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Peroral endoscopic myotomy using an endoscopic dissector: another novel device in our toolbox
Peroral endoscopic myotomy (POEM) is a safe and effective technique for the management of achalasia and other nonachalasia motility disorders.1 However, it is technically challenging and time consuming with the use of multiple instruments often required for performing various steps associated with the procedure. While the procedural technique has remained homogeneous, various electrosurgical knives continue to evolve to prevent injuries to the surrounding structures and reduce the need for device changes.Modification of the endoscopic hemostatic powder application technique
EndoClot Polysaccharide Hemostatic System (EndoClot PHS; Micro-Tech Europe, Dusseldorf, Germany) is a starch-derived compound that consists of biocompatible absorbable hemostatic polysaccharides that absorb water when in contact with blood or liquids, creating a gelled matrix over the bleeding lesion. It also accelerates the in situ coagulation process through hyperconcentration of platelets and coagulation factors.1 Hemostatic powders are considered an endoscopic hemostatic option for upper and lower nonvariceal bleeding, which are easy to use and have a good safety profile.Utility of a super-soft hood for esophageal endoscopic submucosal dissection below an esophageal stricture
Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) has been widely performed.1 ESCC is frequently associated with head and neck cancer.2 In patients with head and neck cancer, esophageal stricture because of radiation therapy sometimes occurs.3 For ESD for ESCC, a transparent hood is almost essential; however, in some cases, after radiation therapy for head and neck cancer, the hood or scope may not pass through the esophageal stricture. The super-soft hood (Space Adjuster; TOP, Tokyo, Japan) that adjusts to narrow spaces has recently become commercially available (Fig. 1).Endoscopic submucosal dissection of a gigantic gastric polyp aided by a novel retraction device and complicated by upper esophageal sphincter laceration during retrieval
An 87-year-old woman with chronic renal insufficiency and coronary artery disease on clopidogrel was found to have a sizable adenomatous gastric polyp. She was referred for endoscopic resection after declining surgery. On endoscopy, a gigantic polypoid lesion was found measuring 11 × 8 cm (Fig. 1) with a broad short stalk (Fig. 2). The surface pattern was irregular without ulceration. For the most part, the vascular pattern was a mesh of well-connected vessels. However, it contained an area of irregular vascular patterns worrisome for high-grade dysplasia.Emergent endoscopic submucosal dissection for a polypoid fibroadipose tumor accidentally disgorged from the mouth: an organ-preserving minimally invasive treatment
A 74-year-old woman presented with dysphagia. EGD at a previous hospital showed a giant pedunculated polyp from the entrance of the esophagus to the esophagogastric junction. She was referred to our hospital for treatment. On EGD, the polyp was covered with normal epithelium with a swollen and ulcerated head, measuring 17 cm in length. A CT scan revealed an intraluminal tumor in the esophagus with low density and no findings of metastasis (Fig. 1A). Positron emission tomography–CT revealed a highly concentrated area in the esophagus (Fig. 1B).Wide-field ESD for Barrett's adenocarcinoma at the gastroesophageal junction: technical approaches to facilitate en bloc R0 resection
Endoscopic submucosal dissection (ESD) for Barrett's esophagus (BE) neoplasia is associated with high en bloc resection and an acceptable safety profile but with suboptimal curability rates (range, 56%-59%).1 Two large Western studies showed that low R0 resection rates resulted from the high rate of positive lateral margins in ESD specimens (range, 82%-86%), which prompted either salvage ESD or additional surgical treatment.2,3 A U.S. multicenter ESD study found positive lateral margins in up to 70% of Barrett's adenocarcinoma (BA) at the gastroesophageal junction (GEJ) because of the increased technical complexity, poor maneuverability, and difficulty in evaluating the lesion’s margin.Transpyloric lumen-apposing metal stent for management of persistent post-esophagogastrectomy leak
Anastomotic leaks are an adverse event complication of GI surgery that contribute to increased hospital stays, morbidity, and mortality. Endoscopic therapy via endoscopic closure techniques or covered metal stent placement has increasingly been used for primary therapy of anastomotic leaks.Recurrence after Zenker’s peroral endoscopic myotomy despite complete septotomy: how far to go with myotomy on the esophageal side
Zenker’s diverticulum (ZD) is the most common diverticular disease found in the pharyngo-esophageal region.1 Zenker’s peroral endoscopic myotomy (Z-POEM) has been used incrementally for ZD with good efficacy and safety.2 Although Z-POEM provides the platform of submucosal tunneling that ensures a complete septotomy, recurrence to the tune of 14.7% are still reported after Z-POEM.3 Here we present a case of ZD that had recurrence after Z-POEM because of incomplete myotomy on the esophageal side, which was subsequently tackled with flexible endoscopic division of the residual esophageal muscular bridge.EUS–guided biopsy of an intraventricular mass in a patient with ventricular tachycardia
Endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) is a minimally invasive procedure commonly used for diagnostic purposes. Because of the accuracy and safety of EUS, both intraluminal and extraluminal lesions can be sampled. Traditional methods of cardiac biopsy, typically through an endovascular approach, are well established. However, few EUS-guided cardiac interventions have been published,1-3 as they are rarely performed. Potential risks for cardiac biopsy, regardless of modality, include hemorrhage, perforation, arrhythmia, and valvular damage.An endoscopic approach to therapy for spontaneous esophageal rupture
Boerhaave syndrome is among the most lethal GI tract disorders with a reported mortality rate of up to 40%.1-3 Spontaneous perforations are caused by sudden intraesophageal pressure elevations leading to transmural injury and subsequent mediastinal inflammation, subcutaneous emphysema, and/or necrosis secondary to spillage of gastric contents. Management was historically surgical, but stable patients may benefit from the reduced morbidity and mortality associated with less invasive percutaneous and endoscopic approaches.Antireflux band mucosectomy: a novel minimally invasive approach for the treatment of refractory gastroesophageal reflux disease
Endoscopic therapies in the treatment of refractory GERD have largely been regarded as inferior as surgical intervention. Procedures such as the transoral endoscopic incisionless fundoplication (TIF), Stretta, and antireflux mucosectomy (ARMS) are less invasive but produce outcomes that are middling to lackluster, with many patients having to continue proton pump therapy without resolution of symptoms. Antireflux band mucosectomy (ARBM), in which the cardia is banded, may provide more effective relief.Helix tack suspension for esophageal stent fixation
Fully covered self-expanding metal stents were developed as a removable prosthesis for esophageal obstruction. They are highly effective at relieving dysphagia and are covered with an impermeable membrane to prevent tissue ingrowth. Unfortunately, these stents carry a significant risk of migration,1 with risk for subsequent adverse events including intestinal obstruction2 and, rarely, perforation.3 If the esophageal stricture is endoscopically nonpassable, there is also a risk of requiring surgical removal.Endoscopic suturing for repair of an obstructing Zenker’s diverticulum using a bidirectional endoscopic approach for lumen delineation
Endoscopic suturing is a technique that can be applied to several disease processes, such as repair of fistulae or perforations, endoluminal stent anchoring, and for endobariatric procedures. We describe a case of suturing to repair an obstructing Zenker's diverticulum (Video 1, available online at www.giejournal.org ).Successful D-POEM after failed surgical myotomy and diverticulectomy
Peroral endoscopic myotomy with diverticulotomy (D-POEM) is feasible for management of achalasia with an epiphrenic diverticulum (ED).1-3 In a study of 14 patients with ED and underlying motility disorders with isolated lower esophageal sphincter (LES) POEM, all had postoperative Eckardt score improvement.4 Diverticulotomy is second-line treatment.4-7Peroral endoscopic myotomy (POEM) for achalasia developing after vertical banded gastroplasty with asymptomatic gastro-gastric fistula
Peroral endoscopic myotomy (POEM) has revolutionized the treatment landscape for achalasia. Randomized trials and meta-analyses have shown that its efficacy is comparable to the traditional reference-standard surgical approach represented by laparoscopic Heller’s myotomy (LHM), with an outstanding safety profile1,2; higher postoperative reflux rates seem to be associated with POEM over LHM, owing to the absence of an antireflux procedure. POEM has consequently been proposed as a first-line option over LHM, which may carry higher perioperative and postoperative risk, for patients with previous abdominal surgery or obesity.Gauze extension method for specimens resected by endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) is a standard and reliable procedure for resection of GI neoplasms. Although ESD allows en bloc resection of large GI neoplasms,1 ESD specimens tend to contract because of burning and scarring of the margins during ESD (Fig. 1). When preparing ESD specimens for pathologic examination, including evaluation of the margins, specimens should be extended and pinned on a fixing board as quickly as possible.2,3 However, in most cases, the normal marginal mucosa from ESD specimens is thin and fragile, especially from the colon.A novel and effective EUS training program that enables visualization of the learning curve: Educational Program of Kindai system (EPOK)
EUS is currently regarded as a tool that enables not only observation but also diagnosis and treatment. The basis of all EUS-related procedures is the EUS screening technique. However, it can be challenging for trainees to master the technique. Several studies have investigated training methods for EUS screening that are based on memorization of typical EUS images.1 Hands-on training also is considered useful.2-5 The American Society for Gastrointestinal Endoscopy guidelines suggest that at least 225 hands-on EUS procedures are required to achieve competency in biliopancreatic EUS.Modified submucosal tunneling endoscopic resection for postcricoid esophageal subepithelial tumor
Submucosal tunneling endoscopic resection (STER) has been described as a technique for endoscopic resection of GI subepithelial tumors (SETs) arising from the muscularis propria layer1 and is an accepted treatment modality for these SETs.2 The standard STER technique involves submucosal elevation 3 to 5 cm proximal to the SET along its longitudinal axis, mucosotomy, submucosal tunneling, dissection of the SET within the tunnel, enucleation from the deep muscle layer, and specimen delivery followed by mucosal closure.Septal wall divides esophagus into double lumen: successful endoscopic septotomy
Intraluminal esophageal diverticulum is a rare condition identified by a collection of intraluminal barium with surrounding radiolucent halo on barium swallow.1-3 Historically, management has comprised proton pump inhibitor therapy, lifestyle modification, and esophageal dilation.1,2 Limited literature exists on the endoscopic management of this condition. Our case highlights the use of minimally invasive endoscopic techniques to manage intraluminal esophageal diverticulum.Endoscopic submucosal dissection and tunneling procedures using novel image-enhanced technique
Recent innovations in image-enhanced endoscopy allow early detection and management of GI lesions. In this study, we aim to analyze the utility of texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) during endoscopic submucosal dissection (ESD) and submucosal tunneling procedures.The utility of image-enhanced endoscopy and Lugol’s for the assessment of esophageal squamous carcinoma
Esophageal squamous cell carcinoma (ESCC) is the most commonly diagnosed esophageal cancer.1 Previously, diagnoses in the late stages of disease led to a poor prognosis and limited treatment. However, advancements in optical diagnosis and resection techniques have allowed for improved detection, characterization, and therapy. We present a case that highlights the utility of image-enhanced endoscopy and Lugol’s in the assessment of ESCC (Video 1, available online at www.giejournal.org ).Balloon tamponade for control of myotomy bleeding during peroral endoscopic myotomy
Peroral endoscopic myotomy has revolutionized the management of achalasia. Although capnoperitoneum or capnomediastinum are not uncommonly seen in the immediate postprocedure setting, severe adverse events such as perforation and bleeding requiring cessation of the procedure are rare. Individuals with a sigmoid-shaped esophagus are known to be at increased risk for adverse events. Minor bleeding is relatively common during submucosal tunneling and is treated easily using coagulation from the dissecting needle itself, cap tamponade, or coagulation forceps for larger vessels.Endoscopic through-the-scope suturing
There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine.Peroral endoscopic myotomy for a residual Zenker’s diverticulum following endoscopic myotomy
Symptomatic Zenker’s diverticulum can be associated with significant morbidity. Zenker’s diverticulum can persist after flexible endoscopic myotomy. Several endoscopic and surgical techniques can be considered, but it is unclear which interventions are feasible and appropriate for residual Zenker’s diverticulum.Balloon-compression endoscopic injection sclerotherapy for the treatment of esophageal varices
Endoscopic injection sclerotherapy (EIS) is an effective therapeutic option for esophageal varices (EVs). However, the outflow of sclerosant impairs its effectiveness and increases the incidence of adverse events. Hence, we developed a novel EIS technique with compression by an inflated balloon. The present study reports a case of EVs treated with balloon-compression EIS (bc-EIS).
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