Introduction

Per-oral endoscopic myotomy (POEM) is an established treatment modality for achalasia cardia. Submucosal fibrosis (SMF) is rare, but the most important reason for technical failure during POEM. Prediction of SMF may be crucial to improve technical outcomes with POEM.

Aims & Methods

In this study we aim to evaluate the predictors for SMF in cases with achalasia cardia.Consecutive patients with achalasia cardia who underwent POEM (Aug 2021 to October 2022) were included in the study, prospectively. Various factors were analysed for prediction of SMF including age, gender, stasis esophagitis, type of achalasia, duration of disease, lower esophageal sphincter pressure (LESP), height of barium column on barium esophagogram and severity of symptoms (Eckardt score). Esophageal mucosa was graded for the severity of stasis esophagitis (grade I to grade III) based on vascular pattern, mucosal thickening, ulceration and nodularity. SMF was graded (I minimal, II moderate, III severe) according to mucosal lift, difficulty in entry, density of SM fibers, separation of mucosa and muscle.

Results

240 patients (males 139, mean age 44.4±14.7 years) underwent POEM during the study period. The subtypes of achalasia included type I in 29, type II in 201, type III in 10. Median symptom duration was 24 (1-240) months and mean pre-POEM Eckardt score was 7.6±1.8. Majority (93.3%) of the patients were treatment naïve and underwent POEM via posterior route (91.2%). Stasis esophagitis was evident in 122 (50.8%) patients including grade I in 99 (41.3%), grade II in 16 (6.7%) and grade III in 7 (2.9%) patients. SMF was detected in 87 (36.3%) patients including grade I in 52 (21.7%), grade II in 30 (12.5%) and grade III in 5 (2.1%) patients. Mean age, duration of symptoms, width of esophagus and procedure duration were significantly higher in cases with submucosal fibrosis. (Table 1) Significantly higher proportion of patients with type I achalasia (62.1%) had SMF as compared to type II (33.8%) and type III achalasia (10%) [p=0.013]. On multivariate analysis, the presence of stasis esophagitis and width of esophagus on timed barium were predictors of significant (≥grade II) SMF.

Conclusion

Severe SMF (grade III) is uncommon in cases with achalasia cardia. The presence of stasis esophagitis and width of esophagus are predictors of SMF during POEM.

References

1. Wu QN, Xu XY, Zhang XC, Xu MD, Zhang YQ, Chen WF, Cai MY, Qin WZ, Hu JW, Yao LQ, Li QL. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017 Aug;49(08):736-44.
2. Feng X, Linghu E, Chai N, Ding H. New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis. Saudi journal of gastroenterology: official journal of the Saudi Gastroenterology Association. 2018 Mar;24(2):122.

Disclosure

Nothing to disclose

Introduction

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, there are limited studies on the long-term outcomes of POEM in patients with failed Heller’s myotomy (HM).

Aims & Methods

Aims: In this study, we aimed to evaluate the long-term outcomes of POEM in cases with prior failed HM.
Methods: The data of all the patients with recurrence of symptoms after HM who underwent POEM (Sep 2013 to March 2023) was analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES) <3]. Secondary outcomes included improvement of manometry parameters, barium emptying at five minutes and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM.

Results

72 cases (45.9±13.4y, 43 males) with history of HM underwent POEM during the study period. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), spastic motility disorders (2.8%) and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), LHM plus pneumatic dilatation and Botox in 4 (5.5%). All the POEM procedures were performed by posterior route and technical success was achieved in all the cases. The mean length of myotomy was 10.7±3.3 cm and mean procedure duration was 59.1±25.9 min. There was significant improvement in ES (pre-POEM 6.5±1.8 vs post-POEM 0.7±0.7), LES pressures (31.7±12.5 vs 13.3±5.7 mmHg) and barium emptying (14.2±4.2 vs 2.4±3.1 cm) at 1-yr follow-up. At a median follow-up of 63-months (IQR 40-95), clinical success (ES<3) was documented in 58 (87.9%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 (57.1%) and 11 (55%), respectively.

Conclusion

POEM is a durable treatment modality in cases with relapse of symptoms after Heller’s myotomy. Gastroesophageal reflux is common after POEM and should be systematically evaluated.

Disclosure

No disclosures

Introduction

POEM is an established treatment modality for achalasia cardia. Monopolar knives (MPK) are typically used for submucosal dissection as well as myotomy during POEM. More recently, a novel bipolar device (BPD) is commercially available for endoscopic dissection and resection procedures.

Aims & Methods

In this study, we aim to compare the performance of MPK with BPD during POEM. This is a prospective, multicenter cohort study including consecutive cases with achalasia cardia who underwent POEM using conventional MPK or a novel BPD from Dec 2019 to Jan 2023. The primary aim of the study was to evaluate the requirement for accessory exchange during POEM procedure. The secondary objectives included technical success, procedure time, adverse events, post-procedure pain and clinical success (Eckardt≤3). Post-operative pain scores were assessed on the day of procedure and first post-operative day using a standardized scale i.e. visual analog scale (VAS). The severity of pain was graded as mild (0-30), moderate (>30-70) and severe (>70).

Results

278 cases (40.9y, 162 males) with achalasia underwent POEM using either a monopolar knife (n=220) or bipolar device (n=58). All the procedures were performed by posterior route (5 O’clock). Median exchange of accessories was significantly lower in the BPD group [3 (2-8) vs 1 (1-2), p=0.001). The use of coagulation forceps for hemostasis or pre-coagulation was significantly less in the BPD group [1(0-6) vs 0(0-1), p=0.001]. There was no difference in technical success, procedure duration and adverse events between the two groups. Post-operative pain was significantly less in the BPD group [40(20-90) vs 40 (20-80), p=0.021]. The proportion of cases with moderate to severe post-operative pain was significantly higher in the MPK group (79.6% vs 56.9%, p=0.001). (Table 1)

Table 1. Comparison of technical and clinical outcomes between the two groups

Conclusion

The novel BPD is safe and effective for performing POEM procedures with the added advantage of minimum exchange of accessories and reduced post-operative pain as compared to MPK.

References

Nabi Z, Chavan R, Ramchandani M, Tsiamoulos Z, Basha J, Goud R, Darisetty S, Reddy N. Endoscopic submucosal dissection and tunneling procedures using a novel all-in-one bipolar device. Endosc Int Open. 2020 Oct;8(10):E1302-E1307.

Disclosure

Dr Zaheer Nabi and Mohan Ramchandani have consultant agreement with Creo Medical

Introduction

Gastroesophageal reflux disease (GERD) is common after per-oral endoscopic myotomy (POEM). Selective sparing of oblique fibers (OFS) during POEM may reduce the incidence of reflux esophagitis after POEM.

Aims & Methods

Aim: In this study, we aim to compare the incidence of GERD between conventional (CM) versus oblique fiber sparing (OFS) techniques of endoscopic myotomy in cases with idiopathic achalasia.
Methods: Eligible patients with type I and II achalasia who underwent POEM from Jan 2020 to October 2020 were randomized into two groups (CM and OFS). Exclusion criteria were: type III achalasia, sigmoid esophagus and history of Heller’s myotomy with fundoplication. The primary outcome of the study was comparison of reflux esophagitis in the two groups. The secondary aims included reflux symptoms, esophageal acid exposure, and clinical success.

Results

115 patients were randomized in CM (58) and OFS (57) groups. Both the groups were similar with regards to the symptom scores, sub-types of achalasia and history of previous treatment. The mean operation time was similar in both the groups (CM 43.7±23.8 mins versus OFS 46.4±24.7 mins). Mean length of total myotomies were comparable in the two groups (9.9±3.0cm vs 9.5 ±3.1cm). Clinical success (Eckardt≤3) was recorded in all the patients. Overall, reflux esophagitis was found in 56 (48.7%) patients. Grade B or higher esophagitis was similar in the two groups (25.9% vs 31.6%, p=0.541). The mean number of reflux episodes (48.2±36.6 vs 48.9±40.3, p=0.933), proportion of patients with increased esophageal acid exposure >6% (45.5% vs 31.7%, p=0.266) and high DeMeester scores (>14.7) (38.6% vs 41.5%, p=0.827) were similar in both the groups. Symptomatic GERD (GERDQ>7) and use of PPIs at 1-year was similar in the two groups (GERDQ>7: 29.8% vs 26.5%, 0.822)(PPIs: 34% vs 28.6%, p=0.661).

Conclusion

Sparing of sling fibers has no significant impact on the incidence of GERD after POEM. Novel strategies need to be explored to prevent GERD after POEM. (NCT04229342)

Disclosure

No disclosure

Introduction

With the improvement of endoscopic resection techniques, there has been recent interest in real-time in vivo characterization of polyp histology. Of all the new imaging technologies for characterizing polyp histology, narrow-band imaging (NBI) has been the most extensively studied and is easy to feasible. Correct histological prediction allows determining the optimal endoscopic technique for resection of lesions with the achievement of R0 resection. The NBI International Colorectal Endoscopic Classification (NICE) and the Japanese NBI Expert Team (JNET) classification are mostly used to predict the depth of invasion. However, the effectiveness of diagnostics using NBI in clinical practice is variable and is associated with low sensitivity for superficial invasive carcinoma.

Aims & Methods

Primary aim was to determine and compare the diagnostic accuracy of NICE and JNET classifications in predicting histology in community practice. Secondary aim was to determine the positive predictive value (PPV) for the NICE and JNET classification.
In this single-center prospective study we have included 211 patients aged 18–75 years (130 men, 62%; 81 women, 38%; mean age 60 years) who underwent colonoscopies with endoscopic resection of advanced colorectal neoplasia (defined by size lesions ≥ 10 mm). The NICE and JNET classifications were used for each lesion. The results were compared with the final histopathological finding to determine and compare NICE and JNET classification accuracy.

Results

257 lesions were analyzed including 8 (3.1 %) hyperplastic polyps, 47 (18.3 %) sessile serrated polyps, 152 (59.1 %) adenomas with low grade dysplasia, 36 (14.0 %) high-grade adenomas, 12 (4,7 %) intramucosal carcinomas, 1 (0.4 %) T1sm1 carcinoma and 1 (0.4 %) T2 carcinoma. A total of 199 lesions (77.4 %) were correctly classified according to the JNET classification and 241 lesions (93.8 %) were correctly classified according to the NICE classification. The PPV for NICE 1 lesion was 95.9 %, NICE 2 97.0 % and NICE 3 22.0 %. The PPV for JNET 1 lesions was 95.9 %, JNET 2A 83.0 %, JNET 2B 52.2 % and JNET 3 22.5 %.

Conclusion

The NICE classification was associated with a higher proportion of correctly classified lesions (93.8 %) compared to the JNET classification (77.4 %). However, NBI virtual chromoendoscopy shows a low PPV for HGD adenomas, intramucosal carcinomas and T1sm1 carcinomas (NICE 2 22.1 %, JNET 2B 52.2 %). Therefore, additional investigations in these lesions are still required with magnifying chromoendoscopy prior a final decision of endoscopic therapy. Improvement of predictive accuracy of these lesions and determining the limiting factors will be the subject of further investigation.
Supported by program projects of the Ministry of Health of the Czech Republic with reg. no. NV18-08-00246, NU22-08-00424, MO1012 and Cooperatio.

References

Kobayashi S et al. Diagnostic yield of the Japan NBI Expert Team (JNET) classification for endoscopic diagnosis of superficial colorectal neoplasms in a large-scale clinical practice database. United European Gastroenterology Journal 2019;7(7):914- 923.
Hayashi N et al. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the narrow-band imaging international colorectal endoscopic (NICE) classification. Gastrointest Endosc 2013;78:625–632.
Sano Y et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016;28:526–533.
Wang Y et al. Diagnostic performance of narrow-band imaging international colorectal endoscopic and Japanese narrow-band imaging expert team classification systems for colorectal cancer and precancerous lesions. World J Gastrointest Oncol 2021;13(1):58-68.

Introduction

Red dichromatic imaging (RDI) is a next-generation image enhancement technique which works by employing green, amber and red wavelengths. The blood vessels in the deeper tissues absorb the amber light because of strong affinity with hemoglobin. Even though red light can penetrate deep into the tissue, it is weakly absorbed by hemoglobin. RDI enhances the visibility of deep blood vessels and bleeding sources. Hence it leads to early identification of bleeding sources and quicker hemostasis. RDI enhances the contrast between diluted blood and highly concentrated blood, thereby clearly visualizing the bleeding source. Bleeding during POEM is not very uncommon(0.5-0.7%). Early recognition of bleeding points and quicker hemostasis help in decreasing complications. The utility of RDI in the peroral endoscopic myotomy is not studied so far to our knowledge.

Aims & Methods

To assess the reduction in total procedural time using Red dichromatic imaging (RDI) compared to white light imaging in achieving haemostasis during POEM. To identifying avascular mucosal site by identifying and avoiding deep blood vessels using RDI, use of RDI in comparison with white light imaging (WLI) in achieving haemostasis, ease of mucosal entry by using RDI when compared to WLI and psychological stress experienced by endoscopists during haemostasis treatment.
A single centre prospective, randomized study conducted at tertiary referral centre. Patient with achalasia cardia who are undergoing POEM procedure are randomized into two groups- Group 1- Patient undergoing POEM using novel GF 1500 UGI Scope (RDI) and Group 2- patient undergoing procedure using regular white light endoscope. In group 1, RDI mode 2 was used for mucosal injection and incision and RDI mode 1 was used for identifying and controlling bleeding during the procedure.

Results

Achalasia cardia patients(n=103) undergoing POEM procedure where enrolled in this study, with 52 subjects in RDI Group and 51 subjects in WLI group. The mean age in the RDI group was 49.01± 14.78 years and in WLI group was 46.68± 15.58 years (p=0.32). The Eckardt score improved significantly in the both groups and adverse events where similar in both the groups. The total hemostasis time was significantly better (p=0.02) in the RDI group (7.9±12.02 sec) compared to WLI group (18.92±25.89 sec). Therefore the total procedural time was significantly quicker (p=0.02) in the RDI group when compared to the WLI group. However there was no significant advantage (p=0.18) of RDI over WLI in preventing mucosal entry point bleed. The RDI group had significant advantage in parameters like ease of entry (p=0.0001) and stress encountered by the operator (p=0.028).

Conclusion

Bleeding during POEM procedure can be daunting for even an experienced endoscopist and RDI can be helpful in this regard. The total hemostasis time, total procedural time, ease of submucosal entry and stress of the operator is seen to be significantly better using novel RDI. Hence RDI helps in early identification of bleeding sources and quicker hemostasis during POEM.

References

1. Maehata T, Fujimoto A, Uraoka T, Kato M, Horii J, Sasaki M, Kiguchi Y, Akimoto T, Nakayama A, Ochiai Y, Goto O. Efficacy of a new image-enhancement technique for achieving hemostasis in endoscopic submucosal dissection. Gastrointestinal Endoscopy. 2020 Sep 1;92(3):667-74.
2. Hirai Y, Fujimoto A, Matsutani N, Murakami S, Nakajima Y, Miyanaga R, Nakazato Y, Watanabe K, Kikuchi M, Yahagi N. Evaluation of the visibility of bleeding points using red dichromatic imaging in endoscopic hemostasis for acute GI bleeding (with video). Gastrointestinal Endoscopy. 2022 Apr 1;95(4):692-700.
3. Anudeep KV, Ramchandani M, Inavolu P, Nabi Z, Reddy DN. Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique. VideoGIE. 2021 May 1;6(5):203-6.