Marta A. Dabezies

Treatment of symptomatic nonachalasia esophageal motor disorders with botulinum toxin injection at the lower esophageal sphincter

The purpose of this study was to determine if botulinum toxin injection at the lower esophageal sphincter improves symptoms in patients with nonachalasia spastic esophageal motility disorders. Fifteen patients with nonachalasia spastic esophageal motility disorders (diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction) unresponsive to medical therapy underwent endoscopic injection of botulinum toxin at the level of the gastroesophageal junction. Symptoms were scored (0=no symptoms, 1=mild, 2=moderate, 3=severe and 4=very severe) before treatment, at seven days and every 30 days after treatment. There was significant improvement in chest pain, dysphagia, and regurgitation at 7, 30, 60 and 90 days after treatment. At one month after treatment, 11 of 15 (73%) patients had a good or excellent response to treatment. At the last patient interview (mean follow-up of 10.6 months), five (33%) patients continued to have a good to excellent response, whereas 10 (67%) underwent subsequent treatment with repeat botulinum toxin, pneumatic dilation, or bougienage. We conclude that botulinum toxin injection at the gastroesophageal junction leads to significant symptom improvement in patients with nonachalasia esophageal motility disorders. These results suggest that botulinum toxin may be an effective treatment option in some of these patients not responsive to conventional medical therapy.

Use of high-resolution endoscopic ultrasonography to assess esophageal wall damage after pneumatic dilation and botulinum toxin injection to treat achalasia

OBJECTIVE The purpose of this study was to utilize high-resolution endoscopic ultrasonography to assess esophageal wall damage in patients with achalasia treated by either pneumatic dilation or botulinum toxin injection and to compare their symptomatic response. METHODS Twenty-nine patients were treated with pneumatic dilation (11) or botulinum toxin injection (18) in a nonrandomized, controlled manner. An achalasia balloon dilator inflated at the gastroesophageal junction was used for dilation. Botulinum toxin was injected during endoscopy into the gastroesophageal junction. Endoscopic ultrasonography was performed at the level of the diaphragm before, immediately after, and 24 hours after treatment. Symptoms were assessed before and 7, 30, 60, and 90 days after therapy. RESULTS The mucosal-submucosal thickness increased significantly immediately after pneumatic dilation, but normalized by 24 hours. No significant change in mucosal-submucosal thickness occurred after botulinum toxin injection. No significant alteration in muscularis propria thickness was observed after either procedure. Dysphagia and regurgitation improved significantly at 7, 30, 60, and 90 days after both procedures. CONCLUSIONS Pneumatic dilation produced transient thickening of the mucosa-submucosa, but no thickening or breaks in the muscularis propria. This transient wall damage suggestive of edema was not seen after botulinum toxin injection. Over a 3-month period, botulinum toxin was equivalent to pneumatic dilation in relieving dysphagia and regurgitation in patients with achalasia.

Use of Botulinum Toxin in the Treatment of Achalasia

Achalasia is a chronic esophageal motor disorder characterized by failure of the lower esophageal sphincter (LES) to relax during swallowing, aperistalsis of the esophageal body, and, often, an elevated resting LES pressure. Pneumatic dilation and Heller cardiomyotomy have been the time-honored, accepted treatments, but each may carry significant morbidity. Recently, intrasphincteric injection of botulinum toxin has been shown to be an effective treatment for achalasia, probably by reducing the excitatory cholinergic tone of the LES. Subjective and objective improvement have been reported in many patients with few reported adverse reactions. Clinical improvement generally lasts 2–6 months with patients often requiring repeat treatment. Although studies directly comparing botulinum toxin injection with pneumatic dilation and surgical myotomy are needed, botulinum toxin injection has rapidly become another therapeutic option in the treatment of achalasia.

Nonexpandable silicone esophageal stents for treatment of malignant tracheoesophageal fistulas: complications and radiographic appearances.

Abstract.Background: The aim was to evaluate the radiologic appearances and complications that occurred after placement of nonexpandable silicone stents used as palliative therapy for patients with malignant tracheoesophageal fistulas (TEFs). Methods: Records of 11 patients (6 males, 5 females) who underwent placement of esophageal stents for malignant TEF between 1988 and 1994 were reviewed. Nine patients had esophageal carcinoma and two patients bronchogenic carcinoma. A TEF was documented radiographically in all patients. Silicone stents were placed in all patients under endoscopic guidance. A chest radiograph was obtained for each patient immediately following stent placement to confirm proper positioning and to assess complications. A contrast study was performed within 24 hours after the procedure to evaluate the function of the stent and its efficacy for occluding the fistulous tract. The patients were followed until January 1995 or until their death (range 1.5–24.0 months). Results: Seven of the patients developed stent-related complications. Within the first 24 hours after stent insertion (which was successful in 100% of cases), 2 of the 11 patients developed minor complications. One patient had pooling of contrast around the proximal portion of the stent leading to aspiration of contrast, and one patient experienced transient, asymptomatic, idiopathic, esophagovenous intravasation. Delayed (>24 hours) complications related to stent placement occurred in five of the patients: one patient each had pooling at the proximal end of the stent with aspiration, worsening esophageal dysphagia causing reflux through the stent, caudad stent migration, superior stent migration, epithelial hyperplasia causing obstruction of the stent, and pressure necrosis. There were no cases of hemorrhage. Two patients were lost to long-term follow-up, and eight patients died of their disease, all unrelated to the stent placement. Conclusion: Silicone esophageal stents provide successful short-term palliation for most patients with malignant TEF but are not without associated complications. These complications, however, can usually be detected early using radiographic imaging, permitting remediation.

Agenesis of dorsal pancreas in a patient with weight loss and diabetes mellitus

Agenesis of the dorsal pancreas is a rare congenital anomaly that arises f rom the failure of the dorsal pancreat ic bud of endodermal cells to form the body and tail of the pancreas . While agenesis of both ventra l and dorsal pancreas is incompatible with life (1, 2), comple te or partial agenesis of the dorsal pancreas has been repor ted in a small number of pediatr ic and adult pat ients (3-11). We descr ibe a pat ient with diabetes melli tus and evidence of pancreat ic exocrine insufficiency who was shown to have agenesis of the dorsal pancreas b y endoscopic re t rograde cholangiopancrea tography (ERCP) and cont ras t -enhanced abdominal computed tomography (CT). The relationship be tween the absence of the dorsal pancreas and the presence of pancreat ic endocr ine and exocrine insufficiency is discussed.

Video small bowel enteroscopy: early experience with a prototype instrument

A commercial grade of India ink was used and prepared in the following manner: Higgins black India (4418) waterproof drawing ink was diluted with sterile bacteriostatic water in a ratio of 5 parts ink to 2 parts water. This was done to allow the ink to pass through a filter more easily. Ink (114 ml) was mixed with 46 ml of water in a 250-ml Vioflex bag. The solution was then passed through a Travenol 5-/-Lm pore size particulate filter into sterile lO-ml vials to remove any large particulate material. The vials were then autoclaved for 40 min. Sterility of opened vials was 2 hours in duration, and unopened vials were considered sterile for 6 months. Colonic injection catheters (Wilson Cook Inc., WinstonSalem, N.C. or Olympus Corporation of America, Lake Success, N.Y.) were used with a 3-ml syringe to inject 0.1 ml of ink into the submucosa at points just proximal and distal or to the right and left of the excised lesion after the polypectomy in order to bracket the area to be re-examined (Fig. lC). If this area is within the reach of a flexible sigmoidoscope, esophageal variceal injection needles can be used.

THE EFFECT OF ENDOSCOPIC LASER THERAPY ON SURVIVAL IN PATIENTS WITH SQUAMOUS-CELL CARCINOMA OF THE ESOPHAGUS : FURTHER EXPERIENCE

Although endoscopic laser therapy is effective for symptom palliation in esophageal cancer, few studies have investigated its effect on survival. We previously reported a 300% improvement in survival in 10 patients with squamous-cell carcinoma of the esophagus after endoscopic Nd:YAG laser energy. We now report a study to determine if the survival advantage persisted after treating an additional 26 patients. Thirty-six patients with squamous-cell carcinoma of the esophagus treated with endoscopic laser therapy were compared to 20 controls identified by our hospital Tumor Registry. There was no difference between the groups with respect to age, sex, race, location of tumor, or clinical stage. More control patients (25%) had previously undergone surgery than laser patients (0%) (p less than 0.05). Survival analysis demonstrated a significant improvement in overall survival (p less than 0.05), with an improvement in median survival from 5.7 to 9.7 months (p less than 0.05). One-year survival was 38% in laser patients, compared to 20% in control patients. Our experience continues to demonstrate that endoscopic laser therapy is effective in prolonging life as well as palliating the symptoms of patients with squamous-cell esophageal carcinoma.

Nonsteroidal antiinflammatory drugs and upper gastrointestinal hemorrhage in an urban hospital

Aspirin and nonsteroidal antiinflammatory drugs have been implicated in the pathogenesis of gastrointestinal hemorrhage. To evaluate their impact on inpatients, charts from Temple University Hospital with a discharge ICD-9 code which included upper gastrointestinal hemorrhage during a one-year period were reviewed. Aspirin and/or nonaspirin nonsteroidal antiinflammatory drug (NSAID) use was identified in 34 patients (19 daily users and 15 intermittent users). Sixty-seven patients who bled, but did not use these agents, served as controls. Daily NSAID users were older than intermittent users and controls (P<0.05). A higher frequency of bleeding ulcers was associated with NSAID use. Patients using NSAIDs spent more time in intensive care than controls (median 1 day vs 0 days). Daily users had a higher transfusion requirement (4 units) than non-users (0 units;P<0.05). This study suggests that NSAID use has a substantial impact on health care resource utilization in patients admitted to an urban hospital for upper gastrointestinal hemorrhage.

An overtube for decompression of sigmoid volvulus

known colon carcinoma.! Persons with clinically inapparent colon carcinoma are, thus, at risk for cecal perforation following routine or therapeutic upper endoscopy. Because the colon is unprepped in this setting, these perforations are likely to be fatal. Douglas K. Rex, MD Robert H. Hawes, MD Department of Medicine Division of GastroenterologyjHepatology Indiana University Medical Center Robert J. Goulet, MD Department of Surgery Indiana University Medical Center Indianapolis, Indiana