Efficacy and safety of per-oral endoscopic myotomy for the treatment of achalasia cardia in Malaysia: a single centre study

INTRODUCTION: Peroral Endoscopic Myotomy (POEM), introduced in 2010, has become a widely accepted treatment for achalasia cardia. However, POEM procedure is technically challenging and recommended to be performed by experienced endoscopists. Our objective was to assess the efficacy and safety of POEM procedures performed in a tertiary referral centre. METHODOLOGY: This is a retrospective single-centre study. All consecutive achalasia patients that underwent POEM procedure (posterior approach) from November 2015 to June 2022 were recruited. Demographic data, achalasia type, technical success, procedure duration, myotomy length, duration of hospital stay, clinical success and adverse events were recorded. Technical success was defined as completion of POEM procedure from mucosa incision, to tunnel creation followed by myotomy and finally, mucosal closure. Clinical success was defined as a post-procedure Eckardt score ≤3, or a reduction of 4 or more points at 2 months or more after a successful procedure. All POEM procedures were performed by 3 endoscopists (2 gastroenterologists and 1 surgeon) who have had experience in ESD or Heller’s myotomy. RESULT: A total of 86 patients were recruited. The detailed results are summarised in Table 1. CONCLUSION: The high efficacy (with good intermediate to long-term outcome follow up) and good safety profile of the POEM procedure for achalasia cardia in our centre are comparable with the published literature. Adverse events were generally mild, and all were managed conservatively. The improvement seen in the technical success rate after the first 20 cases is in line with mastering the POEM skill after the initial learning experience

When is poem truly equivalent to LHM? A comparison of complication rates during the learning curve

INTRODUCTION: Per-Oral Endoscopic Myotomy (POEM) has been shown to be an effective treatment for Achalasia, but the endoscopic technique required is complex and not routinely performed. We believe that, for any new procedure, competency can be demonstrated when the complication rate of a new procedure (POEM) equals that of an established one, ie Laparoscopic Heller’s Myotomy + Fundoplication (LHM+F). METHODS: A multicentre, retrospective cohort, comparing complication rates during the learning curve of POEM to a historical cohort of LHM+F, was conducted. A direct head-to-head comparison was performed, followed by a population pyramid of complication frequency. Case sequence was then divided into blocks of 5, and the complication rates during each block was compared to the historical cohort. RESULTS: A total of 123 cases ( LHM+F n=60, POEM n=63) were analysed. Mean age was lower for the POEM group (41.7 years vs 48.1 years, p = 0.03), but there was no difference in gender nor type of Achalasia. The POEM group recorded a shorter overall procedural time (125.9 minutes vs 144.1 minutes, p = 0.023) and longer myotomies (10.1cm vs 6.2cm, p = 0.023). Complication rates were higher in the POEM group (20.6% vs 10.0%, p=0.10), but was not statistical significant. Complication frequency tapered off dramatically after the 25th case in the sequence, and subsequently equalled that of LHM+F. Length of stay was shorter for the POEM group (3.4 days vs 4.8 days, p = 0.014). The post-procedural findings favoured LHM+F, with the post-procedural Eckardt scores significantly lower (0.4 vs 1.6, p < 0.001) and the usage of PPIs lower in this group (20.7% vs 39.4%, p = 0.03). CONCLUSION: POEM is challenging even for experienced endoscopists. From our data, complication rates between POEM and LHM+F equalize after approximately 25 POEMs

A Giant Gastric Bezoar in Billroth II Stomach: A Case Report on Successful Endoscopic Removal via Repeated Fragmentation and Dissolution Technique Negating the Need for Surgical Intervention

A 76-year-old gentleman presented with anemia. He had a history of perforated duodenal ulcer six years ago, with Billroth II repair performed. A large gastric bezoar (8×6 cm2) with a clean base ulcer at the anastomotic junction was found during the initial oesophago- gastro-duodenoscopy (OGDS). Rapid urease test was negative. He presented with melena during the subsequent follow up (OGDS showed a Forrest Ib prepylori ulcer). We have successfully removed the gastric bezoar with dissolution therapy initially (injection of cokecola into the bezoar, followed by drinking 325 mL Coca-ColaTM twice daily), followed by four attempts of OGDS with endoscopic fragmentation. Histopathology reported as degenerated vegetable matter, acellular debris mixed with scattered fungal and bacterial colonies, which was compatible with bezoar. Follow-up OGDS showed complete clearance of the bezoar. Coca-ColaTM ingestion should be considered as initial treatment as it is non-invasive, and it enables further successful endoscopic fragmentation

Resistance towards metronidazole in Blastocystis sp.: A pathogenic consequence

Blastocsytis sp. is a protozoan parasite that has been linked to common gastrointestinal illnesses. Metronidazole, the first line therapy, was reported to show frequent inefficacy. Previously, Blastocystis sp. isolated from different population showed varying metronidazole resistance. However, the effect of metronidazole treatment on pathogenic potentials of Blastocystis sp. isolated from different populations, which is known to have different gut environment, is unclear. This study investigates the in vitro effect of metronidazole on the pathogenic potentials of Blastocystis sp. isolated from urban and orang asli individuals. Blastocystis sp. ST 3 isolated from symptomatic and asymptomatic individuals were treated with a range of metronidazole concentration. The parasites’ growth characteristics, apoptotic rate, specific protease activity and the ability to proliferate cancer cells were analyzed upon treatment with 0.001 mg/l metronidazole. The study demonstrates that Blastocystis sp. isolates showed increase in the parasite numbers especially the amoebic forms (only in urban isolates) after treating with metronidazole at the concentration of 0.001 mg/ml. High number of cells in post-treated isolates coincided with increase of apoptosis. There was a significant increase in cysteine protease of Blastocystis sp. isolates upon treatment despite the initial predominance of serine protease in asymptomatic isolates. Metronidazole resistant Blastocystis sp. also showed significant increase in cancer cell proliferation. Resistance to metronidazole did not show significant different influence on the pathogenicity between Blastocystis sp. isolated from urban and orang asli individual. However, an increase in parasite numbers, higher amoebic forms, cysteine protease and ability to proliferate cancer cells implicates a pathogenic role. The study provides evidence for the first time, the effect of metronidazole towards enhancing pathogenic potentials in Blastocystis sp. when isolated from different gut environment. This necessitates the need for reassessment of metronidazole treatment modalities. © 2019 Rajamanikam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Distinct Phenotypic Variation of Blastocystis sp. ST3 from Urban and Orang Asli Population&mdash;An Influential Consideration during Sample Collection in Surveys

Blastocystis sp. is a globally distributed protozoan parasite with uncertain pathogenicity. Phenotypic variation in Blastocystis sp. suggests its adaptation; however, the phenotypic features of Blastocystis sp. ST3 from a distinct source of isolation is unknown. Blastocystis sp. isolated from individuals in urban and orang asli (indigenous population in Selangor, Malaysia) settlements were studied for phenotypic characteristics such as growth profile, morphology, ultrastructure, and resistance to harsh conditions. Subsequently, pathogenic potentials, such as in protease activity and the ability to stimulate the proliferation of cancer cells, were assessed. Higher parasite counts with granular and apoptotic forms were found in Blastocystis sp. from orang asli individuals. Cells with fuzzy coats and amoebic structures which seemingly implicate increased interaction with bacteria were seen predominantly in urban symptomatic persons. Also, Blastocystis sp. from orang asli isolates resisted harsh environments, suggesting longer co-adaptation to the hosts. Urban and orang asli symptomatic isolates possessed a predominance of only cysteine protease, whereas all the asymptomatic isolates showed significantly higher cysteine, serine, or aspartic protease activity. However, only solubilized antigen from urban symptomatic isolates showed significant stimulation of cancer cell proliferation. For the first time, our findings demonstrate significant phenotypic variation in a single subtype, ST3 of Blastocystis sp., isolated from urban and orang asli populations that are known to have distinct gut microbial compositions. The outcome emphasizes the importance of identifying people&rsquo;s locations and lifestyles during sample collection before forming conclusions on the prevailing data and implicating subtypes to pathogenicity. The environment plays a significant role in Blastocystis sp. infection

Efficacy and safety of per-oral endoscopic myotomy for the treatment of Achalasia Cardia in Malaysia: a single centre study

Background and Aim: Peroral Endoscopic Myotomy (POEM), introduced in 2010, has become a widely accepted treatment for achalasia cardia. How- ever, POEM procedure is technically challenging and recommended to be performed by experienced endoscopists. Our objective was to assess the ef- ficacy and safety of POEM procedures performed in a tertiary referral cen- tre. Methods: This is a retrospective single-centre study. All consecutive achalasia patients that underwent POEM procedure (posterior approach) from November 2015 to May 2021 were recruited. Demographic data, acha- lasia type, technical success, procedure duration, myotomy length, duration of hospital stay, clinical success and adverse events were recorded. Techni- cal success was defined as completion of POEM procedure from mucosa in- cision, to tunnel creation followed by myotomy and finally, mucosal closure. Clinical success was defined as a post-procedure Eckardt score ≤3, or a reduction of 4 or more points at 2 months or more after a successful procedure. All POEM procedures were performed by 3 endoscopists (2 gas- troenterologists and 1 surgeon) who have had experience in ESD or Heller’s myotomy. Results: A total of 65 patients were recruited. The detailed results are summarised in Table 1. Conclusion: The high efficacy (with good inter- mediate to long-term outcome follow up) and good safety profile of the POEM procedure for achalasia cardia in our centre are comparable with the published literature. Adverse events were generally mild, and all were managed conservatively. The improvement seen in the technical success rate after the first 20 cases is in line with mastering the POEM skill after the initial learning experience

Novel Use of a Self-Expandable Metal Stent with an Anti-Migration System for Palliative Drainage of a Pancreatic Cystic Neoplasm

Context There is scanty data on endoscopic palliative management of pancreatic cystic lesions that cause gastric outlet obstruction (GOO). This is the first case report that illustrates the use of a covered self-expandable metal stent (CSEMS) with an anti-migration system in the management of a symptomatic neoplastic cystic pancreatic lesion. Case report A 92-year-old Chinese female presented with partial GOO for 3 months. Examination revealed a non-tender epigastric mass with moderate abdominal distension. Esophagogastroduodenoscopy (EGD) showed a significant bulge at the posterior wall of the gastric antrum and food residue in the stomach. A CT scan of the abdomen showed a large pancreatic tail cystic lesion. Endoscopic ultrasound (EUS) showed a clear, non-septated cystic lesion measuring 9.7x10 cm arising from the pancreatic tail. Analysis of the aspirate revealed the following: Amylase: 3,200 units/L, CEA: 411 ng/mL, CA 19-9 812 U/mL and no malignancy. A Niti-STM Biliary Stent (NAGITM) was used for a cystogastrostomy. This procedure was complicated by a self-limiting intra-abdominal leak, stent migration and bleeding from a splenic artery pseudoaneurysm which was arrested with coil embolization. She progressed well after that with significant symptom improvement and no further complications. Conclusion This is the first case of a CSEMS with an anti-migration system that was used for decompression of a pancreatic cystic neoplasm (PCN). Novel use of this stent is a viable option as palliative management of a PCN in those not fit for surgery but caution needs to be exercised as there can be significant complications.Image: CT abdomen showing stent in-situ