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No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety.This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered.A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.

BACKGROUND Pelvic collections may occur after surgery or in medical diseases. EUS transmural (TM) treatment has been shown as highly effective and safe, becoming an alternative to surgery or radiology. We aimed to assess the results of EUS management of pelvic collections. METHODS Retrospective, single-center observational study conducted between 2004 and 2018. Patients with symptomatic collections treated by EUS-TM approach were enrolled. The procedures were performed with a therapeutic EUS-scope, following two possible options: puncture-aspiration-injection of antibiotics PAIA (group 1) or EUS-drainage by plastic double pigtail stents (DPS) with an ano-cavitary drain (ACD) or lumen-apposing metal Stent (LAMS) (group 2). The main objective was to assess the clinical effectiveness based on symptoms and collection resolution. RESULTS Seventy-three patients were included. Mean age was 42.5 years [12-87]. 30 patients in group 1 (41%) underwent PAIA and 43 in group 2 (59%) underwent DPS ± ACD in 41 patients (95%) and LAMS in 2. The collection was postoperative in 58%. The mean size was 48.9 mm [8-120], 33 +/- 17 mm in group 1, compared to 67 ± 21 mm in group 2 (p

Background and study aims Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for pancreatic neuroendocrine tumors (NETs) and intraductal pancreatic mucinous neoplasia (IPMN) with worrisome features or high-risk stigmata (WF/HRS) has been evaluated in few series with short-term outcomes. This studyʼs primary endpoint was to assess the long-term efficacy of EUS-RFA in patients with NETs or pancreatic cystic neoplasms (PCNs) over at least 3 years. Patients and methods Twelve patients had 14 NETs with a mean 13.4-mm size (10–20) and 17 patients had a cystic tumor (16 IPMN, 1 MCA) with a 29.1-mm mean size (9–60 were included. They were treated with EUS-guided RFA, evaluated prospectively at 1 year, and followed annually for at least 3 years. Results The mean duration of follow-up was 42.9 months (36–53). Four patients died during follow-up (17–42 months) from unrelated diseases.At 1-year follow-up, and 85.7 % complete disappearance was seen in 12 patients with 14 NETs. At the end of follow-up (45.6 months), complete disappearance of tumors was seen in 85.7 % of cases. One case of late liver metastasis occurred in a patient with initial failure of EUS-RFA. At 1-year follow-up, a significant response was seen in 70.5 % of 15 patients with PCNs. At the end of the follow-up, there was a significant response in 66.6 % with no mural nodules. Two cases of distant pancreatic adenocarcinoma unrelated to IPMN occurred. Conclusions EUS-RFA results for pancreatic NETs or PCNs appear to be stable during 42 months of follow-up.

Background Natural orifice transluminal endoscopy surgery (NOTES) gastrojejunal anastomosis (GJA) with duodenal exclusion (DE) could be used as a less invasive alternative to surgical gastric bypass. The aim of this study was to compare the efficacy and safety of both methods for bariatric purpose. Methods This was a prospective, experimental and comparative study on obese living pigs, comparing 4 groups: GJA alone (group 1, G1), GJA + DE (group 2, G2), surgical gastric bypass (group 3, G3), control group (group 4, G4). GJA was endoscopically performed, using NOTES technic and LAMS, while DE was performed surgically for limb length selection. Animals were followed for 3 months. Primary outcome included technical success and weight evolution, while secondary endpoints included the rate of perioperative mortality and morbidity, histological anastomosis analysis and biological analysis. Results Technical success was 100% in each intervention groups. No death related to endoscopic procedures occurred in endoscopic groups, while early mortality (

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.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).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.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.

Background Endoscopic internal drainage (EID) with double-pigtail stents or low negative-pressure endoscopic vacuum therapy (EVT) are treatment options for leakage after upper gastrointestinal oncologic surgery. We aimed to compare the effectiveness of these techniques. Methods Between 2016 and 2019, patients treated with EID in five centers in France and with EVT in Göttingen, Germany were included and retrospectively analyzed using univariate analysis. Pigtail stents were changed every 4 weeks; EVT was repeated every 3–4 days until leak closure. Results 35 EID and 27 EVT patients were included, with a median (interquartile range [IQR]) leak size of 0.75 cm (0.5–1.5). Overall treatment success was 100 % (95 % confidence interval [CI] 90 %–100 %) for EID vs. 85.2 % (95 %CI 66.3 %–95.8 %) for EVT (P = 0.03). The median (IQR) number of endoscopic procedures was 2 (2–3) vs. 3 (2–6.5; P = 0.003) and the median (IQR) treatment duration was 42 days (28–60) vs. 17 days (7.5–28; P Conclusion EID and EVT provide high closure rates for upper gastrointestinal anastomotic leaks. EVT provides a shorter treatment duration, at the cost of a higher number of procedures.

SCOPUS: re.j, info:eu-repo/semantics/published

Background: Data on the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis are lacking. We report the results of a large multicenter long-term follow-up study of G-POEM for refractory gastroparesis. Methods: This was a retrospective multicenter study of all G-POEM operations performed in seven expert French centers for refractory gastroparesis with at least 1 year of follow-up. The primary endpoint was the 1-year clinical success rate, defined as at least a 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI). Results: 76 patients were included (60.5 % women; age 56 years). The median symptom duration was 48 months. The median gastric retention at 4 hours (H4) before G-POEM was 45 % (interquartile range [IQR] 29 % – 67 %). The median GCSI before G-POEM was 3.6 (IQR 2.8 – 4.0). Clinical success was achieved in 65.8 % of the patients at 1 year, with a median rate of reduction in the GCSI score of 41 %. In logistic regression analysis, only a high preoperative GCSI satiety subscale score was predictive of clinical success (odds ratio [OR] 3.41, 95 % confidence interval [CI] 1.01 – 11.54; P = 0.048), while a high rate of gastric retention at H4 was significantly associated with clinical failure (OR 0.97, 95 %CI 0.95 – 1.00; P = 0.03). Conclusions: The results confirm the efficacy of G-POEM for the treatment of refractory gastroparesis, as evidenced by a 65.8 % clinical success rate at 1 year. Although G-POEM is promising, prospective sham-controlled trials are urgently needed to confirm its efficacy and identify the patient populations who will benefit most from this procedure.

BACKGROUND: Per-oral esophageal myotomy endoscopic (E-POEM) has clearly proved safety and efficiency in the treatment of esophageal spastic disorders. Recent studies on endoscopic pyloromyotomy (G-POEM) suggest good efficiency and safety in the treatment of gastroparesis. In recent literature, some reports showed both esophageal motility disorders and gastroparesis. METHODS: We report the case of four patients with esophageal and gastric motility disorders who were successfully treated with DUAL POEM (E-POEM and G-POEM) in two separate procedures. RESULTS: Clinical improvement was reported in all patients with a decrease of the Eckardt score for esophageal motility disorders and a decrease of the GCSI score for gastroparesis. No adverse events occurred after any procedure. These reported cases suggest that is possible to perform an E-POEM and a G-POEM in the same patient in two distinct procedures. CONCLUSIONS: DUAL POEM seems to be faisable in patient with esophageal motility disorders associated with gastroparesis. The possibility of the concomitant occurrence of esophageal and gastric motility disorders could lead to change in practices with an overall assessment including gastric empting scintigraphy, high resolution manometry and pH-impedancemetry for patients with digestive motility disorders.

Introduction Laparoscopic fundoplication is the treatment of severe and refractory gastroesophageal reflux disease (GERD). It induces dysphagia in 5 % – 10 % owing to a tight valve ± esophageal motility disorders (EMD), with challenging management. We assessed the first case series assessing peroral endoscopic myotomy (POEM) in such a situation. Methods A retrospective case series including eight patients with severe dysphagia after laparoscopic fundoplication who were treated by POEM. They were assessed clinically by Eckardt and Mellow – Pinkas dysphagia scores, and by high resolution manometry (HRM). The procedure was a regular esophageal POEM, mainly posterior, including a myotomy of the wrap. The objectives were to evaluate the clinical efficacy, technical difficulties, and complications of this approach. Results HRM showed aperistalsis in 6 /8 patients and raised lower esophageal sphincter (LES) pressure in 5 /8. The median preoperative Eckardt and dysphagia scores were 5 and 3.5, respectively. The procedure was completed in 7 /8 patients, with a clinical efficacy rate (normalization of both scores) of 75 % (6 /8). Although the submucosa seemed more fibrotic and vascularized, no severe complications occurred. Conclusion POEM is a newly described therapeutic option to consider for managing dysphagia due to EMD after laparoscopic fundoplication.

Background Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the reference surgical treatment for patients with ulcerative colitis (UC) refractory to medical treatment. One of the complications is leaving a strip of rectal mucosa which can be a cause of persistent inflammation or cuffitis. The objective of our study is to present an endoscopic approach for the treatment of cuffitis. Methods This retrospective study included three patients who suffered from cuffitis after a proctocolectomy with IPAA for UC refractory to medical treatment. An endoscopic resection of the cuffitis was performed by the same operator. Two different techniques were used: hybrid endoscopic submucosal dissection (ESD) for one patient and mucosectomy with cap and resection for the two others. Results The endoscopic treatment was performed successfully in all three patients. The only complication observed was rectal bleeding which did not require endoscopic revision. The three patients are now asymptomatic. Conclusion Endoscopic treatment of cuffitis appears to be an interesting approach with few complications in the short term and good clinical efficacy.

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). 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. 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. 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.

Background and study aims Antireflux mucosectomy band ligation (ARM-b) is an endoscopic procedure that mimics a fundoplication for managing gastroesophoageal reflux disease (GERD). The aim of this study was to assess safety and feasibility of ARM-b. Patients and methods This was a single-center study on consecutive patients operated between June 2017 and January 2019 with refractory GERD, confirmed with pH-metry and without motility disorder at high-resolution manometry. A piecemeal mucosectomy of three quarters of circumference of esophagogastric junction was performed using a band ligation system and a hexagonal snare. The primary objective was to assess procedural safety and feasibility. The secondary objective was to document the clinical improvement at 3 and 6 months based on patient satisfaction, proton pump inhibitor (PPI) intake, symptoms, and quality of life scores. Results Twenty-onepatients (11 men) with mean age 56.9 ± 14.4 years were analyzed. The technical success rate was 100 % (mean duration 35 ± 11 min). Four patients (19 %) had mild adverse events: one delayed bleeding at Day 1 managed conservatively, and three dysphagia endoscopically managed. Mean follow-up was 10 ± 5 months. Decrease/discontinuation of PPI intake was 76 % at 3 months and 72 % at 6 months. Improvement in mean symptoms and quality of life scores (GERD-Q and GERD-HQL) were statistically significant. One patient required laparoscopic fundoplication after ARM-b failure without complication. Conclusion ARM-b is safe, feasible, and symptom-effective for treating refractory GERD, and it can be performed in the ambulatory setting. Further prospective studies are required to confirm these promising outcomes.

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 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. 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

OBJECTIVES: Endoscopic ultrasound-guided digestive anastomosis (EUS-A) is a new alternative under evaluation in patients presenting with afferent limb syndrome (ALS) after Whipple surgery. The aim of the present study is to analyze the safety and effectiveness of EUS-A in ALS. METHODS: This is an observational multicenter study. All patients ≥18 years old with previous Whipple surgery presenting with ALS who underwent an EUS-A using a lumen-apposing metal stent (LAMS) between 2015 and 2021 were included. The primary outcome was clinical success, defined as resolution of the ALS or ALS-related cholangitis. Furthermore, technical success, adverse event rate, and mortality were evaluated. RESULTS: Forty-five patients (mean age: 65.5 ± 10.2 years; 44.4% male) were included. The most common underlying disease was pancreatic cancer (68.9%). EUS-A was performed at a median of 6 weeks after local tumor recurrence. The most common approach used was the direct/freehand technique (66.7%). Technical success was achieved in 95.6%, with no differences between large (≥15 mm) and small LAMS (97.4% vs. 100%, P = 0.664). Clinical success was retained in 91.1% of patients. A complementary treatment by dilation of the stent followed by endoscopic retrograde cholangiopancreatography through the LAMS was performed in three cases (6.7%). There were six recurrent episodes of cholangitis (14.6%) and two procedure-related adverse events (4.4%) after a median follow-up of 4 months. Twenty-six patients (57.8%) died during the follow-up due to disease progression. CONCLUSION: EUS-A is a safe and effective technique in the treatment of malignant ALS, achieving high clinical success with an acceptable recurrence rate. ispartof: DIGESTIVE ENDOSCOPY vol:34 issue:7 pages:1433-1439 ispartof: location:Australia status: published

Objectives A single-use duodenoscope (SUD) has been recently developed to overcome issues with endoscopic retrograde cholangiopancreatography (ERCP)-related cross-infections. The aim was to evaluate SUD safety and performance in a prospective multi-centre study. Methods All consecutive patients undergoing ERCP in six French centers were prospectively enrolled. All procedures were performed with the SUD; in case of ERCP failure, operators switched to a reusable duodenoscope. Study outcomes were the successful completion of the procedure with SUD, safety and operators' satisfaction based on a VAS 0-10 and on 22 qualitative items. The study protocol was approved by French authorities and registered (ID-RCB: 2020-A00346-33). External companies collected the database and performed statistical analysis. Results Sixty patients (34 females, median age 65.5 years old) were enrolled. Main indications were bile duct stones (41.7%) and malignant biliary obstruction (26.7%). Most ERCP were considered ASGE grade 2 (58.3%) or 3 (35.0%). Fifty-seven (95.0%) procedures were completed using the SUD. Failures were unrelated to SUD (one duodenal stricture, one ampullary infiltration, and one tight biliary stricture) and could not be completed with reusable duodenoscopes. Median operators' satisfaction was 9 (7-9). Qualitative assessments were considered clinically satisfactory in a median of 100% of items and comparable to a reusable duodenoscope in 97.9% of items. Three patients (5%) reported an adverse event. None was SUD-related. Conclusions The use of a SUD allows ERCP to be performed with an optimal successful rate. Our data show that SUD could be used for several ERCP indications and levels of complexity.

Bariatric endoscopic procedures are emerging as alternatives to bariatric surgical procedures. This study aimed to assess if a natural orifice transluminal endoscopic surgery (NOTES) bariatric procedure could be converted to a surgical duodenal-jejunal bypass (DJB) or sleeve gastrectomy (SG).This 12-week prospective study compared 4 test pigs to 3 control (no procedures) pigs aged 3 months at baseline. The test pigs received a fully endoscopic NOTES-based bypass including measurement of the bypassed limb and creation of a gastrojejunal anastomosis (GJA) using gastrojejunal lumen-apposing metal stents (GJ-LAMS) at Week 0, placement of a duodenal exclusion device (DED) at Week 2, and randomization to DJB or SG surgery at Week 8 with subsequent 4-week follow-up. At Week 12, the pigs were sacrificed and necropsy was performed.Endoscopic procedures were technically successful. One pig did not receive a DED due to early GJ-LAMS migration leading to premature closure of the GJA. At Week 8, all 4 pigs were doing well, and the remaining 3 GJ-LAMS and 3 DEDs were uneventfully endoscopically removed. Two one-anastomosis DJB were performed, and 2 SG were performed, closing in one case the site of the previous GJA. The surgical procedures were technically feasible and uneventful during follow-up. Necropsy assessments showed no local or peritoneal inflammation or abscess and no leakage or fistula.An endoscopic bariatric bypass can be transitioned to a one-anastomosis duodenal-jejunal bypass or sleeve gastrectomy, without complications.

Background and study aims Ischemic colitis (IC) is potentially lethal. Clinical and biology information and results of computed tomography (CT) scan and/or colonoscopy are used to assess its severity. However, decision-making about therapy remains a challenge. Patients and methods This was a retrospective, single-center study between 2006 and 2015. Patients with severe IC who underwent endoscopic evaluation were included. The aims were to determine outcomes depending on endoscopic findings and assess the role of endoscopy in the management. Results A total of 71 patients were included (men = 48 (68%), mean age = 71 ± 13 years). There was hemodynamic instability in 29 patients (41 %) and severity signs on CT scan in 18 (38 %). Twenty-nine patients (41 %) underwent surgery and 24 (34 %) died. The endoscopic grades were: 15 grade 1 (21 %), 32 grade 2 (45 %), and 24 grade 3 (34%). Regarding patients with grade 3 IC, 55 % had hemodynamic instability, 58 % had severity signs on CT scan, 68 % underwent surgery, and 55 % died. The decision to perform surgery was based on hemodynamic status in 62 % of cases, CT scan data in 14 %, endoscopic findings in 10 %, and other in 14 %. Colectomy was more frequent in patients with grade 3 IC (P 5 (P Conclusions This study suggests a low impact of endoscopy on surgical decision making. Hemodynamic instability was the first indication for colectomy. A discrepancy between endoscopic mucosal (necrosis) and surgical serous (normal) aspects was frequently noted.

Limited data exist concerning the long-term efficiency of gastric peroral endoscopic myotomy (G-POEM) as a treatment of refractory gastroparesis. This study evaluated the 3-year results of G-POEM in patients with refractory gastroparesis.This was a prospective multicenter study of all G-POEM operations performed in 2 expert French centers for 46 patients with refractory gastroparesis with at least 3 years of follow-up.Clinical success was 65.2% at 36 months. There was significant improvement in symptom severity. Median Gastroparesis Cardinal Symptom Index decreased from 3.33 to 1.80 (P .0001), with improvement in all subscales. We created a predictive score concerning G-POEM success (G-POEM predictive score) to which points were assigned as follows: nausea subscale 2: predictive of success, 1 point; satiety subscale4: predictive of success, 1 point; bloating subscale3.5: predictive of success, 1 point; percentage of gastric retention at 4 hours on scintigraphy50%: 1 point. A threshold of 2 was identified by receiver operating characteristic curve analysis with an area under the curve of .825 that predicted clinical success with a sensitivity of 93.3% (95% confidence interval [CI], .77-.99), specificity of 56.3% (95% CI, .33-.77), positive predictive value of 80% (95% CI, .67-.93), negative predictive value of 81.8% (95% CI, .59-1.00), and accuracy of 80.4% (95% CI, .69-.92). Patients with a score ≥2 were significantly more likely to be responders at 3 years than were patients with a score 2 (80% and 18%, respectively; P = .0004).The clinical success of G-POEM for refractory gastroparesis was 65.2% at 36 months. Our predictive score offers an easy tool that needs to be confirmed in other studies.