Safety and effectiveness of peroral endoscopic myotomy in patients on antiplatelet or anticoagulant therapy: an international multicenter case-control study.

BACKGROUND AND AIMS: The risk of bleeding and thromboembolic events in patients undergoing peroral endoscopic myotomy (POEM) who are receiving antithrombotic therapy is unknown. Our primary aim was to assess the safety of POEM in this patient subset. Secondary outcomes were rates of clinical success, GERD, and procedure-related outcomes. METHODS: This was an international, 1:1, case-control study performed at 10 centers using prospectively maintained databases. All consecutive patients who underwent POEM before November 2019 were considered for inclusion. Cases were patients on antiplatelet and/or anticoagulant therapy. Controls not receiving antithrombotics were matched for age and esophageal motility disorder. Primary outcomes were major bleeding and thromboembolic events on postprocedural day 30. RESULTS: Of 2895 patients who underwent POEM, 126 cases (103 on antiplatelets, 35 anticoagulants, 12 both) and 126 controls were enrolled. The rate of major bleeding was higher for the antithrombotics users (5.6% vs 0.8%, P = .03). Anticoagulants and clopidogrel were temporarily interrupted in all cases. Aspirin was continued in 40.5% of users without increasing the bleeding risk. One thromboembolic event occurred in each group (0.79%; P = 1.00). No POEM-related deaths were noted. Rates of clinical success (91.7% vs 96% in controls, P = .20), postprocedural GERD, and technical-related outcomes were similar in both groups. Antithrombotic management was heterogeneous, and guidelines were not adhered to in 23.8% of cases. CONCLUSIONS: POEM is safe and effective in patients receiving antithrombotic therapy although it is associated with a greater risk of major bleeding.

The Value of Audio Devices in the Endoscopy Room (VADER) study: a randomised controlled trial.

OBJECTIVE: To evaluate the effect of Star Wars music (SWM) compared with endoscopist-selected popular music (PM) on quality outcomes in colonoscopy. DESIGN AND SETTING: A single-centre, prospective, randomised controlled trial conducted in an endoscopy suite within a quaternary-centre gastroenterology unit, Melbourne, Australia. MAIN OUTCOME MEASURES: The primary outcome measures were procedure time, polyp detection rate (PDR) and adenoma detection rate (ADR). The secondary outcome measure was adenomas per colonoscopy (APC). RESULTS: 103 colonoscopies were analysed: 58 in the SWM group and 45 in the PM group. Bowel preparation was assessed as good or excellent in 57% of the SWM group compared with 69% of the PM group (P < 0.01). The PDR was significantly higher in the SWM group than in the PM group (60% v 35%; P = 0.006). Similarly, the ADR was significantly higher in the SWM group than in the PM group (48% v 27%; P = 0.01). The APC in the SWM group was 84% compared with 35% in the PM group (P = 0.01). CONCLUSION: SWM compared with PM improves key quality outcomes in colonoscopy, despite poorer bowel preparation.

Repetitive endoscopic drainage as initial intervention is safe and effective for early treatment of pancreatic necrotic collections.

BACKGROUND: While endoscopic step-up approach with delayed drainage (more than 28 days from diagnosis) was shown to produce the best outcomes in the treatment of pancreatic walled-off necrosis (WON), we assessed our single centre experience of early versus delayed endoscopic drainage of pancreatic necrotic collections. METHODS: Patients who underwent endoscopic drainage of pancreatic necrotic collections between 2011 and 2022 under Monash Health were identified. They were excluded if below 18 years old or their follow up data were missing. The included patients' medical records, pathology results, and imaging findings were retrospectively reviewed. RESULTS: A total of 60 patients were included. 31.58% required percutaneous drainage and 15% received either endoscopic or surgical necrosectomy. The disease related mortality was 8.47% and the average length of stay (LOS) was 70.92 days. No significant difference was shown in disease-related mortality (10.5% vs. 7.5%, P = 0.697) or LOS (75.35 vs. 68.7, P = 0.644) between early and delayed drainage cohorts, but patients who received early drainage have higher qSOFA score on the day of drainage (2 vs. 0, P = 0.004). DISCUSSION: Repetitive endoscopic drainage with selective percutaneous drainage is effective in the management of pancreatic necrotic collections. Early drainage should be considered in patients who developed severe sepsis.

Gastric intestinal metaplasia: Prevalence in a large Australian center and nationwide survey of endoscopic practice.

Background and Aim: Atrophic gastritis (AG) and gastric intestinal metaplasia (GIM) are early changes in the stepwise progression to gastric adenocarcinoma. There is heterogeneity in international guidelines regarding the endoscopic diagnosis and surveillance of AG and GIM. This study aims to determine the prevalence of GIM in an Australian center and assess the approach of Australian endoscopists for these two conditions. Methods: We conducted a single-center retrospective study of adult patients between January 2015 and December 2020 diagnosed with GIM on gastric biopsy following upper gastric endoscopy. A web-based, 25-question, investigator-designed, multiple-choice survey was distributed among all registered endoscopists in Australia. Results: The overall prevalence of GIM within a single Australian center was 11.7% over 5 years. Of the 1026 patients identified, only 58.7% underwent mapping biopsies using the modified Sydney protocol. Among the cohort, 1.6% had low-grade dysplasia, 0.9% had high-grade dysplasia, and 1.8% had malignancy on initial gastroscopy. Two hundred and sixty-seven (7.2%) endoscopists completed the survey, 44.2% indicated they would perform mapping for all patients, and 36% only for high-risk patients. Only 1.5% (n = 4) of respondents were able to correctly identify all six endoscopic photos of GIM/AG. Conclusion: This study demonstrates that in a large tertiary center, GIM is a prevalent endoscopic finding, but the associated rates of dysplasia and cancer were low. Additionally, among a small proportion of surveyed Australian endoscopists, there is notable variability in the endoscopic approach for AG and GIM and significant knowledge gaps. More training is required to increase the recognition of GIM and compliance with histological mapping.

Changes in weight following peroral endoscopic myotomy: results from a North American center.

Background and study aims Weight loss is a feature of untreated achalasia. While weight gain after achalasia treatment is expected, little data exist about the extent of it, particularly after peroral endoscopic myotomy (POEM). We aimed to describe the changes in weight after POEM. Patients and methods A retrospective analysis was performed of patients from March 2016 to March 2020 undergoing POEM by an experienced operator at an academic referral center in Kingston, Ontario, Canada. Data examined included pre- and post-POEM body mass index (BMI), procedural characteristics, and Eckardt scores. Results Ninety-two patients underwent POEM during the study period, for 77 of whom follow-up data were available including BMI. Prior to POEM, the median BMI was 26. Six patients (7.8 %) were considered to be underweight, 24 (31.2 %) were normal, 26 (33.8 %) were pre-obese, and 21 (27.2 %) were obese. At a median follow-up of 15 months, the clinical success rate was 95 %. Patients in the normal weight and pre-obesity categories had a significant increase in weight post-POEM. Of the underweight patients, two (33.3 %) moved up to a normal weight category and two (33.3 %) became pre-obese. In the normal BMI category, eight (37.5 %) became pre-obese and one patient (4.2 %) became obese. Ten of the 26 pre-obese patients (38.4 %) were obese post-POEM. Seven of the obese patients (33.3 %) reached Class III (morbid) obesity at follow-up.  Conclusions Patients may experience a marked increase in BMI following POEM, with over one-third of patients becoming pre-obese, obese or morbidly obese at follow-up in our study in a North American population. Further study is required to analyze weight gain patterns post-POEM.

Novel triangle tip-jet knife increases efficiency in peroral endoscopic myotomy for achalasia.

BACKGROUND AND AIM: Peroral endoscopic myotomy (POEM) is performed globally for the treatment of achalasia. A newly available endoscopic knife, the triangle tip-jet (TTJ) (Olympus Triangle TipKnife-J, KD-645L), has the capability of knife dissection along with submucosal injection. We aim to present our experience with the TTJ knife in comparison to the conventional TT knife in POEM, with a focus on procedural characteristics including time, efficiency, and the number of instrument exchanges. METHODS: All patients with achalasia who underwent POEM between March 2016 and March 2020 at a single tertiary academic center were included in the retrospective cohort. Demographic, procedural, and outcomes data were compared. RESULTS: Ninety-two procedures, 48 using the TT knife, and 44 with the TTJ knife were analyzed. Demographic data were similar. Procedure time was reduced using the TTJ knife (87 vs 61 min, P = <0.001) despite similar myotomy lengths (16.5 vs 15.2 cm, P = 0.09). Efficiency was increased in the TTJ group (5.5 vs 4.3 min/cm of procedure, P = 0.005). The number of instrument exchanges (16.7-1.7, P = <0.001) and usage of coagulation forceps decreased (1.7-0.5, P = <0.001). There was no difference in the procedural difficulty (POEM difficulty score [PDS] 2.2 vs 2.4, P = 0.4). Patients with higher procedural difficulty saw a greater improvement in procedural outcomes. Procedural success was high in both groups (96% vs 100%, P = 0.2). No serious adverse events were reported. CONCLUSIONS: The use of the TTJ knife increases efficiency during POEM for Achalasia. The total procedure time is decreased by 28-41%, and procedural efficiency is increased by 22-34%.

Taking the Next Steps in Endoscopic Visual Assessment of Barrett's Esophagus: A Pilot Study.

PURPOSE: Patients with Barrett's esophagus (BE) undergo surveillance endoscopies to assess for pre-cancerous changes. We developed a simple endoscopic classification method for predicting non-dysplastic BE (NDBE), low-grade dysplasia (LGD)/indefinite for dysplasia (ID) and high-grade dysplasia (HGD)/early esophageal adenocarcinoma (EAC). PATIENTS AND METHODS: Twenty-two patients with BE underwent endoscopy using the PENTAX Medical MagniView gastroscope and OPTIVISTA processor. Sixty-six video-still images were analyzed to characterize the microsurface, microvasculature and the presence of a demarcation line. Class A was characterized by regular microvascular and microsurface patterns and absence of a demarcation line, class B by changes in the microvascular and/or microsurface patterns compared to the background mucosa with presence of a demarcation line, and class C by irregular microvascular and/or irregular microsurface patterns with presence of a demarcation line. RESULTS: Of the class A images, 97.9% were NDBE. For class B, 69.2% were LGD/ID and 30.8% NDBE. One hundred percent of the class C samples were HGD/EAC. The sensitivity of our classification system was 93.8%, specificity 92%, positive predictive value 78.9%, negative predictive value 97.9% and an accuracy 92.4%. CONCLUSION: In this study, we developed a simple classification system for the prediction of NDBE, LGD/ID and HGD/EAC. Its real-time clinical applicability will be validated prospectively.

Cerebral oxygenation is highly sensitive to blood pressure variability in sick preterm infants.

OBJECTIVES: The significance of blood pressure variability (BPV) for cerebral oxygenation in extremely preterm infants has not been explored, though BPV may well be associated with end organ injury. We hypothesized that increased BPV in sick preterm infants, by exceeding the cerebral autoregulatory capacity, is associated with cerebral oxygenation changes which closely follow the blood pressure fluctuations. We assessed the autoregulatory capacity in the early postnatal period, by determining the correlation between BPV (mmHg(2)) and coherence of mean arterial blood pressure (MABP mmHg) and cerebral oxygenation (tissue oxygenation index, TOI %). STUDY DESIGN: Thirty-two preterm infants of mean gestational age of 26.3 (± 1.5) weeks were studied on the first 3 postnatal days. Spectral analysis (Coherence and transfer-function gain analysis) was used to calculate coherence of MABP and TOI; BPV was quantified using power spectral density of MABP. RESULTS: Overall, maximum Coherence showed a trend for positive correlation with BPV (n = 32, p = 0.06). Infants identified as clinically unstable with documented brain injury (n = 7) had high Coherence values at low BPV. Separate analysis of stable infants (excluding the 7 critically ill infants) revealed a significant association between maximum Coherence and BPV (n = 25, p = 0.006). CONCLUSIONS: Fluctuation in cerebral oxygenation is closely associated with increased BPV in preterm infants undergoing intensive care. Moreover, in the critically sick preterm infant, blood pressure-dependent variations in cerebral oxygenation occur even with relatively lower BPV, suggesting they have severely impaired autoregulation, and placing them at greater vulnerability to cerebral injury arising from blood pressure fluctuations.