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McKeon M, McCoy N, Johnson C, Allen J, Altaye M, Amin M, Bayan S, Belafsky P, DeSilva B, Dion G, Ekbom D, Friedman A, Fritz M, Giliberto JP, Guardiani E, Kasperbauer J, Kim B, Krekeler BN, Kuhn M, Kwak P, Ma Y, Madden LL, Matrka L, Mayerhoff R, Piraka C, Rosen CA, Tabangin M, Wahab S, Wilson K, Wright C, Young VN, Postma G, Howell RJ. Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative. Laryngoscope 2024; 134:2678-2683. [PMID: 38146791 DOI: 10.1002/lary.31226] [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] [Received: 04/21/2023] [Revised: 11/02/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVES The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE Level III Laryngoscope, 134:2678-2683, 2024.
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Affiliation(s)
- Mallory McKeon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Nicole McCoy
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Christopher Johnson
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University Health, Augusta, Georgia, U.S.A
| | - Jacqui Allen
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Milan Amin
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, New York, U.S.A
| | - Semirra Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California - Davis, Davis, California, U.S.A
| | - Brad DeSilva
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Greg Dion
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Dale Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron Friedman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Mark Fritz
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
| | - John Paul Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Elizabeth Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, U.S.A
| | - Jan Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Brandon Kim
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Brittany N Krekeler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Communication Sciences and Disorders, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Maggie Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California - Davis, Davis, California, U.S.A
| | - Paul Kwak
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, New York, U.S.A
| | - Yue Ma
- Department of Otolaryngology-Head and Neck Surgery, University of California - San Francisco, San Francisco, California, U.S.A
| | - Lyndsay L Madden
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Laura Matrka
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Ross Mayerhoff
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Cyrus Piraka
- Department of Gastroenterology/Hepatology, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California - San Francisco, San Francisco, California, U.S.A
| | - Meredith Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Shaun Wahab
- Department of Radiology, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Keith Wilson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Carter Wright
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - VyVy N Young
- Department of Otolaryngology-Head and Neck Surgery, University of California - San Francisco, San Francisco, California, U.S.A
| | - Gregory Postma
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University Health, Augusta, Georgia, U.S.A
| | - Rebecca J Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
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Howell R, Johnson C, Allen J, Altaye M, Amin M, Bayan S, Belafsky P, Cervenka B, Desilva B, Dion GR, Ekbom D, Friedman A, Fritz M, Giliberto JP, Guardiani E, Kasperbauer J, Kim B, Krekeler BN, Kuhn M, Kwak P, Ma Y, Madden LL, Matrka L, Mayerhoff R, McKeon M, Piraka C, Rosen CA, Tabangin M, Wahab SA, Wilson K, Wright C, Young VN, Postma G. Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study. Laryngoscope 2024; 134:97-102. [PMID: 37191092 DOI: 10.1002/lary.30753] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE 3 Laryngoscope, 134:97-102, 2024.
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Affiliation(s)
- Rebecca Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Christopher Johnson
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Jacqui Allen
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Milan Amin
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A
| | - Semirra Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Davis, California, U.S.A
| | - Brian Cervenka
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Brad Desilva
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Gregory R Dion
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Dale Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron Friedman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Mark Fritz
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
| | - John Paul Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Elizabeth Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, U.S.A
| | - Jan Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Brandon Kim
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Brittany N Krekeler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Communication Sciences and Disorders, University of Cincinnati College of Allied Health Sciences, Cincinnati, Ohio, U.S.A
| | - Maggie Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Davis, California, U.S.A
| | - Paul Kwak
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A
| | - Yue Ma
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Lyndsay L Madden
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Laura Matrka
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Ross Mayerhoff
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Mallory McKeon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Cyrus Piraka
- Department of Gastroenterology/Hepatology, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Meredith Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Keith Wilson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Carter Wright
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - VyVy N Young
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Gregory Postma
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
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Ichkhanian Y, Al-Haddad MA, Jacobs CC, Schlachterman A, Yang J, Canakis A, Kim R, Guerson-Gil A, D'Souza LS, Alsheik E, Ginnebaugh BD, Khashab MA, Zuchelli T, McFarlin K, Piraka C. Gastric peroral endoscopic myotomy for management of refractory gastroparesis in patients with gastric neurostimulator devices: a multicenter retrospective case control study. Gastrointest Endosc 2023; 98:559-566.e1. [PMID: 37121364 DOI: 10.1016/j.gie.2023.04.2079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/28/2023] [Accepted: 04/19/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND AIMS Gastric neurostimulation (GNS) and gastric peroral myotomy (G-POEM), therapies for refractory gastroparesis, are associated with suboptimal outcomes. We studied the role of G-POEM as a salvage therapy in patients with refractory symptoms after GNS implantation. METHODS This was a multicenter, retrospective, matched case-control study. Consecutive patients with a GNS device and who underwent G-POEM as a salvage therapy for clinical failure (cases) and patients without GNS implantation and who underwent G-POEM for refractory gastroparesis (control) between October 2018 and August 2021 were included. The primary outcome was clinical success after G-POEM. RESULTS A total of 123 patients (mean age 45.7 ± 14.7 years; 88 female subjects [72%]) underwent G-POEM therapy during the study: 41 cases and 82 controls. Clinical success was achieved in 66% in the case group and 65% in the control group (P = .311), during a median total clinical follow-up time of 11.8 (interquartile range, 2.4-6.3) months. In the case group, the mean Gastroparesis Cardinal Symptom Index score decreased from 2.8 ± 1.8 to 1.5 ± 1.9 (P = .024), and gastric retention at 4 hours improved from 45% ± 25.8% to 16.6% ± 13.1% (P = .06). The mean delta improvement in the subscales of nausea/vomiting (1.3 ± .6 vs .9 ± 1.1, P = .044) and bloating (1.6 ± 1.3 vs 1.2 ± 1.4, P = .041) were significantly higher in cases than in controls. CONCLUSIONS Among patients with refractory symptoms after GNS, G-POEM can be a reasonable salvage therapy to provide further symptomatic relief with evidence of a potential additive effect of both G-POEM and GNS.
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Affiliation(s)
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Chelsea C Jacobs
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Raymond Kim
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Arcelia Guerson-Gil
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Lionel S D'Souza
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | | | | | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA (10)Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | | | - Kellie McFarlin
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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4
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Howell R, Tang A, Allen J, Altaye M, Amin M, Bayan S, Belafsky P, Cervenka B, deSilva B, Dion G, Ekbom D, Friedman A, Fritz M, Giliberto JP, Guardiani E, Harmon J, Kasperbauer JL, Khosla S, Kim B, Kuhn M, Kwak P, Ma Y, Madden L, Matrka L, Mayerhoff R, Piraka C, Rosen C, Tabangin ME, Wahab SA, Wilson K, Wright SC, Young V, Yuen S, Postma GN. Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review. Laryngoscope 2023; 133:2110-2115. [PMID: 36453465 DOI: 10.1002/lary.30508] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD). METHODS Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report. RESULTS A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03). CONCLUSION KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2110-2115, 2023.
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Affiliation(s)
- Rebecca Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alice Tang
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jacqui Allen
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Milan Amin
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, New York, USA
| | - Semirra Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Davis, California, USA
| | - Brian Cervenka
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brad deSilva
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, USA
| | - Greg Dion
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Dale Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron Friedman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mark Fritz
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - John Paul Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Elizabeth Guardiani
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Jeffrey Harmon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jan L Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sid Khosla
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brandon Kim
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, USA
| | - Maggie Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Davis, California, USA
| | - Paul Kwak
- Department of Otolaryngology-Head and Neck Surgery, New York University, New York, New York, USA
| | - Yue Ma
- Department of Otolaryngology-Head and Neck Surgery, University of California - San Francisco, San Francisco, California, USA
| | - Lyndsay Madden
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Laura Matrka
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, USA
| | - Ross Mayerhoff
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Cyrus Piraka
- Department of Gastroenterology/Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Clark Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California - San Francisco, San Francisco, California, USA
| | - Meredith E Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Keith Wilson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - S Carter Wright
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Vyvy Young
- Department of Otolaryngology-Head and Neck Surgery, University of California - San Francisco, San Francisco, California, USA
| | - Sonia Yuen
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Gregory N Postma
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University Health, Augusta, Georgia, USA
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5
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Obri M, Ichkhanian Y, Brown P, Almajed MR, Nimri F, Taha A, Agha Y, Jesse M, Singla S, Piraka C, Zuchelli TE. Full-thickness resection device for management of lesions involving the appendiceal orifice: Systematic review and meta-analysis. Endosc Int Open 2023; 11:E899-E907. [PMID: 37810898 PMCID: PMC10558260 DOI: 10.1055/a-2131-4891] [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: 01/29/2023] [Accepted: 07/11/2023] [Indexed: 10/10/2023] Open
Abstract
Background and study aims Endoscopic resection of lesions involving the appendiceal orifice is technically challenging and is commonly referred for surgical resection. However, post-resection appendicitis is a concern. Many studies have varying rates of post-procedure appendicitis. We aim to report the rate of post-resection appendicitis by performing a systematic review and meta-analysis. Methods Studies that involved the use of a full-thickness resection device (FTRD) for management of appendiceal polyps were included. The primary outcome was appendicitis after FTRD and a subgroup analysis was performed on studies that only included FTRD performed at the appendiceal orifice. Results Appendicitis was encountered in 15% (95%CI: [11-21]) of the patients with 61% (95% CI: [44-76]) requiring surgical management. Pooled rates of technical success, histologic FTR, and histologic R0 resection in this sub-group (n=123) were 92% (95% CI: [85-96]), 98% (95% CI: [93-100]), and 72% (95% CI: [64-84%]), respectively. Post-resection histopathological evaluation revealed a mean resected specimen size of 16.8 ± 5.4 mm, with non-neoplastic pathology in 9 (7%), adenomas in 103 (84%), adenomas + high-grade dysplasia (HGD) in nine (7%), and adenocarcinoma in two (2%). The pooled rate for non-appendicitis-related surgical management (technical failure and/or high-risk lesions) was 11 % (CI: 7-17). Conclusions FTRD appears to be an effective method for managing appendiceal lesions. However, appendicitis post-resection occurs in a non-trivial number of patients and the R0 resection rate in appendiceal lesions is only 72%. Therefore, caution should be employed in the use of this technique, considering the relative risks of surgical intervention in each patient.
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Affiliation(s)
- Mark Obri
- Internal Medicine, Henry Ford Health System, Detroit, United States
| | | | - Patrick Brown
- Division of Gastroenterology, Henry Ford Health System, Detroit, United States
| | | | - Faisal Nimri
- Division of Gastroenterology, Henry Ford Health System, Detroit, United States
| | - Ashraf Taha
- Division of Gastroenterology, Henry Ford Health System, Detroit, United States
| | - Yasmine Agha
- Division of Gastroenterology, Henry Ford Health System, Detroit, United States
| | - Michelle Jesse
- Internal Medicine, Henry Ford Health System, Detroit, United States
| | - Sumit Singla
- Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, United States
| | - Cyrus Piraka
- Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, United States
| | - Tobias E. Zuchelli
- Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, United States
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Hartgerink C, Nimri FM, Zuchelli T, Jafri SM, Piraka C. Band Ligation Can Be Used to Treat Barrett's Esophagus and Concurrent Esophageal Varices: A Case Series. Dig Dis Sci 2022; 68:1381-1385. [PMID: 36131048 DOI: 10.1007/s10620-022-07696-1] [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: 03/25/2022] [Accepted: 09/05/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with Barrett's esophagus (BE) and esophageal varices present a unique management dilemma. Endoscopic ablation and endoscopic resection are not suitable treatment options due to bleeding risk. Data are limited on successful eradication of BE and esophageal varices utilizing band ligation. AIMS To assess the outcomes of patients with BE and esophageal varices treated with banding. METHODS Retrospective analysis of patients with BE and esophageal varices who were treated with band ligation. RESULTS A total of eight patients were included in the case series. In all eight cases, BE and esophageal varices were successfully treated with band ligation alone. There were no bleeding, perforation or infectious complications in any patients undergoing banding for treatment of BE. Four patients had biopsy-proven dysplasia prior to treatment with band ligation. After band ligation, the 2 of 4 dysplastic cases that had repeat biopsies showed histologic resolution of the dysplasia. All patients who received banding for BE were followed at least yearly except for one patient lost to follow up. No interval esophageal cancers were reported in any patients with BE that were banded. CONCLUSIONS Band ligation was used to treat BE pathology in eight patients with esophageal varices. Treatment of dysplasia through this method yielded negative biopsies both for dysplasia and BE on repeat endoscopy. This case series highlights the value of utilizing band ligation to address the management dilemma of BE in the context of esophageal varices.
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Affiliation(s)
- Colin Hartgerink
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA.
| | - Faisal M Nimri
- Department of Gastroenterology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Tobias Zuchelli
- Department of Gastroenterology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Syed-Mohammed Jafri
- Department of Gastroenterology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Cyrus Piraka
- Department of Gastroenterology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
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Ichkhanian Y, Brewer Gutierrez O, Roman S, Yoo IK, Canakis A, Pawa R, Koch K, Su B, Ujiki M, Alsheik E, Zuchelli T, Piraka C, Ghandour B, Zhang L, Sloan JA, Khashab MA. Role of functional luminal imaging probe in the management of postmyotomy clinical failure. Gastrointest Endosc 2022; 96:9-17.e3. [PMID: 35149045 DOI: 10.1016/j.gie.2022.02.002] [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: 10/22/2021] [Accepted: 02/01/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment. METHODS This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy. RESULTS One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm2/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03). CONCLUSIONS The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.
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Affiliation(s)
- Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA; Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Sabine Roman
- Department of Gastroenterology, Edouard Herriot Hospital, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - In Kyung Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rishi Pawa
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kenneth Koch
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bailey Su
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Eva Alsheik
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Cyrus Piraka
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Linda Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
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Ichkhanian Y, Hwang JH, Ofosu A, Li AA, Szvarca D, Draganov PV, Yang D, Alsheik E, Zuchelli T, Piraka C, Mony S, Khashab MA. Role of gastric per-oral endoscopic myotomy (G-POEM) in post-lung transplant patients: a multicenter experience. Endosc Int Open 2022; 10:E832-E839. [PMID: 35692909 PMCID: PMC9187381 DOI: 10.1055/a-1797-9587] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
Background and study aims Gastroparesis post-lung transplant (LTx) can lead to increased risk of gastroesophageal reflux (GER) and accelerated graft dysfunction. We aimed to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM), a promising tool in patients with refractory gastroparesis, for managing refractory gastroparesis and GER in post-LTx patients. Patents and methods This was a multicenter retrospective study on post-LTx patients who underwent G-POEM for management of gastroparesis and GER that were refractory to standard medical therapy. The primary outcome was clinical success post-G-POEM. Secondary outcomes included the rate of post-G-POEM objective esophageal pH exam normalization, rate of gastric emptying scintigraphy (GES) normalization, technical success, and adverse events. Results A total of 20 patients (mean age 54.7 ± 14.1 years, Female 50 %) underwent G-POEM at a median time of 13 months (interquartile range 6.5-13.5) post-LTx. All G-POEM procedures were technically successful. Clinical success was achieved in 17 (85 %) patients during a median follow-up time of 8.9 (IQR: 3-17) months post-G-POEM. Overall GCSI and two of its subscales (bloating and postprandial fullness/early satiety) improved significantly following G-POEM. Two patients (10 %) developed post-procedural AEs (delayed bleeding 1, pyloric stenosis 1, both moderate in severity). Post-G-POEM GES improvement was achieved in 12 of 16 patients (75 %). All 20 patients were on proton pump inhibitors pre-G-POEM, as opposed to five post-G-POEM. Post-G-POEM PH study normalization was noted in nine of 10 patients (90 %) who underwent both pre- and post-G-poem pH testing. Conclusions G-POEM is a promising noninvasive therapeutic tool for management of refractory gastroparesis and GER post-LTx.
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Affiliation(s)
- Yervant Ichkhanian
- Henry Ford Health System, Department of Internal Medicine, Detroit, Michigan, United States
| | - Joo Ha Hwang
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Andrew Ofosu
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Andrew A Li
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Daniel Szvarca
- Johns Hopkins Hospital, Department of Internal Medicine, Baltimore, Maryland, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Eva Alsheik
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Tobias Zuchelli
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Cyrus Piraka
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Shruti Mony
- Johns Hopkins Hospital, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Johns Hopkins Hospital, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
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Dang DT, Suresh S, Vance RB, Singla S, Javia S, Watson A, Chathadi KV, Katukuri V, Pompa R, Stidham RW, Zuchelli T, Piraka C. Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study. Gastrointest Endosc 2022; 95:1176-1182. [PMID: 34971667 DOI: 10.1016/j.gie.2021.12.018] [Citation(s) in RCA: 4] [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: 06/27/2021] [Accepted: 12/17/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Nonampullary small-bowel adenomas ≥10 mm are typically resected using cautery-based polypectomy, which is associated with significant adverse events. Studies have demonstrated the safety and efficacy of piecemeal cold snare EMR for removing large colon polyps. Our aim was to assess the safety and efficacy of cold snare EMR for removal of large adenomas in the small bowel. METHODS A retrospective study of patients who underwent lift and piecemeal cold snare EMR of small-bowel adenomas ≥1 cm between January 2014 and March 2019 was conducted at a tertiary care medical center. Polyp characteristics at the time of index and surveillance endoscopy were collected. Primary outcomes were residual or recurrent adenoma (RRA) seen on surveillance endoscopy, polyp eradication rate, and number of endoscopic procedures required for eradication. Adverse events including immediate and delayed bleeding, perforation, stricture, pancreatitis, and postpolypectomy syndrome were assessed. RESULTS Of 43 patients who underwent piecemeal cold snare EMR, 39 had follow-up endoscopy. Polyps ranged in size from 10 to 70 mm (mean, 26.5 mm). RRA was found in 18 patients (46%), with increased polyp size correlating with higher recurrence (P < .001). Polyp eradication was observed in 35 patients (89%), requiring a median of 2 (range, 1-6) endoscopic procedures. Only 1 patient (2.3%) had immediate postprocedural bleeding. No cases of perforation or postpolypectomy syndrome were seen. CONCLUSIONS Piecemeal cold snare EMR may be a feasible, safe, and efficacious technique for small-bowel polyps >10 mm. Prospective, randomized studies are needed to assess how outcomes compare with traditional cautery-based polypectomy.
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Affiliation(s)
- Duyen T Dang
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Suraj Suresh
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - R Brooks Vance
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Sumit Singla
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Siddharth Javia
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Andrew Watson
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | | | - Vinay Katukuri
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Robert Pompa
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ryan W Stidham
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - Tobias Zuchelli
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Cyrus Piraka
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
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Ichkhanian Y, Zuchelli T, Watson A, Piraka C. Evolving management of colorectal polyps. Ther Adv Gastrointest Endosc 2021; 14:26317745211047010. [PMID: 34604745 PMCID: PMC8485258 DOI: 10.1177/26317745211047010] [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: 05/01/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Advances in endoscopic technology have led to increased success in colorectal cancer (CRC) screening and polyp management, with reduction of CRC incidence and mortality. Despite these advances, CRC is still one of the leading causes of cancer deaths, and half of all CRC develops from lesions that were missed during colonoscopy while one-fifth of CRC arise from prior incomplete resection. Techniques to improve polyp detection are needed, along with optimization of complete resection of any abnormal lesions that are found. This article will review the currently available endoscopic resection techniques and will discuss where they fit in the management of polyps of different sizes and types, such as pedunculated versus nonpedunculated, and those with or without suspected invasion.
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Affiliation(s)
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI, USA
| | - Andrew Watson
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI, USA
| | - Cyrus Piraka
- Section Chief-Advanced Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA
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11
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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.
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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
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Suresh S, Zhang J, Ahmed A, Abu Ghanimeh M, Elbanna A, Kaur R, Isseh M, Watson A, Dang DT, Chathadi KV, Pompa R, Singla S, Piraka C, Zuchelli T. Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: a retrospective chart review. Endosc Int Open 2021; 9:E867-E873. [PMID: 34079869 PMCID: PMC8159587 DOI: 10.1055/a-1399-8398] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Cold snare endoscopic mucosal resection (EMR) is being increasingly utilized for non-pedunculated polyps ≥ 20 mm due to adverse events associated with use of cautery. Larger studies evaluating adenoma recurrence rate (ARR) and risk factors for recurrence following cold snare EMR of large polyps are lacking. The aim of this study was to define ARR for polyps ≥ 20 mm removed by cold snare EMR and to identify risk factors for recurrence. Patients and methods A retrospective chart review of colon cold snare EMR procedures performed between January 2015 and July 2019 at a tertiary care medical center was performed. During this period, 310 non-pedunculated polyps ≥ 20 mm were excised using cold snare EMR with follow-up surveillance colonoscopy. Patient demographic data as well as polyp characteristics at the time of index and surveillance colonoscopy were collected and analyzed. Results A total of 108 of 310 polyps (34.8 %) demonstrated adenoma recurrence at follow-up colonoscopy. Patients with a higher ARR were older ( P = 0.008), had endoscopic clips placed at index procedure ( P = 0.017), and were more likely to be Asian and African American ( P = 0.02). ARR was higher in larger polyps ( P < 0.001), tubulovillous adenomas ( P < 0.001), and polyps with high-grade dysplasia ( P = 0.003). Conclusions Although cold snare EMR remains a feasible alternative to hot snare polypectomy for resection of non-pedunculated polyps ≥ 20 mm, endoscopists must also carefully consider factors associated with increased ARR when utilizing this technique.
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Affiliation(s)
- Suraj Suresh
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Jinyu Zhang
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Abdelwahab Ahmed
- Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Mouhanna Abu Ghanimeh
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Ahmed Elbanna
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Randeep Kaur
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, United States
| | - Mahmoud Isseh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Andrew Watson
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Duyen T. Dang
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Krishnavel V. Chathadi
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Robert Pompa
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Sumit Singla
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Cyrus Piraka
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
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Reddy CA, Tavakkoli A, Chen VL, Korsnes S, Bedi AO, Carrott PW, Chang AC, Lagisetty KH, Kwon RS, Elmunzer BJ, Orringer MB, Piraka C, Prabhu A, Reddy RM, Wamsteker E, Rubenstein JH. Long-Term Quality of Life Following Endoscopic Therapy Compared to Esophagectomy for Neoplastic Barrett's Esophagus. Dig Dis Sci 2021; 66:1580-1587. [PMID: 32519141 PMCID: PMC8327124 DOI: 10.1007/s10620-020-06377-1] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Endoscopic therapy (ET) and esophagectomy result in similar survival for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC), but the long-term quality of life (QOL) has not been compared. AIMS We aimed to compare long-term QOL between patients who had undergone ET versus esophagectomy. METHODS Patients were included if they underwent ET or esophagectomy at the University of Michigan since 2000 for the treatment of HGD or T1a EAC. Two validated survey QOL questionnaires were mailed to the patients. We compared QOL between and within groups (ET = 91, esophagectomy = 62), adjusting for covariates. RESULTS The median time since initial intervention was 6.8 years. Compared to esophagectomy, ET patients tended to be older, had a lower prevalence of EAC, and had a shorter duration since therapy. ET patients had worse adjusted physical and role functioning than esophagectomy patients. However, the adjusted odds ratio (OR) of having symptoms was significantly less with ET for diarrhea (0.287; 95% confidence interval [CI] = 0.114, 0.724), trouble eating (0.207; 0.0766, 0.562), choking (0.325; 0.119, 0.888), coughing (0.291; 0.114, 0.746), and speech difficulty (0.306; 0.0959, 0.978). Amongst the ET patients, we found that the number of therapy sessions and need for dilation were associated with worse outcomes. DISCUSSION Multiple measures of symptom status were better with ET compared to esophagectomy following treatment of BE with HGD or T1a EAC. We observed worse long-term physical and role functioning in ET patients which could reflect unmeasured baseline functional status rather than a causal effect of ET.
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Affiliation(s)
- Chanakyaram A Reddy
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Anna Tavakkoli
- Division of Gastroenterology, UT Southwestern, Dallas, TX, USA
| | - Vincent L Chen
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Sheryl Korsnes
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Aarti Oza Bedi
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Philip W Carrott
- Division of Thoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Andrew C Chang
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Kiran H Lagisetty
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Richard S Kwon
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Mark B Orringer
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cyrus Piraka
- Division of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Anoop Prabhu
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Rishindra M Reddy
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Erik Wamsteker
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Joel H Rubenstein
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
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Affiliation(s)
- Cyrus Piraka
- Division of Gastroenterology/Hepatology, Henry Ford Health System, Detroit, Michigan, USA
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15
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Brewer Gutierrez OI, Raijman I, Shah RJ, Elmunzer BJ, Webster GJ, Pleskow D, Sherman S, Sturgess RP, Sejpal DV, Ko C, Maurano A, Adler DG, Mullady DK, Strand DS, DiMaio CJ, Piraka C, Sharahia R, Dbouk MH, Han S, Spiceland CM, Bekkali NL, Gabr M, Bick B, Dwyer LK, Han D, Buxbaum J, Zulli C, Cosgrove N, Wang AY, Carr-Locke D, Kerdsirichairat T, Aridi HD, Moran R, Shah S, Yang J, Sanaei O, Parsa N, Kumbhari V, Singh VK, Khashab MA. Safety and efficacy of digital single-operator pancreatoscopy for obstructing pancreatic ductal stones. Endosc Int Open 2019; 7:E896-E903. [PMID: 31281875 PMCID: PMC6609233 DOI: 10.1055/a-0889-7743] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background and study aims The role of the digital single-operator pancreatoscopy (D-SOP) with electrohydraulic (EHL) or laser lithotripsy (LL) in treating pancreatic ductal stones is unclear. We investigated the safety and efficacy of D-SOP with EHL or LL in patients with obstructing pancreatic duct stones.
Patients and methods Retrospective analysis of 109 patients who underwent D-SOP for pancreatic stones at 17 tertiary centers in the United States and Europe from February 2015 to September 2017. Logistic regression was performed to identify factors associated with the need for more than one D-SOP with EHL/LL.
Results Most patients were males (70.6 %),mean age 54.7 years. Fifty-nine (54.1 %) underwent EHL and 50 (45.9 %) underwent LL. Mean procedure time was longer in the EHL group (74.4 min vs 53.8 min; P < 0.001). Ducts were completely cleared (technical success) in 89.9 % of patients (94.1 % in EHL vs 100 % in LL; P = 0.243), achieved in a single session in 73.5 % of patients (77.1 % by EHL and 70 % by LL; P= 0.5).D-SOP failed in 11 patients (10.1 %); 6 patients were treated with extracorporeal shockwave lithotripsy (ESWL), 1 with surgery,1 with combined treatment (ESWL + D-SOP EHL) and 3 with other. Fourteen adverse events occurred in 11 patients (10.1 %). Patients with more than three ductal stones were more likely to have technical failure compared to those with less than three stones (17 % vs. 4.8 %; P = 0.04). Having more than three stones was independently associated with the need for more than one D-SOC EHL/LL session (OR 2.94, 95 % CI 1.13 – 7.65).
Conclusion D-SOP with EHL or LL is effective and safe in patients with pancreatic ductal stones.
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Affiliation(s)
| | - Isaac Raijman
- Greater Houston Gastroenterology, Texas, United States
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology University of Colorado-Denver Medical School, Colorado, United States
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology. Medical University of South Carolina, Charleston, South Carolina, United States
| | | | - Douglas Pleskow
- Division of Gastroenterology and Hepatology Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology Indiana University Medical Center, Indiana, United States
| | - Richard P. Sturgess
- Division of Gastroenterology and Hepatology, Aintree University Hospital, Liverpool, United Kingdom
| | - Divyesh V. Sejpal
- Division of Gastroenterology and Hepatology Hofstra-Northwell School of Medicine, New York, United States
| | - Christopher Ko
- Division of Gastroenterology and Hepatology University of Southern California Keck School of Medicine, California, United States
| | - Attilio Maurano
- University Hospital of Salerno, G. Fucito Center, Mercato San Severino (SA), Italy
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology University of Utah School of Medicine, Utah, United States
| | - Daniel K. Mullady
- Division of Gastroenterology and Hepatology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Daniel S. Strand
- Division of Gastroenterology and Hepatology University of Virginia Health System, Virginia, United States
| | - Christopher J. DiMaio
- Division of Gastroenterology Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, United States
| | - Cyrus Piraka
- Henry Ford Hospital, Detroit, Michigan, United States
| | - Reem Sharahia
- Division of Gastroenterology and Hepatology Weil Cornell, New York, New York, United States
| | - Mohamad H. Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Samuel Han
- Division of Gastroenterology and Hepatology University of Colorado-Denver Medical School, Colorado, United States
| | - Clayton M. Spiceland
- Division of Gastroenterology and Hepatology. Medical University of South Carolina, Charleston, South Carolina, United States
| | | | - Moamen Gabr
- Division of Gastroenterology and Hepatology Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology Indiana University Medical Center, Indiana, United States
| | - Laura K. Dwyer
- Division of Gastroenterology and Hepatology, Aintree University Hospital, Liverpool, United Kingdom
| | - Dennis Han
- Division of Gastroenterology and Hepatology Hofstra-Northwell School of Medicine, New York, United States
| | - James Buxbaum
- Division of Gastroenterology and Hepatology University of Southern California Keck School of Medicine, California, United States
| | - Claudio Zulli
- University Hospital of Salerno, G. Fucito Center, Mercato San Severino (SA), Italy
| | - Natalie Cosgrove
- Division of Gastroenterology and Hepatology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Andrew Y. Wang
- Division of Gastroenterology and Hepatology University of Virginia Health System, Virginia, United States
| | - David Carr-Locke
- Division of Gastroenterology and Hepatology Weil Cornell, New York, New York, United States
| | | | - Hanaa Dakour Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Shawn Shah
- Division of Gastroenterology and Hepatology Weil Cornell, New York, New York, United States
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Nasim Parsa
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland United States,Corresponding author Mouen A. Khashab, MD Johns Hopkins Hospital1800 Orleans StreetSheikh Zayed TowerBaltimore, MD 21287+1-410-502-7010
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Wani S, Keswani RN, Han S, Aagaard EM, Hall M, Simon V, Abidi WM, Banerjee S, Baron TH, Bartel M, Bowman E, Brauer BC, Buscaglia JM, Carlin L, Chak A, Chatrath H, Choudhary A, Confer B, Coté GA, Das KK, DiMaio CJ, Dries AM, Edmundowicz SA, Chafic AHE, Hajj IE, Ellert S, Ferreira J, Gamboa A, Gan IS, Gangarosa LM, Gannavarapu B, Gordon SR, Guda NM, Hammad HT, Harris C, Jalaj S, Jowell PS, Kenshil S, Klapman J, Kochman ML, Komanduri S, Lang G, Lee LS, Loren DE, Lukens FJ, Mullady D, Muthusamy VR, Nett AS, Olyaee MS, Pakseresht K, Perera P, Pfau P, Piraka C, Poneros JM, Rastogi A, Razzak A, Riff B, Saligram S, Scheiman JM, Schuster I, Shah RJ, Sharma R, Spaete JP, Singh A, Sohail M, Sreenarasimhaiah J, Stevens T, Tabibian JH, Tzimas D, Uppal DS, Urayama S, Vitterbo D, Wang AY, Wassef W, Yachimski P, Zepeda-Gomez S, Zuchelli T, Early D. Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice. Gastroenterology 2018; 155:1483-1494.e7. [PMID: 30056094 PMCID: PMC6504935 DOI: 10.1053/j.gastro.2018.07.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [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: 06/21/2018] [Revised: 07/18/2018] [Accepted: 07/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.
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Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado.
| | - Rajesh N. Keswani
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Samuel Han
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | | | - Violette Simon
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | | | - Todd H. Baron
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael Bartel
- Mayo Clinic School of Graduate Medical Education, Jacksonville, Florida
| | | | - Brian C. Brauer
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | - Linda Carlin
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Hemant Chatrath
- University of California-Los Angeles, Los Angeles, California
| | | | | | - Gregory A. Coté
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | | | | | | | | | - Swan Ellert
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Jason Ferreira
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Ian S. Gan
- Virginia Mason Medical Center, Seattle, Washington
| | - Lisa M. Gangarosa
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Hazem T. Hammad
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Cynthia Harris
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | - Sujai Jalaj
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Sana Kenshil
- University of Alberta, Edmonton, Alberta, Canada
| | - Jason Klapman
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gabriel Lang
- Washington University in St Louis, St Louis, Missouri
| | - Linda S. Lee
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Frank J. Lukens
- Mayo Clinic School of Graduate Medical Education, Jacksonville, Florida
| | | | | | | | | | | | | | | | | | | | | | | | - Brian Riff
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Shreyas Saligram
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | | | - Raj J. Shah
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Rishi Sharma
- University of California-Davis, Davis, California
| | | | - Ajaypal Singh
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Muhammad Sohail
- University of Massachusetts Medical Center, Worcester, Massachusetts
| | | | | | | | | | - Dushant S. Uppal
- University of Virginia School of Medicine, Charlottesville, Virginia
| | | | | | - Andrew Y. Wang
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wahid Wassef
- University of Massachusetts Medical Center, Worcester, Massachusetts
| | | | | | | | - Dayna Early
- Washington University in St Louis, St Louis, Missouri
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Zuchelli T, Piraka C. Many Options for Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Masses, but Any Differences? Clin Gastroenterol Hepatol 2018; 16:1712-1713. [PMID: 30120997 DOI: 10.1016/j.cgh.2018.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 07/25/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Tobias Zuchelli
- Section of Advanced Therapeutic Endoscopy, Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan
| | - Cyrus Piraka
- Section of Advanced Therapeutic Endoscopy, Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan
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18
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Piraka C. Cold Snare Resection of Large Duodenal and Colonic Polyps. Gastroenterol Hepatol (N Y) 2018; 14:539-541. [PMID: 30364360 PMCID: PMC6194660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Cyrus Piraka
- Chief and Fellowship Program Director Section of Advanced Therapeutic Endoscopy Division of Gastroenterology Henry Ford Hospital Detroit, Michigan
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19
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Wani S, Keswani R, Hall M, Han S, Ali MA, Brauer B, Carlin L, Chak A, Collins D, Cote GA, Diehl DL, DiMaio CJ, Dries A, El-Hajj I, Ellert S, Fairley K, Faulx A, Fujii-Lau L, Gaddam S, Gan SI, Gaspar JP, Gautamy C, Gordon S, Harris C, Hyder S, Jones R, Kim S, Komanduri S, Law R, Lee L, Mounzer R, Mullady D, Muthusamy VR, Olyaee M, Pfau P, Saligram S, Piraka C, Rastogi A, Rosenkranz L, Rzouq F, Saxena A, Shah RJ, Simon VC, Small A, Sreenarasimhaiah J, Walker A, Wang AY, Watson RR, Wilson RH, Yachimski P, Yang D, Edmundowicz S, Early DS. A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills Study. Clin Gastroenterol Hepatol 2017; 15. [PMID: 28625816 PMCID: PMC7042954 DOI: 10.1016/j.cgh.2017.06.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS On the basis of the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) by using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. METHODS ASGE recognized training programs were invited to participate, and AETs were graded on ERCP and EUS exams by using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done by using a 4-point scoring system, and a comprehensive data collection and reporting system was built to create learning curves by using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. RESULTS Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range, 155-650) and 350 (125-500), respectively. Overall, 3786 exams were graded (EUS, 1137; ERCP-biliary, 2280; ERCP-pancreatic, 369). Learning curves for individual end points and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS, 82%; ERCP, 60%) and cognitive (EUS, 76%; ERCP, 100%) competence at conclusion of training. CONCLUSIONS These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP. ClinicalTrials.gov: NCT02509416.
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Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | | | - Matt Hall
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samuel Han
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Meer Akbar Ali
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Brian Brauer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Linda Carlin
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Dan Collins
- Carolinas Medical Center, Charlotte, North Carolina
| | - Gregory A. Cote
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | - Andrew Dries
- Carolinas Medical Center, Charlotte, North Carolina
| | | | - Swan Ellert
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | | | - Ashley Faulx
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St Louis, Missouri
| | - Seng-Ian Gan
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Stuart Gordon
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Sarah Hyder
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ross Jones
- Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen Kim
- University of California, Los Angeles, Los Angeles, California
| | | | - Ryan Law
- Northwestern University, Chicago, Illinois
| | - Linda Lee
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rawad Mounzer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Mullady
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | | | | | | | | | - Fadi Rzouq
- University of Kansas, Kansas City, Kansas
| | | | - Raj J. Shah
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Aaron Small
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Andrew Y. Wang
- University of Virginia Health System, Charlottesville, Virginia
| | | | - Robert H. Wilson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Dennis Yang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Dayna S. Early
- Washington University School of Medicine, St Louis, Missouri
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Abstract
Background and study aims Colonic polyps > 1 cm in size are commonly managed using hot polypectomy techniques. The most frequent adverse events (delayed bleeding, post-polypectomy syndrome, and perforation) are related to electrocautery-induced injury. We hypothesized that cold resection of large polyps may have similar efficacy and improved safety compared to hot polypectomy. Our aims were to evaluate efficacy and safety of piecemeal cold snare resection of colonic polyps > 1 cm. Patients and methods Patients undergoing lift and piecemeal cold snare polypectomy of non-pedunculated colon polyps > 1 cm from October 2013 to September 2015 were identified retrospectively. Efficacy was defined by the absence of residual adenomatous tissue at endoscopic follow-up. Adverse events (AEs), including post-procedural bleeding, bowel perforation, or post-procedural pain requiring hospitalization were assessed by chart review and telephone follow-up. Results Seventy-three patients underwent piecemeal cold snare polypectomy for 94 colon polyps > 1 cm with 56 of 73 patients completing follow-up on 72 polyps. Residual or recurrent adenoma was found in 7 cases (9.7 %). Median polyp size was significantly greater in those with residual/recurrent adenoma (37.1 vs. 19.1 mm, P < .0001). There were no AEs among all 73 patients enrolled. Conclusions Piecemeal cold snare resection of colon polyps > 1 cm is feasible, safe and efficacious when compared to published hot polypectomy data. Additional observational and randomized comparative effectiveness studies are necessary to demonstrate comparable adenoma eradication and improved safety advantage over existing hot snare polypectomy techniques.
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Affiliation(s)
- Cyrus Piraka
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, United States,Corresponding author Cyrus Piraka, MD, FASGE Division of GastroenterologyHenry Ford Hospital2799 West Grand Boulevard, K7Detroit, MI United States 48202Office: 313.916.8632+1-313-812-9491+1-313-916-5960
| | - Ahmed Saeed
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Akbar K. Waljee
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, United States,Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Ajish Pillai
- Division of Gastroenterology, College of Medicine, Drexel University, Philadelphia, Pennsylvania, United States
| | - Ryan Stidham
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
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Parekh R, Krol G, Piraka C, Batra S. A Rare Case of Intraductal Papillary Mucinous Neoplasm of the Biliary Duct in a Patient with Prostate Adenocarcinoma. Case Rep Gastroenterol 2017; 10:743-748. [PMID: 28100995 PMCID: PMC5216234 DOI: 10.1159/000450539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 07/01/2016] [Accepted: 08/31/2016] [Indexed: 01/29/2023] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are mucin-producing papillary neoplasms of the pancreatic or biliary ductal system that exhibit variable cellular atypia and cause ductal dilation. There are few reported cases of IPMN arising from the biliary tree in the literature. It has a higher propensity to undergo malignant transformation compared to IPMN arising from the pancreatic duct. An 80-year-old male underwent cross-sectional tomography (CT) imaging of the abdomen for evaluation of prostate adenocarcinoma, which revealed an incidental 2.3 × 2.7 cm soft tissue mass centered at the porta hepatis with diffuse dilatation of the left intrahepatic biliary ductal system and mild prominence of the right intrahepatic ductal system. Endoscopic ultrasound showed 2 adjacent hilar masses involving the common hepatic duct and the left hepatic duct with protrusion of the tissue into the lumen of the duct and upstream ductal dilatation. Endoscopic retrograde cholangiopancreatography revealed a large filling defect in the common hepatic duct extending into the left hepatic duct. A large amount of clot and soft tissue with a fish-egg appearance was retrieved. The patient underwent left hepatic lobectomy, radical resection of the common hepatic duct with Roux-en-Y hepaticojejunostomy to the right hepatic duct. Histopathological examination of the resected specimen revealed intraductal papillary mucinous neoplasm with diffuse high-grade dysplasia. Follow-up CT scan of the abdomen 2 months after the surgery was negative for any masses.
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Joshi BP, Duan X, Kwon RS, Piraka C, Elmunzer BJ, Lu S, Rabinsky EF, Beer DG, Appelman HD, Owens SR, Kuick R, Doguchi N, Turgeon DK, Wang TD. Multimodal endoscope can quantify wide-field fluorescence detection of Barrett's neoplasia. Endoscopy 2016; 48:A1-A13. [PMID: 26426999 PMCID: PMC5011967 DOI: 10.1055/s-0034-1392803] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [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: 12/20/2022]
Abstract
BACKGROUND AND STUDY AIMS To demonstrate the clinical use of a multimodal endoscope with a targeted fluorescently labeled peptide for quantitative detection of Barrett's neoplasia. PATIENTS AND METHODS We studied 50 patients with Barrett's esophagus using a prototype multimodal endoscope with a fluorescently labeled peptide. Co-registered fluorescence and reflectance images were converted to ratios to correct for differences in distance and geometry over the image field of view. The ratio images were segmented using a unique threshold that maximized the variance between high and low intensities to localize regions of high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). RESULTS Early neoplasia (HGD and EAC) was identified with 94 % specificity and 96 % positive predictive value at a threshold of 1.49. The mean results for HGD and EAC were significantly greater than those for squamous/Barrett's esophagus and low grade dysplasia by one-way analysis of variance (ANOVA). The receiver operator characteristic curve for detection of early neoplasia had an area under the curve of 0.884. No adverse events associated with the endoscope or peptide were found. CONCLUSION A multimodal endoscope can quantify fluorescence images from targeted peptides to localize early Barrett's neoplasia. (ClinicalTrials.gov number NCT01630798.).
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Affiliation(s)
- Bishnu P. Joshi
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Xiyu Duan
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard S. Kwon
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Cyrus Piraka
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - B. Joseph Elmunzer
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Shaoying Lu
- Department of General Surgery, First Affiliated Hospital, Medical School of Xi’an Jiaotong University, People’s Republic of China
| | - Emily F. Rabinsky
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - David G. Beer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Henry D. Appelman
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott R. Owens
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Rork Kuick
- University of Michigan Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - D. Kim Turgeon
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas D. Wang
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA,Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA
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D'Souza SL, Anderson MA, Korsnes SJ, Elmunzer BJ, Piraka C, Menees S, Wamsteker EJ, Kwon RS, Scheiman JM, Elta GH. EUS Diagnostic Criteria for Chronic Pancreatitis: A Comparison of Conventional Versus Rosemont Criteria. Dig Dis Sci 2015. [PMID: 26195310 DOI: 10.1007/s10620-015-3788-4] [Citation(s) in RCA: 3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
OBJECTIVE To compare the Rosemont criteria, which are graded features chosen by experts in 2007, versus the conventional criteria, which require ≥ 3-5 of the 9 features that are "counted as equal," for the diagnosis of chronic pancreatitis by EUS. METHODS This is a retrospective cohort study. EUS examinations were scored using both criteria, and the following categories compared: 3-CC versus "consistent with" chronic pancreatitis by RC; 3-CC versus "consistent with" and "suggestive of" chronic pancreatitis by RC; 5-CC versus "consistent with" chronic pancreatitis by RC; and 5-CC versus "consistent with" and "suggestive of" chronic pancreatitis by RC. RESULTS There was a statistically significant difference between 3-CC and RC, either "consistent with" alone or both "consistent with" and "suggestive of" (p < 0.0001). Comparing 5-CC and "consistent with" showed a statistical difference (p = 0.0014), but no difference comparing 5-CC to "consistent with" and "suggestive of." CONCLUSION CC diagnose more cases of chronic pancreatitis than RC when using 3-CC or when comparing 5-CC to "consistent with" chronic pancreatitis by Rosemont, indicating that the Rosemont criteria are more stringent.
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Affiliation(s)
- Sharlene L D'Souza
- Division of Gastroenterology, Department of Internal Medicine, Oregon Health & Science University, Portland Veterans Administration Healthcare System, 3710 SW U.S. Veterans Hospital Rd., P3GI, Portland, OR, 97230, USA.
| | - Michelle A Anderson
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
| | - Sheryl J Korsnes
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
| | - B Joseph Elmunzer
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
| | - Cyrus Piraka
- Division of Gastroenterology, Department of Internal Medicine, Henry Ford Hospital, 2799 West Grand Blvd, K7, Detroit, MI, 48202, USA.
| | - Stacy Menees
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
| | - Erik-Jan Wamsteker
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
| | - Richard S Kwon
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
| | - James M Scheiman
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
| | - Grace H Elta
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
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Choksi N, Elmunzer BJ, Stidham RW, Shuster D, Piraka C. Cold snare piecemeal resection of colonic and duodenal polyps ≥1 cm. Endosc Int Open 2015; 3:E508-13. [PMID: 26528509 PMCID: PMC4612226 DOI: 10.1055/s-0034-1392214] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [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: 11/26/2014] [Accepted: 04/13/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Endoscopic removal of duodenal and colorectal adenomas is currently considered to be the standard of care for prevention of adenocarcinoma. The use of cautery carries a risk of delayed bleeding, post-polypectomy syndrome, and perforation. We examined the safety and feasibility of removing colonic and duodenal polyps ≥ 1 cm using a piecemeal cold snare polypectomy technique. PATIENTS The study included 15 patients with duodenal polyps ≥ 1 cm and 15 patients with colonic polyps ≥ 1 cm. MAIN OUTCOME MEASUREMENTS Bleeding, perforation, abdominal pain, or hospitalization occurring within 2 weeks of polypectomy. RESULTS Between 24 August 2011 and 29 April 2013, 15 patients had removal of duodenal polyps ≥ 1 cm. Mean patient age was 64 years and 9/15 patients were male. The mean polyp size was 24 mm (10 - 60 mm). All polyps were removed with a cold snare and some required cold biopsy forceps. One patient required hospitalization for gastrointestinal blood loss 7 days post-polypectomy; this patient was using Coumadin. Between 27 February 2012 and 30 May 2013, 15 patients underwent resection of a ≥ 1 cm colonic polyp. Mean patient age was 68 years and 9/15 were male. The mean polyp size was 20 mm (10 - 45 mm). All polyps were primarily removed with a cold snare. None of the patients required hemostatic clips for control of immediate bleeding. One patient presented to the emergency department with abdominal pain 1 day after initial endoscopy. CT scan showed no abnormalities and the patient was discharged. CONCLUSIONS Cold snare polypectomy for large duodenal and colonic polyps is technically feasible and may have a favorable safety profile compared to standard electrocautery-based endoscopic resection. Comparative trials are required to determine the relative safety and efficacy of cold snare techniques for complete and durable resection of large polyps compared to standard hot snare methods.
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Affiliation(s)
- Neel Choksi
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Ryan W. Stidham
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, USA
| | - Dmitry Shuster
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, USA
| | - Cyrus Piraka
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA,Corresponding author Cyrus Piraka, MD Division of GastroenterologyHenry Ford Hospital2799 West Grand BoulevardDetroitMI 48202USA
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Singla S, Piraka C. Endoscopic retrograde cholangiopancreatography. Clin Liver Dis (Hoboken) 2015; 4:133-137. [PMID: 30992940 PMCID: PMC6448759 DOI: 10.1002/cld.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sumit Singla
- Division of GastroenterologyHenry Ford Health SystemDetroitMI
| | - Cyrus Piraka
- Section of Advanced Therapeutic Endoscopy, Division of GastroenterologyHenry Ford Health SystemDetroitMI
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Sturm MB, Joshi BP, Lu S, Piraka C, Khondee S, Elmunzer BJ, Kwon RS, Beer DG, Appelman HD, Turgeon DK, Wang TD. Targeted imaging of esophageal neoplasia with a fluorescently labeled peptide: first-in-human results. Sci Transl Med 2013; 5:184ra61. [PMID: 23658246 DOI: 10.1126/scitranslmed.3004733] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Esophageal adenocarcinoma is rising rapidly in incidence and usually develops from Barrett's esophagus, a precursor condition commonly found in patients with chronic acid reflux. Premalignant lesions are challenging to detect on conventional screening endoscopy because of their flat appearance. Molecular changes can be used to improve detection of early neoplasia. We have developed a peptide that binds specifically to high-grade dysplasia and adenocarcinoma. We first applied the peptide ex vivo to esophageal specimens from 17 patients to validate specific binding. Next, we performed confocal endomicroscopy in vivo in 25 human subjects after topical peptide administration and found 3.8-fold greater fluorescence intensity for esophageal neoplasia compared with Barrett's esophagus and squamous epithelium with 75% sensitivity and 97% specificity. No toxicity was attributed to the peptide in either animal or patient studies. Therefore, our first-in-human results show that this targeted imaging agent is safe and may be useful for guiding tissue biopsy and for early detection of esophageal neoplasia and potentially other cancers of epithelial origin, such as bladder, colon, lung, pancreas, and stomach.
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Affiliation(s)
- Matthew B Sturm
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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Sturm MB, Piraka C, Elmunzer BJ, Kwon RS, Joshi BP, Appelman HD, Turgeon DK, Wang TD. In vivo molecular imaging of Barrett's esophagus with confocal laser endomicroscopy. Gastroenterology 2013; 145:56-58. [PMID: 23684943 PMCID: PMC3818787 DOI: 10.1053/j.gastro.2013.05.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/10/2013] [Indexed: 12/13/2022]
Affiliation(s)
- Matthew B. Sturm
- Department of Internal Medicine, Division of
Gastroenterology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Cyrus Piraka
- Department of Internal Medicine, Division of
Gastroenterology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Badih J. Elmunzer
- Department of Internal Medicine, Division of
Gastroenterology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Richard S. Kwon
- Department of Internal Medicine, Division of
Gastroenterology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Bishnu P. Joshi
- Department of Internal Medicine, Division of
Gastroenterology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Henry D. Appelman
- Department of Pathology, University of Michigan, Ann Arbor,
MI, 48109, United States
| | - D. Kim Turgeon
- Department of Internal Medicine, Division of
Gastroenterology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Thomas D. Wang
- Department of Internal Medicine, Division of
Gastroenterology, University of Michigan, Ann Arbor, MI, 48109, United States,Department of Biomedical Engineering, University of
Michigan, Ann Arbor, MI, 48109, United States,Department of Mechanical Engineering, University of
Michigan, Ann Arbor, MI, 48109, United States
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Li M, Anastassiades CP, Joshi B, Komarck CM, Piraka C, Elmunzer BJ, Turgeon DK, Johnson TD, Appelman H, Beer DG, Wang TD. Affinity peptide for targeted detection of dysplasia in Barrett's esophagus. Gastroenterology 2010; 139:1472-80. [PMID: 20637198 PMCID: PMC3319360 DOI: 10.1053/j.gastro.2010.07.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [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: 05/23/2010] [Revised: 06/30/2010] [Accepted: 07/07/2010] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Dysplasia is a premalignant condition in Barrett's esophagus that is difficult to detect on endoscopy because of its flat architecture and patchy distribution. Peptides are promising for use as novel molecular probes that identify cell surface targets unique to disease and can be fluorescence-labeled for detection. We aim to select and validate an affinity peptide that binds to esophageal dysplasia for future clinical studies. METHODS Peptide selection was performed using phage display by removing nonspecific binders using Q-hTERT (intestinal metaplasia) cells and achieving specific binding against OE33 (esophageal adenocarcinoma) cells. Selective binding was confirmed on bound phage counts, enzyme-linked immunosorbent assay (ELISA), flow cytometry, competitive inhibition, and fluorescence microscopy. On stereomicroscopy, specific peptide binding to dysplasia on endoscopically resected specimens was assessed by rigorous registration of fluorescence intensity to histology in 1-mm intervals. RESULTS The peptide sequence SNFYMPL was selected and showed preferential binding to target cells. Reduced binding was observed on competition with unlabeled peptide in a dose-dependent manner, an affinity of K(d) = 164 nmol/L was measured, and peptide binding to the surface of OE33 cells was validated on fluorescence microscopy. On esophageal specimens (n = 12), the fluorescence intensity (mean ± SEM) in 1-mm intervals classified histologically as squamous (n = 145), intestinal metaplasia (n = 83), dysplasia (n = 61), and gastric mucosa (n = 69) was 46.5 ± 1.6, 62.3 ± 5.8, 100.0 ± 9.0, and 42.4 ± 3.0 arb units, respectively. CONCLUSIONS The peptide sequence SNFYMPL binds specifically to dysplasia in Barrett's esophagus and can be fluorescence labeled to target premalignant mucosa on imaging.
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Affiliation(s)
- Meng Li
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China,Department of Pharmacy, State Key Laboratory of Cancer Biology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Costas P. Anastassiades
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Bishnu Joshi
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Chris M. Komarck
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Cyrus Piraka
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Badih J. Elmunzer
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Danielle K. Turgeon
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | | | - Henry Appelman
- Department of Pathology, University of Michigan, Ann Arbor, MI, 48109
| | - David G. Beer
- Department of Thoracic Surgery, University of Michigan, Ann Arbor, MI, 48109
| | - Thomas D. Wang
- Department of Medicine, Division of Gastroenterology, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109
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Piraka C, Shah RJ, Fukami N, Chathadi KV, Chen YK. EUS-guided transesophageal, transgastric, and transcolonic drainage of intra-abdominal fluid collections and abscesses. Gastrointest Endosc 2009; 70:786-92. [PMID: 19577742 DOI: 10.1016/j.gie.2009.04.049] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [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: 11/20/2008] [Accepted: 04/27/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND The therapeutic role of EUS is evolving. We report our experience with EUS-guided transesophageal, transgastric, and transcolonic drainage of various intra-abdominal fluid collections. OBJECTIVE To determine the technical feasibility and clinical outcomes of EUS-guided drainage. DESIGN Prospective case series. SETTING Academic tertiary referral center. PATIENTS Patients referred for endoscopic drainage of intra-abdominal fluid collections; pancreatic pseudocysts amenable to conventional transgastric or transduodenal drainage were excluded. INTERVENTIONS Single-step EUS-guided drainage of fluid collections by using a therapeutic linear-array echoendoscope with fluoroscopic guidance. MAIN OUTCOME MEASUREMENTS Technical success, relief of symptoms, and procedural complications. RESULTS Nine consecutive patients deemed appropriate for EUS-guided drainage of intra-abdominal fluid collections included transesophageal drainage of pseudocysts (n = 2), transgastric drainage of biloma (n = 2) and upper intra-abdominal abscesses (n = 2), transcolonic drainage of diverticular abscess (n = 1), Crohn's abscess (n = 1), and postoperative hematoma (n = 1). Endoscopic drainage was successful in all patients. Confirmation of complete resolution of the target fluid collection and symptom relief was achieved in 8 (89%) of 9 patients. Pneumothorax and mediastinitis developed in 1 patient after transesophageal drainage, which resolved with chest tube and medical therapy. During multiple stent placement, one of the stents was fully deployed into the abscess cavity in 2 patients; both were successfully retrieved either endoscopically (Crohn's abscess) or at the time of primary colonic resection (diverticular abscess). LIMITATION Limited number of patients. CONCLUSIONS EUS-guided transenteric drainage of bilomas, hematomas, abscesses, and inflammatory fluid collections is technically feasible and generally results in complete drainage and symptom relief. Procedural complications may be minimized with more experience.
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Affiliation(s)
- Cyrus Piraka
- Division of Gastroenterology, University of Colorado Denver, Aurora, Colorado, USA
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Kwon RS, Piraka C, Scheiman JM. Extending our scope to intramural lesions and beyond! Gastrointest Endosc 2008; 67:1167-9. [PMID: 18513558 DOI: 10.1016/j.gie.2008.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Accepted: 02/19/2008] [Indexed: 12/10/2022]
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Abstract
BACKGROUND & AIMS There are limited prospective data and long-term follow-up on cholangioscopy-directed management of difficult bile duct stones. The study objectives were to evaluate the safety and efficacy of cholangioscopy-directed lithotripsy in patients who had failed standard endoscopic retrograde cholangiopancreatography (ERCP) techniques and to determine the stone recurrence rate. METHODS Consecutive patients with biliary stones referred for cholangioscopy after failure of conventional stone therapy were enrolled and followed prospectively. RESULTS Between February 2000-October 2004, 32 consecutive patients had cholangioscopy-directed lithotripsy (30 electrohydraulic lithotripsy, 2 mechanical) after a mean of 3.3 (range, 2-14) failed ERCPs. Stones were intrahepatic (N = 8); extrahepatic (N = 18); or both (N = 6). Biliary strictures were present in 20 (63%) patients. Cholangioscopy identified additional stones not seen at ERCP in 9 (28%) patients. A mean of 1.4 lithotripsy sessions achieved complete (N = 26, 81%), partial (N = 5, 16%), or failed (N = 1, 3%) stone clearance. Follow-up was available in 28 (88%) patients for a mean of 29.2 months (95% confidence interval, 20.3-38.1 months). Stone recurrence occurred in 4 of 22 (18%) patients with complete clearance and follow-up data; 3 had primary sclerosing cholangitis. There were 2 minor periprocedural complications and 1 late complication. CONCLUSIONS Cholangioscopy-directed lithotripsy is a safe and effective treatment in patients who have failed standard ERCP stone removal techniques. Stone recurrence is low in patients who had complete stone clearance except in patients with primary sclerosing cholangitis. Cholangioscopy detects stones missed by cholangiography.
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Affiliation(s)
- Cyrus Piraka
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Abstract
OBJECTIVES Assess the role of cholangioscopy in primary sclerosing cholangitis for 1) detection of cholangiocarcinoma using cholangioscopy-assisted biopsy 2) detection of stones not seen on cholangiography 3) stone removal with cholangioscopy-directed lithotripsy. METHODS Prospective cohort of consecutive patients referred for cholangioscopy to evaluate dominant strictures or stones. A data collection sheet was employed. Follow-up was by chart review/phone contact. Clinical improvement was defined as resolution of jaundice or > or =50% reduction in pain or cholangitis episodes requiring hospitalization. RESULTS 41 patients (30M, 11F) had 60 cholangioscopy procedures (55 per oral, 5 percutaneous). 33/41 (80%) patients underwent 44 tissue sampling events. HISTOLOGY positive for extrahepatic cholangiocarcinoma (N = 1), negative/atypical (N = 31), and inadequate (N = 1). Stones were found in 23/41 (56%) patients, of which 7/23 (30%) were missed on cholangiography and detected only by cholangioscopy. 9/23 (39%) underwent cholangioscopy-directed lithotripsy. Stone clearance: complete (N = 10, 7 by cholangioscopy-directed lithotripsy after failed conventional stone extraction); partial (N = 7); and not attempted (N = 6). Median follow-up was 17.0 months (range 1-56). Clinical improvement was achieved in 25/40 (63%). Eight patients have undergone transplant and cholangiocarcinoma was present in the explant of two at 1 and 12 months post-cholangioscopy, respectively. CONCLUSIONS This is the first series of patients with primary sclerosing cholangitis undergoing cholangioscopy for the evaluation of dominant strictures and cholangioscopy-directed stone therapy with demonstrable clinical benefits. Stones detected by cholangioscopy were missed by cholangiography in nearly one of three patients. Cholangioscopy-directed lithotripsy may be superior to conventional ERCP for achieving complete stone clearance. Despite the use of cholangioscopy, diagnosis of cholangiocarcinoma remains technically challenging.
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Affiliation(s)
- Nida S Awadallah
- Division of Gastroenterology, Department of Internal Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA
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