Chiaki Sato

Per-Oral Endoscopic Myotomy: A Series of 500 Patients.

BACKGROUNDnAfter the first case of per-oral endoscopic myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical myotomy and is now established as an excellent treatment option for achalasia. This study aimed to examine the safety and outcomes of POEM at our institution.nnnSTUDY DESIGNnPer-oral endoscopic myotomy was performed on 500 consecutive achalasia patients at our institution between September 2008 and November 2013. A review of prospectively collected data was conducted, including procedure time, myotomy location and length, adverse events, and patient data with short- (2 months) and long-term (1 and 3 years) follow-up.nnnRESULTSnPer-oral endoscopic myotomy was successfully completed in all patients, with adverse events observed in 3.2%. Two months post-POEM, significant reductions in symptom scores (Eckardt score 6.0 ± 3.0 vs 1.0 ± 2.0, p < 0.0001) and lower esophageal sphincter (LES) pressures (25.4 ± 17.1 vs 13.4 ± 5.9 mmHg, p < 0.0001) were achieved, and this persisted at 3 years post-POEM. Gastroesophageal reflux was seen in 16.8% of patients at 2 months and 21.3% at 3-year follow-up.nnnCONCLUSIONSnPer-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy.

Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos).

BACKGROUNDnPer-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side.nnnOBJECTIVEnTo evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging.nnnDESIGNnProspective.nnnSETTINGnSingle-center study.nnnPATIENTSnTwenty-one achalasia patients who received POEM with GC myotomy.nnnINTERVENTIONSnPOEM.nnnMAIN OUTCOME MEASUREMENTSnEfficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events.nnnRESULTSnIdentification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6±1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2±7.3 vs 10.5±2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) (P<.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered.nnnLIMITATIONSnSingle center.nnnCONCLUSIONSnGC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.

Peroral endoscopic myotomy for esophageal achalasia

Peroral endoscopic myotomy (POEM) is one of the alternative treatment for achalasia. Due to concept of natural orifice transluminal endoscopic surgery (NOTES), it becomes popular and widely accepted. With the endoluminal technique, submucosal tunnel was created followed by endoscopic myotomy. POEM is not only indicated in classical achalasia but also other abnormal esophageal motility disorders. Moreover, failures of endoscopic treatment or surgical attempted cases are not contraindicated for POEM. The second attempted POEM is also safe and technically feasible. Even though the legend of success of POEM is fruitful, the possible complications are very frightened. Good training and delicate practice will reduce rate of complications. This review provides a summary of current state-of-the-art of POEM, including indication equipments, technique and complications. This perfect procedure may become the treatment of choice of achalasia and some esophageal motility disorders in the near future.

Utility of intrapapillary capillary loops seen on magnifying narrow-band imaging in estimating invasive depth of esophageal squamous cell carcinoma

BACKGROUND AND STUDY AIMSnIntrapapillary capillary loops (IPCLs) have been used to estimate histopathological atypia and the invasion depth of squamous cell carcinoma (SCC). The aim of this study was to evaluate the clinical significance of IPCLs.nnnPATIENTS AND METHODSnA total of 358 consecutive patients with esophageal neoplasia on magnifying narrow-band imaging (M-NBI) were studied. The lesions were categorized according to the IPCL classification of Inoue et al. and were subsequently resected. Resected specimens were histopathologically analyzed to determine the invasion depth. The inter- and intraobserver agreements in the interpretation of IPCL images were also investigated.nnnRESULTSnA total of 446 lesions were diagnosed on M-NBI as IPCL type V lesions, which were further classified as 185 IPCL type V1, 109 type V2, 104 type V3, and 48 type Vn. Sensitivity and specificity of IPCL type V1-2 for invasion confined to the epithelium or lamina propria mucosa (m1-2) were 89.5u200a% (95u200a% confidence interval [CI] 85.4u200a%u200a-u200a92.7u200a%) and 79.6u200a% (95u200a%CI 72.3u200a%u200a-u200a85.7u200a%), respectively. Sensitivity and specificity of IPCL type V3 for invasion confined to the muscularis mucosa or slight submucosal invasion (m3-sm1) were 58.7u200a% and 83.8u200a%, respectively. Sensitivity and specificity of IPCL type Vn for deeper invasion (sm2-3) were 55.8u200a% and 98.6u200a%, respectively. Interobserver agreement was substantial (κu200a=u200a0.609, 0.641, and 0.705), as was intraobserver agreement (κu200a=u200a0.705 and κu200a=u200a0.819).nnnCONCLUSIONnChanges in the morphology of IPCLs on M-NBI correlated with the depth of SCC invasion, and results were reproducible and reliable among observers. Identification of IPCL type V1-2 proved useful for the intraprocedural identification of m1-2 lesions, which are considered an absolute indication for endoscopic resection.

In vivo histopathology using endocytoscopy for non-neoplastic changes in the gastric mucosa: a prospective pilot study (with video)

BACKGROUNDnEndocytoscopy (EC), as a novel ultrahigh magnification technology, enables inxa0vivo histopathological diagnoses of the GI tract. EC is particularly exceptional when comparing dysplastic and neoplastic tissue with normal tissue. There are, however, no detailed data for minute or minimal changes in the gastric mucosa.nnnOBJECTIVEnTo describe non-neoplastic EC patterns of the gastric mucosa correlated with histopathological findings and to determine any relationship with Helicobacter pylori (HP) infection.nnnDESIGNnA pilot prospective study.nnnSETTINGnTertiary care referral center.nnnPATIENTSnSixty-four participants undergoing upper endoscopy for various indications.nnnMETHODSnAntral mucosal patterns on EC were divided into 4 categories: type 1 (normal), each papilla/pit has round smooth structure; type 2 (gastritis), extended, notched, and distorted structure with some necrotic tissue; type 3(atrophy), neighboring papilla/pit take on a lobulated appearance; type 4 (intestinal metaplasia [IM]), goblet cells are identified in a completely stained crypt. Target biopsy specimens were obtained from the region identified with these patterns, and multiple HP tests were performed.nnnRESULTSnHP positivity was 0%, 40.9%, 50.0%, and 58.3% in types 1, 2, 3, and 4, respectively. The sensitivity and specificity of types 2+3+4 for HP positivity were 100％ and 42.5%, respectively. The positive predictive values of type 1 for normal, type 2 for chronic gastritis, type 3 for atrophic gastritis, and type 4 for IM were 100%, 62.5%, 40.0%, and 100%, respectively. The sensitivity and specificity of types 3+4 for atrophic gastritis to IM were 87.0% and 95.1%, respectively.nnnLIMITATIONSnSmall, single-center, pilot study.nnnCONCLUSIONSnEC can differentiate gastric mucosal patterns of minimal, non-neoplastic change and appears to reliably exclude HP infection.

In vivo histopathological assessment of the muscularis propria in achalasia by using endocytoscopy (with video)

Background: The histopathology of the muscularis propria (MP) is unknown in patients with achalasia. Endocytoscopy (EC) was developed as an ultra-high magnification endoscopy, and the submucosal tunnel created during peroral endoscopic myotomy (POEM) not only provides access to the MP but also enables subsequent endoscopic assessment of the MP. Patients and methods: In seven patients with achalasia (meanu200a±u200aSD; 35u200a±u200a18.1 years; men:women, 4:3) who underwent POEM (myotomy length: 12u200a±u200a2.2u200acm), subsequent EC examination was performed from the mid-esophagus to the gastric side. EC images were compared to the results of histopathologic examination (two biopsies from the mid-esophagus and lower esophageal sphincter), which was the standard. Results: In all patients, favorable EC images were obtained, and spindle-shaped smooth muscle cells were detected. In our series, we observed no notable features such as atrophy or hypertrophy of smooth muscle cells. In addition, the EC assessment was consistent with the results of biopsy. No complications were encountered during any of the procedures. Conclusion: In a clinical setting, real-time assessment of the MP using EC is feasible. This technique may play an important role in determining the pathology of achalasia and other diseases that affect gastrointestinal function.

In vivo gastric mucosal histopathology using endocytoscopy.

AIMnTo study the ability of endocytoscopy to identify normal gastric mucosa and to exclude Helicobacter pylori (H. pylori) infection.nnnMETHODSnEndocytoscopic examination of the gastric corpus and antrum was performed in 70 consecutive patients. Target biopsy specimens were also obtained from the assessed region and multiple H. pylori tests were performed. The normal endocytoscopy patterns of the corpus and antrum were divided into the normal pit-dominant type (n-Pit) or the normal papilla-dominant type (n-Pap), respectively characterized as either regular pits with capillary networks or round, smooth papillary structures with spiral capillaries. On the other hand, normal mucosa was defined as mucosa not demonstrating histological abnormalities, including inflammation and atrophy.nnnRESULTSnThe sensitivity and specificity of n-Pit for normal mucosa in the gastric corpus were 94.4% and 97.1%, respectively, whereas those of n-Pap for normal mucosa in the antrum were 92.0% and 86.7%, respectively. The positive predictive values of n-Pit and n-Pap for H. pylori-negative tissue were 88.6% and 93.1%, respectively, and their negative predictive values for H. pylori-negative tissues were 42.9% and 41.5%, respectively. The inter-observer agreement for determining n-Pit and n-Pap for normal mucosa were 0.857 and 0.769, respectively, which is considered reliable.nnnCONCLUSIONnN-Pit and n-Pap, seen using EC, are considered useful predictors of normal mucosa and the absence of H. pylori infection.

Endoscopic features of early-stage signet-ring-cell carcinoma of the stomach

AIMnTo identify the features of early signet ring cell gastric carcinoma using magnification endoscopy with narrow band imaging (NBI).nnnMETHODSnA retrospective review was conducted of 12 cases of early signet ring cell gastric carcinoma who underwent treatment in a single institution between January 2009 and April 2013. All patients had magnification endoscopy with NBI and indigo carmine contrast to closely examine the mucosal architecture, including the microvasculature and arrangement of gastric pits. Histologic examination of the final endoscopic submucosal dissection or gastrectomy specimen was performed and compared with the endoscopic findings to identify patterns specific to signet ring cell carcinoma.nnnRESULTSnTwelve patients with early signet ring cell gastric carcinoma were identified; 75% were male, and average age was 61 years. Most of the lesions were stage T1a (83%), while the remainder were T1b (17%). The mean lesion size was 1.4 cm(2). On standard endoscopy, all 12 patients had a pale, flat lesion without any evidence of mucosal abnormality such as ulceration, elevation, or depression. On magnification endoscopy with NBI, all of the patients had irregularities in the glands and microvasculature consistent with early gastric cancer. In addition, all 12 patients exhibited the stretch sign, an elongation or expansion of the architectural structure. Histologic examination of the resected specimens demonstrated an expanded and edematous mucosal layer infiltrated with tumor cells.nnnCONCLUSIONnThe stretch sign appears to be specific for signet ring cell carcinoma and may aid in the early diagnosis and treatment of this aggressive pathology.

New endoscopic classification of the cardiac orifice in esophageal achalasia: Champagne glass sign

Endoscopy, barium esophagram and manometry are used in the diagnosis of achalasia. In the case of early achalasia, characteristic endoscopic findings are difficult to recognize. As a result, the diagnosis of achalasia is often made several years after symptom onset. Therefore, we examined the endoscopic findings of the cardiac orifice in achalasia and propose a new classification.