Endoprosthetics for malignant esophageal disease

Currently used stents for malignant esophageal strictures include self-expanding metal stents (SEMS), self-expanding plastic stents (SEPS), and biodegradable stents. For the palliative treatment of malignant dysphagia, both SEMS and SEPS effectively provide rapid relief of dysphagia. SEMS are preferred over SEPS as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, stent migration, and both tumoral and nontumoral tissue overgrowths are common. Complication rates are probably also affected by stent “behavior” in the esophagus, with radial and axial forces being important determinants. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer has not convincingly been proven. Concurrent treatment with chemotherapy and radiotherapy seems to be safe and effective, although biodegradable stents have shown disappointing results. It can be expected that removable stents will increasingly be used as bridge to surgery to maintain luminal patency during neoadjuvant treatment.     

Intestinal interposition for benign esophageal disease

Opinion statement Various options exist for intestinal interposition for benign, but debilitating, end-stage esophageal disorders. Principally, the stomach, colon, or jejunum is used for esophageal replacement. Much debate exists regarding the ideal esophageal replacement option. The conduit choice must be tailored to the individual patient. Unlike malignant processes, the conduit choice for benign disorders must be sufficiently durable and functional. Colonic interposition meets both criteria. However, this operative procedure’s technical difficulty increases the complexity of this already challenging clinical problem, as seemingly small errors in judgment and technique can significantly impact graft viability and long-term function. Using a gastric tube also provides durability and functionality, but with an operative procedure that is less technically demanding. A minimally invasive laparoscopic transhiatal esophagectomy offers the patient even more benefit in terms of shorter operative times and intensive care unit and recovery periods. However, the advent of surgical robotic technology augments these benefits even further. Robotic technology arms the surgeon with improved dexterity and three-dimensional visualization. These revolutionary improvements allow the surgeon to overcome many of the operative limitations that exist with the open and minimally invasive approaches to esophagectomy, thus potentially offering patients reduced morbidity and mortality rates.     

Screening pre-bariatric surgery patients for esophageal disease with esophageal capsule endoscopy

AIM:To determine if esophageal capsule endoscopy(ECE)is an adequate diagnostic alternative to esophagogastroduodenoscopy(EGD)in pre-bariatric surgery patients.METHODS:We conducted a prospective pilot study to assess the diagnostic accuracy of ECE(PillCam ESO2,Given Imaging)vs conventional EGD in pre-bariatric surgery patients.Patients who were scheduled for bariatric surgery and referred for pre-operative EGD were prospectively enrolled.All patients underwent ECE followed by standard EGD.Two experienced gastroenterologists blinded to the patient’s history and the findings of the EGD reviewed the ECE and documented their findings.The gold standard was the findings on EGD.RESULTS:Ten patients with an average body mass index of 50 kg/m2were enrolled and completed the study.ECE identified 11 of 14(79%)positive esophageal/gastroesophageal junction(GEJ)findings and 14of 17(82%)combined esophageal and gastric findings identified on EGD.Fisher’s exact test was used to compare the findings and no significant difference was found between ECE and EGD(P=0.64 for esophageal/GEJ and P=0.66 for combined esophageal and gastric findings respectively).Of the positive esophageal/GEJ findings,ECE failed to identify the following:hiatal hernia in two patients,mild esophagitis in two patients,and mild Schatzki ring in two patients.ECE was able to identify the entire esophagus in 100%,gastric cardia in0%,gastric body in 100%,gastric antrum in 70%,pylorus in 60%,and duodenum in 0%.CONCLUSION:There were no significant differences in the likelihood of identifying a positive finding using ECE compared with EGD in preoperative evaluation of bariatric patients.     

Bare-Metal Stents Versus Drug-Eluting Stents for Primary Angioplasty: Long-Term Outcome

Percutaneous transluminal coronary intervention (PCI) is the most used myocardial revascularization technique for patients with coronary artery disease. Primary PCI with stent implantation is widely considered the gold standard for the treatment of ST-elevation myocardial infarction patients. Coronary stents, compared with balloon angioplasty, have reduced focal lesion restenosis. To reduce in-stent restenosis, drug-eluting stents (DES) were designed to locally release drugs inhibiting neointimal growth. Recent concerns have emerged on the potential higher risk of stent thrombosis with DES that might be even more pronounced among myocardial infarction patients. For these reasons, DES for primary PCI remains an “off-label” use. In the last several years, a number of randomized trials and registries have tested the safety and efficacy of DES in primary PCI. Data from these studies were analyzed in several meta-analyses, reasonably consistently demonstrating that the use of DES significantly decreased the need for revascularization without an increase in the incidence of death, recurrent infarction, or stent thrombosis at long-term follow-up.     

Polymer-Free Biolimus-Eluting Stents or Polymer-Based Zotarolimus-Eluting Stents for Coronary Bifurcation Lesions

BackgroundA polymer-free biolimus-eluting stent (PF-BES) and a zotarolimus-eluting stent (ZES) recently showed similar clinical profiles and appear to be competing options in specific clinical settings of patients undergoing percutaneous coronary intervention (PCI). Whether they perform similarly also in complex procedural settings as coronary bifurcation lesions remains unaddressed.MethodsAll consecutive patients undergoing coronary bifurcation PCI with PF-BES or the new iteration of the ZES from three large multicenter real-world registries were included. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), target lesion revascularization (TLR) and stent thrombosis (ST). Multiple analyses to adjust for baseline differences were carried out including propensity-score matching, propensity-score stratification and inverse-probability-weighting. Outcomes are reported according to Cox proportional hazard models censored at 400-day follow-up.Results1169 patients treated with PF-BES (n = 440) or ZES (n = 729) on the main branch of a coronary bifurcation lesion were included (mean age 69 ± 11 years, 75.4% male, 53.8% acute coronary syndrome at presentation, 26.6% left main bifurcation, median dual antiplatelet therapy duration 12 [range 12–12] months). MACE, all-cause death, TLR and ST tended towards non-statistically higher rates with the PF-BES as compared to the ZES. Higher MI and target vessel revascularization occurrence was observed with PF-BES.ConclusionsIn this large contemporary cohort of patients undergoing coronary bifurcation PCI, the occurrence of MACE was non-statistically different with the use of PF-BES and ZES devices. However, differences favoring the ZES device that may entail clinical relevance were observed. Further studies are needed to confirm these findings and explore whether they remain valid when a short dual antiplatelet therapy is adopted.     

分叉专用支架的进展

分叉病变的介入治疗具有很大的挑战性,分叉专用支架是为克服常规的分叉病变介入治疗的局限性而设计。大多数分叉专用支架的目的就是易于在必要时置入边支支架。这是一种令人激动的全新技术,可能使复杂的分叉病变治疗简单化。目前有11种分叉专用支架完成或正在进行人体试验。随着更多的药物释放支架平台和更大规模的对照试验出现,在不久的将来成为正式的治疗方法前其真正的临床价值、有效性和安全性会得到充分证明。     

Radiation-induced heart disease after treatment for esophageal cancer

Recently, the development of radiotherapy technology and to radiation-induced heart disease in patients with esophageal cancer. Investigations using chemotherapy has improved treatment results for esophageal cancer, and attention has been paidSEER for esophageal cancer showed that the hazard ratio of heart-related death was 1.62–1.96. Herein we review published literature regarding the mechanism of and countermeasures for radiation-induced heart disease and discuss the potential of concurrent chemotherapy, molecular-targeted agents and lifestyle for exacerbating radiation-induced heart disease.     

药物洗脱支架联用普通金属支架治疗多支冠状动脉病变的疗效评价

目的探讨多支冠状动脉病变患者药物洗脱支架与普通金属支架(普通支架)联用预防再狭窄的疗效及安全性。方法801例行多支冠状动脉内支架置入术达到完全血运重建的冠心病患者分3组。药物洗脱支架组206例、药物洗脱支架与普通支架联用组(联用组)158例及普通支架组437例。比较3组支架术后近期及远期结果。结果3组患者冠心病危险因素、心功能、冠状动脉病变程度、支架术成功率及并发症发生率均无显著差异。术后平均随访(17.3±10.9)个月,总随访率和造影随访率无显著差异。联用组普通支架置入于31.3%的前降支病变(均为A、B1型病变)及81.6%的回旋支病变和69.9%的右冠状动脉病变。与普通支架组相比,药物洗脱支架组和联用组造影再狭窄率明显降低,分别为20.3%vs7.3%和8.8%(P均<0.05),且主要不良心脏事件发生率均较低,分别为18.4%vs6.5%和9.9%(P均<0.05)。但药物洗脱支架组与联用组相比上述各指标无显著差异。结论多支冠状动脉病变患者单用药物洗脱支架或合理联用普通支架后再狭窄率降低,安全性近似,均优于单用普通支架。     

Emerging endoscopic techniques for the identification of esophageal disease

Esophageal diseases, both benign and malignant, impose an increasing burden to global health. In the West, gastroesophageal reflux disease (GERD) and Barrett’s esophagus are increasing in prevalence and impact. In the East, squamous esophageal cancer remains a large burden, but increasingly, precancerous lesions related to GERD are recognized. We review the various advanced endoscopic techniques that have been developed to improve the accuracy of endoscopic identification of esophageal disease. These techniques are designed to increase the sensitivity of detecting disease and high-risk lesions, enable targeted biopsies, decrease total number of biopsies and costs for surveillance, but also guide therapy in real-time. After proper clinical validation, the widespread use of these technologies will lead to improved outcomes, mostly in cancer prevention.     

Retrievable Esophageal Stents for Benign Indications

Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.     

Hodgkin's disease with esophageal involvement

INTRODUCTION: Esophageal involvement in Hodgkin's disease, commonly known as a belated localization of the advanced forms, has been seldom reported (3 to 5% in post-mortem series and 0.7% in clinical series). EXEGESIS: We report the case of a 61-year-old man who had an esophagus localization revealing Hodgkin's disease stage IV EBb of Ann Arbor classification. The originality of this case was represented by: the revelation mode of the esophageal involvement such as dysphagia and upper gastrointestinal bleeding; the localization at the distal third of the esophagus with contiguous involvement of the gastric fundus; the absence of mediastinal nodes showing the primitive character of the esophageal injury. CONCLUSION: This observation incites us to consider Hodgkin's disease in the list of differential diagnoses of tumoral dysphagia, even if there was no ganglionic and/or visceral localization of the disease.     

Darier's disease with esophageal involvement

Abstract

Objective. Nowadays, capsule endoscopy (CE) is the first-line procedure after negative upper and lower gastrointestinal (GI) endoscopy for obscure gastrointestinal bleeding (OGIB). Approximately, two-thirds of patients undergoing CE for OGIB will have a small-bowel abnormality. However, several patients who underwent CE for OGIB had the source of their blood loss in the stomach or in the colon. The aim of the present study is to determine the incidence of bleeding lesions missed by the previous gastroscopy/colonoscopy with CE and to evaluate the indication to repeat a new complete endoscopic workup in subjects related to a tertiary center for obscure bleeding before CE. Methods and methods. We prospectively reviewed data from 637/1008 patients underwent to CE for obscure bleeding in our tertiary center after performing negative gastroscopy and colonoscopy. Results. CE revealed a definite or likely cause of bleeding in stomach in 138/637 patients (yield 21.7%) and in the colon in 41 patients (yield 6.4%) with a previous negative gastroscopy and colonoscopy, respectively. The lesions found were outside the small bowel in only 54/637 (8.5%) patients. In 111/138 patients, CE found lesions both in stomach and small bowel (small-bowel erosions in 54, AVMs in 45, active small-bowel bleeding in 4, neoplastic lesions in 3 and distal ileum AVMs in 5 patients). In 24/41 (58.5%) patients, CE found lesions both in small bowel and colon (multiple small-bowel erosions in 15; AVMs in 8 and neoplastic lesion in 1 patients. All patients underwent endoscopic therapy or surgery for their nonsmall-bowel lesions. Conclusions. Lesions in upper or lower GI tract have been missed in about 28% of patients submitted to CE for obscure bleeding. CE may play an important role in identifying lesions missed at conventional endoscopy.