Alexander J. Eckardt

Treatment and surveillance strategies in achalasia: an update

Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10–15 years.

Endosonographic large-bore biopsy of gastric subepithelial tumors: a prospective multicenter study.

Background Once gastric subepithelial lesions (SEL) are found, tissue diagnosis is required, considering the possible differential diagnosis of gastrointestinal stromal tumors (GIST). Previous studies have shown insufficient accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) using cytologic analysis. Methods The feasibility and yield of EUS–FNA-based histologic tissue acquisition for gastric SEL, using 19 G large-bore needles, was assessed in a 4-year multicenter, prospective study. All consecutive patients, who were referred for EUS–FNA for all SEL greater than 1 cm, were included. Results Of 100 patients with suspected gastric SEL, 71 lesions were found to be eligible. Endoscopic biopsies or resections or surgery were used alternatively for a variety of reasons in 25 patients. EUS–FNA using the 19 G needle was finally performed in 46/71 cases (65%) with one to four needle passes. Sufficient material for a definite or a suspected histological diagnosis was obtained in 52 and 7% of the cases, respectively. In 41%, the samples were not informative. Immunohistochemistry was possible in 91% of cases with sufficient amounts of tissue; 30% were GIST. Self-limited, mild hemorrhage occurred in 22%; one patient developed a fatal abscess. Conclusion Even when intended, EUS-guided 19 G FNA is only feasible in 46% of gastric SEL. The diagnostic yield of 19 G FNA was only 52%, but with excellent differentiation between GIST and leiomyoma. Infectious complications must be prevented.

Three-year results of a multicenter prospective study of transoral incisionless fundoplication

Background. To date, there are no long-term data on the use of transoral incisionless fundoplication (TIF) for the treatment of chronic gastroesophageal reflux disease (GERD). We sought to prospectively evaluate the long-term safety and durability of TIF in a multi-center setting. Methods. A longitudinal per protocol (PP) and a modified intention-to-treat (mITT) analysis at 1 and 3 years consisted of symptom evaluation using the GERD health-related quality of life (GERD-HRQL) questionnaire, medication use, upper gastrointestinal endoscopy, and pH-metry. Results. Of 79 patients previously reported at 1 year, 12 were lost to follow-up, and 1 died from an unrelated cause. The remaining 66 patients were followed up and analyzed (mITT). Of 66 patients, 12 underwent revisional procedures, leaving 54 patients for PP analysis at a median of 3.1 years (range = 2.9-3.6). No adverse events related to TIF were reported at 2- or 3-year follow-up. On PP analysis, median GERD-HRQL score off proton pump inhibitors (PPIs) improved significantly to 4 (range 0-32) from both off (25 [13-38], P < .0001) and on (9 [0-22], P < .0001) PPIs. Discontinuation of daily PPIs was sustained in 61% (mITT) and 74% (PP) of patients. Of 11 patients with pH data at 3 years (PP), 9 (82%) remained normal. Based on mITT analysis, 9/23 (39%) remained normal at 3 years. Conclusions. The clinical outcomes at 3 years following TIF, patient satisfaction, healing of erosive esophagitis, and cessation of PPI medication support long-term safety and durability of the TIF procedure for those with initial treatment success. Although complete normalization of pH studies occurred in a minority of patients, successful cases showed long-term durability.

Colonoscopy without premedication versus barium enema: a comparison of patient discomfort

BACKGROUND Colonoscopy is considered a painful procedure requiring routine intravenous sedation. We investigated whether unsedated colonoscopy causes more discomfort than barium enema. METHODS Procedure-related discomfort was determined in 100 consecutive patients undergoing colonoscopy without premedication and in an equal number of patients referred for sigmoidoscopy and barium enema. All patients underwent such examinations for the first time and had no history of previous bowel surgery. During colonoscopy, sedation was offered if significant pain or discomfort occurred. RESULTS In patients without stenosis and with satisfactory preparation, the completion rate of colonoscopy was 95%. Five percent of all patients undergoing endoscopy required sedation. On an analog scale ranging from 1 to 9, patients undergoing colonoscopy and barium enema reported similar ratings for procedure related discomfort (3.2 +/- 1.7 and 3.1 +/- 1.9) and for discomfort caused by bowel preparation (3.2 +/- 2.1 and 3.1 +/- 1.8). Eighty-seven percent of all patients undergoing colonoscopy stated that they would prefer no premedication in the event of repeated examinations. CONCLUSIONS Colonoscopy with sedation on demand does not cause more discomfort than barium enema and will be accepted by the vast majority of patients undergoing this procedure.

Does trainee participation during colonoscopy affect adenoma detection rates

INTRODUCTION: Training future endoscopists is essential to meeting the increasing demands for colonoscopy. It remains unknown whether adenoma detection rates are adversely affected by trainee participation. METHODS: This is a single-center, prospective study. The primary aim of this study was to investigate whether adenoma detection rates differed between procedures with or without trainee involvement. A total of 368 consecutive patients entered the analysis (181 with trainee participation and 187 without). RESULTS: Adenomas were detected in 19.3% of experienced physician-only procedures and in 14.9% of procedures with trainee participation. Advanced adenomas were detected in 8.6% of experienced physicians’ procedures vs. 4.9% of trainee procedures. Polyp detection was nearly identical in both groups (32% for experienced physicians; 33% for trainees). Trainee participation delayed the procedure by a mean of seven minutes. CONCLUSION: Adenoma detection rates did not differ significantly, whether there was trainee involvement or not. A trend toward finding more adenomas or advanced adenomas in the absence of a trainee was observed, but it was lower than previously reported interobserver variability among experienced physicians. The small difference in adenoma detection was not observed for polyp detection, which may be explained by the more frequent removal of hyperplastic polyps by trainees.

Endoscopic findings in patients with Schatzki rings： Evidence for an association with eosinophilic esophagitis

AIM To investigate endoscopic findings in patients with Schatzki rings (SRs) with a focus on evidence for eosinophilic esophagitis (EoE). METHODS We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic, Wiesbaden, Germany between July 2007 and July 2010. All patients with endoscopically diagnosed SRs, defined as thin, symmetrical, mucosal structures located at the esophagogastric junction, were prospectively registered. Additional endoscopic findings, clinical information and histopathological findings with a focus on esophageal eosinophilia (≥ 20 eosinophils/high power field) were recorded. The criteria for active EoE were defined as: (1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf; (2) symptoms of esophageal dysfunction; and (3) exclusion of other causes of esophageal eosinophilia. Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy. The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia. RESULTS A SR was diagnosed in 171 (3.3%; 128 males, 43 females, mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinal-endoscopy. Twenty of the 116 patients (17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia (≥ 20 eosinophils/hpf). Nine of these patients (8 males, 1 female, mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE, whereas in 11 (9%) patients with ≥ 20 eosinophils/hpf, a definite diagnosis of EoE was made. Three of the 11 patients (27%) with definite EoE had no suspicious endoscopic features of EoE. In contrast, in the 25 patients in whom EoE was suspected by endoscopic features, EoE was only confirmed in 7 (28%) patients. Patients with EoE were younger (mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years, P = 0.012), were more likely to have a history of allergies (73% vs 29%, P = 0.007) and complained more often of dysphagia (91% vs 34%, P = 0.004) and food impaction (36% vs 6%, P = 0.007) than patients without EoE. Endoscopically, additional webs were found significantly more often in patients with EoE than in patients without EoE (36% vs 11%, P = 0.04). Furthermore, the SR had a tendency to be narrower in patients with EoE than in those without EoE (36% vs 18%, P = 0.22). The percentage of males (73% vs 72%, P = 1.0) and frequency of heartburn (27% vs 27%, P = 1.0) were not significantly different in both groups. The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger (mean age 49 ± 10 years vs 58 ± 6 years, P = 0.0008) and were more likely to have a history of allergies (78% vs 24%, P = 0.003) than patients with < 20 eosinophils/hpf. Predictors of EoE were younger age, presence of dysphagia or food impaction and a history of allergies. CONCLUSION A significant proportion of patients with SRs also have EoE, which may not always be suspected according to other endoscopic features.

Editorial : Cancer Surveillance in Achalasia: Better Late Than Never?

Patients with achalasia have an increased risk for the development of esophageal squamous cell cancer. Endoscopic surveillance in long-standing achalasia has been advocated by some, but the most recent American Society of Gastrointesinal Endoscopy guidelines regard current data as insufficient to support such an approach. In this issue of the American Journal of Gastroenterology, Leeuwenburgh and colleagues report on the results of a long-term prospective study with fixed surveillance intervals. The authors confirm earlier observations of an increased cancer risk after 10 years of symptomatic achalasia. Despite some limitations, this study and earlier data suggest that it might be worthwhile to consider endoscopic surveillance in patients with long-standing achalasia.

Murine genetic deficiency of neuronal nitric oxide synthase (nNOS(-/-) ) and interstitial cells of Cajal (W/W(v) ): Implications for achalasia?

Nitric oxide (NO) is an important inhibitory mediator of esophageal function, and its lack leads to typical features of achalasia. In contrast, the role of intramuscular interstitial cells of Cajal (ICC‐IM) and vasoactive intestinal peptide (VIP) in lower esophageal sphincter (LES) function is still controversial. Therefore, we examined the function and morphology of the LES in vivo in NO‐deficient (nNOS‐/‐), ICC‐IM‐deficient (W/Wv)‐, and wild‐type (WT) mice.

Achalasia: Should pneumatic dilation be the primary treatment strategy?

The best long-term treatment results for patients with idiopathic achalasia have been achieved with pneumatic dilation or surgical myotomy. A new study adds evidence that good or excellent symptomatic results can be achieved in the long term when pneumatic dilation is used as the primary treatment strategy. In cases of early treatment failure (<2 years), surgery was found to be the best rescue therapy.

Prospective evaluation of the routine use of a nasopharyngeal airway (Wendl Tube) during endoscopic propofol-based sedation.

Background/Aims: Insertion of a nasopharyngeal airway (NPA) during endoscopic sedation is only recommended in the event of respiratory problems. We evaluated the safety and efficacy of routine insertion of an NPA during sedation in gastrointestinal (GI) endoscopy. Methods: Between July 2009 and April 2012, patients with colonoscopy or expected longer-lasting or therapeutic upper GI endoscopy were pseudo-randomized in a weekly alternating fashion to perform sedation (midazolam in combination with propofol) with or without NPA insertion. The primary outcome measure was respiratory depression (oxygen saturation <90%). Secondary measures included hypotension (systolic blood pressure <90 mm Hg), bradycardia (heart rate <40 beats/min) or nasopharyngeal damage after NPA insertion. Results: 216 (106 females, mean age 60.7 ± 9.65 years) were enrolled. Colonoscopy was performed in 131 patients and upper endoscopy in 85 patients. In 105 patients an NPA was used (intervention group). Five (4.7%) of those patients showed minor nasopharyngeal injury. Respiratory depression (13.5 vs. 1.9%, p = 0.002) and hypotension (11 vs. 5%, p = 0.09) occurred more frequently in the control than in the intervention group. Conclusion: The routine placement of an NPA can reduce the frequency of hypoxemic events during endoscopic sedation with minor risks for nasopharyngeal injury.