1
|
Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, Kushnir V, Barthet M, Apovian CM, Boskoski I, Chapman CG, Davidson P, Donatelli G, Kumbhari V, Hayee B, Esker J, Hucl T, Pryor AD, Maselli R, Schulman AR, Pattou F, Zelber-Sagi S, Bain PA, Durieux V, Triantafyllou K, Thosani N, Huberty V, Sullivan S. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Endoscopy 2024. [PMID: 38641332 DOI: 10.1055/a-2292-2494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.
Collapse
Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Árpád V Patai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stefan K Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Vladimir Kushnir
- Department of Medicine-Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marc Barthet
- Department of Hepatogastroenterology, Faculty of Medicine, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christopher G Chapman
- Center for Interventional and Therapeutic Endoscopy, Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois USA
| | - Paul Davidson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France and Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bu Hayee
- Division of Gastroenterology, Kings College London, London, United Kingdom
| | - Janelle Esker
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Aurora D Pryor
- Department of Surgery, Long Island Jewish Medical Center, Queens, New York, USA
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Clinical and Research Center IRCCS, Endoscopy Unit, Rozzano, Italy
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francois Pattou
- Department of Endocrine and Metabolic Surgery, CHU Lille, University of Lille, Inserm, Institut Pasteur Lille, Lille, France
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel and Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles, Brussels, Belgium
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, Division of Gastroenterology Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Vincent Huberty
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Shelby Sullivan
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
2
|
Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, Kushnir V, Barthet M, Apovian CM, Boskoski I, Chapman CG, Davidson P, Donatelli G, Kumbhari V, Hayee B, Esker J, Hucl T, Pryor AD, Maselli R, Schulman AR, Pattou F, Zelber-Sagi S, Bain PA, Durieux V, Triantafyllou K, Thosani N, Huberty V, Sullivan S. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Gastrointest Endosc 2024:S0016-5107(23)03148-6. [PMID: 38639680 DOI: 10.1016/j.gie.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 04/20/2024]
Abstract
This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.
Collapse
Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Árpád V Patai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stefan K Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Vladimir Kushnir
- Department of Medicine-Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marc Barthet
- Department of Hepatogastroenterology, Faculty of Medicine, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christopher G Chapman
- Center for Interventional and Therapeutic Endoscopy, Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois USA
| | - Paul Davidson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France and Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bu Hayee
- Division of Gastroenterology, Kings College London, London, United Kingdom
| | - Janelle Esker
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Aurora D Pryor
- Department of Surgery, Long Island Jewish Medical Center, Queens, New York, USA
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Clinical and Research Center IRCCS, Endoscopy Unit, Rozzano, Italy
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francois Pattou
- Department of Endocrine and Metabolic Surgery, CHU Lille, University of Lille, Inserm, Institut Pasteur Lille, Lille, France
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel and Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles, Brussels, Belgium
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, Division of Gastroenterology Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Vincent Huberty
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Shelby Sullivan
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
3
|
Affiliation(s)
- Vivek Kumbhari
- Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, United States
| |
Collapse
|
4
|
Osagiede O, Nayar K, Raimondo M, Kumbhari V, Lukens FJ. The Determinants of Inpatient Palliative Care Use in Patients With Pancreatic Cancer. Am J Hosp Palliat Care 2023:10499091231218257. [PMID: 37991926 DOI: 10.1177/10499091231218257] [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: 11/24/2023] Open
Abstract
INTRODUCTION Symptom burden management is a major goal of pancreatic cancer care given that most patients are diagnosed late. Early palliative care is recommended in addition to concurrent active treatment; however, disparities exist. We sought to determine the factors associated with inpatient palliative treatment among pancreatic cancer patients and compare treatment outcomes in terms of mortality, discharge disposition and resource utilization. METHODS We conducted a retrospective study of 22,053 pancreatic cancers using the National Inpatient Sample (NIS) database (January - December 2020). Patient and hospital characteristics, mortality, discharge disposition, length of stay (LOS), hospital costs and charges were compared between pancreatic cancer patients based on palliative treatment. Multivariate regression was used to evaluate patient and hospital characteristics and outcomes associated with palliative treatment. RESULTS A total number of 3839 (17.4%) patients received palliative care. Patients who received palliative care were more likely to be older, Medicaid insured, and nonobese. Patients were less likely to receive palliative care if they are males, Medicare insured, had a lower Charlson comorbidity score, or treated in Urban nonteaching hospitals. Patients who received palliative care displayed higher odds of in-hospital mortality and prolonged LOS. The adjusted additional mean hospital cost and charges in patients who received palliative care were lower by $1459, and $4222 respectively. CONCLUSIONS Inpatient palliative treatment in pancreatic cancer patients is associated with an older age, a higher comorbidity burden, non-obesity, insurance status and urban teaching hospitals. Our study suggests that inpatient palliative treatment decreased hospital resource utilization without prolonging survival.
Collapse
Affiliation(s)
- Osayande Osagiede
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Kapil Nayar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Massimo Raimondo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Frank J Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| |
Collapse
|
5
|
Nikiforova MN, Wald AI, Spagnolo DM, Melan MA, Grupillo M, Lai YT, Brand RE, O’Broin-Lennon AM, McGrath K, Park WG, Pfau PR, Polanco PM, Kubiliun N, DeWitt J, Easler JJ, Dam A, Mok SR, Wallace MB, Kumbhari V, Boone BA, Marsh W, Thakkar S, Fairley KJ, Afghani E, Bhat Y, Ramrakhiani S, Nasr J, Skef W, Thiruvengadam NR, Khalid A, Fasanella K, Chennat J, Das R, Singh H, Sarkaria S, Slivka A, Gabbert C, Sawas T, Tielleman T, Vanderveldt HD, Tavakkoli A, Smith LM, Smith K, Bell PD, Hruban RH, Paniccia A, Zureikat A, Lee KK, Ongchin M, Zeh H, Minter R, He J, Nikiforov YE, Singhi AD. A Combined DNA/RNA-based Next-Generation Sequencing Platform to Improve the Classification of Pancreatic Cysts and Early Detection of Pancreatic Cancer Arising From Pancreatic Cysts. Ann Surg 2023; 278:e789-e797. [PMID: 37212422 PMCID: PMC10481930 DOI: 10.1097/sla.0000000000005904] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE We report the development and validation of a combined DNA/RNA next-generation sequencing (NGS) platform to improve the evaluation of pancreatic cysts. BACKGROUND AND AIMS Despite a multidisciplinary approach, pancreatic cyst classification, such as a cystic precursor neoplasm, and the detection of high-grade dysplasia and early adenocarcinoma (advanced neoplasia) can be challenging. NGS of preoperative pancreatic cyst fluid improves the clinical evaluation of pancreatic cysts, but the recent identification of novel genomic alterations necessitates the creation of a comprehensive panel and the development of a genomic classifier to integrate the complex molecular results. METHODS An updated and unique 74-gene DNA/RNA-targeted NGS panel (PancreaSeq Genomic Classifier) was created to evaluate 5 classes of genomic alterations to include gene mutations (e.g., KRAS, GNAS, etc.), gene fusions and gene expression. Further, CEA mRNA ( CEACAM5 ) was integrated into the assay using RT-qPCR. Separate multi-institutional cohorts for training (n=108) and validation (n=77) were tested, and diagnostic performance was compared to clinical, imaging, cytopathologic, and guideline data. RESULTS Upon creation of a genomic classifier system, PancreaSeq GC yielded a 95% sensitivity and 100% specificity for a cystic precursor neoplasm, and the sensitivity and specificity for advanced neoplasia were 82% and 100%, respectively. Associated symptoms, cyst size, duct dilatation, a mural nodule, increasing cyst size, and malignant cytopathology had lower sensitivities (41-59%) and lower specificities (56-96%) for advanced neoplasia. This test also increased the sensitivity of current pancreatic cyst guidelines (IAP/Fukuoka and AGA) by >10% and maintained their inherent specificity. CONCLUSIONS PancreaSeq GC was not only accurate in predicting pancreatic cyst type and advanced neoplasia but also improved the sensitivity of current pancreatic cyst guidelines.
Collapse
Affiliation(s)
- Marina N. Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Abigail I. Wald
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Daniel M. Spagnolo
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa A. Melan
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Maria Grupillo
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yi-Tak Lai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Randall E. Brand
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anne Marie O’Broin-Lennon
- The Sol Goldman Pancreatic Cancer Research Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Walter G. Park
- Department of Medicine, Stanford University, Stanford, CA
| | - Patrick R. Pfau
- Department of Medicine, University of Wisconsin, Madison, WI
| | - Patricio M. Polanco
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nisa Kubiliun
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN
| | - Jeffrey J. Easler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN
| | - Aamir Dam
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL
| | - Shaffer R. Mok
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL
| | - Michael B. Wallace
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Brian A. Boone
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, WV
| | - Wallis Marsh
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, WV
| | - Shyam Thakkar
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, WV
| | - Kimberly J. Fairley
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, WV
| | - Elham Afghani
- The Sol Goldman Pancreatic Cancer Research Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Yasser Bhat
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, CA
| | - Sanjay Ramrakhiani
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, CA
| | - John Nasr
- Department of Medicine, Wheeling Hospital, West Virginia University Health Sciences Center, Morgantown, WV
| | - Wasseem Skef
- Division of Gastroenterology and Hepatology, Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA
| | - Nikhil R. Thiruvengadam
- Division of Gastroenterology and Hepatology, Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA
| | - Asif Khalid
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth Fasanella
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jennifer Chennat
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rohit Das
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Harkirat Singh
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Savreet Sarkaria
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Charles Gabbert
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tarek Sawas
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Thomas Tielleman
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Anna Tavakkoli
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lynette M. Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | - Katelyn Smith
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Phoenix D. Bell
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ralph H. Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth K. Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melanie Ongchin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Herbert Zeh
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, TX
| | - Rebecca Minter
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Jin He
- The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Aatur D. Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
6
|
Hayat M, Schlachterman A, Schiavone G, Mizrahi M, Park JK, Kumbhari V, Cheesman A, Draganov PV, Hasan MK, Yang D. Initial multicenter experience using a novel articulating through-the-scope traction device for endoscopic submucosal dissection. Endosc Int Open 2023; 11:E778-E784. [PMID: 37593157 PMCID: PMC10431969 DOI: 10.1055/a-2117-8444] [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] [Received: 04/13/2023] [Accepted: 06/20/2023] [Indexed: 08/19/2023] Open
Abstract
Background and study aims A single-operator, articulating, through-the-scope (TTS) traction device was recently developed to facilitate endoscopic submucosal dissection (ESD). Clinical data on the performance of this device are limited. We report an initial multicenter experience with ESD using this articulating TTS traction device. Patients and methods Retrospective analysis on all consecutive patients who underwent ESD using this traction device (T-ESD) at five centers between August 2021 and December 2022. Endpoints included: rates of en-bloc resection, R0 resection, curative resection, and adverse events. Results Thirty-six patients (median age 64.8 years; 47.2% women) underwent ESD (median lesion size 40 mm; interquartile range [IRQ]: 27.5-67.5) for lesions in the esophagus (n=2), stomach (n=8), sigmoid colon (n=6), and rectum (n=20). Submucosal fibrosis was encountered in one-third of the lesions (33.3%). Median ESD time was 104.6 minutes (IQR: 65-122). En-bloc, R0 and curative resection were achieved in 94.4%, 91.6%, and 97.2%, respectively. The single patient with non-curative resection of an invasive rectal adenocarcinoma underwent surgery. There were no cases of delayed bleeding or perforation. There was no recurrence on surveillance endoscopy (n=20) at a median of 6 months (IQR: 3.75-6). Conclusions This initial multicenter experience demonstrates high resection rates and excellent safety profile when performing ESD with this novel articulating TTS device. Dynamic real-time traction may lower the technical difficulty of ESD. Additional studies are needed to assess its cost-effectiveness and compare its usefulness with other traction devices and techniques during ESD.
Collapse
Affiliation(s)
- Maham Hayat
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| | - Alexander Schlachterman
- Division of Gastroenterology, Hepatology & Nutrition, University of Florida, Gainesville, United States
| | - Grace Schiavone
- Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, United States
| | - Meir Mizrahi
- Gastroenterology, Florida Center for Gastroenterology, Key Largo, United States
| | - Jong Kyu Park
- Gastroenterology, Mayo Clinic in Florida, Jacksonville, United States
| | - Vivek Kumbhari
- Gastroenterology, Mayo Clinic in Florida, Jacksonville, United States
| | | | - Peter V Draganov
- Medicine/Gastroenterology, University of Florida, Gainesville, United States
| | - Muhammad Khalid Hasan
- Center for Interventional Endoscopy, Florida Hospital Orlando, Orlando, United States
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, United States
| |
Collapse
|
7
|
Bakheet N, Badurdeen D, Sartoretto A, Kumbhari V. Endoluminal bariatric and metabolic therapies: state-of-the-art. Curr Opin Gastroenterol 2023:00001574-990000000-00087. [PMID: 37522920 DOI: 10.1097/mog.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of these endoluminal bariatric and metabolic procedures. RECENT FINDINGS The landscape of endoluminal devices and techniques for treating obesity has expanded significantly, with FDA-approved therapies currently available to patients with a body mass index values as high as 50 kg/m2. Although notable advancements have been made in this area, there is a need for further emphasis to be placed on the metabolic improvements resulting from these therapies, in addition to the conventional focus on weight loss outcomes. Some of these procedures are now FDA approved for the treatment of metabolic disease as opposed to weight loss. To achieve the most favorable results, it is imperative that all endoluminal interventions are combined with a moderately intensive diet and lifestyle program lasting at least 12 months. SUMMARY Endoluminal metabolic and bariatric therapy represents a bridge between lifestyle counseling, pharmaceutical interventions, and the most efficacious treatment for obesity, bariatric surgery. By virtue of its minimally invasive approach, this therapy may be an appealing option for patients who are ineligible for, or averse to, bariatric surgery and who have experienced suboptimal outcomes or unable to afford medical treatments. Furthermore, these interventions may be particularly beneficial in the early stages of obesity.
Collapse
Affiliation(s)
- Nader Bakheet
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| |
Collapse
|
8
|
Akshintala VS, Kanthasamy K, Bhullar FA, Sperna Weiland CJ, Kamal A, Kochar B, Gurakar M, Ngamruengphong S, Kumbhari V, Brewer-Gutierrez OI, Kalloo AN, Khashab MA, van Geenen EJM, Singh VK. Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials. Gastrointest Endosc 2023; 98:1-6.e12. [PMID: 37004815 DOI: 10.1016/j.gie.2023.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 06/04/2021] [Revised: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to determine the incidence, severity, and mortality of PEP in consecutive and high-risk patients based on a systemic review and meta-analysis of patients in placebo and no-stent arms of randomized control trials (RCTs). METHODS The MEDLINE, Embase, and Cochrane databases were searched from the inception of each database to June 2022 to identify full-text RCTs evaluating PEP prophylaxes. The incidence, severity, and mortality of PEP from the placebo or no-stent arms of RCTs were recorded for consecutive and high-risk patients. A random-effects meta-analysis for a proportions model was used to calculate PEP incidence, severity, and mortality. RESULTS One hundred forty-five RCTs were found with 19,038 patients in the placebo or no-stent arms. The overall cumulative incidence of PEP was 10.2% (95% confidence interval [CI], 9.3-11.3), predominantly among the academic centers conducting such RCTs. The cumulative incidences of severe PEP and mortality were .5% (95% CI, .3-.7) and .2% (95% CI, .08-.3), respectively, across 91 RCTs with 14,441 patients. The cumulative incidences of PEP and severe PEP were 14.1% (95% CI, 11.5-17.2) and .8% (95% CI, .4-1.6), respectively, with a mortality rate of .2% (95% CI, 0-.3) across 35 RCTs with 3733 patients at high risk of PEP. The overall trend for the incidence of PEP among patients randomized to placebo or no-stent arms of RCTs has remained unchanged from 1977 to 2022 (P = .48). CONCLUSIONS The overall incidence of PEP is 10.2% but is 14.1% among high-risk patients based on this systematic review of placebo or no-stent arms of 145 RCTs; this rate has not changed between 1977 and 2022. Severe PEP and mortality from PEP are relatively uncommon.
Collapse
Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kavin Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Merve Gurakar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Erwin-Jan M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
9
|
Kim DH, Lukens FJ, Ko D, Salazar M, Kröner PT, Elli EF, Kumbhari V, Palacios Argueta P. Incidence, Burden, and Predictors of 11-Month Readmission in Patients Undergoing Bariatric Surgery. Obes Surg 2023; 33:94-104. [PMID: 36319825 DOI: 10.1007/s11695-022-06343-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/14/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bariatric surgery (BSx) is one of the most common surgical procedures performed in the USA. Nonetheless, data regarding 11-month period after BSx remain limited. METHODS A retrospective cohort study using the 2016 National Readmission Database. Adult patients admitted for BSx in January were included. The follow-up period was 11 months (February-December). The primary outcome was all-cause 11-month readmission. Secondary outcomes were index admission (IA) and readmission in-hospital mortality rate and healthcare resource use associated with readmission. Multivariate regression was performed to identify independent risk factors for readmission. RESULTS A total of 13,278 IA were included. The 11-month readmission rate was 11.1%. The mortality rate of readmission was 1.4% and 0.1% for IA (P < 0.01). The most common cause of readmission was hematemesis. Independent predictors were Charlson comorbidity index (CCI) score ≥ 3 (adjusted hazard ratio [aHR] 1.34; P = 0.05), increasing length of stay (aHR 1.01; P < 0.01), transfer to rehabilitation facilities (aHR 5.02; P < 0.01), undergoing laparoscopic Roux-en-Y gastric bypass (aHR 1.71; P = 0.02), adjustable gastric band (aHR 14.09; P < 0.01), alcohol use disorder (2.10; P = 0.01), and cannabis use disorder (aHR 3.37; P = 0.01). Private insurance as primary payer (aHR 0.65; P < 0.01) and BMI 45-49 kg/m2 (aHR 0.72; P < 0.01) were associated with less odds of readmission. The cumulative total hospitalization charges of readmission were $69.9 million. CONCLUSIONS The 11-month readmission rate after BSx is 11.1%. Targeting modifiable predictors of readmission may help reduce the burden of readmissions on our healthcare system.
Collapse
Affiliation(s)
- Do Han Kim
- School of Medicine, Universidad Francisco Marroquin, Guatemala City, Guatemala
| | - Frank J Lukens
- Gastroenterology and Hepatology Department, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Donghyun Ko
- School of Medicine, Universidad Francisco Marroquin, Guatemala City, Guatemala
| | - Miguel Salazar
- Gastroenterology and Hepatology Department, University of California Riverside, Riverside, CA, USA
| | - Paul T Kröner
- Department of Gastroenterology, Riverside Regional Medical Center, Newport News, VA, USA
| | - Enrique F Elli
- General Surgery Department, Mayo Clinic, Jacksonville, FL, USA
| | - Vivek Kumbhari
- Gastroenterology and Hepatology Department, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Pedro Palacios Argueta
- Gastroenterology and Hepatology Department, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| |
Collapse
|
10
|
Gudenkauf FJ, Mehta A, Ferri L, Aihara H, Draganov PV, Yang DJ, Jue TL, Munroe CA, Boparai ES, Mehta NA, Bhatt A, Kumta NA, Othman MO, Mercado M, Javaid H, Aadam AA, Siegel A, James TW, Grimm IS, DeWitt JM, Novikov A, Schlachterman A, Kowalski T, Samarasena J, Hashimoto R, Chehade NEH, Lee JG, Chang K, Su B, Ujiki MB, Sharaiha RZ, Carr-Locke DL, Chen A, Chen M, Chen YI, Tomizawa Y, von Renteln D, Kumbhari V, Khashab MA, Bechara R, Karasik M, Patel NJ, Fukami N, Nishimura M, Hanada Y, Song LMWK, Laszkowska M, Wang AY, Hwang JH, Friedland S, Sethi A, Ngamruengphong S. Factors Associated With Advanced Histological Diagnosis and Upstaging After Endoscopic Submucosal Dissection of Superficial Gastric Neoplasia. Techniques and Innovations in Gastrointestinal Endoscopy 2023; 25:2-10. [DOI: 10.1016/j.tige.2022.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
|
11
|
Cortés P, Kumbhari V, Antwi SO, Wallace MB, Raimondo M, Ji B, Bi Y. Simple risk score to predict the likelihood of a positive EUS in idiopathic acute pancreatitis. Gastrointest Endosc 2022; 96:993-1001.e5. [PMID: 35850170 DOI: 10.1016/j.gie.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/09/2022] [Accepted: 07/12/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS We sought to derive a risk score, DORM65, of known variables to predict the likelihood of a positive EUS in patients with idiopathic acute pancreatitis (IAP). METHODS A retrospective cohort study of 180 patients with IAP was performed across 3 tertiary care centers between January 2018 and December 2021. Multivariate logistic regression modeling was performed to predict a positive EUS. Accuracy of the models was assessed by the area under the receiver-operating characteristic curve (AUROCC). RESULTS The diagnostic yield of EUS was 58.9% (95% confidence interval [CI], 51.7-66.1). The DORM65 scores of 5 predictors present before EUS with the best discrimination were a delayed EUS (defined as ≥82 days from the last episode of AP), obesity, not having had a repeated transabdominal US, male sex, and age ≥65 years at the time of EUS. For those at the lowest risk score group, the positive EUS rate was 13.0% compared with 100% in those at the highest risk group (relative risk, 7.67; P < .001). A score of 3 or more had a positive predictive value of 86.0% with a sensitivity of 34.9% and specificity of 91.9%. The model had a high predictive accuracy (AUROCC, .774; 95% CI, .707-.841). Adding 3 additional predictors (no cholecystectomy, no MRCP, and a single episode of AP) did not increase the accuracy significantly (AUROCC, .805; 95% CI, .742-.867). CONCLUSIONS DORM65 is easily calculated and accurately predicts a positive EUS in patients with IAP. Further validation is needed.
Collapse
Affiliation(s)
- Pedro Cortés
- Division of Internal Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Samuel O Antwi
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA; Division of Gastroenterology and Hepatology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Massimo Raimondo
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Baoan Ji
- Department of Cancer Biology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Yan Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| |
Collapse
|
12
|
Maranki JL, Schwaitzberg SD, Sharaiha RZ, Kushnir VM, Badurdeen DS, Kumbhari V, Gómez V, Kumta NA, Waye JD, Nieto J, Ujiki MB, Benias PC, Miller LS, Kedia P, Tarnasky P, Mathew A, Levenick JM, Inamdar S, Tharian B, Nersesova Y, Fredell L, Serra S, Kochman ML. Challenges of developing and executing a multi-site registry for a novel device with evolving indications for use. Surg Endosc 2022; 36:9123-9128. [PMID: 35920904 PMCID: PMC9362130 DOI: 10.1007/s00464-022-09392-7] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/06/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The introduction of new technologies in endoscopy has been met with uncertainty, skepticism, and lack of standardization or training parameters, particularly when disruptive devices or techniques are involved. The widespread availability of a novel endoscopic suturing device (OverStitch™) for tissue apposition has enabled the development of applications of endoscopic suturing. METHODS The American Gastroenterological Association partnered with Apollo Endosurgery to develop a registry to capture in a pragmatic non-randomized study the safety, effectiveness, and durability of endoscopic suturing in approximating tissue in the setting of bariatric revision and fixation of endoprosthetic devices. RESULTS We highlight the challenges of the adoption of novel techniques by examining the process of developing and executing this multicenter registry to assess real-world use of this endoscopic suturing device. We also present our preliminary data on the safety and effectiveness of the novel device as it is applied in the treatment of obesity. CONCLUSIONS The Prospective Registry for Trans-Orifice Endoscopic Suturing Applications (ES Registry) was an effective Phase 4, postmarketing registry aimed at capturing pragmatic, real-world use of a novel device. These findings serve to solidify the role of endoscopic suturing in clinical practice.
Collapse
Affiliation(s)
- Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA.
| | | | - Reem Z Sharaiha
- Gastroenterology Division, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Dilhana S Badurdeen
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Victoria Gómez
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Nikhil A Kumta
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jerome D Waye
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jose Nieto
- Division of Gastroenterology, Borland-Groover Clinic, Jacksonville, FL, USA
| | - Michael B Ujiki
- Division of Gastrointestinal and General Surgery, NorthShore University Health System, Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Petros C Benias
- Division of Gastroenterology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, NY, USA
| | - Larry S Miller
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY, USA
| | | | | | - Abraham Mathew
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - John M Levenick
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Sumant Inamdar
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Benjamin Tharian
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Lydia Fredell
- American Gastroenterological Association, Bethesda, MD, USA
| | - Sonya Serra
- American Gastroenterological Association, Bethesda, MD, USA
| | - Michael L Kochman
- Center for Endoscopic Innovation, Research, and Training, Gastroenterology Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
13
|
Vargas EJ, Kumbhari V, Chapman C, Teixeira A, Ujiki M, Thaemert B, Sharaiha RZ, Thompson CC, Abu Dayyeh BK. IBCOx-12 The Endoscopic Sleeve Gastroplasty Produces Durable Physiologic Changes: Results from a Randomized US Clinical Trial. Br J Surg 2022. [DOI: 10.1093/bjs/znac402.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Abstract
Background
Obesity is associated with faster gastric emptying and altered appetite. Endoscopic sleeve gastroplasty (ESG) has gained global adaptation, but our understanding of its physiologic mechanism of action and durability is limited. We sought to determine changes in gastric emptying, weight loss, and eating behaviors after ESG when compared to moderate-intensity lifestyle interventions (LS) in the short and long-term.
Methods
This is an a priori designed sub-study of a large ongoing multicenter US RCT (MERIT trial), where adults with BMI 30-40 kg/m2 were randomized to ESG versus moderate-intensity LS alone. We measured gastric emptying (T1/2) using a 4- hour gastric emptying breath test at baseline, 3 and 12 months into the study. We reported weight loss outcomes as percent total body weight lost (%TBWL). Changes in three eating behaviour domains (Cognitive Restraint [CR], Emotional Eating [EE], Uncontrolled Eating [UE]) were assessed using the Three-Factor Eating Questionnaire (TFEQ) at 6 months. The primary outcome was the change in T1/2 (minutes) at 3 months, and secondary outcomes were changes in T1/2 at 12 months, %TBWL, and eating behaviours. We used the t-test for the analyses. Linear regression was performed to determine the association between gastric emptying and weight loss.
Results
46 patients were randomized in the study (ESG n=26; LS n=20). Baseline characteristics were similar between the two groups. Out of n=46, n=43, and n=31 subjects have reached 3 and 12 months, respectively. Three patients dropped out of the study. At 3 months, T1/2 (minutes) was delayed in the ESG group (n=24) compared to the LS group (n=19) (170.8 vs. 87.5; p<0.0001). At 12 months, T1/2 was still delayed in the ESG group (n=17) vs. control group (n=14) (133.4 vs. 87.6; p=0.0005), and delayed compared to baseline. %TBWL in the ESG group was 12.3%, 15.1% and 15.7% at 3, 6 and 12 months (p <0.01 compared to baseline), while it was 2.3%, 2.2% and 0.3% (p>0.05 compared to baseline) in the LS group. Greater delays in gastric emptying at 3 months correlated with weight loss at all time points. (Figure 1) At 6 months, significant improvements in the EE and UE domains were seen in both groups, but for CR, only significant improvements were seen in the ESG group. Percent total fasting ghrelin, GLP-1, and PYY increased at 12 months in the ESG group compared to LS control (51%, 51%, 6.3% vs. -9%, 4%, -10.5%). Only 1 SAE managed endoscopically with full recovery was reported in the ESG group.
Conclusions
ESG produces sustained physiologic alterations in appetite regulatory pathways and durable weight-loss. This provides further evidence supporting the clinical adoption of the technique as a durable and effective obesity therapy.
Collapse
|
14
|
Osagiede O, Lukens FJ, Kumbhari V, Corral JE. Endoscopic Retrograde Cholangiopancreatography Performed by Trainees Is Not Associated with Increased Immediate Adverse Events or Technical Failure Rates. Dig Dis Sci 2022; 68:1747-1753. [PMID: 36355334 DOI: 10.1007/s10620-022-07753-9] [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: 04/12/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND/AIM Training endoscopists to perform endoscopic retrograde cholangiopancreatography (ERCP) is critical to address the increasing patient population with pancreatobiliary diseases. Concerns remain about ERCP safety and success involving trainees. We compared the technical success and immediate adverse events between ERCP with and without trainee involvement. METHODS Retrospective analysis of 28,271 ERCP procedures in a national sample of the United States over 12 years. Demographics, procedure and fluoroscopy time, visualization and cannulation of main structures, adverse events, and technical success rates were compared between ERCP with and without trainees. Categorical variables were compared using Pearson's chi-square test and continuous variables using a standard t-test. Univariate and multivariate regressions were performed adjusting for age, gender, ethnicity, US region, ASA class and clinical setting. RESULTS Approximately 49.5% of ERCPs had a trainee involved. The ampulla was visualized in 97.4% with trainee vs. 97.3% without trainee involvement (P = 0.858). The common bile duct was visualized and cannulated in 90.4% with trainees vs. 91.7% without trainees involved (P < 0.001). The ERCP was incomplete in 5.9% of cases with trainees vs. 6.4% without trainees involved (P = 0.207). Trainee participation added 8.7 min to average procedure time (aOR: 1.02, P < 0.001) and 2.0 min to fluoroscopy time (aOR: 1.00, P = 0.796). Adverse events (aOR: 0.89, P = 0.704) and technical success (aOR: 0.83, P = 0.571) were similar in both groups. CONCLUSIONS Trainee involvement leads to increased procedure duration but is not associated with increased immediate adverse events, or technical failure. Our study supports ERCP safety and success with trainee participation.
Collapse
Affiliation(s)
- Osayande Osagiede
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL, 32224, USA.
| | - Frank J Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL, 32224, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL, 32224, USA
| | - Juan E Corral
- Division of Gastroenterology and Hepatology, Presbyterian Healthcare Services, Albuquerque, NM, USA
| |
Collapse
|
15
|
Badurdeen DS, Kumbhari V, Gómez V. "Fast and furious": Endoscopic gastrojejunostomy revision for treatment of dumping syndrome? Gastrointest Endosc 2022; 96:645-647. [PMID: 35985859 DOI: 10.1016/j.gie.2022.06.023] [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: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Dilhana S Badurdeen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Victoria Gómez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| |
Collapse
|
16
|
Abu Dayyeh BK, Bazerbachi F, Vargas EJ, Sharaiha RZ, Thompson CC, Thaemert BC, Teixeira AF, Chapman CG, Kumbhari V, Ujiki MB, Ahrens J, Day C, Galvao Neto M, Zundel N, Wilson EB. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet 2022; 400:441-451. [PMID: 35908555 DOI: 10.1016/s0140-6736(22)01280-6] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [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: 06/11/2022] [Revised: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Endoscopic sleeve gastroplasty (ESG) is an endolumenal, organ-sparing therapy for obesity, with wide global adoption. We aimed to explore the efficacy and safety of ESG with lifestyle modifications compared with lifestyle modifications alone. METHODS We conducted a randomised clinical trial at nine US centres, enrolling individuals aged 21-65 years with class 1 or class 2 obesity and who agreed to comply with lifelong dietary restrictions. Participants were randomly assigned (1:1·5; with stratified permuted blocks) to ESG with lifestyle modifications (ESG group) or lifestyle modifications alone (control group), with potential retightening or crossover to ESG, respectively, at 52 weeks. Lifestyle modifications included a low-calorie diet and physical activity. Participants in the primary ESG group were followed up for 104 weeks. The primary endpoint at 52 weeks was the percentage of excess weight loss (EWL), with excess weight being that over the ideal weight for a BMI of 25 kg/m2. Secondary endpoints included change in metabolic comorbidities between the groups. We used multiple imputed intention-to-treat analyses with mixed-effects models. Our analyses were done on a per-protocol basis and a modified intention-to-treat basis. The safety population was defined as all participants who underwent ESG (both primary and crossover ESG) up to 52 weeks. FINDINGS Between Dec 20, 2017, and June 14, 2019, 209 participants were randomly assigned to ESG (n=85) or to control (n=124). At 52 weeks, the primary endpoint of mean percentage of EWL was 49·2% (SD 32·0) for the ESG group and 3·2% (18·6) for the control group (p<0·0001). Mean percentage of total bodyweight loss was 13·6% (8·0) for the ESG group and 0·8% (5·0) for the control group (p<0·0001), and 59 (77%) of 77 participants in the ESG group reached 25% or more of EWL at 52 weeks compared with 13 (12%) of 110 in the control group (p<0·0001). At 52 weeks, 41 (80%) of 51 participants in the ESG group had an improvement in one or more metabolic comorbidities, whereas six (12%) worsened, compared with the control group in which 28 (45%) of 62 participants had similar improvement, whereas 31 (50%) worsened. At 104 weeks, 41 (68%) of 60 participants in the ESG group maintained 25% or more of EWL. ESG-related serious adverse events occurred in three (2%) of 131 participants, without mortality or need for intensive care or surgery. INTERPRETATION ESG is a safe intervention that resulted in significant weight loss, maintained at 104 weeks, with important improvements in metabolic comorbidities. ESG should be considered as a synergistic weight loss intervention for patients with class 1 or class 2 obesity. This trial is registered with ClinicalTrials.gov, NCT03406975. FUNDING Apollo Endosurgery, Mayo Clinic.
Collapse
Affiliation(s)
- Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, MN, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham & Women's Hospital, Boston, MA, USA
| | | | - Andre F Teixeira
- Weight Loss and Bariatric Surgery Institute, Orlando Health, Orlando, FL, USA
| | - Christopher G Chapman
- Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, IL, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Chicago, IL, USA
| | | | - Courtney Day
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Manoel Galvao Neto
- Division of Gastrointestinal Endoscopy, ABC Medical School, São Paulo, Brazil
| | - Natan Zundel
- Department of Surgery, State University of New York, Buffalo, NY, USA
| | - Erik B Wilson
- Department of Surgery, The University of Texas Health Science Center, Houston, TX, USA
| |
Collapse
|
17
|
Sullivan S, Jirapinyo P, Kumbhari V. Clinical Care Pathway for the Risk Stratification and Management of Patients With Non-alcoholic Fatty Liver Disease. Gastroenterology 2022; 162:2131-2132. [PMID: 35032500 DOI: 10.1053/j.gastro.2022.01.013] [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: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 12/02/2022]
|
18
|
Fayad L, Schweitzer M, Itani M, Farha J, Hedjoudje A, Badurdeen D, Kumbhari V. Does endoscopic mean safer? A comparison of the short-term safety of endoscopic versus laparoscopic bariatric therapies. Endosc Int Open 2022; 10:E307-E310. [PMID: 35433204 PMCID: PMC9010103 DOI: 10.1055/a-1783-8573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 01/25/2021] [Accepted: 01/31/2022] [Indexed: 10/27/2022] Open
Abstract
Background and study aims There is minimal research on real-world, large-volume data comparing endoscopic bariatric therapy (EBT) to laparoscopic bariatric therapy (LBT). This study aimed to compare 30-day postoperative morbidity and mortality outcomes of primary EBT vs LBT using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Patients and methods Patients aged 18 to 80 with body mass index (BMI) 35 to 40 kg/m 2 undergoing primary procedures were included. Propensity score matching 1:50 was performed for EBT versus LBT based on age, sex, and BMI. Results We matched 211 EBTs with 9,059 LBTs. Operative length (63.9, 95 % confidence interval [CI]: 57.9, 69.8 versus 81.1, 95 % CI: 80.1, 82.1) and length of stay (0.49 days, 95 % CI: 0.29, 0.69 versus 1.43 days, 95 % CI: 1.41, 1.45) were significantly lower in the EBT group than the LBT group. There was no difference between EBT and LBT in the odds of readmission (odds ratio [OR] = 0.31, 95 % CI: 0.08, 1.25), reoperation (OR = 0.39, 95 % CI: 0.05, 2.84), or reintervention (OR = 0.98, 95 % CI: 0.24, 3.99). After controlling for chronic obstructive pulmonary disease, sleep apnea, history of myocardial infarction, hypertension requiring medications, and diabetes, EBT continued to be associated with lower odds of having any adverse event (AE) than LBT, with an OR of 0.34 (95 % CI: 0.16, 0.69). Subgroup analysis comparing EBT to laparoscopic sleeve gastrectomy (LSG) showed that EBT was associated with a lower risk having any AE than LSG, with an OR of 0.39 (95 % CI: 0.19, 0.79). Conclusions EBT is associated with a lower 30-day AE rate and shorter procedural length and length of stay than LBT, with similar rates of readmission, reintervention, and reoperation.
Collapse
Affiliation(s)
- Lea Fayad
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | | | - Mohamad Itani
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Jad Farha
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | | | - Dilhana Badurdeen
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | | |
Collapse
|
19
|
Oberbach A, Schlichting N, Hagl C, Lehmann S, Kullnick Y, Friedrich M, Köhl U, Horn F, Kumbhari V, Löffler B, Schmidt F, Joskowiak D, Born F, Saha S, Bagaev E. Four decades of experience of prosthetic valve endocarditis reflect a high variety of diverse pathogens. Cardiovasc Res 2022; 119:410-428. [PMID: 35420122 DOI: 10.1093/cvr/cvac055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 12/03/2021] [Revised: 03/04/2022] [Accepted: 03/23/2022] [Indexed: 01/18/2023] Open
Abstract
Prosthetic valve endocarditis (PVE) remains a serious condition with a high mortality rate. Precise identification of the PVE-associated pathogen/s and their virulence is essential for successful therapy, and patient survival. The commonly described PVE-associated pathogens are staphylococci, streptococci and enterococci, with Staphylococcus aureus being the most frequently diagnosed species. Furthermore, multi-drug resistance pathogens are increasing in prevalence, and continue to pose new challenges mandating a personalized approach. Blood cultures in combination with echocardiography are the most common methods to diagnose PVE, often being the only indication, it exists. In many cases, the diagnostic strategy recommended in the clinical guidelines does not identify the precise microbial agent and to frequently, false negative blood cultures are reported. Despite the fact that blood culture findings are not always a good indicator of the actual PVE agent in the valve tissue, only a minority of re-operated prostheses are subjected to microbiological diagnostic evaluation. In this review, we focus on the diversity and the complete spectrum of PVE-associated bacterial, fungal and viral pathogens in blood, and prosthetic heart valve, their possible virulence potential, and their challenges in making a microbial diagnosis. We are curious to understand if the unacceptable high mortality of PVE is associated with the high number of negative microbial findings in connection with a possible PVE. Herein, we discuss the possibilities and limits of the diagnostic methods conventionally used and make recommendations for enhanced pathogen identification. We also show possible virulence factors of the most common PVE-associated pathogens and their clinical effects. Based on blood culture, molecular biological diagnostics, and specific valve examination, better derivations for the antibiotic therapy as well as possible preventive intervention can be established in the future.
Collapse
Affiliation(s)
- Andreas Oberbach
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany.,Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany
| | - Nadine Schlichting
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany.,Munich Heart Alliance, Partner Site German Centre for Cardiovascular Disease (DZHK), Munich, Germany
| | - Stefanie Lehmann
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Yvonne Kullnick
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Maik Friedrich
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Ulrike Köhl
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Friedemann Horn
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Florida, USA
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Frank Schmidt
- Proteomics Core, Weill Cornell Medical Centre Qatar, Doha, Qatar
| | - Dominik Joskowiak
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Shekhar Saha
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Erik Bagaev
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| |
Collapse
|
20
|
Zhang LY, Canto MI, Schweitzer MA, Khashab MA, Kumbhari V. Gastric per-oral endoscopic myotomy (G-POEM) for the treatment of gastric sleeve stenosis: a feasibility and safety study. Endoscopy 2022; 54:376-381. [PMID: 34225370 DOI: 10.1055/a-1544-4923] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Traditional endoscopic treatments have limited success in gastric sleeve stenosis (GSS). Gastric peroral endoscopic myotomy (G-POEM) could conceivably obliterate the twist/angulation that causes GSS through a tunneled stricturotomy. We report early outcomes of G-POEM for GSS treatment. METHODS We retrospectively reviewed all patients with GSS treated with G-POEM at our center. The primary end point was clinical success, defined as symptom improvement with resumption of adequate oral intake, without requiring further intervention. RESULTS 13 patients (mean age 43 ± 10.9 years; 12 female) underwent G-POEM for predominantly helical (11/13, 85 %) GSS. Three (23 %) had concurrent sleeve leak and 10 (77 %) had prior GSS treatment. Two intraoperative complications occurred, with no deviation to the procedure; no major complications occurred. At median follow-up of 175 (interquartile range [IQR] 119-260) days, clinical success was achieved in 10 patients (77 %). Median Gastroparesis Cardinal Symptom Index score in responders decreased from 2.06 (IQR 1.5-2.8) to 0.39 (IQR 0.2-0.5). Three patients (23 %) required surgical revision. CONCLUSIONS G-POEM was feasible and safe, and may provide an alternative option for those averse to undergoing surgical revision for treatment of GSS.
Collapse
Affiliation(s)
- Linda Y Zhang
- Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Marcia I Canto
- Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Michael A Schweitzer
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Mouen A Khashab
- Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States.,Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, United States
| |
Collapse
|
21
|
Al Ghamdi SS, Farha J, Moran RA, Pioche M, Moll F, Yang DJ, Hernández Mondragón OV, Ujiki M, Wong H, Tantau A, Sedarat A, Fejleh MP, Chang K, Lee DP, Nieto JM, Andrawes S, Ginsberg GG, Saumoy M, Bapaye A, Dashatwar P, Aghaie Meybodi M, Lopez AC, Sanaei O, Yousaf MN, Jovani M, Ichkhanian Y, Brewer Gutierrez OI, Kumbhari V, O'Rourke AK, Lentsch EJ, Elmunzer BJ, Khashab MA. Zenker's peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker's diverticulum: a multicenter retrospective comparison. Endoscopy 2022; 54:345-351. [PMID: 34198355 DOI: 10.1055/a-1518-7223] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. METHODS Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. RESULTS 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P < 0.05). CONCLUSIONS There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.
Collapse
Affiliation(s)
- Sarah S Al Ghamdi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Robert A Moran
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Mathieu Pioche
- Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Frédéric Moll
- Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Dennis J Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | | | - Michael Ujiki
- Division of Minimally Invasive Surgery, NorthShore's Grainger Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Harry Wong
- Division of Minimally Invasive Surgery, NorthShore's Grainger Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Alina Tantau
- Department of Gastroenterology, the 4th Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alireza Sedarat
- Ronald Reagan UCLA Medical Center, UCLA Medical Center, Los Angeles, California, United States
| | - M Phillip Fejleh
- Ronald Reagan UCLA Medical Center, UCLA Medical Center, Los Angeles, California, United States
| | - Kenneth Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Irvine, California, United States
| | - David P Lee
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Irvine, California, United States
| | - Jose M Nieto
- Borland Groover Clinic Advance Therapeutic Endoscopy Center and Baptist Medical Center, Jacksonville, Florida, United States
| | - Sherif Andrawes
- Division of Gastroenterology and Hepatology, Staten Island University Hospital - Northwell Health, Staten Island, New York, United States
| | - Gregory G Ginsberg
- Endoscopic Services, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Monica Saumoy
- Endoscopic Services, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Parag Dashatwar
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Mohamad Aghaie Meybodi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Ariana C Lopez
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Olaya I Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Ashli K O'Rourke
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Eric J Lentsch
- Department of Otolaryngology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| |
Collapse
|
22
|
Kruse RL, Huang Y, Kumbhari V. How to Embrace Gene Therapy in Gastroenterology. Gastroenterology 2022; 162:1019-1023. [PMID: 35122741 DOI: 10.1053/j.gastro.2022.01.026] [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: 12/02/2022]
Affiliation(s)
- Robert L Kruse
- Joint Program in Transfusion Medicine, Harvard Medical School, Boston, Massachusetts
| | - Yuting Huang
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, Maryland
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida.
| |
Collapse
|
23
|
Keane MG, Mony S, Wood LD, Kumbhari V, Khashab MA. Prophylactic appendiceal retrograde intraluminal stent placement (PARIS). VideoGIE 2021; 6:552-554. [PMID: 34917867 PMCID: PMC8646081 DOI: 10.1016/j.vgie.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Margaret G Keane
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Shruti Mony
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Laura D Wood
- Sol Goldamn Pancreatic Cancer Research Center, Johns Hopkins University, Baltimore, Maryland
| | - Vivek Kumbhari
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Mouen A Khashab
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| |
Collapse
|
24
|
Kruse RL, Huang Y, Shum T, Bai L, Ding H, Wang ZZ, Selaru FM, Kumbhari V. Endoscopic-mediated, biliary hydrodynamic injection mediating clinically relevant levels of gene delivery in pig liver. Gastrointest Endosc 2021; 94:1119-1130.e4. [PMID: 34197834 PMCID: PMC8605992 DOI: 10.1016/j.gie.2021.06.016] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/18/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Gene therapy could provide curative therapies to many inherited monogenic liver diseases. Clinical trials have largely focused on adeno-associated viruses (AAVs) for liver gene delivery. These vectors, however, are limited by small packaging size, capsid immune responses, and inability to redose. As an alternative, nonviral, hydrodynamic injection through vascular routes can successfully deliver plasmid DNA (pDNA) into mouse liver but has achieved limited success in large animal models. METHODS We explored hydrodynamic delivery of pDNA through the biliary system into the liver of pigs using ERCP and a power injector to supply hydrodynamic force. Human factor IX (hFIX), deficient in hemophilia B, was used as a model gene therapy. RESULTS Biliary hydrodynamic injection was well tolerated without significant changes in vital signs, liver enzymes, hematology, or histology. No off-target pDNA delivery to other organs was detected by polymerase chain reaction. Immunohistochemistry revealed that 50.19% of the liver stained positive for hFIX after hydrodynamic injection at 5.5 mg pDNA, with every hepatic lobule in all liver lobes demonstrating hFIX expression. hFIX-positive hepatocytes were concentrated around the central vein, radiating outward across all 3 metabolic zones. Biliary hydrodynamic injection in pigs resulted in significantly higher transfection efficiency than mouse vascular hydrodynamic injection at matched pDNA per liver weight dose (32.7%-51.9% vs 18.9%, P < .0001). CONCLUSIONS Biliary hydrodynamic injection using ERCP can achieve higher transfection efficiency into hepatocytes compared with AAVs at magnitudes of less cost in a clinically relevant human-sized large animal. This technology may serve as a platform for gene therapy of human liver diseases.
Collapse
Affiliation(s)
- Robert L Kruse
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuting Huang
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, Maryland, USA
| | - Thomas Shum
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lu Bai
- Department of Biology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hui Ding
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zack Z Wang
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Florin M Selaru
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Division of Gastroenterology & Hepatology, Department of Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| |
Collapse
|
25
|
Itani MI, Oberbach A, Salimian KJ, Enderle M, Hahn H, Abbarh S, Kendrick K, Schlichting N, Anders RA, Besharati S, Farha J, Fayad L, Kalloo AN, Badurdeen D, Kumbhari V. Gastric Mucosal Devitalization (GMD): Using the Porcine Model to Develop a Novel Endoscopic Bariatric Approach. Obes Surg 2021; 32:381-390. [PMID: 34797503 DOI: 10.1007/s11695-021-05773-4] [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] [Received: 04/11/2021] [Revised: 10/10/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS As the pig model has similar gastrointestinal anatomy and physiology to humans, we used pigs to create a gastric mucosal devitalization (GMD) model in preparation for clinical translation of this technique as an endoscopic bariatric therapy (EBT). The aims of this study were to determine the ablation parameters and technique for a successful, safe, and feasible large surface area GMD that produces weight loss. METHODS We performed GMD using argon plasma coagulation (APC) in 3 phases. Phase 1 assessed the ablation energy required to accomplish selective mucosal ablation using ex vivo pig stomachs (n = 2). Phase 2 assessed the optimal percentage of mucosal surface area to be treated and was performed on 10 pigs. Phase 3 assessed feasibility, efficacy, and safety with 8 pigs randomized into GMD (n = 4) or sham (SH, n = 4) and survived for 1 month. Body weights (GMD, n = 4, SH, n = 4) were measured daily in phase 3 for 1 month, and relative body weights were calculated and analyzed using one-tailed Student's t-test. Percent body fat was compared between GMD and SH at baseline and 1 month post-GMD. RESULTS Phase 1 identified the optimal ablation parameters (120 W) that were then used in phase 2. Phase 2 revealed a trend that was suggestive that the optimal percent surface area to ablate was similar to that which is removed at laparoscopic sleeve gastrectomy. In phase 3, GMD was performed over 70% surface area of the greater curvature of the stomach in four pigs. GMD pigs had significantly lower relative body weight increase compared to SH at 1 month (1.375 ± 0.085 vs 1.575 ± 0.047, p = 0.0435). MRI showed a significantly lower body fat mass at 1 month in GMD pigs (5.9 ± 0.4% vs 12.7 ± 2.3%, p = 0.026) compared to SH. CONCLUSIONS GMD resulted in decreased weight gain in the GMD group as evidenced by a lower relative body weight at 1 month. GMD in an animal model appears to show promise as a potential weight loss therapy.
Collapse
Affiliation(s)
- Mohamad I Itani
- Department of Internal Medicine, Wayne State University, Detroit, MI, 48201, USA.,Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Andreas Oberbach
- Department of Diagnostics, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Kevan J Salimian
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | | | | | - Shahem Abbarh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Katherine Kendrick
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Nadine Schlichting
- Department of Diagnostics, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Robert A Anders
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Sepideh Besharati
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA. .,Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, 32224, USA.
| |
Collapse
|
26
|
Farha J, Gebran S, Itani MI, Simsek C, Abbarh S, Lopez A, Haq Z, Koller K, Dunlap M, Adam A, Khashab MA, Oberbach A, Schweitzer M, Badurdeen D, Kumbhari V. Transoral outlet reduction: could additional sutures cause more harm? Endoscopy 2021; 53:1059-1064. [PMID: 33254242 DOI: 10.1055/a-1325-4324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastrojejunal anastomosis (GJA). However, there is a paucity of literature pertaining to post-TORe stenosis as an adverse event. Our aim was to determine the rate of stenosis, its potential predictors, and other complications of DPSP TORe. METHODS We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019. RESULTS The adverse event rate of TORe was 17.1 % (n = 22), with a 13.3 % (n = 17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter pre- and post-TORe, the difference between these values, and procedure duration were not predictive of stenosis. Of patients who developed stenosis, 10 (58.8 %) responded to endoscopic balloon dilation and 7 (41.2 %) required stent placement. CONCLUSION As the DPSP technique is a challenging procedure, with high complication rate and limited benefit, it should not be used for TORe.
Collapse
Affiliation(s)
- Jad Farha
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Selim Gebran
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Mohamad I Itani
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Cem Simsek
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Shahem Abbarh
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Ariana Lopez
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Zadid Haq
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Kristen Koller
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Margo Dunlap
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Atif Adam
- Department of Mental Health at The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Andreas Oberbach
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Diagnostics, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Michael Schweitzer
- Department of Surgery, The Johns Hopkins Center for Bariatric Surgery, Baltimore, Maryland, United States
| | - Dilhana Badurdeen
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| |
Collapse
|
27
|
Shinn B, Boortalary T, Raijman I, Nieto J, Khara HS, Kumar SV, Confer B, Diehl DL, El Halabi M, Ichkhanian Y, Runge T, Kumbhari V, Khashab M, Tyberg A, Shahid H, Sarkar A, Gaidhane M, Bareket R, Kahaleh M, Piraka C, Zuchelli T, Law R, Sondhi A, Kedia P, Robbins J, Calogero C, Bakhit M, Chiang A, Schlachterman A, Kowalski T, Loren D. Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration. Gastrointest Endosc 2021; 94:727-732. [PMID: 33957105 DOI: 10.1016/j.gie.2021.04.022] [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: 01/18/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. METHODS We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. RESULTS Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. CONCLUSIONS Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.
Collapse
Affiliation(s)
- Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tina Boortalary
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida, USA
| | | | - S Vikas Kumar
- Geisinger Health System, Danville, Pennsylvania, USA
| | | | - David L Diehl
- Geisinger Health System, Danville, Pennsylvania, USA
| | - Maan El Halabi
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | | | - Thomas Runge
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Mouen Khashab
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Amy Tyberg
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Monica Gaidhane
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Romy Bareket
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Michel Kahaleh
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Cyrus Piraka
- Henry Ford Health System, Detroit, Michigan, USA
| | | | - Ryan Law
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Arjun Sondhi
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | - Justin Robbins
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cristina Calogero
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mena Bakhit
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Austin Chiang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Thomas Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Loren
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
28
|
Jovani M, Zhang L, Huang Y, Kumbhari V. Multi-layer endoscopic suturing: a novel method of gastric fistula closure. Endosc Int Open 2021; 9:E1520-E1523. [PMID: 34540544 PMCID: PMC8445670 DOI: 10.1055/a-1517-4405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/04/2021] [Indexed: 11/17/2022] Open
Abstract
Background and study aims Current endoscopic methods of treating gastric fistulas are either too complex or have high rates of recurrence. We aimed to provide a novel endoscopic method for robust fistula closure. Patients and methods This was a single-center, retrospective study of five patients who underwent multi-layer endoscopic suturing for closing of a chronic fistula (> 4 weeks). Devitalization of the fistula tract was achieved with argon plasma coagulation, followed by endoscopic suturing of the fistula. Then, endoscopic suturing of the gastric wall surrounding the fistula was performed, creating an overlay of healthy gastric mucosa around the fistula. Results Technical success (fistula closure on the day of the procedure) was achieved in all five patients, with no complications. After a median follow up of 5 months (range 2-23 months), there was a 100 % clinical success rate (no fistula recurrence). Conclusions Our single-operator method of multi-layer endoscopic suturing provides a robust fistula closure with minimal to no risk of recurrence. In light of limitations of current fistula closure methods, further investigations are warranted to better define long-term outcomes with it compared to alternative methods.
Collapse
Affiliation(s)
- Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Linda Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Yuting Huang
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States,Gastroenterology and Hepatology, Mayo Clinic, Florida, United States
| |
Collapse
|
29
|
Mehta A, Shah S, Dawod E, Hajifathalian K, Kumar R, Igel LI, Saunders KH, Kumbhari V, Farha J, Badurdeen D, Itani MI, Moore RL, Starpoli AA, Carr-Locke DL, Shukla A, Aronne LJ, Sharaiha RZ. Impact of Adjunctive Pharmacotherapy With Intragastric Balloons for the Treatment of Obesity. Am Surg 2021:31348211038579. [PMID: 34384255 DOI: 10.1177/00031348211038579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND We conducted this study to compare the weight loss outcome of intragastric balloons (IGBs) in conjunction with pharmacotherapy vs IGB and intensive lifestyle changes alone. METHODS This was a multicenter, non-randomized, retrospective study involving 4 academic hospitals. Patients underwent IGB placement with or without concomitant anti-obesity pharmacotherapy. The primary outcome was percent total weight loss (TBWL) after IGB placement at 6 and 12 months. RESULTS This study included 102 patients, with 23 patients (mean age 46.6 years, 82.6% female) treated with IGB/pharmacotherapy and 79 patients (mean age 46.0 years, 88.6% female) treated with IGB/lifestyle modifications. Patients had a 100% follow-up rate at 6 and 12 months. At 6 months following IGB placement, both groups achieved a similar %TBWL. At 12 months, %TBWL was greater in the IGB/pharmacotherapy group (12.6% ± 1.2 vs 9.7% ± 0.7, P = .04). 65.2% of patients achieved ≥10% TBWL at 12 months in the IGB/pharmacotherapy group, compared to 38.0% in the IGB/lifestyle group (P < .05). The proportion of patients that achieved ≥15% weight loss at 12 months was also significantly different between the IGB/pharmacotherapy and IGB/lifestyle groups (30.4% vs 20.3%, P < .05). DISCUSSION IGB with concomitant use of pharmacotherapy did not improve weight loss while the IGB was in place compared to IGB and lifestyle changes. However, patients receiving IGB with pharmacotherapy did have greater weight loss and diminished weight regain after balloon removal compared to those receiving just IGB and lifestyle changes.
Collapse
Affiliation(s)
- Amit Mehta
- Division of Gastroenterologyatology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Shawn Shah
- Division of Gastroenterologyatology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Enad Dawod
- Division of Gastroenterologyatology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Kaveh Hajifathalian
- Division of Gastroenterologyatology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Rekha Kumar
- Division of Endocrinology, Diabetes, & Metabolism, 159947Weill Cornell Medicine, New York, NY, USA
| | - Leon I Igel
- Division of Endocrinology, Diabetes, & Metabolism, 159947Weill Cornell Medicine, New York, NY, USA
| | - Katherine H Saunders
- Division of Endocrinology, Diabetes, & Metabolism, 159947Weill Cornell Medicine, New York, NY, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, 156400Mayo Clinic, Jacksonville, FL, USA
| | - Jad Farha
- Division of Gastroenterology and Hepatology, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohamad I Itani
- Division of Gastroenterology and Hepatology, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - David L Carr-Locke
- Division of Gastroenterologyatology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Alpana Shukla
- Division of Endocrinology, Diabetes, & Metabolism, 159947Weill Cornell Medicine, New York, NY, USA
| | - Louis J Aronne
- Division of Endocrinology, Diabetes, & Metabolism, 159947Weill Cornell Medicine, New York, NY, USA
| | - Reem Z Sharaiha
- Division of Gastroenterologyatology, 159947Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
30
|
Kumbhari V, Cummings DE, Kalloo AN, Schauer PR. AGA Clinical Practice Update on Evaluation and Management of Early Complications After Bariatric/Metabolic Surgery: Expert Review. Clin Gastroenterol Hepatol 2021; 19:1531-1537. [PMID: 33741500 DOI: 10.1016/j.cgh.2021.03.020] [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: 08/20/2020] [Revised: 01/20/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023]
Abstract
DESCRIPTION Endoscopic techniques are paramount in the identification and management of complications after surgery, though collaboration with other specialties is obligatory. Unfortunately, the evaluation and treatment algorithms are not standardized and there is a paucity of high-quality prospective studies to provide clarity regarding the best approach. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery. METHODS The best practice advice outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. BEST PRACTICE ADVICE 1: Clinicians performing endoscopic approaches to treat early major postoperative complications should do so in a multidisciplinary manner with interventional radiology and bariatric/metabolic surgery co-managing the patient. Daily communication is advised. BEST PRACTICE ADVICE 2: Clinicians embarking on incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a comprehensive knowledge of the indications, contraindications, risks, benefits, and outcomes of each of the endoscopic treatment techniques. They should also have knowledge of the risks and benefits of alternative methods such as surgical and interventional radiological based approaches. BEST PRACTICE ADVICE 3: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have expertise in interventional endoscopy techniques, including but not limited to: using concomitant fluoroscopy, stent deployment and retrieval, managing stenosis, and managing percutaneous drains. BEST PRACTICE ADVICE 4: Clinicians should screen all patients undergoing endoscopic management of bariatric/metabolic surgical complications and dietary intolerance for comorbid medical (nutrient deficiencies, infection, pulmonary embolism) and psychological (depression, anxiety) conditions. BEST PRACTICE ADVICE 5: Endoscopic approaches to managing complications of bariatric/metabolic surgery may be considered for patients in the immediate, early and late postoperative periods depending on hemodynamic stability. BEST PRACTICE ADVICE 6: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a detailed understanding of the pathophysiologic mechanisms initiating and perpetuating conditions such as staple-line leaks. This will allow for a prompt diagnosis and appropriate therapy to be targeted not only at the area of interest, but also any concomitant downstream stenosis. BEST PRACTICE ADVICE 7: Clinicians should recognize that the goal for endoscopic management of staple-line leaks are often not necessarily initial closure of the leak site, but rather techniques to promote drainage of material from the perigastric collection into the gastric lumen such that the leak site closes by secondary intention.
Collapse
Affiliation(s)
- Vivek Kumbhari
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.
| | - David E Cummings
- UW Medicine Diabetes Institute, University of Washington, Seattle, Washington; Weight Management Program, VA Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Anthony N Kalloo
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Philip R Schauer
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana
| |
Collapse
|
31
|
Ngamruengphong S, Ferri L, Aihara H, Draganov PV, Yang DJ, Perbtani YB, Jue TL, Munroe CA, Boparai ES, Mehta NA, Bhatt A, Kumta NA, Othman MO, Mercado M, Javaid H, Aadam AA, Siegel A, James TW, Grimm IS, DeWitt JM, Novikov A, Schlachterman A, Kowalski T, Samarasena J, Hashimoto R, Chehade NEH, Lee J, Chang K, Su B, Ujiki MB, Mehta A, Sharaiha RZ, Carr-Locke DL, Chen A, Chen M, Chen YI, Pourmousavi Khoshknab M, Wang R, Kerdsirichairat T, Tomizawa Y, von Renteln D, Kumbhari V, Khashab MA, Bechara R, Karasik M, Patel NJ, Fukami N, Nishimura M, Hanada Y, Wong Kee Song LM, Laszkowska M, Wang AY, Hwang JH, Friedland S, Sethi A, Kalloo AN. Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America. Clin Gastroenterol Hepatol 2021; 19:1611-1619.e1. [PMID: 32565290 DOI: 10.1016/j.cgh.2020.06.023] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/07/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. METHODS We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death. RESULTS Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD. CONCLUSIONS ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.
Collapse
Affiliation(s)
| | - Lorenzo Ferri
- Division of Thoracic Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Dennis J Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Terry L Jue
- Division of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
| | - Craig A Munroe
- Division of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
| | - Eshandeep S Boparai
- Division of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
| | - Neal A Mehta
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Mohamed O Othman
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, Texas
| | - Michael Mercado
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, Texas
| | - Huma Javaid
- Division of Gastroenterology and Hepatology, Baylor University Medical Center, Houston, Texas
| | - Abdul Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University Medical Center, Chicago, Illinois
| | - Amanda Siegel
- Division of Gastroenterology and Hepatology, Northwestern University Medical Center, Chicago, Illinois
| | - Theodore W James
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John M DeWitt
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Aleksey Novikov
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jason Samarasena
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Rintaro Hashimoto
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Nabil El Hage Chehade
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - John Lee
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Kenneth Chang
- Division of Gastroenterology and Hepatology, University of California, Irvine, Irvine, California
| | - Bailey Su
- Department of Surgery, NorthShore University Health System, Evanston, Illinois
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, Illinois
| | - Amit Mehta
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - David L Carr-Locke
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Alex Chen
- Division of Thoracic Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Michael Chen
- Division of Thoracic Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Rui Wang
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Yutaka Tomizawa
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington
| | - Daniel von Renteln
- Division of Gastroenterology, University of Montreal Hospital Research Centre, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Robert Bechara
- Division of Gastroenterology, Queen's University, Kingston, Ontario, Canada
| | - Michael Karasik
- Department of Gastroenterology, Hartford Hospital, Hartford, Connecticut
| | - Neej J Patel
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Makoto Nishimura
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yuri Hanada
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Monika Laszkowska
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Joo Ha Hwang
- Department of Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Shai Friedland
- Department of Gastroenterology, Hartford Hospital, Hartford, Connecticut
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York
| | - Antony N Kalloo
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
32
|
Staudenmann DA, Sui Z, Saxena P, Kaffes AJ, Marinos G, Kumbhari V, Aepli P, Sartoretto A. Endoscopic bariatric therapies for obesity: a review. Med J Aust 2021; 215:183-188. [PMID: 34333788 DOI: 10.5694/mja2.51179] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 12/24/2022]
Abstract
▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two-thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15-20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.
Collapse
Affiliation(s)
- Dominic A Staudenmann
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW.,Praxis Balsiger Seibold und Partner, Bern, Switzerland.,Université de Fribourg, Fribourg, Switzerland
| | | | | | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW
| | | | | | | | | |
Collapse
|
33
|
Kumbhari V, le Roux CW, Cohen RV. Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review. Obes Surg 2021; 31:4624-4633. [PMID: 34331187 DOI: 10.1007/s11695-021-05603-7] [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] [Received: 04/07/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.
Collapse
Affiliation(s)
- Vivek Kumbhari
- Department of Gastroenterology and Hepatology, The Johns Hopkins University, 1800 Orleans St, Suite 7125B, Baltimore, MD, USA. .,Department of Gastroenterology and Hepatology, Mayo Clinic, 1800 Orleans St, Suite 7125B, Florida, FL, USA.
| | - Carel W le Roux
- Diabetes Complications Research Centre, University College Dublin, Dublin, Ireland
| | - Ricardo V Cohen
- The Center for the Treatment of Obesity and Diabetes, Hospital Oswaldo Cruz, Sao Paulo, Brazil
| |
Collapse
|
34
|
Gomez V, Badurdeen D, Kumbhari V. Rejuvenate and repopulate: renaissance of the duodenum. Gastrointest Endosc 2021; 94:121-123. [PMID: 34148569 DOI: 10.1016/j.gie.2021.01.039] [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: 01/15/2021] [Accepted: 01/29/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Victoria Gomez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
35
|
Farha J, McGowan C, Hedjoudje A, Itani MI, Abbarh S, Simsek C, Ichkhanian Y, Vulpis T, James TW, Fayad L, Khashab MA, Oberbach A, Badurdeen D, Kumbhari V. Endoscopic sleeve gastroplasty: suturing the gastric fundus does not confer benefit. Endoscopy 2021; 53:727-731. [PMID: 32777827 DOI: 10.1055/a-1236-9347] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 12/31/2022]
Abstract
BACKGROUND : There is heterogeneity regarding the technical aspects of endoscopic sleeve gastroplasty (ESG), such as applying fundal sutures. Our aim was to determine whether ESG with fundal suturing (ESG-FS) affects weight loss and the serious adverse event (SAE) rate when compared with ESG with no fundal suturing (ESG-NFS). METHODS: We conducted a two-center retrospective analysis of 247 patients who underwent ESG with or without fundal suturing. The primary outcome was percentage excess weight loss (%EWL) at 3, 6, and 12 months post-ESG. The secondary outcomes included the SAE rate and procedure duration. RESULTS: At 3, 6, and 12-months, ESG-NFS had a significantly greater mean %EWL compared with ESG-FS (38.4 % [standard deviation (SD) 15.3 %] vs. 31.2 % [SD 13.9 %], P = 0.001; 54.7 % [SD 19.2 %] vs. 37.7 % [SD 17.3 %], P < 0.001; 65.3 % [SD 21.1 %] vs. 40.6 % [SD 23.5 %], P < 0.001, respectively). There was no statistically significant difference in the SAE rates for ESG-NFS (n = 2; 2.0 %) and ESG-FS (n = 4; 2.6 %; P > 0.99). The mean procedure time was significantly shorter in the ESG-NFS group at 59.1 minutes (SD 32.7) vs. 93.0 minutes (35.5; P < 0.001), and a lower mean number of sutures were used, with 5.7 (SD 1.1) vs. 8.4 (SD 1.6; P < 0.001). CONCLUSION : ESG-NFS demonstrated greater efficacy and shorter procedure duration. Therefore, fundal suturing should not be performed.
Collapse
Affiliation(s)
- Jad Farha
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Abdellah Hedjoudje
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mohamad I Itani
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Shahem Abbarh
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Cem Simsek
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Trish Vulpis
- WakeMed Cary Hospital, Cary, North Carolina, USA
| | - Theodore W James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Andreas Oberbach
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| |
Collapse
|
36
|
Benias PC, Kumbhari V, Kumta NA, Sethi A, D’Souza LS, Tyberg A, Brewer Gutierrez O, Miller LS, Carr-Locke DL, Khashab MA. Single session per oral endoscopic myotomy and trans oral incisionless fundoplication - can we prevent reflux in patients with achalasia? Endosc Int Open 2021; 9:E828-E835. [PMID: 34079863 PMCID: PMC8159615 DOI: 10.1055/a-1395-5667] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 09/18/2020] [Accepted: 11/12/2020] [Indexed: 12/19/2022] Open
Abstract
Background and study aims The rate of gastroesophageal reflux disease (GERD) after per oral endoscopic myotomy (POEM) is concerning. Endoscopic anti-reflux methods, such as Trans Oral Incisionless Fundoplication (TIF), are crucial for the long-term success of POEM, especially if they can be performed in the same session. Methods We completed a proof-of-concept canine pilot study (n = 6) to assess safety and feasibility of POEM and TIF in a single session (POEM-TIF). Subsequently, POEM-TIF was also performed in patients with achalasia (n = 5). Herein, we report on the safety, technical and clinical success of the first-in-human cases with symptom follow-up at 1, 3 and 6 months and pH testing at 6 months. Results POEM was completed successfully in six canines (3 anterior and 3 posterior myotomies), followed by TIF in the same session. Necropsy and extensive testing demonstrated no evidence of mucosal injury and no leaks. The reconstructed valve was 220 to 240 degrees, 3 to 4 cm in length, and resulted in concomitant esophageal lengthening (2-5 cm). Using similar principles, the first-in-human cases were performed without intraprocedural or delayed adverse events. pH testing at 6 months showed that four of five patients had no evidence of GERD (DeMeester > 14.72), and in one case, there was evidence of esophagitis. Conclusions Single session POEM-TIF appears to be safe and feasible. Early clinical human data suggests that it may be able to reduce post POEM GERD, however the additional secondary benefits such as lengthening and straightening of the esophagus, may prove to be equally important for the long-term success of POEM.
Collapse
Affiliation(s)
- Petros C. Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Nikhil A. Kumta
- Division of Gastroenterology and Hepatology, Mount Sinai, New York, New York, United States.
| | - Amrita Sethi
- Division of Gastroenterology, Columbia University Medical Center, New York, New York.
| | - Lionel S. D’Souza
- Division of Gastroenterology and hepatology, Stony Brook School of Medicine, East Setauket, New York, United States
| | - Amy Tyberg
- Department of Gastroenterology, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, United States.
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Larry S. Miller
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, United States
| | - David L. Carr-Locke
- Division of Gastroenterology and Hepatology, Weil Cornell School of Medicine, New York Hospital, New York, New York, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| |
Collapse
|
37
|
Moran RA, Gutierrez OIB, Rahden B, Chang K, Ujiki M, Yoo IK, Gulati S, Romanelli J, Al-Nasser M, Shimizu T, Hedberg MH, Cho JY, Hayee B, Desilets D, Filser J, Fortinsky K, Haji A, Fayad L, Sanaei O, Dbouk M, Kumbhari V, Wolf BJ, Elmunzer BJ, Khashab MA. Impedance planimetry values for predicting clinical response following peroral endoscopic myotomy. Endoscopy 2021; 53:570-577. [PMID: 33147642 PMCID: PMC8395534 DOI: 10.1055/a-1268-7713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/21/2022]
Abstract
BACKGROUND There is growing interest in developing impedance planimetry as a tool to enhance the clinical outcomes for endoscopic and surgical management of achalasia. The primary aim of this study was to determine whether impedance planimetry measurements can predict clinical response and reflux following peroral endoscopic myotomy (POEM). METHODS A multicenter cohort study of patients with achalasia undergoing POEM was established from prospective databases and retrospective chart reviews. Patients who underwent impedance planimetry before and after POEM were included. Clinical response was defined as an Eckardt score of ≤ 3. Tenfold cross-validated area under curve (AUC) values were established for the different impedance planimetry measurements associated with clinical response and reflux development. RESULTS Of the 290 patients included, 91.7 % (266/290) had a clinical response and 39.4 % (108/274) developed reflux following POEM. The most predictive impedance planimetry measurements for a clinical response were: percent change in cross-sectional area (%ΔCSA) and percent change in distensibility index (%ΔDI), with AUCs of 0.75 and 0.73, respectively. Optimal cutoff values for %ΔCSA and %ΔDI to determine a clinical response were a change of 360 % and 272 %, respectively. Impedance planimetry values were much poorer at predicting post-POEM reflux, with AUCs ranging from 0.40 to 0.62. CONCLUSION Percent change in CSA and distensibility index were the most predictive measures of a clinical response, with a moderate predictive ability. Impedance planimetry values for predicting reflux following POEM showed weak predictive capacity.
Collapse
Affiliation(s)
- Robert A. Moran
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States,Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Olaya I. Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Burkhard Rahden
- Department of Surgery Paracelsus, Medical Private Unviersity, Salzburg, Austria
| | - Kenneth Chang
- Department of Gastroenterology, University of California Irvine Health, Irvine, California, United States
| | - Michael Ujiki
- Department of Gastroenterology, North Shore University Health System, Evanston, Illinois, United States
| | - In Kyung Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Shraddha Gulati
- Department of Gastroenterology, King’s College Hospital, London, United Kingdom
| | - John Romanelli
- Department of Gastroenterology, University of Massachusetts Medical School/Baystate, Baystate Medical Center, Springfield, Massachusetts, United States
| | - Mohammed Al-Nasser
- Department of Surgery Paracelsus, Medical Private Unviersity, Salzburg, Austria
| | - Toshitaka Shimizu
- Department of Gastroenterology, University of California Irvine Health, Irvine, California, United States
| | - Mason H. Hedberg
- Department of Gastroenterology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Joo Young Cho
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Bu Hayee
- Department of Gastroenterology, King’s College Hospital, London, United Kingdom
| | - David Desilets
- Department of Gastroenterology, University of Massachusetts Medical School/Baystate, Baystate Medical Center, Springfield, Massachusetts, United States
| | - Jörg Filser
- Department of Surgery, InnKlinikum Altötting, Altötting, Germany
| | - Kyle Fortinsky
- Department of Gastroenterology, University of California Irvine Health, Irvine, California, United States
| | - Amyn Haji
- Department of Gastroenterology, King’s College Hospital, London, United Kingdom
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Bethany J. Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| |
Collapse
|
38
|
Badurdeen D, Hoff AC, Hedjoudje A, Adam A, Itani MI, Farha J, Abbarh S, Kalloo AN, Khashab MA, Singh VK, Oberbach A, Neto MG, Barrichello S, Kumbhari V. Endoscopic sleeve gastroplasty plus liraglutide versus endoscopic sleeve gastroplasty alone for weight loss. Gastrointest Endosc 2021; 93:1316-1324.e1. [PMID: 33075366 DOI: 10.1016/j.gie.2020.10.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 05/04/2020] [Accepted: 10/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic sleeve gastroplasty (ESG) has been shown to be effective for inducing weight loss. The efficacy of liraglutide, a glucagon-like peptide-1 agonist, to augment weight loss after ESG is unknown. This study aims to evaluate the efficacy of ESG and liraglutide (ESG-L) compared with ESG alone. METHODS This was a retrospective study of prospectively collected data from patients undergoing ESG at 3 outpatient clinics in Brazil between November 2017 and July 2018. Liraglutide was offered to all patients 5 months after ESG. Patients who opted to take liraglutide (ESG-L) were matched 1:1 to patients who declined it (ESG). The primary outcome was percent total body weight loss (%TBWL), and percent excess weight loss (%EWL) 7 months after initiation of liraglutide (12 months after ESG). The secondary outcome was change in percent body fat 12 months after ESG. ESG technique and postprocedure follow-up were identical at all 3 sites. RESULTS Propensity score matching yielded 26 matched pairs. Adjusted comparisons between the 2 groups showed that patients who opted to take liraglutide had a superior mean %TBWL 7 months after initiation of liraglutide (ESG-L) compared with those who declined it (ESG) (24.72% ± 2.12% vs 20.51% ± 1.68%, respectively; P < .001). ESG-L had a statistically greater reduction in percent body fat compared with ESG (7.85% ± 1.26% vs 10.54% ± 1.88%, respectively; P < .001) at 12 months. CONCLUSIONS Addition of liraglutide at 5 months results in superior weight loss and improved efficacy as demonstrated by decreased body fat 12 months after ESG. Further studies are imperative to determine optimal dose, timing, and duration of liraglutide.
Collapse
Affiliation(s)
- Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Abdellah Hedjoudje
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Atif Adam
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad I Itani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Shahem Abbarh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Andrea Oberbach
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Manoel Galvao Neto
- Division of Gastrointestinal Endoscopy, ABC Medical School, São Paulo, Brazil
| | | | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
39
|
Wang R, Mohapatra S, Jovani M, Akshintala VS, Kamal A, Brewer OG, Kumbhari V, Shin EJ, Canto MI, Khashab MA, Singh VK, Lennon AM, Kalloo AN, Ngamruengphong S. Risk factors for lymph node metastasis and survival of patients with nonampullary duodenal carcinoid tumors treated with endoscopic therapy versus surgical resection: analysis of the Surveillance, Epidemiology, and End Results program. Gastrointest Endosc 2021; 93:1384-1392. [PMID: 33347833 DOI: 10.1016/j.gie.2020.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 09/07/2020] [Accepted: 12/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic therapy (ET) has been used to treat nonampullary duodenal neuroendocrine tumors (NAD-NETs) ≤10 mm in size, but data on long-term outcomes are limited. In addition, management of 11- to 19-mm NAD-NETs is not well defined because of variable estimates of risk of metastasis. We aimed to determine the prevalence and risk factors of metastasis of NAD-NETs ≤19 mm and evaluate the long-term survival of patients after ET as compared with radical surgery. METHODS The Surveillance Epidemiology and End Result database was used to identify 1243 patients with T1-2 histologically confirmed NAD-NETs ≤19 mm in size. Cancer-specific survival (CSS) and overall survival (OS) were calculated. RESULTS Overall, 4.8% of cases had metastasis at the time of diagnosis, with lower prevalence in ≤10-mm lesions (3.1%) versus 11- to 19-mm lesions (11.7%, P < .001). The risk factors for metastases included invasion to the muscularis propria (odds ratio, 25.95; 95% confidence interval, 9.01-76.70), age <65 years (odds ratio, 1.93), submucosal involvement (odds ratio, 3.1), and 11 to 19 mm in size (vs ≤10 mm). In patients with well- to moderately differentiated T1-2N0M0 NAD-NETs ≤19 mm confined to the mucosa/submucosa who underwent ET or surgery, the 5-year CSS was 100%. The 5-year OS was similar between the ≤10-mm and 11- to 19-mm groups (86.6% vs 91.0%, P = .31) and the ET and surgery groups (87.4% vs 87.5%, P = .823). CONCLUSIONS In NAD-NETs, invasion to the muscularis propria is the strongest risk factor for metastasis. In the absence of metastasis, in lesions with well/moderate differentiation and without muscle invasion, ET is adequate for NAD-NETs ≤10 mm and is a viable option for 11- to 19-mm lesions.
Collapse
Affiliation(s)
- Rui Wang
- Gastroenterology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Manol Jovani
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Venkata S Akshintala
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Olaya Gutierrez Brewer
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcia I Canto
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anne Marie Lennon
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anthony Nicholas Kalloo
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
40
|
Runge TM, Chiang AL, Kowalski TE, James TW, Baron TH, Nieto J, Diehl DL, Krafft MR, Nasr JY, Kumar V, Khara HS, Irani S, Patel A, Law RJ, Loren DE, Schlachterman A, Hsueh W, Confer BD, Stevens TK, Chahal P, Al-Haddad MA, Mir FF, Pleskow DK, Huggett MT, Paranandi B, Trindade AJ, Brewer-Gutierrez OI, Ichkhanian Y, Dbouk M, Kumbhari V, Khashab MA. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study. Endoscopy 2021; 53:611-618. [PMID: 32882722 DOI: 10.1055/a-1254-3942] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 02/07/2023]
Abstract
BACKGROUND Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered. METHODS This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula. RESULTS 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases. CONCLUSIONS The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.
Collapse
Affiliation(s)
- Thomas M Runge
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Austin L Chiang
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Theodore W James
- Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Jose Nieto
- Borland Groover Clinic, Advanced Therapeutic Endoscopy Center, Jacksonville, Florida, USA
| | - David L Diehl
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Matthew R Krafft
- Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
| | - John Y Nasr
- Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
| | - Vikas Kumar
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Harshit S Khara
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Arpan Patel
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan J Law
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - David E Loren
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alex Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - William Hsueh
- Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
| | - Bradley D Confer
- Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Tyler K Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Prabhleen Chahal
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Fahad Faisal Mir
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | - Douglas K Pleskow
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | - Matthew T Huggett
- Department of Gastroenterology, St. James' University Hospital, Leeds, UK
| | - Bharat Paranandi
- Department of Gastroenterology, St. James' University Hospital, Leeds, UK
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York, USA
| | - Olaya I Brewer-Gutierrez
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
41
|
Zhang LY, Runge TM, Ichkhanian Y, Kumbhari V, Khashab MA. Percutaneous transcystic cholangioscopy-assisted rendezvous ERCP in a hostile abdomen. VideoGIE 2021; 6:215-218. [PMID: 34027251 PMCID: PMC8117940 DOI: 10.1016/j.vgie.2021.01.012] [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: 10/27/2022] Open
Abstract
Video 1Percutaneous transcystic cholangioscopy-assisted rendezvous ERCP in a hostile abdomen.
Collapse
Affiliation(s)
- Linda Y Zhang
- Division of Gastroenterology & Hepatology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Thomas M Runge
- Division of Gastroenterology & Hepatology, Johns Hopkins Medicine, Baltimore, Maryland.,Division of Gastroenterology, Hepatology & Nutrition, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yervant Ichkhanian
- Division of Gastroenterology & Hepatology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Vivek Kumbhari
- Division of Gastroenterology & Hepatology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Mouen A Khashab
- Division of Gastroenterology & Hepatology, Johns Hopkins Medicine, Baltimore, Maryland
| |
Collapse
|
42
|
Hedjoudje A, Farha J, Cheurfa C, Grabar S, Weiss E, Badurdeen D, Kumbhari V, Prat F, Levy P, Piton G. Serum phosphate is associated with mortality among patients admitted to ICU for acute pancreatitis. United European Gastroenterol J 2021; 9:534-542. [PMID: 33951327 PMCID: PMC8259433 DOI: 10.1002/ueg2.12059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/27/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIMS Routine laboratory tests can be useful predictors in the early assessment of the severity and mortality of acute pancreatitis (AP). The aim of this study was to evaluate the accuracy of clinical and laboratory parameters for the prediction of mortality among patients admitted to the intensive care unit (ICU) for AP. METHODS We conducted a retrospective analysis of prospectively collected data from Beth Israel Deaconess Hospital made publicly available to examine the relationship between routine clinical and laboratory parameters with respect to mortality for AP. Cox proportional hazard ratio was used to evaluate the impact of several routine laboratory markers on mortality. Receiver operation characteristic (ROC) curve was performed to determine the accuracy of diagnosis of laboratory tests by using area under curve (AUC) for the respective analysis. RESULTS In total, 499 patients were admitted to the ICU for AP. Several factors for predicting mortality in AP at admission were identified in the multivariate analysis: alkaline phosphatase hazard ratio (HR) = 1.00 (1.00-1.00, p = 0.024), anion gap HR = 1.09 (1.00-1.20, p = 0.047), bilirubin total HR = 1.11 (1.06-1.17, p < 0.001), calcium total HR = 0.59 (0.42-0.84, p = 0.004), phosphate HR = 1.51 (1.18-1.94, p = 0.001), potassium HR = 1.91 (1.03-3.55, p = 0.041), white blood cells HR = 1.04 (1.00-1.07, p = 0.028). The AUC of serum phosphate level for mortality was 0.7 in the ROC analysis. The optimal cut-off value of serum phosphate level for prediction of mortality was 3.78 mg/dl (sensitivity, 0.58; specificity, 0.78). CONCLUSION In this large cohort, we identified baseline serum phosphate as the most valuable single routine laboratory test for predicting mortality in AP. Future prospective studies are required to confirm these results.
Collapse
Affiliation(s)
- Abdellah Hedjoudje
- DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Jad Farha
- Division of Gastro-enterology, Johns Hopkins Hospital, Baltimore, USA
| | - Chérifa Cheurfa
- Service de Réanimation Chirurgicale, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Sophie Grabar
- INSERM UMR-S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Emmanuel Weiss
- Service de Réanimation Chirurgicale, DMU PARABOL, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Dilhana Badurdeen
- Division of Gastro-enterology, Johns Hopkins Hospital, Baltimore, USA
| | - Vivek Kumbhari
- Division of Gastro-enterology, Johns Hopkins Hospital, Baltimore, USA
| | - Frédéric Prat
- DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Philippe Levy
- DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Gaël Piton
- Service de Réanimation Médicale, CHRU Jean Minjoz, Besançon, France
| |
Collapse
|
43
|
Huang Y, Kruse RL, Ding H, Itani MI, Morrison J, Wang ZZ, Selaru FM, Kumbhari V. Parameters of biliary hydrodynamic injection during endoscopic retrograde cholangio-pancreatography in pigs for applications in gene delivery. PLoS One 2021; 16:e0249931. [PMID: 33909609 PMCID: PMC8081268 DOI: 10.1371/journal.pone.0249931] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/27/2021] [Indexed: 11/23/2022] Open
Abstract
The biliary system is routinely accessed for clinical purposes via endoscopic retrograde cholangiopancreatography (ERCP). We previously pioneered ERCP-mediated hydrodynamic injection in large animal models as an innovative gene delivery approach for monogenic liver diseases. However, the procedure poses potential safety concerns related mainly to liver or biliary tree injury. Here, we sought to further define biliary hydrodynamic injection parameters that are well-tolerated in a human-sized animal model. ERCP was performed in pigs, and hydrodynamic injection carried out using a novel protocol to reduce duct wall stress. Each pig was subjected to multiple repeated injections to expedite testing and judge tolerability. Different injection parameters (volume, flow rate) and injection port diameters were tested. Vital signs were monitored throughout the procedure, and liver enzyme panels were collected pre- and post-procedure. Pigs tolerated repeated biliary hydrodynamic injections with only occasional, mild, isolated elevation in aspartate aminotransferase (AST), which returned to normal levels within one day post-injection. All other liver tests remained unchanged. No upper limit of volume tolerance was reached, which suggests the biliary tree can readily transmit fluid into the vascular space. Flow rates up to 10 mL/sec were also tolerated with minimal disturbance to vital signs and no anatomic rupture of bile ducts. Measured intrabiliary pressure was up to 150 mmHg, and fluid-filled vesicles were induced in liver histology at high flow rates, mimicking the changes in histology observed in mouse liver after hydrodynamic tail vein injection. Overall, our investigations in a human-sized pig liver using standard clinical equipment suggest that ERCP-guided hydrodynamic injection will be safely tolerated in patients. Future investigations will interrogate if higher flow rates and pressure mediate higher DNA delivery efficiencies.
Collapse
Affiliation(s)
- Yuting Huang
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, Maryland, United States of America
| | - Robert L. Kruse
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Hui Ding
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mohamad I. Itani
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jonathan Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Zack Z. Wang
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Florin M. Selaru
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail: (VK); (FMS)
| | - Vivek Kumbhari
- Division of Gastroenterology & Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Division of Gastroenterology & Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, United States of America
- * E-mail: (VK); (FMS)
| |
Collapse
|
44
|
Kumbhari V. Why are weight loss outcomes unequal despite similar reductions in gastric volume? Endoscopy 2021; 53:244-245. [PMID: 33631822 DOI: 10.1055/a-1290-7639] [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)
- Vivek Kumbhari
- Department of Bariatric Endoscopy, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
45
|
Maselli DB, Alqahtani AR, Abu Dayyeh BK, Elahmedi M, Storm AC, Matar R, Nieto J, Teixeira A, Al Khatry M, Neto MG, Kumbhari V, Vargas EJ, Jaruvongvanich V, Mundi MS, Deshmukh A, Itani MI, Farha J, Chapman CG, Sharaiha R. Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study. Gastrointest Endosc 2021; 93:122-130. [PMID: 32473252 DOI: 10.1016/j.gie.2020.05.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 01/11/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort. METHODS Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months. RESULTS Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation. CONCLUSIONS R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.
Collapse
Affiliation(s)
- Daniel B Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aayed R Alqahtani
- Department of Surgery, College of Medicine, King Saud University, and New You Medical Center, Riyadh, Saudi Arabia
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Elahmedi
- Department of Surgery, College of Medicine, King Saud University, and New You Medical Center, Riyadh, Saudi Arabia
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Reem Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida
| | - Andre Teixeira
- Orlando Regional Medical Center, Orlando Health, Orlando, Florida, USA
| | - Maryam Al Khatry
- Department of Gastroenterology, Obaidulla Hospital, Ras Al Khaimah, United Arab Emirates
| | | | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Mohamad I Itani
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Jad Farha
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Christopher G Chapman
- University of Chicago Medicine, Center for Endoscopic Research and Therapeutics, Chicago, Illinois
| | - Reem Sharaiha
- Department of Gastroenterology, Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
46
|
Hedjoudje A, Cheurfa C, Farha J, Jaïs B, Aubert A, Lorenzo D, Maire F, Badurdeen D, Kumbhari V, Prat F. Safety of different electrocautery modes for endoscopic sphincterotomy: a Bayesian network meta-analysis. Ther Adv Gastrointest Endosc 2021; 14:26317745211062983. [PMID: 34993472 PMCID: PMC8725216 DOI: 10.1177/26317745211062983] [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] [Received: 01/12/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background and aims: Post-endoscopic retrograde cholangiopancreatography acute pancreatitis (PAP)
and post-sphincterotomy hemorrhage are known adverse events of
post-endoscopic retrograde cholangiopancreatography. Various electrosurgical
currents can be used for endoscopic sphincterotomy. The extent to which this
influences adverse events remains unclear. We assessed the comparative
safety of different electrosurgical currents, through a Bayesian network
meta-analysis of published studies merging direct and indirect comparison of
trials. Methods: We performed a Bayesian random-effects network meta-analysis of randomized
controlled trials that compared the safety of different electrocautery modes
for endoscopic sphincterotomy. Results: Nine studies comparing four electrocautery modes (blended cut, pure cut,
endocut, and pure cut followed by blended cut) with a combined enrollment of
1615 patients were included. The pooled results of the network meta-analysis
did not show a significant difference in preventing post-sphincterotomy
pancreatitis when comparing electrocautery modes. However, pure cut was
associated with a statistically significant increased risk of bleeding
compared with endocut [relative risk = 4.30; 95% confidence interval
(1.53–12.87)]. On the other hand, the pooled results of the network
meta-analysis showed no significant difference in prevention of bleeding
when comparing blended cut versus endocut, pure cut
followed by blended cut versus endocut, pure cut followed
by blended cut versus blended cut, pure cut
versus blended cut, and pure cut
versus pure cut followed by blended cut. The results of
rank probability found that endocut was most likely to be ranked the
best. Conclusion: No electrocautery mode was superior to another with regard to preventing PAP.
Endocut was superior with respect to preventing bleeding. Therefore, we
suggest performing endoscopic sphincterotomy with endocut.
Collapse
Affiliation(s)
- Abdellah Hedjoudje
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, 100 boulevard du Général Leclerc, 92110 Clichy, France. Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Chérifa Cheurfa
- Université de Paris, Epidemiology and Statistics, Sorbonne Paris Cité Research Center, (CRESS-UMR1153), INSERM, Cochrane France, Paris, France
| | - Jad Farha
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Bénédicte Jaïs
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Alain Aubert
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Diane Lorenzo
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Frédérique Maire
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| | - Dilhana Badurdeen
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Frédéric Prat
- Service d'endoscopie digestive, DMU Digestif, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France
| |
Collapse
|
47
|
Jaruvongvanich V, Vantanasiri K, Laoveeravat P, Matar RH, Vargas EJ, Maselli DB, Alkhatry M, Fayad L, Kumbhari V, Fittipaldi-Fernandez RJ, Hollenbach M, Watson RR, Gustavo de Quadros L, Galvao Neto M, Aepli P, Staudenmann D, Brunaldi VO, Storm AC, Martin JA, Gomez V, Abu Dayyeh BK. Endoscopic full-thickness suturing plus argon plasma mucosal coagulation versus argon plasma mucosal coagulation alone for weight regain after gastric bypass: a systematic review and meta-analysis. Gastrointest Endosc 2020; 92:1164-1175.e6. [PMID: 32692991 DOI: 10.1016/j.gie.2020.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 04/30/2020] [Accepted: 07/05/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic transoral outlet reduction (TORe) has been used to manage weight regain after Roux-en-Y gastric bypass. We conducted a meta-analysis to summarize the efficacy and safety of the two most commonly used techniques: full-thickness suturing plus argon plasma mucosal coagulation (ft-TORe) and argon plasma mucosal coagulation alone (APMC-TORe). METHODS A literature search of publication databases was performed from their inception to February 2020 for relevant studies. The outcomes of interest were percentage total body weight loss, gastrojejunal anastomosis (GJA) diameter, and adverse events (AEs). The pooled effect estimates were analyzed using a random-effects model. Meta-regression was conducted to identify associations between GJA diameter and weight loss. RESULTS Nine ft-TORe (n = 737) and 7 APMC-TORe (n = 888) studies were included. APMC-TORe was performed as a series of sessions (mean number of sessions ranging from 1.2 to 3), whereas ft-TORe was mostly performed as a single session. Percentage total body weight loss was 8.0% (95% confidence interval [CI], 6.3%-9.7%), 9.5% (95% CI, 8.1%-11.0%), and 5.8% (95% CI, 4.3%-7.1%) after ft-TORe and 9.0% (95% CI, 4.1%-13.9%), 10.2% (95% CI, 8.4%-12.1%), and 9.5% (95% CI, 5.7%-13.2%) after APMC-TORe at 3, 6, and 12 months, respectively, with no weight-loss difference at 3 and 6 months (P > .05). Only one severe AE was observed after APMC-TORe and none after ft-TORe. Stricture formation was the most common AE (ft-TORe 3.3% and APMC-TORe 4.8%, P = .38). All were successfully treated by endoscopic dilation or conservative treatment. Smaller aperture of the post-TORe GJA and greater change in the GJA diameter correlated with greater weight loss in APMC-TORe and numerical trends in ft-TORe. CONCLUSIONS This meta-analysis demonstrates that both ft-TORe and APMC-TORe offer significant and comparable weight-loss outcomes with a high and comparable safety profile. However, APMC-TORe typically required multiple endoscopic sessions. Identifying a goal for the final and change in GJA diameter could be useful treatment targets.
Collapse
Affiliation(s)
| | - Kornpong Vantanasiri
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Reem H Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Daniel B Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Maryam Alkhatry
- Division of Gastroenterology, IBHO hospital, Ras Al Khaimah, United Arab Emirates
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | | | - Marcus Hollenbach
- Medical Department II - Gastroenterology, Hepatology, Infectious Diseases, Pulmonology - University of Leipzig Medical Center, Leipzig, Germany
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Patrick Aepli
- Gastroenterology and Hepatology Unit, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Dominic Staudenmann
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Victoria Gomez
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
48
|
Hasan NM, Johnson KF, Yin J, Baetz NW, Fayad L, Sherman V, Blutt SE, Estes MK, Kumbhari V, Zachos NC, Kovbasnjuk O. Intestinal stem cell-derived enteroids from morbidly obese patients preserve obesity-related phenotypes: Elevated glucose absorption and gluconeogenesis. Mol Metab 2020; 44:101129. [PMID: 33246140 PMCID: PMC7770968 DOI: 10.1016/j.molmet.2020.101129] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 08/31/2020] [Revised: 10/28/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022] Open
Abstract
Objective The mechanisms behind the efficacy of bariatric surgery (BS) for treating obesity and type 2 diabetes, particularly with respect to the influence of the small bowel, remain poorly understood. In vitro and animal models are suboptimal with respect to their ability to replicate the human intestinal epithelium under conditions induced by obesity. Human enteroids have the potential to accelerate the development of less invasive anti-obesity therapeutics if they can recapitulate the pathophysiology of obesity. Our aim was to determine whether adult stem cell-derived enteroids preserve obesity-characteristic patient-specific abnormalities in carbohydrate absorption and metabolism. Methods We established 24 enteroid lines representing 19 lean, overweight, or morbidly obese patients, including post-BS cases. Dietary glucose absorption and gluconeogenesis in enteroids were measured. The expression of carbohydrate transporters and gluconeogenic enzymes was assessed and a pharmacological approach was used to dissect the specific contribution of each transporter or enzyme to carbohydrate absorption and metabolism, respectively. Results Four phenotypes representing the relationship between patients’ BMI and intestinal dietary sugar absorption were found, suggesting that human enteroids retain obese patient phenotype heterogeneity. Intestinal glucose absorption and gluconeogenesis were significantly elevated in enteroids from a cohort of obese patients. Elevated glucose absorption was associated with increased expression of SGLT1 and GLUT2, whereas elevated gluconeogenesis was related to increased expression of GLUT5, PEPCK1, and G6Pase. Conclusions Obesity phenotypes preserved in human enteroids provide a mechanistic link to aberrant dietary carbohydrate absorption and metabolism. Enteroids can be used as a preclinical platform to understand the pathophysiology of obesity, study the heterogeneity of obesity mechanisms, and identify novel therapeutics. Human stem cell-derived enteroids preserve the heterogeneity of obesity-related phenotypes. Four phenotypes representing the relationship between patients' BMI and intestinal dietary glucose absorption were found. Glucose absorption and gluconeogenesis were elevated in enteroids from a cohort of obese patients. Elevated glucose absorption was associated with increased expression of SGLT1 and GLUT2 in enteroids. Elevated gluconeogenesis was associated with increased expression of GLUT5, PEPCK1, and G6Pase in enteroids.
Collapse
Affiliation(s)
- Nesrin M Hasan
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA; Department of Surgery, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Kelli F Johnson
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
| | - Jianyi Yin
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Nicholas W Baetz
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
| | - Lea Fayad
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
| | - Vadim Sherman
- Department of Surgery, Minimally Invasive Bariatric and General Division, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Sarah E Blutt
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Mary K Estes
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
| | - Nicholas C Zachos
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA.
| | - Olga Kovbasnjuk
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA; Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA.
| |
Collapse
|
49
|
Farha J, Abbarh S, Haq Z, Itani MI, Oberbach A, Kumbhari V, Badurdeen D. Endobariatrics and Metabolic Endoscopy: Can We Solve the Obesity Epidemic with Our Scope? Curr Gastroenterol Rep 2020; 22:60. [PMID: 33205261 DOI: 10.1007/s11894-020-00798-8] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Obesity is a chronic relapsing disease that results in cardiovascular disease, diabetes mellitus, and non-alcoholic fatty liver disease. Currently, surgery represents the most effective treatment. However, the advent of minimally invasive endoscopic bariatric therapy (EBT) has shifted the treatment paradigm to less invasive, cost-effective procedures with minimal complications and recovery time that are preferred by patients. In this review, we will describe current and future EBTs, focusing on outcomes and safety. RECENT FINDINGS The endoscope has provided an incisionless portal into the gastrointestinal tract for placement of space-occupying devices and intraluminal procedures. EBTs are no longer solely manipulating anatomic alterations; instead, they aim to improve metabolic parameters such as glycated hemoglobin, low-density lipoprotein, cholesterol, and hepatic indices by targeting the mucosal layer of the gastrointestinal tract. The endoscope has succeeded in facilitating clinically meaningful weight loss and improvement of metabolic parameters. Future, solutions to the obesity epidemic will likely entail genetic testing, evaluation of the microbiome, and delivery of personalized therapy, utilizing combination endoscopic modalities that change the anatomy and physiology of individual patients, with new targets such as the abnormal metabolic signal.
Collapse
Affiliation(s)
- Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Shahem Abbarh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Zadid Haq
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mohamad I Itani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Andreas Oberbach
- Department of Diagnostics, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| |
Collapse
|
50
|
de Moura DTH, Badurdeen DS, Ribeiro IB, Leite EFMDSD, Thompson CC, Kumbhari V. Perspectives toward minimizing the adverse events of endoscopic sleeve gastroplasty. Gastrointest Endosc 2020; 92:1115-1121. [PMID: 32562607 DOI: 10.1016/j.gie.2020.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 04/17/2020] [Accepted: 06/11/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Endoscopy Unit, Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Dilhana S Badurdeen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Igor Braga Ribeiro
- Endoscopy Unit, Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|