Zuzana Vackova

Current treatment options for esophageal diseases.

Exciting new developments—pharmacologic, endoscopic, and surgical—have arisen for the treatment of many esophageal diseases. Refractory gastroesophageal reflux disease presents a therapeutic challenge, and several new options have been proposed to overcome an insufficient effectiveness of proton pump inhibitors. In patients with distal esophageal spasm, drugs and endoscopic treatments are the current mainstays of the therapeutic approach. Treatment with proton pump inhibitors (or antireflux surgery) should be considered in patients with Barretts esophagus, since a recent meta‐analysis demonstrated a 71% reduction in risk of neoplastic progression. Endoscopic resection combined with radiofrequency ablation is the standard of care in patients with early esophageal adenocarcinoma. Mucosal squamous cancer may also be treated endoscopically, preferably with endoscopic submucosal dissection. Patients with upper esophageal cancer often refrain from surgery. Robot‐assisted, thoracolaparoscopic, minimally invasive esophagectomy may be an appropriate option for these patients, as the robot facilitates a good overview of the upper mediastinum. Induction chemoradiotherapy is currently considered as standard treatment for patients with advanced squamous cell carcinoma, while the role of neoadjuvant therapy for adenocarcinoma remains controversial. A system for defining and recording perioperative complications associated with esophagectomy has been recently developed and may help to find predictors of mortality and morbidity.

Improved specimen adequacy using jumbo biopsy forceps in patients with Barrett's esophagus.

AIM To assess the sampling quality of four different forceps (three large capacity and one jumbo) in patients with Barretts esophagus. METHODS This was a prospective, single-blind study. A total of 37 patients with Barretts esophagus were enrolled. Targeted or random biopsies with all four forceps were obtained from each patient using a diagnostic endoscope during a single endoscopy. The following forceps were tested: A: FB-220K disposable large capacity; B: BI01-D3-23 reusable large capacity; C: GBF-02-23-180 disposable large capacity; and jumbo: disposable Radial Jaw 4 jumbo. The primary outcome measurement was specimen adequacy, defined as a well-oriented biopsy sample 2 mm or greater with the presence of muscularis mucosa. RESULTS A total of 436 biopsy samples were analyzed. We found a significantly higher proportion of adequate biopsy samples with jumbo forceps (71%) (P < 0.001 vs forceps A: 26%, forceps B: 17%, and forceps C: 18%). Biopsies with jumbo forceps had the largest diameter (median 2.4 mm) (P < 0.001 vs forceps A: 2 mm, forceps B: 1.6 mm, and forceps C: 2mm). There was a trend for higher diagnostic yield per biopsy with jumbo forceps (forceps A: 0.20, forceps B: 0.22, forceps C: 0.27, and jumbo: 0.28). No complications related to specimen sampling were observed with any of the four tested forceps. CONCLUSION Jumbo biopsy forceps, when used with a diagnostic endoscope, provide more adequate specimens as compared to large-capacity forceps in patients with Barretts esophagus.

First genotype-phenotype study reveals HLA-DQβ1 insertion heterogeneity in high-resolution manometry achalasia subtypes

Background Achalasia is a primary oesophageal motility disorder. Although aetiology remains mainly unknown, a genetic risk variant, rs28688207 in HLA-DQB1, showed strong achalasia association suggesting involvement of immune-mediated processes in the pathogenesis. High-resolution manometry recognises three types of achalasia. The aim of our study was to perform the first genotype-phenotype analysis investigating the frequency of rs28688207 across the high-resolution manometry subtypes. Methods This was a cross-sectional retrospective study. Achalasia patients from tertiary centres in the Czech Republic (n = 163), Germany (n = 114), Greece (n = 70) and controls were enrolled. All subjects were genotyped for the rs28688207 insertion. The Kruskal–Wallis test was used for the genotype-phenotype analysis. Results A total of 347 achalasia patients (type I – 89, II – 210, III – 48) were included. The overall frequency of the rs28688207 was 10.3%. The distribution of the insertion was significantly different across the high-resolution manometry subtypes (p = 0.038), being most prevalent in type I (14.6%), followed by type II (9.5%) and III (6.3%). Conclusion The frequency of the HLA-DQB1 insertion differs among high-resolution manometry achalasia subtypes. The insertion is most prevalent in type I, suggesting that immune-mediated mechanisms triggered by the insertion may play a more prominent role in the pathogenesis of this subtype.

Peroral endoscopic myotomy and peroral endoscopic pyloromyotomy as a single procedure for concomitant achalasia and gastroparesis

Peroral endoscopic myotomy (POEM) has become a standard treatment for achalasia, and peroral endoscopic pyloromyotomy (G-POEM) represents an emerging endoscopic method in the management of refractory gastroparesis. We present a successful procedure combining POEM and G-POEM in one session in a patient with concomitant achalasia and refractory gastroparesis. Although G-POEM and subsequent POEM (after 4 days) have already been performed in one patient [1], a simultaneous myotomy on the lower esophageal sphincter (LES) and the pyloric muscle within a single procedure has not been described. A 74-year-old woman was referred to our center with achalasia, which was confirmed as type II by high resolutionmanometry (HRM). She had suffered from long-standing dysphagia and regurgitation, but also complained of vomiting and abdominal fullness. A gastroscopy revealed esophageal stagnation of liquids and spasm of the LES, but also impaired evacuation of the stomach with retained food and spastic pylorus. Delayed gastric emptying was confirmed on the gastric emptying study (GES). First, we performed an anterior myotomy, 12 cm in length, in the esophagus (▶Fig. 1) using a standard tunneling technique with a triangle knife. After completing POEM, we proceeded with a gastric mucosal incision and creation of a short submucosal tunnel along the greater curvature towards the pylorus. Following pyloromyotomy, 3 cm in length, the incision was closed using endoclips (▶Video1). The total duration of the procedure was 74 minutes and it was free of adverse events. On the first postoperative day, an X-ray with water-soluble contrast excluded leakage from both incisions (▶Fig. 2). The patient was discharged on the third postoperative day and her symptoms had improved tremendously (Eckardt score dropped from 5 to 0; Gastroparesis Cardinal Symptom Index from 3.5 to 1). HRM, GES, and gastroscopy (▶Fig. 3) 1 month after the procedure showed sustained favorable findings, and 1 year after the procedure, the patient had not experienced recurrence of either disease.

Erratum to: Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety

The Given Names and Family Names were all inadvertently inverted. The correct order is: Jan Martinek, Hana Svecova, Zuzana Vackova, Radek Dolezel, Ondrej Ngo, Jana Krajciova, Eva Kieslichova, Radim Janousek, Alexander Pazdro, Tomas Harustiak, Lucie Zdrhova, Pavla Loudova, Petr Stirand, Julius Spicak. The original article was corrected.