Objectives
The clinical success of per‐oral endoscopic myotomy (POEM) has led to the development of a new field of ‘submucosal endoscopy’. This study aimed to evaluate the safety, efficacy, and ...limitations of per‐oral endoscopic tumor resection (POET) in the management of submucosal tumors (SMTs) in the esophagus and the gastric cardia.
Methods
POET was performed in 47 patients from January 2011 to December 2017. The indication for POET was SMTs ≤ 30 mm in minor axis diameter. Patient and tumor characteristics (age, gender, tumor location, size, and histology), operative and clinical results of POET (procedure time and completion rate, en bloc resection rate, length of hospitalization, adverse events and tumor recurrence) were analyzed retrospectively.
Results
POET was successfully completed in 43 patients (91.5%) without any major adverse events (Clavien‐Dindo IIIb‐IV). Four patients required conversion to an open surgical procedure due to suboptimal visualization during POET. Four patients underwent piecemeal resection of their SMTs including GISTs. Median follow‐up was 44 months (10–96 months), during that time, there were no incidences of tumor recurrence. Tumors that had a minor axis diameter > 30 mm or a tumor mass index (TMI) major axis diameter (mm) × minor axis diameter (mm) >1000 had a high likelihood of being converted to surgical resection.
Conclusions
POET is a safe and effective treatment for SMTs. However, in patients where the minor axis diameter is > 30 mm or the TMI > 1000, surgical excision should be considered. Furthermore, application of POET for SMTs with malignant potential should be carefully considered to ensure optimal oncologic outcomes.
Endoscopic technologies have been continuously advancing throughout the years to facilitate improvement in the detection and diagnosis of gastric lesions. With the development of different endoscopic ...diagnostic modalities for EGC, several classifications have been advocated for the evaluation of gastric lesions, aiming for an early detection and diagnosis. Sufficient knowledge on the appearance of EGC on white light endoscopy is fundamental for early detection and management. On the other hand, those superficial EGC with subtle morphological changes that are challenging to be detected with white light endoscopy may now be clearly defined by means of image-enhanced endoscopy (IEE). By combining magnifying endoscopy and IEE, irregularities in the surface structures can be evaluated and highlighted, leading to improvements in EGC diagnostic accuracy. The main scope of this review article is to offer a closer look at the different classifications of EGC based on several endoscopic diagnostic modalities, as well as to introduce readers to newer and novel classifications, specifically developed for the stomach, for the assessment and diagnosis of gastric lesions.
Objectives
Anti‐reflux mucosectomy (ARMS) and anti‐reflux mucosal ablation (ARMA) were developed as interventions for proton pump inhibitor (PPI)‐refractory/‐dependent gastroesophageal reflux disease ...(GERD). Although ARMS and ARMA are established treatments for PPI‐refractory GERD, reliance on natural healing for ulcer scar formation introduces uncertainty and bleeding risk. To address these issues, we introduced a novel approach called anti‐reflux mucoplasty (ARM‐P), which involves immediate closure of mucosal defects following mucosectomy. This pilot study aims to evaluate the safety, feasibility, and efficacy of ARM‐P.
Methods
A retrospective single‐center study was conducted using prospectively collected data from October 2022 to July 2023. Patients with PPI‐refractory/‐dependent GERD who underwent ARM‐P were included. The study evaluated technical success of ARM‐P, before and after ARM‐P GERD‐Health Related Quality of Life Questionnaire, GerdQ, and Frequency Scale for the Symptoms of GERD scores, along with PPI discontinuation and endoscopic esophagogastric junction morphology.
Results
A total of 20 patients with a median age of 61.5 years underwent the ARM‐P procedure. The procedure achieved 100% technical success without adverse events. After ARM‐P, 55.0% discontinued PPI usage and 15.0% reduced PPI dose by half. Median GERD‐Health Related Quality of Life Questionnaire score improved from 21 to 6 (P = 0.0026), median GerdQ score improved from 9 to 7 (P = 0.0022), and median Frequency Scale for the Symptoms of GERD score decreased from 16 to 7 (P = 0.0003). Median Hill's Classification significantly improved from grade III to grade I (P = 0.0001).
Conclusions
This study presents the first pilot report of ARM‐P, demonstrating its procedural safety, technical feasibility, and short‐term efficacy.
Objectives
Reports on learning curve for peroral endoscopic myotomy (POEM) in therapeutic endoscopy nonexperts are limited. We aimed to assess the number of cases required to achieve POEM proficiency ...for endoscopic submucosal dissection (ESD) experts and nonexperts.
Methods
This is a retrospective study at the largest POEM referral center in Japan. POEM between April 2014 and December 2020 were included. Nonexperts and ESD experts were divided by training phases: A, 1–20; B, 21–40; C, 41–60; D, 61–80; and E, 81–100 cases. Primary outcome was operation time, and the phase to reach target time (83 min) was investigated. Secondary outcomes were clinical success rate, adverse events, and post‐POEM gastroesophageal reflux disease (GERD).
Results
Five hundred and sixty‐six cases were performed by 14 nonexperts, and 555 cases by 15 ESD experts. As the primary outcome, operation time in nonexperts was: A, 95 (79–115.8); B, 86.5 (71–105); C, 80 (70–100); D, 73 (64.5–100.5); and E, 73.5 (57.8–88.8) min, while in ESD experts: A, 90 (74–128); B, 77 (70–92); and C, 77 (70–93.5) min (median interquartile range). Operation time decreased significantly as experience increased in both groups (P < 0.001), and nonexperts required 41–60 cases to achieve proficiency, while experts required 21–40 cases. As secondary outcomes, in nonexperts, clinical success was 96.9–100%, adverse events were 5.0–9.2%, symptomatic GERD was 11.8–26.5%, and proton pump inhibitor (PPI) intake was 11.5–18.7% in each phase. While in experts, clinical success was 96.2–100%, adverse events were 3.0–5.8%, symptomatic GERD was 14.6–22.0%, and PPI intake was 12.6–17.9%. There were no significant differences among training phases.
Conclusions
Non‐ESD experts require more cases to achieve proficiency in POEM. These results are useful for establishing POEM training programs and institutional implementation of the procedure.
Abstract
Background
The incidence of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) has been increasing. While surgical intervention with Laparoscopic Nissen ...Fundoplication remains the gold standard, less invasive anti-reflux interventions are desired. We have developed a minimally invasive anti-reflux mucosal ablation (ARMA) treatment. Herein, we report its technical details and describe its feasibility, safety, and efficacy in PPI-refractory GERD.
Methods
We conducted a prospective single-center single-arm interventional trial evaluating the outcome of ARMA in 12 patients with PPI-refractory GERD. GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) evaluation, Frequency Scale for the Symptoms of GERD (FSSG) assessment, and impedance-pH monitoring were performed at baseline and at 2 months post-ARMA.
Results
A total of 12 patients underwent ARMA with a median follow-up duration of 9 months (range: 6 – 14 months). Median GERD-HRQL score significantly improved from 30.5 to 12 (
P
= 0.002); median FSSG score significantly improved from 25 to 10.5 (
P
= 0.002), and median DeMeester score decreased from 33.5 to 2.8 (
P
= 0.049) at 2 months follow-up. No immediate complications were observed.
Conclusion
Our pilot study has shown that ARMA, a new endoscopic treatment for PPI-refractory GERD, is simple, safe, and improves GERD-related symptoms and objective acid reflux parameters.
Objectives
Endoscopic pressure study integrated system (EPSIS) is a novel diagnostic tool for gastroesophageal reflux disease (GERD). EPSIS has been developed to evaluate lower esophageal sphincter ...function by monitoring the intragastric pressure (IGP) while insufflating the stomach during gastroscopy. Based on previous data, EPSIS could diagnose GERD with good accuracy by assessing IGP waveform pattern. This study aimed to further characterize the waveform to improve the diagnostic yield of EPSIS.
Methods
We conducted a retrospective analysis of patients with typical GERD symptoms who underwent both EPSIS and 24‐h impedance‐pH monitoring (MII‐pH) at a single tertiary referral center from October 2018 to May 2020. EPSIS was performed by using a through‐the‐scope catheter connected to the pressure measuring system (TR‐W550, TR‐TeH08, AP‐C35; Keyence, Osaka, Japan) to monitor IGP. Abnormal acid reflux was defined as acid exposure time (AET) over 6.0%. Pressure waveform was characterized as follows: (i) Basal IGP, (ii) Maximum IGP, (iii) Pressure difference, (iv) Gradient of the waveform.
Results
A total of 57 patients with GERD symptoms were analyzed. Twenty‐one patients presented abnormal AET on MII‐pH. Among EPSIS parameters, pressure difference during insufflation correlated with AET (ρ = −0.66, P < 0.01) and showed the best diagnostic accuracy for AET with the cutoff value of 4.7 mmHg (area under the curve AUC, 0.87). The gradient of EPSIS waveform also revealed good diagnostic accuracy for abnormal AET with the cutoff value of 0.07 mmHg/s (AUC, 0.81).
Conclusions
Endoscopic pressure study integrated system waveform parameters, especially pressure difference, presented high diagnostic accuracy for the presence of abnormal acid reflux.
Endoscopic pressure study integrated system (EPSIS) is a novel tool for the diagnosis of gastroesophageal reflux disease. It enables the evaluation of the function of the lower esophageal sphincter ...by monitoring intragastric pressure (IGP) while insufflating the stomach during esophagogastroduodenoscopy. EPSIS can predict abnormal acid reflux with high accuracy based on previous studies. IGP was measured by inserting through the working channel of the scope an intragastric catheter connected to a pressure measuring device. Herein, we assess the feasibility of an updated EPSIS system, which can be performed just by connecting a flush tube to the working channel. This method does not require inserting foreign objects in the stomach and spares catheter insertion in order to simplify the procedure and reduce costs. A single‐center pilot study was conducted to evaluate the association between catheter‐based EPSIS and the updated EPSIS. The results of EPSIS in 20 patients who underwent both methods were assessed. In all cases, the waveform pattern of IGP measured by catheter‐based EPSIS and updated EPSIS was consistent with 15 uphill pattern and five flat pattern. Intraobserver agreement of waveform pattern was perfect between two examiners with kappa value = 1. Intraclass correlation coefficient (ICC) for intraobserver reliability for maximum IGP was excellent with 0.91 (95% confidence interval CI of 0.77 < ICC < 0.96) and for pressure gradient was also good with 0.89 (95% CI of 0.71 < ICC < 0.95). In conclusion, our study suggests that the updated EPSIS can be performed without the use of a catheter.
Objectives
Endocytoscopy (EC) is an ultra‐high magnification endoscopy designed to provide in vivo histologic assessment. This study aimed to evaluate the diagnostic yield of the newly developed ...fourth‐generation EC for esophageal squamous lesions by using a modified EC classification.
Methods
A total of 2548 EC images of 57 esophageal targeted areas between June 2015 and October 2017 were retrospectively collected. Two lesions with low‐quality images were excluded. Only EC images were independently reviewed by two expert and two non‐expert endoscopists. The lesions were classified according to a three‐tier modified EC classification. We used a multilevel logistic regression to analyze the data.
Results
The sensitivity and specificity of diagnosing non‐squamous cell cancer (SCC) vs SCC were 82.5% and 83.0% by the experts; 90.1% and 75.0% by non‐experts. The interobserver agreement among the four raters was good (kappa statistic 0.59). The diagnostic accuracy of experts and non‐experts was similar (P = 0.16 for specificity and P = 0.20 for sensitivity). The sensitivity and specificity of EC for non‐neoplasia vs neoplasia were 88.7% and 74.6% by experts; 90.3 and 52.1% by non‐experts. The interobserver agreement among the four raters was moderate (kappa statistic 0.44). The specificity of experts was higher compared to non‐experts, although the difference did not reach statistical significance (P = 0.08 for specificity and P = 0.93 for sensitivity).
Conclusions
Fourth‐generation EC offers acceptable diagnostic accuracy and reliability in both experts and non‐experts, especially when diagnosing SCC lesions.
Endoscopic balloon dilatation is an established treatment for benign gastrointestinal strictures. In order to dilatate safely, it is necessary to dilatate gradually and preferably under direct ...endoscopic visualization. However, it is currently difficult to achieve dilatation widths of 20–30 mm with commercial products and of over 30‐mm with endoscopic visualization. Therefore, a safe and innovative application technique is needed for patients who need these 20‐mm or greater dilatation widths. We have developed two methods that enable more than 20‐mm dilatation under direct visualization. (i) Single‐barrel method: an endoscopic balloon dilatation catheter was fixed with grasping forceps at the tip of the endoscope and carried into the stomach. The balloon catheter was released from the endoscope to create a retroflexed view. The endoscope and balloon were positioned adjacent to each other at the gastric cardia. The balloon was inflated gradually and the esophagogastric junction was dilatated under direct visualization. (ii) Double‐barrel method: the same procedure was repeated with two balloons. Theoretically, we achieved a dilatation of >30‐mm in diameter. These modified methods may be helpful for esophagogastric junction strictures, such as esophageal achalasia (serving as an initial endoscopic balloon dilatation prior to using a 30‐mm achalasia balloon), or for functional strictures after Nissen fundoplication. In conclusion, our simple, modified method enables safe and gradual dilatation under direct endoscopic visualization. Additionally, combination of the sizes of one or two balloons can achieve various widths of dilatation.
Objectives
Per‐oral endoscopic myotomy (POEM) is a safe and effective treatment for achalasia and esophageal motility disorders. The role of second‐look endoscopy (SE) on postoperative day 1 has not ...been examined. This study aimed to evaluate the findings and need of SE after POEM.
Methods
This is a single‐center, retrospective study. All consecutive patients who underwent POEM and SE on postoperative day 1 between December 2017 and September 2019 were included. The primary endpoint was the rate of newly‐detected adverse events (nAE) during SE that required endoscopic intervention or deviation from the normal postoperative course. Multivariate logistic regression was used to identify predictors of nAE.
Results
Four‐hundred‐ninety‐seven patients (mean age, 50.3 years; female, 49.9%) were included. SE identified abnormal findings in a total of 71 patients (14.3%). nAE which required endoscopic intervention or deviation from the normal postoperative course were identified in 12 patients (2.4%): eight (1.6%) entry site dehiscence; two (0.4%) submucosal hemorrhage or hematoma; and two (0.4%) dehiscence of an intraoperative perforation site after endoclip closure. Other findings such as mucosal thermal damage without perforation and small submucosal hematoma were found in 54 patients (10.9%) and five patients (1.0%), respectively. Multivariate analysis showed that longer operation time and intraoperative adverse events (AE) were associated with clinically significant nAE during SE.
Conclusions
Second‐look endoscopy can detect and treat nAE that may lead to severe AE. Thus, SE should be highly considered before starting oral ingestion in all cases, and especially in those who present an intraoperative AE and longer operation time.
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