Esperanza Grace Santi

Peroral Endoscopic Myotomy Is a Viable Option for Failed Surgical Esophagocardiomyotomy Instead of Redo Surgical Heller Myotomy: A Single Center Prospective Study

BACKGROUNDnSurgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence.nnnSTUDY DESIGNnA total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line rescue treatment, and only if PBD failed were patients considered for rescue POEM.nnnRESULTSnThe PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed.nnnCONCLUSIONSnShort-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited.

Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone

BACKGROUNDnRecent technological advances have allowed superficially spreading intramucosal carcinomas of the esophagus to be successfully resected by circumferential endoscopic submucosal dissection (cESD). After this procedure, esophageal strictures develop in most patients and are mainly treated by endoscopic balloon dilation (EBD).nnnOBJECTIVEnTo compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD.nnnDESIGNnRetrospective cohort study.nnnSETTINGnTertiary-care referral center.nnnPATIENTSnWe studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barretts esophagus).nnnINTERVENTIONnAfter cESD, patients were managed with EBD alone (EBD, n = 13) or with EBD and oral prednisolone (steroid + EBD, n = 10), 30 mg daily, started 2 days after cESD and gradually tapered and discontinued after 8 weeks.nnnMAIN OUTCOME MEASUREMENTSnTotal number of EBD sessions and total EBD period (months).nnnRESULTSnSteroid + EBD patients required fewer sessions (13.8 ± 6.9 vs 33.5 ± 22.9; P < .001) and a shorter management period (4.8 ± 2.3 vs 14.2 ± 17.5 months, P = .005) compared with the EBD group. An additional 3 patients received oral steroids a mean interval of 158 days after cESD. These patients required more EBD sessions (46.3 ± 30.0; P = .002), and the EBD period was significantly longer (17.5 ± 13.0 months; P = .005) than in the early steroid + EBD group.nnnLIMITATIONSnNonrandomized study; retrospective analysis.nnnCONCLUSIONnAfter cESD, oral steroid therapy dramatically reduced the need for EBD. We conclude that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete cESD.

Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist

With advances in endoscopic imaging and image enhancement, it is now possible to reliably differentiate non-neoplastic pathology from cancer throughout the GI tract. Techniques developed and reported in the Japanese literature provide a wealth of information that is not immediately accessible or easy to interpret. Despite this, along with many other challenges facing the “Western” endoscopist, much of this experience can be translated and summarized in a diagnostic algorithm. In this review, we collate the Japanese data on the use of magnifying endoscopy and narrow-band imaging in the stomach.

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.

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.

Surgical Outcomes and Clinicopathological Characteristics of Patients Who Underwent Potentially Noncurative Endoscopic Resection for Gastric Cancer: A Report of a Single-Center Experience

Background. Standard treatment of early gastric cancer (EGC) after endoscopic resection with risk factors of nodal metastases and incomplete resection is controversial. We investigated optimal management for the patients with potentially noncurative EGC after endoscopic resection. Methods. We retrospectively examined clinicopathological data and surgical outcomes of all patients with clinically solitary gastric adenocarcinoma who underwent curative surgery after a single peroral endoscopic resection at the Digestive Disease Center of Showa University Northern Yokohama Hospital between April 2001 and December 2012. Fishers exact test was used for univariate analysis. For multivariate analysis, stepwise multiple linear regression was used to identify independent predictors related to lymph node metastasis and remnant of primary tumor. Results. A total of 41 patients were studied. Four patients (9.8%) had lymph node metastases. Primary tumors remained in 6 patients (14.6%). Only venous invasion was statistically significant to lymph node metastasis (P = 0.017). With respect to remnant of the primary tumor, pT1b2 tumor invasion (P = 0.015) and horizontal margin (P = 0.013) were statistically significant. Conclusions. Surgery with limited lymphadenectomy is recommended for tumors with venous invasion or pT1b2 tumor invasion, and additional endoscopic resection may be allowed for tumors with horizontal involvement.

Submucosal Endoscopy: From ESD to POEM and Beyond

Peroral endoscopic myotomy (POEM) is an evolving minimally invasive endoscopic surgical procedure, with no skin incision, intended for long-term recovery from symptoms of esophageal achalasia. POEM was developed based on both the already established surgical principles of esophageal myotomy and the advanced techniques of endoscopic submucosal dissection. This article relates how POEM was developed, and its use in practice is reported and discussed. As an extension of the POEM technique, submucosal endoscopic tumor resection is introduced.

Microvascular caliber changes in intramucosal and submucosally invasive esophageal cancer.

BACKGROUND AND STUDY AIMnIntrapapillary capillary loops (IPCLs) show distinct pattern changes corresponding to tumor progression and depth of invasion, important for in vivo characterization of superficial squamous cell carcinoma (SCC). We examined the relation between invasion depth and histopathologic IPCL diameter.nnnPATIENTS AND METHODSnProspectively, before lesion resection, magnification endoscopy and narrow band imaging were used to identify IPCL patterns of type V1 (corresponding to tumors limited to the mucosa; 10 patients) and type Vn (submucosally invading tumors; 10 patients). Post-resection, IPCL samples (type I [normal mucosa], n = 103; V1, n = 113; Vn, n = 100) were stained with hematoxylin & eosin, CD34, and desmin, and vessel diameter measured using light microscopy.nnnRESULTSnMean (standard deviation [SD]) histopathologic calibers of IPCLs of types I, V1, and Vn were significantly different, being 7.7 (2.8) µm, 21.9 (7.4) µm, and 65.2 (22.9) µm; type 1 vs. V1, P < 0.001; V1 vs. Vn, P < 0.001.nnnCONCLUSIONSnMagnification endoscopy observation of IPCLs allows in vivo discrimination between intramucosal and submucosally invasive cancer.

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.