Resolution Of Dysphagia Research Articles

Resolution of dysphagia due to secondary achalasia with neuropathic chronic intestinal pseudo-obstruction by peroral endoscopic myotomy.

Chronic intestinal pseudo-obstruction (CIPO) is a rare condition affecting the motility of the lower gastrointestinal tract, while achalasia is an uncommon esophageal motility disorder. The coexistence of both conditions is extremely rare. We present the case of a patient who had both pathologies, admitted for dysphagia and oral intolerance, the symptoms finally resolved by performing a POEM.

6671 A Recurrent Mass After Thyroid Cancer Treatment

Abstract Disclosure: N. Sekhon: None. K.Z. Win: None. Background: Differentiated thyroid cancers have an excellent prognosis if completely resected and their recurrence rate varies depending on the nature and type of the thyroid tumor. We report a case of symptomatic recurrent mass 1.5 years after hemithyroidectomy for a small locally invasive follicular thyroid cancer. The recurrent mass mimicked malignancy on ultrasound but was pathologically determined to be a suture granuloma. Case: A 62-year-old male with history of follicular thyroid cancer s/p left thyroidectomy presented with a symptomatic neck mass, dysphagia, voice change, and worsening snoring. Thyroid tumor pathology was reported as follicular carcinoma pT1bpNX, 1.4 cm in size, clear margins, no vascular invasion with one focus of transcapsular invasion. He had normal surveillance investigations including thyroglobulin and thyroid ultrasound. He had a normal esophagogastroduodenoscopy which was performed for dysphagia and choking. The thyroid ultrasound showed an indeterminate solid heterogeneous and hypoechoic ovoid soft tissue node measuring 6 mm x 3 mm x 5 mm just right of midline and a 4 mm left neck hypoechoic nodule with no central fatty hilus located lateral to the jugular vein. The lymph node morphology was not typically benign and the patient underwent fine needle aspirate of the mass suggestive of a benign mass. This was followed by surgical removal of the mass and pathologic identification of a suture granuloma. There was resolution of dysphagia after removal of the mass. Discussion: Thyroid tumor recurrence rate is about 15% and is usually seen in aggressive forms or in incomplete resections due to the unrecognized extent of the tumor. Recurrences can be local, regional or distant. Suture granuloma is a rare complication after thyroidectomy and reflects an inflammatory response to retained foreign material. It develops slowly after the thyroidectomy and presents as a painless mass mimicking malignancy or lymph node metastasis. Other lesions that can mimic thyroid cancer on ultrasonography include chronic granulomatous lesions, traumatic neuroma and surgical clip. Conclusion: Our case highlights that suture granuloma should be considered in addition to malignant recurrence in cases of painless mass at the site of thyroidectomy.

Swallowing outcomes after tracheal resection and anastomosis: full versus mini infrahyoid laryngeal drop

IntroductionTracheal resection anastomosis has been established as the definitive surgery for high grade postintubation subglottic stenosis. To achieve a relaxed tension-free anastomosis, various laryngeal release techniques were discussed in literature with potential effect on postoperative swallowing dysfunction. This study aims to compare the difference in swallowing outcomes following two methods of infrahyoid laryngeal release: with and without fracture of the superior thyroid horns.MethodsA retrospective cohort study was carried out at our tertiary referral hospitals including cases with grade III and IV subglottic stenosis treated by partial crico-tracheal resection with thyro-tracheal anastomosis. The patients were divided into two groups according to the method used in laryngeal release; mini infrahyoid release (group A) or infrahyoid full release (group B) where full means with fracture of the superior thyroid horn bilaterally while mini means their preservation. Swallowing assessment preoperatively and postoperatively was done by comparing swallowing dysfunction symptoms, Gugging swallowing screen (GUSS) score and fiberoptic endoscopic evaluation of swallowing (FEES) according to penetration aspiration scale (PAS).ResultsA total of 71 patients were included; 46 in Group A and 25 in Group B. Clinical swallowing evaluation one week postoperatively showed statistically significant difference between the two groups being affected in 80.04% and 100% of patients in group A and B, respectively. The mean postoperative GUSS were 18 ± 1.32 in group A patients in comparison to 8.84 ± 5.18 in group B (p-value < 0.001). With FEES assessment, group A had full improvement of their swallowing abilities one month after the surgery while patients in group B had significantly lower PAS scores. Unfavourable scores for both the GUSS test and PAS were associated with increasing patients’ age in group B.ConclusionIn this retrospective cohort study, cases with mini infrahyoid laryngeal release had significantly better swallowing outcomes and full resolution of dysphagia in comparison to full laryngeal release. Also, full laryngeal release is associated with delayed resolution of swallowing difficulty in older patients. This point should be considered during preoperative patient selection and counselling.

Vascular Ring Surgical Repair: Re-Implantation of the Left Subclavian Artery into the Left Carotid Artery in a Pediatric Patient.

Vascular rings are a rare congenital anomaly of the aortic arch, in which a ring-shaped structure forms, surrounding the trachea and/or esophagus, potentially causing compression. We describe the case of a 14-month-old female patient with failure to thrive secondary to dysphagia, and a vascular ring formed by a right aortic arch, an aberrant left subclavian artery, and a left ligamentum arteriosum. Surgical repair involved ligamentum arteriosum division, Kommerell's diverticulum obliteration, and left subclavian artery re-implantation into the left carotid artery. Endoscopy and EndoFLIPTM evaluated the intraoperative improvement in esophageal narrowing and impedance, respectively. The postoperative period was uneventful, and follow-up visits demonstrated dysphagia resolution and a patent re-implanted left subclavian artery.

Resolution of dysphagia following endoscopic resection of a large, nodular, esophageal inlet patch with low grade dysplasia.

Resolution of dysphagia following endoscopic resection of a large, nodular, esophageal inlet patch with low grade dysplasia.

Peroral endoscopic myotomy and its use in non-achalasia disorders.

The aim of this review is to provide an overview of per-oral endoscopic myotomy (POEM) and its utilization in non-achalasia disorders of the esophagus. POEM, a relatively novel endoscopic technique, involves submucosal tunneling to access esophageal muscle layers, enabling selective myotomy and mitigating the consequences of motor disorders of the esophagus. POEM is an effective treatment modality for diffuse esophageal spasm providing resolution of chest pain and dysphagia in a majority of patients who have refractory symptoms despite medical therapy. The results of POEM are more equivocal compared to esophagogastric junction outflow obstruction (EGJOO). POEM in EGJOO has been shown to have a 93% clinical success rate in 6months. POEM appears to be more effective in motor disorders that affect the lower esophageal sphincter, such as EGJOO and opioid-induced esophageal dysfunction. While the current data for POEM in other entities such as DES and HE are positive, more supportive data are required to make POEM a consistent recommendation for patients.

Dysphagia Outcomes Before and After Adenotonsillectomy in Children With Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) and tonsil hypertrophy may be associated with dysphagia. However, randomized clinical trials assessing dysphagia outcomes in children randomized to adenotonsillectomy (AT) vs watchful waiting with supportive care (WWSC) are lacking. To assess dysphagia outcomes in children with OSA and tonsil hypertrophy managed with AT or WWSC. This secondary analysis of a multicenter randomized clinical trial, the Childhood Adenotonsillectomy Trial (CHAT), was conducted at tertiary children's hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to AT or WWSC and underwent polysomnography at baseline and 7 months. Caregivers completed the OSA-18 questionnaire, which includes an item on difficulty in swallowing at baseline and 7 months. The current secondary analysis was conducted from December 1, 2022, to January 10, 2023. AT vs WWSC. Prevalence of dysphagia, based on parental responses to the difficulty in swallowing item on the OSA-18 questionnaire, was redefined as a binary outcome at baseline and 7-month follow-up. In total, 386 children were included (199 female [51.6%]; median [IQR] age, 6.0 [5.0-8.0] years). Of the total, 207 children were Black (53.6%). At baseline, the number of children with dysphagia was similar (4.0%; 95% CI, -4.9% to 12.9%) between the AT group (56 [29.8%]) and the WWSC group (51 [25.8%]). Following AT, a decrease was observed (21.3%; 95% CI, 13.5%-28.9%) in the prevalence of dysphagia among the children. In contrast, the prevalence of dysphagia did not change significantly (1.0%; 95% CI, -7.6% to 9.6%) in the WWSC group. Children in the AT group were more likely to experience a resolution of dysphagia than those in the WWSC group (adjusted odds ratio, 4.84; 95% CI, 1.91-12.25). Higher baseline AHI was associated with a lower resolution of dysphagia (AOR, 0.91; 95% CI, 0.83-0.98). This secondary analysis of the CHAT randomized clinical trial suggested that children with dysphagia and OSA undergoing AT may experience dysphagia improvement. A prospective randomized trial that uses a validated dysphagia survey is needed to verify the effectiveness of AT in treating dysphagia. ClinicalTrials.gov Identifier: NCT00560859.

Timeline to dysphagia resolution after endoscopic intervention of an interarytenoid defect based on Video Fluoroscopic Swallow Study dysphagia severity.

We previously reported that endoscopic repair of a Type 1 Laryngeal Cleft (LC1) or Deep Interarytenoid Groove (DIG) improves swallowing function postoperatively. However, caregivers often ask about the timeline to resolution of the need for thickening. This study re-examines this cohort to answer this important caregiver-centered question. We reassessed a 3-year retrospective, single-center dataset of children with dysphagia found to have a LC-1 or DIG on endoscopic exam. The primary outcome was rate of complete resolution of dysphagia at 2, 6, and 12 months after endoscopic intervention. A sub-group analysis was made based on severity of dysphagia prior to intervention and by type of endoscopic repair. Thirty-nine patients with mean age 1.35 years that had a LC-1 or DIG met criteria for inclusion. Rate of complete dysphagia resolution increased over time. Those with mild dysphagia (flow-reducing nipple and/or IDDSI consistency 1 or 2) had brisker resolution than those with moderate dysphagia (IDDSI consistency 3 or 4) at 2 months (67% vs 5%, p<0.01) and at 6 months (80% vs 18%, p<0.01) after endoscopic repair. There was no difference in dysphagia resolution between patients grouped by type of endoscopic repair. Addressing an interarytenoid defect in patients will not result in immediate, complete dysphagia resolution in most patients. However, patients that only require a flow-reducing nipple and/or thickening to an IDDSI consistency 1 or 2 have brisker resolution of the need for thickening than those that require an IDSSI consistency 3 or 4 prior to intervention. These results inform pre-operative discussions of the timeline to resolution based upon severity of dysphagia and help manage caregiver expectations.

PSAT356 Propranolol Improves Bulbar Dysfunction Seen in Hyperthyroidism

Abstract Background Many symptoms of hyperthyroidism are mediated by the augmented activity of the adrenergic central nervous system. Rarely, symptoms of bulbar dysfunction are seen with thyrotoxicosis such as dysphagia and dysarthria. Beta blockers can abort or reduce these symptoms before anti-thyroid drugs are used. Case A 59-year-old woman with hypertension and gout, presented to the emergency department with poor oral intake and difficulties swallowing. Symptoms initially started as hoarseness of voice for 3 weeks then progressed to Globus sensation, difficulties swallowing and aspiration of solids and liquids. She also reported generalized muscle weakness, palpitations, increased sweating, tremors and 20 pounds weight loss in the preceding 2 months. Physical exam showed an ill-appearing, catechetic woman. Luedde exophthalmometry showed an absence of proptosis measuring 15 mm bilaterally without lid lag or stare and extraocular muscles were intact. The skin was silky without edema. The strength in the lower extremities was decreased and she was unable to squat or raise from a seated position. Labs showed creatinine of 2.7 mg/dL (0.4–1 mg/dL), BUN 49 (6–20 mg/dL), potassium of 3.1 (3.5–5.1 mmol/L), TSH &amp;lt; 0.02 (0.34–5.60 uIU/mL), FT4: 3.72. CT of the neck was obtained and multiple sub-centimetric hypodense thyroid nodules with calcifications were noted in the left thyroid lobe. Intravenous potassium chloride was given without improvement of dysphagia. 10 milligrams (mg) of propranolol were ordered to be given every 8 hours. After the first dose and over the next 24 hours she reported rapid improvement in dysphagia and muscle weakness. She was discharged on 15 mg of methimazole twice daily and propranolol 10 mg thrice daily. TSI and TRAB were elevated at 1.03 (normal &amp;lt; 0.54 IU/L) and 2.20 (normal&amp;lt;1.75 IU/L) respectively and the diagnosis of Graves’ disease was made. At her 3 weeks follow up, TSH was &amp;lt;0.02 (0.34–5.60 uIU/mL) with normal FT4. She reported complete resolution of dysphagia and improvement in lower extremities weakness. Discussion Hyperthyroidism may exert powerful effects on the neuro-muscular system. The pathogenesis of myopathy in hyperthyroidism is not fully understood. In hyperthyroid periodic paralysis, hypokalemia is present, and paresis is corrected with potassium supplementation. Our patient's symptoms did not improve with potassium supplement but dramatically improved after propranolol use and before the thyroid function was normalized. This implies a role of adrenergic overactivity in myopathy of hyperthyroidism. A study1 was conducted to quantify muscular weakness in hyperthyroidism and assess the response to therapy concluded that propranolol improves muscular weakness. Conclusion Prior to normalization of thyroid function, the use of beta blockers can alleviate symptoms of bulbar dysfunction. (1)Olson BR, Klein I, Benner R, Burdett R, Trzepacz P, Levey GS. Hyperthyroid myopathy and the response to treatment. Thyroid. 1991;1(2): 137-41. doi: 10.1089/thy.1991.1.137. PMID: 1688015. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia.

Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution. Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared. 58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106min. vs. 145min., p = 0.003) and longer median myotomy length (11cm vs. 8cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029). POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

S2435 A Rare Case of Plummer-Vinson Syndrome Treated With Pneumatic Dilations and Iron Supplementation

Introduction: Plummer-Vinson Syndrome (PVS), also known as Paterson-Kelly syndrome, presents with a classic triad of dysphagia, iron-deficiency anemia and esophageal webs. Although this triad of disease is increasingly less prevalent, early detection and intervention are imperative to reduce mortality given increased risk of malignant transformation.1 Case Description/Methods: A 22-year-old female with a history of iron deficiency anemia presented to the emergency department with syncope in the setting of palpitations and dyspnea. The patient endorsed alarm symptoms including hematochezia over the past 6 weeks, 20-lb unintentional weight loss and dysphagia. Initial labs were remarkable for a hemoglobin of 11.1 g/dL, and microcytic indices, with an MCV of 72.4 fL. The patient underwent esophagogastroduodenoscopy (EGD) to investigate the etiology of iron deficiency anemia. EGD revealed a prominent esophageal web (Figure A) in the proximal esophagus with associated erythema and mucosal friability. Significant narrowing impeded safe passage of the endoscope and thus serial pneumatic dilations to 10 mm were performed. Following pneumatic dilation, the endoscope was successfully advanced beyond the web (Figure B) to the gastroesophageal junction. The patient tolerated the procedure well and had immediate resolution of dysphagia following EGD with pneumatic dilation. She was then continued on iron supplementation as previously prescribed at discharge. Discussion: Plummer-Vinson Syndrome comprises the pathological triad of dysphagia, esophageal web, and iron deficiency anemia. Other signs and symptoms can include glossitis, angular cheilitis, and koilonychia. The decreased incidence of this syndrome parallels the decreased prevalence of iron deficiency in the developed world. Iron deficiency induces an iron-dependent enzyme dysfunction which causes oxidative stress, mucosal DNA damage and ultimately potentiates the formation of esophageal webs. 2 Without intervention, patients with this syndrome may develop absolute dysphagia, aspiration pneumonia and other complications. Due to increased risk of malignancy, surveillance EGDs are necessary to screen for esophageal carcinoma in patients with PVS.Figure 1.: Esophageal Web pre dilation (a) and post dilation (b).

S3709 A Novel Way to Administer Chemotherapy Medication in a Patient With Esophageal Stenosis Secondary to Metastatic Breast Cancer

Introduction: Breast cancer can present as cervical lymph node enlargement causing dysphagia due to esophageal compression. We present a case of esophageal stenosis requiring placement of gastrostomy for administration of Palbociclib, which cannot be crushed or split. Case Description/Methods: 64 year-old female with history of breast cancer treated with lumpectomy and adjuvant radiation therapy, 7 years ago presented with dysphagia and weight loss. Upper endoscopy (Fig. 1) showed extrinsic stenosis at cricopharyngeus 6 mm (diameter) × 2 cm (length). CT scan showed posterior triangle right cervical lymph nodes measuring 16 mm × 16 mm and a 20 mm × 23 mm mass along the right posterior para-tracheal/para-esophageal distribution. Endobronchial ultrasound guided biopsy was obtained. Pathology (Fig. 2 and 3) showed degenerated clusters of (GATA-3 positive) malignant cells suggestive of metastatic breast cancer. PET/CT confirmed irregular soft tissue mass near the right tracheoesophageal groove with intense FDG uptake. There was regional metastatic lymphadenopathy in the right neck at the level IIA and IIIA regions. Oncology recommended radiation treatment. Due to dysphagia and weight loss, a 20 French PEG tube was placed using an ultraslim upper endoscope. Repeat PET/CT showed partial response and patient was recommended 125 mg Palbociclib tablet daily. The pill cannot be crushed or split and is oval, measuring 16.2 mm × 8.6 mm. Repeat upper endoscopy was performed, gastrostomy was dilated to 30 French, and a 30 French gastrostomy tube was placed. Due to the pill’s dimensions, it could not flush down the 30 French tube. Patient was instructed to remove the peg tube daily by suctioning saline from the retention balloon, place Palbociclib directly into the stomach via the gastrostomy, replace gastrostomy tube, and inflate the retention balloon with saline. Nine months later patient had resolution of dysphagia. She was not using her PEG tube and the CT scan showed no residual disease (Figure 1). Discussion: We present a case of metastatic cancer causing esophageal stenosis, requiring treatment with a chemotherapy pill that cannot be crushed, split, or flushed down the largest (30 French diameter) available gastrostomy tube. Removing the gastrostomy tube, administering the pill directly into the stomach via gastrostomy, and replacing the tube, patient could self-administer the medication. We present a novel technique of medication administration when substitution of form, route of administration, and medication are not possible.Figure 1.: EGD showing extrinsic stenosis at cricopharyngeus.Figure 2.: Pathology with H&E stain showing presence of malignant cells.Figure 3.: Pathology with GATA-3 immunostain positive metastatic breast cancer cells.

S2403 A Rare Case of Lymphocytic Esophagitis Presenting With Food Impaction

Introduction: Lymphocytic esophagitis (LyE) was first described in the literature in 2006 and remains a very rare diagnosis, with diagnostic criteria being met in only 0.1% of esophageal biopsies. LyE shares features with GERD and eosinophilic esophagitis and is often misdiagnosed. It is most common in middle-aged women and presents with very nonspecific symptoms, most commonly dysphagia. Esophageal biopsy is the gold standard for diagnosis and LyE is currently defined solely on histological criteria. Treatment options are limited, with proton-pump inhibitors (PPIs) being the first line treatment. Case Description/Methods: A 71-year-old male with a past medical history of hypertension and tobacco and alcohol use disorder presented after experiencing an episode of acute dysphagia to solids and liquids. Urgent EGD was performed, which showed a large food bolus at the distal esophagus/gastroesophageal junction. This was fragmented and pushed distally into the stomach by an endoscopic retrieval device. Several ulcers were present in the lower esophagus and biopsies taken showed mild erosive gastropathy and duodenitis. Repeat EGD was performed 8 weeks later, and a distal esophageal stricture was noted and was dilated with a balloon dilator to 15mm. Biopsies taken of the proximal and distal esophagus showed squamous mucosa with >20 intraepithelial lymphocytes per high-power field with rare neutrophils and rare eosinophils with associated patchy, peripapillary lymphocytic infiltrates, consistent with LyE. Patient was placed on a proton-pump inhibitor twice daily with reported improvement of symptoms and resolution of dysphagia at follow-up. Discussion: Lymphocytic esophagitis (LyE) is a very rare cause of esophagitis and is often misdiagnosed due to its variable symptoms and nonspecific gross appearance on endoscopy. Diagnosis can only be made with biopsy, specifically the presence of >20 intraepithelial lymphocytes per high-power field. Food impaction is a rare presentation of LyE and has only been shown in around 9% of cases. Although the pathogenesis remains unknown, inflammation has been associated with the development of this condition. LyE was diagnosed in this male patient after endoscopic removal of food impaction, resulting in stricture. This could support the theory that inflammation due esophageal trauma/injury could be associated with the development of LyE. This diagnosis is important to keep on the differential for causes of esophagitis.

Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM? : Which modality offers superior outcomes?

Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy. We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3. 103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72min, p < 0.01) as was mean length of stay (1.56 vs 0.3days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD. Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.

Impedance planimetry (EndoFLIP) assisted laparoscopic esophagomyotomy in pediatric population

IntroductionFunctional lumen imaging probe (EndoFLIP) is a diagnostic technology that assesses esophageal cross-sectional area via impedance planimetry during controlled volumetric distention. The purpose of this study is to evaluate the utility of EndoFLIP intraoperatively during laparoscopic esophagomyotomy. MethodsWe performed a retrospective cohort study reviewing all patients undergoing EndoFLIP assisted laparoscopic esophagomyotomy for achalasia between January and December 2021 (n = 10). Twenty-two patients with achalasia that underwent traditional laparoscopic esophagomyotomy between July 2014 and September 2019 served as a comparison. Primary outcome evaluated was resolution of symptoms at discharge. Secondary outcomes included change in distensibility index (DI), operative time, length of stay, time to regular diet, and reinterventions. ResultsAll patients managed with EndoFLIP assistance had resolution of dysphagia and postprandial vomiting following intervention. Mean change in DI was 5.32 mm2/mmHg with a myotomy length of 3.6 cm. Operative time was shorter in the EndoFLIP cohort (97 min versus 185 min, p = <0.001). Study patients did not undergo an antireflux operation. There was no difference in length of stay or time to soft diet between groups. All patients were discharged on postoperative day 1 tolerating a mechanical soft diet. No acid suppressive medications were prescribed during the observation period. One patient required dilation for recurrent symptoms and one required reoperation for mucosal leak. ConclusionEndoFLIP assisted laparoscopic esophagomyotomy results in similar short-term outcomes to traditional surgical technique. EndoFLIP allows for focused myotomy length and a shorter operative time.Level of evidence: III

525 Dysphagia in Thermal Injury: The Impact of Inhalation Injury on Incidence and Recovery

IntroductionDysphagia is known to be a prevalent condition in the burn population. Dysphagia can lead to adverse events such as aspiration pneumonia, dehydration, and malnutrition. However, there is little data on the incidence and duration of dysphagia specifically in the inhalation injury subset of burn patients. The aim of this study is to determine the incidence and factors that contribute to dysphagia in the inhalation injury burn population as compared to the cutaneous burn population.MethodsA retrospective study was conducted of patients admitted to a burn center from January 2016 - January 2021 and intubated for >48 hours. Patients who died during hospitalization or transferred hospitals were excluded. Dysphagia duration was analyzed based on days free from the ventilator. Two groups were compared: 1) non-inhalational injury vs inhalational injury patients and 2) Grade 1 vs Grade ≥2 inhalational injury patients. Statistical analysis included student’s t-test, chi-square test, and Kruskal-Wallis test. Bayesian generalized linear models were created to measure the independent association of inhalational injuries with the outcomes.ResultsDuring the study period, 142 patients were admitted, of whom 49 patients had inhalation injury (35%). Inhalational injury patients had a lower %TBSA burn than non-inhalational injury patients (mean 18% ± 21% vs 31% ± 15%, p< 0.001). There were no significant differences in age, sex, tracheostomy placement, ventilator days, or hospital length of stay between the two groups. The inhalational injury group had a higher rate of dysphagia at the first Speech Language Pathologist (SLP) instrumental assessment (88% versus 51%, p< 0.001) and at discharge (55% versus 28%, p=0.001). After controlling for %TBSA, inhalational injury was independently associated with an increased odds of dysphagia at first SLP instrumental assessment (OR 13.0, 95% CrI 4.7-43.4, posterior probability ≥99%) and at discharge (OR 3.2, 95% CrI 1.5-6.9, posterior probability ≥99%). Additionally, inhalational injury patients had a longer period of dysphagia post-extubation with an average of 9.5 vs 7.1 days to any diet (p< 0.006) and average of 12.6 vs 7 days to a regular texture diet (p < 0.001). Grade 1 inhalational injuries had no difference in duration of dysphagia or dysphagia at discharge compared to Grade ≥2 inhalational injury patients.ConclusionsInhalational injury was independently associated with dysphagia upon initial SLP instrumental assessment and at discharge. Patients with an inhalational injury also had a longer dysphagia resolution time. The severity of the inhalation injury did not impact dysphagia incidence.

Сравнительный анализ стентирования и гастростомии у больных со злокачественной патологией пищевода и пищеводно-желудочного перехода

Objective — to analyze the results of esophageal stenting in comparison with gastrostomy in patients with malignant dysphagia. Material and methods. The first group consists of 100 men and 42 women with malignant dysphagia, who underwent stenting of the esophagus and cardia with self-expanding metal stents. The group consists of 142 people aged 43 to 90 years. Stenting of the esophagus in this group was performed with the aim of resolving malignant stenosis of the esophagus in 71 patients: malignant stenosis of the esophageal-gastric junction in 59 patients and extraorgan compression of the esophagus from the outside in 12 patients. The second group consisted of 164 people in the age group from 33 to 89 years — 140 men and 24 women who underwent gastrostomy by the laparotor method according to Topprover in order to resolve malignant dysphagia. Gastrostomy was imposed on 110 patients due to malignant stenosis of the esophagus: with malignant stenosis of the esophageal-gastric junction in 44 patients and as a result of external compression in 10 patients. Results. Complications in patients after stenting in the remote period occurred in 17 cases. In the group of patients who underwent gastrostomy, complications requiring gastrostomy replacement occurred in 23 patients. Death occurred in one patient as a result of specific complications after gastrostomy. Life expectancy as a percentage, regardless of the pathology of the disease, does not have a large spread in the comparison groups and is approximately the same. The results of studies on life expectancy depending on the type of treatment (stenting-gastrostomy) and the location of the tumor lesion did not reveal statistically significant differences. Conclusions. Comparison of the results of implantation of self-expanding metal esophageal stents and gastrostomy by the laparotomic method in malignant dysphagia of the esophagus and esophagogastric junction was performed for the first time. In the course of the study, it was revealed that in the studied groups of patients, life expectancy in percentage terms, regardless of the pathology of the disease, does not have a wide spread and is approximately the same. There are no statistically significant differences in life expectancy depending on the type of treatment (stenting-gastrostomy) and the location of the tumor lesion in the analysis of variance according to the criterion of the least significant difference. Esophageal stenting with self-expanding metal stents is the least traumatic and effective method of choosing the resolution of malignant dysphagia of the esophagus and gastroesophageal junction with low complication rates, which allows to restore adequate nutrition, thereby improving the quality of life in incurable patients.

S3679 Development of Eosinophilic Esophagitis Following Adalimumab Treatment in Two Adolescents With Crohn's Disease

Introduction: Adalimumab is an anti-tumor necrosis factor-alpha (TNF-alpha) used in the treatment of Crohn’s disease (CD). There have been reported associations of CD and Eosinophilic Esophagitis (EoE); A recent study found that the prevalence of Inflammatory Bowel Disease (IBD) in the EoE population was 2.2% and the prevalence of EoE in the IBD population was 1.5%. A second study found that patients with IBD are four times more likely to develop EoE than the general population. In a small case series, 10 children with CD were diagnosed with EoE while on biologic therapy with infliximab. We describe two adolescents who developed EoE while on adalimumab therapy for CD. Case Description/Methods: Case 1: A 16-year-old male with CD and Down’s syndrome underwent an upper endoscopy and colonoscopy for monitoring of IBD activity. On gross examination, the esophagus appeared erythematous and biopsies of the mid and distal esophagus revealed 50-100 eos/hpf consistent with EoE. He had initiated adalimumab therapy three years prior to EoE diagnosis when esophageal biopsies were normal. Adalimumab level at this time was 6.79 ug/mL. He had no issues with dysphagia, but his weight gain was sub-optimal. After initiation of topical esophageal steroid therapy his weight gain improved and adalimumab therapy has been continued. Due to the current pandemic, follow up biopsies have been postponed. Case 2: A 14-year-old female with CD underwent an upper endoscopy and colonoscopy for monitoring of IBD activity. On gross examination, the esophagus had furrowing and biopsies of the mid and distal esophagus revealed 25-50 eos/hpf consistent with EoE. She had initiated adalimumab therapy one year prior to EoE diagnosis when esophageal biopsies showed mild chronic esophagitis (0-2 eos/hpf). Colonic biopsies showed active disease. Adalimumab level at this time was 17 ug/mL. She reported symptoms of dysphagia. Adalimumab therapy was changed to infliximab due to insufficient disease control and she was started on a high dose proton pump inhibitor to treat EoE with resolution of dysphagia. Due to the current pandemic, follow up biopsies have been postponed. Discussion: These two cases highlight the development of EoE in children with IBD on anti-TNF therapy. To our knowledge, based on a PubMed search, this is the first case report of children developing EoE while on adalimumab therapy for CD.

Per‐oral endoscopic myotomy as treatment for Killian–Jamieson diverticulum

Killian–Jamieson diverticulum (KJD) is a rare type of esophageal diverticulum less commonly encountered compared with Zenker's diverticulum (ZD). Endoscopic approach for these diverticula has been rapidly evolving. Currently, a flexible endoscopic septum division is considered the first‐line treatment for symptomatic ZD patients, however reported recurrence rates are over 10% according to recent literature. With the advent of submucosal tunneling technique established by per‐oral endoscopic myotomy for achalasia, it has been applied to treat ZD named as Zenker's diverticulum per‐oral endoscopic myotomy (Z‐POEM) as a minimally invasive treatment. Although there are very few reports utilizing submucosal tunneling approach to KJD, we have opted to perform Z‐POEM in order to safely perform complete dissection of the muscle septum while maintaining mucosal integration. Due to the difficulty of anatomical location of KJD, we created mucosal incision and subsequent submucosal tunnel directly at the level of the septum as opposed to creating a submucosal tunnel few centimeters proximal to the septum as being previously proposed. We report a case in which this technique was successfully performed with complete resolution of dysphagia without any adverse event. This technique permits to perform complete myotomies without the fear of causing perforation. Although larger cohorts are required to assess its safety and efficacy, Z‐POEM to treat KJD seems to be promising.

P24. Dysphagia and Odynophagia following zero profile ACDF: Incidence, severity and resolution

<h3>BACKGROUND CONTEXT</h3> Stand-alone or zero-profile devices for anterior cervical discectomy and fusion (ACDF) have become popular in the management of degenerative cervical pathology in order to mitigate some of the complications associated with anterior cervical plating. <h3>PURPOSE</h3> To determine the incidence, severity and resolution of dysphagia and odynophagia following zero-profile ACDF. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study of prospectively collected data. <h3>PATIENT SAMPLE</h3> Patients who had undergone zero-profile ACDF between 2017-2020. <h3>OUTCOME MEASURES</h3> Patient-reported Outcome Measure (PROMs) - Patient reported responses on the Dysphagia, Odynophagia and Voice (DOV) Questionnaire. In particular, the "Swallowing" and "Pain with Swallowing" components of the DOV Questionnaire were used for this study. <h3>METHODS</h3> Patients completed the DOV Questionnaire preoperatively and postoperatively (2 weeks, 6 weeks, 12 weeks, 6 months, 1 year and 2 years). Patients selected one of five answer choices (0-4) for dysphagia and one of four choices (0-3) for odynophagia, with zero indicating no symptoms and higher point values indicating worse symptomatology. Scores of 1, 2, 3, and 4 were graded as mild, moderate, severe, and very-severe, respectively. <h3>RESULTS</h3> Forty-eight patients, with a mean age of 58.46 ± 9.74 years, mean BMI of 27.38 ± 4.76 kg/m^2 and comprised of 31 males (64.6%) and 17 females (35.4%) were included. There were 17 single-level (35.4%), 24 two-level (50.0%) and 7 three-level (14.6%) surgeries. Nine (18.8%) patients reported dysphagia preoperatively, all of whom had symptom resolution. Ten (20.8%) patients reported dysphagia at 2 weeks postoperatively, which was mild in all patients. Of these, 5 had resolution during follow-up, with a majority reporting resolution by 6 weeks. Of the 5 patients that did not report resolution, 4 did not have follow-up data available beyond 6 weeks, and 1 reported persistent dysphagia at 2 years. Seven (16.7%) patients reported new-onset dysphagia at 6 weeks, which was mild in all patients. Of these, 5 had resolution, with a majority reporting resolution by 12 weeks. Of the 2 patients that did not report resolution, 1 patient did not have long-term follow-up available, and 1 reported persistent dysphagia at 1 year. Six (12.5%) patients reported odynophagia preoperatively, all of whom had complete symptom resolution. Eleven (22.9%) patients reported odynophagia at 2 weeks postoperatively, which was mild in all patients. Of these, 8 had resolution during the available follow-up, with a majority reporting resolution by 12 weeks. The 3 patients that did not report resolution did not have long-term follow-up data available. In addition, 5 (10.4%) patients reported new-onset, odynophagia after 2 weeks postoperatively, which was mild in all patients. Of these 5 patients, 4 reported resolution while 1 reported persistent symptoms at 1 year. Further, 6/48 (12.5%) patients reported only dysphagia, 4/48 (8.3%) patients reported only odynophagia, and 11/48 (22.9%) patients reported both dysphagia and odynophagia. <h3>CONCLUSIONS</h3> All cases of postoperative dysphagia and odynophagia were mild and a majority resolved by 6-12 weeks postoperatively. Only 2 (4.2%) patients reported persistent dysphagia and only 1 (2.1%) patient reported persistent odynophagia at or after 1 year postoperatively, which was mild in all cases. <h3>FDA DEVICE/DRUG STATUS</h3> Stand-alone ACDF cage (Approved for this indication).