Cutting-Edge Technologies for Gastrointestinal Therapeutic Endoscopy.

With advancements in the development of flexible endoscopes and endoscopic devices and the increased demand for minimally invasive treatments, the indications of therapeutic endoscopy have been expanded. Methods of endoscopic treatment used for tissue removal, hemostasis, and dilatation are as follows. Endoscopic submucosal dissection (ESD) is considered the gold standard curative method for removal of gastrointestinal node-negative neoplasms, regardless of their size or the presence of ulcer formation. Laparoscopic endoscopic cooperative surgery (LECS), which incorporates ESD, was introduced for removal of lesions in deeper layers. Another technique is endoscopic full-thickness resection, which is challenging without the assistance of laparoscopy. In terms of hemostasis, management of iatrogenic bleeding after endoscopic treatment is an important issue. Shielding methods and suturing techniques have been introduced for large mucosal defects after ESD, and their efficacy has been investigated clinically. Peroral endoscopic myotomy (POEM) is a new alternative surgical approach for minimally invasive treatment of esophageal achalasia. Furthermore, endoscopic fundoplication after POEM was devised to prevent post-POEM gastroesophageal reflux disease. Many endoscopic treatments, including ESD, LECS, and POEM, have been introduced in Japan. With the aging of the population, more attention will be directed toward therapeutic endoscopy for elderly patients, because it is less invasive. Development of endoscopic treatments with expanded indications is expected.

Feasibility of using an led-probe in third-space endoscopy: a clinical study.

BACKGROUND: Third-space endoscopy is a novel, safe, and effective method for treating different gastrointestinal conditions. However, several failed endoscopic procedures are attributed to incomplete myotomy. Lighting devices are used to prevent organic injuries. We aimed to investigate the feasibility of using a hand-made LED-probe (LP) in third-space procedures. METHODS: This prospective study was conducted in a tertiary-care center in Mexico between December 2016 and January 2019. We included peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy(G-POEM) procedures. Pseudoachalasia, peptic ulcer, normal gastric emptying scintigraphy (GES) and prepyloric tumors were excluded. LP was used to guide or confirm procedures. Clinical and procedural characteristics were recorded and analyzed. RESULTS: Seventy third-space procedures were included (42POEM,28G-POEM), with an average patient age of 46.7 ± 14.3 and 43.7 ± 10.1 years, respectively. For the POEM and G-POEM groups, respectively, 18/42(42.9%) and 13/28(46.7%) patients were males; median procedure times were 50 (interquartile range [IQR]: 38-71) and 60(IQR: 48-77) min, median LP placement times were 5(IQR: 4-6) and 6(IQR: 5-7) min, mild adverse events occurred in 4(9.4%) and 4(14.2%) of cases, and clinical success at 6 months occurred in 100 and 85.7% of cases. Integrated relaxation pressure (IRP) improved from 27.3 ± 10.8 to 9.5 ± 4.1 mmHg (p < 0.001); retention percentage at 4 h also improved. LP was successfully placed and adequate myotomy confirmed including 14.2 and 17.8% of POEM and G-POEM difficult patients. CONCLUSIONS: Using an LP is promising and allows guiding during third-space procedures either for submucosal tunnel creation or myotomy confirmation, with excellent safety and efficacy in clinical practice.

Calf Reduction by Partial Resection of Gastrocnemius Using a Suction-Assisted Cartilage Shaver.

BACKGROUND: Long-term aesthetic reduction of the legs in Asians is gaining increasing popularity among cosmetic patients. Current treatment options include botulinum toxin injection, radiofrequency, neurectomy, and total, subtotal, or partial muscle resection of the gastrocnemius. Partial resection using Kelly forceps was introduced in 2000. This article presents the use of a suction-assisted cartilage shaver to perform partial resection, describing the procedures and shaver modifications and evaluating its use. METHODS: A retrospective review of 71 cases with a minimum 6-month follow-up (average, 36.5 months; range, 6 to 160 months) was performed. Twenty partial calf reductions were performed with a short shaver, 27 with a long shaver, and 24 with an endoscope-guided long shaver. RESULTS: Mean reduction of calf circumference was 2 cm (range, -1 to 6 cm); the mean preoperative and postoperative calf circumferences were 35.8 cm and 33.8 cm, respectively. Mean tissue reduction per calf was 110 g (range, 25 to 300 g).Two patients developed larger calves after surgery, one because of weight gain and the other because of weight training. Complications included surface irregularity (n = 4, 5.6 percent), numbness over the lateral ankle or lateral foot (n = 9, 12.7 percent), hematoma clot requiring surgical evacuation (n = 11, 15.5 percent), prolonged seroma (n = 2, 2.8 percent), and left ankle plantar-flexion contracture due to tight, sustained postsurgery bandaging (n = 1, 1.5 percent). Scar-related complications were hyperpigmentation (n = 6, 8.5 percent), depressed scars (n = 5, 7 percent), and hypertrophic scars (n = 2, 2.8 percent). CONCLUSIONS: Short, long, and endoscope-guided long suction-assisted cartilage shavers for partial resection of calf muscles can be used effectively to reduce the calf. Several mostly treatable complications were noted. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Juntos a la par: La acalasia en Síndrome de Down / Together at the same time: Achalasia in Down Syndrome

El síndrome de Down es la anomalía cromosómica más común, encontrándose asociado hasta en un 77 % de los casos con anomalías gastrointestinales que pueden ser de naturaleza estructural o funcional2. La Acalasia es un trastorno motor primario del esófago, de etiología desconocida e incurable1.La probabilidad de encontrar un paciente con síndrome de Down y acalasia es extremadamente rara. La prevalencia de Acalasia en el síndrome de Down es mayor, lo que implica una asociación única entre estas dos condiciones poco comunes(1). Los 3 tratamientos endoscópicos establecidos son: la aplicación de toxina botulínica y las dilataciones neumáticas, además de otro llamado POEM (per-oral endoscopic myotomy).Se presenta el caso clínico de paciente masculino de 45 años con diagnóstico de Síndrome de Down y Acalasia evaluado por el nuestro servicio. El principal objetivo es determinar la relación entre estas dos patologías, también revisamos las diversas opciones terapéuticas disponibles como así también como llegar al diagnóstico debido a que son pacientes poco colaboradores para la realización de estudios contrastados y manométricos. Se realizó una sesión de dilatación neumática como puente al tratamiento definitivo con posterior realización de Miotomía endoscópica perioral (POEM) presentando mejoría sintomatológica

Endoscopic techniques for myotomy of the lower esophageal sphincter and pylorus.

PURPOSE OF REVIEW: Peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy (G-POEM) are minimally invasive endoscopic procedures for the treatment of esophageal motility disorders and refractory gastroparesis, respectively. In this review, we highlight the most recent publications on the technical aspects of POEM and G-POEM. RECENT FINDINGS: POEM has evolved into a standard therapeutic option in patients with all achalasia subtypes with excellent durability and safety profile. G-POEM is a novel endoscopic procedure with promising results in terms of efficacy, safety, and symptom improvement in patients with refractory gastroparesis. SUMMARY: POEM and G-POEM are novel endoscopic procedures. Practice patterns vary among endoscopists and procedure techniques continue to evolve. Comparative studies examining outcomes of different techniques are needed.

Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment.

Esophageal diverticula are rare conditions that cause esophageal symptoms, such as dysphagia, regurgitation, and chest pain. They are classified according to their location and characteristic pathophysiology into three types: epiphrenic diverticulum, Zenker's diverticulum, and Rokitansky diverticulum. The former two disorders take the form of protrusions, and symptomatic cases require interventional treatment. However, the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum, particularly when it is located closer to the oral orifice. Since the condition itself is not malignant, minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms. Several types of endoscopic devices and techniques are currently employed, including peroral endoscopic myotomy (POEM). However, the use of minimally invasive endoscopic approaches, like POEM, has allowed the development of new disorder called iatrogenic esophageal diverticula. In this paper, we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.

Feasibility of the peroral endoscopic myotomy (POEM) procedure with a new small-caliber endoscope (thin-POEM) in patients with achalasia.

BACKGROUND: Peroral endoscopic myotomy (POEM) is a recognized technique for patients with achalasia. We aimed to evaluate the feasibility of using a small-caliber endoscope (thin-POEM) to perform POEM in patients with achalasia. METHODS: Naïve or previously treated patients were included between February 2016 and April 2018. A small-caliber (5.9 mm) nasoendoscope was used, with a modified closure method using cyanoacrylate. Strict follow-up was performed. RESULTS: 45 patients were included, aged 45.5 years (interquartile range [IQR] 22 - 69); 53 % (24/45) had type II achalasia. Median total time for thin-POEM was 54 minutes (IQR 37 - 77) and median myotomy length was 13.5 cm (IQR 6 - 20). Results pre-procedure and 3 months post were Eckardt score 10 vs. 1 (P < 0.001), integrated relaxation pressure (IRP) 25.3 vs. 8.5 mmHg (P < 0.001), and timed barium esophagram (TBE) 100 % severely delayed vs. 86 % normal (P < 0.001), respectively. Type III patients had the longest thin-POEM times (median 58 minutes [IQR 52 - 77]). Reflux was confirmed at 3 months clinically in 17 % of patients, endoscopically in 20 %, and on pH monitoring in 53 %. At 6 months and 12 months, 40 % and 33 % of patients remained positive on pH monitoring and were medically managed. CONCLUSIONS: Thin-POEM seems to be a safe, effective, and efficient procedure for POEM in patients with achalasia, with good short-term follow-up results.

Flexible endoscopic treatment for Zenker's diverticulum - experience on 31 patients.

BACKGROUND AND AIMS: The aim of this study is to present the experience of our center over the last 8 years in a series of patients with Zenker's diverticulum (ZD), treated using an endoscopic, minimally invasive procedure. METHODS: We retrospectively included 31 patients with a previously established diagnosis of ZD based on endoscopic and oral contrast examinations. Patients' age, comorbidities, size of the diverticulum or previous endoscopic treatment were not considered exclusion criteria. A soft, flexible diverticuloscope to expose the septum and a dual knife for "cutting" the diverticular septum were used. We analyzed the short term efficacy based on symptomatic relief and occurrence of side effects, and long term efficiency at 6 and 12 months by clinical assessment, upper gastrointestinal endoscopy and oral contrast media passage. RESULTS: Patients had a mean age of 67 years (range 42-86); 55% of them were male. All patients reported symptom relief after the procedure. A decrease of more than 70% from the initial size of the diverticulum was noted. There were 3 cases (9.67%) of intraprocedural hemorrhage, endoscopically managed. No serious post-procedural complications and no mortality were reported. The mean procedural time was 21.87 minutes (range 15-25 minutes). Average hospitalization was 2.5 days. Five patients developed recurrence and needed a second session of endoscopic treatment for achieving complete myotomy. CONCLUSIONS: Endoscopic management for ZD was efficient and safe in our series of patients. A short hospitalization period was required.

Cricopharyngeal myotomy with flexible endoscope for Zenker's diverticulum using hook knife and endoclips (with video describing an objective measurement of the cutting length).

Cricopharyngeal myotomy with flexible endoscope is a well-known and safe treatment for Zenker's diverticulum. We describe hereafter how we perform this flexible endotherapy. From January 2011 to January 2017, we treated 28 patients with this endotherapy. Our technique is described step-by-step in the paper: the main principle is to perform an endoscopic cut of the diverticular septum and cricopharyngeal muscle's fibers (see the video). We describe an objective measurement of the cutting length and depth of the myotomy. Technical success was achieved in all the patients. As to clinical success, 76.2% of patients showed a significant improvement and relevant disappearance of preoperative dysphagia. The present follow-up ranges from 6 months to 5 years. This flexible endoscopic technique can overcome some limitations of rigid endoscopic technique (i.e., upper teeth protrusion, inadequate jaw opening, or limited neck mobility). The main indication was based on clinical presentation and referred to the diverticular dimensions between 2 and 5 cm. Tips for the technique are described in the paper. This variant of cricopharyngeal myotomy with flexible endoscopy is feasible and effective for the treatment of Zenker's diverticulum in selected patients.

Miotomia glabelar fechada: uma nova abordagem cirúrgica para tratar rugas sem cicatrizes / Closed glabellar myotomy: a new surgical approach to treat wrinkles without scarring

Introdução: A hiperatividade da musculatura glabelar e as consequentes rugas são queixas frequentes na cirurgia plástica. O tratamento consiste em impedimento dos músculos relacionados. Propomos uma abordagem fechada para o tratamento da musculatura glabelar. Métodos: 78 pacientes foram operados entre abril de 2012 e agosto de 2015. A miotomia é realizada guiada pela marcação e tem início utilizando fio de poliglactina 0 ou fio de aço, passando várias vezes através das linhas marcadas, entrando pelo supercílio e utilizando o plano justaperiostal, retornando através do mesmo orifício da agulha em direção ao orifício de entrada, agora usando o plano subcutâneo. Resultados: Foram obtidos bons resultados em todos os casos com impedimento da atividade da musculatura glabelar durante o período avaliado (pelo menos 1 ano), com melhora das rugas e hiperatividade. As complicações observadas foram parestesia temporária na região frontal central (35 casos) e recidiva parcial (4 casos). Não foi observado nenhum caso de recorrência completa. As opções de tratamento cirúrgico de longo prazo para rugas glabelar são miotomia, neurotomia parcial ou miectomia. A miotomia glabelar fechada evita algumas possíveis complicações associadas a essas opções, diminui o tempo cirúrgico utilizando instrumentos cirúrgicos convencionais, permite a correção de assimetria, com menos edema, menos equimoses e evita cicatrizes. Conclusão: A miotomia glabelar fechada parece ser uma boa alternativa às outras opções cirúrgicas tradicionais, porque evita cicatrizes, permite correção de assimetria e apresenta bons resultados a longo prazo.

Introduction: Hyperactivity of the glabellar musculature and resulting wrinkles are frequent complaints in the field of plastic surgery. Treatment consists of blocking the involved muscles. We propose a closed approach for the treatment of glabellar musculature. Methods: Seventy-eight patients underwent operation between April 2012 and August 2015. Myotomy includes the use of markings and polyglactin 0 wire or steel wire, passing through the marked lines several times, entering the eyebrow and using the juxtaperiostal plane, returning through the same orifice of the needle toward the entry hole, and using the subcutaneous plane. Results: Good results were obtained in all cases by preventing glabellar muscle activity during the period evaluated (at least 1 year), with improvement in wrinkles and muscle hyperactivity. The complications observed included temporary paresthesia in the frontal region (35 cases) and partial recurrence (4 cases). There was no case of total recurrence. The options for long-term surgical treatment of glabellar wrinkles are myotomy, partial neurotomy, or myectomy. Closed glabellar myotomy prevents some possible complications associated with these options, reduces the surgical time, requires the use of conventional surgical instruments, eliminates scarring, and causes asymmetric correction, less edema, and fewer bruises. Conclusion: Closed glabellar myotomy seems to be a good alternative compared to other traditional surgical options, because it eliminates scarring, allows correction of asymmetry, and presents good long-term results.

Outcome of peroral endoscopic myotomy in achalasia cardia: Experience with a new triangular knife.

Background and Aim: Peroral endoscopic myotomy (POEM) is a technically demanding procedure. Recently, a new triangular knife with integrated water jet function (TTJ) has been introduced. The present study was aimed to analyze and compare the operating time, efficacy, and adverse events (AEs) between the conventional (TT knife) and new knife (TTJ). Patients and Methods: All patients with achalasia cardia (AC) who underwent POEM between August 2015 and November 2016 were analyzed retrospectively. Operating time (OT), technical success, and AEs were assessed and compared between TT and TTJ knife. Results: A total of 193 patients with AC underwent POEM during the specified period. Both groups had equivalent number of different subtypes of AC (I, II, and III). There was no difference in technical success between the two groups (TT, 99% vs TT, 98.9%). OT was significantly less in the TTJ group as compared to TT group (53.8 ± 15.2 vs 66.26 ± 19.2; P = 0.0001). On subanalysis, OT taken for submucosal tunneling was significantly less with TTJ knife (34.6 ± 10.1 vs 45.83 ± 14.80), whereas OT was similar for myotomy and clipping in both the groups. Significantly fewer use of coagulation forceps and exchanges of accessories were required in TTJ knife group (2.92 ± 1.77 vs 10.5 ± 3.58; P = 0.0001). There were no major AEs. Minor AEs were noted in 21.5% and 31% of patients in TTJ and TT knife groups, respectively. Conclusion: New triangular knife reduces procedure time and technical difficulty with POEM. POEM is an efficacious treatment for achalasia and can be safely executed in an endoscopy unit.