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Che SYW, Joseph S, Kuchta K, Amundson JR, VanDruff VN, Ishii S, Zimmermann CJ, Hedberg HM, Ujiki MB. Outcomes after per-oral endoscopic myotomy for Zenker's diverticula (Z-POEM) and correlation with impedance planimetry (FLIP). Surg Endosc 2024; 38:957-963. [PMID: 37935919 DOI: 10.1007/s00464-023-10512-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/08/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Zenker's diverticulum (ZD) is a false pulsion diverticulum of the cervical esophagus. It is typically found in older adults and manifests with dysphagia. The purpose of this study is to describe our experience with Per-oral endoscopic myotomy for Zenker's (Z-POEM) and intraoperative impedance planimetry (FLIP). METHODS We performed a single institution retrospective review of patients undergoing Z-POEM in a prospective database between 2014 and 2022. Upper esophageal sphincter (UES) distensibility index (DI, mm2/mmHg) was measured by FLIP before and after myotomy. The primary outcome was clinical success. Secondary outcomes included technical failure, adverse events, and quality of life as assessed by the gastroesophageal health-related quality of life (GERD-HRQL), reflux severity index (RSI), and dysphagia score. A statistical analysis of DI was done with the paired t-test (p < 0.05). RESULTS Fifty-four patients underwent Z-POEM, with FLIP measurements available in 30 cases. We achieved technical success and clinical success in 54/54 (100%) patients and 46/54 patients (85%), respectively. Three patients (6%) experienced contained leaks. Three patients were readmitted: one for aforementioned contained leak, one for dysphagia, and one post-operative pneumonia. Three patients with residual dysphagia underwent additional endoscopic procedures, all of whom had diverticula > 4 cm. Following myotomy, mean DI increased by 2.0 ± 1.7 mm2/mmHg (p < 0.001). In those with good clinical success, change in DI averaged + 1.6 ± 1.1 mm2/mmHg. Significant improvement was found in RSI and GERD-HRQL scores, but not dysphagia score. CONCLUSION Z-POEM is a safe and feasible for treatment of ZD. We saw zero cases of intraoperative abandonment. We propose that large diverticula (> 4 cm) are a risk factor for poor outcomes and may require additional endoscopic procedures. An improvement in DI is expected after myotomy, however, the ideal range is still not known.
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Affiliation(s)
- Simon Y W Che
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA.
| | - Stephanie Joseph
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
| | - Julia R Amundson
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Vanessa N VanDruff
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Shun Ishii
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
| | - Christopher J Zimmermann
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
| | - Herbert M Hedberg
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, GCSI Suite B665, 2650 Ridge Ave, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
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Ward MA, Fair L, Misenhimer J, Esteva S, Greenberg I, Ogola G, Aladegbami B, Leeds SG, Kedia P. Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study. Dis Esophagus 2023; 36:doad041. [PMID: 37391268 DOI: 10.1093/dote/doad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/14/2023] [Indexed: 07/02/2023]
Abstract
Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p < 0.0001), 6 (2.5 vs 0, p < 0.0001), and 12 months (2.5 vs 0, p = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p < 0.0001) and 6 months (40 vs 1, p = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. .
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Affiliation(s)
- Marc A Ward
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | - Lucas Fair
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Jennifer Misenhimer
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
| | - Simón Esteva
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | | | - Gerald Ogola
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Bola Aladegbami
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | - Steven G Leeds
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
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Bahdi F, Labora A, Shah S, Farooq M, Wangrattanapranee P, Donahue T, Issa D. From Scalpel to Scope: How Surgical Techniques Made Way for State-of-The-Art Endoscopic Procedures. GASTRO HEP ADVANCES 2023; 3:370-384. [PMID: 39131137 PMCID: PMC11307641 DOI: 10.1016/j.gastha.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/30/2023] [Indexed: 08/13/2024]
Abstract
The continuous evolution of endoscopic tools over the years has paved the way for minimally invasive alternatives to surgical procedures for multiple gastrointestinal conditions. While few endoscopic techniques have supplanted their surgical counterparts like percutaneous gastrostomy tubes, many have emerged as noninferior, less morbid alternatives for such diverse conditions as achalasia (peroral endoscopic myotomy), obesity (endoscopic sleeve gastroplasty), drainage of pancreatic walled off necrosis (EUS-guided cystogastrostomy), and gastric outlet obstruction (EUS-guided gastrojejunostomy). These techniques were based on surgical concepts and would not have been feasible without collaboration between surgeons and endoscopists. Such collaboration is exemplified by the antireflux fundoplication, which features combined hiatal hernia repair with transoral and incisionless fundoplication. The burgeoning armamentarium of endoscopic alternatives to traditional surgical procedures requires a multidisciplinary discussion and individually tailored treatment plans that consider patient preferences as well as the relative risks and benefits of surgical and endoscopic approaches. As technological advances give rise to ever more innovative endoscopic techniques, studies to evaluate clinical outcomes and define their role in treatment algorithms will be required.
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Affiliation(s)
- Firas Bahdi
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Amanda Labora
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sagar Shah
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Maryam Farooq
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peerapol Wangrattanapranee
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Timothy Donahue
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Danny Issa
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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5
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Zhu Q, Zhang H, Huang S, Gan P, Wang R, Peng Y, Lü M, Tang X. Research hotspots and trend of a emerging novel endoscopic technique of peroral endoscopic myotomy from 2010 to 2022: A bibliometric analysis. Medicine (Baltimore) 2023; 102:e35009. [PMID: 37682198 PMCID: PMC10489447 DOI: 10.1097/md.0000000000035009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023] Open
Abstract
Peroral endoscopic myotomy (POEM), which has been used to treat achalasia and other esophageal motility disorders for the past 10 years, has proven to be secure and efficient. Every year, more and more essays on this subject are published. We sought to investigate the global scientific outputs and hotspots of POEM produced by various nations, organizations, and authors. From 2010 to October 2022, there were 875 papers on POEM that were found in the Web of Science Core database. The bibliometric visualization analyses of nations/regions, institutions, authors, journals, references, and keywords were conducted by CiteSpace V.5.8.R3. Eight hundred seventy-five publications were included in this analysis. With 68 publications, Inoue H had the highest output. While Showa University in Japan was the most productive institution, the United States was the most productive nation. Among the journals, Surgical Endoscopy published the highest number of articles, followed by Gastrointestinal Endoscopy and Endoscopy. The top 10 keywords that appeared most frequently were achalasia, peroral endoscopic myotomy, POEM, myotomy, esophageal achalasia, dysphagia, heller myotomy, endoscopy, gastroparesis and peroral endoscopic myotomy. Seven frontiers, including meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, endoscopic submucosal dissection, and gastric peroral endoscopic myotomy, had an impact on future research on POEM. The previous 10 years have seen a considerable rise in POEM research, and this trend will continue. The most recent research frontiers, which require more attention, are meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, and gastric peroral endoscopic myotomy.
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Affiliation(s)
- Qingliang Zhu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Han Zhang
- Department of Gastroenterology, Zigong First People’s Hospital, Zigong, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui County People’ Hospital, Huaian, China
| | - Peiling Gan
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ruiyu Wang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Fuentes KMI, Seastedt KP, Kidane B, Servais EL. Advanced Endoscopy for Thoracic Surgeons. Thorac Surg Clin 2023; 33:251-263. [PMID: 37414481 DOI: 10.1016/j.thorsurg.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
The thoracic surgeon, well versed in advanced endoscopy, has an array of therapeutic options for foregut pathologic conditions. Peroral endoscopic myotomy (POEM) offers a less-invasive means to treat achalasia, and the authors' preferred approach is described in this article. They also describe variations of POEM, such as G-POEM, Z-POEM, and D-POEM. In addition, endoscopic stenting, endoluminal vacuum therapy, endoscopic internal drainage, and endoscopic suturing/clipping are discussed and can be valuable tools for esophageal leaks and perforations. Endoscopic procedures are advancing rapidly, and thoracic surgeons must maintain at the forefront of these technologies.
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Affiliation(s)
- Kathleen M I Fuentes
- Department of General Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Kenneth P Seastedt
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Biniam Kidane
- Department of Surgery, University of Manitoba, Room GE-611, 820 Sherbook Street, Winnipeg, Manitoba R3A 1R9, Canada
| | - Elliot L Servais
- Division of Thoracic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
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Cadena Aguirre DP, de Moura DTH, Hirsch B, Peixoto de Oliveira GH, Kum AST, Mahmood S, Bernardo WM, Sharma NR, De Moura EG. Flexible Endoscopy Versus Rigid Endoscopy or Surgery for the Management of Zenker's Diverticulum: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e43021. [PMID: 37680421 PMCID: PMC10480577 DOI: 10.7759/cureus.43021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 09/09/2023] Open
Abstract
Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques. Frequently, the choice of treatment depends on the physician's preference or experience, as well as the institution's resources and capacity. Therefore, this study aims to define the best approach based on the highest efficacy and the lowest severe adverse events. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed. Only comparative studies were included, analyzing flexible endoscopy versus rigid endoscopy or surgery. The outcomes analyzed were clinical and technical success, severe adverse events, length of stay, and duration of the procedure. Analysis was performed using Review Manager 5.4.1 (RevMan 5.4, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Eight retrospective cohort studies met the inclusion criteria. A total of 1281 patients were identified, 492 underwent flexible endoscopy, 453 underwent rigid endoscopy, and 336 underwent surgery. There was no difference in clinical success [risk difference (RD), 0.07 (95% CI -0.05 to 0.19%); P = 0.26], technical success [RD, 0.07 (95% CI -0.03 to 0.16); P = 0.18], severe adverse events [RD, -0.03 (95% CI -0.13 to 0.07; P = 0.052), perforation [RD, 0.07 (95% CI -0.04 to 0.19); P = 0.22] or procedure time [mean difference (MD), - 10.03 (95% CI -26.93 to 6.88); P = 0.24). There was lower length of stay with flexible endoscopy compared to the other approaches [MD, -1.98 (95% CI -3.56 to -0.40); P = 0.001]. Based on the current evidence, the three main techniques are effective for the treatment of Zenker's diverticulum. Although there was no significant difference in the safety of each technique in this meta-analysis, this result should be interpreted cautiously due to the limited data and the risk of vies between the techniques, considering that the results tend to favor flexible endoscopy, mainly explained by the newer and safer devices. Length of stay is lower with flexible endoscopy versus the other techniques, which can be beneficial considering the geriatric populations where Zenker's diverticulum mainly occurs.
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Affiliation(s)
- Diego P Cadena Aguirre
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Bruno Hirsch
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Guilherme Henrique Peixoto de Oliveira
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Angelo So Taa Kum
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | | | - Wanderley Marques Bernardo
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Neil R Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, USA
| | - Eduardo Guimarães De Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
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Jena A, Jain S, Sundaram S, Singh AK, Chandnani S, Rathi P. Electrosurgical unit in GI endoscopy: the proper settings for practice. Expert Rev Gastroenterol Hepatol 2023; 17:825-835. [PMID: 37497836 DOI: 10.1080/17474124.2023.2242243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 06/14/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Electrosurgical unit (ESU) is integral to the endoscopy unit. The proper knowledge of the Mode with setting is essential for good therapeutic outcomes and the safety of the patients. AREAS COVERED ESU generates high-frequency electric current, which could perform cutting and coagulation for various therapeutic interventions. We review the proper settings for common endoscopic interventions like hemostasis, polypectomy, sphincterotomy, and advanced procedures like endoscopic ultrasound-guided cysto-gastrostomy, bile duct drainage, and endoscopic Ampullectomy. We review the various waveforms of ESU in practice in endoscopy, including special conditions like patients with pacemakers. EXPERT OPINION Knowledge of the waveforms' duty cycle and crest factor is necessary. A high-duty cycle and lower crest factor lead to a good cutting effect on the tissue. Endocut is the most commonly used Mode in ESU in endoscopic practices like sphincterotomy and polypectomy. Endocut I mode (effect 1-2, duration 3, interval 3) is used for endoscopic sphincterotomy, while Forced Coag mode (Effect 2, 60 W) controls post-sphincterotomy bleeding. Endocut Q mode (Effect 2-3, duration 1, interval 3) is used for cutting the polyp, while Forced Coag mode (Effect 2, 60 W) is used before cutting for pre-coagulation of the stalk.
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Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Shubham Jain
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Chandnani
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
| | - Pravin Rathi
- Department of Gastroenterology, BYL Nair Hospital and Topiwala National Medical College, Mumbai, India
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Zhang LY, Hernández Mondragón O, Pioche M, Steinway SN, Nieto J, Ujiki MB, VanDruff VN, Kim RE, Canakis A, Tantau M, Tantau A, Pop A, Jacques J, Lajin M, Desai P, Shrigiriwar A, Bejjani M, Kumta NA, Khashab MA. Zenker's peroral endoscopic myotomy for management of large Zenker's diverticulum. Endoscopy 2023; 55:501-507. [PMID: 36827992 DOI: 10.1055/a-2025-0715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Zenker's diverticulum peroral endoscopic myotomy (zPOEM) is a minimally invasive treatment strategy for Zenker's diverticulum, with excellent results for management of small-to-moderate Zenker's diverticulum. We evaluated its use in the management of large Zenker's diverticulum. METHODS This was a retrospective multicenter cohort study across 11 international centers including adult patients with large Zenker's diverticulum ≥ 40 mm treated by zPOEM between March 2017 and March 2022. The primary outcome was clinical success (dysphagia score ≤ 1 without need for further intervention). Secondary outcomes included technical success (complete myotomy as intended), adverse events (AEs), and rate of recurrence. RESULTS 83 patients (male 62.7 %, mean age 72.6 [SD 11.5] years) underwent zPOEM for treatment of large Zenker's diverticulum (median size 50 mm, interquartile range [IQR] 41-55 mm, range 40-80 mm). The zPOEM procedure was technically successful in 82 patients (98.8 %), with a mean procedure time of 48.7 (SD 23.2) minutes. Clinical success was achieved in 71 patients (85.5 %). Median (IQR) symptom scores improved significantly from baseline for dysphagia (2 2 3 vs. 0 [0-2]; P < 0.001), regurgitation (3 2 3 4 vs. 0 [0-0]; P < 0.001), and respiratory symptoms (2 [0-3] vs. 0 [0-0]; P < 0.001). Among patients achieving clinical success, only one recurrence (1.4 %) was recorded during a median follow-up of 12.2 months (IQR 3-28). Post-procedure AEs, all mild to moderate, occurred in four patients (4.8 %). CONCLUSION This study demonstrated safe and effective use of zPOEM in the management of large Zenker's diverticulum.
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Affiliation(s)
- Linda Y Zhang
- Johns Hopkins Medicine, Baltimore, Maryland, United States
| | | | | | | | - Jose Nieto
- Borland Groover, Jacksonville, Florida, United States
| | - Michael B Ujiki
- NorthShore University Health System, Evanston, Illinois, United States
| | | | - Raymond E Kim
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Marcel Tantau
- "Prof Dr Octavian Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Cluj, Romania
| | - Alina Tantau
- Gastroenterology and Hepatology Medical Center, Cluj-Napoca, Cluj, Romania
| | - Anamaria Pop
- Gastroenterology and Hepatology Medical Center, Cluj-Napoca, Cluj, Romania
| | - Jérémie Jacques
- Hôpital Dupuytren, Servìce de Gastroentérologie, Limoges, France
| | - Michael Lajin
- Sharp HealthCare, San Diego, California, United States
| | - Pankaj Desai
- Department of Gastroenterology, Endoscopy Unit, SIDS Hospitals, Surat, India
| | | | | | - Nikhil A Kumta
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
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A Look into the Future of Endoscopic Submucosal Dissection and Third Space Endoscopy: The Role for Robotics and Other Innovation. Gastrointest Endosc Clin N Am 2023; 33:197-212. [PMID: 36375883 DOI: 10.1016/j.giec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Endoscopic resection has been widely applied especially in endoscopic submucosal dissection and third space endoscopy (TSE). Flexible endoluminal robotics allow performance of endoscopic submucosal dissection with exposure of the submucosal plane for precise dissection using two robotic arms. The introduction of TSE revolutionized the horizon of therapeutic endoscopy to the submucosal space beneath and beyond the mucosa. Advantages of TSE include avoidance of full thickness incision in gastrointestinal tract through the submucosal tunneling for performance of peroral endoscopic myotomy and submucosal tunneling endoscopic resection. In future, robotic-driven devices should be developed to enhance performance of complex endoluminal procedures and TSE.
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Shimamura Y, Fujiyoshi Y, Fujiyoshi MRA, Inoue H. Evolving field of third-space endoscopy: Derivatives of peroral endoscopic myotomy. Dig Endosc 2023; 35:162-172. [PMID: 35816387 DOI: 10.1111/den.14400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 01/24/2023]
Abstract
Third-space endoscopy, also known as submucosal endoscopy, allows for a wide range of therapeutic interventions within the submucosal layer and even into the muscular or subserosal layers of the gastrointestinal lumen. The technical development of peroral endoscopic myotomy (POEM) for achalasia has revolutionized the field of therapeutic endoscopy and the method has been continuously refined and modified. Although POEM has been applied to treat primary achalasia, it shows a favorable clinical response in other esophageal motility disorders and as a salvage treatment after previously failed intervention. Gastroesophageal reflux after POEM has drawn considerable attention and there have been major advancements in its prevention and management. POEM has led to advantageous derivatives such as peroral endoscopic tumor resection or submucosal tunneling endoscopic resection for resection of subepithelial lesions, Zenker POEM for hypopharyngeal diverticula, diverticular POEM for epiphrenic esophageal diverticula, and gastric POEM for refractory gastroparesis. These techniques have a similar concept, which constitutes submucosal tunneling with a mucosal flap valve and secure mucosal incision closure. The submucosal tunneling technique is widely accepted and continues to evolve. This study aimed to review in detail the indications, outcomes, and technical variations in POEM and explore several emerging submucosal tunneling procedures. This review will benefit future studies by providing a summary of recent developments in this field.
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Affiliation(s)
- Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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