Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience.

Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.

Impact of endoscopic assessment and treatment on operative and non-operative management of acute oesophageal perforation.

BACKGROUND: Surgeons have not typically utilized an endoscopic approach for diagnosis and management of acute oesophageal perforation, mainly due to fears of increased mediastinal contamination. This study assessed the evolution of endoscopic approaches and their effect on outcomes over time in acute oesophageal perforation. METHODS: All patients with documented acute oesophageal perforation between 1990 and 2009 were enrolled prospectively in an Institutional Review Board-approved database. RESULTS: Of 81 patients who presented during the study period, 52 had upper gastrointestinal endoscopy for diagnosis alone (12 patients; 23 per cent) or as a component of acute management (40 patients; 77 per cent). Use of endoscopy increased from four of 13 patients in the first 5 years of the study to 20 of 24 patients in the final 5 years. Endoscopy was used in conjunction with surgery in 28 patients, of whom 21 underwent primary repair, three had resection, and one a diversion; 12 patients in this group had hybrid operations (combination of surgical and endoscopic management). Primary endoscopic treatment was used in 15 patients (29 per cent), most commonly involving stent placement (7). Of those having endoscopy, complication rates improved (from 3 of 4 to 8 of 20 patients), as did mean length of stay (from 21·8 to 13·4 days) between the initial and final 5 years of the study. There were two deaths (4 per cent). Of 21 patients who had both endoscopic assessment and management in the operating room, endoscopy identified additional pathology in ten, leading to a change in management plan in five patients. CONCLUSION: Endoscopy is a safe and important component of the management of acute oesophageal perforation. It provides additional information that modifies treatment, and its wider use should result in improved outcomes.

Esophageal reconstitution by simultaneous antegrade/retrograde endoscopy: re-establishing patency of the completely obstructed esophagus.

Complete obstruction of the proximal esophagus is an uncommon complication of radiotherapy. Standard endoscopic dilation is not possible because no lumen exists. We describe a retrospective case series in which rendezvous endoscopy, tissue puncture, dilation, and stenting were used to restore function to a group of patients with complete esophageal obstruction. The series consisted of patients referred for complete esophageal obstruction after radiation therapy over 5 years. Ultimately, five patients underwent successful initial recanalization via rendezvous endoscopy. All patients were able to resume eating and four have been able to maintain oral alimentation with periodic dilation. One patient developed self-limited pneumomediastinum after needle puncture and cervical osteomyelitis after stenting, and another developed an anterior neck abscess after stenting. Rendezvous endoscopy can successfully treat complete esophageal obstruction resulting from radiation therapy. Temporary stenting may allow patients to swallow immediately and leave the hospital sooner but does not appear to reduce the need for subsequent dilation and may result in serious complications.

Polyflex self-expanding, removable plastic stents: assessment of treatment efficacy and safety in a variety of benign and malignant conditions of the esophagus.

BACKGROUND: Historically, esophageal fistulas, perforations, and benign and malignant strictures have been managed surgically or with the placement of permanent endoprostheses or metallic stents. Recently, a removable, self-expanding, plastic stent has become available. The authors investigated the use of this new stent at their institution. METHODS: The study reviewed all the patients who received a Polyflex stent for an esophageal indication at the authors' institution between January 2004 and October 2006. Duration of placement, complications, and treatment efficacy were recorded. RESULTS: A total of 37 stents were placed in 30 patients (14 women and 16 men) with a mean age of 68 years (range, 28-92 years). Stent placement included 7 for fistulas, 3 for perforations, 1 for an anastomotic leak, 7 for malignant strictures, and 19 for benign strictures (8 anastomotic, 1 caustic, 5 reflux, 2 radiation, and 2 autoimmune esophagitis strictures, and 1 post-Nissen gas bloat stricture). The mean follow-up period was 6 months. Stent deployment was successful for all the patients, and no complications resulted from stent placement or removal. Nine stents migrated spontaneously. Three of three perforations and three of five fistulas sealed. Only one stent was removed because of patient discomfort. One patient with a radiation stricture experienced tracheoesophageal fistulas secondary to pressure necrosis. Of 20 patients with stricture, 18 experienced improvement in their dysphagia. CONCLUSION: Self-expanding, removable plastic stents are easily and safely placed and removed from the esophagus. This has facilitated their use in the authors' institution for an increasing number of esophageal conditions. Further studies to help define their ultimate role in benign and malignant esophageal pathology are warranted.

Endoscopic full-thickness plication for the treatment of GERD: long-term multicenter results.

BACKGROUND: The purpose of the present study was to assess the long-term safety and durability of effect for endoscopic full-thickness plication for the treatment of symptomatic gastroesophageal reflux disease (GERD). The Plicator (NDO Surgical, Inc., Mansfield, MA) used delivers a transmural suture through the gastric cardia to restructure the antireflux barrier. Published reports have shown the Plicator procedure to be effective in reducing GERD symptoms and medication use at 1 year post-plication. METHODS: Twenty-nine patients with chronic heartburn requiring maintenance daily anti-secretory therapy were treated at five sites. Patients received a single full-thickness plication in the gastric cardia 1cm below the gastroesophageal junction (GE) junction. Re-treatments were not permitted. Patients were evaluated at baseline for GERD symptoms and medication use. Intermediate (12 month) and long-term subject follow-up (median follow-up: 36.4 months; range, 31.2-43.9 months) were completed to evaluate procedure safety and durability of effect. RESULTS: Twenty-nine patients completed the 12-month and 36-month follow-up. All procedure-related adverse events occurred acutely, and no new events were observed during extended follow-up. At 36-months post-procedure, 57% (16/28) of baseline proton pump inhibitor (PPI)-dependent patients remained off daily PPI therapy. Treatment effect remained stable from 12- to 36-months, with 21/29 patients off daily PPI at 12 months compared to 17/29 patients at 36-months. Median GERD- Health Related Quality of Life (HRQL) scores remained significantly improved at 36 months versus baseline off-meds scores (8 versus 19, p < 0.001). In addition, the proportion of patients achieving > or = 50% improvement in GERD-HRQL score was consistent from 12 months (59%) to 36 months (55%). CONCLUSIONS: Endoscopic full-thickness plication can reduce GERD symptoms and medication use for at least 3-years post-procedure. Treatment effect is stable from 1 to 3 years, and there are no long-term procedural adverse effects.

Pancreatic ERCP.

Like biliary endoscopy, pancreatic endoscopic retrograde pancreatography (ERCP) has evolved from being a diagnostic procedure to a therapeutic one. The advent of magnetic resonance cholangiopancreatography and endoscopic ultrasonography have limited the need for anatomic definition and transpapillary tissue sampling, respectively. This review is therefore limited to studies published during the past year concerned either with efforts to limit the incidence of post-ERCP pancreatitis or with critical reviews of therapeutic pancreatography, including the treatment of strictures, stones, and ductal disruption.

Therapeutic pancreatic endoscopy.

Over the past decade, endoscopic retrograde cholangiopancreatography (ERCP) has developed from being a diagnostic tool to become one that is primarily used to provide therapy. This development occurred first for biliary disorders and more recently for primary diseases of the pancreas. Not only can new-generation computed tomography (CT), magnetic resonance imaging, and magnetic resonance cholangiopancreatography procedures suggest a diagnosis in the majority of individuals with pancreatic diseases today; in addition, ERCP-related complications can be minimized or avoided altogether in conjunction with positron-emission tomography or directed cytology or biopsy, either using ultrasound or CT guidance, or with tissue obtained during endoscopic ultrasonography. It is against this background that papers on therapeutic pancreatic endoscopy published during approximately the last year are reviewed here. Despite these developments, however, the following three issues concerning current advances in pancreatic endotherapy should be emphasized: firstly, most of the techniques reviewed here affect only a small number of patients; secondly, most of the techniques have been reported only by expert centers; and thirdly, most of the studies concerned have lacked control groups, and there is still a paucity of studies investigating endoscopic techniques on a randomized basis in comparison with surgery or medical therapy for the treatment of most benign and malignant pancreatic disorders.

Endoscopic palliation of esophageal malignancy.

Historically, the development and marketing of the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser was associated with the insertion of markedly fewer conventional prostheses for the palliation of malignant dysphagia. Subsequently, the introduction of self-expandable metal stents (SEMS) has, in turn, led to a diminished role not only for laser therapy but also for other ablative modalities, including bipolar cautery, argon plasma coagulation (APC), and the injection of caustics. Two ablative modalities deserve ongoing consideration, but not because they have been proven to be better or more cost-effective than SEMS. These include photodynamic therapy (PDT), because of its potential to ablate large areas of low-grade malignancy, and injection of chemotherapeutic agents or T-lymphocytes sensitized to an individual malignancy. The latter, while theoretically promising, will require considerably more study before widespread clinical application.

Removal of esophageal expandable metal stents: description of technique and review of potential applications.

BACKGROUND: Expandable metallic stents (EMS) have seen wide application in patients with malignant stricture and fistulas. They have not seen wide application for benign disease because of concern over acute complications and long-term sequelae. METHODS: Between June 1999 and October 2000, six patients with EMS in place for malignant stricture (n = 3), benign stricture (n = 1), anastomotic leak (n = 1) and benign esophagorespiratory fistula (n = 1) had their stents endoscopically removed. Removal was performed secondarily to the following complications: secondary stricture (n = 1), epidural abscess (n = 1), diskitis (n = 1), resolution of fistula (n = 2), and resolution of anastomotic leak (n = 1). RESULTS: Four patients had one EMS: Ultraflex (n = 3) and Z-stent (n = 1). In two patients, two stents (Ultraflex and Z-stent) were retrieved simultaneously. No procedurally related complications occurred. Two patients with esophageal cancer required additional stents. All three patients with benign fistula and stricture recovered uneventfully. CONCLUSIONS: The safe removal of current brands of EMS may facilitate the wider application of these devices to include selective patients with benign disease.

Therapeutic pancreatic endoscopy.

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of pancreatic diseases is continuing to evolve. This article reviews recent publications spanning a wide range of topics related to therapeutic pancreatic endoscopy: Over the last 12 months, several case series have added to the literature on the short-term and long-term effectiveness of endoscopic therapy of pseudocysts, pancreatic abscesses and fistulas. Identification of a communication between pancreatic duct and a pseudocyst has been suggested to predict response to percutaneous drainage. The importance of identifying pancreatic leaks in patients with severe pancreatitis has been stressed. In addition, endotherapy has been reported to be effective in patients with idiopathic chronic pancreatitis. Endoscopic removal of pancreatic stones after extracorporeal lithotripsy has been shown to result in long-term improvement in clinical outcomes in patients with chronic calcific pancreatitis. Other interesting publications addressed new techniques and tricks to achieve access to the difficult pancreatic duct. Finally, no review of pancreatic endotherapy would be complete without a reminder--as recently stated by a National Institutes of Health consensus panel--that there is considerable need for higher-quality and controlled trials in this and other areas of interventional endoscopy.