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Issa D, Benias PC, Carr-Locke DL. Achalasia and gastroparesis: Coexisting entities or consequence of therapy? Endosc Int Open 2021; 9:E1222-E1226. [PMID: 34447868 PMCID: PMC8383087 DOI: 10.1055/a-1492-2487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/03/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Danny Issa
- Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angele, California, United States
| | - Petros C. Benias
- Department of Medicine, Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, New York, United States
| | - David L. Carr-Locke
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital and Weill Cornell Medical Center, New York, New York, United States
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Three-Dimensional High-Resolution Esophageal Manometry Study of the Esophagogastric Junction in Patients with Achalasia. Dig Dis Sci 2020; 65:1092-1098. [PMID: 31541368 DOI: 10.1007/s10620-019-05824-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND A novel three-dimensional high-resolution esophageal manometry provides a dynamic 360° representation of the pressure at the esophagogastric junction. AIMS To describe the three-dimensional high-resolution esophageal manometry patterns of achalasia. METHODS We retrospectively included all consecutive patients who underwent three-dimensional high-resolution esophageal manometry before and after treatment (pneumatic dilatation or per-oral endoscopic myotomy) for achalasia between November 2016 and July 2017. The distribution of the pressures at the esophagogastric junction on three-dimensional high-resolution esophageal manometry was determined. RESULTS Eighteen patients were included. Mean integrated relaxation pressure was 20.7 mmHg, and median (range) Eckardt score was 7 (4-10). Nine patients were treated by pneumatic dilatation and seven by myotomy. Nine patients underwent three-dimensional high-resolution esophageal manometry after treatment. Before treatment, the esophagogastric junction pressure distribution was best observed at end expiration and during the 4 s of the integrated relaxation pressure measurement. During the integrated relaxation pressure, the lower esophageal sphincter was asymmetric in 12 patients with a high-pressure zone between the left and the posterior side of the esophagogastric junction. After treatment, five patients had a residual high-pressure point on the left or the posterior side of the esophagogastric junction. CONCLUSIONS Three-dimensional high-resolution esophageal manometry allows a simple assessment of the pressure topography at the EGJ. In patients with achalasia, we found the esophagogastric junction pressure to be asymmetric with a peak pressure on the greater curvature side. Three-dimensional high-resolution esophageal manometry has the potential to guide initial and redo treatments.
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Jung Y, Kwon CI, Chung IK, Kim G, Ko KH, Hong SP, Jeong S, Lee DH. Novel submucosal lifting gel for performing endoscopic mucosal resection after precutting in large gastric lesions: An animal feasibility study. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii190020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Il-Kwun Chung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Gwangil Kim
- Department of Pathology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sung Pyo Hong
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seok Jeong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Don Haeng Lee
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
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Castro R, Libânio D, Pita I, Dinis-Ribeiro M. Solutions for submucosal injection: What to choose and how to do it. World J Gastroenterol 2019; 25:777-788. [PMID: 30809079 PMCID: PMC6385015 DOI: 10.3748/wjg.v25.i7.777] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/18/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
During the past decades, endoscopic resection techniques have gradually improved and gained more importance for the management of premalignant lesions and early cancers. These endoscopic resection techniques can be divided in 3 major groups: snare polipectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The use of submucosal injection is essential for the majority of EMR techniques and is an integral part of ESD, whereas during polipectomy it is not crucial in most cases except to prevent bleeding in large polyps and/or those with large stalks as an alternative to mechanical methods. Injection provides a lifting up effect of the lesion separating it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding while also facilitating en-bloc resection by improving technical feasibility. With this work, we aim to review the most common endoscopic resection techniques and the importance of submucosal injection in each one of them. For that, we present some of the most commonly used submucosal injection solutions, taking into account their advantages and disadvantages. We also discuss, based on current recommendations and our own experience, how and when to preform submucosal injection, depending on lesions features and endoscopic resection technique that´s being used, to assure complete resection and to prevent associated adverse events. Finally, we also present and discuss some new proposed submucosal injection solutions, endoscopic resection techniques and devices that may have a major impact on the future of therapeutic endoscopy.
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Affiliation(s)
- Rui Castro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Inês Pita
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
- CIDES/CINTESIS, Faculty of Medicine, University of Porto, Porto 4200-319, Portugal
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Abstract
Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.
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Affiliation(s)
- Antonio M Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Fransisco Borja De Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Silvia Valverde
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
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Abstract
The last decade has seen growing insight into the pathophysiology of achalasia, and current treatments decreasing the resting pressure in the lower esophageal sphincter by endoscopic (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy) or surgical means (Heller myotomy). Manometry is considered the gold standard to confirm the diagnosis of achalasia. Pneumatic dilation and laparoscopic Heller myotomy have similar effectiveness and are both more successful in patients with type II achalasia. Laparoscopic myotomy when combined with partial fundoplication is an effective surgical technique and has been considered the operative procedure of choice until recently. Peroral endoscopic myotomy is an emerging therapy with promising results since it offers a minimally invasive and efficacious option especially in type III achalasia. However, it remains to be determined if peroral endoscopic myotomy offers long-term efficacy.
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Zhou JQ, Tang XW, Ren YT, Wei ZJ, Huang SL, Gao QP, Zhang XF, Yang JF, Gong W, Jiang B. Endoscopic submucosal tunnel dissection of upper gastrointestinal submucosal tumors: A comparative study of hook knife vs hybrid knife. World J Gastroenterol 2017; 23:1843-1850. [PMID: 28348490 PMCID: PMC5352925 DOI: 10.3748/wjg.v23.i10.1843] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 12/18/2016] [Accepted: 01/18/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the efficacy and safety of a hook knife (HO) with a hybrid knife (HK) during endoscopic submucosal tunnel dissection (ESTD) procedure.
METHODS Between August 2012 and December 2015, the ESTD procedure was performed for 83 upper GI submucosal lesions, which originated from the muscularis propria layer identified by upper endoscopy and endoscopic ultrasonography. Of these, 34 lesions were treated by a HO, whereas 49 lesions were treated by a HK. Data regarding age, gender, presenting symptoms, tumor location and size, procedure time, complications, en bloc resection rate and others were analyzed and compared between the two groups.
RESULTS There were no significant differences in the age, gender, presenting symptoms and tumor location between the two groups. ESTD was successfully completed in all the patients, and no case was converted to laparoscopy. The mean procedure time was significantly shorter in the HK group than in the HO group (41.3 ± 20.3 min vs 57.2 ± 28.0 min, P = 0.004). The mean frequency of device exchange was 1.4 ± 0.6 in the HK group and significantly less than 3.3 ± 0.6 in the HO group (P < 0.001). The differences in tumor size and histopathological diagnoses were not significant between the two groups (P = 0.813, P = 0.363, respectively). Both groups had an equal en bloc resection rate and complete resection rate. Additionally, the complication rate was similar between the two groups (P = 0.901). During the follow-up, no recurrence occurred in either group.
CONCLUSION We demonstrate for the first time that HO and HK do not differ in efficacy or safety, but HK reduces the frequency of device exchange and procedure time.
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Tang X, Gong W, Deng Z, Zhou J, Ren Y, Zhang Q, Chen Z, Jiang B. Comparison of conventional versus Hybrid knife peroral endoscopic myotomy methods for esophageal achalasia: a case-control study. Scand J Gastroenterol 2016. [PMID: 26212517 DOI: 10.3109/00365521.2015.1059878] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Peroral endoscopic myotomy (POEM) has been developed to treat achalasia as a novel less invasive modality. We aimed to compare the efficacy and safety of conventional knife versus Hybrid knife (HK) during POEM procedure. MATERIALS AND METHODS Between June 2012 and July 2014, 31 patients underwent POEM using HK in our department (HK group), and 36 patients underwent POEM using conventional method (injection needle and triangular tip [TT] knife, TT group). Procedure-related parameters, symptom relief, adverse events were compared between two groups. RESULTS There were no significant differences in the age, sex and other baseline characteristics between the two groups. The mean procedural time was significantly shorter in HK group than TT group (53.0 ± 17.2 vs. 67.6 ± 28.4 min, p = 0.015). The mean frequency of devices exchange was 4.7 ± 1.7 in HK group and 10.9 ± 1.8 in TT group (p = 0.000). No serious adverse events occurred postoperatively in both groups. At one-year follow-up, a total of 94% treatment success was achieved in all patients (93.5% in HK group and 94.4% in TT group, p = 0.877). CONCLUSION HK in POEM can shorten the procedural time, and achieve similar treatment success compared to conventional TT knife.
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Affiliation(s)
- Xiaowei Tang
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China.,b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
| | - Wei Gong
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Zhiliang Deng
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Jieqiong Zhou
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China.,b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
| | - Yutang Ren
- b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
| | - Qiang Zhang
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Zhenyu Chen
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Bo Jiang
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China.,b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
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Concurrent myotomy and tunneling after establishment of a half tunnel instead of myotomy after establishment of a full tunnel: a more efficient method of peroral endoscopic myotomy. Endosc Int Open 2016; 4:E403-8. [PMID: 27092318 PMCID: PMC4831933 DOI: 10.1055/s-0042-101787] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/05/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Peroral endoscopic myotomy (POEM) is a time-consuming and challenging procedure. Traditionally, the myotomy is done after the submucosal tunnel has been completed. Starting the myotomy earlier, after submucosal tunneling is half completed (concurrent myotomy and tunneling), may be more efficient. This study aims to assess if the method of concurrent myotomy and tunneling may decrease the procedural time and be efficacious. PATIENTS AND METHODS This is a retrospective case series of patients who underwent modified POEM (concurrent myotomy and tunneling) or traditional POEM at a tertiary care medical center. Modified POEM or traditional POEM was performed at the discretion of the endoscopist in patients presenting with achalasia. The total procedural duration, myotomy duration, myotomy length, and time per unit length of myotomy were recorded for both modified and traditional POEM. RESULTS Modified POEM was performed in 6 patients whose mean age (± standard deviation [SD]) was 58 ± 13.3 years. Of these, 5 patients had type II achalasia and 1 patient had esophageal dysmotility. The mean Eckardt score (± SD) before the procedure was 8.8 ± 1.3. The modified technique was performed in 47 ± 8 minutes, with 6 ± 1 minutes required per centimeter of myotomy and 3 ± 1 minutes required per centimeter of submucosal space. The Eckardt score was 3 ± 1.1 at 1 month and 3 ± 2.5 at 3 months. The procedure time for modified POEM was significantly shorter than that for traditional POEM. CONCLUSIONS Modified POEM with short submucosal tunneling may be more efficient than traditional POEM with long submucosal tunneling, and outcomes may be equivalent over short-term follow-up. Long-term data and randomized controlled studies are needed to compare the clinical efficacy of modified POEM with that of the traditional method.
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Onimaru M, Inoue H, Ikeda H, Sato C, Sato H, Phalanusitthepha C, Santi EG, Grimes KL, Ito H, Kudo SE. Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos). Gastrointest Endosc 2016; 81:1370-7. [PMID: 25686872 DOI: 10.1016/j.gie.2014.11.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 11/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side. OBJECTIVE To evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging. DESIGN Prospective. SETTING Single-center study. PATIENTS Twenty-one achalasia patients who received POEM with GC myotomy. INTERVENTIONS POEM. MAIN OUTCOME MEASUREMENTS Efficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events. RESULTS Identification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6±1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2±7.3 vs 10.5±2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) (P<.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered. LIMITATIONS Single center. CONCLUSIONS GC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.
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Affiliation(s)
- Manabu Onimaru
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Chiaki Sato
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hiroki Sato
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | | | - Esperanza Grace Santi
- Section of Gastroenterology and Digestive Endoscopy, De La Salle University Medical Center, Cavite, Philippines
| | - Kevin L Grimes
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hiroaki Ito
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Kumbhari V, Khashab MA. Peroral endoscopic myotomy. World J Gastrointest Endosc 2015; 7:496-509. [PMID: 25992188 PMCID: PMC4436917 DOI: 10.4253/wjge.v7.i5.496] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/15/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.
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Chen J, Fang L, Shi RH. Peroral endoscopic myotomy for treatment of achalasia. Shijie Huaren Xiaohua Zazhi 2015; 23:1903-1909. [DOI: 10.11569/wcjd.v23.i12.1903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Achalasia is a motility disorder of the esophagus, characterized by aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter (LES). Peroral endoscopic myotomy (POEM) is an emerging novel endoscopic procedure for the treatment of achalasia by incision of LES via a submucosal tunnel. On the basis of initial data suggesting an acceptable safety profile and excellent short-term symptom resolution, there is growing enthusiasm in favor of POEM. In this review we outline the technical aspects of POEM, summarize the available data on safety and outcomes, and suggest future directions for further advancement of this minimally invasive approach for the treatment of achalasia.
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Next step in minimally invasive surgery: hybrid image-guided surgery. J Pediatr Surg 2015; 50:30-6. [PMID: 25598089 DOI: 10.1016/j.jpedsurg.2014.10.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 10/06/2014] [Indexed: 02/07/2023]
Abstract
Surgery, interventional radiology, and advanced endoscopy have all developed minimally invasive techniques to effectively treat a variety of diseases with positive impact on patients' postoperative outcomes. However, those techniques are challenging and require extensive training. Robotics and computer sciences can help facilitate minimally invasive approaches. Furthermore, surgery, advanced endoscopy, and interventional radiology could converge towards a new hybrid specialty, hybrid image-guided minimally invasive therapies, in which the three fundamental disciplines could complement one another to maximize the positive effects and reduce the iatrogenic footprint on patients. The present manuscript describes the fundamental steps of this new paradigm shift in surgical therapies that, in our opinion, will be the next revolutionary step in minimally invasive approaches.
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Chen WF, Li QL, Zhou PH, Yao LQ, Xu MD, Zhang YQ, Zhong YS, Ma LL, Qin WZ, Hu JW, Cai MY, He MJ, Cui Z. Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study. Gastrointest Endosc 2015; 81:91-100. [PMID: 25088923 DOI: 10.1016/j.gie.2014.06.035] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 06/16/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been developed to provide a less-invasive myotomy for achalasia in adults but seldom has been used in pediatric patients. OBJECTIVE To evaluate the feasibility, safety, and efficacy of POEM for pediatric patients with achalasia. DESIGN Single-center, prospective study. SETTING Academic medical center. PATIENTS A total of 27 pediatric patients (mean age 13.8 years, range 6-17 years) with achalasia. INTERVENTIONS POEM MAIN OUTCOME MEASUREMENTS The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤3. Secondary outcomes were procedure-related adverse events, clinical reflux adverse events, and lower esophageal sphincter (LES) pressure on manometry before and after POEM. RESULTS A total of 26 cases (96.3%) underwent successful POEM. A submucosal tunnelling attempt failed in 1 case because of serious inflammation and adhesion. No serious adverse events related to POEM were encountered. During a mean follow-up period of 24.6 months (range 15-38 months), treatment success was achieved in all patients (mean score before vs after treatment 8.3 vs 0.7; P < .001). Mean LES pressure also decreased from a mean of 31.6 mm Hg to 12.9 mm Hg after POEM (P < .001). Five patients developed clinical reflux adverse events (19.2%). LIMITATIONS Single center and lack of some objective evaluations. CONCLUSION This relatively long-term follow-up study adds to the evidence that POEM seems to be a promising new treatment for pediatric patients with achalasia, resulting in long-term symptom relief in all cases and without serious adverse events.
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Affiliation(s)
- Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Li Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Meng-Jiang He
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhao Cui
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Kumta NA, Mehta S, Kedia P, Weaver K, Sharaiha RZ, Fukami N, Minami H, Casas F, Gaidhane M, Lambroza A, Kahaleh M. Peroral endoscopic myotomy: establishing a new program. Clin Endosc 2014; 47:389-97. [PMID: 25324996 PMCID: PMC4198553 DOI: 10.5946/ce.2014.47.5.389] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/01/2014] [Accepted: 04/27/2014] [Indexed: 02/06/2023] Open
Abstract
Achalasia is an esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Treatment of achalasia is aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM), derived from natural orifice transluminal endoscopic surgery (NOTES) and advances in endoscopic submucosal dissection (ESD), presents a novel, minimally invasive, and curative endoscopic treatment for achalasia. POEM involves an esophageal mucosal incision followed by creation of a submucosal tunnel crossing the esophagogastric junction and myotomy before closure of the mucosal incision. Although the procedure is technically demanding and requires a certain degree of skill and competency, treatment success is high (90%) with low complication rates. Since the first described POEM in humans in 2010, it has been used increasingly at centers worldwide. This article reviews available published clinical studies demonstrating POEM efficacy and safety in order to present a proposal on how to establish a dedicated POEM program and reach base proficiency for the procedure.
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Affiliation(s)
- Nikhil A Kumta
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Shivani Mehta
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Prashant Kedia
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kristen Weaver
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Fernando Casas
- Gastroenterología y Endoscopia Digestiva, Hospital Central de la Policía Nacional, Bogota, Colombia
| | - Monica Gaidhane
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Arnon Lambroza
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Khashab MA, Saxena P, Sharaiha R, Messallam A, Akshintala VS, Singh VK, Lennon AM, Canto MI, Kalloo AN, Pasricha PJ. Pilot study of 'Scissorhands' technique for gastric endoscopic submucosal dissection using novel gel and endoscopic scissors in a porcine model (with video). Dig Endosc 2014; 26:365-8. [PMID: 24877237 DOI: 10.1111/den.12186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection (ESD) is a complex procedure and is associated with significant risks. The aims of this pilot study were to study feasibility and procedural times of gastric ESD using a novel gel and endoscopic scissors in a porcine model. METHODS Simulated 3-cm gastric submucosal lesions were created in a porcine model. Subsequently, viscous gel was injected into the created bleb. A needle knife was used to create an initial incision when needed. Endoscopic scissors were then used for circumferential incision around the simulated submucosal lesions. The inserted coil (i.e. submucosal lesion) was then removed. The submucosal surface was carefully examined for signs of injury. Procedural times were recorded. RESULTS ESD was carried out in four consecutive pigs using the 'Scissorhands' technique. A small submucosal incision was created a using needle knife in the first pig and electrocautery was not used in the remaining three pigs. Circumferential incision using the scissors was done successfully in all pigs. Submucosal dissection was not required in any case. 'Auto-dissection' of created lesions by the gel was noted to be complete in all cases. Inserted coils were noted in the submucosal space during all experiments and were removed. All lesions were successfully resected en bloc. The mean procedure time was 19 min (range 13-22 min). CONCLUSION The combined technique of endoscopic scissors for circumferential incision and viscous gel for submucosal dissection permitted easy, safe and efficient gastric ESD. Electrocautery may be avoided and its consequent adverse events (e.g. perforation).
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Affiliation(s)
- Mouen A. Khashab
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Payal Saxena
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Reem Sharaiha
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Ahmed Messallam
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Venkata S. Akshintala
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Vikesh K. Singh
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Anne Marie Lennon
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Marcia I. Canto
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Anthony N. Kalloo
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Pankaj J. Pasricha
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
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Bredenoord AJ, Rösch T, Fockens P. Peroral endoscopic myotomy for achalasia. Neurogastroenterol Motil 2014; 26:3-12. [PMID: 24304406 DOI: 10.1111/nmo.12257] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 10/06/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment of achalasia is complicated by symptom recurrence and a significant risk for severe complications. Endoscopic myotomy was developed in the search for a highly efficacious treatment with lower risks. Since its introduction in 2010, several centers have adopted the technique and published excellent short-term results of open label series. Randomized trials with long-term endpoint comparing per-oral endoscopic myotomy (POEM) with the established treatments such as balloon dilation and surgical myotomy are now warranted, before POEM can be regarded as the routine clinical care for achalasia patients. PURPOSE This review describes the development, technical aspects, efficacy, and complications of POEM.
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Affiliation(s)
- A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Peroral endoscopic myotomy for the treatment of achalasia: an analysis. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2013; 2013:389596. [PMID: 24282373 PMCID: PMC3825053 DOI: 10.1155/2013/389596] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 09/13/2013] [Indexed: 02/07/2023]
Abstract
Achalasia is a motility disorder of the esophagus, characterized by aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter (LES). Treatment of achalasia is currently aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM) is an emerging novel endoscopic procedure for the treatment of achalasia with initial data suggesting an acceptable safety profile, excellent short-term symptom resolution, low incidence of postprocedural gastroesophageal reflux (GER), and improvement in manometric outcomes. Further prospective randomized trials are required to evaluate the long-term effectiveness of this promising technique compared to other treatment modalities for achalasia. In this review we outline the technical aspects of POEM, summarize the available data on safety and outcomes, and suggest future directions for further advancement of this minimally invasive approach for the treatment of achalasia.
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Abstract
Gastrointestinal endoscopy is a rapidly evolving field. Techniques in endoscopy continue to become more sophisticated, as do the devices and platforms, particularly in colonoscopy and endoscopic resection. This article reviews new platforms for endoscopic imaging of the colon, and discusses new endoscopic accessories and developments in endoscopic resection.
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Abstract
PURPOSE OF REVIEW Standard endoscopic polypectomy is a powerful technique to remove most polyps found in the gastrointestinal tract. However, a small percentage of polyps can be classified as difficult, based on size, location, and/or configuration. Traditionally, these difficult polyps were referred for surgical segmental colectomy. Recently, with advancements in endoscopic techniques and accessories, a majority of these difficult polyps are now able to be completely resected using entirely endoscopic techniques. RECENT FINDINGS Endoscopic techniques and accessories have been evolving during recent years, including increased dissemination of techniques of endoscopic submucosal dissection to the western hemisphere. In addition to refinement of endoscopic techniques, there has been increased interest in developing improved endoscopic accessories, including novel submucosal injectate with auto-dissecting properties, to improve safety and efficiency of endoscopic resection of difficult polyps. SUMMARY This article will review currently available techniques and strategies for successful endoscopic resection for difficult polyps.
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Li QL, Chen WF, Zhou PH, Yao LQ, Xu MD, Hu JW, Cai MY, Zhang YQ, Qin WZ, Ren Z. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013; 217:442-51. [PMID: 23891074 DOI: 10.1016/j.jamcollsurg.2013.04.033] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/01/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. STUDY DESIGN According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. RESULTS The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38). CONCLUSIONS Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.
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Affiliation(s)
- Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Novel technique for submucosal tunneling and endoscopic resection of submucosal tumors (with video). Gastrointest Endosc 2013; 77:646-8. [PMID: 23352498 DOI: 10.1016/j.gie.2012.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/07/2012] [Indexed: 02/06/2023]
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Khashab MA, Saxena P, Sharaiha RZ, Chavez YH, Zhang F, Kord Valeshabad A, Aguila G, Canto MI, Pasricha PJ, Kalloo AN. A novel submucosal gel permits simple and efficient gastric endoscopic submucosal dissection. Gastroenterology 2013; 144:505-7. [PMID: 23313267 DOI: 10.1053/j.gastro.2013.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 01/01/2013] [Accepted: 01/08/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA.
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Khashab MA. Thoughts on starting a peroral endoscopic myotomy program. Gastrointest Endosc 2013; 77:109-10. [PMID: 23261100 DOI: 10.1016/j.gie.2012.10.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 10/23/2012] [Indexed: 12/11/2022]
Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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