Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis

Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy for the treatment of achalasia. This review aims to assess subjective and objective metrics of achalasia treatment efficacy, perioperative adverse events and the incidence of postoperative gastroesophageal reflux disease in patients treated with POEM. Secondary aims include a pooled analysis comparison of the clinical outcomes and procedural safety of POEM versus laparoscopic Heller's myotomy (LHM). A systematic review of the literature, up to and including January 15, 2015, was conducted for studies reporting POEM outcomes. Studies comparing POEM to LHM were also included for the purpose of pooled analysis. Outcomes from 1122 POEM patients, from 22 studies, are reported in this systematic review. Minor operative adverse events included capno/pneumo‐peritoneum (30.6%), capno/pneumo‐thorax (11.0%) and subcutaneous emphysema (31.6%). Major operative adverse events included mediastinal leak (0.3%), postoperative bleeding (1.1%) and a single mortality (0.09%). There was an improvement in lower esophageal sphincter pressure and timed barium esophagram column height of 66% and 80% post‐POEM, respectively. Symptom improvement was demonstrated with a pre‐ and post‐POEM Eckardt score ± standard deviation of 6.8 ± 1.0 and 1.2 ± 0.6, respectively. Pre‐ and post‐POEM endoscopy showed esophagitis in 0% and 19% of patients, respectively. The median (interquartile range) points scored for study quality was 15 (14–16) out of total of 32. Pooled analysis of three comparative studies between LHM and POEM showed similar results for adverse events, perforation rate, operative time and a nonsignificant trend toward a reduced length of hospital stay in the POEM group. In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia‐related symptoms. Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality for achalasia.     

Staging accuracy of esophageal cancer by endoscopic ultrasound：A meta-analysis and systematic review

AIM： To evaluate the accuracy of endoscopic ultrasound （EUS） in the staging of esophageal cancer. METHODS： Only EUS studies confirmed by surgery were selected. Articles were searched in Medline and Pubmed. Two reviewers independently searched and extracted data. Meta-analysis of the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both the Mantel-Haenszel method （fixed effects model） and DerSimonian Laird method （random effects model）. The heterogeneity of studies was tested using Cochran’s Q test based upon inverse variance weights. RESULTS： Forty-nine studies （n = 2558） which met the inclusion criteria were included in this analysis. Pooled sensitivity and specificity of EUS to diagnose T1 was 81.6% （95% CI： 77.8-84.9） and 99.4% （95% CI： 99.0-99.7）, respectively. To diagnose T4, EUS had a pooled sensitivity of 92.4% （95% CI： 89.2-95.0） and specificity of 97.4% （95% CI： 96.6-98.0）. With Fine Needle Aspiration （FNA）, sensitivity of EUS to diagnose N stage improved from 84.7% （95% CI： 82.9-86.4） to 96.7% （95% CI： 92.4-98.9）. The P value for the χ2 test of heterogeneity for all pooled estimates was 〉 0.10. CONCLUSION： EUS has excellent sensitivity and specificity in accurately diagnosing the TN stage of esophageal cancer. EUS performs better with advanced （T4） than early （T1） disease. FNA substantially improves the sensitivity and specificity of EUS in evaluating N stage disease. EUS should be strongly considered for staging esophageal cancer.     

Same site submucosal tunneling for a repeat per oral endoscopic myotomy: A safe and feasible option

Per oral endoscopic myotomy (POEM) is a novel endoscopic procedure for achalasia treatment. Due to its novelty and high success rates, a repeat procedure is usually not warranted, making the feasibility and safety of such approach unknown. We report the first case of a successful repeat POEM done at the same site of a previously uncompleted POEM. An 84-year-old female with type 2 achalasia presented for a POEM procedure. The procedure was aborted at the end of tunneling and before myotomy due to hypotension, which later resolved spontaneously. POEM was re-attempted at the same site of the original tunnel 1 year afterward, and surprisingly we didn’t encounter any submucosal fibrosis. The procedure felt similar to a native POEM and a myotomy was performed uneventfully. Our case is the first to suggest that submucosal tunneling during a repeat POEM can be done at the same site. Hypotension during POEM is a rare complication that should be recognized as a potential result of tension capnothorax, it can however, be managed with close supportive care.     

Gastric peroral endoscopic myotomy for gastroparesis: A systematic review of efficacy and safety

IntroductionTo assess the efficacy and safety of gastric peroral endoscopic myotomy for the treatment of gastroparesis.MethodsPubMed, Embase, Cochrane Library and Web of Science databases were searched from their earliest records to May 2018. The evaluation of clinical efficacy and safety was based on gastric emptying scintigraphy normalization, the improvement in clinical symptoms and adverse event rate. R 3.5.0 software was used to calculate the pooled estimate rates by meta-analysis. The improvement rate of the Gastroparesis Cardinal Symptom Index score was analyzed at different follow-up times.ResultsFourteen studies with a total of 276 patients were included in this systematic review. The pooled gastric emptying scintigraphy normalization rate was 61.3% (95% CI, 51.5–70.8%) and clinical symptom improvement rate was 88.2% (95% CI, 83.6–93.1%). Intra-operative complications were found in about 3.2% (95% CI, 0.1–4.2%) of all included patients, and postoperative adverse events in 2.1% (95% CI, 0.3–4.8%). The mean Gastroparesis Cardinal Symptom Index score improvement rate was about 90.2% at one month follow-up, 83.3% at three months, 70.3% at six months, 52.4% at twelve months and 57.1% at eighteen months.DiscussionOur systematic review demonstrates that gastric peroral endoscopic myotomy is a safe and effective treatment for gastroparesis. Though the short-term outcomes are promising, prospective, randomized, controlled studies with large sample size and long-term follow-up are required to further confirm these results.     

Diagnosis and endoscopic treatment of esophageal leakage: a systematic review

When esophageal leakage is suspected, diagnostic work-up usually starts with endoscopy followed by CT of the thorax. Clinicians should consider esophageal leakage a clinical emergency as early diagnosis and treatment are associated with improved outcome. Upon diagnosis, acute therapeutic management in a specialized center with appropriate multidisciplinary infrastructure and expertise is indicated as innovative endoscopic treatment options have become reasonable alternatives to invasive surgical interventions. Promising endoscopic treatment options include esophageal stent placement, endoscopic vacuum therapy, and over-the-scope clip placement. In effort to evaluate the current literature, a systematic literature search was performed on studies reporting clinical outcome of patients treated with these endoscopic treatment options for benign esophageal perforations and anastomotic leakage. The systematic search yielded 15 studies (932 patients) discussing stent placement, 14 studies (295 patients) discussing endoscopic vacuum therapy, and 8 studies (41 patients) discussing over-the-scope clip placement. Clinical success was achieved in the majority of all patients. However, the studies predominantly consisted of small single-center retrospective case series. Careful selection of patients is therefore recommended when considering endoscopic therapy for esophageal leakage. Furthermore, clinical tools may aid in predicting patients’ prognosis and selection of patients that could benefit from endoscopic therapy. In the future, randomized studies comparing available endoscopic treatment options are needed to guide treatment choice for patients with esophageal leakage in daily clinical practice.     

Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients. A systematic review

Objectives: Achalasia is a primary motility disorder of the esophagus characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Treatment of achalasia aims at reducing LES pressure. The common treatment modalities are laparoscopic Heller myotomy and pneumatic dilatation, but during the last decade, a promising treatment, per oral endoscopic myotomy (POEM), has been introduced. The aim of the present study was to perform a systematic review of the literature to assess the outcome of POEM in treatment-naive patients.

Materials and methods: A systematic literature search in PubMed, Embase and Cochrane databases was performed using the terms ‘Achalasia AND (POEM OR peroral endoscopic myotomy OR per-oral endoscopic myotomy)’. Inclusion criteria were: original article; English language; n?≥?20 with ≥90% treatment-naive patients; follow-up ≥3 months; and outcome evaluation of POEM including symptom score and objective tests. Exclusion criteria were: reviews and meta-analyses; pediatric data; duplicates; and articles with overlapping data material.

Results: Of the 1641 articles identified, seven were included. The included studies all reported a short-term clinical success of >90%. Clinical success including post-POEM reflux was mainly estimated by symptom scorings. There were few procedure-related complications.

Conclusions: The studies of treatment-naive patients indicate a high rate of clinical success. Nevertheless, a more systematic and standardized evaluation is recommended to improve the reports on outcome of POEM. The follow-up rate should be high and the evaluation protocol should include both symptom scoring and objective testing with predefined treatment goals.     

Peroral endoscopic myotomy for esophageal achalasia: Indication and technique

Since the inception of peroral endoscopic myotomy (POEM) in 2008, more than 2000 POEMs have been performed to date in the world. The technique has been standardized to include the following 5 steps: mucosectomy, submucosal tunnel creation, esophageal myotomy, cardiomyotomy, and mucosectomy closure. Minor technique variations do exist as far as the equipment utilized as well as with the orientation and completeness of the myotomy. This article describes the equipment used during POEM as well as the essential steps to have a safe and successful procedure.     

Peroral endoscopic myotomy (POEM) for esophageal motility disorders other than achalasia

Peroral endoscopic myotomy (POEM) is a novel minimally invasive procedure that has demonstrated excellent results in patients with all achalasia subtypes. In patients with non-achalasia disorders, POEM is more complex both in terms of preoperative evaluation and surgical technique. There are multiple studies that reported the results of POEM in patients with diffuse esophageal spasm and Jackhammer esophagus. POEM can potentially be the ideal endoscopic therapy for these motility disorders as it not only allows myotomy of the lower esophageal sphincter but also of the esophageal body, where the hypertensive contractions occur. In these patients, manometric diagnosis should be clear on careful review of their motility tracing. There have been promising reports of POEM in patients with esophago-gastric junction outflow obstruction, however, the data are still limited. In general, non-achalasia esophageal motility disorders are very rare and multicenter collaboration is required to develop an evidence-based methodology for POEM application in these disorders. The key to performa successful POEM is based on careful patient selection and complete pre-operative evaluation. GERD after POEM is common and management, goals of therapy, and long-term outcomes of GERD after POEM are unclear. Candidates should be appropriately counseled on expected outcomes and the need for long-term surveillance.     

Cyclophosphamide for scleroderma lung disease: a systematic review and meta-analysis

To assess the effectiveness of cyclophosphamide in the management of scleroderma-related interstitial lung disease (ILD). In this systematic review study, the primary outcome measures were change in forced vital capacity (FVC) and diffusing capacity of the lung for carbon monoxide (D_LCO) of the patients after 6 and 12?months. To assess the effect of cyclophosphamide on early stage of ILD, alveolitis, in SSc patients, we selected the studies that used the BAL findings or HRCT or recent deterioration of PFT with minimal chest X-ray finding in early stage of disease as diagnosis of alveolitis. A sensitive systematic search strategy was used to find all relevant studies. Finally, 17 trials were included in the analysis that was performed using STATA. (Version 8) and Review Manager (version 4.1; MetaView version 4.1) softwares. Results from 10 studies were pooled for the outcome variable of FVC after 12?months. The summary WMD (random effects) was 2.45 (95% CI, 0.760–4.149 P?=?0.005), which means that cyclophosphamide was able to prevent deterioration of FVC after 12?months. In pooled data of 13 studies, about DLCO after 12?months WMD (random effects) was 2.003 2.96 (95% CI, ?0.228 to 6.159 P?=?0.069), which means that cyclophosphamide was not able to prevent deterioration of D_LCO after 12?months. If we considered clinically sensible improvement as absolute value ≥10% in DLCO and VC, then result of treatment with cyclophosphamide treatment in scleroderma patients with ILD was not significant.     

Early oral feeding after pancreatoduodenectomy: a systematic review and meta-analysis

BackgroundThe effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS).MethodsA systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN).ResultsFour studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44–1.24; p = 0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31–2.21; p = 0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference ?3.40 days; 95% ?6.11-0.70 days; p = 0.01).ConclusionCurrent available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.     

Switching between direct oral anticoagulants: a systematic review and meta-analysis

Journal of Thrombosis and Thrombolysis - Crossover between direct oral anticoagulants (DOACs) has been underinvestigated, but happens frequently in clinical practice. It is still unknown whether...     

Aspirin and non-aspirin NSAIDs increase risk of colonic diverticular bleeding: a systematic review and meta-analysis

Lower gastrointestinal bleeding is a frequent cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Colonic diverticular bleeding is the most common form of lower gastrointestinal bleeding and is responsible for 30–40 % of bleeding episodes. Risk factors associated with diverticular bleeding include obesity, hypertension, anticoagulants, diabetes mellitus, and ischemic heart disease. Recent studies have suggested a relationship between usage of non-steroidal anti-inflammatory drugs (NSAIDs) and colonic diverticular bleeding; however, most studies were small with wide confidence intervals. We identified studies by searching the PubMed and Scopus databases (from inception through 31 December 2012) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of six studies (five case–control studies and one cohort study) met inclusion criteria for analysis. Non-aspirin NSAIDs (NANSAIDs) and aspirin were associated with an increased risk of colonic diverticular bleeding (summary RR = 2.48, 95 % CI 1.86–3.31), with moderate heterogeneity among these studies (P heterogeneity = 0.11, I ² = 44.4 %). Stratification to evaluate the heterogeneity found that both NANSAIDs (summary RR = 2.24, 95 % CI 1.63–3.09; 5 studies) and aspirin (summary RR = 1.73; 95 % CI 1.31–2.30; 3 studies) were associated with the risk of diverticular bleeding. Aspirin/NANSAIDs use was strongly and consistently associated with an increased risk of colonic diverticular bleeding. Further studies are needed to stratify individuals at risk of diverticular bleeding associated with the use of these agents.