Search

GERD is common after peroral endoscopic myotomy (POEM). Selective sparing of oblique fibers may reduce the incidence of reflux esophagitis after POEM. In this study, we compared the incidence of GERD between conventional myotomy (CM) versus oblique fiber-sparing (OFS) myotomy in patients with achalasia. Eligible patients with type I and II achalasia who underwent POEM from January 2020 to October 2020 were randomized into 2 groups (CM and OFS myotomy). Exclusion criteria were type III achalasia, sigmoid esophagus, and history of Heller's myotomy. The primary study outcome was incidence of reflux esophagitis (at least grade B) in the 2 groups. Secondary outcomes were reflux symptoms, esophageal acid exposure, clinical success, and adverse events. One hundred fifteen patients were randomized into CM (n = 58) and OFS myotomy (n = 57) groups. POEM was technically successful in all patients. Overall, reflux esophagitis was found in 56 patients (48.7%). The incidence of at least grade B esophagitis was similar in both groups (CM vs OFS myotomy: 25.9% vs 31.6%, P =.541). The mean number of reflux episodes (48.2 ± 36.6 vs 48.9 ± 40.3, P =.933), increased esophageal acid exposure >6% (45.5% vs 31.7%, P =.266), and high DeMeester scores (38.6% vs 41.5%, P =.827) were similar in both groups. There was no difference in the rate of symptomatic reflux (GERD questionnaire score >7) or use of proton pump inhibitors at 1 year. Sparing of sling fibers has no significant impact on the incidence of significant reflux esophagitis after POEM. Novel strategies need to be explored to prevent reflux after POEM. (Clinical trial registration number: NCT04229342.) [Display omitted] [ABSTRACT FROM AUTHOR]

Both single-balloon enteroscopy (SBE) and the novel motorized spiral enteroscopy (NMSE) are effective techniques for device-assisted enteroscopy (DAE). To date, no study has prospectively compared both modalities in suspected Crohn's disease (CD). Patients with suspected CD undergoing either SBE or NMSE between March 2021 and December 2021 in a high-volume tertiary center were prospectively compared for technical success (ability to reach the lesion), diagnostic yield, depth of maximal insertion (DMI), procedure time, and total enteroscopy rates. One hundred seventy-seven patients (37.2% female; aged 7-75 years) with suspected CD underwent 201 DAEs. Technical success was 83% (SBE 81.5% vs NMSE 87.3%, P =.61) and impacted subsequent management in 92% (SBE 88.5% vs NMSE 97.8%, P =.2). Technical success with antegrade NMSE was significantly higher (81.4%) than antegrade SBE (33.3%, P =.007) for lesions in the proximal ileum and beyond. There was no significant difference in the diagnostic yield (SBE 80.8% vs NMSE 83.6%, P =.65). Median procedure time was significantly lower in both antegrade (NMSE, 40 minutes [range, 10-75]; SBE, 60 minutes [range, 20-180]; P <.0001) and retrograde (NMSE, 25 minutes [range, 20-60]; SBE, 60 minutes [range, 20-180]; P <.0001) NMSE. Median DMI was higher with antegrade NMSE (NMSE, 400 cm [range, 70-600]; SBE, 180 cm [range, 60-430]; P <.0001). The total enteroscopy rate was higher with NMSE (37% vs.7% with SBE, P <.0001). All adverse events were mild. Both NMSE and SBE are safe and effective for small-bowel evaluation in suspected CD. NMSE is superior to SBE with regard to deeper small-bowel evaluation with complete small-bowel coverage and shorter procedure time. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: There is limited data on long-term outcomes of per-oral endoscopic myotomy (POEM). In this study, we aim to evaluate the efficacy of POEM in patients who completed a minimum follow-up of 5 years. Methods: Data of patients who underwent POEM and completed ≥ 5-year follow-up were analyzed, retrospectively. Primary outcome of study was clinical success (Eckardt ≤ 3) at ≥ 5 years after POEM. Secondary outcomes included predictors of dysphagia and symptomatic gastroesophageal reflux disease (GERD) on long-term follow-up. Results: Three hundred nineteen patients (males 182, mean age 40.5 ± 14.2 years) completed a median of 73-(60–89) month follow-up. Esophageal motility disorders included idiopathic achalasia (type I 26.6%, type II 60.8%, type III 5.6%) and Jackhammer esophagus or distal esophageal spasm (2.8%). POEM was technically successful in 307 (96.2%) patients. Long-term success was 92.6% (overall), 92.1% (type I), 94.7% (type II), 87.5% (type III), and 75% (Jackhammer esophagus/distal esophageal spasm). Symptomatic GERD and reflux esophagitis were detected in 28.9% and 35.3% patients, respectively. On multivariate analysis, young age and female gender were independent risk factors for recurrent dysphagia (p = 0.037) and symptomatic GERD after POEM (p = 0.025), respectively. Lower post-POEM lower esophageal sphincter pressure was an independent predictor for reflux esophagitis (p = 0.016). Conclusion: POEM is an effective and durable treatment for achalasia and non-achalasia spastic motility disorders. Young patients and females may be at higher risk for recurrent dysphagia and symptomatic GERD, respectively. [ABSTRACT FROM AUTHOR]

Device assisted enteroscopy is the cornerstone for small bowel evaluation. However, the data are limited in pediatric patients. In this study, we aim to evaluate the safety and utility of single balloon enteroscopy (SBE) in children. The data of children (≤18-years) who underwent SBE from November 2010 to July 2020 was analyzed, retrospectively. The safety and diagnostic yield of SBE were assessed. 189-SBE procedures (males 117, mean age 15.1 ± 2.76, range 3–18 years) were performed in 174-children. The indications for SBE were chronic abdominal pain in 119 (68.4%), gastrointestinal bleed 17 (9.8%), chronic diarrhea 17 (9.8%) and vomiting 13 (7.5%). Antegrade, retrograde and combined SBE were performed in 98 (51.8%), 77 (40.7%), 7 (3.7%) children, respectively. The mean length of small bowel intubation in antegrade and retrograde SBE groups were 168.9 ± 58.6 cm and 120.7 ± 52.1 cm, respectively. Overall, a positive finding was seen in 117 (67.2%) cases. The most common findings were ileal and jejunal ulcers with or without strictures in 76 (64.9%) children. A total of 18 therapeutic enteroscopic procedures were performed. There were no major adverse events. SBE is a safe and effective procedure for the evaluation and management of small bowel diseases in children. [ABSTRACT FROM AUTHOR]

Novel motorized spiral enteroscopy (NMSE) is a recent advancement in the field of enteroscopy and offers multiple features, including self-propulsion, better irrigation, and shorter enteroscope length with a larger channel. The aim of this study was to evaluate the efficacy in terms of diagnostic yield and therapeutic success of NMSE in patients undergoing enteroscopy by antegrade and/or retrograde approaches for suspected small-bowel disease. We retrospectively evaluated consecutive patients with symptomatic small-bowel disease who underwent enteroscopy over a 6-month period. Diagnostic yield, therapeutic success, total enteroscopy rate (TER), technical success, total procedural time, depth of maximal insertion, and adverse events related to the NMSE procedure were noted. Of 61 patients (mean age, 45.67 ± 15.37 years; 43 men) included for NMSE, 57 patients underwent successful enteroscopy with a technical success of 93.4%. The overall diagnostic yield was 65.5% (95% confidence interval, 52.31-77.27) and 70.1% (95% confidence interval, 56.60-81.57) in patients who underwent successful NMSE; TER was 60.6%: 31.1% by the antegrade approach and 29.5% by a combined antegrade and retrograde approach. Depth of maximal insertion and procedural time was of 465 cm (range, 100-650) and 40 minutes (range, 25-60), respectively, by the antegrade approach and 140 cm (range, 50-200) and 35 minutes (range, 30-60) by the retrograde route. Lesions were classified as inflammatory (n = 25), vascular (n = 10), and mass (n = 4). Biopsy specimens were obtained in 50.8% subjects, and 23% patients underwent therapeutic procedures. No major adverse events were seen. NMSE is a promising technology, showing high efficacy as a diagnostic and therapeutic tool in the management of otherwise difficult-to-treat small-bowel disease. [ABSTRACT FROM AUTHOR]

Peroral endoscopic myotomy (POEM) is emerging as an effective treatment for achalasia in children. Long-term outcomes of POEM and impact of prior treatment are not known in pediatric population. In this study, we aim to evaluate the long-term efficacy of POEM in children with achalasia. Children (≤ 18 years) with achalasia who underwent POEM and completed at least 36 months of follow-up were included in the study. Long-term clinical success (Eckardt ≤ 3) was evaluated and compared between treatment naïve versus prior treated cases. A total of 53 children underwent POEM at our center during the study period. Of these, 17 children completed at least 3 years of follow-up and were included in the study. Eight children had prior treatment including pneumatic dilatation (6), Heller's myotomy (1) and both Heller's myotomy and pneumatic dilatation (1). POEM was successfully completed in all the children. Median procedure duration was 95.76 ± 47.98 min (38–240 min.). Long-term clinical success was found in 88.2% children. The mean follow-up was 55.06 ± 10.65 months (range 36–67 months). There was no significant difference in the success rate between treatment naïve and prior treatment failure cases. POEM is a safe, effective and durable treatment for achalasia in children. Prior treatment does not affect the outcomes of POEM in children. Retrospective comparative study. III. [ABSTRACT FROM AUTHOR]

Background and Aims Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR. Methods In this randomized, controlled, international, multicenter study (11 centers), patients (aged ≥50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR. Results One thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy n = 396; balloon-assisted colonoscopy n = 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; P =.0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (P =.0033) flat adenomas (P <.0001) and sessile serrated adenomas/polyps (P =.0026). Conclusion Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.) [ABSTRACT FROM AUTHOR]

Keywords: Esophageal Achalasia; Peroral Endoscopic Myotomy; Follow-up Study EN Esophageal Achalasia; Peroral Endoscopic Myotomy; Follow-up Study 530 532 3 02/26/21 20210201 NES 210201 Introduction Sigmoid achalasia may develop in up to 10% of patients with longstanding achalasia.[1] Heller's myotomy (HM) is considered the preferred modality of treatment in these patients. However, symptom scores and barium esophagogram findings deteriorate with increasing duration of follow-up warranting close follow-up in these patients. The mean duration of symptoms was significantly more in patients with relapse of symptoms (166.40 ± 44.77 vs 101.04 ± 32.81 months; I p i = 0.001) (Table 1). [Extracted from the article]

Background and Aims Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events by using a 0.025-inch and 0.035-inch guidewire. Methods A randomized, single blinded, prospective, multicenter trial at 9 high-volume tertiary-care referral centers in the Asia-Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have malignancy in the head of the pancreas or ampulla and were undergoing ERCP were recruited. ERCP was performed by using a standardized cannulation algorithm, and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire-guided cannulation and the incidence of PEP. Overall successful cannulation and ERCP adverse events also were studied. Results A total of 710 patients were enrolled in the study. The primary wire-guided biliary cannulation rate was similar in 0.025-inch and 0.035-inch wire groups (80.7% vs 80.3%; P = .90). The rate of PEP between the 0.025-inch and the 0.035-inch wire groups did not differ significantly (7.8% vs 9.3%; P = .51). No differences were noted in secondary outcomes. Conclusion Similar rates of successful cannulation and PEP were demonstrated in the use of 0.025-inch and 0.035-inch guidewires. (Clinical trial registration number: NCT01408264.) [ABSTRACT FROM AUTHOR]

Per-oral endoscopic myotomy (POEM) has surfaced as an effective endoscopic treatment modality for achalasia cardia (AC). Promising results in short- and mid-term follow-up studies have increased the use of POEM for the management of AC. POEM can be safely performed in an endoscopy suit, and major adverse events (AEs) are uncommon. AEs encountered during POEM or during the perioperative period principally include insufflation-related AEs, mucosal injuries, bleeding, pain, and aspiration pneumonia. Most insufflation-related AEs do not require an active intervention and therefore should not be considered as AEs in the true sense. When management of AEs is required, most intraoperative AEs can be managed at the same time without untoward consequences. Occurrences of AEs lessen after completion of the learning curve. However, experience alone does not ensure “zero” incidence of AEs, and early recognition remains essential. Postoperative AEs, like leaks, delayed bleeding, and delayed mucosal perforations, may pose special challenges for diagnosis and management. There is no standardized classification system for grading the severity of AEs associated with POEM, resulting in wide variation in their reported occurrences. Uniform reporting of AEs is not only crucial to comprehensively analyze the safety of POEM but also for comparison with other established treatment modalities like Heller’s myotomy. GERD is an important long-term AE after POEM. Unlike the perioperative AEs, little is known regarding the intraoperative or patient-related factors that influence the occurrence of post-POEM GERD. Large prospective studies with long-term follow-up are required to determine the procedural factors associated with GERD after POEM. [ABSTRACT FROM AUTHOR]

Background and Aims Extension of ampullary adenomas into the common bile duct (CBD) or pancreatic duct (PD) may be difficult to treat endoscopically. We evaluated the feasibility, safety, and efficacy of endoscopic radiofrequency ablation (RFA) in the management of ampullary neoplasms with intraductal extension. Methods This was a multicenter, retrospective analysis of all patients with intraductal extension of ampullary neoplasms treated with endoscopic RFA between February 2012 and June 2015. Treatment success was defined as the absence of detectable intraductal polyps by ductography, visual inspection, and biopsy sampling. Results Fourteen patients with adenoma extension into the CBD (13 ± 7 mm, n = 14) and PD (7 ± 2 mm, n = 3) underwent a median of 1 RFA sessions (range, 1-5). Additional modalities (thermal probes, argon plasma coagulation, and/or photodynamic therapy) were also used in 7 patients, and prophylactic stents were routinely placed. Thirteen assessable patients underwent a median of 2 surveillance ERCPs after completion of treatment over a median follow-up of 16 months (range, 5-46), with intraductal biopsy specimens showing no neoplasm in 12 patients at the conclusion of endoscopic treatment. Treatment success was achieved in 92%, including 100% of those treated with RFA alone. Adverse events occurred in 43% and included ductal strictures (5 patients) and retroduodenal abscess (1 patient), all of which were successfully treated endoscopically. Conclusions Endoscopic RFA, alone or in combination with other modalities, may effectively treat intraductal extension of ampullary neoplasms. Ductal strictures were common after RFA but responded to endoscopic stent therapy. RFA may be appropriate in selected patients, particularly when the main treatment alternative is pancreaticoduodenectomy. [ABSTRACT FROM AUTHOR]

Background and Aims EUS-guided drainage using plastic stents may be inadequate for treatment of walled-off necrosis (WON). Recent studies report variable outcomes even when using covered metal stents. The aim of this study was to evaluate the efficacy of a dedicated covered biflanged metal stent (BFMS) when adopting an endoscopic “step-up approach” for drainage of symptomatic WON. Methods We retrospectively evaluated consecutive patients with symptomatic WON who underwent EUS-guided drainage using BFMSs over a 3-year period. Reassessment was done between 48 and 72 hours for resolution. Endoscopic reinterventions were tailored in nonresponders in a stepwise manner. Step 1 encompassed declogging the blocked lumen of the BFMS. In step 2, a nasocystic tube was placed via BFMSs with intermittent irrigation. Step 3 involved direct endoscopic necrosectomy (DEN). BFMSs were removed between 4 and 8 weeks of follow-up. The main outcome measures were technical success, clinical success, adverse events, and need for DEN. Results Two hundred five WON patients underwent EUS-guided drainage using BFMSs. Technical success was achieved in 203 patients (99%). Periprocedure adverse events occurred in 8 patients (bleeding in 6, perforation in 2). Clinical success with BFMSs alone was seen in 153 patients (74.6%). Reintervention adopting the step-up approach was required in 49 patients (23.9%). Incremental success was achieved in 10 patients with step 1, 16 patients with step 2, and 19 patients with step 3. Overall clinical success was achieved in 198 patients (96.5%), with DEN required in 9.2%. Four patients failed treatment and required surgery (2) or percutaneous drainage (2). Conclusions The endoscopic step-up approach using BFMSs was safe, effective, and yielded successful outcomes in most patients, reducing the need for DEN. [ABSTRACT FROM AUTHOR]

Fully covered self-expandable metal stents (FCSEMSs) may offer a treatment option for pain associated with a dilated pancreatic duct (PD) in chronic pancreatitis (CP), but optimal patient selection and FCSEMS design, efficacy, and safety remain uncertain. We studied an investigational pancreatic FCSEMS for treatment of CP-associated pain. Patients with painful CP, a dominant distal PD stricture, and PD dilation upstream were enrolled in a prospective, multicenter, single-arm trial studying 6-month indwell of a 4- to 6-cm-long soft pancreatic FCSEMS. Primary efficacy and safety endpoints were pain reduction 6 months after FCSEMS indwell (performance goal ≥53%) and PD stenting–related serious adverse events (SAEs), respectively (performance goal <32%). The primary efficacy endpoint was assessed in patients with sufficiently severe and frequent pain at FCSEMS placement as a first stent or in exchange of a plastic stent. Among 67 patients (mean age, 52.7 ± 12.5 years; mean time since CP diagnosis, 6.4 ± 6.4 years), 34 (50.7%) had plastic stent placement within 90 days of FCSEMS placement, and 46 patients were eligible for the primary efficacy endpoint analysis. Technical success was 97.0% (65/67). The observed primary efficacy (26.1%, 12/46) and safety endpoints (31.3%, 21/67) failed to meet the a priori study hypotheses. Study stent migration occurred in 47.7% of patients (31/65). Six-month treatment with an FCSEMS did not lead to an expected degree of pain reduction, and migrations and SAEs were common. Further study is needed to clarify optimal decompressive strategy, FCSEMS design, and patient selection. (Clinical trial registration number: NCT02802020.) [Display omitted] [ABSTRACT FROM AUTHOR]

Background and Aims Insulinomas are one of the most common functional pancreatic neuroendocrine tumors. Surgical removal is the standard of care. Patients unfit for or refusing surgery need an alternative nonsurgical method to alleviate symptoms. EUS has been used to localize, aspirate, and tattoo insulinomas and to inject alcohol for local ablation. This study is aimed at assessing the feasibility of EUS-guided radiofrequency ablation (EUS-RFA) for managing patients with a symptomatic insulinoma by using a novel EUS-RFA needle electrode. Methods The EUS-RFA system used consists of a prototype 19-gauge needle electrode, generator, and internal cooling system. EUS-guided RFA is performed under real-time visualization at 50 W to ablate pancreatic insulinomas. Results In this observational human case series from a tertiary care center, 3 patients with a symptomatic pancreatic insulinoma, not eligible for surgery, underwent EUS-RFA by using an internally cooled prototype needle electrode. All had rapid symptom relief with biochemical improvement and remained symptom free at 11 to 12 months of follow-up. There were no procedure-related adverse events. Conclusions EUS-RFA with the novel device can be considered in select patients with a symptomatic pancreatic insulinoma based on preliminary findings of a beneficial effect without adverse events. Assessment of the safety profile requires larger prospective trials. [ABSTRACT FROM AUTHOR]