Introduction

Peroral endoscopic myotomy (POEM) is a less invasive endoscopic treatment for stenotic diseases caused by oesophageal motility dysfunction. During this procedure, the insufflation gas supplied from the endoscope migrates to the abdominal cavity, resulting in pneumoperitoneum. For excessive pneumoperitoneum, transabdominal puncture should be performed to rapidly decrease the intraabdominal pressure. However, the timing of puncture depends subjectively on the operator’s decision.

Aims & Methods

In this study, we retrospectively analysed the factors leading to pneumoperitoneum and clarified the objective indicators to determine the timing of abdominocentesis. A total of 100 consecutive patients who underwent POEM at our hospital from October 2018 to December 2023 were included. In univariate analyses, patient-related (age, sex, body surface area [BSA], body mass index), disease-related (diagnosis, preoperative Eckardt score), and treatment-related factors (operator's POEM experience, myotomy length, peak end-tidal carbon dioxide concentration [ETCO₂]) were compared between Puncture and Nonpuncture groups. In these parameters, sex and BSA, which correlated with the intraabdominal space, and factors that were supposed to influence the severity of pneumoperitoneum and the need for subsequent abdominocentesis by showing p-values of less than 0.1 were enrolled for subsequent multivariate analyses.

Results

The mean age was 58 (standard deviation [SD], 19) and 51% of them were male. The mean Eckardt score was 6 (SD, 3). Most patients (n = 92, 92%) were diagnosed with oesophageal achalasia. The mean procedure time was 88 min (SD, 35 min). Abdominocentesis was performed in 65 patients (68%), who were allocated into the Puncture group. In the univariate analyses, the peak ETCO₂ was significantly higher in the Puncture group than in the Nonpuncture group (p <0.01). In the multivariate analyses using sex, BSA, and the peak ETCO₂, high peak ETCO₂ was a single independent factor associated with abdominocentesis (odds ratio = 1.25, 95% confidence interval: 1.11–1.41, p <0.01). The receiver operating characteristic curve indicated that the two groups were divided with a maximal area under the curve (0.76) when a cut-off value of the peak ETCO₂ was set at 44.5 mmHg (sensitivity, 0.79; specificity, 0.65).

Conclusion

This study demonstrated that the intraoperative ETCO₂ level was a significant independent factor related to severe pneumoperitoneum in POEM, and 45 mmHg of peak ETCO₂ was an optimal cut-off value to differentiate the Puncture group from the Nonpuncture group. This result should be clinically useful as an objective reference to determine abdominocentesis in patient with pneumoperitoneum due to CO₂ leakage to the abdominal space.

Introduction

Gastric peroral endoscopic myotomy (G-POEM) is an emerging endoscopic technique for the treatment of refractory gastroparesis, particularly benefiting patients with pylorospasm. It is considered a safe procedure with a low risk of adverse events when performed by experienced endoscopists. Our aim was to perform a comprehensive analysis of all adverse events associated with G-POEM.

Aims & Methods

We performed a retrospective analysis of prospectively collected data from all patients who underwent G-POEM for gastroparesis at our centers (Prague, Brno) between November 2017 and April 2025. All procedures were performed by a single endoscopist (JM). The primary outcome was procedure-related adverse events rate and severity occurring during the perioperative and early postoperative period. Adverse events were categorized as follows: deviations from the expected peri and postoperative course were defined as "undesirable events." Undesirable events that met the criteria of the Clavien Dindo surgical classification (C-D) were considered "true adverse events".

Results

Out of 70 procedures, no true adverse or undesirable events occurred in 51 procedures (72.9%). Perioperatively, the following undesirable events occurred in 18 patients: : gastric (4; 5.7%) and duodenal mucosal injuries (2; 2.8%), major bleeding during the procedure treated endoscopically (1; 1.4%), serosal perforation (10; 14.3%), capnoperitoneum requiring puncture (3; 4.3%), and subcutaneous emphysema (1; 1.4%). In the early postoperative period, adverse events occurred in 3 patients: one patient complained of significant abdominal pain necessitating analgetics, subsequently, a small leak from the pyloric region to the subhepatic region was described on CT and gastroscopy confirmed ulceration at the tunnel site. The patient responded well to treatment with intravenous proton pump inhibitors. In two other cases, both involving patients with diabetic gastroparesis, decompensation of diabetes occurred during the hospital stay post-procedure. The following “undesirable” events were considered true adverse events according to the C-D classification: serosal perforation (10; C-D I), leak requiring prolonged hospitalization (1; C-D IIIa) and diabetes decompensation (2; C-D II). These complications occurred in 13 procedures (18.6%).
The mean duration of hospitalization after the procedure was 2 days (range 1-7). Three months after the procedure, 1 patient developed mild dumping syndrome, which was successfully treated conservatively.

Conclusion

G-POEM is a safe procedure. The rate of true adverse events according to Clavien-Dindo classification is low and severe AEs occurs rarely.

Introduction

Endoscopic treatment using peroral/anal flexible endoscopy and dedicated through-the-scope electrocautery devices has been developed as a less-invasive intraluminal surgery. However, pure endoscopic treatment has limitations for lesions at the deeper layer or excessively close to the mouth/anus. Conversely, surgical approach sometimes leads to wider resection and subsequent decreases in the patient’s quality of life. Collaborative surgery by both endoscopists and surgeons is considered effective for providing less-invasive local resection of gastrointestinal tumours to offset limitations either in pure endoscopic treatments or surgical intervention.

Aims & Methods

To investigate the feasibility and safety of this approach, we here retrospectively evaluated the clinical outcomes of collaborative surgery with endoscopists and surgeons. We consecutively collected data of patients who underwent collaborative surgery for lesions located from the laryngopharynx to the anus between October 2017 and December 2023. Collaborative surgery was indicated after the agreement on both flexible endoscopists and surgeons, considering possible benefits of the cooperation in terms of invasiveness, technical difficulty, and safety. Laryngopharyngeal lesions and cervical oesophageal cancer were removed using the ESD technique under laryngeal expansion using a curved laryngoscope by the otolaryngologist’s manipulation. With gastrointestinal surgeons, subepithelial tumours in the gastrointestinal tract and deeply invasive gastric cancers were removed in a full-layered fashion, followed by surgical suturing. Large duodenal cancers were principally treated by ESD followed by sero-muscular suturing for the reinforcement of the mucosal defects. In large anal canal cancer with pagetoid spread, a dermatologist externally dissected the perianally expanded area following ESD from the rectal side. Collaboration completeness, technical success, procedure time, postoperative hospitalization period, and occurrence of adverse events were analyzed.

Results

Collaboration surgery was performed for 134 lesions (33 laryngopharyngeal, 2 oesophageal, 89 gastric, 8 duodenal, and 2 recto-anal lesions, respectively) in 131 patients. Collaboration completeness was achieved in 129 lesions (96%). The en-bloc resection and pathological R0 resection of lesions were obtained in 127 (95%) and 124 (93%) lesions, respectively. The mean procedure time was 188 min. Patients were discharged on the mean postoperative day of 11. Five patients (4%) developed relevant postoperative adverse events.

Conclusion

The results indicated that collaborative surgery by endoscopists and surgeons was feasible and safe, and should contribute to providing less-invasive treatment than conventional approaches. The frequency of adverse events was considered acceptable. Collaborative surgery is worth considering as a flexible and reliable surgical option when cooperation should outperform a single treatment by either of endoscopists or surgeons. To establish this concept, further accumulation of cases and pieces of evidence by well-designed studies is desired.

Introduction

The development of peroral endoscopic myotomy (POEM) has led to a paradigm shift in the treatment of esophageal motility disorders^1-5. Hiatal hernia (HH) has been reported in approximately 4-20% of patients with achalasia^6-8. Due to the altered position of the proximal stomach entering thoracic cavity, careful anatomical inspection at the completion of myotomy is essential to minimize the risk of adverse events⁷. Although two observational studies suggested that the presence of HH did not significantly affect clinical outcomes^9-10, these studies were limited by small sample sizes from single centers, with 13 and 56 cases of HH, respectively. Further study involving larger cohorts is needed to enable meaningful comparisons and to elucidate the impact of HH on POEM outcomes.

Aims & Methods

We hypothesized that the coexistence of a HH may be associated with adverse events, such as mediastinitis and esophageal perforation, or incomplete myotomy due to the technical challenges of approaching the esophagogastric junction^6-7. This retrospective cohort study aimed to compare outcomes between patients with and without HH undergoing POEM. Using the Nationwide Inpatient Sample in the United States from 2016 through 2022, we identified 6572 patients undergoing POEM for achalasia or non-achalasia spastic disorders. One-to-one propensity score matching was performed to compare adverse events, defined as any adverse event associated with an extended length of stay (>3 days), reintervention, 30-day mortality, and length of stay between the groups.

Results

	HH (n=1276)	Non-HH (n=1276)	P value
Adverse events	107 (8.4)	80 (6.3)	0.04
Infection (peritonitis, mediastinitis, sepsis)	62 (4.9)	42 (3.3)	0.04
Bleeding (gastrointestinal bleeding, hematoma)	32 (2.3)	26 (2.0)	0.49
Perforation (esophageal perforation, laceration)	9 (0.7)	8 (0.6)	0.52
Trauma (pneumothorax, injuries to other organs)	14 (1.1)	5 (0.4)	0.03
Reintervention	92 (7.2)	67 (5.3)	0.04
Pneumatic dilatation	88 (6.9)	67 (5.3)	0.08
Laparoscopic Heller myotomy	18 (1.4)	6 (0.5)	0.01
Second POEM	0 (0)	4 (0.3)	0.05

In the propensity score-matched analysis involving 1276 pairs, the HH group had significantly higher rates of adverse events (8.4% vs 6.3%; p = 0.04) and reintervention (7.2% vs 5.3%; p = 0.04) compared to the non-HH group (Table). The most common adverse events were infections, such as peritonitis and mediastinitis (4.9% vs 3.3%; p = 0.04). A longer length of stay (median: 4 vs 3 days; p < 0.01) was observed in the HH group. No significant difference in 30-day mortality was noted between the groups. On logistic regression analysis, HH (OR 1.33; 95% CI, 1.06–1.68) and achalasia (vs. non-achalasia spastic disorders; OR 1.54; 95% CI, 1.17–2.02) were associated with adverse events.

Conclusion

The risk of adverse events and reintervention were higher in the HH group. These findings highlight the need for tailored management in POEM for HH cases.

References

[1] Inoue H, et al. POEM for esophageal achalasia. Endoscopy. 2010;42:265-71.
[2] Ramchandani M, et al. Recent Advancements and Future Perspectives of POEM. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2024;22:1983-96.e2.
[3] Inoue H, et al. Statement for GERD after POEM from an international multicenter experience. Esophagus. 2020;17:3-10.
[4] Ponds FA, et al. Effect of POEM vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. Jama. 2019;322:134-44.
[5] Inoue H, et al. Clinical practice guidelines for POEM. Digestive endoscopy. 2018;30:563-79.
[6] Ushimaru Y, et al. Occult Hiatal Hernia in Achalasia Patients: Its Incidence and Treatment Options. Dig Surg. 2019;36:418-25.
[7] Fletcher PR. Acute hiatal hernia with oesophageal perforation following Heller's operation. Br J Surg. 1978;65:486-8.
[8] Sanei-Moghaddam A, et al. Cricopharyngeal myotomy for cricopharyngeus stricture in an inclusion body myositis patient with hiatus hernia: a learning experience. BMJ case reports. 2013;2013.
[9] Xu P, et al. Peroral endoscopic myotomy is an effective treatment for achalasia combined with hiatal hernia. Surgical endoscopy. 2024;38:4543-9.
[10] Tutuian G, et al. Achalasia and Hiatal Hernia: A Rare Association and a Therapeutic Challenge. J Neurogastroenterol Motil. 2023;29:455-9.

Disclosure

No disclosures for this study

Introduction

In intraoperative bleeding during endoscopic submucosal dissection (ESD) by using a needle-tip type electrocautery knife, spray coagulation is considered helpful compared to swift coagulation. In this study, we compared the hemostatic effect of two coagulation modes (swift coagulation and spray coagulation) on intraoperative bleeding during gastric ESD in a propensity score analysis.

Aims & Methods

In an intraoperative bleeding strategy, we changed “swift-dependent” hemostasis to “spray-switching” one in 2021. Therefore, 202 bleeding events before April 2020 (33 lesions, Swift group) and 203 bleeding events after April 2022(36 lesions, Spray group) were consecutively collected. In the Swift group, hemostasis was attempted firstly by swift coagulation by using a retracted tip of the needle-type knife, and if hemostasis was not achieved, hemostatic forceps were used. In the Spray group, when hemostasis was attempted several times by swift coagulation but hemostasis was not achieved or when hemostasis was not expected by swift coagulation, spray coagulation was used. If hemostasis was not achieved by spray coagulation, hemostatic forceps were finally used. The two coagulation modes were determined by one endoscopist who retrospective observed the difference of sparks that occurred in hemostasis on video. We performed a post-hoc propensity score-matched analysis to compare the two groups.

Results

In comparison of patient background (age, gender, whether or not intraoperative antithrombotic medication was taken) and lesion background (site of lesion occupation, resection diameter, depth, presence or absence of ulcer, histological type, etc.) between the two groups, the larger number of patients in the Swift group had antithrombotic agents on ESD (p=0.016), while no significant differences were observed in other parameters. A propensity score matching was performed in defining intraoperative administration of antithrombotic agents, location, resection size, pathology, and presence or absence of ulcer as covariates. A total of 106 events were matched per event in the two group, respectively. There was no significant difference in the hemostatic duration per event in the two group (Swift vs. Spray: 48.2 sec. vs. 55.3 sec., p=0.22). The number of coagulations per event in the Swift group was less than that of Spray group (4.3 times vs. 5.8 times, p=0.008). The hemostatic forceps was significantly less frequently used in the Spray group than in the Swift group (31.1% vs. 17.0%, p=0.016). The cumulative success rate of hemostasis with electrocautery knives was likely to be higher in the Spray group (p=0.104), although there was no significant difference between the two groups. In the Swift group, two patients had postoperative hemorrhage and one patient had delayed perforation, whereas no adverse events were observed in the Spray group.

Conclusion

The data suggested that spray coagulation by the tip of the needle-type knife could reduce the use of hemostatic forceps. In gastric ESD, spray coagulation may facilitate the hemostasis of intraoperative bleeding.

Introduction

Barrett’s esophagus (BE) is known to be a precursor of esophageal and gastroesophageal junctional adenocarcinoma¹. Adenocarcinoma of the esophagus based on BE is still relatively rare in Japan, but the Westernization of dietary habits, the increase in obese patients, and the eradication of Helicobacter pylori (HP) infection may increase the number of cases in the future. In Japan, the prevalence of long-segmented BE (LSBE), which is common in the Western world, is relatively low, whereas SSBE is frequently observed². Atrophic gastritis (AG) caused by HP infection is also frequently observed in Japan, and the diagnosis of Japanese SSBE may be modulated by HPinfection/AG. In this study, we retrospectively investigated whether the morphology of SSBE could be influenced by HP status.

Aims & Methods

In our institution, 60 patients who had endoscopic ultra-short segmented Barrett’s esophagus (USBE; length of <1cm) were retrospectively collected and divided into two groups: 30 cases with AG caused by current HP infection (AG group) or without AG (non-AG group). As patient characteristics, we investigated age, sex, presence of reflux esophagitis (RE), presence of hiatus hernia, and use of proton pump inhibitor (PPI) therapy from the medical records. To objectively evaluate the roughness of the SCJ, we compared the morphology of USBE by measuring the respective perimeters of EGJ and SCJ, followed by the calculation of the SCJ/EGJ ratio. As a sub-analysis in the AG group, the SCJ/EGJ ratio was similarly compared in terms of the degree of AG (closed-type, n = 3; open-type, n = 27) according to the Kimura-Takemoto classification.

Results

In terms of patient characteristics, the median age was higher in the AG group than in the non-AG group (72 years old vs. 49 years old, p <0.001), and RE was less common in the AG group than in the non-AG group (3% vs. 36%, p = 0.004). There were no statistical differences between the two groups in sex, presence of hiatus hernia, and use of PPI. The mean SCJ/EGJ ratio was significantly higher in the AG group than in the non-AG group (2.26 vs. 1.43, p <0.001). In the sub-analysis, the mean SCJ/EGJ ratio was likely to be higher in open-type atrophy than in closed-type atrophy (2.33 vs. 1.58, p = 0.092).

Conclusion

In endoscopically diagnosed USBE, the circumference of SCJ appeared rough in the AG group, which suggested that the morphology of BE is influenced by HP infection and subsequent AG development. Particularly in Japan, simple rough margins of SCJ influenced by HP/AG may be estimated as USBE. In diagnosing BE, the morphological characteristics of SCJ and the HP/AG status should be taken into consideration.

References

1. Haggitt RC et al. Barrett's esophagus, dysplasia, and adenocarcinoma. Hum Pathol. 1994; 25: 982-93.
2. Manabe N et al. Does short-segment columnar-lined esophagus elongate during a mean follow-up period of 5.7 years? Dig Endosc. 2011; 23: 166-72.

Disclosure

There is no conflict of interest in this study.

Introduction

Endoscopic hand suturing (EHS), which enables intraluminal running suturing by using a through-the-scope type needle holder and an absorbable barbed suture, is expected to be applied to various situations. This technique is sometimes difficult to complete according to location, and if successful in suturing, dehiscence sometimes occurs afterward.

Aims & Methods

We aimed to investigate the technical difficulty and clinical courses of EHS for mucosal defect closure after gastric endoscopic submucosal dissection (ESD). We collected 74 lesions in 72 patients (15 prospectively-enrolled lesions for this analysis and 59 lesions from published data), including 49 patients (68%) having antithrombotic agents without cessation perioperatively. EHS was performed to close the mucosal defect immediately after gastric ESD, by suturing the mucosal layer continuously. A normal dose of antisecretory agents (proton-pump inhibitor or potassium-competitive acid blocker) was administered from the operative day to at least the postoperative day (POD) 28. A scheduled second-look endoscopy (SLE) was performed on POD 3 in 64 patients and on POD 7 in 8 patients, respectively. Technical success, closure maintenance on SLE, suturing speed (min/stitch), delayed bleeding, and severe adverse events (SAE) were evaluated. Furthermore, the difficulty and the clinical courses in EHS according to the location were assessed.

Results

EHS was performed on the upper (U)/middle (M)/lower (L) stomach in 10/32/32 lesions, and on the anterior wall (AW)/lesser curve (LC)/posterior wall (PW)/greater curve (GC) in 14/28/14/18 lesions, respectively. The mean diameter of the mucosal defects was 33 mm. The defect was completely closed in 73 lesions (99%), and the closure was maintained on SLE in 65 lesions (88%). The mean suturing duration and stitches were 41 min and 7 stitches, respectively, which indicated the suturing speed of 5.5 min/stitch. Delayed bleeding occurred in 2 lesions (3%), and no SAE was presented. The technical success rates were U/M/L: 90%/100%/100% (p = 0.039), and AW/LC/PW/GC: 100%/96%/100%/100% (p = 0.645), respectively. The closure maintenance rates were U/M/L: 80%/84%/94% (p = 0.371), whereas AW/LC/PW/GC: 100%/75%/93%/95% (p = 0.062). The suturing speed was not significantly different among the location.

Conclusion

This study showed that EHS was technically difficult on the upper third and the closure was inclined to dehisce on the lesser curvature side. For lesions on the upper stomach, it is desirable to perform EHS after obtaining sufficient experience. Furthermore, EHS should be provided more carefully and precisely for lesions on the lesser curvature to avoid postoperative dehiscence.