esophagus. In the later group of patients, 95/102 (93%) had good swallow function and only 7/102 (6.8%) had major early complications. Caustic stricture of the hypopharyngoesophagus is a challenging reconstructive problem. A successful reconstruction requires a correct hypopharyngeal opening and anastomosis, a good esophageal substitute, and a patent esophageal route and airway.

Functional assessment of colonic interposition with 99Tc m-labeled milk

A prospective study was performed to evaluate the use of radionuclide imaging in the assessment of patients who have undergone esophageal reconstruction. Dynamic radionuclide imaging was performed on ten patients aged 11 months to 11 years who had undergone colon interposition via the normal esophageal route for esophageal atresia. Patients were considered clinically unsatisfactory if at the time of imaging feeding was troubled, or if weight gain had fallen to below the third centile before operation and remained below after operation. Each patient underwent erect imaging with a small milk feed labeled with 10 to 20 MBq (250 to 500 muCi) 99Tcm DTPA adjusted according to body surface area; supine studies were subsequently performed on five patients. All five clinically unsatisfactory patients showed conduit emptying delayed beyond 45 minutes and/or spontaneous reflux, significantly different from the clinically satisfactory patients (X2 = 6.4, P less than .02). Conduit complications were subsequently identified in three of the five clinically unsatisfactory patients. Radionuclide imaging with radiolabeled milk was found to be well tolerated, and obtained results that were clinically useful. These results suggest that dynamic radionuclide imaging can be more widely applied in the assessment of esophageal substitutes.

Colon interposition: A modification of the Waterston technique using the normal esophageal route

Intrathoracic colon interposition in children with esophageal atresia has been available for 30 yr. The retrosternal and left pleural cavity have been the preferred routes. The posterior mediastinal route does not appear to have been tried in children. Sixteen cases treated by the principle author (N.V.F.) using this route are presented. The mortality, anastomotic leakage and stricture rate (at each anastomosis) were 12.5%, respectively. The posterior mediastinal route is suggested as an alternative route for interposition of the colon or any other conduit.