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Zhang LY, Bejjani M, Ghandour B, Khashab MA. Through-the-scope suture closure of peroral endoscopic myotomy mucosal incision sites. Endoscopy 2023; 55:186-191. [PMID: 35926541 DOI: 10.1055/a-1890-4917] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND : Peroral endoscopic myotomy (POEM) is now widely used for esophageal motility disorders including achalasia. Closure of the mucosal incision site is a critical step of the procedure. We evaluated the use of a novel through-the-scope (TTS) suture system for closure of POEM mucosal incision sites. METHODS : We retrospectively reviewed consecutive patients who underwent POEM with TTS suture closure at our institution between February and July 2021. Technical success was defined as complete mucosal incision site closure using TTS suturing, without the need for adjunctive devices. Continuous variables are presented as median (interquartile range [IQR]) or mean (SD). RESULTS : 35 consecutive patients (median age 58 years [IQR 46.5-72]; 54.3 % female) underwent POEM with attempted mucosal closure by TTS suturing. Technical success was achieved in 32 patients (91.4 %) with a mean closure time of 12.4 (SD 6.9) minutes. The median mucosal incision length at time of closure was 2.5 cm (IQR 2-2.5). Overall, 17 patients (53.1 %) required ≥ 2 TTS suture systems and 3 patients (8.6 %) required additional TTS clips to achieve secure mucosal closure. No adverse events were encountered. CONCLUSIONS : TTS suturing was effective and safe for POEM mucosotomy closure. However, prospective comparative trials and cost-effectiveness analyses are warranted before routine adoption.
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Affiliation(s)
- Linda Yun Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
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Leung LJ, Ma GK, Lee JK, Fukami N, Chang H, Svahn J, Xu MM, Lam S, Risbud A, Jue TL. Successful Design and Implementation of a POEM Program for Achalasia in an Integrated Healthcare System. Dig Dis Sci 2023; 68:2276-2284. [PMID: 36725765 PMCID: PMC9891752 DOI: 10.1007/s10620-023-07839-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/15/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Per Oral Endoscopic Myotomy (POEM) is a minimally invasive treatment for achalasia with results comparable to laparoscopic Heller myotomy (LHM). Studies have described the development of proficiency for endoscopists learning to perform POEM, and societies have defined educational and technical objectives for advanced endoscopy fellows in training. However, there is limited guidance on the organizational strategy and educational plan necessary to develop an achalasia service with POEM expertise. AIMS We aim to outline the steps for design and implementation of a successful POEM program. METHODS We reported our experience developing a multi-disciplinary clinical program for POEM and the steps taken to achieve procedural proficiency. We also reported our technical success (successful tunneling into the gastric cardia and myotomy of LES muscle fibers) and clinical success (post-procedure Eckardt score ≤ 3) at 3-6 months and 12 months post-procedure. Adverse events were classified per the ASGE lexicon for endoscopic adverse events. RESULTS After creating a multi-disciplinary clinical program for achalasia and completing procedural proficiency for POEM, our technical success rate was 100% and clinical success rate 90% for the first 41 patients. One adverse event (2.4%) occurred, moderate in severity per the American Society of Gastrointestinal Endoscopy (ASGE) lexicon for adverse endoscopic events. CONCLUSION In this study, we outlined the steps involved to establish a POEM service in a large integrated healthcare system. Prior competency in interventional endoscopy, procedural training models, POEM observation and education, proctorship, and interdisciplinary patient care are recommended.
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Affiliation(s)
- Lawrence Jun Leung
- grid.414890.00000 0004 0461 9476Department of Internal Medicine, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Gene K. Ma
- grid.492756.b0000 0004 0444 0628Department of Gastroenterology, Kaiser Permanente San Jose, San Jose, CA USA
| | - Jeffrey K. Lee
- grid.414890.00000 0004 0461 9476Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Norio Fukami
- grid.417468.80000 0000 8875 6339Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ USA
| | - Howard Chang
- grid.414886.70000 0004 0445 0201Department of Gastroenterology, Kaiser Permanente Oakland, Oakland, CA USA
| | - Jonathan Svahn
- grid.414886.70000 0004 0445 0201Department of Surgery, Kaiser Permanente Oakland, Oakland, CA USA
| | - Ming-Ming Xu
- grid.280062.e0000 0000 9957 7758Department of Gastroenterology, Kaiser Permanente West LA, Los Angeles, CA USA
| | - Steven Lam
- grid.414890.00000 0004 0461 9476Department of Internal Medicine, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Amita Risbud
- grid.414890.00000 0004 0461 9476Department of Internal Medicine, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Terry L. Jue
- grid.414890.00000 0004 0461 9476Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA USA ,grid.417468.80000 0000 8875 6339Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ USA
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3
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Sarkis Y, Al-Haddad MA, Siwiec R, Kessler WR, Wo JM, Stainko S, Perkins A, DeWitt JM. Safety of same-day discharge after peroral endoscopic myotomy. Dis Esophagus 2022; 36:6747074. [PMID: 36190182 DOI: 10.1093/dote/doac068] [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: 06/29/2022] [Revised: 08/21/2022] [Accepted: 09/04/2022] [Indexed: 12/11/2022]
Abstract
There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6 months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30 days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6 months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.
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Affiliation(s)
- Yara Sarkis
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Robert Siwiec
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - William R Kessler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M Wo
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Anthony Perkins
- Department of Biostatistics, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
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Rodríguez de Santiago E, Dinis-Ribeiro M, Pohl H, Agrawal D, Arvanitakis M, Baddeley R, Bak E, Bhandari P, Bretthauer M, Burga P, Donnelly L, Eickhoff A, Hayee B, Kaminski MF, Karlović K, Lorenzo-Zúñiga V, Pellisé M, Pioche M, Siau K, Siersema PD, Stableforth W, Tham TC, Triantafyllou K, Tringali A, Veitch A, Voiosu AM, Webster GJ, Vienne A, Beilenhoff U, Bisschops R, Hassan C, Gralnek IM, Messmann H. Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement. Endoscopy 2022; 54:797-826. [PMID: 35803275 DOI: 10.1055/a-1859-3726] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10: ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Mario Dinis-Ribeiro
- Porto Comprehensive Cancer Center (Porto.CCC), and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, and Section of Gastroenterology and Hepatology, VA White River Junction, Vermont, USA
| | - Deepak Agrawal
- Division of Gastroenterology and Hepatology, Dell Medical School, University of Texas Austin, Texas, USA
| | - Marianna Arvanitakis
- Department of Gastroenterology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Robin Baddeley
- King's Health Partners Institute for Therapeutic Endoscopy, King's College Hospital, and Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
| | - Elzbieta Bak
- Department of Gastroenterology and Internal Medicine, Clinical Hospital of Medical University of Warsaw, Warsaw, Poland
| | | | - Michael Bretthauer
- Clinical Effectiveness Research Group, University of Oslo, and Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Patricia Burga
- Endoscopy Department, University Hospital of Padua, Italy
| | - Leigh Donnelly
- Endoscopy Department, Northumbria Healthcare NHS Trust, Northumberland, United Kingdom
| | - Axel Eickhoff
- Klinik für Gastroenterologie, Diabetologie, Infektiologie, Klinikum Hanau, Hanau, Germany
| | - Bu'Hussain Hayee
- Department of Gastroenterology, University College London Hospitals, London, United Kingdom
| | - Michal F Kaminski
- Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Katarina Karlović
- Clinical Hospital Center Rijeka , Department of Gastroenterology, Endoscopy Unit, Rijeka, Croatia
| | - Vicente Lorenzo-Zúñiga
- Department of Gastroenterology, University and Polytechnic La Fe Hospital/IIS La Fe, Valencia, Spain
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clinic of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), and Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Mathieu Pioche
- Endoscopy Unit, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Keith Siau
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, United Kingdom
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - William Stableforth
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, United Kingdom
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Alberto Tringali
- Digestive Endoscopy Unit, ULSS 2 Marca Trevigiana, Conegliano Hospital, Conegliano, Italy
| | - Andrew Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Andrei M Voiosu
- Department of Gastroenterology and Hepatology, Colentina Clinical Hospital, Bucharest, Romania
| | - George J Webster
- Department of Gastroenterology, University College London Hospitals, London, United Kingdom
| | | | | | - Raf Bisschops
- Department of Gastroenterology and Hepatology, Catholic University of Leuven (KUL), TARGID, University Hospitals Leuven, Leuven, Belgium
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, and Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, and Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Helmut Messmann
- III Medizinische Klinik Universitätsklinikum Augsburg, Augsburg, Germany
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5
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Hasan A, Low EE, Fehmi SA, Yadlapati R. Evolution and evidence-based adaptations in techniques for peroral endoscopic myotomy for achalasia. Gastrointest Endosc 2022; 96:189-196. [PMID: 35278427 PMCID: PMC9838104 DOI: 10.1016/j.gie.2022.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/03/2022] [Indexed: 02/08/2023]
Abstract
Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis. Common clinical manifestations include dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, resulting in significant morbidity and healthcare burden. Historically, surgical Heller myotomy and pneumatic dilation were the first-line therapeutic options for achalasia. This convention was shaken in 2009 when Inoue and colleagues introduced an endoscopic approach to dissect the muscle fibers of the LES, known as peroral endoscopic myotomy (POEM). Since incorporation of POEM into standard practice, the overall myotomy technique has remained unchanged; however, adaptations in the thickness and length of myotomy have evolved. Full-thickness myotomy is recognized to have similar clinical success and faster procedure times compared with selective circular muscle myotomy. Although myotomy length for type 1 and type 2 achalasia has classically been >6 cm, recent studies demonstrated similar outcomes with reduction of myotomy length to <3 cm. Length of myotomy for type 3 achalasia has been tailored to treat the entire length of spastic muscle segment, and the modality to gauge the optimal thickness and length of myotomy in this group has yet to be established. In addition to changes in POEM technique, the postoperative management of POEM has also changed, favoring reduced postprocedure imaging, antibiotic use, and hospitalizations.
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Affiliation(s)
- Aws Hasan
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Eric E. Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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