Radu Pescarus

Peroral Endoscopic Myotomy (POEM) for Esophageal Primary Motility Disorders: Analysis of 100 Consecutive Patients

IntroductionPeroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for axa0 myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice.MethodsComprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6–12xa0months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2xa0days.ResultsOne hundred POEM patients were included in the final analysis. The mean age was 58xa0years (18–83xa0years). Primaryxa0presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16xa0months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES.The mean operative time was 128xa0min. The median hospital length of stay (LOS) was 1xa0day. The overall morbidity was 6xa0%; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvie’s, and one required prolonged intubation for CO2 retention).The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90xa0% on TBS with 93xa0% patients demonstrating >90xa0% emptying at 1xa0min. Of the achalasia patients, 36xa0% (17/47) showed some return of normal peristalsis (≥70xa0% peristalsis) on post-op HRM.Abnormal acid exposure was present on postoperative testing in 38xa0% (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97xa0% with a complete resolution accomplished in 89xa0%. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8xa0%) vs. non-achalasia patients (17/24; 70.8xa0%). Of those with preoperative chest pain, 91.5xa0% reported complete relief.Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations.ConclusionThis study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97xa0%) and chest pain (91.5xa0%) for patients with esophageal spastic disorders with acceptable procedural morbidity.

Early human experience with per-oral endoscopic pyloromyotomy (POP)

IntroductionGastroparesis is a condition characterized by delayed gastric emptying, and a constellation of symptoms, including nausea, vomiting, early satiety, and bloating. Although current surgical options such as pyloroplasty have been shown to be effective, an endoscopic submucosal myotomy technique may be applied to divide the pyloric sphincter without surgical access. Such endoscopic technique may provide the benefits of a natural orifice procedure, and improve gastric emptying in gastroparetic patients.Methods and proceduresPer-oral pyloromyotomy (POP) was performed in seven female patients aged 33–65xa0years (mean 51xa0years). All patients had a pre-operative work-up that included upper endoscopy,xa0and a gastric emptying study. A pH study, and esophageal manometryxa0were also performed when a concomitant fundoplication was considered.ResultsPOP was technically successful in all seven cases. There were no immediate procedural complications. Perioperative, complications included: one patient with an upper GI bleed 2xa0weeks post-procedure, necessitating transfusions, and endoscopic clipping of a pyloric channel ulcer; one patient who experienced difficulty swallowing post operatively, delaying discharge by 1xa0day; and one patient who developed a hospital-acquired pneumonia, delaying discharge by several days. Six of the seven patients experienced significant symptomatic improvement following the procedure. Three month follow-up nuclear medicine solid-phase gastric emptying studies are currently available for 5 of the 7 patients. Normal gastric emptying at 4xa0h was noted in four of five patients (80xa0%). One patient did not respond to endoscopic management subsequently underwent an uneventful laparoscopic pyloroplasty, which also failed to significantly improve her symptoms.ConclusionPOP is a technically safe and feasible endoscopic procedure. Early follow-up suggests promising symptomatic improvement as well as objective improvement in gastric emptying. Additional clinical experience is required to establish the role of this technique in the management of gastroparesis.

Per-Oral Endoscopic Myotomy (POEM) for Esophageal Achalasia

Per-oral endoscopic myotomy (POEM) is a new minimally invasive endoscopic treatment for achalasia. Since the first modern human cases were published in 2008, around 2,000 cases have been performed worldwide. This technique requires advanced endoscopic skills and a learning curve of at least 20 cases. POEM is highly successful with over 90xa0% improvement in dysphagia while offering patients the advantage of a low impact endoscopic access. The main long-term complication is gastroesophageal reflux (GER) with an estimated incidence of 35xa0%, similar to the incidence of GER post-laparoscopic Heller with fundoplication. Although POEM represents a paradigm shift in the treatment of achalasia, more long-term data are clearly needed to further define its role in the treatment algorithm of this rare disease.

Hill procedure for recurrent GERD post-Roux-en-Y gastric bypass

BackgroundRoux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB.MethodsAfter placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance.ResultsNo peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6xa0months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6xa0months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism.ConclusionThe Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population.

Sleeve endoscopic esophageal mucosotomy

Complete circumferential endoscopic submucosal dissection (ESD) techniques have been used recently to remove specimens en bloc. Although evaluation ofmargins remains a benefit, scar formation and strictures remain major problems. Stenting with or without biologic matrix may be helpful in preventing strictures, but deployment remains problematic. We present a modified technique of circumferential ESD with a novel over-the-scope stent technique to place a biologic matrix into the mucosal defect. A 12-cm segment of circumferential Barrett’s esophagus with multifocal intramucosal cancer was resected endoscopically by using a modified ESD technique. A novel, over-the-scope technique of deploying a metal stent fully covered with a biologic scaffold is shown (Fig. 1; Video 1, available online at www.giejournal.org). The patient was treated with systemic steroids for 2 weeks. The stent was removed after 5 weeks, and EGD showed partial growth of the matrix on the esophageal muscular wall with no stricture. At 3 months, mild stricturing was treated

In vivo observation of perforating submucosal pancreatic ducts during endoscopic submucosal dissection of a gastric heterotopic pancreas

Heterotopic pancreas is defined by the presence of pancreatic tissue in an abnormal location without ductal or vascular connections to the normal pancreas. It is most commonly found in the upper GI tract and measures 1 to 2 cm in size. Usual locations include the gastric antrum (predominantly along the greater curvature), duodenum, and proximal jejunum. Heterotopic pancreatic tissue is usually asymptomatic, although a minority of patients may present with symptoms, typically abdominal pain. The most common endoscopic appearance is that of a raised submucosal lesion with central umbilication, which corresponds to the opening of a duct. The ectopic pancreatic tissue is typically located in the submucosa, although it may occasionally extend deeper to the muscularis or subserosal layers. An incidentally found, asymptomatic lesion with a typical appearance on endoscopy and EUS may not require any further management or surveillance. The management of symptomatic or atypical-appearing heterotopic pancreatic tissue may also include observation, surgical resection, and, increasingly, endoscopic resection. This video demonstrates endoscopic submucosal dissection (ESD) of an ectopic pancreatic lesion in the gastric antrum. The lesion was originally found on an upper endoscopy performed for vague abdominal pain. It was thought that