Search

Background: Peroral endoscopic myotomy (POEM) is a very effective treatment for achalasia. However, training remains non-standardized. We evaluated a training curriculum, including ex vivo cases, followed by patients' cases under expert supervision. The objective was to establish a learning curve of POEM. Materials and Methods: Four operators having completed advanced endoscopy fellowship were involved. They had already observed > 30 cases performed by experts. They performed 30 POEMs standardized (tunnel and myotomy lengths) procedures on ex vivo porcine model. Procedural times, number/volume of injections, mucosal and serous perforations, and myotomy length were collected. The learning curve was assessed using dissection speed (DS) and a dedicated performance score (PS), including learning rate (LR) and learning plateau (LP). Results: The operators completed all cases within 4 months (median of 3.5 cases/week). The mean procedural time was 43.3 min ± 14.4. Mean myotomy length was 70.0 mm ± 15.6 mm. Dissection speed averaged 1.78 mm/min ± 0.78. Using DS and PS as parameter, the LR was reached after 12.2 cases (DS = 2.0 mm/min) and 10.4 cases, respectively. When comparing the LP and the plateau phase, the DS was slower (1.3 ± 0.5 mm/min versus 2.1 ± 0.54 mm/min, p < 0.005) and perforations were decreased: 0.35 ± 0.82 in LP vs. 0.16 ± 0.44 in PP. Following this training, all operators performed 10 supervised cases and are competent in POEM. Conclusion: The association of observed cases and supervised ex vivo model training is effective for starting POEM on patients. The learning curve is 12 cases to reach a plateau. [ABSTRACT FROM AUTHOR]

Introduction: In patients with benign and refractory esophageal strictures (BES), repeating initial dilations in short intervals could be recommended, but little data are available to validate this strategy. Our aim was to evaluate long-term results of a scheduled program of repeated and sustained esophageal dilations in patients with refractory strictures. Methods: Patients with BES requiring five or more dilations were retrospectively included and divided in two groups for analysis: a SCHEDULED group (SDG) where patients were systematically rescheduled for the 5 first dilations; ON-DEMAND group (ODG) where patients were dilated only in case of recurrence of the dysphagia. Comparison between SDG and ODG was done with a 1:1 matching analysis and etiology of stricture. Clinical success was defined as the absence of dysphagia for more than a year. Results: 39 patients with refractory BES were included with post-operative stenosis in 51.2% and post-caustic injury 28.2%; 10 were in SDG and 29 in ODG. In overall analysis (39 patients), the follow-up was 64.4 ± 32 months, success rate was 79.5% and duration of treatment was 27.3 ± 20 months, and mean number of dilations was 11.7 per patient. The need for dilations decreased significantly after 18 months of treatment with an average of 0.56 dilations per semester. Self-expandable metallic stent insertion was associated with an increased rate of complications (5.9% vs 59.1% p = 0.001). In matched analysis (10 ODG vs 10 SDG patients), the duration of treatment was lower in SDG (18.8 vs 41.4 months, p = 0,032) with a higher probability of remission (survival analysis, Log-rank: p = 0,019) and the success rate did not differ between ODG and SDG patients (80% vs 90%; NS). Conclusion: Overall, long-term esophageal dilations resulted in a 79.5% success rate and the need for further dilatations decreased significantly in both groups after 18-month follow-up. A scheduled dilation program was associated with a higher probability of final success and lower treatment duration. [ABSTRACT FROM AUTHOR]

Introduction: Per-oral endoscopic myotomy (POEM) is effective in achalasia. The objective of this study was to evaluate the short-term clinical efficacy of POEM in non-achalasia esophageal motility disorders (NAEMD). Patients and methods: Patients with NAEMD diagnosed by high-resolution manometry were included in a retrospective multicentric study. For each individual case, two controls paired on gender and age were matched: one with type I/II achalasia and one with type III achalasia. The clinical response, defined by an Eckardt score ≤ 3, was assessed at 3 and 6 months. Results: Ninety patients (mean age 66 years, 57 men) were included, 30 patients with NAEMD (13 jackhammer esophagus, 6 spastic esophageal disorders, 4 nutcracker esophagus, and 7 esophagogastric junction obstruction), 30 patients with type I–II achalasia, and 30 patients with type III achalasia. The 3-month response rates were 80% (24/30), 90% (27/30), and 100% (30/30) in NAEMD, type I–II achalasia and type III achalasia, respectively (p < 0.01). Eckardt scores improved from preoperative baseline in all groups (median scores 2.0 after POEM vs. 6.5 before POEM, 1.3 vs. 7.2, and 0.5 vs. 6.1 in NAEMD, type I//I and Type III, respectively). No predictive factor of response was identified. In NAEMD patients, there was a significant improvement of dysphagia, regurgitation, and chest pain scores. The 6-month response rates were 63.2% (12/19), 95.5% (21/22), and 87.0% (20/23) in NAEMD, type I–II achalasia and type III achalasia, respectively (p = 0.03). Conclusion: Although less effective than in achalasia, POEM is an effective treatment for NAEMD. Long-term follow-up data are needed to further confirm that POEM may be a valid treatment of NAEMD. [ABSTRACT FROM AUTHOR]

Background and Aims: Epinephric diverticula are frequently associated with esophageal motility disorder. Their management implies surgery, with 15% morbidity and 3% mortality rates. Flexible endoscopy could be an effective and safer approach for treating esophageal diverticulum with motility disorder. We report our experience of seven consecutive cases treated with per-oral endoscopic submucosal septotomy and myotomy (D-POEM).Methods: Seven consecutive patients were referred for symptomatic non-zenker's esophageal diverticulum. The steps of the procedure were as follows: (i) analysis of the esophageal anatomy; (ii) vertical mucosal incision just above the upper edge of the diverticulum; (iii) submucosal tunneling by submucosal dissection, alongside the submucosal window of the diverticulum and the downstream septum; (iv) identification of the septum and the diverticular area; (v) diverticular septotomy followed by antegrade esocardial myotomy up to 2 cm below the cardia; and (vi) closure of the mucosal incision.Results: Three men and four women aged from 62 to 90 years were treated. Four patients had a diet with adapted texture before the treatment and five patients had weight loss (4 kg to 24 kg). At preoperative evaluation, all had an esophageal motility disorder at high-resolution manometry. The procedures were successfully performed in all the patients without per-operative complications. During the 30 postoperative days, no significant adverse events occurred. Three months after treatment, six patients (85%) had clinical improvement with complete or partial regression of dysphagia. All the patients stabilized or gained weight after the treatment.Conclusion: The D-POEM technique is a mini-invasive effective and safe technique to treat symptoms due to both esophageal motility disorder and distal esophageal diverticula. It could be a very interesting solution for non-surgical patients in the first time that could be extended to other patients after favorable larger series. [ABSTRACT FROM AUTHOR]

Background: Nonmalignant esophago-respiratory fistulas (ERF) are frightening clinical situations, involving surgery with high morbi-mortality rate. We described the endoscopic management of benign ERF. The aim of the study was to describe outcomes of endoscopic treatment of nonmalignant ERF and to analyze factors associated with its success.Methods: This is a retrospective study involving patients managed for benign ERF in our center between 2012 and 2016. The ERFs were classified into three groups of sizes: (I) punctiform, (II) medium, and (III) large. The primary aim was to document the endoscopic success (= fistula's healing after 6 months). The secondary objectives were characteristics of endoscopic treatment, the functional success and death, and identifying factors associated with success and death.Results: 22 patients were included. The etiologies of ERF were surgery in 12 patients, esophageal dilatation in 3, invasive ventilation in 3, radiation therapy in 2, and tracheostomy in 2. Ninety-three procedures were performed (mean of number: 4.2 ± 4.5/patient). Twenty-one patients had stent placement, eight over-the-scope clips (OTSC), and seven a combined therapy. The endoscopic success rate was 45.5% (n = 10; 67% in punctiform, 50% in medium, and 14% in large ERF), and the functional success was 55% (n = 12). Serious adverse events occurred in 9 patients (40.9%). Six patients died (27%). The persistence of the orifice after 6 months of endoscopic treatment was associated with failure (OR 44; IC95: 3.38-573.4; p = 0.004 multivariate analysis). The orifice's size was associated with mortality [71% of death if large fistulas (p = 0.001) univariate analysis].Conclusion: Endoscopic treatment of ERF leads to 45.5% of successful endoscopic closure and 55.5% of functional success, depending on fistula's orifice size. After 6 months without healing, the chances for success dramatically decrease. [ABSTRACT FROM AUTHOR]

Background: Endoscopic submucosal dissection (ESD) is increasingly being used in Asia as a minimally invasive therapy to eradicate large laterally spreading superficial tumors in the colon. To date, the learning curve and effectiveness of ex vivo simulators in colonic ESD training remain unclear. The aim of the study is to determine the learning curve of colonic ESD in an ex vivo simulator.Methods: We conducted a prospective study of colon ESD in ex vivo porcine colons in a prototype simulator. Three endoscopists with prior experience in gastric ESD but with no experience in colonic ESD each performed 30 ESD resections on standardized lesions in the rectosigmoid and left colon of the porcine simulator. Procedure time, en bloc resection status, and perforation were recorded.Results: All 90 lesions were resected using the ESD technique. The mean time of procedure was 49.6 min (standard deviation 29.6 min). The aggregate rate of perforation was 14.4% and the aggregate rate of non-en bloc resection was 5.6%. Using a composite quality score integrating complications and procedural time, it was found that there was a significant difference between two local polynomial regression lines when using a cut-point at the 9th procedure (p = 0.04), reflecting the point at which most of the learning curve is traversed.Conclusions: In this study, there were significant improvements realized in colonic ESD performance after 9 colon ESD procedures in ex vivo specimens. Although training will depend on endoscopist skill and expertise, we suggest at least 9 ex vivo procedures prior to moving to live animal or proctored training in colonic ESD. [ABSTRACT FROM AUTHOR]

Background and Aims: Anastomotic leakages are severe and often lethal adverse events of surgery for esophageal cancer. The endoscopic treatment is growing up in such indications. The aim was to evaluate the efficacy and describe the strategy of the endoscopic management of anastomotic leakages/fistulas after esophageal oncologic surgery.Methods: Single-center retrospective study on 126 patients operated for esophageal carcinomas between 2010 and 2014. Thirty-five patients with postoperative fistulas/leakages (27 %) were endoscopically managed and included. The primary endpoint was the efficacy of the endoscopic treatment. The secondary endpoints were: delays between surgery, diagnosis, endoscopy and recovery; number of procedures; material used; and adverse events rate. Uni- and multivariate analyses were carried out to determine predictive factors of success.Results: There were mostly men, with a median age of 61.7 years ± 8.9 [43-85]. 48.6 % underwent Lewis-Santy surgery and 45.7 % Akiyama's. 71.4 % patients received neo-adjuvant chemo-radiation therapy. The primary and secondary efficacy was 48.6 and 68.6 %, respectively. The delay between surgery and endoscopy was 8.5 days [6.00-18.25]. Eighty-eight percentages of the patients were treated using double-type metallic stents, with removability and migration rates of 100 and 18 %, respectively. In the other cases, we used over-the-scope clips, naso-cystic drain or combined approach. The mean number of endoscopy was 2.6 ± 1.57 [1-10]. The mortality rate was 17 %, none being related to procedures. No predictive factor of efficacy could be identified.Conclusions: The endoscopic management of leakages or fistulas after esophageal surgery reached an efficacy rate of 68.8 %, mostly using stents, without significant adverse events. The mortality rate could be decreased from 40-100 to 17 %. [ABSTRACT FROM AUTHOR]

Introduction: The management of post-operative anastomotic leakage and fistulas of the upper GI tract remains challenging. Fully covered stents are used despite a high risk of migration because of a better removability. The goal of our study was to evaluate the effectiveness of this new type of endoscopic stent in this indication. The secondary objective was to determine the ability of withdrawing this stent. Methods: Thirty-six patients treated for upper GI fistula using a double-type metallic stent (DTMS) (Taewoong, Korea) for a benign indication were included in this retrospective study. This stent associates an outer uncovered metallic stent, decreasing the risk of migration, to an inner fully covered stent that ensured its tightness. The DTMS was removed after 4 weeks of treatment. Results: Twenty-four patients had a post-operative fistula (15 sleeve gastrectomies), eight had an anastomotic leakage, and four had an esophageal perforation. Seventeen patients underwent a previous failed stenting, and fourteen had an associated treatment with OTSC clips. A final complete healing was achieved in twenty-six patients (72 %). For patients with fistulas, the overall success rate was 66.6 % (16/24) mostly in case of post sleeve fistula (80 %), and it was 75 % (6/8) for patients with anastomotic leakages (3/4). We reached a primary success (one session) in twenty-one cases (58.3 %), and a second session was required in five cases. All the stents were removed without complications after a median stenting time of 32 [20-71] days. The spontaneous migration rate was 16.6 %. Conclusion: This new double-type stent is a new and efficient way to treat post-operative fistulas and leakages in the upper GI tract. The stents were always removable despite the external uncovered part with a low migration rate. [ABSTRACT FROM AUTHOR]