Anthony Y. Teoh

Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video).

BACKGROUND Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy through a long submucosal tunnel. OBJECTIVE This study aimed to investigate the feasibility and safety of POEM for treatment of achalasia. DESIGN Preclinical animal study and prospective clinical study. PATIENTS Consecutive patients diagnosed with achalasia with high-resolution manometry. INTERVENTIONS POEM was standardized for preclinical and clinical studies. After submucosal injection, a mucosal incision was made 15 cm above the gastroesophageal junction (GEJ). A long submucosal tunnel was created to extend below the GEJ. The endoscopic myotomy started 10 cm above and extended 2 cm below the GEJ. We first conducted a preclinical animal study to confirm the safety of POEM. POEM was then performed for the treatment of achalasia in humans. MAIN OUTCOME MEASUREMENTS Relief from dysphagia assessed by the dysphagia score and Eckhardt score. High-resolution manometry and pH monitoring were performed to evaluate the posttreatment effects and esophageal acid exposure. RESULTS Seven 30-kg porcine models underwent POEM in the survival study. All of the pigs survived except 1, which sustained pneumomediastinum. POEM was performed for the treatment of achalasia in 16 patients. The mean operating time was 117.0 ± 34.1 minutes. All patients tolerated food on day 2, with a contrast study confirming no leakage. The median follow-up was 176.5 days (range 98-230 days). The postoperative basal lower esophageal sphincter pressure was significantly reduced (mean reduction, 13.9 ± 14.5 mm Hg; P = .005) and 4-second integrated relaxation pressure of the GEJ (mean reduction, 10.1 ± 7.4 mm Hg; P = .001). Of these patients, 58.3% had a normalized 4-second integrated relaxation pressure, whereas 20% had excessive esophageal acid exposure after the procedure. There was a significant improvement in quality of life 6 months after POEM measured by the Short Form-36 questionnaire. LIMITATION Small sample size. CONCLUSIONS POEM is a feasible, safe, and effective treatment for achalasia.

A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers

BACKGROUND In patients with bleeding peptic ulcers in whom endoscopic hemostasis fails, surgery usually follows. Transarterial embolization (TAE) has been proposed as an alternative. OBJECTIVE To compare the outcomes of TAE and salvage surgery for patients with peptic ulcers in whom endoscopic hemostasis failed. DESIGN Retrospective study. SETTING A university hospital. PATIENTS Patients with peptic ulcer bleeding in whom endoscopic hemostasis failed. INTERVENTIONS TAE and surgery as salvage of peptic ulcer bleeding. MAIN OUTCOMES MEASUREMENTS All-cause mortality, rebleeding, reintervention, and complication rate. RESULTS Thirty-two patients underwent TAE and 56 underwent surgery. In those who underwent TAE, the bleeding vessels were gastroduodenal artery (25 patients), left gastric artery (4 patients), right gastric artery (2 patients), and splenic artery (1 patient). Active extravasation was seen in 15 patients (46.9%). Embolization was attempted in 26 patients, and angiographic coiling was successful in 23 patients (88.5%). Bleeding recurred in 11 patients (34.4%) in the TAE group and in 7 patients (12.5%) in the surgery group (P=.01). More complications were observed in patients who underwent surgery (40.6% vs 67.9%, P=.01). There was no difference in 30-day mortality (25% vs 30.4%, P=.77), mean length of hospital stay (17.3 vs 21.6 days, P=.09), and need for transfusion (15.6 vs 14.2 units, P=.60) between the TAE and surgery groups. LIMITATIONS Retrospective study. CONCLUSIONS In patients with ulcer bleeding after failed endoscopic hemostasis, TAE reduces the need for surgery without increasing the overall mortality and is associated with fewer complications.

Randomized Trial of Endoscopic Sphincterotomy With Balloon Dilation Versus Endoscopic Sphincterotomy Alone for Removal of Bile Duct Stones

BACKGROUND & AIMS Limited endoscopic sphincterotomy with large balloon dilation (ESBD) is an alternative to endoscopic sphincterotomy (ES) for removing bile duct stones, but it is not clear which procedure is most effective. We compared the 2 techniques in removal of bile duct stones. METHODS Between September 2005 and September 2011, 156 consecutive patients with suspected of having, or known to have, common bile duct stones were randomly assigned to groups that underwent ES or ESBD. Patients in the ESBD group underwent limited sphincterotomy (up to half of the sphincter) followed by balloon dilation to the size of the common bile duct or 15 mm, and patients in the ES group underwent complete sphincterotomy alone. Stones were then removed using standard techniques. The primary outcome was percentage of stones cleared, and secondary outcomes included procedural time, method of stone extraction, number of procedures required for stone clearance, morbidities and mortality within 30 days, and direct cost. RESULTS There was no significant difference between groups in percentage of stones cleared (ES vs ESBD: 88.5% vs 89.0%). More patients in the ES group (46.2%) than the ESBD group (28.8%) required mechanical lithotripsy (P = .028), particularly for stones ≥15 mm (90.9% vs 58.1%; P = .002). Morbidities developed in 10.3% of patients in the ES group and 6.8% of patients in the ESBD group (P = .46). The cost of the hospitalization was also significantly lower in the ESBD group (P = .034). CONCLUSIONS ESBD and ES clear bile stones with equal efficacy. However, ESBD reduces the need for mechanical lithotripsy and is less expensive; ClinicalTrials.gov number, NCT00164853.

Biliary cystadenoma and other complicated cystic lesions of the liver: diagnostic and therapeutic challenges.

Biliary cystadenomas are complicated cystic lesions of the liver. They are rare and pose considerable diagnostic and therapeutic challenges. We present our experience managing these lesions by performing a retrospective review of all patients with a preoperative diagnosis of or histologically proven biliary cystadenoma who underwent surgery between January 1995 and January 2005 at our institution. Altogether, 20 patients (16 women, 4 men) with a mean age of 58 years underwent a total of 22 operations. The diagnosis of biliary cystadenoma was based on exclusion of other pathologic entities and the presence of radiologic characteristics of biliary cystadenoma. Abdominal ultrasonography (US), computed tomography, or both were performed in all patients. US-guided fine-needle aspiration cytology was performed in seven patients and all of them were negative for malignancy. A preoperative diagnosis of biliary cystadenoma was made in 16 patients based on clinical and radiologic features and was correct in 6 of them. Diagnosis of biliary cystadenoma was not suspected in four patients. The overall diagnostic accuracy was 30%. Enucleation was the most common surgical procedure and was performed in 10 patients. The mean follow-up period was 5.5 ± 2.8 years. No recurrence was detected in patients with confirmed biliary cystadenoma after adequate excision. The findings of this study highlight the difficulty with preoperative diagnosis of biliary cystadenoma, which has seldom been discussed in the literature. Preoperative differentiation by means of radiologic imaging is inaccurate (30%). Any therapy short of complete excision leads to local recurrence and risk of malignant transformation. Complete excision of any suspicious lesion remains the best method of diagnosis and treatment.

A double-blinded randomized controlled trial of laparoendoscopic single-site access versus conventional 3-port appendectomy.

Objective:The aim of the current study was to perform a multicentered prospective double-blinded randomized controlled trial comparing laparoendoscopic single-site access (LESS) versus conventional three-port laparoscopic appendectomy (TPLA). Background:The clinical benefits and disadvantages of LESS appendectomy are uncertain. Methods:Between October 2009 and March 2011, consecutive patients admitted with clinical or radiological evidence of appendicitis were randomly assigned to receive either LESS or TPLA. The main outcome measurement was overall pain score. Secondary outcome measurements included operative time, conversion rates, morbidity rates, activity pain scores, activity scores, patient satisfaction, and cosmesis scores. Results:During the study period, 200 patients were recruited to the study. There were no significant differences in the morbidity rates, operative time, conversion rates, and postoperative recovery. There were also no differences in the overall pain score and pain score at rest. However, patients in the LESS group experienced significantly more pain upon coughing or standing and required more intravenous analgesics (P = 0.001, 0.038, and 0.035, respectively). Wound cosmesis and satisfaction scores on the contrary were better in the LESS group (P = 0.002 and P = 0.052). No differences in the quality-of-life assessments were present at 2 weeks after operation. Conclusions:LESS and conventional appendectomy resulted in similar perioperative outcomes. However, LESS appendectomy resulted in worst pain scores upon exertion and required a higher dosage of intravenous analgesics when compared with TPLA. On the contrary, wound cosmesis and satisfaction scores were better in the LESS group. Hence, adoption of the technique for appendectomy will depend on patient preferences and the presence of local expertise.

Functional performance and quality of life in patients with squamous esophageal carcinoma receiving surgery or chemoradiation: Results from a randomized trial

Objective:The aim of this study was to compare the 2-year functional performance and quality of life in patients with operable squamous cell carcinoma of the esophagus, who have received either surgery or definitive chemoradiation (CRT). Summary Background Data:The functional outcomes and quality of life in patients receiving esophagectomy or definitive CRT is uncertain. Methods:Data were extracted from the database of a prospective randomized controlled trial that included patients with resectable mid or lower thoracic esophageal cancers. The patients were randomized to either standard esophagectomy or definitive CRT. Quality of life assessments were performed using the EORTC QLQ-C30 and QLQ-OES24 modules. Other functional assessments included pulmonary and eating functions. Results:From July 2000 to December 2004, a total of 81 patients were enrolled into the study. No significant longitudinal changes were detected in the global health status in both groups upon available follow-up. Surgery was associated with worsened physical functioning and fatigue symptoms up to 6 months after treatment (P < 0.001 and P = 0.021, respectively) and these scales improved at 2 years. In terms of pulmonary function, dyspnoic and coughing symptoms were significantly worsened 3 months after surgery (P = 0.024 and P = 0.036, respectively) whereas symptoms in the CRT group progressively deteriorated over time. Concerning the eating function, both groups had improvements in dysphagia but there were frequent need for endoscopic intervention. This study has been registered with clinicaltrials.gov and the clinicaltrials.gov ID number is NCT01032967. Conclusion:Neither surgery nor definitive CRT significantly impaired the global health status of patients. Surgery was associated with a short-term negative impact in some aspects of health related quality of life assessments but these changes became insignificant 2 years after treatment. However, CRT was associated with progressive deteriorations in pulmonary function in the longer term.

EUS-guided gall bladder drainage with a lumen-apposing metal stent: a prospective long-term evaluation

Endoscopic ultrasound-guided gall bladder drainage (EUS-GBD) has been shown to be comparable with percutaneous gall bladder drainage (PTGBD) in terms of technical feasibility and clinical efficacy for the treatment of acute cholecystitis in high-risk surgical patients.1 However, a potential serious complication of this technique is air or bile leakage into the peritoneal cavity, since insertion of a drain or plastic stent requires a fistula tract with a diameter larger than the diameter of the inserted drain or stent. Therefore, a specifically designed lumen-apposing metal stents (LAMSs) has been developed for transenteric drainage and successfully tested in animal models.2 ,3 Preliminary clinical experience with LAMSs for drainage of peri-pancreatic fluid collections (PFCs) appears to be consistent with anchoring features tested in animal models.4–6 However, reports on the use of LAMSs for gall bladder drainage are limited to case reports and small case series without long-term follow-up.3 ,5 ,7–12 We performed a multicentre, prospective study to determine the feasibility and safety of the use of LAMS for EUS-GBD in high-risk surgical patients with acute cholecystitis. A total of 30 patients were included. Technical success was achieved in 27 of 30 patients (90%) (figure 1) and clinical success in 26 of 27 patients (96%). Two of 27 patients (7%) developed recurrent cholecystitis due to LAMS obstruction. Successful LAMS removal was performed in 15 of 30 patients (50%) after a mean of 91 days (SD±24 days). In 15 patients (50%), no LAMS removal was performed because of death (n=5), significant tissue overgrowth (n=2) or other causes (n=8). Mean follow-up was 298 days (SD±82 days) for all patients and 364 days (SD±82 days) for the patients alive at the end of the study. A total of 15 serious adverse events (SAEs) (50%) were …

Long-term survival outcomes after definitive chemoradiation versus surgery in patients with resectable squamous carcinoma of the esophagus: results from a randomized controlled trial

BACKGROUND The aim of this study was to report on the 5-year survival outcomes of patients with resectable esophageal carcinoma who were treated by definitive chemoradiotherapy (CRT) or standard esophagectomy. PATIENTS AND METHODS Between July 2000 and December 2004, 81 patients with resectable squamous cell carcinoma of the mid- or lower thoracic esophagus were randomized to receive esophagectomy or definitive CRT. The primary outcome was the overall survival and secondary outcomes included disease-free survival, morbidities and mortalities. RESULTS Forty-five patients received esophagectomy and 36 patients were treated by definitive CRT. The overall 5-year survival favors CRT but the difference did not reach statistical significance (surgery 29.4% and CRT 50%, P=0.147). A trend to improved 5-year survival was observed for patients suffering from node-positive disease (P=0.061). The 5-year disease-free survival also showed a trend to significance favoring CRT (P=0.068), particularly for patients suffering from node-positive disease (P=0.017). Both the stage of the disease and albumin level were significant predictors to mortality and disease-free survival. CONCLUSIONS Definitive CRT for squamous esophageal carcinoma resulted in comparable long-term survival to surgery. Further large-scale studies would be required to further investigate the role of CRT in node-positive patients. Clinicaltrials.gov identifier: NCT01032967.

Use of the Over-The-Scope Clip for treatment of refractory upper gastrointestinal bleeding: a case series.

The Over-The-Scope Clip (OTSC; Ovesco, Tübingen, Germany) is a novel endoscopic clipping device designed for tissue approximation. The device has been used in the closure of fistulas and perforations. We hereby report on a series of patients in whom OTSCs were used for endoscopic control of refractory or major upper gastrointestinal bleeding from lesions in the gastroduodenal tract between 1 July and 31 December 2012. Nine patients were included (median age 72.5 years, range 39 - 91) with bleeding gastric ulcers (n = 2), bleeding duodenal ulcers (n = 5), bleeding gastrointestinal stromal tumor in the stomach (n = 1), and bleeding from ulcerative carcinoma of the pancreas (n = 1). The median size of the ulcers was 2.5 cm (range 1 - 4). Six of the nine patients had undergone previous endoscopic hemostasis. Technical success was achieved in all patients and the clinical effectiveness was 77.8 %. The OTSC is a safe and effective method of endoscopic hemostasis for major bleeding from miscellaneous upper gastrointestinal causes and should be considered in patients with refractory bleeding after failure of conventional methods of endoscopic hemostasis.

A case-controlled comparison of single-site access versus conventional three-port laparoscopic appendectomy

BackgroundThe aim of this study was to compare patients who underwent single-site access laparoscopic appendectomy (SSALA) to those who underwent conventional three-port laparoscopic appendectomy (TPLA) in a case-controlled manner.MethodsConsecutive patients who underwent SSALA for suspected acute appendicitis between April and September 2009 were retrospectively compared to those who underwent TPLA between January and December 2008 in a case-controlled manner. The patients were matched for age, gender, and pathological findings. The main outcome measurements included postoperative recovery, morbidities, and mortalities.ResultsDuring the study period, a total of 30 patients underwent SSALA and these were matched with 60 TPLA patients. There were no significant differences in the mean operative time, hospital stay, and 30-day morbidity rate between the two groups. None of the patients required conversion. Two patients with significant contamination and abscess collection noted during SSALA required a relaparotomy for peritoneal lavage and adhesiolysis due to prolonged ileus.ConclusionsSSALA is feasible and the perioperative outcome was comparable to that of TPLA. However, future prospective studies will need to evaluate whether SSALA can adequately tackle patients with significant peritoneal contamination.