Risk assessment of esophageal ulceration following left atrial radiofrequency linear ablation.

INTRODUCTION: Esophageal safety following radiofrequency (RF) left atrial (LA) linear ablation has not been established. To determine the esophageal safety profile of LA linear RF lesions, we performed systematic esophagogastroduodenoscopy in all patients with intraesophageal temperature rise (ITR) ≥ 38.5°C. METHODS AND RESULTS: Between December 2021 and July 2023, a total of 200 consecutive patients with atrial tachyarrhythmia (ATA) underwent linear ablation with posterior dome (roof or floor) or posterior mitral isthmus line transection. Patients with ITR ≥ 38.5°C were scheduled for esophageal endoscopy ~3 weeks after ablation. Patient and ATA characteristics, procedural parameters, endoscopy findings and ablation lesion data were collected and analyzed. One hundred thirty-three out of 200 (67%) patients showed ITR ≥ 38.5°C during LA linear ablation. ITR (with maximal temperature of 45.7°C) was more frequently observed during floor line ablation (82% of cases). ITR was less observed during roof line ablation (34%) and posterior mitral isthmus ablation (4%). Endoscopy, performed in 115 patients after 24 ± 10 days, showed esophageal ulceration in four patients (two patients Kansas City classification [KCC] 2a and two patients KCC 2b). No patient showed esophageal perforation or fistula. CONCLUSION: Temperature rise during LA linear ablation is frequent and ulceration risk exists, particularly when floor line is performed. Safety measures are needed to avoid potential severe complications like esophageal perforation and fistula.

Age at Initiation and Frequency of Screening to Prevent Esophageal Squamous Cell Carcinoma in High-risk Regions: an Economic Evaluation.

The aim of this study was to identify the economic screening strategies for esophageal squamous cell carcinoma (ESCC) in high-risk regions. We used a validated ESCC health policy model for comparing different screening strategies for ESCC. Strategies varied in terms of age at initiation and frequency of screening. Model inputs were derived from parameter calibration and published literature. We estimated the effects of each strategy on the incidence of ESCC, costs, quality-adjusted life-year (QALY), and incremental cost-effectiveness ratios (ICERs). Compared with no screening, all competing screening strategies decreased the incidence of ESCC from 0.35% to 72.8%, and augmented the number of QALYs (0.002-0.086 QALYs per person) over a lifetime horizon. The screening strategies initiating at 40 years of age and repeated every 1-3 years, which gained over 70% of probabilities that was preferred in probabilistic sensitivity analysis at a $1,151/QALY willingness-to-pay threshold. Results were sensitive to the parameters related to the risks of developing basal cell hyperplasia/mild dysplasia. Endoscopy screening initiating at 40 years of age and repeated every 1-3 years could substantially reduce the disease burden and is cost-effective for the general population in high-risk regions.

Tips for the Budding Esophagologist.

PURPOSE OF REVIEW: The specialty of gastroenterology has evolved such that there are now multiple areas of "superspecialty" within the field. Interest in "esophagology" has expanded as options for medical therapy, advanced optics, motility testing and reflux monitoring, and minimally invasive and endoscopic therapeutics have grown. For a multitude of reasons, academic and private practices alike are looking to expand in this growing superspecialty. RECENT FINDINGS: Several articles offer criteria for competency in manometry. This article discusses in detail multiple options for developing skills in diagnosis and treatment of esophageal disease with "tips for the budding esophagologist."

Diffuse Esophageal Leiomyomatosis in Pediatric Patients: A Systematic Review and Quality of Evidence Assessment.

BACKGROUND: Diffuse esophageal leiomyomatosis (DEL) is a rare disorder characterized by benign hypertrophy of esophageal smooth muscle cells. No rigorous summary of available evidence on how to best manage these patients exists. OBJECTIVE: To define the clinical features and outcomes of pediatric patients with DEL. MATERIALS AND METHODS: A systematic literature search of the PubMed and Cochrane databases was performed with respect to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (end-of-search date: October 6, 2018). The algorithm: "esophageal leiomyomatosis AND (children OR pediatric*)" was implemented. RESULTS: Thirty-five studies including a total of 58 patients were analyzed. The female:male ratio was 1.45:1. Mean patient age was 8.54 ± 4.67 years. The most common disease manifestations were dysphagia and gastrointestinal symptoms (90.0%, 95% confidence interval [CI]: 78.2-96.1), followed by failure to thrive (57.9%, 95% CI: 36.2-76.9) and pulmonary symptoms (56.4%, 95% CI: 41.0-70.7). Alport syndrome (AS) was seen in 57.7% (95% CI: 44.2-70.1) of the patients. The most commonly implemented procedure was esophagectomy (85.2%; n = 46/54; 95% CI: 73.1-92.6) with gastric transposition (37.8%; n = 17/45; 95% CI: 25.1-52.4). Postoperative complications developed in 33.3% (n = 15/45; 95% CI: 21.3-48) of the patients. All-cause mortality was 7.0% (95% CI: 2.3-17.2) and disease-specific mortality was 3.5% (95% CI: 0.3-12.6). CONCLUSION: DEL is an uncommon condition that typically occurs in the setting of AS. Esophagectomy with gastric transposition is the mainstay of treatment. Although complications develop in one-third of the patients, mortality rates are low.

Assessment of modified Rodnan skin score and esophageal manometry in systemic sclerosis: a study correlating severity of skin and esophageal involvement by objective measures.

INTRODUCTION: Systemic sclerosis (SSc) is a multisystem connective tissue disease characterized by immune-mediated activation of tissue fibroblasts and consequent fibrosis, vascular abnormalities, and inflammation. The skin and esophagus are the two most frequently involved organs in this disease. Data regarding the correlation between the severity of skin and esophageal involvement in SSc by objective measures are negligible so far. METHODS: Thirty-one patients with SSc were subjected to esophageal manometry. A correlation between modified Rodnan skin score (MRSS) and esophageal manometric parameters of lower esophageal sphincter pressure (LESP), percentage relaxation of the lower sphincter, amplitude, and duration of the peristaltic waves was established. RESULTS: The mean MRSS was found to be 16.9 ± 8.7. There was no statistical correlation between MRSS and LESP (p = 0.496), percentage relaxation (p = 0.070), amplitude (p = 0.531), and duration (p = 0.459) of the contractions. No difference between these manometric parameters was found if the patients were divided into limited and diffuse subsets. CONCLUSION: There exists no correlation between the severity of skin involvement measured by MRSS and manometric abnormalities in SSc. All patients with SSc should undergo esophageal manometry irrespective of the extent of skin involvement.

Structured Diagnostic Approach and Risk Assessment in Mucous Membrane Pemphigoid with Oesophageal Involvement.

Oesophageal involvement in mucous membrane pemphigoid is considered rare, but it may be underdiagnosed. To assess the incidence of oesophageal involvement in a group of patients with newly diagnosed mucous membrane pemphigoid we retrospectively analysed the medical records of 30 consecutive patients with mucous membrane pemphigoid diagnosed between 2006 and 2016 at the Department of Dermatology, University Hospital Würzburg. Twenty-one patients (70%) reported symptoms indicative of oesophageal mucous membrane pemphigoid. Twelve patients (40%) underwent oesophagogastroduodenoscopy, and oesophageal pathology compatible with mucous membrane pemphigoid was endoscopically found in 9 cases (30%). In all patients indirect and direct immunofluorescence were performed. Patients with and without oesophageal involvement did not differ with regard to the results of indirect immunofluorescence on salt-split human skin and monkey oesophagus. Study results demonstrate the necessity of a standardized diagnostic work-up, including adequate tissue samples for direct immunofluorescence, to prevent underdiagnosis of oesophageal mucous membrane pemphigoid.

Providing cardiothoracic services in 2035: Signs of trouble ahead.

OBJECTIVE: As the population ages, we will present the reality around being able to meet the health care needs of our population. In particular, we will present that providing cardiothoracic services in 2035 with a shortage of surgeons and an unknown caseload may be an impossibility. METHODS: By using data from the American Board of Thoracic Surgery, we estimate that in 2010, 4000 cardiothoracic surgeons performed more than 530,000 cases. Additionally, cardiothoracic residency programs train and certify on average 90 new surgeons every year. To estimate the number of cases for 2035, we consulted the Census Bureau figures for 2010 and population projections for 2035. We then estimated the expected caseload for cardiothoracic surgeons relative to heart surgery, as well as lung and esophageal surgery. We found that among 2010 cardiothoracic surgeons in the United States, they completed more than 530,000 cases. RESULTS: We project that by 2035 there will be 853,912 cases to perform, representing an increase from 2010 to 2035 of approximately 61% nationally. The cases per surgeon, per year, in 2010 averaged 135 for almost each of the 4000 surgeons. In 2035, the average caseload per surgeon will be 299 cases, representing an increase of 121% for the individual surgeon. CONCLUSIONS: We conclude that by 2035, cardiothoracic surgeons will be responsible for more than 850,000 patients requiring surgery. This represents a 61% increase in the national case load and a potential for a 121% increase for each cardiothoracic surgeon. We believe this is not feasible and a sign of trouble ahead.

Esophageal function testing: Billing and coding update.

BACKGROUND AND PURPOSE: Esophageal function testing is being increasingly utilized in diagnosis and management of esophageal disorders. There have been several recent technological advances in the field to allow practitioners the ability to more accurately assess and treat such conditions, but there has been a relative lack of education in the literature regarding the associated Common Procedural Terminology (CPT) codes and methods of reimbursement. This review, commissioned and supported by the American Neurogastroenterology and Motility Society Council, aims to summarize each of the CPT codes for esophageal function testing and show the trends of associated reimbursement, as well as recommend coding methods in a practical context. We also aim to encourage many of these codes to be reviewed on a gastrointestinal (GI) societal level, by providing evidence of both discrepancies in coding definitions and inadequate reimbursement in this new era of esophageal function testing.

Whole greater than the parts: integrated esophageal centers (IEC) and advanced training in esophageal diseases.

An integrated esophageal center (IEC) is a multidisciplinary team with expertise, skill, range, and facilities necessary to achieve optimal outcomes in patients with esophageal diseases efficiently and expeditiously. Within IEC, patients presenting with esophageal symptoms undergo a detailed clinical, functional and structural evaluation of their esophagus prior to implementation of tailored medical, endoscopic or surgical therapy. Serving as a core, the IEC clinical practice also supports research and innovation in esophageal diseases as well as public and physician education. Referrals to the unit may be primary, either from primary care or self-initiated, or secondary from other specialty practices, to reassess patients who have previously failed therapies and to manage complex or complicated cases. The fundamental goals of the IEC are to provide value for patients with esophageal diseases, streamlining complex diagnostic investigations and expediting therapies aiming at reducing costs while improving clinical outcomes, and to accelerate knowledge generation through robust interaction and cross-training across disciplines. The organization of the IEC goes beyond traditional academic and clinical silos and involves a director and administrative team coordinating faculty and fellows from both medical and surgical disciplines and supported by other clinical lines, such as radiology, pathology, etc., while it interfaces with physicians, the public, basic, translational and clinical research groups, and related industry partners.

The diagnostic yield of upper endoscopy procedures in children- is it cost effective?

Upper endoscopy is an invaluable tool for the diagnosis and treatment of various gastrointestinal symptoms in children. Over the years, the number of endoscopic procedures performed in different medical centers has increased considerably and the cost associated with the procedure has become unsustainable. Recently, the US government has investigated this topic and has suggested steps to reduce the cost and use of endoscopic procedures in the adult population, changes that have not been accepted favorably by the American Gastroenterology Associations (AGA). In the present report, we evaluate the diagnostic yield of the procedure in children and suggest steps to reduce the annual number of upper endoscopic procedures in children. The diagnostic yield and the cost-effectiveness of the procedure are also discussed.

Gastrointestinal endoscopy in a low budget context: delegating EGD to non-physician clinicians in Malawi can be feasible and safe.

Gastrointestinal endoscopy is rarely performed in low-income countries in sub-Saharan Africa. One reason is the lack of available medical doctors and specialists in these countries. At Zomba Central Hospital in Malawi, clinical officers (non-physician clinicians with 4 years of formal training) were trained in upper gastrointestinal endoscopy. Prospectively recorded details of 1732 consecutive esophagogastroduodenoscopies (EGDs) performed between September 2001 and August 2010 were analyzed to evaluate whether upper gastrointestinal endoscopy can be performed safely and accurately by clinical officers. A total of 1059 (61.1%) EGDs were performed by clinical officers alone and 673 (38.9%) were carried out with a medical doctor present who performed or assisted in the procedure. Failure and complication rates were similar in both groups (P=0.105). Endoscopic diagnoses for frequent indications were generally evenly distributed across the two groups. The main difference was a higher proportion of normal findings and a lower proportion of esophagitis in the group with a doctor present, although this was significant only in patients who had presented with epigastric/abdominal pain (P<0.001). In conclusion, delegating upper gastrointestinal endoscopy to clinical officers can be feasible and safe in a setting with a shortage of medical doctors when adequate training and supervision are provided.

The esophagus: do sex and gender matter?

The esophagus has a single rudimentary function of active transport of solids and liquids from the pharynx to the stomach and, rarely, venting of the stomach with retrograde passage of gastric contents into the pharynx. It is void of any digestive, absorptive, metabolic, or endocrine functions. Despite this simplicity of function, sex (biological and physiological characteristics, ie, male versus female) and gender (roles, behaviors, activities, and attributes that a given society considers appropriate, ie, man versus woman) differences exist in both normal esophageal function and esophageal disease. Some components of esophageal function are sex-dependent, and these differences must be considered in the interpretation of functional testing. In esophageal disease, particularly gastroesophageal reflux disease, Barrett esophagus, esophageal cancer, acquired immune deficiency syndrome, and scleroderma, there are sex and gender differences in the pathophysiology and response to treatment. Although discussions of treatment and outcomes might differ between the sexes and genders, there are no important data to support different care on the basis of sex or gender.

Capsule endoscopy: no longer limited to the small bowel.

Capsule endoscopy is the latest evolution in gastrointestinal endoscopy and the first to enable complete investigation of the small bowel. Recent new developments in the field of capsule endoscopy include the esophageal capsule (Pilcam ESO) and the colonic capsule (PillCam Colon). esophageal and colonic capsules have two heads with two lenses and cameras. The new capsules have the capability of taking more frames from both sides. The indications for the esophageal capsule examination are diagnosis and follow-up of Barrett's esophagus and esophageal varices. The colonic capsule can be used for colorectal cancer screening and for incomplete colonoscopy. Regarding other new technologies, continuous quality control is needed for the performance, appropriateness of the indications, diagnostic yield, procedure-specific outcome assessment, and cost-effectiveness.

Gender-related differences in upper gastrointestinal endoscopic findings: an assessment of 4,700 cases from Iran.

BACKGROUND AND OBJECTIVE: Regarding the high prevalence of gastrointestinal symptoms in our country, the probable overuse or even late usage of upper gastrointestinal endoscopy for unnecessary reasons and gender influences on both internal and external fate and effects, we decided to evaluate the gender-related differences in upper gastrointestinal endoscopic findings to provide gastroenterologists with information which they can perform better interpretation of their patient's symptoms before performing upper gastrointestinal endoscopy. DESIGN: A descriptive cross-sectional study performed to evaluate gender-related differences in the upper endoscopy findings. SETTING: The study was performed in the upper endoscopy ward of a general hospital in Tehran, Iran. PATIENTS: Four thousand and seven hundred Iranian patients undergo upper endoscopy between 1992 and 2002. MAIN OUTCOME MEASUREMENTS: Upper endoscopy findings RESULTS: After age adjustment, oesophageal tumour, gastroesophageal reflux disease (GERD), gastric tumour, oesophageal varices, gastritis, hiatal hernia, gastric ulcer and erosive gastropathy, all p < 0.001 were significantly more common among men rather than women. Male gender predicts the presence of hiatal hernia (odds ratio (OR) = 1.9, p < 0.001), GERD (OR = 1.6, p < .001), gastric ulcer (OR = 2.3, p < 0.001), duodenal ulcer (OR = 2.3, p < 0.001) and duodenal varices (OR = .6, p = .044). LIMITATION: Backward study CONCLUSION: Our regression models revealed that male gender is a risk factor for hiatal hernia, GERD, gastric ulcer and duodenal ulcer but not for other upper endoscopic findings.

Capsule endoscopy for the detection of oesophageal mucosal disorders: a comparison of two different ingestion protocols.

OBJECTIVE: To assess the accuracy of a new ingestion protocol for capsule endoscopy (CE) in evaluating patients with gastro-oesophageal reflux disease (GORD). METHODS: Oesophago-gastroduodenoscopy (OGD) was performed 1 week prior to CE. The first 28 subjects swallowed the capsule following the original ingestion protocol (OIP) and the subsequent 30 subjects following a simplified ingestion protocol (SIP). CE videos were reviewed by two independent investigators who were blinded to the OGD findings. RESULTS: Of 48 patients included, 24 were diagnosed with reflux oesophagitis (67% male, mean age 49.5+/-13 years) and 24 with Barrett oesophagus (BO) (88% male, 55.6+/-10 years) by OGD. In addition, 10 asymptomatic healthy controls (50% male, 45.8+/-7.1 years) were included. Oesophageal transit time was faster in patients using the SIP compared to the OIP (126+/-26 s versus 214+/-33; p=0.04). Complete evaluation of the Z-line was possible in 19/28 (68%) of the OIPs compared to 28/30 (93%) of the SIPs (p=0.04). Sensitivity for detecting any oesophageal abnormality was higher in the SIP group than in the OIP group (97% versus 89%; p=0.11). Overall, CE detected oesophagitis in 22/24 patients (sensitivity, 92%; specificity, 88%) and BO in 23/24 patients (sensitivity, 96%; specificity, 91%). Furthermore, 41/44 (93%) preferred CE over OGD and experienced less discomfort and pain during CE. CONCLUSION: CE is an accurate method for detecting mucosal oesophageal abnormalities. The new ingestion protocol improves the visualization of the Z-line, which is likely to increase the diagnostic yield of CE.

Esophageal capsule endoscopy in patients with suspected esophageal disease: double blinded comparison with esophagogastroduodenoscopy and assessment of interobserver variability.

BACKGROUND AND STUDY AIMS: The study aim was to compare the diagnostic yield of capsule endoscopy and esophagogastroduodenoscopy (EGD) in patients with suspected esophageal disease. Secondary aims were to assess interobserver variability of capsule endoscopy readings and safety. PATIENTS AND METHODS: In total, 98 patients (53 men, 53 +/- 13 years) with an indication for EGD were included. The patient population was artificially enriched to include two thirds of patients with abnormal esophageal findings at EGD, which was followed by capsule endoscopy. Capsule recordings were blindly read by three endoscopists, one from the center that recruited the patient and two from the other center. Study outcomes were the findings described on EGD and capsule endoscopy, agreement between EGD and capsule endoscopy for findings, quality of the capsule recording, and interobserver agreement for capsule endoscopy quality and findings. RESULTS: EGD was normal in 34 patients and showed esophageal findings in 62 (esophagitis 28, hiatus hernia 21, varices 21, Barrett's esophagus 11, others 7). Average esophageal transit time of the capsule was 361 +/- 393 seconds. Capsule endoscopy was normal in 36 patients but detected esophagitis in 23, hiatus hernia in 0, varices in 23, Barrett's esophagus in 18, and others in 4. The positive predictive value of capsule endoscopy was 80.0 % and the negative predictive value was 61.1 %. Overall agreement per patient was moderate between EGD and capsule endoscopy for the per-patient (kappa = 0.42) and per-findings (kappa = 0.40) analyses. Interobserver agreement between capsule endoscopy readings was moderate for findings (kappa = 0.39) and quality assessment (kappa = 0.24). No adverse event was observed after either EGD or capsule endoscopy. CONCLUSION: In this study, despite artificial prevalence enrichment, capsule endoscopy showed a moderate sensitivity and specificity in the detection of esophageal diseases.

Esophageal manometry: assessment of interpreter consistency.

BACKGROUND AND AIMS: Manometry is used widely in the evaluation of esophageal disorders. Our aim was to assess the intra- and interobserver reliability of esophageal manometry and identify potential causes for diagnostic variability. METHODS: Seventy-two esophageal manometry tracings were selected randomly from archives. Eight interpreters randomly and blindly evaluated tracings. Interpreters were divided into 3 groups: highly experienced (N = 3), moderately experienced (N = 3), and inexperienced (N = 2). Each tracing was examined for abnormalities involving the lower-esophageal sphincter (LES) and esophageal body. Interpreters rendered a single diagnosis from a list of 7 manometric diagnoses: normal, nutcracker, hypertensive LES, hypotensive LES, diffuse esophageal spasm (DES), nonspecific/ineffective esophageal motility (IEM), and achalasia. Intra- and interobserver agreements were determined and reasons for varied diagnoses were investigated. RESULTS: Overall intraobserver agreement was good (kappa = .63, P < .0001). There was no difference ( P = .9) between the highly and midexperienced interpreters (kappa = .61 and .65, respectively). Interobserver agreement for the diagnosis of achalasia and normal motility was good (kappa = .65 and .56, respectively). However, other manometric diagnoses yielded only fair interobserver agreement (kappa = .27). DES, nonspecific/ineffective esophageal motility (IEM), and hypo- and hypertensive LES diagnoses showed the least agreement. Poor adherence to established manometric criteria, misinterpretation of intrabolus pressure, and technical inadequacy were the most common sources of inconsistency in interpretations. CONCLUSIONS: Manometric diagnoses of conditions other than normal or achalasia are variable and have poor interobserver variability. Given their uncertain clinical implications, we must either redefine them or eliminate them from practice.