Yutang Ren

Comparison of conventional versus Hybrid knife peroral endoscopic myotomy methods for esophageal achalasia: a case–control study

Abstract Objective. Peroral endoscopic myotomy (POEM) has been developed to treat achalasia as a novel less invasive modality. We aimed to compare the efficacy and safety of conventional knife versus Hybrid knife (HK) during POEM procedure. Materials and methods. Between June 2012 and July 2014, 31 patients underwent POEM using HK in our department (HK group), and 36 patients underwent POEM using conventional method (injection needle and triangular tip [TT] knife, TT group). Procedure-related parameters, symptom relief, adverse events were compared between two groups. Results. There were no significant differences in the age, sex and other baseline characteristics between the two groups. The mean procedural time was significantly shorter in HK group than TT group (53.0 ± 17.2 vs. 67.6 ± 28.4 min, p = 0.015). The mean frequency of devices exchange was 4.7 ± 1.7 in HK group and 10.9 ± 1.8 in TT group (p = 0.000). No serious adverse events occurred postoperatively in both groups. At one-year follow-up, a total of 94% treatment success was achieved in all patients (93.5% in HK group and 94.4% in TT group, p = 0.877). Conclusion. HK in POEM can shorten the procedural time, and achieve similar treatment success compared to conventional TT knife.

Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized, Controlled Studies Based on the PRISMA Statement

AbstractThe evidence for optimal endoscopic management of bleeding gastric varices is lacking. The clinical outcome is controversial in trials comparing cyanoacrylate injection and band ligation. To help guide endoscopic decisions regarding acute gastric variceal bleeding, a meta-analysis was conducted.Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched for all randomized controlled trials (RCTs) containing the 2 interventions. The main outcomes evaluated in the meta-analysis were active bleeding control, blood transfusion, rebleeding, recurrence of varices, complications, and survival.Three RCTs were identified, which included 194 patients with active gastric variceal bleeding from Taiwan and Romania. Active bleeding control was achieved in 46 of 49 (93.9%) patients in the cyanoacrylate injection group, compared with 35 of 44 (79.5%) in the band ligation group (P = 0.032), for a pooled odds ratio of 4.44 (95% confidence interval, 1.14–17.30). Rebleeding rate was comparable in type 2 gastroesophageal varices (GOV2) between the 2 interventions (35.7% vs 34.8%, P = 0.895), but cyanoacrylate injection seemed superior for reducing rebleeding rate in type 1 gastroesophageal varices (GOV1, 26.1% vs 47.7%, P = 0.035) and type 1 isolated gastric varices (IGV1, 17.6% vs 85.7%, P = 0.015). Cyanoacrylate injection was also superior in controlling recurrence of gastric varices to band ligation (36.0% vs 66.0%, P = 0.002). There was no difference in complications or mortality between the 2 interventions. The major limitation of this meta-analysis is the small number of studies/patients included.Compared with band ligation, injection cyanocrylate have an advantage in the control of acute gastric variceal bleeding, also with lower recurrence rate and rebleeding (except GOV2). The limited amount of studies included attenuates the strength of this meta-analysis; therefore, more high-quality RCTs are needed.

Training in early gastric cancer diagnosis improves the detection rate of early gastric cancer: an observational study in China.

Abstract Few studies have analyzed the training of endoscopists in the diagnosis of early gastric cancer (EGC). This study assessed whether specific training of endoscopists improves the detection rate of EGC. The rates of detection of EGC by endoscopists at the Digestive Endoscopy Center of the Affiliated Nanfang Hospital of China Southern Medical University between January 2013 and May 2014 were retrospectively analyzed. Because some endoscopists received training in the diagnosis of EGC, beginning in September 2013, the study was divided into 3 time periods: January to September 2013 (period 1), September 2013 to January 2014 (period 2), and January to May 2014 (period 3). The rates of EGC detection during these 3 periods were analyzed. From January 2013 to May 2014, a total of 25,314 gastroscopy examinations were performed at our center, with 48 of these examinations (0.2%) detecting EGCs, accounting for 12.1% (48/396) of the total number of gastric cancers detected. The EGC detection rates by trained endoscopists during periods 1, 2, and 3 were 0.3%, 0.6%, and 1.5%, respectively, accounting for 22.0%, 39.0%, and 60.0%, respectively, of the gastric cancers detected during these time periods. In comparison, the EGC detection rates by untrained endoscopists during periods 1, 2, and 3 were 0.05%, 0.08%, and 0.10%, respectively, accounting for 3.1%, 6.0%, and 5.7%, respectively, of the gastric cancers detected during these times. After training, the detection rate by some trained endoscopists markedly increased from 0.2% during period 1 to 2.3% during period 3. Further, the use of magnifying endoscopy with narrow-band imaging (M-NBI) (odds ratio = 3.1, 95% confidence interval 2.4–4.1, P < 0.001) contributed to the diagnosis of EGC. In conclusion, specific training could improve the endoscopic detection rate of EGC. M-NBI contributed to the diagnosis of EGC.

A stepwise approach for peroral endoscopic myotomy for treating achalasia: from animal models to patients

Abstract Objectives. Peroral endoscopic myotomy (POEM) was initially developed for the treatment of achalasia. This study aimed to investigate the feasibility and safety of a stepwise approach for POEM in the management of achalasia. Methods. A total of five ex-vivo porcine esophagus-stomach training models were created and POEM was performed. Then, 25 patients with achalasia were treated similarly. The Eckardt score, barium esophagrams, and high-resolution manometry were used to evaluate its efficacy. Results. POEM procedures were completed in five stomach-esophagus models, with perforations in the initial three and success in the last two. A total of 36 achalasia patients (22 males, 14 females) with achalasia successfully underwent POEM. The mean operation time was 72.0 min (range, 45–180 min). There were two complications in three patients: one case of severe bleeding and two cases of pneumothorax, which were treated successfully. During the follow-up period, the median Eckardt score decreased dramatically from 8 to 1 (p = 0.000). The lower basal esophageal sphincter pressure (36.1 ± 14.3 vs. 11.9 ± 4.6 mmHg, p = 0.000), as well as the 4-s integrated relaxation pressure (12.9 ± 13.0 vs. 6.6 ± 2.9 mmHg, p = 0.000). Additionally, the maximum esophagus width was significantly reduced (mean reduced width: 1.6 ± 1.1 cm, p = 0.000). Conclusions. The ex-vivo porcine esophagus-stomach can be used as a simple and cheap training model that mimics the POEM procedure. POEM is a safe and effective therapy for achalasia patients.

Myotomy of Distal Esophagus Influences Proximal Esophageal Contraction and Upper Esophageal Sphincter Relaxation in Patients with Achalasia After Peroral Endoscopic Myotomy

Background/Aims The motility change after peroral endoscopic myotomy (POEM) in achalasia is currently focused on lower esophageal sphincter (LES). This study aims to investigate the correlation of motility response between distal and proximal esophagus after POEM. Methods A total of 32 achalasia patients who received POEM and high-resolution manometry (HRM) were included for analysis. Eckardt score was used to assess symptom improvement. HRM was applied for studying motility. Main parameters analyzed were (1) LES: resting pressure (restP), 4-second integrated relaxation pressure; (2) esophageal body (EB): contractile integral of distal segment with myotomy (CI-DM) and proximal segment without myotomy (CI-PNM); and (3) upper esophageal sphincter (UES): relaxation pressure (UES-RP). Results There were 6 type I, 17 type II, and 9 type III achalasia patients included for analysis. (1) Eckardt score, LES tone, CI-DM, CI-PNM and UES-RP were reduced remarkably after POEM (P < 0.001). (2) no significant correlation was noted between LES tone and contractile intergral of EB. (3) a positive linear correlation of CI-DM and CI-PNM changes was detected (P < 0.001). (4) the change of UES-RP was positively correlated with the change of contractile integral of EB (P < 0.001). Conclusions Myotomy of the distal esophagus would attenuate proximal EB contraction and assist UES relaxation in achalasia patients after POEM.

Endoscopic Submucosal Tunnel Dissection for Upper Gastrointestinal Submucosal Tumors Originating from the Muscularis Propria Layer: A Single-Center Study

Background/Aims In recent years, endoscopic submucosal tunnel dissection (ESTD) has gained popularity worldwide. The aim of this study was to evaluate the safety and efficacy of ESTD in treating upper gastrointestinal submucosal tumors (SMTs) in a large-volume endoscopic center. Methods Patients with SMTs were enrolled in this study between January 2012 and January 2015. Demographic data, clinical data, and treatment outcome were collected and analyzed. Results Seventy SMTs originating from the muscularis propria (MP) layer were identified in 69 patients. All patients successfully underwent the ESTD procedure. The mean procedure time was 49.0±29.5 minutes, and the mean tumor size was 18.7±7.2 mm. Among all lesions, the majority (70.0%) were located in the esophagus, 12.9% in the cardia, and 17.1% in the stomach. Complete resection was achieved in 67 lesions (95.7%). Perforation occurred in three patients (4.3%), who were treated by endoclips. Pneumothorax occurred in two patients (2.9%) and was successfully managed by thoracic drainage. During a median follow-up of 18.1 months, patients were free of local recurrence or distant metastasis. Conclusions Our results demonstrated the feasibility and safety of ESTD in treating upper gastrointestinal SMTs originating from the MP layer. Large-scale comparative studies with other treatment methods should be conducted in the future.

Peroral endoscopic myotomy is safe and effective in achalasia patients aged older than 60 years compared with younger patients

Peroral endoscopic myotomy (POEM) has been proven to be effective for treating achalasia, but there are limited data on POEM in elderly patients. We therefore aimed to assess the role of POEM for achalasia in patients aged ≥60 years.

Endoscopic submucosal tunnel dissection of upper gastrointestinal submucosal tumors: A comparative study of hook knife vs hybrid knife

AIM To compare the efficacy and safety of a hook knife (HO) with a hybrid knife (HK) during endoscopic submucosal tunnel dissection (ESTD) procedure. METHODS Between August 2012 and December 2015, the ESTD procedure was performed for 83 upper GI submucosal lesions, which originated from the muscularis propria layer identified by upper endoscopy and endoscopic ultrasonography. Of these, 34 lesions were treated by a HO, whereas 49 lesions were treated by a HK. Data regarding age, gender, presenting symptoms, tumor location and size, procedure time, complications, en bloc resection rate and others were analyzed and compared between the two groups. RESULTS There were no significant differences in the age, gender, presenting symptoms and tumor location between the two groups. ESTD was successfully completed in all the patients, and no case was converted to laparoscopy. The mean procedure time was significantly shorter in the HK group than in the HO group (41.3 ± 20.3 min vs 57.2 ± 28.0 min, P = 0.004). The mean frequency of device exchange was 1.4 ± 0.6 in the HK group and significantly less than 3.3 ± 0.6 in the HO group (P < 0.001). The differences in tumor size and histopathological diagnoses were not significant between the two groups (P = 0.813, P = 0.363, respectively). Both groups had an equal en bloc resection rate and complete resection rate. Additionally, the complication rate was similar between the two groups (P = 0.901). During the follow-up, no recurrence occurred in either group. CONCLUSION We demonstrate for the first time that HO and HK do not differ in efficacy or safety, but HK reduces the frequency of device exchange and procedure time.

Gastrointestinal: Peroral endoscopic myotomy for distal esophageal spasm: Gastrointestinal: Peroral endoscopic myotomy for distal esophageal spasm

A 63-year-old man was referred with 2 years of dysphagia. His esophagogram and esophagogastroduodenoscopy showed synchronous contractions in the middle and lower parts of the esophagus (Fig. 1a,b). High-resolution esophageal manometry revealed premature spastic contractions (distal latency: 4.1 s), normal esophagogastric junction relaxation, and high distal contraction integral (1255.2 cm*s*mmHg) (Fig. 2a). Based on the Chicago classification, he was diagnosed with distal esophageal spasm. After obtaining written informed consent, peroral endoscopic myotomy (POEM) was performed using a high-definition gastroscope fitted with a transparent cap. The patient was under general anesthesia with endotracheal intubation. The procedural steps are demonstrated in Figure 1c–h. The POEM procedure was performed successfully without complication, and the patient was discharged after 5 days with proton pump inhibitor therapy. At 12 months, his dysphagia symptom scores had markedly improved (Eckardt score: 2), and his esophagogram showed complete absence of abnormal contractions on the anterior wall of esophagus (Fig. 1i). Additionally, highresolution esophageal manometry after POEM disclosed that the distal contraction integral (22.6 cm*s*mmHg) decreased significantly (Fig. 2b). Presently, POEM has been demonstrated to be effective and safe for achalasia. The technique cuts the esophageal circular muscle bundle by creating a submucosal tunnel, to access the entire esophageal body. Myotomy is performed where needed. In addition to achalasia, POEM was also used for treating some spastic esophageal disorders, also with excellent clinical outcomes. A longer myotomy is usually required. In this case, extensive myotomy with the length of 19 cm was performed, doubling the typical length performed for achalasia. Our case demonstrates the efficacy and safety of POEM for distal esophageal spasm. Further clinical trials are warranted to clearly define the durability of the procedure.

EDUCATION AND IMAGING. Gastrointestinal: Endoscopic submucosal tunnel dissection of a giant cardiac leiomyoma.

Figure 1 (a) A submucosal tumor (SMT) located at the cardia. (b) Endoscopic ultrasonography revealed a 3.9×1.8 cmhypoechoic submucosal lesion originating from the muscularis propria layer. (c,d) After submucosal injection, a longitudinal mucosal incision wasmade, approximately 4 cm proximal to the SMT; submucosal dissection was done, creating a submucosal tunnel until the tumor was visible. (e) Dissection was performed along the margin of the tumor until it was completely dissected. (f,g) The tumor was fragmentated by snare and extracted by piecemeal through the tunnel. (h) Endoscopic view of submucosal tunnel after removal of tumor. (i) Endoclips were used to close the entry of the submucosal tunnel. igure 2 (a) The resected specimen consisted of eight piecemeal leions and measured 8 cm in size. (b) Pathological examination revealed at the resected specimens were leiomyoma.