BFMS appear to be superior to MPS for EUS-guided WON drainage in terms of clinical success, number of DEN sessions, adverse events, need for salvage surgery and hospital stay.

Hirschsprung's disease (HD) is a congenital disorder characterized by the absence of intrinsic ganglion cells in submucosal and myenteric plexuses of the hindgut; and presents with constipation, intestinal obstruction and/or megacolon. HD commonly involves the rectosigmoid region (short segment HD), although shorter and longer variants of the disease are described. Standard treatment involves pull-through surgery for short segment HD or posterior anorectal myotomy in selected ultrashort segment candidates. Third space endoscopy has evolved during the past few years. Per oral endoscopic myotomy and per oral pyloromyotomy are described for treatment of achalasia cardia and refractory gastroparesis, respectively. Using the same philosophy of muscle/sphincter disruption for spastic bowel segments, per rectal endoscopic myotomy could be considered as a treatment option for short segment HD. A 24-year-old male patient presented with refractory constipation since childhood, and habituated to high-dose laxative combinations. Diagnosis was confirmed as adult short segment HD by barium enema, colonoscopic deep suction mucosal biopsies and anorectal manometry. Histopathology confirmed aganglionosis in the distal 15 cm. By implementing principles of third space endoscopy, per rectal endoscopic myotomy 20 cm in length was successfully carried out. At 24-week follow up, the patient reported significant relief of constipation and associated symptoms. Sigmoidoscopy, anorectal manometry and barium enema confirm improved rectal distensibility and reduced rectal pressures. The present case report describes the first human experience of per rectal endoscopic myotomy for successful treatment of adult short segment HD.

Background and Aim Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia (AC), however post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM+F) was recently described to reduce post-POEM GER. This single-center study reports medium-term outcomes of POEM+F. Patients and Methods Retrospective analysis of prospectively maintained database of patients undergoing POEM+F. Abstracted data – demographics, achalasia type, pre-POEM Eckardt score (ES), prior therapy, follow-up. Follow-up was 3-monthly for one-year. Follow-up assessments included post-POEM ES, GerdQ score, EGD – wrap integrity and esophagitis, and pH studies. GER was defined according to Lyon consensus. Data was recorded as mean (SD) or median (IQR), P-value < 0.05 was considered statistically significant. Results 25 patients underwent POEM+F, mean age (SD) – 40.13 (13.66) years, 12 females. POEM+F was technically successful in 23/25 (92%). Significant dysphagia improvement was seen in all 25 (mean [SD] pre- and post-POEM ES 8.21 [1.08] and 0.1 [0.3] respectively, p < 0.05). Mean total procedure and fundoplication time (SD) – 115.6 (27.2) and 46.7 (12.4) minutes respectively. Time reduced significantly after initial 5 cases. Median follow-up was 12-months (IQR 9 – 13). Intact wrap was seen in 19/23 (82.6%). GER (abnormal EAET) was seen in 2/18 (11.1%); one reported GerdQ > 8. Borderline GER (asymptomatic grade A esophagitis, normal EAET) was identified in 4/22 (18.1%). Two (8%) minor delayed adverse events required no intervention. Conclusions POEM+F is safe and reproducible. At 12-months follow-up, incidence of post-POEM+F GER was low and acceptable.

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Background This is a report of an IRB-approved pilot study of 13 patients who received a trans-oral anterior partial fundoplication for the treatment of GERD using an ultrasound-guided, flexible surgical stapler. All patients had a history of PPI use, objective evidence of GERD, and no significant comorbidity. Under general anesthesia, a flexible stapler was passed trans-orally into the stomach and placed two or three quintuplets of titanium staples approximately 3 cm above the gastroesophageal junction. The stapler contains an ultrasonic range finder, video camera, and illuminator.MethodsPrimary follow-up at 6 weeks included pH metrics, GERD-HRQL scores, and PPI use. The protocol allowed annual telephone interviews for the following 5 years to collect GERD-HRQL scores, PPI use, satisfaction with the procedure, and willingness to have the procedure again.ResultsAt 6 weeks, mean total acid exposure was significantly reduced, and 12/13 patients reduced GERD-HRQL scores by ≥50 %. Twelve of 13 patients had stopped daily GERD medications, and nine of 13 had stopped all GERD medications. Each year, 11 of the 13 patients could be reached with all 13 patients having at least 4-year follow-up. Throughout the follow-up period, GERD-HRQL scores were normal (<10) in all but one patient. All patients would agree to do the procedure again. The median satisfaction score is 8 (range 6–10) on a scale of 1–10. None reported dysphagia. At 1 year, 54 % of respondents (6/11) had eliminated PPI use, with another 27 % (3/11) taking a reduced dose. Combining respondents at 4 and 5 years to account for all patients, 54 % (7/13) had eliminated and another 23 % (3/13) reduced PPI use ≥50 %.ConclusionAt 5 years, the procedure remained effective as demonstrated by the improved quality of life and changes in PPI use. The results remained stable after the second year.