Karl-Hermann Fuchs

Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Prospective Single Center Study

OBJECTIVES:Endoscopic balloon dilatation and laparoscopic myotomy are established treatments for achalasia. Recently, a new endoscopic technique for complete myotomy was described. Herein, we report the results of the first prospective trial of peroral endoscopic myotomy (POEM) in Europe.METHODS:POEM was performed under general anesthesia in 16 patients (male:female (12:4), mean age 45 years, range 26–76). The primary outcome was symptom relief at 3 months, defined as an Eckhard score ≤3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM.RESULTS:A 3-month follow-up was completed for all patients. Treatment success (Eckhard score ≤3) was achieved in 94% of cases (mean score pre- vs. post-treatment (8.8 vs. 1.4); P<0.001). Mean LES pressure was 27.2 mm Hg pre-treatment and 11.8 mm Hg post-treatment (P<0.001). No patient developed symptoms of gastro-esophageal reflux after treatment, but one patient was found to have an erosive lesion (LA grade A) on follow-up esophagogastroduodenoscopy. No patient required medication with proton pump inhibitors or antacids after POEM.CONCLUSIONS:POEM is a promising new treatment for achalasia resulting in short-term symptom relief in >90% of cases. Studies evaluating long-term efficacy and comparing POEM with established treatments have been initiated.

Euro-NOTES Status Paper: from the concept to clinical practice.

BackgroundThe concept of natural orifice transluminal endoscopic surgery (NOTES) consists of the reduction of access trauma by using a natural orifice access to the intra-abdominal cavity. This could possibly lead to less postoperative pain, quicker recovery from surgery, fewer postoperative complications, fewer wound infections, and fewer long-term problems such as hernias. The Euro-NOTES Foundation has organized yearly meetings to work on this concept to bring it safely into clinical practice. The aim of this Euro-NOTES status update is to assess the yearly scientific working group reports and provide an overview on the current clinical practice of NOTES procedures.MethodsAfter the Euro-NOTES meeting 2011 in Frankfurt, Germany, an analysis was started regarding the most important topics of the European working groups. All prospectively documented information was gathered from Euro-NOTES and D-NOTES working groups from 2007 to 2011. The top five topics were analyzed.ResultsThe statements of the working group activities demonstrate the growing information and changing insights. The most important selected topics were infection issue, peritoneal access, education and training, platforms and new technology, closure, suture, and anastomosis. The focus on research topics changed over time. The principle of hybrid access has overcome the technical and safety limitations of pure NOTES. Currently the following NOTES access routes are established for several indications: transvaginal access for cholecystectomy, appendectomy and colon resections; transesophageal access for myotomy; transgastric access for full-thickness small-tumor resections; and transanal/transcolonic access for rectal and colon resections.ConclusionsNOTES and hybrid NOTES techniques have emerged for all natural orifices and were introduced into clinical practice with a good safety record. There are different indications for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication.

Endoscopic full-thickness plication for the treatment of GERD by application of multiple Plicator implants: a multicenter study (with video)

BACKGROUND The full-thickness Plicator allows transmural suturing at the gastroesophageal (GE) junction to restructure the antireflux barrier. Studies of the Plicator procedure to date have been limited to placement of a single transmural suture to create the endoscopic gastroplication. OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of placing multiple transmural sutures for the treatment of GERD. DESIGN Open-label, prospective, multicenter study. SETTING Four tertiary-referral centers. PATIENTS Subjects with symptomatic GERD who require daily maintenance proton pump inhibitor (PPI) therapy. Study exclusions were hiatal hernia >3 cm, grades III and IV esophagitis, Barretts epithelium, and esophageal dysmotility. INTERVENTIONS Forty-one patients received two or more transmural sutures placed linearly in the anterior gastric cardia approximately 1 cm below the GE junction. MAIN OUTCOME MEASUREMENTS Six months after the procedure, median GERD-health-related quality of life (HRQL) improved 76% compared with off-medication baseline (6.0 vs 25.0, P < .001), with 75% of patients (32/40) achieving >50% improvement in their baseline GERD-HRQL score. Six months after the procedure, daily PPI therapy was eliminated in 70% of patients (28/40). Heartburn symptoms improved 80% compared with off-medication baseline (16.0 vs 84.0, P < .001). Median esophagitis grade improved 75% compared with baseline (0.0 vs 1.0, P = .005). Esophageal pH assessed as median distal esophageal-acid exposure (percentage time pH < 4.0) improved 38% compared with baseline (9.0 vs 11.0, P < .020; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data) and manometric outcomes were also improved compared with baseline (median lower esophageal sphincter resting pressure improved 25% [10.0 vs 6.0, P < .017; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data]) and median amplitude of contraction improved 11% (70.0 vs 62.0, P < .037; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data). LIMITATIONS Small sample size. No randomized comparison with a single implant group. CONCLUSIONS Endoscopic full-thickness plication with multiple serially placed implants was safe and effective in reducing GERD symptoms, medication use, esophageal-acid exposure, and esophagitis.

Endoskopisches Operieren über natürliche Körperöffnungen (NOTES) in Deutschland: Zusammenfassung der Arbeitsgruppensitzungen der „D-NOTES 2009”

The D-NOTES-group met in June 2009 for an evaluation of ongoing preclinical and clinical activities in natural orifice endoscopic surgery and the further coordination of research in Germany. Different working groups with various topics were formed. Consensus statements among various participants with different scientific and medical background were initiated. In summary, important topics were handled such as the correct handling of bacterial contamination and related complications, the question of the ideal entry point and a secure closure, interdisciplinary cooperation, and matters related to training and education. Furthermore, participants agreed on terminological basics. A to-do-list for medical engineering was formulated.

NOTES in Europe: summary of the working group reports of the 2012 EURO-NOTES meeting

The sixth EURO-NOTES workshop (4 - 6 October 2012, Prague, Czech Republic) focused on enabling intensive scientific dialogue and interaction between surgeons, gastroenterologists, and engineers/industry representatives and discussion of the state of the practice and development of natural orifice transluminal endoscopic surgery (NOTES) in Europe. In accordance with previous meetings, five working groups were formed. In 2012, emphasis was put on specific indications for NOTES and interventional endoscopy. Each group was assigned an important indication related to ongoing research in NOTES and interventional endoscopy: cholecystectomy and appendectomy, therapy of colorectal diseases, therapy of adenocarcinoma and neoplasia in the upper gastrointestinal tract, treating obesity, and new therapeutic approaches for achalasia. This review summarizes consensus statements of the working groups.

Laparoskopische Fundoplicatio: Lösung des Problems?

Die gastroösophageale Refluxkrankheit ist die am häufigsten vorkommende gutartige Funktionsstörung mit chirurgischer Relevanz in den westlichen Industrieländern. Da bei dieser Erkrankung die medikamentöse Therapie die wesentliche Behandlungsoption für die übergroße Mehrheit der Patienten darstellt, kommt der Indikationsstellung zur Operation nach gründlicher Diagnostik und Selektion der Patienten eine ebenso große Bedeutung zu wie der optimalen chirurgischen Technik. Für den Behandlungserfolg ist es von entscheidender Bedeutung, dass eine detaillierte Diagnostik erfolgt, um die optimale Patientenselektion für die Operation zu gewährleisten. Deswegen ist es bedeutsam, dass der behandelnde Chirurg entweder selbst oder mit seinem kooperierenden Gastroenterologen in der Lage ist, auf die Besonderheiten dieser Erkrankung sowie dieser Patienten einzugehen, eine detaillierte Diagnostik interpretieren und eine kritische und sorgfältige Patientenselektion zur Operationsindikation vornehmen zu können sowie etablierte und besondere Operationsverfahren, in aller Regel in der minimal invasiven Operationstechnik, gegebenenfalls auch in der offenen Technik, in besonderen Situationen anwenden zu können. Bei den Patienten, die für eine operative Therapie ausgewählt werden, sollte es sich in aller Regel um optimal konservativ vorbehandelte Patienten und solche mit besonders schwerem und kompliziertem Verlauf handeln.

NOTES Rigid Transvaginal Cholecystectomy

Cholecystectomy is one of the most frequently performed operative procedures in gastrointestinal abdominal surgery. The concept of NOTES moves the reduction in access trauma one step further by using a natural orifice as an access route to the intra-abdominal cavity. NOTES stands for a reduction in access trauma by approaching the abdominal cavity by natural orifices as much as possible for a safe performance of the necessary procedure. Based on their previous experience with colpotomy and surgical procedures, transvaginal hybrid NOTES technique with rigid standard instruments for cholecystectomy was developed. On the contrary to the method with flexible endoscopy, this technique was comprehensible to surgeons. The most common techniques of NOTES cholecystectomy have been the hybrid transvaginal with the aid of rigid laparoscope. The need to convert to laparoscopy was absolutely minimal. The overall incidence of postoperative complication was extremely low and similar between the two most frequently used techniques. First comparative trials have been published demonstrating the only possible advantage of these NOTES Hybrid procedures over classic laparoscopic cholecystectomy regarding the cosmetic result.

The Endoscopic Treatment of Iatrogenic Gastrointestinal Perforation

BACKGROUND Iatrogenic gastrointestinal perforation is a life-threatening complication that arises very rarely in routine endoscopic procedures, with an incidence of 0.03-0.8%. It is more likely in highly complex and invasive therapeutic interventions. In certain situations, endoscopic closure of the perforation and treatment with antibiotics can obviate the need for emergency surgical repair. METHODS This review is based on pertinent articles retrieved by a selective literature search in PubMed and on a relevant position paper. RESULTS Existing clinical studies of treatment for iatrogenic gastrointestinal perforation are mainly retrospective and uncontrolled. No randomized and controlled trials have been performed to date. If the perforation is discovered soon after it arises, endoscopic treatment can be considered. Gastrointestinal perforations that are less than 30 mm in size can be closed with a clip. In the esophagus, expanding metal stents can be used as well. Clip application is successful in 80-100% of cases of gastrointestinal perforation, and the perforation remains permanently closed in 60-100% of cases. Reports on the endoscopic treatment of esophageal perforation show mixed results, with closure rates of roughly 90% and clinical success rates of roughly 80%. If endoscopic treatment is not possible, timely laparoscopic or open surgical repair is needed. CONCLUSION The endoscopic treatment of iatrogenic perforations is safe and reliable. Success depends on early detection, adequate endoscopic closure with properly mastered technique, and the early initiation of concomitant antibiotic treatment, which must be continued for a full course. Most patients who are treated in this way do not need emergency surgery.

Transoral Esophageal Myotomy for Achalasia

Patients with achalasia usually present with occasional to persistent dysphagia, regurgitation, retrosternal pain and/or heartburn. The major clinical problem is intermittent obstruction of the esophageal transit of food and/or fluids. The underlying disorder consists of incomplete relaxation of the lower esophageal sphincter during swallowing, increased resting tone of the sphincter, and aperistalsis of the esophageal body