Patients with end-stage achalasia may not be candidates for a transhiatal minimally invasive esophageal resection because of anatomic challenges and adhesions from previous interventions, namely, thoracotomy. Given the tactile feedback provided through a GelPort laparoscopic system (Applied Medical, Rancho Margarita, CA) we proposed that a minimally invasive transhiatal esophagectomy would be feasible in this patient cohort. The procedure was successful in 4 patients; seven complications occurred in 3 of the patients. At follow-up all patients demonstrated that they were meeting their nutritional needs with an oral diet.

Retroflexion of the colonoscope to examine the rectal vault is considered an essential part of colonoscopy because of significant information provided by retroflexed view compared with standard forward view.1,2 Only a few cases of rectal perforation secondary to retroflexion are reported.3 We describe a case of rectal perforation after retroflexion of the colonoscope in a healthy rectum during a screening colonoscopy.

The primary extranodal B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) is a distinct clinical pathologic entity that develops in diverse anatomic locations such as the stomach, salivary gland, thyroid, lung, and breast; however, colorectal involvement is rare. To the best of our knowledge, only 30 cases of primary rectal MALT lymphoma have been published in the English language literature, mostly from Japan. A single case has been reported from the US before this report. The most common symptoms ranged from asymptomatic to occult or gross gastrointestinal bleeding. Simultaneous involvement of the cecum or colon was seen in 20% of the patients. Ninety percent of the patients were classified as low grade, Stage 1 at the time of diagnosis. Polypoid lesions were 10-fold more common than ulcerative lesions. Seven patients were reported to have H pylori in the stomach. The majority of the patients underwent surgical or endoscopic resection as a cure; however, controversy exists with regards to antibiotic treatment or observation alone because of unknown etiopathogenesis. Infection with microorganisms other than H pylori has been postulated in the development of rectal MALT lymphoma; however, this hypothesis remains unproven. The overall prognosis of rectal MALT lymphoma appears favorable; however, long-term follow-up data is lacking. Therefore, periodic clinical monitoring should be done in these patients.

Background: An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems. Methods: Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia. Results: Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula. Conclusions: Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula. (Gastrointest Endosc 1997;46:156-60.)

BACKGROUND:Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications.METHODS:All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival.RESULTS:Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent).CONCLUSIONS:The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.

The majority of duodenal diverticula are asymptomatic and seldom cause gastrointestinal hemorrhage. We observed a 58-year-old woman who presented with melena. On admission her vital signs were stable and hematocrit was 27.5 %. Emergency upper endoscopy using a forward-viewing endoscope (Olympus XQ 20, Olympus America Inc., Lake Success, N.Y.) was performed but there was no evidence of bleeding. Conservative treatment was initiated and her condition remained stable until she had a maroon stool the next morning. Upper endoscopy using the same endoscope was repeated but there was no evidence of bleeding again. Angiography also failed to demonstrate extravasation. Duodenoscopy using a side-viewing endoscope (Olympus JF 1T-20) revealed a diverticulum in the beginning of the third portion with a blood clot at the base. After irrigation, a red protuberance with a glistening surface was observed, and heater-probe therapy was applied to this area. Unfortunately, this application provoked further bleeding and the patient required an emergency laparotomy. Following duodenotomy, she was treated with diverticuloplasty. Recovery was uneventful. Duodenal diverticulum is a rare source of gastrointestinal bleeding and when it occurs it is difficult to diagnose. Usually the diagnosis is considered by exclusion of other bleeding sources and repeated examinations may be necessary. Endoscopic verification of bleeding duodenal diverticula and endoscopic management with injection therapy have been reported previously. 13 Duodenoscopy with a side-viewing endoscope is recommended, as in our case.

Stricture formation in the gastrointestinal tract is quite common. The majority of these are peptic strictures of the esophagus related to gastroesophageal reflux and can be effectively managed with standard mercury bougies and medical antireflux therapy.l,2 However, strictures occur in the setting of malignancy, postoperative anastomoses, caustic injury, and less often peptic injury where the lumen is severely narrowed, irregular, and tortuous and mercury-filled bougies either will not reach or not pass. The irregularity of a stricture may increase the possibility of perforation.3 When these types of strictures are encountered, a variety of other therapies are employed, including surgery4-9 or Eder-Puestow dilation.3,lo-12 Strictures beyond the esophagus have been almost exclusively managed by surgery, but recently there have been several reports of utilization of coaxial balloon dilation of the pylorus and biliary tree.13,14 Coaxial balloon technology for the management of strictures has solved some of the problems related to dilation of severe esophageal strictures and that of access to areas like the pylorus and biliary tree.14,15 However, since the use of coaxial balloon dilators requires that they be passed over a guide wire to allow exchange of catheters and prevent lumen injury, passage of a guide wire through the area of stricture is essential. The passage of this guide wire, however, may be very difficult if not impossible at times. We report a method employing the toposcopic balloon catheter which allows passage of a guide wire through irregular or tortuous areas.