Alan H. Tieu

Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study.

Background and study aims: Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients. Patients and methods: A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events. Results: Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01). Conclusions: POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.

Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case–control study

Background and study aims The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER. Patients and methods All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥ 14.72 (cases) and 2) DeMeester score of < 14.72 (controls). Asymptomatic GER was defined as a patient with a DeMeester score ≥ 14.72 who was not consuming proton pump inhibitor (PPI). Results A total of 282 patients (female 48.2 %, Caucasian 84.8 %; mean body mass index 24.1 kg/m2) were included. Clinical success was achieved in 94.3 % of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10 - 24 months). A DeMeester score of ≥ 14.72 was seen in 57.8 % of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95 % confidence interval 1.04 - 2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2 %) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1 %. Conclusion Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique.

Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video).

BACKGROUND An adequate myotomy on the gastric side is considered essential to optimize outcomes in patients undergoing per-oral endoscopic myotomy (POEM). An objective method to measure the length of gastric myotomy has not yet been reported. OBJECTIVE To evaluate a new method of precisely determining the length of the submucosal tunnel below the esophagogastric junction (EGJ) using intraprocedural fluoroscopy. DESIGN Single-center cohort study. SETTING Academic tertiary care center. PATIENTS Twenty-four consecutive patients who underwent POEM for management of achalasia. INTERVENTIONS A radiopaque marker (endoscopic clip placed at the EGJ or fluoroscopically guided placement of a 19-gauge needle on the skin) was used to mark the EGJ. The endoscope was inserted to the most distal aspect of the submucosal tunnel and, using fluoroscopy, the distance between the radiopaque marker and the tip of the endoscope was measured. MAIN OUTCOME MEASUREMENTS Technical success, procedural impact, duration of technique, and adverse events. RESULTS Technical success was achieved in 100% of patients. The submucosal tunnel was extended in 5 patients (20.8%) with a mean extension of 1.4±.5 cm. The mean increase in procedure time was 4 minutes with the endoscopic clip and 2 minutes with the 19-gauge needle. There were no adverse events associated with this technique. LIMITATIONS Need for fluoroscopy. Absence of available criterion standard. CONCLUSIONS Intraprocedural fluoroscopy was an efficient and safe method of objectively documenting the extent of gastric myotomy during POEM. This may benefit those investigating the anatomic and physiologic changes that occur during the myotomy and those early in their experience performing POEM.

Iatrogenic pharyngoesophageal perforations treated with fully covered self-expandable metallic stents (with video)

BackgroundIatrogenic pharyngoesophageal perforations are a rare but serious complication of endoscopy. Surgical and non-surgical approaches have been reported but result in a significant morbidity and extended hospital stay. Therefore, an unmet need exists for an alternative management technique. We demonstrate a new endoscopic approach for the management of iatrogenic pharyngoesophageal perforations through the use of esophageal fully covered self-expandable metallic stents (FCSEMS).Patients and methodsTwo patients who underwent flexible endoscopy each suffered a large iatrogenic perforation detected intraprocedurally. After emergency intubation, an esophageal FCSEMS was deployed in the hypopharynx and the patient admitted to the intensive care unit. On day 3, the patients underwent an esophagogastroduodenoscopy with stent removal.ResultsThere was complete closure of the perforations on day 3. The patients were extubated and subsequently tolerated a soft diet. The patients were discharged home on day 4.ConclusionsThe placement of a removable FCSEMS in the setting of an acutely diagnosed perforation may be a suitable minimally invasive approach for the management of iatrogenic pharyngoesophageal perforations.

Endoscopic reversal of gastric bypass for severe malnutrition after Roux-en-Y gastric bypass surgery.

Severe malnutrition has been reported in 4% of patients after Roux-en-Y gastric bypass surgery. This condition leads to hospitalization in 54% of patients, with a mortality rate of 18%. The common causes of severe malnutrition after bariatric surgery include surgical mechanical adverse events and noncompliance with nutritional supplements. The treatment involves nutritional support and correction of the underlying causes; surgical reversal is required in some cases. In this video, we demonstrate endoscopic fistulization and stent bridge of the functional and defunctionalized stomach as a therapeutic option for severe malnutrition after Roux-en-Y gastric bypass surgery. A 38year-old woman who had undergone Roux-en-Y gastric bypass surgery was admitted with ongoing weight loss and anorexia. Her body mass index (BMI) was 16. She had had multiple hospitalizations because of malnutrition and dehydration. An extensive workup including abdominal imaging studies and deep enteroscopy was unrevealing.

Double peroral endoscopic myotomy for achalasia

As experience grows with peroral endoscopic myotomy (POEM), operators are taking on more anatomically challenging cases. Additionally, we are now seeing patients who relapse after a prior POEM. Therefore, the operator must be aware of the steps necessary to adequately investigate and treat such patients. For example, it is of no benefit to continue to target the lower esophageal sphincter if this already has been treated effectively. We herein present 2 different teaching cases in which 2 POEM procedures (double POEM) were performed in each of the patients (Video 1, available online at www. giejournal.org). The first case is a patient who was initially diagnosed with type II achalasia and underwent POEM. The patient did not respond adequately after 6 months, and repeat investigation revealed that the patient in fact had type III achalasia. He therefore required proximal extension of the myotomy. To avoid a new second POEM with a long myotomy on the posterior wall, the decision was made

Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic heller myotomy

Background/Aim: Several uncontrolled studies comparing peroral endoscopic myotomy (POEM) and Heller myotomy have demonstrated equivalent short-term efficacy and safety. However, no data exists rergarding the cost of POEM and how it compares to that of robotic Heller myotomy (RHM). The primary aim of this study was to compare the inpatient charges incurred in patients who underwent POEM or RHM for the treatment of achalasia. Patients and Methods: A retrospective single center review was conducted among 52 consecutive POEM patients (2012–2014) and 52 consecutive RHM patients (2009–2014). All RHM procedures included a Toupet fundoplication and were performed via a transabdominal approach. All POEM procedures were performed by a gastroenterologist in the endoscopy unit. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤I. All procedural and facility charges were obtained from review of the hospital finance records. Results: There was no difference between POEM and RHM with regards to age, gender, symptom duration, achalasia subtype, manometry findings, or Eckardt symptom stage. There was no significant difference in the rate of adverse events (19.2% vs 9.6%, P = 0.26) or the length of stay (1.9 vs. 2.3, P = 0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the RHM group (94.3% vs. 88.5%, P = 0.48). POEM incurred significantly less total charges compared to LHM (

Novel technique for the management of staple line leaks after sleeve gastrectomy

14481 vs.

Novel endoscopic approach for a large intraluminal duodenal ("windsock") diverticulum

17782, P = 0.02). Conclusions: POEM when performed in an endoscopy unit was similar in efficacy and safety to RHM. However, POEM was associated with significant cost savings (

Endoscopic Therapy With Lumen-apposing Metal Stents Is Safe and Effective for Patients With Pancreatic Walled-off Necrosis.

3301/procedure).