Haruo Ikeda

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

BACKGROUND After 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. STUDY DESIGN Per-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. RESULTS Per-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. CONCLUSIONS Per-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.

Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia

BACKGROUND AND STUDY AIMS Resection of submucosal tumors by means of endoscopy has been reported using a variety of techniques, but cannot be performed safely in tumors originating from the muscularis propria. Using the submucosal tunnel created by the technique of peroral endoscopic myotomy (POEM), we report the first series describing the new technique of submucosal endoscopic tumor resection (SET) for tumors of the esophagus and cardia. PATIENTS AND METHODS SET was attempted in nine consecutive patients with tumors (size >2cm) of either the esophagus or cardia with clinical indications for lesion removal. Following creation of a submucosal tunnel from 5 cm above the tumor, as described previously, the tumor was dissected from the overlying mucosa/submucosa and then carefully removed from the muscular layer using triangle-tip and insulated-tip knives. Following specimen retrieval through the tunnel, the orifice was closed by clips. RESULTS Of the nine patients, two had tumors that were too large (60 mm and 75 mm, respectively) to allow safe removal due to loss of endoscopic overview. All remaining tumors (maximal tumor extension 12-30 mm) could be resected safely using this method. No complications occurred and follow-up was unremarkable. On histology, all tumors were resected completely (one gastrointestinal stromal tumor, five leiomyomas). The technique had to be modified in one patient with an aberrant pancreas. CONCLUSIONS SET is a promising new technique for selected submucosal tumors in the esophagus and cardia up to a size of 4 cm and should be studied further.

Peroral Endoscopic Myotomy for Esophageal Achalasia: Technique, Indication, and Outcomes

Peroral endoscopic myotomy (POEM) has been developed as an incisionless, minimally invasive endoscopic treatment intending a permanent cure for esophageal achalasia. The concept of endoscopic myotomy was first reported about 3 decades ago, but the direct incision method through the mucosal layer was not considered to be a safe and reliable approach. A novel method of endoscopic myotomy was developed and established by the authors. In this article, the current techniques, applications, and clinical results of POEM are described.

Endoscopic mucosal resection, endoscopic submucosal dissection, and beyond: full-layer resection for gastric cancer with nonexposure technique (CLEAN-NET).

Mucosal cancer in the gastrointestinal tract generally has low risk of lymph node metastasis. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are techniques of local excision of neoplasia confined to the mucosal layer. Specimens from EMR/ESD contribute to several diagnoses, and histologic results affect treatment decisions. A combined laparoscopic and endoscopic approach to neoplasia with a nonexposure technique allows full-thickness resection of the stomach wall without exposing the gastric lumen to the peritoneal cavity, preventing cancer cell dissemination to the peritoneal cavity. This article reviews EMR/ESD and describes a new full-thickness resection method using the nonexposure technique (CLEAN-NET).

Training in peroral endoscopic myotomy (POEM) for esophageal achalasia

Video abstract Video

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

BACKGROUND Recent 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). OBJECTIVE To compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS We studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barretts esophagus). INTERVENTION After 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. MAIN OUTCOME MEASUREMENTS Total number of EBD sessions and total EBD period (months). RESULTS Steroid + 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. LIMITATIONS Nonrandomized study; retrospective analysis. CONCLUSION After 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.

Peroral endoscopic myotomy: an evolving treatment for achalasia

Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.

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.

Use of surface-enhanced Raman scattering for detection of cancer-related serum-constituents in gastrointestinal cancer patients

UNLABELLED Laser-mediated surface-enhanced Raman scattering (SERS) has industrial and biological applications. We have developed a rapid and simple method for generating silver nanoscale hexagonal columns (NHCs) on the surface of a phosphor bronze chip for measurement of SERS spectra. This was used to detect SERS spectra from blood samples obtained from patients with gastric cancer, colorectal cancer, or benign diseases (n=12 each) using a low intensity helium-neon red laser beam with a 632.8-nm wavelength; the intensity of the SERS spectra was compared among the patient groups. The peak heights of SERS spectra from patients with benign diseases were significantly lower than those from patients with gastric or colorectal cancer, whereas those from patients with gastric cancer and colorectal cancer did not differ significantly. Thus, SERS using NHC chips holds promise for the easier and faster detection of cancer-related serum-constituents as biomarkers. FROM THE CLINICAL EDITOR In this study, laser-mediated surface-enhanced Raman scattering (SERS) was utilized as a sensitive detection method of cancer-related serum-constituents in gastric and colorectal cancer, via the use of silver nanoscale hexagonal columns on the surface of a phosphor bronze chip for measurement of SERS spectra, paving the way to the development of a rapid and high throughput tool for cancer screening and therapy monitoring.

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

BACKGROUND Per-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. OBJECTIVE To 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. DESIGN Prospective. SETTING Single-center study. PATIENTS Twenty-one achalasia patients who received POEM with GC myotomy. INTERVENTIONS POEM. MAIN OUTCOME MEASUREMENTS Efficacy 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. RESULTS Identification 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. LIMITATIONS Single center. CONCLUSIONS GC 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.