Publications by authors named "Payal Saxena"

125 Publications

Endoscopic ultrasound-guided gallbladder and bile duct drainage with lumen apposing metal stent: A large multicenter cohort (with videos).

J Gastroenterol Hepatol 2021 Sep 25. Epub 2021 Sep 25.

Department of Gastroenterology and Hepatology, Austin Health, Heidelberg, Victoria, Australia.

Background And Aim: Cholecystectomy and endoscopic retrograde cholangiopancreatography are the gold standard for managing acute cholecystitis and malignant biliary obstruction, respectively. Recent advances in therapeutic endoscopic ultrasound (EUS) have provided alternatives for managing patients in whom these approaches fail, namely, EUS-guided gallbladder drainage (EUS-GB) and EUS-guided bile duct drainage (EUS-BD). We aimed to assess the technical and clinical success of these techniques in the largest multicenter cohort published to date.

Methods: A retrospective, multicenter, observational study involving 17 centers across Australia and New Zealand was conducted. All patients who had EUS-GB or EUS-BD performed in a participating center using a lumen apposing metal stent between 2016 and 2020 were included. Primary outcome was technical success, defined as intra-procedural successful drainage. Secondary outcomes included clinical success and 30-day mortality.

Results: One hundred and fifteen patients underwent EUS-GB (n = 49) or EUS-BD (n = 66). EUS-GB was technically successful in 47 (95.9%) while EUS-BD was successful in 60 (90.9%). All failed cases were due to maldeployment of the distal flange outside of the targeted lumen. Clinical success of EUS-GB was achieved in 39 (79.6%). No patients required subsequent cholecystectomy. Clinical success of EUS-BD was achieved in 52 (78.8 %). Thirty-day mortality was 14.3% for EUS-GB and 12.1% for EUS-BD.

Conclusions: EUS-guided gallbladder drainage and EUS-BD are promising alternatives for managing nonsurgical candidates with cholecystitis and malignant biliary obstruction following failed endoscopic retrograde pancreatography. Both techniques delivered high technical success with acceptable clinical success. Further research is needed to investigate the gap between technical and clinical success.
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http://dx.doi.org/10.1111/jgh.15688DOI Listing
September 2021

Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system.

J Gastroenterol Hepatol 2021 Aug 9. Epub 2021 Aug 9.

Department of Gastroenterology, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand.

Background And Aim: Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice.

Methods: A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers.

Results: Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion.

Conclusions: This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.
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http://dx.doi.org/10.1111/jgh.15658DOI Listing
August 2021

Endoscopic bariatric therapies for obesity: a review.

Med J Aust 2021 08 1;215(4):183-188. Epub 2021 Aug 1.

The BMI Clinic, Sydney, NSW.

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two-thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15-20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.
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http://dx.doi.org/10.5694/mja2.51179DOI Listing
August 2021

SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia.

Surg Endosc 2021 05 9;35(5):1931-1948. Epub 2021 Feb 9.

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

Background: Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) OBJECTIVE: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia.

Results: The panel agreed on 4 recommendations for adults and children with achalasia.

Conclusions: Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.
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http://dx.doi.org/10.1007/s00464-020-08282-0DOI Listing
May 2021

Endoscopic Ultrasound-Guided Vascular Procedures: A Review.

Clin Endosc 2020 Sep 29;53(5):519-524. Epub 2020 Sep 29.

AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.

Since the 1980s, endoscopic ultrasound has advanced from being purely diagnostic to an interventional modality. The gastrointestinal tract offers an exceptional window for assessing the vascular structures in the mediastinum and in the abdomen. This has led to a rapidly growing interest in endoscopic ultrasound-controlled vascular interventions as a minimally invasive alternative to surgical and radiological procedures.
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http://dx.doi.org/10.5946/ce.2020.222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548160PMC
September 2020

Emerging role of endoscopic ultrasound-guided liver biopsy.

Gut 2020 Sep 18. Epub 2020 Sep 18.

AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia

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http://dx.doi.org/10.1136/gutjnl-2020-322704DOI Listing
September 2020

To evaluate the minimum number of renal scans required to follow pediatric patient postpyeloplasty.

World J Nucl Med 2020 Apr-Jun;19(2):106-110. Epub 2020 Jan 17.

Department of Pathology, Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh, India.

The aim of the study is to evaluate the minimum number of renal scans required to follow pediatric patients postpyeloplasty. We prospectively reviewed the renal scans of 145 children with unilateral pelvi-ureteric junction obstruction who underwent dismembered pyeloplasty. Patients were then divided into four groups based on preoperative split renal function. All patients were followed with renal scan and ultrasound for minimum of 4 years. Renal scan and ultrasound were done after stent removal at 3, 6, and 12 months and then yearly after surgery. Drainage pattern (T1/2) was seen in all groups, except in patients where there was no comment on drainage pattern. Statistical analysis was performed using the Friedman ANOVA and Wilcoxon signed-ranks test as a post hoc test with Bonferroni correction and Kruskal-Wallis test with Mann-Whitney U-test as a post hoc test with Bonferroni correction. On comparison of the pattern of drainage with time in Groups 1-4, it was found that there was no significant difference with time in Group 1. Then, further, using Wilcoxon signed-rank test as post hoc test for Friedman ANOVA, Group 2 showed statistically significant difference in drainage pattern in scans between 6 months and 1 year, Group 3 showed statistically significant difference in drainage pattern in scans between 3 months and 1 year, and Group 4 showed statistically significant difference in drainage pattern in scans done between 3 and 6 months ( < 0.05). Minimum of three renal scans were required for paediatric patients post pyeloplasty at 3 months, 6 months and 1 year in the follow up period.
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http://dx.doi.org/10.4103/wjnm.WJNM_3_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478307PMC
January 2020

Benign Biliary Strictures: A Systematic Review on Endoscopic Treatment Options.

Diagnostics (Basel) 2020 Apr 15;10(4). Epub 2020 Apr 15.

Interventional Endoscopy, Chris O Brien Lifehouse, Missenden Road, Camperdown 2050, Australia.

Benign biliary strictures can be difficult to manage. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The management landscape is constantly evolving, with the development of modifiable self-expandable metal stents and biodegradable stents. This review critically appraises current endoscopic treatment strategies, in particular focusing on the shortfalls, such as stent migration and stricture recurrence. It also proposes a treatment algorithm based on aetiologias and the location of the strictures.
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http://dx.doi.org/10.3390/diagnostics10040221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235774PMC
April 2020

A Rare Case of Duodenal Adenocarcinoma Presenting as a Subepithelial Lesion in a Patient Undergoing Investigation for Iron Deficiency Anaemia.

Case Rep Gastrointest Med 2019 7;2019:3434620. Epub 2019 Oct 7.

A.W. Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.

Introduction: Adenocarcinomas account for approximately 40% of small bowel cancers. They are typically mucosal lesions with distinctive features on endoscopy. We describe a rare case of duodenal adenocarcinoma presenting as a subepithelial lesion which posed a diagnostic challenge.

Case: An 85-year-old male patient presented for investigation of iron deficiency anaemia. Initial upper endoscopy found a subepithelial duodenal lesion with central depression but otherwise normal appearing mucosa. Superficial biopsies of the duodenal lesion were unremarkable. Subsequent antegrade single balloon enteroscopy revealed active bleeding from the lesion which was refractory to endoscopic treatment. A complete local excision of the lesion via laparotomy was necessary to achieve haemostasis. Histopathology from the lesion showed a moderately differentiated duodenal adenocarcinoma with invasion into the submucosa but no evidence of lymphovascular spread.

Conclusion: Duodenal adenocarcinomas are rare gastrointestinal tumours associated with a poor prognosis. This case report outlines a rare presentation of duodenal adenocarcinoma and highlights the importance of judicious assessment of lesions found on endoscopy. Advances in endoscopic diagnostic modalities could facilitate early diagnosis and improve therapeutic outcomes.
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http://dx.doi.org/10.1155/2019/3434620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800942PMC
October 2019

The ideal technique for processing SpyBite tissue specimens: a prospective, single-blinded, pilot-study of histology and cytology techniques.

Endosc Int Open 2019 Oct 1;7(10):E1241-E1247. Epub 2019 Oct 1.

AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.

 Diagnostic sensitivity for indeterminate biliary lesions remains suboptimal. Cytology techniques may mitigate the impediment of small cholangioscopic specimens. Our primary aim was to compare cell block cytology (CB) with standard histology for foregut SpyBite (SB) specimens. Our secondary aim was to assess CB in biliary SB biopsies.  This was a two-phase prospective pilot study. In phase one, a prospective pilot study, foregut SB specimens from three sites (4 per site per patient per processing technique) were allocated to CB or histology, and assessed by a single, blinded pathologist. The gold standard comprised two standard forceps (CFB) histological specimens per site per patient. Specimen ease of processing, size and number, adequacy for diagnosis and artefact were evaluated. In phase two, CB was used for consecutive patients with indeterminate biliary lesions, and compared with phase one CB results.  In phase one, 240 SB foregut biopsies were performed in 10 patients, 227 specimens recorded by pathologist. Specimen origin was identified in 100 % and 97 % of histology and CB batches respectively. Specimens were significantly larger in the histology group (2.02 mm vs 1.49 mm,  < 0.05). There was a trend to less crush artifact with CB, and no difference in processing difficulty. In phase two, 11 patients (63.0 ±12.7 years, 91 % female) underwent SpyGlass (SG) assessment of suspected indeterminate stricture (n = 8) or mass (n = 3), and six underwent SB. All CB specimens were adequate for diagnosis. Specimen parameters were not significantly different from luminal CB outcomes.  In this pilot study, cell block cytology showed similar results as histological analysis of SpyBite specimens in the analysis of biliary stricture.
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http://dx.doi.org/10.1055/a-0950-9554DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773591PMC
October 2019

An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions.

Endosc Ultrasound 2019 Nov-Dec;8(6):418-427

Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.

Background And Objectives: Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field.

Methods: A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized.

Results: Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year.

Conclusion: Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.
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http://dx.doi.org/10.4103/eus.eus_61_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927137PMC
September 2019

Spot diagnosis of intermittent gastrointestinal bleeding.

Endosc Int Open 2018 Oct 8;6(10):E1276-E1277. Epub 2018 Oct 8.

Royal Prince Alfred Hospital, Sydney, NSW, Australia.

 In this case report with video, we present a unique image of a rare, but important cause of gastrointestinal bleeding which often is missed due to its intermittent nature.
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http://dx.doi.org/10.1055/a-0629-8109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175679PMC
October 2018

Maintaining hemostasis during third-space endoscopy.

VideoGIE 2018 Oct 8;3(10):304-305. Epub 2018 Aug 8.

Royal Prince Alfred Hospital, Sydney, NSW, Australia.

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http://dx.doi.org/10.1016/j.vgie.2018.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162334PMC
October 2018

First-line EUS-guided biliary drainage or ERCP in patients with biliary obstruction and in situ duodenal stent?

Gastrointest Endosc 2018 07;88(1):76-78

Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.

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http://dx.doi.org/10.1016/j.gie.2018.04.2339DOI Listing
July 2018

Overtube-Assisted EUS-Guided Access of the Common Bile Duct in a Patient With Roux-en-Y Gastric Bypass Anatomy.

Am J Gastroenterol 2018 08;113(8):1116

Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA. Division of Gastroenterology and Liver Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.

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http://dx.doi.org/10.1038/s41395-018-0164-yDOI Listing
August 2018

Adverse events of pancreatic fluid collections.

VideoGIE 2018 Feb 18;3(2):68-72. Epub 2017 Dec 18.

Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1016/j.vgie.2017.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968021PMC
February 2018

Assessment of digital literacy and use of smart phones among Central Indian dental students.

J Oral Biol Craniofac Res 2018 Jan-Apr;8(1):40-43. Epub 2017 Oct 5.

Indian Agricultural Research Institute-Regional Station, Indore, Madhya Pradesh, India.

Objectives: Education has largely been digitalized. More so, for professional education, keeping updated in this fast paced world has become a necessary requisite and dentistry has not been left untouched. This cross sectional questionnaire based study aimed to assess the digital literacy and smartphone usage amongst the 260 Central Indian dental students including their perspicacity about smartphone/internet usage for learning purposes. The students' attitude for implementation of digital technology in study programs/education system was also evaluated.

Methods: The questionnaire was distributed among total 260 dental students from different dental institutes of Central India. The data was collected and analyzed using SPSS software.

Results: Out of 260 students, 250 were internet users, out of which 56% had internet access all time. 94.23% students owned a smartphone. 46.53% (114/245) students had some app related to the dentistry in their smartphone device. The commonest site for surfing related to knowledge seeking was google scholar (72%) followed by Pubmed and others. Nearly 80% dental students believed that social media helps them in their professional course studies. Post graduate students showed statistitically significant difference from undergraduates and interns in terms of knowledge of keywords, dental apps and reading research journals. 89.23% students were keen for implementation of e-learning in their curriculum.

Conclusion: This study reflects willingness of dental students to adopt digital revolution in dental education which in turn may present an opportunity for educators and policy makers to modify educational methods and thereby advance student's current learning approaches.
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http://dx.doi.org/10.1016/j.jobcr.2017.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5854558PMC
October 2017

EUS-guided pancreatic duct drainage: Approach to a challenging procedure.

Endosc Ultrasound 2018 Jul-Aug;7(4):284-285

Department of Gastroenterology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.4103/eus.eus_104_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6106148PMC
March 2018

EUS-guided biliary drainage: A comprehensive review of the literature.

Endosc Ultrasound 2018 Jan-Feb;7(1):4-9

AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.

EUS-guided biliary drainage (EUS-BD) has emerged as a technique for gaining biliary access when ERCP fails. This article gives a comprehensive review on the role and technique of EUS-BD. Moreover, we propose an algorithm guiding the clinician when to consider EUS-BD after failed ERCP or in anticipated difficult cannulations.
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http://dx.doi.org/10.4103/eus.eus_105_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838726PMC
February 2018

Prevalence and outcomes of pancreatic cystic neoplasms in liver transplant recipients.

World J Gastroenterol 2017 Dec;23(48):8526-8532

AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia

Aim: To determine the prevalence, characteristics and clinical course of pancreatic cystic neoplasms (PCNs) in liver transplantation (LT) recipients.

Methods: We retrospectively studied consecutive patients who underwent LT between January 1998 to April 2016. Clinical and laboratory data were obtained from patient medical records. Imaging findings on computed tomography and magnetic resonance cholangiopancreatography were reviewed by two radiologists.

Results: During the study period, 872 patients underwent cadaveric LT. Pancreatic cysts were identified in 53/872 (6.1%) and 31/53 (58.5%) were PCNs [28 intraductal papillary mucinous neoplasm (IPMN), 2 mucinous cystic neoplasm (MCN), 1 serous cystadenoma]. Patients with PCNs exhibited less male predominance (55% 73%, = 0.03) compared to patients without pancreatic cysts. Thirteen patients (42%) were diagnosed with PCN pre-LT while 18 patients (58%) developed PCN post-LT. The median size of PCNs was 13mm [interquartile range (IQR) 10-20 mm]. All IPMNs were side-branch type. Most PCNs were found in the head and body of pancreas (37% each), followed by the tail (25%). Five patients underwent further evaluation with endoscopic ultrasound. Progress imaging was performed on 81% of patients. PCNs remained stable in size and number in all but 2 patients. During a median follow up of 39 mo (IQR 26-58 mo), the 2 (6%) patients with MCN underwent pancreatectomy. No PCN patient developed pancreatic adenocarcinoma, while 5 died from illnesses unrelated to the PCN. Among patients without PCN, 1/841 (0.1%) developed pancreatic adenocarcinoma.

Conclusion: The prevalence of PCNs in LT recipients was similar to the general population (3.6%, 31/872). Side-branch IPMNs do not appear to have accelerated malignant potential in post-LT patients, indicating the current surveillance guidelines are applicable to this group.
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http://dx.doi.org/10.3748/wjg.v23.i48.8526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752712PMC
December 2017

Oral health of pregnant females in central India: Knowledge, awareness, and present status.

J Educ Health Promot 2017 4;6:102. Epub 2017 Dec 4.

Resident, Hindu Rao Hospital, Malka, New Delhi, India.

Background: The oral health of pregnant females needs attention, especially in developing countries like India where oral checkup and care is not considered to be a part of mandatory antenatal protocols.

Objective: This study aimed to evaluate the oral health status of pregnant females in Central India including the assessment of their knowledge, attitude, and awareness about oral health.

Materials And Methods: The study population comprised of 320 pregnant females, and a control group consisted of 103 age-matched nonpregnant females. A cross-sectional self-reported questionnaire-based survey and clinical examination was conducted.

Results: Out of 320, 192 (60%) pregnant females had some dental problem during pregnancy. Community periodontal index (CPI) score for total pregnant females (2.16) was significantly higher in comparison to control group (1.29). Nearly 72.81% of pregnant females had never attended the dentist. Trimester-wise comparison showed time-dependent increase in CPI score. Low educational status, older age, earlier issues, poor hygiene habits, and tobacco use showed a direct effect on compromised oral health.

Conclusion: The study highlights the need of interaction between dental practitioners and gynecologists including routine dental checkup during antenatal visits of pregnant females as essential.
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http://dx.doi.org/10.4103/jehp.jehp_146_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747225PMC
December 2017

Stylet slow-pull versus standard suction for endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic lesions: a multicenter randomized trial.

Endoscopy 2018 05 22;50(5):497-504. Epub 2017 Dec 22.

Division of Gastroenterology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, United States.

Background And Study Aim: Standard endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) procedures involve use of no-suction or suction aspiration techniques. A new aspiration method, the stylet slow-pull technique, involves slow withdrawal of the needle stylet to create minimum negative pressure. The aim of this study was to compare the sensitivity of EUS-FNA using stylet slow-pull or suction techniques for malignant solid pancreatic lesions using a standard 22-gauge needle.

Patients And Methods: Consecutive patients presenting for EUS-FNA of pancreatic mass lesions were randomized to the stylet slow-pull or suction techniques using a 22-gauge needle. Both techniques were standardized for each pass until an adequate specimen was obtained, as determined by rapid on-site cytology examination. Patients were crossed over to the alternative technique after four nondiagnostic passes.

Results: Of 147 patients screened, 121 (mean age 64 ± 13.8 years) met inclusion criteria and were randomized to the stylet slow-pull technique (n = 61) or the suction technique (n = 60). Technical success rates were 96.7 % and 98.3 % in the slow-pull and suction groups, respectively ( > 0.99). The sensitivity for malignancy of EUS-FNA was 82 % in the slow-pull group and 69 % in the suction group ( = 0.10). The first-pass diagnostic rate (42.6 % vs. 38.3 %;  = 0.71), acquisition of core tissue (60.6 % vs. 46.7 %;  = 0.14), and the median (range) number of passes to diagnosis (2 1 2 3 vs. 1 1 2;  = 0.71) were similar in the slow-pull and suction groups, respectively.

Conclusions: The stylet slow-pull and suction techniques both offered high and comparable diagnostic sensitivity with a mean of 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique during FNA.
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http://dx.doi.org/10.1055/s-0043-122381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441969PMC
May 2018

Double-balloon enteroscopy-assisted dilatation avoids surgery for small bowel strictures: A systematic review.

World J Gastroenterol 2017 Dec;23(45):8073-8081

AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, Sydney NSW 2050, Australia.

Aim: To evaluate the therapeutic role of double-balloon enteroscopy (DBE) in small bowel strictures and to propose a standard approach to small bowel strictures.

Methods: Systematic review of studies involving DBE in patients with small bowel strictures. Only studies limited to small bowel strictures were included and those with ileo-colonic strictures were excluded.

Results: In total 13 studies were included, in which 310 patients were dilated. The average follow-up time was 31.8 mo per patient. The complication rate was 4.8% per patient and 2.6% per dilatation. Surgery was avoided in 80% of patients. After the first dilatation, 46% were treated with re-dilatation and only 17% required surgery.

Conclusion: DBE-assisted dilatation avoids surgery in 80% of patients with small bowel strictures and is safe and effective. We propose a standardized approach to small bowel strictures.
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http://dx.doi.org/10.3748/wjg.v23.i45.8073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725302PMC
December 2017

Practice guidelines for endoscopic ultrasound-guided celiac plexus neurolysis.

Endosc Ultrasound 2017 Nov-Dec;6(6):369-375

Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, Bronx, New York, USA.

Objectives: The objective of guideline was to provide clear and relevant consensus statements to form a practical guideline for clinicians on the indications, optimal technique, safety and efficacy of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN).

Methods: Six important clinical questions were determined regarding EUS-CPN. Following a detailed literature review, 6 statements were proposed attempting to answer those questions. A group of expert endosonographers convened in Chicago, United States (May 2016), where the statements were presented and feedback provided. Subsequently a consensus group of 35 expert endosonographers voted based on their individual level of agreement. A strong recommendation required 80% voter agreement. The modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria were used to rate the strength of recommendations and the quality of evidence.

Results: Eighty percent agreement was reached on 5 of 6 consensus statements, 79.4% agreement was reached on the remaining one.

Conclusions: EUS-CPN is efficacious, should be integrated into the management of pancreas cancer pain, and can be considered early at the time of diagnosis of inoperable disease. Techniques may still vary based on operator experience. Serious complications exist, but are rare.
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http://dx.doi.org/10.4103/eus.eus_97_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752758PMC
December 2017

Peroral endoscopic myotomy as salvation technique post-Heller: International experience.

Dig Endosc 2018 Jan 8;30(1):52-56. Epub 2017 Aug 8.

Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA.

Background: Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM).

Methods: Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded.

Results: Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively.

Conclusion: For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed.
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http://dx.doi.org/10.1111/den.12918DOI Listing
January 2018

Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study.

Am J Gastroenterol 2017 Aug 23;112(8):1267-1276. Epub 2017 May 23.

Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.

Objectives: The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM.

Methods: Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case-control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders).

Results: A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs.

Conclusions: This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.
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http://dx.doi.org/10.1038/ajg.2017.139DOI Listing
August 2017

A welcome diagnosis for painless biliary dilatation (with video).

Gastrointest Endosc 2017 09 21;86(3):568-569. Epub 2017 Apr 21.

AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.

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http://dx.doi.org/10.1016/j.gie.2017.03.020DOI Listing
September 2017

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy.

Clin Gastroenterol Hepatol 2017 Oct 9;15(10):1531-1537.e3. Epub 2017 Feb 9.

Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.

Background & Aims: In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM.

Methods: We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months.

Results: POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups.

Conclusions: POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.
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http://dx.doi.org/10.1016/j.cgh.2017.01.031DOI Listing
October 2017

Endoscopic Management of Esophageal Perforations: Who, When, and How?

Curr Treat Options Gastroenterol 2017 Mar;15(1):35-45

Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St, Suite 7125B, Baltimore, MD, 21205, USA.

Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.
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http://dx.doi.org/10.1007/s11938-017-0117-3DOI Listing
March 2017
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