Wen-Zheng Qin

Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study.

BACKGROUND AND STUDY AIMS Recurrence/persistence of symptoms occurs in approximately 20 % of patients after Heller myotomy for achalasia. Controversy exists regarding the therapy for patients in whom Heller myotomy has failed. The aim of the current study was to evaluate the efficacy and feasibility of peroral endoscopic myotomy (POEM), a new endoscopic myotomy technique, for patients with failed Heller myotomy. PATIENTS AND METHODS A total of 12 patients with recurrence/persistence of symptoms after Heller myotomy, as diagnosed by established methods and an Eckardt score of ≥ 4, were prospectively included. The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤ 3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM. RESULTS All 12 patients underwent successful POEM after a mean of 11.9 years (range 2 - 38 years) from the time of the primary Heller myotomy. No serious complications related to POEM were encountered. During a mean follow-up period of 10.4 months (range 5 - 14 months), treatment success was achieved in 11/12 patients (91.7 %; mean score pre- vs. post-treatment 9.2 vs. 1.3; P < 0.001). Mean LES pressure was 29.4 mmHg pre-treatment and 13.5 mmHg post-treatment (P < 0.001). One patient developed mild reflux symptoms and required intermittent medication with proton pump inhibitors. CONCLUSIONS POEM seems to be a promising new treatment for failed Heller myotomy resulting in short-term symptom relief in > 90 % of cases. Previous Heller myotomy may make subsequent endoscopic remyotomy more challenging, but does not prevent successful POEM.

Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos)

U T t s u g e o i T ( a ( f Upper GI submucosal tumors (SMTs) 3 cm are generally considered benign tumors. However, some such umors, especially mesenchymal neoplasms (including GI tromal tumors originating from the muscularis propria MP]), do have malignant potential.2 If tissue diagnosis is ttempted, the most challenging aspect in the diagnosis of MTs by needle biopsy is the sampling error when taking iopsy specimens of GI stromal tumors, which may show nly focal areas of malignant change.2 Asymptomatic GI MTs 3 cm could be followed-up with periodic endoscopy nd/or EUS or resection.3 However, some patients become tressed when told that they require periodic follow-up. As a esult, they feel the urge to seek a safe and efficacious reatment during the follow-up time. Conventional endocopic resection of tumors originating from the MP layer used o be discouraged because of incomplete resections or risk of erforation during procedures. This left such patients with wo choices: surgical resection or endoscopic follow-up. Enoscopic submucosal dissection (ESD)2 and new, emerging endoscopic techniques such as endoscopic full-thickness resection4 are now options for these patients.

Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Clinical Comparative Study of Endoscopic Full-Thickness and Circular Muscle Myotomy

BACKGROUND A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. STUDY DESIGN According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. RESULTS The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38). CONCLUSIONS Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.

Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video)

Peroral endoscopic myotomy (POEM) has recently been described as a scar-free and less-invasive surgical myotomy option for treating achalasia. This procedure incorporates concepts of natural orifice transluminal endoscopic surgery and achieves endoscopic myotomy by using a submucosal tunnel as the operating space. Initial published experience in humans is more than encouraging despite a relatively short follow-up. Common complications of POEM include mucosal injury, subcutaneous emphysema, mediastinal emphysema, pneumothorax, pneumoperitoneum, and pleural effusion. Postoperative delayed bleeding in the submucosal tunnel is a rare complication after POEM, and only 1 patient with delayed bleeding has been reported in the literature to date. Despite its low incidence, delayed bleeding can result in serious conditions, such as massive bleeding, hemorrhagic shock, and death. Thus, early

Endoscopic submucosal dissection for foregut neuroendocrine tumors： An initial study

AIM To evaluate the feasibility and efficacy of endoscopic submucosal dissection (ESD) for foregut neuroendocrine tumors (NETs). METHODS From April 2008 to December 2010, patients with confirmed histological diagnosis of foregut NETs were included. None had regional lymph node enlargement or distant metastases to the liver or lung on preoperative computerized tomography scanning or endoscopic ultrasonography (EUS). ESD was attempted under general anesthesia. After making several marking dots around the lesion, a mixture solution was injected into the submucosa. The mucosa was incised outside the marking dots. Dissection of the submucosal layer beneath the tumor was performed under direct vision to achieve complete en bloc resection of the specimen. Tumor features, clinicopathological characteristics, complete resection rate, and complications were evaluated. Foregut NETs were graded as G1, G2, or G3 on the basis of proliferative activity by mitotic count or Ki-67 index. All patients underwent regular follow-up to evaluate for any local recurrence or distant metastasis. RESULTS Those treated by ESD included 24 patients with 29 foregut NETs. The locations of the 29 lesions are as follows: esophagus (n = 1), cardia (n = 1), stomach (n = 23), and duodenal bulb (n = 4). All lesions were found incidentally during routine upper gastrointestinal endoscopy for other indications, and none had symptoms of carcinoid syndrome. Preoperative EUS showed that all tumors were confined to the submucosa. Among the 24 gastric lesions, 16 lesions in 11 patients were type I gastric NETs arising in chronic atrophic gastritis with hypergastrinemia, while the other 8 solitary lesions were type III because of absence of atrophic gastritis in these cases. All of the tumors were removed in an en bloc fashion. The average maximum diameter of the lesions was 9.4 mm (range: 2-30 mm), and the procedure time was 20.3 min (range: 10-45 min). According to the World Health Organization 2010 classification, histological evaluation determined that 26 lesions were NET-G1, 2 gastric lesions were NET-G2, and 1 esophageal lesion was neuroendocrine carcinoma (NEC). Complete resection was achieved in 28 lesions (28/29, 96.6%), and all of them were confined to the submucosa in histopathologic assessment with no lymphovascular invasion. The remaining patient with NEC underwent additional surgery because the resected specimens revealed angiolymphatic and muscularis invasion, as well as incomplete resection. Delayed bleeding occurred in 1 case 3 d after ESD, which was managed by endoscopic treatment. There were no procedure-related perforations. During a mean follow-up period of 24.4 mo (range: 12-48 mo), local recurrence occurred in only 1 patient 7 mo after initial ESD. This patient successfully underwent repeat ESD. Metastasis to lymph nodes or distal organs was not observed in any patient. No patients died during the study period. CONCLUSION ESD appears to be a safe, feasible, and effective procedure for providing accurate histopathological evaluations and curative treatment for eligible foregut NETs.

Colorectal lateral spreading tumor subtypes: clinicopathology and outcome of endoscopic submucosal dissection

PurposeThis study aims to investigate the clinicopathological features of specific subtypes of laterally spreading tumor (LST) and assessed the outcome of endoscopic submucosal dissection (ESD) based upon subdifferentiation status.MethodsA total of 137 LSTs were present in 135 patients; 96 were granular and 41 exhibited a nongranular pattern. Granular LSTs, subdivided into homogeneous and nodular mixed, and nongranular LSTs, subdivided into flat-elevated and pseudodepressed, were retrospectively evaluated with respect to clinicopathological features and results of ESD (en bloc R0 curative resection, procedure time, complication, and recurrence rate) according to specific subtype.ResultsThe distribution of high-grade intraepithelial neoplasia and submucosal carcinomas was more prominent among granular nodular mixed tumors than among granular homogeneous tumors (P = 0.007), whereas there was no significant difference between nongranular pseudodepressed tumors and flat-elevated tumors. The frequency of en bloc R0 curative resection did not differ significantly among specific subtypes. For nodular mixed and pseudodepressed lesions, the median tumor size was significantly larger (P < 0.001 for each) and mean procedure time was also longer (P < 0.05 for each) than for the other two subtypes. All complications, which included three perforations, five episodes of postoperative bleeding, and one recurrence, occurred in granular nodular mixed and nongranular pseudodepressed tumors.ConclusionThe risk of cancer varies with the subtypes of LSTs. ESD is an effective treatment for LSTs, however ESD is more technically demanding and carries more complications in pseudodepressed and granular mixed subtypes.

Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures

Background and aims Peroral endoscopic myotomy (POEM) is now an established treatment for esophageal achalasia. The standard protocol ensures a smooth operation in most patients, but technical challenges and failures exist and little is known about the incidence, causes, and impact of aborted procedures. Here, using a large patient cohort, we attempted to answer these questions. Methods All patients admitted for planned POEM between August 2010 and July 2015 underwent chart review. Aborted POEM was defined as the inability to finish the procedure after submucosal injection. The cause of the failure, clinical course, management, and follow-up data were analyzed. Results Thirteen of the 1693 POEMs (0.77 %) were aborted. Out of the 13 failures, 12 (92.3 %) were due to severe submucosal fibrosis, which precluded tunneling, and one (7.7 %) was due to atrial fibrillation related to the electric current of the endoscopic knife. Submucosal fibrosis, prior Heller myotomy, and age ( ≥ 60 years) were related to technical failure, while a disease duration of ≥ 6 years, sigmoid esophagus, mucosal edema, and prior interventions were risk factors for the presence of fibrotic changes. In turn, fibrosis was correlated with a prolonged operation, longer hospital stay, more mucosal injuries, and more major perioperative adverse events. Finally, the yearly frequency of aborted POEMs decreased after the second year as operators became more experienced. Conclusions Aborted POEM is a rare event and is largely due to the presence of submucosal fibrosis, which not only causes increased procedural difficulties, but also gives rise to major adverse events.

Comprehensive Evaluation of the Learning Curve for Peroral Endoscopic Myotomy

Background & Aims Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic surgical procedure that is effective in treatment for spastic esophageal motility disorders. However, little is known about the learning curve for endoscopists. We aimed to evaluate the effects of various factors on the POEM learning curve. Methods We performed a retrospective study of 1346 patients who underwent POEM for achalasia at Shanghai Zhongshan Hospital in China from August 2010 through July 2015. We used risk‐adjusted cumulative sum and moving average methods to evaluate outcomes. The primary outcome was a composite of technical failure and adverse events. Secondary outcomes included procedure time and the composite outcome of technical failure, adverse events, and clinical failure of the first 192 cases performed by only the original, training surgeon. Results The primary composite outcome occurred in 54 (4%) of the 1346 patients: 10 technical failures and 44 adverse events. This composite outcome was independently associated with the case number (P = .010), full‐thickness myotomy (P = .002), and procedure time (P = .001). After we adjusted for these risk factors, cumulative sum analysis showed that the primary composite outcome decreased gradually after 100 cases. The procedure time was high during the first few cases and decreased after endoscopists performed 70 cases. The secondary composite outcome of technical failure, adverse events, and clinical failure for the 192 cases performed by only the original surgeon gradually decreased after 90–100 cases. Conclusions In a retrospective analysis of POEM procedures, we found that 100 cases were required to decrease the risk of technical failure, adverse events, and clinical failure (the learning curve). Seventy cases can be considered the threshold for decreasing procedure time.

Treatment of leakage via metallic stents placements after endoscopic full-thickness resection for esophageal and gastroesophageal junction submucosal tumors

Abstract Objective: The objective of this study is to evaluate the feasibility and efficacy of endoscopic full-thickness resection (EFTR) and fully covered retrievable self-expandable metal stents (SEMSs) placement for this kind of tumors. Methods: A total of six consecutive patients, presenting with esophageal and GE junction SMTs, received EFTR and SEMSs placement at the our endoscopic center between January 2015 and June 2015. Their medical records were thoroughly investigated. Results: EFTR was performed successfully in all cases. The en bloc resection rate was 100%. The final pathological diagnoses were leiomyomas in all six cases. No patients developed delayed bleeding. SEMSs were placed immediately after EFTR during the same endoscopic session except patient #1. Complete healing of esophageal leakage after stent placement was achieved for 6/6 patients (100%) without the need for surgical interventions. Stent migration occurred in one patient. No residual tumor or tumor recurrence was observed during the follow-up period. Conclusions: EFTR combined with fully covered retrievable self-expandable metallic stents placement is a feasible and effective new method for providing radical treatments for SMTs from the deep MP layer of esophagus and GE junction. Standardization of the procedure should be studied further.

The effect of prior treatment on clinical outcomes in patients with achalasia undergoing peroral endoscopic myotomy

BACKGROUND  Peroral endoscopic myotomy (POEM) is a treatment option for patients with previous surgical or endoscopic treatment. We aimed to evaluate the influence of prior treatment on perioperative and follow-up outcomes in patients undergoing POEM. METHODS  From August 2010 to December 2014, a total of 1384 patients with achalasia underwent POEM at our center. We retrospectively reviewed 849 patients who completed follow-up. Patients with an Eckardt score ≥ 4 after POEM were considered to have a clinical failure. We compared variables between patients with and without prior treatment. We analyzed risk factors for perioperative major adverse events, and clinical reflux and failure during follow-up.  RESULTS:  245 patients (28.9 %) had undergone prior treatment, and 34 patients (4.0 %) experienced a major adverse event associated with the POEM procedure. During a median follow-up of 23 months (range 1 - 71), clinical reflux occurred in 203 patients (23.9 %) and clinical failure was recorded for 94 patients (11.1 %). Patients with prior treatment had a longer procedure duration (P = 0.001) and longer hospital stay after POEM (P = 0.001). Prior treatment was not an independent risk factor for major adverse events or clinical reflux (odds ratio [OR] 1.19, P = 0.65; OR 1.26, P = 0.19; logistic regression), but it did increase the rate of clinical failure during follow-up (hazard ratio 1.90, P = 0.002; Cox regression). CONCLUSIONS  POEM was performed safely with a low rate of major adverse events in patients with achalasia who had undergone prior surgical or endoscopic treatment. However, prior treatment increased the risk of clinical failure after POEM.