I) Third Space Endoscopy – 2021 Update

Symposium (I)

THIRD SPACE ENDOSCOPY – 2021 UPDATE

POEM FOR ESOPHAGEAL MOTILITY DISEASE. WHO, WHEN AND HOW?

Yin-Yi Chu Ultrasonography and Endoscopy Center, New Taipei Municipal Tuchen Hospital, New Taipei City, Taiwan Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan

High-resolution manometry is now the gold standard diagnostic tool for esophageal motility diseases, which classified on the basis of lower esophageal sphincter (LES) relaxation and motility of esophageal body: (1) incomplete LES relaxation, including achalasia and EGJ outflow obstruction; (2) major motility disorders, including absent contractility, distal esophageal spasm etc.; (3) minor motility disorders; (4) normal esophageal motility.

Third space endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa. The era of third space endoscopy started with peroral endoscopic myotomy (POEM) for treatment of achalasia and has expanded to treat various other gastrointestinal disorders. This topic focus on POEM application to various esophageal motility diseases, (1) the indications of POEM, including non-achalasia spastic esophageal motility disorders, the extreme of age and failed previous treatment of achalasia, (2) advancements in procedural techniques such as detection of EGJ and adequacy myotomy, length and site of myotomy, full thickness or circular myotomy, (3) the effectiveness, outcomes and advers events of POEM. Up to now, POEM is rapidly emerging as minimally invasive alternatives to conventional surgery.

Symposium (I)

THIRD SPACE ENDOSCOPY – 2021 UPDATE

GASTRIC-POEM. WHO, WHEN AND HOW?

Mouen A. Khashab Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

Gastroparesis is a morbid disorder, characterised by delayed gastric emptying in the absence of mechanical obstruction.1 Over the past two decades, gastroparesis has been a growing concern in terms of prevalence, economic cost and its negative effect on quality of life.2–4 Despite its high burden, gastroparesis remains a difficult-to-treat condition with limited treatment options. One large multicentre prospective study showed that only 28% of patients had clinical success at 48 weeks after receiving treatment according to the standard of care.5 Impairment of fundic accommodation, antral contractility, pyloric relaxation and/or duodenal feedback may contribute to delayed gastric emptying and clinical symptoms.6,7 Treatment of gastroparesis remains challenging due to contribution of various pathophysiologic mechanisms to the disease. Diet modification and prokinetic medications are first-line therapies of gastroparesis. However, prokinetics are not tolerated well due to their significant side effects and have suboptimal efficacy.8 Pylorospasm, detected by manometry9 and endoluminal impedance planimetry (EndoFLIP; Medtronic, Minneapolis, Minnesota),10–12 has been shown to correlate with gastroparesis symptoms. Based on these findings, pyloric-directed interventional procedures such as botulinum toxin injection, transpyloric stent placement and pneumatic dilation of the pylorus have been developed.13–16

Gastric per-oral endoscopic myotomy (G-POEM) was introduced by Khashab et al17 in 2013 as a minimally invasive pyloric-directed procedure for the management of refractory gastroparesis. This was followed by several studies, mostly retrospective with short follow-up periods, which showed encouraging results.18,19 Two meta-analyses reported pooled symptomatic improvement rates of 83.9% and 82% and adverse events (AEs) rate of 6.8% and 6.1%, respectively.20,21 These results have contributed to our knowledge about efficacy and safety of G-POEM.

Reference:

1. Jung H-K, Choung RS, Locke GR, et al. The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006.

Gastroenterology 2009;136:1225–33. 2. Wang YR, Fisher RS, Parkman HP. Gastroparesis-related hospitalizations in the United States: trends, characteristics, and outcomes, 1995-2004. Am J Gastroenterol 2008;103:313–22. 3. Wadhwa V, Mehta D, Jobanputra Y, et al. Healthcare utilization and costs associated with gastroparesis. World J Gastroenterol 2017;23:4428. 4. Lacy BE, Crowell MD, Mathis C, et al.

Gastroparesis: quality of life and health care utilization. J Clin Gastroenterol 2018;52:20–4. 5. Pasricha PJ, Yates KP, Nguyen L, et al.

Outcomes and factors associated with reduced symptoms in patients with gastroparesis.

Gastroenterology 2015;149:1762–74. 6. Kashyap P, Farrugia G. Diabetic gastroparesis: what we have learned and had to unlearn in the past 5 years. Gut 2010;59:1716–26. 7. Feldman M, Lawrence Friedman LB. Pathophysiology, Diagnosis, Management, Expert Consult Premium Edition - Enhanced Online Features and Print, 2010. Available: https://www.elsevier.com/books/sleisengerand-fordtrans-gastrointestinal-and-liverdisease2-volume-set/feldman/978-1-4160-6189-2 [Accessed 09 Apr 2020]. 8. Ehrenpreis ED, Deepak P, Sifuentes H, et al. The metoclopramide black box warning for tardive dyskinesia: effect on clinical practice, adverse event reporting, and prescription drug lawsuits. Am J Gastroenterol 2013;108:866–72. 9. Mearin F, Camilleri M, Malagelada JR.

Pyloric dysfunction in diabetics with recurrent nausea and vomiting. Gastroenterology 1986;90:1919–25. 10. Gourcerol G, Tissier F, Melchior C, et al.

Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. Aliment Pharmacol Ther 2015;41:360–7. 11. Malik Z, Sankineni A, Parkman HP. Assessing pyloric sphincter pathophysiology using

EndoFLIP in patients with gastroparesis. Neurogastroenterol Motil 2015;27:524–31. 12. Vosoughi K, Ichkhanian Y, Jacques J, et al.

Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video). Gastrointest Endosc 2020;91:1289–99. 13. Clarke JO, Sharaiha RZ, Kord Valeshabad A, et al. Through-the-scope transpyloric stent

placement improves symptoms and gastric emptying in patients with gastroparesis. Endoscopy 2013;45 Suppl 2 UCTN:E189–90. 14. Gourcerol G, Tissier F, Melchior C, et al.

Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. Aliment Pharmacol Ther 2015;41:360–7. 15. Arts J, Holvoet L, Caenepeel P, et al. Clinical trial: a randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis. Aliment Pharmacol Ther 2007;26:1251–8. 16. Wellington J, Scott B, Kundu S, et al. Effect of endoscopic pyloric therapies for patients with nausea and vomiting and functional obstructive gastroparesis. Auton Neurosci 2017;202:56 17. Khashab MA, Stein E, Clarke JO, et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest

Endosc 2013;78:764–8. 18. chkhanian Y, Vosoughi K, Aghaie Meybodi M, et al. Comprehensive analysis of adverse events associated with gastric peroral endoscopic myotomy: an international multicenter study.

Surg Endosc 2021;35:1755–64. 19. Benias PC, Khashab MA. Gastric peroral endoscopic pyloromyotomy therapy for refractory gastroparesis. Curr Treat Options

Gastroenterol 2017;15:637–47. 20. Meybodi MA, Qumseya BJ, Shakoor D. Efficacy and feasibility of G-POEM in management of patients with refractory gastroparesis: a systematic review and metaanalysis. Endosc

Int open 2019;7:E322–9. 21. Spadaccini M, Maselli R, Chandrasekar VT, et al. Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis.

Gastrointest Endosc 2020;91:746–52.

Symposium (I)

THIRD SPACE ENDOSCOPY – 2021 UPDATE

POCKET CREATION METHOD FOR EARLY GI CANCER ESD. WHO, WHEN AND HOW?

Hironori Yamamoto Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan

Who?

The pocket-creation method is recommended not only for experts but also for beginners.

This is because it is easy for beginners to learn as long as they get the hang of it, and stable ESD is possible. ESD is a relatively difficult procedure that requires advanced skill, but one of the factors that makes it difficult for beginners is the problem of unstable endoscope operation. Stable endoscopic operation is required for delicate treatment that does not allow an error of 1 mm. In the pocket-creation method, the control of endoscope tip is stabilized because it is fixed in the submucosal pocket. In addition, since the operation is performed in the submucosal layer, luminal insufflation is not necessary. With the lumen collapsed without insufflation, the approach to the lesion in the tangential direction becomes easy. Avoiding overinsufflation also reduces the patient’s discomfort.

When?

We use the pocket-creation method as the first choice as a standard procedure for any lesions in the esophagus, stomach, duodenum, and large intestine. Although pocket-creation method is particularly useful for overcoming difficult cases with fibrosis, it is also useful to perform highquality ESD as a standard procedure, not limited to difficult cases.

How?

In the pocket-creation method, mucosal incision is limited to be about 2 cm length only for the entrance of the submucosal pocket. Submucosal dissection under the lesion is prioritized over mucosal incision. ST hood is useful for pocket-creation method because it helps easy entrance to the submucosal space and provides stable condition of the endoscope tip. In the submucosal pocket, traction and counter traction can be applied by the outer side of the ST hood. Severe fibrosis can be overcome by creating submucosal pockets to both sides of the fibrosis. Even if the lesion is located on a prominent fold, the fold can be flattened by the tip of ST hood during the submucosal dissection using pocket-creation method. Bleeding control is also easier in pocketcreation method because the level of dissection plane can be selected at the level where blood vessels are sparse. In this lecture, I would like to explain the tips and tricks of the pocket-creation method of ESD.

Symposium (I)

THIRD SPACE ENDOSCOPY – 2021 UPDATE

STER AND EFTR. WHO, WHEN AND HOW?

Chen-Shuan Chung Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan Ultrasound and Endoscopy Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan

The prevalence of gastrointestinal (GI) tract subepithelial tumors (SETs) is not well understood but definitely increasing due to widespread use of GI endoscopy. Although the majority of small GI SETs remain unchanged in size but the natural course is still inconclusive. Some of GI SETs have malignant potential, particularly for gastrointestinal stromal tumors (GISTs). Tissue acquisition of GI SETs is important for preoperative histological diagnosis of GISTs. However, the yielding rate of several techniques for tissue acquisition, such as stacked or mucosa-incision biopsy and endoscopic ultrasound-guided fine needle aspiration/biopsy, are not 100%. Therefore, en-bloc removal of the tumor by endoscopic resection could provide definite histological diagnosis and curative resection while clinically suspicious of GISTs. These advanced techniques include submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (ETFR). In this lecture, I will introduce the application of STER and EFTR for GI SETs in terms of indications and technical aspects.