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Clipmaster3 clip versus standard endoscopic clip. a Clipmaster3 clip. b Clipmaster3 device. c Closed mucosal incision with Clipmaster3. d Olympus clip. e Rotatable Clip Delivery device. f Closed mucosal incision with Olympus clips (© 2016 olympus europa SE & Co. UG).
Source publication
Background and aims: After Peroral Endoscopic Myotomy (POEM), the mucosal incision is closed with endoscopically applied clips. After each clip placement, a subsequent clipping device has to be introduced through the working channel. With the Clipmaster3, three consecutive clips can be placed without reloading which could reduce closure time. We pe...
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Citations
... There are two comparative studies on closure techniques, but no randomizations were performed, both had small sample sizes, and there is a suspicion of considerable bias [39,40]. Neither study found a difference between single clips vs. multi-firing clips or single clips vs. endoscopic suturing. ...
Main Recommendations
ESGE recommends the use of a graded pneumatic dilation protocol in achalasia, starting with a 30-mm dilation and followed by a 35-mm dilation at a planned interval of 2 – 4 weeks, with a subsequent 40-mm dilation when there is insufficient relief, over both a single balloon dilation procedure or the use of a larger balloon from the outset.
Strong recommendation, high quality of evidence, level of agreement 100 %.
ESGE recommends being cautious in treating spastic motility disorders other than achalasia with peroral endoscopic myotomy (POEM).
Strong recommendation, very low quality of evidence, level of agreement 87.5 %.
ESGE recommends against the routine use of botulinum toxin injections to treat patients with non-achalasia hypercontractile esophageal motility disorders (Jackhammer esophagus, distal esophageal spasm). However, if, in individual patients, endoscopic injection of botulinum toxin is chosen, ESGE recommends performing injections into four quadrants of the lower esophageal sphincter and in the lower third of the esophagus.
Strong recommendation, low quality of evidence, level of agreement 78.6 %.
ESGE recommends that endoscopic pylorus-directed therapy should be considered only in patients with symptoms suggestive of gastroparesis in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed.
Strong recommendation, very low quality of evidence, level of agreement 100 %.
ESGE recommends against the use of botulinum toxin injection in the treatment of unselected patients with gastroparesis.
Strong recommendation, high quality of evidence, level of agreement 92.9 %.
ESGE recommends consideration of gastric peroral endoscopic myotomy (G-POEM) in carefully selected patients only, because it is an emerging procedure with limited data on effectiveness, safety, and durability. G-POEM should be performed in expert centers only, preferably in the context of a clinical trial.
Strong recommendation, low quality of evidence, level of agreement 100 %.
Improvement and innovation have been ongoing in gastrointestinal (GI) endoscopy for the last few years, including highly maneuverable endoscopes, high-definition visualization, digital chromoendoscopy, and wide working channels, which allow a correct identification, catheterization, and delimitation of early neoplastic lesions. Technological innovation has also provided novel devices, both to perform treatments and prevent complications.
Background and aims:
Per-oral endoscopic myotomy (POEM) has been demonstrated to be safe and effective for treating achalasia. Two approaches-anterior myotomy and posterior myotomy-are used during POEM. However, little is known about the comparison between the two different approaches. The objective of the study is to compare the safety and short-term efficacy of the 2 approaches for treating achalasia.
Methods:
From October 2015 to December 2016, 63 consecutive patients with achalasia without prior treatment or sigmoid-type esophagus were prospectively recruited. They were randomly assigned to an anterior or posterior myotomy group. Clinical data about general characteristics, operative parameters, pre- and postoperative Eckardt score, esophageal manometry results, 24-hour pH test, and adverse events were recorded and compared between the 2 groups.
Results:
The anterior group included 31 patients, and the posterior group included 32 patients. All patients underwent POEM successfully, and treatment success (defined as an Eckardt score ≤3) was achieved in all patients during a mean follow-up of 15.5 months. Mean Eckardt score, lower esophageal sphincter pressure and 4-s integrated relaxation pressure were significantly decreased (6.2 ± 1.3, 37.5 ± 6.7 mm Hg and 27.3 ± 4.9 mm Hg vs 0.70 ± 0.70, 12.8 ± 2.8 mm Hg and 11.1 ± 2.3 mm Hg, respectively, p<0.01). There was no significant difference between the two groups in terms of general characteristics, treatment success, pre- and postoperative esophageal manometry, Eckardt score, and adverse events (P>0.05).
Conclusions:
The short-term treatment efficacy, manometry outcomes and adverse events were comparable between the anterior and posterior myotomy groups. Large-scale studies with long-term follow-up are warranted for a more definitive conclusion.
