Ten Initial Cases of Peroral Endoscopic Myotomy for Treatment of Esophageal Motility Disorders at Okayama University Hospital

Peroral endoscopic myotomy (POEM) for treatment of esophageal motility disorders has recently been reported to be highly effective and less invasive than other treatment. POEM was recently introduced in Okayama University Hospital under the supervision of a physician from a high-volume center. To verify the safety and efficacy of POEM during its introduction in our institution. We examined 10 cases in whom POEM was performed between January 2016 and April 2017. The patients included 7 men and 3 women, with a median age (range) of 49 years (17-74) and median symptom duration of 6 years (1-21). Seven patients had a straight esophagus, and the remaining 3 had a sigmoid esophagus. According to the Chicago classification, 6 patients were diagnosed with type I achalasia, 2 with type II achalasia, and 2 with distal esophagus spasm. Treatment outcomes and adverse events were evaluated. Treatment success was defined as a > 3 decrease in Eckardt score or a score of <3 at the time of discharge. The treatment success rate was 90%, with the average Eckardt score decreasing significantly, from 4.7 to 0.9 (p<0.05). No mucosal perforation, severe infection, mediastinitis, severe bleeding, or gastroesophageal reflux occurred intraoperatively or postoperatively. POEM was introduced to Okayama University Hospital, and the first 10 cases were accomplished safely and effectively under the supervision of an expert physician from a high-volume center

Comparison of Two Electrosurgical Modes for Endoscopic Submucosal Dissection of Superficial Colorectal Neoplasms: A Prospective Randomized Study

Endoscopic submucosal dissection (ESD) is reportedly one of the standard treatment strategies for large superficial colorectal neoplasms in Japan because of its high en bloc resection rate. A few technical issues regarding ESD should be considered, one of which is the selection of the Endo-cut I mode versus the Swift-coagulation mode as the electrosurgical unit mode setting during submucosal dissection. We seek to determine which of these two modes is more suitable for submucosal dissections of colorectal tumors with regard to procedure time and safety

Endscopic Submucosal Dissection of a Heterotopic Gastric Mucosa in the Stomach: Report of a Case

A 38-year-old man with a submucosal tumor (SMT) at the anterior wall of the pylorus underwent upper gastrointestinal endoscopy. The tumor was 40 mm in diameter with a long stalk extending into the duodenal bulb. In addition, the long stalk had an ulcer with a blood vessel. Removal of this tumor was initially considered to be possible only by distal gastrectomy. However, endoscopic ultrasound (EUS) was subsequently proven to be a reliable investigative procedure for evaluating the lesion. The tumor was characterized by its origin in the second layer, and endoscopic submucosal dissection (ESD) was performed. En bloc resection of a 32 × 20 × 40 mm area of tissue with tumor-free lateral/vertical margins was accomplished without complication. Histopathological examination confirmed a heterotopic gastric mucosa. By immunostaining, the neoplasm was positive for MUC6 and negative for amylase and trypsin. In this case, EUS was used to investigate a heterotopic gastric mucosa that originated in the second layer, with no infiltration of the fourth layer under the tumor. Therefore, we performed successful ESD at the appropriate layer

Observer agreement for the diagnosis of intestinal acute graft‑vs.‑host disease based on the presence of villous atrophy in the terminal ileum

Intestinal graft‑vs.‑host disease (GVHD) is a serious complication of allo‑hematopoietic stem cell transplantation (allo‑HSCT). Villous atrophy in the terminal ileum is considered a useful diagnostic indicator for GVHD. However, the inter‑ and intra‑observer agreement regarding the ileocolonoscopic findings indicative of acute intestinal GVHD, i.e., villous atrophy in the terminal ileum, are currently insufficient in multiple institutions. Thus, the present study aimed to investigate the incidence of villous atrophy in the terminal ileum to diagnose acute intestinal GVHD and determine the inter‑ and intra‑observer agreement regarding this result for experienced endoscopists from multiple institutions. Consecutive patients who underwent allo‑HSCT were referred to our institution between May 2008 and September 2015. A total of 54 patients underwent total ileocolonoscopy after allo‑HSCT due to suspected intestinal acute GVHD. Subsequently, three observers from different institutions evaluated the cases for the presence of villous atrophy in the terminal ileum. In this study, the pathology results were a gold standard to evaluate the predictive value of ileocolonoscopy detection. Definitive pathological and non‑pathological GVHD was diagnosed in 22 and 32 cases, respectively. The results of examining whether villous atrophy could predict GVHD were as follows. For three observers (A, B and C), the sensitivity of villous atrophy in the terminal ileum was 86.4, 77.3 and 79.2%, respectively, whereas the specificity was 62.5, 62.5 and 86.7%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) of villous atrophy for GVHD were as follows: The PPV of appearance was 61.3, 58.6 and 82.6%, respectively, whereas the NPV was 87.0, 80.0 and 83.9%, respectively. Kappa coefficients for the inter‑observer reliability were 0.85, 0.63 and 0.63 for observers A and B, A and C, and B and C, respectively. The intra‑observer kappa coefficient was 0.88 for observer A, 0.73 for observer B and 0.75 for observer C. A substantial observer agreement was achieved for the analysis of villous atrophy in the terminal ileum and the agreement for the predictive histological diagnosis was also excellent. Based on the results of the present study, identification of villous atrophy in the terminal ileum was a clinically effective diagnostic parameter, even if different endoscopists were involved in the diagnosis at multiple institutions. The present study was registered as a trial with the University Hospital Medical Information Network (UMIN; registration no. UMIN000025390)

A Case of Diffuse Esophageal Spasm Treated with Peroral Endoscopic Myotomy

The indications for peroral endoscopic myotomy (POEM) have been expanded to include diffuse esophageal spasm (DES). A 67-year-old Japanese man presented with a 4-year history of dysphagia. Endoscopy and upper gastrography revealed abnormal peristaltic movements involving interruption of normal peristalsis, and a diverticulum located at the 2 o’clock esophageal position. High-resolution manometry indicated DES. POEM with a long (15 cm) myotomy was performed for the abnormal contractions, which subsequently disappeared along with dysphagia improvement. Our results suggest that esophageal motility disorders accompanying a diverticulum may be eliminated by POEM without treating the diverticulum itself. We speculate that POEM ameliorates esophageal diverticulum by reducing internal esophageal pressure

Successful antihypertensive treatment using sacubitril/valsartan alone in a patient with obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (O-SAS) induces excessive activity of the sympathetic nervous system, resulting in secondary hypertension. Although continuous positive airway pressure (CPAP) is the first-line therapy for O-SAS, poor adherence to CPAP induces uncontrollable resistant hypertension. We present a case of O-SAS-related hypertension successfully treated with sacubitril/valsartan alone. Polysomnography before treatment showed a markedly increased apnoea-hypopnoea index (44.8/hour). While receiving treatment with CPAP and azilsartan, his in-office blood pressure remained within the acceptable range (120–130/80–85 mmHg). However, his blood pressure increased again after quitting CPAP. Subsequently, we switched to sacubitril/valsartan alone and succeeded in improving his blood pressure from 145/95 to 120/80 mmHg. Furthermore, sacubitril/valsartan improved sleep quality in terms of blood pressure (from non-dipper type to dipper type) and apnoea-hypopnoea index (38.3/hour). This case indicates that sacubitril/valsartan has great potential for antihypertensive effects in patients with severe O-SAS, even without CPAP. Resumen: El síndrome de apnea obstructiva del sueño (SAOS) induce actividad excesiva del sistema nervioso simpático, ocasionando hipertensión secundaria. Aunque la presión positiva continua en vía respiratoria (CPAP) es el tratamiento inicial para SAOS, mala adherencia a CPAP provoca hipertensión resistente incontrolable. Presentamos un caso de hipertensión relacionada con SAOS tratada exitosamente solo con sacubitril/valsartán. La polisomnografía pre-tratamiento mostró un índice de apnea-hipopnea notablemente aumentado (44,8/hora). Tratando con CPAP y azilsartán, su presión arterial en consultorio permaneció en rango aceptable (120-130/80-85 mmHg). Pero, su presión arterial volvió a aumentar tras dejar la CPAP. Posteriormente, cambiamos a solo sacubitril/valsartán, consiguiendo mejorar su presión arterial (de 145/95 a 120/80 mmHg). Además, sacubitril/valsartán mejoró la calidad de sueño durante el sueño en términos de presión arterial (tipo no dipper a tipo dipper) y del índice de apnea-hipopnea (38,3/hora). Este caso demuestra que sacubitril/valsartán tiene un gran potencial de efectos antihipertensivos en pacientes con SAOS grave, incluso sin CPAP