Hard to Swallow Results.

The American Neurogastroenterology and Motility Society (ANMS) proposed quality measures (QMs) for performance and interpretation of esophageal manometry (EM). We implemented a quality improvement (QI) study at a large community hospital to assess and improve procedural adherence and interpretation of EM studies based on the ANMS QMs using the Chicago Classification 3.0 (CC) Guidelines. For pre-intervention, three motility independent reviewers reinterpreted 60 EM studies conducted by community gastroenterologists without Tier II-III motility training from October to December 2018 for compliance with pre-procedural, procedural, and data interpretation ANMS QMs. In December 2018, we developed a pre-procedural form, educated nurses on EM procedural compliance, and provided preliminary pre-intervention results to gastroenterologists along with literature utilizing the CC 3.0 Guidelines. For post-intervention, we reinterpreted 54 EM studies from January to August 2019 and investigated whether they met QMs for data interpretation with respect to the CC Guidelines and resulted in appropriate treatment. We found a statistically significant improvement in procedural compliance among nursing staff for 30 s of swallows (76% post-intervention versus 12% pre-intervention, p < 0.001) and 7 evaluable swallows (94% post-intervention versus 53% pre-intervention, p < 0.001). However, quality metrics within data interpretation by physicians post-intervention showed mixed results. An incorrect diagnosis was made in 50% (n = 27)) of studies with 72% (n = 39) having at least one missing item based on the CC. The most missed diagnosis was fragmented peristalsis (30%, n = 29). Among the 39% (n = 21) of surgery referrals, 24% (n = 5) were incorrectly referred. Our study shows poor data interpretation by community gastroenterologists without formal motility training despite adequate performance by nursing staff. This further supports the need for a national ANMS certification process for formal HRM education.

Successful endoscopic resection of adenocarcinoma arising in an esophageal inlet patch.

An esophageal inlet patch is an area of heterotopic gastric mucosa in the upper esophagus. Most are asymptomatic and found incidentally. There are only 43 case reports of adenocarcinoma arising in an inlet patch, and the majority of these underwent surgical resection. We present the case of a 77-year-old man with intramucosal adenocarcinoma of the cervical esophagus, found within an esophageal inlet patch, staged T1a N0 Mx by endosonographic criteria. He was successfully treated with endoscopic therapy alone. One year following the endoscopic resection, there are no signs of residual or recurrent disease. This case highlights that adenocarcinoma can be a rare complication of an esophageal inlet patch, and that if found early, endoscopic resection appears safe and efficacious.