Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial.

BACKGROUND: Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy (POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy, has emerged as a promising minimally invasive technique for the management of this condition. AIM: To compare POEM and laparoscopic myotomy and partial fundoplication (LM-PF) regarding their efficacy and outcomes for the treatment of achalasia. METHODS: Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria (dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis (as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min (on a barium esophagogram), pressure at the LES, the occurrence of adverse events (AEs), length of stay (LOS), and quality of life (QoL). RESULTS: There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up (P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group (P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group (185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min, respectively; P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group. CONCLUSION: POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia, shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

Stent versus Balloon Dilation for the Treatment of Dominant Strictures in Primary Sclerosing Cholangitis: A Systematic Review and Meta-Analysis.

BACKGROUND/AIMS: The endoscopic management of primary sclerosing cholangitis (PSC)-associated dominant strictures remains challenging. This systematic review and meta-analysis aimed to compare balloon dilation and stent placement in the treatment of dominant strictures among PSC patients. METHODS: Literature searches on MEDLINE, EMBASE, Cochrane CENTRAL and Lilacs/Bireme were performed for studies published until December 2020. Measured outcomes included clinical efficacy, stricture recurrence, cumulative recurrencefree rate, transplant rate, 5-year survival rate, and adverse events (i.e., pancreatitis, cholangitis, bleeding, perforation and death). RESULTS: A total of 5 studies (n=467) were included. Based on pooled analyses, there were no differences in clinical efficacy (risk difference [RD], -0.13; 95% confidence interval [CI], -0.58 to 0.33; I2=93%) or transplant rates (RD, -0.09; 95% CI, -0.19 to 0.01; I2=0%); however, the risk of occurrence of adverse events was lower with balloon dilatation than with stent placement (RD,-0.34; 95% CI, -0.45 to -0.23; I2=61%). Among the types of adverse events reported, only the rates of cholangitis/bacteremia were significantly lower in balloon dilation patients (RD, -0.19; 95% CI, -0.25 to -0.13; I2=51%). CONCLUSION: Compared to balloon dilation, stent placement for dominant strictures in PSC appeared to have higher complication rates without significant differences in efficacy.

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy in solid lesions: A multi-center analysis.

BACKGROUND: While endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is considered a preferred technique for tissue sampling for solid lesions, fine needle biopsy (FNB) has recently been developed. AIM: To compare the accuracy of FNB vs FNA in determining the diagnosis of solid lesions. METHODS: A retrospective, multi-center study of EUS-guided tissue sampling using FNA vs FNB needles. Measured outcomes included diagnostic test characteristics (i.e., sensitivity, specificity, accuracy), use of rapid on-site evaluation (ROSE), and adverse events. Subgroup analyses were performed by type of lesion and diagnostic yield with or without ROSE. A multivariable logistic regression was also performed. RESULTS: A total of 1168 patients with solid lesions (n = 468 FNA; n = 700 FNB) underwent EUS-guided sampling. Mean age was 65.02 ± 12.13 years. Overall, sensitivity, specificity and accuracy were superior for FNB vs FNA (84.70% vs 74.53%; 99.29% vs 96.62%; and 87.62% vs 81.55%, respectively; P < 0.001). On subgroup analyses, sensitivity, specificity, and accuracy of FNB alone were similar to FNA + ROSE [(81.66% vs 86.45%; P = 0.142), (100% vs 100%; P = 1.00) and (88.40% vs 85.43%; P = 0.320]. There were no difference in diagnostic yield of FNB alone vs FNB + ROSE (P > 0.05). Multivariate analysis showed no significant predictor for better accuracy. On subgroup analyses, FNB was superior to FNA for non-pancreatic lesions; however, there was no difference between the techniques among pancreatic lesions. One adverse event was reported in each group. CONCLUSION: FNB is superior to FNA with equivalent diagnostic test characteristics compared to FNA + ROSE in the diagnosis of non-pancreatic solid lesions. Our results suggest that EUS-FNB may eliminate the need of ROSE and should be employed as a first-line method in the diagnosis of solid lesions.

Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: Systematic review and meta-analysis.

BACKGROUND: Upper gastrointestinal fistulas, leaks, and perforations represent a high cost burden to health systems worldwide, with high morbidity and mortality rates for affected patients. Management of these transmural defects remains therapeutically challenging. OBJECTIVES: The aim of this study is to perform a systematic review and meta-analysis to investigate the efficacy and safety of self-expanding metal stents (SEMS) versus endoscopic vacuum therapy (EVT) for treatment of upper gastrointestinal transmural defects. METHODS: Searches were performed on MEDLINE, EMBASE, Central Cochrane, Latin American and Caribbean Health (LILACS), and gray literature, as well as a manual search to identify studies comparing SEMS versus EVT to treat upper gastrointestinal transmural defects. Evaluated outcomes were: rates of successful closure, mortality, length of hospital stay, duration of treatment, and adverse events. RESULTS: Five studies with a total of 274 patients were included. There was a 21% increase in successful fistula closure attributed to EVT compared with the SEMS group (RD 0.21, CI 0.10-0.32; P = 0.0003). EVT demonstrated a 12% reduction in mortality compared to stenting (RD 0.12, CI 0.03-0.21; P = 0.006) and an average reduction of 14.22 days in duration of treatment (CI 8.38-20.07; P < 0.00001). There was a 24% reduction in adverse events (RD 0.24, CI 0.13-0.35; P = 0.0001. There were no statistical differences between the studied therapies regarding the length of hospital stay. CONCLUSION: Endoscopic vacuum therapy proves to be superior in successful defect closure, mortality, adverse events and duration of treatment.

Argon plasma coagulation alone versus argon plasma coagulation plus full-thickness endoscopic suturing to treat weight regain after Roux-en-Y gastric bypass: a prospective randomized trial (with videos).

BACKGROUND AND AIMS: A significant number of patients regain weight after Roux-en-Y gastric bypass. Ablation with argon plasma coagulation (APC) plus endoscopic full-thickness suturing (FTS-APC) and ablation alone have been reported for treating weight regain when associated with gastrojejunostomy (GJ) dilation. However, comparative controlled data are still lacking. METHODS: This was a pilot single-center open-label randomized trial comparing the effectiveness and safety of APC alone versus FTS-APC for transoral outlet reduction. Patients with at least 20% weight regain from the nadir, and GJ ≥15 mm were considered eligible. The primary outcome was percentage total weight loss (%TWL) at 12 months. Secondary outcomes were the incidence of adverse events, amelioration of metabolic laboratory parameters, and improvement in quality of life and eating behavior. RESULTS: Forty patients meeting the eligibility criteria were enrolled from October 2017 to July 2018. Technical and clinical success rates were similar between the groups. At 12 months, the mean %TWL was 8.3% ± 5.5% in the APC alone group versus 7.5% ± 7.7% in the FTS-APC group (P = .71). The pre-revisional % solid gastric retention at 1 hour positively correlated with the probability of achieving ≥10% TWL at 12 months. Both groups experienced significant reductions in low-density lipoprotein and triglyceride levels at 12 months, and improvement in eating behavior and quality of life at 3 months. There were 2 cases of stenoses (1 from each group), which were successfully treated with endoscopic balloon dilation. CONCLUSION: APC alone is similar to FTS-APC in terms of technical and clinical outcomes within 1 year of follow-up. (Clinical trial registration number: NCT03094936.).

Endoscopic Ultrasound Fine-Needle Aspiration versus Fine-Needle Biopsy for Lymph Node Diagnosis: A Large Multicenter Comparative Analysis.

BACKGROUND/AIMS: Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is preferred for sampling of lymph nodes (LNs) adjacent to the gastrointestinal wall; however, fine-needle biopsy (FNB) may provide improved diagnostic outcomes. This study aimed to evaluate the comparative efficacy and safety of FNA versus FNB for LN sampling. METHODS: This was a multicenter retrospective study of prospectively collected data to evaluate outcomes of EUS-FNA and EUS-FNB for LN sampling. Characteristics analyzed included sensitivity, specificity, accuracy, the number of needle passes, diagnostic adequacy of rapid on-site evaluation (ROSE), cell-block analysis, and adverse events. RESULTS: A total of 209 patients underwent EUS-guided LN sampling. The mean lesion size was 16.22±8.03 mm, with similar sensitivity and accuracy between FNA and FNB ([67.21% vs. 75.00%, respectively, p=0.216] and [78.80% vs. 83.17%, respectively, p=0.423]). The specificity of FNB was better than that of FNA (100.00% vs. 93.62%, p=0.01). The number of passes required for diagnosis was not different. Abdominal and peri-hepatic LN location demonstrated FNB to have a higher sensitivity (81.08% vs. 64.71%, p=0.031 and 80.95% vs. 58.33%, p=0.023) and accuracy (88.14% vs. 75.29%, p=0.053 and 88.89% vs. 70.49%, p=0.038), respectively. ROSE was a significant predictor for accuracy (odds ratio, 5.16; 95% confidence interval, 1.15-23.08; p=0.032). No adverse events were reported in either cohort. CONCLUSION: Both EUS-FNA and EUS-FNB are safe for the diagnosis of LNs. EUS-FNB is preferred for abdominal LN sampling. EUS-FNA+ ROSE was similar to EUS-FNB alone, showing better diagnosis for EUS-FNB than traditional FNA. While ROSE remained a significant predictor for accuracy, due to its poor availability in most centers, its use may be limited to cases with previous inconclusive diagnoses.

The importance of endoscopic ultrasound fine-needle aspiration in the diagnosis of solid pseudopapillary tumor of the pancreas: two case reports.

BACKGROUND: Solid pseudopapillary tumor of the pancreas, otherwise known as solid and cystic tumor or Frantz tumor, is an unusual form of pancreatic carcinoma, with unknown etiopathogenesis, that accounts for 0.2 to 2.7% of all pancreatic tumors. It is defined as an exocrine pancreatic neoplasia that mainly affects women between the second and third decade of life, and its management is not well defined. Endoscopic ultrasound offers a key anatomical advantage in accessing the pancreas and endoscopic ultrasound fine-needle aspiration has become the gold standard method for the diagnosis of pancreatic lesions. CASE PRESENTATION: Case 1: A 31-year-old white Hispanic woman presented with epigastric pain for 5 months. An abdominal ultrasound revealed a single 2 cm nodule in the uncinate process of her pancreas. Endoscopic ultrasound showed a regular, well-defined solid lesion with alternating cystic areas at the uncinate process of her pancreas, measuring 1.7 × 1.4 cm; endoscopic ultrasound fine-needle aspiration was then performed with cytopathological analysis compatible with solid pseudopapillary tumor. Body computed tomography confirmed the absence of metastases and she underwent conventional duodenopancreatectomy. However, she died 4 days after surgery due to postoperative surgical complications. Case 2: A 35-year-old Hispanic woman presented with left upper quadrant abdominal pain for 3 months, associated with a palpable mass at this region. A computed tomography scan showed a solitary nodule in the pancreatic body. Endoscopic ultrasound showed a regular, well-defined, homogeneous lesion with small anechoic (cystic) areas, measuring 2 × 2 cm, in between the pancreatic body and neck. Endoscopic ultrasound fine-needle aspiration was performed and cytopathological analysis was suggestive of a pseudopapillary solid tumor. She underwent a body-tail laparoscopic pancreatectomy with splenectomy. Nine months after the diagnosis, she remains asymptomatic, continuing regular follow-up in the oncology out-patient clinic. CONCLUSIONS: Solid pseudopapillary tumor is a rare pancreatic malignancy. Endoscopic ultrasound fine-needle aspiration is the gold standard method to characterize and diagnose this type of pancreatic lesion, making this an invaluable tool to help guide clinical management and improve the preoperative diagnostic yield.