Per-oral endoscopic myotomy for the treatment of non-achalasia esophageal dysmotility disorders: experience from a single high-volume center

BACKGROUND

Achalasia is a rare disorder of esophageal motility that induces progressive intolerance to oral intake. Other esophageal dysmotility disorders include esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypercontractile esophagus (HE), and other minor disorders of peristalsis (MDP) and can present similarly to achalasia despite different pathophysiologies. Prior studies have demonstrated the safety and efficacy of POEM in the treatment of achalasia, but little is reported regarding POEM's role in treating non-achalasia esophageal dysmotility disorders (NAEDD). This study aims to assess the safety and efficacy of POEM in the treatment of NAEDD.

STUDY DESIGN

This is a retrospective review of consecutive POEM cases from June 1, 2011, to February 1, 2021. NAEDD were characterized according to the Chicago classification. Primary outcome measure was the resolution of preoperative symptoms. Secondary outcomes include preoperative diagnosis, myotomy length, conversion to laparoscopic or open procedure, operative time, and length of stay (LOS). Technical success was defined as the completion of an 8 cm myotomy including the esophagogastric junction (EGJ) and extending 2 cm distal to the EGJ. Clinical success was defined as a postoperative Eckardt score ≤ 3.

RESULTS

Of 124 cases of POEM performed during the study period, 17 were performed for NAEDD. Technical success was achieved in all 17 patients (100%). Of the fifteen patients that had documented postoperative Eckardt scores, 13 were ≤ 3, achieving a clinical success rate of 87%. Subgroup analysis (HE/MDP/DES vs. EGJOO) showed no significant differences in the preoperative or postoperative Eckardt scores between groups, and both groups demonstrated a significant decrease in Eckardt scores after POEM. No cases were aborted for technical or clinical reasons, and there were no adverse outcomes.

CONCLUSION

POEM is a safe and efficacious treatment modality for NAEDD. Further work is needed to develop optimal treatment strategies for this complex group of diseases.

Giardia lamblia Diagnosed Incidentally by Duodenal Biopsy

Giardia lamblia (also referred to as Giardia intestinalis and Giardia duodenalis) is the most common intestinal parasite in the world, affecting approximately 200 million people annually. Symptoms of Giardia include foul-smelling diarrhea, abdominal cramping, bloating, gas, and nausea. Although usually self-limiting, Giardia can progress to dehydration, malnutrition, and failure to thrive, especially in immunocompromised individuals. Early diagnosis and treatment is imperative to prevent and control infection of Giardia. Infectious Disease Society of America diagnostic guidelines recommend obtaining stool studies to diagnose Giardia; when stool studies are negative but suspicion remains high, duodenal aspirate microscopy is the only alternative diagnostic strategy suggested. We report a patient diagnosed incidentally with Giardia from a duodenal biopsy specimen obtained during a workup for a gastrointestinal bleed. There are limited cases of Giardia diagnosed by duodenal biopsy reported in the literature. We review studies that suggest duodenal biopsy can be a very sensitive strategy for the diagnosis of Giardia.

Abrikossoff Tumor (Granular Cell Tumor) Presenting in the Esophagus

Abrikossoff tumors, also known as granular cell tumors, are rare and often benign soft tissue neoplasms of Schwann cell origin. The vast majority of cases are reported in the skin and subcutaneous tissue. Only 0.001% of Abrikossoff tumors are estimated to occur in the esophagus. We report a rare case of Abrikossoff tumor of the esophagus in a patient who underwent esophagogastroduodenoscopy for abdominal pain and nausea.

Efficacy of cryotherapy as first line therapy in patients with Barrett's neoplasia: a systematic review and pooled analysis

Cryotherapy has been used as salvage therapy; however, its efficacy as first line treatment in patients with Barrett's esophagus (BE) neoplasia has not been well studied. The aim of this paper was to perform a systematic review to look at the efficacy of cryotherapy as the primary treatment of BE. An electronic database search was performed (PubMed, Embase, Cochrane, and Google Scholar) to search for studies with cryotherapy as the initial primary modality of ablation in patients with BE neoplasia. Studies that included patients with other prior forms of therapy were excluded. The primary outcomes were the pooled rates of complete eradication of intestinal metaplasia (CE-IM) and CE of neoplasia (CE-N). Secondary outcomes were recurrence rates of neoplasia and intestinal metaplasia (IM) and adverse events. The statistical software OpenMetaAnalyst was used for analysis with pooled estimates reported as proportions (%) with 95% confidence intervals (CI) with heterogeneity (I2) among studies. The search revealed 6 eligible studies with a total of 282 patients (91.5% male, average age 65.3 years) with 459 person years of follow-up. 69.35% [95% CI (52.1%-86.5%)] of patients achieved CE-IM and 97.9% (95% CI: 95.5%-100%) had CE-N. 7.3% of patients had persistent dysplasia with 4% progressing to cancer. The recurrence rate of neoplasia was 10.4 and that of IM was 19.1 per 100 patient years of follow-up. The overall rate of stricture formation was 4.9%. There are scarce data on the use of cryotherapy as the primary modality for the treatment of BE dysplasia. The published data demonstrate efficacy rates of 69% and 98% for complete eradication of metaplasia and neoplasia, respectively. These results need to be assessed in prospective, comparative trials with other forms of therapy.

Sensory characterization of bowel cleansing solutions

AIM: To evaluate the sensory characteristics of commercial bowel cleansing preparations.

METHODS: Samples of 4 commercially available bowel cleansing preparations, namely polyethylene glycol electrolyte solution (PEG), PEG + ascorbic acid (PEG-Asc), sodium picosulfate (SPS), and oral sodium sulfate (OSS) were prepared according to the manufacturer’s instructions. Descriptive analysis was conducted (n = 14) using a 15-cm line scale with the Compusense at-hand^® sensory evaluation software. Acceptability testing (n = 80) was conducted using the 9-point hedonic scale. In addition, a Just-About-Right (JAR) scale was included for the four basic tastes to determine their intensity compatibility with acceptability levels in the products.

RESULTS: Samples were significantly different, in descriptive analysis, for all attributes (P < 0.05) except for sweetness. SPS received the highest ratings for turbidity, viscosity appearance, orange odor and orange flavor; PEG-Asc for citrus odor and citrus flavor; OSS for sweetener taste, sweet aftertaste, bitterness, astringency, mouthcoating, bitter aftertaste and throatburn, and along with PEG-Asc, the highest ratings for saltiness, sourness and adhesiveness. Acceptability results showed significant differences between the various samples (P < 0.05). SPS received significantly higher ratings for overall acceptability, acceptability of taste, odor and mouthfeel (P < 0.05). JAR ratings showed that PEG and PEG-Asc were perceived as slightly too salty; SPS and OSS were slightly too sweet, while SPS, PEG-Asc and OSS were slightly too sour and OSS slightly too bitter. While using small sample volumes was necessary to avoid unwanted purgative effects, acceptability ratings do not reflect the true effect of large volumes intake thus limiting the generalization of the results.

CONCLUSION: Further improvements are needed to enhance the sensory profile and to optimize the acceptability for better compliance with these bowel cleansing solutions.