Yuyong Tan

Peroral endoscopic myotomy for treatment of achalasia in children and adolescents

BACKGROUND Peroral endoscopic myotomy (POEM) is a novel endoscopic technique for treatment of achalasia (AC) and has shown exciting results in adults. However, little is known about the safety and efficacy of POEM in children and adolescents. Herein we report our preliminary results of POEM for children and adolescents with AC. METHODS POEM was performed in 9 consecutive patients with AC, whose age ranged from 10 to 17years. After submucosal injection, a submucosal tunnel was created. Endoscopic myotomy of muscle bundles was then achieved under direct vision. The mucosal entry was closed by several clips. A validated clinical symptom score (Eckardt score), LES pressure, esophageal diameters and procedure-related complications were used to evaluate the outcomes. RESULTS All 9 patients underwent POEM successfully. Mean operation time was 56.7minutes. Mean myotomy length was 8.3cm. Among them, 4 patients underwent circular myotomy and 5 underwent full-thickness myotomy. Symptoms remitted in all of the cases during a follow-up of 3-30months, Eckardt score was significantly reduced (preoperation vs postoperation, 7.0±1.9 vs 0.8±0.8, P<0.05). Mean LES pressure decreased from 26.8mm Hg to 9.1mm Hg. Mean diameter of esophagus was dramatically decreased (preoperation vs postoperation, 50.6±4.9mm vs 29.6±3.7mm, P<0.05). No serious complications related to POEM were encountered. CONCLUSIONS Our initial experience suggests that POEM is a safe and effective method for treatment of achalasia in children and adolescents. Further evaluation and long-term data are mandatory for a more confirmed conclusion.

Submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer.

Objective To estimate the safety and efficacy of submucosal tunneling endoscopic resection (STER) for upper gastrointestinal submucosal tumors (SMTs) originating from the muscularis propria layer. Methods During October 2011 and May 2014, a total of 80 patients with SMTs underwent STER at our hospital. A submucosal tunnel was created from 3–5 cm above the tumor. Endoscopic submucosal dissection of the SMT was performed, and then the mucosal incision was closed with several clips after the tumor was removed. Results All the 80 patients underwent STER successfully, with a mean operation time of 61.2 min. Eighty-three SMTs were removed; among these, 67 were located in the esophagus and 16 in the gastric cardia, 68 were leiomyoma, and 15 were gastrointestinal stromal tumors, and 13 had a diameter no less than 35 mm. The mean tumor size was 23.2 mm; en-bloc resection was performed in 97.6% (81/83) of the tumors. Complications were noted in 8.75% (7/80) of the cases, and all of them resolved without the need for additional surgery. No recurrence was noted during a mean follow-up of 10.2 months. Conclusion STER appears to be a feasible, safe, and effective method for upper gastrointestinal SMTs originating from the muscularis propria layer, even when the size of the tumor was larger than 35 mm.

Peroral endoscopic full-thickness myotomy for the treatment of sigmoid-type achalasia: outcomes with a minimum follow-up of 12 months.

Objective To explore the feasibility, safety, and efficacy of peroral endoscopic full-thickness myotomy (fPOEM) for the treatment of sigmoid-type achalasia. Methods From August 2011 to June 2014, a total of 23 sigmoid-type achalasia patients received fPOEM at our hospital. Among these patients, 19 had sigmoid-type 1 achalasia and the other four had sigmoid-type 2 achalasia. Clinical data of general characteristics, procedure-related parameters and adverse events, symptom relief, and manometry outcomes before and during the periodic follow-up were retrospectively collected and analyzed. Results All the patients successfully received fPOEM, with a mean procedure time of 67.6 min; six patients received a conventional fPOEM whereas the other 17 received a modified fPOEM. During a median follow-up of 18 months, the median Eckardt score decreased obviously (pre-POEM vs. post-POEM, 7.0 vs. 1.0, P<0.05), the mean lower esophageal sphincter pressures and 4s integrated relaxation pressure decreased (pre-POEM vs. post-POEM, 34.78±4.51 vs. 11.50±2.56 mmHg and 29.52±3.67 vs. 10.61±1.54 mmHg, P<0.01), and the esophageal diameter decreased (pre-POEM vs. post-POEM, 58.2±11.6 vs. 37.5±7.3 mm, P<0.05). Overall treatment success was achieved in 95.6% of the patients (22/23), and morphological improvement was observed in 95% (19/20) of the patients. In 10 patients (43.5%) complications were encountered, including gas-related complications, mucosal perforation, and reflux esophagitis. There was no significant difference in terms of efficacy between conventional fPOEM and modified fPOEM, but modified fPOEM may reduce the occurrence of gas-related complications. Conclusion fPOEM is feasible, safe, and effective for the treatment of sigmoid-type achalasia. A modified fPOEM may reduce the occurrence of gas-related complications. Yet, further experiences and long-term results are warranted.

Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease

AIM To compare long-term occurrence of gastroesophageal reflux disease (GERD) between two different types of peroral endoscopic myotomy (POEM) for achalasia. METHODS We included all patients with achalasia who underwent POEM at our hospital from August 2011 to October 2012 and had complete GERD evaluation with ≥ 3 years of follow-up. They were divided into circular or full-thickness myotomy groups according to the depth of myotomy. Demographics, Eckardt score, manometry results, 24-h pH monitoring, and GERD symptoms were recorded and compared between the two groups. RESULTS We studied 56 patients (32 circular myotomy and 24 full-thickness myotomy) with complete GERD evaluation. There was no significant difference between the two groups in terms of treatment success (defined as Eckardt score ≤ 3), postoperative Eckardt score, mean basal lower esophageal sphincter pressure, and 4-s integrated relaxation pressure (4sIRP). Postoperative abnormal esophageal acid exposure was found in 25 patients (44.6%). A total of 13 patients (23.2%) had GERD symptoms and 12 had esophagitis (21.4%). Clinically relevant GERD (abnormal esophageal acid exposure associated with GERD symptoms and/or esophagitis) was diagnosed in 13 patients (23.2%). Multivariate analysis revealed that full-thickness myotomy and low level of postoperative 4sIRP were predictive factors for clinically relevant GERD. CONCLUSION Efficacy and manometry are comparable between achalasia patients treated with circular or full-thickness myotomy. But patients with full-thickness myotomy and low postoperative 4sIRP have more GERD.

Comparison of peroral endoscopic myotomy and endoscopic balloon dilation for primary treatment of pediatric achalasia

BACKGROUND Both peroral endoscopic myotomy (POEM) and endoscopic balloon dilation (EBD) are effective method for pediatric achalasia, however little is known about the comparison between them. Herein we compare the safety and efficacy of them for primary treatment of pediatric achalasia. METHODS We retrospectively reviewed the medical records of pediatric patients who received POEM or EBD for their primary therapy of achalasia at our hospital from January 2007 to June 2015, they were divided into the POEM group and EBD group. Demographics, and data about safety and efficacy were retrospectively collected and compared between the two groups. RESULTS A total of 21 patients (Female/male: 11/10, aged 6~17year-old) were enrolled, 12 of them received POEM, while the other 9 received EBD. As for the short-term efficacy, the treatment success (Eckardt score≤3) rate of POEM and EBD 3, 6 and 12months after the primary treatment were comparable (100% vs 100%, 100% vs 88.9%, 100% vs 66.7%, P>0.05). As for the medium to long-term efficacy, the treatment success rate of POEM 24 and 36months after the primary treatment was higher than that of EBD (100% vs 44.4%, 100% vs 33.3%, P<0.05). Two cases in the POEM group suffered from esophagitis, and there was no significant difference between POEM and EBD (P>0.05). No severe complications were observed during operation and periodical follow-up. CONCLUSIONS Short-term efficacy of POEM and EBD for primary treatment of pediatric achalasia was comparable, however POEM could result in a better intermediate and long-term efficacy. Large scale, randomized study is necessary for a confirmed conclusion.

Peroral endoscopic myotomy for achalasia in patients aged≥ 65 years

AIM To investigate the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia in patients aged ≥ 65 years. METHODS From November 2011 to August 2014, 15 consecutive patients (aged ≥ 65 years) diagnosed with achalasia were prospectively recruited and all underwent POEM at our institution. Eckardt score, lower esophageal sphincter (LES) pressure, esophageal diameter, SF-36 questionnaire, and procedure-related complications were used to evaluate the outcomes. RESULTS All 15 patients were treated successfully by POEM, with a median operation time of 55 min. Median myotomy length was 10 cm. Three patients underwent circular myotomy and 12 full-thickness myotomies. Symptoms remitted in all cases during post-POEM follow-up of 6-39 mo. Eckardt score reduced significantly (pre-operation vs post-operation: 8.0 vs 1.0, P < 0.05). Median LES pressure decreased from 27.4 to 9.6 mmHg (P < 0.05). Median diameter of the esophagus was significantly decreased (pre-operation vs post-operation: 51.0 mm vs 30.0 mm, P < 0.05). Only one patient had reflux, which was resolved with oral proton pump inhibitors. No serious complications related to POEM were found. The quality of life of the 15 patients improved significantly after POEM. CONCLUSION POEM is a safe and effective technique for treatment of achalasia in patients aged ≥ 65 years, with improvement in symptoms and quality of life.

Endoscopic Incision for the Treatment of Refractory Esophageal Anastomotic Strictures in Children.

Objectives: The aim of the present study was to assess the safety and efficacy of endoscopic incision (EI) for the treatment of refractory anastomotic esophageal strictures in pediatric patients. Methods: We retrospectively reviewed the medical records of pediatric patients with refractory anastomotic strictures after surgical repair of esophageal atresia who underwent ≥3 sessions of endoscopic treatments (dilation and/or stenting). They were treated with EI alone or together with esophageal stenting. Efficacy and safety were evaluated during periodical follow-up. Results: All of the 7 children received the procedure successfully with the operation time of 15 to 60 minutes. Four of them received EI alone, whereas the other 3 received EI with esophageal stenting (EIES). The symptoms remitted in all of the patients, and the dysphagia score decreased from 3–4 to 0–1 during follow-up from 1 to 21 months. The average diameter of stricture was enlarged from 3 mm (range 2–5 mm) to 10.6 mm (range 8–12 mm). One patient suffered from chest pain, which resolved within 3 days. Patient 1 had recurrence 11 months after EIES, and patient 6 had recurrence 3 months after EI. They all underwent an additional EI to maintain patency. No severe complications were observed during operation and periodical follow-up. Conclusions: EI is safe and appears effective for refractory esophageal anastomotic strictures in children in the short term. Large comparative studies are warranted to further confirm our findings. The long-term follow-up is necessary for assessing the long-term efficacy of the new technique.

Endoscopic resection of gastric gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract, and about 60% of them are found in the stomach. With the widespread application of endoscopy and endoscopic ultrasonography (EUS), more and more gastric GISTs are being found in an early stage (with a relative small diameter and no metastasis), giving the chance of complete resection. Endoscopic resection such as endoscopic band ligation (EBL), endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER), is a minimally invasive method compared with the conventional surgical approaches (open or laparoscopic), and has been demonstrated to be safe and effective for treating gastric GISTs. This review summarizes the recent advances on endoscopic resection of gastric GISTs, aiming to provide a rational management strategy for gastric GISTs.

Current status of submucosal tunneling endoscopic resection for gastrointestinal submucosal tumors originating from the muscularis propria layer (Review)

Gastrointestinal submucosal tumors (SMTs) have been increasingly identified via the use of endoscopic ultrasonography, and removal is often recommended for SMTs that are >2 cm in diameter or symptomatic. Submucosal tunneling endoscopic resection (STER), also known as submucosal endoscopic tumor resection, endoscopic submucosal tunnel dissection or tunneling endoscopic muscularis dissection, is a novel endoscopic technique for treating gastrointestinal SMTs originating from the muscularis propria layer, and has been demonstrated to be effective in the removal of SMTs with a decreased rate of recurrence by clinical studies. STER may be performed for patients with esophageal or cardia SMTs, and its application has expanded beyond these types of SMTs due to modifications to the technique. The present study reviewed the applications, procedure, efficacy and complications associated with STER.

Submucosal tunneling endoscopic resection for seven esophageal leiomyomas

A 47-year-old man came to our hospital with half a year’s history of chest discomfort. An upper gastrointestinal endoscopy detected seven protruding lesions distributed in a dispersed fashion on different areas of the esophageal walls (▶Fig. 1), about 23–32 cm from the incisors. Endoscopic ultrasound (EUS) revealed the tumors to be originating from the muscularis propria layer, without any malignant features (▶Fig. 2). Although he was told that a “wait and see” approach could be taken at first, the patient requested active treatment. Given our previous success in creating a tortuous tunnel to resect two contralateral esophageal leiomyomas [1], submucosal tunneling endoscopic resection (STER) was performed. A longitudinal mucosal incision was made on the axis where most of the tumors were located, 3 cm above the most proximal one. A submucosal tunnel was created, and the first tumor was revealed. The second one was not aligned with the first, so could not be directly reached by a straight tunnel; therefore, a tortuous tunnel was created. Methylene blue was injected at the site of the second tumor, indicating the tunnel route, and the two tumors were identified (▶Fig. 3 a). We then repeated the submucosal injection and tunneling procedure from the oral side to the anal side, and identified the seven tumors one by one. All of the tumors were then clearly exposed. Meticulous resection was performed with an insulated-tip knife (IT knife), and all of the tumors were dissected off the muscularis propria layer (▶Fig. 3b, c). Visible blood vessels were coagulated, and the mucosal entry site was closed (▶Video1). The procedure took 190 minutes and there were no adverse events. The diameter of the largest tumor was 1.8 cm and all of the tumors were leiomyomas histopathologically (▶Fig. 4). The patient did not complain of further chest discomfort during the 3-month follow-up period, and no recurrence was noticed.