Endoscopic Submucosal Dissection (ESD) Offers a Safer and More Cost-effective Alternative to Transanal Endoscopic Microsurgery (TEM): An International Collaborative Study.

BACKGROUND: Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that treat early rectal cancer (ERC). Both are effective treatments, yet there are very few studies comparing them. The aim of our study was to identify ideal candidates for each procedure. MATERIALS AND METHODS: Between January 2016 and November 2019, 204 ERC patients were managed with either ESD (n=101) or TEM (n=103) at 7 international centers. Data analyzed included clinical success, tumor characteristics, procedure info, and recurrence rates. RESULTS: Median tumor size was 40 mm±23.9 in the ESD group and 56 mm±27.9 in the TEM group, significantly larger in the latter ( P <0.00001). Average procedure time was 131.5±67.9 minutes in ESD group and 104.9±28.4 minutes in TEM group ( P =0.000347). Average hospital stay was 3.3±2.6 days in the ESD group and 4.7±0.7 days in the TEM group ( P <0.00001). Adverse event rate was 6.8% in the ESD group and 24% in the TEM group. There were no significant difference in the rate of en bloc resection, technical success, tumor location, necessity of additional procedures, and tumor recurrence rates. CONCLUSION: Compared with TEM, ESD is a safer procedure with shorter hospital stay and should be offered for patients who have ERC.

Per Oral Endoscopic Myotomy for Zenker's Diverticulum: A Novel and Superior Technique Compared With Septotomy?

INTRODUCTION: Endoscopic management of Zenker diverticuli (ZD) has traditionally been via septotomy technique. The recent development of tunneling technique has shown to be both efficacious and safe. The aim of this study is to evaluate the tunneling technique using per oral endoscopic myotomy (Z-POEM) versus septotomy. METHODS: Patients who underwent endoscopic management of ZD either by Z-POEM or septotomy from March 2017 until November 2020 from 9 international academic centers were included. Demographics, clinical data preprocedure and postprocedure, procedure time, adverse events, and hospital length of stay were analyzed. RESULTS: A total of 101 patients (mean age 74.9 y old, 55.4% male) were included: septotomy (n=49), Z-POEM (n=52). Preprocedure Functional Oral Intake Scale score and Eckardt score was 5.3 and 5.4 for the septotomy group and 5.9 and 5.15 for the Z-POEM group. Technical success was achieved in 98% of the Z-POEM group and 100% of the septotomy group. Clinical success was achieved in 84% and 92% in the septotomy versus Z-POEM groups. Adverse events occurred in 30.6% (n=15) in septotomy group versus 9.6% (n=5) in the Z-POEM group (P=0.017). Reintervention for ongoing symptoms occurred in 7 patients in the septotomy group and 3 patients in the Z-POEM group. Mean hospital length of stay was shorter for the Z-POEM group, at 1.5 versus 1.9 days. CONCLUSIONS: A tunneling technique via the Z-POEM procedure is an efficacious and safe endoscopic treatment for ZD. Z-POEM is a safer procedure with a statistically significant reduction in adverse events compared with traditional septotomy technique.

Durability of per-oral endoscopic myotomy beyond 6 years.

Background and study aims The aim of this study was to assess long-term clinical outcomes beyond 6 years in patients who underwent per-oral endoscopic myotomy (POEM) for the treatment of achalasia. Patients and methods Patients with achalasia who underwent POEM between 2010 and 2012 and had follow-up of at least 6 years were retrospectively identified at eight tertiary care centers. The primary outcome evaluated was clinical success defined by an Eckardt symptom score (ESS) ≤ 3 for the duration of the follow-up period. The clinical success cohort was compared to failure (ESS > 3 at any time during follow-up) in order to identify characteristics associated with symptom relapse. The incidence of patient-reported gastroesophageal reflux (GER) was also evaluated. Results Seventy-three patients with 6-year follow-up data were identified. Sustained clinical remission was noted in 89 % (65/73) at 6-years. Mean ESS decreased from 7.1 ±â€Š2.3 pre-procedure to 1.1 ±â€Š1.1 at 6 years ( P  < 0.001). Symptomatic reflux was reported by 27 of 72 patients (37.5 %). Type I achalasia (OR 10.8, P  = 0.04) was found to be associated with clinical failure on logistic regression analysis. Conclusions In patients with achalasia, POEM provides high initial clinical success with excellent long-term outcomes. There are high rates of patient-reported gastroesophageal reflux post-procedure which persist at long-term follow-up.

Management of patients after failed peroral endoscopic myotomy: a multicenter study.

BACKGROUND: Although peroral endoscopic myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aimed to compare the outcomes of different management strategies in patients who had failed POEM. METHODS: This was an international multicenter retrospective study at 16 tertiary centers between January 2012 and November 2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score > 3) were included. The primary outcome was to compare the rates of clinical success (Eckardt score ≤ 3) between different management strategies. RESULTS : 99 patients (50 men [50.5 %]; mean age 51.4 [standard deviation (SD) 16.2]) experienced clinical failure during the study period, with a mean (SD) Eckardt score of 5.4 (0.3). A total of 29 patients (32.2 %) were managed conservatively and 70 (71 %) underwent retreatment (repeat POEM 33 [33 %], pneumatic dilation 30 [30 %], and laparoscopic Heller myotomy (LHM) 7 [7.1 %]). During a median follow-up of 10 (interquartile range 3 - 20) months, clinical success was highest in patients who underwent repeat POEM (25 /33 [76 %]; mean [SD] Eckardt score 2.1 [2.1]), followed by pneumatic dilation (18/30 [60 %]; Eckardt score 2.8 [2.3]), and LHM (2/7 [29 %]; Eckardt score 4 [1.8]; P = 0.12). A total of 11 patients in the conservative group (37.9 %; mean Eckardt score 4 [1.8]) achieved clinical success. CONCLUSION : This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and pneumatic dilation achieved acceptable clinical success, with excellent safety profiles.

Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4†years: a multicenter study.

Background and study aims Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82 % to 100 % in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia. Methods This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4 years follow-up. Clinical response was defined by an Eckardt score ≤ 3. Results A total of 146 patients were included from 11 academic medical centers. Mean (±â€ŠSD) age was 49.8 (±â€Š16) years and 79 (54 %) were female. The most common type of achalasia was type II, seen in 70 (47.9 %) patients, followed by type I seen in 41 (28.1 %) patients. Prior treatments included: pneumatic dilation in 29 (19.9 %), botulinum toxin injection in 13 (8.9 %) and Heller myotomy in seven patients (4.8 %). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5 %). Median follow-up duration was 55 months (IQR 49.9-60.6). Clinical response was observed in 139 (95.2 %) patients at follow-up of ≥ 48 months. Symptomatic reflux after POEM was seen in 45 (32.1 %) patients, while 35.3 % of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8 % of patients who underwent endoscopy. Conclusion POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response.

Successful peroral endoscopic myotomy performed in Endoscopy Department as a radical, long-term treatment for esophageal achalasia - the Greek experience.

INTRODUCTION: Peroral endoscopic myotomy (POEM) has been considered as a minimal-invasive, innovative technique for long-term treatment of all types of esophageal achalasia and other esophageal motility disorders. PATIENTS AND METHODS: We report on 20 consecutive Greek patients with manometrically proved esophageal achalasia (14 patients with type I, 4 with type II, 2 with type III, and 4 with sigmoid esophagus), with an age range of 32-92 years, mean age 59 years, 12 males, successfully treated by POEM from 2013 to 2015. The Eckardt score was 7-12 (type III). Seventeen (85%) POEM procedures were performed in the Endoscopy Department, according to a previous study. During POEM, CO2 insufflation was mandatory, while the Triangle Tip knife was the only knife used in all procedures. Eckardt score, esophagogram and manometry before and after performing POEM were used for evaluation of our results. The follow-up period was 6 months to 3 years. RESULTS: Selective circular myotomy, 10-13 cm in length, was successfully completed in all patients without severe acute or late complications. Three patients (15%) showed moderate pneumomediastinum and pneumoperitoneum, which was successfully managed by abdominal needle drainage during the procedure. One patient showed mild pleural collection, and in one patient the clip-endoloop technique was used to successfully close the mucosal entry after the completion of POEM. The outcome was uneventful without any further clinical consequences. No other short- or long-term serious complications were reported. Patients were discharged after 1-3 days of hospitalization. Six months to 3 years after the POEM procedure, all patients were alive; the majority (90%) had complete clinical improvement, while two patients with sigmoid-type achalasia showed moderate-to-significant clinical improvement. Erosive esophagitis was reported in 15%. CONCLUSION: Our results are in accordance with international data, and proved the safety and efficacy of the POEM technique for radical long-term treatment of all types of achalasia, including end-stage sigmoid-type achalasia, in the Endoscopy Department. However, long-term follow-up is necessary and awaited.

Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection.

Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.

Endoscopic Ex Vivo Evaluation of Bile Concentrations by Narrow Band Imaging: A Pilot Study.

Background. Bile juice plays a major role in duodenogastroesophageal reflux (DGERD). Several devices to directly measure the bile concentration have been proposed. We aimed to ex-vivo evaluate the bile concentration by narrow band imaging (NBI). Method. From six surgical cholecystectomies, the content of the gallbladders was aspirated and the total biliary acid (TBA) concentration was evaluated. 2 mL was employed for serial twofold dilutions. Each dilution was scoped. Images on white light (WL) and NBI were captured and grouped accordingly to NBI-appearance and TBA-concentration. Results. Nondiluted bile had a TBA-concentration of 61965 ± 32989 µmol/L. Final dilution (1 : 4096) had 1.16 µmol/L. NBI and correspondent WL images were grouped into seven groups, and an NBI/Bile scale was created. Conclusion. The scale showed that not only NBI scale but also white light scale could be useful to predict the bile concentration. This initial study shows that NBI has a potential role in the detection of DGERD and further investigation is warranted to distinguish the presence and the concentration of bile, especially at very low TBA concentrations.

Effective optical identification of type "0-IIb" early gastric cancer with narrow band imaging magnification endoscopy, successfully treated by endoscopic submucosal dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) is currently considered the minimal invasive endoscopic treatment for early gastric cancer. Most superficial gastric neoplastic lesions are depressed type "0-IIc" (70-80%), while totally flat, classified as type "0-IIb" early gastric cancer, is rarely reported (0.4%). The aim of the present study was to assess the efficacy of narrow band imaging (NBI) magnification endoscopy in identifying type "0-IIb" early gastric cancer and ESD treatment with curative intention. METHODS: Twelve of 615 (2%) patients (10 males, median 72 years), treated by ESD at our center, were diagnosed as type "0-IIb" gastric cancer. Ten had exclusively type "0-IIb", while two had combined types "0-IIb+IIc" and "0-IIa+IIb" gastric cancer. Initial diagnosis was made during screening gastroscopy, while NBI magnification endoscopy combined with indigo-carmine chromoendoscopy were also used. RESULTS: White light endoscopy showed only superficial redness. One patient with signet-ring carcinoma showed whitish appearance. Indigo-carmine chromoendoscopy showed better visualization, while NBI magnification endoscopy revealed abnormal mucosal microsurface and microvascular findings which enabled border marking. ESD with curative intention was completed without complications. Histological examination showed complete (R0) resection, in 10 patients (83%). One patient with positive margins received additional surgery (8%). Mean procedure time was 149 (range 60-190) min. One to six years post-ESD all patients remain alive. CONCLUSIONS: ESD is considered a safe and effective curative treatment for type "0-IIb" gastric cancer, resulting in long-term disease-free survival. NBI magnification endoscopy is effective for accurate optical identification and border marking of type "0-IIb" early gastric cancer.

Magnification endoscopy in esophageal squamous cell carcinoma: a review of the intrapapillary capillary loop classification.

Recent developments in image-enhancement technology have enabled clear visualization of the microvascular structure of the esophageal mucosa. In particular, intrapapillary capillary loops (IPCLs) are observed as brown loops on magnification endoscopy with narrow-band imaging (NBI). IPCLs demonstrate characteristic morphological changes according to the structural irregularity of esophageal epithelium and cancer infiltration, summarized in the IPCL classification. In this review, the process from the first endoscopic description of IPCLs to the eventual development of the IPCL classification is described and discussed, particularly focusing on early stage squamous cell carcinoma of the esophagus.

Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: a pilot study.

BACKGROUND: In our previous case report of circumferential mucosal resection for short-segment Barrett's esophagus with high-grade dysplasia, symptoms of gastro-esophageal reflux disease (GERD) were significantly improved. This observation suggests that anti-reflux mucosectomy (ARMS) could represent an effective anti-reflux procedure, with the advantage that no artificial devices or prostheses would be left in situ. METHODS: In this pilot study, 10 patients with treatment-refractory GERD received ARMS, 2 of whom circumferential, and the remaining 8 crescentic. RESULTS: Key symptoms of GERD improved significantly after ARMS. In the DeMeester score, mean heartburn score decreased from 2.7 to 0.3 (P=0.0011), regurgitation score from 2.5 to 0.3 (P=0.0022), and total score from 5.2 to 0.67 (P=0.0011). At endoscopic examination, the flap valve grade decreased from 3.2 to 1.2 (P=0.0152). In 24-h esophageal pH monitoring the fraction of time at pH <4 improved from 29.1% to 3.1% (P=0.1). Fraction time absorbance more than >0.14 of bile reflux was controlled from 52% to 4% (P=0.05). In 2 cases of total circumferential resection, repeat balloon dilation was necessary to control stenosis. In all cases, proton pump inhibitor prescription could be discontinued with no ill effects. CONCLUSION: This initial case series demonstrated the potential anti-reflux effect of ARMS, with a crescentic mucosal resection appearing adequate. Further longitudinal study of patients without sliding hiatus hernia will be required to establish ARMS as an effective technique to control GERD in this setting.

Improved optical identification of laterally spreading type "0-IIb" gastric lesion with narrow band imaging magnification endoscopy.

Endoscopic submucosal dissection (ESD) has become the treatment of choice for early gastric cancer. Accurate identification of tumor borders is crucial for curative ESD. Narrow band imaging magnification endoscopy (NBI-ME) has been effectively used for assessment of superficial gastric lesions; however, international experience in type "0-IIb" gastric lesions is limited. Successful endoscopic tissue characterization of laterally spreading type "0-IIb" early gastric cancer in a 74-year-old male with known type "0-IIa" lesion, using zoom NBI-ME, is reported. While the type "0-IIa" gastric lesion was clearly recognized by white light endoscopy and indigo carmine chromoendoscopy, the laterally spreading type "0-IIb" gastric cancer was only identified on the basis of NBI-ME malignant microvascular and mucosal microsurface pattern. Based on NBI-ME findings, accurate border marking approximately 1 mm apart from the demarcation line and complete en bloc ESD resection of both tumors was successfully succeeded. Recovery was uneventful. Histopathology showed moderately differentiated gastric adenocarcinoma in type "0-IIa" lesion and a small area of low-grade well-differentiated gastric adenocarcinoma in type "0-IIb" lesion. Conclusively, improved real-time optical identification of laterally spreading type "0-IIb" gastric lesion was achieved with NBI-ME.

Fine-needle aspiration biopsy and endoscopic ultrasound for pretreatment pathological diagnosis of gastric gastrointestinal stromal tumors.

Background. Although it is possible to visualize gastrointestinal stromal tumors (GIST) of the stomach by endoscopy, their pretreatment histological diagnosis is often difficult. The aim of this study was to investigate predictors of accurate preoperative pathological diagnosis of gastric GIST. Material and Methods. We retrospectively studied patients with gastric GIST who had undergone pretreatment endoscopic biopsy and surgery, and examined their clinicopathological data. Results. Twenty-three patients were eligible. Thirty-four endoscopic biopsies (mean 2.6, range 1-8) were obtained. Preoperative pathological diagnoses of GIST were made in 18 patients. Precise diagnoses were made in 18 (52.9%) of the 34 biopsies. Endoscopic ultrasound (EUS) resulted in precise diagnoses in 11 (91.7%) of the 12 biopsy specimens. Fine-needle aspiration (FNA) biopsy resulted in precise diagnoses in 11 (84.6%) of the 13 biopsy specimens. The accuracy of pathological diagnosis by EUS-guided FNA biopsy was 100%. The procedure of EUS-guided FNA biopsy had no complications or recurrent disease. In a multivariate analysis, only EUS achieved a significantly superior rate of diagnosis (odds ratio, 11.884; 95% confidence interval, 1.204-289.230; P = 0.034). Conclusion. EUS-guided FNA biopsy is the most accurate for pretreatment pathological diagnosis of gastric GIST and for prevention of both of early complications and disease recurrence.

Clinicopathological characteristics and treatment strategies in early gastric cancer: a retrospective cohort study.

BACKGROUND: Both endoscopic and surgical approaches are employed in the treatment of early gastric cancer (EGC). The aim of this study was to establish appropriate treatment strategies for early gastric cancer. METHODS: We retrospectively examined clinicopathological data of EGC patients who had undergone surgery. RESULTS: A total of 327 patients (204 males and 123 females, mean age 63.2 years) were eligible for inclusion in the study. The median follow-up period was 31 months. Of 161 mucosal (pT1a) tumors, 87 were mainly undifferentiated and 110 had an undifferentiated component. Four patients with pT1a tumors had lymph node metastases; all these tumors were signet-ring cell carcinomas and were macroscopic type 0-IIc with ulceration, and only one of them had lymphatic invasion. Among patients with submucosal tumors, four of 43 patients with pT1b1 tumors and 37 of 123 patients with pT1b2 tumors had nodal metastases. Lymph node metastases were significantly higher in mixed undifferentiated type group than differentiated type group for both groups, pT1a-pT1b1 (p = 0.0251) and pT1b2 (p = 0.0430) subgroups. Only four of 45 patients with nodal metastases were diagnosed preoperatively by computed tomography (sensitivity 8.9%, specificity 96.2%). Nine patients with pT1b tumors had recurrence after surgery, and died. The sites of initial recurrence were liver, bone, peritoneum, distant nodes, and the surgical anastomosis. CONCLUSIONS: The incidence of nodal metastases was approximately 5% in undifferentiated type mucosal (pT1a) tumors, and higher in submucosal (pT1b) tumors. The sensitivity of preoperative diagnosis of nodal metastases in EGC using computed tomography was relatively low in this study. Therefore at present surgery with adequate lymphadenectomy should be performed as curative treatment for undifferentiated type EGC.