Comprehensive Analysis of Adverse Events Associated with Gastric Peroral Endoscopic Myotomy: An International Multicenter Study.

BACKGROUND: Gastric peroral endoscopic myotomy (G-POEM) has emerged as an effective management approach for patients with refractory gastroparesis. This study aims to comprehensively study the safety of G-POEM and describe the predictive factors of adverse events (AEs) occurrence. METHODS: This study is a retrospective study involving 13 tertiary care centers (7 USA, 1 South America, 4 Europe, and 1 Asia). Patients who underwent G-POEM for refractory gastroparesis were included. Cases were identified by the occurrence of AEs. For each case, two controls were randomly selected and matched for age (± 10 years), gender, and etiology of gastroparesis. RESULTS: A total of 216 patients underwent G-POEM for gastroparesis. Overall, 31 (14%) AEs were encountered [mild 24 (77%), moderate 5 (16%), and severe 2 (6%)] during the duration of the study. The most common AE was abdominal pain (n = 16), followed by mucosotomy (n = 5) and capnoperitoneum (n = 4), and AEs were most commonly identified within the first 48-h post-procedure 18 (58%). The risk of adverse event occurrence was significantly higher for endoscopists with experience of < 20 G-POEM procedures (OR 3.03 [1.03-8.94], p < 0.05). CONCLUSION: G-POEM seems to be a safe intervention for refractory gastroparesis. AEs are most commonly mild and managed conservatively. Longitudinal mucosal incision, use of hook knife, use of clips for mucosal closure and endoscopist's experience with > 20 G-POEM procedures is significantly associated with decreased incidence of AEs.

An alternative method for mucosal flap closure during peroral endoscopic myotomy using an over-the-scope clipping device.

Maintaining the integrity of the mucosal flap and the reliable closure of mucosal entry during peroral endoscopic myotomy (POEM) is paramount in preventing leakage of esophageal contents into the mediastinal space. We describe our experience with POEM, the problems encountered with closure of mucosal flaps, and successful closure with over-the-scope clips (OTSC). Two patients with achalasia underwent successful endoscopic myotomy during POEM. During both procedures, the proximal end of the longitudinal mucosal incision was noted to be gaping and completion of the closure with standard clips was unsuccessful. The sides of the flap were approximated using a Twin Grasper followed by placement of OTSC. Closure of the mucosal entry appeared to be complete at the end of the procedures. Esophagram the following day revealed no leaks in either patient. There were no other complications and patients were discharged home after 1 - 2 days of hospital observation. Patients reported complete resolution of achalasia symptoms during follow-up. We propose closure of mucosal incisions during POEM using one to two OTSC as an alternative to described techniques. The use of OTSC may simplify the procedure and result in a more durable (i. e. full-thickness) closure.

Endoscopic ultrasound-guided fine-needle aspiration with or without flow cytometry for the diagnosis of primary pancreatic lymphoma - a case series.

The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with flow cytometry for the diagnosis of primary pancreatic lymphoma (PPL) has not been previously described. Our aims were to describe the EUS features of PPL and the role of EUS-FNA with and without flow cytometry in the diagnosis of 16 patients. When EUS-FNA with flow cytometry was compared with EUS-FNA without flow cytometry, the sensitivities for diagnosing non-Hodgkin's lymphoma were 84.6 % versus 30.8 %, respectively ( P = 0.01). EUS-FNA with flow cytometry is a valuable tool to diagnose PPL. Flow cytometry analysis complements traditional assessment by standard cytology.

Frequency of sphincter of Oddi dysfunction in patients with previously normal sphincter of Oddi manometry studies.

BACKGROUND AND STUDY AIMS: Sphincter of Oddi manometry (SOM), performed at endoscopic retrograde cholangiopancreatography (ERCP), is the gold standard for diagnosing sphincter of Oddi dysfunction (SOD). The question remains as to whether the short-term manometric recordings reflect the 24-hour pathophysiology of the sphincter. The aim of this study was to determine the frequency of SOD in persistently symptomatic patients with previously normal SOM studies. PATIENTS AND METHODS: All patients who underwent ERCP for suspected SOD over a 13-year period (1994 - 2007) were considered for inclusion in the study. Patients with an intact papilla and a previously normal SOM who had a repeat ERCP for persistent symptoms formed the study group. SOM was performed in conventional retrograde fashion. RESULTS: In all, 5352 patients without prior papillary intervention underwent SOM during the study period. A total of 1037 patients had normal SOM, and of these, 30 patients (27 female, mean age 40.1 years) underwent repeat ERCP for persistent symptoms. The median duration between the two ERCPs was 493.5 days (range 52-3538 days). In these 30 patients, SOD classification prior to the initial ERCP was: type I in one patient (not treated in 1994), type II in 17 patients, and type III in 12 patients. Of the 30 patients, 12 (40%) had normal SOM at repeat ERCP; SOD was diagnosed in 18/30 (60%) patients. CONCLUSIONS: A single SOM study may not represent the day-to-day physiology of the sphincter of Oddi; sphincter pathology may progress over time. One normal exam may not rule out SOD. A repeat ERCP with manometry may be warranted in a subset of patients with persistent debilitating symptoms and a high index of suspicion for SOD. Outcome data are needed to determine whether this approach justifies the potential risks of ERCP.

Colorectal anatomy in adults at computed tomography colonography: normal distribution and the effect of age, sex, and body mass index.

BACKGROUND AND STUDY AIMS: Computed tomography colonography (CTC) is an accurate tool for assessing the large intestinal anatomy. Our aims were to determine the normal distribution of in vivo colorectal anatomy and to investigate the effect of age, sex, and body mass index (BMI) on colorectal length. PATIENTS AND METHODS: Asymptomatic adults who underwent primary CTC examination at a single institution over an 8-month period were evaluated. The interactive three-dimensional map was used to determine total and segmental lengths and number of acute-angle flexures. The two-dimensional multiplanar display was used to measure luminal diameters. The effects of age, sex, and BMI on colorectal lengths were examined. RESULTS: The study cohort consisted of 505 consecutive adults (266 women, mean age 56.6 years). Mean total colorectal length was 189.5 +/- 26.3 cm and mean number of acute-angle flexures was 10.9 +/- 2.4. Total length for older adults (> 60 years) did not significantly differ from those who were younger than 60 years ( P = 0.22), although the transverse colon was significantly longer in older adults ( P = 0.04). Women had significantly longer colons than men (193.3 cm vs. 185.4 cm, P = 0.002), whereas overweight adults (BMI > 25) had significantly shorter colons compared with those with BMI

What is the clinical significance of esophagogastric junction outflow obstruction? evaluation of 60 patients at a tertiary referral center.

BACKGROUND: Esophagogastric junction (EGJ) outflow obstruction (EGJOO) is characterized by impaired EGJ relaxation with intact or weak peristalsis. Our aims were to evaluate: (i) prevalence, (ii) yield of fluoroscopy, endoscopy, and endoscopic ultrasound (EUS), (iii) outcomes, and (iv) whether this data differed based on quantitative EGJ relaxation. METHODS: Studies that met criteria for EGJOO were identified. Demographics, encounters, endoscopy, radiology, treatment decisions, and outcomes were extracted. KEY RESULTS: Sixty studies were identified. Dysphagia was the most common symptom. Forty patients underwent barium esophagram (BE): normal (11), hiatal hernia (20), spasm/dysmotility (17), EGJ narrowing (10), compression (2), Schatzki's ring (5), malrotation (1), gastric volvulus (1), mass (1). Esophagogastroduodenoscopy (EGD) was performed in 41 patients: normal (19), hiatal hernia (13), Schatzki's ring (6), esophagitis (3), esophageal candidiasis (3), mass (1). EUS was performed in 20 patients and was frequently normal. Twenty-two patients underwent intervention. While transient improvement was noted in the majority, persistent improvement was seen in only one of nine patients (dilatation), four of six patients (botulinum toxin), and three patients who underwent per-oral endoscopic myotomy. No patients treated with medical therapy alone had improvement in dysphagia. There was no difference in symptoms or outcomes based on quantitative EGJ relaxation. CONCLUSIONS & INFERENCES: The manometric criterion EGJOO defines a heterogeneous clinical group. While BE, EGD, and EUS all provide complementary information, a significant percentage of these studies will be normal. For patients with dysphagia, outcome may depend on EGJ disruption. There were no differences in symptoms our outcomes based on quantitative EGJ relaxation.

Efficacy and tolerability of a new formulation of sodium phosphate tablets (INKP-101), and a reduced sodium phosphate dose, in colon cleansing: a single-center open-label pilot trial.

BACKGROUND: The tablet form of sodium phosphate for bowel preparation for colonoscopy contains microcrystalline cellulose. This inactive ingredient produces a residue that obscures mucosal visualization and is time-consuming to remove during colonoscopy. AIM: To perform an open-label study of efficacy and tolerability of a modified formulation with microcrystalline cellulose reduced by 50% (code named INKP-101) and a lower total dose of sodium phosphate. METHODS: Patients scheduled for colonoscopy self-administered 28 INKP-101 tablets (42 g sodium phosphate). Colon cleansing efficacy was evaluated using a standard 4-point scoring system and the amount of microcrystalline cellulose present and time spent removing it using an 8-point scale. RESULTS: A total of 31 patients were screened and enrolled. Thirty patients had a colonoscopy and were evaluated for colon cleansing efficacy. Overall colon cleansing was rated as excellent and good in 90% and 10% of patients respectively. About 77% of patients had microcrystalline cellulose scores of 2 or 3 (corresponding to <1 or 1-2 min spent removing microcrystalline cellulose, respectively). The drug was well-tolerated and adverse events were generally benign. CONCLUSION: A new formulation of sodium phosphate with reduced microcrystalline cellulose and a lower total dose of sodium phosphate was effective for colonoscopy and well-tolerated.

Cavernous haemangioma of the submandibular salivary gland.

Salivary gland haemangioma is more common in the parotid than in any other salivary gland. Parotid haemangioma is considered to be the most common salivary gland tumour in infants, but is also occasionally encountered in adults. A case of cavernous haemangioma affecting the submandibular salivary gland in an adult woman is presented. The striking histological feature is the presence of numerous vascular channels assuming a periductal arrangement.

Calcium homeostasis in untreated pulmonary tuberculosis II--dynamic study.

Oral calcium tolerance test was done for 17 normal subjects and 26 pulmonary tuberculous patients. Ingestion of 1 gm calcium did not alter serum calcium levels significantly, while urinary calcium significantly increased in normal controls (p less than 0.001) and significantly decreased in tuberculous patients. The decrease in urinary calcium in untreated TB patients may be attributed to the associated decrease in serum concentration of 25-hydroxyvitamin D. Serum PTH and nephrogenous cAMP showed insignificant changes both in controls and TB patients. Meanwhile, these changes are antiparallel to serum calcium, denoting a normal response (function) of parathyroid gland to serum calcium alterations.