Ahmed M. Sharata

A Comparative Study on Comprehensive, Objective Outcomes of Laparoscopic Heller Myotomy With Per-Oral Endoscopic Myotomy (POEM) for Achalasia

Objective:To compare symptomatic and objective outcomes between HM and POEM. Background:The surgical gold standard for achalasia is laparoscopic Heller myotomy (HM) and partial fundoplication. Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their safety and efficacy. Methods:Data on consecutive HMs and POEMs for achalasia from 2007 to 2012 were collected. Primary outcomes: swallowing function—1 and 6 months after surgery. Secondary outcomes: operative time, complications, postoperative gastro-esophageal reflux disease (GERD). Results:There were 101 patients: 64 HMs (42% Toupet and 58% Dor fundoplications) and 37 POEMs. Presenting symptoms were comparable. Median operative time (149 vs 120 min, P < 0.001) and mean hospitalization (2.2 vs 1.1 days, P < 0.0001) were significantly higher for HMs. Postoperative morbidity was comparable. One-month Eckardt scores were significantly better for POEMs (1.8 vs 0.8, P < 0.0001). At 6 months, both groups had sustained similar improvements in their Eckardt scores (1.7 vs 1.2, P = 0.1).Both groups had significant improvements in postmyotomy lower esophageal sphincter profiles. Postmyotomy resting pressures were higher for POEMs than for HMs (16 vs 7.1 mm Hg, P = 0.006). Postmyotomy relaxation pressures and distal esophageal contraction amplitudes were not significantly different between groups. Routine postoperative 24-hour pH testing was obtained in 48% Hellers and 76% POEMs. Postoperatively, 39% of POEMs and 32% of HM had abnormal acid exposure (P = 0.7). Conclusions:POEM is an endoscopic therapy for achalasia with a shorter hospitalization than HM. Patient symptoms and esophageal physiology are improved equally with both procedures. Postoperative esophageal acid exposure is the same for both. The POEM is comparable with laparoscopic HM for safe and effective treatment of achalasia.

End of the Road for a Dysfunctional End Organ: Laparoscopic Gastrectomy for Refractory Gastroparesis

IntroductionGastroparesis is a functional disorder resulting in debilitating nausea, esophageal reflux, and abdominal pain and is frequently refractory to medical treatment. Therapies such as pyloroplasty and neurostimulators can improve symptoms. When medical and surgical treatments fail, palliative gastrectomy is an option. We examined outcomes after gastrectomy for postoperative, diabetic, and idiopathic gastroparesis.MethodsA prospective database was queried for gastrectomies performed for gastroparesis from 1999 to 2013. Primary outcomes were improvements in pre- versus postoperative symptoms at last follow-up, measured on a five-point scale. Secondary outcome was operative morbidity.ResultsThirty-five patients underwent laparoscopic total or near-total gastrectomies for postoperative (43 %), diabetic (34 %), or idiopathic (23 %) gastroparesis. Antiemetics and prokinetics afforded minimal relief for one third of patients. There were no mortalities. Six patients suffered a leak, all treated with surgical reintervention. With a median follow-up of 6 months, nausea improved or resolved in 69 %. Chronic abdominal pain improved or resolved in 70 %. Belching and bloating resolved for 79 and 89 %, respectively (p < 0.01).ConclusionsRegardless of etiology, medically refractory gastroparesis can be a devastating disease. Near-total gastrectomy can ameliorate or relieve nausea, belching, and bloating. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can effectively palliate symptoms of gastroparesis.

Sleeve endoscopic esophageal mucosotomy

Complete circumferential endoscopic submucosal dissection (ESD) techniques have been used recently to remove specimens en bloc. Although evaluation ofmargins remains a benefit, scar formation and strictures remain major problems. Stenting with or without biologic matrix may be helpful in preventing strictures, but deployment remains problematic. We present a modified technique of circumferential ESD with a novel over-the-scope stent technique to place a biologic matrix into the mucosal defect. A 12-cm segment of circumferential Barrett’s esophagus with multifocal intramucosal cancer was resected endoscopically by using a modified ESD technique. A novel, over-the-scope technique of deploying a metal stent fully covered with a biologic scaffold is shown (Fig. 1; Video 1, available online at www.giejournal.org). The patient was treated with systemic steroids for 2 weeks. The stent was removed after 5 weeks, and EGD showed partial growth of the matrix on the esophageal muscular wall with no stricture. At 3 months, mild stricturing was treated

In vivo observation of perforating submucosal pancreatic ducts during endoscopic submucosal dissection of a gastric heterotopic pancreas

Heterotopic pancreas is defined by the presence of pancreatic tissue in an abnormal location without ductal or vascular connections to the normal pancreas. It is most commonly found in the upper GI tract and measures 1 to 2 cm in size. Usual locations include the gastric antrum (predominantly along the greater curvature), duodenum, and proximal jejunum. Heterotopic pancreatic tissue is usually asymptomatic, although a minority of patients may present with symptoms, typically abdominal pain. The most common endoscopic appearance is that of a raised submucosal lesion with central umbilication, which corresponds to the opening of a duct. The ectopic pancreatic tissue is typically located in the submucosa, although it may occasionally extend deeper to the muscularis or subserosal layers. An incidentally found, asymptomatic lesion with a typical appearance on endoscopy and EUS may not require any further management or surveillance. The management of symptomatic or atypical-appearing heterotopic pancreatic tissue may also include observation, surgical resection, and, increasingly, endoscopic resection. This video demonstrates endoscopic submucosal dissection (ESD) of an ectopic pancreatic lesion in the gastric antrum. The lesion was originally found on an upper endoscopy performed for vague abdominal pain. It was thought that

620 End of the Road for a Dysfunctional End-Organ: Gastrectomy for Refractory Gastroparesis

INTRODUCTION Gastroparesis is a functional disorder resulting in debilitating nausea, overflow esophageal reflux & abdominal pain and is frequently refractory to medical treatment. Surgical therapies such as pyloroplasty and neurostimulators aim to facilitate emptying. When treatments to facilitate gastric emptying fail, subtotal gastrectomy has been employed with varying success. Herein, we examined outcomes after gastrectomy for diabetic and idiopathic gastroparesis. METHODS A prospective database was queried for gastrectomies with Roux-en-Y reconstruction performed for gastroparesis from 1993-2013. Primary outcomes were improvements in preversus post-operative symptoms at last followup, measured on a 5-point scale. Secondary outcomewas operative morbidity. RESULTS Thirty-five patients underwent total or near-total gastrectomies for idiopathic (23%), post-operative(43%), or diabetic (34%) gastroparesis. Anti-emetics and pro-kinetics afforded no relief in 34.5% of patients. There were no operative mortalities. Six patients suffered a leak requiring anastomotic revision. With a median follow-up of 11.4 months, nausea improved or resolved in 70% after surgery. Chronic abdominal pain improved or resolved in 69% of patients. Belching and bloating resolved for 75% & 81%, respectively (p<0.01). CONCLUSIONS Regardless of etiology, medically-refractrory gastroparesis is a chronic and devastating disease. Surgery can ameliorate, and often relieve symptoms of nausea, excessive belching and gas bloat. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can palliate symptoms of gastroparesis.