Argon Plasma Coagulation of Gastric Inlet Patches of the Cervical Esophagus Relieves Vocal and Respiratory Symptoms in Selected Patients

A systematic review of fully circumferential inlet patches (heterotopic gastric mucosa): More complicated than regular inlet patches

BACKGROUND AND OBJECTIVES

Inlet patches (IP) are usually small islands of ectopic gastric mucosa found in the proximal esophagus, but rare cases of large, fully circumferential IP (FCIP) have been reported. To better understand the clinical course of patients with FCIP, we sought to perform a systematic review of all published cases.

METHODS

A systematic review of cases of FCIP was performed according to Preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines after thorough searches of PubMed and journal databases for appropriate cases. No restrictions were placed as to article type, country of origin or publication year.

RESULTS

Total 30 cases of FCIP from 27 articles were identified. These included patients from 10 different countries published between 1985 and 2024. The mean age was 55.7 with 82.1% men and a mean circumferential IP length of 3.4 cm. A majority of patients were symptomatic with dysphagia and/or a history of food impactions (72.4%). Most cases involved complications from the IP, including a benign stricture/ring/web (20, 66.7%), adenocarcinoma (4, 13.3%) or ulcers/erosions (2, 6.7%). The benign strictures were usually treated by dilation together with anti-secretory medication (10, 50%) or just dilation or medication. The adenocarcinoma cases were treated by surgery (two cases) or endoscopic resection (two cases), while the ulcer cases were treated medically. All cases with follow-up reported a good clinical outcome.

CONCLUSIONS

Patients with FCIP are frequently symptomatic with dysphagia or food impactions and often have complications, including a stricture/ring or cancer. Despite this, they have good clinical outcomes. Given the risk of malignancy, endoscopic surveillance may be warranted.

Risk Factors for Symptoms in Patients With Heterotopic Gastric Mucosa in the Upper Esophagus

Goal: This study is aimed at comparing the clinical characteristics and histological types of symptomatic and asymptomatic patients with heterotopic gastric mucosa in the upper esophagus (HGMUE) and exploring the factors influencing the occurrence and severity of laryngopharyngeal reflux (LPR) symptoms in these patients. Background: HGMUE is a potential cause of LPR symptoms. Study: This retrospective analysis evaluated 70 patients with HGMUE using a detailed questionnaire. Clinical, histological, high-resolution manometry, and 24-h pH impedance monitoring data were compared between symptomatic (n = 49) and asymptomatic (n = 21) patients. Results: The diameter of HGMUE was significantly larger in the symptomatic group (p < 0.05), and the incidence of LPR symptoms increased with larger diameter grades; male patients were more likely to have LPR symptoms. The incidence of LPR symptoms varied significantly across histological classifications, being highest in patients with the fundic type (χ 2 = 6.64, p < 0.05). Binary logistic regression analysis identified sex and histological type as risk factors for LPR symptoms, with odds ratios of 8.996 (95% confidence interval (CI): 1.350-59.962) and 8.493 (95% CI: 1.486-48.522), respectively. The mean nocturnal baseline impedance (MNBI) in the upper esophagus was significantly lower in the symptomatic group (1676.82 ± 739.09 Ω vs. 2441.01 ± 604.11 Ω; p < 0.05). Clinical and demographic characteristics did not significantly affect the severity of LPR symptoms. Conclusion: The diameter, histological type, and sex of patients are risk factors for the occurrence of LPR symptoms in patients with HGMUE. More attention should be paid to patients with these factors. The MNBI is an effective indicator of the symptoms and treatment.

A multidisciplinary approach to identifying and managing heterotopic gastric inlet patches

INTRODUCTION

Gastric inlet patches are often incidental, but can also be a treatable cause of laryngo-esophageal symptoms.

METHODS

We retrospectively reviewed all patients whose gastric inlet patches were diagnosed following assessment for laryngopharyngeal and swallowing symptoms. Improvement following Argon Plasma Coagulation (APC) was assessed using Minimum Clinically-Important Difference methodology combining voice, throat, and swallowing domains. Correlations between APC response and measures of reflux and mucosal barrier integrity, measured during 24-h pH-impedance manometry, were obtained. Proximal and Distal Mean Nocturnal Baseline Impedance (MNBI) values were separately calculated and the novel variable of Mucosal Impedance Gradient was derived as [((Distal MNBI-Proximal MNBI)/((Distal MNBI + Proximal MMBI)/2)) x 100].

KEY RESULTS

Inlet patches were detected in 57 of 651 patients who had Transnasal Panendoscopy (8.7 ± 2.2%). There were 34 males. Mean age was 58 years. Mean duration of symptoms was 2 years. The commonest symptoms were hoarseness (n = 33), throat symptoms (n = 24), and dysphagia (n = 21), respectively. APC was used to ablate patches in 34 patients. Treatment response was 71% at a mean followup of 5.5 months. MIG > - 25% predicted response to APC, with area under the receiver operating characteristic curve of 0.875 (Sensitivity = 81%; Specificity = 100%; p < 0.0001).

CONCLUSIONS

Gastric inlet patches are common and under-recognized. They can cause protracted pharyngo-esophageal symptoms. Patch ablation is an effective treatment for carefully selected patients. Optimal patient selection requires multidisciplinary teamwork. Mucosal Impedance Gradient could further refine patient selection.