 Okay, I'm going to discuss the management of acute and acute anachronic esophageal obstruction today. Just to start out with a simple definition, acute or acute anachronic esophageal obstruction is the sudden or on a sudden complete or near complete blockage of the esophagus manifested by the inability or the impedance of movement of fluids and solids from the oropharynx to the stomach. Pain is sometimes present, but not always. And common complications include aspiration, perforation and bleeding. We're not going to focus today on the complications of it, since that was covered mostly by DJ and Anthony's talk on esophageal perforation and bleeding. But I'm going to try and look at the management of it. So my approach to this topic today is decided to focus it a little, looking more specifically at foreign body ingestion in children as a cause of acute esophageal obstruction. And then in terms of acute and acute anachronic obstruction in adults, just looking at a broad classification and approach to the problem, and then specific management of acolysia as a cause of esophageal obstruction, read a little bit around stenting as well in terms of new plasms as a cause of obstruction. And we'll briefly discuss that at the end. So if we look at obstruction just coming up with a little flow diagram or recipe, a very simple way of classifying it is obstruction from inside the lumen or outside the lumen, inside the lumen looking at foreign bodies or food boluses as a foreign body, quite common or new plasms, and then also what we can also be there is a benign disease, changing the physiological functioning or anatomical functioning of the esophagus and then outside the lumen compression. So again, looking at inside the lumen, if you look on acute anachronic obstruction, there can be benign causes and malignant causes for that benign causes being, we will, I will talk about that a little bit later. But for example, your acolysias, et cetera, a stricter formation for whatever reason, and then your esophageal new plasms, and then acutely, mostly foreign bodies, food boluses, et cetera. The foreign body, as I say, sometimes it is as simple as a foreign body that gets stuck in the esophagus. But more often than not, especially in adults, when there is a foreign body as stuck in the esophagus causing obstruction, you have to ask yourself whether this has underlying mechanical explanation and your plastic explanation or whether you are looking at a mutility disorder. So a foreign body isn't always just a foreign body. So going back and just starting by looking specifically at foreign body ingestion in kids, it's quite common and you will often and you will see quite a lot of it, especially if you work at Red Cross. And it literally can be any object. Most commonly reported and a lot of studies done on ingestion of coins, toys, and the one that definitely is worth mentioning is battery ingestion, because it has a little bit of other or it has more implications than a lot of the other foreign bodies that could be swallowed. And then of course, food boluses, bony ingestion, et cetera, bones getting stuck in the esophagus, et cetera. So in kids as an adult, there is certain predisposing factors that you have to think about, less common in kids than in adults, but still worth thinking about. Esophageal atresia at birth, the patient would have had previous surgery. Anastomosis would have been done. And that predisposes the child to narrowing, stricter formation and potential abnormal mutility of the esophagus. Vascular ring formation, ectopic salivary glands, cartilaginous res, a middle midiastinal mass, esophageal stricter, echolasia also in kids and duplication cysts that can all predispose the child to foreign body obstruction. Where does the majority of foreign bodies get stuck? 63 to 83 percent at the cryopharyngeal muscle, which is the narrowest part, and then the other two narrowings of the aorta, the aorta crossover, mid esophagus, about 10 to 17 percent, and then at the lowest of a joll swinger, 5 to 20 percent. Symptoms that kids present with is anything from completely asymptomatic and unrecognised, just verbally confessing to ingesting something, to quite severe symptoms, especially respiratory symptoms. So blood coughing, drooling dysphagia, going all the way down to respiratory distress, strida, tachypnea, dyspnea, vomiting and wheezing, and the big risk factor of course is aspiration that you're worried about and that you want to prevent. So as I said, battery ingestion is probably worth mentioning separately. Quite a few studies have been done looking specifically at the implication of battery ingestion. Because this, it can also cause caustic ingestion, can cause pressure necrosis, tissue necrosis from electrical discharge from the battery, as well as toxin release, especially one often mentioned is mercury poisoning. So be mindful when you see that, that will definitely put a rush on your management of these patients and is a definite indication for endoscopic removal of the foreign body. So a review of reported cases showed that batteries less than 15 millimeters almost never become larger than esophagus, whereas those that are larger than 20 millimeter account for most of the reported esophageal injuries. So three volt lithium battery is enough to cause cellular electrolyte flux, releasing intracellular potassium and can result in cell death and tissue necrosis. Complications of battery ingestion specifically, these can apply to other foreign bodies as well, but looking specifically at batteries is a tracheosophageal fistula, esophageal burn with or without perforation, they auto esophageal fistulas, esophageal strictures and of course death. Emergency endoscopy must therefore be performed for all battery ingestions. Just in terms of diagnostics that you can help with the workup of these patients. Radiology mostly x-rays and contrast studies is what you're looking at, must include a lateral view and an anterior posterior view of both the neck and the chest, mainly for your own to see if there's already complications of the ingestion on your lateral view of your neck, you can see free prevertible air, also housed with the exact location of the foreign body where it is stuck and then often these foreign bodies aren't easy to see, so you want to maximize your chances of seeing it, therefore the different views. The radiological evaluation of a child with a history of possible swallowing a point or a radiopeic object is highly sense-different specific. Objects that are only faintly radiopeic such as bones or small items of aluminium are often seen only on the lateral views because the in non-view increases their radiogeneity. Contrast study, totally radiolucent foreign bodies such as plastic beads or toys present a much more difficult radiological challenge and is often very difficult to see. In these cases suspicion must be high enough to use contrast studies for the diagnosis. What you're looking at is using an esophagram that may demonstrate a radiolucent foreign body as a filling defect and may also reveal anomalies as compression by a vascular ring or intrinsic structure as an underlying cause for your esophageal obstruction by foreign body. Even though preoperative radiographic evaluation is accurate in demonstrating a foreign body in a child the clinical situation should dictate the decision to perform an esophagoscopy. In an attempt to minimise the complications associated with the delay in diagnosis, endoscopy for suspicious cases with or without radiological confirmation has been advocated. So when to remove basically rapid diagnosis and treatment of foreign bodies in the esophagus will decrease mobility as well as links length of hospital stay. Quite a few studies have been done in terms of watchful waiting especially in terms of coin ingestion. It has been shown that about 60 to 80 percent of coins ingested will pass spontaneously within 8 to 16 hours and chances of the coin passing spontaneously of increases with the child's age of course. So there is there is enough I think re-evidence to depending on the child's age the clinical condition of the child to watch and wait and see whether the child will pass the coin spontaneously. In terms of other toys and other foreign bodies really as I said battery ingestion is a definite indication and then you have to let yourself be led by you know what the child if it's something with shop edges something that you're concerned about perforation, funny shape, stuck already, child is symptomatic of course you're going to do an emergency endoscopic removal of the of the foreign body. Various studies have been done and attempting or attempts have been made at using glucagon to stimulate passage of the foreign body through the esophagus especially with food bolus obstruction. This is now there's quite there's enough evidence I think now to this has been shown to be ineffective and and not a good choice when managing obstruction. There is more than one method of retrieval however endoscopic retrieval is the gold standard. I will briefly just discuss Foley catheter extraction and Bouginage to push the foreign body into the stomach as other options if you don't have endoscopy available. However I don't think these these two approaches is really acceptable in a in a tertiary tertiary level setting. For Foley catheter retrieval Foley catheter is it's generally quite easy to use and is and is quite successful in removing smooth objects in the upper two thirds of the esophagus. The procedure is very cost-efficient and can be performed without anesthesia and fluoroscopic guidance. The risk of the procedures are potential e-way compromise. The patient can aspirate the foreign body as well as esophageal injury inability to visualize the esophageal reaction to the foreign body and discomfort in the awake child. The success rate of 84 to 96 percent of Foley catheter extraction is less than less than with endoscopy and Foley catheter insertion itself has resulted in pushing the foreign bodies further down into the stomach. Bujanage, the Bujanage has been shown to be successful in only selected cases. Patient has usually ingested the single coin within 24 hours of presentation is very stable has no history of esophageal abnormalities or previous foreign body aspiration. You use a blunt tip to weighted esophageal bougie introduced and then advanced to the foreign body and then literally push the coin or the other smooth object into the stomach with the expectation that the object will then spontaneously be passed per rectum by the child. Roughly 90 to 95 percent of these objects will be evacuated spontaneously. The concern of course with the Bujanage is that the non-evacuated foreign bodies can lead to obstruction or perforation of the small intestine requiring more difficult endoscopic retrieval or even surgical exploration. Endoscopic retrieval as I said the gold standard. Rigid endoscopy is the most reliable and successful method used in the retrieval of esophageal foreign bodies. The safety and success rate with rigid endoscopy has approached 100 percent with minimal complications. Procedure is performed in a controlled environment. Patient is placed in a supine position with the head in the neutral sniffing position. The cervical spine is straight allowing for passage of the endoscope over the cervical kyphosis and yeah as I said very good results and definitely gold standard for immoral foreign bodies. So just going back to the broad approach in terms of adults to remind you what we said previously looking at reasons inside the lumen as a cause of obstruction, benign causes, malignant causes and then foreign bodies and as I said with foreign bodies remember that they might be mechanical neoplastic or motility disorders as an underlying cause. So just looking at that common causes, motility disorders that might predispose the patient to acute esophageal obstruction. Ecclesia being the most common one diffuse esophageal spasm, systemic sclerosis and then a condition that's been written about quite a lot recently and has been shown to account for about 50% of episodes of acute esophageal obstruction in adults and in a big centre in the States is is eucenophilic esophagitis and then rare causes for instance chakras disease. Looking at oropharyngeal motility order specifically because remember obstruction or the acute obstruction can happen in any part of the anatomical esophagus and oropharyngeal motility disorder shouldn't be forgotten which can broadly be classified into neurological underlying pathology and muscular pathology, strokes, motoneuron disease, multiple sclerosis and Parkinson's and then muscular causes myestemia, demyocytus, muscular dystrophy, chakras pharyngeal incoordination etc. Then looking at common mechanical causes, peptic structure probably the most common one and then lower esophageal rings or your shachke rings weeps, previous surgical anastomosis caustic ingestion and its complications then extrinsic compression as well as new plasms. In terms of extrinsic compression vascular causes is quite commonly thoracic aortic aneurysms massively dilated atria abnormalities with the subclavian vasculature etc as well as mid esophageal or mid thoracic tumors and that can cause compression of the of the esophagus. It is however fairly rare as a cause of compression and interestingly enough new plasm very rarely presents with acute obstruction esophageal obstruction and these patients meaning what I mean to say by that is that these patients don't don't present with a foreign body stuck in the esophagus. It's so gradual and on say that these patients naturally will eat a softer diet, will change to liquids etc it's very rare that you would see a patient with a foreign body stuck in the esophagus causing acute obstruction with a new plasm as the underlying cause. So just zooming in a little bit on ecolasia as a underlying cause for acute esophageal obstruction. Ecolasia is esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal swinter. It is characterized by incomplete lower esophageal swinter relaxation, increased lower esophageal swinter tone and a lack of peristalsis of the esophagus in the absence of another cause. Since this talk is mostly about management I'm not going to go in into any other details around the condition but specifically going to discuss the three treatment options of ecolasia because should these patients present you would manage the acute obstruction endoscopically preferably and then go on to manage the underlying go on to manage ecolasia as underlying cause. You can consider medical management as well as endoscopic management and finally surgical management. Medical management basically the philosophy behind it is the elimination of the outflow resistance caused by the hypotensives and the non-relaxing lower esophageal swinter. Calcium channel blockers and nitrates are commonly used to try and achieve this but only has about a 10% success rate. So really only for patients that there is absolute contraindications for any other intervention you would consider this or an add-on to endoscopic or surgical management. Endoscopic treatment has become more popular and as I said that's the gold standard in the acute setting to remove the obstructive bolus. For more definitive care in terms of endoscopic treatment you can you have three options that you can consider. Intra swinteric botulin toxin injection, pneumatic dilatation and then a fairly novel approach per oral endoscopic myotomy. There's not a lot published on it yet. Quite a bit of research needs to be done about it but it also still needs to be done but in preliminary studies it has been shown to be as effective if not more effective than pneumatic dilatation. So just looking at Botox is an option that philosophy is you block the release of the acetylcholine at the level of the lower esophageal swinter to restore the balance between the excitatory and the inhibitory neurotransmitters. It has our ever only limited value. Only about 30% of patients have relief one year post-treatment has significantly higher symptom recurrence in comparison to pneumatic dilatation and laparoscopic myotomy. It can also cause an inflammatory reaction that can complicate your definitive management later on and can make a myotomy incredibly difficult. It is an appropriate option to consider in an older patient that is a poor candidate for dilatation or for definitive surgery. Pneumatic dilatation is recommended where surgery is not appropriate. It should be done by a fairly experienced gastroenterologist or endoscopist. The balloon is inflated at the level of the gastroesophageal junction to blindly rupture the muscle fibres while leaving the mucosa intact. It's got a 70 to 80% success rate but also as a perforation rate of about 5% which is actually quite high. 50% of patients require more than one dilatation and the incidence, big problem with this is the incidence of pathological gastroesophageal reflux disease after the procedure approaches 30% which is also very high and actually quite unacceptable. And then the new novice approach to poor oral endoscopic myotomy quite a difficult procedure to also requires the hands of a fairly experienced experiencing endoscopist. My slide where I put it this is gone. Basically it seems to be a promising procedure however there are some concerns about the the technique it's a very demanding procedure requires major skill the very long learning curve although several studies have reported significant reduction of the lower esophageal pressure as demonstrated by manometry the less pressure was often between 15 and 20 and you really want it below 10 and it has been shown that a higher pressure than 10 is a poor predictor for long-term success rate. And then the procedure of choice in the management of acolytus surgical laparoscopic haloma myotomy and partial fund application and it's been shown to have excellent results. Patients generally have a very short hospital stay a very fast recovery and what's very nice is that you can achieve the balance between relieving symptoms and preventing reflux by adding a partial wrap. Basically very simply use five trochars you have control division of the muscle fibers of the lower five centimeters of the esophagus and 1.5 centimeters of the proximal stomach and that is then followed by a partial anterior fund application and has been shown to have the best long-term results of all three of the treatment options for acolysia. I'm not going to say much about stenting it is something that definitely should be considered in the patient presenting with a new plasm as an underlying cause for esophageal obstruction and this is more talking about a chronic onset of the obstruction. There's a very nice review article that I will make available to you guys recently published in the May Journal of the American Society for Gastroenterologists a review article on all the available stents currently on the market. In summary covering the self-expanding metal stents comparing them to the self-expanding plastic stents also quite a good comparison in terms of covered and uncovered stents. Let's quickly do so basically I'll quickly talk you through what I have here. You have extrinsic esophageal compression due to primary or secondary tumours or you have malignant esophageal obstructions stenting is a very good option to think about can also use it for a fractory or recurrent esophageal structures tracking esophageal fistulas and esophageal perforations or leaks. Two stents multiple types of prosthesis are available from various manufacturers throughout the world. The list is quite long. Stents made of alloy, nickel, titanium and to a lesser extent self-expanding plastic stents now dominate the US market and the plastic stents mainly because of their ability to conform to the anatomical angulations and then the alloy nickel for their removable. The available stents instant material design luminal diameter radial force exerted flexibility and the degree of shortening after use all these influencing the prognosis and palliation of the patient. The self-expanding metal stents you have partially covered and uncovered stents. There is evidence that the covered self-expanding metal stents are far better than the uncovered stents. It should be noted that the described studies comparing the covered with uncovered stents used only partially covered self-expanding metal stents. So the uncovered portion of the partially covered stent allows for embedding and anchoring which is important to remember because one of the problems could be stent migration etc. So just remember that partially covered self-expanding metal stents have been shown to be superior. Recently a fully covered nitenol prosthesis has been approved by the FDA allowing the option of removing the stent. But it is also potentially associated with increased risk of migration. Fully published data is still awaiting these stents. Then the self-expanding plastic stents have been shown to be very safe and effective in the palliation of malignant dysphagia. In a case a series of 33 patients with malignant dysphagia will underwent self-expanding plastic stent placement. Improvement in dysphagia was noted in all the patient. Stent occlusion as a result of tumor overgrowth occurred at a rate of 12.1 percent. Stent migration rate was 6 percent and the overall re-intervention rate was 21.1 percent. Compe is fairly reasonably well to the metal stents. Although the metal stents seems to still be superior. The use of the self-expanding metal stents is associated with significantly fewer complications in the plastic stents when inserted for malignant disease. Quality of evidence for this recommendation is moderate and the strength of the recommendation is quite strong. Just remember when you insert the stent that it's not without complications. Just listed a few of the most common one, aspiration, malposition, delivery, system entrapment, stent dislodgement, perforation, bleeding, chest pain, nausea, recurrent dysphagia and gastroesophageal reflux disease and aspiration. So in summary basically look at your patient. Is this an adult patient? Is this a child? Does the patient have any underlying disease or facility that could explain the foreign body impaction or the acute obstruction? Remove the obstruction preferably endoscopically and then treat the underlying cause if it is indicated. Thank you.