Abstract : Establishing a submucosal endoscopy program in a new unit is a difficult but exciting task. There are several key steps and teams involved in the success and failure of this endeavour. Careful thought, planning and implementation at the start will allow an easier transition to the development and progression of this program. An interested gastrointestinal unit with skilled proceduralists holds the key to the commencement of a submucosal program. The opportunity for ongoing learning and training through animal models and simulations, are important for proceduralists to continue to enhance their skills and train other staff. A collaborative team with surgical, nursing and technical support, hospital board approval, and credentialing, as well as the acquisition of appropriate equipment are essential components.
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Abstract : Therapeutic endoscopy has evolved tremendously over the past decades and the development of submucosal endoscopy opens the third space for treatment of gastrointestinal diseases. This review focused on the recent development in third space endoscopy, with introduction of its development from peroral endoscopic myotomy (POEM) to beyond. Two recent randomized trials comparing POEM against pneumatic dilation and laparoscopic Heller myotomy (LHM) demonstrated significantly better relief of dysphagia for POEM compared to pneumatic dilation, while POEM achieved similar outcomes compared to LHM. Apart from achalasia, third space endoscopy is now developed to manage spastic esophageal motility disorders, esophageal diverticular diseases, gastroparesis, and Hirschsprung’s disease. Subepithelial tumors can also be resected through tunneling and endoscopic full-thickness resection. In future, third space endoscopy will be one of the major areas in development of diagnostic and therapeutic endoscopy using novel imaging technologies and therapeutic devices.
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Abstract : Achalasia cardia is a rare esophageal motility disorder. Although a primary neurological disorder, the treatment modalities of achalasia are primarily endoscopic or surgical. Pneumatic dilatation (PD) or laparoscopic Heller’s myotomy (LHM) have been the mainstay of achalasia management for several decades. With the introduction of third space endoscopy, the endoscopic management of achalasia has revolutionized. Randomized studies have concluded the superiority of per-oral endoscopic myotomy (POEM) over PD. In addition, the short-term outcomes of POEM are similar to LHM. POEM is a relatively new technique and long-term data is eagerly awaited. The main concern after POEM is a high incidence of gastroesophageal reflux disease (GERD) which is found in about half of the patients undergoing this procedure. GERD is higher after POEM when compared to PD and LHM with fundoplication. The management of achalasia should be individualized and based on factors like patient characteristics (age, sex, comorbidities), subtyping on high resolution manometry, patient/doctor preference, and surgical risk of the patient.
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Abstract : Peroral endoscopic myotomy (POEM) has today evolved to be the gold standard for the treatment of achalasia cardia and other spastic esophageal disorders. Its minimal invasive nature, safety and encouraging outcomes have made POEM the most commonly practiced submucosal tunneling procedure. Gastroesophageal reflux disease (GERD) or abnormal esophageal acid exposure time (AET), however, continues to haunt and dampen the encouraging clinical outcome after a POEM procedure. This is mainly because as against a laparoscopic Heller’s myotomy, the procedure of POEM is not combined with an anti-reflux procedure. The incidence of GERD or AET after the POEM procedure has been shown to be, however, dissimilar in various studies. This is probably due to the inconsistency in the definitions of GERD and AET seen on 24-hr-pH studies. It is a known fact that continued abnormal esophageal acid exposure can lead to erosive esophagitis, Barrett’s metaplasia, and esophageal cancer in the long run. Current literature also suggests that almost 50% of patients do develop abnormal acid exposure after a POEM procedure though only around one third develop symptoms or have erosive esophagitis. This concern has led to the development of techniques like POEM with fundoplication wherein an endoscopic fundoplication is performed in the same sitting of the POEM procedure, or even some techniques of endoscopic full-thickness plication/trans-oral incisionless fundoplication which can be performed after the POEM procedure selectively. Given the fact that almost 50% of patients undergoing POEM do develop an abnormal acid exposure, it is imperative that we need to clearly develop a rational strategy to deal with this reality. This review aims to realign the facts and fictions of the menace of post-POEM GERD and suggest a rational algorithmic approach.
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Abstract : Major disorders of esophageal peristalsis other than achalasia include Jackhammer esophagus (JHE), distal esophageal spasm (DES), and esophagogastric junction outflow obstruction (EGJOO). These disorders are rare, distinct from achalasia and characterized by high resolution manometry. Unlike achalasia, the treatment strategies are not well defined in these disorders. Therapies directed at lower esophageal sphincter may be inadequate in JHE and DES as a variable length of esophageal body is also involved in symptom generation. On the other hand, EGJOO is a more heterogenous group and the decision for endoscopic treatment is based on comprehensive evaluation of the underlying etiology. A subset of patients with EGJOO without significant stasis may improve on conservative treatment. Per-oral endoscopic myotomy (POEM) is a newer endoscopic treatment modality that has established its role in the management of achalasia. Limited studies suggest the efficacy of POEM in non-achalasia esophageal motility disorders as well. The ability to perform long esophageal myotomies with POEM makes it an attractive management tool for these patients.
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Abstract : After the clinical success of per-oral endoscopic myotomy (POEM) for treatment of achalasia cardia, the principle of submucosal tunneling and mucosal flap valve has been used in several other areas of the gastrointestinal tract. Gastric per-oral endoscopic pyloromyotomy (G-POEM, POEP, POP) is a relatively new procedure described for the treatment of refractory gastroparesis. This review discusses the indications, patient selection, pre-procedure workup, and procedure details of G-POEM. It also reviews the current literature on this procedure and provides insights and future directions for research on this topic.
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Abstract : Zenker’s diverticulum (ZD) is a rare condition that predominantly effects elderly population. Dysphagia and regurgitation are the common presenting symptoms in patients with ZD. Flexible endoscopic diverticulotomy (FED) of the cricopharyngeal septum is the mainstay of management in symptomatic ZD. The outcomes of FED compare favorably to open surgical and trans-oral rigid endoscopic treatment methods. Moreover, FED is associated with relatively fewer morbidities as compared to surgery. Bleeding and micro-perforation are the most commonly reported immediate adverse events. Majority of the adverse events are mild and severe adverse events are rare with FED. Recurrence of symptoms remain the most important long-term concern after FED. Nevertheless, majority of the recurrences respond to a repeat session of endoscopic treatment. Lately, new electrosurgical knives and novel endoscopic techniques of cricopharyngeal myotomy have been evaluated for the treatment of ZD. Novel techniques include double incision with snare resection and submucosal tunneling endoscopic septum division. The proposed advantage with these techniques is possible reduced incidence of recurrences after endoscopic treatment. Randomized comparison studies are required between new and conventional flexible endoscopic techniques. In addition, standardized reporting of clinical success, and adverse events is required in future studies.
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Abstract : Third space endoscopy (TSE) is a ‘magnum opus’ in the field of therapeutic gastrointestinal (GI) endoscopy that has led to a paradigm shift in the management of various GI disorders. TSE or submucosal endoscopy is based on the concept of mucosal flap safety valve technique. Since, the basic principle is more or less similar for all the TSE procedures, the nature of major adverse events (AE) also shares some similarity across the spectrum of TSE procedures. These AE include insufflation related AE, bleeding, perforation, and infection. Insufflation related events are among the most commonly encountered AEs. However, majority of the insufflation related AE do not require a specific intervention and not regarded as AE in true sense. Identification of risk factors and adaptation of preventative strategies may help in reducing the incidence of AE. At the same time, early recognition and expeditious management is paramount to reduce morbidities associated with these AE. Due to heterogeneity in the reporting of AE, it is difficult to estimate the actual incidence of AE and compare the results between different studies. Therefore, universal adaptation of a standard reporting system is required to quantify the true incidence of AE for each procedure.
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