1: A POEM equipment checklist should be used before commencing the procedure to ensure the availability and proper functioning of all necessary materials. 2: A thorough esophageal cleansing before mucosal incision is mandatory. There should be no residual dietary liquid or food in the lumen. 3: Use at least 5-10 mL of lifting agent, which should be injected using a needle at the desired point where the mucosotomy will commence. 4: To create the mucosotomy, the first incision should be made at the site of previous injection with the fewest possible taps on the electrosurgical unit using a cutting mode, with the knife tip at 45-80° to the mucosal surface. 5: After adequate submucosal injection (through a needle or knife), the incision should be extended by 1.5-2 cm in the longitudinal axis from cranial to caudal, in the planned direction of the tunnel. 6: Dissection within the tunnel should be performed using sequential injection of saline and chromic dye (if available using the knife jet function) and dissection with the knife. Pushing the endoscope forward gently against the advancing submucosa-muscularis propria interface is important to facilitate mucosal tunneling. 7: The myotomy should be performed in a cranial to caudal manner, starting 2 cm or more below the caudal extent of the mucosotomy site. 8: ESGE recommends that the myotomy should be extended 2-3 cm distal to the gastroesophageal junction to allow complete disruption of the lower esophageal sphincter. 9: ESGE recommends that POEM can be performed on either the anterior (1-2 o'clock in supine position) or posterior (5-6 o'clock) side. 10: ESGE recommends that the myotomy length should be tailored to the disease being treated, with evidence favoring short esophageal-side myotomy if indicated because of decreased adverse events and procedure times. 11: ESGE recommends the use of through-the-scope clips for mucosal closure owing to their high efficacy and availability, and lower price compared with other closure methods. 12: Mucosal injury during POEM should be proactively sought during the procedure and particularly before completion. Mucosal injury can be represented on a spectrum from whitening of the overlying mucosa to a full-thickness perforation. 13: ESGE recommends performing POEM using low flow CO2 insufflation. 14: In the absence of adverse events, resume fluids on day 1, soft diet on day 3, and normal diet on day 7 post-POEM. 15: ESGE recommends against the routine use of standard or computed tomography fluoroscopic esophagrams after POEM in asymptomatic patients.
- Publikační typ
- časopisecké články MeSH
Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure that has become a first-line treatment for esophageal achalasia and other esophageal spastic disorders. Structured training is essential to optimize the outcomes of this technique. The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in POEM. This Position Statement presents the results of a systematic review of the literature and a formal Delphi process, providing recommendations for an optimal training program in POEM that aims to produce endoscopists competent in this procedure. In a separate document (POEM curriculum Part II), we provide technical guidance on how to perform the POEM procedure based on the best available evidence. 1: POEM trainees should acquire a comprehensive theoretical knowledge of achalasia and other esophageal motility disorders that encompasses pathophysiology, diagnostic tool proficiency, clinical outcome assessment, potential adverse events, and periprocedural management. 2: Experience in advanced endoscopic procedures (endoscopic mucosal resection and/or endoscopic submucosal dissection [ESD]) is encouraged as a beneficial prerequisite for POEM training. 3: ESGE suggests that POEM trainees without ESD experience should perform an indicative minimum number of 20 cases on ex vivo or animal models before advancing to human POEM cases with an experienced trainer. 4: ESGE recommends that the trainee should observe an indicative minimum number of 20 live cases at expert centers before starting to perform POEM in humans. 5: The trainee should undertake an indicative minimum number of 10 cases under expert supervision for the initial human POEM procedures, ensuring that trainees can complete all POEM steps independently. 6: ESGE recommends avoiding complex POEM cases during the early training phase. 7: POEM competence should reflect the technical success rate, both the short- and long-term clinical success rates, and the rate of true adverse events. 8: A POEM center should maintain a prospective registry of all procedures performed, including patient work-up and outcomes, procedural techniques, and adverse events.
- Publikační typ
- časopisecké články MeSH
BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is an established treatment for achalasia with compelling midterm efficacy. In this study, we analyzed the long-term efficacy, sought predictors of failure, and comprehensively assessed post-POEM reflux. METHODS: We performed a retrospective analysis of a prospective database of patients undergoing POEM at a high-volume center from December 2012 to June 2023. Patients who had completed a 3-month follow-up were included. Efficacy was assessed at 3, 6, and 8 years using the Eckardt score (ES). An ES ≤2 was considered treatment success. At 3 months, gastroscopy, manometry, 24-hour pH monitoring, and fluoroscopy were performed, and gastroscopy was repeated at 2 and 3 years. At each visit, patients were assessed for reflux symptoms and quality of life. RESULTS: From 496 included patients, 3-, 6-, and 8-year follow-ups were completed in 302, 115, and 40 patients, respectively. The treatment success rates at 3, 6, and 8 years according to the Kaplan-Meier analysis were 90.2% (95% confidence interval [CI], 87.2-93.3), 82.3% (95% CI, 77.3-87.6), and 73.5% (95% CI, 64.8-83.5), respectively. Year of procedure was the only predictor of outcome. Fifty-three patients (10.7%) encountered failure or recurrence. Treatment success of redo-POEM (n = 20) at 1 year was significantly lower (62.9% [95% CI, 44.3-89.2] vs 96.9% [95% CI, 95.3-98.5], P < .001). At 3 months, 40.4% of patients had reflux esophagitis (RE), 43.6% of patients had an acid exposure time >4.5%, 39.2% of patients were using proton pump inhibitors (PPIs), but only 24.2% had reflux symptoms. At 2 to 3 years, 50.8% of patients took PPIs, whereas 39.6% were symptomatic. RE decreased to 20.2% at 6 years. CONCLUSIONS: The treatment success of POEM declines over time but remains sufficiently high in the long term. Experience with the procedure improves the outcome. Gastroesophageal reflux affects almost half of patients early after POEM and decreases substantially over time together with a rise in PPI use.
- MeSH
- achalázie jícnu * chirurgie patofyziologie MeSH
- časové faktory MeSH
- centra terciární péče MeSH
- dolní jícnový svěrač * chirurgie MeSH
- dospělí MeSH
- endoskopické operace přirozenými otvory * metody MeSH
- fluoroskopie MeSH
- gastroezofageální reflux * etiologie epidemiologie MeSH
- gastroskopie MeSH
- kvalita života MeSH
- lidé středního věku MeSH
- lidé MeSH
- manometrie MeSH
- monitorování jícnového pH MeSH
- následné studie MeSH
- pooperační komplikace * epidemiologie MeSH
- pyloromyotomie * metody MeSH
- recidiva MeSH
- retrospektivní studie MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
With technical progress of gastrointestinal functional testing, there has been a demand for more comprehensive examination of esophageal physiology and pathophysiology beyond high-resolution manometry. A new interventional technology based on impedance planimetry, the functional lumen imaging probe (FLIP), enables intraluminal measurement of distensibility and compliance of hollow organs. EndoFLIP uses balloon catheters to measure diameter and distension pressure to calculate cross-sectional area and distensibility in different organs (mostly esophagus, stomach, anorectal region) and can be used in wide variety of indications (diagnostics, pre- and post-treatment evaluation) and currently serves as a helpful adjunctive tool in ambiguous clinical cases. EsoFLIP is a therapeutic variation that uses a stiffer balloon catheter allowing for dilation. The trend to simplify the clinical process from diagnosis to treatment tends to a one-session procedure combining diagnostics and therapeutic interventions. In specified conditions like e.g. achalasia or gastroparesis, a combination of EndoFLIP and EsoFLIP procedures may therefore be useful. The aim of this narrative review is to introduce the clinical use of FLIP and its potential benefit in combined diagnostic-therapeutic procedures.
- MeSH
- achalázie jícnu * diagnóza MeSH
- gastrointestinální endoskopie MeSH
- lidé MeSH
- manometrie metody MeSH
- žaludek MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
BACKGROUND: Peroral endoscopic myotomy (POEM) is nowadays a standard method for treatment of achalasia; nevertheless, it remains an invasive intervention with corresponding risk of adverse events (AEs). The classification and grading of AEs are still a matter of discussion. The aim of our retrospective study was to assess the occurrence of all "undesirable" events and "true" adverse events in patients undergoing POEM and to compare the outcomes when either Clavien-Dindo classification (CDC) or American Society of Gastrointestinal Endoscopy (ASGE) lexicon classification applied. METHODS: This was a retrospective analysis of prospectively managed database of all patients who had undergone POEM between December 2012 and August 2018. We assessed the pre-, peri-, and early-postoperative (up to patient's discharge) undesirable events (including those not fulfilling criteria for AEs) and "true" AEs according the definition in either of the classifications. RESULTS: A total of 231 patients have successfully undergone 244 POEM procedures (13 × re-POEM). Twenty-nine procedures (11.9%) passed uneventfully, while in 215 procedures (88.1%), a total of 440 undesirable events occurred. The CDC identified 27 AEs (17 minor, 10 major) occurring in 23/244 (9.4%) procedures. The ASGE lexicon identified identical 27 AEs (21 mild or moderate, 6 severe or fatal) resulting in the severity distribution of AEs being the only difference between the two classifications. Only the absence of previous treatment was found to be a risk factor [p = 0.047, OR with 95% CI: 4.55 (1.02; 20.25)] in the combined logistic regression model. CONCLUSION: Undesirable events are common in patients undergoing POEM but the incidence of true AEs is low according to both classifications. Severe adverse events are infrequent irrespective of the classification applied. CDC may be more appropriate than ASGE lexicon for classifying POEM-related AEs given a surgical nature of this procedure.
- Klíčová slova
- Achalasia, Adverse events, Peroral endoscopic myotomy,
- MeSH
- achalázie jícnu * chirurgie MeSH
- chirurgie trávicího traktu * MeSH
- dolní jícnový svěrač chirurgie MeSH
- endoskopické operace přirozenými otvory * metody MeSH
- lidé MeSH
- myotomie * metody MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
OBJECTIVE: Endoscopic pyloromyotomy (G-POEM) is a minimally invasive treatment option with promising uncontrolled outcome results in patients with gastroparesis. DESIGN: In this prospective randomised trial, we compared G-POEM with a sham procedure in patients with severe gastroparesis. The primary outcome was the proportion of patients with treatment success (defined as a decrease in the Gastroparesis Cardinal Symptom Index (GCSI) by at least 50%) at 6 months. Patients randomised to the sham group with persistent symptoms were offered cross-over G-POEM. RESULTS: The enrolment was stopped after the interim analysis by the Data and Safety Monitoring Board prior to reaching the planned sample of 86 patients. A total of 41 patients (17 diabetic, 13 postsurgical, 11 idiopathic; 46% male) were randomised (21 G-POEM, 20-sham). Treatment success rate was 71% (95% CI 50 to 86) after G-POEM versus 22% (8-47) after sham (p=0.005). Treatment success in patients with diabetic, postsurgical and idiopathic gastroparesis was 89% (95% CI 56 to 98), 50% (18-82) and 67% (30-90) after G-POEM; the corresponding rates in the sham group were 17% (3-57), 29% (7-67) and 20% (3-67).Median gastric retention at 4 hours decreased from 22% (95% CI 17 to 31) to 12% (5-22) after G-POEM and did not change after sham: 26% (18-39) versus 24% (11-35). Twelve patients crossed over to G-POEM with 9 of them (75%) achieving treatment success. CONCLUSION: In severe gastroparesis, G-POEM is superior to a sham procedure for improving both symptoms and gastric emptying 6 months after the procedure. These results are not entirely conclusive in patients with idiopathic and postsurgical aetiologies. TRIAL REGISTRATION NUMBER: NCT03356067; ClinicalTrials.gov.
- Klíčová slova
- GASTRIC EMPTYING, GASTROPARESIS,
- MeSH
- gastroparéza * etiologie chirurgie MeSH
- gastroskopie metody MeSH
- lidé MeSH
- prospektivní studie MeSH
- pyloromyotomie * škodlivé účinky metody MeSH
- vyprazdňování žaludku MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
INTRODUCTION: Esophageal achalasia is a primary motility disorder. Although the exact pathogenesis is unknown, autoimmune, and neurodegenerative processes seem to be involved similarly to neurodegenerative and/or demyelinating disorders (NDDs). We hypothesized that the prevalence of NDD may be higher among patients with achalasia and vice versa as the background pathogenetic mechanisms are similar. METHODS: This was a prospective, comparative questionnaire-based study. Patients with achalasia and patients with NDD were enrolled. Selected patients with achalasia were thoroughly examined by a neurologist and selected patients with NDD were examined by a gastroenterologist to confirm or rule out NDD or achalasia. We assessed the prevalence of both achalasia and NDD and compared them with their prevalence in general population. RESULTS: A total of 150 patients with achalasia and 112 patients with NDD were enrolled. We observed an increased prevalence of NDD among patients with achalasia (6.0% (9/150); 95% CI (confidence interval): 3.1-11.2%) as compared to the estimated 2.0% prevalence in general population (p = 0.003). Although 32 out of 112 patients (28.6%) with NDD reported dysphagia, we did not observe significantly increased prevalence of achalasia in these patients (1.8% (2/112) vs 0.8% in general population, p = 0.226). CONCLUSION: The prevalence of NDD was significantly higher among patients with achalasia (6.0%) compared to general population (2.0%), suggesting an association of these disorders. Large-volume studies are necessary to confirm this finding.
- Klíčová slova
- achalasia, demyelinating process, neurodegeneration,
- Publikační typ
- časopisecké články MeSH
BACKGROUND AND AIMS: There are no agreed-on endoscopic signs for the diagnosis of villous atrophy (VA) in celiac disease (CD), necessitating biopsy sampling for diagnosis. Here we evaluated the role of near-focus narrow-band imaging (NF-NBI) for the assessment of villous architecture in suspected CD with the development and further validation of a novel NF-NBI classification. METHODS: Patients with a clinical indication for duodenal biopsy sampling were prospectively recruited. Six paired NF white-light endoscopy (NF-WLE) and NF-NBI images with matched duodenal biopsy sampling including the bulb were obtained from each patient. Histopathology grading used the Marsh-Oberhuber classification. A modified Delphi process was performed on 498 images and video recordings by 3 endoscopists to define NF-NBI classifiers, resulting in a 3-descriptor classification: villous shape, vascularity, and crypt phenotype. Thirteen blinded endoscopists (5 expert, 8 nonexpert) then undertook a short training module on the proposed classification and evaluated paired NF-WLE-NF-NBI images. RESULTS: One hundred consecutive patients were enrolled (97 completed the study; 66 women; mean age, 51.2 ± 17.3 years). Thirteen endoscopists evaluated 50 paired NF-WLE and NF-NBI images each (24 biopsy-proven VAs). Interobserver agreement among all validators for the diagnosis of villous morphology using the NF-NBI classification was substantial (κ = .71) and moderate (κ = .46) with NF-WLE. Substantial agreement was observed between all 3 NF-NBI classification descriptors and histology (weighted κ = 0.72-.75) compared with NF-WLE to histology (κ = .34). A higher degree of confidence using NF-NBI was observed when assessing the duodenal bulb. CONCLUSIONS: We developed and validated a novel NF-NBI classification to reliably diagnose VA in suspected CD. There was utility for expert and nonexpert endoscopists alike, using readily available equipment and requiring minimal training. (Clinical trial registration number: NCT04349904.).
- MeSH
- atrofie patologie MeSH
- celiakie * diagnostické zobrazování MeSH
- dospělí MeSH
- duodenum diagnostické zobrazování patologie MeSH
- endoskopie MeSH
- lidé středního věku MeSH
- lidé MeSH
- senioři MeSH
- úzkopásmové zobrazení MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
BACKGROUND/AIMS: Several studies have reported partial recovery of peristalsis in patients with achalasia after myotomy. The aim of our study is to analyze esophageal motility patterns after peroral endoscopic myotomy (POEM) and to assess the potential predictors and clinical impact of peristaltic recovery. METHODS: We performed a retrospective analysis of prospectively collected data of consecutive patients with achalasia undergoing POEM at a tertiary center. High-resolution manometry (HRM) studies prior to and after POEM were reviewed and the Chicago classification was applied. RESULTS: A total of 237 patients were analyzed. The initial HRM diagnoses were achalasia type I, 42 (17.7%); type II, 173 (73.0%); and type III, 22 (9.3%). Before POEM, peristaltic fragments were present in 23 (9.7%) patients. After POEM the Chicago classification diagnoses were: 112 absent contractility, 42 type I achalasia, 15 type II, 11 type III, 26 ineffective esophageal motility, 18 esophagogastric junction outflow obstruction, 10 fragmented peristalsis, and 3 distal esophageal spasm. Altogether 68 patients (28.7%) had signs of contractile activity, but the contractions newly appeared in 47 patients (47/214, 22.0%). Type II achalasia showed a trend for appearance of contractions (P = 0.097). Logistic regression analysis did not identify any predictors of peristaltic recovery. The post-POEM Eckardt score did not differ between patients with and without contractions nor did the parameters of timed barium esophagogram. CONCLUSIONS: More than 20% of achalasia patients have signs of partial recovery of esophageal peristalsis after POEM. It occurs predominantly in type II achalasia but the clinical relevance seems to be negligible.
- Klíčová slova
- Esophageal achalasia, Manometry, Myotomy, Peristalsis,
- Publikační typ
- časopisecké články MeSH
