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Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence., Competing Interests: Declaration of competing interest Mouen Khashab: consultant for Boston Scientific, Olympus, and Medtronic. Rami El Abiad: none. Munish Ashat: none., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Benign biliary strictures (BBS) ensue from inflammatory conditions (e.g., chronic pancreatitis) or post surgery (e.g., cholecystectomy and liver transplant). High-quality cross-sectional imaging studies such as computed tomography or magnetic resonance cholangiopancre atography are essential in the diagnosis and planning of therapeutic interventions and in ruling out malignancy. Endoscopic retrograde cholangiopancreatography with dilation and stenting is the mainstay treatment for BBS, while surgery is reserved for failed endoscopy or refractory cases.

Background: Glenoid bone loss (GBL) is common in patients with shoulder instability and plays a major role in surgical decision-making. While a plethora of GBL estimation methods exist, all of which present specific challenges, recent studies have developed simple linear formulas estimating GBL based on glenoid height., Purpose: To assess the correlation between glenoid height and width, and to develop specific formulas based on age and sex to calculate the native glenoid width in the Lebanese population., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Computed tomography scans for 202 normal shoulders were extracted from our database. The glenoids were reconstructed in 3 dimensions and their width and height were measured. Glenoid width and height were compared between male and female groups. Correlation analysis was also performed on the width, height, age, and body mass index. Formulas estimating glenoid width were developed using regression analysis including all variables significantly influencing the model. Results were then compared with the values calculated using previously published formulas to determine the external validity when using linear formulas to estimate GBL., Results: Significant differences were found between men and women. Regression analysis found that glenoid height and width strongly influenced the model, and that age showed a weak but significant correlation; therefore, the following 2 sex-specific formulas were developed: width (mm) = 6.1 + 0.51 × height + 0.03 × age , and width (mm) = 4.55 + 0.51 × height + 0.03 × age , in men and women, respectively. The values yielded from the formulas developed in this study and the true width significantly differed from those calculated from previous reports., Conclusion: A strong correlation was found between glenoid height and width in a the Lebanese population and demonstrated that glenoid width can be accurately calculated based on the glenoid height and patient's age and sex using the following simplified formulas: width (mm) = 6 + 0.5 × height + 0.03 × age , and width (mm) = 4.5 + 0.5 × height + 0.03 × age , in men and women, respectively., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Interventional endoscopic ultrasound has fueled remarkable advancements in the field of therapeutic procedures, revolutionizing minimally invasive interventions for a diverse range of conditions. This review highlights the latest breakthroughs and advancements in therapeutic endoscopic ultrasound, showcasing its potential to transform patient care., (Copyright © 2023 by The American College of Gastroenterology.)

Purpose of Review: Gastric outlet obstruction (GOO) occurs from benign or malignant causes. Historically, the treatment of benign strictures revolved around endoscopic balloon dilation, whereas, in the case of malignant strictures, the placement of self-expandable metallic stents was the focus. The advent of lumen-apposing metal stent has opened new horizons in addressing shortcomings of enteral stenting and surgical gastroenterostomies. The purpose of the review is to discuss the endoscopic approaches to small bowel strictures and to examine the supporting data behind each practice., Recent Findings: Given the risk and futility of balloon dilation for malignant strictures, enteral stenting is pursued in patients who are poor surgical candidates and with life expectancy less than 6 months. For patients with longer survival, surgical gastroenterostomy (S-GE) should be considered. Recent data have shown comparable technical and clinical success rates between EUS-gastroenterostomy and S-GE but with lower adverse event rate and hospital length of stay., Summary: In recurrent benign strictures and malignant GOO, EUS-GE has recently gained momentum in providing an effective and a well tolerated alternative. Individualized therapy centered around the patient's prognosis and preference while factoring in the local expertise for the specific indication is vital., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Zenker diverticulum (ZD) is the most common hypopharyngeal diverticulum seen often in septuagenarian and octogenarian males. Oropharyngeal dysphagia is the most common presenting symptom. Treatment of ZD has been advancing with the introduction of a wide variety of accessory devices, primarily focusing on obliteration of the septum by complete transection of the cricopharyngeus muscle to recreate the common cavity and restore normal pharyngo-esophageal bolus outflow. This review aimed to provide an overview of the various surgical and endoscopic treatment options for ZD, while focusing specifically on Zenker peroral endoscopic myotomy.

Since its implementation, the rates of failure of total shoulder arthroplasty which may be due to malpositioning pushed to improve this surgery by creating new techniques and tools to help perioperatively. Augmented reality, a newly used tool in orthopedic surgery can help bypass this problem and reduce the rates of failure faced in shoulder replacement surgeries. Although this technology has revolutionized orthopedic surgery and helped improve the accuracy in shoulder prosthesis components positioning, it still has some limitations such as inaccurate over-imposition that should be addressed before it becomes of standard usage., (© 2023 The Author(s).)

Background and Aims: Dysphagia is a common complaint for patients after radiation therapy for head and neck cancer. Chronic dysphagia ensues when the radiation-induced injury matures into a fibrotic stricture, with the severity of symptoms paralleling the degree of stenosis. Most patients experience progressive dysphagia that prompts medical attention before complete esophageal obliteration. Rarely, patients present late with inability to clear their secretions because of complete obstruction, also termed acquired atresia. These patients represent a challenge and require aggressive and unconventional interventions to reestablish lumenal patency. Using a case series, we hereby describe a novel yet simple technique to treat patients with acquired esophageal atresia., Methods: Five patients with head and neck cancer in various stages who all underwent nonsurgical treatment with definitive chemotherapy and radiation along with enteral feeding tube placement prior to/during treatment presented with acquired esophageal atresia. All patients underwent an EGD to reestablish lumenal patency. This was accomplished with gentle pressure that was applied in a to-and-fro semi-circular rotational manner as if pushing a corkscrew and twisting it in alternating clockwise and counterclockwise manner., Results: In all cases we were able to reestablish esophageal lumenal patency with a single procedure. There were no adverse events. Four of the 5 patients required additional dilations for symptomatic management. However, all patients' esophageal lumens remained patent., Conclusions: We describe a novel yet simple technique to treat acquired esophageal atresia after radiation for head and neck cancer. This technique allows for generous dilation yielding complete resolution of the stenosis in a single session. When our approach is used, the patient can be discharged home the same day and resume immediate oral intake., (© 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Acrometastasis are rare and can be exceptionally indicative of an occult carcinoma. The prognosis is generally poor. The radiological and immunohistochemical findings can be of great value to determine the primary and to guide treatment. We report a case of a 56-years-old man with acrometastasis at the fourth finger of the left hand revealing a pulmonary adenocarcinoma. Histopathological analysis showed a cribriform adenocarcinoma with an unusual cytoplasmic co-expression of TTF1 and Hepar-1 upon immunohistochemical analysis. There was no nuclear TTF1 immunostaining. Imaging explorations showed a 6-cm mass of the left superior pulmonary lobe. The patient received immunochemotherapy. Upon follow-up, there was evidence of disease progression on chest computed tomography scan., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches., Competing Interests: Conflict of interest statement: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2021.)

Background and Aims: EUS-guided FNA primarily provides cytologic samples. EUS-guided fine-needle biopsy (FNB) with needles that provide histologic specimens may enhance diagnostic yield and facilitate accessory tissue staining. Several different needle designs are currently available and design superiority is unknown. We designed a randomized controlled trial to compare 2 commonly used EUS-FNB needles in their ability to provide histologic tissue samples (primary endpoint) and to reach an accurate diagnosis (secondary endpoint)., Methods: A total of 150 lesions from 134 patients (November 2018 to June 2019) were randomized 1:1 between biopsy with a Franseen needle and a Fork-tip needle. The groups were compared regarding the quality of the tissue samples and diagnostic accuracy., Results: Of 150 lesions, 75 were pancreatic and 75 were other solid lesions in and around the GI tract. There was no statistically significant difference between the Franseen needle and the Fork-tip needle in the yield of adequate histologic samples, 71 of 75 (94.7%) versus 72 of 75 (96%), (P = 1.00), an absolute difference of -1.3% (95% confidence interval [CI], -8.1% to 5.4%). The 2 groups were similar in the diagnostic accuracy of histologic analysis, 64 of 75 (85.3%) versus 68 of 75 (90.7%) (P = .45), absolute difference -5.4% (95% CI, -15.7% to 5%); and in the diagnostic accuracy of combined cytologic and histologic analysis, 65 of 75 (86.7%) versus 69 of 75 (92%) (P = .43), absolute difference -5.3% (95% CI, -15.2% to 4.5%)., Conclusions: There was no significant difference in the performance of the Franseen needle versus the Fork-tip needle. Both needles achieved a high yield of histologic tissue samples and high diagnostic accuracy. (Clinical trial registration number: NCT03672032.)., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background/aims: Endoscopic ultrasound (EUS)-guided fine-needle aspiration is very effective for providing specimens for cytological evaluation. However, the ability to provide sufficient tissue for histological evaluation has been challenging due to the technical limitations of dedicated core biopsy needles. Recently, a modified EUS needle has been introduced to obtain tissue core samples for histological analysis. We aimed to determine (1) its ability to obtain specimens for histological assessment and (2) the diagnostic accuracy of EUS-guided fine-needle biopsy (EUS-FNB) using this needle., Methods: We retrospectively analyzed consecutive cases of FNB using modified EUS needles for 342 lesions in 303 patients. The cytology and histological specimens were analyzed. Diagnostic accuracy was calculated., Results: Adequate cytological and histological assessment was possible in 293/342 (86%) and 264/342 (77%) lesions, respectively. Diagnostic accuracy of the cytological specimen was 294/342 (86%) versus 254/342 (74%) for the histological specimen (p<0.01). Diagnostic accuracy of the combined cytological and histological assessment was 323/342 (94.4%), which was significantly higher than that of both histology alone (p<0.001) and cytology alone (p=0.001)., Conclusion: EUS-FNB with the modified EUS needle provided histologic tissue cores in the majority of cases and achieved excellent diagnostic accuracy with few needle passes.

Case: We report the case of 2 patients presenting with advanced isolated radiolunate arthritis with limited wrist strength and range of motion (ROM). After failure of conservative therapy, both patients underwent lunate excision and scaphocapitate and triquetrohamate joints fusion using compression headless screws. Improved functional outcomes are reported at 4 years of follow-up with painless wrists and increased grip strength and ROM., Conclusions: Lunate excision and partial bicolumnar wrist fusion lead to increased grip strength and wrist ROM. This is a unique alternative for people suffering isolated radiolunate osteoarthritis, for which no standard surgical care exists.

Background: Obesity is public health problem of epidemic proportions. Esophageal dysmotility including achalasia is more commonly seen in an obese population. Standard therapy for achalasia can be complicated by hepatomegaly and a post-surgical anatomy in a pre- and post-bariatric population. Peroral endoscopic myotomy (POEM) has not been adequately studied in this population., Methods: A retrospective review of a prospectively collected database was completed. Patients who had undergone a Roux-en-y gastric bypass (RYGB) prior to or following a POEM were enrolled. Patient demographics, operative information and post-operative course data was collected., Results: Six patients underwent POEM prior to or after RYGB. There were no peri-operative complications with an average length of stay of 1.2 days. Five patients experienced a clinical success with excellent symptom resolution. The one failure was in the setting of type III achalasia, but did have objective evidence of lower esophageal sphincter (LES) relaxation post-operatively., Conclusion: POEM in the setting of bariatric surgery is safe and feasible. The potential increase in GERD following POEM is obviated by RYGB anatomy. In an obese individual, a staged POEM prior to or following a RYGB is an appropriate treatment algorithm for obese and achalasia.

Background: Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achalasia. A multidisciplinary approach may allow safe and early adoption of POEM into clinical practice., Materials and Methods: We performed a retrospective review of our initial POEM cases. All procedures were performed by a team of interventional gastroenterologist and thoracic surgeon. We analyzed demographics, comorbidities, achalasia subtypes, length of hospital stay, duration of surgery, morbidity, mortality, length of myotomy, preoperative and postoperative Eckardt scores., Results: Thirty-one consecutive patients underwent POEM during the 24-month period from January 2014 to December 2015. Eighteen patients (58%) had prior non-operative interventions. Average duration of follow-up was 9.6 months. Seventeen patients (66.8%) had follow-up of 12 months and longer. Average preoperative Eckardt score was 6.3 (3-10), median 6. Average postoperative Eckardt score was 1.4 (0-8), median 1, in 1 month and an average 2.2, median 1, in 1 year. Patients with type III achalasia were most refractory to treatment, while patients with type II had the best results. Average LOS was 1.3 days (1-5), median 1 day. Average DOS was 106 min (60-148), median 106. Average LOM was 13 cm (10-15), with median of 13 cm. We had one 30-day mortality secondary to coronary artery disease. Four patients had prior Heller myotomies and underwent a posterior myotomy during POEM, with outcomes similar to patients with no prior myotomy., Conclusions: We demonstrated safety and efficiency of a multispecialty approach for achalasia with POEM with a low rate of complications.

Background and Objectives: Mesenchymal (spindle cell) neoplasms (SCN) of the gastrointestinal (GI) tract are an important subtype of subepithelial lesions that need subclassification to assess their malignant potential. Reported success rates of accurate subclassification with endoscopic ultrasound (EUS)-guided biopsies are variable. Our goal was to analyze our experience using EUS-guided TruCut biopsy (EUS-TCB) in the majority of patients., Methods: Retrospective analysis in patients who underwent EUS with biopsies for suspected SCN at our tertiary referral center between 2004 and 2013., Results: A total of 146 patients with suspected SCN underwent EUS with tissue acquisition. Thirteen patients were excluded from analysis because tissue acquisition established a definite diagnosis other than SCN. In the remaining 133 patients, tissue acquisition was diagnostic of SCN in 118 (88.7%) and nondiagnostic in 15 (11.3%). Subclassification based on immunohistochemistry (IHC) was possible in 109 of the 133 cases (81.9%). The final diagnosis was GI stromal tumor in 64, leiomyoma in 39, and schwannoma in 6 cases. The percentage of patients who were subclassified by the various EUS-guided techniques together was 72.18%, and the percentage of patients who were subclassified specifically with EUS-TCB was 61.65%. Tissue specimens that enabled a specific diagnosis based on histological or cytological characteristics in conjunctions with IHC were obtained with EUS core biopsy in 83 (TCB in 82 and ProCore needle biopsy in 1), fine-needle aspiration in 13, mucosal resection in 10, and forceps biopsies (bite-on-bite) in 3 cases., Conclusion: EUS with endoscopic tissue acquisition is accurate in the diagnosis and subclassification of SCN. In experienced hands, the EUS-TruCut needle is a valuable tool with a high success rate for this indication.

Aim: Double balloon enteroscopy (DBE) is a relatively new endoscopic technique that allows endoscopic access into the small intestine. It has been studied in adults, but the literature remains scarce in the paediatric age group., Methods: We retrospectively assessed our experience with DBE in children., Results: We describe four procedures performed on three patients. The diagnostic yield was high (100%) with one major complication (perforation) encountered. A review of the benefits and risks in this cohort, and the available literature is included., Conclusions: DBE is a promising endoscopic modality in children, but some aspects remain unanswered. There is a great need for a prospective study to better assess benefit and risk in this population.

Gastric cancer is common and is a cause of severe morbidity and mortality. Early diagnosis can improve the chances of cure and prolong survival because prognosis is inversely related to the disease stage. Endoscopy plays an important role in diagnosis. Emerging adjunct technologies such as image-enhanced endoscopy and magnification endoscopy aid in early cancer detection. Endoscopic ultrasonography is an additional useful tool for preoperative staging. Endoscopy for screening, except for high-risk patients, and outside areas of high prevalence, remains controversial., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose of the Study: Conventional techniques proposed for total knee arthroplasty (TKA), necessarily require an acceptable alignment of the lower limb. Computer-assisted surgery is becoming increasingly popular in order to improve the precision of the component alignment, an essential element for good long-term results. The purpose of this prospective study was to present our preliminary results with computer-assisted implantation of TKA., Material and Methods: This was a prospective study of 55 patients (60 knees) included at random for computer-assisted TKA between April 2004 and September 2005. Mean age was 70.5 years. The preoperative assessment noted genu varum in 56 knees and genu valgum in four knees. Three knees with unilateral degenerative disease presented a post traumatic tibia malunion. The same surgeon performed all of the operations using the same prosthesis and navigation system (P.F.C. Sigma). Lower limb alignment and orientation of the prosthetic implants were assessed with standard pre- and postoperative gonometry. Sagittal alignment was measured on the standard X-rays (lateral and anteroposterior view)., Results: Knee alignment improved from 8.1+/-4.5 degrees varus (10 degrees valgus to 18 degrees varus) preoperatively, to 0.4+/-0.6 degrees varus (1 degrees valgus to 2 degrees varus) postoperatively. In the frontal plane, the mean angle of the femoral component on the anteroposterior (ap) view was 89.7+/-0.7 degrees (88-91 degrees). The mean angle of the tibial component on the ap view was 89.9+/-0.7 degrees (88.5-91 degrees). The femorotibial mechanical axis was within +/-2 degrees for all prostheses. In the sagittal plane, the mean angle of the femoral component on the lateral view was 4.8 degrees (3-6.5 degrees). The mean tibial slope was 2.7 degrees (1-4 degrees) for the prostheses with a fixed tibial plateau and 0.2 degrees (-1 degrees to +1 degrees) for those with a rotating plateau. The mean operative time was 135 min (110-180 min) and was inversely proportional to experience. There was one conversion to conventional surgery due to software dysfunction. There were no complications related to the operative technique., Discussion: The best outcome, particularly in terms of aseptic loosening, is reported for knees with a valgus or varus angle within 3 degrees . The improved accuracy of computer-assisted implantation has enabled better orientation of the components in the frontal, sagittal and horizontal planes with implantations well within this range.

The purpose of this study was to determine the long-term results of uncemented humeral components in shoulder arthroplasty. We reviewed 37 shoulder arthroplasties with press-fit humeral components with a mean follow-up of 9.2 years (range, 5.8-13.6 years). The mean Constant score was 57 points (range, 16-95 points), and the results in 70% of the patients remained satisfactory. No complications or revisions occurred related to the uncemented humeral component. On radiographic analysis, none of the humeral components showed subsidence. Of the components, 22 (59%) showed radiolucency, 12 (32%) had endosteal erosion, and 5 (14%) had tilted. Of the humeral components, 7 (19%) were judged to be at risk for loosening. The prevalence of an at-risk humeral component was not associated with increasing pain or deteriorating function. This study shows favorable results with the use of uncemented humeral components in shoulder arthroplasty, with a low prevalence of clinical loosening at long-term follow-up.

Purpose of the Study: We report a retrospective analysis of 16 patients with rheumatoid arthritis treated with a total humero-ulnar and humero-radial GUEPAR prosthesis (GIII)., Material and Methods: The GUEPAR III elbow prosthesis is an anatomic polyethylene-metal gliding prosthesis designed to maintain physiological valgus. Right and left models are available in two sizes. On the humero-ulnar side of the prosthesis, was associated with a radial head, born on an intramedullary metallic stem, that can be fit with several sizes of mobile polyethylene cups. The 16 GIII prostheses were implanted in 1997 to 2001 in accordance with the manufacturers instructions. Mean follow-up was 2 years., Results: Before surgical treatment, all patients had moderate or severe but invalidating pain. The Mayo Clinic score was 33 points. The Larsen radiographic score was grade III (7 elbows) or grade IV (9 elbows). Patients were reassessed 1 to 5 years after implantation of the GIII (mean follow-up 2 years). At last follow-up the mean Mayo Clinic score had improved from 33 to 90 points. Outcome was considered excellent for 15 elbows and fair for 1., Discussion: We review the indications for total elbow arthroplasty in patients with rheumatoid arthritis. Semi-constrained prostheses are useful and necessary for the treatment of elbows exhibiting massive destruction, but the use of minimally constrained prostheses such as the GUEPAR III is becoming increasingly widespread. We use the GUEPAR III for 70% of our patients, particularly those with rheumatoid arthritis.

Infection by Toxoplasma gondii and Toxocara canis is getting much important nowadays. Both are soil transmitted infections. The present study was planned to detect the incidence of T. gondii and T. canis antibodies among 100 patients attending the outpatient clinics in Research Institutes of Ophthalmology (RIO), whose urine and stool were free from other parasitic stages. Patients were classified into two groups, group I; (70 ocular cases) and group II, (30 non-occular cases). Control group (group III); 30 healthy persons. Sera from all individuals were subjected to IFAT and IHAT to detect Toxoplasma antibodies and IFAT to detect Toxocara antibodies. By using IFAT for Toxoplasma revealed, 25% as a total incidence, 21.4% in group I, 33.3% in group II and 6.6% in group III. While IHAT revealed 51% as a total incidence, 51.4% in group I, 50% in group II and 23.3% in group III. Among group I, retinochoroiditis cases showed the highest incidence and titre. While hydrocephalic cases showed highest incidence and titre in group II. T. canis antibodies revealed 23% as a total incidence, 14.3% in group I, 43.3% in group II and 5% in group III. Cases presented with retinal detachment showed the highest incidence and titre in group I while in group II hepatomegalic cases gave the highest incidence and titre. Concomitant infection of both Toxoplasma and Toxocara was detected in 8% of positive cases.