The field of minimally invasive endoscopic treatment has seen a continual progression, marked by significant advancements in treatment devices and the refinement of endoscopic techniques. While endoscopic resection has become the standard for treating superficial gastrointestinal neoplasms, a proactive approach becomes imperative when dealing with lesions that extend beyond the submucosal layer and deeper into the muscularis propria. The ongoing evolution of endoscopic closure techniques has facilitated the introduction of advanced procedures such as endoscopic muscularis dissection, endoscopic subserosal dissection, and endoscopic full-thickness resection. This evolution is achieved by the commitment to improve the efficacy and precision in treating challenging lesions. Nevertheless, there is currently a lack of definitive guidelines or consensus regarding the specifics of deeper layer dissection. Drawing from prior research and clinical insights, this review discusses indications, techniques, clinical outcomes, and future perspectives of deeper layer dissection.
BACKGROUND AND AIMS: Killian-Jamieson diverticulum (KJD) is a relatively uncommon variant of pharyngoesophageal diverticula, distinct from the more prevalent Zenker diverticulum. However, literature on endoscopic management of KJD remains limited. This study aimed to elucidate the efficacy and safety of peroral endoscopic septotomy (POES) as a treatment approach for symptomatic KJD. METHODS: In this retrospective observational study, we investigated the outcomes of nine consecutive patients who underwent POES for KJD between January 2019 and May 2023. Follow-up data of at least 2 months post-treatment were analyzed. The primary outcome measure was the technical success rate of POES. Secondary outcomes encompassed the clinical success rate, defined as symptomatic improvement 2 months after POES, and the incidence of adverse events. RESULTS: All patients presented with dysphagia, with a median symptom duration of 6 months (interquartile range [IQR]: 3-12 months). The median diverticulum size was 32 mm (IQR: 24-42 mm). The median duration of the operation time was 66 min (IQR: 60-109). A 100% technical success rate was achieved, with complete closure of the defect in all cases. There were no adverse events related to this treatment. The median hospitalization duration was 5 days (IQR: 4-6), and the clinical success rate was 88.9%. Follow-up barium esophagograms exhibited significant improvement in the flow of the barium for all patients. CONCLUSIONS: Despite the relatively limited case volume, our findings underscore that POES is a safe and efficacious approach for managing symptomatic KJD.
Video 1Demonstration of endoscopic mucoplasty for benign esophageal strictures (multiple Schatzki rings).
Video 1Video demonstrating the endoscopic full-thickness resection of an exophytic subepithelial lesion with "double scope traction" technique.
Killian-Jamieson diverticulum (KJD) is a rare type of esophageal diverticulum less commonly encountered compared with Zenker's diverticulum (ZD). Endoscopic approach for these diverticula has been rapidly evolving. Currently, a flexible endoscopic septum division is considered the first-line treatment for symptomatic ZD patients, however reported recurrence rates are over 10% according to recent literature. With the advent of submucosal tunneling technique established by per-oral endoscopic myotomy for achalasia, it has been applied to treat ZD named as Zenker's diverticulum per-oral endoscopic myotomy (Z-POEM) as a minimally invasive treatment. Although there are very few reports utilizing submucosal tunneling approach to KJD, we have opted to perform Z-POEM in order to safely perform complete dissection of the muscle septum while maintaining mucosal integration. Due to the difficulty of anatomical location of KJD, we created mucosal incision and subsequent submucosal tunnel directly at the level of the septum as opposed to creating a submucosal tunnel few centimeters proximal to the septum as being previously proposed. We report a case in which this technique was successfully performed with complete resolution of dysphagia without any adverse event. This technique permits to perform complete myotomies without the fear of causing perforation. Although larger cohorts are required to assess its safety and efficacy, Z-POEM to treat KJD seems to be promising.
Endoscopic pressure study integrated system (EPSIS) is a novel tool for the diagnosis of gastroesophageal reflux disease. It enables the evaluation of the function of the lower esophageal sphincter by monitoring intragastric pressure (IGP) while insufflating the stomach during esophagogastroduodenoscopy. EPSIS can predict abnormal acid reflux with high accuracy based on previous studies. IGP was measured by inserting through the working channel of the scope an intragastric catheter connected to a pressure measuring device. Herein, we assess the feasibility of an updated EPSIS system, which can be performed just by connecting a flush tube to the working channel. This method does not require inserting foreign objects in the stomach and spares catheter insertion in order to simplify the procedure and reduce costs. A single-center pilot study was conducted to evaluate the association between catheter-based EPSIS and the updated EPSIS. The results of EPSIS in 20 patients who underwent both methods were assessed. In all cases, the waveform pattern of IGP measured by catheter-based EPSIS and updated EPSIS was consistent with 15 uphill pattern and five flat pattern. Intraobserver agreement of waveform pattern was perfect between two examiners with kappa value = 1. Intraclass correlation coefficient (ICC) for intraobserver reliability for maximum IGP was excellent with 0.91 (95% confidence interval [CI] of 0.77 < ICC < 0.96) and for pressure gradient was also good with 0.89 (95% CI of 0.71 < ICC < 0.95). In conclusion, our study suggests that the updated EPSIS can be performed without the use of a catheter.
Gastroesophageal Reflux , Esophageal Sphincter, Lower , Gastroesophageal Reflux/diagnosis , Heartburn , Humans , Manometry , Pilot Projects , Reproducibility of Results
