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Background : : Having a clean esophagus is an integral part of the peroral endoscopic myotomy (POEM) procedure for ensuring safety and success. Conventional preparation is a tricky, because there is no defined definite timeline of fasting for the different types of achalasia. The present study introduces a simple yet effective preparation of esophageal clearance. Methods : : All patients who underwent POEM were included. Patients were stratified in novel and conventional preparation groups by a random selection. In the novel preparation, the cases were maintained on lukewarm water and carbonated drink followed by nil per oral (NPO) prior to the procedure. In conventional preparation, the controls were maintained on clear liquid followed by NPO. Success rate of preparation and procedure related outcomes were compared using independent t tests and chi-squared tests. Results : : A total of 150 patients (male 54.0%; mean age 41.2 ± 15.5 years) were included in the study. Known baseline and clinical factors which could affect esophageal clearance were evenly distributed between the two groups. Novel preparation had provided absolute esophageal clearance (97.3%) without the requirement of pre-POEM endoscopic cleaning. Moreover, Novel preparation demonstrates several advantages over the conventional preparation: decreased anesthesia aspiration risk (P < 0.0001), reduced preoperative hospitalization (P < 0.0001), and hospital stays (P < 0.005). Conclusion : : Evidently, the novel preparation is very simple, efficient, safe and appropriate for all types of achalasia. Moreover, novel preparation provides absolute esophageal clearance without requiring prolonged period of liquid diet, fasting and pre-POEM endoscopic cleaning.

Background : : To assess the usefulness of endoscopic pancreatography without contrast agents and efficacy of transpapillary intervention for pancreatic duct (PD) rupture in chronic pancreatitis. Methods : : We retrospectively analyzed all cases of chronic pancreatitis with ductal rupture causing ascites, effusions and pseudocysts. We performed magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde pancreatography (ERP) without contrast. Results : observed based on the possibility of wire crossing the leak or not and their resolutions were noted. Results : : We performed ERP in 1,324 patients. Ductal disruptions in 321/1,324 (24.2%). We divided cases into two groups. Group 1 involves disruptions causing ascites in 60 cases (18.7%) and effusions in 34 cases (10.6%), and group 2 involves pseudocysts in 227 cases (70.7%). In group 1, 82 patients (87.2%) experienced successful cannulation of PD. Leak crossed in 70 (74.5%) with complete resolution in all. Leak did not cross in 12 cases of which 8 (8.5%) installed stents resolved while four (4.3%) did not resolve. In group 2, 219 (96.5%) PD cannulated. Leak did not cross but stents put in cyst (176, 77.5%). Complete resolution occurred without infection. Leaks were crossed in 43 (18.9%); complete resolution, 14 (32.6%). Complete regression was not achieved in 19 (8.3%). Eight cysts were not resolved (3.5%). Transmural drainage was done. Infection was noted in 2 cases (0.9%). Sites of leak in pseudocysts were jenu & body, 167 (73.6%); tail, 60 (26.4%). We recorded pancreas divisum in 24/321 (7.5%). ERP failed in 20 (6.2%). Three were managed medically (1.3%), 5 with distal pancreatectomy (2.2%), 4 with lateral pancreatico jejunostomy (1.8%), and 8 with transmural drainage (3.5%). Conclusion : : PD rupture in chronic pancreatitis can be managed transpapillary, without any contrast during ERP. In majority, endosonography aspiration and transmural drainage are needed only when transpapillary fails. Leak from tail responded better than those from proximal duct with ERP.