Hon Chi Yip

Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia

This retrospective cohort study compared clinical outcomes and quality of life after peroral endoscopic myotomy (POEM) against laparoscopic Heller myotomy (LHM) for treatment of achalasia.

Similar Efficacies of Endoscopic Ultrasound Gallbladder Drainage With a Lumen-Apposing Metal Stent Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis

Background & Aims Acute cholecystitis in patients who are not candidates for surgery is often managed with percutaneous transhepatic gallbladder drainage (PT‐GBD). Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) with a lumen‐apposing metal stent (LAMS) is an effective alternative to PT‐GBD. We compared the technical success of EUS‐GBD versus PT‐GBD, and patient outcomes, numbers of adverse events (AEs), length of hospital stay, pain scores, and repeat interventions. Methods We performed a retrospective study to compare EUS‐GBD versus PT‐GBD at 7 centers (5 in the United States, 1 in Europe, and 1 in Asia), from 2013 through 2015, in management of acute cholecystitis in patients who are not candidates for surgery. A total of 90 patients (56 men) with acute cholecystitis (61 calculous, 29 acalculous) underwent EUS‐GBD (n = 45) or PT‐GBD (n = 45). Data were collected on technical success, clinical success (resolution of symptoms or laboratory and/or radiologic abnormalities within 3 days of intervention), and need for repeat intervention. Characteristics were compared using Student t tests for continuous variables and the chi‐square test, or the Fisher exact test, when appropriate, for categorical variables. Adverse events were graded according to American Society for Gastrointestinal Endoscopy definitions and compared using the Fisher exact test. Postprocedure pain scores were compared using the Mann‐Whitney U test. Results Baseline characteristics, type, and clinical severity of cholecystitis were comparable between groups. In the EUS‐GBD group, noncautery LAMS were used in 30 patients and cautery‐enhanced LAMS were used in 15. Technical success was achieved for 98% of patients in the EUS‐GBD and 100% of the patients in the PT‐GBD group (P = .88). Clinical success was achieved by 96% of patients in the EUS‐GBD group and 91% in the PT‐GBD group (P = .20). There was a nonsignificant trend toward fewer AEs in the EUS‐GBD group (5 patients; 11%) than in the PT‐GBD group (14 patients; 32%) (P = .065). There were no significant differences in the severity of the AEs: mild, 2 in the EUS‐GBD group versus 5 in the PT‐GBD group (P = .27); moderate, 4 versus 3 (P = .98); severe, 1 versus 3 (P = .62); or deaths, 1 versus 3 (P = .61). The mean postprocedure pain score was lower in the EUS‐GBD group than in the PT‐GBD group (2.5 vs 6.5; P < .05). The EUS‐GBD group had a shorter average length of stay in the hospital (3 days) than the PT‐GBD group (9 days) (P < .05) and fewer repeat interventions (11 vs 112) (P < .05). The average number of repeat interventions per patients was 0.2 ± 0.4 EUS‐GBD group versus 2.5 ± 2.8 in the PT‐GBD group (P < .05). Median follow‐up after drainage was comparable in EUS‐GBD group (215 days; range, 1–621 days) versus the PT‐GBD group (265 days; range, 1–1638 days). Conclusions EUS‐GBD has similar technical and clinical success compared with PT‐GBD and should be considered an alternative for patients who are not candidates for surgery. Patients who undergo EUS‐GBD seem to have shorter hospital stays, lower pain scores, and fewer repeated interventions, with a trend toward fewer AEs. A prospective, comparative study is needed to confirm these results.

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy

BACKGROUND & AIMS: In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS: We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non‐HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS: POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non‐HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non‐HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non‐HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS: POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.

Current status and future applications of contrast-enhanced endoscopic ultrasonography

Endoscopic ultrasonography (EUS) is currently an integral investigation of many gastrointestinal disorders. It has been shown to have a higher efficacy than conventional computed tomography in detection and characterization of small lesions especially in the pancreas. Much effort has been put to further improve the sensitivity, specificity and overall accuracy of EUS. One of the major advances is the utilization of contrast agents for better delineation of the vascularity and tissue perfusion of the target lesion. This article describes the basic principles of ultrasound contrast agents and the different modalities used in contrast-enhanced EUS (CE-EUS) including contrast-enhanced Doppler EUS (CED-EUS) and contrast-enhanced harmonic EUS (CEH-EUS). In addition, the current applications of contrast enhanced EUS in different gastrointestinal conditions were discussed. Furthermore, the future development of hybrid approaches combining CE-EUS with other imaging modalities and the potential therapeutic aspect of using it as a vector for drug delivery were also discussed.

Removal of submucosal embedded fish bone in the esophagus with endoscopic submucosal dissection

If a foreign body is deeply embedded into the wall of the esophagus after accidental ingestion, surgical exploration for removal and repair is usually required. We report a rare case of foreign body embedment in the esophageal wall and its successful removal by endoscopic submucosal dissection (ESD). A 77-year-oldwomanpresentedwith odynophagia after fish bone ingestion. Initial endoscopy showed a hematoma 1 cm below the cricopharyngeus, but the foreign body was not identified. A CT scan revealed a 2-cm linear foreign body at the cervical esophagus. Repeated endoscopy showed a 2-cm submucosal bulge at the cervical esophagus. After submucosal injection of amixture of normal saline solution and indigo carmine, a mucosal incision was created with an ESD knife. The fish bone was then identified at the submucosal plane of the esophagus and was removed with forceps (Fig. 1; Video 1, available online at www.VideoGIE.org). The mucosal defect was closed with endoscopic clips. The patient recovered uneventfully after the endoscopic procedure. ESD was used in this case for removal of an esophageal foreign body, avoiding the need for surgical exploration of the esophagus. With increasing experience

Endoscopic Management of Peri-Pancreatic Fluid Collections

In the past decade, there has been a progressive paradigm shift in the management of peri-pancreatic fluid collections after acute pancreatitis. Refinements in the definitions of fluid collections from the updated Atlanta classification have enabled better communication amongst physicians in an effort to formulate optimal treatments. Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has emerged as the procedure of choice over surgical cystogastrostomy. The approach provides similar success rates with low complications and better quality of life compared with surgery. However, an endoscopic “step up” approach in the management of pancreatic walled-off necrosis has also been advocated. Both endoscopic and percutaneous drainage routes may be used depending on the anatomical location of the collections. New-generation large diameter EUS-specific stent systems have also recently been described. The device allows precise and effective drainage of the collections and permits endoscopic necrosectomy through the stents.