Publications by authors named "Nirav Thosani"

115 Publications

Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis.

Gastrointest Endosc 2021 Sep 6. Epub 2021 Sep 6.

Center for interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, Houston, TX, USA. Electronic address:

Background And Aims: Endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied.

Methods: We developed a decision tree for diagnosing IPC (base case probability: 50%; range 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested include (1) Laparoscopic cholecystectomy with IOC (LC-IOC), (2) MRCP, (3) single-session EUS + ERCP, and (4) separate session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by (1) assigning utility scores to health states, (2) the average proportion of true positive diagnosis of IPC, and (3) the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB), and average cost per true positive diagnosis.

Results: LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategy 2 (MRCP), 3 (single-session EUS+ERCP), and 4 (separate-session EUS+ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses.

Conclusion: For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten length of hospital stay. Our findings may be used to design institutional and organizational management protocols.
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http://dx.doi.org/10.1016/j.gie.2021.08.024DOI Listing
September 2021

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

Surg Endosc 2021 Sep 19;35(9):4903-4917. Epub 2021 Jul 19.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-021-08625-5DOI Listing
September 2021

Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up.

Endosc Int Open 2021 Jul 21;9(7):E1097-E1107. Epub 2021 Jun 21.

Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore, Maryland, United States.

Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 %  = 0.001; 90.6 % vs 74.8 %,  = 0.004; 88.4 % vs 72.2 %,  = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %,  = 0.01; 92.3 % vs 80.3 %,  = 0.01; 92.3 %v 41.9 %,  = 0.01 respectively) Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97;  = 0.001 & 5.64;  = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95,  = 0.02 and by endoscopic findings: 6.98,  = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %,  = 0.8) and significant bleeding (0.4 % vs 0.7 %,  = 0.56) were comparable between POEM and PD groups. POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.
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http://dx.doi.org/10.1055/a-1483-9406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216779PMC
July 2021

Lymphocytic Esophagitis Is Not Similar to Eosinophilic Esophagitis Except for Seasonal Variation.

Ann Clin Lab Sci 2021 May;51(3):347-351

Department of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA

Objective: Unlike eosinophilic esophagitis (EoE), there is no consensus on the minimum number of intraepithelial lymphocytes (IEL) that is diagnostic of lymphocytic esophagitis (LyE). The aim of this study was to determine whether significant correlations exist between the numbers of intraepithelial lymphocytes (IEL) in esophageal biopsies and clinical and endoscopic manifestations usually associated with EoE.

Methods: H&E slides from esophageal biopsies from 330 patients were reviewed. The number of IEL and intraepithelial eosinophils (IEE) per mm was counted in the area with the highest concentration in each biopsy. The numbers were then correlated with clinical and endoscopic findings.

Results: As expected, a higher number of IEE was significantly associated with food impaction (=0.001), dysphagia (=0.021), esophageal stricture (=0.017), rings (<0.0001), and furrows (<0.0001). By contrast, there was no significant association between increased IEL and any of the aforementioned clinical and endoscopic features in the original 330 patients or in a subset of 233 patients with no IEE. Interestingly, the number of both IEE and IEL varied significantly by the season when the biopsy was obtained, being lowest in the fall and highest in the spring (=0002 for IEE and <0.0001 for IEL).

Conclusion: In esophageal biopsies, increased IEL has no significant correlation with food impaction or dysphagia or with esophageal stricture, rings, or furrows. There is significant variation in the number of IEL depending on the season when the biopsy is obtained, which has not been previously reported.
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May 2021

Bleeding Risk and Mortality Associated With Uninterrupted Antithrombotic Therapy During Percutaneous Endoscopic Gastrostomy Tube Placement.

Am J Gastroenterol 2021 09;116(9):1868-1875

Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, Texas, USA.

Introduction: Antithrombotic therapy is often interrupted before the placement of a percutaneous endoscopic gastrostomy (PEG) tube because of potentially increased risk of hemorrhagic events. The aim of our study was to evaluate the risk of bleeding events and overall complication rates after PEG in patients on uninterrupted antiplatelet and anticoagulation therapy in a high-volume center.

Methods: Data regarding demographics, diagnoses, comorbidities, and clinical outcomes pertinent to PEG were collected from 2010 to 2016. Furthermore, data regarding antithrombotic therapy along with the rate of minor or major complications including bleeding associated with this procedure were analyzed. Significant bleeding was defined as postprocedure bleeding from PEG site requiring a blood transfusion and/or surgical/endoscopic intervention.

Results: We included 1,613 consecutive PEG procedures in this study, of which 1,540 patients (95.5%) received some form of uninterrupted antithrombotic therapy. Of those patients, 535 (34.7%) were on aspirin, 256 (16.6%) on clopidogrel, and 119 (7.7%) on both aspirin and clopidogrel. Subcutaneous heparin was uninterrupted in 980 (63.6%), intravenous heparin in 34 (2.1%), warfarin in 168 (10.9%), and direct-acting oral anticoagulation in 82 (5.3%) patients who overlapped on multiple drugs. We observed 6 significant bleeding events in the entire cohort (0.39%), and all were in subcutaneous heparin groups either alone or in combination with aspirin. No clinically significant bleeding was noted in patients on uninterrupted aspirin, warfarin, clopidogrel, or direct-acting oral anticoagulation groups. Only 5 patients (0.31%) had PEG-related mortality.

Discussion: The risk of significant bleeding associated with the PEG placement was minimal in patients on uninterrupted periprocedural antithrombotic therapy.
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http://dx.doi.org/10.14309/ajg.0000000000001348DOI Listing
September 2021

Response.

Gastrointest Endosc 2021 07;94(1):205-206

Department of Gastroenterology, University of Florida, Gainesville, Florida, USA.

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http://dx.doi.org/10.1016/j.gie.2021.03.059DOI Listing
July 2021

It's not a mystery, it's in the history: Multidisciplinary management of multiple endocrine neoplasia type 1.

CA Cancer J Clin 2021 Sep 1;71(5):369-380. Epub 2021 Jun 1.

Department of Surgical Oncology, Section of Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, Texas.

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http://dx.doi.org/10.3322/caac.21673DOI Listing
September 2021

ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction.

Gastrointest Endosc 2021 08 20;94(2):222-234.e22. Epub 2021 May 20.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses primary drainage modality (percutaneous transhepatic biliary drainage [PTBD] vs endoscopic biliary drainage [EBD]), drainage strategy (unilateral vs bilateral), and stent selection (plastic stent [PS] vs self-expandable metal stent [SEMS]). Regarding drainage modality, in patients with MHO undergoing drainage before potential resection or transplantation, the panel suggests against routine use of PTBD as first-line therapy compared with EBD. In patients with unresectable MHO undergoing palliative drainage, the panel suggests PTBD or EBD. The final decision should be based on patient preferences, disease characteristics, and local expertise. Regarding drainage strategy, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placement of bilateral stents compared with a unilateral stent in the absence of liver atrophy. Finally, regarding type of stent, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placing SEMSs or PSs. However, in patients who have a short life expectancy and who place high value on avoiding repeated interventions, the panel suggests using SEMSs compared with PSs. If optimal drainage strategy has not been established, the panel suggests placing PSs. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.
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http://dx.doi.org/10.1016/j.gie.2020.12.035DOI Listing
August 2021

ASGE guideline on the management of cholangitis.

Gastrointest Endosc 2021 08 20;94(2):207-221.e14. Epub 2021 May 20.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention (<48 hours vs >48 hours), and extent of initial intervention (comprehensive therapy vs decompression alone). Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to formulate recommendations on these topics. The ASGE suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours. Additionally, the panel suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment.
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http://dx.doi.org/10.1016/j.gie.2020.12.032DOI Listing
August 2021

From bench to bedside: Is it time to incorporate molecular testing for diagnostic and management algorithms for pancreatic cystic lesions?

Gastrointest Endosc 2021 05;93(5):1034-1037

Center for Interventional Gastroenterology at the University of Texas, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA; Division of Gastroenterology and Hepatology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

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http://dx.doi.org/10.1016/j.gie.2021.01.041DOI Listing
May 2021

Hepatocellular carcinoma masquerading as nodular Barrett's esophagus.

Gastrointest Endosc 2021 May 22;93(5):1182-1183. Epub 2021 Jan 22.

Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA.

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http://dx.doi.org/10.1016/j.gie.2021.01.011DOI Listing
May 2021

An international study of interobserver variability of "string sign" of pancreatic cysts among experienced endosonographers.

Endosc Ultrasound 2021 Jan-Feb;10(1):39-50

Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background And Objectives: No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the "string sign" test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied.

Methods: An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: "Is the string sign positive?" and "If the string sign is positive, what is the length of the formed string?" Also asked "What is the cutoff length for string sign to be considered positive?" Interobserver variability was assessed using the kappa statistic (κ).

Results: A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive.

Conclusion: String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.
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http://dx.doi.org/10.4103/eus.eus_73_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980687PMC
January 2021

Multisociety guideline on reprocessing flexible GI endoscopes and accessories.

Gastrointest Endosc 2021 01;93(1):11-33.e6

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

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http://dx.doi.org/10.1016/j.gie.2020.09.048DOI Listing
January 2021

Removal of a lodged pancreatic duct stone using a retrieval snare.

VideoGIE 2020 Dec 11;5(12):670-672. Epub 2020 Aug 11.

Division of Gastroenterology, Hepatology, & Nutrition, University of Texas Health Science Center at Houston, Houston, Texas.

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http://dx.doi.org/10.1016/j.vgie.2020.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729847PMC
December 2020

Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques.

World J Gastroenterol 2020 Nov;26(41):6391-6401

Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA 94304, United States.

Background: At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period.

Aim: To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors.

Methods: Demographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as "standard" or "advanced" and duodenoscope position was labeled as "standard" (short position) or "non-standard" ( long, semi-long).

Results: Patients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years 55.1 ± 14.7, < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 ( < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) ( < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) ( < 0.001). Primary mass size > 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques ( < 0.03 for each).

Conclusion: Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures.
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http://dx.doi.org/10.3748/wjg.v26.i41.6391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656203PMC
November 2020

ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.

Gastrointest Endosc 2021 02 7;93(2):309-322.e4. Epub 2020 Nov 7.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.
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http://dx.doi.org/10.1016/j.gie.2020.07.063DOI Listing
February 2021

Comparing diagnostic accuracy of current practice guidelines in predicting choledocholithiasis: outcomes from a large healthcare system comprising both academic and community settings.

Gastrointest Endosc 2021 06 5;93(6):1351-1359. Epub 2020 Nov 5.

Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA.

Background And Aims: The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. We aim to compare the performance and diagnostic accuracy of 2019 versus 2010 ASGE criteria for suspected choledocholithiasis.

Methods: We performed a retrospective chart review of a prospectively maintained database (2013-2019) of over 10,000 ERCPs performed by 70 gastroenterologists in our 14-hospital system. We randomly selected 744 ERCPs in which the primary indication was suspected choledocholithiasis. Patients with a history of cholecystectomy or prior sphincterotomy were excluded. The same patient cohort was assigned as low, intermediate, or high risk according to the 2010 and 2019 guideline criteria. Overall accuracy of both guidelines was compared against the presence of stones and/or sludge on ERCP.

Results: Of 744 patients who underwent ERCP, 544 patients (73.1%) had definite stones during ERCP and 696 patients (93.5%) had stones and/or sludge during ERCP. When classified according to the 2019 guidelines, fewer patients were high risk (274/744, 36.8%) compared with 2010 guidelines (449/744, 60.4%; P < .001). Within the high-risk group per both guidelines, definitive stone was found during ERCP more frequently in the 2019 guideline cohort (226/274, 82.5%) compared with the 2010 guideline cohort (342/449, 76.2%; P < .001). In our patient cohort, overall specificity of the 2010 guideline was 46.5%, which improved to 76.0% as per 2019 guideline criteria (P < .001). However, no significant change was noted for either positive predictive value or negative predictive value between 2019 and 2010 guidelines.

Conclusions: The 2019 ASGE guidelines are more specific for detection of choledocholithiasis during ERCP when compared with the 2010 guidelines. However, a large number of patients are categorized as intermediate risk per 2019 guidelines and will require an additional confirmatory imaging study.
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http://dx.doi.org/10.1016/j.gie.2020.10.033DOI Listing
June 2021

Endoscopic Gastrointestinal Anastomosis Using Lumen-apposing Metal Stent (LAMS) for Benign or Malignant Etiologies: A Systematic Review and Meta-Analysis.

J Clin Gastroenterol 2021 08;55(7):e56-e65

Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX.

Background And Aim: Endoscopic gastrointestinal anastomosis using lumen-apposing metal stents (EGAL) is a new technique that is used as an alternative method to bypass benign or malignant strictures. Endoscopists take advantage of 2 bowel loops that are close to each other and place a stent between the lumen of these 2 bowel loops. The authors performed this systematic review and meta-analysis to evaluate the efficacy and safety of this rising procedure.

Methods: Electronic database searches were conducted for full eligible articles that were published from the inception to July 2019 using the EGAL procedure to bypass malignant or benign obstruction or to restore bowel integrity after a gastrointestinal altering surgery. The primary outcome of this meta-analysis was to assess efficacy through technical and clinical success. Secondary outcomes were to assess safety through adverse events and to assess the rate of stent maldeployment and the rate of reintervention during the study period.

Results: Eight studies were eligible, providing data on 269 patients who underwent 271 EGAL procedures. The median age was 65 years (interquartile range: 63 to 66) with 46% male individuals. Out of 269 patients, 203 underwent EGALs because of malignant etiology and 66 underwent EGAL for benign etiology. The median duration of follow-up was 114 days (interquartile range: 78 to 121). Technical success rate was 94.1% [95% confidence interval (CI), 91.4%-96.9%]. Clinical success rate was 91.4% (95% CI, 88.1%-94.7%). Adverse events rate was 8.5% (95% CI, 4.7%-12.3%). Stent maldeployment rate was 9.5% (95% CI, 3.5%-15.4%) of the total performed EGALs and the reintervention rate was 6.0% (95% CI, 2.3%-9.8%).

Conclusion: EGAL procedure has high efficacy and a relatively safe profile and it can be performed in selected patients. Comparison between EGAL and other conventional therapies is difficult because of the lack of randomized trials.
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http://dx.doi.org/10.1097/MCG.0000000000001453DOI Listing
August 2021

Endoscopic ultrasound-guided parenchymal liver biopsy: a systematic review and meta-analysis.

Surg Endosc 2021 Oct 14;35(10):5546-5557. Epub 2020 Oct 14.

UTHealth McGovern Medical School, Houston, TX, USA.

Background: Endoscopic ultrasonography (EUS)-guided liver biopsy is a novel technique to obtain adequate liver samples for diagnosis of liver parenchymal diseases. There are studies that have evaluated the feasibility and safety of EUS-guided parenchymal liver biopsy (EUS-LB), however, factors that can influence specimen quality are yet to be determined. Our aim was to determine the diagnostic accuracy of EUS-LB and evaluate factors associated with specimen quality.

Methods: We performed a detailed search of PubMed/MEDLINE and Web of Science™ databases to identify studies in which results of EUS-guided liver parenchymal biopsies were reported published up to July 2020. A random effects model was used to estimate pooled values (mean ± SE) for total specimen length (TSL) and complete portal tracts (CPT). Subgroup analyses were applied to find out the procedural factors associated with better specimen quality using Cochran's Q test. A total of 10 meta-analyses were done focusing on international studies. Total of 1326 patients who underwent EUS-LB. EUS-LBs performed for suspicion of parenchymal liver disease. Pooled mean values for TSL and CPT with subgroup analyses.

Results: Twenty-three studies with a total of 1326 patients were included in our meta-analysis. Overall pooled mean TSL and CPT were 45.3 ± 4.6 mm and 15.8 ± 1.5, respectively. In subgroup analysis, core biopsy needles proved to better in terms of CPT than fine-needle aspiration needles (18.4 vs 10.99, p = 0.003). FNB with slow-pull or suction technique provided a similar TSL (44.3 vs 53.9 mm, p = 0.40), however, slow-pull technique was better in terms of CPT (30 vs 14.6, p < 0.001). Heterogeneity was present among the studies. Another limitation is the low number randomized control trials.

Conclusion: EUS-guided parenchymal liver biopsy is a good alternative to other methods of liver sampling. Using FNB needles with a slow-pull technique can provide better results.
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http://dx.doi.org/10.1007/s00464-020-08053-xDOI Listing
October 2021

Kras mutation rate precisely orchestrates ductal derived pancreatic intraepithelial neoplasia and pancreatic cancer.

Lab Invest 2021 02 2;101(2):177-192. Epub 2020 Oct 2.

Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, 77030, USA.

Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of cancer-related death in the United States. Despite the high prevalence of Kras mutations in pancreatic cancer patients, murine models expressing the oncogenic mutant Kras (Kras) in mature pancreatic cells develop PDAC at a low frequency. Independent of cell of origin, a second genetic hit (loss of tumor suppressor TP53 or PTEN) is important for development of PDAC in mice. We hypothesized ectopic expression and elevated levels of oncogenic mutant Kras would promote PanIN arising in pancreatic ducts. To test our hypothesis, the significance of elevating levels of K-Ras and Ras activity has been explored by expression of a CAG driven LGSL-Kras allele (cKras) in pancreatic ducts, which promotes ectopic Kras expression. We predicted expression of cKras in pancreatic ducts would generate neoplasia and PDAC. To test our hypothesis, we employed tamoxifen dependent CreER mediated recombination. Hnf1b:CreER;Kras (cKras) mice received 1 (Low), 5 (Mod) or 10 (High) mg per 20 g body weight to recombine cKras in low (cKras), moderate (cKras), and high (cKras) percentages of pancreatic ducts. Our histologic analysis revealed poorly differentiated aggressive tumors in cKras mice. cKras mice had grades of Pancreatic Intraepithelial Neoplasia (PanIN), recapitulating early and advanced PanIN observed in human PDAC. Proteomics analysis revealed significant differences in PTEN/AKT and MAPK pathways between wild type, cKras, cKras, and cKras mice. In conclusion, in this study, we provide evidence that ectopic expression of oncogenic mutant K-Ras in pancreatic ducts generates early and late PanIN as well as PDAC. This Ras rheostat model provides evidence that AKT signaling is an important early driver of invasive ductal derived PDAC.
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http://dx.doi.org/10.1038/s41374-020-00490-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172380PMC
February 2021

Economic model to restart endoscopy practice needs to consider impact on health disparity in minority groups.

Gastrointest Endosc 2020 10;92(4):986-987

McGovern Medical School, The University of Texas Health Science Center, Houston, Texas, USA.

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http://dx.doi.org/10.1016/j.gie.2020.05.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505068PMC
October 2020

Response.

Gastrointest Endosc 2020 08;92(2):458-459

Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA.

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http://dx.doi.org/10.1016/j.gie.2020.05.010DOI Listing
August 2020

Practice patterns, techniques, and outcomes of flexible endoscopic myotomy for Zenker's diverticulum: a retrospective multicenter study.

Endoscopy 2021 Apr 14;53(4):346-353. Epub 2020 Jul 14.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States.

Background:  Flexible endoscopic myotomy has been increasingly performed for Zenker's diverticulum using various endoscopic techniques and devices. The main aims of this study were to assess practice patterns and compare outcomes of endoscopic myotomy for Zenker's diverticulum.

Methods:  Procedures performed at 12 tertiary endoscopy centers from 1/2012 to 12/2018 were reviewed. Patients (≥ 18 years) with Zenker's diverticulum who had dysphagia and/or regurgitation and underwent endoscopic myotomy were included. Outcomes assessed included technical success, clinical success, and adverse events.

Results:  161 patients were included. Traditional endoscopic septotomy was performed most frequently (137/161, 85.1 %) followed by submucosal dissection of the septum and myotomy (24/161, 14.9 %). The hook knife (43/161, 26.7 %) and needle-knife (33/161, 20.5 %) were used most frequently. Overall, technical and clinical success rates were 98.1 % (158/161) and 78.1 % (96/123), respectively. Adverse events were noted in 13 patients (8.1 %). There was no significant difference in technical and clinical success between traditional septotomy and submucosal dissection groups (97.1 % vs. 95.8 %,  = 0.56 and 75.2 % vs. 90.9 %,  = 0.16, respectively). Clinical success was higher with the hook knife (96.7 %) compared with the needle-knife (76.6 %) and insulated tip knife (47.1 %). Outcomes were similar between centers performing > 20, 11 - 20, and ≤ 10 procedures.

Conclusions:  Flexible endoscopic myotomy is an effective therapy for Zenker's diverticulum, with a low rate of adverse events. There was no significant difference in outcomes between traditional septotomy and a submucosal dissection approach, or with centers with higher volume, though clinical success was higher with the hook knife.
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http://dx.doi.org/10.1055/a-1219-4516DOI Listing
April 2021

Initial multicenter experience with nitrous oxide cryoballoon for treatment of flat duodenal adenomas (with video).

Gastrointest Endosc 2021 01 6;93(1):240-246. Epub 2020 Jun 6.

Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background And Aims: EMR is the preferred endoscopic therapy for duodenal adenomas (DAs) but is associated with an overall adverse event rate of 26%. Cryotherapy using a Cryoballoon Focal Ablation System (CbFAS) can safely and effectively eradicate esophageal intestinal metaplasia. We report our first experience with cryoballoon ablation for treatment of flat DAs.

Methods: This was an American, multicenter, retrospective study involving 5 centers. DAs (Paris 0-IIa and 0-IIb) were treated with nitrous oxide for 5 to 12 seconds using CbFAS. Follow-up EGD was performed at 3 to 12 months.

Results: Seventeen DAs (mean size, 22.7 ± 14.3 mm; 12 tubular, 5 tubulovillous) from 13 patients (mean age, 66.5 ± 9.99 years; 61.5% males) were included in the study. Thirteen of 17 DAs (76.5%) had failed previous treatment, and 4 of 17 (23.5%) were treatment naÏve. All procedures were technically successful and achieved a >50% decrease in size after cryoballoon ablation There was no increase in size or progression of disease for any lesions. Overall, treatment was completed in 15 of 17 patients, and recurrence-free survival was achieved in 12 of 17 (71%) after a median follow-up of 15.5 months (interquartile range [IQR], 6.8-19.4). The median cryoablation time per polyp was 4 minutes (IQR, 1-7.5 minutes), and the median total procedure time was 25 minutes (IQR, 22-30.5 minutes). There were no intra- or postprocedural adverse events.

Conclusions: Nitrous oxide cryoballoon ablation of nonpolypoid DAs is feasible, with promising safety and efficacy.
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http://dx.doi.org/10.1016/j.gie.2020.05.048DOI Listing
January 2021

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes.

Gastrointest Endosc 2020 05 10;91(5):963-982.e2. Epub 2020 Mar 10.

Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA.

Familial adenomatous polyposis (FAP) syndrome is a complex entity, which includes FAP, attenuated FAP, and MUTYH-associated polyposis. These patients are at significant risk for colorectal cancer and carry additional risks for extracolonic malignancies. In this guideline, we reviewed the most recent literature to formulate recommendations on the role of endoscopy in this patient population. Relevant clinical questions were how to identify high-risk individuals warranting genetic testing, when to start screening examinations, what are appropriate surveillance intervals, how to identify endoscopically high-risk features, and what is the role of chemoprevention. A systematic literature search from 2005 to 2018 was performed, in addition to the inclusion of seminal historical studies. Most studies were from worldwide registries, which have compiled years of data regarding the natural history and cancer risks in this cohort. Given that most studies were retrospective, recommendations were based on epidemiologic data and expert opinion. Management of colorectal polyps in FAP has not changed much in recent years, as colectomy in FAP is the standard of care. What is new, however, is the developing body of literature on the role of endoscopy in managing upper GI and small-bowel polyposis, as patients are living longer and improved endoscopic technologies have emerged.
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http://dx.doi.org/10.1016/j.gie.2020.01.028DOI Listing
May 2020

Management of Acute Gastric Remnant Complications After Roux-en-Y Gastric Bypass: a Single-Center Case Series.

Obes Surg 2020 Jul;30(7):2637-2641

Department of Surgery, Division of Minimally Invasive and Elective General Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA.

Purpose: Roux-en-Y gastric bypass is a common bariatric procedure. Its configuration creates an excluded gastric remnant, which is subject to potential acute complications such as bleeding, perforation, and necrosis.

Material And Methods: A retrospective analysis of a prospective database including all patients presenting between 2007 and 2019 to our institution with acute gastric remnant complications after RYGB was performed.

Results: Seven patients were included, including 3 hemorrhages, two of which were treated with double-balloon enteroscopy, as well as 3 perforations and 1 necrosis, all of which required emergent surgery. Overall gastric remnant complication rate was 0.3% in this series.

Conclusion: Acute gastric remnant complications after RYGB are infrequent, but their diagnosis and management can be challenging. Double-balloon enteroscopy has diagnostic and therapeutic value for selected patients. Emergent surgery remains the standard of care for unstable patients and should not be delayed.
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http://dx.doi.org/10.1007/s11695-020-04537-wDOI Listing
July 2020

Goff Septotomy Is a Safe and Effective Salvage Biliary Access Technique Following Failed Cannulation at ERCP.

Dig Dis Sci 2021 03 12;66(3):866-872. Epub 2020 Feb 12.

Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA.

Background: Biliary cannulation is readily achieved in > 85% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). When standard cannulation techniques fail, salvage techniques utilized include the needle knife precut, double wire technique, and Goff septotomy.

Methods: Records of patients undergoing ERCP from 2005 to 2016 were retrospectively examined using a prospectively maintained endoscopy database. Patients requiring salvage techniques for biliary access were analyzed together with a control sample of 20 randomly selected index ERCPs per study year. Demographic and clinical variables including indications for ERCP, cannulation rates, and adverse events were collected.

Results: A total of 7984 patients underwent ERCP from 2005 to 2016. Biliary cannulation was successful in 94.9% of control index ERCPs, 87.2% of patients who underwent Goff septotomy (significantly higher than for all other salvage techniques, p ≤ 0.001), 74.5% of patients in the double wire group and 69.6% of patients in the needle knife precut group. Adverse event rates were similar in the Goff septotomy (4.1%) and index ERCP control sample (2.7%) groups. Adverse events were significantly higher in the needle knife group (27.2%) compared with all other groups.

Conclusions: This study represents the largest study to date of Goff septotomy as a salvage biliary access technique. It confirms the efficacy of Goff septotomy and indicates a safety profile similar to standard cannulation techniques and superior to the widely employed needle knife precut sphincterotomy. Our safety and efficacy data suggest that Goff septotomy should be considered as the primary salvage approach for failed cannulation, with needle knife sphincterotomy restricted to Goff septotomy failures.
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http://dx.doi.org/10.1007/s10620-020-06124-6DOI Listing
March 2021

ASGE guideline on minimum staffing requirements for the performance of GI endoscopy.

Gastrointest Endosc 2020 04 6;91(4):723-729.e17. Epub 2020 Feb 6.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Efforts to increase patient safety and satisfaction, a critical concern for health providers, require periodic evaluation of all factors involved in the provision of GI endoscopy services. We aimed to develop guidelines on minimum staffing requirements and scope of practice of available staff for the safe and efficient performance of GI endoscopy. The recommendations in this guideline were based on a systematic review of published literature, results from a nationwide survey of endoscopy directors, along with the expert guidance of the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee members, ASGE Practice Operation Committee members, and the ASGE Governing Board.
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http://dx.doi.org/10.1016/j.gie.2019.12.002DOI Listing
April 2020

Downregulation of Estrogen Receptor Beta1 Expression in Sessile Serrated Adenomas.

Ann Clin Lab Sci 2019 Nov;49(6):699-702

Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, and the Ertan Digestive Diseases Center of Excellence, The University of Texas Health Science Center at Houston McGovern Medical School and Memorial Hermann Hospital-TMC, Houston, TX, USA.

Objective: CpG island methylator phenotype (CIMP)-positive colorectal cancers (CRC) and CRC with microsatellite instability (MSI) were reported to have a decreased expression of estrogen receptor, beta1 (ER-β1), and methylation accompanied by decreased expression for the caudal-related homeobox, transcription factor 2 (CDX2). While precursor lesions of these cancers, known as sessile serrated adenomas (SSA), were found to have decreased CDX2 expression, the status of ER-β1 expression in SSA is unknown. The aim of this study is to determine ER-β1 expression in SSA and its relation to CDX2 expression.

Methods: Sections of formalin fixed and paraffin embedded tissue from 62 consecutive cases of SSA were stained by immunohistochemistry for ER-β1 and CDX2. SSA with ER-β1 or CDX2 expression similar to that of a normal colon were scored as 0, while those with a loss of expression in <10% of SSA crypts as 1, 11-25% as 2, 26-50% as 3, 51-75% as 4, and CDX2 loss in >75% of the SSA crypts scored as 5.

Results: There is a significant correlation between a loss of CDX2 and the loss of ER-β1 scores in SSA (<0.001). The downregulation of CDX2 was greater in SSA arising from the right colon compared to the left colon and rectum (=0.012). Similarly, downregulation of ER-β1 was greater in SSA arising in the right colon compared to the left colon and rectum (=0.014).

Conclusions: Our findings show significant downregulation of both ER-β1 and CDX2 expression in SSA, especially in the right colon. These findings suggest that ER-β1 downregulation plays a significant role in the malignant progression of SSA.
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November 2019
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