Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Abstract

Main RecommendationsESGE suggests flexible endoscopic treatment over open surgical treatment as first-line therapy for patients with a symptomatic Zenker’s diverticulum of any size.Weak recommendation, low quality of evidence, level of agreement 100 %.ESGE recommends that emerging treatments for Zenker’s diverticulum, such as Zenker’s peroral endoscopic myotomy (Z-POEM) and tunneling, be considered as experimental; these treatments should be offered in a research setting only.Strong recommendation, low quality of evidence, level of agreement 100 %.ESGE recommends against the widespread clinical use of transoral incisionless fundoplication (TIF) as an alternative to proton pump inhibitor (PPI) therapy or antireflux surgery in the treatment of gastroesophageal reflux disease (GERD), because of the lack of data on the long-term outcomes, the inferiority of TIF to fundoplication, and its modest efficacy in only highly selected patients. TIF may have a role for patients with mild GERD who are not willing to take PPIs or undergo antireflux surgery.Strong recommendation, moderate quality of evidence, level of agreement 92.8 %.ESGE recommends against the use of the Medigus ultrasonic surgical endostapler (MUSE) in clinical practice because of insufficient data showing its effectiveness and safety in patients with GERD. MUSE should be used in clinical trials only.Strong recommendation, low quality evidence, level of agreement 100 %.ESGE recommends against the use of antireflux mucosectomy (ARMS) in routine clinical practice in the treatment of GERD because of the lack of data and its potential complications.Strong recommendation, low quality evidence, level of agreement 100 %.ESGE recommends endoscopic cecostomy only after conservative management with medical therapies or retrograde lavage has failed.Strong recommendation, low quality evidence, level of agreement 93.3 %.ESGE recommends fixing the cecum to the abdominal wall at three points (using T-anchors, a double-needle suturing device, or laparoscopic fixation) to prevent leaks and infectious adverse events, whatever percutaneous endoscopic cecostomy method is used.Strong recommendation, very low quality evidence, level of agreement 86.7 %.ESGE recommends considering endoscopic decompression of the colon in patients with Ogilvie’s syndrome that is not improving with conservative treatment.Strong recommendation, low quality evidence, level of agreement 93.8 %.ESGE recommends prompt endoscopic decompression if the cecal diameter is > 12 cm and if the Ogilvie’s syndrome exists for a duration of longer than 4 – 6 days.Strong recommendation, low quality evidence, level of agreement 87.5 %.

Insights into the endoscopic management of esophageal achalasia

“…The European Society of Neurogastroenterology and Motility (ESNM) and United European Gastroenterology (UEG) published the European Guideline on Achalasia in 2020. 52 , 53 These guidelines mirror those published by the ASGE and ACG in regard to safety and efficacy. Achalasia subtype, patient-specific characteristics, possible side effects, and the center’s expertise should factor in decision-making.…”

Endoscopic Decompression in Colonic Distension

“…The overall perforation rate was 15% and most of the patients with perforation had ≥6 days of colonic distension. The European Society of Gastrointestinal Endoscopy (ESGE) guideline [13] and American Society for Gastrointestinal Endoscopy (ASGE) guidelines [10,15] refer to the publications by Johnson et al [14] and Vanek and Al-Salti [4] to define the starting point for active treatment as colonic distension ≥12 cm in the cecum and/ or ≥6 days of colonic distension.…”

“…It is important to move to the next therapeutic step without a time delay if neostigmine is not leading to clinical success. The ESGE recommends prompt endoscopic decompression if the cecal diameter is > 12 cm and if the ACPO exists for a duration of longer than 4-6 days [13], to account for the higher risk for perforation with a longer duration of ACPO. Figure 1 summarizes the established therapy for ACPO in a flow chart.…”

“…While there is no causal therapy for ACPO, it is important to optimize factors with known influence on the gastrointestinal motility. The patient-associated factors that can be corrected include electrolyte imbalance, renal insufficiency, hypothyroidism, and infection [13]. It is also important to check therapy-associated factors interacting with colonic motility as morphine derivates, anticholinergics, and calcium-channel antagonists.…”

Zenker's peroral endoscopic myotomy (Z-POEM) for recurrent Zenker diverticulum: not so fast!

“…Finally, flexible endoscopic septal division (FESD) has been shown to effectively improve symptoms in recurrent ZD, with an excellent safety profile [2 -4]. The recent ESGE guidelines still regard Z-POEM as experimental and recommend its use in a research setting for the time being [5].…”