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Introduction: The diagnostic yield (DY) of small-bowel capsule endoscopy (SBCE) varies considerably according to its indication. Some strategies have been used to increase DY with varying results. The intention of this study was to identify whether evaluation of the SBCE recordings by a second reviewer can increase DY and change patient management. Methods: One hundred SBCEs with different indications, already read by an endoscopist were read by a second blinded endoscopist. When the results of the 2 readings were different, the images were discussed by the endoscopists; if no consensus was reached, they took the opinion of a third endoscopist into account. All the participating endoscopists had experience in reading SBCEs (i.e., >50 per year). The SBCE findings were divided into positive (vascular lesions, ulcers, and tumors), equivocal (erosions or red spots), and negative. The interobserver agreement and the increase in DY were assessed as well as the percentage of false-negatives (FNs) in the first evaluation. Results: The indications for SBCE were small-bowel bleeding (SBB) in 48 cases, Crohn's disease (CD) in 30, and other causes (iron-deficiency anemia, small-bowel tumors, and diarrhea) in 22. There was substantial interobserver agreement between evaluations (κ = 0.79). The findings in the first evaluation were positive in 60%, equivocal in 20% and, negative in 20%. In the second evaluation, 66% were positive, 18% were equivocal, and 16% were negative. The increase in DY with the second reading was 6% (p = 0.380), i.e., 6.3% for SBB, 4.4% for CD and 9.2% for other indications, resulting in a change in management of 4% of the patients. FNs in the first SBCE reading were found in 4% of the SBCEs. Discussion: A second evaluation of the SBCE recordings identified significant pathology that the first evaluation had missed, resulting in a nonsignificant 6% increase in DY and a change in the management of 4% of the patients.
Introdução: O rendimento diagnóstico (DY) da enteroscopia por cápsula (SBCE) varia consideravelmente de acordo com as suas indicações. Foram estudadas algumas estratégias para melhorar o DY, com resultados variados. O objetivo deste estudo é avaliar se uma segunda leitura de registos de enteroscopia por cápsula por um segundo endoscopista pode melhorar o DY e alterar o manejo dos doentes. Métodos: 100 SBCE realizadas por indicações variadas, previamente avaliadas por um endoscopista, foram reavaliadas por um segundo endoscopista cego para a primeira leitura. Na presença de resultados discordantes nas 2 leituras, as imagens foram discutidas pelos 2 endoscopistas, e por um terceiro na ausência de consenso entre os 2 primeiros. Todos os endoscopistas são experientes na leitura de SBCE (>50 SBCE/ano). Os achados foram categorizados em positivos (lesões vasculares, úlceras e tumores), equívocos (erosões e pontos vermelhos) e negativos. Foi avaliada a concordância inter-observador e o aumento do DY, bem como a percentagem de falsos negativos da primeira avaliação. Resultados: As indicações para SBCE foram hemorragia do intestino delgado (SBB) em 48 casos, doença de Crohn (CD) em 30 e outras causas (anemia por défice de ferro, pesquisa de tumores do intestino delgado e diarreia) em 22. A concordância inter-observador foi substancial (k = 0.79). Os achados da primeira avaliação foram positivos em 60%, equívocos em 20% e negativos em 20%, enquanto na segunda avaliação foram positivos em 66%, equívocos em 18% e negativos em 16%. O aumento de DY foi de 6% com a segunda leitura (p = 0.38), sendo 6.3% para SBB, 4.4% para CD e 9.2% para outras indicações, resultando numa alteração no manejo de 4% dos doentes. Foram identificados falsos negativos na primeira avaliação em 4% das SBCE. Conclusão: A segunda avaliação dos registos de SBCE identificou patologia significativa previamente não identificada, resultando num aumento não significativo de 6% do DY e numa alteração no manejo de 4% dos doentes.
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BACKGROUND AND AIMS: Gastric peroral endoscopic myotomy (G-POEM) is used for refractory gastroparesis (RG) with good early-term but variable mid- and long-term outcomes. Limited data exist about candidates and long-term clinical and predictive factors. Our aim was to evaluate the 4-year follow-up efficacy and predictive factors in patients with RG. METHODS: Confirmed RG patients were included and evaluated between April 2017 and December 2021. Gastroparesis Cardinal Symptom Index (GCSI) score, retention percentage at 4 hours (RP4H), mean half-emptying time (MHET), and the 36-item short-form survey (SF-36) were performed at 1, 6, 12, 18, 24, 30, 36, 42, and 48 months. RESULTS: After G-POEM, 374 patients with RG were included: 141 patients (37.7%) had diabetic gastroparesis (DG), 115 (30.7%) had idiopathic gastroparesis (IG), 102 (27.3%) had postsurgical gastroparesis (PSG), and 16 (4.3%) had other etiologies. After the 48-month evaluation, 102 patients completed follow-up (DG, 58; IG, 22; PSG, 18; other, 4). Before G-POEM, GCSI score, RP4H, and MHET were 3.84 ± .53, 44% (interquartile range [IQR], 11-68), and 246 minutes (IQR, 150-368), respectively, and after the 48-month evaluation improved to 2.1 ± .70 (P < .001), 15.5% (IQR, 0-36; P = .021), and 135 minutes (IQR, 67-290; P = .045), respectively. At the 48-month evaluation, clinical success was 77.5%. DG showed the best outcomes (DG vs IG vs PSG vs other: 86.5% vs 72.5% [P = .001] vs 72.1% [P = .003] vs 68.8% [P < .001]). Long-term success predictors were DG (odds ratio [OR], 5.113; 95% confidence interval [CI], 1.643-5.981; P = .035), early diagnosis (OR, 2.455; 95% CI, 1.129-3.522; P = .042), nausea/vomiting (OR, 3.541; 95% CI, 1.881-5.511; P = .012), GCSI score at 6 months (1.5-2) (OR, 3.612; 95% CI, 2.122-5.317; P = .022), and RP4H <10% at 6 months (OR, 2.188; 95% CI, 1.435-4.233; P = .039). CONCLUSIONS: G-POEM is an effective 4-year treatment in patients with RG, especially in DG, establishing a potential first-line therapy in these patients. However, randomized controlled clinical trials are needed to confirm these results. (Clinical trial registration number: NTC03126513.).
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Acalasia Esofágica , Gastroparesia , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior , Seguimentos , Esvaziamento Gástrico , Gastroparesia/cirurgia , Humanos , Resultado do TratamentoRESUMO
BACKGROUND: Third-space endoscopy is a novel, safe, and effective method for treating different gastrointestinal conditions. However, several failed endoscopic procedures are attributed to incomplete myotomy. Lighting devices are used to prevent organic injuries. We aimed to investigate the feasibility of using a hand-made LED-probe (LP) in third-space procedures. METHODS: This prospective study was conducted in a tertiary-care center in Mexico between December 2016 and January 2019. We included peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy(G-POEM) procedures. Pseudoachalasia, peptic ulcer, normal gastric emptying scintigraphy (GES) and prepyloric tumors were excluded. LP was used to guide or confirm procedures. Clinical and procedural characteristics were recorded and analyzed. RESULTS: Seventy third-space procedures were included (42POEM,28G-POEM), with an average patient age of 46.7 ± 14.3 and 43.7 ± 10.1 years, respectively. For the POEM and G-POEM groups, respectively, 18/42(42.9%) and 13/28(46.7%) patients were males; median procedure times were 50 (interquartile range [IQR]: 38-71) and 60(IQR: 48-77) min, median LP placement times were 5(IQR: 4-6) and 6(IQR: 5-7) min, mild adverse events occurred in 4(9.4%) and 4(14.2%) of cases, and clinical success at 6 months occurred in 100 and 85.7% of cases. Integrated relaxation pressure (IRP) improved from 27.3 ± 10.8 to 9.5 ± 4.1 mmHg (p < 0.001); retention percentage at 4 h also improved. LP was successfully placed and adequate myotomy confirmed including 14.2 and 17.8% of POEM and G-POEM difficult patients. CONCLUSIONS: Using an LP is promising and allows guiding during third-space procedures either for submucosal tunnel creation or myotomy confirmation, with excellent safety and efficacy in clinical practice.
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Endoscopia do Sistema Digestório/instrumentação , Acalasia Esofágica/cirurgia , Iluminação/instrumentação , Miotomia/instrumentação , Piloromiotomia/instrumentação , Adulto , Endoscopia do Sistema Digestório/métodos , Estudos de Viabilidade , Feminino , Humanos , Masculino , México , Pessoa de Meia-Idade , Boca/cirurgia , Miotomia/métodos , Estudos Prospectivos , Piloromiotomia/métodos , Centros de Atenção Terciária , Resultado do TratamentoRESUMO
BACKGROUNDS AND AIMS: New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT) for control of GERD in patients without hiatal hernia. METHODS: Patients with proton pump inhibitor (PPI)-refractory GERD without hiatal hernia underwent ARAT between January 2016 and October 2019. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL), upper endoscopy, 24-hour pH monitoring, and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT. RESULTS: One hundred eight patients were included (61 men [56.5%]; median age, 36.5 years; range, 18-78 years). ARAT was performed on all patients. At the 36-month evaluation, 84 patients had completed the protocol. Median ARAT time was 35.5 minutes (range, 22-51 minutes), and median circumference ablation was 300° (range, 270°-320°). No major adverse events occurred, and 14 of 108 patients (12.9%) presented with stenosis that was responsive to balloon dilation (<5 sessions). At the 3-month evaluation, the acid exposure time (AET), DeMeester score, and GERD-HRQL score had decreased from 18.8% to 2.8% (P = .001), 42.5 to 9.1 (P = .001), and 36.5 to 10 (P = .02), respectively, and these values were maintained up to 36 months. Success (AET <4%) was achieved in 89% and 72.2% at 3 and 36 months, respectively. Related factors at 36 months were as follows: pre-ARAT Hill type II (odds ratio [OR], 3.212; 95% confidence interval [CI], 1.431-5.951; P = .033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P = .042), and AET <4% at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P = .021). CONCLUSIONS: ARAT is a feasible, safe, and effective therapy for early and mid-term treatment of GERD in patients without a sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role. (Clinical trial registration number: NCT03548298.).
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Técnicas de Ablação , Fundoplicatura , Refluxo Gastroesofágico , Hérnia Hiatal , Técnicas de Ablação/métodos , Adolescente , Adulto , Idoso , Endoscopia Gastrointestinal , Monitoramento do pH Esofágico , Estudos de Viabilidade , Feminino , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/tratamento farmacológico , Hérnia Hiatal/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inibidores da Bomba de Prótons/uso terapêutico , Qualidade de Vida , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: new alternatives for entry site closure (ESC) in per-oral endoscopy myotomy (POEM) and gastric peroral endoscopy myotomy (G-POEM) have appeared. OBJECTIVE: to compare the over-the-scope-clip (OTSC®) and conventional clips (CC) for ESC in POEM and G-POEM. MATERIAL AND METHODS: a retrospective review of a prospective POEM and G-POEM database was performed between January 2015 and August 2019. A description was made of outcomes, using either OTSC® or CC for submucosal tunnel closure. RESULTS: forty-six POEM and 26 G-POEM were included in the study (23/13 per group [CC/OTSC®]). There were no clinical or procedure differences. ESC was performed with 1 OTSC® vs 5 CC and 1 vs 6 (p = 0.01) for POEM and G-POEM, respectively. Adverse events associated with clips were 21.7% vs 13% (p = 0.01) and 7.7% vs 0% (p = 0.02) for CC and OTSC® in POEM and G-POEM, respectively. CONCLUSION: OTSC® represents a safe and effective alternative for entry site closure in POEM and G-POEM cases. Further studies are needed to recommend OTSC® as the first option for submucosal tunnel closure in these procedures.
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Acalasia Esofágica , Cirurgia Endoscópica por Orifício Natural , Piloromiotomia , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Instrumentos Cirúrgicos , Resultado do TratamentoAssuntos
Angiodisplasia , Coagulação com Plasma de Argônio/métodos , Endoscopia por Cápsula/métodos , Enteroscopia de Duplo Balão , Íleo , Jejuno , Angiodisplasia/diagnóstico , Angiodisplasia/fisiopatologia , Angiodisplasia/cirurgia , Enteroscopia de Duplo Balão/instrumentação , Enteroscopia de Duplo Balão/métodos , Humanos , Íleo/irrigação sanguínea , Íleo/diagnóstico por imagem , Jejuno/irrigação sanguínea , Jejuno/diagnóstico por imagem , Masculino , Melena/diagnóstico , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
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.âA small-caliber (5.9âmm) 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] 22â-â69); 53â% (24/45) had type II achalasia. Median total time for thin-POEM was 54 minutes (IQR 37â-â77) and median myotomy length was 13.5âcm (IQR 6â-â20). Results pre-procedure and 3 months post were Eckardt score 10 vs. 1 (Pâ<â0.001), integrated relaxation pressure (IRP) 25.3 vs. 8.5âmmHg (Pâ<â0.001), and timed barium esophagram (TBE) 100â% severely delayed vs. 86â% normal (Pâ<â0.001), respectively. Type III patients had the longest thin-POEM times (median 58 minutes [IQR 52â-â77]). Reflux was confirmed at 3 months clinically in 17â% of patients, endoscopically in 20â%, and on pH monitoring in 53â%. At 6 months and 12 months, 40â% and 33â% 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.
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Endoscópios , Endoscopia do Sistema Digestório , Acalasia Esofágica , Refluxo Gastroesofágico , Miotomia , Cirurgia Endoscópica por Orifício Natural , Complicações Pós-Operatórias/diagnóstico , Endoscopia do Sistema Digestório/efeitos adversos , Endoscopia do Sistema Digestório/instrumentação , Endoscopia do Sistema Digestório/métodos , Desenho de Equipamento , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/epidemiologia , Acalasia Esofágica/cirurgia , Monitoramento do pH Esofágico/métodos , Monitoramento do pH Esofágico/estatística & dados numéricos , Feminino , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/etiologia , Humanos , Masculino , México , Pessoa de Meia-Idade , Miotomia/efeitos adversos , Miotomia/instrumentação , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/instrumentação , Cirurgia Endoscópica por Orifício Natural/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos RetrospectivosAssuntos
Perfuração Esofágica/cirurgia , Estenose Esofágica/cirurgia , Esofagoscopia/métodos , Implantação de Prótese/métodos , Stents , Idoso , Idoso de 80 Anos ou mais , Doenças do Esôfago/patologia , Doenças do Esôfago/cirurgia , Perfuração Esofágica/diagnóstico , Estenose Esofágica/diagnóstico , Junção Esofagogástrica/cirurgia , Feminino , Seguimentos , Humanos , Jejuno , Masculino , Metais , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Cavidade Nasal , Desenho de Prótese , Estudos de Amostragem , Índice de Gravidade de DoençaAssuntos
Endoscopia por Cápsula , Hemorragia Gastrointestinal/etiologia , Infecções por Uncinaria/diagnóstico , Albendazol/uso terapêutico , Anti-Helmínticos/uso terapêutico , Hemorragia Gastrointestinal/diagnóstico por imagem , Infecções por Uncinaria/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
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.
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Acalasia Esofágica/cirurgia , Piloromiotomia , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Anastomose em-Y de Roux/métodos , Doenças Biliares , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia/efeitos adversos , Colecistite/cirurgia , Enteroscopia de Duplo Balão/métodos , Complicações Pós-Operatórias , Idoso , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/patologia , Ductos Biliares/fisiopatologia , Doenças Biliares/diagnóstico , Doenças Biliares/etiologia , Doenças Biliares/cirurgia , Colecistectomia/métodos , Colecistite/diagnóstico , Colecistite/fisiopatologia , Drenagem/métodos , Gastrectomia/métodos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/cirurgia , Estenose Pilórica/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND AND STUDY AIM: Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model. PATIENTS AND METHODS: This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1)â=â30 ex vivo and Group 2 (G2)â=â20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2. RESULTS: A total of 50 POEM were done in both groups (G1â=â30, G2â=â20). The mean times were 90.17âmin (G1) and 89.50âmin (G2) (Pâ=â0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; Pâ=â0.009) with a slightly slower tunnelization (40.35 vs 41.13âmin; Pâ=â0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; Pâ=â0.26). VTM between the groups was similar (G1â=â0.159 vs G2â=â0.157âcm/min; Pâ=â0.925). Complications were: mucosotomy (G1â=â18â%, G2â=â8â%; Pâ=â0.430), mediastinal perforation (G1â=â12â%, G2â=â8â%; Pâ=â1.0), and perforation at the gastroesophageal junction (GEJ) level (G1â=â16â%, G2â=â4â%; Pâ=â0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases. CONCLUSIONS: We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.