Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction

Background

Esophageal food impaction is a common illness presenting to emergency departments (ED), and is frequently resistant to pharmacologic therapy. Several medications have been promoted for this indication, but so far have not proven effective. Endoscopic removal is frequently required to resolve the impaction, resulting in risks from anesthesia and the physical procedure, and in prolonged hospital stay for recovery. Oral nitroglycerin solution was recently used in two such cases and may represent a new therapeutic option.

上消化道胶囊内镜发展与创新北大核心CSCD

上消化道疾病高发,传统插管式胃镜是检查上消化道疾病最常用的检查方法和"金标准"。为了更舒适无创的检查上消化道黏膜,多项研究提出了上消化道胶囊内镜的概念,但是由于上消化道各部位解剖与生理结构的差异,目前可以使用的胶囊内镜如单纯被动式、磁控式、线控式、磁控联合线控式以及侧视胶囊内镜都存在一定的局限性,无法实现对上消化道整体黏膜情况的观察。文章试图通过介绍适用于食管、胃以及十二指肠检测的胶囊内镜,分析各内镜的诊断效能及其不足,探讨未来上消化道胶囊内镜可能的发展方向。     

The Effect of Retinoic Acid and Deoxycholic Acid on the Differentiation of Primary Human Esophageal Keratinocytes

The mechanism linking gastroduodenal reflux disease to intestinal metaplasia in the esophagus (Barrett’s esophagus) has not been determined. Active conjugate metabolites of retinoic acid, in addition to bile acids, undergo an enterohepatic circulation in bile. Retinoic acid and bile acids are candidate mediators of keratinocyte transdifferentiation in Barrett’s esophagus. We studied the effects of retinoic acid on the differentiation of primary human esophageal keratinocytes cultured in vitro. Retinoic acid induces expression of a marker of intestinal differentiation, MUC2, in these cells. However, retinoic acid, alone or in combination with the hydrophobic bile acid, deoxycholic acid, does not affect esophageal keratinocyte squamous differentiation as assessed by involucrin expression and cellular morphology. The ability of retinoic acid to induce MUC2 expression may be relevant to the pathogenesis of Barrett’s esophagus. However, this does not result in suppression of squamous differentiation.     

Experimental reconstruction of dog's esophagus with biotype artificial esophagus

OBJECTIVE: At present, there are few materials available for esophagus reconstruction anywhere in the world. The reported survival rate in animals during the perioperative period is comparatively low. The present study assessed the feasibility of using a biotype artificial esophagus in the reconstruction of a dog's esophagus. METHODS: In 30 mongrel dogs, a portion of the thoracic esophagus was resected and an 8 cm section of artificial esophagus was transplanted to reconstruct the organ. The survival rate, food intake and process of healing were observed. RESULTS: Of the 30 dogs, 28 survived the peri­operative period (93.3% survival). Two dogs (6.7%) developed an anastomotic fistula; 19 dogs survived for 1 year, a survival rate of 79.2% (19/24) with the remaining six dogs were killed according to the experimental protocol. Detachment of the artificial esophagus occurred on average 28.8 days after operation and the dogs suffered from varying degrees of dysphagia 23?45 days after operation. Gradual remission occurred after 4 months. The histological study revealed that the regenerated esophagus was composed of fibrous and connective tissues and the luminal surface was covered with squamous epithelium in 3?6 months. CONCLUSION: The transplanted artificial esophagus detached after the surrounding ‘regenerated esophagus’ had formed, and the squamous epithelium gradually covered the luminal surface. Continuous remodeling of the ‘regenerated esophagus’ gradually relieved the stenosis. Whether detachment of the implant and the postoperative stenosis can be solved is the key problem restricting the use of the biotype artificial esophagus in clinical practice.     

Two-field lymph-node dissection may be enough to treat patients with submucosal squamous cell carcinoma of the thoracic esophagus

Significance of extended radical surgical treatment including three-field lymph node dissection for squamous cell carcinoma (SCC) of the esophagus remains debatable. The aim of the current study was to reconsider the merits and demerits obtained by three-field lymph node dissection for esophageal carcinoma and also to attempt to elucidate an appropriate surgical strategy for submucosal SCC of the thoracic esophagus. Thirty-one patients with SCC of the thoracic esophagus who had been treated with esophagectomy and two-field (thoracic and abdominal) lymph node dissection without preoperative therapies were enrolled. Five-year survival rate was 75.0% and the incidence proportion of postoperative complication was 9.7%. These data regarding postoperative outcome of patients were by no means inferior to those in the previous reports referring the prognosis of patients with esophageal carcinoma who had been treated with three-field lymph node dissection. Authors would like to mention that two-field lymph node dissection associated with reduced incidence of postoperative complications might be enough to treat the submucosal SCC of the thoracic esophagus.     

Critical reappraisal of current surveillance strategies for Barrett's esophagus: analysis of a large German Barrett's database

Endoscopic surveillance is recommended for patients with Barrett's esophagus (BE). Based on a large database, gathered from predominantly community‐based practices in Germany, we aimed to investigate the time‐course of malignant progression and apply these findings to current clinical practice. Data of 1438 patients with BE from a large German BE database were analyzed. Patients with at least one follow‐up endoscopy/biopsy were included. Detection of ‘malignant Barrett’ (either high‐grade intra‐epithelial neoplasia or invasive adenocarcinoma) was considered as study end‐point. Of 1438 patients with BE, 57 patients had low‐grade intra‐epithelial neoplasia (LG‐IN) on initial biopsy and 1381 exhibited non‐neoplastic BE. ‘Malignant Barrett’ was detected in 28 cases (1.9%) during a median follow‐up period of 24 months (1–255), accounting for an incidence of 0.95% per patient year of follow‐up. The frequency of ‘malignant Barrett’ was significantly higher (P < 0.001, χ²‐test) in the LG‐IN group (n = 11, 19.3%) compared with the non‐neoplastic BE group (n = 17, 1.2%). In the non‐neoplastic BE group, ‘malignant Barrett’ was predominantly found during re‐endoscopy within the first year of follow‐up (12 of 17; 70.6%), in contrast to the LG‐IN group, in which ‘malignant Barrett’ was observed predominantly after a time exceeding 12 months (8 of 11, 72.7%; P = 0.05, Fisher's exact test). Initial endoscopic evaluations seem to play the most crucial role in managing BE. After 1 year of follow‐up, endoscopic surveillance should be focused on patients with LG‐IN. In patients with repeatedly proven non‐neoplastic BE, elongation of the follow‐up intervals to the upper limit of current guidelines, that is, 5 years, might be justified.     

Is intestinal metaplasia a necessary precursor lesion for adenocarcinomas of the distal esophagus,gastroesophageal junction and gastric cardia?

Adenocarcinoma of the distal esophagus and gastroesophageal junction are believed to arise in Barrett's esophagus with intestinal metaplasia. Whether adenocarcinoma can arise in columnar lined esophagus without intestinal metaplasia is in doubt. Whether adenocarcinoma of the gastric cardia arises in intestinal metaplasia of the gastric cardia is also in doubt. We aim to evaluate the relationship of size and stage of adenocarcinoma of the distal esophagus, gastroesophageal junction and gastric cardia to intestinal metaplasia and other types of columnar epithelium. Seventy-four patients who had esophagogastrectomy for adenocarcinomas in this region were examined histologically to assess the frequency of residual intestinal metaplasia in the surrounding epithelium. Tumors without residual intestinal metaplasia were evaluated for the presence of other columnar epithelia and correlated with tumor size and stage. Cardiac mucosa was present around all tumors. Residual intestinal metaplasia was present in 48 (65%) tumors, including 33/38 (87%) distal esophageal, 10/25 (45%) junctional and 5/11 (45%) gastric cardia tumors. The prevalence of intestinal metaplasia was 100% in all tumors that were less than 1 cm in maximum diameter and all intramucosal tumors. The prevalence of residual intestinal metaplasia decreased with increasing tumor size and stage. These data strongly support the contention that adenocarcinomas of this region, including those in the gastric cardia, arise in intestinal metaplastic epithelium. The absence of residual intestinal metaplasia in larger tumors is the result of tumor overgrowing the intestinal metaplasia from which it arose.     

Perspectives on the interlinked nature of systemic sclerosis and reflux disease

Introduction: Systemic sclerosis (SSc) is a multisystem connective tissue disease, characterized by chronic inflammation and vascular changes that result in esophageal smooth muscle atrophy and fibrosis. Subsequent progressive loss of peristalsis in the distal esophagus and loss of lower esophageal sphincter function lead to problems with the protective barrier and exposure of sensitive tissues to the gastroduodenal contents, a disorder called reflux disease.

Areas covered: Depending on the range, nature and symptoms of the disease, the term ‘reflux disease’ may refer to gastroesophageal reflux, laryngopharyngeal reflux, microaspiration into the airways and silent reflux. Despite the links between these visceral complications, this connection remains controversial. This is due to a lack of complete understanding, the asymptomatic nature of the disease and the limited diagnostic accuracy of tests, which can delay diagnosis. Such delays are problematic, given that the early detection of GERD in SSc patients, the timing of assessment, the treatment of the organs involved are critical aspects of patient prognosis and disease outcome.

Expert commentary: This review summarizes the most recent knowledge about the pathophysiology, diagnosis and prospective treatment of GERD in SSc patients and highlights how innovative technologies applied through an integrative, interdisciplinary approach may soon lead to effective treatment strategies.     

Esófago de Barrett: experiencia de 10 años en un centro de tercer nivel en México

Introduction

The prevalence of Barrett's esophagus has been calculated at between 1.3 and 1.6%. There is little information with respect to this in Mexico.