Cap-Assisted Argon Plasma Coagulation of Esophageal Inlet Patch

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by Jay Bapaye, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES

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by Jay Bapaye, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

A 38-year-old woman presented with globus sensation, intermittent dysphagia and cough. On EGD two areas of stomach heterotopia were found in the upper esophagus (“inlet patches”) (Figure 1).

Figure 1. Gastric heterotopia of the upper esophagus. A. White light imaging showing one inlet patch measuring about 25 x 15 mm. B. NBI view of inlet patch. C. Two inlet patches facing each other (yellow arrows). D. NB characterization makes these lesions more visible and evident. There were no suspicious mucosal pre-neoplastic changes.

Because this patient was symptomatic a decision to ablate the inlet patches was taken. Multiple studies have shown good results for argon plasma coagulation (APC) in the ablation of symptomatic inlet patches (1-3). It is important to carefully characterize these lesions endoscopically and re ablation biopsies are recommended to evaluate the type of stomach tissue. Cases of adenocarcinoma arising in inlet patches have been described (4-8).

Whereas some experts ablate the lesions just using the argon plasma catheter through the scope, we prefer to use a distant transparent cap (Figure 1E-G). Inlet patches are usually located very close to the upper esophageal sphincter. Thus, a cap will keep the esophageal entrance open while allowing to target the inlet patches with the tip of the argon plasma catheter (Panels F and G). In addition, the cap allows for scrapping off ablated tissue and applying a second or third round of APC. The aim of APC is to change the color of the mucosa to brown color (Panel H), and not to carbonize or charr it black, as this may result in deep tissue injury and subsequent esophageal stenosis. The settings used are 40 to 50 Watts with 0,8-liter flow. However, one can apply lower wattage and flow, if the endoscopist can achieve a controlled mucosal ablation with the movements of the scope and catheter.

References:

1. Bajbouj M, Becker V, Eckel F, Miehlke S, Pech O, Prinz C, Schmid RM, Meining A. Argon plasma coagulation of cervical heterotopic gastric mucosa as an alternative treatment for globus sensations. Gastroenterology. 2009 Aug;137(2):440-4. doi: 10.1053/j.gastro.2009.04.053. Epub 2009 May 4. PMID: 19410576.

2. Brechmann T, Mühlenkamp M, Schmiegel W, Viebahn B. Argon Plasma Coagulation of Gastric Inlet Patches of the Cervical Esophagus Relieves Vocal and Respiratory Symptoms in Selected Patients. Dig Dis Sci. 2023 May;68(5):1936-1943. doi: 10.1007/s10620-022-07745-9. Epub 2022 Nov 14. PMID: 36376579.

3. Meining A, Bajbouj M, Preeg M, Reichenberger J, Kassem AM, Huber W, Brockmeyer SJ, Hannig C, Höfler H, Prinz C, Schmid RM. Argon plasma ablation of gastric inlet patches in the cervical esophagus may alleviate globus sensation: a pilot trial. Endoscopy. 2006 Jun;38(6):566-70. doi: 10.1055/s-2006-925362. PMID: 16802267.

4. Dziadkowiec KN, Sánchez-Luna SA, Stawinski P, Proenza J. Adenocarcinoma Arising From a Cervical Esophageal Inlet Patch: The Malignant Potential of a Small Lesion. Cureus. 2020 Jul 19;12(7):e9284. doi: 10.7759/cureus.9284. Erratum in: Cureus. 2022 Sep 13;14(9):c74. doi: 10.7759/cureus.c74. PMID: 32832282; PMCID: PMC7437138.

5. Ajmal S, Young JS, Ng T. Adenocarcinoma arising from cervical esophageal gastric inlet patch. J Thorac Cardiovasc Surg. 2015 Jun;149(6):1664-5. doi: 10.1016/j.jtcvs.2015.03.050. Epub 2015 Apr 1. PMID: 25911182.

6. Probst A, Schaller T, Messmann H. Adenocarcinoma arising from ectopic gastric mucosa in an esophageal inlet patch: treatment by endoscopic submucosal dissection. Endoscopy. 2015;47 Suppl 1 UCTN:E337-8. doi: 10.1055/s-0034-1392423. Epub 2015 Jul 2. PMID: 26134434.

7. Kadota T, Fujii S, Oono Y, Imajoh M, Yano T, Kaneko K. Adenocarcinoma arising from heterotopic gastric mucosa in the cervical esophagus and upper thoracic esophagus: two case reports and literature review. Expert Rev Gastroenterol Hepatol. 2016;10(3):405-14. doi: 10.1586/17474124.2016.1125780. Epub 2015 Dec 16. PMID: 26610162.

8. Nonaka K, Watanabe M, Yuruki H, Okuda A, Sakurai K, Iyama K, Sasaki Y. Narrow band imaging of adenocarcinoma arising from ectopic gastric mucosa in the upper esophagus. Endoscopy. 2013;45 Suppl 2 UCTN:E112-3. doi: 10.1055/s-0032-1325865. Epub 2013 May 28. PMID: 23716084.

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