Aspects of the assessment and management of pharyngoesophageal dysphagia

Swallowing complaints are common and may have significant consequences for nutrition and pulmonary health. Etiology varies and different aspects of the deglutitive system may be affected. A thorough assessment from the oral cavity to the stomach will provide physiologic information that enables specific targeted management plans to be devised. Although the swallow trajectory bridges anatomic areas, there has previously been a tendency to compartmentalize assessment and treatment by arbitrary anatomic boundaries. It is now clear that this approach fails to appreciate the complexity of swallow mechanics and that systems (oral, pharyngeal, esophageal, and pulmonary) are intertwined and codependent. Swallowing specialists from different backgrounds and with complementary skill sets form a multidisciplinary team that can provide insight and address multiple areas of management. With the advent of new tools for instrumental evaluation, such as manometry, targeted rehabilitative strategies can be informed by physiology, increased in precision and breadth, and assessed quantitatively. Surgical approaches have evolved toward endoscopic techniques, and food technology is expanding options in dietary management. The multidisciplinary team is core to managing this varied and often neglected patient population. This review is for clinicians treating swallowing disorders and will explore the selected aspects of the assessment and management of pharyngoesophageal swallowing disorders.

GIE Editorial Board top 10 topics: advances in GI endoscopy in 2019

The American Society for Gastrointestinal Endoscopy's GIE Editorial Board reviewed original endoscopy-related articles published during 2019 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of disinfection, artificial intelligence, bariatric endoscopy, adenoma detection, polypectomy, novel imaging, Barrett's esophagus, third space endoscopy, interventional EUS, and training. This document summarizes these "top 10" endoscopic advances of 2019.

Effect and safety of mark-guided vs standard peroral endoscopic myotomy: A retrospective case control study

BACKGROUND

Peroral endoscopic myotomy (POEM) is a promising therapeutic modality for esophageal achalasia worldwide. However, clinical failure and adverse events of POEM have still been concerned.

AIM

To compare the efficacy and safety of a novel mark-guided POEM with standard POEM.

METHODS

A total of 133 patients with esophageal achalasia who underwent POEM from May 2013 to May 2019 were enrolled in this retrospective study. Of the 133 patients, there were 64 patients in the mark-guided POEM group and 69 patients in the standard POEM group. The clinical success, procedural duration and adverse events were compared between the two groups at 3 mo, 12 mo and 24 mo postoperatively.

RESULTS

Characteristic baseline was similar in the mark-guided POEM group and standard POEM group. The clinical success was comparable between the two groups, ranging from 92% to 98%, at 3 mo, 12 mo and 24 mo postoperatively (all P > 0.5). Eckart score, Gastroesophageal Reflux Disease Questionnaire score and SF-36 score were not different between the two groups after treatment (all P > 0.05). No severe adverse events occurred in the two groups. However, mark-guided POEM required shorter procedural duration, and less use of proton pump inhibitors and lower incidence of reflux symptoms than the standard POEM (all P < 0.001).

CONCLUSION

Mark-guided POEM and standard POEM were both effective and safe for the treatment of esophageal achalasia. However, the mark-guided POEM was characterized by shorter procedural duration, less use of proton pump inhibitors and lower incidence of reflux symptoms.

Third Space Endoscopy: Lessons Learnt From a Decade of Submucosal Endoscopy

The field of third space endoscopy (TSE), also called submucosal endoscopy using a mucosal flap valve, allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.

Per-oral endoscopic myotomy and gastroesophageal reflux: Where do we stand after a decade of "POETRY"?

Per-oral endoscopic myotomy (POEM) was introduced nearly a decade ago. Since then, the literature on its safety and efficacy has been ever increasing. Initial studies focused solely on the feasibility and efficacy of this procedure in patients with idiopathic achalasia. Subsequent studies analyzed the incidence of gastroesophageal reflux disease (GERD) in addition to the efficacy of POEM. These studies depict a high incidence of GERD after POEM. However, vast majority of these studies lacked a comprehensive evaluation of GERD after POEM. Consequently, it is difficult to provide a true estimate of the incidence of GERD in these patients. Majority of the patients with post-POEM GERD are asymptomatic and those with symptoms usually respond well to proton pump inhibitors. However, the long-term consequences of asymptomatic GERD with increased esophageal acid exposure are not well known. These patients should probably undergo regular surveillance due to theoretical risks of complications like Barrett's esophagus and esophageal adenocarcinoma. It should be acknowledged that there is no well-controlled study to support the strategy of surveillance in this group of patients. Given the high incidence of GERD after POEM, it is time to devise minimally invasive novel strategies to prevent and manage post-POEM GERD. The current literature suggests that the technique of POEM and other factors like type of achalasia do not influence the occurrence of GERD after POEM. Therefore, the endoscopists will need to think out of the box to prevent post-POEM GERD.