Device-assisted enteroscopy: Are we ready to dismiss the spiral?

Motorized spiral enteroscopy (MSE) is the latest advance in device-assisted enteroscopy. Adverse events related to MSE were discussed in a recent large systematic review and meta-analysis and were directly compared with those of balloon enteroscopy in a case-matched study and a randomized controlled trial. Following the real-life application of MSE, an unexpected safety issue emerged regarding esophageal injury and the technique has been withdrawn from the global market, despite encouraging results in terms of diagnostic and therapeutic yield. We conducted an Italian multicenter real-life prospective study, which was prematurely terminated after the withdrawal of MSE from the market. The primary goals were the evaluation of MSE performance (both diagnostic and therapeutic) and its safety in routine endoscopic practice, particularly in the early phase of introduction in the endoscopic unit. A subanalysis, which involved patients who underwent MSE after unsuccessful balloon enteroscopy, demonstrated, for the first time, the promising performance of MSE as a rescue procedure. Given its remarkable performance in clinical practice and its potential role as a backup technique following a previously failed enteroscopy, it may be more appropriate to refine and enhance MSE in the future rather than completely abandoning it.

CT anatomical study of extreme lateral interbody fusion in thoracic spine.

Extreme Lateral Interbody Fusion (XLIF) is currently used in the clinical treatment of thoracic spine disorders and has achieved desirable results. In this study, we selected CT images of the thoracic spine from 54 patients and divided the intervertebral spaces into six regions (A, I, II, III, IV, P) using the Moro method. We observed the adjacent relationships between the thoracic spine and surrounding tissues such as the scapula, esophagus, thoracic aorta, and superior vena cava. We made four main findings: firstly, when the scapulae were symmetrical on both sides, over 80% of patients had the T1-4 II-III region obstructed by the scapulae; secondly, when the esophagus was located on the left side of the vertebral body, 3.7% to 24.1% of patients had the T4-9 region located in the II-III zone; furthermore, when the thoracic aorta was on the left side of the vertebral body, over 80% of individuals in the T4-9 segment occupied the II-III region, with the values being 55.5% and 20.4% for T9/10 and T10/11, respectively; finally, the superior vena cava was located on the right side of the T4/5 vertebra, with 3.7% of individuals having it in the II-III region, while on the left side of T5-9, 3.7% to 18.5% of individuals had it in the II-III region. Based on these findings, we suggest that XLIF should not be performed on the T1-4 vertebrae due to scapular obstruction. Selecting the left-sided approach for XLIF in the T4-11 segments may risk injuring the thoracic aorta, esophagus, and superior vena cava, while the T11/12 segment is considered safe and feasible. Choosing the right-sided approach for XLIF may pose a risk of injuring the superior vena cava in the T4/5 segment, but it is safe and feasible in the T5-12 segments.

Correlation of diaphragm thickening fraction and oesophageal pressure swing in non-invasive ventilation of healthy subjects.

INTRODUCTION: The diaphragm thickening fraction (DTF) may be a valuable tool for estimating respiratory effort in non-invasive ventilation. The primary aim of this physiological study is the investigation of the correlation of DTF with oesophageal pressure swings (ΔPoes). A secondary aim is to assess the discriminatory capacity of the index tests for different exercise loads. METHODS: Healthy volunteers underwent spontaneous breathing and non-invasive ventilation with a sequence of different respirator settings. The first sequence was carried out at rest. The same sequence was repeated twice, with additional ergometry of 25 and 50 Watts, respectively. DTF and ΔPoes were measured during each ventilation configuration. RESULTS: 23 individuals agreed to participate. DTF was moderately correlated with ΔPoes (repeated measures correlation ρ = 0.410, p < 0.001). Both ΔPoes and DTF increased consistently with exercise loading in every ventilation configuration, however ΔPoes showed greater discriminatory capacity. CONCLUSION: DTF was moderately correlated with ΔPoes and could discriminate reasonably between exercise loads in a small cohort of non-invasively ventilated healthy subjects. While it may not accurately reflect the absolute respiratory effort, DTF might help titrating individual non-invasive respiratory support. Further investigations are needed to test this hypothesis. TRIAL REGISTRATION: This study was not prospectively registered.

Successful robotic-assisted resection of an esophageal duplication cyst in the upper thoracic esophagus: A case report with surgical video.

Esophageal duplication cysts are rare congenital noncancerous growths. Symptoms of this disease are reported to be asymptomatic in approximately 70% but include respiratory symptoms such as coughing and difficulty breathing. Minimally invasive removal of these cysts without esophagectomy is typically recommended. However, when the cyst is situated in the upper mediastinum, surgical excision becomes technically challenging. Here, we report a case of an obese female patient with esophageal duplication cyst in the upper mediastinum who underwent successfully robotic-assisted complete removal of the cyst. A 50-year-old woman presented to a local clinic with a persistent cough and hoarseness lasting 4 months. A computed tomography scan revealed a large cystic tumor in the upper mediastinum, causing displacement of the trachea. The resection of the cystic tumor was safely performed with robotic assistance. The use of robotic system for the removal of esophageal duplication cyst is technically safe and feasible.

Enhancing Chicago Classification diagnoses with functional lumen imaging probe-mechanics (FLIP-MECH).

BACKGROUND: Esophageal motility disorders can be diagnosed by either high-resolution manometry (HRM) or the functional lumen imaging probe (FLIP) but there is no systematic approach to synergize the measurements of these modalities or to improve the diagnostic metrics that have been developed to analyze them. This work aimed to devise a formal approach to bridge the gap between diagnoses inferred from HRM and FLIP measurements using deep learning and mechanics. METHODS: The "mechanical health" of the esophagus was analyzed in 740 subjects including a spectrum of motility disorder patients and normal subjects. The mechanical health was quantified through a set of parameters including wall stiffness, active relaxation, and contraction pattern. These parameters were used by a variational autoencoder to generate a parameter space called virtual disease landscape (VDL). Finally, probabilities were assigned to each point (subject) on the VDL through linear discriminant analysis (LDA), which in turn was used to compare with FLIP and HRM diagnoses. RESULTS: Subjects clustered into different regions of the VDL with their location relative to each other (and normal) defined by the type and severity of dysfunction. The two major categories that separated best on the VDL were subjects with normal esophagogastric junction (EGJ) opening and those with EGJ obstruction. Both HRM and FLIP diagnoses correlated well within these two groups. CONCLUSION: Mechanics-based parameters effectively estimated esophageal health using FLIP measurements to position subjects in a 3-D VDL that segregated subjects in good alignment with motility diagnoses gleaned from HRM and FLIP studies.

Accurate object localization facilitates automatic esophagus segmentation in deep learning.

BACKGROUND: Currently, automatic esophagus segmentation remains a challenging task due to its small size, low contrast, and large shape variation. We aimed to improve the performance of esophagus segmentation in deep learning by applying a strategy that involves locating the object first and then performing the segmentation task. METHODS: A total of 100 cases with thoracic computed tomography scans from two publicly available datasets were used in this study. A modified CenterNet, an object location network, was employed to locate the center of the esophagus for each slice. Subsequently, the 3D U-net and 2D U-net_coarse models were trained to segment the esophagus based on the predicted object center. A 2D U-net_fine model was trained based on the updated object center according to the 3D U-net model. The dice similarity coefficient and the 95% Hausdorff distance were used as quantitative evaluation indexes for the delineation performance. The characteristics of the automatically delineated esophageal contours by the 2D U-net and 3D U-net models were summarized. Additionally, the impact of the accuracy of object localization on the delineation performance was analyzed. Finally, the delineation performance in different segments of the esophagus was also summarized. RESULTS: The mean dice coefficient of the 3D U-net, 2D U-net_coarse, and 2D U-net_fine models were 0.77, 0.81, and 0.82, respectively. The 95% Hausdorff distance for the above models was 6.55, 3.57, and 3.76, respectively. Compared with the 2D U-net, the 3D U-net has a lower incidence of delineating wrong objects and a higher incidence of missing objects. After using the fine object center, the average dice coefficient was improved by 5.5% in the cases with a dice coefficient less than 0.75, while that value was only 0.3% in the cases with a dice coefficient greater than 0.75. The dice coefficients were lower for the esophagus between the orifice of the inferior and the pulmonary bifurcation compared with the other regions. CONCLUSION: The 3D U-net model tended to delineate fewer incorrect objects but also miss more objects. Two-stage strategy with accurate object location could enhance the robustness of the segmentation model and significantly improve the esophageal delineation performance, especially for cases with poor delineation results.

Rare type of tracheal agenesis: Unexpected presentation and immediate consideration of emergent esophageal intubation in neonatal resuscitation program. Case reports and review of the literature.

BACKGROUND: Tracheal agenesis, or tracheal atresia, is a rare congenital anomaly. The presence of a tracheoesophageal fistula (TEF) can help with breathing for newborns with tracheal agenesis. In this article, we presented three unique cases and outcomes of neonates with tracheal agenesis along with a review of the literature. METHODS: This study consisted of a single center case series followed by a review of literature. Case reports were generated using both written and electronic medical records from a single hospital. We summarized three unique cases and outcomes of neonates with tracheal agenesis and performed a review of the literature. RESULTS: We identified three cases of tracheal agenesis presented with severe cyanosis without spontaneous crying upon birth. Experienced pediatricians attempted to intubate the babies but were unsuccessful. Endotracheal tubes were subsequently either accidentally or purposely placed into the esophagus, and oxygen saturation levels improved. This suggested tracheal agenesis with TEF. Two cases underwent surgical intervention after resuscitation with esophageal intubation. CONCLUSION: Esophageal intubation may be a life-sustaining ventilation support for patients with tracheal agenesis and TEF at initial resuscitation. Clinicians should suspect tracheal agenesis when a newborn presents with severe cyanosis and voiceless crying upon birth, and esophageal intubation should be immediately attempted.

Optimization of tracheoesophageal fistula model established with T-shaped magnet system based on magnetic compression technique.

BACKGROUND: The magnetic compression technique has been used to establish an animal model of tracheoesophageal fistula (TEF), but the commonly shaped magnets present limitations of poor homogeneity of TEF and poor model control. We designed a T-shaped magnet system to overcome these problems and verified its effectiveness via animal experiments. AIM: To investigate the effectiveness of a T-shaped magnet system for establishing a TEF model in beagle dogs. METHODS: Twelve beagles were randomly assigned to groups in which magnets of the T-shaped scheme (study group, n = 6) or normal magnets (control group, n = 6) were implanted into the trachea and esophagus separately under gastroscopy. Operation time, operation success rate, and accidental injury were recorded. After operation, the presence and timing of cough and the time of magnet shedding were observed. Dogs in the control group were euthanized after X-ray and gastroscopy to confirm establishment of TEFs after coughing, and gross specimens of TEFs were obtained. Dogs in the study group were euthanized after X-ray and gastroscopy 2 wk after surgery, and gross specimens were obtained. Fistula size was measured in all animals, and then harvested fistula specimens were examined by hematoxylin and eosin (HE) and Masson trichrome staining. RESULTS: The operation success rate was 100% for both groups. Operation time did not differ between the study group (5.25 min ± 1.29 min) and the control group (4.75 min ± 1.70 min; P = 0.331). No bleeding, perforation, or unplanned magnet attraction occurred in any animal during the operation. In the early postoperative period, all dogs ate freely and were generally in good condition. Dogs in the control group had severe cough after drinking water at 6-9 d after surgery. X-ray indicated that the magnets had entered the stomach, and gastroscopy showed TEF formation. Gross specimens of TEFs from the control group showed the formation of fistulas with a diameter of 4.94 mm ± 1.29 mm (range, 3.52-6.56 mm). HE and Masson trichrome staining showed scar tissue formation and hierarchical structural disorder at the fistulas. Dogs in the study group did not exhibit obvious coughing after surgery. X-ray examination 2 wk after surgery indicated fixed magnet positioning, and gastroscopy showed no change in magnet positioning. The magnets were removed using a snare under endoscopy, and TEF was observed. Gross specimens showed well-formed fistulas with a diameter of 6.11 mm ± 0.16 mm (range, 5.92-6.36 mm), which exceeded that in the control group (P < 0.001). Scar formation was observed on the internal surface of fistulas by HE and Masson trichrome staining, and the structure was more regular than that in the control group. CONCLUSION: Use of the modified T-shaped magnet scheme is safe and feasible for establishing TEF and can achieve a more stable and uniform fistula size compared with ordinary magnets. Most importantly, this model offers better controllability, which improves the flexibility of follow-up studies.

Monitoring and modulating the trajectory of eosinophilic esophagitis.

Current treatments of eosinophilic esophagitis (EoE) aim to eliminate esophageal mucosal inflammation and attenuate, stabilize, or reverse stricture formation. However, our ability to study the long-term course of esophageal strictures in patients with EoE is hampered by the short-term existence of this disease. It is unclear to what degree of control of inflammation is needed to prevent stricture formation. Additionally, identified phenotypes of EoE may ultimately dictate different levels of concern and time intervals for developing fibrosis. Currently, multiple methods are used to monitor patients' disease progression to fibrosis, as symptoms alone do not correlate with disease activity. Endoscopic findings and mucosal histology are used to monitor disease activity, but these focus on improvements in inflammation with inconsistent evaluation of underlying fibrosis. The use of functional lumen impedance planimetry, barium esophagraphy, and endoscopic ultrasound continues to expand in EoE. The rapid advancements in EoE have led to an armamentarium of measuring tools and therapies that holistically characterize disease severity and response to therapy. Nevertheless, our ability to evaluate gross esophageal fibrosis and stricture formation from a transmural rather than mucosal view should be a focus of future investigations because it is essential to monitoring and modulating the trajectory of EoE.

Four-dimensional impedance manometry volume metrics for predicting abnormal bolus retention.

BACKGROUND: The objective measurement for esophageal bolus volume and bolus clearance could classify abnormal high-resolution manometry (HRM) beyond the current Chicago classification. We aimed to compare the novel four-dimensional impedance manometry (4D HRM) volume metrics with timed barium esophagram (TBE). METHODS: Adults with esophageal symptoms undergoing HRM and TBE were included. A custom-built program for 4D HRM analysis measured esophageal luminal cross-sectional area (CSA) from impedance and subsequently derived esophageal bolus volume and clearance. 4D HRM volume metrics included pre-swallow residual volume, maximal volume, retention volume, and clearance ratio defined as 1.0-retention volume divided by the maximal volume. An abnormal TBE was defined as a column height >5 cm at 1 min or 5 min. KEY RESULTS: A total of 95 patients (normal motility: 33%; ineffective esophageal motility: 12%; absent contractility: 10%; esophagogastric junction outflow obstruction: 30%; type I achalasia: 5%; type II achalasia: 12%) were categorized into normal TBE (58%), abnormal TBE at 1 min (17%), and abnormal TBE at 5 min (25%). The AUROC demonstrated that, among all 4D HRM volume metrics, the clearance ratio had the best performance in predicting abnormal TBE at 5 min (AUROC, 95% confidence interval: 0.89, 0.82-0.96), and exhibited a strong negative correlation with TBE at 5 min (r = -0.65; p < 0.001). CONCLUSIONS & INFERENCES: Novel 4D HRM volume metrics provide objective measurement of esophageal bolus volume and bolus clearance. The clearance ratio has a strong correlation with TBE and could potentially serve as a substitute for TBE to measure esophageal retention.

Swallowed denture stuck in the proximal esophagus.

A 72-year-old male with dementia and Parkinson's disease presented at the otorhinolaryngology outpatient clinic with acute dysphagia. A chest x­ray showed a dental prosthesis in the upper esophagus, which was subsequently extracted via rigid esophagoscopy. Due to suspected esophageal perforation on postoperative CT, a cervical approach to the esophagus and flexible esophagoscopy were used, but no evidence of perforation could be identified. This case highlights challenges in managing high-risk esophageal foreign bodies in the upper esophagus, emphasizing the need for careful assessment and a multidisciplinary approach.