Multi-modality management of defects in the gastrointestinal tract: Where the endoscope meets the scalpel: Endoscopic vacuum therapy in the upper gastrointestinal tract.

BACKGROUND: Transmural defects in the upper gastrointestinal (GI) tract, such as anastomotic leakage and oesophageal perforations, are associated with significant morbidity and mortality risks. Endoscopic vacuum therapy (EVT) is an efficient and safe treatment option for these patients. With the growing use of EVT in the upper GI tract, it is important to share expertise on the topic. AIM: This review explores the emerging role of endoscopic vacuum therapy (EVT) as treatment for transmural defects in the upper GI tract. An overview of the mechanism and procedures, outcomes in current literature and challenges of implementation and application are discussed. CONCLUSION: EVT exhibits great efficacy and safety for the treatment of transmural defects in the upper GI tract. Current use of EVT is mostly experience-based, emphasizing the importance of sharing expertise and performing research to unlock its full potential.

Endoluminal Vacuum Therapy Using a New "Fistula Sponge" in Treating Defects of the Upper Gastrointestinal Tract-A Comparative, Retrospective Cohort Study.

Background and Objectives: Anastomotic insufficiencies (AI) and perforations of the upper gastrointestinal tract (uGIT) result in high morbidity and mortality. Endoscopic stent placement and endoluminal vacuum therapy (EVT) have been established as surgical revision treatment options. The Eso-Sponge® is the only licensed EVT system with limitations in treating small defects (<10 mm). Therefore, a fistula sponge (FS) was developed for the treatment of such defects as a new therapeutic approach. The aim of this study was to evaluate both EVT options' indications, success rates, and complications in a retrospective, comparative approach. Materials and Methods: Between 01/2018 and 01/2021, the clinical data of patients undergoing FS-EVT or conventional EVT (cEVT; Eso-Sponge®, Braun Melsungen, Melsungen, Germany) due to AI/perforation of the uGIT were recorded. Indication, diameter of leakage, therapeutic success, and complications during the procedure were assessed. FSs were prepared using a nasogastric tube and a porous drainage film (Suprasorb® CNP, Lohmann & Rauscher, Rengsdorf, Germany) sutured to the distal tip. Results: A total of 72 patients were included (20 FS-EVT; 52 cEVT). FS-EVT was performed in 60% suffering from AI (cEVT = 68%) and 40% from perforation (cEVT = 32%; p > 0.05). FS-EVT's duration was significantly shorter than cEVT (7.6 ± 12.0 d vs. 15.1 ± 14.3 d; p = 0.014). The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT (p < 0.001). Therapeutic success was achieved in 90% (FS-EVT) and 91% (cEVT; p > 0.05). Conclusions: EVT comprises an efficient treatment option for transmural defects of the uGIT. In daily clinical practice, fistulas < 10 mm with large abscess formations poses a special challenge since intraluminal cEVT usually is ineffective. In these cases, the concept of extraluminal FS placement is safe and effective.

Impact of surgical specialization on emergency upper gastrointestinal surgery outcomes: A systematic review and meta-analysis.

BACKGROUND: Emergency presentations make up a large proportion of a general surgeon's workload. Patients who have emergency surgery carry a higher rate of mortality and complications. We aim to review the impact of surgical subspecialization on patients following upper gastrointestinal (UGI) emergency surgery. METHODS: A systematic search of Ovid Embase, Ovid MEDLINE, and Cochrane databases using a predefined search strategy was completed reviewing studies published from 1st of January 1990 to August 27, 2023. The study was prospectively registered with PROSPERO (CRD42022359326). Studies were reviewed for the following outcomes: 30-day mortality, in-hospital mortality, conversion to open, length of stay, return to theater, and readmission. RESULTS: Of 5181 studies, 24 articles were selected for full text review. Of these, seven were eligible and included in this study. There was a statistically significant improvement in 30-day mortality favoring UGI specialists (OR 0.71 [95% CI 0.55-0.92 and p = 0.009]) and in-hospital mortality (OR 0.29 [95% CI 0.14-0.60 and p = 0009]). There was a high degree of study heterogeneity in 30-day mortality; however, a low degree of heterogeneity within in-hospital mortality. There was no statistical significance when considering conversion to open and insufficient data to allow meta-analysis for return to theater or readmission rates. CONCLUSION: In emergency UGI surgery, there was improved 30-day and in-hospital mortality for UGI specialists. Therefore, surgeons should consider early involvement of a subspecialist team to improve patient outcomes.

The safety and efficacy of endoscopic submucosal fenestration in the treatment of completely embedded upper gastrointestinal foreign body.

BACKGROUND: Upper gastrointestinal foreign body ingestion is a common digestive tract emergency, of which completely embedded ones were challenging for most endoscopists. We aim to evaluate the efficacy and safety of endoscopic submucosal fenestration in the treatment of completely embedded upper gastrointestinal foreign bodies. METHODS: From December 2018 to December 2021, 19 patients with completely embedded upper gastrointestinal foreign bodies who underwent endoscopic submucosal fenestration in Zhongshan Hospital, Fudan University were included. The safety, efficacy, and outcome were retrospectively reviewed. RESULTS: Among the 19 patients, 15 foreign bodies were embedded in the esophagus, 3 located in the gastric wall, and 1 located in the duodenal bulb. The foreign bodies were successfully managed in 12 cases, and 7 failed after attempts of repeated exploration. Two cases confirmed completely traversing into the mediastinum were successfully removed after transfer to surgery. One case had retrieval of a foreign body in a half-year examination. Till now, 3 failed patients had great relief of symptoms and only one patient claimed occasional thoracodynia. Of note, there were neither serious adverse events, nor long-term complications during the follow-up. CONCLUSION: In disposing of foreign bodies completely embedded in the upper gastrointestinal tract, ESF is a safe and effective alternative to surgery.

Optimal time to initiate early oral feeding in postoperative patients with upper gastrointestinal malignancy: A network meta-analysis.

BACKGROUND: With the development of enhanced recovery after surgery, early oral feeding is likely to become the preferred mode of nutrition after surgery for upper gastrointestinal tract malignancies. However, the optimal time to initiate early oral feeding remains unknown. OBJECTIVE: We aimed to compare the effects of different introduction times of early oral feeding in patients with upper gastrointestinal malignancies in terms of safety, tolerance, and effectiveness and to identify the optimal time for early oral feeding after surgery. METHODS: A random-effects meta-analysis was performed to identify evidence from relevant randomized controlled trials. Ten electronic databases were searched for randomized controlled trials from their earliest records to May 2023. Data were analyzed using the Stata 16.0 software. RESULTS: A total of 22 randomized controlled trials including 2510 patients and seven time points for oral feeding after surgery were considered. Regarding safety, oral feeding initiated on postoperative day 3 may be the safest (high-quality evidence) compared with other times. Regarding tolerance, oral feeding initiated on postoperative day 5 may be the most well-tolerated (moderate-quality evidence) compared with other times. Regarding effectiveness, oral feeding initiated on postoperative day 3 may be the most effective (moderate-quality evidence) compared with other times. CONCLUSIONS: Early oral feeding is safe, tolerable, and effective in postoperative patients with upper gastrointestinal malignancies. The optimal time to initiate early oral feeding after surgery was most likely postoperative day 3. The results of this meta-analysis provide evidence-based guidelines for clinical decision-making.

Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry.

INTRODUCTION: Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS: This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS: We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION: EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.

[Anastomotic techniques in minimally invasive esophageal and gastric surgery]. / Anastomosentechniken in der minimal-invasiven Ösophagus- und Magenchirurgie.

In specialized centers minimally invasive surgery has become established as the standard of care for esophageal and gastric surgery. Offering equal oncological outcome, patients benefit with respect to lower postoperative pain and complication rates. The creation of the anastomosis during minimally invasive surgery remains a critical step and the complications are decisive for the immediate postoperative course. So far no clear consensus exists in the literature regarding the recommended techniques for placement of an anastomosis after resections in the upper gastrointestinal tract. This article summarizes and compares the various established anastomotic techniques used in minimally invasive esophageal and gastric surgery.

[Endovascular embolization for prevention of recurrent bleeding from the upper gastrointestinal tract]. / Opyt primeneniya endovaskulyarnoi embolizatsii dlya profilaktiki retsidiva krovotecheniya iz verkhnikh otdelov zheludochno-kishechnogo trakta.

OBJECTIVE: To evaluate the results of preventive endovascular hemostasis in patients with high risk of recurrent bleeding from the upper gastrointestinal tract. MATERIAL AND METHODS: We analyzed treatment outcomes in 158 patients with ulcerative gastroduodenal bleeding and high risk of recurrence (≥17 scores), Forrest 1-2 A/B and mortality (SAPS II score ≥30). Endovascular embolization of the left gastric or gastroduodenal artery was performed to prevent recurrent bleeding. RESULTS: Endovascular hemostasis was technically successful in 94.4% of cases (153 patients). Embolization could not be performed due to technical reasons in 5 patients. One patient developed retroperitoneal hematoma as a complication after transcatheter angiography and embolization that required surgical intervention. Recurrent bleeding after technically successful embolization occurred in 11 (7%) patients. The PVA microemboli and spirals were used for embolization of the left gastric and gastroduodenal arteries, respectively. Additional PVA microemboli were also used in gastroduodenal artery in some cases. Twenty-six (16.5%) patients died. CONCLUSION: Endovascular hemostasis in patients with severe comorbidities (SAPS II score ≥30) and high risk of recurrent bleeding (≥17 scores) reduced the incidence of recurrent bleeding to 6.96% and mortality to 17%.

Endoscopic full-thickness resection for upper gastrointestinal tract lesions: a systematic review and meta-analysis.

INTRODUCTION: Endoscopic full-thickness resection (EFTR) is used to resect difficult superficial mucosal lesions and sub-epithelial lesions (SELs). We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of EFTR for upper gastrointestinal tract (GIT) lesions. METHODS: We conducted a comprehensive literature search of MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov, and Scopus databases for studies published in the English language that addressed outcomes of EFTR for upper GIT lesions through November 2021. The weighted pooled rates with the 95% confidence interval (CI) were calculated. Cochran Q test and I statistics were used to calculate heterogeneity. RESULTS: We identify 740 articles on the initial search and six studies met the inclusion criteria. 140 patients (45.7% females) with 142 lesions were analyzed. Four studies used the full-thickness resection device (FTRD®). EFTR was performed for 26 adenomas, 97 SELs, six adenocarcinomas, and ten full-thickness biopsies. The overall technical success rate was 86.9% (CI 79.8-94%, I 2 = 38.9%), R0 resection was 80% (CI 67.6-92.3%, I 2 = 75.6%), and the overall adverse events rate was 18.6% (9.8-27.2%, I 2 = 49.4%). Major adverse events included six episodes of major bleeding, three micro-perforations, one large duodenal perforation, and one case of mucosal damage from FTRD®. At 3-6 months follow-up, there were only two cases of recurrence (R0 was not achieved in both). CONCLUSION: EFTR has a high technical and clinical success rate in managing upper GIT lesions with an acceptable safety profile. Large prospective studies comparing EFTR with conventional endoscopic resection techniques are needed.

[Endoscopic management of complications of the upper and lower gastrointestinal tract]. / Endoskopisches Komplikationsmanagement am oberen und unteren Gastrointestinaltrakt.

Even when wide-ranging measures for avoidance of complications by improved techniques, training and many other activities are undertaken, postoperative and postinterventional complications still represent a daily problem in clinical medicine. The outcome of the patient is not uncommonly decided by the management of the complications. The failure to rescue or to control complications is increasingly recognized as being decisive for the success of treatment. This article therefore provides a current overview of the endoscopic management of complications of the upper and lower gastrointestinal tract. It describes when endoscopy can be used to detect or exclude a complication. The most important principles of treatment including the indications, limits of performance and technique are presented.

Evolution of endoscopic vacuum therapy for upper gastrointestinal leakage over a 10-year period: a quality improvement study.

BACKGROUND: Endoscopic vacuum therapy (EVT) is an effective treatment option for leakage of the upper gastrointestinal (UGI) tract. The aim of this study was to evaluate the clinical impact of quality improvements in EVT management on patients' outcome. METHODS: All patients treated by EVT at our center during 2012-2021 were divided into two consecutive and equal-sized cohorts (period 1 vs. period 2). Over time several quality improvement strategies were implemented including the earlier diagnosis and EVT treatment and technical optimization of endoscopy. The primary endpoint was defined as the composite score MTL30 (mortality, transfer, length-of-stay > 30 days). Secondary endpoints included EVT efficacy, complications, in-hospital mortality, length-of-stay (LOS) and nutrition status at discharge. RESULTS: A total of 156 patients were analyzed. During the latter period the primary endpoint MTL30 decreased from 60.8 to 39.0% (P = .006). EVT efficacy increased from 80 to 91% (P = .049). Further, the need for additional procedures for leakage management decreased from 49.9 to 29.9% (P = .013) and reoperations became less frequent (38.0% vs.15.6%; P = .001). The duration of leakage therapy and LOS were shortened from 25 to 14 days (P = .003) and 38 days to 25 days (P = .006), respectively. Morbidity (as determined by the comprehensive complication index) decreased from 54.6 to 46.5 (P = .034). More patients could be discharged on oral nutrition (70.9% vs. 84.4%, P = .043). CONCLUSIONS: Our experience confirms the efficacy of EVT for the successful management of UGI leakage. Our quality improvement analysis demonstrates significant changes in EVT management resulting in accelerated recovery, fewer complications and improved functional outcome.

Endoscopic vacuum therapy in the upper gastrointestinal tract: when and how to use it.

BACKGROUND: Endoscopic vacuum therapy (EVT) has emerged as a novel treatment option for upper gastrointestinal wall defects. The basic principle of action of EVT entails evacuation of secretions, removal of wound debris, and containment of the defect. Furthermore, there is increasing evidence that EVT reduces interstitial edema, increases oxygen saturation, and promotes tissue granulation and microcirculation. Various devices, such as macroporous polyurethane sponge systems or open-pore film drains, have been developed for specific indications. Depending on the individual situation, EVT devices can be placed in- or outside the intestinal lumen, as a stand-alone procedure, or in combination with surgical, radiological, and other endoscopic interventions. PURPOSE: The aim of this narrative review is to describe the current spectrum of EVT in the upper gastrointestinal tract and to assess and summarize the related scientific literature. CONCLUSIONS: There is growing evidence that the efficacy of EVT for upper GI leakages exceeds that of other interventional treatment modalities such as self-expanding metal stents, clips, or simple drainages. Owing to the promising results and the excellent risk profile, EVT has become the therapy of choice for perforations and anastomotic leakages of the upper gastrointestinal tract in many centers of expertise. In addition, recent clinical research suggests that preemptive use of EVT after high-risk upper gastrointestinal resections may play an important role in reducing postoperative morbidity.

Endoscopic Vacuum Therapy via Pharyngostomy: Novel Access for Management of Upper Gastrointestinal Defects.

BACKGROUND: Perforation and anastomotic leakage of the upper gastrointestinal tract (UGI) has a high mortality and morbidity rate. Recently, UGI leaks have been treated with endoscopic vacuum therapy (EVT). However, this technique traditionally requires multiple EVT changes and a prolonged and uncomfortable nasoenteric intubation. We describe our experience using EVT through a novel pharyngostomy access to manage UGI leaks. METHODS: We describe our development and implementation of EVT via a novel pharyngostomy access to treat a variety of UGI defects. Preoperative, perioperative, and postoperative data were analyzed. RESULTS: Six patients with UGI perforations or anastomotic leaks were treated with an EVT using a pharyngostomy access. The median age was 69 years (IQR 53-71). Four patients leaked after an Ivor Lewis esophagectomy, one after a robotic para-esophageal hernia repair, and another after a Roux en Y esophagojejunostomy. Defects were detected on a median of 11.5 days (IQR 3-21). Median values for the duration of the EVT therapy and the number of EVT changes were 19.5 days (IQR 14-31) and 7 (IQR 6.5-9), respectively. Four of the patients were discharged with an EVT in place and were successfully managed as outpatients. At a median follow-up of 8 months, two patients developed strictures. None of the patients required any surgical re-intervention, they tolerated oral intake, and all leakages were confirmed closed by imaging and endoscopy. DISCUSSION: Endoscopic vacuum therapy can be successfully managed through a pharyngostomy access, as described. This access is easy, comfortable, and reliable and allows for a transition to outpatient management.

Subestadiamento tomográfico de tumores do trato gastrointestinal alto: estudo retrospectivo e impacto da covid-19 / Tomographic understaging of upper gastrointestinal tract tumors: retrospective study and impact of covid-19

Introdução: O estadiamento dos tumores malignos do trato gastrointestinal é crucial para determinar o prognóstico da doença, bem como para definir o tratamento e o seu tipo. Ele pode determinar se o paciente será submetido ou não a uma cirurgia, além de definir tratamento curativo ou paliativo. Mesmo com a ultrassonografia endoscópica, tomografia computadorizada, ressonância magnética, ainda é comum a incongruência entre o estadiamento dos tumores no pré-operatório a partir dos exames de imagem e os achados no intraoperatório. Objetivo: Analisar a ocorrência de subestadiamento de tumores do trato gastrointestinal alto que são classificados como irressecáveis apenas no ato intraoperatório, durante a pandemia de COVID-19. Método: Trata-se de um estudo retrospectivo de pacientes no Hospital do Servidor Público Municipal, localizado na cidade de São Paulo - SP, portadores de câncer do TGI alto, submetidos à laparotomia exploradora ou laparoscopia, e que tiveram estadiamento modificado no intraoperatório. Resultados: Não houve diferenças estatisticamente significativas entre as idades dos pacientes. Quanto ao sexo, os homens foram os mais afetados. Quanto à iressecabilidade foi observado aumento percentual significativo de ambos os tumores avaliados no ano de 2021 em comparação ao período 2018 / 2019, com aumento da invasão local e carcinomatose peritoneal. Conclusão: A diminuição da procura de assistência médica por parte dos pacientes, devido receio de contrair o vírus da COVID, acarretou em diagnósticos mais tardios e difíceis, levando ao fato da pandemia de COVID-19 aumentar o número de subestadiamentos de pacientes com câncer do trato digestivo alto em nosso Serviço, e elevação do número de casos avançados. Muitos dos casos que poderiam ter sido operados com melhor prognóstico, acabaram tornando-se inoperáveis após a retomada das atividades do Serviço, que havia sido designado para enfrentamento à pandemia. Estes resultados sugerem que, no futuro, caso ocorram situações semelhantes ao que se observou na vigência da pandemia de COVID-19, os serviços de oncologia, incluindo os especializados em tumores do trato gastrintestinal, criem subsídios de forma a manter a rotina, evitando o pior prognóstico dos pacientes neles atendidos. Palavras-chave: Endoscopia. Cirurgia. Câncer. Estadiamento.

Clinical outcomes of endoscopic removal of foreign bodies from the upper gastrointestinal tract.

BACKGROUND: Ingested foreign objects frequently require emergency removal. This study aimed to investigate the clinical outcomes of endoscopic removal of foreign bodies from the upper gastrointestinal tract and the risk factors for adverse events. METHODS: Adults (> 18 years) who underwent endoscopic management of ingested foreign bodies at two centers, one inland and one on the coast, between January 2008 and December 2017 were eligible. Clinical characteristics and procedure-related outcomes were retrospectively reviewed. Patients were divided into two groups, based on whether the foreign bodies were sharp or blunt in shape. RESULTS: A total of 853 patients aged 19-96 years were analyzed. Ingestion of fish bones was more common in the coastal area, whereas ingestion of food boluses was more common in the inland area. The duration of impaction ranged from 1 h to over 1 month and was significantly longer in patients who ingested blunt than sharp foreign bodies (15 vs. 5 h, p < 0.001). Most (98.9%) foreign bodies were successfully removed. Adverse events occurred in 31.2 % of patients, including ulcers (4.0%) and perforations (3.3 %). Multivariate analysis showed that age (odds ratio [OR] 1.015, p = 0.012), sharp foreign bodies (OR 5.133, p < 0.001), location in the esophagus (OR 2.723, p = 0.018), and duration of impaction (OR 1.431, p < 0.001) were factors associated with adverse events. CONCLUSIONS: Early recognition and timely endoscopic removal of ingested foreign bodies, particularly in elderly patients and those with sharp foreign bodies, may improve clinical outcomes.

Successful Endoscopic Management of Suspected Foreign Bodies in Upper Gastrointestinal Tract among Patients Undergoing Upper Gastrointestinal Endoscopy in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Most ingested foreign bodies pass through the gastrointestinal tract spontaneously. However, some foreign bodies may get impacted in the upper gastrointestinal tract. A variety of endoscopic techniques and instruments are indicated for the removal of such impacted foreign bodies. This study was conducted to find out the prevalence of successful endoscopic removal of foreign bodies. METHODS: This descriptive cross-sectional study was conducted among patients who presented at the Department of Gastroenterology with complaints of upper gastrointestinal foreign body ingestion from 2/11/2008 to 23/07/2020 after taking ethical approval of the research proposal was taken from Institutional Review Board (Reference no 13). Convenient sampling was done. The data were entered into Microsoft Excel and analyzed in Statistical Package of Social Sciences version 22. RESULTS: A total of 119 cases were identified with foreign bodies ingestion. In hundred patients, foreign bodies 100 (84 %) (77.41-90.58 at 95% Confidence Interval) were extracted completely. Complete extraction failed in 19 (16%) patients. Six (5%) patients were treated by push technique and 10 (8.4%) patients with failed retrieval, received surgical intervention for foreign body removal. CONCLUSIONS: Endoscopic removal technique of foreign bodies in the upper gastrointestinal tract was successful in most of the cases and is associated with few complications.

[Diagnostic and treatment of foreign bodies of the upper digestive tract]. / Inorodnye tela verkhnikh otdelov zheludochno-kishechnogo trakta.

OBJECTIVE: To evaluate the results of diagnosis and treatment of foreign bodies of the upper gastrointestinal tract. MATERIAL AND METHODS: There were 1187 patients aged 15-99 years with suspected foreign body of the upper gastrointestinal tract. In 536 patients (266 men, 270 women), foreign bodies were detected. Ingestion of a foreign body was more common in patients aged 46-65 years. In 516 patients, foreign bodies were detected in the esophagus (pharyngo-esophageal junction - 25, upper third of the esophagus - 426, middle third of the esophagus - 34, lower third of the esophagus - 21, esophageal-gastric junction - 10). Four patients admitted with esophageal wall perforation. In 3 cases, foreign bodies were localized in the throat, 15 patients - in the stomach, 2 patients - in the duodenum. RESULTS: In most cases, foreign bodies were organic (n=506). Removal was successful in 530 cases. In 4 patients with esophageal wall perforation and mediastinitis, removal was performed intraoperatively. Flexible endoscope was used in 500 cases. In 86 patients, foreign bode was displaced in the stomach using flexible endoscopy. Foreign body removing wasn't successful in 4 cases. In 2 patients, extraction was followed by esophageal wall damage. In 4 patients, esophagotomy was applied to extract foreign body. Suturing the esophageal wall defect was carried out in 2 cases. Abrasion and erosive esophagitis were the most common injuries of esophageal mucosa. Esophageal diseases were detected in 75 cases after foreign body removal (67 cases - benign esophageal diseases). One patient died from bedsore of innominate artery complicated by acute hemorrhage. CONCLUSION: Foreign bodies of the upper gastrointestinal tract are observed in 45% of patients at admission. Neck and chest X-ray examination is obligatory before endoscopy. Flexible endoscopy is a gold standard for diagnosis and extraction of foreign bodies. Repeated endoscopy after foreign body extraction should be mandatory. It is necessary to visualize complications associated with foreign body and identify esophageal diseases.

Towards personalised management for non-variceal upper gastrointestinal bleeding.

Guidelines from national and international professional societies on upper gastrointestinal bleeding highlight the important clinical issues but do not always identify specific management strategies pertaining to individual patients. Optimal treatment should consider the personal needs of an individual patient and the pertinent resources and experience available at the point of care. This article integrates international guidelines and consensus into three stages of management: pre-endoscopic assessment and treatment, endoscopic evaluation and haemostasis and postendoscopic management. We emphasise the need for personalised management strategies based on patient characteristics, nature of bleeding lesions and the clinical setting including available resources.

Individualized endoscopic management strategy for impacting jujube pits in the upper gastrointestinal tract: a 3-year single-center experience in northern China.

BACKGROUND: Impaction of jujube pits in the upper gastrointestinal (GI) tract is a special clinical condition in the northern Chinese population. Endoscopic removal is the preferred therapy, but there is no consensus on the management strategies. We reported our individualized endoscopic strategies on the jujube pits impacted in the upper GI tract. METHODS: In this retrospective study, we included 191 patients (male: 57; female: 134) who presented to our hospital with ingestion of jujube pits between January 2015 and December 2017. Demographic information, times of hospital visiting, locations of jujube pits, endoscopic procedures, post-extraction endoscopic characteristics were analyzed. Management strategies including sufficient suction, repeated irrigation, jejunal nutrition and gastrointestinal decompression were given based on post-extraction endoscopic characteristics and impacted locations. RESULTS: Peak incidence was in the second quarter of each year (85/191 cases, 44.5%). Among the 191 cases, 169 (88.5%) showed pits impaction in the esophagus, 20 (10.5%) in the prepyloric region and 2 (1.0%) in the duodenal bulb. A total of 185 patients (96.9%) had pits removed with alligator jaw forceps, and 6 (3.1%) underwent suction removal with transparent caps placed over the end of the endoscope to prevent injury on removal of these pits with two sharp painted edges. Post-extraction endoscopic manifestations included mucosal erosion (26.7%), mucosa laceration (24.6%), ulceration with a white coating (18.9%) and penetrating trauma with pus cavity formation (29.8%). All patients received individualized endoscopic and subsequent management strategies and showed good outcomes. CONCLUSIONS: Individualized endoscopic management for impacted jujube pits in the upper GI tract based on post-extraction endoscopic characteristics and impacted locations was safe, effective, and minimally invasive.