Over-the-scope clip and self-expandable metal stent: a comprehensive treatment for failed peroral endoscopic myotomy and fibrosis complications in idiopathic achalasia

Achalasia is a rare esophageal motility disorder that affects both sexes and all ages. Peroral endoscopic myotomy (POEM) has been reported as an optional treatment since 2010 [1]. Frequently associated adverse events include pneumoperitoneum, pneumomediastinum, and pneumothorax, which are usually asymptomatic and managed conservatively [2, 3]. Perforation, bleeding, mediastinitis, and peritonitis rarely occur and are often symptomatic. Mucosal injuries (including dehiscence, ulcer, and ischemia) do not alter the post-procedural course [4]. A 31-year-old man, affected by idiopathic achalasia, was admitted as an outpatient to our Gastroenterological Unit owing to symptom recurrence and weight loss (Eckardt score 8). Two years before, he had undergone POEM, which was complicated by pneumomediastinum and ischemic damage of the distal esophagus with residual fibrosis. An esophagogram revealed a dilated esophagus (maximum diameter 60mm) and supracardial stricture extending 15 mm above. His dysphagia was most likely worsened by post-POEM complications. We planned to place a fully covered removable metal stent (SEMS; 60 × 27mm) to achieve progressive, effective dilation of the distal esophagus . The SEMS would be firmly fixed by means of an over-the-scope (OTS) clip. This novel OTS clip device has demonstrated success in reducing SEMS migration even in benign diseases [5]. The SEMS was released 10mm above the post-POEM stricture, 25 mm above the cardia, and fixed by means of the OTS clip. The patient was discharged uneventfully on the same day. An alternative approach (Heller myotomy) was ready to be employed in case of failure. At the 4-week follow-up, dysphagia had improved and the patient had gained weight. Both the OTS clip and the SEMS were removed using the remOVE device (Ovesco Endoscopy AG, Tübingen, Germany) . The patient was discharged uneventfully 12 hours later. After a further 4 weeks, an esophagogram revealed a significant reduction in the esophagus dilation and the patient’s clinical condition had significantly improved (Eckardt score 0)

Distribution of cardiovascular disease and retinopathy in patients with type 2 diabetes according to different classification systems for chronic kidney disease: a cross-sectional analysis of the renal insufficiency and cardiovascular events (RIACE) Italian multicenter study.

Background: The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF's KDOQI) staging system for chronic kidney disease (CKD) is based primarily on estimated GFR (eGFR). This study aimed at assessing whether reclassification of subjects with type 2 diabetes using two recent classifications based on both eGFR and albuminuria, the Alberta Kidney Disease Network (AKDN) and the Kidney Disease: Improving Global Outcomes (KDIGO), provides a better definition of burden from cardiovascular disease (CVD) and diabetic retinopathy (DR) than the NKF's KDOQI classification. Methods: This is a cross-sectional analysis of patients with type 2 diabetes (n = 15,773) from the Renal Insufficiency And Cardiovascular Events Italian Multicenter Study, consecutively visiting 19 Diabetes Clinics throughout Italy in years 2007-2008. Exclusion criteria were dialysis or renal transplantation. CKD was defined based on eGFR, as calculated from serum creatinine by the simplified Modification of Diet in Renal Disease Study equation, and albuminuria, as measured by immunonephelometry or immunoturbidimetry. DR was assessed by dilated fundoscopy. Prevalent CVD, total and by vascular bed, was assessed from medical history by recording previous documented major acute events. Results: Though prevalence of complications increased with increasing CKD severity with all three classifications, it differed significantly between NKF's KDOQI stages and AKDN or KDIGO risk categories. The AKDN and KDIGO systems resulted in appropriate reclassification of uncomplicated patients in the lowest risk categories and a more graded independent association with CVD and DR than the NKF's KDOQI classification. However, CVD, but not DR prevalence was higher in the lowest risk categories of the new classifications than in the lowest stages of the NKF's KDOQI, due to the inclusion of subjects with reduced eGFR without albuminuria. CVD prevalence differed also among eGFR and albuminuria categories grouped into AKDN and KDIGO risk category 1 and moderate, respectively, and to a lesser extent into higher risk categories. Conclusions: Though the new systems perform better than the NKF's KDOQI in grading complications and identifying diabetic subjects without complications, they might underestimate CVD burden in patients assigned to lower risk categories and should be tested in large prospective studies