Introduction

Thoracic surgeries have been the traditional therapeutic approach for esophageal giant subepithelial lesions (g-SELs). Due to the rapid development of endoscopic techniques, increased reports on endoscopic resection (ER) of g-SELs have emerged in recent years.

Aims & Methods

We aimed to summarize the experience of our center on ER of esophageal g-SELs, and also develop a nomogram model to predict the procedural difficulty. 75 patients with g-SELs treated with ER at Zhongshan Hospital were included in the training set. Clinicopathological features, procedure-related characteristics, postprocedural outcomes and follow-up data were gathered and analyzed. A predictive nomogram model for procedural difficulty was proposed based on the risk factors identified by multivariable logistic regression analysis. Internal and external validation were conducted to verify the model performance.

Results

Of the 75 cases, the en bloc resection rate was 93.3%. Intraoperative and postoperative adverse events occurred in 7(9.3%) and 13(17.3%) patients, respectively. No recurrence or metastasis was observed. 32(42.7%) patients underwent a difficult procedure. A younger age, maximal tumor diameter ≥ 8 cm, irregular shape and extraluminal growth pattern were independent risk factors of a difficult procedure, while adopting submucosal tunneling endoscopic resection (STER) as the ER method was inversely correlated with procedural difficulty. The nomogram model showed good discrimination, with the area under the receiver-operating characteristics curve (AUC) of 0.858 and 0.827 of the training and validation set. Calibration curves and Hosmer-Lemeshow tests (P =0.524 of the training set and 0.413 of the validation set) also achieved favorable results.

Conclusion

ER serves as a promising therapeutic option for esophageal g-SELs. A younger age, large tumor size, irregular shape and extraluminal growth may indicate increased ER difficulty, while a STER procedure tends to be of lower difficulty. Our nomogram model performs well to predict ER difficulty for esophageal g-SELs.

Introduction

Gastric subepithelial lesions (SELs) measuring < 20 mm without high-risk features are typically managed with periodic surveillance, while surgical resection is recommended for gastric gastrointestinal stromal tumors (GISTs), in accordance with Japanese guideline. With recent advancements in endoscopic ultrasound-guided tissue acquisition (EUS-TA) needles, collecting larger and more representative tissue samples have become feasible. However, few studies have evaluated the utility of EUS-TA for SELs < 20 mm.

Aims & Methods

This study aimed to assess the usefulness of EUS-TA for gastric SELs measuring < 20 mm. We conducted a retrospective analysis of patients who underwent EUS-TA for SELs at Tonan Hospital between June 2012 and March 2025. Variables related to EUS-TA procedure―such as needle type and the number of passes―histological diagnosis, and adequate specimen collection rates were analyzed. Comparisons were made between lesions < 20 mm and ≥ 20 mm. Rapid On-Site Evaluation (ROSE) was performed for all specimens.

Results

A total of 163 patients were included and categorized into two groups: SELs < 20 mm (n = 50) and SELs ≥ 20 mm (n = 113). The median lesion size was 15.5 mm in the < 20 mm group and 31.7 mm in the ≥ 20 mm group. There was no statistically significant difference in the usage proportion of FNB needles (54% vs. 57.5%), and the most frequent aspiration technique is dry-suction in both groups. The median number of passes required to obtain adequate samples was significantly higher in the < 20 mm group compared to the ≥ 20 mm group (2.5 vs. 2.0, P < 0.05). GIST was the most common pathological diagnosis in both groups, with no significant difference in frequency (56% vs. 61.9%). The adequate specimen collection rate for SELs < 20 mm was not significantly different from SELs ≥ 20 mm (88% vs. 93.8%). In the < 20mm group, 3 out of 26 surgically resected GISTs (11.5%) were classified as high-risk of recurrence. FNB needles did not demonstrate superiority over FNA needles in terms of adequate sample acquisition or diagnostic accuracy regardless of the lesion size.

Conclusion

The diagnostic accuracy of EUS-TA combined with ROSE for SELs < 20 mm is comparable to SELs ≥ 20mm. Given that more than half of gastric SELs < 20 mm are diagnosed as GISTs, and that some of these are at high-risk, proactive use of EUS-TA may be a valuable diagnostic approach even for small SELs.

References

1) Chandrasekhara V, Faulx AL, Kothari S, et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017;85(6): 1117–32.
2) Jacobson BC, Bhatt A, Greer KB, et al. ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions. Am J Gastroenterol. 2023;118(1)46-58.
3) Facciorusso A, Sunny SP, Del Prete V, ET al. Comparison between fine-needle biopsy and fine-needle aspiration for EUS-guided sampling of subepithelial lesions: a meta-analysis. Gastrointest Endosc. 2020;91(1):14-22.

Introduction

Upper dysphagia is a swallowing disorder associated with underlying pathology in the mouth, throat, or esophagus. Cricopharyngeal achalasia (CA) may cause upper dysphagia and its diagnosis is not well established. In case of CA, endoscopic myotomy of upper esophageal sphincter (C-POEM) may be offered to relieve symptoms.

Aims & Methods

We present our experience in diagnosing and managing upper dysphagia with suspicion on CA in patients referred to our center between May 2022 and April 2024. The patients with Zenker diverticulum or organic stricture were not enrolled. All patients underwent X-ray examination, high-resolution manometry and endoscopy. In patients with suspected CA, botulinum toxin injection (100 IU) was administered into the upper esophageal sphincter. After botulinum toxin injection, the follow up visits were scheduled 1, 5 and 12 months after the procedure. In case of a positive effect of the injection, C-POEM (endoscopic myotomy of cricopharyngeal muscle) was considered after the effect of botulinum toxin had vaned. FOSS Function Outcome Swallowing Score and Dakkak and Bennett score of dysphagia were used to assess the severity of the symptoms. The score systems are listed in the table.

Results

Ten patients (4 males, 6 female) were referred to our center with long term upper esophageal dysphagia and considered eligible for botulinum toxin injection. The mean age was 69.7 years (ranges 30, 85), mean duration of symptoms was 8.6 years (SD ± 11) Three patients were unable to swallow safely and PEG tube had to be placed for nutritional support. Aetiologies of dysphagia were cervical injury (n=2), radiotherapy (n=2) and previous neurosurgery (n=1) or idiopathic dysphagia.
All patients underwent botulinum toxin injection. One patient developed vocal cord paresis one week after the injection and her condition improved after corticoid administration. No other adverse events of botulinum toxin were observed.
Improvement of dysphagia occurred in 7 patients after botulinum toxin injection while no change in symptoms was present in 3 patients. One month after the procedure mean
FOSS Function Outcome Swallowing Score improved from 3.3 to 1.56 (p = 0.015) and Dakkak and Bennett score of dysphagia from 2.7 to 1.33 (p=0.012). Two patients received successful C-POEM, the remaining patients will be offered C-POEM once a recurrence of symptoms will occur.
Three patients without effect of botulinum toxin injection were considered endoscopically incurable and referred back to neurology or otorhinolaryngology departments.

Conclusion

Botulinum toxin injection may be effective in treating upper dysphagia caused by a spasm of cricopharyngeal muscle and may serve as a useful selection tool for endoscopic myotomy.

Introduction

Acute esophageal necrosis (AEN) is an uncommon but often fatal esophageal condition with a mortality rate of approximately 30%. AEN predominantly affects elderly, male patients with significant comorbidities and typically presents with signs of upper gastrointestinal hemorrhage. The pathophysiology of AEN is attributed to a combination of local hypoperfusion, loss of mucosal barrier function and acid reflux. However, AEN still remains poorly understood due to its low incidence. In example, it has not been investigated whether celiac trunk stenosis might contribute to AEN development.

Aims & Methods

In this case series, we aimed to review clinical, laboratory and endoscopic features of AEN patients with an additional focus on celiac trunk diameter. 15 patients diagnosed with AEN between 2014 and 2024 at a single center in Berlin, Germany, were included in this study. Clinical data were reviewed and retrospectively analyzed on a case-by-case basis. AEN diagnosis was made endoscopically applying well-described criteria including diffuse, circumferential livid or black discoloration of esophagus mucosa with sparing of the gastroesophageal junction. Celiac trunk was assessed using contrast-enhanced computed tomography imaging to measure the extent of narrowing in the celiac trunk artery. The stenosis was classified into atherosclerotic or median arcuate ligament compression and graded into < 30% (grade 0), 30 - 50% (grade 1), 50 - 80% (grade 2) and > 80% narrowing (grade 3). Laboratory tests were carried out for each patient. However, in some cases not all parameters were available in retrospect.

Results

73% (11/15) of AEN patients were male with a median age of 63.4 years (23 – 85 years). In 47% (7/15) of cases, cardiovascular disease was present. 67% (10/15) of patients presented with gastrointestinal hemorrhage, other clinical presentations included dysphagia, abdominal pain, dyspnea, and shock. 100% (15/15) of patients showed elevated CRP (mean: 70.9 mg/dl, 13.8 - 224.5 mg/l), 92% (11/12) hypalbuminemia (mean: 22.4 g/dl, 6.0 - 36.3 g/dl), 90% (9/10) lactatemia (mean: 97.5 mg/dl, 17 - 259 mg/dl), 82% (9/11) hyperglycemia (mean blood glucose: 146 mg/dl, 73 - 200 mg/dl), 67% (10/15) leukocytosis (mean: 17.96/nl, 4.64 - 42.02/nl) and 67% (10/15) anemia (mean hemoglobin: 11.0 g/dl, 5.0 - 16.1 g/dl). Endoscopy revealed panesophageal necrosis in 71% (10/14) of cases and mid-distal disease in 21% (3/14). Duodenal involvement, mostly reflected by duodenal ulcers, was found in 79% (11/14) of cases. 87% (13/15) of AEN patients showed celiac trunk stenosis. Grade 2 or 3 stenosis was present in 47% (7/15) of cases. 85% (11/13) of celiac trunk stenoses were atherosclerotic, 15% (2/13) were caused by median arcuate ligament compression. Case fatality rate was 40% (6/15) in this series.

Conclusion

Our study confirms that AEN is a potentially life-threatening medical condition often observed in critically ill patients. For the first time, we show that celiac trunk stenosis is associated with this condition. Future research is needed to confirm this data and carve out a possible role for endovascular revascularization in the treatment of AEN patients.

Introduction

Stenosis after esophageal Endoscopic Submucosal Dissection (ESD) has a high incidence of ranks, and muscular injury might be an important risk factor for esophageal stenosis.

Aims & Methods

Our study aimed to classify muscular injury degree and investigate its association with postoperative stenosis. This retrospective study included 1,033 patients with esophageal mucosal lesions treated by ESD between August 2015 and March 2021. Demographic and clinical parameters were analyzed, and stenosis risk factors were identified using multivariate logistic regression. A novel muscular injury classification system was proposed and further used to investigate the association between the different degrees of muscular injury and postoperative stenosis. Finally, a scoring system was established for the prediction of muscular injury.

Results

Of 1,033 patients, 118 (11.4%) had esophageal stenosis. The multivariate analysis demonstrated that the history of endoscopic esophageal treatment, circumferential range, and muscular injury were significant risk factors for esophageal stenosis. Patients with Type II muscular injuries tended to develop complex stenosis (n = 13, 36.1%, p < 0.05). Moreover, Type II muscular injuries were more likely to predispose patients to severe stenosis than Type I (73.3 and 92.3%, respectively). According to the scoring system for predicting muscular injury, patients with high scores (3-6) were more likely to suffer muscular injury. The score model presented good discriminatory power in the internal validation (AUC: 0.706; 95% CI: 0.645-0.767) and goodness-of-fit in the Hosmer-Lemeshow test (p = 0.865).

Conclusion

Muscular injury was an independent risk factor for esophageal stenosis. The scoring system demonstrated good performance in predicting muscular injury during ESD.

References

1. Yang D, Othman M, Draganov PV. Endoscopic Mucosal Resection vs Endoscopic Submucosal Dissection For Barrett's Esophagus and Colorectal Neoplasia. Clin Gastroenterol Hepatol. 2019;17:1019-28.
2. Chen M, Dang Y, Ding C, et al. Lesion size and circumferential range identified as independent risk factors for esophageal stricture after endoscopic submucosal dissection. Surg Endosc. 2020;34:4065-71.
3. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020;32:452-93.
4. Zhang BZ, Zhang Y, Wang YD, et al. Stent placement to prevent strictures after esophageal endoscopic submucosal dissection: a systematic review and meta-analysis. Dis Esophagus. 2021;34.
5. Wu QN, Xu XY, Zhang XC, et al. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017;49:736-44.
6. Nagami Y, Ominami M, Shiba M, et al. Prediction of esophageal stricture in patients given locoregional triamcinolone injections immediately after endoscopic submucosal dissection. Dig Endosc. 2018;30:198-205.
7. Xu Y, Lin Z, Zhong S, et al. Muscular injury was identified the risk factor of post-operative stenosis after large area but non-circumferential esophageal endoscopic submucosal dissection. Scand J Gastroenterol. 2022:1-8.

Introduction

Peroral endoscopic myotomy (POEM) has become the mainstay of treatment of oesophageal achalasia in adult patients and recently also gained acceptance as effective therapy of achalasia in paediatric population. Here we retrospectively reviewed prospectively collected children with achalasia that had been treated with POEM at our institution.

Aims & Methods

Patients that were hospitalized in the Paediatric Clinic for POEM procedure from 11/2017 to 05/2023 were included. All patients had achalasia confirmed by high resolution manometry (HRM). We evaluated their symptoms in terms of duration and intensity (Eckardt score) and the integrated relaxation pressure (IRP) obtained by HRM before POEM. 3 months after POEM during the follow-up visit we determined Eckardt score, IRP and the presence of reflux oesophagitis on upper endoscopy. When finalizing the abstract we conducted a brief telephone survey to determine Eckardt score and presence of reflux symptoms.

Results

10 patients (6 boys and 4 girls), mean age 11.5 (5-18) years were included. 9 of these patients received POEM as their first therapy for achalasia, 1 patient had been previously treated surgically via thoracotomy. The median of the duration of symptoms was 8.5 (range 1-36) months. All patients were diagnosed with type I achalasia according to Chicago classification. Eckardt score decreased significantly 3 months after POEM (7.38±1.68 vs. 0.63±1.06 before and after POEM, respectively, p<0.0001) and sustained unchanged (0.4±0.66) during the median follow-up of 21.5 months (range 1-60 months). IRP also significantly decreased after the intervention (46.5±11.1 mmHg vs. 3.8±5.68 mmHg; before and after POEM, respectively, p=0.0001). Complications occurred in 2 patients. Pleuropneumonia in one patient led to extension of hospital stay and was solved conservatively. Upper GI bleeding occurred in one patient 2 weeks after discharge, was self-limited without any obvious source found. Follow-up endoscopy was performed off PPI therapy and revealed mild esophagitis (LA A) in 2 patients that also reported mild heartburn.

Conclusion

POEM represents an effective therapy for achalasia in paediatric population in mid-term follow-up as it significantly improves symptom and provides effective decrease of the IRP. Although in our case series no severe heartburn or reflux esophagitis occurred, more data with longer follow up are needed to prove either long-term safety with regard to the reflux issue and the need for long term PPI therapy in these patients. Supported by VEGA 1/0060/23.