Correlation between asymptomatic gastroesophageal excessive transmural injury after pulmonary vein isolation and a bonus freeze protocol using the second-generation 28-mm cryoballoon for paroxysmal atrial fibrillation.

BACKGROUND: Second-generation cryoballoon (2G-CB) ablation is highly effective for achieving pulmonary vein isolation (PVI) with a promising clinical outcome. However, the ideal freezing strategy for preventing gastroesophageal excessive transmural injury (ETI) remains under debate. This study aimed to clarify the correlation between gastroesophageal ETI and a bonus-freeze protocol after PVI using 2G-CBs. METHOD: This study included 100 patients who underwent PVI using 2G-CB followed by an endoscopic examination. The freeze-cycle duration was set at 180s. In the first 33 patients a 120s bonus-freeze was applied after successful PVI (bonus group), while in the following 67 the bonus freeze was omitted (non-bonus group). Early freezing interruption was performed when the esophageal temperature reached 25°C. Gastroesophageal ETI was defined as any injury that resulted from the PVI, including esophageal damage or periesophageal nerve injury. RESULTS: Gastroesophageal ETIs were observed in 9 (27.3%) and 6 (9.0%) patients and were all asymptomatic, esophageal damage in 3 and 0, and periesophageal nerve injury in the remaining 6 and 6 in the bonus group and non-bonus group, respectively (p=0.033). In the multivariate analysis, the bonus freeze protocol (odds ratio 3.527; 95% confidence interval 1.110-11.208; p=0.033) was the sole independent predictor of gastroesophageal ETI. During a one-year follow-up 26 of 33 bonus group patients (78.8%) and 52 of 67 (77.6%) non-bonus group patients remained in stable sinus rhythm without any differences between the groups. CONCLUSIONS: In the patients with a bonus-freeze protocol using the 2G-CB, gastroesophageal ETIs were detected more often than in those with the non-bonus freeze protocol. In contrast, freedom from atrial fibrillation after the 2G-CB based PVI was comparable when applying either a bonus or non-bonus freeze protocol.

The microscopic anatomy of the esophagus including the individual layers, specialized tissues, and unique components and their responses to injury.

The esophagus, a straight tube that connects the pharynx to the stomach, has the complex architecture common to the rest of the gastrointestinal tract with special differences that relate to its function as a conduit of ingested substances. For instance, it has submucosal glands that are unique and have a specific protective function. It has a squamous lining that exists nowhere else in the gut except the anus and it has a different submucosal nerve plexus when compared to the stomach and intestines. All of the layers of the esophageal wall and the specialized structures including blood and lymphatic vessels and nerves have specific responses to injury. The esophagus also has unique features such as patches of gastric mucosa called inlet patches at the very proximal part and it has a special sphincter mechanism at the most distal aspect. This review covers the normal microscopic anatomy of the esophagus and the patterns of reaction to stress and injury of each layer and each special structure.

Defining the gastroesophageal junction in trauma: Epidemiology and management of a challenging injury.

BACKGROUND: Injuries to the gastroesophageal (GE) junction are infrequently encountered because of the high mortality of associated injuries. Consequently, there is a paucity of literature on the patient demographics and treatment options. The aim of this study was to examine the epidemiology, surgical management, and outcomes of these rare injuries. METHODS: Patients presenting to LAC + USC Medical Center (January 2008 to August 2016) with traumatic esophageal or gastric injury (DRG International Classification of Diseases-9th Rev.-Clinical Modification and 10th Rev. codes) were extracted from the trauma registry. Patient charts were reviewed, and all patients who sustained an injury to the GE junction were enrolled. Patient demographics, injury characteristics, procedures, and outcomes were analyzed. RESULTS: Of the 238 patients who sustained an injury to the esophagus or stomach during the study period, 28 (12%) were found to have a GE junction injury. Mean age was 26 years (range, 14-57 years), 89% male. Mechanism of injury was penetrating in 96% (n = 27), the majority of which were gunshot wounds (n = 22, 81%). Most patients (n = 18, 64%) were taken directly to the operating room. Ten (36%) underwent computed tomography scan before going to the operating room, all demonstrating a GE junction injury. All patients underwent repair via laparotomy. One (4%) also required thoracotomy to facilitate delayed reconstruction. GE junction injuries were typically managed with primary repair (n = 22, 79%). Associated injuries were frequent (n = 26, 93%), and injury severity was high (mean Injury Severity Score, 25 [9-75]). Mortality was 25% (n = 7), and all patients required intensive care unit admission. Most did not require total parenteral nutrition (n = 25, 89%) or a surgically placed feeding tube (n = 26, 93%). Of the 13 patients who presented for clinical follow-up, all but one (n = 12, 92%) were eating independently by the first clinic visit. CONCLUSION: GE junction injuries are uncommon and occur almost exclusively after penetrating trauma. Patients are severely injured with a high mortality rate and frequently have associated intracavitary injuries. Most can be fixed through the abdomen alone and do not require thoracotomy for repair. Despite the severity of injuries, the majority of survivors are eating independently by the first clinic visit. LEVEL OF EVIDENCE: Epidemiological, level V.

Exposure to non-steroid anti-inflammatory drugs (NSAIDs) and suppressing hydrogen sulfide synthesis leads to altered structure and impaired function of the oesophagus and oesophagogastric junction.

INTRODUCTION: The non-steroid anti-inflammatory drugs (NSAIDs) are among the drugs that can commonly cause injury in the esophagus, such as non-reflux oesophagitis, with important clinical consequences. This injury may be 'silent' and therefore often overlooked. Recently, we established that hydrogen sulfide (H2S) is a critical mediator of esophageal mucosal protection and repair. The aim of the study was to determine the effect of naproxen, the most commonly used NSAIDs, on the oesophagus and oesophagogastric junction and its relation with suppression or stimulation of endogenous H2S synthesis during naproxen-induced oesophageal injury. METHODS: Rats were treated with vehicle (control) or naproxen, with or without being subjected to water immersion restricted stress (Takagi et al. Chem Pharm Bul 12:465-472, 1964). Subgroups of rats were pre-treated with an inhibitor of H2S synthesis cystathionine γ-lyase (CSE) or cystathionine ß-synthase (CBS), or with the Sodium sulphide (NaHS), which spontaneously generates H2S in solution. Damage of the oesophageal mucosa and oesophagogastric junction was estimated and scored using a histological damage index. RESULTS: Treatment with naproxen increased the thickness of the corneal and epithelial layers of the oesophagus, as well as producing disorganization of the muscle plate and irregular submucosal oedema. Both injury factors, stress and suppression of H2S synthesis resulted in the development of severe esophagitis and damage to the oesophagogastric junction. The damage was exacerbated by inhibitors of H2S biosynthesis, and attenuated by treatment with NaHS. CONCLUSIONS: Inhibition of endogenous H2S synthesis provides a novel experimental model that can be useful in preclinical studies NSAID-related non-reflux oesophagitis. H2S contributes significantly to mucosal defence in the oesophagus.

Treatment of experimental esophagogastric myotomy with bone marrow mesenchymal stem cells in a rat model.

BACKGROUND: Over the last 15 years, many studies demonstrated the myogenic regenerative potential of bone marrow mesenchymal stem cells (BM-MSC), making them an attractive tool for the regeneration of damaged tissues. In this study, we have developed an animal model of esophagogastric myotomy (MY) aimed at determining the role of autologous MSC in the regeneration of the lower esophageal sphincter (LES) after surgery. METHODS: Syngeneic BM-MSC were locally injected at the site of MY. Histological and functional analysis were performed to evaluate muscle regeneration, contractive capacity, and the presence of green fluorescent protein-positive BM-MSC (BM-MSC-GFP(+) ) in the damaged area at different time points from implantation. KEY RESULTS: Treatment with syngeneic BM-MSC improved muscle regeneration and increased contractile function of damaged LES. Transplanted BM-MSC-GFP(+) remained on site up to 30 days post injection. Immunohistochemical analysis demonstrated that MSC maintain their phenotype and no differentiation toward smooth or striated muscle was shown at any time point. CONCLUSIONS & INFERENCES: Our data support the use of autologous BM-MSC to both improve sphincter regeneration of LES and to control the gastro-esophageal reflux after MY.

Self-expanding stents in treatment of esophageal leaks post bariatric surgery.

The Alimaxx self-expanding metal stents were used in two morbidly obese patients with esophageal leaks complicating reoperative bariatric surgery. Although the patients could be maintained on oral intake with their sepsis controlled, surgery was ultimately required for non-healing after 3 weeks of conservative management. Self-expanding metal stent should be considered the preferred treatment in small esophageal leaks less than 1 cm in morbidly obese patients who generally pose a higher operative risk due to concomitant co-morbidities. Stents are also useful adjuncts in patients with larger leaks that are either inoperable or need further stabilization at presentation and those preferring an initial 2-3 weeks trial of conservative management before contemplating surgery.

Gastroesophageal junction leak with serious sepsis after gastric bypass: successful treatment with endoscopy-assisted intraluminal esophageal drainage and self-expandable covered metal stent.

We present a case of gastroesophageal junction leak after gastric bypass with serious sepsis and hemodynamic instability. Minimally invasive treatment was performed in two stages: initial sepsis control by lavage and endoscopy-assisted laparoscopic placement of an intraluminal esophageal drainage tube through the leak orifice; this was followed by definitive leak treatment with a self-expandable covered metal stent after achieving hemodynamic stability. Patient evolution was satisfactory without the need for open surgery.

Management of unusually extensive esophagogastric corrosive injuries: emergency measures and gastric reconstruction.

Ingestion of a corrosive substance only rarely presents with life-threatening symptoms because of acute necrosis of the esophagus and/or stomach and necessitates emergency surgery. Once the patient is stabilized, a staged reconstruction of the alimentary tract is planned. The surgeon should be familiar with the various types of gastric reconstruction in conjunction with or without esophageal replacement. The authors report 2 illustrative cases, which presented severe symptoms after corrosive substance ingestion, to emphasize the important aspects of management of this condition. The reconstruction of the gastrointestinal tract in children is managed with a staged approach using various methods, including Hunt-Lawrence J pouch gastric substitution.

Treatment of upper gastrointestinal leaks with a removable, covered, self-expanding metallic stent.

BACKGROUND: Anastomotic and staple line leaks are serious complications after upper gastrointestinal and bariatric procedures. In patients who are actively septic "diversion and drainage" with aspiration of esophageal and gastric secretions, operative placement of perianastomotic drains, bowel rest, and parenteral nutrition form the conventional management strategy of leaks. Treatment of leaks by direct suture repair, revision, patching, and application of fibrin glue to leaks have failed to gain widespread acceptance owing to a high failure rate in the septic patient. This report describes a case series where anastomotic leaks in patients with established sepsis after upper gastrointestinal resections and bariatric procedures as well as Boerhaave syndrome were managed with a combination of surgical drainage and stent placement. A new technique where the stent is sutured into place transluminally to prevent migration is described. METHOD: Seven patients with staple line and anastomotic dehiscences and a single case of Boerhaave syndrome were treated at St George Hospital, Sydney, over the period January 2003 to December 2006 by using a removable, polyester covered self-expanding metal stent (ELLA Boubella, Ella-CS, Hradec, Czech Republic). All patients had active severe sepsis and significant contamination in the abdomen or thorax at the time of stenting. In 4 cases, the stent was sutured in place with dissolvable synthetic sutures with suture bites incorporating the full thickness of the gut wall and the stent itself to prevent stent migration. RESULTS: All patients showed resolution of their intra-abdominal sepsis and were able to resume an oral diet after stenting. All stents were retrieved endoscopically after clinical resolution of the leak. Stent migration after leak resolution was observed in 3 patients. In patients with large defects or minimal anatomic barriers to stent migration, suture fixation stabilized the stent. There were no episodes of persistent leak or development of stricture in this series. CONCLUSIONS: In this small series, the use of a removable covered stent in the setting of anastomotic leak or spontaneous perforation, alone or as an adjunct to conventional surgical management, is feasible in sealing the leak, resolving sepsis, and expediting return to enteral nutrition. Stenting is feasible in cases with substantial tissue loss or contamination. Suturing the stent transluminally stabilizes the stent where risk of migration is high.

CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation.

Rupture of the oesophagus or stomach at the time of cardiopulmonary resuscitation can occur with accidental oesophageal intubation. The common site of rupture is the lesser curvature of the stomach, but can also occur at the oesophagogastric junction. The patient presented with a massive pneumoperitoneum after an out of hospital ventricular fibrillation arrest. CT scanning was helpful in making the diagnosis. In out of hospital resuscitation, current JRCALC (Joint Royal Colleges Ambulance Liaison Committee) recommendations may not avoid this complication.

Achalasia presenting after operative and nonoperative trauma.

Achalasia has been described following fundoplication and is attributed to vagal nerve damage during surgery. Similarly, other traumatic events to the distal esophagus may be linked to the development of achalasia. Operative and nonoperative trauma as a possible factor in the development of achalasia was studied. A retrospective analysis of patients with achalasia (n = 64) at our institution was performed. Collected data included age, gender, symptoms, and history of operative and nonoperative traumatic events. Comparisons were made to a group of patients with similar symptoms but normal esophageal manometry (n = 73). Achalasia was diagnosed by manometry in 125 patients over a 6-year period. All patients with complete medical records (n = 64) were studied. A history of operative or nonoperative trauma to the upper gastrointestinal tract prior to the development of symptomatic achalasia was present in 16 of 64 (25%). Significantly fewer patients (9.5%) with symptoms of dysphagia, but normal manometry and upper endoscopy, had precedent trauma to the upper gastrointestinal tract (P < 0.05). All cases of nonoperative trauma occurred in motor vehicle accidents. Cases of operative trauma included coronary artery bypass surgery (n = 4), bariatric surgery (n = 2), fundoplication (n = 3), heart/lung transplantation (n = 1), and others (n = 5). Patients with proven achalasia and a history of trauma were more likely to have chest pain (RR, 4.5; P = 0.012) but less likely to have regurgitation (RR, 0.51; P = 0.01) or nausea/vomiting (RR, 0.0; P = 0.27) than those without a history of antecedent trauma. In this series, significantly more patients with achalasia had a history of preceding trauma than did patients with similar symptoms and normal esophageal manometry. Following trauma, patients may be at increased risk for developing achalasia, possibly from neuropathic dysfunction due to vagal nerve damage. Patients with posttraumatic achalasia may have symptoms which differ from those of other achalasia patients.

Effects of the laryngeal mask airway on the lower oesophageal barrier pressure in children.

The effects of laryngeal mask airway (LMA) insertion and cuff inflation on lower oesophageal sphincter, gastric and barrier pressure, and the relationship of the LMA cuff pressure and volume on the change in the barrier pressure were studied in 20 children. Subjects were aged one to five years, undergoing eye examination under general anaesthesia. There was no significant change in barrier pressure after insertion and inflation of the LMA compared with baseline measures. The cuff pressure and volume were not related to the change in barrier pressure. Two patients had marked decreases (10 to 15 mmHg) in barrier pressure after the LMA insertion. These decreases in barrier pressure would be expected to increase the risk of gastro-oesophageal reflux. We conclude that, although LMA use had little effect on barrier pressure in most children, occasional children will have potentially clinically significant decreases in barrier pressure with use of the LMA.

Massive gastrointestinal hemorrhage after transoesophageal echocardiography probe insertion.

PURPOSE: To describe a case of a massive gastric bleeding following emergency coronary artery bypass surgery associated with transoesophageal echocardiographic (TEE) examination. CLINICAL FEATURES: A 50-yr-old man was referred for an acute myocardial infarction and pulmonary edema (Killip class 3). Twelve hours after his myocardial infarction, he was still having chest pain despite an i.v. heparin infusion. Coronary angiography revealed severe three-vessel disease with multifocal stenosis of the left anterior descending, circumflex and total occlusion of the right coronary artery. The patient was transferred to the operating room for emergency coronary artery bypass graft surgery. After total systemic heparinization (3 mg.kg-1) was obtained for cardiopulmonary bypass, a multiplane TEE probe was inserted without difficulty to monitor myocardial contractility during weaning from CPB. During sternal closure, the TEE probe was removed and an orogastric tube was inserted with immediate drainage of 1,200 ml red blood. Endoscopic examination demonstrated a mucosal tear near the gastro-oesophageal junction and multiple erosions were seen in the oesophagus. These lesions were successfully treated with submucosal epinephrine injections and the patient was discharged from the hospital eight days after surgery. CONCLUSION: This is a report of severe gastrointestinal hemorrhage following TEE examination in a fully heparinized patient. This incident suggest that, if the use of TEE is expected, the probe should preferably be inserted before the administration of heparin and the beginning of CPB.

Unusual bleeding complications of thrombolytic therapy after cardiopulmonary resuscitation. Three case reports.

The authors present three case reports retrospectively casting doubt on the benefit of thrombolysis after external cardiac massage.