Oscar Víctor Hernández Mondragón

The Per Oral Endoscopic Myotomy (POEM) technique: how many preclinical procedures are needed to master it?

Background and study aim: Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model. Patients and methods: This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1) = 30 ex vivo and Group 2 (G2) = 20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2. Results: A total of 50 POEM were done in both groups (G1 = 30, G2 = 20). The mean times were 90.17 min (G1) and 89.50 min (G2) (P = 0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; P = 0.009) with a slightly slower tunnelization (40.35 vs 41.13 min; P = 0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; P = 0.26). VTM between the groups was similar (G1 = 0.159 vs G2 = 0.157 cm/min; P = 0.925). Complications were: mucosotomy (G1 = 18 %, G2 = 8 %; P = 0.430), mediastinal perforation (G1 = 12 %, G2 = 8 %; P = 1.0), and perforation at the gastroesophageal junction (GEJ) level (G1 = 16 %, G2 = 4 %; P = 0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases. Conclusions: We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.

Long-term quality of life after peroral endoscopic myotomy remains compromised in patients with achalasia type III

Background and study aims Peroral endoscopic myotomy (POEM) is an excellent endoscopic treatment for achalasia. Clinical and manometric parameters are used for evaluation and follow-up. However, clinical success does not guarantee high quality of life (QoL) scores, generating doubts about their direct relationship. We aimed to evaluate QoL scores before and after POEM at medium and long term, to evaluate differences between achalasia subtypes and find which factors related to low QoL scores. Patients and methods Achalasia-confirmed patients undergoing POEM between February 2012 and November 2016. and completing at least 1 year of follow-up, were included. Assessment before and at 1, 6, 12, 24, 36 and 48 months after POEM employed manometry, barium series, Eckardt score, and the AE-18 health-related QoL scale. Demographic, clinical, and procedure characteristics were documented, with comparisons between subgroups. Multiple logistic regression analysis was done. Results 65 of 88 patients were included (38 women, 27 men; median age 47 years, interquartile range [IQR] 20 - 81), and 50 (76.9 %) completed 4 years of follow-up. Eckardt score improved (median, preprocedure 10 vs. post-procedure 2; P = 0.002) and this persisted. There was initial improvement in median integrated relaxation pressure (IRP) (29.4 mmHg [16 - 55] vs. 10.3 mmHg [3 - 18]; P = 0.000) and median QoL scores (40 vs. 68 at 1 month; P = 0.002); however IRP increased and QoL scores decreased. Men with confirmed type III achalasia had low QoL scores. Conclusions All patients had significant clinical improvement after POEM, with medium- to long-term persistence. Though quality of life and IRP initially improved, they deteriorated in the long term. Male sex and type III achalasia seem to be associated with low QoL scores.

Uso de Hemospray® en sangrado post-escleroterapia

BACKGROUND Hemospray® is a new device for endoscopic hemostasis used for non-variceal gastrointestinal bleeding. It enables hemostasis and platelet activation by increasing the concentration of clotting factors and forming a mechanical barrier on the wall of a bleeding vessel creating a mechanical plug at the site of bleeding. Within the main indications for use are: injuries with difficult endoscopic access, massive gastrointestinal bleeding, multiple bleeding sites, modification of the anatomy by previous endoscopic therapy, presence of coagulopathy, difficulty in having direct visualization or when it is impossible to have contact with the bleeding lesion. However, its use in children has not been approved yet by the FDA. There is a case report of an 11-month-old patient successfully treated with Hemospray® for non-variceal gastrointestinal bleeding. CLINICAL CASE We report the case of a 2-year-old female with acute liver failure and primary biliary cirrhosis with portal hypertension and bleeding after sclerotherapy. We analyzed the case to support new therapies for massive bleeding control in post-sclerotherapy esophageal ulcers. CONCLUSIONS The application showed to be safe without side effects. Using Hemospray® is an effective alternative in controlling gastrointestinal bleeding.