Search Results (84)

Background and Clincal significance: Esophageal squamous cell carcinoma (ESCC) classically presents with progressive dysphagia and weight loss, but atypical presentations may redirect the diagnostic workup before the esophageal primary is identified. We report a case illustrating the simultaneous convergence of three diagnostic pitfalls: absence of dysphagia, bone-predominant metastatic presentation initially managed as carcinoma of unknown primary (CUP), and negative p40 staining in a vertebral biopsy in a patient subsequently confirmed to have invasive mid-esophageal squamous cell carcinoma. CasePresentation: A 66-year-old African American man with dementia, active tobacco exposure, and prior alcohol use disorder presented with constipation, abdominal pain, melena, fever, nausea, vomiting, and progressive back pain. Dysphagia or odynophagia was not documented. CT of the abdomen and pelvis demonstrated diffuse lytic osseous metastases. During evaluation and palliation of symptomatic L2 disease, kyphoplasty and radiofrequency ablation were performed, and bilateral core biopsies showed poorly differentiated carcinoma that was AE1/AE3-positive but negative for p40, CK7, CK20, TTF-1, S100, GATA-3, PAX8, and NKX3.1, yielding an initial diagnosis of CUP. Subsequent chest CT revealed esophageal wall thickening with intraluminal debris. Esophagogastroduodenoscopy (EGD) identified a non-obstructive ulcerated mid-esophageal lesion, and biopsy confirmed invasive squamous cell carcinoma. Poor performance status precluded systemic therapy; palliative external-beam radiation was initiated after diagnosis but discontinued because of clinical deterioration, and the patient transitioned to hospice before passing several weeks after diagnosis. Melena is a gastrointestinal alarm feature, and the combination of gastrointestinal bleeding and an esophageal imaging abnormality warrants timely endoscopic evaluation even when dysphagia is not reported or the symptom history is unreliable. Negative p40 staining in a poorly differentiated, potentially decalcified bone specimen may reflect loss of lineage-marker expression, technical antigen degradation, or both. Tissue or plasma genomic profiling and emerging cell-free DNA methylation classifiers could complement the workup but would not replace direct biopsy of a radiographically suspicious esophageal lesion. Conclusions: In metastatic poorly differentiated carcinoma, lack of documented dysphagia should not exclude an esophageal primary, particularly in patients with cognitive impairment. A p40-negative bone biopsy does not rule out squamous lineage. Timely EGD and integrated clinicopathologic assessment are essential when clinical or imaging findings suggest esophageal involvement. Full article

Background/Objectives: Foreign body aspiration is a potentially life-threatening emergency that commonly requires bronchoscopic removal. Dental aspiration in elderly patients may occur following trauma, seizures, or altered mental status and can lead to airway obstruction and respiratory complications. We report a rare case of simultaneous airway and esophageal foreign bodies caused by tooth dislodgement after a generalized seizure in an elderly patient. Methods: An 85-year-old man presented to the emergency department with decreased consciousness and recurrent generalized seizures. Chest computed tomography revealed two tooth-like foreign bodies located in the right main bronchus and the mid-esophagus. Endotracheal intubation was performed because of persistent altered mental status, oral bleeding, and retained airway secretions. Although emergency bronchoscopy was considered necessary, it was not immediately available overnight. Repeated endotracheal suctioning was performed while maintaining airway protection and oxygenation. Results: Approximately 12 h later, a tooth-like foreign body was recovered attached to the tip of the suction catheter immediately after withdrawal during routine endotracheal suctioning, suggesting spontaneous proximal migration before its removal. Follow-up imaging confirmed disappearance of the bronchial foreign body, whereas the esophageal foreign body was subsequently removed endoscopically. The patient remained clinically stable without procedure-related complications. Conclusions: This case demonstrates that routine endotracheal suctioning may occasionally facilitate the incidental removal of a small, mobile tracheobronchial foreign body under exceptional circumstances. To our knowledge, reports of aspirated teeth being removed solely by routine endotracheal suctioning without bronchoscopic intervention are extremely rare. However, bronchoscopy remains the standard treatment for tracheobronchial foreign body removal, and suction-assisted removal should be regarded only as an incidental event rather than an alternative therapeutic strategy. Full article

Background: Esophageal cancer is a highly lethal malignancy, the prognosis of which depends largely on early diagnosis. Artificial intelligence (AI) has emerged as a promising tool to enhance endoscopic detection and characterization of early esophageal cancer. This scoping review aims to map and synthesize the available evidence regarding the diagnostic performance and clinical utility of artificial intelligence systems applied to upper gastrointestinal endoscopy for the detection and characterization of premalignant squamous lesions and early-stage esophageal squamous cell carcinoma (ESCC). Methods: A scoping review was conducted according to Arksey and O’Malley, Levac, Joanna Briggs Institute, and PRISMA-ScR recommendations. The review question focused on patients with premalignant lesions or early ESCC, artificial intelligence-based diagnostic systems, and upper gastrointestinal endoscopy. Searches were performed in PubMed, Scopus, and Embase. Original studies reporting sensitivity, specificity, accuracy, AUC, or F1-score were included. Results: A total of 30 publications were included, consisting mainly of retrospective observational and diagnostic test studies (26/30; 86.7%), followed by randomized clinical trials (3/30; 10.0%) and a multicenter validation study (1/30; 3.3%). The studies were predominantly from China (18/30; 60%), followed by Japan (8/30; 26.7%), Taiwan (3/30; 10%), and the United Kingdom + Taiwan (1/30; 3%). Automatic lesion detection was predominant (21/30; 70.0%), followed by diagnostic classification (11/30; 36.7%), while segmentation (3/30; 10.0%), histological prediction (2/30; 6.7%), estimation of invasion depth (3/30; 10.0%), and lesion delineation (1/30; 3.3%) were evaluated less frequently, and in some cases combined within the same model. The most used endoscopic imaging modalities were narrow-band imaging (23/30; 76.7%) and white light endoscopy (20/30; 66.7%), followed by magnifying endoscopy with narrow-band imaging (5/30; 16.7%), blue light imaging (2/30; 6.7%), and hyperspectral imaging (1/30; 3.3%). Conclusions: Available studies suggest that AI has the potential to achieve high diagnostic performance under controlled conditions. However, the current evidence is derived predominantly from single-center retrospective studies using selected high-quality static images, with limited external, prospective, and real-world validation. Full article

Background: Ultrasonography during medical procedures allows for real-time assessment of the target structure. This design feature could be more advantageous than radiological “snapshot” imaging. Technically, the image resolution of endoscopic ultrasound (EUS) is noticeably higher than that of transesophageal echocardiography (TOE). The benefits of investigating cardiovascular structures using this mode of high-resolution EUS are unknown. Materials and Methods: We present clinical applications in the diagnosis of cardiovascular structures, demonstrated during routine gastrointestinal endosonographic procedures. In some cases, these diagnoses led to changes in management strategies. Results and Discussion: The introduction of high-resolution EUS into cardiology allows for the accurate definition of variable cardiovascular anatomy and early detection of asymptomatic cardiac pathologies. It also prevents double investigations for patients and operators, reduces the risk of esophageal trauma, and highlights the benefits of interdisciplinary teamwork. In addition, the high spatial resolution of EUS facilitates detailed tissue characterization for guiding biopsies, thereby extending the applicability of elastography across various echocardiographic domains. Moreover, the precision of using EUS when targeting and inserting a needle into adjacent organs could facilitate the development of EUS indications for cardiac-based interventions. Conclusions: The use of EUS in cardiology provides high-resolution real-time assessments of cardiovascular anatomy and may facilitate the development of EUS indications for cardiac-based interventions. However, large cohort studies are required. Full article

Background: In locally advanced squamous cell esophageal cancer, concurrent chemoradiotherapy (CRT) is the standard of care, as it especially improves local control and overall survival compared to radiotherapy alone. In contrast, treatment strategies for esophageal adenocarcinoma often parallel those used in gastric cancer, particularly regarding systemic therapy. Objectives: This study aimed to evaluate the clinicopathological factors affecting event-free survival (EFS) and overall survival (OS) following trimodality treatment in patients with non-metastatic esophageal cancer. Methods: A total of 155 patients diagnosed with esophageal cancer between March 2019 and November 2025 were retrospectively analyzed. Response to concurrent chemoradiotherapy was assessed via thoracic magnetic resonance imaging and endoscopic biopsy. Results: Clinicopathological analysis showed that male sex, the presence of lymphovascular invasion, adenocarcinoma histology, poor pathological response and advanced-stage tumors were significantly associated with worse EFS (all p < 0.001). In multivariate analysis, stage IVa disease was identified as an independent predictor of both mortality and relapse, with an approximately five-fold increased risk of death (p = 0.028) and relapse (p = 0.019). Patients with squamous cell carcinoma had a longer median EFS compared to those with adenocarcinoma (18 vs. 8.4 months, respectively). The 3- and 5-year OS rates were 59.2% and 56% in patients with squamous cell carcinoma, compared with 40% and 26% in those with adenocarcinoma, respectively. Conclusions: Survival outcomes were more favorable in patients with squamous cell histology and those diagnosed at an early stage. Active surveillance may be considered in selected patients with a complete clinical response to avoid the perioperative mortality associated with surgery. Full article

Background/Objectives: Congenital esophageal stenosis (CES) is a rare condition that may present with feeding difficulties in infancy, often becoming evident during weaning. We report a case of CES presenting with progressive dysphagia during the introduction of solid foods. Methods: Clinical evaluation, contrast esophagography, endoscopy, and magnetic resonance imaging were performed to characterize the stenosis and guide management. Results: Imaging revealed a fixed narrowing of the mid-distal esophagus with minimal passage of contrast and proximal dilatation. Endoscopy confirmed a non-traversable intrinsic stenosis with macroscopically normal mucosa. The patient underwent three endoscopic dilation sessions under general anesthesia using Savary-Gilliard bougies with progressive diameters (3–5 mm, 3–7 mm, and 7–11 mm). No major procedural complications occurred. At 2-month follow-up after the last dilation, feeding was appropriate for age, dysphagia had improved, and growth was regular. Conclusions: CES should be suspected in infants with feeding difficulties that worsen during weaning, particularly when symptoms are resistant to anti-reflux therapy. Endoscopic dilation can improve feeding tolerance, although repeated and staged sessions may be required. The role of adjunctive therapies such as topical budesonide remains uncertain. Full article

Background/Objectives: Esophageal cancer is one of the major global causes of cancer mortality, and the 5-year survival rate remains below 20% because many cases are detected late. In this study, a Spectral-Aided Vision Enhancer (SAVE) algorithm was utilized to convert conventional white-light endoscopic images (WLI) into hyperspectral-like narrow-band imaging (NBI) images for machine-learning classification of Dysplasia, Normal, and Squamous Cell Carcinoma (SCC). Methods: A total of 762 WLI images obtained from Kaohsiung Medical University were augmented to 1074 using the Al bumentations library, employing vertical flipping, horizontal flipping, and rotations. The SAVE conversion pipeline employs a 24-patch Macbeth color checker for calibration, γ-correction, CIE XYZ transformation, and multivariate regression to interpolate spectral bands, yielding an average color difference of 2.79 (CIEDE2000) from true NBI. The training outcomes and performance metrics illustrate the versatility of the machine learning/deep learning models—Random Forest (RF), Support Vector Machine (SVM), and Convolutional Neural Network (CNN)—which were trained and evaluated on both the original WLI and SAVE datasets. Performance metrics were analyzed based on precision, recall, accuracy, and F1-score. Results: The CNN sample achieved an accuracy of 100 percent on SAVE data, compared to 93 percent for WLI. The accuracy of RF improved, with WLI at 91% and SAVE at 96%, while SVM increased from 79% to 84%. These improvements indicate the diagnostically valuable spectral variations that can be amplified with SAVE, resulting in significant enhancements in pre-cancer/SCC sensitivity. Conclusions: The proposed SAVE method demonstrates significant potential for enhancing endoscopic imaging and advancing computer-aided diagnosis in esophageal cancer screening, with applicability in other gastrointestinal imaging scenarios as well. Full article

Miniprobe endoscopic ultrasonography (mEUS) combines high-resolution imaging of the gastrointestinal (GI) wall and bile ducts with ease of applicability during routine endoscopy. This narrative review aims to provide an overview of known and emerging fields of application for mEUS in gastrointestinal endoscopy. After its initial development in pancreatobiliary scenarios in the early 1990s, mEUS has been recently reconsidered a third-space endoscopic technique that is progressively developing and spreading for the treatment of early gastrointestinal neoplastic lesions. The high spatial resolution of mEUS provides an accurate assessment of the degree of submucosal invasion in early esophageal, gastric, and colorectal neoplasia, while the small caliber of catheters allows for mEUS employment in settings where standard echoendoscopes are impractical (e.g., severe stenoses or proximal colonic lesions). Beyond cancer staging, mEUS offers point-of-care characterization of subepithelial lesions by defining the layer of origin and echo-pattern, eventually defining endoscopic resectability, but definitive diagnosis remains histological. In pancreatobiliary diseases, miniprobe intraductal ultrasonography (IDUS) shows its strongest application for indeterminate biliary strictures when endoscopic retrograde cholangiopancreatography (ERCP)-based sampling strategies and brushing cytology show inconclusive diagnoses, and in choledocholithiasis, particularly for the detection of small stones/sludge and confirmation of duct clearance. IDUS is also valuable for the staging of ampullary tumors, for longitudinal extension mapping in hilar cholangiocarcinoma and for selected portal biliopathy scenarios. Overall, mEUS and IDUS are high-resolution adjuncts that can meaningfully refine local decision-making in the treatment of superficial epithelial/subepithelial tumors or lesions involving the bile ducts. Limitations include shallow penetration, lack of tissue acquisition capability, a relative increase in post-ERCP pancreatitis risk for intraductal use, and substantial cost with limited availability in lower-volume centers. Full article

Background: Aorto-esophageal fistula is a rare but life-threatening condition most often linked to thoracic aortic aneurysms and significant upper gastrointestinal bleeding. Thoracic endovascular aortic repair (TEVAR) is a crucial, life-saving procedure, but delayed complications, such as secondary esophageal fistulas caused by endograft erosion, can develop. Prompt recognition and multidisciplinary management are vital for survival. Case Presentation: We describe a 57-year-old patient with cardiovascular comorbidities and a saccular thoracic aortic aneurysm, who initially presented with massive hematemesis, melena, and hemodynamic instability. Imaging showed an aorto-esophageal fistula. Emergency treatment included placing a fully covered esophageal stent followed by TEVAR. Three weeks later, he experienced fever, chest pain, and worsening dysphagia. Laboratory tests indicated elevated inflammatory markers and hypoalbuminemia. Computed tomography revealed a new retrocardial esophageal fistula at T9, caused by mechanical erosion from the thoracic endograft. Endoluminal vacuum-assisted closure (EndoVAC) therapy was performed, leading to clinical improvement and the return of esophageal function. Conclusions: This case highlights a rare instance of a delayed secondary esophageal fistula after TEVAR beneath a preexisting stent, likely due to chronic contact between the endograft and esophagus. Despite advancements in endoscopic therapy, secondary fistulas after TEVAR are associated with high morbidity. Early diagnosis, aggressive infection management, structured nutritional support, and a multidisciplinary approach are essential. Extraluminal or intraluminal vacuum-assisted closure offers a promising minimally invasive option for managing complex esophageal defects. Full article

Background: Tracheal rupture is a rare, life-threatening condition that may follow blunt trauma, intubation, and, less commonly, esophageal instrumentation. The diagnosis may be challenging due to the subtle, delayed, and wide variety of symptoms. We present a unique case of delayed tracheal rupture secondary to iatrogenic esophageal perforation, presenting months later with a cervical neck insufflation on Valsalva, a novel clinical sign that has not been previously described in the literature. Case Presentation: A 44-year-old male initially presented with esophageal food impactation. Following endoscopic removal attempts, he developed signs consistent with esophageal perforation and was managed conservatively. In follow-up, he reported persistent neck discomfort, facial numbness, and the ability to insufflate the right side of his neck while doing a Valsalva. Flexible bronchoscopy and retrospective review of imaging revealed a proximal posterior tracheal defect, initially misinterpreted as a tracheal diverticulum. Surgical exploration confirmed a 6 cm dehiscence between the membranous trachea and the anterior wall of the esophagus. The defect was repaired using regional muscle flaps with tissue sealant reinforcement. Postoperatively, the patient had complete symptom resolution and no recurrence of neck insufflation. Conclusions: The case underscores the importance of maintaining a high index of suspicion for tracheal injury in patients with persistent or atypical symptoms following esophageal perforation or instrumentation. To our knowledge, we have described a novel clinical finding of neck insufflation upon Valsalva for diagnosing tracheal rupture. Full article

Background/Objectives: Functional lumen imaging probe (FLIP) panometry allows real-time assessment of the esophagogastric junction opening and esophageal body contractile activity during an endoscopic procedure. Despite the development of the Dallas Consensus, FLIP panometry analysis remains complex. Artificial intelligence (AI) models have proven their benefit in high-resolution esophageal manometry; however, data on their role in FLIP panometry are scarce. This study aims to develop an AI model for automatic classification of motility patterns during a FLIP panometry exam. Methods: A total of 105 exams from five centers from both the European and American continents were included. Several machine learning models were trained and evaluated for detection of FLIP panometry patterns. Each exam was classified with an expert consensus-based decision according to the Dallas Consensus, with division into a training and testing dataset in a patient-split design. Models’ performance was evaluated through their accuracy and area under the receiver-operating characteristic curve (AUC-ROC). Results: Pathological planimetry patterns were identified by an AdaBoost Classifier with 84.9% accuracy and a mean AUC-ROC of 0.92. Random Forest identified disorders of the esophagogastric junction opening with 86.7% accuracy and an AUC-ROC of 0.973. The Gradient Boosting Classifier identified disorders of the contractile response with 86.0% accuracy and an AUC-ROC of 0.933. Conclusions: In this study, integrating exams with different probe sizes and demographic contexts, a machine learning model accurately classified FLIP panometry exams according to the Dallas Consensus. AI-driven FLIP panometry could revolutionize the approach to this exam during an endoscopic procedure, optimizing exam accuracy, standardization, and accessibility, and transforming patient management. Full article

Background/Objectives: Zenker’s diverticulum (ZD) is a rare but clinically relevant condition. It is a false, pulsion-type diverticulum due to the protrusion of mucosal and submucosal layers through the Killian’s Triangle. Its pathogenesis is multifactorial and entails cricopharyngeus muscle dysfunction and age-related tissue degeneration. This review addresses the current evidence regarding the anatomy, pathophysiology, clinical presentation, diagnostic approach, and therapeutic management of ZD. Methods: For this literature review, we searched the PubMed and Scopus databases using combinations of keywords relevant to Zenker’s diverticulum, including “Zenker’s diverticulum,” “esophageal diverticula,” “diagnosis,” “endoscopic treatment,” and “surgery”. We included articles published in recent decades, with a focus on most recent ones regarding clinical studies, systematic reviews, meta-analyses, and descriptions of new diagnostic and therapeutic techniques. Results: Characteristic symptoms comprise progressive dysphagia, regurgitation of undigested food, halitosis, and, in advanced cases, aspiration-related respiratory complications. Diagnosis of ZD is primarily based on barium swallow esophagography and endoscopic evaluation, complemented by other imaging techniques. Current therapeutic options include traditional open surgery and endoscopic procedures, including newer minimally invasive techniques. Conclusions: ZD is the most common type of esophageal diverticulum and can have a disabling impact on a patient’s quality of life. It is commonly underdiagnosed or misdiagnosed as another condition, and prevalence is expected to increase with the growing population ageing. Improved understanding of its pathophysiology is needed to refine diagnostic and therapeutic strategies and minimize recurrences and risks. Full article

Boerhaave syndrome, or spontaneous rupture of the esophageal wall, is a rare condition that occurs after a violent increase in intraesophageal pressure associated with negative intrathoracic pressure after forceful vomiting or retching. Rupture, usually transmural, often occurs in the distal esophagus and can be complicated by mediastinitis, sepsis, and multiple organ dysfunction. Despite the aid of imaging in diagnosis and rapid management, it is still characterized by a high mortality rate. Surgical and endoscopic approaches are the mainstays of treatment. Case presentation: Here, we describe three cases of Boerhaave’s syndrome managed with minimally invasive surgical treatment and provide a brief literature review of the treatment methods for this rare condition. Conclusions: Early diagnosis and prompt management by a multidisciplinary team increase the chances of survival. The laparoscopic approach is beneficial and can successfully treat esophageal tears associated with this syndrome in early or delayed timing. Full article

Esophageal squamous cell carcinoma (ESCC) is the most prevalent histological subtype of esophageal cancer worldwide, typically manifesting as an endoluminal mass with overt mucosal involvement. Exceptionally, however, ESCC may present with an intramural growth pattern beneath an apparently intact mucosal surface, a presentation that is exceedingly rare and prone to misdiagnosis. In such cases, repeated endoscopic biopsies are frequently non-diagnostic, thereby delaying appropriate management. Endoscopic ultrasound (EUS) has emerged as the cornerstone for detecting and characterizing intramural lesions, enabling assessment of tumor infiltration depth and nodal status, while complementary imaging with CT and PET contributes to accurate staging. To date, only a handful of intramural ESCC cases have been described, and their clinical, endoscopic, and radiological features remain poorly delineated. This review appraises the existing literature on primary intramural ESCC with intact mucosa, with the dual aims of summarizing the diagnostic challenges and highlighting the value of a multimodal approach to avoid unnecessary surgical interventions. Furthermore, we report an additional case from our experience, which underscores the critical role of EUS and integrated imaging in achieving timely and accurate diagnosis of this unusual entity. Full article

(1) Background: Most robotic MIS platforms lack native haptic feedback, leaving surgeons to infer tissue loads from vision alone—an especially risky limitation in esophageal procedures. (2) Methods: We develop a sensorless, image-only force-estimation pipeline that maps endoscopic video to tool–tissue forces using a lightweight EfficientNetV2B0 CNN. The model is trained on 9691 labeled frames from in vitro esophageal experiments and validated against an FT300 load cell. For intraoperative feasibility, the system is deployed as a plug-in on PARA-SILSROB, consuming the existing laparoscope feed and driving a commercial haptic device. The runtime processes every 10th frame of a 60 FPS stream (≈6 Hz updates) with ~15–20 ms per-prediction latency. (3) Results: On held-out tests, the model achieves MAE = 0.017 N and MSE = 0.0004 N², outperforming a recurrent CNN baseline while maintaining real-time performance on commodity hardware. Integrated evaluations confirm stable operation at the deployed update rate and low latency compatible with closed-loop haptics. (4) Conclusions: By avoiding distal force sensors and preserving sterile workflow, the approach is readily translatable and retrofit-friendly for current robotic platforms. The results support the practical feasibility of real-time, sensorless force feedback for robotic esophagectomy and related MIS tasks, with potential to reduce tissue trauma and enhance operative safety. Full article