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Buckholz A, Wong R, Curry MP, Baffy G, Chak E, Rustagi T, Mohanty A, Fortune BE. MELD, MELD 3.0, versus Child score to predict mortality after acute variceal hemorrhage: A multicenter US cohort. Hepatol Commun 2023; 7:e0258. [PMID: 37695092 PMCID: PMC10497247 DOI: 10.1097/hc9.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/13/2023] [Accepted: 07/20/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Acute variceal hemorrhage is a major decompensating event in patients with cirrhosis and is associated with high 6-week mortality risk. Many prognostic models based on clinical and laboratory parameters have been developed to risk stratify patients on index bleeding presentation, including those based on the Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP). However, consensus on model performance remains unclear. METHODS Using a large US multicenter cohort of hospitalized patients with cirrhosis who presented with acute variceal hemorrhage, this study evaluates, recalibrates, and compares liver severity index-based models, including the more recent MELD 3.0 model, to investigate their predictive performance on 6-week mortality. Models were also recalibrated and externally validated using additional external centers. RESULTS All recalibrated MELD-based and CTP-based models had excellent discrimination to identify patients at higher risk for 6-week mortality on initial presentation. The recalibrated CTP score model maintained the best calibration and performance within the validation cohort. Patients with low CTP scores (Class A, score 5-6) were strongly associated with < 5% mortality, while high CTP score (Class C, score > 9) were associated with > 20% mortality. CONCLUSION Use of liver severity index-based models accurately predict 6-week mortality risk for patients admitted to the hospital with acute variceal hemorrhage and supports the utilization of these models in future clinical trials as well as their use in clinical practice.
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Affiliation(s)
- Adam Buckholz
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, New York, USA
| | - Rochelle Wong
- Department of Internal Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Michael P. Curry
- Division of Gastroenterology/Liver Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gyorgy Baffy
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Eric Chak
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Tarun Rustagi
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Arpan Mohanty
- Section of Gastroenterology, Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Brett E. Fortune
- Division of Hepatology, Montefiore Einstein Medical Center, Bronx, New York, USA
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Lee F, Rustagi T, Frederick RT. Endo-hepatology: Updates for the clinical hepatologist. Clin Liver Dis (Hoboken) 2023; 22:42-49. [PMID: 37663555 PMCID: PMC10473324 DOI: 10.1097/cld.0000000000000072] [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] [Received: 12/16/2022] [Accepted: 05/15/2023] [Indexed: 09/05/2023] Open
Affiliation(s)
- Frances Lee
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, California, USA
| | - Tarun Rustagi
- Department of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - R. Todd Frederick
- Advanced Organ Therapies, Division of Hepatology, California Pacific Medical Center, San Francisco, California, USA
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Garg R, Mohammed A, Singh A, Schleicher M, Thota PN, Rustagi T, Sanaka MR. Anti-reflux mucosectomy for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E854-E864. [PMID: 35692929 PMCID: PMC9187426 DOI: 10.1055/a-1802-0220] [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: 08/23/2021] [Accepted: 11/15/2021] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Anti-reflux mucosectomy (ARMS) is an emerging endoscopic treatment for refractory gastroesophageal reflux disease (GERD). We conducted a systematic review and meta-analysis to evaluate the safety and efficacy ARMS in refractory GERD. Methods A comprehensive search of multiple databases (through March 2020) was performed to identify studies that reported outcomes of ARMS for refractory GERD. Outcomes assessed included technical success, clinical response, and adverse events (AEs). Clinical response was defined as discontinuation (complete) or reduction (partial) of proton pump inhibitors post-ARMS at follow up. Results A total of 307 patients (mean age 46.9 [8.1] years, 41.5 % females) were included from 10 studies. The technical success and clinical response rates were 97.7 % (95 % confidence interval [CI], 94.6-99.0) and 80.1 % (95 % CI, 61.6-91.0), respectively. The pooled rate of complete and partial clinical response was 65.3 % (95 % CI, 51.4-77.0) and 21.5 % (95 % CI, 14.2-31.2), respectively. The rate of AEs was 17.2 % (95 % CI, 13.1-22.2) with most common AE being dysphagia/esophageal stricture followed by bleeding with rates of 11.4 % and 5.0 %, respectively. GERD health-related quality of life (GERD-HRQL) (mean difference [MD] = 14.9, P < 0.001), GERD questionnaire (GERD-Q) (MD = 4.85, P < 0.001) and mean acid exposure time (MD = 2.39, P = 0.01) decreased significantly post-ARMS as compared to pre-procedure. There was no difference in terms of clinical response and AEs between ARMS and ARMS with banding on subgroup analysis. Conclusions ARMS is a safe and effective procedure for treatment of refractory GERD with high rates of clinical response, acceptable safety profile and significant improvement in GERD-related quality of life. Prospective studies are needed to validate our findings.
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Affiliation(s)
- Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Abdul Mohammed
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, United States
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Mary Schleicher
- Cleveland Clinic Alumni library, Cleveland Clinic, Cleveland, Ohio, United States
| | - Prashanthi N. Thota
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Tarun Rustagi
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
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Senussi NH, Falk N, Rustagi T. Ewing's Sarcoma of the Pancreas. Clin Gastroenterol Hepatol 2022; 20:A21-A22. [PMID: 34450296 DOI: 10.1016/j.cgh.2021.08.027] [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] [Received: 05/19/2021] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Nizar H Senussi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico
| | - Nadja Falk
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico
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Garg R, Mohammed A, Singh A, Harnegie MP, Rustagi T, Stevens T, Chahal P. EUS-guided radiofrequency and ethanol ablation for pancreatic neuroendocrine tumors: A systematic review and meta-analysis. Endosc Ultrasound 2022; 11:170-185. [PMID: 35313416 PMCID: PMC9258014 DOI: 10.4103/eus-d-21-00044] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
EUS-guided radiofrequency ablation (RFA) and ethanol ablation (EA) for pancreatic neuroendocrine tumors (PNETs) have recently been reported with good outcomes. We performed a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of EUS-RFA and EUS-EA in the treatment of PNETs. A comprehensive search of multiple databases (through October 2020) was performed to identify studies that reported outcomes of EUS-RFA and EUS-EA of PNETs. Outcomes assessed included clinical success, technical success, and adverse events (AEs). A total of 181 (100 EUS-RFA, 81 EUS-EA) patients (60.7 ± 9.2 years) with 204 (113 EUS-RFA, 91 EUS-EA) PNETs (mean size 15.1 ± 4.7 mm) were included from 20 studies. There was no significant difference in the rates of technical success (94.4% [95% confidence interval (CI): 88.5–97.3, I2 = 0] vs. 96.7% [95% CI: 90.8–98.8, I2 = 0]; P = 0.42), clinical success (85.2% (95% CI: 75.9–91.4, I2 = 0) vs. 82.2% [95% CI: 68.2–90.8, I2 = 10.1]; P = 0.65), and AEs (14.1% [95% CI: 7.1–26.3, I2 = 0] vs. 11.5% [95% CI: 4.7–25.4, I2 = 63.5]; P = 0.7) between EUS-RFA and EUS-EA, respectively. The most common AE was pancreatitis with the rate of 7.8% and 7.6% (P = 0.95) for EUS-RFA and EUS-EA, respectively. On meta-regression, the location of PNETs in head/neck of pancreas (P = 0.03) was a positive predictor of clinical success for EUS-RFA. EUS-RFA and EUS-EA have similar effectiveness and safety for PNETs ablation. Head/neck location of PNETs was a positive predictor for clinical success after EUS-RFA.
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Affiliation(s)
- Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abdul Mohammed
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mary P Harnegie
- Cleveland Clinic Alumni Library, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tarun Rustagi
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tyler Stevens
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
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Garg R, Parikh MP, Chadalvada P, Singh A, Sanaka K, Ahuja KR, Aggarwal M, Veluvolu R, Vignesh S, Rustagi T. Lower rates of endoscopy and higher mortality in end-stage renal disease patients with gastrointestinal bleeding: A propensity matched national study. J Gastroenterol Hepatol 2022; 37:584-591. [PMID: 34989024 DOI: 10.1111/jgh.15771] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Patients with end-stage renal disease (ESRD) on hemodialysis are considered to be at higher risk of gastrointestinal bleeding (GIB) as compared with those without renal disease (NRD). We conducted a population-based study using the National Inpatient Sample (NIS) database to study the outcomes of GIB in ESRD. METHODS Patients admitted with GIB (upper and lower) from 2005 to 2013 were extracted from the NIS database using ICD-9 codes. Patients were divided into NRD and ESRD groups, and a 1:1 propensity matched analysis was performed. Various outcomes were compared in both groups, and subgroup analysis based on the timing of endoscopy was also performed. RESULTS A total of 218 032 patients were included in the study. There was an increase in inpatient admissions among ESRD patients with GIB with significant reduction in mortality (P < 0.001). In-hospital mortality, length of stay, and total costs were significantly higher in ESRD patients as compared with NRD. ESRD patients were less likely to undergo endoscopic evaluation compared with NRD (P < 0.001). Late endoscopy (> 48 h) was associated with increased need for transfusion and health-care utilization but without a significant difference in mortality as compared with early endoscopy. On multivariate analysis, endoscopy was associated with significantly lower rate of mortality in ESRD patients with GIB (odds ratio 0.28, P < 0.0001). CONCLUSION End-stage renal disease patients with GIB had a significantly higher rate of mortality and a higher health-care utilization with a lower rate of endoscopic evaluation. Endoscopy was associated with a lower mortality rate on multivariate analysis.
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Affiliation(s)
- Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Malav P Parikh
- Department of Gastroenterology, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Pravallika Chadalvada
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Krishna Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Keerat R Ahuja
- Department of Cardiology, Tower Health, Philadelphia, Pennsylvania, USA
| | - Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rajesh Veluvolu
- Department of Gastroenterology, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Shivakumar Vignesh
- Department of Gastroenterology, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Tarun Rustagi
- Department of Gastroenterology, University of New Mexico, Albuquerque, New Mexico, USA
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Sobani ZA, Rustagi T. Salvage, reloading, and deployment of a metal biliary stent using an improvised delivery catheter. Endoscopy 2022; 54:E46. [PMID: 33682906 DOI: 10.1055/a-1376-5964] [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: 12/10/2022]
Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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8
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Memon J, Rustagi T. Gastric Dieulafoy Lesion. Clin Gastroenterol Hepatol 2021; 19:A26. [PMID: 32712391 DOI: 10.1016/j.cgh.2020.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Jawairia Memon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
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McCarty TR, Garg R, Rustagi T. Pancreatic cyst fluid glucose in differentiating mucinous from nonmucinous pancreatic cysts: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94:698-712.e6. [PMID: 33964311 DOI: 10.1016/j.gie.2021.04.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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] [Received: 03/15/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Recently, low levels of intracystic glucose acquired with EUS-guided pancreatic cyst fluid sampling have been shown to help to differentiate mucinous from nonmucinous cystic neoplasms. The aim of this study was to perform a systematic review and meta-analysis to evaluate the diagnostic characteristics of pancreatic cyst fluid glucose compared with carcinoembryonic antigen (CEA) for pancreatic cystic lesions. METHODS Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines and meta-analysis analyzed according to Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute pooled sensitivity and specificity, likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristics curve for intracystic glucose or CEA alone or combination testing. RESULTS Eight studies (609 lesions; mean patient age, 63.56 ± 2.75 years; 60.36% women) were included. The pooled sensitivity for pancreatic cyst fluid glucose was significantly higher compared with CEA alone (91% [95% confidence interval {CI}, 88-94; I2 = .00] vs 56% [95% CI, 46-66; I2 = 537.14]; P < .001) with no difference in specificity (86% [95% CI, 81-90; I2 = 24.16] vs 96% [95% CI, 90-99; I2 = 38.06]; P > .05). Diagnostic accuracy was significantly higher for pancreatic cyst fluid glucose versus CEA alone (94% [95% CI, 91-96] vs 85% [95% CI, 82-88]; P < .001). Combination testing with pancreatic cyst fluid glucose and CEA did not improve the diagnostic accuracy compared with glucose alone (97% [95% CI, 95-98] vs 94% [95% CI, 91-96]; P > .05). CONCLUSIONS Low pancreatic cyst fluid glucose was associated with a high sensitivity and specificity with significantly improved diagnostic accuracy compared with CEA alone for the diagnosis of mucinous versus nonmucinous pancreatic cystic lesions.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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Sobani ZA, Paleti S, Rustagi T. Single-session endoscopic ultrasound-directed transgastric ERCP and percutaneous endoscopic gastrostomy (EDGE-PEG). Endoscopy 2021; 53:E386-E387. [PMID: 33336340 DOI: 10.1055/a-1308-0935] [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: 12/10/2022]
Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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Paleti S, Sobani ZA, McCarty TR, Gutta A, Gremida A, Shah R, Nutalapati V, Bazerbachi F, Jesudoss R, Amin S, Okwara C, Kathi PR, Ahmed A, Gessel L, Hung K, Masoud A, Yu J, Mony S, Akshintala V, Jamil L, Nasereddin T, Kochhar G, Vyas N, Saligram S, Garg R, Sandhu D, Benrajab K, Konjeti R, Agnihotri A, Trivedi H, Grunwald M, Mayer I, Mohanty A, Rustagi T. Impact of COVID-19 on gastroenterology fellowship training: a multicenter analysis of endoscopy volumes. Endosc Int Open 2021; 9:E1572-E1578. [PMID: 34540553 PMCID: PMC8445682 DOI: 10.1055/a-1526-1419] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 04/16/2021] [Accepted: 05/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background and study aims The COVID-19 pandemic has had a profound impact on gastroenterology training programs. We aimed to objectively evaluate procedural training volume and impact of COVID-19 on gastroenterology fellowship programs in the United States. Methods This was a retrospective, multicenter study. Procedure volume data on upper and lower endoscopies performed by gastroenterology fellows was abstracted directly from the electronic medical record. The study period was stratified into 2 time periods: Study Period 1, SP1 (03/15/2020 to 06/30/2020) and Study Period 2, SP2 (07/01/2020 to 12/15/2020). Procedure volumes during SP1 and SP2 were compared to Historic Period 1 (HP1) (03/15/2019 to 06/30/2019) and Historic Period 2 (HP2) (07/01/2019 to 12/15/2019) as historical reference. Results Data from 23 gastroenterology fellowship programs (total procedures = 127,958) with a median of 284 fellows (range 273-289; representing 17.8 % of all trainees in the United States) were collected. Compared to HP1, fellows performed 53.6 % less procedures in SP1 (total volume: 28,808 vs 13,378; mean 105.52 ± 71.94 vs 47.61 ± 41.43 per fellow; P < 0.0001). This reduction was significant across all three training years and for both lower and upper endoscopies ( P < 0.0001). However, the reduction in volume was more pronounced for lower endoscopy compared to upper endoscopy [59.03 % (95 % CI: 58.2-59.86) vs 48.75 % (95 % CI: 47.96-49.54); P < 0.0001]. The procedure volume in SP2 returned to near baseline of HP2 (total volume: 42,497 vs 43,275; mean 147.05 ± 96.36 vs 150.78 ± 99.67; P = 0.65). Conclusions Although there was a significant reduction in fellows' endoscopy volume in the initial stages of the pandemic, adaptive mechanisms have resulted in a return of procedure volume to near baseline without ongoing impact on endoscopy training.
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Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology University of New Mexico, Albuquerque, NM
| | - Zain A. Sobani
- Division of Gastroenterology and Hepatology University of New Mexico, Albuquerque, NM
| | - Thomas R. McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School. Boston, Massachusetts, United States
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Anas Gremida
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St Louis, Missouri, United States
| | - Raj Shah
- Division of Gastroenterology and Hepatology, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Venkat Nutalapati
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Randhir Jesudoss
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, Iowa, United States
| | - Shreya Amin
- Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Chinemerem Okwara
- Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Pradeep Reddy Kathi
- Division of Gastroenterology and Hepatology, University of Arizona School of Medicine, Tuscon, Arizona, United States
| | - Ali Ahmed
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States
| | - Luke Gessel
- Division of Gastroenterology and Hepatology, University of Utah, Salt Lake City, Utah, United States
| | - Kenneth Hung
- Division of Gastroenterology and Hepatology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Amir Masoud
- Division of Gastroenterology and Hepatology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Jessica Yu
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, United States
| | - Shruti Mony
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Venkata Akshintala
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Laith Jamil
- Division of Gastroenterology and Hepatology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, United States
| | - Thayer Nasereddin
- Division of Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
| | - Gursimran Kochhar
- Division of Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
| | - Neil Vyas
- Division of Gastroenterology and Hepatology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Shreyas Saligram
- Division of Gastroenterology and Hepatology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Rajat Garg
- Division of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Dalbir Sandhu
- Division of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Karim Benrajab
- Division of Gastroenterology and Hepatology, University of Kentucky, Lexington, Kentucky, United States
| | - Rajesh Konjeti
- Division of Gastroenterology and Hepatology, University of Kentucky, Lexington, Kentucky, United States
| | - Abhishek Agnihotri
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Hirsh Trivedi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Matthew Grunwald
- Division of Gastroenterology and Hepatology, Maimonides Medical Center, New York, New York, United States
| | - Ira Mayer
- Division of Gastroenterology and Hepatology, Maimonides Medical Center, New York, New York, United States
| | - Arpan Mohanty
- Division of Gastroenterology and Hepatology, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology University of New Mexico, Albuquerque, NM
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Wong M, Sánchez-Luna SA, Rustagi T. Erratum: Endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis in patients receiving fully covered self-expandable metal stents for benign biliary stricture. Endosc Int Open 2021; 9:C9. [PMID: 34504739 PMCID: PMC8423535 DOI: 10.1055/a-1627-4763] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
[This corrects the article DOI: 10.1055/a-1500-8028.].
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Affiliation(s)
- Morgan Wong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
| | - Sergio A. Sánchez-Luna
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
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Wong M, Sánchez-Luna SA, Rustagi T. Endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis in patients receiving FCEMS for benign biliary stricture. Endosc Int Open 2021; 9:E1386-E1390. [PMID: 34466363 PMCID: PMC8382500 DOI: 10.1055/a-1500-8028] [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: 12/27/2020] [Accepted: 03/31/2021] [Indexed: 12/03/2022] Open
Abstract
Background and study aims Fully covered self-expanding metal stents (FCSEMS) are being increasingly used for benign biliary strictures (BBS); however, they are associated with risk of acute cholecystitis. Prophylactic endoscopic transpapillary gallbladder stenting (ETPGBS) can facilitate continuous gallbladder drainage and prevent acute cholecystitis from occlusion of cystic duct orifice by the FCSEMS. The aim of this study was to assess the technical feasibility, efficacy, and safety of ETPGBS to prevent acute cholecystitis in patients receiving FCSEMS for BBS. Patients and methods This was a retrospective analysis of a prospectively collected database at a single center of all patients who underwent prophylactic ETPGBS with FCSEMS for BBS between December 1, 2016 and November 30, 2020. Results A total of 71 ETPGBS were placed during the study period. Sixteen patients (mean age: 66.4 ± 19.8 years; 81 % male) underwent ETPGBS prior to biliary FCSEMS during the same endoscopic session. FCSEMS were left in place (stent dwell time) for a median of 173 days (range: 69-473; mean 196 ± 121) with resolution of BBS and successful removal of ETPGBS and FCSEMS in 12 patients. There was significant improvement in total bilirubin level (5.25 ± 5.53 vs 0.94 ± 0.85 gm/dL; P = 0.008). No episodes of acute cholecystitis or any other post-procedural complications were noted during the median follow-up of 337 days (range: 150-856; mean 394 ± 236). Conclusions ETPGBS prevented stent-related acute cholecystitis with continued efficacy of FCSEMS for BBS.
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Affiliation(s)
- Morgan Wong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
| | - Sergio A. Sánchez-Luna
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, New Mexico, United States
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Mohanty A, Kapuria D, Canakis A, Lin H, Amat MJ, Rangel Paniz G, Placone NT, Thomasson R, Roy H, Chak E, Baffy G, Curry MP, Laine L, Rustagi T. Fresh frozen plasma transfusion in acute variceal haemorrhage: Results from a multicentre cohort study. Liver Int 2021; 41:1901-1908. [PMID: 33969607 DOI: 10.1111/liv.14936] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/25/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fresh frozen plasma (FFP) transfusion is often used in the management of acute variceal haemorrhage (AVH) despite best practice advice suggesting otherwise. OBJECTIVE We investigated if FFP transfusion affects clinical outcomes in AVH. DESIGN, SETTING AND PATIENTS We performed a retrospective cohort study of 244 consecutive, eligible patients admitted to five tertiary health care centres between 2013 and 2018 with AVH. MAIN OUTCOME MEASUREMENTS Multivariable regression analyses were used to study the association of FFP transfusion with mortality at 42 days (primary outcome) and failure to control bleeding at 5 days and length of stay (secondary outcomes). RESULTS Patients who received FFP transfusion (n = 100) had higher mean Model for End Stage Liver Disease (MELD) score and more severe variceal bleeding than those who did not received FFP transfusion (n = 144). Multivariable analysis showed that FFP transfusion was associated with increased odds of mortality at 42 days (odds ratio [OR] 9.41, 95% confidence interval [CI] 3.71-23.90). FFP transfusion was also associated with failure to control bleeding at 5 days (OR 3.87, 95% CI 1.28-11.70) and length of stay >7 days (adjusted OR 1.88, 95% CI 1.03-3.42). The independent association of FFP transfusion with mortality at 42 days persisted when the cohort was restricted to high-risk patients and in patients without active bleeding. LIMITATIONS AND CONCLUSIONS Fresh frozen plasma transfusion in AVH is independently associated with poor clinical outcomes. As this an observational study, there may be residual bias due to confounding; however, we demonstrate no benefit and potential harm with FFP transfusions in AVH.
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Affiliation(s)
- Arpan Mohanty
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Devika Kapuria
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
| | - Andrew Canakis
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Honghuang Lin
- Section of Computational Biomedicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Maelys J Amat
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Nicholas T Placone
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Reggie Thomasson
- Department of Pathology and Laboratory Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Hemant Roy
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Eric Chak
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Gyorgy Baffy
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Michael P Curry
- Division of Gastroenterology/Liver Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
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Soota K, Rustagi T. EUS-guided colocolostomy by use of a lumen-apposing metal stent for malignant sigmoid colon obstruction. Gastrointest Endosc 2021; 94:430-431. [PMID: 33845111 DOI: 10.1016/j.gie.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/08/2020] [Accepted: 04/04/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Kaartik Soota
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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16
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Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Edgar G Fischer
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
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Abstract
The mainstay of management of acute cholecystitis is surgical. Despite the advances in anesthesia and laparoscopic surgery, there is a significant pool of patients that are not candidates for surgery given their significant comorbidities and limited functional reserve. Historically percutaneous gallbladder drainage has been utilized to temporize these patients. Recently, endoscopic approaches are being explored with transpapillary and transmural drainage. In this article, we discuss the background, current status, technical challenges, adverse events, and outcomes of endoscopic ultrasound-guided gallbladder drainage for management of acute cholecystitis.
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Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, MSC10 5550, 1, Albuquerque, NM, 87131, USA
| | - Christina Ling
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, MSC10 5550, 1, Albuquerque, NM, 87131, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, MSC10 5550, 1, Albuquerque, NM, 87131, USA.
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Sobani ZA, Paleti S, Rustagi T. Endoscopic ultrasound-guided gastroenterostomy using large-diameter (20 mm) lumen apposing metal stent (LLAMS). Endosc Int Open 2021; 9:E895-E900. [PMID: 34079873 PMCID: PMC8159608 DOI: 10.1055/a-1399-8442] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a 15-mm lumen apposing metal stent (LAMS) has emerged as a viable alternative to surgical gastrojejunostomy for management of gastric outlet obstruction (GOO). However, given the size of the anastomosis created with a 15-mm LAMS, long-term luminal patency and clinical outcomes may be suboptimal. The aim of this study was to evaluate the technical feasibility, efficacy, and safety of EUS-GE with a large-diameter (20 mm) LAMS (LLAMS). Patients and methods A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-GE with LLAMS between December 1, 2018 and September 30, 2020 was performed. All EUS-GEs were performed using a cautery-enhanced LLAMS. Results Thirty-three patients were referred for endoscopic management of GOO. Two patients were excluded due to a lack of an adequate window for EUS-GE. The remaining 31 patients (93.94 %) (mean age: 61.35 ± 16.52 years; 54.84 % males) underwent EUS-GE using LLAMS for malignant (n = 23) and benign (n = 8) GOO. Technical success was achieved in all patients (100 %) with attempted EUS-GE. Complete clinical success (tolerance of regular diet) was achieved in 93.55 % of patients (n = 29). Two patients (6.45 %) had partial clinical success and died of unrelated causes prior to advancing diet beyond full liquids. Overall mean follow-up was 140.84 ± 160.41 days (median 70, range 4-590). All stents remained patent with no evidence of recurrent GOO symptoms. One patient (3.23 %) developed an asymptomatic clean-based jejunal ulcer on 3-month follow-up endoscopy. Conclusions EUS-GE with LLAMS is a technically feasible, effective and safe option for patients with GOO allowing for tolerability of regular diet. Future prospective, ideally randomized studies comparing long-term outcomes of EUS-GE with 20- and 15-mm LAMS are required.
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Affiliation(s)
- Zain A. Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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Sobani ZA, Sánchez-Luna SA, Rustagi T. Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis using Two Gallbladder Stents (Dual Gallbladder Stenting). Clin Endosc 2021; 54:899-902. [PMID: 34053214 PMCID: PMC8652172 DOI: 10.5946/ce.2021.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/14/2020] [Accepted: 04/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background/Aims Endoscopic transpapillary gallbladder drainage (ETPGBD) is gaining popularity for the management of acute cholecystitis (AC) in high-risk patients. However, the stents placed during the procedure are not immune to obstruction. Here we describe a novel technique of stenting with two transpapillary stents and evaluate its technical feasibility, safety, and efficacy in AC.
Methods A retrospective analysis of all patients undergoing ETPGBD using dual stents for AC at our institution between November 1, 2017 and August 31, 2020 was conducted. We abstracted patient data to evaluate technical and clinical success, adverse events, and long-term outcomes. Two stents were placed either during the index procedure or during an interval procedure performed 4–6 weeks after the index procedure.
Results A total of 21 patients underwent ETPGBD with dual stenting (57.14% male, mean age: 62.14±17.21 years). The median interval between the placement of the first and the second stents was 37 days (range: 0–226 days). Technical and clinical success rates were 100%, with a recurrence rate of 4.76% (n=1) and adverse event rate of 9.52% (n=2) during a mean follow-up period of 471.74±345.64 days (median: 341 days, range: 55–1084 days).
Conclusions ETPGBD with dual gallbladder stenting is a safe and effective technique for long-term gallbladder drainage in non-surgical candidates. Larger controlled studies are needed to validate our findings for the widespread implementation of this technique.
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Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
| | - Sergio A Sánchez-Luna
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
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Abstract
The mainstay of management of acute cholecystitis has been surgical, with percutaneous gallbladder drainage in patients deemed high risk for surgical intervention. Endoscopic management of acute cholecytitis with transpapillary and transmural drainage of the gall bladder is emerging as a viable alternative in high-risk surgical patients. In this article, we discuss the background, current status, technical challenges and strategies to overcome them, adverse events, and outcomes of endoscopic transpapillary gallbladder drainage for management of acute cholecystitis.
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Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, MSC10 5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Christina Ling
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, MSC10 5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, MSC10 5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
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21
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McCarty TR, Paleti S, Rustagi T. Molecular analysis of EUS-acquired pancreatic cyst fluid for KRAS and GNAS mutations for diagnosis of intraductal papillary mucinous neoplasia and mucinous cystic lesions: a systematic review and meta-analysis. Gastrointest Endosc 2021; 93:1019-1033.e5. [PMID: 33359054 DOI: 10.1016/j.gie.2020.12.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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] [Received: 05/10/2020] [Accepted: 12/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although molecular analysis of pancreatic cyst fluid may aid pancreatic cyst classification, clinical practice remains highly variable. Therefore, we performed a systematic review and meta-analysis to evaluate the diagnostic performance of KRAS and GNAS mutations in EUS-acquired pancreatic cyst fluid for diagnosis of intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic lesions (MCLs). METHODS Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and meta-analysis analyzed according to the Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute the pooled sensitivity and specificity and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence interval (95% CI). RESULTS Six studies (785 lesions) were included. For IPMNs and MCLs, KRAS + GNAS (combination) had significantly higher diagnostic accuracy than KRAS alone and GNAS alone (all P < .001). The pooled sensitivity, specificity, and diagnostic accuracy of KRAS + GNAS mutations for diagnosis of IPMNs were 94% (95% CI, 72-99; I2 = 86.74%), 91% (95% CI, 72-98; I2 = 89.83), and 97% (95% CI, 95-98), respectively, with each significantly higher compared with carcinoembryonic antigen (CEA) alone (all P < .001). For diagnosis of MCLs, KRAS + GNAS had a similar sensitivity and specificity compared with CEA alone; however, diagnostic accuracy was significantly improved (97% [95% CI, 95-98] vs 89% [95% CI, 86-91]; P < .001). CONCLUSIONS Molecular analysis for KRAS + GNAS mutations in EUS-acquired pancreatic cyst fluid has high sensitivity and specificity with significantly improved diagnostic accuracy for diagnosis of IPMNs and MCLs when compared with CEA alone.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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22
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Garg R, Singh A, Aggarwal M, Bhalla J, Mohan BP, Burke C, Rustagi T, Chahal P. Underwater Endoscopic Mucosal Resection for 10 mm or Larger Nonpedunculated Colorectal Polyps: A Systematic Review and Meta-Analysis. Clin Endosc 2021; 54:379-389. [PMID: 33910271 PMCID: PMC8182235 DOI: 10.5946/ce.2020.276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 10/18/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Recent studies have reported the favorable outcomes of underwater endoscopic mucosal resection (UEMR) for colorectal polyps. We performed a systematic review and meta-analysis evaluating the efficacy and safety of UEMR for nonpedunculated polyps ≥10 mm.
Methods We performed a comprehensive search of multiple databases (through May 2020) to identify studies reporting the outcomes of UEMR for ≥10 mm nonpedunculated colorectal polyps. The assessed outcomes were recurrence rate on the first follow-up, en bloc resection, incomplete resection, and adverse events after UEMR.
Results A total of 1276 polyps from 16 articles were included in our study. The recurrence rate was 7.3% (95% confidence interval [CI], 4.3–12) and 5.9% (95% CI, 3.6–9.4) for nonpedunculated polyps ≥10 and ≥20 mm, respectively. For nonpedunculated polyps ≥10 mm, the en bloc resection, R0 resection, and incomplete resection rates were 57.7% (95% CI, 42.4–71.6), 58.9% (95% CI, 42.4–73.6), and 1.5% (95% CI, 0.8–2.6), respectively. The rates of pooled adverse events, intraprocedural bleeding, and delayed bleeding were 7.0%, 5.4%, and 2.9%, respectively. The rate of perforation and postpolypectomy syndrome was 0.8%.
Conclusions Our systematic review and meta-analysis demonstrates that UEMR for nonpedunculated colorectal polyps ≥10 mm is safe and effective with a low rate of recurrence.
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Affiliation(s)
- Rajat Garg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Jaideep Bhalla
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Carol Burke
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarun Rustagi
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Yaghooti N, Wong M, Rustagi T. Multiple Gastric Ulcers and Lymphadenopathy. Am J Med 2021; 134:e273-e274. [PMID: 33144135 DOI: 10.1016/j.amjmed.2020.09.051] [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: 08/23/2020] [Revised: 09/12/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Negar Yaghooti
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque
| | - Morgan Wong
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque.
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Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico
| | - Nida S Bham
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico
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25
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McCarty TR, Gulati R, Rustagi T. Efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones: a systematic review and meta-analysis. Endoscopy 2021; 53:110-122. [PMID: 32544959 DOI: 10.1055/a-1200-8064] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 12/14/2022]
Abstract
BACKGROUND : Peroral cholangioscopy with intraductal lithotripsy facilitates optically guided stone fragmentation of difficult biliary stones refractory to conventional endoscopic therapy. The aim of this study was to evaluate the efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones. METHODS : Searches of PubMed, EMBASE, Web of Science, and Cochrane databases were performed in accordance with PRISMA and MOOSE guidelines. Measured outcomes included overall fragmentation success, single-session fragmentation and duct clearance, and rate of adverse events. Sensitivity and subgroup analyses were performed based upon cholangioscopy technique and type of lithotripsy (laser versus electrohydraulic). Heterogeneity was assessed with I 2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. RESULTS : 35 studies were included with 1762 participants (43.4 % men; mean age 61.5 [standard deviation (SD) 11.0]). Prior cholecystectomy had been performed in 37 % of patients, with a mean number of 1.6 (SD 0.5) ERCPs performed prior to lithotripsy. Mean stone size was 1.8 (SD 0.3) cm. Peroral cholangioscopy with intraductal lithotripsy achieved an overall stone fragmentation success of 91.2 % (95 %CI 88.1 % - 93.6 %; I 2 = 63.2 %) with an average of 1.3 [SD 0.6] lithotripsy sessions performed. Complete single-session fragmentation success was 76.9 % (95 %CI 71.6 % - 81.4 %; I 2 = 74.3 %). The adverse events rate was 8.9 % (95 %CI 6.5 % - 12.2 %; I 2 = 60.6 %). Mean procedure time for peroral cholangioscopy was 67.1 (SD 21.4) minutes. There was no difference in overall fragmentation rate or adverse events; however, laser lithotripsy was associated with a higher single-session fragmentation rate and shorter procedure time compared with electrohydraulic lithotripsy. CONCLUSIONS : Peroral cholangioscopy with intraductal lithotripsy appears to be a relatively safe and effective modality for difficult biliary stones.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Rishabh Gulati
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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Klair JS, Zafar Y, Nagra N, Murali AR, Jayaraj M, Singh D, Rustagi T, Krishnamoorthi R. Outcomes of Radiofrequency Ablation versus Endoscopic Surveillance for Barrett's Esophagus with Low-Grade Dysplasia: A Systematic Review and Meta-Analysis. Dig Dis 2021; 39:561-568. [PMID: 33503615 DOI: 10.1159/000514786] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/22/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Endoscopic therapy using radiofrequency ablation (RFA) is a recommended treatment for Barrett's esophagus with high-grade dysplasia (BE-HGD) without a visible lesion which is managed by resection. However, currently, there is no consensus on the management of BE with low-grade dysplasia (BE-LGD) - RFA versus endoscopic surveillance. Hence, we performed a systematic review and meta-analysis of these comparative studies to compare the risk of progression to HGD or esophageal adenocarcinoma (EAC) among patients with BE-LGD treated with RFA versus endoscopic surveillance. METHODS The primary outcome was to compare the risk of progression to HGD or EAC among patients with BE-LGD treated with RFA versus endoscopic surveillance. RESULTS Four comparative studies reporting a total of 543 patients with BE-LGD were included in the meta-analysis (234 in RFA and 309 in endoscopic surveillance). The progression of BE-LGD to either HGD or EAC was significantly lower in patients treated with RFA compared to endoscopic surveillance (OR: 0.17, 95% confidence interval [CI]: 0.04-0.65, p = 0.01). The progression to HGD alone was significantly lower in patients treated with RFA versus endoscopic surveillance (OR: 0.23, 95% CI: 0.08-0.61, p = 0.003). The progression to EAC alone was numerically lower in RFA than endoscopic surveillance without statistical significance (OR: 0.44, 95% CI: 0.17-1.16, p = 0.09). Moderate heterogeneity was noted in the analysis. CONCLUSIONS Based on our meta-analysis, there was a significant reduction in the risk of progression to HGD or EAC among patients with BE-LGD treated with RFA compared with those undergoing endoscopic surveillance. Endoscopic eradication therapy with RFA should be the preferred management approach for BE-LGD.
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Affiliation(s)
- Jagpal Singh Klair
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Yousaf Zafar
- Department of Internal Medicine, Naples Community Healthcare, University of Central Florida, Orlando, Florida, USA
| | - Navroop Nagra
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mahendran Jayaraj
- Division of Gastroenterology and Hepatology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Dhruv Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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Abstract
BACKGROUND This study evaluated the feasibility, efficacy, and safety of removal and replacement of a lumen-apposing metal stent (LAMS) to facilitate direct endoscopic necrosectomy (DEN). METHODS Endoscopic ultrasound-guided LAMS placement for walled-off necrosis (WON) was performed. During subsequent endoscopy, the LAMS was removed, DEN was performed, and the same LAMS was redeployed across the transmural tract. RESULTS 140 LAMS were placed for drainage (43 pseudocysts, 97 WON) from 10/1/2016 to 11/15/2019, and 40 patients (mean age 43.9 [SD 15.4] years; 70 % males; mean WON size 10.9 [SD 4.9] × 8.7 [SD 3.8] cm) underwent removal and replacement of the same LAMS for multiple DEN sessions. LAMS was successfully replaced across the transmural tract during all 81 DEN sessions. Complete resolution was achieved after a median of 2 DEN sessions (range 1-7; mean 2.4 [SD 1.5]), with stent retrieval after a mean of 64.1 (SD 31.6) days after initial placement. No stent damage, tissue ingrowth, or major bleeding occurred. CONCLUSIONS Removal and replacement of LAMS during multiple necrosectomies is feasible, safe, and facilitates DEN.
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Affiliation(s)
- Rishabh Gulati
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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Rustagi T. Gastric Varices. Am J Med 2020; 133:e726. [PMID: 32511955 DOI: 10.1016/j.amjmed.2020.04.039] [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] [Received: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque.
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Sánchez-Luna SA, Rustagi T. Endoscopic ultrasound-guided cystesophagostomy using a lumen-apposing metal stent for endoscopic drainage of a large mediastinal cyst. Dig Endosc 2020; 32:1117. [PMID: 32860279 DOI: 10.1111/den.13822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 07/27/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Sergio A Sánchez-Luna
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, USA
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McCarty TR, Sobani Z, Rustagi T. Per-oral pancreatoscopy with intraductal lithotripsy for difficult pancreatic duct stones: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1460-E1470. [PMID: 33043115 PMCID: PMC7541182 DOI: 10.1055/a-1236-3187] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 04/28/2020] [Accepted: 07/14/2020] [Indexed: 12/14/2022] Open
Abstract
Background and study aims Per-oral pancreatoscopy (POP) with intraductal lithotripsy via electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) facilitates optically-guided stone fragmentation of difficult pancreatic stones refractory to conventional endoscopic therapy. The aim of this study was to perform a systematic review and meta-analysis to evaluate the efficacy and safety of POP with intraductal lithotripsy for difficult pancreatic duct stones. Methods Individualized search strategies were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. This was a cumulative meta-analysis performed by calculating pooled proportions with rates estimated using random effects models. Measured outcomes included pooled technical success, complete or partial stone fragmentation success, complete duct clearance after initial lithotripsy session, and adverse events (AEs). Results Ten studies (n = 302 patients; 67.72 % male; mean age 55.10 ± 3.22 years) were included with mean stone size of 10.66 ± 2.19 mm. The most common stone location was in the pancreatic head (66.17 %). Pooled technical success was 91.18 % with an overall fragmentation success of 85.77 %. Single lithotripsy session stone fragmentation and pancreatic duct clearance occurred in 62.05 % of cases. Overall, adverse events were reported in 14.09 % of patients with post-procedure pancreatitis developing in 8.73 %. Of these adverse events, 4.84 % were classified as serious. Comparing POP-EHL vs POP-LL, there was no significant difference in technical success, fragmentation success, single session duct clearance, or AEs ( P > 0.0500). Conclusions Based on this systematic review and meta-analysis, POP with intraductal lithotripsy appears to be an effective and relatively safe procedure for patients with difficult to remove pancreatic duct stones.
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Affiliation(s)
- Thomas R. McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Zain Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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McCarty T, Rustagi T. Endoscopic ultrasound-guided through-the-needle microforceps biopsy improves diagnostic yield for pancreatic cystic lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1280-E1290. [PMID: 33015329 PMCID: PMC7508652 DOI: 10.1055/a-1194-4085] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 02/20/2020] [Accepted: 04/09/2020] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Given variable diagnostic yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for pancreatic cystic lesions (PCLs), a through-the-needle (TTN) microforceps biopsy device passed through a 19-gauge FNA needle has been devised to improve tissue sampling. This was a systematic review and meta-analysis to evaluate the feasibility, diagnostic yield, and safety of EUS-guided TTN microforceps biopsy for diagnosis of PCLs. Methods Individualized searches were developed in accordance with PRISMA and MOOSE guidelines. This was a cumulative meta-analysis performed by calculating pooled proportions with rates estimated using random effects models. Measured outcomes included pooled technical success, diagnostic yield, accuracy, and procedure-associated adverse events (AEs) as well as comparison to conventional FNA. Results Eleven studies (n = 518 patients; mean age 64.13 ± 5.83 years; 58.19 % female) were included. Mean PCL size was 33.39 ± 3.72 mm with the pancreatic head/uncinate (35.50 %) being the most common location. A mean of 2.47 ± 0.92 forceps passes were performed with a mean of 2.79 ± 0.81 microbiopsies obtained per lesion. Pooled technical success was 97.12 % (95 % CI, 93.73-98.71; I 2 = 34.49) with a diagnostic yield of 79.60 % (95 % CI, 72.62-85.16; I 2 = 56.00), and accuracy of 82.76 % [(95 % CI, 77.80-86.80; I 2 = 0.00). The pooled serious adverse event rate was 1.08 % (95 % CI, 0.43-2.69; I 2 = 0.00). Compared to conventional FNA, TTN microforceps biopsy resulted in significant improvement in diagnostic yield [OR 4.79 (95 % CI: 1.52-15.06; P = 0.007)] and diagnostic accuracy [OR 8.69 (95 % CI, 1.12-67.12; P = 0.038)], respectively. Conclusions EUS-guided TTN microforceps biopsy appears to be safe and effective for diagnosis of PCLs with improvement in diagnostic yield and accuracy when compared to FNA alone.
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Affiliation(s)
- Thomas McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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Sobani ZA, Paleti S, Khalid S, Perez ET, Rustagi T. Trends in upper gastrointestinal bleeding during the COVID-19 pandemic. Ann Gastroenterol 2020; 33:543-544. [PMID: 32879606 PMCID: PMC7406813 DOI: 10.20524/aog.2020.0510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
| | - Sameen Khalid
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
| | - Euriko Torrazza Perez
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, NM, USA
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Affiliation(s)
- Zain A Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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Hu S, Rustagi T. Biliary metal stent placement during single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography: Novel stent delivery system to address surgically altered anatomy. Dig Endosc 2020; 32:825. [PMID: 32145710 DOI: 10.1111/den.13665] [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: 02/08/2023]
Affiliation(s)
- Steve Hu
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, USA
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Gulati R, Rustagi T. Bouncing off the balloon: A new trick for selective cystic duct cannulation. J Hepatobiliary Pancreat Sci 2020; 28:e8-e10. [PMID: 32372502 DOI: 10.1002/jhbp.752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/05/2020] [Accepted: 04/11/2020] [Indexed: 11/08/2022]
Abstract
Selective cannulation of the cystic duct for endoscopic transpapillary gallbladder drainage can be challenging in cases with a caudally branching cystic duct. Gulati and Rustagi describe a novel and simple technique in which a guidewire is bounced off a stone extraction balloon and redirected into the cystic duct.
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Affiliation(s)
- Rishabh Gulati
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA
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Paleti S, Sánchez-Luna SA, Gulati R, Rustagi T. High-grade small-bowel obstruction caused by a migrated lumen-apposing metal stent. Gastrointest Endosc 2020; 91:717-718. [PMID: 31593696 DOI: 10.1016/j.gie.2019.10.001] [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] [Received: 05/25/2019] [Accepted: 10/01/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Sergio A Sánchez-Luna
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Rishabh Gulati
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
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Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - Vaishnavi Boppanna
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Zain A Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Denis McCarthy
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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McCarty TR, Garg R, Thompson CC, Rustagi T. Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2019; 7:E1474-E1482. [PMID: 31673620 PMCID: PMC6811354 DOI: 10.1055/a-0996-8178] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [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: 06/12/2019] [Accepted: 07/31/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel endoscopic procedure designed to facilitate sustained luminal patency in patients with gastric outlet obstruction. The primary aim of this study was to evaluate the efficacy and safety of EUS-GE for treatment of gastric outlet obstruction. Methods Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through April 2019. Patients with benign and malignant gastric outlet obstruction were included. Measured outcomes included: immediate technical and clinical success as well as rate of serious adverse events (AEs). Heterogeneity was assessed with Cochran Q test and I 2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. Results A total of five studies (n = 199 patients; 45.73 % male) were included in this study. Four retrospective studies and one prospective study were analyzed. Mean age of patients that underwent the EUS-GE procedure was 64.52 ± 1.37 years with a pooled mean follow-up period of 4.32 ± 1.65 months. In 21 % of patients (n = 43), gastric outlet obstruction was due to benign causes. Immediate technical success was 92.90 % (95 % CI; 88.26 - 95.79; I 2 = 0.00 %) and reported in all studies. The clinical success rate of EUS-GE was 90.11 % (95 % CI; 84.64 - 93.44; I 2 = 0.00 %). Serious AEs occurred in 5.61 % (95 % CI; 2.87 - 10.67; I 2 = 1.67 %) of cases and were related to peritonitis, perforation, bleeding, and abdominal pain. Re-intervention rate was 11.43 % (95 % CI; 7.29 - 17.46; I 2 = 17.38 %). Conclusions EUS-GE appears to provide an effective and safe minimally invasive alternative for treatment of benign and malignant gastric outlet obstruction.
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Affiliation(s)
- Thomas R. McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Rajat Garg
- Cleveland Clinic, Cleveland, Ohio, United States
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, United States,Harvard Medical School, Boston, Massachusetts, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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McCarty TR, Garg R, Rustagi T. Efficacy and safety of radiofrequency ablation for treatment of chronic radiation proctitis: A systematic review and meta-analysis. J Gastroenterol Hepatol 2019; 34:1479-1485. [PMID: 31111527 DOI: 10.1111/jgh.14729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 04/22/2019] [Accepted: 05/11/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Although argon plasma coagulation is the current standard endoscopic treatment for chronic radiation proctitis (CRP), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study is to evaluate the efficacy and safety of RFA for the treatment of CRP. METHODS Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2004 through March 2018. Review and data abstraction were performed independently by two authors. Measured outcomes included hemoglobin, transfusion dependence, number of treatment sessions, RFA settings, and serious adverse events. RESULTS Six studies (n = 71; mean age 73.41 ± 1.88 years; 90.14% male) were included. Thirty-eight percent of patients failed prior treatment with argon plasma coagulation. Patients underwent a mean of 1.71 ± 0.34 RFA sessions with 24.54 ± 16.47 RFA applications per session. Pooled clinical and endoscopic success of RFA was 99% (95% confidence interval [CI]: 90-100; P < 0.001) and 100% (95% CI: 94-100; P < 0.001), respectively. Serious adverse events were reported in one patient-pooled rate of 0% (95% CI: 0-3; P < 0.001). Mean pre-procedure hemoglobin was 10.38 ± 1.82 g/dL with significant improvement observed post-RFA [weighted mean difference 2.49 g/dL (95% CI: 2.16-2.82; P < 0.001)]. Among transfusion-dependent patients, 85% (95% CI: 68-97; P < 0.001) became transfusion-free post-RFA. Pooled mean follow-up was 19.73 ± 9.72 months. CONCLUSION Despite limited long-term data on RFA for CRP, available evidence suggests RFA is an effective and safe treatment.
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Affiliation(s)
- Thomas R McCarty
- Department of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Rajat Garg
- Department of Internal Medicine, Saint John Hospital and Medical Center, Detroit, Michigan, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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Affiliation(s)
- Nina Nandy
- University of New Mexico, Albuquerque, NM
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McCarty TR, O’Brien CR, Gremida A, Ling C, Rustagi T. Efficacy of duodenal bulb biopsy for diagnosis of celiac disease: a systematic review and meta-analysis. Endosc Int Open 2018; 6:E1369-E1378. [PMID: 30410959 PMCID: PMC6221829 DOI: 10.1055/a-0732-5060] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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: 05/07/2018] [Accepted: 07/23/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Although duodenal biopsy is considered the "gold standard" for diagnosis of celiac disease, the optimal location of biopsy within the small bowel for diagnosis remains unclear. The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the diagnostic utility of endoscopic duodenal bulb biopsy for celiac disease. Patients and methods Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2000 through December 2017. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction was performed. Measured outcomes of adult and pediatric patients included location of biopsy, mean number of biopsies performed, and diagnosis of celiac disease as defined by the modified Marsh-Oberhuber classification. Results A total of 17 studies (n = 4050) were included. Seven studies evaluated adults and 11 studies assessed pediatric populations. Mean age of adults and pediatric patients was 46.70 ± 2.69 and 6.33 ± 1.26 years, respectively. Overall, sampling from the duodenal bulb demonstrated a 5 % (95 % CI 3 - 9; P < 0.001) increase in the diagnostic yield of celiac disease. When stratified by pediatric and adult populations, duodenal bulb biopsy demonstrated a 4 % (95 % CI: 1 to 9; P < 0.001) and 8 % (95 % CI: 6 to 10; P < 0.001) increase in the diagnostic yield of celiac disease. Non-celiac histologic diagnoses including Brunner gland hyperplasia and peptic duodenitis were reported more commonly in the duodenal bulb as compared to the distal duodenum with an increase in diagnostic yield of 4 % (95 % CI 3 - 5; P < 0.001) and 1 % (95 % CI 1 - 2; P < 0.001), respectively. Conclusions Based upon our results, biopsy and histologic examination of duodenal bulb during routine upper endoscopy increases the diagnostic yield of celiac disease.
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Affiliation(s)
- Thomas R. McCarty
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Corey R. O’Brien
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Anas Gremida
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Christina Ling
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States,Corresponding author Tarun Rustagi, MD Division of Gastroenterology and HepatologyUniversity of New MexicoMSC10 5550, 1 University of New MexicoAlbuquerque NM 87131+1-505-272-9751
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Affiliation(s)
- Chinemerem J Okwara
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC 10-5550, 87131, Albuquerque, NM, Mexico.
| | - Rishabh Gulati
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC 10-5550, 87131, Albuquerque, NM, Mexico
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC 10-5550, 87131, Albuquerque, NM, Mexico
| | - Aleksandr Birg
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC 10-5550, 87131, Albuquerque, NM, Mexico
| | - Joshua Hanson
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, Mexico
| | - Denis McCarthy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, MSC 10-5550, 87131, Albuquerque, NM, Mexico
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McCarty TR, Itidiare M, Njei B, Rustagi T. Efficacy of transoral incisionless fundoplication for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Endoscopy 2018; 50:708-725. [PMID: 29625507 DOI: 10.1055/a-0576-6589] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [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 Given poor symptomatic response rates and rising awareness of the adverse events associated with the long-term use of proton pump inhibitors (PPIs), endoscopic modalities for treatment of refractory gastroesophageal reflux disease (GERD) have become more prominent. The aim of this study was to perform a systematic review and meta-analysis to evaluate feasibility, efficacy, and tolerability of transoral incisionless fundoplication (TIF) for the treatment of refractory GERD. METHODS Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed to March 2017. Measured outcomes included immediate technical success rate and serious adverse events. Symptomatic improvement was measured using GERD Health-related Quality of Life (HRQL), Gastroesophageal Reflux Symptom Score (GERSS), and Reflux Symptom Index (RSI). Objective success was determined by hiatal hernia reduction and pH monitoring. RESULTS 32 studies (1475 patients; 48.2 % male) met inclusion criteria. TIF success rate was 99 % (95 % confidence interval [CI] 97 to 100; P < 0.001), with an adverse event rate of 2 % (95 %CI 1 to 3; P < 0.001). GERD HRQL, GERSS, and RSI improved significantly post-TIF (mean difference 17.72, 95 %CI 17.31 to 18.14; mean difference 23.78, 95 %CI 22.96 to 24.60; mean difference 14.28, 95 %CI 13.56 to 15.01; all P < 0.001, respectively). Hernia reduction occurred in 91 % of patients (95 %CI 83 to 98; P < 0.001). DeMeester scores improved significantly (mean difference 10.22, 95 %CI 8.38 to 12.12; P < 0.001). PPI therapy was discontinued post-procedure in 89 % of patients (95 %CI 82 to 95; P < 0.001). CONCLUSIONS TIF appears to be a safe and effective endoscopic procedure for patients with refractory GERD. Future controlled trials are needed to directly compare efficacy, long-term durability, and safety between TIF and Nissen fundoplication.
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Affiliation(s)
- Thomas R McCarty
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Michael Itidiare
- Division of Gastroenterology, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, United States
| | - Basile Njei
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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McCarty TR, Rustagi T. New Indications for Endoscopic Radiofrequency Ablation. Clin Gastroenterol Hepatol 2018; 16:1007-1017. [PMID: 29081376 DOI: 10.1016/j.cgh.2017.10.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 02/07/2023]
Abstract
Radiofrequency ablation (RFA) is a well-established treatment for several benign, premalignant, and malignant disorders. Although the role of RFA has been clearly defined, new indications for luminal and extraluminal applications of endoscopic RFA-directed therapies have emerged. RFA has recently produced promising results in patients with a variety of gastrointestinal and hepatopancreatobiliary pathologies. For example, endoscopic RFA has been used to treat patients with gastric antral vascular ectasia, chronic radiation proctitis, malignant biliary strictures, and ampullary adenomas with intraductal extension. Furthermore, endoscopic ultrasound-guided RFA appears to be an effective, minimally invasive treatment for ablation of solid and cystic lesions-particularly in the pancreas. We review the newer indications for RFA and discuss potential limitations of endoscopic RFA.
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Affiliation(s)
- Thomas R McCarty
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico.
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Safadi S, Martin DR, Rustagi T. Pancreatic intraepithelial neoplasia in heterotopic pancreas: incidentally diagnosed on endoscopic mucosal resection of a duodenal polyp. BMJ Case Rep 2018; 2018:bcr-2018-224414. [PMID: 29936443 DOI: 10.1136/bcr-2018-224414] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Heterotopic pancreas is the presence of pancreatic tissue outside its normal location. It can develop similar pathological conditions that develop in the normal pancreas, including adenocarcinoma and its precursor lesions. Due to the rarity of the condition, the diagnosis can be challenging, and treatment is not well established. We present a 47-year-old female patient referred for endoscopic resection of a 2 cm polyp in the second part of her duodenum. Complete endoscopic mucosal resection (EMR) was performed, with pathology revealing low-grade pancreatic intraepithelial neoplasia (PanIN) in heterotopic pancreatic tissue. To the best of our knowledge, this is the first case of heterotopic pancreas with low-grade PanIN in the duodenum to be incidentally diagnosed and treated with EMR.
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Affiliation(s)
- Sarah Safadi
- Department of Internal Medicine, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - David R Martin
- Department of Pathology, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Kumar N, Bazerbachi F, Rustagi T, McCarty TR, Thompson CC, Galvao Neto MP, Zundel N, Wilson EB, Gostout CJ, Abu Dayyeh BK. The Influence of the Orbera Intragastric Balloon Filling Volumes on Weight Loss, Tolerability, and Adverse Events: a Systematic Review and Meta-Analysis. Obes Surg 2018; 27:2272-2278. [PMID: 28285471 DOI: 10.1007/s11695-017-2636-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Orbera intragastric balloon (IGB) has been approved by the US Food and Drug Administration for use in patients with a body mass index (BMI) between 30 and 40 kg/m2 and is in wide use worldwide as a primary and bridge obesity management tool. The balloon filling volume (BFV) ranges between 400 and 700 mL of saline. Our objective was to determine whether there is an association between BFV and clinically relevant endpoints, namely weight loss outcomes, balloon tolerability, and adverse events. METHODS A systematic review of studies investigating the use of the Orbera IGB system for obesity treatment was performed. Data was examined using random effects modelling and meta-regression analyses. RESULTS Forty-four studies (n = 5549 patients) reported BFV and % total body weight loss (TBWL) at 6 months. Pooled %TBWL at 6 months was 13.2% [95% CI 12.3-14.0]. A funnel plot demonstrated a low risk of publication bias. Meta-regression showed no statistically significant association between filling volume and %TBWL at 6 months (p = 0.268). Higher BFV was associated with lower rates of esophagitis (slope = -0.008, p < 0.001) and prosthesis migration (slope = -0.015, p < 0.001). There was no association between BFV and early removal (p = 0.1), gastroesophageal reflux symptom (p = 0.64), or ulcer rates (p = 0.09). CONCLUSIONS No association was observed between Orbera IGB filling volume and weight loss outcomes. Higher volumes appear to be associated with lower migration and esophagitis rates; thus, a balloon filling volume of 600-650 mL is recommended.
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Affiliation(s)
- Nitin Kumar
- Department of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Tarun Rustagi
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Thomas R McCarty
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Natan Zundel
- Department of Surgery, Florida International University, Miami, FL, USA
| | - Erik B Wilson
- Department of Surgery, University of Texas, Houston, TX, USA
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Garg R, Mohan BP, Krishnamoorthi R, Rustagi T. Pre-endoscopic retrograde cholangiopancreatography (ERCP) administration of rectal indomethacin in unselected patients to reduce post-ERCP pancreatitis: A systematic review and meta-analysis. Indian J Gastroenterol 2018; 37:120-126. [PMID: 29619673 DOI: 10.1007/s12664-018-0841-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 03/02/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Previous studies have reported that peri-procedural administration of rectal indomethacin reduces the risk of pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Based on these studies, gastrointestinal (GI) societies recommend prophylactic rectal indomethacin for all patients undergoing ERCP. However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to estimate the pooled relative risk (RR) of post-ERCP pancreatitis (PEP) in unselected patients who received rectal indomethacin before the ERCP (pre-ERCP) compared to patients who received pre-ERCP rectal placebo. METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through September 1, 2017) to identify randomized control trials (RCTs) investigating the role of pre-ERCP rectal indomethacin in reducing the risk of PEP in unselected patients undergoing ERCP. The databases included Ovid, Medline, In-Process, and Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We calculated a pooled estimate of the RR of PEP in patients who received pre-ERCP rectal indomethacin compared to patients who received pre-ERCP rectal placebo. The meta-analysis was performed using the random effects model. RESULTS Six RCTs with a total of 2229 patients were included in the final meta-analysis. There were 1143 patients in the rectal indomethacin group and 1086 patients in the rectal placebo group. There were 71 events of PEP in the rectal indomethacin group and 114 events of PEP in the rectal placebo group. Pre-ERCP administration of rectal indomethacin significantly reduced the risk of PEP compared to pre-ERCP rectal placebo (RR 0.60, 95% CI, 0.45-0.80; p<0.0001). There was no heterogeneity between the studies (I2 = 0). CONCLUSION The results of this meta-analysis support the routine pre-ERCP administration of rectal indomethacin in unselected patients to prevent PEP.
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Affiliation(s)
- Rajat Garg
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, MI, USA
| | - Babu P Mohan
- Department of Internal Medicine, University of Alabama, Tuscaloosa, AL, USA
| | - Rajesh Krishnamoorthi
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, MSC10 5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
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Garg R, Lehrke HD, AbuDayyeh BK, Rustagi T. Incidental giardiasis diagnosed during transduodenal EUS-FNA. Gastrointest Endosc 2018; 87:308-309. [PMID: 28713065 DOI: 10.1016/j.gie.2017.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 04/16/2017] [Accepted: 06/27/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Rajat Garg
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan, USA
| | - Heidi D Lehrke
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K AbuDayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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Gremida A, Rustagi T. White Bile in Malignant Biliary Obstruction: A Poor Prognostic Marker. Clin Endosc 2017; 51:109-110. [PMID: 29032662 PMCID: PMC5806925 DOI: 10.5946/ce.2017.111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Anas Gremida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
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