Outcomes of the management of corrosive injuries of the upper digestive tract in a tertiary care center

Summary Esophageal stricture is the most common delayed sequelae of aerodigestive tract corrosive injuries. Early endoscopic dilatation is an integral part of corrosive injury management. Self-dilatation of the esophagus is effective in preventing stricture recurrence. In this prospective study, we included patients with corrosive aerodigestive tract injury from January 2009 to December 2020. We analyzed the outcome of the endoscopic dilatation and self-dilatation treatments administered to patients with a corrosive esophageal stricture. Among 295 patients, 164 had an esophageal injury, 73 had esophago-gastric injury, 55 had a gastric injury, and 3 had the pharyngeal injury. Of the 295 patients, 194 (81.85%) underwent dilatation, and 13 patients with diffuse esophageal injury underwent upfront surgery. Successful dilatation was performed in 169 (87.11%) patients. Of the 68 patients undergoing self-dilatation, 63 patients achieved nutritional autonomy by 28 days. Early endoscopic dilatation effectively prevents surgery, and self-dilatation appears promising to prevent recurrent esophageal stricture.

First-in-Human Experience and Acute Procedural Outcomes Using a Novel Pulsed Field Ablation System: The PULSED AF Pilot Trial

Background: Pulsed field ablation (PFA) is a novel form of ablation using electrical fields to ablate cardiac tissue. There are only limited data assessing the feasibility and safety of this type of ablation in humans. Methods: PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; https://www.clinicaltrials.gov ; unique identifier: NCT04198701) is a nonrandomized, prospective, multicenter, global, premarket clinical study. The first-in-human pilot phase evaluated the feasibility and efficacy of pulmonary vein isolation using a novel PFA system delivering bipolar, biphasic electrical fields through a circular multielectrode array catheter (PulseSelect; Medtronic, Inc). Thirty-eight patients with paroxysmal or persistent atrial fibrillation were treated in 6 centers in Australia, Canada, the United States, and the Netherlands. The primary outcomes were ability to achieve acute pulmonary vein isolation intraprocedurally and safety at 30 days. Results: Acute electrical isolation was achieved in 100% of pulmonary veins (n=152) in the 38 patients. Skin-to-skin procedure time was 160±91 minutes, left atrial dwell time was 82±35 minutes, and fluoroscopy time was 28±9 minutes. No serious adverse events related to the PFA system occurred in the 30-day follow-up including phrenic nerve injury, esophageal injury, stroke, or death. Conclusions: In this first-in-human clinical study, 100% pulmonary vein isolation was achieved using only PFA with no PFA system–related serious adverse events.

Drug-induced esophageal injuries with an atypical presentation mimicking acute coronary syndrome

Background Pill-induced esophageal injury may cause severe complications if not diagnosed in a timely fashion. The condition is under-recognized and under-reported, and some patients present with atypical clinical or endoscopic features mimicking other common conditions. If the diagnosis is missed the patient will continue to take the offending drug, potentially worsening the illness. We present a case in which acute coronary syndrome was the initial working diagnosis leading to a delay in diagnosis of doxycycline-induced esophageal injury. The patient developed multiple esophageal ulcers and hemorrhage. Case presentation A 50-year-old male driver with a history of hypertension and dyslipidemia was brought to the emergency department with complaints of severe retrosternal chest pain, vomiting, diaphoresis and syncope. On initial evaluation, acute coronary syndrome was considered due to the clinical presentation and history of cardiovascular risk factors. Electrocardiogram and serum troponins were normal. On the second day of his admission, the patient developed odynophagia and bloody vomitus. Esophagogastroduodenoscopy revealed extensive esophageal ulcerations with hemorrhage. The patient was taking Doxycycline capsules for an acute febrile illness. Doxycycline is the oral medication most commonly reported to cause esophageal injury. Doxycycline was discontinued, and the patient was treated with intravenous omeprazole and oral antacid suspension. The patient improved, was discharged after 6 days of hospitalization, and reported resolution of all symptoms at an outpatient follow-up visit 3 weeks later. Conclusion Medication-induced esophageal injury can present with atypical symptoms mimicking acute coronary syndrome. This condition should be included in the initial differential diagnosis of patients presenting with acute chest pain, especially those taking oral medications known to cause esophageal injury.

Nonthermal Irreversible Electroporation to the Esophagus: Evaluation of Acute and Long‐Term Pathological Effects in a Rabbit Model

Background Esophageal ulceration and fistula are severe complications of pulmonary vein isolation using thermal ablation. Nonthermal irreversible electroporation (NTIRE) is a promising new technology for pulmonary vein isolation in patients with atrial fibrillation. NTIRE ablation technology has been used to treat atrial fibrillation; however, the effects of NTIRE on esophageal tissue have not been clearly described. Methods and Results A typical NTIRE electrical protocol was directly applied to esophagi in 84 New Zealand rabbits. Finite element modeling and histological analysis with 120 slices were used to analyze electric field intensity distribution and subsequent tissue changes. A parameter combination of 2000 V/cm multiplied by 90 pulses output is determined to be an effective ablation parameters combination. Within 16 weeks after ablation, no obvious lumen stenosis, epithelial erythema, erosion, ulcer, or fistula was observed in the esophageal tissue. NTIRE effectively results in esophageal cell ablation to death, and subsequently, signs of recovery gradually appear: creeping replacement and regeneration of epithelial basal cells, repair and regeneration of muscle cells, structural remodeling of the muscle layer, and finally the restoration of clear anatomical structures in all layers. Conclusions Monophasic, bipolar NTIRE delivered using plate electrodes in a novel esophageal injury model demonstrates no histopathologic changes to the esophagus at 16 weeks. Data of this study suggest that electroporation ablation is a safe modality for pulsed electroporation ablation near the esophagus.

Impact of High-Power Short-Duration Radiofrequency Ablation on Esophageal Temperature Dynamic

Background: High-power short-duration (HP-SD) radiofrequency ablation (RFA) has been proposed as a method for producing rapid and effective lesions for pulmonary vein isolation. The underlying hypothesis assumes an increased resistive heating phase and decreased conductive heating phase, potentially reducing the risk for esophageal thermal injury. The objective of this study was to compare the esophageal temperature dynamic profile between HP-SD and moderate-power moderate-duration (MP-MD) RFA ablation strategies. Methods: In patients undergoing pulmonary vein isolation, RFA juxtaposed to the esophagus was delivered in an alternate sequence of HP-SD (50 W, 8–10 s) and MP-MD (25 W, 15–20 s) between adjacent applications (distance, ≤4 mm). Esophageal temperature was recorded using a multisensor probe (CIRCA S-CATH). Temperature data included magnitude of temperature rise, maximal temperature, time to maximal temperature, and time return to baseline. In swine, a similar experimental design compared the effect of HP-SD and MP-MD on patterns of esophageal injury. Results: In 20 patients (68.9±5.8 years old; 60% persistent atrial fibrillation), 55 paired HP-SD and MP-MD applications were analyzed. The esophageal temperature dynamic profile was similar between HP-SD and MP-MD ablation strategies. Specifically, the magnitude of temperature rise (2.1 °C [1.4–3] versus 2.0 °C [1.5–3]; P =0.22), maximal temperature (38.4 °C [37.8–39.3] versus 38.5 °C [37.9–39.4]; P =0.17), time to maximal temperature (24.9±7.5 versus 26.3±6.8 s; P =0.1), and time of temperature to return to baseline (110±23.2 versus 111±25.1 s; P =0.86) were similar between HP-SD and MP-MD ablation strategies. In 6 swine, esophageal injury was qualitatively similar between HP-SD and MP-MD strategies. Conclusions: Esophageal temperature dynamics are similar between HP-SD and MP-MD RFA strategies and result in comparable esophageal tissue injury. Therefore, when using a HP-SD RFA strategy, the shorter application duration should not prompt shorter intervals between applications.

Intramural Esophageal Hematoma Following Endoscopic Biopsy

Background: Intramural esophageal hematoma (IEH) is a rare form of esophageal injury, which may occur spontaneously, or be following esophageal dilatation, food impaction, improper swallowing of drug pills, thrombolysis therapy, or coagulopathy. However, it is uncommon that IEH could be induced by endoscopic biopsy.Case presentation: We report a 58-year-old male patient who developed chest pain and hematemesis after endoscopic biopsy. Fourteen days later, esophageal ulcer and hematoma disappeared by conservative management. After 3 months, gastroscopy showed old esophageal scar, and mucous healed completely.Conclusion: IEH is a rare complication of endoscopic biopsy, which is easily ignored. Moreover, It could be cured by conservative treatment.

Procedural time reduction associated with active esophageal cooling during pulmonary vein isolation

Background: Active esophageal cooling is increasingly utilized as an alternative to luminal esophageal temperature (LET) monitoring for protection against thermal injury during pulmonary vein isolation (PVI) when treating atrial fibrillation (AF). Published data demonstrate the efficacy of active cooling in reducing thermal injury, but impacts on procedural efficiency are not as well characterized. LET monitoring compels pauses in ablation due to heat stacking and temperature overheating alarms that in turn delay progress of the PVI procedure, whereas active esophageal cooling allows avoidance of this phenomenon. Objective: Measure the change in PVI procedure duration after implementation of active esophageal cooling as a protective measure against esophageal injury. Methods: We performed a retrospective review under IRB approval of patients with AF undergoing PVI between January 2018 to February 2020. For each patient, we recorded age, gender, and total procedure time. We then compared procedure times before and after the implementation of active esophageal cooling as a replacement for LET monitoring. Results: A total of 373 patients received PVI over the study period. LET monitoring using a multi-sensor probe was performed in 198 patients, and active esophageal cooling using a dedicated device was performed in 175 patients. Patient characteristics did not significantly differ between groups (mean age of 67 years, and gender 37.4% female). Mean procedure time was 146 minutes in the LET monitored patients, and 110 minutes in the actively cooled patients, representing a reduction of 36 minutes, or 24.7% (p<.001). Median procedure time was 141 minutes in the LET monitored patients and 100 minutes in the actively cooled patients, for a reduction of 41 minutes, or 29.1% (p<.001). Conclusions: Implementation of active esophageal cooling for protection against esophageal injury during PVI was associated with a significantly large reduction in procedure duration.