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Al Ghamdi SS, Farha J, Moran RA, Pioche M, Moll F, Yang DJ, Hernández Mondragón OV, Ujiki M, Wong H, Tantau A, Sedarat A, Fejleh MP, Chang K, Lee DP, Nieto JM, Andrawes S, Ginsberg GG, Saumoy M, Bapaye A, Dashatwar P, Aghaie Meybodi M, Lopez AC, Sanaei O, Yousaf MN, Jovani M, Ichkhanian Y, Brewer Gutierrez OI, Kumbhari V, O'Rourke AK, Lentsch EJ, Elmunzer BJ, Khashab MA. Zenker's peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker's diverticulum: a multicenter retrospective comparison. Endoscopy 2022; 54:345-351. [PMID: 34198355 DOI: 10.1055/a-1518-7223] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. METHODS Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. RESULTS 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P < 0.05). CONCLUSIONS There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.
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Affiliation(s)
- Sarah S Al Ghamdi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Robert A Moran
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Mathieu Pioche
- Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Frédéric Moll
- Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Dennis J Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | | | - Michael Ujiki
- Division of Minimally Invasive Surgery, NorthShore's Grainger Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Harry Wong
- Division of Minimally Invasive Surgery, NorthShore's Grainger Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Alina Tantau
- Department of Gastroenterology, the 4th Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alireza Sedarat
- Ronald Reagan UCLA Medical Center, UCLA Medical Center, Los Angeles, California, United States
| | - M Phillip Fejleh
- Ronald Reagan UCLA Medical Center, UCLA Medical Center, Los Angeles, California, United States
| | - Kenneth Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Irvine, California, United States
| | - David P Lee
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Irvine, California, United States
| | - Jose M Nieto
- Borland Groover Clinic Advance Therapeutic Endoscopy Center and Baptist Medical Center, Jacksonville, Florida, United States
| | - Sherif Andrawes
- Division of Gastroenterology and Hepatology, Staten Island University Hospital - Northwell Health, Staten Island, New York, United States
| | - Gregory G Ginsberg
- Endoscopic Services, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Monica Saumoy
- Endoscopic Services, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Parag Dashatwar
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Mohamad Aghaie Meybodi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Ariana C Lopez
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Olaya I Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Ashli K O'Rourke
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Eric J Lentsch
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
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Fejleh MP, Chang M, Anand G, Savides TJ. Use of a large-diameter 30-French venting gastrostomy tube is effective and safe for symptom palliation in patients with malignant bowel obstruction. Ann Gastroenterol 2022; 35:177-181. [PMID: 35479596 PMCID: PMC8922254 DOI: 10.20524/aog.2022.0694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/10/2021] [Indexed: 11/11/2022] Open
Abstract
Background Treatment options for malignant bowel obstruction are limited, particularly in poor surgical candidates. Standard percutaneous endoscopic gastrostomy (PEG) tubes used for venting are of small caliber, limiting success. This study examines outcomes in patients who received larger-caliber 30-Fr PEGs for treatment of malignant bowel obstruction. Method Retrospective chart review for all patients who received a large-caliber venting PEGs for malignant bowel obstruction in a series of patients at a single institution. Results Thirty-six patients were included. The most common primary cancer diagnoses were ovarian (22%), mucinous appendiceal (19%), and colorectal (17%). Symptom relief was achieved in all patients (100%). Four patients (11%) sought medical care for recurrent symptoms due to an incorrect venting technique. Large-caliber venting PEGs were placed on the first admission for obstruction in 17 patients (47%), and were used to replace standard caliber PEGs in 8 patients because of persistent symptoms (22%). Significant ascites was observed in 12 patients (33%), but paracenteses were performed in only 3 of these patients prior to PEG placement. Most large-caliber venting PEGs were placed during hospital admission (34/36, 94%), and facilitated hospital discharge (33/34, 97%). Two significant (6%) and 2 minor adverse events (6%) occurred. Conclusions This study demonstrates the efficacy and safety of large-caliber venting PEGs for malignant bowel obstruction. This facilitated hospital discharge in almost all patients and prevented readmissions when a correct venting technique was utilized; these PEGs were also effective in patients who had failed standard PEG tube venting.
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Affiliation(s)
- M. Phillip Fejleh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, USA (M. Phillip Fejleh, Michael Chang, Gobind Anand, Thomas J. Savides)
- Correspondence to: M. Phillip Fejleh, MD, UC San Diego, 9500 Gilman Drive #0956, La Jolla, CA 92093, USA, e-mail:
| | - Michael Chang
- Division of Gastroenterology, Department of Medicine, University of California San Diego, USA (M. Phillip Fejleh, Michael Chang, Gobind Anand, Thomas J. Savides)
| | - Gobind Anand
- Division of Gastroenterology, Department of Medicine, University of California San Diego, USA (M. Phillip Fejleh, Michael Chang, Gobind Anand, Thomas J. Savides)
| | - Thomas J. Savides
- Division of Gastroenterology, Department of Medicine, University of California San Diego, USA (M. Phillip Fejleh, Michael Chang, Gobind Anand, Thomas J. Savides)
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Fejleh MP, Yadlapati R, Mendler MH, Loomba R, Kwong WT, Abbas Fehmi SM. Complementary role of EUS, EndoFLIP, and manometry for management of type III achalasia with peroral endoscopic myotomy in a patient with compensated cirrhosis and no varices. VideoGIE 2021; 6:167-169. [PMID: 33898892 PMCID: PMC8058387 DOI: 10.1016/j.vgie.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Rena Yadlapati
- University of California, San Diego, La Jolla, California
| | | | - Rohit Loomba
- University of California, San Diego, La Jolla, California
| | - Wilson T Kwong
- University of California, San Diego, La Jolla, California
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Fejleh MP, Yang SE, Kim S. A Patient with Primary Sclerosing Cholangitis and Diffuse Biliary Dilation. Gastroenterology 2021; 160:e17-e18. [PMID: 32598888 DOI: 10.1053/j.gastro.2020.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/02/2022]
Affiliation(s)
- M Phillip Fejleh
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine.
| | - Sung-Eun Yang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Stephen Kim
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine
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Fung BM, Fejleh MP, Tejaswi S, Tabibian JH. Cholangioscopy and its Role in Primary Sclerosing Cholangitis. Eur Med J Hepatol 2020; 8:42-53. [PMID: 32714560 PMCID: PMC7380688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a cholestatic liver disease characterised by chronic inflammation and fibro-obliteration of the intrahepatic and/or extrahepatic bile ducts. It is associated with numerous hepatobiliary complications including an increased risk of malignancy (in particular, cholangiocarcinoma) and biliary tract stone formation. The evaluation of biliary strictures in patients with PSC is especially challenging, with imaging and endoscopic methods having only modest sensitivity for the diagnosis of cholangiocarcinoma, and treatment of biliary strictures poses a similarly significant clinical challenge. In recent years, peroral cholangioscopy has evolved technologically and increased in popularity as an endoscopic tool that can provide direct intraductal visualisation and facilitate therapeutic manipulation of the biliary tract. However, the indications for and effectiveness of its use in patients with PSC remain uncertain, with only a few studies performed on this small but important subset of patients. In this review, the authors discuss the available data regarding the use of peroral cholangioscopy in patients with PSC, with a focus on its use in the evaluation and management of biliary strictures and stones.
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Affiliation(s)
- Brian M. Fung
- Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - M. Phillip Fejleh
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Sooraj Tejaswi
- Division of Gastroenterology & Hepatology, University of California, UC Davis Health, Sacramento, California, USA
| | - James H. Tabibian
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA
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Parsa N, Nieto JM, Powers P, Mitsuhashi S, Abdelqader A, Hadzinakos G, Anderloni AA, Fugazza A, James TW, Arlt A, Ellrichmann M, Aparicio JR, Trindade AJ, Stevens TK, Chahal P, Shah SL, Messallam AA, Lang G, Fejleh MP, Benias PC, Sejpal DV, Jones J, Mir FF, Aghaie Meybodi M, Ichkhanian Y, Vosoughi K, Novikov AA, Irani SS, Pawa R, Ahmed AM, Sedarat A, Hsueh W, Hampe J, Sharaiha RZ, Berzin TM, Willingham FF, Kushnir VM, Brewer Gutierrez OI, Ngamruengphong S, Huggett MT, Baron TH, Repici A, Adler DG, Nasr JT, Kowalski TE, Kumbhari V, Singh VK, Khashab MA. Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using 20-mm versus 15-mm lumen-apposing metal stents: an international, multicenter, case-matched study. Endoscopy 2020; 52:211-219. [PMID: 32000275 DOI: 10.1055/a-1096-3299] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUNDS Endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMSs) has gained popularity for the treatment of pancreatic walled-off necrosis (WON). We compared the 20-mm and 15-mm LAMSs for the treatment of symptomatic WON in terms of clinical success and adverse events. METHODS We conducted a retrospective, case-matched study of 306 adults at 22 tertiary centers from 04/2014 to 10/2018. A total of 102 patients with symptomatic WON who underwent drainage with 20-mm LAMS (cases) and 204 patients who underwent drainage with 15-mm LAMS (controls) were matched by age, sex, and drainage approach. Conditional logistic regression analysis was performed to compare clinical success (resolution of WON on follow-up imaging without reintervention) and adverse events (according to American Society for Gastrointestinal Endoscopy criteria). RESULTS Clinical success was achieved in 92.2 % of patients with 20-mm LAMS and 91.7 % of patients with 15-mm LAMS (odds ratio 0.92; P = 0.91). Patients with 20-mm LAMS underwent fewer direct endoscopic necrosectomy (DEN) sessions (mean 1.3 vs. 2.1; P < 0.001), despite having larger WON collections (transverse axis 118.2 vs. 101.9 mm, P = 0.003; anteroposterior axis 95.9 vs. 80.1 mm, P = 0.01). There was no difference in overall adverse events (21.6 % vs. 15.2 %; P = 0.72) and bleeding events (4.9 % vs. 3.4 %; P = 0.54) between the 20-mm and 15-mm LAMS groups, respectively. CONCLUSIONS The 20-mm LAMS showed comparable clinical success and safety profile to the 15-mm LAMS, with the need for fewer DEN sessions for WON resolution.
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Affiliation(s)
- Nasim Parsa
- University of Missouri Health System, Columbia, Missouri, United States
| | - Jose M Nieto
- Borland Groover Clinic, Jacksonville, Florida, United States
| | - Patrick Powers
- University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, Utah, United States
| | - Shuji Mitsuhashi
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | | | | | | | | | - Theodore W James
- University of North Carolina, Chapel Hill, North Carolina, United States
| | | | | | | | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, United States
| | | | | | - Shawn L Shah
- New York-Presbyterian/Weill Cornell Medical Center, New York, New York, United States
| | - Ahmed A Messallam
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Gabriel Lang
- Washington University School of Medicine, St Louis, Missouri, United States
| | | | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, United States
| | - Divyesh V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, United States
| | - Jason Jones
- Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Fahad Faisal Mir
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | | | | | - Kia Vosoughi
- Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Aleksey A Novikov
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Shayan S Irani
- Virginia Mason Medical Center, Seattle, Washington, United States
| | - Rishi Pawa
- Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Ali M Ahmed
- University of Alabama, Birmingham, Alabama, United States
| | | | - William Hsueh
- West Virginia University Hospital, Morgantown, West Virginia, United States
| | - Jochen Hampe
- University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Reem Z Sharaiha
- New York-Presbyterian/Weill Cornell Medical Center, New York, New York, United States
| | - Tyler M Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | | | - Vladimir M Kushnir
- Washington University School of Medicine, St Louis, Missouri, United States
| | | | | | | | - Todd H Baron
- University of North Carolina, Chapel Hill, North Carolina, United States
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Italy
| | - Douglas G Adler
- University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, Utah, United States
| | - John T Nasr
- West Virginia University Hospital, Morgantown, West Virginia, United States
| | - Thomas E Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Vivek Kumbhari
- Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vikesh K Singh
- Johns Hopkins Hospital, Baltimore, Maryland, United States
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Abstract
Diverticula are the most common incidental finding during routine colonoscopy, and their prevalence increases with patient age. The term “diverticular disease” encompasses the range of clinical manifestations and complications that can occur with colonic diverticula, including diverticular bleeding, diverticulitis-associated strictures, and acute diverticulitis. Colonoscopy is a vital tool in the diagnosis and management of diverticular disease and can be useful in a variety of regards. In this editorial, we concisely delineate the current approach to and practices in colonoscopic management of diverticular disease. In particular, we discuss treatment options for diverticular bleeding, propose consideration of colonic stenting as a bridge to surgery in patients with diverticulitis-associated strictures, and the need for diagnostic colonoscopy following an episode of acute diverticulitis in order to rule out underlying conditions such as colonic malignancy or inflammatory bowel disease. In addition, we offer practical tips for performing safe and successful colonoscopy in patients with dense diverticulosis coli.
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Affiliation(s)
- M Phillip Fejleh
- UCLA Gastroenterology Fellowship Program, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
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Phan J, Dawson D, Sedarat A, Fejleh MP, Marya N, Thaker AM, Rogers M, Kim S, Muthusamy VR. Clinical Utility of Obtaining Endoscopic Ultrasound-Guided Fine-Needle Biopsies for Histologic Analyses of Pancreatic Cystic Lesions. Gastroenterology 2020; 158:475-477.e1. [PMID: 31738913 DOI: 10.1053/j.gastro.2019.10.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/11/2019] [Accepted: 10/15/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Jennifer Phan
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David Dawson
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Alireza Sedarat
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - M Phillip Fejleh
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Neil Marya
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Adarsh M Thaker
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Melinda Rogers
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Stephen Kim
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.
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