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Peroral endoscopic myotomy (POEM) is a safe and effective endoscopic treatment for achalasia and other esophageal motility disorders, and a versatile knife (TriangleTipKnife J [TTJ]; Olympus, Tokyo, Japan) is currently widely used in POEM. Recently, we reported a novel modification of TTJ, which was adjusted to a knife length of 2 mm by attaching a disposable clip (QuickClip Pro; Olympus) sheath to the tip as a hood attachment. This study compares the safety and effectiveness of TTJ and TTJ with a hood attachment (TTJ-H) in POEM. This 1:1 propensity score–matched retrospective cohort study compared the procedure time, myotomy efficiency, number of coagulation forceps usage, adverse events, length of hospital stay after POEM, procedural success, and clinical success between the TTJ and TTJ-H groups. A total of 682 consecutive patients who underwent POEM between January 2021 and June 2023 were examined. We excluded 134 patients who had already undergone POEM or laparoscopic Heller myotomy as prior myotomy. Finally, 98 propensity score–matched pairs (n = 196) were identified. The mean procedure time was shortened from 93.5 minutes to 80.2 minutes (14% reduction, P =.012) when comparing the TTJ-H group versus the TTJ group. The mean myotomy efficiency was improved from 2.76 min/cm to 2.32 min/cm (16% improvement, P ≤.001), and usage of coagulation forceps for hemostasis was decreased from 3.87 to.55 (86% reduction, P ≤.001). This study showed that use of TTJ-H could reduce total procedure time, improve myotomy efficiency, and reduce costs compared with TTJ. [Display omitted] [ABSTRACT FROM AUTHOR]

Endocytoscopy, a next-generation endoscopic system, facilitates observation at a maximum magnification of ×520. To our knowledge, no study has reported high-precision diagnosis of colorectal low-grade adenoma, endoscopically. We aimed to reveal which endocytoscopic findings may be used as indicators of low-grade adenoma and to assess whether a "resect and discard" strategy using endocytoscopy is feasible. Lesions diagnosable with endocytoscopy were examined retrospectively between May 2005 and July 2017. A normal pit-like structure in endocytoscopic images was considered a normal pit (NP) sign and used as an indicator of low-grade adenoma. The primary outcome was the diagnostic accuracy of the NP sign for low-grade adenoma. We evaluated agreement rates between endocytoscopic and pathologic diagnosis for surveillance colonoscopy interval recommendation (SCIR) and performed a validation study to verify the agreement rates. For 748 lesions in 573 cases diagnosed as colorectal adenoma using endocytoscopy, the results were as follows: sensitivity of the NP sign for low-grade adenoma, 85.0%; specificity, 90.7%; positive predictive value, 96.6%; negative predictive value, 66.1%; accuracy, 86.4%; and positive likelihood ratio, 9.2 (P <.001). The agreement rate between endocytoscopic and pathologic diagnosis for SCIR was 94.4% (95% confidence interval [CI], 92.2%-96.1%; P <.001) under United States guidelines and 96.3% (95% CI, 94.5%-97.7%; P <.001) under European Union guidelines. All inter- and intraobserver agreement rates for expert and nonexpert endoscopists had κ values ≥0.8 except one nonexpert pair. Endocytoscopy is an effective modality in determining the differential diagnosis of colorectal low-grade adenoma. (University Hospital Medical Information Network Clinical Trials database registration number: UMIN000018623.) [ABSTRACT FROM AUTHOR]

Background and Aims Per-oral endoscopic myotomy (POEM) has become an accepted treatment for patients with achalasia. Despite its excellent efficacy rate of greater than 80%, a small percentage of patients remain symptomatic after the procedure. Limited data exist as to the best management for recurrence of symptoms after POEM. We present the first international, multicenter experience on the efficacy and safety of a repeat POEM in the management of achalasia. Methods Patients who underwent a redo POEM from 15 centers in 9 countries were included in a dedicated registry. Technical success was defined as successful completion of a second myotomy. Clinical success was defined as an Eckardt score of less than or equal to 3 after the second myotomy. Adverse events including anesthesia-related, operative, and postoperative adverse events were recorded. Results Forty-six patients were included in the study. The average age was 49.3 ± 16.78 years. Twenty (45%) patients were male. The mean pre-redo-POEM Eckardt score was 4.3 ± 2.48. Technical success was achieved in 46 (100%) patients. Clinical success was achieved in 41 patients (85%). The average post-POEM Eckardt score was 1.64 ± 1.67, with a significant difference of 2.58 ( P < .00001). Eight patients (17%) had adverse events consisting of procedural bleeding, all managed endoscopically. There were no deaths. No POEMs were aborted or required surgical conversion or assistance. Discussion For patients with persistent symptoms after POEM, repeat POEM appears to be an efficacious and safe technique. Further randomized trials comparing redo POEM versus Heller should be considered. (Clinical trial registration number: NCT02162589 .) [ABSTRACT FROM AUTHOR]

Background and Aims We investigated endocytoscopy (EC) findings that were considered risk factors for colorectal neoplasms and determined whether they could be used as new indices to identify carcinomas with massive submucosal invasion (SM-m) or worse outcomes. Methods We performed a multivariate analysis of 8 factors on EC images to determine whether they were associated with SM-m or worse. Based on the results, we divided the EC3a category of the EC classification into low grade or high grade and investigated the diagnostic accuracy of this subclassification. In addition, we compared the diagnostic ability of EC for SM-m with that of other modalities (narrow-band imaging and pit pattern). Results The multivariate analysis indicated that unclear glandular lumens (ULs), high degree of nuclear enlargement (HNE), and multilayered nuclei (MNs) were the most useful factors for the diagnosis of SM-m or worse. The odds ratios for these factors were 12.47, 12.29, and 10.48, respectively ( P < .001). The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and positive likelihood ratio for the diagnostic accuracy of the EC3a subclassification were 88.9%, 91.3%, 75.0%, 96.6%, 90.8%, and 10.2, respectively ( P < .001). The sensitivity, negative predictive value, and accuracy of EC were significantly higher than those of narrow-band imaging and pit pattern. Conclusions From the EC findings, the presence of ULs, HNE, and MNs are important risk factors for SM-m or worse outcomes. Furthermore, the EC3a subclassification taking these findings into consideration could be effective for the diagnosis of SM-m or worse. (Clinical trial registration number: UMIN 000014906.) [ABSTRACT FROM AUTHOR]

Peroral endoscopic myotomy (POEM) is conducted for patients with esophageal motility disorders based on high-resolution manometry (HRM) findings. However, the impact of POEM on HRM findings and the associations between post-POEM HRM and outcomes have not been clarified. In a multicenter, observational, cohort study, patients with achalasia treated by POEM received follow-up HRM. Associations between patient characteristics, POEM procedures, and post-POEM HRM findings, including integrated relaxation pressure (IRP) and distal contractile integral (DCI), were investigated. Furthermore, POEM procedure outcomes were compared with post-POEM HRM findings. Of 2171 patients, 151 (7.0%) showed residual high post-POEM IRP (≥26 mm Hg; Starlet [Starmedical Ltd, Tokyo, Japan]). In a multivariate analysis, high pre-POEM IRPs (odds ratio [OR], 24.3) and gastric myotomy >2 cm (OR,.22) were found to be positive and negative predictive factors of high post-POEM IRPs, respectively. Peristalsis recovery (DCI ≥500 mm Hg/cm/s, at least 1 swallow; Starlet) was visible in 121 of 618 patients (19.6%) who had type II to III achalasia. High pre-POEM IRP (OR, 2.65) and DCI ≥500 (OR, 2.98) predicted peristalsis recovery, whereas esophageal dilation (OR,.42) predicted a risk of no recovery. Extended myotomy did not reveal a significant impact on peristalsis recovery. High or low post-POEM IRP and DCI did not increase the incidence of clinical failure, reflux esophagitis, or symptomatic GERD. Extended gastric myotomy decreased IRP values, whereas peristalsis recovery depended on the characteristics of achalasia. A residual high post-POEM IRP does not necessarily mean clinical failure. Routine HRM follow-up is not recommended after POEM. [Display omitted] [ABSTRACT FROM AUTHOR]

Background and Aims Eight years have passed since the introduction of the per-oral endoscopy myotomy (POEM) procedure. POEM was initially received as an investigational procedure, but since the revelation of promising safety and efficacy data, it is becoming the preferred treatment for achalasia. With the recent completion of our 1000th POEM procedure, we share our experience and knowledge through the discussion of clinical pearls, pitfalls, and practical considerations. Methods The various aspects of the procedure and conditions that warrant special attention are discussed from our perspective, with a focus on areas in which there is currently limited evidence. Results The key points on patient position, submucosal tunneling, myotomy, closure, intraprocedural bleeding, and advanced sigmoid achalasia are presented. Conclusions The dissemination of this information serves as a foundation for new POEM operators and as a catalyst for more-experienced operators to further refine and advance their POEM skills and stimulate international discourse and collaboration. [ABSTRACT FROM AUTHOR]

Background We previously reported on the efficacy of endocytoscopic classification (EC-C). However, the correlation of the endocytoscopic vascular (EC-V) pattern with diagnoses was unclear. Objective To assess the diagnostic accuracy of the EC-V pattern for colorectal lesions. Design Retrospective. Setting A university hospital. Patients Patients who underwent endocytoscopy between January 2010 and March 2013. Intervention We evaluated 198 consecutive lesions according to the EC-V pattern (EC-V1, obscure surface microvessels; EC-V2, clearly observed surface microvessels of a uniform caliber and arrangement; and EC-V3, dilated surface microvessels of a nonhomogeneous caliber or arrangement). Main Outcome Measurements The diagnostic accuracy for predicting hyperplastic polyps and invasive cancer were compared between the EC-V pattern and other modalities (narrow-band imaging, pit pattern, and EC-C). Results The sensitivity, specificity, and accuracy of the EC-V1 pattern for diagnosing hyperplastic polyps were 95.5%, 99.4%, and 99.0%, respectively. The sensitivity, specificity, and accuracy of the EC-V3 pattern for diagnosing invasive cancer were 74.6%, 97.2%, and 88.6%, respectively. The diagnostic accuracy of the EC-V pattern for predicting hyperplastic polyps was comparable to the other modalities. For predicting invasive cancer, the EC-V pattern was comparable to narrow-band imaging and pit pattern, although EC-C was slightly more accurate ( P = .04). In the substudy, the diagnosis time by using the EC-V pattern was shorter than that with the EC-C pattern ( P < .001). Limitations A single-center, retrospective study. Conclusions The EC-V pattern saved more time than the EC-C pattern and had a diagnostic ability comparable to that of other optical biopsy modalities. [ABSTRACT FROM AUTHOR]

The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear. A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM. Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR],.28), male sex (OR,.70), prior treatment (OR, 1.39), and sigmoid type (OR,.65) were related to the prevalence of chest pain. Long disease duration (OR,.69) and esophageal dilation (OR,.79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR,.58), male sex (OR,.79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM. The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended. [ABSTRACT FROM AUTHOR]

Background After the first case of per-oral endoscopic myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical myotomy and is now established as an excellent treatment option for achalasia. This study aimed to examine the safety and outcomes of POEM at our institution. Study Design Per-oral endoscopic myotomy was performed on 500 consecutive achalasia patients at our institution between September 2008 and November 2013. A review of prospectively collected data was conducted, including procedure time, myotomy location and length, adverse events, and patient data with short- (2 months) and long-term (1 and 3 years) follow-up. Results Per-oral endoscopic myotomy was successfully completed in all patients, with adverse events observed in 3.2%. Two months post-POEM, significant reductions in symptom scores (Eckardt score 6.0 ± 3.0 vs 1.0 ± 2.0, p < 0.0001) and lower esophageal sphincter (LES) pressures (25.4 ± 17.1 vs 13.4 ± 5.9 mmHg, p < 0.0001) were achieved, and this persisted at 3 years post-POEM. Gastroesophageal reflux was seen in 16.8% of patients at 2 months and 21.3% at 3-year follow-up. Conclusions Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy. [ABSTRACT FROM AUTHOR]

Background Per-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side. Objective To evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging. Design Prospective. Setting Single-center study. Patients Twenty-one achalasia patients who received POEM with GC myotomy. Interventions POEM. Main Outcome Measurements Efficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events. Results Identification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6 ± 1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2 ± 7.3 vs 10.5 ± 2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) ( P < .01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered. Limitations Single center. Conclusions GC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints. [ABSTRACT FROM AUTHOR]

Background Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs). Objective To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia. Design Retrospective study. Setting International, multicenter, academic institutions. Patients All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included. Interventions POEM. Main Outcome Measurements Eckardt score and adverse events. Results A total of 73 patients underwent POEM for treatment of SEDs (diffuse esophageal spasm 9, jackhammer esophagus 10, spastic achalasia 54). POEM was successfully completed in all patients, with a mean procedural time of 118 minutes. The mean length of the submucosal tunnel was 19 cm, and the mean myotomy length was 16 cm. A total of 8 adverse events (11%) occurred, with 5 rated as mild, 3 moderate, and 0 severe. The mean length of hospital stay was 3.4 days. There was a significant decrease in Eckardt scores after POEM (6.71 vs 1.13; P = .0001). Overall, clinical response was observed in 93% of patients during a mean follow-up of 234 days. Chest pain significantly improved in 87% of patients who reported chest pain before POEM. Repeat manometry after POEM was available in 44 patients and showed resolution of initial manometric abnormalities in all cases. Limitations Retrospective design and selection bias. Conclusion POEM offers a logical therapeutic modality for patients with SEDs refractory to medical therapy. Results from this international study suggest POEM as an effective and safe platform for these patients. [ABSTRACT FROM AUTHOR]

Background Endocytoscopy (EC), as a novel ultrahigh magnification technology, enables in vivo histopathological diagnoses of the GI tract. EC is particularly exceptional when comparing dysplastic and neoplastic tissue with normal tissue. There are, however, no detailed data for minute or minimal changes in the gastric mucosa. Objective To describe non-neoplastic EC patterns of the gastric mucosa correlated with histopathological findings and to determine any relationship with Helicobacter pylori (HP) infection. Design A pilot prospective study. Setting Tertiary care referral center. Patients Sixty-four participants undergoing upper endoscopy for various indications. Methods Antral mucosal patterns on EC were divided into 4 categories: type 1 (normal), each papilla/pit has round smooth structure; type 2 (gastritis), extended, notched, and distorted structure with some necrotic tissue; type 3(atrophy), neighboring papilla/pit take on a lobulated appearance; type 4 (intestinal metaplasia [IM]), goblet cells are identified in a completely stained crypt. Target biopsy specimens were obtained from the region identified with these patterns, and multiple HP tests were performed. Results HP positivity was 0%, 40.9%, 50.0%, and 58.3% in types 1, 2, 3, and 4, respectively. The sensitivity and specificity of types 2+3+4 for HP positivity were 100％ and 42.5%, respectively. The positive predictive values of type 1 for normal, type 2 for chronic gastritis, type 3 for atrophic gastritis, and type 4 for IM were 100%, 62.5%, 40.0%, and 100%, respectively. The sensitivity and specificity of types 3+4 for atrophic gastritis to IM were 87.0% and 95.1%, respectively. Limitations Small, single-center, pilot study. Conclusions EC can differentiate gastric mucosal patterns of minimal, non-neoplastic change and appears to reliably exclude HP infection. [ABSTRACT FROM AUTHOR]

Background Endocytoscopy enables in vivo observation of nuclei at 450× magnification during GI endoscopy, thus allowing precise prediction of lesion pathology. However, because it requires training and experience, it may be beneficial only when performed by expert endoscopists. Objective To develop and evaluate a novel computer-aided diagnosis system for endocytoscopic imaging (EC-CAD) of colorectal lesions. Design Pilot study. Setting University hospital. Patients One hundred fifty-two patients with small colorectal polyps (≤10 mm) who had undergone endocytoscopy. Intervention Test sets of white-light endoscopic images and endocytoscopic images from 176 small colorectal polyps (137 neoplastic and 39 non-neoplastic polyps) were assessed by EC-CAD, 2 expert endoscopists, and 2 trainee endoscopists. Main Outcome Measurement Sensitivity, specificity, and accuracy in predicting neoplastic change by EC-CAD comparing expert and trainee endoscopists. Results EC-CAD had a sensitivity of 92.0% and an accuracy of 89.2%; these were comparable to those achieved by expert endoscopists (92.7% and 92.3%; P = .868 and .256, respectively) and significantly higher than those achieved by trainee endoscopists (81.8% and 80.4%; P < .001 and .002, respectively). EC-CAD achieved a specificity of 79.5%; this did not differ significantly from that achieved by the experts and trainees. EC-CAD also enabled instant diagnosis, taking only 0.3 seconds for each lesion with perfect reproducibility. Limitations No sample size calculation. Conclusions EC-CAD provides fully automated instant classification of colorectal polyps with excellent sensitivity, accuracy, and objectivity. Thus, it can be a powerful tool for facilitating decision making during routine colonoscopy. [ABSTRACT FROM AUTHOR]

Background: Accurate endoscopic criteria are needed to differentiate serrated polyps, including hyperplastic polyp (HP), sessile serrated adenoma/polyp (SSA/P), and traditional serrated adenoma (TSA), because some are precursors of colorectal cancers. Objective: To determine the endocytoscopic features of each type of serrated polyp, especially the shapes of lumens and nuclei. Design: Retrospective study. Setting: Single, tertiary-care referral center. Patients: Patients who underwent removal of serrated polyps from May 2005 to December 2012. Intervention: Endocytoscopy was performed. Endocytoscopic images were evaluated by assessing the shapes of the lumens and nuclei of the target lesions. Main Outcome Measurements: The significant endocytoscopic features in differentiating among types of serrated polyps. Results: Of the 58 eligible lesions, 27 were classified as HP, 12 as SSA/P, and 19 as TSA. Most HPs (77.8%) had star-like lumens, and most SSA/Ps (83.3%) had oval lumens. The lumens of TSAs were serrated (31.6%) or villous (68.4%), with both shapes seen only in TSAs. Most HPs (92.6%) and SSA/Ps (75.0%) had small, round nuclei, and all TSAs had fusiform nuclei. Features significantly differentiating TSAs from HPs and SSA/Ps were the presence of fusiform nuclei (P < .001) and villous (P < .001) and serrated (P = .002) lumens. The presence of oval lumens was significantly characteristic of SSA/Ps (P < .001), and the presence of star-like lumens was significantly characteristic of HPs (P < .001). Limitations: Retrospective design. Single-center study. Conclusion: The shape of lumens and nuclei on endocytoscopy can efficiently differentiate among the different types of serrated polyps. (Clinical trial registration number: UMIN Clinical Trials Registry UMIN000007850.) [Copyright &y& Elsevier]

Abstract: Laser-mediated surface-enhanced Raman scattering (SERS) has industrial and biological applications. We have developed a rapid and simple method for generating silver nanoscale hexagonal columns (NHCs) on the surface of a phosphor bronze chip for measurement of SERS spectra. This was used to detect SERS spectra from blood samples obtained from patients with gastric cancer, colorectal cancer, or benign diseases (n=12 each) using a low intensity helium-neon red laser beam with a 632.8-nm wavelength; the intensity of the SERS spectra was compared among the patient groups. The peak heights of SERS spectra from patients with benign diseases were significantly lower than those from patients with gastric or colorectal cancer, whereas those from patients with gastric cancer and colorectal cancer did not differ significantly. Thus, SERS using NHC chips holds promise for the easier and faster detection of cancer-related serum-constituents as biomarkers. From the Clinical Editor: In this study, laser-mediated surface-enhanced Raman scattering (SERS) was utilized as a sensitive detection method of cancer-related serum-constituents in gastric and colorectal cancer, via the use of silver nanoscale hexagonal columns on the surface of a phosphor bronze chip for measurement of SERS spectra, paving the way to the development of a rapid and high throughput tool for cancer screening and therapy monitoring. [Copyright &y& Elsevier]

Background: Surgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. Study Design: A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line “rescue” treatment, and only if PBD failed were patients considered for rescue POEM. Results: The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed. Conclusions: Short-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited. [ABSTRACT FROM AUTHOR]

Background: Recent technological advances have allowed superficially spreading intramucosal carcinomas of the esophagus to be successfully resected by circumferential endoscopic submucosal dissection (cESD). After this procedure, esophageal strictures develop in most patients and are mainly treated by endoscopic balloon dilation (EBD). Objective: To compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD. Design: Retrospective cohort study. Setting: Tertiary-care referral center. Patients: We studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barrett's esophagus). Intervention: After cESD, patients were managed with EBD alone (EBD, n = 13) or with EBD and oral prednisolone (steroid + EBD, n = 10), 30 mg daily, started 2 days after cESD and gradually tapered and discontinued after 8 weeks. Main Outcome Measurements: Total number of EBD sessions and total EBD period (months). Results: Steroid + EBD patients required fewer sessions (13-8 ± 6.9 vs 33.5 ± 22.9; P < .001) and a shorter management period (4.8 ± 2.3 vs 14.2 ± 17.5 months, P = .005) compared with the EBD group. An additional 3 patients received oral steroids a mean interval of 158 days after cESD. These patients required more EBD sessions (46.3 ± 30.0; P = .002), and the EBD period was significantly longer (17.5 ± 13-0 months; P = .005) than in the early steroid + EBD group. Limitations: Nonrandomized study; retrospective analysis. Conclusion: After cESD, oral steroid therapy dramatically reduced the need for EBD. We conclude that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete cESD. [ABSTRACT FROM AUTHOR]

Abstract: Since the inception of peroral endoscopic myotomy (POEM) in 2008, more than 2000 POEMs have been performed to date in the world. The technique has been standardized to include the following 5 steps: mucosectomy, submucosal tunnel creation, esophageal myotomy, cardiomyotomy, and mucosectomy closure. Minor technique variations do exist as far as the equipment utilized as well as with the orientation and completeness of the myotomy. This article describes the equipment used during POEM as well as the essential steps to have a safe and successful procedure. [Copyright &y& Elsevier]

Background: Peroral endoscopic myotomy (POEM) was developed to reduce lower esophageal sphincter pressure in patients with achalasia. POEM is technically challenging and time consuming. The creation of an esophageal submucosal tunnel is a major and integral part of the procedure. Dissection of the submucosal fibers is a lengthy task. Objective: To present our initial experience with the use of a novel gel with dissecting properties for facilitating submucosal tunneling during POEM. Setting: Johns Hopkins Hospital. Intervention: POEM. Results: The gastroscope was successfully introduced into the submucosal space in all pigs. The gel in the submucosal space was easily suctioned through the working channel of the gastroscope and did not interfere with endoscopic visualization. The esophageal submucosal tunnel was noted to be already formed upon entry into the submucosal space in all 5 pigs. Esophageal submucosal dissection was not required in any case. “Auto-tunneling” by the dissecting gel stopped at the level of the lower esophageal sphincter. Further tunneling into the gastric cardia was needed in all pigs. The average procedure (including myotomy) time was 28 minutes. Limitations: Animal experiments. Conclusion: Gel consistently resulted in efficient auto-tunneling without any complications. This gel has the potential to revolutionize POEM and endoscopic submucosal dissection if its safety and efficacy are replicated in other animal studies and subsequently in human trials. [ABSTRACT FROM AUTHOR]

Abstract: Background: Peroral endoscopic myotomy has been developed to provide a less invasive treatment for oesophageal achalasia compared to surgical cardiomyotomy. Aims: To report our initial experience on feasibility, safety and clinical efficacy of peroral endoscopic myotomy. Methods: Eleven patients (eight women, mean age 32, range 24–58) underwent an attempt at peroral endoscopic myotomy under general anaesthesia. After submucosal injection, a mucosal entry into the oesophageal submucosa, and a tunnel extending to the oesophagogastric junction and beyond into the stomach were created (total mean length: 15±1.7cm). Myotomy of the circular oesophageal and gastric muscle bundles was then achieved under direct vision (total mean length: 10.2±2.8cm). Haemostatic clips were used to close the mucosal entry. The Eckardt Score and manometry were used to evaluate the results. Results: Peroral endoscopic myotomy could be completed in 10 out of 11 patients (91%). Mean procedure time was 100.7min (range 75–140min). No major complication occurred. Clinical success was achieved in all patients at 1-month follow-up (Eckardt Score 7.1 vs. 1.1, p =0). Lower oesophageal sphincter pressure decreased from 45.1 to 16.9mmHg (p =0). Conclusions: This initial experience with peroral endoscopic myotomy shows its safety and efficacy in the treatment of achalasia. Further studies are warranted to assess the long-term efficacy and to compare peroral endoscopic myotomy with other treatment modalities. [Copyright &y& Elsevier]

Abstract: Background: Narrow-band imaging magnifying endoscopy is widely used in Japan, but still there is no set of consistent guidelines for gastric lesions. Aims: To introduce a new narrow-band imaging magnifying endoscopic classification and report the accuracy of diagnosis in comparison to underlying histopathology of gastric lesions. Methods: Two hundred and fifty-seven consecutive patients with early gastric cancer lesions were enrolled into this study. Narrow-band imaging magnifying images were classified into four categories based on abnormal microvascular patterns and irregularities in the superficial glandular structure: fine-network pattern, corkscrew pattern, intra-lobular loop pattern-1 and intra-lobular loop pattern-2. The narrow-band imaging magnifying endoscopic classification was compared with the histopathological findings. Results: Amongst the differentiated-type adenocarcinoma lesions, fine-network pattern, intra-lobular loop pattern-1, intra-lobular loop pattern-2 and corkscrew pattern were observed in 15.7%, 59.6%, 24.2% and 0.5%, respectively. Differentiated-type adenocarcinomas mainly exhibited fine-network pattern or intra-lobular loop pattern. In undifferentiated-type adenocarcinoma lesions, intra-lobular loop pattern-2 and corkscrew pattern were observed in 41.2% and 58.8%, respectively. Therefore, undifferentiated-type adenocarcinomas were all classified as intra-lobular loop pattern-2 and corkscrew pattern. The histopathological types were not equivalent with the narrow-band imaging magnifying classification categories (P <0.001). Conclusions: The new narrow-band imaging magnifying classification that incorporates the intra-lobular loop pattern may be able to predict the histological subtype of most gastric carcinomas. [Copyright &y& Elsevier]

Background: Narrow-band imaging (NBI) emphasizes the surface microvasculature of the GI tract and may help in detecting small neoplasms. Objective: The aim of this study was to clarify the value of the NBI system in tissue characterization and differential diagnosis. Design: A prospective study. Setting: Digestive Disease Center of Showa University Northern Yokohama Hospital. Patients: The subjects were 495 patients who, from January 2006 to June 2007, underwent a complete colonoscopic examination. A total of 617 lesions were evaluated in the 495 patients (33 hyperplastic polyps, 532 adenomas, 52 submucosally invasive [T1] cancers). Results: Most hyperplastic polyps showed a faint pattern. The vascular patterns of adenomas were mainly the network pattern or the dense pattern. The major vascular patterns of cancers were the irregular pattern and the sparse pattern. The irregular pattern was characteristic for protruded or flat-elevated cancers, whereas the sparse pattern was unique for depressed cancers. When we assumed that the faint pattern was diagnostic for hyperplastic polyps, we could differentiate between neoplastic and non-neoplastic lesions with a sensitivity of 90.9% and a specificity of 97.1%. Likewise, irregular and sparse patterns were assumed to be indices of massively invasive submucosal cancer, the sensitivity was 100%, the specificity was 95.8%, and the accuracy rate was 96.1%. Limitations: This study was performed at a single center. Conclusions: The NBI system was valuable for distinguishing between neoplastic and non-neoplastic lesions, as well as between cancers and adenomas. Vascular pattern analysis can also be a promising tool for determining treatment selection, either endoscopy or surgery. [Copyright &y& Elsevier]

Background: The histological findings of GI lesions are based on light-microscopic examination of H&E-stained thin-slice specimens. Recently, a concept of optical biopsy has been advocated. A study of the observation of colorectal lesions using endocytoscopy to obtain real-time histological images in vivo during endoscopy was performed. Design: Prospective study. Aim: To evaluate the usefulness of optical biopsy of colorectal lesions with the endocytoscopy (E-C) system. Patients: The subjects were 113 consecutive patients who underwent a complete colonic examination, from April 2003 to March 2004, performed by a single colonoscopist. Setting: Digestive Disease Center of Showa University Northern Yokohama Hospital. Results: With E-C, it was possible to observe lesions at the cellular level and evaluate cellular atypia in addition to structural atypia in vivo. The correlation was statistically significant between the endocytoscopic diagnosis and the histological diagnosis. Limitations: The endocytoscope had to be touched to the target colonic glands. Conclusions: It was possible to distinguish neoplastic from non-neoplastic lesions, and also possible to distinguish invasive cancer from adenoma. ‘Ultra-high’ magnifying endoscopy, the E-C system, provides real-time histological images in vivo, which correspond well with those of H&E-stained microscopic images. [Copyright &y& Elsevier]

Precise optical diagnosis of colorectal polyps could improve the cost-effectiveness of colonoscopy and reduce polypectomy-related complications. However, it is difficult for community-based non-experts to obtain sufficient diagnostic performance. Artificial intelligence-based systems have been developed to analyze endoscopic images; they identify neoplasms with high accuracy and low interobserver variation. We performed a multi-center study to determine the diagnostic accuracy of EndoBRAIN, an artificial intelligence-based system that analyzes cell nuclei, crypt structure, and microvessels in endoscopic images, in identification of colon neoplasms. The EndoBRAIN system was initially trained using 69,142 endocytoscopic images, taken at 520-fold magnification, from patients with colorectal polyps who underwent endoscopy at 5 academic centers in Japan from October 2017 through March 2018. We performed a retrospective comparative analysis of the diagnostic performance of EndoBRAIN vs that of 30 endoscopists (20 trainees and 10 experts); the endoscopists assessed images from 100 cases produced via white-light microscopy, endocytoscopy with methylene blue staining, and endocytoscopy with narrow-band imaging. EndoBRAIN was used to assess endocytoscopic, but not white-light, images. The primary outcome was the accuracy of EndoBrain in distinguishing neoplasms from non-neoplasms, compared with that of endoscopists, using findings from pathology analysis as the reference standard. In analysis of stained endocytoscopic images, EndoBRAIN identified colon lesions with 96.9% sensitivity (95% CI, 95.8%–97.8%), 100% specificity (95% CI, 99.6%–100%), 98% accuracy (95% CI, 97.3%–98.6%), a 100% positive-predictive value (95% CI, 99.8%–100%), and a 94.6% negative-predictive (95% CI, 92.7%–96.1%); these values were all significantly greater than those of the endoscopy trainees and experts. In analysis of narrow-band images, EndoBRAIN distinguished neoplastic from non-neoplastic lesions with 96.9% sensitivity (95% CI, 95.8–97.8), 94.3% specificity (95% CI, 92.3–95.9), 96.0% accuracy (95% CI, 95.1–96.8), a 96.9% positive-predictive value, (95% CI, 95.8–97.8), and a 94.3% negative-predictive value (95% CI, 92.3–95.9); these values were all significantly higher than those of the endoscopy trainees, sensitivity and negative-predictive value were significantly higher but the other values are comparable to those of the experts. EndoBRAIN accurately differentiated neoplastic from non-neoplastic lesions in stained endocytoscopic images and endocytoscopic narrow-band images, when pathology findings were used as the standard. This technology has been authorized for clinical use by the Japanese regulatory agency and should be used in endoscopic evaluation of small polyps more widespread clinical settings. UMIN clinical trial no: UMIN000028843. [ABSTRACT FROM AUTHOR]

Peroral endoscopic myotomy (POEM) is an available treatment modalities for achalasia. The reported efficacy of POEM in the only prospective multicenter study was 82%; however, a retrospective multicenter study in Japan reported a higher efficacy rate of 95%. The aim of this study was to prospectively verify treatment outcomes after POEM at multiple facilities in Japan. This was a prospective single-arm trial of POEM for achalasia at 8 facilities in Japan between April 2016 and March 2018 to evaluate its safety and efficacy. Patients were re-evaluated at 3 months and up to 1 year after POEM. Among the 233 patients with achalasia who underwent POEM, procedure-related adverse events occurred in 24 patients (10.3%), none of whom required surgical intervention. In the 207 patients satisfying the inclusion criteria, the efficacy rate of POEM, defined by an Eckardt score ≤3 at 1 year, was 97.4% (95% CI, 95.3%-99.7%). The Eckardt score decreased significantly from 6.6 ± 2.0 preoperatively to 1.1 ± 1.1, 1 year after POEM. Postoperative reflux esophagitis, severe reflux esophagitis, and symptomatic GERD were reported in 54.2%, 5.6%, and 14.7%, respectively, and proton pump inhibitors were administered in 21.1%. Our prospective multicenter study in Japan showed greater efficacy of POEM for achalasia compared with the results of a previous prospective multicenter study. POEM is safe and highly effective for at least 1 year. (Clinical trial registration number: UMIN 000021550.) [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]