Techniques and Innovations in Gastrointestinal Endoscopy最新文献

The aim of this review is to provide an overview of peroral endoscopic myotomy (POEM) and its utilization in major motor disorders of the esophagus. POEM, a relatively novel endoscopic technique, involves a mucosal incision followed by submucosal tunneling to access esophageal muscle layers, enabling selective myotomy and mitigating the consequences of motor disorders of the esophagus. A number of recent studies have demonstrated noninferiority in shorter myotomy lengths in nonspastic (type I and II) achalasia as compared with standard-length myotomy, which has ramifications for procedural length, reflux disease, and more. Long-term data on POEM as a treatment modality for achalasia have demonstrated its robustness in providing a durable and sustainable treatment response. Challenges of POEM include the learning curve associated with mastering this technique, as well as the management of possible procedural complications including ineffective myotomy, blown-out myotomy, and/or gastroesophageal reflux disease. In conclusion, POEM has been demonstrated to be an effective and durable treatment option for achalasia and has an increasing role in other motility disorders of the esophagus.

Peroral endoscopic myotomy (POEM) is increasingly employed as therapy for sphincteric abnormalities of the gastrointestinal tract, including achalasia, gastroparesis, Zenker's diverticulum, and other esophageal dysmotility syndromes. The capabilities of functional lumen imaging probe (FLIP) testing include measurement of sphincteric distensibility, diameter, cross-sectional area (CSA), and pressure in these disorders before and after POEM. FLIP can also characterize phasic contractility in non-sphincteric regions, including the esophageal body and pre-pyloric gastric antrum. Increases in distensibility and CSA after POEM are associated with reductions in symptoms and improvements in gut transit, including esophageal barium clearance in achalasia and gastric emptying in gastroparesis. Several studies have identified FLIP metrics that are associated with successful POEM outcomes in these 2 conditions. Intraprocedural FLIP can determine the adequacy of the initial myotomy and suggest the need for additional incision before mucosotomy closure. However, the definition of pre-myotomy FLIP parameters that can be used for reliable patient selection for subsequent POEM remains incomplete. Future investigations to establish normal sphincter parameters in healthy controls, standardize FLIP methods across sites, and adopt the technology in multicenter trials are warranted.

In this narrative review, we provide an overview of the current reach of colorectal cancer (CRC) screening in the US population; how persistent inequities in CRC across age and sociodemographic groups and changes in epidemiology, as well as population structure, have increased the urgency of achieving optimal reach; and current and future strategies for optimizing the reach and impact of screening across the population. CRC screening saves lives, but reach across the population, including across age and sociodemographic groups, is highly variable. CRC screening participation in the United States remains at under 60% and has been stagnant over time. Lower screening participation is observed for individuals of younger age; of American Indian/Alaska Native, Asian, and Hispanic backgrounds; with Medicaid insurance; and with recent immigration. Addressing suboptimal reach is increasingly important due to changing CRC epidemiology and US population structure. Recent trends demonstrate increases in early (<50 years) and middle age (50-60 years) onset of CRC and nonlocalized-stage CRC, as well as persistent inequities in CRC outcomes among multiple racial/ethnic groups. These trends exist in a context where the US population is increasingly composed of individuals from diverse backgrounds associated with lower screening rates and higher rates of adverse CRC outcomes. Screening reach can be optimized by building on successes of previous impactful policies, implementing evidence-based interventions for screening, and developing novel strategies that address challenges at patient, clinician, healthcare system, and policy levels. Gastroenterologists, other clinicians, and public health advocates have a major role in leading positive change at each of these levels. Overall, the need to optimize the reach of CRC screening represents a pressing opportunity for improving health equity across all populations in the United States.

Background and Aims

Esophagogastroduodenoscopy (EGD) is routinely performed in patients who undergo conversion from adjustable gastric banding to another bariatric procedure (eg, gastric bypass) of band removal. Band erosion is the main concern in these patients. The objective of this study was to analyze the yield of EGD in these patients.

Methods

All patients between 2008 and 2020 who underwent bariatric surgery with an adjustable gastric band in place were included. Results of EGD were analyzed retrospectively and categorized according to clinical consequences.

Results

Overall, 514 patients (62 male, 452 female; mean age 46 years; mean BMI 40) underwent surgery with an adjustable gastric band in situ. In total, 488 patients (95%) underwent preoperative EGD. No abnormalities were found in 205 patients (42%), 112 patients (23%) had abnormalities without treatment consequences, 156 patients (32%) had findings that required pharmaceutical (ie, proton pump inhibitors and/or antibiotics) intervention, and 15 patients (3.1%) had severe findings altering management (group D). In 5 of these patients (1.0%), surgery was postponed due to Barrett's esophagus, and 10 of these patients (2.0%) had gastric band erosion. No subgroup of patients could be identified to increase the yield of the EGD.

Conclusion

Routine preoperative assessment by EGD in patients before bariatric surgery with an adjustable gastric band in situ still detects some severe abnormalities significantly altering management.