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Nabi Z, Reddy DN. Submucosal endoscopy: the present and future. Clin Endosc 2023; 56:23-37. [PMID: 36617645 PMCID: PMC9902679 DOI: 10.5946/ce.2022.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023] Open
Abstract
Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India,Correspondence: Duvvur Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad 500 082, India E-mail:
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Kamal F, Khan MA, Lee-Smith W, Sharma S, Acharya A, Jowhar D, Farooq U, Aziz M, Kouanda A, Dai SC, Howden CW, Munroe CA. Systematic review with meta-analysis: one-year outcomes of gastric peroral endoscopic myotomy for refractory gastroparesis. Aliment Pharmacol Ther 2022; 55:168-177. [PMID: 34854102 DOI: 10.1111/apt.16725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/05/2021] [Accepted: 11/22/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Several studies have examined the efficacy of gastric peroral endoscopic myotomy (G-POEM) for gastroparesis. AIM To evaluate the mid-term efficacy of G-POEM by meta-analysis of studies with a minimum 1 year of follow-up. METHODS We reviewed several databases from inception to 10 June 2021 to identify studies that evaluated the efficacy of G-POEM in refractory gastroparesis, and had at least 1 year of follow-up. Our outcomes of interest were clinical success at 1 year, adverse events, difference in mean pre- and 1 year post-procedure Gastroparesis Cardinal Symptom Index (GCSI) score, and difference in mean pre- and post-procedure EndoFLIP measurements. We analysed data using a random-effects model and assessed heterogeneity by I2 statistic. RESULTS We included 10 studies comprising 482 patients. Pooled rates (95% CI) of clinical success at 1 year and adverse events were 61% (49%, 71%) and 8% (6%, 11%), respectively. Mean GCSI at 1 year post-procedure was significantly lower than pre-procedure; mean difference (MD) (95% CI) -1.4 (-1.9, -0.9). Mean post-procedure distensibility index was significantly higher than pre-procedure in the clinical success group at 40 and 50 mL volume distension; standardised mean difference (95% CI) 0.82 (0.07, 1.64) and 0.91 (0.32, 1.49), respectively. In the clinical failure group, there was no significant difference between mean pre- and post-procedure EndoFLIP measurements. CONCLUSIONS G-POEM is associated with modest clinical success at 1 year. Additional studies with longer follow-up are required to evaluate its longer-term efficacy.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
| | - Muhammad Ali Khan
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wade Lee-Smith
- Mulford Health Sciences Library, University of Toledo, Toledo, Ohio, USA
| | - Sachit Sharma
- Department of Medicine, University of Toledo, Toledo, Ohio, USA
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ashu Acharya
- Department of Medicine, University of Toledo, Toledo, Ohio, USA
| | - Dawit Jowhar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Umer Farooq
- Department of Medicine, Loyola Medicine/MacNeal Hospital, Berwyn, Illinois, USA
| | - Muhammad Aziz
- Division of Gastroenterology, University of Toledo, Toledo, Ohio, USA
| | - Abdul Kouanda
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
| | - Sun-Chuan Dai
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Craig A Munroe
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
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Abstract
PURPOSE OF REVIEW Third space endoscopy (TSE) or submucosal endoscopy provides with the opportunity for minimally invasive management of various gastrointestinal disorders. TSE is a relatively new field and the knowledge on its utility continues to advance. The purpose of this review is to provide with updated evidence on the efficacy and utility of TSE in gastrointestinal motility disorders including achalasia and refractory gastroparesis. RECENT FINDINGS Peroral endoscopic myotomy (POEM) is a safe procedure with emerging evidence on its durability as well. Major technical variations do not appear to impact the outcomes of POEM. Recent randomized trials suggest superiority of POEM over pneumatic dilatation and noninferiority over Heller's myotomy in idiopathic achalasia. With regard to gastric POEM (G-POEM), recent evidence confirms its efficacy in refractory gastroparesis. Although effective, the long-term outcomes of G-POEM are not well known. In addition, the criteria for patient selection remain elusive. SUMMARY TSE has emerged as a new frontier in the endoscopic management of gastrointestinal motility disorders. While short-term outcomes are encouraging, the durability of TSE remains to be seen in achalasia as well as refractory gastroparesis. Insights regarding patient selection and predictors of outcomes may help optimizing the results of gastric POEM in refractory gastroparesis.
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