Yamile Haito-Chavez

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.

Septotomy: an adjunct endoscopic treatment for post–sleeve gastrectomy fistulas

A 48-year-old woman presented with progressive abdominal pain 2 weeks after she had undergone laparoscopic sleeve gastrectomy (SG). A CT scan of the abdomen demonstrated postsurgical changes related to SG and a large extraluminal collection containing fluid, debris, and air adjacent to the surgical staple line. A percutaneous drain was placed, and endoscopic closure of the defect was attempted. Endoscopy revealed a fistulous opening adjacent to normal gastric lumen. The internal orifice of the gastrocutaneous (GC) fistula conditioned a pouchlike lumen, which was divided from the gastric lumen by a 15-mm-long septum (Fig. 1A). Septotomy was performed with argon plasma coagulation (40W) (ERBE, Tubingen, Germany) and resulted in communication of the 2 lumens (Fig. 1B). The edges of the fistula were ablated with argon plasma coagulation and the defect was closed with an overthe-scope clip (Video 1, available online at www.giejournal. org). Immediate injection of contrast medium into the gastric lumen demonstrated complete closure of the fistula (Fig. 1). The percutaneous drainage was removed 12 days later after progressive output decrement. A CT scan 6 weeks later demonstrated a smaller collection without

Update on Difficult Polypectomy Techniques.

Endoscopists often encounter colon polyps that are technically difficult to resect. These lesions traditionally were managed surgically, with significant potential morbidity and mortality. Recent advances in endoscopic techniques and instruments have allowed endoscopists to safely and effectively remove colorectal lesions with high technical and clinical success and potentially avoid invasive surgery. Endoscopic mucosal resection (EMR) has gained acceptance as the first-line therapy for large colorectal lesions. Endoscopic submucosal dissection (ESD) has been reported to be associated with higher rate of en bloc resection and less risk of short-time recurrence, but with an increased risk of adverse events. Therefore, the role of colorectal ESD should be restricted to lesions with high-risk morphologic features of submucosal invasion. In this article, we review the recent literature on the endoscopic management of difficult colorectal neoplasms.

Which clip? A prospective comparative study of retention rates of endoscopic clips on normal mucosa and ulcers in a porcine model

Background/Aim: There are currently no data on the relative retention rates of the Instinct clip, Resolution clip, and QuickClip2Long. Also, it is unknown whether retention rate differs when clips are applied to ulcerated rather than normal mucosa. The aim of this study is to compare the retention rates of three commonly used endoscopic clips. Materials and Methods: Six pigs underwent upper endoscopy with placement of one of each of the three types of clips on normal mucosa in the gastric body. Three mucosal resections were also performed to create “ulcers”. Each ulcer was closed with placement of one of the three different clips. Repeat endoscopy was performed weekly for up to 4 weeks. Results: Only the Instinct and Resolution clips remained attached for the duration of the study (4 weeks). At each time point, a greater proportion of Instinct clips were retained on normal mucosa, followed by Resolution clips. QuickClip2Long had the lowest retention rate on normal mucosa. Similar retention rates of Instinct clips and Resolution clips were seen on simulated ulcers, although both were superior to QuickClip2Long. However, the difference did not reach statistical significance. All QuickClip2Long clips were dislodged at 4 weeks in both the groups. Conclusions: The Resolution and Instinct clips have comparable retention rates and both appeared to be better than the QuickClip2Long on normal mucosa-simulated ulcers; however this did not reach statistical significance. Both the Resolution clip and the Instinct clip may be preferred in clinical situations when long-term clip attachment is required, including marking of tumors for radiotherapy and anchoring feeding tubes or stents. Either of the currently available clips may be suitable for closure of iatrogenic mucosal defects without features of chronicity.

A novel viscous dissecting gel for endoscopic submucosal dissection: a prospective survival study in a porcine model

BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) is a technically challenging procedure. A novel gel can facilitate ESD due to its submucosal dissecting properties. This prospective porcine survival study evaluated clinical and histologic parameters of hybrid ESD using the gel. PATIENTS AND METHODS Gastric submucosal lesions were created in six pigs and hybrid ESD was performed. Healing was assessed weekly until necropsy at Day 28. RESULTS En bloc resection was achieved in all lesions (mean size 40.7 mm). The mean total procedure time was 13.5 minutes and the mean resection time was 5.5 minutes. The mean total histologic injury score was 4. At necropsy, four ulcers had healed completely and two were < 6 mm in size. CONCLUSION Hybrid ESD of large gastric lesions in a porcine model can be facilitated by the novel gel, dramatically reducing procedure and resection times by eliminating the need for time-consuming submucosal dissection. The novel gel is safe and easy to use, and has the potential to simplify ESD. Further prospective human studies are needed to validate these findings.

Sa1934 ENDOSCOPIC FULL THICKNESS RESECTION USING A CLIP NON-EXPOSED METHOD FOR GASTROINTESTINAL TRACT LESIONS: A META-ANALYSIS

Background and study aims Endoscopic full-thickness resection (EFTR) allows for treatment of epithelial and subepithelial lesions (SELs) unsuitable to conventional resection techniques. This meta-analysis aimed to assess the efficacy and safety of clip-assisted method for non-exposed EFTR using FTRD or over-the-scope clip of gastrointestinal tumors. Methods A comprehensive literature search was performed. The primary outcome of interest was the rate of histologic complete resection (R0). Secondary outcomes of interest were the rate of enbloc resection, FTR, adverse events, and post-EFTR surgery. Random-effects model was used to calculate pooled estimates and generate forest plots. Results Eighteen studies with 730 patients and 733 lesions were included in the analyses. Indications for EFTR were difficult/residual colorectal adenoma, adenoma at a diverticulum or appendiceal orifice and early cancer (n=634), colorectal SELs (n =42), and upper gastrointestinal lesions (n = 51), other colonic lesions (n =6). Median size of lesions was 13.5mm. There were 22 failed EFTR attempts. Pooled overall R0 resection rate was 82% (95% CI: 75, 89). The pooled overall FTR rate was 83% (95% CI: 77, 89). The pooled overall enbloc resection rate was 95 (95% CI: 92, 96). The pooled estimates for perforation and bleeding were <0.1% and 2%, respectively. Following EFTR, a total of 110 patients underwent surgery for any reason [pooled rate 7% (95% 2, 14). The pooled rates for post-EFTR surgery due to invasive cancer, for non-curative endoscopic resection and for adverse events were 4%, <0.1% and <0.1%, respectively. No mortality related to EFTR was noted. Conclusions EFTR appears to be safe and effective for gastrointestinal lesions that are not amenable to conventional endoscopic resection. This technique should be considered as an alternative to surgery in selected cases. Original article Supplementary material Online content viewable at: https://doi.org/10.1055/a-1073-7593 Brewer Gutierrez Olaya I et al. Endoscopic full-thickness resection... Endoscopy International Open 2020; 08: E313–E325 E313 Published online: 2020-02-21

Percutaneously assisted EUS-guided gastrojejunostomy for the treatment of afferent limb syndrome

re 1. Afferent limb syndrome. A, CT view showing dilatation of the intrahepatic and extrahepatic ducts (white arrow), dilatation of the afferent loop arrow), and ascites suggestive of afferent limb syndrome. B, Fluoroscopic view demonstrating a nontraversable stricture 10-cm long at the afferent (red line). C, EUS view also revealing a dilatated loop of small bowel (red arrow), consistent with afferent limb syndrome. D, Instillation of a mixed ion of saline solution, contrast medium, and methylene blue through a previously placed percutaneous transhepatic cholangiography tube to dilate fferent limb; EUS view revealing a dilatated loop of small bowel. The dilated jejunal loop was targeted with a 19-gauge FNA needle and a blue solution uctioned from the jejunal lumen (red arrow), confirming a good position of the FNA needle into the afferent limb lumen. E, Advancement of a LAMS e afferent limb lumen over the guidewire and deployment of the distal flange (red arrow). F, Dilation of the gastrojejunostomy (red arrow). G, Final scopic view of the proximal end of the LAMS (gastric side). LAMS, lumen-apposing metallic stent.