ACUTE DYSPNEA CAUSED BY ACHALASIA

Background: Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural sedation of pediatric emergency department patients. However, many emergency physicians are unfamiliar with its use, and there are no widely adopted guidelines or reviews dedicated to this topic. Objective: Our aim was to provide emergency physicians with an overview of PR procedural sedation medications in pediatric patients. Methods: We performed a PubMed literature search of relevant keywords limited to studies of human subjects published in English between January 1, 1990 and December 31, 2017. We excluded case reports, general review articles, editorial/opinion pieces, correspondence, and abstracts. Two of the authors then conducted a structured review of the selected studies. Results: A total of 315 PubMed citations meeting the search criteria were found. Twenty-eight articles were included for final detailed review. Only 4 of the 28 included studies were conducted in the emergency department setting. A total of 9 different medications have been studied for PR procedural sedation. Sedation effectiveness ranged from 40% to 98%. No life-threatening complications were reported in any of the included clinical trials. Hypoxia was found to occur in up to 10% of those receiving PR sedation. Conclusions: Pediatric procedural sedation with PR medications appears to be feasible, moderately effective, and safe based on our review of the current literature. However, further studies on its applicability in the emergency department setting are needed. (C) 2018 Elsevier Inc. All rights reserved

Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia

Purpose Achalasia is a rare, but well-defined primary esophageal motor disorder. Classic therapeutic approaches include botulinum toxin injection, balloon dilation, and surgical myotomy of the lower esophageal sphincter. This report summarizes our experience with different treatment modalities for achalasia. Methods Forty-three patients with achalasia treated in our hospital were subdivided according to therapeutic strategy: endoscopic botulinum toxin injection into the lower esophageal sphincter (EBTI; n=7), endoscopic esophageal balloon dilation (EBD; n=16), surgical myotomy after failed esophageal balloon dilation (EBD-HM; n=14), and first-line surgical myotomy (HM; n=6). Therapeutic efficiency was evaluated comparing standardized symptom scores preoperatively and at follow-up. Results There was no mortality and no significant difference between the groups for age, sex, or morbidity. The mean follow-up was at 9, 35, 38, and 17 months. At follow-up, recurrent or persistent symptoms were found in 71.4%, 6.3%, 35.7%, and 16.7% in EBTI, EBD, EBD-HM, and HM, respectively. Considering EBD-HM patients as failures of esophageal dilation, the total rate of recurrent or persistent symptoms after EBD was 50%. Poor symptomatic outcome was correlated to a low esophageal sphincter pressure during pretherapeutic manometry (p=0.03) and to sigmoid-shaped esophageal dilatation (p=0.06). Conclusion Surgical myotomy is the most reliable first-line therapy for achalasia, particularly in patients with a high sphincter pressure and moderate esophageal dilatation. Botox injection has a high failure rate and should be reserved for exceptional cases. Endoscopic dilation provides about 50% of patients with long-term symptomatic relief; in most cases, failure can be successfully treated surgically

Peroral endoscopic myotomy (POEM) is effective in treatment of noncardiac chest pain caused by hypercontractile esophageal motility disorders: results of the POEM-HYPE-Study

Background Noncardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. In gastroenterology, managing of patients with NCCP is ambiguous to detect gastroesophageal reflux and hypercontractile esophageal motility disorders. Recently, peroral endoscopic myotomy (POEM) was established as treatment option in achalasia. However, limited data exist on the effectivity of POEM in NCCP with hypercontractile esophageal motility disorders. Material and methods In this prospective study (POEM-HYPE), we evaluated 14 patients with NCCP and hypercontractile esophageal motility disorders (type III achalasia, n = 7; hypercontractile esophagus, n = 6; distal esophageal spasm, n = 1). All patients underwent standardized diagnostic work-up including esophagogastroduodenoscopy with esophageal biopsies, high-resolution esophageal manometry, and combined intraluminal impedance and pH testing before and 3 weeks after POEM. A standardized symptom questionnaire was disposed before POEM, 3 weeks after, and every 6 months after the POEM. Results After POEM, 12 patients showed significant symptom relief (pre-Eckardt score: 7.78 +/- 1.47, 3 weeks post: 1.64 +/- 1.44, 6 months: 2.0 +/- 1.84 and 1.86 +/- 1.89 after 15.0 +/- 10.0 months post-intervention). High-resolution manometry showed significant reduction in integrated relaxation pressure (pre-POEM: 24.74 +/- 18.9mm Hg, post-POEM: 13.8 +/- 16.5 mm Hg) and distal contractile integral (pre-POEM: 2880 +/- 3700 mm Hg* s* cm, post-POEM: 1109 +/- 1042 mm Hg* s* cm). One lesion of the submucosal tunnel occurred as a moderate adverse event and was handled endoscopically. The long-term clinical success rate was 85.7 %. No severe gastroesophageal reflux occurred after interventions. Two patients required secondary therapy with injection of botulinum toxin in the tubular esophagus and balloon dilation. Conclusion The results suggest that POEM is an effective and safe therapeutic option for patients with NCCP and hypercontractile esophageal motility disorders

Efficacy and feasibility of OverStitch suturing of leaks in the upper gastrointestinal tract

Background Management of upper gastrointestinal leaks is challenging. A new potential treatment option for this complication is endoscopic suturing with the OverStitch system (Apollo Endosurgery, Texas, USA), which is today mainly used for endoscopic sleeve gastroplasty. The aim of this study was to analyze the efficacy and feasibility of this new treatment option in patients with leaks in the upper gastrointestinal tract. Methods We performed a retrospective, single-center study of all patients who underwent endoscopic suturing with OverStitch of leaks in the upper gastrointestinal tract. Results Endoscopic suturing was performed on 13 patients (mean age, 59.62 +/- 16.29 years; mean leak size, 22.31 +/- 22.6 mm) over a period of 8 months. Postoperative leaks were detected in 10 patients (76.9%) after foregut surgery. Interventional success was achieved in all endoscopic attempts (n = 16, 100%) with a mean closure time of 28.0 +/- 12.36 min per patient. Follow-up technical success rate for each suture was (n = 8, 50.0%). Clinical success, including repeated suture attempts was achieved in 8 of the 13 patients (61.5%). These 8 patients had not received prior treatment for the leak. No immediate or delayed serious complications occurred as a result of OverStitch. The mean follow-up was 95 +/- 91.07 days. Conclusions Endoscopic suturing with OverStitch for leaks in the upper gastrointestinal tract is feasible and effective in patients who have not received prior treatment. This minimally invasive technique seems to be a promising option especially for patients with large leaks and significant comorbidities

Patient- and procedure-related factors affecting proximal and distal detection rates for polyps and adenomas: results from 1603 screening colonoscopies

Screening colonoscopy is less effective in reducing the incidence of proximal compared to distal colorectal cancer, presumably because of missed adenomas and advanced lesions during endoscopy. Thus, effectiveness and success of colorectal cancer (CRC) screening programs depend decisively on the quality of the endoscopic procedures. A retrospective analysis of 1603 average risk screening colonoscopies to calculate and to identify determinants of separate detection rates for proximally and distally located polyps, adenomas, and advanced adenomas was performed. 56.1 % of 1603 individuals included were men, and the mean age was 60.2 +/- 10.2 years. Distal detection rates were markedly higher compared to proximal detection rates for polyps (40.9 vs. 23.8 %), adenomas (21.3 vs. 16.2 %), and advanced adenomas (4.0 vs. 2.0 %). A gradual increase in detection rates with increasing age was found for proximal and distal localization. Gender difference was also seen for polyps and adenomas, but not for advanced adenomas. In multivariate analysis, age < 65.0 years and female gender were independently associated with a lower separate polyp detection rate (PDR) and adenoma detection rate (ADR). The use of propofol was the only procedure-related variable significantly associated with higher polyp detection rate. Since age and gender affect detection rates of proximally and distally located polyps and adenomas, the requirement of a specific gender-related limit in total detection rates may be insufficient as a quality indicator for screening colonoscopies