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.

Per-oral Endoscopic Myotomy (POEM): A safe and effective treatment for achalasia in geriatric patients / Miotomía endoscópica a través de la boca (POEM): una alternativa endoscópica segura y efectiva para el tratamiento de la acalasia en pacientes geriátricos

Background: Esophageal achalasia is a primary motor disorder of the esophagus characterized by impair relaxation of the lower esophageal sphincter and absent of esophageal peristalsis. Per-oral endoscopic myotomy is an alternative treatment to surgical Heller myotomy in patients over 65 years old. The aim of this paper was to describe the results of peroral endoscopic myotomy (POEM) or the treatment of achalasia in geriatric patients. Methods: We included patients over 65 years old with POEM, from retrospective cohort review, in which POEM was performed with a standardized technique in our department. Results: 12 patients were included, the procedure was successful in 98% of patients, minor adverse events occurred without mortality. Conclusions: POEM is a safe and effective technique for the treatment of achalasia, the results of the study are similar to those reported in the literature.

Introducción: La acalasia es un trastorno motor primario del esófago caracterizado por falla en la relajación del esfínter esofágico inferior y ausencia de peristalsis esofágica sin una causa identificable de obstrucción en el esófago distal. La miotomía endoscópica a través de la boca es un tratamiento alternativo a la cardiomiotomía de Heller laparoscópica en pacientes mayores de 65 años. El objetivo de este trabajo fue describir los resultados la miotomía endoscópica a través de la boca (POEM), en pacientes mayores de 65 años. Métodos: Estudio retrospectivo con diagnóstico manométrico de acalasia, de pacientes mayores de 65 años de edad. Resultados: Se incluyeron 12 pacientes, se consideró tratamiento exitoso cuando el paciente alcanza un índice de Eckardt < 3. El procedimiento fue exitoso en el 98% de los pacientes, se presentaron eventos adversos menores en la mayoría de los pacientes. Conclusiones: La miotomía endoscópica a través de la boca es una técnica segura y efectiva para el tratamiento de acalasia en adultos mayores, los resultados del estudio son similares a los reportados en la literatura.

[Guidelines for diagnosis and treatment of constipation in Mexico. B) Diagnostic approach]. / Guías de diagnóstico y tratamiento del estreñimiento en México. B) Abordaje diagnóstico.

BACKGROUND: Constipation is a heterogeneous symptom so an accurate diagnosis requires an appropriate approach. OBJECTIVE AND METHODS: To establish the clinical guidelines for diagnosis and treatment of chronic constipation in Mexico we have reviewed the diagnostic aspects of constipation according to the availability of resources in our country. In addition, evidence-based recommendations have been provided. RESULTS: The symptoms that best define constipation in our population are infrequent stool, hard stool expulsion, excessive effort and sensation of incomplete evacuation. Digital rectal examination is a useful diagnostic tool to discard organic diseases and pelvic floor dyssynergia. Patients with risk factors such as recent onset of constipation, family history of inflammatory bowel disease or colon cancer and those with alarm signs (unintentional weight loss and significant anemia, blood in stool) should undergo endoscopic diagnostic studies. If they are available, the most useful tests in evaluating patients with functional constipation are colonic transit with radiopaque markers and anorectal manometry with balloon expulsion test. CONCLUSIONS: Patients with symptoms of chronic constipation should undergo advanced colorectal physiological studies to try to establish the cause of constipation.