Non-achalasia esophageal motility disorders: Role of per-oral endoscopic myotomy

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.2

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.

Endoscopic management of Zenker’s diverticulum

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.2

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.

Non-achalasia esophageal motility disorders: Role of per-oral endoscopic myotomy

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.2

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.

Endoscopic management of Zenker’s diverticulum

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.2

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.

Adverse events associated with third space endoscopy: Diagnosis and management

Radhika Chavan,Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.2

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.

Adverse events associated with third space endoscopy: Diagnosis and management

Radhika Chavan,Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.2

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.