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Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in Japan used to treat esophageal achalasia and esophageal motility disorders. This technique has been rapidly accepted and widely disseminated throughout our clinical practice because of its low invasiveness, technical novelty, and high efficacy. Since the advent of POEM, there have been no clinical guidelines that clearly indicated its standard of care, and these guidelines have been anticipated both nationally and internationally by clinicians who engage in POEM practice. In 2017, to meet these needs, the Japan Gastroenterological Endoscopy Society (JGES) launched the guideline committee for POEM. Based on the guideline development process proposed by the Medical Information Network Distribution Service (MINDS), the guideline committee initially created research questions on POEM and conducted a systematic review and meta‐analysis on each topic. The clinical research extracted from databases for these clinical questions and the systematic review mainly comprised a few retrospective studies with a small number of participants and short trial periods; hence, the strength of the evidence and recommendations derived from these results was low. Throughout this process, the guideline committee met thrice: once on May 13, 2017, and again on September 17, 2017, to formulate the draft. A consensus meeting was then held on January 14, 2018, in Tokyo to establish the guideline statements and finalize the recommendations using the modified Delphi method. This manuscript presents clinical guidelines regarding current standards of practice and recommendations in terms of the nine chief topics in POEM. [ABSTRACT FROM AUTHOR]

Abstract: Background and Aim: Although propofol has been widely used for sedation during esophagogastroduodenoscopy (EGD), adverse events including hypoxia and hypotension may be a concern in the propofol‐based sedation. We aimed to analyze whether administration of midazolam would improve safety and efficacy of propofol‐based sedation in EGD. Methods: One hundred twenty patients who were scheduled to undergo diagnostic EGD were randomly assigned to either midazolam plus propofol (MP) or propofol alone groups. In the MP group, 2 mg of midazolam and 10 mg of propofol were given initially. In the propofol alone group, 40–60 mg of propofol was given initially. In both groups, 20 mg of propofol was given repeatedly to maintain moderate sedation as needed. Vital signs including oxygen saturation were monitored every 2 min. After the patients fully recovered, satisfaction score was investigated from endoscopists, nurses, and patients, respectively. Results: The baseline characteristics did not differ between the MP and propofol alone groups. The mean required doses of propofol was (mean ± standard deviation) 0.3 ± 0.3 and 0.8 ± 0.2 mg/kg in the MP and propofol alone groups, respectively (P < 0.001). In addition, sedation‐related adverse events and recovery time did not differ between the two groups. The proportion of satisfactory did not differ between the two groups (MP vs propofol alone; proportion; patient, 95.0% vs 93.3%, P > 0.999; endoscopist, 73.3% vs 80.0%, P = 0.064; nurse, 73.3% vs 76.7%, P = 0.551). Conclusion: Adding midazolam to propofol did not reduced the safety and efficacy, and sedation using propofol alone could be suitable for sedation during diagnostic EGD. [ABSTRACT FROM AUTHOR]

Abstract: Herein, we described a novel method as the use of AcuBlade robotic microsurgery system to manage idiopathic subglottic stenosis in a 73‐y‐old lady. Compared to traditional CO2 lasers, AcuBlade facilitated the scar resection by the generation of different shape of beams (straight, curved, or disk). The same setting used for phonomicrosurgery (1‐mm beam length, power of 10 W and pulse duration of 0.05‐s) allowed to obtain fast, long, and uniform cuts. In addition, the reduction of the number of laser passes over the same area prevented injury of adjacent tissue and thus reduced the risk of recurrence. [ABSTRACT FROM AUTHOR]

Background Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM). Methods Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded. Results Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. Conclusion For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed. [ABSTRACT FROM AUTHOR]

The Tokyo Guidelines 2013 (TG13) recommend that endoscopic drainage should be the first-choice treatment for biliary decompression in patients with acute cholangitis. Timing of biliary drainage for acute cholangitis should be based on the severity of the disease. For patients with severe acute cholangitis, appropriate organ support and urgent biliary drainage are needed. For patients with moderate acute cholangitis, early biliary drainage is needed. For patients with mild acute cholangitis, biliary drainage is needed when initial treatment such as antimicrobial therapy is ineffective. There are three methods of biliary drainage: endoscopic drainage, percutaneous transhepatic drainage, and surgical drainage. Endoscopic drainage is less invasive than the other two drainage methods. The drainage method (endoscopic nasobiliary drainage and stenting) depends on the endoscopist's preference but endoscopic sphincterotomy should be selected rather than endoscopic papillary balloon dilation from the aspect of procedure-related complications. In the TG13, balloon enteroscopy-assisted and endoscopic ultrasound-guided biliary drainages have been newly added as specific drainage methods. Recent studies have demonstrated their usefulness and safety. These drainage methods will become more widespread in the future. [ABSTRACT FROM AUTHOR]

Acute cholangitis is infectious disease of the biliary system and potentially can cause significant morbidity and mortality. With advances in intensive care, antibiotic therapy advances and endoscopic and other modalities of biliary drainage, mortality rates have significantly come down of late. Although most cases respond to antibiotics alone, definitive therapy is required later in most of the patients. Increased biliary pressure leads to biliovenous reflux of bacteria and purulent bile into the circulation leading to systemic inflammation and sepsis with subsequent organ dysfunction. Biliary decompression increases antibiotic penetration in bile. Therefore, patients with high-risk factors and organ dysfunction require early and urgent biliary drainage, respectively, as they are unlikely to respond with antibiotics alone. Biliary decompression is best achieved by endoscopic retrograde cholangiopancreatography ( ERCP) compared to percutaneous and surgical decompression. ERCP can be technically difficult and sometimes unsuccessful especially in patients with altered anatomy and upper gastrointestinal obstruction. Earlier percutaneous transhepatic biliary drainage ( PTBD) and surgery were the only viable options in those patients. PTBD requires a dilated biliary system, is more invasive and cannot achieve ductal clearance in cholangitis as a result of choledocholithiasis, whereas surgery is associated with high morbidity and mortality. Advances in therapeutic endoscopy such as balloon enteroscopy-guided biliary drainage or endoscopic ultrasound guided-biliary drainage have added new dimensions to endoscopic management of acute cholangitis as a result of choledocholithiasis obviating the need for more invasive procedures. [ABSTRACT FROM AUTHOR]

Background and Aim At the pancreatobiliary session of Endoscopic Forum Japan ( EFJ) 2016, current strategies for the endoscopic management of acute cholangitis were discussed. The topics consisted of two major parts, namely endoscopic management of acute cholangitis caused by common bile duct stones ( CBDS) and biliary stent occlusion. Methods Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion. Results Strategies for management of cholangitis due to CBDS were agreed upon, and the clinical guideline of acute cholangitis (Tokyo guidelines 2013) was accepted. The best timing for drainage in Grade 2 (moderate) cholangitis urgent or early (<24 h) was inconclusive, and more data is required on this issue. Another controversy was the feasibility of one step stone extraction in the patient with cholangitis vs stone removal after the cholangitis had resolved. There were various opinions with regards to the management of acute cholangitis due to stent occlusion, and the strategies differed according to the stricture location (distal or hilar) and stent type initially placed (Covered or uncovered metal stent). Conclusion Strategies for management of cholangitis caused by CBD stones are well established according to the TG13. More evidence is required before further recommendations can be made with regards to cholangitis due to stent occlusion. We aim to clarify this in the near future with questionnaires and consensus from experts. [ABSTRACT FROM AUTHOR]

The article discusses the 95th Congress of the Japan Gastroenterological Endoscopy Society (JGES) held with three international joint symposiums in Tokyo, 2018. Topic of the conference was endoscopic diagnosis, endoscopic retrograde cholangiopancreatography (ERCP) and the therapy for pancreatobiliary diseases. The symposium featured several presenters and chairpersons from the endoscopy society.

Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background: A health utility value represents an individual's preference for living in a specific health state and is used in cost-utility analyses. This study investigates the impact of continuing medical therapy on health utility outcomes in patients with chronic rhinosinusitis (CRS). Methods: The Medical Outcomes Study Short Form- 6D (SF-6D) questionnaire was administered to patients prospectively enrolled in a longitudinal study examining treatment outcomes for CRS. Patients were prescribed robust, initial medical therapy and then elected to continue with medical therapy (n = 40) or undergo endoscopic sinus surgery (ESS), followed by medical therapy (n = 152). Patients observed through treatment crossover to ESS were also evaluated (n = 20). Health utility values (SF-6D) were generated at baseline, 6-months, and 12-months follow-up for both cohorts and evaluated using repeated measures analysis of variance (ANOVA). Results: Treatment crossover patients were found to have a significantly higher prevalence of previous sinus surgery compared to medical management (χ² = 6.91; p = 0.009) and surgical intervention (χ² = 8.11; p = 0.004) subgroups. Mean baseline utility value for the medical therapy cohort was significantly better compared to the ESS cohort (mean ± standard deviation; 0.76 ± 0.12 vs 0.70 ± 0.15; p = 0.023). Significant improvement in health utility was reported in the ESS cohort (F(2) = 37.69; p < 0.001), whereas values remained stable, without significant improvement, in both themedical therapy cohort (F(2) =0.03; p=0.967) and treatment crossover cohort (F(2) = 2.36; p = 0.115). Conclusion: Patients electing continued medical management report better baseline health utility compared to patients electing ESS. Patients electing ESS show signifi- cant improvement in health utility, whereas those electing continuedmedical management demonstrate stable health utility over 12 months. [ABSTRACT FROM AUTHOR]

Background Treatment of achalasia is complicated by symptom recurrence and a significant risk for severe complications. Endoscopic myotomy was developed in the search for a highly efficacious treatment with lower risks. Since its introduction in 2010, several centers have adopted the technique and published excellent short-term results of open label series. Randomized trials with long-term endpoint comparing per-oral endoscopic myotomy ( POEM) with the established treatments such as balloon dilation and surgical myotomy are now warranted, before POEM can be regarded as the routine clinical care for achalasia patients. Purpose This review describes the development, technical aspects, efficacy, and complications of POEM. [ABSTRACT FROM AUTHOR]

The challenge for the pancreatologist managing patients with infected pancreatic necrosis is to devise a treatment algorithm that enables recovery but at the same time limits the morbidity and mortality. The current gold standard remains open necrosectomy. Recent literature contains scattered reports of endoscopic, radiologic, laparoscopic, percutaneous and lumbotomy approaches to managing patients with this condition. This literature review addresses the role of techniques that aim to minimize the physiological insult to the patient with infected pancreatic necrosis. [ABSTRACT FROM AUTHOR]

Objective– To evaluate a method for endoscopically guided nasojejunal tube placement allowing short-term postduodenal feeding and chyme withdrawal in dogs. Design– Pilot study. Setting– University teaching hospital. Animals– Three healthy Beagle dogs with jejunal nipple valve fistulas. Interventions– After the dogs were anesthetized, an 8 Fr, 250-cm polyvinyl chloride catheter was advanced through a gastroscope into the jejunum. Correct jejunal placement was established using endoscopic visualization and confirmed by fluoroscopy and radiography. The proximal end of the tube was pulled out through 1 nostril and sutured to the skin of the forehead. Thereafter, jejunal feeding was administered for 4 days. Follow-up examinations included daily confirmation of the tube's position using radiography, physical examination, and blood analyses. Withdrawal of jejunal chyme was performed after jejunal and oral feeding. Measurements and Main Results– Fluoroscopic examination confirmed that endoscopic visualization alone allowed correct jejunal placement. During a 4-day postduodenal feeding period, repeated radiographic examination revealed stable positioning of the tubes within the jejunum with minor cranial displacement. The tubes were functional throughout the study without causing identifiable problems. Repeated physical examinations and blood analysis showed no abnormalities. We were able to administer the daily caloric requirements as a liquid diet. Jejunal chyme was successfully withdrawn via the tube. Conclusions– Endoscopically guided nasojejunal tube placement was shown to be a minimally invasive, well-tolerated method for short-term jejunal feeding in healthy dogs. This technique is a viable option for dogs requiring jejunal feeding but not laparotomy. The feasibility of chyme sampling is another unique application of the procedure. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the clinical efficacy of intravenous sedation for pediatric gastrointestinal endoscopy (GIE) at a tertiary care teaching hospital in a developing country. Methods: We undertook a retrospective review of the sedation service records of pediatric patients who underwent GIE. All endoscopies were performed by a pediatric gastroenterologist. All of the sedation was administered by staff anesthesiologist or anesthetic personnel in the gastroenterology procedure room. Results: Sedation was provided for 222 procedures in 214 patients ranged in age from younger than 1 to 17 years and in weight from 2.7 to 80.0 kg. Intravenous sedation was provided in 176 patients (82.2%). Of these patients, 185 procedures were performed and reviewed, with 152 (82.2%) procedures were esophagogastroduodenoscopy (EGD) alone, 14 (7.6%) procedures were colonoscopy alone, 18 (9.7%) procedures were EGD and colonoscopy, and one procedure was endoscopic ultrasonography (EUS). Most common indications of the procedure were screening for esophageal varices (25.2%), abdominal pain (15.9%), history of upper gastrointestinal hemorrhage (13.6%), and unexplained anemia (10.3%). The majority of preanesthetic problems were hematologic disease, anemia (38.2%); liver disease, cirrhosis (13.5%); and electrolyte imbalance (13.5%). Propofol (94.0%), fentanyl (87.0%), and midazolam (67.8%) were frequently used. The mean dose of propofol was 7.8 ± 4.1 mg·kg−1·h−1, fentanyl 2.3 ± 1.1 mcg·kg−1·h−1, and midazolam 0.1 ± 0.1 mg·kg−1·h−1. Most of them were used in combination. The combination of propofol, fentanyl, and midazolam was commonly employed (46.4%). The mean sedation time of all procedures was 28.2 min and was different according to procedure type. Complications occurred infrequently (13.5%) and were medication or airway related. All complications were easily treated, with no adverse sequelae. Intravenous sedation was successful except for one patient who required general anesthesia. However, all procedures were completed successfully. Conclusions: In the setting of the developing country, intravenous sedation for pediatric GIE by trained anesthetic personnel with appropriate monitoring was safe and effective. Serious adverse events were rare in our population. [ABSTRACT FROM AUTHOR]

Background and Aim: The aim of the present study was to investigate the clinical effectiveness, safety, and outcome associated with the use of covered expandable Nitinol stents (Taewoong Medical, Seoul, Korea) for the treatment of malignant gastroduodenal obstructions. Methods: Between March 2001 and October 2004, covered expandable Nitinol stents were placed in 68 consecutive patients under endoscopic and fluoroscopic guidance for the following reasons: gastric carcinoma ( n = 49), recurrent carcinoma after partial gastrectomy ( n = 7), or another malignant neoplasm involving the duodenum ( n = 12). Results: Technical success was achieved in 60 of the 68 patients (88.2%). After stent placement, mean dysphagia score improved from a mean of 3.5 to 1.2 ( P < 0.001). The mean period of primary stent patency was 107.2 days. During follow up (mean 4.4 months; range, 1–15 months), major complications (migration [6], bleeding [3], perforation [1], ingrowth [1], overgrowth [7], fistula [1]) occurred in 19 patients (27.9%), and stent migration occurred in six (8.8%) (proximal migration into the stomach [ n = 3], or distal migration [ n = 3]). Recurrent dysphagia (mainly due to tumor ingrowth/overgrowth) occurred in eight patients (11.8%). Conclusion: Covered expandable Nitinol stents appear to offer an effective and feasible palliative therapy in patients with a malignant gastroduodenal obstruction. [ABSTRACT FROM AUTHOR]

Endoscopic papillary large-balloon dilation (EPLBD) has been popular worldwide for difficult stones. At the primary stage, EPLBD is done immediately after endoscopic sphincterotomy (ES) or after previous ES. Recently, several endoscopists have reported the feasibility and safety of EPLBD without ES and postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) as adverse events. Herein, we encountered a case of PEP in which EPLBD was carried out through a spontaneous fistula in the papillary roof, although there was no manipulation of the pancreatic duct. We learned a lesson from the present case in which possible PEP might occur during the procedure of EPLBD without ES. [ABSTRACT FROM AUTHOR]

An unusual case of jejunal mucosal diaphragm with enterolith causing liver dysfunction and fever in a 36-year-old man is reported. The diagnosis of jejunal mucosal diaphragm was made by panendoscopy. Treatment of the jejunal mucosal diaphragm was by dilatation of the diaphragm. The enterolith was removed by panendoscopy. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 78-year-old man early gastric cancer who was treated with the help of using endoscopic submucosal dissection (ESD) technique. It reports that the patient was conducted with a novel post-endoscopic submucosal dissection ulcer method using a polyglycolic acid sheets (PGA) and with a fibrin glue. The patient's abdominal computed tomography (CT) and endoscopy evaluation was done to detect distal or lymph node metastases.

The author discusses the development of less invasive surgery to help manage reproduction in reptiles. He mentions several endoscopic techniques that were designed for reptile reproduction including endoscopic surgery, endoscopy of the urinary bladder, and saline-infusion cystoscopy. He stresses that using endoscopic surgical techniques save veterinary surgeon's time and minimize the time necessary to maintain anaesthesia.

The article focuses on the aspects colonic polyps. Topics discussed include the most common form of colonic polyps which is the adenomatous neoplastic polyps considering its risk in high population and its recognition as pre-cursor lesion for invasive colorectal cancer, the impact of several methods on colorectal polyp management including endoscopy, endomucosal resection (EMR), and endoscopic submucosal dissection (ESD), and the challenges brought by the development of management methods.

The present paper discusses where endoscopic diagnosis and treatment will be in 10 years. The demand for gastroenterologist services is growing, driven partly by the aging population and the popularity of screening colonoscopy. Hopefully, along with better genetic and fecal markers, it will allow colonoscopy to be used much more efficiently in patients who really need it. Innovations in reduction of pressure on patients by decreasing the diameter of the electron endoscope, particularly the transnasal endoscope, are continued, in parallel with the development and research of capsule endoscopy as a tentative measure. There will be issues regarding will perform the screening test, and how the medical expenses should be established. In contrast, highly precise imaging techniques are progressing. The most important theme of endoscopic medicine is the further prevalence of and development of therapeutic endoscopy in such situation as gastroesophageal reflux disease, obesity, hemostasis, luminal stenosis, endoscopic submucosal dissection for early gastrointestinal cancer, stenting, endoscopic shincterotomy and natural orifice translumenal endoscopic surgery for pancreatic biliary or other diseases. In addition, the field of gastroenterology and gastrointestinal endoscopy will need to evolve into one of the digestive health sciences, a new multidisciplinary specialty. It will be required to have a department of digestive diseases integrating all specialists in this field. [ABSTRACT FROM AUTHOR]