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Abstract Background It has been suggested that intrasphincteric injection of botulinum toxin (BTX) may represent an alternative therapy to balloon dilatation in achalasia. The aim of the present study was to test the effectiveness of botulinum toxin injections in achalasia patients, as assessed using lower oesophageal sphincter pressure (LOSP) and symptom scores, and to compare the response in patients with different types of pretreatment (no previous treatment, balloon dilatation, myotomy, BTX injection). Methods Forty patients who presented with symptomatic achalasia were treated with BTX injection (48 injections in 40 patients). Some of the patients had received prior treatment (seven with myotomy, seven with dilatation and eight with BTX). The symptoms were assessed using a global symptom score (0–10), which was evaluated before treatment, 1 week afterwards, and 1 month afterwards. Manometry was also carried out before and after treatment. Three different selections of patients were studied: all patients; untreated patients; and patients with prior BTX, dilatation, or myotomy. Results After BTX injection, there was a significant reduction in LOSP (before, 38.2 ± 11.3 mmHg; 1 week after, 20.5 ± 6.9 mmHg; 1 month after, 17.8 ± 6.8 mmHg; P < 0.001). The global symptom score and symptom subscores (dysphagia, regurgitation, chest pain) were significantly decreased after 1 week and 1 month. When the beneficial effects following BTX injection were compared (untreated vs. pretreated), neither changes in LOSP nor beneficial effects on the symptom scores significantly differed. After 6 months, 67.7% of all treated patients were still in symptomatic remission (subgroups: previously untreated patients, 61.5%, n = 26; prior dilatation, 71.4%, n = 7; prior myotomy, 71.4%, n = 7; prior BTX, 73.9%, n = 8). Conclusions BTX injection offers an alternative treatment for achalasia which is safe and can be performed in an outpatient setting. The initial response to BTX, in terms of symptom scores and LOSP, appears to be independent of any prior treatment. A number of patients do not adequately respond to balloon dilatation or myotomy, which are the first-line treatment modalities in achalasia patients. BTX injection can be performed in these patients, and symptomatic benefit can be expected in the same percentages as with BTX injection in untreated patients.

Often, the interpretation of experiments concerning the manipulation of the energy distribution of laser-accelerated ion bunches is complicated by the multitude of competing dynamic processes simultaneously contributing to recorded ion signals. Here we demonstrate experimentally the acceleration of a clean proton bunch. This was achieved with a microscopic and three-dimensionally confined near critical density plasma, which evolves from a 1 μm diameter plastic sphere, which is levitated and positioned with micrometer precision in the focus of a Petawatt laser pulse. The emitted proton bunch is reproducibly observed with central energies between 20 and 40 MeV and narrow energy spread (down to 25%) showing almost no low-energetic background. Together with three-dimensional particle-in-cell simulations we track the complete acceleration process, evidencing the transition from organized acceleration to Coulomb repulsion. This reveals limitations of current high power lasers and viable paths to optimize laser-driven ion sources. [ABSTRACT FROM AUTHOR]

Background: Barrett esophagus (BE) is a major risk factor for adenocarcinoma of the distal esophagus. Reliable detection of BE during upper endoscopy is therefore mandatory. According to most guidelines, diagnosis of BE requires both endoscopy and histology for confirmation. However, since adenocarcinomas were also described in patients with indeterminate BE, i.e. endoscopic visible columnar metaplasia but no histological confirmation of goblet cells or vice versa, debate has risen on the risk of malignancy and the need for endoscopic surveillance in such patients. Patients and Methods: The study was aimed to assess long-term follow-up data on 209 patients with indeterminate BE (on histopathology or endoscopy) initially examined between 1999 and 2000. Patients or referring physicians were contacted concerning the most recent endoscopic and histopathological results. Results: Follow-up data could be assessed in 149/209 patients (65.1%) after a mean follow-up period of 9.4 years (SD ±2.4 years). Neoplasia was not reported for any patient. The previous endoscopic-histopathological diagnoses could be confirmed in 3 patients only. In the group with endoscopic diagnosis of BE but no histopathological confirmation, BE was described histopathologically in 1 patient during follow-up. Conclusion: Persistence of indeterminate BE is poor during long-term follow up. The risk of cancer appears to be negligible. Hence, surveillance of these patients appears equivocal. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article presents the 19th United European Gastroenterology Week (UEGW) 2011 report on gastrointestinal endoscopy. Topics of the report include the advacement of traditional endoscopic mucosal resection (EMR) to tissue resection by endoscopic submucosal dissection (ESD), factors that may have an impact of ESD outcome, and screening and surveillance colonoscopy for the diagnosis of colorectal cancer.

Background: Preclinical studies have demonstrated the over-the-scope clip (OTSC) to be feasible and safe for closure of gastric, duodenal, and colonic perforations. A retrospective clinical study demonstrated the feasibility and preliminary safety of the OTSC for the treatment of GI bleeding and closure of acute GI perforations. Objective: Because the OTSC allows rapid and easy endoscopic organ wall closure, we hypothesized that it might be a useful tool to close GI fistulae. Design: Case series. Setting: Academic medical center. Patients: Four consecutive patients with GI fistulae. Interventions: In all patients, a 12-mm OTSC, in combination with the dedicated twin grasper, anchor device, or endoscopic suction, was used to facilitate endoscopic closure. Main Outcome Measurements: In 2 cases, OTSCs allowed complete closure of a posttraumatic esophagopulmonary fistula and a chronic gastrocutaneous fistula. Leak tests and follow-up examination demonstrated complete leakproof closures. In 1 esophagopulmonary fistula and 1 jejunocutaneous fistula, the initial closure attempts using OTSCs were not successful because of chronic fibrotic changes and scarring at the fistula site. Both OTSCs were removed by using an endoscopic grasping forceps. The mean procedure time was 54 minutes (range 24-93 minutes). There were no procedure-related complications. Limitations: Small sample size. Conclusions: The OTSC seems to be a feasible device to close chronic fistulae of the GI tract. It can achieve leakproof, full-thickness closure of transmural defects. Nevertheless, in circumstances of severe fibrosis and scarring, complete incorporation of the defect into the applicator cap and successful OTSC application might not be possible. [ABSTRACT FROM AUTHOR]

Objective: The biggest challenge in endoscopic surveil lance of Barrett's oesophagus is better detection of neoplasia in mucosa of normal macroscopic appearanc~ We evaluated in vivo miniprobe confocal laser microsco~ (CLM) for the detection of invisible Barrett's neoplasia. Design: Prospective two-centre trial in two phases: phase I to establish criteria of Barrett's neoplasia and phase II to test these criteria. Patients and intervention: 296 biopsy sites in 38 consecutive patients with Barrett's oesophagus (mean age 62.1 years, 89.5% men, median length of the Barrett's oesophagus, 3 cm) were examined with standard high-resolution endoscopy and by miniprobe CLM, with precise matching of CLM recordings to biop~ sites. CLM image criteria for normal versus neoplastic Barrett's oesophagus were established from 95 biopsie of 15 patients (phase I); these criteria were then prospectively tested on 201 biopsies from the remainin patients without visible focal changes (phase II). All 20 CLM video recordings from phase II cases were randomised and blindly evaluated by two gastroenterol- ogists. Main outcome measure: The primary endpoints wer~ accuracy values in diagnosing HGIN or early carcinoma (EC) on a per-biopsy basis. Secondary endpoints include inter-observer agreement. Results: All initially defined miniprobe CLM criteria (phase I) were significantly more frequently detected ir HGIN/EC sites compared with sites with no or low grad neoplasia (phase II). In a per-biopsy analysis, sensitivit~ and specificity for two independent investigators were 75.0% and 88.8%, and 75.0% and 91.0%, respectively, translating at best into a positive predictive value of 44.4% and a negative predictive value of 98.8%. Inter- observer agreement was good (kappa 0.6). Conclusion: Miniprobe CLM showed a high negative predictive value for the diagnosis of endoscopically invisible neoplasia in Barrett's oesophagus; sensitivity, however, has still to be improved. [ABSTRACT FROM AUTHOR]