Per-Oral Endoscopic Myotomy: A Series of 500 Patients Inoue, Haruhiro, MD, PhD; Sato, Hiroki, MD, PhD; Ikeda, Haruo, MD ...
Journal of the American College of Surgeons,
08/2015, Volume:
221, Issue:
2
Journal Article
Peer reviewed
Background After the first case of per-oral endoscopic myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical myotomy and is now established as an ...excellent treatment option for achalasia. This study aimed to examine the safety and outcomes of POEM at our institution. Study Design Per-oral endoscopic myotomy was performed on 500 consecutive achalasia patients at our institution between September 2008 and November 2013. A review of prospectively collected data was conducted, including procedure time, myotomy location and length, adverse events, and patient data with short- (2 months) and long-term (1 and 3 years) follow-up. Results Per-oral endoscopic myotomy was successfully completed in all patients, with adverse events observed in 3.2%. Two months post-POEM, significant reductions in symptom scores (Eckardt score 6.0 ± 3.0 vs 1.0 ± 2.0, p < 0.0001) and lower esophageal sphincter (LES) pressures (25.4 ± 17.1 vs 13.4 ± 5.9 mmHg, p < 0.0001) were achieved, and this persisted at 3 years post-POEM. Gastroesophageal reflux was seen in 16.8% of patients at 2 months and 21.3% at 3-year follow-up. Conclusions Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy.
Background Surgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is ...controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. Study Design A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line “rescue” treatment, and only if PBD failed were patients considered for rescue POEM. Results The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed. Conclusions Short-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited.
Background We previously reported on the efficacy of endocytoscopic classification (EC-C). However, the correlation of the endocytoscopic vascular (EC-V) pattern with diagnoses was unclear. Objective ...To assess the diagnostic accuracy of the EC-V pattern for colorectal lesions. Design Retrospective. Setting A university hospital. Patients Patients who underwent endocytoscopy between January 2010 and March 2013. Intervention We evaluated 198 consecutive lesions according to the EC-V pattern (EC-V1, obscure surface microvessels; EC-V2, clearly observed surface microvessels of a uniform caliber and arrangement; and EC-V3, dilated surface microvessels of a nonhomogeneous caliber or arrangement). Main Outcome Measurements The diagnostic accuracy for predicting hyperplastic polyps and invasive cancer were compared between the EC-V pattern and other modalities (narrow-band imaging, pit pattern, and EC-C). Results The sensitivity, specificity, and accuracy of the EC-V1 pattern for diagnosing hyperplastic polyps were 95.5%, 99.4%, and 99.0%, respectively. The sensitivity, specificity, and accuracy of the EC-V3 pattern for diagnosing invasive cancer were 74.6%, 97.2%, and 88.6%, respectively. The diagnostic accuracy of the EC-V pattern for predicting hyperplastic polyps was comparable to the other modalities. For predicting invasive cancer, the EC-V pattern was comparable to narrow-band imaging and pit pattern, although EC-C was slightly more accurate ( P = .04). In the substudy, the diagnosis time by using the EC-V pattern was shorter than that with the EC-C pattern ( P < .001). Limitations A single-center, retrospective study. Conclusions The EC-V pattern saved more time than the EC-C pattern and had a diagnostic ability comparable to that of other optical biopsy modalities.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background and Aims We investigated endocytoscopy (EC) findings that were considered risk factors for colorectal neoplasms and determined whether they could be used as new indices to identify ...carcinomas with massive submucosal invasion (SM-m) or worse outcomes. Methods We performed a multivariate analysis of 8 factors on EC images to determine whether they were associated with SM-m or worse. Based on the results, we divided the EC3a category of the EC classification into low grade or high grade and investigated the diagnostic accuracy of this subclassification. In addition, we compared the diagnostic ability of EC for SM-m with that of other modalities (narrow-band imaging and pit pattern). Results The multivariate analysis indicated that unclear glandular lumens (ULs), high degree of nuclear enlargement (HNE), and multilayered nuclei (MNs) were the most useful factors for the diagnosis of SM-m or worse. The odds ratios for these factors were 12.47, 12.29, and 10.48, respectively ( P < .001). The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and positive likelihood ratio for the diagnostic accuracy of the EC3a subclassification were 88.9%, 91.3%, 75.0%, 96.6%, 90.8%, and 10.2, respectively ( P < .001). The sensitivity, negative predictive value, and accuracy of EC were significantly higher than those of narrow-band imaging and pit pattern. Conclusions From the EC findings, the presence of ULs, HNE, and MNs are important risk factors for SM-m or worse outcomes. Furthermore, the EC3a subclassification taking these findings into consideration could be effective for the diagnosis of SM-m or worse. (Clinical trial registration number: UMIN 000014906.)
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Endocytoscopy enables in vivo observation of nuclei at 450× magnification during GI endoscopy, thus allowing precise prediction of lesion pathology. However, because it requires training ...and experience, it may be beneficial only when performed by expert endoscopists. Objective To develop and evaluate a novel computer-aided diagnosis system for endocytoscopic imaging (EC-CAD) of colorectal lesions. Design Pilot study. Setting University hospital. Patients One hundred fifty-two patients with small colorectal polyps (≤10 mm) who had undergone endocytoscopy. Intervention Test sets of white-light endoscopic images and endocytoscopic images from 176 small colorectal polyps (137 neoplastic and 39 non-neoplastic polyps) were assessed by EC-CAD, 2 expert endoscopists, and 2 trainee endoscopists. Main Outcome Measurement Sensitivity, specificity, and accuracy in predicting neoplastic change by EC-CAD comparing expert and trainee endoscopists. Results EC-CAD had a sensitivity of 92.0% and an accuracy of 89.2%; these were comparable to those achieved by expert endoscopists (92.7% and 92.3%; P = .868 and .256, respectively) and significantly higher than those achieved by trainee endoscopists (81.8% and 80.4%; P < .001 and .002, respectively). EC-CAD achieved a specificity of 79.5%; this did not differ significantly from that achieved by the experts and trainees. EC-CAD also enabled instant diagnosis, taking only 0.3 seconds for each lesion with perfect reproducibility. Limitations No sample size calculation. Conclusions EC-CAD provides fully automated instant classification of colorectal polyps with excellent sensitivity, accuracy, and objectivity. Thus, it can be a powerful tool for facilitating decision making during routine colonoscopy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Recent technological advances have allowed superficially spreading intramucosal carcinomas of the esophagus to be successfully resected by circumferential endoscopic submucosal dissection ...(cESD). After this procedure, esophageal strictures develop in most patients and are mainly treated by endoscopic balloon dilation (EBD). Objective To compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD. Design Retrospective cohort study. Setting Tertiary-care referral center. Patients We studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barrett's esophagus). Intervention After cESD, patients were managed with EBD alone (EBD, n = 13) or with EBD and oral prednisolone (steroid + EBD, n = 10), 30 mg daily, started 2 days after cESD and gradually tapered and discontinued after 8 weeks. Main Outcome Measurements Total number of EBD sessions and total EBD period (months). Results Steroid + EBD patients required fewer sessions (13.8 ± 6.9 vs 33.5 ± 22.9; P < .001) and a shorter management period (4.8 ± 2.3 vs 14.2 ± 17.5 months, P = .005) compared with the EBD group. An additional 3 patients received oral steroids a mean interval of 158 days after cESD. These patients required more EBD sessions (46.3 ± 30.0; P = .002), and the EBD period was significantly longer (17.5 ± 13.0 months; P = .005) than in the early steroid + EBD group. Limitations Nonrandomized study; retrospective analysis. Conclusion After cESD, oral steroid therapy dramatically reduced the need for EBD. We conclude that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete cESD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Narrow-band imaging (NBI) emphasizes the surface microvasculature of the GI tract and may help in detecting small neoplasms. Objective The aim of this study was to clarify the value of the ...NBI system in tissue characterization and differential diagnosis. Design A prospective study. Setting Digestive Disease Center of Showa University Northern Yokohama Hospital. Patients The subjects were 495 patients who, from January 2006 to June 2007, underwent a complete colonoscopic examination. A total of 617 lesions were evaluated in the 495 patients (33 hyperplastic polyps, 532 adenomas, 52 submucosally invasive T1 cancers). Results Most hyperplastic polyps showed a faint pattern. The vascular patterns of adenomas were mainly the network pattern or the dense pattern. The major vascular patterns of cancers were the irregular pattern and the sparse pattern. The irregular pattern was characteristic for protruded or flat-elevated cancers, whereas the sparse pattern was unique for depressed cancers. When we assumed that the faint pattern was diagnostic for hyperplastic polyps, we could differentiate between neoplastic and non-neoplastic lesions with a sensitivity of 90.9% and a specificity of 97.1%. Likewise, irregular and sparse patterns were assumed to be indices of massively invasive submucosal cancer, the sensitivity was 100%, the specificity was 95.8%, and the accuracy rate was 96.1%. Limitations This study was performed at a single center. Conclusions The NBI system was valuable for distinguishing between neoplastic and non-neoplastic lesions, as well as between cancers and adenomas. Vascular pattern analysis can also be a promising tool for determining treatment selection, either endoscopy or surgery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background and Aims Per-oral endoscopic myotomy (POEM) has shown promising safety and efficacy in short-term studies. However, long-term follow-up data are very limited. The aims of this study were ...to assess (1) clinical outcome of patients with a minimum post-POEM follow-up of 2 years and (2) factors associated with long-term clinical failure after POEM. Methods A retrospective chart review was performed that included all consecutive patients with achalasia who underwent POEM with a minimum follow-up of 2 years at 10 tertiary-care centers. Clinical response was defined by a decrease in Eckardt score to 3 or lower. Results A total of 205 patients (45.8% men; mean age, 49 years) were followed for a median of 31 months (interquartile range, 26-38 months). Of these, 81 patients (39.5%) had received previous treatment for achalasia before POEM. Clinical success was achieved in 98% (185/189), 98% (142/144), and 91% (187/205) of patients with follow-up within 6 months, at 12 months, and ≥24 months, respectively. Of 185 patients with clinical response at 6 months, 11 (6%) experienced recurrent symptoms at 2 years. History of previous pneumatic dilation was associated with long-term treatment failure (odds ratio, 3.41; 95% confidence interval, 1.25-9.23). Procedure-related adverse events occurred in 8.2% of patients and only 1 patient required surgical intervention. Abnormal esophageal acid exposure and reflux esophagitis were documented in 37.5% and 18% of patients, respectively. However, these rates are simply a reference number among a very selective group of patients. Conclusions POEM is safe and provides high initial clinical success and excellent long-term outcomes. Among patients with confirmed clinical response within 6 months, 6% had recurrent symptoms by 2 years.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Peroral endoscopic myotomy (POEM) has been developed as an incisionless, minimally invasive endoscopic treatment intending a permanent cure for esophageal achalasia. The concept of endoscopic myotomy ...was first reported about 3 decades ago, but the direct incision method through the mucosal layer was not considered to be a safe and reliable approach. A novel method of endoscopic myotomy was developed and established by the authors. In this article, the current techniques, applications, and clinical results of POEM are described.
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