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Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM. [ABSTRACT FROM AUTHOR]

The gallbladder can be situated in a variety of anomalous positions. An intrahepatic gallbladder – the second most common ectopic location of the gallbladder – is one that is completely embedded within the liver parenchyma. Described in the literature as early as 1935, intrahepatic gallbladders predominantly result from a developmental anomaly but in some instances have been reported to be secondary to chronic inflammation. The significance of an intrahepatic gallbladder lies in the fact that 60% of the cases are associated with gallstones and may present a challenge for the general surgeon during cholecystectomy and other biliary operations in addition to causing misdiagnosis on imaging. Intrahepatic gallbladders are unusual, but the incidence of an intrahepatic gallbladder with a cholecystogastric fistula is rare. Cholecystogastric fistulas commonly are a complication of long-term cholelithiasis or chronic cholecystitis with subsequent gallstone ileus. Herein, we present the case of an 80- year-old man who presented with 2 months of progressive weakness, fatigue, decreased appetite, and intermittent right-sided abdominal pain, and was found to have a markedly distended and irregular intrahepatic gallbladder measuring 12.2 × 11.5 × 13.4 cm on CT, as well as a cholecystogastric fistula on esophagogastroduodenoscopy. During esophagogastroduodenoscopy, the gallbladder was entered directly via the fistulous tract. The patient was on i.v. antibiotics with tube feeds via a nasojejunal tube initially, followed by p.o. which he tolerated. He was eventually discharged with referral for surgical evaluation. Given the potential for cholelithiasis and fistulation, physicians should have a high index of suspicion and recommend timely endoscopic and/or surgical management to avoid future complications. [ABSTRACT FROM AUTHOR]

Colon capsule endoscopy utilizing PillCam COLON 2 capsule allows for visualization potentially of the entire colon and is currently approved for patients who cannot withstand the rigors of traditional optical colonoscopy (OC) and associated sedation as well as those that had an OC that was incomplete for technical reasons other than a poor preparation. We will then describe the prior experience and current status of colon capsule endoscopy. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) can fail in 3-10% of the cases even in experienced hands. Although percutaneous transhepatic cholangiography (PTC) and surgery are the traditional alternatives, there are morbidity and mortality associated with both. In this paper, we have discussed the efficacy and safety of endoscopic-ultrasound-guided cholangiopancreatography (EUS-CP) in decompression of biliary and pancreatic ducts. The overall technical and clinical success rates are around 90% for biliary and 70% for pancreatic duct drainage. The overall EUS-CP complication rate is around 15%. EUSCP is, however, a technically challenging procedure and should be performed by an experienced endoscopist skilled in both EUS and ERCP. Same session EUS-CP as failed initial ERCP is practical and may result in avoidance of additional procedures. With increasing availability of endoscopists trained in both ERCP and EUS, the role of EUS-CP is likely to grow in clinical practice. [ABSTRACT FROM AUTHOR]

The article focuses on a study conducted to analyze the role of computed tomographic colonography (CTC) in the diagnosis of colon cancer. It informs that CTC is widely used by gastroenterologists and also discusses the efficiency of optical colonoscopy in diagnosis of the disease. Colonoscopy is used in CRC screening as it allows the removal of precancerous adenomatous polyps. INSET: Key Points.

Endoscopic ultrasound (EUS) is the most sensitive imaging modality for solid pancreatic lesions. The specificity, however, is low (about 75%). It can be increased to 100% with an accuracy of 95% by the addition of fine-needle aspiration (FNA). Cytopathology plays an important role. The final diagnosis is based upon the correlation of clinical, EUS, and cytologic features. A close interaction with the cytopathologist is required in improving the diagnostic yield. In this paper, we present an overview of the role of EUSguided FNA and importance of close interaction with the cytopathologist. Day to day examples of different solid pancreatic lesions have been presented at the end. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS) is the most sensitive imaging modality for solid pancreatic lesions. The specificity, however, is low (about 75%). It can be increased to 100% with an accuracy of 95% by the addition of fine-needle aspiration (FNA). Cytopathology plays an important role. The final diagnosis is based upon the correlation of clinical, EUS, and cytologic features. A close interaction with the cytopathologist is required in improving the diagnostic yield. In this paper, we present an overview of the role of EUSguided FNA and importance of close interaction with the cytopathologist. Day to day examples of different solid pancreatic lesions have been presented at the end. [ABSTRACT FROM AUTHOR]

The article presents an overview of pancreatic cystic lesions. It states that pancreatic cystic neoplasm is difficult to distinguish from pseudocysts even with the use of high-resolution modalities like computed tomography and magnetic resonance imaging because of its incidental discovery on patients with symptoms like abdominal pain and nausea. Meanwhile, surgery is considered in patients with imaging, cytologic or cyst fluid characteristics and those with benign but symptomatic lesions.

The article discusses research being done on gastroenterology fellowship training. It references the study "Effect of Starting a Gastroenterology Fellowship Training Program on Quality of Measures of Colonoscopy," by S. Elhanafi et al. in the 2017 issue. The variables considered include the number of procedures needed to accurately determine an individual's colonoscopy adenoma detection rate (ADR), the impact of colonoscopy on colorectal cancer mortality and endoscope withdrawal.

Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy. [ABSTRACT FROM AUTHOR]

Aim: To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy.Methods: Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria.Results: Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM.Conclusion: This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists. [ABSTRACT FROM AUTHOR]

The article presents a letter to the editor in response to case study 24-2004 which was published in the July 29, 2004 issue.

Comments to a study on colon cancer screening guidelines. Bias towards less agressive screening and treatment in the elderly.

The authors offer a commentary on a review published in "Southern Medical Journal" about vitamin D insufficiency/deficiency in a group of ambulatory patients seen in an internal medicine clinic in Johnson City, Tennessee. A background of the importance of vitamin D to human health is provided. They outline the major findings of the review. They emphasize the importance of counseling regarding increased sunlight exposure and ingestion of vitamin D-rich foods before supplementation.

The author discusses the use of self-expanding metal stents (SEMS) in palliating colorectal obstruction secondary to prostate cancer. He notes that prostate cancer is the most commonly diagnosed cancer in American men and through prostate specific antigen (PSA) it is increasingly diagnosed in younger men and at the early stage. He states that the proximity of the rectum to prostate predisposes it to obstruction which can be managed via SEMS placed endoscopically with fluoroscopic guidance.

The author reflects on the differentiation of a colon polyp from an inverted diverticulum by application of a water perfusion technique. The author claims that water jet liquid pressure can be used to evert a diverticulum that is protruding into the colon lumen and mimicking a polyp. He adds that inverted colon diverticula (ICD) are not the only potential mimics of colon polyps. Moreover, he emphasizes that water infusion maneuver is a useful adjunct in making critical differentiation.

The article focuses on a study that examined the life-threatening retroperitoneal bleed after duodenal biopsies during a routine esophagogastroduodenoscopy (EGD). It states that bleeding with cold biopsy forces during EGD occurs in less than 0.5% of cases and this unpredictable occurrence has some risks. According to the author, the described retroperitoneal bleed in the study is both unusual and sobering.

A letter to the editor is presented in response to the article "Rethinking the Role of Tube Feeding in Patients With Advanced Dementia," by M.R. Gillick, previously published in the January 20, 2000 issue of the "New England Journal of Medicine."

Background: Per oral endoscopic myotomy (POEM) represents a Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to Heller myotomy. Even though we are now entering an exponential phase of growth with a large number of centers interested in POEM, published data to guide them are limited. As part of the July 2012 NOSCAR meeting, a conference was organized to review POEM and develop a consensus document. Authors SNS and TS who chaired the NOSCAR panel recognized the dearth of published data, which also may lag the rapid developments in POEM. Therefore, they undertook a survey of early POEM adopters around the world to rapidly obtain global, extensive, and current data on POEM. The raw survey data were made available to NOSCAR panel participants to assist with their presentations. We summarize the salient findings of the survey. Methods: A comprehensive POEM survey was created and tested. The final survey instrument consisted of 197 questions that covered all aspects of POEM, including operator discipline, prior training, patient selection, setting, technique preference, results, adverse events, regulatory requirements, and perspectives on the future. An automated online response collector was used. Results: The International Per Oral Endoscopic Myotomy Survey (IPOEMS) involved 16 expert centers, 7 in North America, 5 in Asia, 4 in Europe, including all high-volume centers (≥30 POEMs per center), as of July 2012. These centers had performed 841 POEMs. There were modest variations among centers in technique and periprocedural management, but all centers uniformly reported excellent efficacy and safety outcomes. Conclusions: The international POEM survey provides a 'global snapshot' of the experience of early adopters. The excellent outcomes over a large cumulative volume of procedures are in line with those of published small series and lend further support to the notion that POEM represents a paradigm shift in the treatment of achalasia. [ABSTRACT FROM AUTHOR]

Brunner glands are compound tubular submucosal glands typically found in the duodenal bulb. The most common benign tumors of the small intestine are adenoma, and 25% of these occur in the duodenum. Among the benign tumors of the duodenum, 30-50% arise from the Brunner glands. Most of the literature describes their presentations as ranging from benign, nonspecific, epigastric discomfort to obstruction and intestinal bleeding. A good percentage of them are surgically resected; however, there has been an advancement to remove them endoscopically. We present one of the first cases of an endoscopic ultrasound (EUS) approach to the diagnosis and therapeutic removal of a brunneroma. [ABSTRACT FROM AUTHOR]

The article presents the results of a study showing the reasons for the misapplication of percutaneous endoscopically inserted gastrostomy (PEG) in providing nutrition to patients with dementia, and how they can be averted. It asserts that most of these reasons stem from the general incapability of patients with dementia, who are mostly old, to decide for themselves if they wish to avail of PEG. It states the methods used in doing the study and the data that was analyzed. It contends that a more thorough procedure for PEG consent is needed.

The article presents case studies on medical topics such as one involving a 37-year-old woman with acute pancreatitis in gastric aberrant pancreas and another involving an 83-year-old man diagnosed with excavated duodenal gastrointestinal stromal tumor after undergoing standard endoscopic biopsy.

An abstract of the article "Trends in mortality from upper gastrointestinal bleeding," by Michael L. Mlecko and colleagues is presented.