Proximal Esophagus Research Articles

LET'S MEET IN THE MIDDLE: SIMULTANEOUS ENDOSCOPIC AND BRONCHOSCOPIC SUTURE REPAIR TO CLOSE A LEFT MAIN-STEM MALIGNANT BRONCHO-ESOPHAGEAL FISTULA

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: This case highlights a unique approach to manage broncho-esophageal fistula which is refractory to esophageal stenting. CASE PRESENTATION: We describe the case of a 68 year old female with stage IV squamous cell carcinoma of the esophagus status post chemotherapy, immunotherapy and radiation complicated by esophageal stricture requiring a fully covered 18mmx12.3cm WallFlex stent. Approximately three months after stent placement, she developed coughing with oral intake. Swallow study revealed contrast refluxing into the trachea, and CT scan showed presence of left mainstem broncho-esophageal fistula. Bronchoscopy demonstrated thick purulent secretions and a 1-1.5 cm defect of the left main, 5mm distal to the main carina. The esophageal stent was visualized through the defect. She underwent EGD with removal of the stent and was also found to have a large 3cm deep defect in the proximal esophagus and ulceration throughout the mid-esophagus. Due to high risk of perforation, the esophagus was not stable enough to safely allow stent replacement. Her defect was deemed non-operable. Bronchial stenting was considered; however, there was increased risk of pressure necrosis and mediastinits plus proximity of the fistula to the main carina made stenting difficult to size. We opted to pursue simultaneous flexible endoscopy with rigid bronchoscopy to close her broncho-esophageal fistula. We utilized an X-Tack Endoscopic HeliX Tacking System with one running suture as well as placed two 2.0 36 inch braided non-absorbable pledgeted sutures from the esophageal side with closure on the bronchial side with a Cor-Knot device. There was no evidence of saline leak over the fistula. Post-closure, she tolerated bedside swallow and was able to drink liquid without coughing. Follow up esophagram is pending. DISCUSSION: The current standard of care for management of malignant tracheal-esophageal fistula is esophageal with/without broncho-tracheal stent and is palliative in intent. Stenting was not a safe option in our patient. The use sutures placed via rigid scopes from the esophageal side to tracheal side with closure with a Cor-Knot device for management of tracheo-esophageal fistula has been described in one prior case report.(1) Our case further demonstrates the feasibility of this technique for management of airway-esophageal fistula. Our case is unique as it treats a fistula in the left mainstem bronchus as opposed to the trachea. Due to the distal location of the defect, we were unable to use the rigid esophageal tube to pass the sutures, so we straightened the sutures and successfully passed them through a flexible EGD scope. Our case also used an X-Tack running suture device to further stabilize our closure. CONCLUSIONS: This case demonstrates an effective alternative approach and potentially more viable solution to treat broncho-esophageal fistulas when endoscopic/endobronchial stenting is not permissible. REFERENCE #1: Mozer AB, Michel E, Gillespie C, Bharat A. Bronchoendoscopic Repair of Tracheoesophageal Fistula. Am J Respir Crit Care Med. 2019 Sep 15;200(6):774-775. doi: 10.1164/rccm.201812-2255IM. PMID: 30973758; PMCID: PMC6775884. DISCLOSURES: No relevant relationships by Navtej Buttar, source=Web Response No relevant relationships by Sangita Goel, source=Web Response No relevant relationships by Ryan Kern, source=Web Response No relevant relationships by John Mullon, source=Web Response No relevant relationships by Darlene Nelson, source=Web Response Research grant relationship with Intuitive Surgical Please note: $5001 - $20000 by Janani Reisenauer, source=Web Response, value=Grant/Research Support No relevant relationships by Linh Vu, source=Web Response

S2079 Granulomatous Esophageal Disease Mimicking Esophageal Malignancy

Introduction: We present a case of a young female patient with chronic dysphagia found to have an ulcerative esophageal mass. Pathology surprisingly demonstrated granulomatous inflammation. This case highlights the diagnostic challenges of gastrointestinal granulomatous disease mimicking esophageal malignancy. Case Description/Methods: A 22-year-old female presented with five years of progressive dysphagia to solid foods. Past medical history was significant for papillary thyroid carcinoma status post thyroidectomy two years prior (T1bN0M0) and psoriasis treated with topical corticosteroids. Upper endoscopy revealed a 2 cm ulcerated, partially obstructive mass in the lower third of the esophagus, Figure. Biopsy demonstrated granulomatous inflammation without neoplastic changes. Grocott’s methenamine silver stain (GMS) and Steiner stain showed small irregular structures in the granulomas. Acid-fast bacilli (AFB) stain was negative. A repeat upper endoscopy with endoscopic ultrasound (EUS) revealed an additional hypoechoic lesion in the proximal esophagus. EUS-guided fine needle aspiration of this lesion and repeat biopsy of the ulcerative mass both showed non-necrotizing granulomas without eosinophilia. GMS and AFB stains resulted negative. Colonoscopy with ileal and random biopsies was unremarkable. Interferon-gamma release assay, Treponema pallidum antibody, Legionella urine antigen, H. pylori stool antigen, and Histoplasma urine and serum antigens resulted negative. Computed tomography (CT) scan of the chest showed 1.1 cm and 0.6 cm right lower lobe pulmonary nodules and an enlarged right hilar node at 1.9 x 1.2 cm. The patient is awaiting pulmonary nodule biopsy given high suspicion for sarcoidosis. Discussion: Granulomatous disease of the gastrointestinal tract can be seen in infections, Crohn’s disease, sarcoidosis, malignancy, and immunodeficiency syndromes. The clinical context, morphology of the granuloma, and specialized stains for organisms can support a suspected diagnosis. Necrotizing granulomas are most frequently implicated in M. tuberculosis infection, while non-necrotizing granulomas have a wider differential diagnosis which includes infection, autoimmune disease, toxins, and medications. Sarcoidosis is suspected in our patient given the clinical history, negative diagnostic workup for infections and Crohn’s disease, and CT chest findings. In patients found to have gastrointestinal granulomas, a broad differential should be considered with thorough evaluation to obtain definitive diagnosis.Figure 1.: Lower third of the esophagus showing multiple yellowish plaque lesions.

S2096 Development of Achalasia in Chronic Intestinal Pseudo-Obstruction (CIPO)

Introduction: Neuroendocrine carcinoma (NEC) of the esophagus is a rare malignancy and represents approximately 0.4-2% of all esophageal cancer. Histologically, two types of NEC of the esophagus have been described: small cell NEC and large cell NEC. Small cell NEC is the more common type, comprising almost 95% of all NEC of the esophagus. Case Description/Methods: We present a 52-year-old Hispanic male with 30 pack year smoking history and chronic alcohol abuse presented with sore throat and worsening dysphagia to both liquids and solids for 3 weeks. Physical examination revealed anterior cervical swelling which was tender to palpation. The oropharynx looked moist with mild tonsillar erythema. Complete blood chemistry showed mild leucocytosis. COVID-19 PCR and streptococcal Ag test came back negative. The computer tomography (CT) of the neck with contrast revealed an esophageal mass at the level of T1- T2 with paratracheal extension associated with enlarged paratracheal lymph nodes. The endoscopic evaluation revealed a large bloody, exophytic, friable, and necrotic mass in the oropharynx which was partially obstructing the airway. A large, circumferential, ulcerating and partially obstructing mass was found in the proximal esophagus. Immunohistochemistry was positive for synaptophysin and chromogranin and negative for CK5/6 and p63. KI-67 was greater than 90%. The biopsies were consistent with a neuroendocrine malignancy. The decision was made to start him on cisplatin, etoposide with the addition of Durvalumab and radiation therapy. Discussion: Neuroendocrine tumors of the esophagus have an aggressive nature, with no current standard treatment guidelines. From the limited literature available, The treatment strategy is dictated by the extent of disease with surgery being the preference in limited disease and a combination of chemotherapy, immunotherapy, and radiation therapy for the extended disease. The most commonly used chemotherapy is cisplatin with etoposide and the addition of immunotherapy, durvalumab. An alternative chemotherapy regimen that may be used if patients exhibit intolerance to cisplatin includes carboplatin with etoposide and the addition of durvalumab. In our case, we used cisplatin, Etoposide, Durvalumab and radiotherapy which is protocol for small cell carcinoma of lung.Although many recent advances were made in NEC management, there are no definitive guidelines. As of now, despite all aggressive measures, NEC of the esophagus has a poor overall prognosis.

S1998 Two Scopes Are Better Than One: Esophageal Recanalization With the Rendezvous Procedure

Introduction: Esophageal strictures can occur in patients with head & neck cancers treated with radiotherapy. Rate of stricture in these cases is estimated to be between 2-16%. We present a case of severe esophageal stricture treated with combined antegrade-retrograde endoscopic dilation and biliary stent placement. Case Description/Methods: 76-year-old female with squamous cell carcinoma of the hypopharynx, with PEG tube for nutrition, presented with persistent dysphagia following completion of radiotherapy. Barium esophagram showed severe pharyngeal dysphagia with esophageal backflow and aspiration. Laryngoscopy and transnasal esophagoscopy revealed a blind ending pouch in the proximal esophagus. After unsuccessful attempts to pass a guidewire through the stenosis under direct visualization, we were consulted to discuss a combined approach. Rendezvous recanalization with access through both the mouth and gastrostomy site was planned. An endoscope was passed through the mouth to the level of the esophagus, revealing severe stenosis with complete obstruction in the hypopharynx. Under fluoroscopic guidance, we attempted to advance a guidewire through the stenosis, but were unsuccessful. An endoscope was then reintroduced through the mature gastrostomy. The scope was advanced to the esophageal stricture in retrograde. A transnasal esophagoscope was used through the mouth for antegrade access. From the retrograde endoscope, a guidewire was passed through the stenosis and captured through the mouth. Under fluoroscopy, a 6-7-8mm x 5.5cm CRE balloon dilator was passed over guidewire through the mouth, and dilation was performed to 6mm. We decided to use a biliary stent given the location of the stricture in the hypopharynx where placement of a larger esophageal stent is not feasible and would cause severe discomfort given the larger diameter. A 10mm x 60mm WallFlex biliary stent was successfully deployed across the stenosis. After repeat dilation was performed twice more 2 weeks apart, her esophagus remains patent at 18mm. On latest follow-up, she is able to tolerate PO liquids and pureed food. Discussion: High-grade stenosis is difficult to treat, often requiring a multidisciplinary approach. In cases of high-grade esophageal stenosis, an antegrade-retrograde endoscopic approach can be employed to dilate the esophageal segment. Recent meta-analysis shows esophageal recanalization using the rendezvous procedure to have a technical success rate >85%, dysphagia improvement rate >55%, and PEG-tube free rate >40%.Figure 1.: Endoscopic view of esophageal stricture (a), fluoroscopic image of antegrade and retrograde scope with wire passing through the stricture (b), endoscopic view of biliary stent in place (c), fluoroscopic image of biliary stent in place (d). Watch the video at https://bit.ly/3eNvMxi.

S2172 Dysphagia Lusoria: A Rare Case of Aberrant Right Subclavian Artery Causing Esophageal Compression

Introduction: Dysphagia lusoria is a rare disorder found in only a small percentage of individuals with an anomalous right subclavian artery causing extrinsic compression of the esophagus. Diagnosis often requires a comprehensive evaluation of dysphagia and a high index of suspicion. We present a case of dysphagia lusoria followed by a review of the pathogenesis, clinical presentation, and management of this rare condition. Case Description/Methods: A 36-year-old female was admitted to our hospital with severe sepsis secondary to a UTI. During her hospitalization, she complained of progressive dysphagia to solids for approximately 6 months. She reported intermittent globus sensation and reflux for many years. An upper endoscopy was performed and revealed a pulsatile narrowing of the proximal esophagus. Gastric and esophageal biopsies were negative. CT angiogram identified possible extrinsic esophageal compression by an aberrant right subclavian artery (ARSA). High-resolution manometry demonstrated impression at the level of the upper esophagus with an increased pressure band likely due to the ARSA. Overall impedance to solids and liquids was normal and no underlying dysmotility was identified. A diagnosis of dysphagia lusoria was made based on these findings. Unfortunately, dietary modifications and maximal medical therapy proved ineffective. Due to the severity of her symptoms, surgical repair of the aberrant vessel was ultimately recommended. Discussion: Involution of the fourth vascular arch during embryogenesis leads to the formation of the ARSA from the persisting dorsal aortic arch distal to the left subclavian artery. Because the vessel most commonly crosses between the esophagus and vertebral column, retroesophageal compression can occur. However, dysphagia lusoria is an exceedingly rare cause of dysphagia in adults. A thorough evaluation of dysphagia with endoscopic, radiologic, and manometric testing is necessary to rule out other potential etiologies before the diagnosis can be made. Patients often complain of solid-food dysphagia (most common), regurgitation, postprandial bloating, chest pain, and coughing. Treatment strategies depend on the severity of symptoms, response to conservative therapies, and candidacy for surgical intervention. Mild symptoms can often be managed using a combination of dietary and lifestyle modifications and medical therapy. Surgical evaluation for repair of the aberrant vessel is indicated for severe or refractory symptoms.Figure 1.: Figure A. Upper endoscopy demonstrating extrinsic compression of the proximal esophagus. The narrowed segment was measured at 18 cm from the incisors and had a pulsatile appearance. Figures B & C. Computed tomography angiogram of the chest (axial and coronal cuts) demonstrating the aberrant right subclavian artery (yellow arrows) with its origin from the distal aortic arch. Figure D. High-resolution manometry study demonstrating impression with an increased pressure band in the upper to mid esophagus caused by the aberrant right subclavian artery. Overall impedance to solids and liquids was within normal limits (90% complete clearance of liquid bolus swallows) with normal esophageal motility (9/10 swallows had normal contraction pattern with a mean DCI of 3127 mmHg-s-cm).

S3558 Esophageal Candidiasis Leading to Spontaneous Esophageal Rupture

Introduction: Spontaneous esophageal perforation (SEP) is a rare and potentially life-threatening condition usually caused by esophageal trauma due to instrumentation or prolonged vomiting and retching. SEP due to esophageal candidiasis (EC) is extremely rare. We present a case of SEP in a patient with EC despite treatment with systemic antifungals. Case Description/Methods: A 53-year-old woman with a history of stage IV lung adenocarcinoma treated with chemoradiotherapy and immunotherapy presented with fever, abdominal pain, diarrhea and hematochezia. Her symptoms were consistent with immune-checkpoint inhibitor colitis, similar to a recent episode that improved with corticosteroids. She has a history of radiation esophagitis in the form of superficial ulceration and stenosis affecting the proximal esophagus. High-dose intravenous corticosteroids were initiated. Due to minimal response, infliximab was administered. Colonoscopy was unremarkable and random biopsies were negative for cytomegalovirus (CMV). Upper endoscopy (EGD) revealed resolution of the initially seen ulceration and no evidence of stricture or stenosis. However, a new distal superficial esophageal CMV ulcer was found. CMV viral load was 6,810 IU/mL and was successfully treated with intravenous ganciclovir leading to viral clearance. EGD for ongoing hematochezia revealed severe esophageal candidiasis (EC) confirmed with histopathology (Figure 1). Despite completing a 14-day course of intravenous fluconazole was, she developed septic shock due to SEP leading to a hydropneumothorax (Figure 2 and 3). Pleural fluid culture was positive for C. albicans. At that stage, family decided to enroll her in home hospice where she died a few days later. Discussion: Although, EC is not uncommon in immunocompromised patients, it is usually treated successfully with antifungal agents in 80-90% of cases. Transmural invasive Candida infection, however, is exceptionally rare with only 4 confirmed cases in the literature. It may lead to esophageal perforation and esophageal-pleural fistula formation. A second-look EGD with culture and sensitivity is recommend in symptomatic patients with EC who fail to improve with treatment. However, there are no guidelines recommending a repeat EGD in immunocompromised patients who initially had minimal symptoms. Our case suggests that for those patients a repeat EGD should be done to ensure resolution of EC and discontinuation of immunosuppressive therapy should be considered.Figure 1.: Endoscopic picture showing mucosal yellow-white plaques throughout entire esophagus, consistent with candidiasis.Figure 2.: Non-enhanced CT (axial view) demonstrating right hydropneumothorax with loculated fluid components.Figure 3.: Esophagram with extravasation of contrast from superior upper esophagus extending into right upper chest.

720 CONVENTIONAL AND SIMPLE METHODS OF MEASURING MEAN NOCTURNAL BASELINE IMPEDANCE SHOW EXCELLENT AGREEMENT

Abstract Mean nocturnal baseline impedance (MNBI) is a measurement that shows promise in investigating reflux disease by reflecting esophageal mucosal integrity. The conventional method of measuring MNBI is time-consuming and operator-dependent. A new, simple method of measuring MNBI has been suggested. This study aimed to report MNBI measurements by both conventional and simple methods in a cohort of laryngopharyngeal reflux (LPR) and gastro-esophageal reflux disease (GERD) patients to validate the simple measurement method. Methods 187 patients were divided into LPR (n = 105) or GERD (n = 82) groups by predominant symptom profile, and underwent off-therapy impedance-pH monitoring. MNBI was blindly measured by both conventional and simple methods, and values were correlated. Bland–Altman plots were constructed to assess mean differences and to identify bias between the two measurement methods. Results For the two measurement methods, mean difference in the distal esophagus was −89 (±328) ohms, in the proximal esophagus was −6 (±653) ohms, and in the pharynx was 128 (±577) ohms. There was strong correlation between conventional and simple MNBI values, with r = 0.940 in the distal esophagus, r = 0.463 in the proximal esophagus, and r = 0.712 in the pharynx (all p < 0.001). Conclusion There was excellent agreement between conventional and simple methods of measuring MNBI, with no evidence of proportional bias. Conventional and simple MNBI values correlated excellently in the distal esophagus, and moderately well in the proximal esophagus and pharynx. This study supports the use of the simple method of measuring MNBI to enhance diagnosis of reflux disease.

719 REDUCED MEAN NOCTURNAL BASELINE IMPEDANCE AIDS DIAGNOSIS OF GASTRO-ESOPHAGEAL REFLUX DISEASE AND LARYNGOPHARYNGEAL REFLUX DISEASE

Abstract Laryngopharyngeal reflux disease (LPR) and gastro-esophageal reflux disease (GERD) occur due to acidic gastric refluxate causing symptoms. Baseline esophageal impedance has been shown to be reduced with prolonged acid exposure. Mean nocturnal baseline impedance (MNBI) is a novel measure that has shown promise in GERD but has not been evaluated in LPR. This study aimed to assess the role of MNBI in LPR and GERD patients. Methods Off-therapy impedance-pH tracings were blindly reviewed for 187 patients previously prospectively allocated clinical diagnoses of LPR (n = 105) or GERD (n = 82). Conventional impedance-pH measures and MNBI were analysed for the two groups. Results MNBI was significantly lower in the distal esophagus in GERD patients compared with LPR (1679 ± 914 vs. 2109 ± 863; p = 0.001). Similarly, in the proximal esophagus, MNBI was lower in GERD than LPR (2289 ± 579 vs. 2541 ± 471; p = 0.001). In the pharynx, MNBI was similar between the two groups (2116 ± 699 vs. 2133 ± 770; p = 0.878). Distal acid exposure time (AET) and the number of distal acid reflux episodes negatively correlated with distal esophageal MNBI (r = −0.195; p = 0.007) and (r = −0.330; p < 0.001) respectively. Conclusion Baseline impedance was reduced in both LPR and GERD at both distal and proximal esophageal measurements, and more severely reduced in GERD. Baseline impedance is strongly and inversely related to acid exposure in the esophagus. Pharyngeal MNBI was not reduced or different between groups. Distal and proximal esophageal MNBI may be useful in diagnosis of LPR as well as GERD.

709 PL11.05 NOVEL DIGITAL REFLUX SCINTIGRAPHY DETECTS PULMONARY MICROASPIRATION IN SEVERE GASTRO-OESOPHAGEAL AND LARYNGOPHARYNGEAL REFLUX DISEASE

Abstract No gold-standard diagnostic test for laryngopharyngeal reflux (LPR) exists. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-oesophageal reflux disease (GORD). The present study aimed to describe the results of a novel digital technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux. Methods A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GORD or LPR. All patients underwent novel reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal oesophagus, and delayed contamination of the pharynx and lungs after two hours. Results The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GORD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GORD 87.7%, LPR 90.4%; p = 0.133), and at the proximal oesophagus in 89.7% (GORD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GORD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GORD 36.6%, LPR 53.3%; p = 0.023). Conclusion Reflux scintigraphy demonstrated a high rate of digitally identified reflux pulmonary aspiration. Contamination of the proximal oesophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GORD and LPR.

708 A NEW DIAGNOSTIC PARADIGM FOR LARYNGOPHARYNGEAL REFLUX DISEASE: CORRELATION OF IMPEDANCE-PH MONITORING AND DIGITAL REFLUX SCINTIGRAPHY RESULTS

Abstract No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR. Methods Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated. Results 105 patients with LPR (31 males (29.5%), median age 60 years (range: 20–87)) were studied. Scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). Abnormal reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and longer bolus clearance times (p = 0.002). Conclusion Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.

500 THE PATHOLOGICAL GASTROESOPHAGEAL REFLUX IN PATIENTS WITH CYSTIC FIBROSIS

Abstract The presence of gastroesophageal reflux in patients after lung transplantation rises the risk of posttransplantant complications. The aim of our study was to evaluate the severity of gastroesophageal reflux (GER) in patients with cystic fibrosis before lung transplantation. Methods 14 patients with cystic fibrosis, who refferred to our Centre, were included in this study, mean age 28,86 ± 2,5 (6 males and 8 females). The diagnosis of cystic fibrosis was established at the age of 1–5 y.o. according to clinic, sweet test and genetic tests. All patients were performed upper endoscopy, X-ray, esophageal manometry and 24 h impedance monitoring. PPI treatment was excluded for 7 days before monitoring. Pathologic GER was established when total number of refluxes in distal esophagus was more than 75, the total number of refluxes in proximal esophagus was more than 20% of those in the distal part. Results According to endoscopy, none of patients had erosions of the esophagus. Five patients had ineffective motility and one—diffuse esophageal spazm. 56% of patients had pathologic number of refluxes in distal esophagus. 80% subjects had pathologic refluxes in proximal esophagus. The mean number of total refluxes in distal part was 54,93 ± 5,7, in proximal part—27,64 ± 2,6 (it is 40% of those in distal part). The distribution of acid and non-acid refluxes in patients with pathologic refluxes was 2:1. We didn’t reveal any correlation between number of refluxes, ineffective motility and gastric emptying. Conclusion despite normal upper endoscopy, 56% of patients with cystic fibrosis have pathologic gastroesophageal reflux. Besides, the study showed high propagation of GER to proximal esophagus in 80% of subjects, which may play role in posttransplantation period.

779 USE OF INDOCYANINE GREEN TO ASSESS THE CORRECT VASCULARIZATION OF GASTROPLASTY IN MCKWEON ESOPHAGECTOMY

Abstract Cervical anastomostic leakage in esophageal surgery is one of the most serious complications and its incidence is 10–30% according to series. ndocyanine green is being used in multitude of surgical procedures in colorectal and hepatobiliary surgery. In this video we try to prove its usefulness to assess the adequate vascularization of the gastroplasty with the aim of reducing anastomotic leak due to not-well perfusion. Methods A left lateral cervicotomy was performed and proximal esophagus was divided. Then a handsewn purse-string suture was performed and the anvil of CEA 25 stapler was introduced into the esophagus. Gastroplasty was performed with endoGIA section by minilaparotomy. An intravenous infussion of Indocyanine green was used to assess the vascularization "in situ" of the gastroplasty. The gastroplasty was pull up through the retrosternal space and when the plasty was positioned in a correct way, the optimal site for the anastomosis was chosen. Mechanical T-L anastomosis with CEA 25 stapler was performed and it was covered with an omental flap. Video https://drive.google.com/file/d/1kqmNzJCdlJFOcxKBYRp0jamoHz6Gwgt7/view?usp=sharing.

Endoscopic tissue sampling - Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least six biopsies should be taken, two to four biopsies from the distal esophagus and two to four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities. Distal and proximal biopsies should be placed in separate containers.Strong recommendation, low quality of evidence. 2: ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis.Strong recommendation, low quality of evidence. 3: ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal cancer and suspected advanced gastric cancer.Strong recommendation, moderate quality of evidence. 4: ESGE recommends taking only one to two targeted biopsies for lesions in the esophagus or stomach that are potentially amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm the diagnosis and not compromise subsequent endoscopic resection.Strong recommendation, low quality of evidence. 5: ESGE recommends obtaining two biopsies from the antrum and two from the corpus in patients with suspected Helicobacter pylori infection and for gastritis staging.Strong recommendation, low quality of evidence. 6: ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric adenomas.Strong recommendation, moderate quality of evidence. 7: ESGE recommends fine-needle aspiration (FNA) and fine-needle biopsy (FNB) needles equally for sampling of solid pancreatic masses.Strong recommendation, high quality evidence. 8: ESGE suggests performing peroral cholangioscopy (POC) and/or endoscopic ultrasound (EUS)-guided tissue acquisition in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred, with POC where this is not diagnostic.Weak recommendation, low quality evidence. 9: ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected malignant lesions to prevent intraluminal spread of malignant disease.Weak recommendation, low quality of evidence. 10: ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending on local experience.Weak recommendation, low quality evidence.

753 SCARLESS APPROACH FOR KILLIAN JAMIESON DIVERTICULUM: TRANSORAL ENDOSCOPIC ASSISTED ESOPHAGODIVERTICULOSTOMY

Abstract Killian-Jamieson Diverticulum (KJD) is a rare variant of proximal esophageal diverticulum that arises from the Killian-Jamieson area (antero-lateral). It differs from the more common Zenkers diverticulum which usually arise from the posterior aspect of the proximal esophagus. The choice of surgical intervention for symptomatic KJD is still unclear due its rare incidence and surgeons still prefer the transcutaneous cervical approach. Here we present the transoral endoscopic assisted esophagodiverticulostomy approach and the relevant literature. Methods 26 year old male presented with progressive dysphagia for the past two years. A Killian-Jamieson Diverticulum was diagnosed after an Oesophagogastroduodenoscopy and Barium swallow. Patient underwent a transoral endoscopic assisted esophagodiverticulostomy. Results The surgery was uneventful and no complications were observed post-operatively. A year after the surgery patient is asymptomatic and no sign of recurrence. Conclusion Transoral endoscopic assisted esophagodiverticulostomy is a safe approach for treatment of symptomatic KJD. In this era of minimally invasive surgery it should be considered when formulating a treatment approach based on its obvious advantages.

Association of Functional Outcomes in Tracheoesophageal Voicing With Intratracheal Pressures and Esophagram Findings

Tracheoesophageal voice prosthesis (TEP) is a commonly used device for alaryngeal voicing following total laryngectomy. Variability in TEP voice and speech production may be reflected in differences in intratracheal pressures. To examine the association between intratracheal manometric pressure (IMP), speech function, and proximal esophageal abnormalities in patients with TEP. This retrospective cohort study was conducted at a single academic institution and included all patients with a history of total laryngectomy and TEP who completed a radiographic esophagram and intratracheal manometry between September 9, 2019, and December 4, 2019. Intratracheal manometric pressures during sustained phonation, conversational speech, and maximum loudness tasks were obtained for 22 patients. Pressure metrics, phonation duration time, and fluency of speech production were compared between patients with dysphagia with those without swallowing complaints. The association between pressure and speech metrics was also assessed. Of 22 patients, 17 (77.2%) were men, 5 (22.7%) were women, and the mean (SD) age was 66.6 (8.8) years. The mean (SD) sustained phonation duration time was 9.3 (5.2) seconds, and the mean (SD) IMP during sustained phonation was 50.5 (21.4) cm H20. The IMPs during sustained phonation were strongly correlated with conversational speech (r = 0.712; 95% CI, 0.384-1.039) and moderately correlated with maximum loudness tasks (r = 0.524; 95% CI, 0.127-0.921). The IMPs during conversational speech were moderately correlated with maximum loudness task (r = 0.538; 95% CI, 0.145-0.931). Increased IMP during sustained phonation was moderately correlated with decreased sustained phonation duration time (r = -0.450; 95% CI, -0.867 to -0.034) and conversational speech was moderately correlated with decreased sustained phonation duration time (r = -0.524; 95% CI, -0.921 to -0.127). Patients with subjective swallowing complaints and proximal esophagus abnormalities had a shorter maximum phonation time (mean [SD], 7.08 [5.03] seconds) compared with patients without subjective dysphagic complaints (mean [SD], 11.95 [4.40] seconds), with a large effect size (Cohen d = 1.031; 95% CI, 0.141-1.92). All patients with nonfluent TEP speech production had structural abnormalities of the proximal esophagus. No difference in pressure or speech metrics was observed for primary closure vs reconstructive flap type. This cohort study found that increased IMP and abnormalities of the proximal esophagus were associated with worse TEP speech quality. Evaluation of the esophagus should be considered in patients who are experiencing difficulties with TEP voicing. Further investigation of intratracheal manometry as a biofeedback tool to improve TEP voicing is needed.

Dysphagia in an Adolescent with Iron Deficiency Anemia.

Dysphagia in an Adolescent with Iron Deficiency Anemia.

Heterotopic gastric mucosa (inlet patch): Endoscopic prevalence and association with supraesophageal and upper esophageal symptoms

Objective: To determine the frequency, demographic and clinical features of the heterotopic gastric mucosa (inlet patch). 
 Methods: This retrospective study involves 244 patients who applied to the gastroenterology outpatient clinic with different symptoms between September 2016 and December 2019, and who were diagnosed with inlet patch in elective esophagogastroduodenoscopy. All endoscopic procedures were performed by the same clinical endoscopist. All medical records of patients including demographic and clinical features and endoscopy findings were reviewed.
 Results: Considering 2823 patients who underwent elective esophagogastroduodenoscopy in the same study period, inlet patch was detected in 224 (8.6%). The number of male patients was 138 (56.6%) and there was no statistical difference between the two genders. The mean age of the patients was 37.73 ± 13.01 years. Single lesion was detected in 204 (83.6%) patients. The size of the largest lesion was 4.5 cm and the smallest lesion was 0.3 cm. All of the lesions were in the proximal esophagus. 54 patients (22.1%) had at least one supraesophageal or upper esophageal symptom. The most common symptom was globus sensation (64.8%). Patients with large lesions were more likely to experience symptoms (28.2% vs. 13.7%, p=0.008). 
 Conclusion: Careful examination of the proximal esophagus may increase the chance of detecting inlet patch and may explain persistent symptoms in patients without a specific cause. Further understanding of the clinical significance of the disease may also prevent unnecessary diagnostic interventions.

Zenker\u2019s diverticulum in an 85-year-old Ugandan man

BackgroundZenker’s diverticulum (ZD) is an uncommon disorder due to an outpouching of tissue through the Killian triangle that is thought to be caused by dysfunction of the cricopharyngeal muscle.Case presentationAn 85-year-old male patient presented with odynophagia and dysphagia of initially solid food followed by fluids that was associated with a significant weight loss over a one-year period. Barium swallow videofluoroscopy demonstrated a posterior outpouching of proximal esophagus that was 2 cm from the epiglottis. With the diagnosis of medium sized ZD, the patient underwent endoscopy guided diverticulotomy. Six months after the procedure, he was asymptomatic and had gained weight.ConclusionsDysphagia and weight loss raises a clinical suspicion for a malignancy. Barium swallow examination is an inexpensive method for the diagnosis of ZD.

Özofageal inlet patch: Hastaların demografik ve endoskopik karakteristikleri ve litaratürün gözden geçirilmesi

Background and Aims: An esophageal inlet patch is crucial in swallowing difficulty, laryngopharyngeal reflux symptoms, and rarely in the etiology of proximal esophagus adenocarcinoma. We aimed to evaluate the endoscopic and demographic features of patients with esophageal inlet patch during endoscopic evaluation and compare them with those of the literature. Material and Method: Between January 2017 and January 2021, we evaluated the age, gender ratio, inlet patch size, and number along with the other endoscopic findings in patients with proximal esophageal inlet patch. Results: Overall, 53 patients (women, 36 (68%); mean age, 46.3 ± 15.8 years; range, 19–83 years) were included the study. Only 13 patients (24.5%) had specific symptoms of esophageal inlet patch. The median esophageal inlet patch size was 7.0 mm in women (range, 4–30), while it was 8 mm (range, 5–20) in men. The median inlet patch number was 1 in both sexes (range, 1–3 in women, 1–2 in men). Forceps biopsy was possible in 30 (56.6%) patients. We found no additional esophageal pathology in 45 (84.9%) patients, normal lower esophageal sphincter in 39 (73.5%), incompetent lower esophageal sphincter in 14 (26.4%), hiatal diaphragmatic hernia in 1 (1.8%), and endoscopic antral gastritis in 29 (55.7%) patients. Twelve (54.5%) of 22 endoscopic biopsies were positive for Helicobacter pylori. We detected esophageal inlet patch in the distal esophagus in 2 (3.7%) patients. Conclusion: Esophageal inlet patch was more common in women, unrelated to gastroesophageal reflux disease, and most patients were asymptomatic, with a median size of 8 mm (range, 4–30), with no gender difference. Moreover, inlet patch size was not associated with presence of symptoms. Evidence of malignancy in the biopsied inlet patches was not observed.

Pathomorphological and immunohistochemical features of the esophageal mucosa in children with asthma combined with reflux esophagitis

The most common comorbid pathology in children with asthma is gastroesophageal reflux disease (GERD) associated with reflux esophagitis (RE), which ranges from 32 % to 80 %. Histological changes of the esophageal mucosa in RE have been described in adults and children, but there are only isolated studies that describe the morphological features of the esophageal mucosa in combined pathology, taking into account the severity of asthma. The aim is to study the histological and immunohistochemical features of the esophageal mucosa in children with asthma combined with reflux esophagitis. Materials and methods. In 43 children aged 6–17 years with RE and severe asthma (group 1), with mild/moderate asthma (group 2) and without asthma (group 3), mucosal biopsies from the distal and proximal esophagus were examined by histolo­gical and immunohistochemical methods. Immunohistochemical research was performed in serial paraffin sections according to standard protocols using monoclonal antibodies to Ki-67, MMP-9, VEGF, BCL-2, IgE and CD68. Results. In children with asthma combined with RE, the structural changes of the esophageal mucosa differed depending on the severity of asthma. Severe basal epithelial hyperplasia was registered in 92.31 % of children in group 1, and its frequency was significantly different from children in groups 2 and 3. A characteristic feature of children with asthma and reflux eso­phagitis was dyschronosis, which was characterized by foci of hypo- and hypertrophy of basal layer cells (92.31 % of children in group 1 and 37.50 % of children in group 2). Severe elongation of the “papillae” was found only in 38.46 % of children in group 1. Immunohistochemical features of the esophageal mucosa of children with asthma and reflux esophagitis revealed the expression of Ki-67 antigen, IgE and a weak macrophage response (CD68), the severity of which differed from children with reflux esophagitis without asthma. Conclusions. Morphological changes in the esophageal mucosa of children with reflux esophagitis and asthma differ from children with reflux esophagitis without asthma in the presence of severe epithelial damage, dyschronosis of changes, severe elongation of the “papillae”, pronounced cell proliferation (Ki-67) and local IgE expression.