Recent advances in diagnostic tools and procedures have invigorated the field of gastroenterology.
POEM is a novel and minimally invasive way to treat achalasia.
Candy cane syndrome is now being treated endoscopically.
When it comes to any type of technology advancement, AI and deep learning are on the tips of every tongue. The same is true in the field of gastroenterology, with these technologies improving diagnosis, documentation, and more. However, AI is not the only advancement to pay heed.
Here are three notable technologies changing the way we treat GI disease.
POEM for achalasia
Peroral endoscopic myotomy (POEM) is a minimally invasive intervention that treats achalasia, noted by authors writing in Journal of Thoracic Disease. It is the endoscopic equivalent of Heller myotomy. This procedure is an iteration of natural orifice transluminal endoscopic surgery that is completed by opening a submucosal tunnel at the level of the lower esophagus to reach the inner circular muscle bundles of the lower esophageal sphincter (LES) to perform myotomy. POEM preserves outer longitudinal muscle bundles.
The result of POEM is lower resting pressure of the LES, thus facilitating the passage of foods and liquids. "POEM was initially introduced to treat achalasia by targeting the LES," the Journal of Thoracic Disease authors note, "[and] has expanded to include gastric POEM (G-POEM), myotomy of the pyloric sphincter to treat gastroparesis, and per rectal endoscopic myotomy to treat adult Hirschsprung’s disease."
The complexity of POEM means serious complications can arise if a surgeon lacks the necessary skills, and it is generally only performed in highly specialized hospitals and clinics.
They recommend that endoscopists should be familiar with recognizing structures beyond mucosa, including vasculature nerves and the anatomy of the mediastinum. “Initially the endoscopist should observe the procedure performed by experienced operators, [and] familiarize themselves with all equipment needed for the intervention including the tools to control possible adverse events,” they explained. Finally, the endoscopist should perform POEM on animal models before transitioning to human patients.
Results of a recent meta-analysis found that the success rate among a pool of 2,373 patients was achieved in 98% of patients (ie, Eckardt score ≤ 3). Following the procedure, there were decreases in the mean lower esophageal sphincter pressure, integrated relaxation pressure, and the mean heights of the barium column after a timed barium esophagogram post-procedure. At 8 months, the rates of symptomatic gastroesophageal reflux were 8.5%; rates of esophagitis on esophagogastroduodenoscopy were 13%; and abnormal acid exposure, 47 %.
“POEM appears to be safe and effective based on the large body of current evidence, and warrants consideration as first-line therapy when an expert operator is available,” the authors of the meta-analysis concluded.
Crohn’s disease (CD) is characterized by transmural involvement. The introduction of biologics have moved the goalposts of CD treatment to mucosal healing (MH).
Researchers compared simple endoscopic scores for CD (SES-CD) and simplified magnetic resonance index of activity (MARIAs) in matched segments of the ileum based on balloon-assisted enteroscopy (BAE) and magnetic resonance enterography (MRE) in a study of 50 patients with small bowel CD, publishing their results in the journal Gut and Liver.
”There are arguments that TH [transmural healing] should be considered a therapeutic goal, going one step further. However, TH is not well defined due to inconsistent definitions in each study using CSI [cross-sectional imaging] or sonography. TH was defined as without any suspicious findings of active inflammation radiologically. However, this could not be called TH in the true sense because whether MH was achieved was unknown,” the study authors wrote.
“Furthermore, there was a limitation in that MH was assessed by ileocolonoscopy. For example, in patients with small bowel CD, it is desirable to define TH when MH is verified on BAE and when transmural inflammation is improved on CSI. Therefore, the best way to find concordance or discrepancy between MH and TH is to compare BAE and magnetic resonance enterography (MRE) findings in small bowel CD patients segment-by-segment,” they added.
MRE is an objective diagnostic tool used to analyze transmural inflammation. MARIA was developed in 2009 and is an oft-used MRE index to assess disease activity.
MARIA, however, has limitations including the measurement of relative contrast enhancement, which is complex and time consuming. There are also issues of subjectivity with the interpretation of ulcer, thus impacting reproducibility. In light of these limitations, MARIAs was developed to be calculated without contrast enhancement.
It should be noted that the researchers validated the applicability of MARIAs vs BAE-based ileal SES-CDa/SES-CD.
Candy cane procedure
Candy cane syndrome (CCS) occurs post-gastrectomy or gastric bypass and is an underrecognized pathology. It refers to a particular type of blind pouch syndrome, first described in 2007. It results in gastrointestinal symptoms linked to a long blind loop proximal to the gastro-jejunostomy after gastric bypass and creation of an end-to-side anastomosis to a jejunal loop.
Treatment of candy cane syndrome usually involves laparoscopic resection of the redundant blind afferent limb, which although effective, results in complications. Recently, candy cane syndrome has been successfully treated via endoscopic revision of the gastrojejunal anastomosis.
What this means for you
Advanced gastro technologies represent new and more effective means to treat patients. Some of these technologies incur a bit of a learning curve, meaning observation, hands-on practice, and proper credentialing are initially necessary.