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There is limited data on long-term outcomes of per-oral endoscopic myotomy (POEM). In this study, we aim to evaluate the efficacy of POEM in patients who completed a minimum follow-up of 5 years.Data of patients who underwent POEM and completed ≥ 5-year follow-up were analyzed, retrospectively. Primary outcome of study was clinical success (Eckardt ≤ 3) at ≥ 5 years after POEM. Secondary outcomes included predictors of dysphagia and symptomatic gastroesophageal reflux disease (GERD) on long-term follow-up.Three hundred nineteen patients (males 182, mean age 40.5 ± 14.2 years) completed a median of 73-(60-89) month follow-up. Esophageal motility disorders included idiopathic achalasia (type I 26.6%, type II 60.8%, type III 5.6%) and Jackhammer esophagus or distal esophageal spasm (2.8%). POEM was technically successful in 307 (96.2%) patients. Long-term success was 92.6% (overall), 92.1% (type I), 94.7% (type II), 87.5% (type III), and 75% (Jackhammer esophagus/distal esophageal spasm). Symptomatic GERD and reflux esophagitis were detected in 28.9% and 35.3% patients, respectively. On multivariate analysis, young age and female gender were independent risk factors for recurrent dysphagia (p = 0.037) and symptomatic GERD after POEM (p = 0.025), respectively. Lower post-POEM lower esophageal sphincter pressure was an independent predictor for reflux esophagitis (p = 0.016).POEM is an effective and durable treatment for achalasia and non-achalasia spastic motility disorders. Young patients and females may be at higher risk for recurrent dysphagia and symptomatic GERD, respectively.

Background Haematopoietic stem cell (HSC) infusion has demonstrated short-term improvement in liver functions in patients with chronic liver disease. The combination of HSC with mesenchymal stem cells (MSCs), which has an immunomodulatory effect, may augment the effects and enhance the duration of improvements on liver functions. The aim of the present study was to assess the safety of infusing the combination of autologous HSCs and MSCs in decompensated liver cirrhosis. Methods In phase I of the study, in vitro assessment was performed to observe the effect of coculturing MSCs with HSCs on their viability and cytokine profiles. Phase II of the study was to assess the safety of combination of stem cell infusions. Bone marrow (50 ml) was aspirated for MSC isolation and expansion using standard protocol. Patients received subcutaneous doses (n = 5) of granulocyte colony-stimulating factor (G-CSF) for stem cell mobilization followed by leukapheresis for harvesting HSCs using CliniMacs. HSCs and MSCs were infused through the hepatic artery under fluoroscopic guidance and were monitored for any adverse effects. Results In vitro studies revealed 94% viable HSCs in coculture similar to monoculture. HSCs released only interleukin (IL)-8, whereas MSCs secreted IL-8 and IL-6 in monocultures, and both IL-8 and IL-6 were secreted in coculture. G-CSF administration– and bone marrow aspiration–related complications were not observed. Infusion of the cells through the hepatic artery was safe, and no postprocedural complications were noted. Conclusion The combination of autologous HSC and MSC infusion is a safe procedure in patients with decompensated liver cirrhosis, and the outcomes needed to be assessed in larger studies. Trial number NCT04243681 .

Gastric lipomas are rare benign tumors and account for 1–3% of all benign gastric tumors. Majority of the gastric lipomas are asymptomatic and do not demand resection. However, large gastric lipomas may present with upper gastrointestinal bleeding and more rarely gastric outlet obstruction. Traditionally, surgery has been utilized for the management of giant gastric lipomas. More recently, endoscopic techniques are increasingly utilized for the resection of gastric submucosal lesions. Here we describe a case with large gastric lipoma who presented with symptoms suggestive of gastric outlet obstruction. Gastroscopy revealed a large (6 cm) submucosal lesion with a broad peduncle located in antrum. The tumor was prolapsing into duodenum thereby, completing occluding the pylorus. In this case, we performed endoscopic submucosal dissection using a novel, bipolar radiofrequency device. The dissection was completed without any complications.

ObjectiveRecent studies have shown that motorised spiral enteroscopy (MSE) enables deeper and total small bowel evaluation compared with single-balloon enteroscopy (SBE) in suspected Crohn’s disease (CD) when analysed per procedure. However, no randomised controlled study has compared bidirectional MSE with bidirectional SBE in suspected CD.DesignPatients with suspected CD requiring small bowel enteroscopy were randomly assigned to either SBE or MSE between May 2022 and September 2022 in a high volume tertiary centre. Bidirectional enteroscopy was done if intended lesion could not be reached on unidirectional study. Comparison was made with regard to technical success (ability to reach lesion), diagnostic yield, depth of maximal insertion (DMI), procedure time and total enteroscopy rates. Depth:time ratio was calculated to avoid confounding for the location of lesion.ResultsAmong 125 suspected patients with CD (28% female, 18–65 years, median 41 years), 62 and 63 underwent MSE and SBE, respectively. The overall technical success (98.4 %: MSE, 90.5 %: SBE; p=0.11), diagnostic yield (95.2%: MSE; 87.3%: SBE, p=0.2) and procedure time were not significantly different. However, MSE appeared to have higher technical success (96.8% vs 80.7%, p=0.08) in deeper small bowel (distal jejunum/proximal ileum) with higher DMI, higher depth:time ratio and total enteroscopy rates when attempted (77.8% vs 11.1%, p=0.0007). Both the modalities were safe although minor adverse events were more common with MSE.ConclusionMSE and SBE have comparable technical success and diagnostic yield for small bowel evaluation in suspected CD. MSE scores over SBE with regard to deeper small bowel evaluation with complete small bowel coverage and higher depth of insertion in a shorter time.Trial registration numberNCT05363930.

Background and aim The incidence of gastroesophageal reflux disease (GERD) is high after per‐oral endoscopic myotomy (POEM). GERD after POEM may be qualitatively different from GERD in patients without motility disorders. In this study, we aimed to analyze and compare different aspects of GERD between patients with post‐POEM GERD and nonachalasia GERD. Methods The data of patients with GERD after POEM (January 2018 to June 2019) were compared with that of a control group (nonachalasia GERD group), which included patients presenting with typical reflux symptoms without associated major motility disorders. Patients with lower esophageal sphincter pressure lower than 10 mmHg were excluded from the study. GERD was evaluated at 3 months after POEM. Esophageal acid exposure time higher than 4.2% was used to define GERD. The primary outcome of the study was comparison of GERD‐related quality of life and reflux symptom severity between the two groups. In addition, the severity of erosive esophagitis and reflux‐symptom association were also recorded in the two groups. Results A total of 100 patients were included in the study, with 50 patients in each group (post‐POEM GERD vs. controls). The baseline parameters were comparable between the two groups. Median interquartile range of GERD‐related quality of life score was significantly lower in the post‐POEM group (11 [0–23.3] versus 34 [24–44]; p, Key Summary What is known Gastroesophageal reflux disease (GERD) after per‐oral endoscopic myotomy (POEM) is common and subclinicalData on GERD related quality of life and reflux‐symptom association after POEM is limited. What is new here Reflux symptoms after POEM are milder and have poor association with reflux episodesTriviality of symptoms despite high acid exposure and severe esophagitis suggests esophageal hyposensitivity

Background/Aims Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia. The technique of POEM is still evolving and the impact of length of esophageal myotomy on the outcomes of POEM is not known. In this study, we aim to compare the outcomes of short (3 cm) versus long (6 cm and above) esophageal myotomy in patients undergoing POEM for achalasia cardia. Methods Consecutive patients with idiopathic achalasia (type I and II) were randomized to receive short (3 cm) or long esophageal myotomy (≥ 6 cm). Both groups were compared for clinical success, operative time, adverse events, and gastroesophageal reflux disease (GERD). Results Seventy-one consecutive patients with type I and II achalasia underwent POEM with short (n = 34) or long (n = 37) esophageal myotomy techniques. Mean length of esophageal myotomy in short and long groups was 2.76 ± 0.41 and 7.97 ± 2.40, respectively (P < 0.001). Mean operative time was significantly shorter in short myotomy group (44.03 ± 13.78 minutes and 72.43 ± 27.28 minutes, P < 0.001). Clinical success was comparable in both arms at 1-year (Eckardt score 0.935 ± 0.929 vs 0.818 ± 0.983, P = 0.627). Improvement in objective parameters including integrated relaxation pressure and barium column height at 5 minutes was similar in both groups. GERD was detected in 50.88% patients with no significant difference in short and long myotomy groups (44.44% vs 56.67%, P = 0.431). Conclusions A short esophageal myotomy is non-inferior to long myotomy with regards to clinical success, adverse events, and GERD in cases with type I and II achalasia. Reduced operating duration favors short esophageal myotomy in these patients. (J Neurogastroenterol Motil 2021;27:63-70)

Background and Aims: Long-term data on cell-based therapies, including hematopoietic stem cell infusion in cirrhosis, are sparse and lacking. Methods: Patients with cirrhosis of non-viral etiology received either standard-of-care (n = 23) or autologous CD34+ cell infusion through the hepatic artery (n = 22). Study patients received granulocyte colony-stimulating factor (commonly known as G-CSF) injections at 520 µgm per day for 3 days, followed by leukapheresis and CD34+ cell infusion into the hepatic artery. The Control group received standard-of-care treatment. Results: Mean CD34+ cell count on the third day of G-CSF injection was 27.00 ± 20.43 cells/µL 81.84 ± 11.99 viability and purity of 80-90%. Significant improvement in the model of end-stage liver disease (commonly known as MELD) score (15.75 ± 5.13 vs. 19.94 ± 6.68, p = 0.04) was noted at end of 3 months and 1 year (15.5 ± 5.3 vs. 19.8 ± 6.4, p = 0.04) but was not statistically different at end of the second (17.2 ± 5.5 vs. 20.3 ± 6.8, p = 0.17) and third-year (18.4 ± 6.1 vs. 21.3 ± 6.4, p = 0.25). No difference in mortality (6/23 vs. 5/23) was noted. Conclusions: Autologous CD34+ cell infusion effectively improved liver function and MELD score up to 1 year but the sustained benefit was not maintained at the end of 3 years, possibly due to ongoing progression of the underlying disease.

Background and aim Peroral endoscopic myotomy (POEM) is emerging as an effective treatment for achalasia in children. Long-term outcomes of POEM and impact of prior treatment are not known in pediatric population. In this study, we aim to evaluate the long-term efficacy of POEM in children with achalasia. Methods Children (≤ 18 years) with achalasia who underwent POEM and completed at least 36 months of follow-up were included in the study. Long-term clinical success (Eckardt ≤ 3) was evaluated and compared between treatment naive versus prior treated cases. Results A total of 53 children underwent POEM at our center during the study period. Of these, 17 children completed at least 3 years of follow-up and were included in the study. Eight children had prior treatment including pneumatic dilatation (6), Heller's myotomy (1) and both Heller's myotomy and pneumatic dilatation (1). POEM was successfully completed in all the children. Median procedure duration was 95.76 ± 47.98 min (38–240 min.). Long-term clinical success was found in 88.2% children. The mean follow-up was 55.06 ± 10.65 months (range 36–67 months). There was no significant difference in the success rate between treatment naive and prior treatment failure cases. Conclusion POEM is a safe, effective and durable treatment for achalasia in children. Prior treatment does not affect the outcomes of POEM in children. Type of study Retrospective comparative study. Level of evidence III.

Background Gastroesophageal reflux disease (GERD) is an important concern after peroral endoscopic myotomy (POEM). However, there are limited data on the risk factors for post-POEM GERD and its responsiveness to proton pump inhibitors (PPIs). In this study, we aimed to analyze the variables affecting the occurrence of GERD and its response to PPI therapy. Methods Consecutive patients with idiopathic achalasia who underwent POEM (December 2016 to January 2018) were evaluated for GERD using 24-hour pH impedance, esophagogastroduodenoscopy (EGD), and symptoms. Multivariate analysis was performed to identify the variables affecting the incidence of post-POEM GERD. Results A total of 209 patients with esophageal motility disorders, including 194 patients with non-sigmoid achalasia, underwent POEM during the study period. Comprehensive evaluation of GERD was completed on 167 patients (86.1 %): 47.3 % women with a mean (standard deviation) age of 41 (14.42) years and body mass index of 22.2 (3.89) kg/m2; the majority (70.7 %) were treatment naïve. A high DeMeester score (> 14.72), reflux esophagitis, and symptomatic GERD were identified in 47.9 %, 41.9 %, and 29.3 % of patients, respectively. On logistic regression analysis, type of achalasia, technique of POEM (anterior vs. posterior), pre- or post-POEM esophageal manometry variables, and patient characteristics were not associated with post-POEM GERD. Erosive esophagitis responded to PPI therapy in the majority of patients (81.4 %). Conclusion The incidence of GERD is high after POEM. Most of the reflux esophagitis is mild and responsive to PPI therapy. There are no procedural or patient-related variables that appear to affect the incidence of post-POEM GERD.

Submucosal tunneling techniques have expanded the horizon of therapeutic endoscopy. One such procedure, submucosal tunneling endoscopic resection (STER), enables the endoscopic removal of gastrointestinal (GI) sub-epithelial tumors. In this study, we aimed to evaluate the safety and efficacy of STER in patients with sub-epithelial lesions localized to the upper GI tract. Consecutive subjects with a sub-epithelial lesion of ≥ 1 cm size in the upper GI tract were enrolled in the study. STER was performed using the standard technique in an endoscopy suite. A modified technique (double-opening STER) was used in cases with difficult en bloc resection of the tumor. Outcome measures included technical success, en bloc resection rates, adverse events, and recurrence. A total of 104 patients with sub-epithelial tumors were evaluated for STER. Of them, 44 subjects (mean age 44.68 ± 12.82, 52.3% males) underwent standard STER. Majority (31, 70.4%) of the lesions were located in the esophagus and cardia. Technical success and en bloc removal of the tumor were achieved in 97.7% and 88.4% of cases, respectively. There was no major adverse event. Minor adverse events were recorded in 7 (15.9%) cases. Majority (31, 70.4%) of the tumors originated from muscularis propria, followed by submucosa (8, 18.2%) and muscularis mucosa (5, 11.4%). The most common histological diagnosis was leiomyoma (59.1%) followed by GI stromal tumors (20.4%). At a mean follow up of 12.36 ± 7.63 months, there was no incidence of tumor recurrence in en bloc as well as piecemeal resection groups. STER is a safe and efficacious procedure for sub-epithelial tumors in the upper GI tract. Novel strategies need to be developed to ensure en bloc removal of large lesions.

Background Per-oral endoscopic myotomy (POEM) is an established modality of treatment in achalasia. However, there is limited data on the long-term outcomes of POEM. In this study, we aim to evaluate the efficacy of POEM in patients with a minimum follow-up of five years. Methods The data of patients who underwent POEM and completed at least five-years follow-up were analyzed, retrospectively. The primary outcome of the study was a clinical success (Eckardt≤3) at ≥5-years after POEM. The secondary outcomes included the prevalence of dysphagia and symptoms of gastroesophageal reflux disease (GERD). Multivariate analysis was performed to analyze the predictors of dysphagia and symptomatic GERD on long-term follow-up. Results 319 patients (males 182, mean age 40.5±14.2 years) completed a median of 73 (60-89) months follow-up. The spectrum of motility disorders included idiopathic achalasia (type I 26.6%, type II 60.8%, type III 5.6%) and Jackhammer esophagus or distal esophageal spasm (2.8%). POEM was technically successful in 307 (96.2%) patients. The data for long-term follow-up was available in 283 (88.7%) patients. The overall long-term success was 92.6%, 92.1% (type I), 94.7% (type II), 87.5% (type III) and 75% (Jackhammer esophagus/distal esophageal spasm) (IDDF2021-ABS-0058 Figure 1. Clinical response to POEM at 5-years follow-up on intention to treat and per-protocol population) (IDDF2021-ABS-0058 Figure 2. Change in mean Eckardt score at 1- and 5-years after POEM compared to baseline). Young age was an independent risk factor for the development of dysphagia on follow-up (p=0.037) (IDDF2021-ABS-0058 Table 1). Clinical GERD was detected in 28.6% of patients. On multivariate analysis, female sex was an independent predictor of symptomatic GERD after POEM (p=0.025) (IDDF2021-ABS-0058 Table 2). Conclusions POEM is an effective and durable treatment modality for achalasia and other non-achalasia spastic motility disorders. Young patients and females may be at higher risk for recurrent dysphagia and GERD, respectively.

Objectives Disconnected pancreatic duct syndrome (DPDS) is frequently encountered in cases with walled off necrosis (WON). The impact of DPDS on the outcomes of pancreatic fluid collections (PFCs) is not well known. In this study, we aim to evaluate the incidence of DPDS and its clinical impact on the outcomes of endoscopic ultrasound (EUS)-guided drainage of PFC in children. Methods All children with symptomatic WON who underwent EUS-guided drainage using metal stents were included in the study. At 4 weeks, pancreatic ductal anatomy was evaluated, and metal stents removed. All the children were followed at regular intervals and evaluated for the recurrence of PFC and the development of new-onset diabetes. Results A total of 32 children (28 boys, median age 15 years) underwent EUS-guided drainage of WON. Resolution of WON was documented in all children at 4 weeks. Pancreatic ductal anatomy using magnetic resonance retrograde cholangiopancreatography and endoscopic retrograde pancreatography was available in 30 (93.7%) children. Of these, DPDS was documented in 25 (83.3%) children including proximal disconnection in 12 and distal disconnection in 13 children. Recurrent PFC and new-onset diabetes were found in 5 (20%) and 2 (8%) children with DPDS, respectively. Of the 5 recurrences of PFC, endoscopic reintervention was required in 3 children. Conclusions Majority of the children with DPDS do not develop a symptomatic recurrence of PFC after the removal of cystogastric stents. DPDS may be a risk factor for the development of new-onset diabetes. However, future prospective studies are needed.

Endoscopic resection is recommended for small duodenal neuroendocrine tumors DNETs. However, there is limited data on the outcomes of endoscopic submucosal dissection (ESD) in DNETs. In this study, we aimed to evaluate the outcomes of ESD in DNETs. Data of consecutive patients who underwent ESD for DNETs from January 2018 to December 2019 were analyzed, retrospectively. All the cases of ESD were performed with or without traction using rubber band and two endoclips. En-bloc resection, complete endoscopic resection (C-ER), complete pathological resection (C-PR), adverse events, and recurrence were evaluated. Twenty patients (19 males, 57.50 ± 9.32 years) underwent ESD for DNETs. DNETs measured ≤ 10 mm (7), 10–15 mm (12), and > 15 mm (1). ESD was performed with and without traction in 10 cases each. Mean operating time was 61 ± 17.38 min. En-bloc resection, C-ER, and C-PR were recorded in 90%, 95%, and 75%, respectively. Vertical margins were positive in five patients. Adverse events included perforations in 4 (20%) cases and major bleeding in one case. There was no recurrence at a mean follow-up of 17.20 ± 7.37 months. ESD is feasible and effective for the management of DNETs. However, caution is advised due to a high risk of adverse events and pathologically incomplete resection.

Esophageal epiphrenic diverticula (EED) are rare pulsion-type outpouchings at the lower end of esophagus. Traditionally, surgery has been performed in EED. More recently, per-oral endoscopic myotomy with septotomy (D-POEM) has emerged as an option in these cases. In this study, we aim to determine the efficacy and safety of D-POEM in cases with EED. The data of cases who underwent D-POEM in cases with EED from March 2013 to Nov 2020 were analyzed, retrospectively. The primary outcome of the study was clinical success. Secondary outcomes included technical success, procedure duration, reflux esophagitis, and adverse events. 13 patients (males 9, 48.07 ± 17.55 years) with EED underwent D-POEM during the study period. Median size of the EED was 45 mm (range 25–70). Associated esophageal motility disorder was found in 10 (76.9%) cases including type II achalasia (3), type I (3), hypercontractile esophagus (2), and unspecified (2). Technical success was achieved in 12 (92.3%) cases. Median length of total and gastric myotomies were 10 cm (range 6–20) and 3 cm (1–3), respectively. At a median follow-up of 25 months, clinical success was achieved in 84.6% cases. Mean integrated relaxation pressures reduced significantly after POEM procedure (25.80 ± 13.24 vs 9.40 ± 3.10, p = 0.001). There was one major adverse event requiring surgical intervention. D-POEM is an effective procedure in cases with EED. Long-term follow-up studies are required to ascertain the durability of response in these cases.

Background and study aims Recent innovations in devices and techniques have revolutionized the field of endoscopic resection procedures. In this study, we evaluated the safety and feasibility of endoscopic submucosal dissection and tunneling procedures with a novel, multipurpose bipolar device. Patients and methods Data from consecutive patients who underwent per-oral endoscopic myotomy (POEM), submucosal tunneling endoscopic resection (STER), and endoscopic submucosal dissection (ESD) using a novel bipolar device (December 2019 to February 2020) were analyzed retrospectively. Procedure duration, technical success, and adverse events (AEs) were recorded. Results A total of 10 procedures were performed using the novel bipolar device during the study period. The procedures included POEM (n = 7), STER for esophageal sub-epithelial tumor (n = 1), ESD for rectal polyp (n = 1), and gastric neuroendocrine tumor (n = 1). POEM was successfully completed in all patients. In patients who underwent STER and ESD, en-bloc resection was achieved in all. Mean procedure time for submucosal tunneling procedures (POEM and STER) was 59.12 ± 31.12 minutes. The procedures were completed without the requirement for exchange of accessories in eight cases (80 %). There were no major AEs. Mild and moderate AEs occurred during POEM and included capno-peritoneum (n = 1), retroperitoneal CO2 (n = 1), and empyema (n = 1). Conclusion ESD and tunneling procedures can be safely performed without the need for exchange of accessories using a novel bipolar device. Randomized comparison with conventional knives isrequired to confirm the utility of this device.

BackgroundThe majority of endoscopic antireflux procedures for GERD are cumbersome to use and randomised long-term data are sparse. We conducted such a trial to determine the efficacy and safety of a novel, easy to use endoscopic full-thickness fundoplication (EFTP) device in patients with GERD.DesignPatients with proton pump inhibitor (PPI)-dependent GERD were randomised to either EFTP or a sham procedure in 1:1 ratio. The primary endpoint was ≥50% improvement in the health-related quality of life (GERD-HRQL) score at 3 months. Secondary end points included improvement in GERD-HRQL, reflux symptom scores, PPI usage, oesophageal acid exposure and reflux episodes and endoscopic findings at 3, 6 and 12 months.ResultsSeventy patients were randomised; 35 in each group with a median (IQR) age of 36 (29–42) years, 71.4% males. 70% had non-erosive reflux disease on endoscopy with a mean DeMeester score of 18.9 (±19.93). The mean (±SD) duration of EFTP procedure was 17.4 (±4) min. The primary end point was more frequently achieved in the EFTP group (65.7% vs 2.9%; pConclusionEFTP using a novel device is safe and effective in improving quality of life in patients with PPI dependent mostly non-erosive reflux disease at short and long terms; objective parameters showed a limited response rate.Trial registration numberNCT03322553.

Spastic esophageal motility disorders (SEMD) are a rare group of motility disorders including type III achalasia, distal esophageal spasm (DES), and Jackhammer esophagus (JHE). Limited data suggest that per-oral endoscopic myotomy (POEM) may be effective in these disorders. In this study, we aimed to evaluate the long-term outcomes of POEM in SEMD.The data of patients with SEMD who underwent POEM (January 2013 to December 2019) were analyzed, retrospectively. The following outcomes were recorded: POEM procedure details, technical and clinical success, adverse events, and gastroesophageal reflux disease (GERD). Clinical success was classified as immediate (1 y), short-term (1 to 3 y), medium term (3 to 5 y), and long-term (5 y).A total of 1115 POEM procedures were performed during the study period for achalasia and nonachalasia spastic motility disorders. POEM was performed for SEMD in 74 (6.6%) patients including type III in 53, DES in 11, and JHE in 10 patients. Technical success was achieved in all the patients. The median follow-up for the entire group was 47.5 months (range: 2 to 77 mo). Clinical success at short-term (1 to 3 y) and long-term follow-up (5 y) was attained in 85.2% and 82.6% patients, respectively. There was no significant difference in the clinical success between type III achalasia and JHE/DES. Mild and moderate adverse events were recorded in 21 (28.4%) cases. GERD was detected in 23 (56.1%) patients with 24-hour pH study. Erosive esophagitis and symptomatic GERD were found in 36 (48.6%) and 16 (21.6%) patients, respectively.POEM is a safe, effective, and durable treatment modality for spastic motility disorders of the esophagus. However, GERD is found in about half of the patients mandating close monitoring after POEM.

Background and study aims Peroral endoscopic myotomy (POEM) can be performed via an anterior or posterior approach, depending on the operator’s preference. Data are lacking on comparative outcomes of both approaches. Patients and methods This is a pilot randomized study comparing endoscopic anterior and posterior myotomy during POEM in patients with Achalasia cardia (AC). Patients were randomized into 2 groups (n = 30 in each group); anterior myotomy group (AG) and posterior myotomy group (PG) and were followed at 1, 3 and 6 months after POEM. Results Technical success was achieved in 100 % of cases in both groups and total operative time was comparable (AG – 65 ± 17.65 minutes versus PG – 61.2 ± 16.67; P = 0.38); Mucosotomies were more frequent in AG (20 % vs 3.3 %; P = 0.02). Difference in other perioperative adverse events (AE) including insufflation-related AE and bleeding in both groups were statistically insignificant. At 1-month follow-up Eckardt score AG 0.57 ± 0.56 vs PG 0.53 ± 0.71; (P = 0.81), mean LES pressure AG 11.93 ± 6.36 vs PG 11.77 ± 6.61; (P = 0.59) and esophageal emptying on timed barium swallow at 5 minutes AG 1.32 ± 1.08 cm vs PG 1.29 ± 0.79 cm; (P = 0.09) were comparable in both groups. At 3 months, Eckardt score (0.52 ± 0.59 vs 0.63 ± 0.62; P = 0.51) was similar in both groups. Incidence of esophagitis on EGD was comparable in both groups (24 % vs 33.3 %; P = 0.45), however, pH metry at 3 months showed significantly more esophageal acid exposure in posterior group (2.98 % ± 4.24 vs 13.99 % ± 14.48; P Conclusion Anterior and posterior approaches to POEM seem to have equal efficacy. However, the occurrence of mucosotomies was higher in the anterior myotomy group and acid exposure was higher with the posterior myotomy approach during POEM.

Gastroesophageal reflux disease (GERD) is the most common chronic gastrointestinal disorder, affecting one third of the population worldwide. Recently, there has been a renewed interest in Stretta therapy in view of potential long-term side effects of PPIs and the durability of relief with fundoplication. Prospective randomized study comparing the Stretta treatment with controls receiving PPIs. Patient (> 18 years, n = 20) with symptoms of heartburn, regurgitation, abnormal esophageal acid exposure (≥ 4%), and endoscopically confirmed esophagitis were included into the study. The primary measure was improvement in quality of life (QOL) and decrease in the frequency and severity of GERD symptoms. The mean age of the patients was 39 (± 15) years and controls were 34 (± 11) years. Three months after Stretta, 80% reported improvement in QOL compared to 40% in the control group. At the end of 3 months, significant (p

Background/Aims Achalasia cardia (AC) is a motility disorder, characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis. AC is rare in children with unclear optimum management strategies. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with encouraging results in adult patients. The efficacy and safety of POEM is not known for pediatric AC. The aim of our study was to evaluate the safety and efficacy of POEM in children with achalasia cardia. Methods The data of all children (< 18 years) who underwent POEM at our center was retrospectively analysed. Symptoms were analysed using a validated score (Eckardt score) at regular predefined intervals. Objective parameters including high-resolution manometry, timed barium swallow and esophagogastroduodenoscopy were assessed before the procedure and at 1-year follow-up. Clinical success was defined as an Eckardt score ≤ 3. Results A total of 15 children underwent POEM during the specified period. Ten out of 15 (10/15) completed 1-year follow-up. Median operative time was 100 (38-240) minutes. Mean pre and post procedure LES pressure were 36.64 ± 11.08 mmHg and 15.65 ± 5.73 mmHg, respectively (P = 0.001). Mean Eckardt score before and after the POEM was 7.32 ± 1.42 and 1.74 ± 0.67, respectively (P = 0.001). Mean percentage improvement in barium emptying at 5 minutes was 63.70 ± 4.46%. All children had complete resolution of symptoms at 1 year. Median weight gain of children at 1 year was 0.65 kg (range, 0.0-4.6). Conclusions POEM is safe and effective for children and adolescents with achalasia. Future trials with larger sample size are warranted to establish its efficacy in pediatric AC.