Papers by Mohamad Erlangga Zein
Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association
Optical colonoscopy (OC) is the primary modality for investigation of colonic pathology. Although... more Optical colonoscopy (OC) is the primary modality for investigation of colonic pathology. Although there is data on demographic factors for incomplete OC, paucity of data exists for anatomic variables that are associated with an incomplete OC. These anatomic variables can be visualized using computed tomographic colonography (CTC). We aim to retrospectively identify variables associated with incomplete OC using CTC and develop a scoring method to predict the outcome of OC. In this case-control study, 70 cases ( with incomplete OC) and 70 controls (with complete OC) were identified. CTC images of cases and controls were independently reviewed by a single CTC radiologist. Demographic and anatomical parameters were recorded. Data was examined using descriptive linear statistics and multivariate logistic regression model. On analysis, female gender (80% vs 58.6% P = 0.007), prior abdominal/pelvic surgeries (51.4% vs 14.3% P < 0.001), colonic length (187.6 ± 30.0 cm vs 163.8 ± 27.2 cm ...
Endoscopy International Open, 2016
Gastrointestinal endoscopy, 2016
Gastrointestinal Endoscopy, 2016
Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-gui... more Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study
Surgical Endoscopy, 2015
Background Peroral endoscopic myotomy (POEM) has been introduced as an endoscopic alternative to ... more Background Peroral endoscopic myotomy (POEM) has been introduced as an endoscopic alternative to surgical myotomy. The endoluminal functional lumen imaging probe (endoFLIP) evaluates esophagogastric junction (EGJ) distensibility based on cross-sectional area and pressure in response to volume distension. The aim of this study was to evaluate whether there is a correlation between endoFLIP measurements during POEM and postoperative clinical outcomes in terms of symptom relief and development of post-procedure reflux. Methods We conducted a retrospective review of achalasia patients who underwent POEM and intraoperative endoFLIP at three tertiary centers. Patients were divided into two groups based on clinical response measured by Eckardt score (ES): good response (ES \ 3) or poor response (ES C 3). Post-procedure reflux was defined as the presence of esophagitis and/or abnormal pH study. EGJ diameter, cross-sectional area, and distensibility measured by endoFLIP were compared. Results Of the 63 treated patients, 50 had good and 13 had poor clinical response. The intraoperative final EGJ cross-sectional area was significantly higher in the goodresponse group versus poor-response group; median (interquartile range): 89.0 (78.5-106.7) versus 72.4 (48.8-80.0) mm 2 [p = 0.01]. The final EGJ cross-sectional area was also significantly higher in patients who had reflux esophagitis after POEM: 99.5 (91.2-103.7) versus 79.3 (57.1-94.2) mm 2 [p = 0.02]. Conclusion Intraoperative EGJ cross-sectional area during POEM for achalasia correlated with clinical response and post-procedure reflux. Impedance planimetry is a potentially important tool to guide the extent and adequacy of myotomy during POEM. Keywords Endoluminal functional lumen imaging probe Á Esophagogastric junction Á Peroral endoscopic myotomy Á Achalasia Abbreviations CSA Cross-sectional areas ES Eckardt score endoFLIP Endoluminal functional lumen imaging probe EGJ Esophagogastric junction IQR Interquartile range IRP Integrated relaxation pressure LES Lower esophageal sphincter Electronic supplementary material The online version of this article (
Gastrointestinal Endoscopy, 2016
A 48-year-old woman presented with progressive abdominal pain 2 weeks after she had undergone lap... more A 48-year-old woman presented with progressive abdominal pain 2 weeks after she had undergone laparoscopic sleeve gastrectomy (SG). A CT scan of the abdomen demonstrated postsurgical changes related to SG and a large extraluminal collection containing fluid, debris, and air adjacent to the surgical staple line. A percutaneous drain was placed, and endoscopic closure of the defect was attempted. Endoscopy revealed a fistulous opening adjacent to normal gastric lumen. The internal orifice of the gastrocutaneous (GC) fistula conditioned a pouchlike lumen, which was divided from the gastric lumen by a 15-mm-long septum (Fig. 1A). Septotomy was performed with argon plasma coagulation (40W) (ERBE, Tubingen, Germany) and resulted in communication of the 2 lumens (Fig. 1B). The edges of the fistula were ablated with argon plasma coagulation and the defect was closed with an overthe-scope clip (Video 1, available online at www.giejournal. org). Immediate injection of contrast medium into the gastric lumen demonstrated complete closure of the fistula (Fig. 1). The percutaneous drainage was removed 12 days later after progressive output decrement. A CT scan 6 weeks later demonstrated a smaller collection without
Gastrointestinal Endoscopy, 2015
Medical treatment options for gastroparesis are limited. Data from studies of botulinum toxin and... more Medical treatment options for gastroparesis are limited. Data from studies of botulinum toxin and surgical pyloroplasty suggest that disruption of the pylorus can result in symptomatic improvement in some patients with refractory gastroparetic symptoms. The aim of this study was to determine the clinical response to transpyloric stent (TPS) placement in patients with gastroparetic symptoms refractory to standard therapy. Patients with gastroparesis refractory to medical treatment were referred for TPS placement for salvage therapy. Self-reported symptom improvement, stent migration rate, and pre- and post-stent gastric-emptying study results were collected. A total of 30 patients with refractory gastroparesis underwent 48 TPS procedures. Of these, 25 of 48 (52.1%) were performed in patients admitted to the hospital with intractable gastroparetic symptoms. Successful stent placement in the desired location across the pylorus (technical success) was achieved during 47 procedures (98%). Most (n = 24) stents were anchored to the gastric wall by using endoscopic suturing with a mean number of sutures of 2 (range 1-3) per procedure. Clinical response was observed in 75% of patients, and all inpatients were successfully discharged. Clinical success in patients with the predominant symptoms of nausea and vomiting was higher than in those patients with a predominant symptom of pain (79% vs 21%, P = .12). A repeat gastric-emptying study was performed in 16 patients, and the mean 4-hour gastric emptying normalized in 6 patients and significantly improved in 5 patients. Stent migration was least common (48%) when stents were sutured. TPS placement is a feasible novel endoscopic treatment modality for gastroparesis and improves both symptoms and gastric emptying in patients who are refractory to medical treatment, especially those with nausea and vomiting. TPS placement may be considered as salvage therapy for inpatients with intractable symptoms or potentially as a method to select patients who may respond to more permanent therapies directed at the pylorus.
Gastrointestinal Endoscopy, 2016
The safety and efficacy of peroral endoscopic myotomy (POEM) when performed by gastroenterologist... more The safety and efficacy of peroral endoscopic myotomy (POEM) when performed by gastroenterologists in the endoscopy unit are currently unknown. The aims of this study were to assess (1) the safety and efficacy of POEM in which all procedures were performed by 1 gastroenterologist in the endoscopy unit, and (2) the predictors of adverse events and nonresponse. All consecutive patients who underwent POEM at 1 tertiary center were included. Clinical response was defined by a decrease in the Eckardt score to 3 or lower. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s severity grading system. A total of 60 consecutive patients underwent POEM in the endoscopy suite with a mean procedure length of 99 minutes. The mean length of submucosal tunnel was 14 cm and the mean myotomy length was 11 cm. The median length of hospital stay was 1 day. Among 52 patients with a mean follow-up period of 118 days (range 30-750), clinical response was observed in 48 patients (92.3%). There was a significant decrease in Eckardt score after POEM (8 vs 1.19,…
Gastrointestinal Endoscopy, 2015
As experience grows with peroral endoscopic myotomy (POEM), operators are taking on more anatomic... more As experience grows with peroral endoscopic myotomy (POEM), operators are taking on more anatomically challenging cases. Additionally, we are now seeing patients who relapse after a prior POEM. Therefore, the operator must be aware of the steps necessary to adequately investigate and treat such patients. For example, it is of no benefit to continue to target the lower esophageal sphincter if this already has been treated effectively. We herein present 2 different teaching cases in which 2 POEM procedures (double POEM) were performed in each of the patients (Video 1, available online at www. giejournal.org). The first case is a patient who was initially diagnosed with type II achalasia and underwent POEM. The patient did not respond adequately after 6 months, and repeat investigation revealed that the patient in fact had type III achalasia. He therefore required proximal extension of the myotomy. To avoid a new second POEM with a long myotomy on the posterior wall, the decision was made
Gastrointestinal Endoscopy, 2015
Gastrointestinal Endoscopy, 2015
Gastrointestinal Endoscopy, 2015
of malignant nature and prognosis among these subtypes have been shown. Methods: The subjects wer... more of malignant nature and prognosis among these subtypes have been shown. Methods: The subjects were 62 patients with surgically confirmed IPMNs, who underwent PJC preoperatively by endoscopic retrograde cholangiopancreatography. Histological subtyping of cytological samples with or without MUC stain (MUC1, MUC2, and MUC5AC) was compared with that of resected specimens. Results: Histologically, low-grade dysplasia was found in 4 patients, intermediate in 19, high grade in 19, and invasive carcinoma in 20. Gastric, intestinal, pancreatobiliary, and oncocytic subtypes corresponded to 29, 24, 8, and 1 patient, respectively. The rate of high-grade dysplasia (HGD) and/or invasive IPMNs was 34.4% for gastric subtype, 87.5% for intestinal subtype, and 100% for both pancreatobiliary and oncocytic subtypes, showing a significant correlation between histological subtype and rate of HGD and/or invasive IPMN(P ! 0.01 for gastric vs nongastric). Histological subtype was successfully diagnosed by PJC in 90.3% (56/62) with MUC stain .The sensitivity, specificity, and overall accuracy of PJC with MUC stain were 91%, 100%, and 95% for intestinal subtype, respectively. On the other hand, PJC based on the grade of cellular dysplasia showed sensitivity of 37.8%, specificity 100%, and 62.9% accuracy. Conclusions: Preoperative PJC with MUC stain proved to be highly reliable for identifying the histological subtype of IPMN and may provide useful information for deciding surgical indication.
Gastrointestinal Endoscopy, 2015
Gastrointestinal Endoscopy, 2015
Objective: To assess the value of endoscopic full-thickness resection (EFTR) technique for gastri... more Objective: To assess the value of endoscopic full-thickness resection (EFTR) technique for gastric and duodenal submucosal tumors (SMTs) originating from the muscular propria (MP) layer. Methods: A total of 276 patients with solitary gastric SMT originating from the MP layer underwent EFTR between January, 2010 and February, 2014. The tight adhesion of the tumor to gastric or duodenal serosal layer was revealed in all cases on endoscopic ultrasound before the procedure. EFTR was performed using a standard ESD technique without laparascopic assistance under direct endoscopic view. The defect of gastric and duodenal wall was closed after resection. Results: There were 94 males and 182 females. The median age was 57.8 years (range, 30-81 years). Among all the 276 lesions, 165 located in the gastric fundus, 96 located in the gastric body, 8 located in the gastric antrum, 1 located in the angle of stomach, and 6 located in the duodenum. The median lesion size was 1.7 cm (range 0.7-6.0 cm). The success rate of EFTR was 98.9% (273/276). EFTR was failed in 3 cases: one case was out of control because of bleeding into enterocoelia, two cases required conversion into laparoscopic surgery because of giant lobulations of the tumor outside the cavity. The median operation time was 65 min (range, 14-210 min). En bloc resection rate was 98.1% (268/273), while piecemeal resection rate was 1.9% (5/273). The median length of hospital stays was 4.4 days (range, 1-23 days). Pathological outcomes revealed 137 (49.7%) gastrointestinal stromal tumors (GISTs), 103 (37.3%) leiomyomas, 13 (4.7%) schwannomas, 8 (2.9%) calcifying fibrous tumors, 7 (2.5%) glomus tumors, 5 (1.8%) ectopic pancreas, and 3 (1.1%) fibroblastomas. The procedure-related complications were as follows. Pneumoperitoneum occurred in all the patients and were treated successfully with peritoneocentesis decompression. Different degrees of epigastric pain occurred in 168 (60.9%) cases, and 24 (8.7%) of them required analgesics. Seroperitoneum occurred in 15 (5.4%) cases. Localized peritonitis occurred in 3 (1.1%) cases, and digestive tract leakage occurred in 1 (0.4%) case. All the cases with above complications recovered spontaneously or after conservative treatments. No massive bleeding or adominal abscess was found after EFTR. None of the 273 cases developed procedure-related death. No tumor residual or recurrence was found during the follow-up period ranging 3-55 months. Conclusions: EFTR without laparoscopic assistance is minimally invasive, safe, and effective for treating gastric and duodenal SMTs originating from the MP layer and adhering tightly to the serosa. High en bloc resection rate could be achieved. However, a larger number of the cases and long-term outcome deserve further research.
Gastrointestinal Endoscopy, 2015
Gastrointestinal Endoscopy, 2015
univariate analysis, there was no significant difference between the groups with regards to pre p... more univariate analysis, there was no significant difference between the groups with regards to pre procedural characteristics including age, sex, race, BMI, achalasia subtype, HREM findings, prior therapy and Eckardt score. There was no significant differences in the length of esophageal or gastric myotomy between the groups. An anterior myotomy was a significant risk factor for GER (92% vs 81%, OR 2.57, 95% CI 1.04-6.41, pZ0.04). A full thickness myotomy had a trend towards increasing risk of GER (84% vs 73%, OR 2.05, 95% CI 0.98-4.31, pZ0.06). Multivariate analysis demonstrated that none of the studied variables was associated with GER post POEM. HREM findings (pre, post or the delta) were not predictive of GER. Follow up EGD was performed in 78% and majority (69%) of patients with GER had no endoscopic stigmata of reflux. Conclusions: In this large international multicenter study, the prevalence of GER was 61%. GER was mostly asymptomatic and not reliably identified by EGD. No preprocedural or intraprocedural factors were associated with occurrence of GER.
Gastrointestinal Endoscopy, 2015
Endoscopic Retrograde Cholangiopancreatography (ERCP) is one of the most technically demanding pr... more Endoscopic Retrograde Cholangiopancreatography (ERCP) is one of the most technically demanding procedures in gastrointestinal endoscopy. It carries the highest complication rate of almost 5%. Most common indication for ERCP is suspected choledocholithiasis, a condition commonly affects obese patients, who are at increased risk of sedative complication. Propofol is preferred during elective ERCP as it can provide faster induction and shorter recovery time compared to conscious sedation. However, routine anesthesiologist-assisted deep sedation may not always be available or cost-effective. This study aims to evaluate the safety and efficacy of moderate sedation for obese patients undergoing ERCP for suspected choledocholithiasis.A retrospective case-control study evaluating all ERCPs performed for suspected choledocholithiasis during January 1 st 2011 and September 1 st 2014 in our institution was conducted. Out of a total of 63 ERCPs, 29 (46%) were performed for patients whose body mass index (BMI) was more than 30 with 10 (16%) procedures were performed for morbidly obese patients (BMI O 35). Majority of the population studied were African-American (86%) and female (90%) with a mean age of 36 years old. Among ERCPs for obese patients, 55% were performed using moderate sedation with fentanyl or meperidine and midazolam, while the other 45% were performed with general anesthesia. There was no direct correlation between increased BMI and selected method of sedation. There was no statistically significant difference in complication rate between two methods of sedation (odds ratio 0.14; 95% CI 0.01-3.18, p Z 0.22). No sedative-specific complications were observed in both groups. The technical success rate was lower in moderate sedation group (62.5%) compared to general anesthesia group (92%) however, this difference was not statistically significant (OR 7.2; 95% CI 0.7-70.2, p Z 0.08). Reasons for failure were inability to cannulate the duct (43%), inability to extract the stone (43%), and patient's intolerability to sedation (14%).Moderate sedation is a safe and viable mean of sedation in obese patients undergoing ERCP for suspected choledocholithiasis. However, despite its non-statistical significance, the lower success rate in moderate sedation group is concerning and larger prospective trials are warranted. We believe that inadequate sedation and patient's movement contributed to higher technical failure rate. Obesity alone cannot determine the proper method of sedation. Overall risk and complexity of the procedure need to also be taken into consideration.
Gastrointestinal Endoscopy, 2015
One large academic referral center. Patients: A total of 5 patients with a staple-line leak after... more One large academic referral center. Patients: A total of 5 patients with a staple-line leak after LSG Interventions. A novel fully-covered, self-expanding endoscopically deployed metal stent (Niti-S from, Korea) Main Outcome Measurements:Complete leak repair and fistula closure. Results: A total of 5 patient of post sleeve gastrectomy leak and one patient with gastrobronchial fistula underwent endoscopic stenting with Niti-S fully covered long stents. The average age was 36 years and the average BMI was 42, male was 80% of patients were and female were 20%. The median time of stent was 4 days. The average duration of stent placement was 7 weeks. The Successful treatment of gastric leak was in 5 patients (100 %) patients, as confirmed by gastrografin swallow 2-3 days after stent removal. There was no significant different between the time of the surgery and stent placement in team of higher success rate of leak seal. A complete leak repair was achieved in all 5 patients and complete fistula closured. No stent migration occurred. No recurrent leak occurred in any patients.Limitation:-Single center and small series. Conclusions: A case series suggests that patients with post-LSG staple-line leaks may be safely and effectively managed with the endoscopic placement of a novel FC-SEMS (Niti-S)
Gastrointestinal Endoscopy, 2015
Background: None of the gastrointestinal or surgical societies have incorporated peroral endoscop... more Background: None of the gastrointestinal or surgical societies have incorporated peroral endoscopic myotomy (POEM) into their treatment algorithm for achalasia. Laparoscopic Heller myotomy (HM) remains the current gold standard therapy. Several uncontrolled studies comparing POEM and HM revealed equivalent shortterm efficacy and safety. However, no data exists on the cost of POEM and how it compares to that of HM. Aims: To compare 1) the efficacy and safety and 2) the inpatient charges incurred in patients who underwent POEM or HM for the treatment of achalasia. Methods: A retrospective single center review was conducted of 52 consecutive POEM patients (2012-2014) and 52 consecutive HM patients (2009-2014). All HM included a Toupet fundoplication and were performed robotically via a transabdominal approach. All POEM were performed by a gastroenterologist in the endoscopy unit. Endoscopic and surgical procedural data were abstracted and preand post-procedural symptoms (e.g. Eckardt stage) were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to % I. Adverse events were graded according to the ASGE lexicon's severity grading system. All procedural and facility charges were obtained from review of the hospital finance records. Results: There was no difference between POEM and HM with regards to age, gender, symptom duration, achalasia subtype, HREM findings or Eckardt symptom stage (stage III: 82% vs. 84%, pZ1) at baseline. Patients in the POEM cohort were less likely to have a sigmoid esophagus (2.8% vs. 20%, pZ0.02). With regards to intraprocedural characteristics, patients in the POEM cohort had a significantly longer length of myotomy (11.6cm vs. 8.6cm, p!0.0001) despite a significantly shorter procedure time (106mins vs. 263 mins, p!0.0001). There was no significant difference in the rate of adverse events (9.6% vs 9.6%, pZ1) or the length of stay (1.9 vs. 2.3, pZ0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the HM group (94.3% vs. 88.5%, pZ0.48), though the duration of follow up (months) was significantly shorter (4.3 vs. 8.9, pZ0.01). POEM incurred significantly less total charges compared to HM
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Papers by Mohamad Erlangga Zein