Resolution Of Dysphagia Research Articles

24‐h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy

The most effective treatment for achalasia is pneumatic dilation or myotomy. The best option is still controversial and incidence of complications could help choosing. Gastro-oesophageal reflux (GER) is the most frequent complication after treatment for achalasia. The 24-h pH monitoring (24-h pH) is the best method to evaluate true GER. To analyse the 24-h pH patterns after treatment, correlating with therapeutic success. Untreated patients with achalasia were randomized to pneumatic dilation or laparoscopic Heller myotomy with fundoplication (LHM+Fp) and evaluated with clinical/manometric results and 24-h pH. Ninety-four patients were analysed pre-treatment and 85 post-treatment. Clinical success was 73.8% in pneumatic dilation group and 88.3% in LHM+Fp group (P = 0.08). The incidence of GER was 31% in pneumatic dilation, and 4.7% in LHM+Fp (P = 0.001). The occurrence of hypotensive lower oesophageal sphincter (LES) was 53.3% in patients who developed GER and 28.6% in patients with 24-h pH suggesting fermentation (P = 0.019). The rates of dysphagia resolution in patients with 24-h pH of GER and fermentation were respectively 86.7% and 85.7% (P = 0.89). True GER 24-h pH is more frequent after pneumatic dilation for achalasia, and it is associated with a hypotensive LES. A 24-h pH suggestive of fermentation or true GER is not associated with worse clinical/manometric results.

A 74-Year-Old Woman With Dysphagia: What Is Your Diagnosis by Endoscopic and Barium Swallow Finding?

A 74-year-old woman visited the department of gastroenterology by 4 months of dysphagia. Dysphagia was intermittent, nonprogressive and occurred with solid foods. The patient underwent an upper gastrointestinal endoscopy, which showed a clearly demarcated smooth concentric narrowing at 2 cm above the squamocolumnar junction (Fig. 1A). A barium swallow showed a focal smooth narrowing in the distal esophagus, with openings of variable diameter during the course of examination (Fig. 1B and 1C). What is your diagnosis by endoscopy and barium swallow finding? Considering a possibility of a muscular ring in the distal esophagus, endoscopic ultrasound examination with conventional radial echoendoscopy was performed. Focal thickening of inner circular muscle layer at 2 cm above the squamocolumnar junction was noted. Esophageal manometry was performed by standard techniques using a water-perfused catheter system (Fig. 2). The lower esophageal sphincter pressure was 63.3 mmHg and relaxed completely with swallows. Postrelaxation high-amplitude contractions of lower esophageal sphincter were observed with intermittent multiple-peaked contractions. Amplitudes of the esophageal contraction waves were normal and propagated well. High-amplitude, long-duration contraction of esophageal body was not observed during 10 wet swallows. She was diagnosed as having a lower esophageal muscular ring and treated with calcium channel blocker. On follow-up after 6 months, she was doing well and complete resolution of dysphagia was noted. Esophageal muscular ring is an uncommon cause of dysphagia.1-3 Distinguishing the muscular ring from achalasia and other causes of focal esophageal stenosis is important because of the differences in treatment and outcome.4 Figure 1 (A) Upper gastrointestinal endoscopic finding shows a concentric ring-like mucosal narrowing just above the squamocolumnar junction. (B) Barium esophagogram shows focal luminal constriction through which a small amount of barium transit into the stomach. ... Figure 2 Esophageal manometric findings. Wet swallows evoke normal peristaltic contractions of esophageal body and complete relaxation of lower esophageal sphincter (LES). Postrelaxation high-amplitude contractions of LES are also observed with intermittent multiple-peaked ...

Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer

Self-expanding metal stents (SEMS) are used to treat obstructive malignancies of the esophagus or esophagogastric junction; however, a potential complication is recurrent dysphagia because of tissue in/overgrowth. The placement of a second SEMS is one strategy to re-establish patency of the esophageal lumen. We evaluated the safety and efficacy of an alternative and likely less costly approach: placing a self-expanding plastic stent (SEPS) to manage relapsing dysphagia in patients previously treated with a partially covered SEMS. From December 2007 to January 2009, 13 patients previously treated with a SEMS for malignant dysphagia underwent treatment by inserting a SEPS to palliate relapsing dysphagia, as a result of tissue in/overgrowth. Stenosis was located in the upper esophagus in one patient, in the middle in four patients, and in the lower esophagus in eight patients. Clinical evaluation was performed at the time of stent placement, after 1 week, and then, monthly until death. The SEPS was successfully placed in a single treatment session for all patients. No preliminary dilation was required, and no further treatment was necessary for any patient. Before stenting, the median dysphagia score was 4 (range 3-4), and 1 week later the score was 0 for all patients. The resolution of dysphagia persisted until patient death (from tumor progression). The mean survival after the SEPS insertion was 4 months (range 3-8). This case series supports the use of a SEPS to palliate dysphagia from tissue in/overgrowth of a SEMS. Future clinical trials with larger patient samples are warranted.

Transoral resection of short segment Zenker's diverticulum and cricopharyngeal myotomy: An alternative minimally invasive approach

Transoral treatment of cricopharyngeal bar and small Zenker's diverticulum remains a challenge. We propose a new transoral approach for transoral cricopharyngeal myotomy (TOCPM) for patients with cricopharyngeal spasm and pharyngeal bar, and for transoral resection of diverticula (TORD) with cricopharyngeal myotomy in the patient with small (<3 cm) Zenker's diverticulum. A retrospective review was conducted of 45 patients with cricopharyngeal spasm (21) and Zenker's diverticulum (24), where 14 patients were considered suitable for TORD and TOCPM. TOCPM used the Weerda laryngoscope (Karl Storz, Tuttlingen, Germany) to expose the cricopharyngeal bar using a microscope; the mucosa is cut and then the muscle is transected using monopolar cautery. A 0 degrees endoscope is inserted through the incision to ensure complete myotomy. Incision closure is by interrupted 4-0 Vicryl sutures (Ethicon Inc., Somerville, NJ) and fibrin glue. For the TORD procedure, the diverticular sac is everted and then resected using scissors. Through the sac opening, the TOCPM is completed. The sac opening is then closed as described in TOCPM. The patients are kept without food for 24 hours, followed by feeding and discharge. Modified barium swallow (MBS) evaluated functional results. Fourteen patients underwent TOCPM (eight), and TOCPM+TORD (six). There was one case of TOCPM that was aborted due to excessive bleeding, which prevented full myotomy. The rest did well. All were discharged the next day. Two poor results from the TOCPM and TOCPM+TORD group were due to poor esophageal motility. The remainder of patients had resolution of dysphagia and normalized MBS. No patient developed stricture or complications. Short segment Zenker's diverticulum and cricopharyngeal bar can now be addressed completely with a transoral approach. Because there is complete closure of the mucosal incision, prolonged hospitalization can be avoided.

Eosinophilic esophagitis in a dog

A 4-year-old spayed female mixed-breed dog with a history of allergic skin disease was examined because of regurgitation, coughing, and dysphagia that began 15 days after abdominal surgery for correction of gastric dilatation and volvulus. Severe diffuse esophagitis, esophageal dysmotility, and a benign esophageal stricture at the level of the base of the heart were identified via contrast videofluoroscopy and esophagoscopy. Severe diffuse eosinophilic ulcerative esophagitis was confirmed by histologic examination of esophageal biopsy specimens and cytologic evaluation of specimens obtained by use of a cytology brush. Esophageal eosinophils were evident (14% to 50% of the inflammatory cell population and > 25 eosinophils/hpf). No clinical or endoscopic improvement was evident after treatment with antireflux medications, including a proton-pump inhibitor, following an initial esophageal bougienage procedure. An excellent response characterized by resolution of dysphagia and regurgitation with marked improvement of the esophageal mucosa was evident following intralesional and systemic administration of glucocorticoids, 2 additional esophageal bougienage procedures, and feeding of an elimination diet. To our knowledge, the information reported here is the first description of eosinophilic esophagitis (EE) in a dog. Many similarities exist between the condition in the dog reported here and EE in humans. This clinical report highlights the need to consider EE as a differential diagnosis for esophagitis and esophageal strictures in dogs. When appropriate, esophageal biopsy or cytologic specimens should be obtained and examined to investigate the possibility of EE.

Long-term symptomatic outcomes after Collis gastroplasty with fundoplication

Collis gastroplasty with fundoplication is an accepted treatment for gastroesophageal reflux disease (GERD) complicated by short esophagus. The procedure can be done either via left thoracotomy or using minimally invasive laparoscopic techniques. Few centers have reported long-term follow-up for patients undergoing a Collis gastroplasty using both the open and minimal access techniques. Retrospective review of prospectively collected data at Creighton University was done to identify patients who underwent Collis gastroplasty with fundoplication for GERD. After approval from the institutional review board, the patients were contacted and administered a questionnaire regarding symptoms and satisfaction. Data were entered in a dataset and analyzed from the patient's perspective. Eighty-five patients underwent a Collis gastroplasty procedure over a period of 13 years. Forty-eight percent (41 cases) were performed laparoscopically, and a transthoracic open repair was performed in the rest. Long-term data (more than 9 months) was available on 52 patients. Surgery resulted in complete resolution of heartburn, chest pain, regurgitation, and dysphagia in 52, 22, 54, and 29% of patients, respectively. More than 75% of the patients were satisfied with the outcome of surgery, and more than 85% would recommend the procedure to another patient. Collis gastroplasty with fundoplication results in good long-term patient satisfaction and symptom control.

Dysphagia due to anterior cervical hyperosteophytosis

Background Anterior cervical hyperosteophytosis describes the excessive formation of osteophytes along the ventral spine. Dysphagia due to ACH is considered an uncommon entity described mainly in case reports. Symptomatic ACH has been attributed to multiple etiologies including DISH, trauma, postlaminectomy syndromes, and cervical spondylosis. We report one of the largest series of patients with ACH-induced dysphagia requiring surgery. Methods After IRB approval, a retrospective chart review was completed. From 2001 to 2006, 9 patients presented with dysphagia due to ACH requiring surgical treatment. Results Eight patients were male, and the mean age was 65.1 years. Cervical spine x-rays and CT clearly demonstrated ACH in each case. Esophagram or a video fluoroscopic swallowing study was used to verify that dysphagia was caused by osteophytic overgrowth in all instances but one. In 2 patients, a focal osteophyte had formed adjacent to a previously fused segment. Of the remaining 7 patients, osteophytic formation was attributed to cervical spondylosis in 2 patients and DISH in 5 patients. All patients underwent osteophytectomy without spinal fusion. Average follow-up was 9.8 months. Although all 9 patients experienced resolution of dysphagia, improvement was delayed in 2 patients. Conclusions Diffuse idiopathic skeletal hyperostosis and spondylosis are the most common etiologies accounting for ACH-induced dysphagia. Adjacent segment disease may also be a potential cause of symptomatic ACH and has not been previously reported. Regardless of etiology, surgical resection is highly successful if conservative measures fail.

A phase II trial evaluating capecitabine and irinotecan as second line treatment in patients with oesophago-gastric cancer who have progressed on, or within 3 months of platinum-based chemotherapy

There is no standard second line therapy for relapsed oesophago-gastric (O-G) cancer. We recruited 29 eligible patients with relapsed O-G cancer who had progressed during or within 3 months of prior chemotherapy to assess the efficacy and toxicity of capecitabine [2,000 mg/(m(2) day) on days 1-14] and irinotecan (250 mg/m(2)) given every 3 weeks. Five patients (17%) demonstrated objective response, while a further seven patients (24%) achieved disease stabilisation. Median progression-free survival and overall survival were 3.1 months (95% CI = 2.2-4.1 months) and 6.5 months (95%CI = 6-7.1 months), respectively. Among symptomatic patients, palliation of tumour-related symptoms included resolution of reflux (5/12 pts), dysphagia (3/9 pts) and weight loss (4/9 pts), improvements in anorexia (4/10 pts), nausea (3/4 pts), vomiting (4/6 pts) and pain (4/16 pts). Grade 3-4 toxicities were diarrhoea (15%), nausea and vomiting (7%), lethargy (31%), neutropenia (31%), anemia (14%) and thrombocytopenia (7%). Capecitabine and irinotecan has anti-tumour activity as second line treatment for relapsed O-G cancer, and provides an important improvement in disease related symptoms.

Is Immunofluoresence Staining for Eosinophil Derived Neurotoxin Useful in the Diagnosis of Eosinophilic Esophagitis?

Purpose: We have shown that patients with low level esophageal eosinophilia (1–20 eos/hpf) have similar demographics, dysphagia history, and endoscopic findings as patients with classic eosinophilic esophagitis (EoE) with 20 eos/hpf. Some of the low-level eosinophilia patients will have eosinophil counts >20 /hpf at a second endoscopy and will have resolution of their dysphagia with topical steroid therapy. Other low-level eosinophilia patients will have resolution of dysphagia with PPI therapy. Esophageal eosinophil counts can fluctuate with time, and maximum eosinophil counts in esophageal mucosa might not be the best diagnostic tool for the diagnosis of EoE. We performed immunofluorescence staining of esophageal biopsy specimens for Eosinophil Derived Neurotoxin (EDN) in several groups of patients to evaluate its potential use as a marker for EoE. Methods: We performed staining for EDN with qualitative and semiquantitative analysis of esophageal biopsy specimens from four groups of patients: A) normals, B) low level eosinophilia –GERD patients (LL-GERD) (LA grade B-D esophagitis and dysphagia responding to PPI therapy), C) low level eosinophilia – emerging EoE patients (LL-EE) (>20 eos/hpf on second endoscopy and dysphagia response to topical steroid therapy), and D) classical EoE patients (25 to 100 eos/hpf). Specimens were scored on a 0–3 scale for intracellular (IC) and extracellular (EC) EDN deposition by two authors, and the scores were averaged. Results: The semiquantitative results are displayed in Table 1. IC and EC EDN scores were negligible in the normals and elevated in the other groups. The EC EDN score and percentage of patients with an abnormal score (>1.3) trended to be higher in the EoE and LL- EoE groups. Qualitatively, intense extracellular EDN deposition was typically observed in the papillae and on the luminal surface of the epithelium in biopsies from the EoE patients, while deposition in the LL-GERD patients, with one exception, was scattered throughout the mucosa with relatively little uptake on the luminal surface and in the papillae. The LL-EoE group had a very similar pattern to the EoE group.Table 1Conclusion: This pilot study suggests: 1) Patients with low level eosinophil density in esophageal biopsies have significant EDN immunofluorescence staining. 2) EDN staining particularly extracellular staining on the luminal mucosa has potential to be a better marker for EoE than maximum eosinophil count and should be further evaluated.

A New Therapy for Eosinophilic Esophagitis in Adults

Purpose: Topical steroid therapy such as aerosolized fluticasone has been demonstrated to be an effective treatment of Eosinophilic Esophagitis (EE) but may have oral side effects. We hypothesized that delivery of a budesonide gel specifically formulated to increase the contact time of the gel to the esophageal mucosa will result in a greater reduction in clinical symptoms of dysphagia and less oral side effects. Methods: An oral gel combining budesonide with the mucosal adherent preparation Rincinol (BRG) was compounded. Patients with abnormal Mayo dysphagia questionnaires underwent EGD with biopsies. 16 patients with greater than 15 eos/HPF and solid food dysphagia were enrolled in the study and treated with BRG. Patients were instructed to take BRG 3 mg/10 cc BID. If patients noted marked improvement at one week, they were switched to once daily BRG for 6 weeks; otherwise they were continued on BID BRG for a total of 6 weeks. Dysphagia symptoms and BRG side effects over the last two weeks of treatment were assessed by personal interview. Symptoms were evaluated on a scale of dysphagia resolution: <25%, 25–49%, 50–74%, 75–99% or complete resolution. Those patients, who had previously utilized topical fluticasone for EE, were asked to compare BRG vs topical fluticasone with respect to treatment effect and tolerance. Results: See Table 1 regarding the baseline clinical features of our EE patients. After 6 weeks of BRG therapy, all patients reported at least a 75% improvement in dysphagia symptomatology. 56% (9/16) of patients reported complete dysphagia resolution and 44% (7/16) reported a 75–99% reduction in dysphagia symptoms. Patients who transitioned from BID to once daily BRG noted no increase in dysphagia symptomatology. There was no significant difference in treatment response observed between the dosing regimens (Table 2). With respect to side effects, 13% (2/16) reported hoarseness and 6% (1/16) unpleasant taste. No oral candidiasis was observed with BRG therapy. Of the patients who had previously received fluticasone for treatment of EE, 38% (3/8) felt BRG was more effective, 62% (5/8) had no preference and none preferred fluticasone. When asked about tolerance, 50% (4/8) of patients tolerated both preparations equally, whereas 25% (2/8) favored fluticasone and 25% (2/8) favored budesonide.Table 2: BRG Dosing Regimen and Patient Reported Treatment EffectTable 1: Baseline Clinical Characteristics of Study PatientsConclusion: BRG effectively relieved symptoms of dysphagia in patients with esophageal eosinophilia with minimal side effects in this study. BRG may also be effective in treating EE patients who have previously failed fluticasone. Further studies should be performed to validate these findings.

Endoscopic, Radiologic, and Manometric Features of an Incomplete Heller Myotomy for Achalasia

Purpose: Laparoscopic Heller myotomy is an effective surgical therapy for idiopathic achalasia. Unfortunately 5–10% of patients develop recurrent dysphagia or chest pain in the early postoperative period. The most common cause for recurrence is an incomplete myotomy, in which the muscle fibers at the distal end of the myotomy are not completely released. Proper recognition of an incomplete myotomy is poorly described in the literature and the best approach to therapy is unclear. Methods: A 63 yo female with diabetes and hypertension who presented with dysphagia to solids and liquids and a 40 pound weight loss was diagnosed with achalasia on barium esophogram and manometry. The manometry showed a hypertensive lower esophageal sphincter (LES), incomplete LES relaxation, and aperistalsis with low-amplitude, simultaneous contractions after all wet swallows. She underwent a laparoscopic Heller myotomy with Dor fundoplication which was initially successful. However, she returned one year later with recurrent dysphagia, chest pain and weight loss. Results: Evaluation with esophogram and endoscopy showed a focal distal stenosis lacking the appearance of a peptic or fibrotic stricture (see Figure). Repeat manometry showed an isolated high-pressure zone (HPZ) with failure of relaxation within the proximal margin of the LES. This HPZ was consistent with intact residual LES fibers from an incomplete myotomy. Thus, pneumatic dilation (PD) was chosen as the therapeutic approach instead of a repeat surgery. The dilation was performed with a 3 cm balloon and was successful – at follow-up 1 and 4 months later she reported resolution of dysphagia and chest pain and had a weight gain of 8 pounds.FigureConclusion: This case nicely illustrates what might be observed in a patient with achalasia and recurrent symptoms due to an incomplete myotomy. A focal residual HPZ at the proximal end of the LES was observed on endoscopy, radiology, and manometry. Our case is interesting in that the residual HPZ was located at the proximal rather than distal margin of the LES. The use of PD following incomplete myotomy has been reported in the literature with success rates as high as 80 percent. More studies are needed to improve recognition of an incomplete myotomy and to develop criteria for the selection of patients who would benefit most from PD after failed myotomy.

Laparoscopic retrieval of intraabdominal foreign bodies

The use of laparoscopy has been described as the means of removing intraabdominal foreign bodies, both intraperitoneal and intraluminal, from the stomach or bowel. An early report detailed the laparoscopic removal of translocated intrauterine devices from the peritoneal cavity. Laparoscopic removal of a retained surgical sponge also has been reported. For large ingested objects that cannot be retrieved by flexible endoscopy, laparoscopic gastrotomy and foreign body removal have been described. The authors recently had three cases of laparoscopic foreign body retrieval. The first case involved a young man who had ingested latex gloves, causing gastrointestinal bleeding. Endoscopic retrieval was unsuccessful. A laparoscopic gastrotomy was performed, with the retrieval of four gloves, followed by intracorporeal, sutured closure of the gastrotomy. The second case involved the laparoscopic removal of a Penrose drain around the distal esophagus. The patient had initially undergone a laparoscopic Nissen fundoplication, vagotomy, and gastrojejunostomy for the management of reflux and a duodenal stricture. He had persistent dysphagia after surgery, prompting takedown of the fundoplication several months later. When his dysphagia did not improve, a retained Penrose drain that had been placed around the distal esophagus at the initial operation was discovered on computed tomography. This was removed laparoscopically. At this writing, 18 months after the initial operation, the patient has complete resolution of dysphagia. The third case involved a duodenojejunal fistula caused by multiple ingested magnets that had eroded through the bowel wall. The fistula was divided laparoscopically, and 16 disk-shaped magnets were removed. The duodenum and jejunum were repaired with laparoscopic suturing and stapling. All three patients did well after surgery. Laparoscopy can be an excellent method for abdominal foreign body retrieval. The online version of this article (doi: 10.1007/s00464-006-9011-0) contains supplementary material, which is available to authorized users.

Critical Evaluation of Esophageal Dilation in Nonobstructive Dysphagia With and Without Esophageal Rings

To evaluate the therapeutic efficacy of esophageal dilation compared with medical treatment in patients with nonobstructive dysphagia (NOD). Clinical studies evaluating the role of esophageal dilation in patients with NOD have reported conflicting results. In addition, studies suggesting beneficial effects of esophageal dilation in this group of patients have not compared it with medical treatment. We conducted a retrospective study in 107 patients with NOD and divided these patients into 2 groups. Group 1 included patients who received esophageal dilation with a polyvinyl bougie along with adjunctive medical treatment, and group 2 included patients who received medical treatment alone. Complete resolution of symptoms occurred in 41 of the 60 patients (68.3%) who received esophageal dilation. In the group that received medical treatment alone (n=47), 28 patients (59.5%) had complete resolution of symptoms. There was no statistically significant difference in symptom resolution between the 2 groups. In addition, among 22 patients with esophageal rings, 17 patients (77%) had complete symptomatic relief with dilation, as compared with 63% patients without esophageal rings. Although there was a trend towards higher frequency of dysphagia resolution with esophageal dilation in patients with NOD and esophageal rings, the difference failed to reach statistical significance. Esophageal dilation and medical therapy are equally efficacious (60% to 70% of cases) in resolving symptoms of dysphagia in patients with NOD. Patients with NOD and esophageal rings may represent the subgroup of patients who are more likely to benefit from esophageal dilation.

Effect of Erosive Esophagitis (EE) at Baseline on Symptom Resolution in Gastroesophageal Reflux Disease (GERD) after 4 Weeks of Esomeprazole Treatment

Purpose: To compare rates of GERD symptom resolution in patients with and without EE at baseline after 4 weeks of treatment with oral esomeprazole 40 mg daily. Methods: Adults aged 18–70 y with a history of frequent heartburn (≥2 d/wk for the past week and on average for the past 3 months) were eligible for this multicenter, open-label study (D9612L00083). Baseline endoscopy established presence and severity of EE (Los Angeles [LA] grades A–D; patient-blinded). After stratification by presence or absence of EE, all patients received oral esomeprazole 40 mg daily for 4 weeks. When a stratum reached its predetermined quota of ∼175 patients, additional patients received no treatment, but endoscopy results were retained for prevalence estimates. GERD symptoms were reassessed at 2 and 4 weeks by questionnaire; symptom resolution was defined as patients recording ‘none’ on a scale of ‘none’, ‘mild’, ‘moderate’ or ‘severe’. χ2 Tests were performed to compare symptom resolution rates in patients with and without EE. Results: Of 399 patients who underwent endoscopy, 205 had EE, for an EE prevalence of 51.4%. Of those with EE, 29%, 38%, 26%, and 7% had LA grades A, B, C, and D, respectively. The intention-to-treat population was composed of 356 patients (men, 42%; white, 81%; mean age, 44 y; mean BMI, 30.1 kg/m2). After 2 and 4 weeks of esomeprazole treatment, heartburn resolution rates were higher in patients with EE (N = 179) than without EE (N = 177) at baseline (table). At baseline, all patients had heartburn and most had acid regurgitation (87%) and epigastric pain (79%). Only 47% had dysphagia at baseline, which likely decreased the power to detect between-group differences in dysphagia resolution rates.Table: Patients (%) who had GERD symptom resolution after esomeprazole treatment, stratified by presence or absence of EE at baselineConclusions: GERD symptom resolution rates were higher in patients with EE than those without EE after 4 weeks of daily esomeprazole 40-mg treatment. Given this observation, GERD symptom resolution should not be accepted as an indicator of benign esophageal mucosal pathology. Supported by AstraZeneca LP

Endoscopic Revision of an Esophageal Polyflex® Stent

Options are limited for the management of individuals with benign recurrent esophageal strictures who have failed proton pump inhibitor therapy. Esophageal stents are helpful in these individuals, however these temporary stents are usually removed after 6–8 weeks. Management of complications and efficacy beyond 11 months has not been reported. We present, in this report, a case of endoscopic repair of a disrupted Polyflex® stent (Boston Scientific Corp) 18 months after placement. Case: This is a report of an 81 y/o woman with a 3-year history of a benign esophageal stricture who presented with increasing dysphagia to liquids and solids with secondary 30 lb. weight loss. Her past management had included repeated esophageal dilation with biopsies and twice daily proton pump inhibitor therapy. At upper endoscopy she had a distal esophageal stricture extending from 37 to 40 cm from the central incisors with no evidence for a hiatal hernia. Multiple biopsies were consistent with gastroesophageal reflux disease with no evidence of Barrett's metaplasia, dysplasia, or malignancy so she underwent placement of a 12 cm x 18 mm Polyflex® plastic stent. At follow-up 8 weeks later, she reported complete resolution of dysphagia and had regained 12 lbs. At that time she refused to have the stent removed, as recommended by the manufacturer. Repeat endoscopy at 6 months and 11 months had demonstrated a completely intact stent in excellent position. At 18 months, repeat endoscopy for stent follow-up showed separation and proximal inversion of the stent. The remainder of the stent remained patent and in good position. She had no symptoms of dysphagia or odynophagia. A standard rat-tooth forcep was used and with mild-moderate amount of upward traction, the separated and inverted portion of the stent was removed. The remainder of the stent remained in position and patent at the end of procedure. Since placement of the stent, she has regained 40 lbs. Endoscopic revision of an esophageal Polyflex® stent is possible. In select individuals with benign esophageal strictures, placement of a Polyflex® stent provides a safe and effective long-term option (now > 18 months) for management of dysphagia and weight loss.

Technique and follow-up of minimally invasive Heller myotomy for achalasia

Laparoscopic Heller myotomy has been proven effective. Reliable predictive factors for outcome and the true benefit of the da Vinci robotic system, however, remain unknown. Seventy patients underwent laparoscopic Heller myotomy. The number of intraoperative perforations and the symptom-predictive value of postoperative esophagogram width measurement at the gastroesophageal junction were analyzed. The overall complication rate was 11%. Four patients experienced intraoperative perforation during the laparoscopic technique. No perforations were experienced with the da Vinci robotic system (n = 19). Of the total, 82% of patients had resolution of dysphagia, 91% of regurgitation, 91% of heartburn and 82% of chest pain. Immediate postoperative esophagogram gastroesophageal junction width demonstrated a positive predictive trend from 0 to 10 mm for dysphagia. Laparoscopic Heller myotomy is an effective treatment for achalasia. Immediate postoperative esophagogram gastroesophageal junction width measurement as a predictor for symptom resolution requires further study.

Clinical Presentation, Endoscopic Findings and Treatment of Eosinophilic Esophagitis in Adults

Purpose: Eosinophilic esophagitis is a chronic inflammatory disorder of the esophagus characterized by heavy infiltration of eosinophils of the esophagus. The etiology, pathogenesis, natural history and optimal treatment of eosinophilic esophagitis in adults are unknown. Here we present the largest case series of eosinophilic esophagitis in adults to date, and to provide evidence that eosinophilic esophagitis in adults is related to gastroesophageal reflux disease (GERD). Methods: In our group practice of 20 gastroenterologists, we identified a total of 61 consecutive adult patients with a histological diagnosis of eosinophilic esophagitis from our pathology database between 2002 and 2004. The medical records of these patients were reviewed. Data on clinical presentation, endoscopic findings, treatment, and response to treatment were collected and analyzed. Results: Among the 61 patients with a histological diagnosis of eosinophilic esophagitis, 38 patients (60%) presented with solid food dysphagia and 12 patients (20%) had a history of food impaction. Twenty-five patients (41%) presented symptoms of GERD, either with (14 patients) or without (11 patients) concurrent dysphagia, as their main complaints. The classical endoscopic finding of ringed esophagus was present in only 32 patients (52%), and 8 patients (13%) had normal esophagus at endoscopy. In parallel with the abundance of clinical symptoms of GERD, endoscopic findings associated with GERD were common, with hiatal hernia present in 30 patients (49%), reflux esophagitis in 11 patients (18%), peptic stricture in 4 patients (7%), and Barrett's esophagus in 2 patients. While esophageal dilation, either alone or in conjunction with treatment with a proton pump inhibitor (PPI), was effective in relieving dysphagia, medical treatment with a PPI alone without dilation also resulted in resolution of dysphagia in all 9 patients whose follow-up information was available. Conclusions: The presence of clinical and endoscopic features of GERD and the response to treatment with proton pump inhibitors in many of our patients strongly implicate GERD in the pathogenesis of eosinophilic esophagitis in adults. In adult patients with eosinophilic esophagitis who present with dysphagia, we suggest treatment with a PPI before performing esophageal dilation.

A Total Fundoplication Is Not an Obstacle to Esophageal Emptying After Heller Myotomy for Achalasia

The aim of this study was to evaluate the role and efficacy of a total 360 degrees wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia. Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to esophageal emptying. Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12-79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry. In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 +/- 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 +/- 1.1 days (range, 1-12 days). At a mean clinical follow up of 83.2 +/- 7 months (range, 3-141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0-1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients. Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.

Effectiveness of esophageal dilation for symptomatic cricopharyngeal bar

The cricopharyngeal (CP) bar is an uncommon but important cause of oropharyngeal dysphagia (OPD). Treatment options include CP myotomy, which can be problematic, because CP bars primarily occur in elderly patients who are at higher risk for perioperative complications. The effectiveness of esophageal dilation for patients with symptoms caused by a CP bar is not well studied. A review of medical records (1999 to 2002) identified 32 patients with CP bar. Six of these patients who had OPD that could only be attributed to a CP bar underwent EGD and dilation with either over-the-guidewire polyvinyl dilators (5) or a balloon (1). All 6 patients experienced immediate relief of dysphagia. Five had continued improvement at short-term follow-up (1 to 4 weeks). Three patients still had complete resolution of dysphagia at long-term follow-up (range 8 to 27 months). CP bar is an important cause of dysphagia in elderly patients. Esophageal dilation of a CP bar can produce long-term relief of dysphagia.

ESOPHAGEAL PLASTIC STENTS (EPS) FOR REFRACTORY BENIGN ESOPHAGEAL STRICTURES (RBES) A NEW APPROACH WITH DISAPPOINTING OUTCOMES

Metal stents have poor long-term outcomes for treatment of RBES. Recently, a removable EPS (Polyflex, Boston Scientific, USA) was approved in the US for management of RBES. An EPS is an ideal option for the management of RBES, but data on outcomes of EPS in RBES are lacking. Aim: To study the outcome of EPS in patients with RBES. Patients and Methods: A retrospective review of 3 patients that underwent EPS placement for dysphagia due to RBES that were resistant to conventional dilation therapy. Patient #1: A 56 yo WF with esophageal cancer resected after neo-adjuvant chemoradiation with an anastomotic stricture (diameter 3mm). There was no evidence of residual cancer. She underwent 19 attempts at dilation of the stricture (Savary-6 (maximum dilation 36 Fr), TTS balloon-5 (60 Fr), TTS balloon with triamcinolone injection-4 (54 Fr), needleknife stricturoplasty followed by TTS balloon-4 (54 Fr)). #2: A 37 yo WF with a stricture (6 cm in length, 11 mm in diameter) due to lye ingestion, treated with self-dilations (38 Fr/week) but with some residual dysphagia. #3: A 47 yo WM with laryngeal cancer treated with total laryngectomy and radiation with an anastomotic (3mm) and a radiation stricture (5mm). Patient underwent 2 Maloney dilations (45 Fr) by ENT without resolution of dysphagia. Results: All patients had successful EPS placement for their RBES. Patient 1 had 5 migrations of the EPS treated with endoscopic EPS repositioning and later with placement of a larger EPS that also migrated. Patient 2 developed severe chest pain post EPS placement requiring hospitalization and EPS removal on day 7. Endoscopy revealed severe ulceration and granulation at the proximal phalange of the EPS. Patient 3 developed cellulitis in the neck region on day 6 post EPS placement. Barium swallow revealed a contained perforation at the proximal phalange of the EPS. Endoscopy revealed significant ulceration due to pressure necrosis at the proximal phalange and a contained perforation. All patients required EPS removal and are currently being managed satisfactorily with esophageal self-dilation. Conclusions: EPS are a promising technique to manage RBES. EPS are technically easy to place and remove. However, our initial experience reveals poor outcomes due to adverse events. Improvements in EPS design aimed at preventing stent migration and avoiding ulceration and granulation tissue formation at the proximal phalange may improve outcomes.