Initial experience with per-rectal endoscopic myotomy for Hirschsprung’s disease: medium and long term outcomes of the first case series of a novel third-space endoscopy procedure
Abstract:Introduction
Hirschsprung’s disease (HSCR) is congenital aganglionosis affecting hindgut and presents with constipation. Surgical pull-through is current standard but has morbidity. Per-rectal endoscopic myotomy (PREM) is a novel third space endoscopy technique for treating SS-HSCR.
Methods
Retrospective series of SS-HSCR patients diagnosed on history, contrast enema, rectal biopsies, anorectal manometry and treated by PREM. Aganglionic segment mapped pre-PREM. PREM performed using third space endoscopy pri… Show more
“…Despite the delay, our results demonstrate excellent functional outcomes. The median age of patients in our study was 4 years and not 7.5 years as stated by the authors (Table 1 s) 1 .…”
supporting
confidence: 47%
“…
We thank Dr. Chung and colleagues for their comments on our study [1]. The following are our responses to the queries raised.
“…Despite the delay, our results demonstrate excellent functional outcomes. The median age of patients in our study was 4 years and not 7.5 years as stated by the authors (Table 1 s) 1 .…”
supporting
confidence: 47%
“…
We thank Dr. Chung and colleagues for their comments on our study [1]. The following are our responses to the queries raised.
“…65 Subsequently, the authors reported the outcomes of PREM in nine patients with short-segment HD. 67 The mean age of patients was 7.5 ± 5.2 years and the average length of aganglionic segment was 6.3 cm. The procedure was successfully performed in all the cases with a mean operative time of 96.1 minutes.…”
Section: Per-rectal Endoscopic Myotomymentioning
confidence: 97%
“…64 Recently, endoscopic management (utilizing the principles of third space endoscopy) has shown encouraging results in these cases. [65][66][67] The technique of per-rectal endoscopic myotomy (PREM) as described by Bapaye and colleagues is discussed here. 65 The first and foremost step involves mapping of aganglionic segment by analyzing serial biopsies obtained using the technique of band assisted endoscopic mucosal resection (EMR) described by Nabi and colleagues.…”
Third space or submucosal space is a potential space which on expansion allows the endoscopist to execute a multitude of therapeutic procedures for various gastrointestinal diseases like achalasia, subepithelial tumors, Zenker’s diverticulum, and refractory gastroparesis. Third space was first utilized for performing endoscopic myotomy in cases with achalasia cardia about a decade ago. Since then, the field of submucosal endoscopy has witnessed an exponential growth. The present review focuses on recent advances in the field of third-space endoscopy. With regard to per-oral endoscopic myotomy (POEM) in achalasia cardia, several recent studies have evaluated the long-term outcomes of POEM, compared endoscopic myotomy with pneumatic dilatation (PD) and surgical myotomy, and evaluated the outcomes of short- versus long-esophageal myotomy. In addition, the utility of multiple dose antibiotic prophylaxis to prevent infections after POEM has been questioned. Overall, the results from these studies indicate that POEM is a durable treatment modality, equally effective to Heller’s myotomy and superior to PD. With regard to gastric-POEM (G-POEM), recent studies suggest only modest efficacy in cases with refractory gastroparesis. Therefore, quality studies are required to identify predictors of response to optimize the outcomes of G-POEM in these cases. Another third-space endoscopy procedure that has gained popularity is endoscopic division of septum in cases with esophageal diverticula including Zenker’s POEM and epiphrenic diverticula POEM (Z-POEM and D-POEM, respectively). The technique of diverticulotomy using the principles of submucosal endoscopy appears safe and effective in short term. Data on term outcomes are awaited and comparative trials with flexible endoscopic myotomy required. Per-rectal endoscopic myotomy (PREM) is the most recent addition to third space endoscopy procedures for the management of short-segment Hirschsprung’s disease. Limited data suggest that PREM may be a promising alternative surgery in these cases. However, quality studies with long-term follow-up are required to validate the outcomes of PREM.
“…We read with great interest the article by Bapaye et al who described per-rectal endoscopic myotomy as a treatment for Hirschsprungʼs disease (HSCR) 1 . We congratulate the authors on their novel technique but have concerns regarding patient selection, outcome assessment, and the long-term results reported in this study.…”
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