Jérôme Rivory

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.

Comprehensive Analysis of Adverse Events Associated with per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study

Objectives:The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM.Methods:Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case–control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders).Results:A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs.Conclusions:This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.

Traction strategy with clips and rubber band allows complete en bloc endoscopic submucosal dissection of laterally spreading tumors invading the appendix

Endoscopic submucosal dissection (ESD) is now the reference method for en bloc resection of large colorectal neoplasia [1]. Nevertheless, appendix invasion is still considered a contraindication to resection because of the risk of perforation and the difficulty in finding the dissection space at the bottom of the appendix. We report on the case of a 72-yearold man referred for resection of a 4 cm granular laterally spreading tumor (LST) of the cecum (▶Fig. 1, ▶Video 1). The lesion had developed on the appendiceal orifice, invading it deeply. As previously demonstrated, we used a traction strategy with two clips and a rubber band [2]. After complete circumferential incision and trimming, we caught the lesion edge with the first clip, which was grasping a rubber band (▶Fig. 2). The second clip was then used to grasp the rubber band and stretch the lesion; the clip was then fixed to the opposite wall of the colon (▶Fig. 3). This traction method is flexible using stretching and relaxing of the rubber band to produce more or less traction, respectively. Greater stretching of the band resulted in strong traction, which allowed the mucosa of the appendix to be dissected and extracted through the appendiceal orifice (▶Fig. 4). Finally, we were able to cut the deep fibrotic fibers that fixed the mucosa at the bottom of the appendix. Pathological examination revealed a granular LST with high grade dysplasia, which was completely removed with free margins. There were no complications either during the procedure or in the postoperative period. The patient was monitored for 48 hours, given the known risk of early and late acute appendicitis of 3% and 5%, respectively [3]. In patients with an intact appendix, there is a high risk of incomplete resection for lesions that reach and enter the appendiceal orifice with invisible margins (Type 3) [4]. Video 1 Endoscopic submucosal dissection procedure with double clip and rubber band traction to allow complete R0 resection of a laterally spreading tumor invading the appendix. ▶ Fig. 1 Granular laterally spreading tumor with regular mucosal and vascular patterns. a White-light imaging; the appendiceal orifice is indicated by the blue arrow. b Far view with narrow-band imaging (NBI). c, d Close-up views with NBI. E-Videos

A self-assembling matrix-forming gel can be easily and safely applied to prevent delayed bleeding after endoscopic resections

Background: Endoscopic resections have low morbidity and mortality. Delayed bleeding has been reported in approximately 1 – 15 % of cases, increasing with antiplatelet/anticoagulant therapy or portal hypertension. A self-assembling peptide (SAP) forming a gel could protect the mucosal defect during early healing. This retrospective trial aimed to assess the safety and efficacy of SAP in preventing delayed bleeding after endoscopic resections. Methods: Consecutive patients with endoscopic resections were enrolled in two tertiary referral centers. Patients with a high risk of bleeding (antiplatelet agents, anticoagulation drugs with heparin bridge therapy, and cirrhosis with portal hypertension) were also included. The SAP gel was applied immediately after resection to cover the whole ulcer bed. Results: In total, 56 patients were included with 65 lesions (esophagus [n = 8], stomach [n = 22], duodenum [n = 10], ampullary [n = 3], colon [n = 7], and rectum [n = 15]) in two centers. Among those 65 lesions, 29 were resected in high risk situations (9 uninterrupted aspirin therapy, 6 heparin bridge therapies, 5 cirrhosis and portal hypertension, 1 both cirrhosis and heparin bridge, 3 both cirrhosis and uninterrupted aspirin, 3 large duodenal lesions > 2 cm, and 2 early introduction of clopidogrel at day 1). The resection technique was endoscopic submucosal dissection (ESD) in 40 cases, en bloc endoscopic mucosal resection (EMR) in 16, piecemeal EMR in 6, and ampullectomy in 3. The mean lesion size was 37.9 mm (SD: 2.2 mm) with a mean area of 6.3 cm2 (SD: 3.5 cm2). No difficulty was noted during application. Four delayed overt bleedings occurred (6.2 %) (3 hematochezia, 1 hematemesis) requiring endoscopic hemostasis. The mean hemoglobin drop off was 0.6 g/dL (– 0.6 to 3.1 g/dL). No adverse events occurred. Conclusion: The use of this novel extracellular matrix scaffold may help to reduce post-endoscopic resection bleedings including in high risk situations. Its use is easy and safe but further comparative studies are warranted to completely evaluate its effectiveness.

Double-clip counter-traction using a rubber band is a useful and adaptive tool for colonic endoscopic submucosal dissection

The colon is the most technically challenging location for endoscopic submucosal dissection (ESD) of large, superficial, precancerous and cancerous lesions [1]. Appropriate exposure of the submucosal space can be very difficult, even when performed by experts, owing to the thinness of the submucosal space in this location and because the gravitational assistance is not constant. Moreover, the presence of colonic loops, bowel and respiratory movements, and position modifications resulting from insufflation increase the difficulty of performing ESD in this location. Various strategies have been proposed to overcome these challenges, including pocket ESD [2] and the clip-with-line technique [3]. We recently reported the double-clip counter-traction method using a rubber band for large adenomas involving the appendix [4]. Here, we report a new strategy, which involves double-clip counter-traction using a rubber band and adjustment of the countertraction during the procedure. As shown in ▶Fig. 1 and ▶Video1, after hemicircumferential mucosal incision of a large sigmoid adenoma, the first clip was attached to the anal side of the lesion, grasping both the specimen and the rubber band. A second clip was then placed on the bowel wall in front of the lesion on the cecum side of the colonic wall to allow exposure of the submucosal space. Rapid and safe dissection was performed using this counter-traction method. However, the submucosal space narrowed progressively as the counter-traction effect subsided due to the specimen turning in on itself (▶Fig. 1 c). The clip that was attached to the colonic wall was therefore removed using a 10-mm polypectomy snare with gentle traction. A new clip, grasping the rubber band, was then placed on the colonic wall in front of the lesion on the anal side of the colonic wall, 5 cm distal to the specimen, to create traction in a tent-like fashion (▶Fig. 1d). Traction allowed rapid and safe completion of the dissection of this 7-cm adenoma with low grade dysplasia in less than 2 hours. E-Videos

A combination of pocket, double-clip countertraction, and isolated HybridKnife as a quick and safe strategy for colonic endoscopic submucosal dissection

The colon is considered to be one of the most technically challenging locations for endoscopic submucosal dissection (ESD) when superficial neoplastic lesions are being treated [1]. The difficulties include: the colonic loops, intestinal motility, the folded anatomy, problems caused by inconstant gravity, and constant modification of the operative fieldof-view attributable to insufflation. Good exposure of the submucosal layer is key for safe and efficient ESD; this can be particularly challenging in the colon where it is difficult to maintain a tangential position close to the muscle layer. Many tips and tricks have been reported to facilitate colonic ESD, including: ▪ the use of gravity; ▪ creation of a pocket [2]; ▪ tunnel dissection; ▪ clip [3] or double-clip countertraction (ring-thread countertraction [4]); ▪ the use of a waterjet injection knife [5]. Although individual physicians will prefer certain tips or tricks with which they are familiar, little information is available on combinations of these technical approaches. As case numbers are increasing worldwide, and as colorectal cancer screening programs are becoming more common and effective, further technical improvements are imperative. Here, we report on our treatment strategy for colonic ESD and seek to facilitate the resection of large superficial colonic lesions.

Anchoring the snare tip by means of a small incision facilitates en bloc endoscopic mucosal resection and increases the specimen size

Endoscopic mucosal resection (EMR) allows curative resection of superficial colorectal neoplasms up to 2 cm in diameter. En bloc resection is generally not possible for larger lesions and for some smaller very flat lesions because of the difficulty in capturing them appropriately [1]. Piecemeal EMR is possible for larger colonic lesions, but carries a high risk (~20%) of recurrence [2]. Hybrid procedures, involving use of an endoscopic submucosal dissection (ESD) device to make mucosal incisions around the lesion, have been proposed for the colon, to increase the lesion size for which en bloc snare resection is possible, and to achieve snare resection in all cases of very flat lesions. However, in the colon, ESD is particularly technically challenging [3], and mucosal incision can be quite time-consuming and risky in nonexpert hands in this location because of the folded anatomy and the bowel movement. Moreover the ESD devices are expensive, with no specific reimbursement in most European countries. We here propose a new, simple, and reproducible maneuver to facilitate colonic mucosal resection. In the case of large (2–3-cm) colonic polyps (▶Fig. 1, ▶Video1) or very flat lesions (▶Fig. 2, ▶Video2), after submucosal injection, we have made a small (0.2-mm) incision at the distal part of the lesion, using the tip of the snare with an endocut current. This incision allows anchoring of the snare tip and thereby opening of the snare in a circular shape. This method holds the snare in place and avoids slippage during the resection. Moreover, the circular opening allows a larger resection. We currently use this trick for borderline lesions (approximately 2 cm) or very flat lesions in the colon, and no complications due to the small incision have been observed. This method is useful in cases of difficult or very flat lesions, or large colonic polyps, for increasing the en bloc resection rate, allowing higher quality pathological analysis, and decreasing the risk of residual or recurrent disease. E-Videos

Deep endoscopic submucosal dissection of a refractory tracheoesophageal fistula using clip-and-line traction: a successful closure

Chronic tracheoesophageal fistula is a rare disease presenting a therapeutic challenge. Unlike the case with most digestive fistulas, drainage with a pigtail stent [1] is not possible. We present here the case of a 47-yearold man referred for a chronic 2-mm tracheoesophageal fistula (23 cm from mouth) of unknown cause. His past history revealed several pulmonary infections since childhood. Several endoscopic treatments were attempted with clip closure and then hot biopsy forceps abrasion of the surrounding mucosa, but complete closure was not obtained. We therefore proposed endoscopic submucosal dissection (ESD) of the surrounding mucosa, namely a 1-cm mucosal patch (▶Fig. 1 and ▶Fig. 2, ▶Video1) centered on the fistula, as previously described [2]. The patient underwent tracheal intubation with balloon placement just under the fistula. To allow deep dissection of the fistula tract we added a clip-and-line traction (▶Fig. 3) [3] to pull the fistula Trachea a b c Fistula

Macroscopically visible flat dysplasia in the fundus of 3 patients with familial adenomatous polyposis

We report 3 patients with familial adenomatous polyposis (FAP) followed up with gastroscopy. All lesions were diagnosed with well-demarcated whitish flat areas of the fundus, within fundic gland polyposis (FGP) with dysplasia. On the edges of those lesions, FGP were partially covered by the whitish dysplastic area (A). The whitish and flat aspects of those 3 lesions clearly contrasted with the surrounding FGP mucosa (B, C). Under narrow-band imaging and dual focus, those lesions showed light blue crests (D) as described as usual intestinal metaplasia features. All lesions underwent endoscopic submucosal dissection (ESD) to obtain en bloc R0 resection. ESD is a good option for achieving complete resection but it is relatively difficult compared with usual resections because of fibrosis and FGP on the surrounding mucosa. Histologic examination confirmed low-grade dysplasia in 1 patient (D) and highgrade dysplasia in 2. None of the patients were seen to have gastric atrophy, Helicobacter pylori infection, or proton pump inhibitor treatment, underlining a different

Feasibility, safety, and diagnostic yield of the Extra Wide Angle View (EWAVE) colonoscope for the detection of colorectal lesions

BACKGROUND AND STUDY AIMS The adenoma detection rate (ADR) of conventional colonoscopy can still be improved. We conducted a prospective multicenter cohort study to assess the feasibility, safety, and diagnostic yield of the Extra Wide Angle View (EWAVE) colonoscope, which offers a 235° view obtained from a forward-viewing and two lateral backward-viewing lenses incorporated into one image. PATIENTS AND METHODS The study was performed between November 2015 and June 2016. EWAVE colonoscopy was performed in patients with an increased risk of colorectal cancer by experienced and EWAVE-trained endoscopists (≥ 500 colonoscopies, ≥ 10 with the EWAVE system). RESULTS A total of 193 patients underwent EWAVE colonoscopy. The cecal intubation rate was 97.4 %. EWAVE colonoscopy had a polyp detection rate (PDR) of 61.1 % (118 /193), ADR of 39.9 % (77 /193), and advanced ADR of 13.5 % (26 /193). No adverse events occurred. CONCLUSIONS EWAVE colonoscopy is feasible and safe. The ADR appears comparable to those achieved with conventional colonoscopes in similar patient populations. To further elucidate the additional benefits of wide-angle-view colonoscopes, randomized trials would be required.