Psychosocial factors and their association with reflux oesophagitis,Barrett's oesophagus and oesophageal adenocarcinoma

AIM:To investigate the role of psychological characteristics as risk factors for oesophageal adenocarcinoma(OAC),as well as the reflux-mediated precursor pathway.METHODS:An all-Ireland population-based case-control study recruited 230 reflux oesophagitis(RO),224 Barrett's oesophagus(BO) and 227 OAC patients and 260 controls.Each case/control group completed measures of stress,depression,self-efficacy,self-esteem,repression and social support.A comparative analysis was undertaken using polytomous logistic regression adjusted for potential confounders.RESULTS:Compared to controls,OAC patients were almost half as likely to report high stress levels over their lifetime(P = 0.010,OR 0.51;95%CI:0.29-0.90)and 36% less likely to report having experienced depression(OR 0.64;95%CI:0.42-0.98).RO patients reported significantly higher stress than controls particularly during middle-and senior-years(P for trends < 0.001).RO patients were 37% less likely to report having been highly emotionally repressed(OR 0.63;95%CI:0.41-0.95).All case groups(OAC,RO and BO) were more likely than controls to report having had substantial amounts of social support(OR 2.84;95%CI:1.63-4.97;OR 1.97;95%CI:1.13-3.44 and OR 1.83;95%CI:1.03-3.24,respectively).CONCLUSION:The improved psychological profile of OAC patients may be explained by response shift.The role of psychological factors in the development of OAC requires further investigation.

Treatment of dysplastic Barrett's Oesophagus in lower volume centres after structured training

AIM: To investigate whether dysplastic Barrett's Oesophagus can be safely and effectively treated endoscopically in low volume centres after structured training. METHODS: After attending a structured training program in Amsterdam on the endoscopic treatment of dysplastic Barrett's Oesophagus, treatment of these patients was initiated at St Marys Hospital. This is a retrospective case series conducted at a United Kingdom teaching Hospital, of patients referred for endoscopic treatment of Barrett's oesophagus with high grade dysplasia or early cancer, who were diagnosed between January 2008 and February 2012. Data was collected on treatment provided(radiofrequency ablation and endoscopic resection), and success of treatment both at the end of treatment and at follow up. Rates of immediate and long term complications were assessed. RESULTS: Thirty-two patients were referred to St Marys with high grade dysplasia or intramucosal cancer within a segment of Barrett's Oesophagus. Twentyseven met the study inclusion criteria, 16 of these had a visible nodule at initial endoscopy. Treatment was given over a median of 5 mo, and patients received a median of 3 treatment sessions over this time. At the end of treatment dysplasia was successfully eradicated in 96% and intestinal metaplasia in 88%, on per protocol analysis. Patients were followed up for a median of 18 mo. At which time complete eradication of dysplasia was maintained in 86%. Complications were rare: 2 patients suffered from post-procedural bleeding, 4 cases were complicated by oesophageal stenosis. Recurrence of cancer was seen in 1 case. CONCLUSION: With structured training good outcomes can be achieved in low volume centres treating dysplastic Barrett's Oesophagus.

Benign Stenosis of Oesophagus: About 101 Cases in the Digestive Endoscopy Department of the General Idrissa Pouye Hospital (Dakar, Senegal)

Introduction: Benign oesophageal strictures are defined as narrowing of the oesophageal lumen not related to neoplastic pathology. They are frequently encountered during endoscopic practice and are often responsible for a reduction in the quality of life of patients due to the appearance of dysphagia. In sub-Saharan Africa, little data are available on these benign esophageal strictures. The objective of our study was to determine the sociodemographic, diagnostic and therapeutic aspects of benign oesophageal strictures in a digestive endoscopy centre in Senegal. Patients and Methods: This was a retrospective, descriptive study analysing reports of upper GI endoscopies performed between January 2015 and December 2017 in a hospital in Senegal. Reports that concluded to have non-neoplastic oesophageal stenosis were collated. Sociodemographic data, indications for and results of endoscopy, and therapeutic modalities were collected. These data were analysed using the Sphinx version 5 software. Results: We collected 101 cases of benign oesophageal stenosis, representing a prevalence of 2.1% in the endoscopy centre. The mean age of the patients was 34 years (range 2 and 83 years) with a median of 37.9 years. There was a female predominance with a sex ratio of 0.38 (73 females). Dysphagia, the main symptom, was present in 87 patients (86.1% of cases) with a Dysphagia score greater than or equal to 2 in 51 patients (50.5%). The average duration of this dysphagia, excluding caustic stenosis, was 4 years (extremes 1 and 15 years). Endoscopy revealed simple stenosis in 76 cases (75.2% of cases). A membranous ring of the cervical oesophagus, suggestive of the Plummer-Vinson syndrome ring, was found in 60 patients (59.4% of cases) and was the primary cause;other aetiologies were dominated by caustic stenosis (19 cases), Schatzki rings (8 cases) and peptic stenosis (4 cases). Endoscopic dilatation was performed in 90 patients (89.1% of cases) with Savary Gilliard bougies (87 cases) and hydrostatic balloons (3 cases). The average number of dilatation sessions was 1.69. In 10 patients (11.1%), refractory stenosis was observed. This stenosis could be resolved after further dilatation in 8 cases before the 8th session. In 2 patients, dilatation failed. Conclusion: Benign oesophageal strictures in our digestive endoscopy centre in Senegal mainly affect young adults, with a predominance of women. Diagnosis is often late. Cervical oesophageal rings in the context of Plummer-Vinson syndrome are the main cause. Oesophageal dilatation with bougies is of great therapeutic value.

Radiotherapy of carcinoma of oesophagus in China

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Applications of endoscopic vacuum therapy in the upper gastrointestinal tract

Endoscopic vacuum therapy(EVT)is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract.After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery,it was also implemented for a wide range of defects,including acute perforations,duodenal lesions,and postbariatric complications.Apart from the initially proposed handmade sponge inserted using the“piggyback”technique,further devices were used,such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage.The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly,but all available evidence highlights the efficacy of EVT,with high success rates and low morbidity and mortality,so that in many centers it is considered to be a first-line treatment,especially for anastomotic leaks.

Three-field vs two-field lymph node dissection for esophageal cancer:A meta-analysis

AIM:To assess the effects of 3-field lymphadenectomy for esophageal carcinoma.METHODS:We conducted a computerized literature search of the Pub Med,Cochrane Controlled Trials Register,and EMBASE databases from their inception to present.Randomized controlled trials(RCTs)or observational epidemiological studies(cohort studies)that compared the survival rates and/or postoperative complications between 2-field lymphadenectomy(2FL)and3-field lymphadenectomy(3FL)for esophageal carcinoma with R0 resection were included.Meta-analysis was conducted using published data on 3FL vs 2FL in esophageal carcinoma patients.End points were 1-,3-,and 5-year overall survival rates and postoperativecomplications,including recurrent nerve palsy,anastomosis leak,pulmonary complications,and chylothorax.Subgroup analysis was performed on the involvement of recurrent laryngeal lymph nodes.RESULTS:Two RCTs and 18 observational studies with over 7000 patients were included.There was a clear benefit for 3FL in the 1-(RR=1.16;95%CI:1.09-1.24;P<0.01),3-(RR=1.44;95%CI:1.19-1.75;P<0.01),and 5-year overall survival rates(RR=1.37;95%CI:1.18-1.59;P<0.01).For postoperative complications,3FL was associated with significantly more recurrent nerve palsy(RR=1.43;95%CI:1.28-1.60;P=0.02)and anastomosis leak(RR=1.26;95%CI:1.05-1.52;P=0.09).In contrast,there was no significant difference for pulmonary complications(RR=0.93;95%CI:0.75-1.16,random-effects model;P=0.27)or chylothorax(RR=0.77;95%CI:0.32-1.85;P=0.69).CONCLUSION:This meta-analysis shows that 3FL improves overall survival rate but has more complications.Because of the high heterogeneity among outcomes,definite conclusions are difficult to draw.

Upper gastrointestinal tract capsule endoscopy using a nurse-led protocol: First reported experience

AIM To test the feasibility and performance of a novel upper gastrointestinal(GI) capsule endoscope using a nurse-led protocol. METHODS We conducted a prospective cohort analysis of patients who declined gastroscopy(oesophagogastroduodenoscopy, OGD) but who consented to upper GI capsule endoscopy. Patients swallowed the upper GI capsule following ingestion of 1 liter of water(containing simethicone). A series of positional changes were used to exploit the effects of water flow and move the upper GI capsule from one gravity-dependent area to another using a nurse-led protocol. Capsule transit time, video reading time, mucosal visualisation, pathology detection and patient tolerance was evaluated.RESULTS Fifty patients were included in the study. The mean capsule transit times in the oesophagus and stomach were 28 s and 68 min respectively. Visualisation of the following major anatomical landmarks was achieved(graded 1-5: Poor to excellent): Oesophagus, 4.8(± 0.5); gastro-oesophageal junction(GOJ), 4.8(± 0.8); cardia, 4.8(± 0.8); fundus, 3.8(± 1.2); body, 4.5(± 1); antrum, 4.5(± 1); pylorus, 4.7(± 0.8); duodenal bulb, 4.7(± 0.7); second part of the duodenum(D2), 4.7(± 1). The upper GI capsule reached D2 in 64% of patients. The mean video reading time was 48 min with standard playback mode and 20 min using Quickview(P = 0.0001). No pathology was missed using Quickview. Procedural tolerance was excellent. No complications were seen with the upper GI capsule. CONCLUSION The upper GI capsule achieved excellent views of the upper GI tract. Future studies should compare the diagnostic accuracy between upper GI capsule and OGD.

Reduced esophageal cancer incidence in statin users,particularly with cyclo-oxygenase inhibition

AIM:To examine the association between statin use and the development of esophageal cancer METHODS:We performed a systematic review and meta-analysis.Multiple databases(Pubmed,EMBASE,Cochrane Library,Web of Science,Wiley Interscience and Google Scholar) were systematically searched for studies reporting the association of statin use and the development of esophageal cancer.Literature searching and data abstraction were performed independently by two separate researchers.The quality of studies reviewed was evaluated using the Newcastle-Ottawa Quality assessment scale.Meta-analysis on the relationship between statin use and cancer incidence was performed.The effect of the combination of statin plus a cyclo-oxygenase inhibitor was also examined.RESULTS:Eleven studies met eligibility criteria,9 high and 2 medium quality.All were observational studies.Studies examining adenocarcinoma development in Barrett's esophagus included 317 cancers and 1999 controls,population-based studies examining all esophageal cancers included 371203 cancers and 6083150 controls.In the Barrett's population the use of statins(OR = 0.57;95%CI:0.43-0.75) and cyclo-oxygenase inhibitors(OR = 0.59;95%CI:0.45-0.77) were independently associated with a reduced incidence of adenocarcinoma.Combined use of a statin plus cyclooxygenase inhibitor was associated with an even lower adenocarcinoma incidence(OR = 0.26;95%CI:0.1-0.68).There was more heterogeneity in the population-based studies but pooled adjusted data showed that statin use was associated with a lower incidence of all combined esophageal cancers(OR = 0.81;95%CI:0.75-0.88).CONCLUSION:Statin use in patients with Barrett's oesophagus is associated with a significantly lower incidence of adenocarcinoma.The chemopreventive actions of statins,especially combined with cyclooxygenase inhibitors deserve further exploration.

Unsteady peristaltic transport of Maxwell fluid through finite length tube:application to oesophageal swallowing

This paper analytically investigates the unsteady peristaltic transport of the Maxwell fluid in a finite tube. The walls of the tube are subjected to the contraction waves that do not cross the stationary boundaries. The analysis is carried out by a long wavelength approximation in the non-dimensional form. The expressions for the axial and radial velocities are derived. The pressures across the wavelength and the tubelength are also estimated. The reflux phenomenon is discussed, which culminates into the determination of the reflux limit. Mathematical formulations are physically interpreted for the flow of masticated food materials such as bread and white eggs in the oesophagus. It is revealed that the Maxwell fluids are favorable to flow in the oesophagus as compared with the Newtonian fluids. This endorses the experimental finding of Takahashi et al. （Takahashi, T., Ogoshi, H., Miyamoto, K., and Yao, M. L. Viscoelastic properties of commercial plain yoghurts and trial foods for swallowing disorders. Rheology, 27, 169- 172 （1999））. It is further revealed that the relaxation time does not affect the shear stress and the reflux limit. It is found that the pressure peaks are identical in the integral case while different in the non-integral case.

Endoscopic resection techniques and ablative therapies for Barrett’s neoplasia

Esophageal adenocarcinoma is the most rapidly increas- ing cancer in western countries.High-grade dysplasia (HGD)arising from Barrett’s esophagus(BE)is the most important risk factor for its development,and when it is present the reported incidence is up to 10% per patient-year.Adenocarcinoma in the setting of BE develops through a well known histological sequence,from non-dysplastic Barrett’s to low grade dysplasia and then HGD and cancer.Endoscopic surveillance programs have been established to detect the presence of neo- plasia at a potentially curative stage.Newly developed endoscopic treatments have dramatically changed the therapeutic approach of BE.When neoplasia is confined to the mucosal layer the risk for developing lymph node metastasis is negligible and can be successfully eradi- cated by an endoscopic approach,offering a curative in- tention treatment with minimal invasiveness.Endoscopic therapies include resection techniques,also known as tissue-acquiring modalities,and ablation therapies or non-tissue acquiring modalities.The aim of endoscopic treatment is to eradicate the whole Barrett’s segment,since the risk of developing synchronous and metachro- nous lesions due to the persistence of molecular aberra- tions in the residual epithelium is well established.

Squamous cell carcinoma after radiofrequency ablation for Barrett's dysplasia

Barrett’s oesophagus(BO)is a usually indolent condition that occasionally requires endoscopic therapy.Radiofrequency ablation(RFA)is an effective endoscopic treatment for high grade dysplasia(HGD)and intramucosal cancer in BO.It has a good efficacy,durability and safety profile although complications can occur.Here we describe a case of RFA in a patient with high grade dysplasia.Although the response to treatment was initially very good with the development of neosquamous epithelium,the patient very rapidly developed a squamous cell cancer of the oesophagus confirmed on radiology,histology and immunohistochemistry.Sanger sequencing confirmed that the original HGD and the squamous cell cancer(SCC)were derived from separate clonal origins.The report highlights the fact that SCC of the oesophagus has been noted after endoscopic ablation for BO previously and suggest that ablation of BO may encourage the clonal expansion of cells carrying carcinogenic mutations once a dominant clonal population has been eradicated.

Dysphagia lusoria: A late onset presentation

Dysphagia lusoria is a term used to describe dysphagia secondary to vascular compression of the oesophagus. The various embryologic anomalies of the arterial brachial arch system often remain unrecognised and asymptomatic, but in 30%-40% of cases can result in tracheo-oesophageal symptoms, which in the majority of cases manifest as dysphagia. Diagnosis of dysphagia lusoria is via barium swallow and chest Computed tomography scan. Manometric abnormalities are variable, but age-related manometric changes may contribute to clinically relevant dysphagia lusoria in patients who present later in life. Our report describes a case of lateonset dysphagia secondary to a right aortic arch with an aberrant left subclavian artery, which represents a rare variant of dysphagia lusoria. The patient had proven additional oesophageal dysmotility with solid bolus only and a clinical response to dietary modification.

Role of artificial intelligence in the diagnosis of oesophageal neoplasia:2020 an endoscopic odyssey

The past decade has seen significant advances in endoscopic imaging and optical enhancements to aid early diagnosis.There is still a treatment gap due to the underdiagnosis of lesions of the oesophagus.Computer aided diagnosis may play an important role in the coming years in providing an adjunct to endoscopists in the early detection and diagnosis of early oesophageal cancers,therefore curative endoscopic therapy can be offered.Research in this area of artificial intelligence is expanding and the future looks promising.In this review article we will review current advances in artificial intelligence in the oesophagus and future directions for development.

Semi-Solid and Solid Bolus Swallows in High-Resolution Oesophageal Manometry for the Detection of Motility Disorders

Background/Aims: High-resolution oesophageal manometry utilises water swallows to evaluate oesophageal function. However, small volumes of water are not representative of normal eating and as a result often produce normal manometry studies in patients with dysphagia. This study sets out to establish optimal diagnostic thresholds for semi-solid solid swallows and evaluate their ability to uncover motility abnormalities in patients with motility disorders. Method: Manometry was performed using ten 5-mL single water swallows followed by two semi-solid and two solid swallows in the upright position. Normative values for the adjunctive tests were obtained from patient controls while patients with major motility disorders were used to establish the optimal diagnostic thresholds. Diagnostic thresholds identified were prospectively tested in patients with normal water swallows but oesophagus related symptoms and in those with minor and major motility disorders. Results: Normal values for semi-solid and solid were determined in patient controls (n = 100). Development of diagnostic thresholds included 120 patients with major motility disorders. Optimal diagnostic thresholds identified for oesophagogastric junction dysfunction in semi-solid and solid swallows (IRP > 15.5 mmHg). Hypercontractilty and spasm used existing thresholds (>8000 mmHg-s-cm and < 4.5 s, respectively) but modified frequency of ≥50% of adjunctive swallows. Diagnostic thresholds were applied to symptomatic patients with normal water swallows (n = 70) identifying 12/70 (17%) to have abnormal adjunctive swallows. One of 30 patients (3%) with ineffective motility had abnormal adjunctive swallow and 12 patients with oesophageal spasm, oesophagogastric junction obstruction, and hypercontractility had abnormal adjunctive swallows that moved them up the motility disorder hierarchy. Conclusions: Semi-solid and solid challenge increase diagnostic yield of motility disorders.

A Simple Combined Antegrade Radiological and Retrograde Endoscopic Procedure to Recanalise Fibrotic Hypopharyngo-Oesophageal Occlusions: Technical Description and Lessons from Clinical Outcome in Three Cases

Background: Complete hypopharyngo-oesophageal occlusion is a rare complication of head and neck radiotherapy and a range of other conditions. Absolute dysphagia is accompanied by aspiration and dependence on gastrostomy feeding. The condition presents a substantial management challenge. Surgical approaches to re-establish pharyngo-oesophageal continuity are varied, highly invasive and are associated with unpredictable outcomes. Minimally invasive techniques employing endoscopic and radiological techniques are emerging. This report describes a multidisciplinary approach which translates two interventional radiology techniques used in the management of central venous occlusions and biliary strictures to the management of three cases of complete hypopharyngo-oesophageal occlusion. Methods: Three cases with different underlying aetiologies had treatment initiated between 2009 and 2011. Antegrade pharyngoscopic access to the occlusions was accompanied by retrograde endoscopic access via a small gastrostomy. Luminal continuity was re-established by the interventional radiology technique of “sharp recanalisation” followed by passage of a wide bore nasogastric tube which was maintained in situ for 4-6 months, a duration of treatment analogous to that applied in the radiological management of fibrotic biliary strictures. After treatment a radiological contrast swallows examination was performed to gauge the calibre of the re-established lumen, assess functionality and to rule out aspiration. Results: Pharyngo-oesophageal continuity was re-established in all three cases on the first attempt. No complications occurred as a result of the procedures. In two cases, the excellent swallowing function was re-established, although one of these required prolonged post-treatment adjuvant interventions. In one case no swallowing function resulted, despite apparently successful re-establishment of luminal continuity. Conclusions: Complete fibrotic occlusion of the hypopharyngo-oesophageal lumen is rare and presents a substantial management challenge. A minimally invasive treatment combining antegrade radiological and retrograde endoscopic approaches resulted in successful re-establishment of luminal continuity in three cases of complete fibrotic occlusion of the hypopharyngo-oesophageal lumen. However variable responses to treatment suggest that both the underlying aetiology and the chronicity of the occlusion may influence the likelihood of a successful functional outcome. Until definitive management guidelines are established, we suggest that such cases are managed only by motivated multidisciplinary teams keen to develop their expertise in this area.

Artificial intelligence in endoscopy:The challenges and future directions

Artificial intelligence based approaches,in particular deep learning,have achieved state-of-the-art performance in medical fields with increasing number of software systems being approved by both Europe and United States.This paper reviews their applications to early detection of oesophageal cancers with a focus on their advantages and pitfalls.The paper concludes with future recommendations towards the development of a real-time,clinical implementable,interpretable and robust diagnosis support systems.

Peristaltic transport in an elastic tube under the influence of dilating forcing amplitudes

We investigate flow through an elastic tube which is constrained to a prescribed external forcing consisting of a progressive travelling wave.Such a flow dynamics is closely related to that in the oesophageal tube.The mechanics of the tube is characterized by a relationship between transmural pressure difference and radial variation of the tube.Dimensionless radial variation,assumed to be small,is studied by perturbation techniques.Hesults demonstrate that the elasticity of the tube plays a significant role in the flow dynamics.An increment in the forcing amplitude of the inward radial force enhances pressure,time-averaged volume flow rate and hence axial and radial velocities.lt is revealed that the elastic nature of the oesophageal tube favors swallowing.