Parit Mekaroonkamol

Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes.

Gastroparesis is a poorly understood, chronic, debilitating motility disorder with very limited medical therapeutic options. Gastric peroral endoscopic pyloromyotomy (G‐POEM) is an emerging novel endoscopic technique as an incisionless pyloroplasty for refractory cases. Effective information of G‐POEM on different types of gastroparesis is sparse.

Portal hypertensive enteropathy

Portal hypertensive enteropathy (PHE) is a condition that describes the pathologic changes and mucosal abnormalities observed in the small intestine of patients with portal hypertension. This entity is being increasingly recognized and better understood over the past decade due to increased accessibility of the small intestine made possible by the introduction of video capsule endoscopy and deep enteroscopy. Though challenged by its diverse endoscopic appearance, multiple scoring systems have been proposed to classify the endoscopic presentation and grade its severity. Endoscopic findings can be broadly categorized into vascular and non-vascular lesions with many subtypes of both categories. Clinical manifestations of PHE can range from asymptomatic incidental findings to fatal gastrointestinal hemorrhage. Classic endoscopic findings in the setting of portal hypertension may lead to a prompt diagnosis. Occasionally histopathology and cross sectional imaging like computed tomography or magnetic resonance imaging may be helpful in establishing a diagnosis. Management of overt bleeding requires multidisciplinary approach involving hepatologists, endoscopists, surgeons, and interventional radiologists. Adequate resuscitation, reduction of portal pressure, and endoscopic therapeutic intervention remain the main principles of the initial treatment. This article reviews the existing evidence on PHE with emphasis on its classification, diagnosis, clinical manifestations, endoscopic appearance, pathological findings, and clinical management. A new schematic management of ectopic variceal bleed is also proposed.

The role of pyloric manometry in gastric per-oral endoscopic pyloromyotomy (G-POEM): response to Jacques et al.

Dear editors, We thank Jacques et al.1 for their interest in our study, “Gastric peroral endoscopic pyloromyotomy (GPOEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes,”2 and appreciate their shared common notion to identify which subgroup of gastroparesis patients would benefit most from this novel procedure. The authors’ befitting proposal on using pyloric manometry or impedance planimetry in Endoluminal Functional Lumen Imaging Probe system (Crospon LTD., Galway, Ireland) to evaluate pyloric pressure and distensibility before the procedure should be commended. We agree that these measurements could have provided additional information on the disease pathogenesis and should be further evaluated in future studies to help identify patients with pylorospasm. However, their role as a surrogate marker for gastroparesis symptoms and treatment response have not been consistent in previous studies3,4 and it is probably too soon to use them solely to determine the candidacy for pyloromyotomy procedure, especially when the procedure is offered only as a salvage therapy in refractory cases. Gastroparesis is a complex disease that is multifactorial in nature.5,6 As pathogenesis of gastropareasis is yet to be fully unfolded, other factors involved in pyloric function such as the direction and frequency of pyloric contraction would not have been accounted for in such measurements.7, 8 Moreover, considering a remarkable symptomatic improvement and reduction in gastric emptying time of 82–96% after laparoscopic pyloroplasty on all comers, regardless of subtype,9 it was anticipated that endoscopic pyloromytomy would provide a similar response. In regards to reported gastric emptying scintigraphy (GES), our institution follows the consensus recommendations from the joint report of the Society of Nuclear Medicine and the American Neurogastroenterology and Motility Society10 but also adopted a revised protocol that allows shortening the duration of the study in the event that the result showed residual content more than 65% at 2 hours. This protocol was validated with an accuracy of 0.966, compared to standard Tougas 4hour study.11,12 Therefore, the 4hour GES results were not available in all patients but preand postprocedure comparison were made at the same studied time. Lastly, we thank the authors for correctly pointing out that the knife in Figure 1 was indeed a hybrid knife Itype (ERBE, Tubingen, Germany). We used a hook knife (KD620LR; Olympus, Tokyo, Japan) in case 1 and 2, while a hybrid knife was used in case 3. In our experience, the multifunctional integrated electrocautery and waterjet function of a hybrid knife helps simplify the relevant steps and allows simultaneous injection and dissection process, thus significantly reduces the procedure time. Compared to conventional dissection technique, the hybrid knife was also associated with fewer bleeding episodes.13 We agree with Jacques et al. that a hook knife has the advantage of being able to selectively catch and resect muscle fiber in a traction fashion and, perhaps, should be preferred for myotomy. However, to the best of our knowledge, there has been no study comparing safety and efficacy of different types of endoscopic knife for pyloromyotomy. The types of knife used in previous studies were summarized in Table 4 in our paper,2 all of which yielded a similar success rate.4–18 We believe that ultimately, the choice of endoscopic device still largely depends on the endoscopist’s preference.

Fluoroscopic gastric peroral endoscopic pyloromyotomy (G-POEM) in patients with a failed gastric electrical stimulator

Abstract Background Gastric electrical stimulators (GESs) have been used to treat refractory gastroparesis in patients who fail initial therapies such as dietary modifications, control of psychological stressors and pharmacologic treatment. More recently, gastric peroral endoscopic pyloromyotomy (G-POEM) has emerged as a novel endoscopic technique to treat refractory gastroparesis. We present a case series of patients with refractory gastroparesis who failed treatment with an implanted GES that were safely treated with G-POEM performed under fluoroscopy as a salvage therapy. Methods Cases of G-POEM performed on patients with refractory gastroparesis who failed treatment with a GES were retrospectively reviewed. All G-POEM procedures were performed under fluoroscopic guidance with the GES still in place. Gastroparesis Cardinal Symptoms Index (GCSI) and gastric emptying scintigraphy were assessed before and after the procedure. Patients were followed up for up to 18 months post procedure. Results Five patients underwent G-POEM after failing treatment with a GES. Under fluoroscopy, the GES and their leads were visualized in different parts of the stomach. One GES lead was observed at the antrum near the myotomy site. All procedures were successfully completed without complications. Patients’ GCSI decreased by an average of 62% 1 month post procedure. Patients also had notable improvements in gastric emptying 2 months post procedure. Conclusion In patients with refractory gastroparesis who have failed treatment with a GES, G-POEM can be safe and effective without removing the GES. To visualize the GES and avoid cutting GES leads during myotomy, the procedure should be performed under fluoroscopy.

Gastric Peroral Endoscopic Pyloromyotomy Reduces Symptoms, Increases Quality of Life, and Reduces Health Care Use For Patients With Gastroparesis

BACKGROUND & AIMS: Gastric peroral endoscopic pyloromyotomy (GPOEM) is becoming a promising treatment option for patients with refractory gastroparesis. We aimed to systematically assess the efficacy of GPOEM and its effects on health care use. METHODS: We performed a retrospective study on 30 patients with refractory gastroparesis who underwent GPOEM from June 2015 through July 2017 at a tertiary center. We compared outcomes with those of 7 patients with refractory gastroparesis who did not undergo the procedure (controls). The primary outcomes were patient‐reported reductions in symptoms, based on the gastroparesis cardinal symptom index (GCSI), and increases in 8 aspects of quality of life, based on Short Form 36 (SF‐36) scores. Data were collected on the day of the procedure (baseline) and at 1 month, 6 months, 12 months, and 18 months afterward. Secondary outcomes included visits to the emergency department or hospitalization for gastroparesis‐related symptoms. RESULTS: GPOEM was technically successful in all patients and significantly reduced GCSI scores in repeated‐measure analysis of variance (F2.044, 38.838 = 22.319; P < .0005). The mean score at baseline was 3.5 ± 0.6, at 1 month after GPOEM was 1.8 ± 1.0 (P < .0005), at 6 months after was 1.9 ± 1.2 (P < .0005), at 12 months after was 2.6 ± 1.5 (P < .026), and at 18 months after was 2.1 ± 1.3 (P < .016). GPOEM was associated with improved quality of life: 77.8%, 76.5%, and 70% of patients had significant increases in SF‐36 scores, compared with baseline, at 1 month, 6 months, and 12 months after GPOEM, respectively (F1.71,18.83 = 14.16; P < .0005). Compared with controls, patients who underwent GPOEM had significant reductions in GCSI, after we controlled for baseline score and duration of the disease (F1,31 = 9.001; P = .005). Patients who received GPOEM had significant reductions in number of emergency department visits (from 2.2 ± 3.1 times/mo at baseline to 0.3 ± 0.8 times/mo; P = .003) and hospitalizations (from 1.7 ± 2 times/mo at baseline to 0.2 ± 0.4 times/mo; P = .0002). CONCLUSIONS: In a retrospective study of patients who underwent GPOEM for refractory gastroparesis, we found the procedure significantly improved symptoms, increased quality of life, and reduced health care use related to gastroparesis.

Endoscopic Management of Foreign Bodies

Foreign body ingestion including food impaction is one of the most common gastrointestinal emergencies that can lead to serious complications and occasionally death if left untreated. There are over 100,000 cases of foreign body ingestion with approximately 1500 deaths reported each year in the United Sates. Even though most ingested foreign bodies pass spontaneously, in 10–20% of the patients they may not, increasing the risk for perforation, and may require intervention. Fortunately, with nearly 95% success rate of endoscopic treatment, surgery is rarely needed. Therefore, early recognition of high-risk cases and timely endoscopic intervention are the cornerstone of management in patients presenting with foreign body ingestion. This chapter summarizes the approach, techniques, and existing evidence on endoscopic management of foreign body ingestion.

Editorial: ERCP-Related Radiation Cataractogenesis: Is It Time to Be Concerned?

Abstract: With the growing number of fluoroscopic guided endoscopic procedures, radiation-related risk needs to be further assessed. Recent evidence indicates that radiation cataractogenesis occurs at a lower dose threshold than previously believed. While body aprons and thyroid shields are well-established standard protection during fluoroscopy, ocular safety and the use of protective eyewear are not as well defined. This prospective study answered two important questions: Does the standard body dosimeter provide an accurate ocular dosimetry? And what is the time of fluoroscopy needed to warrant using lens protection? It also raises the question whether current guidelines need to be updated.

Long -Term Survival in Stage IV Esophageal Adenocarcinoma with Chemoradiation and Serial Endoscopic Cryoablation

Esophageal cancer has a poor overall prognosis and is frequently diagnosed at a late stage. Conventional treatment for metastatic esophageal cancer involves chemotherapy and radiation. Local disease control plays a significant role in improving survival. Endoscopic spray cryotherapy is a novel modality that involves freezing and thawing to produce local ablation of malignant tissue via ischemic mechanisms. Spray cryotherapy has been shown to be effective, particularly for early T-stage, superficial esophageal adenocarcinomas. We present the case of a 72-year-old-male with locally recurrent stage IV esophageal adenocarcinoma and long-term survival of 7 years to date, with concurrent chemoradiation and serial cryoablation. He remains asymptomatic and continues to undergo chemotherapy and sequential cryoablation. The findings highlight the long-term safety and efficacy of cryotherapy in combination with chemoradiation, and suggest that cryoablation may have an additive role in the treatment of advanced stage esophageal adenocarcinoma.

Less Common Solid Tumors of Pancreas

Primary neoplastic change can occur in all of the histological components of the pancreas. The term “pancreatic cancer” is commonly used to describe pancreatic ductal adenocarcinoma and its associated variants, which arise from the ductal cells and account for 85–90 % of all pancreatic neoplasms. However, neoplasms can also arise from other components of the gland, including stem cells, neuroendocrine cells, lymphoid and stromal cells. Rarely, metastases to the gland also occur. It is important to recognize and understand these tumors as their natural history can differ significantly from pancreatic adenocarcinomas.