Is transoral incisionless fundoplication (TIF) an answer to post-peroral endoscopic myotomy gastroesophageal reflux? A multicenter retrospective study.

BACKGROUND: The use of peroral endoscopic myotomy (POEM) for achalasia has a high incidence of post-procedural gastroesophageal reflux (GER). Transoral incisionless fundoplication (TIF) may be an ideal endoscopic treatment. We report our experience with the use of post-POEM TIF. METHODS: In this multicenter retrospective study, post-POEM patients with GER who underwent TIF were included. The study end points were: (i) technical success; (ii) safety; (iii) effectiveness (changes in symptoms, scores, proton pump inhibitor [PPI] use, pH studies). RESULTS: 12 patients underwent TIF after POEM, nine of whom had daily symptoms, with 91.7% requiring twice daily (BID) PPIs. Technical success was achieved in all patients. Two adverse events occurred. There were significant decreases in the percentage of patients on BID PPIs (P = 0.03), frequency of daily symptoms (P = 0.03), Reflux Severity Index questionnaire, and GERD Health-related Quality of Life scores (P = 0.03 and P = 0.003; n = 6). pH studies performed in seven of the patients showed a significant reduction in the mean DeMeester score (P = 0.05) and mean percentage acid exposure time (P = 0.04). CONCLUSION: Our experience suggests that TIF may be effective and safe in treating GER after POEM. Larger prospective trials are needed.

Deep enteroscopy with standard endoscopes using a novel through-the-scope balloon.

BACKGROUND AND STUDY AIMS: A new on-demand enteroscopy (ODE) device has been designed to allow deep enteroscopy using a standard adult colonoscope with the aid of a novel through-the-scope balloon. The aims of the current study were to establish the feasibility, efficacy, and safety of ODE in performing anterograde and retrograde enteroscopy. PATIENTS AND METHODS: A retrospective, single-center study of 28 consecutive deep ODE procedures (11 anterograde and 17 retrograde) was performed. Diagnostic yield, therapeutic yield, technical success, procedure time, depth of maximal insertion (DMI), time to DMI, and adverse events were recorded. RESULTS: The mean diagnostic and therapeutic yields were 45 % and 36 % for anterograde enteroscopy and 59 % and 47 % for retrograde enteroscopy, respectively. Technical success was achieved in 100 %. For anterograde enteroscopy, the mean total procedure time was 24 minutes, with a mean DMI of 1.2 m. For retrograde enteroscopy, the mean total procedure time was 31 minutes, with a mean DMI of 1.1 m. No adverse events were recorded. CONCLUSION: Deep enteroscopy using a novel through-the-scope balloon and standard endoscope appeared to be feasible and safe, with rapid procedures times.

Patient- and cyst-related factors for improved prediction of malignancy within cystic lesions of the pancreas.

BACKGROUND AND AIMS: Early diagnosis of cancer in pancreatic cysts is important for timely referral to surgery. The aim of this study was to develop a predictive model for pancreatic cyst malignancy to improve patient selection for surgical resection. METHODS: We performed retrospective analyses of endoscopic ultrasound (EUS) and pathology databases identifying pancreatic cysts with available final pathological diagnoses. Main-duct intraductal papillary mucinous neoplasms (IPMNs) were excluded due to the clear indication for surgery. Patient demographics and symptoms, cyst morphology, and cyst fluid characteristics were studied as candidate risk factors for malignancy. RESULTS: 270 patients with pancreatic cysts were identified and analyzed (41% men, mean age 61.8 years). Final pathological diagnoses were branch-duct IPMN (n = 118, 50% malignant), serous cystadenoma (n = 71), pseudocyst (n = 37), mucinous cyst adenoma/adenocarcinoma (n = 36), islet cell tumor (n = 4), simple cyst (n = 3), and ductal adenocarcinoma with cystic degeneration (n = 1). Optimal cut-off points for surgical resection were cyst fluid carcinoembryonic antigen (CEA) > or =3,594 ng/ml, age >50, and cyst size >1.5 cm. Cyst malignancy was independently associated with white race (OR = 4.1, p = 0.002), weight loss (OR = 3.9, p = 0.001), cyst size >1.5 cm (OR = 2.4, p = 0.012), and high CEA > or =3,594 (OR = 5.3, p = 0.04). In white patients >50 years old presenting with weight loss and cyst size >1.5 cm, the likelihood of malignancy was nearly sixfold greater than in those patients who had none of these factors (OR = 5.8, 95% CI = 2.1-16.1, p = 0.004). CONCLUSIONS: Risk factors other than cyst size are important for determination of malignancy in pancreatic cysts. Exceptionally high cyst fluid CEA levels and certain patient-related factors may help to better predict cyst malignancy and the need for surgical treatment.