Alba Azola

The Relationship Between Submental Surface Electromyography and Hyo-Laryngeal Kinematic Measures of Mendelsohn Maneuver Duration

PURPOSE The Mendelsohn Maneuver (MM) is a commonly prescribed technique that is taught to individuals with dysphagia to improve swallowing ability. Due to cost and safety concerns associated with videofluoroscopy (VFS) use, submental surface electromyography (ssEMG) is commonly used in place of VFS to train the MM in clinical and research settings. However, it is unknown whether ssEMG accurately reflects the prolonged hyo-laryngeal movements required for execution of the MM. The primary goal of this study was to examine the relationship among ssEMG duration, duration of laryngeal vestibule closure, and duration of maximum hyoid elevation during MM performance. METHOD Participants included healthy adults and patients with dysphagia due to stroke. All performed the MM during synchronous ssEMG and VFS recording. RESULTS Significant correlations between ssEMG duration and VFS measures of hyo-laryngeal kinematic durations during MM performance ranged from very weak to moderate. None of the correlations in the group of stroke patients reached statistical significance. CONCLUSION Clinicians and researchers should consider that the MM involves novel hyo-laryngeal kinematics that may be only moderately represented with ssEMG. Thus, there is a risk that these target therapeutic movements are not consistently being trained.

Closure methods in submucosal endoscopy.

Submucosal endoscopy requires transforming the submucosal layer into an endoscopic working space to allow safe access to the muscularis propria and beyond. The submucosal tunnel places the mucosal incision proximal to the area of interest, thereby simplifying closure to merely mucosal apposition. The earliest clinical adaptation of submucosal endoscopy was peroral endoscopic myotomy for the management of achalasia. More recently, submucosal tunneling endoscopic resection has been demonstrated to be a suitable alternative to surgical removal of tumors originating from the muscularis propria. Reliable closure of mucosal incision and inadvertent mucosotomy during submucosal endoscopy is paramount in preventing leakage of esophageal contents into the mediastinal and peritoneal spaces. The use of endoclips and endoscopic suturing are currently accepted as “firstline” closure methods. When aforementioned techniques fail to achieve closure, most commonly because of the large size of the mucosal incision, there is no consensus as to which “salvage” method should be used. Available options include the over-the-scope clip, fully covered self-expandable metallic stent, and combination therapies such as over-the-scope clip and topical cyanoacrylate. We herein present 3 cases that demonstrate first-line closure

Closure of a chronic tracheoesophageal fistula by use of a cardiac septal occluder

In adults, an acquired tracheoesophageal fistula (TEF) is most commonly the result of cuff-induced tissue necrosis from prolonged mechanical ventilation. These patients are often poor surgical candidates, and hence a minimally invasive technique for closure may offer significant benefits. In this video, we demonstrate the use of a cardiac septal occluder (Amplatzer; St Jude Medical, Plymouth, Minn,) to close a TEF. This device is a self-expandable double umbrella-shaped polyester covered nitinol wire mesh. A 72-year-old woman was seen for management of a chronic, iatrogenic TEF as a result of tracheal stenting to manage a tracheal stricture as a consequence of prolonged intubation. A combined bronchoscopic, esophagoscopic, and fluoroscopic approach was used. The fistula was located 2 cm below the upper esophageal sphincter and measured 10 mm. The cardiac septal occluder was deployed across the fistula during a procedure time of 10 minutes (Fig. 1; Video 1, available online at www.giejournal.org). The patient was discharged home the same day, and a swallow test with contrast medium at 6 weeks revealed no active fistula. The patient recommenced a normal diet and remains well without episodes of aspiration pneumonia.

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

Percutaneous through-the-stent assisted ERCP in patients with Roux-en-Y gastric bypass.

ASGE VIDEO FORUM AND/OR WORLD CUP OF ENDOSCOPY / ERCP A Novel Method for ERCP in the Gastric Bypass Patient Dead End Ducts. Rendezvous Techniques for Reconnecting the Obstructed Pancreas. Percutaneous Through-the-Stent Assisted ERCP in Patients With Roux-en-Y Gastric Bypass Resection of a Large Periampullary Lipoma in a Patient With Recurrent Pancreaticobiliary Pain Transenteric Anastomosis With LumenApposing Metal Stent (Lams) As Conduit for Iterative Endotherapy of Malignant Biliary Obstruction in Altered Anatomy

Swallowing Kinematic Differences Across Frozen, Mixed, and Ultrathin Liquid Boluses in Healthy Adults: Age, Sex, and Normal Variability

Purpose The aim of this study was to examine the effects of frozen and mixed-consistency boluses on the swallowing physiology of younger and older adults. We also aimed to quantify factors that lead to increased variability in swallowing outcomes (i.e., age, sex, bolus type). Method Forty-one healthy adults (18-85 years old) swallowed 5 blocks of 5 different boluses: 10-ml ultrathin liquid, a teaspoon of iced barium, a teaspoon of room-temperature pudding, a teaspoon of frozen pudding, and ultrathin barium with chocolate chips. All data were recorded with videofluoroscopy and underwent detailed timing kinematic measurements. Results Neither barium ice nor frozen pudding sped up swallow responses. Many healthy adults initiated swallowing with the bolus as deep as the pyriform sinuses. Swallowing temporal kinematics for ultrathin liquid consistencies are most different from all others tested, requiring the best possible physiological swallowing performance in younger and older healthy individuals (i.e., faster reaction times, longer durations) compared with other bolus types tested. In each measure, older adults had significantly longer durations compared with the younger adults. More variability in swallowing kinematics were seen with age and laryngeal vestibule kinematics. Conclusion This study provides important contributions to the literature by clarifying normal variability within a wide range of swallowing behaviors and by providing normative data from which to compare disordered populations.

Stylet slow-pull versus standard suction for endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic lesions: a multicenter randomized trial

BACKGROUND AND STUDY AIM Standard endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) procedures involve use of no-suction or suction aspiration techniques. A new aspiration method, the stylet slow-pull technique, involves slow withdrawal of the needle stylet to create minimum negative pressure. The aim of this study was to compare the sensitivity of EUS-FNA using stylet slow-pull or suction techniques for malignant solid pancreatic lesions using a standard 22-gauge needle. PATIENTS AND METHODS Consecutive patients presenting for EUS-FNA of pancreatic mass lesions were randomized to the stylet slow-pull or suction techniques using a 22-gauge needle. Both techniques were standardized for each pass until an adequate specimen was obtained, as determined by rapid on-site cytology examination. Patients were crossed over to the alternative technique after four nondiagnostic passes. RESULTS Of 147 patients screened, 121 (mean age 64 ± 13.8 years) met inclusion criteria and were randomized to the stylet slow-pull technique (n = 61) or the suction technique (n = 60). Technical success rates were 96.7 % and 98.3 % in the slow-pull and suction groups, respectively (P > 0.99). The sensitivity for malignancy of EUS-FNA was 82 % in the slow-pull group and 69 % in the suction group (P = 0.10). The first-pass diagnostic rate (42.6 % vs. 38.3 %; P = 0.71), acquisition of core tissue (60.6 % vs. 46.7 %; P = 0.14), and the median (range) number of passes to diagnosis (2 1 2 3 vs. 1 1 2; P = 0.71) were similar in the slow-pull and suction groups, respectively. CONCLUSIONS The stylet slow-pull and suction techniques both offered high and comparable diagnostic sensitivity with a mean of 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique during FNA.

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

A 59-year-old woman presented for evaluation of recurrent acute pancreatitis over 8 years and had previously undergone a cholecystectomy. Additionally, she had a longstanding history of foregut symptoms with multiple prior upper endoscopies not identifying an abnormality. Cross-sectional imaging revealed a dilated common bile duct with no mass seen on EUS. At attempted ERCP, a structure was identified that was in the correct location for the major papilla but was odd in appearance. This was subsequently found to be a large intraluminal duodenal “windsock” diverticulum (Fig. 1). The actual major papilla was identified, and she underwent ERCP and biliary sphincterotomy. Despite this, her symptoms persisted. A diverticulotomy was subsequently arranged. A through-the-scope 18 80 mm fully covered selfexpandable metallic stent was inserted into the diverticulum in such a manner that the distal end exited into the true lumen of the second part of the duodenum. The septum was cut with a needle-knife, care being taken to cut toward and onto the stent. At completion of the procedure, only 1 lumen existed (Video 1, available online at

Intraoperative determination of the adequacy of myotomy length during peroral endoscopic myotomy (POEM): The double-endoscope transillumination for extent confirmation technique (DETECT)

BACKGROUND AND STUDY AIMS Precise identification of the gastroesophageal junction (GEJ) is a challenging prerequisite for adequate length of an esophageal myotomy. Multiple standard methods to identify the GEJ have been described; however, a more objective modality is needed to ensure effective peroral endoscopic myotomy (POEM). PATIENTS AND METHODS In the double-endoscope transillumination for extent confirmation technique (DETECT), an ultraslim gastroscope is passed to the most distal aspect of the submucosal tunnel created during POEM. A regular gastroscope is advanced into the stomach, and the visualization of transillumination from the ultraslim gastroscope enables identification of the extent of the submucosal tunnel. RESULTS A total of 10 patients underwent POEM with DETECT. Initial submucosal tunneling was performed based on a determination of the GEJ location via standard methods. DETECT indicated the tunnel extent to be inadequate in 50% of patients, and the tunnel was extended a further 1 to 2cm. The mean initial tunnel length was 15.4cm, with a mean initial myotomy length of 11.9cm. DETECT was performed in less than 10 minutes without complications. CONCLUSION DETECT is an objective method for determining the adequacy of the submucosal tunnel length during POEM.

Tu1978 LES Pressures Are Inversely Correlated to Esophagogastric Junction Diameter and Cross-Sectional Area in Achalasia

G A A b st ra ct s each method are shown in Table 1. Among these candidate methods, optimal discrimination from type I achalasia was achieved using the 4s-IRP method and receiver operating curve analysis revealed an optimal threshold %EGJR to be (<40%, sensitivity 100%, specificity 88%). The Figure shows %EGJR data using the 4s-IRP method for all patients compared to controls. As a single metric, the IRP exhibited superior discriminative performance to %EGJR among diagnoses. However, in certain instances, %EGJR was a useful secondary metric. Specifically, 100%(25 patients) of the Jackhammer group, a classification which may present with an elevated IRP and have an erroneous diagnosis of type III achalasia, fell within the normative range for percent EGJ relaxation. However, with low baseline EGJ pressure, %EGJR performed poorly in discriminating between patients with absent peristalsis(24/25 of whom had a collagen vascular disease or reflux disease) and type I achalasia. Conclusions: This study discounts the viability of the %EGJR metric as a stand-alone tool for assessing the adequacy of EGJ relaxation within the framework of the CC of motility disorders. However, there may be a supplementary role for this metric in identifying borderline cases of achalasia from mechanical causes of EGJ outflow obstruction and in differentiating Jackhammer cases from type III achalasia.