Patient with mediastinitis caused by delayed mucosal damage after peroral endoscopic myotomy.

Peroral endoscopic myotomy (POEM) is a groundbreaking procedure for treating esophageal achalasia, and many reports from various facilities have described its safety and efficacy. However, there have been few reports on adverse events. Here, we report a case of a patient with mediastinitis caused by delayed mucosal damage after POEM. This case was the most severe among all POEM cases at our hospital. A 58-year-old man had experienced dysphagia and chest tightness since he was around 50 years old. At a previous hospital, he had been diagnosed with nonerosive reflux disease and had undergone fundoplication. As his symptoms did not improve, he was referred to our department. POEM was able to be finished but a stable visual field could not be maintained throughout procedure because of strong esophageal contractions. From findings of endoscopy and esophagography after POEM, the patient was diagnosed mediastinitis caused by delayed esophageal perforation. In this case, conservative treatment (fasting, antibiotic therapy, and enteral feeding) was successful. However, the option to administer surgical treatment, such as drainage, must not be overlooked.

Valores de referencia de manometría esofágica de alta resolución mediante sistema de perfusión / Normal values for water-perfused esophageal high-resolution manometry

ANTECEDENTES: los valores de referencia de la manometría esofágica de alta resolución mediante sistema de perfusión aún no han sido establecidos en nuestro medio, a pesar de su empleo generalizado en múltiples Unidades de Motilidad y la recomendación de determinar valores de referencia propios de cada Unidad en función de sus equipos. Actualmente se utilizan como referencia los valores de normalidad de la manometría de alta resolución en estado sólido. OBJETIVOS: el objetivo de este estudio es establecer los valores de normalidad para la manometría de alta resolución de perfusión de 22 canales a partir del análisis de la motilidad esofágica de individuos sanos. MÉTODOS: se incluyeron 16 voluntarios sanos, sin patología digestiva ni síntomas esofágicos, a los que se realizó una manometría de alta resolución mediante sistema de perfusión de 22 canales. RESULTADOS: los datos vienen referidos como la media y el rango comprendido entre los percentiles 5 y 95. Los percentiles 5 y 95 de cada uno de los parámetros fueron de 40-195 mmHg para la presión de reposo del esfínter esofágico superior (PRESS), 30-115 mmHg para la presión residual del esfínter esofágico superior (PResEES), 2,4-7,1 cm/s para la velocidad de frente contráctil (VFC), 285-2.820 mmHg.s.cm para la integral contráctil distal (ICD), 6,1-10,9 s para la latencia distal (LD), 7-19 mmHg para la presión intrabolo (PIB), 2-20 mmHg para la presión de relajación integrada a los 4 segundos (PRI4s) y 5-54 mmHg para la presión de reposo del esfínter esofágico inferior (PREEI). Los percentiles 5 y 95 del acortamiento esofágico (aE) fueron 0,3-1,3 cm y del ascenso del esfínter esofágico inferior (aEEI) 0,1-1,2 cm. CONCLUSIÓN: los rangos de normalidad obtenidos mediante sistema de perfusión de 22 canales para los parámetros manométricos más importantes (PRI4s, LD, VFC) son similares a los previamente publicados con equipos de perfusión, existiendo variaciones pequeñas, pero significativas, respecto a los valores establecidos por equipos de estado sólido

BACKGROUND: Normal values for water-perfused esophageal high-resolution manometry have still not been established in our environment, despite its generalized use and the recommendation to determine reference values for each Motility Unit based on their equipment. Normal values established with solid-state highresolution manometry are currently being used as reference values for water-perfused high-resolution manometry. OBJECTIVES: To obtain normal values for water-perfused esophageal high-resolution manometry, based on the esophageal motility analysis of healthy subjects. METHODS: 16 healthy volunteers without history of digestive complaints or esophageal symptoms were included. 22-channel water-perfused high-resolution manometry was performed. RESULTS: Normal values were calculated as 5th-95th percentile ranges for the following parameters; upper esophageal sphincter resting pressure (UESRP) (40-195 mmHg); upper esophageal sphincter residual pressure (UESResP) (30-115 mmHg), contractile front velocity (CFV) (2.4-7.1 cm/s), distal contractile integral (DCI) (285-2820 mmHg.s.cm), distal contraction latency (DL) (6.1-10.9 s), intrabolus pressure (IBP) (7-19 mmHg), integrated relaxation pressure (IRP 4s) (2-20 mmHg), lower esophageal sphincter resting pressure (LESRP) (5-54 mmHg), esophageal shortening (Es) (0.3-1.3 cm) and lower esophageal sphincter lift (LESL) (0,1-1,2 cm). CONCLUSION: Normal values for the most important parameters (such as IRP 4s, DL and CFV), obtained using a 22-channel waterperfused system resemble previously published data from other perfusion devices. However, there exist small but significant variations compared with values established with solid-state highresolution manometry. Thus, when using water-perfused catheters, caution is required when normative values are used that were established with solid-state catheters

Esophageal perforation, inflammatory mediastinitis and pseudoaneurysm of the thoracic aorta as potential complications of botulinum toxin injection for achalasia.

Primary achalasia is a motility disorder of the esophagus involving impaired relaxation of the esophageal sphincter and, in later stages, dilatation and aperistalsis of the tubular esophagus. Endoscopic botulinum toxin injection to the lower esophageal sphincter is an effective and safe option in the treatment algorithm of achalasia, particularly in high-surgical-risk patients. In the present case report, we describe a rare complication of esophageal perforation following botulinum injection, resulting in associated inflammatory mediastinitis and formation of a pseudoaneurysm in the descending aorta. To the authors' knowledge, this is the first report in the literature of this rare complication of endoscopic botulinum injection. A contributing factor might have been the use of an injecting device with a significantly longer adjustable needle. Endoscopists should remain clinically vigilant to the potential complications associated with this common procedure.

Endotherapy for a 5-cm mid-esophageal perforation with tandem stenting above the lower esophageal sphincter (with videos).

BACKGROUND: Esophageal perforation, whether spontaneous or more commonly as a result of instrumentation, is a life-threatening condition and carries high mortality despite recent advances. Outcome is dependent on etiology, location of injury, and interval between perforation and initiation of therapy. Successful management of esophageal perforation entails combination of: (1) control of the leakage site either surgically or endoscopically to prevent further contamination, (2) drainage of contamination, and (3) appropriate antibiotics along with nutritional support. METHODS: We report one case with a 5-cm-long iatrogenic mid-esophageal perforation. The perforation was successfully managed with esophageal tandem stenting above the lower esophageal sphincter (LES). RESULTS: The radial expansile force of the inner stent and its anchorage by LES holds the outer stent in place and prevents the tandem stents migrating distally. CONCLUSIONS: Successful management of esophageal perforation depends on early diagnosis, control of site of leak, drainage of accompanying collections, and antibiotic and nutritional support.

Prolonged esophagitis after primary dysfunction of the pyloric sphincter in the rat and therapeutic potential of the gastric pentadecapeptide BPC 157.

Seven or fourteen days or twelve months after suturing one tube into the pyloric sphincter (removed by peristalsis by the seventh day), rats exhibit prolonged esophagitis with a constantly lowered pressure not only in the pyloric, but also in the lower esophageal sphincter and a failure of both sphincters. Throughout the esophagitis experiment, gastric pentadecapeptide BPC 157 (PL 14736) is given intraperitoneally once a day (10 microg/kg, 10 ng/kg, last application 24 h before assessment), or continuously in drinking water at 0.16 microg/ml, 0.16 ng/ml (12 ml/rat per day), or directly into the stomach 5 min before pressure assessment (a water manometer connected to the drainage port of a Foley catheter implanted into the stomach either through an esophageal or duodenal incision). This treatment alleviates i) the esophagitis (macroscopically and microscopically, at either region or interval), ii) the pressure in the pyloric sphincter, and iii) the pressure in the lower esophageal sphincter (cmH2O). In the normal rats it increases lower esophageal sphincter pressure, but decreases the pyloric sphincter pressure. Ranitidine, given using the same protocol (50 mg/kg, intraperitoneally, once daily; 0.83 mg/ml in drinking water; 50 mg/kg directly into the stomach) does not have an effect in either rats with esophagitis or in normal rats.

Spontaneous esophageal perforation in a patient with achalasia cardia and rheumatoid arthritis.

Perforation of stasis ulcers in achalasia cardia has not been reported in literature. We report a 45-year-old lady with achalasia and rheumatoid arthritis who developed perforation and esophago-mediastinal sinus at the site of stasis ulcers. She succumbed to respiratory infection after resection of the sinus tract, Heller's cardiomyotomy, cervical esophagostomy and feeding jejunostomy.