Background Peroral endoscopic myotomy (POEM) was developed by our group to provide a less invasive permanent treatment for esophageal achalasia. Patients and methods POEM was performed in 17 consecutive patients with achalasia (10 men, 7 women; mean age 41.4 years). A long submucosal tunnel was created (mean length 12.4 cm), followed by endoscopic myotomy of circular muscle bundles of a mean total length of 8.1 cm (6.1 cm in distal esophagus and 2.0 cm in cardia). Smooth passage of an endoscope through the gastroesophageal junction was confirmed at the end of the procedure. Results In all cases POEM significantly reduced the dysphagia symptom score (from mean 10 to 1.3; P = 0.0003) and the resting lower esophageal sphincter (LES) pressure (from mean 52.4 mmHg to 19.9 mmHg; P = 0.0001). No serious complications related to POEM were encountered. During follow-up (mean 5 months), additional treatment or medication was necessary in only one patient (case 17) who developed reflux esophagitis (Los Angeles classification B); this was well controlled with regular intake of protein pump inhibitors (PPIs). Conclusions The short-term outcome of POEM for achalasia was excellent; further studies on long-term efficacy and on comparison of POEM with other interventional therapies are awaited.

http://dev.laparoskopi.nu/_uploads/files/poem.pdf

Peroral endoscopic myotomy (POEM) for esophageal achalasia.

Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Prospective Single Center Study

Importance Achalasia significantly affects patients’ quality of life and can be difficult to diagnose and treat. Objective To review the diagnosis and management of achalasia, with a focus on phenotypic classification pertinent to therapeutic outcomes. Evidence Review Literature review and MEDLINE search of articles from January 2004 to February 2015. A total of 93 articles were included in the final literature review addressing facets of achalasia epidemiology, pathophysiology, diagnosis, treatment, and outcomes. Nine randomized controlled trials focusing on endoscopic or surgical therapy for achalasia were included (734 total patients). Findings A diagnosis of achalasia should be considered when patients present with dysphagia, chest pain, and refractory reflux symptoms after an endoscopy does not reveal a mechanical obstruction or an inflammatory cause of esophageal symptoms. Manometry should be performed if achalasia is suspected. Randomized controlled trials support treatments focused on disrupting the lower esophageal sphincter with pneumatic dilation (70%-90% effective) or laparoscopic myotomy (88%-95% effective). Patients with achalasia have a variable prognosis after endoscopic or surgical myotomy based on subtypes, with type II (absent peristalsis with abnormal pan-esophageal high-pressure patterns) having a very favorable outcome (96%) and type I (absent peristalsis without abnormal pressure) having an intermediate prognosis (81%) that is inversely associated with the degree of esophageal dilatation. In contrast, type III (absent peristalsis with distal esophageal spastic contractions) is a spastic variant with less favorable outcomes (66%) after treatment of the lower esophageal sphincter. Conclusions and Relevance Achalasia should be considered when dysphagia is present and not explained by an obstruction or inflammatory process. Responses to treatment vary based on which achalasia subtype is present.

https://jamanetwork.com/journals/jama/articlepdf/2290638/jrv150005.pdf

Achalasia: A Systematic Review

https://www.gastrojournal.org/article/S0016-5085(13)00709-9/pdf

Peroral Endoscopic Myotomy for the Treatment of Achalasia: An International Prospective Multicenter Study

Background
Strongyloidiasis is frequently under diagnosed since many infections remain asymptomatic and conventional diagnostic tests based on parasitological examination are not sufficiently sensitive. Serology is useful but is still only available in reference laboratories. The need for improved diagnostic tests in terms of sensitivity and specificity is clear, particularly in immunocompromised patients or candidates to immunosuppressive treatments. This review aims to evaluate both conventional and novel techniques for the diagnosis of strongyloidiasis as well as available cure markers for this parasitic infection.

http://www.iacld.ir/DL/elm/thelaboratorydiagnosisandfollowupofStrongyloidiasisasystematicreview.pdf

The laboratory diagnosis and follow up of strongyloidiasis: a systematic review.

BACKGROUND AND STUDY AIMS: The most permanent method of treating achalasia is a surgical myotomy. Because of the requirement for a mucosal incision and the risk of perforation, this procedure has not generally been approached endoscopically. We hypothesized that we could perform a safe and robust myotomy by working in the submucosal space, accessed from the esophageal lumen. MATERIALS AND METHODS: Four pigs were used for this experiment. Baseline lower esophageal sphincter (LES) pressures were recorded and the pigs underwent upper endoscopy using a standard endoscope. A submucosal saline lift was created approximately 5 cm above the LES and a small nick was made in the mucosa in order to facilitate the introduction of a dilating balloon. After dilation, the scope was introduced over the balloon into the submucosal space and advanced toward the now visible fibers of the LES. The circular layer of muscle was then cleanly incised using an electrocautery knife in a distal-to-proximal fashion, without complications. The scope was then withdrawn back into the lumen and the mucosal defect was closed with endoscopically applied clips. The entire procedure took less than 15 minutes. Manometry was repeated on day 5 after the procedure and the animals were euthanized on day 7. RESULTS: LES pressures fell significantly from an average of 16.4 mm Hg to an average of 6.7 mm Hg after the myotomy. The necropsy examinations revealed no evidence of mediastinitis or peritonitis. CONCLUSIONS: Endoscopic submucosal esophageal myotomy is feasible, safe, and effective in the short term. It has the potential for being useful in patients with achalasia. The submucosal space is a novel and potentially important field of operation for endoscopic procedures.

Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.

Submucosal Endoscopic Esophageal Myotomy: A Novel Experimental Approach for the Treatment of Achalasia

In up to 10% to 20% of colonoscopies, complete intubation of the colon may be considerably difficult. A principal cause of difficulty is looping of the endoscope shaft in a floppy, often tortuous segment of the colon that typically happens in the sigmoid colon. Also, if looping is not recognized and the scope is advanced with abandon, the risk of perforation will rise. Special "variable stiffness" colonoscopies are expensive and have not been unequivocally shown to be useful in preventing looping. The simplest approach to prevent looping is perhaps the use of an over-tube to prevent the shaft from bowing out. The ShapeLock could offer an ideal over-tube that is flexible enough to safely and easily negotiate bends in the colon but when needed be rigid enough to prevent looping with just a snap of its handle. It also has potential other applications including enteroscopy, transgastric endoscopy and access to difficult regions of the upper gastrointestinal tract.

Rami Hawari

Papers

Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.

Submucosal Endoscopic Esophageal Myotomy: A Novel Experimental Approach for the Treatment of Achalasia

Going for the loop: a unique overtube for the difficult colonoscopy.

Strongyloidiasis: endoscopic diagnosis.

Images in clinical medicine. Eosinophilic esophagitis.