Vincent Huberty

Endoscopic treatment for Zenker's diverticulum: long-term results (with video)

BACKGROUND Diverticulotomy is a standard treatment for Zenkers diverticulum (ZD). This technique was adapted to flexible endoscopy. OBJECTIVE We report our long-term results of ZD treatment by using flexible endoscopy assisted by a soft diverticuloscope. DESIGN Follow-up study. SETTING Academic hospital. Tertiary-care referral center. PATIENTS A total of 150 patients with ZD were treated with the same technique from July 2002 to June 2011. INTERVENTION The procedure was performed by using a soft diverticuloscope to expose the septum, which was then cut with a needle-knife, and the procedure was completed by use of endoclip placement at the bottom of the section. MAIN OUTCOME MEASUREMENTS Symptoms were compared before and after the procedure, 1 month later, and at the end of follow-up. RESULTS The median size of the ZD was 3 cm (range 1-8 cm). The endoscopic incision was performed in one session (range 1-3 sessions). Clinical success at 1 month was 90.3%. Four adverse events (2.2%) occurred and were managed conservatively. Symptom evaluation at 1 month and at the end of follow-up was obtained in 103 and 134 patients, respectively. The dysphagia score dropped from 1.88 to 0.29 (P < .01) and 0.34 (P < .05) at 1 month and at the end of follow-up, respectively (median 43 months, range 13-121 months). Regurgitations and chronic cough dropped from 73% and 27% to 11% and 2% at the end of follow-up, respectively. Symptom recurrence occurred in 31 patients (23.1%); among them 23 had a second treatment, and only 5 required a third one. LIMITATIONS Retrospective study, single center. CONCLUSION Endoscopic incision of ZD by using a soft diverticuloscope and completed by endoclips is safe and efficient at short term and long term.

Novel biliary self-expanding metal stents: indications and applications

Endoscopic insertion of a self-expanding metal stent (SEMS) through a malignant common bile duct stricture is the first line of palliation for malignant jaundice. Patency of these stents remains a major concern. SEMS dysfunction can result from tumor ingrowth, overgrowth and/or clogging. Initial SEMS modifications involved covering the central part of the stent in order to reduce ingrowth and ultimately increase patency. Fully covered stents became available shortly after reports of their use in human patients. The potential removability and radial strength of SEMS have led to evaluation of their use in new indications including benign biliary strictures, post sphincterotomy bleeding and perforation. Other aspects of development include the addition of features such as anti-reflux valves, drug elution and spontaneous biodegradability. These aspects and their clinical implications are reviewed and discussed.

In vivo validation of a less invasive gastrostimulator

Gastrointestinal stimulator implants have recently shown promising results in helping obese patients lose weight. However, to place the implant, the patient currently needs to undergo an invasive surgical procedure. We report a less invasive procedure to stimulate the stomach with a gastrostimulator. After attempting fully endoscopic implantation, we more recently focused on a single incision percutaneous procedure. In both cases, the challenges in electronic design of the implant are largely similar. This article covers the work achieved to meet these and details the in vivo validation of a gastrostimulator aimed to be endoscopically placed and anchored to the stomach.

Design and Implementation of a Less Invasive Gastrostimulator

Gastrointestinal stimulator implants have recently shown positive results in helping obese patients lose weight. However, to place the implant, the patient currently needs to undergo an invasive surgical procedure. Our team is aiming for a less invasive procedure to stimulate the stomach with a gastrostimulator. Attempts covered fully endoscopic implantation and, more recently, we have focussed on a single incision laparoscopic procedure. Whatever the chosen implantation solution, the electronic design of the implant system shares many challenges. This paper covers the work achieved to meet these.

Peroral endoscopic myotomy as a versatile approach to treating complex esophageal disorders

Since 2008, peroral endoscopic myotomy (POEM) has evolved as a technique for managing esophageal achalasia [1]. POEM has also recently emerged as a potential therapeutic tool in treating other esophageal motility disorders [2, 3], including Jackhammer esophagus and Zenker’s diverticulum [4]. However, for mid or lower esophageal diverticulum, the surgical treatment is still recommended, despite being associated with high morbidity. In this video case we report the application of the POEM technique as a therapeutic approach in a patient affected by Jackhammer esophagus, distal esophageal spasm, and a large distal esophageal diverticulum (▶Fig. 1,▶Fig. 2 a). The aim of this POEM variation was to create a submucosal tunnel as a single access both to the diverticular septum, to perform septotomy, and to the esophageal wall muscle and lower esophageal sphincter (LES), in order to perform myotomy (▶Fig. 3, ▶Video1). Compared with the classical POEM procedure, five phases were defined. After mucosa incision and submucosal tunneling, the myotomy was performed as a hybrid technique. Initially, an anterograde section of the esophageal wall muscle was dissected, starting from the fibers below the diverticular septum, progressing downstream, and ending in the stomach, beyond the LES section. Next, a retrograde septotomy was performed, beginning from the most distal septal fibers and working toward the proximal ones. At the end, the tunnel entry was sealed using hemostatic clips. This case report shows that POEM is versatile, safe, effective (▶Fig. 2b), and minimally invasive. Its evaluation as a therapeutic tool in patients having mid or distal esophageal symptomatic diverticulum, whether associated with motility disorders or not, should be encour▶ Fig. 1 Barium study showing a large distal esophageal diverticulum and multiple tertiary contractions, suggesting the diagnosis of Jackhammer esophagus.

The use of enteral access for continuous delivery of levodopa-carbidopa in patients with advanced Parkinson’s disease

Background Continuous delivery to the jejunum of levodopa-carbidopa is a promising therapy in patients with advanced Parkinson’s disease, as it reduces motor fluctuation. Percutaneous endoscopic gastrostomy and jejunal tube (PEG-J) placement is a suitable option for this. However, studies focused in PEG-J management are lacking. Objectives We report our experience regarding this technique, including technical success, adverse events and outcomes, in patients with advanced Parkinson’s disease. Methods Twenty-seven advanced Parkinson’s disease patients (17 men, median age: 64 years, median disease duration: 11 years) were included in a retrospective study from June 2007 to April 2015. The median follow-up period was 48 months (1–96). Results No adverse events were noted during and after nasojejunal tube insertion (to assess treatment efficacy). After a good therapeutic response, a PEG-J was placed successfully in all patients. The PEG tube was inserted according to Ponsky’s method. The jejunal extension was inserted during the same procedure in all patients. Twelve patients (44%) experienced severe adverse events related to the PEG-J insertion, which occurred after a median follow-up of 15.5 months. Endoscopy was the main treatment modality. Patients who experienced severe adverse events had a higher comorbidity score (p = 0.011) but were not older (p = 0.941) than patients who did not. Conclusions While all patients responded well to levodopa-carbidopa regarding neurological outcomes, gastro-intestinal severe adverse events were frequent and related to comorbidities. Endoscopic treatment is the cornerstone for management of PEG-J related events. In conclusion, clinicians and endoscopists, as well as patients, should be fully informed of procedure-related adverse events and patients should be followed in centres experienced in their management.

Endoscopic gastric reduction with an endoluminal suturing device: a multicenter prospective trial with 1-year follow-up

BACKGROUND Obesity is the pandemic disease of this century. Surgery is the only effective treatment but cannot be offered to every patient. Endoscopic sutured gastroplasty is a minimally invasive technique that may potentially fill the gap between surgery and behavioral therapy. In this study, we prospectively investigated the efficacy and safety of a novel suturing device. METHODS After a pre-bariatric multidisciplinary work-up, class 1 and 2 obese patients were included. Using a simple triangulation platform, transmural sutures with serosa-to-serosa apposition were performed in the gastric cavity. Patients were followed according to the same routines as those performed for bariatric procedures. RESULTS Between November 2015 and December 2016, 51 patients were included across three European Centers. Mean body mass index at baseline was 35.1 kg/m2 (SD 3.0). Excess weight loss and total body weight loss at 1 year were 29 % (SD 28) and 7.4 % (SD 7), respectively, for the whole cohort (45 patients). At follow-up gastroscopy, 88 % of sutures were still in place (30 patients). No severe adverse events were observed. CONCLUSIONS Endoscopic sutured gastroplasty using this novel device is safe and achieved weight loss results in line with criteria expected for these endoluminal techniques. Further prospective studies vs. placebo or nutritional support are needed.

Endoscopic Duodenal Mucosal Resurfacing for the Treatment of Type 2 Diabetes

Type 2 diabetes is a pandemic disease with an incidence that has risen steadily over recent decades. Experimental evidence in animals has demonstrated that intestinal bypass surgery of the upper small intestine, particularly the duodenum, has an important role in glucose homoeostasis. Furthermore, Roux-en-Y bypass performed as bariatric surgery has shown to correct hyperglycaemia from the first postoperative days in obese diabetic patients. Therefore, on the basis of these considerations, duodenal mucosal resurfacing was studied in type 2 diabetes patients as a minimally invasive procedure that could offer an alternative treatment for these patients. Further studies, and particularly large controlled trials, are needed to determine the place of this procedure in the treatment of type 2 diabetes as well as other metabolic diseases such as non-alcoholic fatty liver disease/non-alcoholic steatohepatitis.