Per-oral endoscopic myotomy:Major advance in achalasia treatment and in endoscopic surgery

Per-oral endoscopic myotomy(POEM)represents a natural orifice endoscopic surgery(NOTES)approach to laparoscopy Heller myotomy(LHM).POEM is arguably the most successful clinical application of NOTES.The growth of POEM from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed attests to the success of POEM.Initial efficacy,safety and acid reflux data suggest at least equivalence of POEM to LHM,the previous gold standard for achalasia therapy.Adjunctive techniques used in the West include impedance planimetry for real-time intraprocedural luminal assessment and endoscopic suturing for challenging mucosal defect closures during POEM.The impact of POEM extends beyond the realm of esophageal motility disorders as it is rapidly popularizing endoscopic submucosal dissection in the West and spawning offshoots that use the submucosal tunnel technique for a host of new indications ranging from resection of tumors to pyloromyotomy for gastroparesis.

Per-oral endoscopic myotomy for achalasia: An American perspective

Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter.Per-oral endoscopic myotomy(POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons.It represents a natural orifice transluminal endoscopic surgery(NOTES) approach to Heller myotomy.POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy.POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery.Initial high success and low complications rates promise a great future for this technique.In fact,POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response.The volume of POEMs performed worldwide has grown exponentially.In fact,surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia.However,the niche of POEM remains to be defined and long term results are awaited.We describe our experience with POEM having performed the first POEM outside of Japan in 2009,the evolution of our technique,and give our perspective on its future.

Introduction of endoscopic submucosal dissection in the West

Endoscopic submucosal dissection(ESD) is well established in Asia as a modality for selected advancedlesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due to a variety of reasons. These include competition from traditional surgery, minimally invasive surgery and endoscopic mucosal resection. Other obstacles to ESD introduction in the West include time commitment for learning and doing procedures, a steep learning curve, special equipment, lack of mentors, cost issues, interdisciplinary conflicts, concern regarding complications and lack of support from institutions and interfacing departments. There are intrinsic differences in pathology prevalence(e.g., early gastric cancer) between the two regions that are less conducive for ESD implementation in the West. We will elaborate on these issues and suggest measures as well as a protocol to overcome these obstacles and hopefully allow introduction of ESD as a tenable option for appropriate patients.

Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

AIM To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography(ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.METHODS Systematic computerized literature search performed using PubMed with the key words "ERCP" and "pregnancy". Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubM ed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.RESULTS Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in nonpregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.CONCLUSION This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.

Current applications of endoscopic suturing

Endoscopic suturing had previously been considered an experimental procedure only performed in a few centers and often by surgeons. Now, however, endoscopic suturing has evolved sufficiently to be easily implemented during procedures and is more commonly used by gastroenterologists. We have employed the Apollo Over Stitch suturing device in a variety of ways including closure of perforations, closure of full thickness defects in the gastrointestinal wall created during endoscopic full thickness resection, closure of mucosotomies during peroral endoscopic myotomy, stent fixation, fistula closure, post endoscopic submucosal dissection, endoscopic mucosal resection and Natural Orifice Transluminal Endoscopic Surgery defect closures, post-bariatric surgery gastrojejunal anastomosis revision and primary sleeve gastroplasty.

煽动性的肠疾病苛评的内视镜的管理

Stricture formation is a common complication of Crohn’s disease, occurring in approximately one third of all patients with this condition. While the traditional management of such strictures has been largely surgical, there have been case series going back three decades high-lighting the potential role of endoscopic balloon dilation in this clinical setting. This review article summarizes the stricture pathogenesis, focusing on known clinical and genetic risk factors. It then highlights the endo-scopic balloon dilation research to date, with particular emphasis on three large recent case series. It concludes by describing the literature consensus regarding specific methodology and presenting avenues for future investigations.

Gastrointestinal endoscopy in the pregnant woman

About 20000 gastrointestinal endoscopies are performed annually in America in pregnant women. Gastrointestinal endoscopy during pregnancy raises the critical issue of fetal safety in addition to patient safety. Endoscopic medications may be potentially abortifacient or teratogenic. Generally, Food and Drug Administration category B or C drugs should be used for endoscopy. Esophagogastroduodenoscopy(EGD) seems to be relatively safe for both mother and fetus based on two retrospective studies of 83 and 60 pregnant patients. The diagnostic yield is about 95% when EGD is performed for gastrointestinal bleeding. EGD indications during pregnancy include acute gastrointestinal bleeding, dysphagia > 1 wk, or endoscopic therapy. Therapeutic EGD is experimental due to scant data, but should be strongly considered for urgent indications such as active bleeding. One study of 48 sigmoidoscopies performed during pregnancy showed relatively favorable fetal outcomes, rare bad fetal outcomes, and bad outcomes linked to very sick mothers. Sigmoidoscopy should be strongly considered for strong indications,including significant acute lower gastrointestinal bleeding, chronic diarrhea, distal colonic stricture, suspected inflammatory bowel disease flare, and potential colonic malignancy. Data on colonoscopy during pregnancy are limited. One study of 20 pregnant patients showed rare poor fetal outcomes. Colonoscopy is generally experimental during pregnancy, but can be considered for strong indications: known colonic mass/stricture, active lower gastrointestinal bleeding, or colonoscopic therapy. Endoscopic retrograde cholangiopancreatography(ERCP) entails fetal risks from fetal radiation exposure. ERCP risks to mother and fetus appear to be acceptable when performed for ERCP therapy, as demonstrated by analysis of nearly 350 cases during pregnancy. Justifiable indications include symptomatic or complicated choledocholithiasis, manifested by jaundice, cholangitis, gallstone pancreatitis, or dilated choledochus. ERCP should be performed by an expert endoscopist, with informed consent about fetal radiation risks, minimizing fetal radiation exposure, and using an attending anesthesiologist. Endoscopy is likely most safe during the second trimester of pregnancy.

Rare presentation of primary (AL) amyloidosis as gastrointestinal hemorrhage without systemic involvement

We are reporting a rare case of a patient with primary(AL) amyloidosis presenting with an acute non-varicealupper gastrointestinal hemorrhage in the absence ofother systemic involvement. The case report involves a58-year-old woman with significant cardiac history andhereditary blood disorder who came in complaining ofabdominal pain and coffee-ground emesis for two days.Computed tomography(CT) scan of the abdomen andpelvis with contrast revealed segmental wall thickeningof the proximal jejunum with hyperdense, heterog-enous luminal content. Similar findings were evident inthe left lower small bowel region, suspicious for smallbowel hematoma and the possibility of intraluminalclots. Esophagogastroduodenoscopy performed postresuscitation showed punctate, erythematous lesionsthroughout the stomach as well as regions of smallbowel mucosa that appeared scalloped, ulcerated, andhemorrhaged on contact. Despite initial treatment for immunostain-positive focal cytomegalovirus gastritis, follow-up esophagogastroduodenoscopy after two months continued to demonstrate friable and irregular duodenal mucosa hinting at a different underlying etiol-ogy. Pathology reports from analyses of biopsy samples highlighted infiltration and expansion of the lamina pro-pria and submucosa. Subsequent staining with congo red/crystal violet and appropriate subtyping established the diagnosis of AL(kappa)-type amyloidosis. The sig-nificance of this case lies in the fact that our patient did not have the typically seen diagnostic systemic involvements-namely of heart and kidneys-usually seen in primary(AL) amyloidosis patients. It was the persis-tent endoscopic findings and biopsy results which gave clues to the physicians regarding the possibility of an abnormal protein-deposition entity.

Potential role of new technological innovations in nonvariceal hemorrhage

The present armamentarium of endoscopic hemostatic therapy for non-variceal upper gastrointestinal hemorrhage includes injection,electrocautery and clips.There are newer endoscopic options such as hemostatic sprays,endoscopic suturing and modifications of current options including coagulation forceps and over-the-scope clips.Peptic hemorrhage is the most prevalent type of nonvariceal upper gastrointestinal hemorrhage and traditional endoscopic interventions have demonstrated significant hemostasis success.However,the hemostatic success rate is less for other entities such as Dieulafoy’s lesions and bleeding from malignant lesions.Novel innovations such as endoscopic submucosal dissection and peroral endoscopic myotomy has spawned a need for dependable hemostasis.Gastric antral vascular ectasias are associated with chronic gastrointestinal bleeding and usually treated by standard argon plasma coagulation (APC),but newer modalities such as radiofrequency ablation,banding,cryotherapy and hybrid APC have been utilized as well.We will opine on whether the newer hemostatic modalities have generated success when traditional modalities fail and should any of these modalities be routinely available in the endoscopic toolbox.

Burgeoning study of sentinel-node analysis on management of early gastric cancer after endoscopic submucosal dissection

Endoscopic submucosal dissection(ESD)represents an organ-preserving alternative to surgical resection of early gastric cancer.However,even with ESD yielding en-bloc resection specimens,there are concerns regarding tumor spread such as with larger lesions,ulcerated lesions,undifferentiated pathology and submucosal invasion.Sentinel node navigational surgery(SNNS)when combined with ESD offers a minimally invasive alternative to the traditional extended gastrectomy and lymphadenectomy if lack of lymph node spread can be confirmed.This would have a clear advantage in terms of potential complications and quality of life.However,SNNS,though useful in other malignancies such as breast cancer and melanoma,may not have a sufficient sensitivity for malignancy and negative predictive value in EGC to justify this as standard practice after ESD.The results of SNNS may improve with greater standardization and more involved dissection,technological innovations and more experience and validation such that the paradigm for post-ESD resection of EGC may change and include SNNS.