Karl C. Yu Kim Teng

Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett's oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial

Objective After focal endoscopic resection (ER) of high-grade dysplasia (HGD) or early cancer (EC) in Barretts oesophagus (BO), eradication of all remaining BO reduces the recurrence risk. The aim of this study was to compare the safety of stepwise radical ER (SRER) versus focal ER followed by radiofrequency ablation (RFA) for complete eradication of BO containing HGD/EC. Methods A multicentre randomised clinical trial was carried out in three tertiary centres. Patients with BO ≤5 cm containing HGD/EC were randomised to SRER or ER/RFA. Patients in the SRER group underwent piecemeal ER of 50% of BO followed by serial ER. Patients in the ER/RFA group underwent focal ER for visible lesions followed by serial RFA. Follow-up endoscopy with biopsies (four-quadrant/2 cm BO) was performed at 6 and 12 months and then annually. The main outcome measures were: stenosis rate; complications; complete histological response for neoplasia (CR-neoplasia); and complete histological response for intestinal metaplasia (CR-IM). Results CR-neoplasia was achieved in 25/25 (100%) SRER and in 21/22 (96%) ER/RFA patients. CR-IM was achieved in 23 (92%) SRER and 21 (96%) ER/RFA patients. The stenosis rate was significantly higher in SRER (88%) versus ER/RFA (14%; p<0.001), resulting in more therapeutic sessions in SRER (6 vs 3; p<0.001) due to dilations. After median 24 months follow-up, one SRER patient had recurrence of EC, requiring ER. Conclusions In patients with BO ≤5 cm containing HGD/EC, SRER and ER/RFA achieved comparably high rates of CR-IM and CR-neoplasia. However, SRER was associated with a higher number of complications and therapeutic sessions. For these patients, a combined endoscopic approach of focal ER followed by RFA may thus be preferred over SRER. Clinical trial number NTR1337.

EUS 2008 Working Group document : evaluation of EUS-guided drainage of pancreatic-fluid collections (with video)

Pelvic-fluid collections or abscesses often present a clinical challenge because of their location: surrounded by the bony pelvis, bladder, bowel, uterus, vagina, prostrate, rectum, and other neurovascular structures. These collections may occur as a common complication of surgery and medical diseases. An anastomotic leak after large-bowel resection, particularly low anterior resection, is the most common surgical cause and may occur in 0.5% to 30% of cases. 1-4 Diverticulitis, ischemic colitis, Crohns disease, appendicitis, and sexually transmitted diseases are other etiologies. 5 Because US often fails to detect deep or multifocal collections, the best diagnostic modality for patients suspected to have pelvic-fluid collections is a CT of the abdomen and pelvis. 5 The CT findings, in combination with the patients clinical status, determine the most appropriate mode of treatment. This section of the EUS 2008 Working Group Proceedings evaluates the current evidence and potential role of EUS in the management of patients with pelvic-fluid collections that encompasses abscesses.

LONG‐TERM RESULTS AFTER ENDOSCOPIC DRAINAGE AND NECROSECTOMY OF SYMPTOMATIC PANCREATIC FLUID COLLECTIONS

Aims:  To determine the immediate and long‐term results of endoscopic drainage and necrosectomy for symptomatic pancreatic fluid collections.

EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis.

Endoscopic ultrasound (EUS)‐guided drainage has emerged as the leading treatment modality for symptomatic pancreatic fluid collections. Endoscopic ultrasound‐guided endoscopic drainage is less invasive than surgery and avoids local complications related to percutaneous drainage. In addition, unlike non‐EUS guided endoscopic drainage, EUS‐guided drainage is able to drain non‐bulging fluid collections and may reduce the risk of procedure‐related bleeding. Excellent treatment success rates exceeding 90% have been reported for pancreatic pseudocysts and abscesses. In the context of infected pancreatic necrosis, adjunctive endoscopic necrosectomy is required for effective treatment. With such an aggressive approach, the treatment success rate may reach 81%–92%. The potential complications of concern for EUS‐guided drainage are severe bleeding and perforation. To minimize risk, only fluid collections with a mature wall and within 1 cm of the gastrointestinal lumen should undergo endoscopic drainage. Any coagulopathy, if present, should be corrected. Patients with pseudocysts undergoing drainage should also receive prophylactic antibiotics in order to prevent secondary infection of a sterile collection.

Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis.

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

Dynamic lumen obstructing angulation in advanced sigmoid-type achalasia successfully treated by additional proximal curve myotomy

Peroral endoscopy myotomy (POEM) is now well accepted as primary treatment for achalasia [1–3]. It is also effective after failed Heller myotomy [4] and can be repeated when symptoms recur [5]. In patients with advanced sigmoid-type achalasia, in addition to failure of relaxation at the lower esophageal sphincter (LES), there may be an additional dynamic obstruction of the distal esophagus due to an acute angulation (▶Fig. 1). This will redirect the flow of food backwards and inferiorly, which can potentially aggravate the downward bend of the esophagus till it goes below the level of the LES, further worsening food stasis. A real-time dynamic esophagogram is needed to demonstrate this dynamic obstruction. In such cases, myotomy of the LES alone is inadequate, and an additional short myotomy to reduce this acute angulation is needed in order to change flow dynamics and allow free passage of food distally (▶Fig. 1). We report three cases of symptomatic advanced sigmoid-type achalasia with an acute dynamic angulation at the distal esophagus causing lumen obstruction that were treated successfully with an additional curve cutting myotomy during POEM. The first case was a 60-year-old man with type 1 achalasia who had previously been treated by balloon dilation. The second case was a 53-year-old woman with type 1 achalasia who had previously undergone balloon dilation and two Heller myotomy procedures. The third case was a 73-year-old woman with previous balloon dilation, botox injection, and POEM. Real-time esophagograms demonstrated the obstruction at the LES and at the acute dynamic angulation of the distal esophagus caused by the sigmoidtype morphology. Standard POEM was combined with a short proximal curve myotomy. Post myotomy, the barium esophagogram demonstrated resolution of the obstruction (▶Video1). E-Videos