Background: The mechanism of esophageal thermal injury (ETI; esophageal mucosal injury and periesophageal nerve injury leading to gastric hypomotility) remains unknown when using a high-power short-duration (HP-SD) setting. This study sought to evaluate the characteristics of esophageal injuries in atrial fibrillation ablation using a HP-SD setting. Methods: After exclusion of 5 patients with their esophagus at the right portion of left atrium and 21 patients with additional ablations such as box isolation and low voltage area ablation in left atrium posterior wall, 271 consecutive patients (62±10 years, 56 women) who underwent pulmonary vein isolation by radiofrequency catheter ablation were analyzed. In the 101 patients, a HP-SD setting at 45 to 50 W with an Ablation Index module was used (HP-SD group). In the remaining 170 patients before introduction of the HP-SD setting, a conventional power setting of 20 to 30 W with contact force monitoring was used (conventional group). We performed esophagogastroduodenoscopy after pulmonary vein isolation in all patients and investigated the incidence and characteristics of ETI. Results: Although the incidence of ETI was significantly higher in the HP-SD group compared with the conventional group (37% versus 22%, P =0.011), the prevalence of esophageal lesions did not differ between the groups (7% versus 8%). Multivariate logistic regression analysis revealed that the use of the HP-SD setting (odds ratio, 6.09, P <0.001), and the parameters that suggest anatomic proximity surrounding the esophagus, were independent predictors of ETI. However, the majority of ETI in the HP-SD group was gastric hypomotility, and the thermal injury was limited to the shallow layer of the periesophageal wall using the HP-SD setting. Conclusions: Although the use of the HP-SD setting was a strong predictor of ETI, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.

Background and study aims Fixation of an esophageal self-expandable metal stent (SEMS) with an over-the-scope-clip (OTSC) system for a benign stricture to prevent migration has been reported. However, the efficacy of SEMS fixation with an OTSC for malignant esophageal stricture remains unclear. The aim of this retrospective study was to evaluate the feasibility of SEMS fixation with an OTSC for a malignant esophageal stricture. Patients and methods Twelve patients who underwent esophageal SEMS placement and fixation with an OTSC for a malignant esophageal stricture were included in this retrospective study. The primary endpoint was technical success. The secondary endpoint was clinical success, which was defined as an improvement of at least 1 grade in the dysphagia score 1 week after SEMS placement or changes in the dysphagia score from before SEMS placement to 1 week after SEMS placement. Results The technical success rate was 100 %. The clinical success rate was 92.3 %. In 6 mild stricture cases in which a standard peroral endoscope could be used, no migration of the SEMS was observed. The median dysphagia score before and at 1 week after SEMS placement was 3 (range 2 – 4) and 0 (0 – 4), respectively, which indicated improvement at 1 week after SEMS placement compared with before SEMS placement (P = 0.002). There were no adverse events associated with placement of SEMS and deployment of an OTSC. Conclusions SEMS fixation with an OTSC is feasible for prevention of migration due to a malignant esophageal stricture.

Background and study aims The safety and efficacy of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in very elderly patients remains unclear. The aim of this study was to evaluate the safety and efficacy of ESD for EGC in patients age 85 years and older. Patients and methods Patients who underwent ESD for EGC between September 2003 and April 2015 were divided into 3 groups: the very elderly (≥ 85 years; 43 patients), the elderly (65 – 84 years; 511 patients), and the non-elderly ( ≤ 64 years; 161 patients). Adverse events (AEs) were used as the primary endpoint to assess the safety of ESD, and the ESD treatment outcomes (i. e., en bloc resection rate, complete en bloc resection rate, and curative resection rate) and the overall survival rate after ESD were the secondary endpoints. These parameters were retrospectively evaluated in the 3 groups. Results There were no significant differences in AEs (non-elderly, elderly, and very elderly: 7.3, 9.5, and 12.5 %, respectively, P = 0.491) or in the en bloc resection and complete en bloc resection rates among the three groups. However, there was a significant difference in the curative resection rates (non-elderly, elderly, and very elderly: 91.5, 84.1, and 77.1 %, respectively, P = 0.014). Regarding overall survival, there was a significant difference among the three groups (1-, 5-, and 10-year overall survival rates: non-elderly: 98.6, 90.2, and 74.7 %; elderly: 97.2, 86.2, and 61.9 %; and very elderly: 92.7, 66.8, and 34.4 %, respectively, P = 0.001). Moreover, the overall survival rate in the very elderly patients with cardiovascular disease was significantly lower than that in the very elderly patients without cardiovascular disease (P < 0.001). Conclusions ESD is an acceptable treatment for EGC in patients 85 years of age or older in terms of safety. However, the overall survival after ESD in the very elderly patients with cardiovascular disease was short.