Vivien W. Wong

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy

BACKGROUND & AIMS: In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS: We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non‐HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS: POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non‐HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non‐HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non‐HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS: POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.

Comprehensive Analysis of Adverse Events Associated with per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study

Objectives:The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM.Methods:Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case–control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders).Results:A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs.Conclusions:This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.

Preemptive dilatation gives good outcome to early esophageal stricture after circumferential endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is gaining popularity over endoscopic mucosal resection for treatment of superficial upper gastrointestinal cancers. It allows a more controlled en-bloc resection of intramucosal neoplasia allowing larger lesion in both stomach and esophagus to be resected. Lower local recurrence rate can be achieved. This is particularly important in the esophagus, as luminal stricture and deep fibrosis often hinder the possibility of repeat endoscopic resection of recurrences. The exact incidence of benign luminal strictures after the ESD of the esophagus lesion is unknown, but the risk is related to the circumferential extent of the lesion being resected, which is expected to develop in cases with post-ESD ulcer more than two-thirds of the circumference. We report 2 patients with early stenosis after circumferential ESD. We have also showed that scheduled early regular endoscopic balloon dilatation was effective in controlling and preventing post-ESD stricture. In conclusion, we suggest early follow-up esophagogastroduodenoscopy to be done for patients with circumferential ESD to determine the need of preemptive dilatation.

Topical application of povidone‐iodine before wound closure is associated with significant increase in serum iodine level

Aim:  To determine serum iodine level before and after local application of povidone‐iodine before wound closure in cardiac surgery patients. Povidone‐iodine is a popular antiseptic solution that has been widely used in perioperative wound management of surgical patients. Despite its widespread usage, little is known concerning the absorption profile and potential systemic toxicity.

Giant Meckel's diverticulitis: a rare condition complicating pregnancy.

A 33-year-old pregnant woman presented with peritonitis at the right iliac fossa. Preoperative ultrasonography identified an 8-cm tubular structure at the tender point that was mistaken as appendicitis. Emergency operation finally confirmed a 12-cm giant Meckels diverticulum with genuine inflammation and imminent perforation. The patient made an uneventful recovery after Meckels diverticulectomy.

Endoscopic Treatment of Subepithelial Lesions of the Gastrointestinal Tract

AbstractPurpose of Review The study aimed to discuss novel endoscopic approaches to resection of submucosal lesions. Recent Findings Endoscopic resection by excavation, full-thickness resection, and submucosal tunneling are by now well-documented techniques for submucosal tumor resection. Combined approaches with laparoscopy such as several variations of laparoscopic endoscopic cooperation surgery (LECS) and non-exposed wall-inversion surgery (NEWS) are also possible now. Reports of these approaches show good results. However, lesion size is the main limitation to these approaches. Summary Endoscopic submucosal tumor resection can be effectively done endoscopically or by endoscopy combined with laparoscopy. These techniques allow localized resection of lesions at difficult locations such as in the gastroesophageal junction with limited influence on the normal anatomy. Variations in techniques are being practiced worldwide striving to achieve complete resection with minimal disturbance of function or contamination. The choice between approaches depends largely on the size and site of the lesion and expertise available.

Povidone‐iodine wound irrigation: A word of caution

Iodine‐based disinfectants are widely used by various surgical specialties to prevent and treat wound infection; however, its detrimental effects are often overlooked. We hereby report a dialysis‐dependent renal failure patient with clinical manifestation of systemic iodine toxicity after irrigation of an infected mediastinal wound with povidone‐iodine solution. Further study is required to determine the systemic absorption and side‐effect profile of povidone‐iodine especially when used for irrigation of deep body structures.

Chilaiditi's syndrome: a nonemergent cause of "free gas under diaphragm".

A 52-year-old woman had a chest radiograph performed for dysphagia. Apart from the related esophageal abnormality, another striking feature was noted: free gas under the diaphragm. The patient, however, complained of no other gastrointestinal symptom and showed no sign of peritonism.

Lower Esophageal Sphincter Efficacy Following Laparoscopic Antireflux Surgery with Hiatal Repair: Role of Fluoroscopy, High-Resolution Impedance Manometry and FLIP in Detecting Recurrence of GERD and Hiatal Hernia

Hiatus hernia is an important risk factor for the development of gastroesophageal reflux disease. Hiatus hernia promotes gastric acid access to the esophagus and impairs its clearance. Surgical repair for hiatus hernia has developed over the years and show good results but there is still a need for development of current techniques due to the anatomical and physiological complexity of the esophago-gastric junction in health and disease. This chapter provides an insight into the complex anatomy and physiology of the esophago-gastric junction including the lower esophageal sphincter under physiological and remodeled conditions as observed in herniation and during surgical repair like fundoplication. The chapter deals in particular with efficacy evaluation based on fluoroscopy, impedance manometry, and FLIP.

Endoscopic hemithyroidectomy using bilateral axillo‐breast approach

Minimally-invasive thyroidectomy (MIT) is an emerging technique in modern thyroid surgery for its cosmetic superiority that can satisfy the high expectation of patients and the major pursuit of surgeons. In the past two decades, there has been an explosive worldwide development and an evolution of different surgical techniques in MIT. Despite having a longer operative time and cost, recent meta-analyses have suggested that MIT actually compares more favourably than open procedure for better cosmesis, higher patient satisfaction, less postoperative pain and similar complication rates. Techniques of MIT are broadly classified into cervical (access to thyroid through the neck) and extra-cervical approaches (access to thyroid remote from the neck). In this report, we describe the technique of bilateral axillo-breast approach (BABA) endoscopic hemithyroidectomy in a 28-year-old woman who was referred for right hemithyroidectomy for the management of a 2.5-cm right thyroid nodule that was shown to be a follicular neoplasm on fine-needle aspiration cytology.