Ming-Yan Cai

Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study.

BACKGROUND AND STUDY AIMS Recurrence/persistence of symptoms occurs in approximately 20 % of patients after Heller myotomy for achalasia. Controversy exists regarding the therapy for patients in whom Heller myotomy has failed. The aim of the current study was to evaluate the efficacy and feasibility of peroral endoscopic myotomy (POEM), a new endoscopic myotomy technique, for patients with failed Heller myotomy. PATIENTS AND METHODS A total of 12 patients with recurrence/persistence of symptoms after Heller myotomy, as diagnosed by established methods and an Eckardt score of ≥ 4, were prospectively included. The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤ 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 All 12 patients underwent successful POEM after a mean of 11.9 years (range 2 - 38 years) from the time of the primary Heller myotomy. No serious complications related to POEM were encountered. During a mean follow-up period of 10.4 months (range 5 - 14 months), treatment success was achieved in 11/12 patients (91.7 %; mean score pre- vs. post-treatment 9.2 vs. 1.3; P < 0.001). Mean LES pressure was 29.4 mmHg pre-treatment and 13.5 mmHg post-treatment (P < 0.001). One patient developed mild reflux symptoms and required intermittent medication with proton pump inhibitors. CONCLUSIONS POEM seems to be a promising new treatment for failed Heller myotomy resulting in short-term symptom relief in > 90 % of cases. Previous Heller myotomy may make subsequent endoscopic remyotomy more challenging, but does not prevent successful POEM.

Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos)

U T t s u g e o i T ( a ( f Upper GI submucosal tumors (SMTs) 3 cm are generally considered benign tumors. However, some such umors, especially mesenchymal neoplasms (including GI tromal tumors originating from the muscularis propria MP]), do have malignant potential.2 If tissue diagnosis is ttempted, the most challenging aspect in the diagnosis of MTs by needle biopsy is the sampling error when taking iopsy specimens of GI stromal tumors, which may show nly focal areas of malignant change.2 Asymptomatic GI MTs 3 cm could be followed-up with periodic endoscopy nd/or EUS or resection.3 However, some patients become tressed when told that they require periodic follow-up. As a esult, they feel the urge to seek a safe and efficacious reatment during the follow-up time. Conventional endocopic resection of tumors originating from the MP layer used o be discouraged because of incomplete resections or risk of erforation during procedures. This left such patients with wo choices: surgical resection or endoscopic follow-up. Enoscopic submucosal dissection (ESD)2 and new, emerging endoscopic techniques such as endoscopic full-thickness resection4 are now options for these patients.

Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Clinical Comparative Study of Endoscopic Full-Thickness and Circular Muscle Myotomy

BACKGROUND A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. STUDY DESIGN According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. RESULTS The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38). CONCLUSIONS Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.

Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video)

Peroral endoscopic myotomy (POEM) has recently been described as a scar-free and less-invasive surgical myotomy option for treating achalasia. This procedure incorporates concepts of natural orifice transluminal endoscopic surgery and achieves endoscopic myotomy by using a submucosal tunnel as the operating space. Initial published experience in humans is more than encouraging despite a relatively short follow-up. Common complications of POEM include mucosal injury, subcutaneous emphysema, mediastinal emphysema, pneumothorax, pneumoperitoneum, and pleural effusion. Postoperative delayed bleeding in the submucosal tunnel is a rare complication after POEM, and only 1 patient with delayed bleeding has been reported in the literature to date. Despite its low incidence, delayed bleeding can result in serious conditions, such as massive bleeding, hemorrhagic shock, and death. Thus, early

Endoscopic submucosal dissection for foregut neuroendocrine tumors： An initial study

AIM To evaluate the feasibility and efficacy of endoscopic submucosal dissection (ESD) for foregut neuroendocrine tumors (NETs). METHODS From April 2008 to December 2010, patients with confirmed histological diagnosis of foregut NETs were included. None had regional lymph node enlargement or distant metastases to the liver or lung on preoperative computerized tomography scanning or endoscopic ultrasonography (EUS). ESD was attempted under general anesthesia. After making several marking dots around the lesion, a mixture solution was injected into the submucosa. The mucosa was incised outside the marking dots. Dissection of the submucosal layer beneath the tumor was performed under direct vision to achieve complete en bloc resection of the specimen. Tumor features, clinicopathological characteristics, complete resection rate, and complications were evaluated. Foregut NETs were graded as G1, G2, or G3 on the basis of proliferative activity by mitotic count or Ki-67 index. All patients underwent regular follow-up to evaluate for any local recurrence or distant metastasis. RESULTS Those treated by ESD included 24 patients with 29 foregut NETs. The locations of the 29 lesions are as follows: esophagus (n = 1), cardia (n = 1), stomach (n = 23), and duodenal bulb (n = 4). All lesions were found incidentally during routine upper gastrointestinal endoscopy for other indications, and none had symptoms of carcinoid syndrome. Preoperative EUS showed that all tumors were confined to the submucosa. Among the 24 gastric lesions, 16 lesions in 11 patients were type I gastric NETs arising in chronic atrophic gastritis with hypergastrinemia, while the other 8 solitary lesions were type III because of absence of atrophic gastritis in these cases. All of the tumors were removed in an en bloc fashion. The average maximum diameter of the lesions was 9.4 mm (range: 2-30 mm), and the procedure time was 20.3 min (range: 10-45 min). According to the World Health Organization 2010 classification, histological evaluation determined that 26 lesions were NET-G1, 2 gastric lesions were NET-G2, and 1 esophageal lesion was neuroendocrine carcinoma (NEC). Complete resection was achieved in 28 lesions (28/29, 96.6%), and all of them were confined to the submucosa in histopathologic assessment with no lymphovascular invasion. The remaining patient with NEC underwent additional surgery because the resected specimens revealed angiolymphatic and muscularis invasion, as well as incomplete resection. Delayed bleeding occurred in 1 case 3 d after ESD, which was managed by endoscopic treatment. There were no procedure-related perforations. During a mean follow-up period of 24.4 mo (range: 12-48 mo), local recurrence occurred in only 1 patient 7 mo after initial ESD. This patient successfully underwent repeat ESD. Metastasis to lymph nodes or distal organs was not observed in any patient. No patients died during the study period. CONCLUSION ESD appears to be a safe, feasible, and effective procedure for providing accurate histopathological evaluations and curative treatment for eligible foregut NETs.

Management of the complications of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors

BACKGROUND AND STUDY AIMS Submucosal tunneling endoscopic resection (STER) has become a potential option for the endoscopic treatment of a selected group of patients with submucosal tumors (SMTs) originating from the muscularis propria layer in the upper gastrointestinal tract. The aim of this retrospective study was to analyze the incidence and management of STER-related complications. PATIENTS AND METHODS From January 2011 to August 2013, 290 patients with upper gastrointestinal SMTs treated by STER were included in the study. Clinicopathological characteristics and complication data were collected and analyzed retrospectively. RESULTS Mucosal injury occurred in three cases (1.0 %) and major bleeding occurred in five cases (1.7 %). The gas-related complications were very common; however, only nine cases of major pneumothorax (> 30 % lung collapse) needed therapeutic intervention (3.1 %). Thoracic effusion occurred in 49 patients, 11 of whom had low grade fever or segmental atelectasis that required thoracentesis and drainage (3.8 %). Thus, although the overall incidence of complications was 23.4 % (68/290), only 10.0 % of procedures (29/290) required intervention for complications. Based on the statistical analysis, irregular shape, tumor in the deep muscularis propria layer, long procedure time, and air insufflation were risk factors of STER-related major complications. CONCLUSION Although the incidence of STER-related complications was relatively high, most of these complications were minor and did not require therapeutic intervention. STER is a safe technique for the treatment of upper gastrointestinal SMTs.

Conventional vs. waterjet-assisted endoscopic submucosal dissection in early gastric cancer: a randomized controlled trial.

BACKGROUND AND STUDY AIMS A hybrid knife was recently developed to allow waterjet-assisted endoscopic submucosal dissection, which aims to speed up and simplify the procedure. This technique has been shown to be effective and safe for the treatment of early gastric cancer (EGC) but it has not yet been compared with conventional ESD. PATIENTS AND METHODS In this two-center study, patients with an endoscopic and histopathological diagnosis of gastric adenoma or early gastric adenocarcinoma (meeting the extended Japanese criteria for local resection) were randomized to either conventional or waterjet-assisted ESD. The choice of knife was left to the endoscopist in the conventional group whereas the hybrid knife was used in the waterjet group. The primary end point was procedure time, and secondary outcomes included rates of en bloc resection, R0 resection, and complications. RESULTS A total of 117 patients (mean age 63.0 ± 10.6 years, 76 men) were randomized to either conventional ESD (n  = 59; control group) or waterjet-assisted ESD (n = 58). There were no significant differences in patient demographics or lesion features between the groups. The mean procedure time was significantly shorter in the waterjet group compared with the conventional group (27.5  ±  30.6 vs. 35.0  ± 22.5 minutes; P = 0.0008), and a change of accessories was less frequently required (mean number of changes 1.4  ±  2.0 vs. 23.0  ±  15.4; P < 0.0001). There was no significant difference between the groups in the size of resected specimen, R0 resection rates, number of perforations, major delayed bleedings, or rates of complete remission of neoplasia after 3 months. CONCLUSIONS Waterjet-assisted ESD and conventional ESD are comparably effective and safe techniques for the local treatment of EGC. The waterjet-assisted technique is a faster and simpler procedure and requires fewer accessory changes compared with conventional ESD.

Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures

Background and aims Peroral endoscopic myotomy (POEM) is now an established treatment for esophageal achalasia. The standard protocol ensures a smooth operation in most patients, but technical challenges and failures exist and little is known about the incidence, causes, and impact of aborted procedures. Here, using a large patient cohort, we attempted to answer these questions. Methods All patients admitted for planned POEM between August 2010 and July 2015 underwent chart review. Aborted POEM was defined as the inability to finish the procedure after submucosal injection. The cause of the failure, clinical course, management, and follow-up data were analyzed. Results Thirteen of the 1693 POEMs (0.77 %) were aborted. Out of the 13 failures, 12 (92.3 %) were due to severe submucosal fibrosis, which precluded tunneling, and one (7.7 %) was due to atrial fibrillation related to the electric current of the endoscopic knife. Submucosal fibrosis, prior Heller myotomy, and age ( ≥ 60 years) were related to technical failure, while a disease duration of ≥ 6 years, sigmoid esophagus, mucosal edema, and prior interventions were risk factors for the presence of fibrotic changes. In turn, fibrosis was correlated with a prolonged operation, longer hospital stay, more mucosal injuries, and more major perioperative adverse events. Finally, the yearly frequency of aborted POEMs decreased after the second year as operators became more experienced. Conclusions Aborted POEM is a rare event and is largely due to the presence of submucosal fibrosis, which not only causes increased procedural difficulties, but also gives rise to major adverse events.

CURRENT STATUS OF ENDOSCOPIC RESECTION IN CHINA

The early diagnosis of early gastrointestinal (GI) diseases is becoming easier than ever before, due to the rapid development of all kinds of endoscopic techniques, including chromoendoscopy, narrowband imaging, magnifying endoscopy, confocal microscopy and autofluorescence imaging. Endoscopic resection is gradually becoming the optimal choice, which is significantly less invasive than conventional surgical interventions. In China, endoscopic resection techniques have been developed very quickly after several pioneers learned from Japanese gastroenterologists. Endoscopic submucosal dissection (ESD) has achieved remarkable initial outcomes, however, large‐scale, multicenter, retrospective studies of the long‐term follow up of ESD outcomes in China are still lacking. New endoscopic interventions are also being developed from the ESD technique, namely, endoscopic full‐thickness resection of gastric submucosal tumors, peroral endoscopic myotomy and submucosal tunneling endoscopic resection techniques. Here, we discuss the current status of endoscopic resection in China and several problems: (i) the lack of guideline or consensus from academic society; (ii) approximately half of the ESD are performed on benign submucosal tumors, so the diagnosis of mucosal cancers needs to be increased; (iii) the standard technique used, results, management of complications and follow‐up should be standardized; and (iv) the minimum training requirements, the step‐by‐step approach should also need to be standardized.

The Rise of Tunnel Endoscopic Surgery: A Case Report and Literature Review

There has been booming interest in natural orifice transluminal surgery since it was first described. Several techniques first developed for the safe transluminal access now derive into independent endoscopic surgical procedures. In this paper, we describe a case treated by a novel procedure by submucosal tunnelling technique and provide a literature review of the rise of tunnel endoscopic surgery.