Objectives: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed freque... more Objectives: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed frequently in asymptomatic patients. It is still not clear what follow-up is indicated for patients not undergoing surgical resection. Methods: Review of all reports of magnetic resonance cholangiopancreatography (MRCP) from June 2005 to June 2010, identifying all patients diagnosed with IPMN; subsequent reconstruction of the initial therapeutic decision, indications for and adherence to scheduled follow-up, and IPMN evolution by morphology and by biology. Results: Overall, 4943 MRCP reports were analyzed, identifying 234 patients with IPMN. Although 143 (61.1%) of these were comprised in Sendai criteria for resection, surgical resection was considered in only 42 (17.9%) patients. Of the remainder, 52 were not subjected to any control, 58 to a single short time check, 77 to MRCP-based regular annual followup, and 5 were treated for associated ductal adenocarcinoma. With a median follow-up of 39.5 months (range, 12Y72), 37.6% of 125 patients in follow-up had a morphological evolution, but only 2.4% has developed a malignant IPMN. No deaths were recorded, directly related to IPMN, in all 187 conservatively managed patients. Conclusions: In the analyzed series, fewer patients than expected underwent surgical resection, and only 67.2% undergo regular follow-up, but no more than 2.4% developed malignancy.
Background and AimsDysphagia is a common complaint for patients after radiation therapy for head ... more Background and AimsDysphagia is a common complaint for patients after radiation therapy for head and neck cancer. Chronic dysphagia ensues when the radiation-induced injury matures into a fibrotic stricture, with the severity of symptoms paralleling the degree of stenosis. Most patients experience progressive dysphagia that prompts medical attention before complete esophageal obliteration. Rarely, patients present late with inability to clear their secretions because of complete obstruction, also termed acquired atresia. These patients represent a challenge and require aggressive and unconventional interventions to reestablish lumenal patency. Using a case series, we hereby describe a novel yet simple technique to treat patients with acquired esophageal atresia.MethodsFive patients with head and neck cancer in various stages who all underwent nonsurgical treatment with definitive chemotherapy and radiation along with enteral feeding tube placement prior to/during treatment presented with acquired esophageal atresia. All patients underwent an EGD to reestablish lumenal patency. This was accomplished with gentle pressure that was applied in a to-and-fro semi-circular rotational manner as if pushing a corkscrew and twisting it in alternating clockwise and counterclockwise manner.ResultsIn all cases we were able to reestablish esophageal lumenal patency with a single procedure. There were no adverse events. Four of the 5 patients required additional dilations for symptomatic management. However, all patients’ esophageal lumens remained patent.ConclusionsWe describe a novel yet simple technique to treat acquired esophageal atresia after radiation for head and neck cancer. This technique allows for generous dilation yielding complete resolution of the stenosis in a single session. When our approach is used, the patient can be discharged home the same day and resume immediate oral intake.
Background: Pancreatic neuroendocrine tumors (pNETs) account for 1-2% pancreatic tumors and requi... more Background: Pancreatic neuroendocrine tumors (pNETs) account for 1-2% pancreatic tumors and require differentiation from carcinomas since their prognosis and management differ significantly. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is routinely employed in grading pNETs through estimation of Ki67 index on cytology samples. Therefore, obtaining sufficient cytology sample for accurate tumor grading is essential for prognostication and guiding management. We aimed to report our diagnostic yield for obtaining adequate sample on EUS-FNA for diagnosis and tumor grading based on Ki67 index for pNETs. We also aimed to assess the procedural predictors of adequate sampling. Methods: A single center retrospective study including patients with suspected pNETs based on imaging findings (computed tomography and magnetic resonance imaging) were enrolled between January 2008 and October 2017.Collected data included age, sex, adequacy of sample for Ki67 index estimation, FNA needle gauge, approach to FNA, number of passes, location and size of tumor were recorded. The primary outcome was the ability to diagnose and grade pNET using cytological samples obtained through EUS-FNA. Cytological diagnosis of pNET was confirmed if the EUS-FNA sample tested positive for neuroendocrine markers such as chromogranin, synaptophysin and CD56 on immunocytochemical studies. Categorical variables were compared using the chi-squared test or Fisher exact test. A two-tailed p-value <0.05 was used to denote statistical significance. Results: Of the 57 patients included in the study, all were diagnosed with pNET based on cytology samples obtained by EUS-FNA. Furthermore, 77% patients (nZ44) had sufficient cytology sample to allow tumor grading through estimation of Ki67 index. The mean age was 58 AE 14 years and 63% were men. 56% (nZ32) patients had grade I tumors (nZ32), 11% (nZ2) had grade 2 tumors, 11% (nZ2) had grade 3 tumors, while tumor grading could not be determined due to sub-optimal cytology sample in 23% of patients (nZ 13). There was no difference in sample adequacy for Ki67 index between the trans-gastric (76%) and trans-duodenal (66%) approach (pZ0.63), tumor size < 2 vs. ! 2 cm (pZ0.74), tumor location (pancreatic head, body or tail) (pZ0.54), needle size (22 vs. 25 gauge) (pZ0.69), presence of liver metastasis (pZ0.150) and number of passes < 3 vs. ! 3 passes (pZ 0.31). Patients with and without pancreatic ductal dilation had comparable cytology samples to obtain a Ki67 index (75% Vs. 78%, pZ1.00). Conclusion: Our study shows that EUS-FNA is an excellent diagnostic modality to obtain adequate samples for performing cytological diagnosis of pNETs with a yield of 77% to be able to obtain sufficient cytology samples for estimation of Ki67 index. The results suggest that EUS-FNA can be a reliable method for diagnosing and grading of pNETs.
Surgical Endoscopy and Other Interventional Techniques, Jan 18, 2018
Background Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achal... more Background Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achalasia. A multidisciplinary approach may allow safe and early adoption of POEM into clinical practice. Materials and methods We performed a retrospective review of our initial POEM cases. All procedures were performed by a team of interventional gastroenterologist and thoracic surgeon. We analyzed demographics, comorbidities, achalasia subtypes, length of hospital stay, duration of surgery, morbidity, mortality, length of myotomy, preoperative and postoperative Eckardt scores. Results Thirty-one consecutive patients underwent POEM during the 24-month period from January 2014 to December 2015. Eighteen patients (58%) had prior non-operative interventions. Average duration of follow-up was 9.6 months. Seventeen patients (66.8%) had follow-up of 12 months and longer. Average preoperative Eckardt score was 6.3 (3-10), median 6. Average postoperative Eckardt score was 1.4 (0-8), median 1, in 1 month and an average 2.2, median 1, in 1 year. Patients with type III achalasia were most refractory to treatment, while patients with type II had the best results. Average LOS was 1.3 days (1-5), median 1 day. Average DOS was 106 min (60-148), median 106. Average LOM was 13 cm (10-15), with median of 13 cm. We had one 30-day mortality secondary to coronary artery disease. Four patients had prior Heller myotomies and underwent a posterior myotomy during POEM, with outcomes similar to patients with no prior myotomy. Conclusions We demonstrated safety and efficiency of a multispecialty approach for achalasia with POEM with a low rate of complications. Keywords Achalasia • Per oral endoscopic myotomy • Heller myotomy Achalasia is an incurable, primary esophageal motor disorder of unknown etiology characterized manometrically by incomplete relaxation of the lower esophageal sphincter and altered peristalsis of the esophageal body [1, 2]. The Eckardt score is commonly used for the grading of achalasia symptoms and evaluation of treatment efficacy (Table 1) [2]. There are three subtypes described according to the Chicago classification [3]: type I, or absent peristalsis, as demonstrated on high-resolution manometry, type II, or panesophageal pressurization, and type III, known as spastic achalasia. According to three separate retrospective cohort studies, type II has the best prognosis, and type III is the most refractory to treatment [3-5]. Historically, achalasia has been treated to palliate symptoms by various non-surgical approaches, including Botox injections, balloon dilation, and pharmacologic therapy, as well as surgical intervention such as Heller myotomy. Nonsurgical approaches may require multiple interventions to become effective. Heller myotomy demonstrates durable long-term results with reported mean 5-and 10-year remission rates of only 76.1 and 79.6%, respectively [6].
The American Journal of Gastroenterology, Oct 1, 2019
for BC (P 5 0.005 vs 3 mg BRG BID), and 60.0% for LBRG (P 5 0.06 vs 3 mg BRG BID). Symptomatic re... more for BC (P 5 0.005 vs 3 mg BRG BID), and 60.0% for LBRG (P 5 0.06 vs 3 mg BRG BID). Symptomatic remission was similar between groups, as was change in EREFS and change in eosinophil counts. Non-responders to HBRG had mean decrease in eosinophil count of only 0.3/hpf (vs 53.2/hpf for responders, P , 0.003) and mean change in EREFS of 11.6 (vs 21.1 for responders, P , 0.001). 62.5% of non-responders to HBRG actually had increase in eosinophil count after steroids. Response rate to HBRG at , 5 eos/hpf was 77.8% overall and 94.6% in those achieving remission. CONCLUSION: A higher remission rate achieved with a more viscous steroid preparation compared to other formulations suggests the importance of both dose and esophageal delivery in treatment of EoE. Further, with adequate mucosal delivery and dosing of topical steroids, steroid refractory EoE appears to be uncommon. On the other hand, these results suggest the existence of a small truly steroid refractory group of EoE patients with negligible histologic, symptomatic and endoscopic response to high dose steroids that warrant further investigation.
A 32-year-old homosexual male presented with suprapubic pain. Computed tomography showed rectal w... more A 32-year-old homosexual male presented with suprapubic pain. Computed tomography showed rectal wall thickening. Flexible sigmoidoscopy showed small pockets of pus that were opened with mucosal biopsies, and additional pus was diffusely expressed from the rectal wall by applying blunt pressure with the biopsy forceps. Cultures from the pus grew Prevotella bivia. Symptoms resolved after treatment with doxycycline and metronidazole. Proctitis due to P. bivia was not previously reported.
Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatri... more Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was &lt;3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.
The American Journal of Gastroenterology, Oct 1, 2016
Background/Aims: Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-... more Background/Aims: Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-line treatment for bleeding gastric varices (GV) there is still limited experience with this method in the US. Our aim was to analyze our 10-year experience of ECGI for treatment and prophylaxis of gastric variceal bleeding. Methods: Records of patients undergoing ECGI of GV at our US tertiary care center between 6/2005 and 5/2015 were reviewed. Assessed outcomes were primary hemostasis, early rebleeding during hospitalization, recurrent bleeding during follow-up, eradication and recurrence of GV. Results: Prophylactic ECGI was performed in 16 patients with large GV. Eradication was achieved in 15 (94%). During the median follow-up of 27 (IQR 7-47) months, 4 patients (26.6%) had variceal bleeding; all were treated successfully with ECGI. Fifty-seven patients underwent ECGI for GV bleeding. Primary hemostasis was achieved in all. Early rebleeding occurred in 2 (3.5%) and durable hemostasis could not be achieved. Follow-up beyond initial hospitalization was available in 41 patients. Bleeding recurred in 8 (19.5%) patients during a median follow-up of 12 (IQR, 3-51) months. Eradication of GV was achieved in 92% of patients but recurrent varices were found in 44% during a median follow up period of 33 months. Conclusion: ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable.
In recent years, the increased interest in minimally invasive procedures including natural orific... more In recent years, the increased interest in minimally invasive procedures including natural orifice endoscopic surgery (NOTES) and endolumenal interventional endoscopy has led to the emergence and resurgence of tools that provide secure anastomoses. The ability to deploy magnets and lumen-apposing metal stents (LAMS) endoscopically and create a minimally invasive sutureless anastomoses is appealing especially if it proves to be safe and equivalent to anastomoses created by suturing or stapling techniques. This chapter discusses the role of magnets and LAMS as options capable of offering safe sutureless alternatives to the traditional surgical anastomoses.
procedures and computed tomography (CT) scans. Methods: This was a retrospective cohort study usi... more procedures and computed tomography (CT) scans. Methods: This was a retrospective cohort study using the 2012 National Inpatient Sample (NIS), a nationally representative database of inpatient admissions. Adult patients were included if they had an ICD-9 CM code indicating a diagnosis of gastric bypass surgery. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity measured by shock and intensive care unit (ICU) admission, and resource utilization measured by upper endoscopic procedures, computed tomography (CT) scans, length of stay (LOS), and total hospitalization charges. Patients were divided into two groups based on the presence or absence of marginal ulceration as a secondary diagnosis. A Multivariate regression analysis were used to adjusted odds ratios and means for the following confounders: Age, sex, race, income in patients' zip code, Charlson Comorbidity Index, hospital region, location, size and teaching status. Results: A total of 254,650 discharges met inclusion criteria, 12,290 of whom had a secondary diagnosis of marginal ulceration. All adjusted odds ratios, adjusted means and p-values are shown in Table 1. The mean adjusted additional length of stay and total charges were significantly increased for RYGB patients who had a secondary diagnosis of marginal ulceration as compared to those who did not. Furthermore, patients with a secondary diagnosis of marginal ulceration were more likely to have ICU admission and shock, and underwent more upper endoscopies (therapeutic and non-therapeutic) and abdominal CT scans. Inpatient mortality between the groups did not differ. Conclusions: Hospitalized patients with a secondary diagnosis of marginal ulceration have significantly increased LOS, total hospital charge, ICU admissions, and number of procedures (endoscopies and abdominal CT scans) as compared to those without, regardless of reason for admission. The profound impact of this secondary diagnosis suggests a more aggressive prevention and early treatment plan should be employed for treatment of marginal ulceration.
Background: Per oral endoscopic myotomy (POEM) has emerged as a preferred and durable treatment o... more Background: Per oral endoscopic myotomy (POEM) has emerged as a preferred and durable treatment option for palliation of symptoms in achalasia. However, approximately 10% to 20% of patients have recurrent symptoms on longterm followup. We present a new treatment in which POEM was successful by creation of a second submucosal tunnel. Method: 35 achalasia patients were randomized into single-and double-tunnel POEM groups. In the double-tunnel group, the first long tunnel was created at the posterior wall of esophagus while the second short tunnel was created at the opposite of the long tunnel. Also, we done the endoscopic muscle incision and tunnel creation at the same time. Prospectively collected data were analyzed, including procedure times, hospitalization time and clinical outcomes. Results: Double-tunnel POEM and traditional POEM were completed with high rates of technical and clinical success. The double-tunnel POEM resulted in a 24 min increase in procedure time (77 vs. 53 min, pZ0.003) and no decrease in hospitalization time (7.14 vs. 7.93 days, pZ0.3967). The Eckardt score was decreased in both double-tunnel(from 5.20 to 1.60, pZ0.0114) and one-tunnel group(from 5.34 to 1.31, p ＜ 0.0001). Conclusion: A double-tunnel is useful for ensuring a complete myotomy during POEM. With increase in procedure time and no increase hospitalization time, it may be particularly useful for specific achalasia patients for a personalized treatment.
Background Management of duodenal neuroendocrine tumors (DNETs) is not standardized, with smaller... more Background Management of duodenal neuroendocrine tumors (DNETs) is not standardized, with smaller lesions (< 1–2 cm) generally treated by endoscopic mucosal resection (EMR) and larger DNETs by surgical resection (SR). This study reviewed how patients were selected for treatment and compared outcomes. Patients and Methods Patients with DNETs undergoing resection were identified through institutional databases, and clinicopathologic data recorded. χ 2 and Wilcoxon tests compared variables. Survival was determined by Kaplan–Meier, and Cox regression tested association with survival. Results Among 104 patients, 64 underwent EMR and 40 had SR. Patients selected for SR had larger tumor size, younger age, and higher T, N, and M stage. There was no difference in progression-free (PFS) or overall survival (OS) between SR and EMR. In 1–2 cm DNETs, there was no difference in PFS between SR and EMR [median not reached (NR), P = 0.1]; however, longer OS was seen in SR (median NR versus 112 months, P = 0.03). In 1–2 cm DNETs, SR patients were more likely to be node-positive and younger. After adjustment for age, resection method did not correlate with survival. Comparison of surgically resected DNETs versus jejunoileal NETs revealed longer PFS (median NR versus 73 months, P < 0.001) and OS (median NR versus 119 months, P = 0.004) Discussion In 1–2 cm DNETs, there was no difference in survival between EMR and SR after adjustment for age. Recurrences could be salvaged, suggesting that EMR is a reasonable strategy. Compared with jejunoileal NETs, DNETs treated by SR had improved PFS and OS.
Objectives: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed freque... more Objectives: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed frequently in asymptomatic patients. It is still not clear what follow-up is indicated for patients not undergoing surgical resection. Methods: Review of all reports of magnetic resonance cholangiopancreatography (MRCP) from June 2005 to June 2010, identifying all patients diagnosed with IPMN; subsequent reconstruction of the initial therapeutic decision, indications for and adherence to scheduled follow-up, and IPMN evolution by morphology and by biology. Results: Overall, 4943 MRCP reports were analyzed, identifying 234 patients with IPMN. Although 143 (61.1%) of these were comprised in Sendai criteria for resection, surgical resection was considered in only 42 (17.9%) patients. Of the remainder, 52 were not subjected to any control, 58 to a single short time check, 77 to MRCP-based regular annual followup, and 5 were treated for associated ductal adenocarcinoma. With a median follow-up of 39.5 months (range, 12Y72), 37.6% of 125 patients in follow-up had a morphological evolution, but only 2.4% has developed a malignant IPMN. No deaths were recorded, directly related to IPMN, in all 187 conservatively managed patients. Conclusions: In the analyzed series, fewer patients than expected underwent surgical resection, and only 67.2% undergo regular follow-up, but no more than 2.4% developed malignancy.
Background and AimsDysphagia is a common complaint for patients after radiation therapy for head ... more Background and AimsDysphagia is a common complaint for patients after radiation therapy for head and neck cancer. Chronic dysphagia ensues when the radiation-induced injury matures into a fibrotic stricture, with the severity of symptoms paralleling the degree of stenosis. Most patients experience progressive dysphagia that prompts medical attention before complete esophageal obliteration. Rarely, patients present late with inability to clear their secretions because of complete obstruction, also termed acquired atresia. These patients represent a challenge and require aggressive and unconventional interventions to reestablish lumenal patency. Using a case series, we hereby describe a novel yet simple technique to treat patients with acquired esophageal atresia.MethodsFive patients with head and neck cancer in various stages who all underwent nonsurgical treatment with definitive chemotherapy and radiation along with enteral feeding tube placement prior to/during treatment presented with acquired esophageal atresia. All patients underwent an EGD to reestablish lumenal patency. This was accomplished with gentle pressure that was applied in a to-and-fro semi-circular rotational manner as if pushing a corkscrew and twisting it in alternating clockwise and counterclockwise manner.ResultsIn all cases we were able to reestablish esophageal lumenal patency with a single procedure. There were no adverse events. Four of the 5 patients required additional dilations for symptomatic management. However, all patients’ esophageal lumens remained patent.ConclusionsWe describe a novel yet simple technique to treat acquired esophageal atresia after radiation for head and neck cancer. This technique allows for generous dilation yielding complete resolution of the stenosis in a single session. When our approach is used, the patient can be discharged home the same day and resume immediate oral intake.
Background: Pancreatic neuroendocrine tumors (pNETs) account for 1-2% pancreatic tumors and requi... more Background: Pancreatic neuroendocrine tumors (pNETs) account for 1-2% pancreatic tumors and require differentiation from carcinomas since their prognosis and management differ significantly. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is routinely employed in grading pNETs through estimation of Ki67 index on cytology samples. Therefore, obtaining sufficient cytology sample for accurate tumor grading is essential for prognostication and guiding management. We aimed to report our diagnostic yield for obtaining adequate sample on EUS-FNA for diagnosis and tumor grading based on Ki67 index for pNETs. We also aimed to assess the procedural predictors of adequate sampling. Methods: A single center retrospective study including patients with suspected pNETs based on imaging findings (computed tomography and magnetic resonance imaging) were enrolled between January 2008 and October 2017.Collected data included age, sex, adequacy of sample for Ki67 index estimation, FNA needle gauge, approach to FNA, number of passes, location and size of tumor were recorded. The primary outcome was the ability to diagnose and grade pNET using cytological samples obtained through EUS-FNA. Cytological diagnosis of pNET was confirmed if the EUS-FNA sample tested positive for neuroendocrine markers such as chromogranin, synaptophysin and CD56 on immunocytochemical studies. Categorical variables were compared using the chi-squared test or Fisher exact test. A two-tailed p-value <0.05 was used to denote statistical significance. Results: Of the 57 patients included in the study, all were diagnosed with pNET based on cytology samples obtained by EUS-FNA. Furthermore, 77% patients (nZ44) had sufficient cytology sample to allow tumor grading through estimation of Ki67 index. The mean age was 58 AE 14 years and 63% were men. 56% (nZ32) patients had grade I tumors (nZ32), 11% (nZ2) had grade 2 tumors, 11% (nZ2) had grade 3 tumors, while tumor grading could not be determined due to sub-optimal cytology sample in 23% of patients (nZ 13). There was no difference in sample adequacy for Ki67 index between the trans-gastric (76%) and trans-duodenal (66%) approach (pZ0.63), tumor size < 2 vs. ! 2 cm (pZ0.74), tumor location (pancreatic head, body or tail) (pZ0.54), needle size (22 vs. 25 gauge) (pZ0.69), presence of liver metastasis (pZ0.150) and number of passes < 3 vs. ! 3 passes (pZ 0.31). Patients with and without pancreatic ductal dilation had comparable cytology samples to obtain a Ki67 index (75% Vs. 78%, pZ1.00). Conclusion: Our study shows that EUS-FNA is an excellent diagnostic modality to obtain adequate samples for performing cytological diagnosis of pNETs with a yield of 77% to be able to obtain sufficient cytology samples for estimation of Ki67 index. The results suggest that EUS-FNA can be a reliable method for diagnosing and grading of pNETs.
Surgical Endoscopy and Other Interventional Techniques, Jan 18, 2018
Background Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achal... more Background Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achalasia. A multidisciplinary approach may allow safe and early adoption of POEM into clinical practice. Materials and methods We performed a retrospective review of our initial POEM cases. All procedures were performed by a team of interventional gastroenterologist and thoracic surgeon. We analyzed demographics, comorbidities, achalasia subtypes, length of hospital stay, duration of surgery, morbidity, mortality, length of myotomy, preoperative and postoperative Eckardt scores. Results Thirty-one consecutive patients underwent POEM during the 24-month period from January 2014 to December 2015. Eighteen patients (58%) had prior non-operative interventions. Average duration of follow-up was 9.6 months. Seventeen patients (66.8%) had follow-up of 12 months and longer. Average preoperative Eckardt score was 6.3 (3-10), median 6. Average postoperative Eckardt score was 1.4 (0-8), median 1, in 1 month and an average 2.2, median 1, in 1 year. Patients with type III achalasia were most refractory to treatment, while patients with type II had the best results. Average LOS was 1.3 days (1-5), median 1 day. Average DOS was 106 min (60-148), median 106. Average LOM was 13 cm (10-15), with median of 13 cm. We had one 30-day mortality secondary to coronary artery disease. Four patients had prior Heller myotomies and underwent a posterior myotomy during POEM, with outcomes similar to patients with no prior myotomy. Conclusions We demonstrated safety and efficiency of a multispecialty approach for achalasia with POEM with a low rate of complications. Keywords Achalasia • Per oral endoscopic myotomy • Heller myotomy Achalasia is an incurable, primary esophageal motor disorder of unknown etiology characterized manometrically by incomplete relaxation of the lower esophageal sphincter and altered peristalsis of the esophageal body [1, 2]. The Eckardt score is commonly used for the grading of achalasia symptoms and evaluation of treatment efficacy (Table 1) [2]. There are three subtypes described according to the Chicago classification [3]: type I, or absent peristalsis, as demonstrated on high-resolution manometry, type II, or panesophageal pressurization, and type III, known as spastic achalasia. According to three separate retrospective cohort studies, type II has the best prognosis, and type III is the most refractory to treatment [3-5]. Historically, achalasia has been treated to palliate symptoms by various non-surgical approaches, including Botox injections, balloon dilation, and pharmacologic therapy, as well as surgical intervention such as Heller myotomy. Nonsurgical approaches may require multiple interventions to become effective. Heller myotomy demonstrates durable long-term results with reported mean 5-and 10-year remission rates of only 76.1 and 79.6%, respectively [6].
The American Journal of Gastroenterology, Oct 1, 2019
for BC (P 5 0.005 vs 3 mg BRG BID), and 60.0% for LBRG (P 5 0.06 vs 3 mg BRG BID). Symptomatic re... more for BC (P 5 0.005 vs 3 mg BRG BID), and 60.0% for LBRG (P 5 0.06 vs 3 mg BRG BID). Symptomatic remission was similar between groups, as was change in EREFS and change in eosinophil counts. Non-responders to HBRG had mean decrease in eosinophil count of only 0.3/hpf (vs 53.2/hpf for responders, P , 0.003) and mean change in EREFS of 11.6 (vs 21.1 for responders, P , 0.001). 62.5% of non-responders to HBRG actually had increase in eosinophil count after steroids. Response rate to HBRG at , 5 eos/hpf was 77.8% overall and 94.6% in those achieving remission. CONCLUSION: A higher remission rate achieved with a more viscous steroid preparation compared to other formulations suggests the importance of both dose and esophageal delivery in treatment of EoE. Further, with adequate mucosal delivery and dosing of topical steroids, steroid refractory EoE appears to be uncommon. On the other hand, these results suggest the existence of a small truly steroid refractory group of EoE patients with negligible histologic, symptomatic and endoscopic response to high dose steroids that warrant further investigation.
A 32-year-old homosexual male presented with suprapubic pain. Computed tomography showed rectal w... more A 32-year-old homosexual male presented with suprapubic pain. Computed tomography showed rectal wall thickening. Flexible sigmoidoscopy showed small pockets of pus that were opened with mucosal biopsies, and additional pus was diffusely expressed from the rectal wall by applying blunt pressure with the biopsy forceps. Cultures from the pus grew Prevotella bivia. Symptoms resolved after treatment with doxycycline and metronidazole. Proctitis due to P. bivia was not previously reported.
Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatri... more Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was &lt;3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.
The American Journal of Gastroenterology, Oct 1, 2016
Background/Aims: Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-... more Background/Aims: Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-line treatment for bleeding gastric varices (GV) there is still limited experience with this method in the US. Our aim was to analyze our 10-year experience of ECGI for treatment and prophylaxis of gastric variceal bleeding. Methods: Records of patients undergoing ECGI of GV at our US tertiary care center between 6/2005 and 5/2015 were reviewed. Assessed outcomes were primary hemostasis, early rebleeding during hospitalization, recurrent bleeding during follow-up, eradication and recurrence of GV. Results: Prophylactic ECGI was performed in 16 patients with large GV. Eradication was achieved in 15 (94%). During the median follow-up of 27 (IQR 7-47) months, 4 patients (26.6%) had variceal bleeding; all were treated successfully with ECGI. Fifty-seven patients underwent ECGI for GV bleeding. Primary hemostasis was achieved in all. Early rebleeding occurred in 2 (3.5%) and durable hemostasis could not be achieved. Follow-up beyond initial hospitalization was available in 41 patients. Bleeding recurred in 8 (19.5%) patients during a median follow-up of 12 (IQR, 3-51) months. Eradication of GV was achieved in 92% of patients but recurrent varices were found in 44% during a median follow up period of 33 months. Conclusion: ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable.
In recent years, the increased interest in minimally invasive procedures including natural orific... more In recent years, the increased interest in minimally invasive procedures including natural orifice endoscopic surgery (NOTES) and endolumenal interventional endoscopy has led to the emergence and resurgence of tools that provide secure anastomoses. The ability to deploy magnets and lumen-apposing metal stents (LAMS) endoscopically and create a minimally invasive sutureless anastomoses is appealing especially if it proves to be safe and equivalent to anastomoses created by suturing or stapling techniques. This chapter discusses the role of magnets and LAMS as options capable of offering safe sutureless alternatives to the traditional surgical anastomoses.
procedures and computed tomography (CT) scans. Methods: This was a retrospective cohort study usi... more procedures and computed tomography (CT) scans. Methods: This was a retrospective cohort study using the 2012 National Inpatient Sample (NIS), a nationally representative database of inpatient admissions. Adult patients were included if they had an ICD-9 CM code indicating a diagnosis of gastric bypass surgery. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity measured by shock and intensive care unit (ICU) admission, and resource utilization measured by upper endoscopic procedures, computed tomography (CT) scans, length of stay (LOS), and total hospitalization charges. Patients were divided into two groups based on the presence or absence of marginal ulceration as a secondary diagnosis. A Multivariate regression analysis were used to adjusted odds ratios and means for the following confounders: Age, sex, race, income in patients' zip code, Charlson Comorbidity Index, hospital region, location, size and teaching status. Results: A total of 254,650 discharges met inclusion criteria, 12,290 of whom had a secondary diagnosis of marginal ulceration. All adjusted odds ratios, adjusted means and p-values are shown in Table 1. The mean adjusted additional length of stay and total charges were significantly increased for RYGB patients who had a secondary diagnosis of marginal ulceration as compared to those who did not. Furthermore, patients with a secondary diagnosis of marginal ulceration were more likely to have ICU admission and shock, and underwent more upper endoscopies (therapeutic and non-therapeutic) and abdominal CT scans. Inpatient mortality between the groups did not differ. Conclusions: Hospitalized patients with a secondary diagnosis of marginal ulceration have significantly increased LOS, total hospital charge, ICU admissions, and number of procedures (endoscopies and abdominal CT scans) as compared to those without, regardless of reason for admission. The profound impact of this secondary diagnosis suggests a more aggressive prevention and early treatment plan should be employed for treatment of marginal ulceration.
Background: Per oral endoscopic myotomy (POEM) has emerged as a preferred and durable treatment o... more Background: Per oral endoscopic myotomy (POEM) has emerged as a preferred and durable treatment option for palliation of symptoms in achalasia. However, approximately 10% to 20% of patients have recurrent symptoms on longterm followup. We present a new treatment in which POEM was successful by creation of a second submucosal tunnel. Method: 35 achalasia patients were randomized into single-and double-tunnel POEM groups. In the double-tunnel group, the first long tunnel was created at the posterior wall of esophagus while the second short tunnel was created at the opposite of the long tunnel. Also, we done the endoscopic muscle incision and tunnel creation at the same time. Prospectively collected data were analyzed, including procedure times, hospitalization time and clinical outcomes. Results: Double-tunnel POEM and traditional POEM were completed with high rates of technical and clinical success. The double-tunnel POEM resulted in a 24 min increase in procedure time (77 vs. 53 min, pZ0.003) and no decrease in hospitalization time (7.14 vs. 7.93 days, pZ0.3967). The Eckardt score was decreased in both double-tunnel(from 5.20 to 1.60, pZ0.0114) and one-tunnel group(from 5.34 to 1.31, p ＜ 0.0001). Conclusion: A double-tunnel is useful for ensuring a complete myotomy during POEM. With increase in procedure time and no increase hospitalization time, it may be particularly useful for specific achalasia patients for a personalized treatment.
Background Management of duodenal neuroendocrine tumors (DNETs) is not standardized, with smaller... more Background Management of duodenal neuroendocrine tumors (DNETs) is not standardized, with smaller lesions (< 1–2 cm) generally treated by endoscopic mucosal resection (EMR) and larger DNETs by surgical resection (SR). This study reviewed how patients were selected for treatment and compared outcomes. Patients and Methods Patients with DNETs undergoing resection were identified through institutional databases, and clinicopathologic data recorded. χ 2 and Wilcoxon tests compared variables. Survival was determined by Kaplan–Meier, and Cox regression tested association with survival. Results Among 104 patients, 64 underwent EMR and 40 had SR. Patients selected for SR had larger tumor size, younger age, and higher T, N, and M stage. There was no difference in progression-free (PFS) or overall survival (OS) between SR and EMR. In 1–2 cm DNETs, there was no difference in PFS between SR and EMR [median not reached (NR), P = 0.1]; however, longer OS was seen in SR (median NR versus 112 months, P = 0.03). In 1–2 cm DNETs, SR patients were more likely to be node-positive and younger. After adjustment for age, resection method did not correlate with survival. Comparison of surgically resected DNETs versus jejunoileal NETs revealed longer PFS (median NR versus 73 months, P < 0.001) and OS (median NR versus 119 months, P = 0.004) Discussion In 1–2 cm DNETs, there was no difference in survival between EMR and SR after adjustment for age. Recurrences could be salvaged, suggesting that EMR is a reasonable strategy. Compared with jejunoileal NETs, DNETs treated by SR had improved PFS and OS.
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Papers by Henning Gerke