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Achalasia is an esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Treatment of achalasia is aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM), derived from natural orifice transluminal endoscopic surgery (NOTES) and advances in endoscopic submucosal dissection (ESD), presents a novel, minimally invasive, and curative endoscopic treatment for achalasia. POEM involves an esophageal mucosal incision followed by creation of a submucosal tunnel crossing the esophagogastric junction and myotomy before closure of the mucosal incision. Although the procedure is technically demanding and requires a certain degree of skill and competency, treatment success is high (90%) with low complication rates. Since the first described POEM in humans in 2010, it has been used increasingly at centers worldwide. This article reviews available published clinical studies demonstrating POEM efficacy and safety in order to present a proposal on how to establish a dedicated POEM program and reach base proficiency for the procedure.

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Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is one of the least invasive and most effective modality in diagnosing pancreatic adenocarcinoma in solid pancreatic lesions, with a higher diagnostic accuracy than cystic tumors. EUS-FNA has been shown to detect tumors less than 3 mm, due to high spatial resolution allowing the detection of very small lesions and vascular invasion, particularly in the pancreatic head and neck, which may not be detected on transverse computed tomography. Furthermore, this minimally invasive procedure is often ideal in the endoscopic procurement of tissue in patients with unresectable tumors. While EUS-FNA has been increasingly used as a diagnostic tool, most studies have collectively looked at all primary pancreatic solid lesions, including lymphomas and pancreatic neuroendocrine neoplasms, whereas very few studies have examined the diagnostic utility of EUS-FNA of pancreatic ductal carcinoma only. As with any novel and advanced endoscopic procedure that may incorporate several practices and approaches, endoscopists have adopted diverse techniques to improve the tissue procurement practice and increase diagnostic accuracy. In this article, we present a review of literature to date and discuss currently practiced EUS-FNA technique, including indications, technical details, equipment, patient selection, and diagnostic accuracy.

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Currently, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary drainage for various pancreatico-biliary disorders. ERCP is successful in 90% of the cases, but is unsuccessful in cases with altered anatomy or with tumors obstructing access to the duodenum. Due to the morbidity and mortality associated with surgical or percutaneous approaches in unsuccessful ERCP cases, biliary endoscopists have been using endoscopic ultrasound-guided biliary drainage (EUS-BD) more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that incorporates various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS-BD techniques. Indications for EUS-BD include failed conventional ERCP, altered anatomy, tumor preventing access into the biliary tree and contraindication to percutaneous access (i.e., ascites, etc.). EUS-BD utilizing EUS-guided rendezvous technique is conducted by creating a tract from either the stomach or the duodenum into the bile duct. Although EUS-BD has rapidly been gaining attraction and popularity in the endoscopic world, the indications and methods have yet to be standardized. There are several access routes and techniques that are employed by advanced endoscopists throughout the world for BD. This article reviews the indications and currently practiced EUS-BD techniques, including indications, technical details (intrahepatic or extrahepatic approach), equipment, patient selection, complications, and overall advantages and limitations.

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