Incidence and clinical relevance of upper gastrointestinal pathology during preprocedural endoscopy in patients undergoing pulmonary vein isolation.

BACKGROUND: Reflux-induced esophagitis might facilitate ablation-induced esophageal lesions (ELs) following pulmonary vein isolation (PVI), and these may progress to atrio-esophageal fistula (AEF). In contrast, preexisting ELs are not prone to progression but may affect procedure planning. OBJECTIVE: To study the incidence of preexisting esophageal and upper gastrointestinal (UGI) pathology in patients undergoing PVI, and the relation to ablation-induced ELs. METHODS: From 08/2018 to 09/2021, consecutive patients undergoing (radiofrequency [RF] or cryoballoon [CB]) PVI were examined by esophagogastroscopy (EGD) before and following ablation. Postprocedural endoscopic ultrasound (EUS) was added in 2021. RESULTS: 412 patients (median age 67.5 [IQR 61.3-75.0] years, 56.1% male) were studied. Preprocedural EGD showed abnormalities in 226/399 patients, 15% in the lower third of the esophagus. Half (99/226) were relevant for PVI, 13 procedures were postponed, 6 due to pathological EGD results. A third of the patients with new esophageal injury following ablation had preexisting esophagitis which was associated with a trend for a higher incidence of ELs after RF ablation (12.5 vs. 6.9%, p = 0.232), and a six- and two-fold higher rate of food retention after CB-PVI (28.6 vs. 4.5%, p = 0.008) and RF ablation (8.3 vs. 4.4%, p = 0.279), respectively. CONCLUSION: (1) EGD before PVI showed UGI abnormalities in > 50% of patients, one-fourth of these relevant for PVI. (2) Esophageal inflammation was associated with a higher incidence of post-ablation (peri)-esophageal injury. Whether having this information before ablation is able to reduce ELs or AEF remains to be shown.

Temperature monitoring and temperature-driven irrigated radiofrequency energy titration do not prevent thermally induced esophageal lesions in pulmonary vein isolation: A randomized study controlled by esophagoscopy before and after catheter ablation.

BACKGROUND: Endoscopically detected esophageal lesions (EDELs) are common following pulmonary vein isolation (PVI) and may progress to atrioesophageal fistula (AEF). OBJECTIVE: The purpose of this study was to study (1) the benefit of luminal esophageal temperature (LET) monitoring and (2) the impact of esophagogastroduodenoscopy (EGD) in detecting EDEL and defining pre-existing lesions. The primary endpoint was the number of ablation-induced lesions. METHODS: Patients with atrial fibrillation were randomized to PVI with LET monitoring (LET[+]) or without LET monitoring (LET[-]). All patients underwent EGD before and after PVI. Ablation power at the left atrial (LA) posterior wall was limited to 25 W in all patients and was titrated to a minimum of 10 W guided by esophageal temperature in the LET[+] group. RESULTS: Eighty-six patients (age 67 ± 10 years; 57% male) were included (44 LET[+], 42 LET[-]). PVI was achieved in all, and additional linear LA lesions were done in 50%. Eight patients developed EDEL (6 LET[+], 2 LET[-]; P = NS). Whereas LET <41°C did not differentiate with regard to EDEL formation, temperature overshooting ≥42°C was associated with a higher risk for new EDEL. Two-thirds of patients showed incidental findings (esophagitis, gastric ulcer) on preprocedural EGD; 8 esophageal lesions were pre-existing. Four patients in the LET[+] group developed epistaxis following insertion of the probe. CONCLUSION: Monitoring of LET does not prevent ablation-induced esophageal lesions. Patients without temperature surveillance were not at higher risk, but temperatures ≥42°C were associated with increased likelihood of mucosal lesions.

Laparoscopy combined with esophagogastroscopy for achalasia of the cardia:Report of 25 cases / 中国微创外科杂志

Objective To investigate the value of laparoscopy combined with esophagogastroscopy in the treatment of achalasia of the cardia. Methods Twenty-five patients with achalasia of the cardia between October 2003 and April 2006 in this department underwent the HellerDor operation under laparoscopy combined with esophagogastroscopy.Results A1l the operations were successfully accomplished.The operating time was 60~240 min(mean,107 min) and the intraoperative blood loss,5~60 ml(mean,22 ml).Intraoperative mucosal perforation was encountered in 4 patients.All the patients got out of bed for activities at 8 hours after operation,with first passage of flatus,removal of the gastric tube,and liquid diet intake at 1~3 days after operation(mean,1.5 days).The esophageal manometry showed the lower esophageal sphincter(LES) pressure had decreased to normal levels at 7 days after operation.The 24-hour ambulatory pH studies showed a high reflex index in 3 patients,but without symptoms.Upper gastrointestinal barium swallow showed the dilated esophagus had a 8~26 mm(mean,18 mm) decrease in diameter at 8 days after operation.The length of postoperative hospitalization was 8~11 days(mean,8.5 days).Follow-up for 1~30 months(mean,5.4 months) in all the patients showed 23 patients were asymptomatic and 2 had intermittent dysphagia.Conclusions Heller-Dor operation under laparoscopy combined with esophagogastroscopy has advantages of precise positioning,little invasion,less pain,and good effects,increasing the quality of operation as well as decreasing the incidence of complications.

4 Cases of Mucosal Bridges in the Esophagus / 대한소화기내시경학회지

Mucosal bridge, endoscopically observed, is a cord-like mucosal connection across the lumen. The bridge is very elastic and stretches easily, unlike granulation tissue. Mucosal bridges of the esophagus have been occasionally described in various circumstances, particularly in congenital or acquired origin as the inflammatory diseases. The occurrence of mucosal bridges due to inflammatory process may arise anywhere from the esophagus to the colon. It has been more frequently reported in the colon than in the esophagus, stomach, and duodenum. We experienced four cases of esophageal mucosal bridges and three of them were accompanied by esophageal diverticulum. We report these cases with a review of relevant literatures.

4 Cases of Mucosal Bridges in the Esophagus / 대한소화기내시경학회지

Mucosal bridge, endoscopically observed, is a cord-like mucosal connection across the lumen. The bridge is very elastic and stretches easily, unlike granulation tissue. Mucosal bridges of the esophagus have been occasionally described in various circumstances, particularly in congenital or acquired origin as the inflammatory diseases. The occurrence of mucosal bridges due to inflammatory process may arise anywhere from the esophagus to the colon. It has been more frequently reported in the colon than in the esophagus, stomach, and duodenum. We experienced four cases of esophageal mucosal bridges and three of them were accompanied by esophageal diverticulum. We report these cases with a review of relevant literatures.