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Alrajhi S, Barkun A, Adam V, Callichurn K, Martel M, Brewer O, Khashab MA, Forbes N, Almadi MA, Chen YI. Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective. Therap Adv Gastroenterol 2021; 14:17562848211031388. [PMID: 34804204 PMCID: PMC8600178 DOI: 10.1177/17562848211031388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis. METHODS A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases. RESULTS The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295. CONCLUSIONS Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.
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Affiliation(s)
- Saad Alrajhi
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Alan Barkun
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Viviane Adam
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Kashi Callichurn
- Department of Internal Medicine, University of Montreal, Montreal, QC, Canada
| | - Myriam Martel
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Majid A. Almadi
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, Canada
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Glen Site, 1001 Décarie Blvd., Montreal, QC H4A 3J1, Canada
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Alrajhi S, Barkun AN, Adam V, Callichurn K, Martel M, Brewer O, Khashab M, Forbes N, Chen Y. A274 EARLY SINGLE-OPERATOR CHOLANGIOSCOPY ASSISTED ELECTROHYDRAULIC LITHOTRIPSY (SOC-EHL) IN THE MANAGEMENT OF DIFFICULT BILIARY STONES IS COST-EFFECTIVE WHEN COMPARED TO A DELAYED STEP-UP APPROACH TO LATER SOC-EHL. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.273] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Single-operator cholangioscopy assisted electrohydraulic lithotripsy is the standard of care for difficult common bile duct (CBD) stones with failed clearance using standard ERCP. This technology is expensive and optimal timing of its use in terms of cost-effectiveness in the management algorithm of patients with difficult CBD stones remains unclear
Aims
To determine the cost-effective timing of SOC-EHL utilization in the management of difficult CBD stones
Methods
A decision model was developed assessing 4 strategies and progressively delayed introduction of SOC-EHL in relation to ERCP over 6-months. Difficult stones were defined as having failed CBD clearance via standard ERCP. Probability estimates for each health state were obtained from a literature systematic review. For each strategy, outpatients undergoing ERCP underwent different timings of SOC-EHL introduction from the first to the fourth ERCP and were followed for subsequent need for re-intervention, adverse events, need for surgery, and/or successful endoscopic CBD clearance. The unit of effectiveness was complete CBD clearance without need for surgery. Deterministic sensitivity analyses were performed varying all 50 model variables across ranges spanning 30% of their respective values. Costs are in 2018US$ based on US data.
Results
Performing SOC-EHL immediately during the first ERCP is the least expensive approach when compared to delaying SOC-EHL. This strategy costs $15,528 on average per patient with CBD clearance avoiding surgery and can save between $260 to $720 compared to the 3 other strategies, which introduce SOC-EHL during the second to the fourth ERCP. Effectiveness is clinically comparable between the four strategies ranging from 97–99%. Deterministic sensitivity analysis shows changes in the results when the ERCP complication rate (baseline probability of 6%) decreases to 4.5%, when the SOC-EHL (baseline costs of $2,450) costs more than $2,670, or when the ERCP facility fees (baseline costs of $4,292) are less than $3,425. In all 3 scenarios, delaying the first SOC-EHL use to the fourth procedural attempt becomes the dominant strategy. Variations of the other 47 variables did not alter results.
Conclusions
Although SOC-EHL is expensive, this analysis demonstrates that among patients who have failed a prior attempt at stone extraction, utilization of SOC-EHL at the next (first subsequent) ERCP is less costly when compared to its delayed introduction. However, postponing the use of SOC-EHL to the fourth ERCP could be identified as the most cost-effective strategy when facility fees or ERCP complications rates are below certain thresholds, or when the costs of SOC-EHL extend beyond a defined threshold.
Funding Agencies
None
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Affiliation(s)
- S Alrajhi
- McGill University, Montreal, QC, Canada
| | | | - V Adam
- McGill University, Montreal, QC, Canada
| | | | - M Martel
- McGill University, Montreal, QC, Canada
| | | | | | - N Forbes
- University of Calgary, Calgary, AB, Canada
| | - Y Chen
- McGill University, Montreal, QC, Canada
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Bukhari MA, Brewer O, Chen YI, Ngamruengphong S, Sanaei O, Saxena P, Khashab MA. Endosonography-guided alteration of upper surgical anatomy to facilitate endoscopic management of biliary cast syndrome post-liver transplantation. Endoscopy 2019; 51:E374-E375. [PMID: 31261425 DOI: 10.1055/a-0929-3529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Majidah A Bukhari
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Division of Medicine and Gastroenterology and Hepatology, International Medical City in Jeddah, Saudi Arabia
| | - Olaya Brewer
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Omid Sanaei
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Payal Saxena
- Gastroenterologist and Interventional Endoscopist, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, Sydney, Australia
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Yang J, Chen YI, Friedland S, Holmes I, Paiji C, Law R, Hosmer A, Stevens T, Matheus F, Pawa R, Mathur N, Sejpal D, Inamdar S, Berzin TM, DiMaio CJ, Gupta S, Yachimski PS, Anderloni A, Repici A, James T, Jamil LH, Ona M, Lo SK, Gaddam S, Dollhopf M, Alammar N, Shieh E, Bukhari M, Kumbhari V, Singh V, Brewer O, Sanaei O, Fayad L, Ngamruengphong S, Shin EJ, Baron TH, Khashab MA. Correction: Lumen-apposing stents versus plastic stents in the management of pancreatic pseudocysts: a large, comparative, international, multicenter study. Endoscopy 2019; 51:C5. [PMID: 30769348 DOI: 10.1055/a-0852-9243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA.,Division of Gastroenterology and Hepatology, McGill University Health Center, McGill University, Montreal, Québec, Canada
| | - Shai Friedland
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Ian Holmes
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Christopher Paiji
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Amy Hosmer
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Tyler Stevens
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Franco Matheus
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forrest School of Medicine, Winston Salem, North Carolina, USA
| | - Nihar Mathur
- Division of Gastroenterology and Hepatology, Wake Forrest School of Medicine, Winston Salem, North Carolina, USA
| | - Divyesh Sejpal
- Division of Gastroenterology and Hepatology, North Shore-Long Island Jewish Health System, New York, New York, USA
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, North Shore-Long Island Jewish Health System, New York, New York, USA
| | - Tyler M Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sanchit Gupta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Theodore James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laith H Jamil
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mel Ona
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Simon K Lo
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Srinivas Gaddam
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Markus Dollhopf
- Department of Gastroenterology, Klinikum Neuperlach, Munich, Germany
| | - Nuha Alammar
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Eugenie Shieh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
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Yang J, Chen YI, Friedland S, Holmes I, Paiji C, Law R, Hosmer A, Stevens T, Matheus F, Pawa R, Mathur N, Sejpal D, Inamdar S, Berzin TM, DiMaio CJ, Gupta S, Yachimski PS, Anderloni A, Repici A, James T, Jamil LH, Ona M, Lo SK, Gaddam S, Dollhopf M, Alammar N, Shieh E, Bukhari M, Kumbhari V, Singh V, Brewer O, Sanaei O, Fayad L, Ngamruengphong S, Shin EJ, Baron TH, Khashab MA. Lumen-apposing stents versus plastic stents in the management of pancreatic pseudocysts: a large, comparative, international, multicenter study. Endoscopy 2019; 51:1035-1043. [PMID: 30536255 DOI: 10.1055/a-0759-1353] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [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: 12/12/2022]
Abstract
BACKGROUND Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs). METHODS We performed a multicenter, international, retrospective study between January 2012 and August 2016. A total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery. RESULTS Technical success was similar between the LAMS and the DPPS groups (97.5 % vs. 99.2 %; P = 0.32). Clinical success was higher for LAMSs than for DPPSs (96.3 % vs. 87.2 %; P = 0.03). While the need for surgery was similar between the two groups (1.3 % vs. 4.9 %, respectively; P = 0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3 % vs. 8.8 %; P = 0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7 % vs 18.8 %, respectively; P = 0.12). The rate of adverse events was significantly higher in the DPPS group (7.5 % vs. 17.6 %; P = 0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7]; P = 0.31). CONCLUSION When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events.
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Affiliation(s)
- Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA.,Division of Gastroenterology and Hepatology, McGill University Health Center, McGill University, Montreal, Québec, Canada
| | - Shai Friedland
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Ian Holmes
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Christopher Paiji
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Amy Hosmer
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Tyler Stevens
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Franco Matheus
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forrest School of Medicine, Winston Salem, North Carolina, USA
| | - Nihar Mathur
- Division of Gastroenterology and Hepatology, Wake Forrest School of Medicine, Winston Salem, North Carolina, USA
| | - Divyesh Sejpal
- Division of Gastroenterology and Hepatology, North Shore-Long Island Jewish Health System, New York, New York, USA
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, North Shore-Long Island Jewish Health System, New York, New York, USA
| | - Tyler M Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sanchit Gupta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Theodore James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laith H Jamil
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mel Ona
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Simon K Lo
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Srinivas Gaddam
- Division of Digestive and Liver Diseases, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Markus Dollhopf
- Department of Gastroenterology, Klinikum Neuperlach, Munich, Germany
| | - Nuha Alammar
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Eugenie Shieh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
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Yang J, Kaplan JH, Sethi A, Dawod E, Sharaiha RZ, Chiang A, Kowalski T, Nieto J, Law R, Hammad H, Wani S, Wagh MS, Yang D, Draganov PV, Messallam A, Cai Q, Kushnir V, Cosgrove N, Ahmed AM, Anderloni A, Adler DG, Kumta NA, Nagula S, Vleggaar FP, Irani S, Robles-Medranda C, El Chafic AH, Pawa R, Brewer O, Sanaei O, Dbouk M, Singh VK, Kumbhari V, Khashab MA. Safety and efficacy of the use of lumen-apposing metal stents in the management of postoperative fluid collections: a large, international, multicenter study. Endoscopy 2019; 51:715-721. [PMID: 31174225 DOI: 10.1055/a-0924-5591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 12/12/2022]
Abstract
BACKGROUND Multiple studies have examined the use of lumen-apposing metal stents (LAMSs) for the drainage of peripancreatic fluid collections. Data on the use of LAMSs for postoperative fluid collections (POFCs) are scarce. POFCs may lead to severe complications without appropriate treatment. We aimed to study the outcomes (technical success, clinical success, rate/severity of adverse events, length of stay, recurrence) of the use of LAMSs for the drainage of POFCs. METHODS This international, multicenter, retrospective study involved 19 centers between January 2012 and October 2017. The primary outcome was clinical success. Secondary outcomes included technical success and rate/severity of adverse events using the ASGE lexicon. RESULTS A total of 62 patients were included during the study period. The most common etiology of the POFCs was distal pancreatectomy (46.8 %). The mean (standard deviation) diameter was 84.5 mm (30.7 mm). The most common indication for drainage was infection (48.4 %) and transgastric drainage was the most common approach (82.3 %). Technical success was achieved in 60/62 patients (96.8 %) and clinical success in 57/62 patients (91.9 %) during a median (interquartile range) follow-up of 231 days (90 - 300 days). Percutaneous drainage was needed in 8.1 % of patients. Adverse events occurred intraoperatively in 1/62 patients (1.6 %) and postoperatively in 7/62 (11.3 %). There was no procedure-related mortality. CONCLUSION This is the largest study on the use of LAMSs for POFCs. It suggests good clinical efficacy and safety of this approach. The use of LAMSs in the management of POFCs is a feasible alternative to percutaneous and surgical drainage.
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Affiliation(s)
- Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Jeremy H Kaplan
- Division of Digestive and Liver Disease, Columbia University Medical Center, New York, New York, USA
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Medical Center, New York, New York, USA
| | - Enad Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, New York, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, New York, USA
| | - Austin Chiang
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose Nieto
- Division of Gastroenterology and Hepatology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Ahmed Messallam
- Division of Digestive Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Qiang Cai
- Division of Digestive Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University in Saint Louis, St. Louis, Missouri, USA
| | - Natalie Cosgrove
- Division of Gastroenterology, Washington University in Saint Louis, St. Louis, Missouri, USA
| | - Ali Mir Ahmed
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrea Anderloni
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Satish Nagula
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Frank P Vleggaar
- Division of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital OMNI, Guayaquil, Ecuador
| | | | - Rishi Pawa
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
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Bukhari M, Kowalski T, Nieto J, Kunda R, Ahuja NK, Irani S, Shah A, Loren D, Brewer O, Sanaei O, Chen YI, Ngamruengphong S, Kumbhari V, Singh V, Aridi HD, Khashab MA. An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc 2018; 88:486-494. [PMID: 29730228 DOI: 10.1016/j.gie.2018.04.2356] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 04/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ERCP is challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy. EUS-guided gastrogastrostomy (GG) creation is a promising novel technique to access the excluded stomach to facilitate conventional ERCP. We aimed to compare procedural outcomes and adverse events (AEs) between EUS-guided GG-assisted ERCP (EUS-GG-ERCP) and enteroscopy-assisted ERCP (e-ERCP) in patients with RYGB. METHODS Patients with RYGB anatomy who underwent EUS-GG-ERCP or e-ERCP between 2014 and 2016 at 5 tertiary centers were included. The primary outcome was technical success of ERCP, defined as successful cannulation of the selected duct with successful intervention as intended. Secondary outcomes included total procedural time (in the EUS-GG group, total procedural time included EUS-GG creation plus ERCP procedure time), length of hospital stay, and rate/severity of AEs graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS A total of 60 patients (mean age, 57.2 ± 13.2; 75% women) were included, of whom 30 (50%) underwent EUS-GG-ERCP and 30 (50%) underwent e-ERCP (double-balloon enteroscope ERCP, 19; single-balloon enteroscope ERCP, 11). The technical success rate was significantly higher in the EUS-GG-ERCP versus the e-ERCP group (100% vs 60.0%, P < .001). Total procedure time was significantly shorter in patients who underwent EUS-GG-ERCP (49.8 minutes vs 90.7 minutes, P < .001). Postprocedure median length of hospitalization was shorter in the EUS-GG group (1 vs 10.5 days, P = .02). Rate of AEs was similar in both groups (10% vs 6.7%, P = 1). CONCLUSIONS EUS-GG-ERCP may be superior to e-ERCP in patients with RYGB anatomy in terms of a higher technical success and shorter procedural times and offers a similar safety profile.
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Affiliation(s)
- Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA; Division of Medicine and Gastroenterology and Hepatology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jose Nieto
- Borland-Groover Clinic, Jacksonville, Florida, USA
| | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Apeksha Shah
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Loren
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Hanaa Dakour Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Khashab MA, Familiari P, Draganov PV, Aridi HD, Cho JY, Ujiki M, Rio Tinto R, Louis H, Desai PN, Velanovich V, Albéniz E, Haji A, Marks J, Costamagna G, Devière J, Perbtani Y, Hedberg M, Estremera F, Martin Del Campo LA, Yang D, Bukhari M, Brewer O, Sanaei O, Fayad L, Agarwal A, Kumbhari V, Chen YI. Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: an international multicenter study. Endosc Int Open 2018; 6:E1031-E1036. [PMID: 30105290 PMCID: PMC6086680 DOI: 10.1055/a-0625-6288] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [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: 09/13/2017] [Accepted: 05/02/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The efficacy of per oral endoscopic myotomy (POEM) in non-achalasia esophageal motility disorders such as esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), and jackhammer esophagus (JE) has not been well demonstrated. The aim of this international multicenter study was to assess clinical outcomes of POEM in patients with non-achalasia disorders, namely DES, JE, and EGJOO, in a large cohort of patients. PATIENTS AND METHODS This was a retrospective study at 11 centers. Consecutive patients who underwent POEM for EGJOO, DES, or JE between 1/2014 and 9/2016 were included. Rates of technical success (completion of myotomy), clinical response (symptom improvement/Eckardt score ≤ 3), and adverse events (AEs, severity per ASGE lexicon) were ascertained . RESULTS Fifty patients (56 % female; mean age 61.7 years) underwent POEM for EGJOO (n = 15), DES (n = 17), and JE (n = 18). The majority of patients (68 %) were treatment-naïve. Technical success was achieved in all patients with a mean procedural time of 88.4 ± 44.7 min. Mean total myotomy length was 15.1 ± 4.7 cm. Chest pain improved in 88.9 % of EGJOO and 87.0 % of DES/JE ( P = 0.88). Clinical success was achieved in 93.3 % of EGJOO and in 84.9 % of DES/JE ( P = 0.41) with a median follow-up of 195 and 272 days, respectively. Mean Eckardt score decreased from 6.2 to 1.0 in EGJOO ( P < 0.001) and from 6.9 to 1.9 in DES/JE ( P < 0.001). A total of 9 (18 %) AEs occurred and were rated as mild in 55.6 % and moderate in 44.4 %. CONCLUSION POEM is effective and safe in management of non-achalasia esophageal motility disorders, which include DES, JE, and EGJOO.
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Affiliation(s)
- Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Corresponding author Mouen A. Khashab, MD Johns Hopkins Hospital1800 Orleans StreetSheikh Zayed TowerBaltimore, MD 21287+1-514-934-8547
| | - Pietro Familiari
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Hanaa Dakour Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Joo Young Cho
- Digestive Disease Center, CHA Budang Medical Center, CHA University, Seongnam, Korea
| | - Michael Ujiki
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, United States
| | - Ricardo Rio Tinto
- Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles
| | - Hubert Louis
- Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles
| | | | - Vic Velanovich
- Division of General Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Eduardo Albéniz
- Division of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Amyn Haji
- Department of Gastroenterology, Kings College Hospital NHS Foundation Trust, London, UK
| | - Jeffrey Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Guido Costamagna
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jacques Devière
- Division of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles
| | - Yaseen Perbtani
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Mason Hedberg
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, United States
| | - Fermin Estremera
- Division of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Luis A. Martin Del Campo
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Amol Agarwal
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Division of Gastroenterology and Hepatology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
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Khashab M, Masckauchan M, Familiari P, Draganov P, Dakour Aridi H, Cho J, Ujiki M, Rio Tinto R, Louis H, Desai P, Velanovich V, Albéniz E, Haji A, Marks J, Costamagna G, Devière J, Perbtani Y, Hedberg M, Estremera F, Martin Del Campo L, Yang D, Bukhari M, Brewer O, Sanaei O, Fayad L, Agarwal A, Kumbhari V, Chen Y. A4 PERORAL ENDOSCOPIC MYOTOMY IS EFFECTIVE AND SAFE IN NON-ACHALASIA ESOPHAGEAL MOTILITY DISORDERS: AN INTERNATIONAL MULTICENTER STUDY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy009.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Khashab
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - P Familiari
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - J Cho
- CHA Bundang Medical Center, Seongnam, Korea (the Republic of)
| | - M Ujiki
- NorthShore University Health System, Evanston, IL
| | - R Rio Tinto
- Erasme University Hospital, Bruxelles, Belgium
| | - H Louis
- Erasme University Hospital, Bruxelles, Belgium
| | - P Desai
- Surat Institute of Digestive Sciences, Surat, India
| | - V Velanovich
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - E Albéniz
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | - A Haji
- Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - J Marks
- University Hospitals Cleveland Medical Center, Cleveland, OH
| | - G Costamagna
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - J Devière
- Erasme University Hospital, Bruxelles, Belgium
| | | | - M Hedberg
- NorthShore University Health System, Evanston, IL
| | - F Estremera
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | - D Yang
- University of Florida, Gainesville, FL
| | - M Bukhari
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - O Brewer
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - O Sanaei
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - L Fayad
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - A Agarwal
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - V Kumbhari
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - Y Chen
- McGill University, Montreal, QC, Canada
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Denisov LN, Tsvetkova ES, Golubev GS, Bugrova OV, Dydykina IS, Dubikov AI, Menshikova LV, Peshekhonova LK, Rebrov AP, Torgashin AN, Trofimov EA, Yakupova SP, Zonova EV, Brewer O, Cooper C, Reginster J, Knyazeva LA. THE EUROPEAN SOCIETY FOR CLINICAL AND ECONOMIC ASPECTS OF OSTEOPOROSIS AND OSTEOARTHRITIS (ESCEO) ALGORITHM FOR THE MANAGEMENT OF KNEE OSTEOARTHRITIS IS APPLICABLE TO RUSSIAN CLINICAL PRACTICE: A CONSENSUS STATEMENT OF LEADING RUSSIAN AND ESCEO OSTEOARTHRITIS EXPERTS. ACTA ACUST UNITED AC 2017. [DOI: 10.14412/1995-4484-2016-641-653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) treatment algorithm for the management of knee osteoarthritis (OA), published in December 2014, provides practical guidance for the prioritization of interventions. This current paper represents an assessment and endorsement of the algorithm by Russian experts in OA for use in Russian clinical practice, with the aim of providing easy-to-follow advice on how to establish a treatment flow in patients with knee OA, in support of the clinicians’ individualized assessment of the patient. Medications recommended by the ESCEO algorithm are available in Russia. In step 1, background maintenance therapy with symptomatic slow-acting drugs for osteoarthritis (SYSADOA) is advised, for which high-quality evidence is provided only for the formulations of patented crystalline glucosamine sulphate (pCGS) (Rottapharm/Meda) and prescription chondroitin sulfate. Paracetamol may be added for rescue analgesia only, due to limited efficacy and increasing safety signals. Topical non-steroidal anti-inflammatory drugs (NSAIDs) may provide additional symptomatic treatment with the same degree of efficacy as oral NSAIDs but without the systemic safety concerns. To be effective, topical NSAIDs must have high bioavailability, and among NSAIDs molecules like etofenamate have high absorption and bioavailability alongside evidence for accumulation in synovial tissues. Oral NSAIDs maintain a central role in step 2 advanced management of persistent symptoms. However, oral NSAIDs are highly heterogeneous in terms of gastrointestinal and cardiovascular safety profile, and patient stratification with careful treatment selection is advocated to maximize the risk: benefit ratio. Intra-articular hyaluronic acid as a next step provides sustained clinical benefit with effects lasting up to 6 months after a short-course of weekly injections. As a last step before surgery, the slow titration of sustained-release tramadol, a weak opioid, affords sustained analgesia with improved tolerability.
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Affiliation(s)
| | | | - G. Sh. Golubev
- Rostov State Medical University, Ministry of Health of Russia
| | - O. V. Bugrova
- Orenburg State Medical University, Ministry of Health of Russia
| | | | - A. I. Dubikov
- Pacific State Medical University, Ministry of Health of Russia
| | | | | | - A. P. Rebrov
- V.I. Razumovsky Saratov State Medical University, Ministry of Health of Russia
| | - A. N. Torgashin
- N.N. Priorov Central Research Institute of Traumatology and Orthopedics, Ministry of Health of Russia
| | - E. A. Trofimov
- I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia
| | - S. P. Yakupova
- Kazan State Medical University, Ministry of Health of Russia
| | - E. V. Zonova
- Railway Clinical Hospital at the Novosibirsk-Main Station, OAO «RZhD»
| | - O. Brewer
- Epidemiology, and Health Economics, Centre Hospitalier Universitaire in Sart-Tilman, Universite de Liege
| | - C. Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton
| | - J. Reginster
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford
| | - L. A. Knyazeva
- Kursk State Medical University, Ministry of Health of Russia
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