Peroral Endoscopic Myotomy in a Patient with Achalasia Cardia with Prior Heller's Myotomy

Achalasia cardia is an esophageal myenteric plexus disorder characterized by absence of or incomplete lower esophageal sphincter relaxation and esophageal aperistalsis; Heller's myotomy is the main treatment of choice due to a lower failure rate. Recently, peroral endoscopic myotomy (POEM) has been reported as an alternative treatment for Achalasia due to persistent symptoms after Heller's myotomy. An Indian male, aged 18 years, was admitted to the hospital due to dysphagia which had started more than 3 years ago. He also complained of occasional regurgitation and retrosternal pain with Eckardt score 6. Heller's myotomy was performed 2 years ago. Barium swallow showed Achalasia cardia and upper gastrointestinal endoscopy found liquid residue and resistance at the gastroesophageal junction. Esophageal manometry is concluded as Achalasia cardia type II with a median integrated relaxation pressure (IRP) of 25.6 mm Hg. He underwent POEM; with the help of a submucosal tunnel, an extension of up to 1 cm beyond the gastroesophageal junction could be achieved with a posterior orientation of myotomy. There were no adverse events after the POEM procedure. He was treated with a soft diet for 10 days and other supportive treatments. Following POEM, barium swallow showed a significant improvement and esophageal manometry exhibited that the basal lower esophageal sphincter pressure was normal with complete relaxation on swallowing and normal median IRP. The post-procedure Eckardt score was 0. We reported an Achalasia patient who received POEM after unsuccessful Heller's myotomy and showed clinical improvement. © 2020 The Author(s). Published by S. Karger AG, Basel

Role of Interventional IBD in Management of Ulcerative Colitis(UC)-Associated Neoplasia and Post-Operative Pouch Complications in UC: A Systematic Review

Interventional inflammatory bowel disease (IIBD) is going to play a major role in complex IBD including ulcerative-colitis associated neoplasia (UCAN) and postoperative complications after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). We performed a literature search in PubMed using keywords such as “UCAN” and “endoscopic management of pouch complications,” After screening 1221 citations, finally, 91 relevant citations were identified for the systematic review. Endoscopic recognition of dysplasia should be done by high-definition white light endoscopy (HD-WLE) or dye-based/virtual chromoendoscopy (CE) especially in known dysplasia or primary sclerosing cholangitis (PSC). Endoscopically visible lesions without deep submucosal invasion can be resected endoscopically with endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or using full-thickness resection device (FTRD). Image-enhanced endoscopy (IEE) and IIBD have an emerging role in screening, diagnosis, and management of colitis-associated neoplasia in UC and can avoid colectomy. IIBD can manage a significant proportion of post-IPAA complications. Pouch strictures can be treated with endoscopic balloon dilation (EBD) or stricturotomy, whereas acute and chronic anastomotic leak or sinuses can be managed with through the scope (TTS)/over the scope clips (OTSC) and endoscopic fistulotomy/sinusotomy

Endoscopic Management of Fistulas and Abscesses in Crohn’s Disease

Fistulas and abscesses in Crohn’s disease (CD) are mechanical complications of long term disease and can indicate an aggressive disease course. Usually chronic inflammation leads to stricture which leads to high intra-luminal pressure with resultant fistula and abscess upstream to stricture. Exceptions to that may include perianal fistulizing CD which may even precede luminal CD. Hence, management of fistula and abscesses entails management of associated strictures without which these are bound to recur. These mechanical complications (stricture/fistula/abscess) usually occur after initial 4–5 years of disease. Traditionally the management of these complications include surgical therapy. However, surgical therapy can be associated with substantial morbidity specially in these patients on immunosuppressive medications and post-operative recurrence is not uncommon. Interventional radiological procedures to drain intra-abdominal/pelvic abscess can be helpful provided that there are no intervening bowel loops. Hence, there is an unmet need of relatively less invasive endoscopic therapies for treatment of CD related fistulas and abscesses. In this chapter, we shall discuss the role of endoscopic therapy in CD related fistula and abscess

Management of chronic pancreatitis: Role of endoscopic therapy

Chronic pancreatitis (CP), a disease of varied etiology can, from the endoscopists perspective present as ductal strictures, stones, ductal leaks and fluid collections, biliary strictures or duodenal narrowing. This article deals with role of ERCP in the management of CP associated strictures and calculi. ERCP has a limited role in the diagnosis CP, though we feel that it is better at identifying small ductal calculi or leaks as compared to MRCP. Major and minor papilla sphincterotomy gives relief from pain in patients with mild or moderate ductal changes. Pancreatic ductal strictures are best managed by stenting. Use of multiple plastic stents (8.5-11Fr diameter) gives relief from pain in 84% and strictures resolution in 95% on follow up of over 3 years. CP associated CBD strictures are also managed by placement of multiple stents. Covered SEMS are increasingly being used in these strictures. Surgery is often the best option for CP associated CBD strictures which recur after adequate endotherapy. ESWL is the standard of therapy for pancreatic ductal calculi which are large, as seen in the tropics and the non alcoholic form of CP. Our experience has shown complete or partial clearance with ESWL in over 90% of patients with large PD calculi. Good pain relief was seen in both on short and long term follow up. In selected patients of CP, ERCP and endotherapy should be offered as first line of treatment, as the results are comparable to surgery. Prior endotherapy also does not interfere with subsequent surgical procedures

The role of SpyGlass Direct Visualization System on Patient with Indeterminate biliary strictures: A case report

Biliary strictures diagnosis has become a challenge where benign conditions could mimic a malignant process. Recently, SpyGlass DS overcame the limitations by allowing direct visualization of the biliary tree. A 65 years old Indian patient complaints of jaundice with total and direct bilirubin of 23.3 mg/dL and 16.2 mg/dL, respectively. Liver function test, gamma-glutamyltransferase and CA 19-9 were increased. Transabdominal ultrasound and abdominal CT supported dilatation of common bile duct (CBD) with abrupt narrowing showing periductal enhancement at supra pancreatic level and stricture. Endoscopic ultrasound showed intrahepatic CBD stricture with dilated proximal CBD and sludge ball. Endoscopic retrograde cholangiopancreatography showed mid CBD stricture. Although brush cytology results suggested low grade dysplasia and no definite evidence of malignancy, cholangioscopy using SpyGlass DS found nodularity with abnormal vascularity seen in mid of CBD suggesting malignancy, confirmed with histopathology as cholangiocarcinoma. We reported additional value of SpyGlass DS for detecting cholangiocarcinoma in an indeterminate biliary stricture patient