Introduction

The cervical inlet patch (CIP) is an islet of heterotopic gastric mucosa that is observed in the upper esophagus during conventional diagnostic esophagogastroduodenoscopy. Commonly encountered laryngopharyngeal symptoms, including globus sensation, hoarseness, odynophagia, and dysphagia, have been linked to CIP. In most cases, medical intervention for symptomatic CIP commences with the administration of potent acid suppressive agents, such as proton-pump inhibitors (PPI); however, the efficacy of these agents is limited. A few Western studies have demonstrated that endoscopic therapy with argon plasma coagulation (APC) is increasingly effective in relieving laryngopharyngeal symptoms in patients with CIP.^1,2 Additionally, long-term effects lasting up to 27 months of follow-up have been documented.³ Regarding the use of APC in patients with CIP, however, no pertinent research has been conducted in Asia-Pacific countries. Therefore, we retrospectively reviewed a cohort with six symptomatic CIP patients recruited for the APC ablation therapy. This case shed light on the possible use of APC for symptomatic CIP patients in Asia-Pacific countries.

Aims & Methods

We recruited a total of six symptomatic patients, proven to be CIP endoscopically and pathologically, from May 22, 2022, to April 20, 2024. We excluded patients who were less than 20 years old and who refused the option of argon plasma coagulation ablation. To ablate the CIP, all recruited patients underwent endoscopic ablation at 60 W and 2 L/min in one session. Questionnaires consisting of visual analog scores (from 0 to 10. The higher the score, the more severe the symptoms) for symptoms of dry throat, burning throat, globus sensation, hoarseness and clearing throat were distributed to patients at the time points of before the use of proton pump inhibitors, after the use of proton pump inhibitors and one month after the endoscopic ablation with APC to assess the efficacy endoscopic procedure. We defined symptomatic CIP with at least one any of the aforementioned symptoms with more than 5 out of 10 of pain score.

Results

The current study recruited a total of six patients. Two-thirds of patients were female (4/6) in gender and had an average age of 41 years. The CIP was located in the upper esophagus at 16.7cm from the incisors (15–18 cm), and two-thirds of the patients had more than one CIP. The average size of CIP was about 0.6 cm (ranging from 0.3cm to 0.8cm). The APC ablation significantly improved the five parameters (dry throat, burning sensation, foreign body sensation, and hoarseness) from more than 4/10 to less than 2/10. Foreign body sensation showed the most prominent improvement, decreasing from 7/10 to 1/10. (Figure1) There were no complications, such as perforation, infection, ulcers, or stricture, after the procedure. One month after the APC procedure, the follow-up EGD of all patients showed no residual CIP.

Conclusion

APC ablation shows a promising results for symptomatic CIP patients with laryngopharyngeal symptoms in Asia-Pacific population. However, further prospective randomized studies with a larger sample size are needed to validate the effectiveness and safety of APC ablation in symptomatic CIP patients in the region.

References

1. Bajbouj M, Becker V, Eckel F, et al. Argon plasma coagulation of cervical heterotopic gastric mucosa as an alternative treatment for globus sensations.
Gastroenterology. 2009 Aug;137(2):440-4.

2. Brechmann T, Muhlenkamp M, Schmiegel W, et al. Argon Plasma Coagulation of Gastric Inlet Patches of the Cervical Esophagus Relieves Vocal and Respiratory Symptoms in Selected Patients. Dig Dis Sci 2023; 68: 1936-1943.

3. Klare P, Meining A, von Delius S, et al. Argon plasma coagulation of gastric inlet patches for the treatment of globus sensation: it is an effective therapy in the long term. Digestion. 2013;88(3):165-71.

Disclosure

There is no conflict of interest among authors

Introduction

Radiofrequency Ablation is the gold standard for ablating neoplastic Barrett Esophagus (BE). Hybrid argon plasma coagulation (H-APC) is a novel technique involving submucosal fluid injection before Argon Plasma Coagulation. We aim to assess its efficacy, safety, and tolerability.

Aims & Methods

We prospectively enrolled patients undergoing H-APC ablation at 4 Italian Hospitals in a multicenter observational study. Included were patients with histopathologically confirmed LGD, HGD, or residual BE after endoscopic resection of visible lesions, and who had not undergone previous ablative treatment. Complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D) were confirmed by biopsy samples from the neo-epithelium. Pain and dysphagia scores within 7 days post-ablation were evaluated by phone by the local investigator.

Results

Among the 61 enrolled patients (mean age 61.05 years, 85.3% males, mean C length 0.52 cm, mean M length 2.36 cm), 45.9% (28/61) had prior endoscopic resection of visible lesions, with adenocarcinoma being the most common worst histology (48.3%). Of the 51 patients who completed treatment sessions until April 2024, all of them achieved complete eradication of intestinal metaplasia by April 2024, with an average of 1.51 (S.D 0.83) sessions. 92 hybrid-APC sessions were performed without major complications, except for one case of post-ablation electrocoagulation syndrome. Mean pain score was 1.38/10 (S.D 2.1), mean dysphagia score was 1.3/5 (S.D. 0.6).

Conclusion

The Hybrid-APC technique shows robust efficacy and safety, with good tolerability in achieving initial CE-D and CE-IM. Definitive evidence of its effectiveness awaits prospective randomized comparative trials.

Introduction

Endoscopic hemostasis is first-line therapy in managing peptic ulcer bleeding (PUB) with high-risk stigmata (Forrest classification Ia, Ib, IIa). While argon plasma coagulation (APC) is widely available and easy to use, there are limited studies with a limited number of patients evaluating its efficacy in PUB. This meta-analysis evaluates the effectiveness of APC in high risk PUB in achieving initial hemostasis and preventing rebleeding.

Aims & Methods

We performed a systematic literature search of PubMed, Embase, Web of Science, and Scopus to identify studies up to October 2024, evaluating APC versus alternative endoscopic hemostasis modalities for high-risk PUB. Eligible studies included those reporting on initial hemostasis and rebleeding outcomes. Two reviewers (KS, MO) independently screened studies and extracted data, resolving discrepancies by consensus. Quality assessments were conducted using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using a random-effects model to account for study heterogeneity, quantified by I^2 statistics.

Results

Fourteen studies met inclusion criteria (7 observational and 7 RCTs), with pooled sample sizes of n=816 and n=975 respectively. Meta-analysis of all studies showed that for the outcome of initial hemostasis, the pooled OR was 1.01 (95% CI: 0.39–2.62, p = 0.976), demonstrating no significant difference between APC and other endoscopic treatments. Similarly, rebleeding rates showed no significant difference (pooled OR: 1.12; 95% CI: 0.69–1.83, p = 0.636). When we limited our meta-analysis to only the 6 RCTs with an active hemostasis treatment control group, we again found similar results for both outcomes of initial hemostasis and rebleeding.

Conclusion

APC appears comparable and non-inferior to other standard of care endoscopic hemostasis modalities in achieving initial hemostasis and preventing rebleeding in high-risk PUB. Updated guidelines will need to re-evaluate and decide where APC fits in with endoscopic hemostasis of high-risk PUB.

References

Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019;171(11):805-22.
Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021;53(3):300-32

Disclosure

Ian Gralnek. has received lecture fees from Astra-Zeneca, Taro Pharma, Vifor Pharma and 3D Matrix. He is also a paid consultant for Boston Scientific, GI View, Motus GI and Symbionix and is a member of the medical advisory board of Motus GI

Introduction

Radiofrequency ablation is considered the standard therapy for flat dysplastic BE. Hybrid APC is a newer under evaluation, less expensive technique, but with the need of a special injection device and catheter. Aim of the study: To evaluate the efficacy of a standard APC catheter after submucosal injection for BE ablation.

Aims & Methods

To evaluate the efficacy of a standard APC catheter after submucosal injection for BE ablation. Naïve or after previous treatments patients with BE and low - grade dysplasia (LGD) were prospectively evaluated. Sodium chloride solution 0.9% was injected submucosally with a 23 G needle followed by APC application with a standard catheter (ERBE APC 300, 45Watts) on the created cushion. The same procedure was repeated for most of BE surface to be cauterized, with special attention not to ablate large circumferential areas. Patients were under high dose PPIs. Biopsies were taken according to the Seattle protocol during the follow-up.

Results

31 patients, 28 males (90.3%), 56.7±12.5 years old. Their initial diagnosis was: 19 patients with LGD (61.3%), 7 with high grade dysplasia (22.6%), and 5 with intramucosal cancer (16.1%). Eleven patients (35.5%) had previous endoscopic mucosal resection (EMR) while 7 (22.6%) had received radiofrequency ablation (RFA). Median BE length with LGD at the beginning of APC was 4cm (25th-75th:2-7, min-max:1-10). Median follow-up:10.1(1-108) months. In total 20 (64.5%) patients completely eradicated BE. For the remaining 11 patients APC led to a substantial reduction of BE length [Initial Median: C3M6 (Min: C0M1, Max: C6M8) to a final median: C0M2 (Min:C0M1, Max:C2M5] but the study is ongoing. Initial BE length was correlated to APC sessions needed (r= 0.54, p<0.01) but was not a limiting factor for complete BE eradication. Instead, smoking was an aggravating factor for BE complete eradication (HR=3.12, 95%CI.: 1.2-8.12, p=0.02). No death, hospitalization, severe hemorrhage, or perforation were observed. In 7 patients moderate pain requiring paracetamol, resolved after a few hours of in hospital supervision while 11 patients had mild dysphagia the following days without permanent stenosis.

Conclusion

Conclusions: 1) Standard APC after submucosal injection is safe and tolerable for BE ablation. 2) It may be applied in naïve patients or if other techniques were previously used. 3) Length increases the number of sessions needed but does not seem to be a limiting factor for APC application.

Introduction

The gold standard for diagnosis of laryngeopharyngeal reflux is 24h MII-pH with localization of impedance nearby the upper esophageal sphincter.

Aims & Methods

The aim of the study was to evaluate high GER in patients with laryngeal symptoms of GERD.
Subjects and methods: 50 patients with extraesophageal manifestations of GERD underwent upper endoscopy, esophageal manometry and 24h MII-pH. Mean age 49,54 ±5,2 y.o. Females – 44%, males – 56%. We used new probes for 24h MII-pH with 2 impedance channels located above lower esophageal sphincter (LES) and 5 impedance channels located under and above upper esophageal sphincter (UES). There were 3 types of probes according to the length of esophagus: 1^st type – for the length 20-22 cm, 2^nd type – 23-25 cm, 3^rd type – 26-28 cm. The pH electrodes were at 5 cm above LES and 1 cm above UES. The location of LES and UES was detected by manometry.

Results

According to the results of 24h MII-pHmetry in the lower third of the pharynx, 21 patients had more than 1 reflux (LFR+ group), 29 patients had no reflux in the pharynx (LFR-). Patients with LFR+ significantly more often complained of hoarseness, slightly more often noted cough, burning in the oral cavity, dysphagia. Patients with LFR- often complained of heartburn, regurgitation, sore throat, lump in the throat. The upper endoscopy showed that the frequency of occurrence of the erosive esophagitis was the equal in both groups, including Barrett's esophagus.
The pathologic GER in the lower third of the esophagus was more common in patients with LFR + (71%) than in patients without LFR (24%). A positive correlation was revealed (r=0.46). The ratio of the physiological amount of GER was 24 and 59%, respectively.

Conclusion

The new probes allow simultaneous assessment of reflux in the lower third of the esophagus and pharynx. The amount of reflux in the lower third of the pharynx correlates with the amount in the lower third of the esophagus. However, there are options when, with a normal number of them, there may be a high spread in the lower third of the esophagus.

Introduction

Patients with multiple Lugol-voiding lesions (mLVLs) in esophageal squamous cell carcinoma (ESCC) were known to have an increased risk of metachronous ESCC or pharyngeal and laryngeal squamous cell carcinoma (PLSCC) following endoscopic resection (ER), necessitating intensive endoscopic surveillance. The Japan Esophageal Cohort study, a multicenter prospective study evaluating the cumulative incidence of metachronous ESCC after esophageal ER, demonstrated that ER was selected as the initial treatment for most newly detected metachronous ESCC (72/74 patients). However, in clinical practice, ESCC or PLSCC outside the indications for ER are occasionally detected. Additionally, patients with mLVLs are known to have a high risk of developing other secondary primary cancers, nonetheless, the long-term clinical course in this population remains unclear.

Aims & Methods

The aim of this retrospective study was to evaluate the long-term prognosis of patients with mLVLs after endoscopic submucosal dissection (ESD) for superficial ESCC. This study included patients with mLVLs who underwent ESD for primary ESCC at our institution between April 2008 and August 2016. The exclusion criteria were patients with non-curative resection after ESD requiring additional treatment, such as submucosal invasion, positive vertical margins (pVM1), or lymphovascular invasion (LVI), and patients with a follow-up period of less than one year. After esophageal ESD, endoscopic surveillance was conducted every six months to one year, and metachronous cancers were considered for treated if detected. The cumulative incidence of metachronous ESCC and PLSCC, as well as the cumulative incidence of metachronous major ESCC and PLSCC, and overall survival (OS) were evaluated. Major ESCC were defined as lesions outside the indications for ER or those in which ER was performed resulting in a non-curative resection. Major PLSCC were defined as lesions outside the indications for ER or endoscopic laryngopharyngeal surgery (ELPS), or those in which ER or ELPS were performed resulting in pVM1 or LVI.

Results

A total of 140 patients were included, with a median age of 69 years (range: 47-86), and 30 patients (21.4%) had a history of head and neck cancer. During the median follow-up of 8.8 years (range: 1.2–15.5), 85 patients (60.7%) developed metachronous ESCC, all of whom were initially treated with ER, and 81 (95.3%) managed with ER alone, including repeated ER. Meanwhile, 35 patients developed metachronous PLSCC, 30 (85.7%) of whom were managed with ELPS alone. The cumulative incidence of metachronous ESCC and PLSCC at 5/10 years was 47.5%/67.1% for ESCC, and 13.8%/35.4% for PLSCC, respectively. The cumulative incidence of metachronous major ESCC and PLSCC at 5/10 years was 0.8%/2.8% for ESCC, and 1.5%/1.5% for PLSCC. Additionally, 30 (21.4%) patients died during follow-up, including progression of superficial metachronous ESCC (n=1) and superficial metachronous PLSCC (n=2) under observation after detection due to poor performance status, recurrences of previously treated PLSCC (n=7), aspiration pneumonia (n=4), hematological malignancies (n=3), tongue cancer (n=2), and others (n=11). The 5- and 10-year OS rates were 92.4%/ 79.5%.

Conclusion

In patients with mLVLs, endoscopic surveillance including pharyngo-laryngeal area following ESD for ESCC enabled early detection of metachronous lesions, the majority of which were successfully treated with ER. However, deaths from other causes were not negligible, highlighting the importance of careful long-term systemic monitoring.

Introduction

Patients presenting with laryngeal complaints are often considered to harbor atypical esophageal laryngo-pharyngeal reflux (LPR). The association between LPR symptoms and gastroesophageal reflux (GER) is an ongoing debate.

Aims & Methods

We aimed to characterize patients referred for investigation of LPR complaints and to compare them to patients referred with classic reflux complaints.

All patients referred for pH-impedance testing were offered to participate in this cross-sectional observational study. Those included underwent a comprehensive workup including medical history (presence of a neurologic disease, diabetes, foregut surgery, depression, a diagnosis of Irritable bowel syndrome (IBS) or peptic disease), filling a symptom questionnaire, Rome 3, SCL 90 and SF 36 questionnaires. IBS, functional dyspepsia (FD) and other conditions were defined according to Rome 3 criteria.
All patients underwent gastroscopy, esophageal HRM (Chicago 3) and pH-impedance testing off therapy.
Classic reflux complaints were defined as heartburn, regurgitation, and chest pain. Atypical reflux/LPR symptoms included cough, hoarseness, throat clearing, globus sensation, and asthma exacerbation.
Of patients with symptoms during the study (104/156=(67%), functional heartburn was diagnosed in 33% vs.50.0%, p=0.094.

Results

156 patients were included, 53% were females and with mean age of 53±17y. The indication for testing was classic reflux in 90 (58%), and 66 (42%) patients were referred for LPR symptoms. No significant differences were found between the groups in demographic parameters, background diseases and psychological profile. Both classic and LPR groups had a high prevalence of Rome 3-IBS (67% and 59%, p-NS) and FD (56% and 32%, p=0.058), respectively.
Patients with classic reflux symptoms, compared to the LPR group, used more PPI`s (90% vs. 73%, p=0.008) and SSRI`s (19% vs. 8%, p=0.053) respectively. Life quality was not different between the groups. Gastroscopy and HRM diagnoses and LES and esophageal body parameters were similar between the 2 groups. A higher upper esophageal sphincter pressure was noted in the classic reflux group (p=0.011). Esophageal acid exposure time (AET) was similar as well in the classic vs. the LPR group: 5% vs.5.4%, p=NS, as was the number of patients with AET>6%: 36% vs. 35%, p=NS, respectively. The median number of weakly acidic reflux and non-acidic episodes was also similar: 27 vs. 24, p=NS and 2 (0-2) vs. 1 (0-2), p=NS, respectively.
Of patients with symptoms during the study (104/156=(67%), functional heartburn was diagnosed in 33% vs.50.0%, p=0.094.

Conclusion

In our cohort, the majority of patients with LPR had normal esophageal acid exposure, while the prevalence of IBS, functional dyspepsia, and functional heartburn was higher than reported world prevalence. While other mechanistic explanations may exist, our study suggests an overdiagnosis of LPR symptoms to be related to acid gastro esophageal reflux.