Anesthesia in per-oral endoscopic myotomy: A large tertiary care centre experience

Background and Objectives

Per-oral endoscopic myotomy (POEM) is safe and efficacious for the management of achalasia cardia (AC). POEM is usually performed under general anesthesia in an endoscopy suite or operating theatre. The current study was conducted with the aim to analyse anesthetic management of patients with AC who underwent POEM at our institution.

Methods

We retrospectively analysed the data of patients with AC who underwent POEM at our institution from January 2013 to September 2016. All cases were performed in an endoscopy suite under supervision of an anesthesia management team. Pre-procedure endoscopic evacuation of esophagogastric contents was done in all cases. Management strategies used for gas-related adverse events and outcomes were assessed.

Results

Four hundred and eighty patients (median age 40 years, range 4–77 years) underwent POEM during the study period. The sub-types of AC were type I (163), type II (297), and type III (20). POEM was successfully completed in 97.5% patients. Gas-related events were noted in 30.6% cases including-capno-thorax in 1%, capno-peritoneum in 12.3%, retroperitoneal air in 16.5%, capno-mediastinum in 0.2%, and capno-pericardium in 0.4% patients. Significant rise in end tidal CO2 (> 45) and peak airway pressure were observed in 8.1% and 5.4% cases, respectively. Drainage was required in 12.3% patients. There was no occurrence of aspiration during or after POEM.

Conclusions

POEM could be safely performed in an endoscopy suite under supervision of an expert anesthesia management team. Gas-related adverse events were common during POEM and could be managed with a standardized approach.

     

A new case of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is a rarely diagnosed condition involving eosinophilic infiltration of the esophageal mucosa The hallmark of this condition is intermittent and often painful dysphagia that may become constant as the disease progresses. It was initially included within the more general condition known as eosinophilic gastroenteritis but it is now considered an independent entity. Attwood et al. called attention to eosinophilic esophagitis as a distinct clinical condition in 1993. Although eosinophilic esophagitis was thought to occur primarily in children, a significant body of evidence suggests that it affects adults as well. We describe a clinical case of a young woman with a long-standing history of dysphagia affected of this rare entity.     

A Japanese case of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is a rarely diagnosed condition involving eosinophilic infiltration of the esophageal mucosa. Here we present a case of EE in a 69-year-old Japanese man, who presented with abdominal pain, appetite loss, and a history of bronchial asthma. Laboratory findings included peripheral eosinophilia and an increased serum immunoglobulin E level. Computed tomography showed diffuse severe thickening of the esophageal wall, and a barium esophagogram revealed a small caliber of the middle and lower portion of the esophagus, without normal peristaltic contractions. Endoscopy of the esophagus showed a pale mucosa, with adherent whitish exudates resembling fungal infection, and prominent ring-like contractions. Histologic examination of a biopsy specimen revealed marked eosinophil infiltration into the esophageal mucosa. Endoscopic ultrasonography (EUS) demonstrated marked circumferential thickening of the esophageal submucosal layer, and an esophageal manometry study showed a high percentage of ineffective esophageal peristalsis and high-amplitude esophageal body contractions. EUS findings showed no change even after oral corticosteroid therapy, although the histological findings were improved. This is thought to be the first documented Japanese case of EE. EE should be considered in the differential diagnosis in cases of esophageal motility disturbance, even if the patients do not complain of dysphagia.     

Clinical and endoscopic features of eosinophilic esophagitis in adults

BACKGROUND: Eosinophilic esophagitis in adults is regarded as unusual, being diagnosed mostly in young men presenting with dysphagia. Mucosal furrows are a sentinel endoscopic feature. This study examined the demographic and clinical profile of adults with eosinophilic esophagitis seen from 1981 to 2002. METHODS: All patients from an Australian provincial city (population 198,000) with otherwise unexplained eosinophilic inflammation of the squamous epithelium (>/=30 eosinophils per high-power field) were included in a retrospective review. RESULTS: A diagnosis of eosinophilic esophagitis was made in 31 patients (24 men, 7 women; mean age 34 years, range 14-77 years). The diagnosis was made in 19 (61%) of the 31 patients during the most recent 2 years (none between 1981 and 1994 vs. 12 between 1995-2000 vs. 19 between 2000-2001). Esophageal mucosal furrows were present in 30 (97%), a finding infrequently recognized before 2001. Dysphagia was documented in 26 (89%). Symptoms had been present for long periods before diagnosis (mean 54 months; range 0-180 months), and diagnosis was delayed in 7 (mean 81 months, range 20-144 months) because sentinel features were overlooked at endoscopy. Strictures, often evident only as a result of mucosal shearing during dilation, were present in 17 (57%). Esophageal dilation preformed in 17 (mean 3.4 dilations per patient, range 1-13) consistently relieved symptoms; tears were recorded in 13 (87%), but no serious complication resulted. CONCLUSIONS: Eosinophilic esophagitis in adults of all ages is more common than recognized. Mucosal furrows are easily overlooked at endoscopy although this finding is an important clue to diagnosis. Strictures, a frequent consequence, can be safely managed by dilation.     

A case of eosinophilic esophagitis with atypical clinical course

Eosinophilic esophagitis is a rare chronic disease that mainly occurs in middle-aged males. Treatment with a glucocorticoid and/or proton pump inhibitor is usually necessary to relieve unpleasant symptoms. An 83-year-old female patient with dysphagia and heartburn was diagnosed with eosinophilic esophagitis based on endoscopic findings, while histological examination identified dense infiltration of intraepithelial eosinophils. The symptoms and eosinophil infiltration spontaneously disappeared without any treatment approximately 2 months later. No obvious lifestyle or dietary changes to explain elimination of possible antigens were identified in this case. We report an atypical case of eosinophilic esophagitis with spontaneous regression.     

A case of infectious esophagitis caused by human papilloma virus

Esophageal infections may be caused by diverse pathogens that alter the mucosal lining and produce mild symptoms or sometimes critical clinical diseases with a high risk of mortality, particularly among the immunocompromised. The most common causes of infectious esophagitis are: herpes virus, candida, cytomegalovirus (CMV), and human immunodeficiency virus (HIV); human papilloma virus (HPV) infections are rare in Western countries. Endoscopic features of infectious esophagitis are specific for different agents; nonetheless, differential diagnosis is difficult and requires biopsy, cultures and brushing. We present the clinical case of a young woman admitted to the Department of General Surgery of A.O.U. Federico II, Naples, for a large, deep ulcerative lesion of the esophagus caused by HPV infection.     

Prevalence of eosinophilic esophagitis in adults with food bolus obstruction of the esophagus

BACKGROUND AND GOALS: Acute food bolus impaction is a common emergency in gastrointestinal practice. Management previously used the endoscope with an overtube to allow retrieval of the bolus per os. The push technique using air insufflation and gentle pressure on the bolus provides an alternative approach. Esophageal mucosal biopsy at the time of the initial endoscopy has not been a part of traditional practice. In view of the increasing recognition of eosinophilic esophagitis (EE) as a cause of dysphagia and food bolus obstruction in adults the etiology needs to be reassessed. STUDY: Forty-three consecutive adults presenting with acute dysphagia secondary to food bolus obstruction of the esophagus were studied. The bolus was advanced into the stomach with the push technique or removed per os with a retrieval net. Protocol biopsies from the proximal and distal esophagus were obtained in 29 patients. Biopsies were contraindicated or not obtained in the remainder. RESULTS: Forty-one patients were successfully treated at endoscopy. Two subjects with a food bolus impacted at the crico-pharyngeal region required general anesthesia with endotracheal intubation for safe removal. Of 29 patients biopsied, 15 had peptic esophageal stricture as the cause. Fourteen patients (all males, mean age 32 y, range 19 to 62 y) had EE identified histologically. This represents 50% of those biopsied. Patients with EE had typical endoscopic features of linear furrows, mucosal rings, or narrow bore esophagus. Most had prior episodes of food bolus obstruction. CONCLUSIONS: Food bolus obstruction can be safely managed by the push technique. EE is an important cause of food bolus obstruction that can be suspected on history and endoscopic appearance and confirmed on histology.     

Proton pump inhibitor therapy reverses endoscopic features of fibrosis in eosinophilic esophagitis

BackgroundLong-standing inflammation leads to esophageal remodeling with stricture formation in patients with eosinophilic esophagitis (EoE). The ability of proton pump inhibitors (PPI) to reverse endoscopic features of fibrosis is still unknown.ObjectiveTo investigate the effect of a short course of PPI treatment in reducing endoscopic findings indicative of esophageal fibrosis in EoE patients.MethodsCross-sectional analysis of the EoE CONNECT registry. Patients who received PPI to induce EoE remission were evaluated. Endoscopic features were graded using the EoE Endoscopic Reference Score (EREFS), with rings and strictures indicating fibrosis. Results were compared to those from patients treated with swallowed topic corticosteroids (STC).ResultsClinico-histological remission was achieved in 83/166 adult patients treated with PPI (50%) and in 65/79 (82%) treated with STC; among responders, 60 (36%) and 57 (72%) patients respectively achieved deep histological remission (<5 eosinophils/hpf). At baseline, mean±SD EREFS was lower in patients treated with PPI compared to those who received STC (p < 0.001). Short term treatment significantly reduced EREFS scores in patients treated either with PPI or STC as well as rings and strictures. Among patients treated with PPI, deep histological remission (<5 eosinophils/hpf) provided further reduction in total EREFS score.ConclusionEffective PPI therapy for EoE significantly reduced endoscopic esophageal fibrosis in the short term.     

A comprehensive review of eosinophilic esophagitis in adults

Eosinophilic esophagitis is a recently described disease characterized by the presence of upper gastrointestinal tract symptoms in association with a dense esophageal eosinophilic infiltrate. The awareness and interest of physicians and researchers in this disease has been increasing as reflected by the number of publications on this topic in the last 5 years. The aim of this review is to summarize the latest evidence with regard to epidemiology, pathogenesis, diagnostic, and management of eosinophilic esophagitis, primarily in adults and selected areas in children.     

Acute eosinophilic pneumonia caused by composter vapor inhalation: A case report

A 65-year-old woman presented to a local hospital with a 4-day history of cough, fever, and dyspnea. She had started using a composter and had been exposed to the vapor for 18 days before her first visit. She was diagnosed with acute eosinophilic pneumonia (AEP) based on her symptoms, the presence of bilateral pulmonary opacities on computed tomography, and alveolar eosinophilia confirmed by bronchoalveolar lavage. Inhalation of the composter vapor was thought to be the cause of AEP. Aspergillus fumigatus was cultured from the composter soil and the bronchoalveolar lavage fluid. She fully recovered without systemic corticosteroid administration by avoiding the composter.