Publications by authors named "Pichamol Jirapinyo"

83 Publications

Endoscopic revision of gastric bypass using plication technique: an adjustable approach.

VideoGIE 2021 Jul 28;6(7):311-315. Epub 2021 May 28.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Video 1This video case presentation highlights a 65-year-old woman with weight regain after Roux-en-Y gastric bypass and a dilated gastrojejunal anastomosis who presented for endoscopic revision of her gastric bypass involving a plication technique, followed by gastrojejunal anastomosis stenosis dilation.
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http://dx.doi.org/10.1016/j.vgie.2021.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270786PMC
July 2021

Endoscopic polypectomy devices.

VideoGIE 2021 Jul 2;6(7):283-293. Epub 2021 Apr 2.

Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.

Video 1Use of submucosal injection prior to en-bloc endoscopic mucosal resection.Video 2Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.
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http://dx.doi.org/10.1016/j.vgie.2021.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267590PMC
July 2021

Reply.

Clin Gastroenterol Hepatol 2021 Jun 26. Epub 2021 Jun 26.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.cgh.2021.06.022DOI Listing
June 2021

Emerging therapies in translational endoscopy: new frontiers in endoscopic submucosal dissection.

VideoGIE 2021 Jun 25;6(6):246-249. Epub 2021 Mar 25.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts.

Video 1New frontiers in endoscopic submucosal dissection.
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http://dx.doi.org/10.1016/j.vgie.2021.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8187128PMC
June 2021

Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison.

Gastrointest Endosc 2021 Jun 11. Epub 2021 Jun 11.

Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women's Hospital. Harvard Medical School. Boston, MA. Electronic address:

Background And Aims: An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y (RYGB) and can be corrected with endoscopic (ENDO) or surgical (SURG) revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (SAE) rates and weight loss profiles between ENDO and SURG revisional techniques over a 5-year period.

Methods: Retrospective matched cohort study of RYGB patients who underwent ENDO or SURG revision for weight regain with an enlarged GJA (>12 mm). ENDO patients were matched 1:1 to SURG patients based on completion of 5-year follow-up, age, sex, body mass index (BMI), initial weight loss, and weight regain. Demographics, GJA size, SAEs, and weight profiles were collected. The primary outcome was comparison of SAE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the SAE rate, and a Student t-test was used for weight comparisons.

Results: Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The adverse event rate in the ENDO group (6.5%) was lower than the SURG group (29.0%); p=0.043. There was a total of 0 (0%) and 6 (19.4%) serious (severe) adverse events in the ENDO and SURG groups, respectively (p=0.02). There was no significant difference in weight loss at 1, 3, and 5 years.

Conclusions: Endoscopic revision of the gastrojejunal anastomosis is associated with significantly fewer total and severe adverse events and similar long-term weight loss when compared with surgical revision.
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http://dx.doi.org/10.1016/j.gie.2021.06.009DOI Listing
June 2021

Devices and techniques for flexible endoscopic management of Zenker's diverticulum (with videos).

Gastrointest Endosc 2021 07 27;94(1):3-13. Epub 2021 Apr 27.

Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.

Background And Aims: Zenker's diverticulum (ZD) has traditionally been treated with open surgery or rigid endoscopy. With the advances in endoscopy, alternative flexible endoscopic treatments have been developed.

Methods: This document reviews current endoscopic techniques and devices used to treat ZD.

Results: The endoscopic techniques may be categorized as the traditional flexible endoscopic septal division and the more recent submucosal tunneling endoscopic septum division, also known as peroral endoscopic myotomy for ZD. This document also addresses clinical outcomes, safety, and financial considerations.

Conclusions: Flexible endoscopic approaches treat symptomatic ZD with results that are favorable compared with traditional open surgical or rigid endoscopic alternatives.
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http://dx.doi.org/10.1016/j.gie.2021.02.020DOI Listing
July 2021

How to Incorporate Bariatric Training Into Your Fellowship Program.

Gastroenterology 2021 Jul 19;161(1):15-20. Epub 2021 Apr 19.

Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address:

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http://dx.doi.org/10.1053/j.gastro.2021.04.030DOI Listing
July 2021

Endoscopic gastric plication for the treatment of GERD and underlying class I obesity.

VideoGIE 2021 Feb 24;6(2):74-76. Epub 2020 Nov 24.

Brigham and Women's Hospital, Boston, Massachusettes.

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http://dx.doi.org/10.1016/j.vgie.2020.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859485PMC
February 2021

Obesity Primer for the Practicing Gastroenterologist.

Am J Gastroenterol 2021 05;116(5):918-934

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.

With worsening of the obesity pandemic, gastroenterologists will see more patients with this chronic disease. Given the association between obesity and several gastrointestinal conditions and the interplay between obesity pathophysiology and gut hormones, gastroenterologists can play an important role in the management of this disease. Furthermore, because more patients undergo bariatric surgery, an understanding of postsurgical anatomy and medical and endoscopic management of bariatric surgical complications is essential. This article provides clinical tools for the assessment and management of obesity for the general gastroenterologist. Tables containing high-yield practical information are also provided for quick reference.
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http://dx.doi.org/10.14309/ajg.0000000000001200DOI Listing
May 2021

Effect of Endoscopic Bariatric and Metabolic Therapies on Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis.

Clin Gastroenterol Hepatol 2021 Mar 13. Epub 2021 Mar 13.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address:

Background & Aims: Weight loss via lifestyle intervention remains the mainstay of treatment for nonalcoholic fatty liver disease (NAFLD). Endoscopic bariatric and metabolic therapies (EBMTs) have recently been developed as an alternative treatment option for obesity. This study aimed to assess the effect of FDA-approved EBMTs on NAFLD.

Methods: We searched MEDLINE, EMBASE, Web of Science and Cochrane Central through December 2020 for studies that assessed changes in liver outcomes following EBMT. Primary Outcomes: Liver fibrosis.

Secondary Outcomes: Liver biochemistry, steatosis, NAFLD histological changes and insulin sensitivity. The Grading of Recommendations, Assessment, Development, and Evidence (GRADE) approach was conducted to assess quality of evidence.

Results: Of 4,994 potential studies, 18 studies with 863 patients were included. Average weight loss was 14.5% of initial weight at a 6 month follow-up. Primary Outcomes: Following EBMT, liver fibrosis significantly reduced by standardized mean difference (SMD) of 0.7 [95% CI, 0.1,1.3] (p = .02).

Secondary Outcomes: There were significant improvements in other NAFLD surrogates including alanine aminotransferase (-9.0 U/L; 95% CI, -11.6,-6.4; p < .0001), hepatic steatosis (SMD: -1.0; 95% CI, -1.2,-0.8, p < .0001) and histologic NAFLD activity score (-2.50; 95% CI, -3.5,-1.5; p < .0001). Other metabolic parameters including insulin resistance and waist circumference also significantly improved. The overall quality of the evidence for primary outcomes was low to very low.

Conclusions: EBMTs appear effective at treating NAFLD with significant improvement in liver fibrosis. Given the worsening NAFLD pandemic and limitations of currently available therapies, EBMTs should be further investigated as a potential treatment option for this patient population.
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http://dx.doi.org/10.1016/j.cgh.2021.03.017DOI Listing
March 2021

Video capsule endoscopy.

Gastrointest Endosc 2021 04 26;93(4):784-796. Epub 2021 Feb 26.

Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1016/j.gie.2020.12.001DOI Listing
April 2021

Test Characteristics of Abdominal Computed Tomography for the Diagnosis of Gastro-gastric Fistula in Patients with Roux-en-Y Gastric Bypass.

Obes Surg 2021 06 22;31(6):2471-2476. Epub 2021 Feb 22.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital. Harvard Medical School, Boston, MA, 02115, USA.

Introduction: Gastrogastric fistulae (GGF) occur in 1-6% of Roux-en-Y gastric bypass (RYGB) patients. Many patients undergo abdominal computed tomography (CT) as an initial test owing to its wide availability; however, CT diagnostic accuracy for GGF is unclear. Our aim was to evaluate test characteristics of abdominal CT compared to upper gastrointestinal series (UGI) and esophagogastroduodenoscopy (EGD) for diagnosing GGF using surgery as a gold standard.

Methods: Retrospective review of RYGB patients who underwent abdominal CT with oral contrast within 1 year. Demographics, weight parameters, and symptoms were collected. Surgery within 1 year of the diagnostic tests was included as the gold standard comparison. Primary outcomes included CT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) for GGF.

Results: One hundred thirty-seven patients were included, where 42 (30.1%) had positive CT and 95 (69.3%) had negative CT for GGF. Compared to surgical confirmation, CT abdomen with PO contrast had sensitivity of 73.1% (59-84.4), specificity of 95.2% (88.3-98.7), PPV 90.5% (77.4-97.3), NPV of 85.1% (76.3-91.2), and DA 89.7%. UGI series had sensitivity of 58.5% (42.1-73.7), specificity of 98.8% (93.5-99.9), PPV of 96% (79.7-99.9), NPV of 82.8% (73.9-89.7), and diagnostic accuracy (DA) of 85.4%. EGD had sensitivity of 78.3% (63.6-89.1), specificity of 98.8% (93.5-99.9), PPV 97.3 (85.8-99.9), and DA 91.5%. There were no significant differences in diagnostic test characteristics among modalities.

Conclusions: Abdominal CT with oral contrast has similar diagnostic test characteristics to UGI and EGD at detecting GGF when using surgical diagnosis as a gold standard.
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http://dx.doi.org/10.1007/s11695-021-05296-yDOI Listing
June 2021

Primary obesity surgery endoluminal (POSE) for the treatment of obesity: a systematic review and meta-analysis.

Surg Endosc 2021 Feb 1. Epub 2021 Feb 1.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Primary obesity surgery endoluminal (POSE) utilizes an incision-less operating platform system to create full-thickness plications in the gastric fundus and body (original POSE). Many studies have demonstrated the safety and efficacy of original POSE for the treatment of obesity.

Objective: We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to evaluate the outcomes of original POSE per the ASGE task force thresholds.

Methods: Bibliographic databases were systematically searched for studies assessing the outcomes of POSE for the treatment of obesity. All randomized controlled trials (RCTs) and observational studies that assessed outcomes of POSE were included. Studies were included if they reported percent total weight loss (%TWL) or percent excess weight loss (%EWL) and the incidence of serious adverse events (SAE).

Results: A total of seven studies with 613 patients were included. Two included studies were RCTs, while the remaining were observational studies. Pooled mean %EWL at 3-6 months and 12-15 months were 42.62 (95% CI 37.56-47.68) and 48.86 (95% CI 42.31-55.41), respectively. Pooled mean %TWL at 3-6 months and 12-15 months was 13.45 (95% CI 8.93-17.97) and 12.68 (95% CI 8.13-17.23), respectively. Subgroup analysis of two RCTs showed that weight loss at 1 year was significantly higher in POSE patients (%EWL difference in means 19.45 (95% CI 4.65-34.24, p value = 0.01). The overall incidence of serious adverse events was only 2.84% and included GI bleeding, extra-gastric bleeding, hepatic abscess, severe pain, severe nausea, and severe vomiting. The mean number of total anchors placed in the fundus and body was 13.18 (95% CI 11.77-14.58), and the mean procedure time was 44.55 min (95% CI 36.44-52.65).

Conclusion: POSE, a minimally invasive endoscopic bariatric therapy, is a safe and effective modality for the treatment of obesity. The outcomes of POSE meet and surpass the ASGE joint task force thresholds. Future studies should evaluate newer versions of this procedure that emphasize gastric body plication sparing the fundus.
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http://dx.doi.org/10.1007/s00464-020-08267-zDOI Listing
February 2021

Multidisciplinary Approach for Weight Regain-how to Manage this Challenging Condition: an Expert Review.

Obes Surg 2021 Mar 3;31(3):1290-1303. Epub 2021 Jan 3.

Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, Av. Dr Eneas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, Sao Paulo, 05403-010, Brazil.

Weight regain is a multifactorial condition that affects many patients following bariatric surgery. The purpose of the paper is to review the multidisciplinary approach for the management of weight regain. We performed a search in current clinical evidence regarding the causes, consequences, and treatments of weight regain. The multidisciplinary approach with periodic monitoring is of fundamental importance to prevent or treat weight regain. Several therapeutic options are ranging from nutritional to surgical options, which should be tailored according to patients' anatomy, lifestyle behavior, and compliance. Specialized multidisciplinary care is the key to achieve optimal long-term weight loss and maintenance goals following bariatric surgery.
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http://dx.doi.org/10.1007/s11695-020-05164-1DOI Listing
March 2021

Association for Bariatric Endoscopy systematic review and meta-analysis assessing the American Society for Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for aspiration therapy.

Gastrointest Endosc 2021 02 18;93(2):334-342.e1. Epub 2020 Nov 18.

Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA.

A subcommittee of the Association for Bariatric Endoscopy, a division of the American Society for Gastrointestinal Endoscopy (ASGE) comprising experts in the subject area, performed this systematic review and meta-analysis. The systematic review and meta-analysis was reviewed by the ASGE Technology Committee and was ultimately submitted to the ASGE Governing Board for approval. The systematic review and meta-analysis underwent peer review by outside experts in statistics and meta-analysis before receiving final ASGE Governing Board approval. The Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) initiative is an ASGE program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice, presuming the appropriate training in that endoscopic technology has been achieved. ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds.
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http://dx.doi.org/10.1016/j.gie.2020.09.021DOI Listing
February 2021

A comparison of clinical outcomes and cost utility among laparoscopy, enteroscopy, and temporary gastric access-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy.

Surg Endosc 2021 Aug 4;35(8):4469-4477. Epub 2020 Sep 4.

Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.

Background And Aims: Gastric Access Temporary for Endoscopy (GATE), also known as EUS-Directed Trangastric ERCP (EDGE), has demonstrated advantages over device-assisted enteroscopy (DAE) and laparoscopic-assisted ERCP (LA-ERCP) for patients with Roux-en-Y gastric bypass (RYGB) anatomy. We aimed to directly compare clinical outcomes and cost utility among the three ERCP modalities.

Methods: Patients with RYGB anatomy who had DAE, LA-ERCP, or GATE from 2009 to 2019 at 2 tertiary centers were included in our review. We measured outcomes in three areas: success rate, post-procedural adverse events (AEs) and hospitalization, and cost utility per Medicare/Medicaid insurance payments.

Results: Cohort Total 130 patients (70 underwent DAE, 42 LA-ERCP, and 18 GATE). Success rate DAE was successful in 59% of patients, compared to success rates of 98 and 100% for LA-ERCP and GATE, respectively (p < 0.001). For DAE, 62% of unsuccessful cases required rescue therapy. Adverse events and hospitalization Patients who underwent GATE had the lowest rate of hospitalization post procedure (44% vs. 77% and 100% for DAE and LA-ERCP, respectively, p < 0.01) and spent the least amount of time hospitalized (median time 0 days vs 2 and 3 days for DAE and LA-ERCP, respectively, p < 0.0001). GATE had lower AE rates than LA-ERCP (6 vs 31%, p = 0.046), and both had similar rates to DAE. Cost utility LA-ERCP carried the highest total procedural and hospitalization cost per Medicare/ Medicaid insurance payments (median payment difference of $9.7 K vs GATE and $7.9 K vs DAE, p < 0.01 for both). Procedural and hospitalization costs were similar between GATE and DAE (p = 0.76).

Conclusions: GATE is a safe modality for ERCP with high success rates in RYGB patients and exhibits the lowest hospitalization time and rate of adverse events when compared to DAE and LA-ERCP. GATE is similar to DAE from a cost utility approach, and both are less costly than LA-ERCP.
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http://dx.doi.org/10.1007/s00464-020-07952-3DOI Listing
August 2021

Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos).

Gastrointest Endosc 2020 Sep 13;92(3):492-507. Epub 2020 Aug 13.

Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.

Background And Aims: As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type.

Methods: The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized.

Results: Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving.

Conclusions: Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.
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http://dx.doi.org/10.1016/j.gie.2020.04.002DOI Listing
September 2020

Techniques and devices for the endoscopic treatment of gastroparesis (with video).

Gastrointest Endosc 2020 Sep 16;92(3):483-491. Epub 2020 Jul 16.

Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.

Background And Aims: Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management.

Methods: In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use.

Results: Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support.

Conclusions: Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed.
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http://dx.doi.org/10.1016/j.gie.2020.03.3857DOI Listing
September 2020

Endoscopic Ultrasound-Guided Coil Embolization With Absorbable Gelatin Sponge Appears Superior to Traditional Cyanoacrylate Injection for the Treatment of Gastric Varices.

Clin Transl Gastroenterol 2020 05;11(5):e00175

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Introduction: Gastric variceal (GV) bleeding is a feared complication of cirrhosis. Traditional endoscopic treatment with cyanoacrylate (CYA) injection can be challenging. Alternatively, endoscopic ultrasound (EUS)-guided delivery of hemostatic coils has shown high therapeutic success without the complications profile of CYA alone. Our aim was to compare the clinical outcomes of EUS-guided coil embolization with endoscopic CYA injection for the treatment of GV.

Methods: We performed a matched cohort study using a prospective registry involving 2 tertiary centers. A total of 10 patients undergoing EUS-based coil therapy were matched in 1:3 fashion to 30 patients who underwent CYA injection. The matching criteria included type of GV, Charlson comorbidity index, and bleeding severity. Primary outcomes were technical success and complications. Secondary outcomes were rebleeding rates, reinterventions rates, total transfusion requirements, and time-to-event analysis (rebleeding, reintervention, and transfusion).

Results: Technical success was 100% for EUS coil therapy vs 96.7% for CYA injection (P = 1.0). Complication rates were 10% in the EUS coil group vs 20% in the CYA group; P = 0.65. At 9 months, no EUS coil patient had rebled compared with 38% of the CYA group. No EUS coil patient required blood transfusion for GV rebleed, whereas over 50% of CYA patients did. Ten percent of EUS coil patients required reintervention compared with 60% of CYA patients. The EUS coil group had superior time to reintervention, GV rebleed, and transfusions (all P < 0.05).

Discussion: Compared with CYA, EUS-guided coil injection appears superior for the treatment of GV and should be considered initial endoscopic treatment of choice in centers with interventional EUS expertise.
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http://dx.doi.org/10.14309/ctg.0000000000000175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263642PMC
May 2020

Devices and techniques for endoscopic treatment of residual and fibrotic colorectal polyps (with videos).

Gastrointest Endosc 2020 Sep 5;92(3):474-482. Epub 2020 Jul 5.

Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.

Background And Aims: Residual neoplasia after macroscopically complete EMR of large colon polyps has been reported in 10% to 32% of resections. Often, residual polyps at the site of prior polypectomy are fibrotic and nonlifting, making additional resection challenging.

Methods: This document reviews devices and methods for the endoscopic treatment of fibrotic and/or residual polyps. In addition, techniques reported to reduce the incidence of residual neoplasia after endoscopic resection are discussed.

Results: Descriptions of technologies and available outcomes data are summarized for argon plasma coagulation ablation, snare-tip coagulation, avulsion techniques, grasp-and-snare technique, EndoRotor endoscopic resection system, endoscopic full-thickness resection device, and salvage endoscopic submucosal dissection.

Conclusions: Several technologies and techniques discussed in this document may aid in the prevention and/or resection of fibrotic and nonlifting polyps.
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http://dx.doi.org/10.1016/j.gie.2020.03.018DOI Listing
September 2020

Evaluation of endoscopic ultrasound fine-needle aspiration versus fine-needle biopsy and impact of rapid on-site evaluation for pancreatic masses.

Endosc Int Open 2020 Jun 25;8(6):E738-E747. Epub 2020 May 25.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston Massachusetts, United States.

 Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is traditionally considered a first-line strategy for diagnosing pancreatic lesions; however, given less than ideal accuracy rates, fine-needle biopsy (FNB) has been recently developed to yield histological tissue. The aim of this study was to compare diagnostic yield and safety between EUS-FNA and EUS-FNB in sampling of pancreatic masses.  This was a multicenter retrospective study to evaluate efficacy and safety of EUS-FNA and EUS-FNB for pancreatic lesions. Baseline characteristics including sensitivity, specificity, and accuracy, were evaluated. Rapid on-site evaluation (ROSE) diagnostic adequacy, cell-block accuracy, and adverse events were analyzed. Subgroup analyses comparing FNA versus FNB route of tissue acquisition and comparison between methods with or without ROSE were performed. Multivariable logistic regression was also performed.  A total of 574 patients (n = 194 FNA, n = 380 FNB) were included. Overall sensitivity, specificity, and accuracy of FNB versus FNA were similar [(89.09 % versus 85.62 %;  = 0.229), (98.04 % versus 96.88 %;  = 0.387), and 90.29 % versus 87.50 %;  = 0.307)]. Number of passes for ROSE adequacy and cell-block accuracy were comparable for FNA versus FNB [(3.06 ± 1.62 versus 3.04 ± 1.88;  = 0.11) and (3.08 ± 1.63 versus 3.35 ± 2.02;  = 0.137)]. FNA + ROSE was superior to FNA alone regarding sensitivity and accuracy [91.96 % versus 70.83 %;  < 0.001) and (91.80 % versus 80.28 %;  = 0.020)]. Sensitivity of FNB + ROSE and FNB alone were superior to FNA alone [(92.17 % versus 70.83 %;  < 0.001) and (87.44 % versus 70.83 %;  < 0.001)]. There was no difference in sensitivity though improved accuracy between FNA + ROSE versus FNB alone [(91.96 % versus 87.44 %;  = 0.193) and (91.80 % versus 80.72 %;  = 0.006)]. FNB + ROSE was more accurate than FNA + ROSE (93.13 % versus 91.80 %  = 0.001). Multivariate analysis showed ROSE was a significant predictor of accuracy [OR 2.60 (95 % CI, 1.41-4.79)]. One adverse event occurred after FNB resulting in patient death.  EUS-FNB allowed for more consistent cell-block evaluation as compared to EUS-FNA. EUS-FNA + ROSE was found to have a similar sensitivity to EUS-FNB alone suggesting a reduced need for ROSE as part of the standard algorithm of pancreatic sampling. While FNB alone produced similar diagnostic findings to EUS-FNA + ROSE, FNB + ROSE still was noted to increase diagnostic yield. This finding may favor a unique role for FNB + ROSE, suggesting it may be useful in cases when previous EUS-guided sampling may have been indeterminate.
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http://dx.doi.org/10.1055/a-1122-8674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247894PMC
June 2020

Effect of Aspiration Therapy on Obesity-Related Comorbidities: Systematic Review and Meta-Analysis.

Clin Endosc 2020 Nov 28;53(6):686-697. Epub 2020 Feb 28.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA.

Background/aims: Aspiration therapy (AT) involves endoscopic placement of a gastrostomy tube with an external device that allows patients to drain 30% of ingested calories after meals. Its efficacy for inducing weight loss has been shown. This study aimed to assess the effect of AT on obesity-related comorbidities.

Methods: A meta-analysis of studies that assessed AT outcomes was conducted through December 2018. Primary outcomes were changes in comorbidities at 1 year following AT. Secondary outcomes were the amount of weight loss at up to 4 years and pooled serious adverse events (SAEs).

Results: Five studies with 590 patients were included. At 1 year, there were improvements in metabolic conditions: mean difference (MD) in systolic blood pressure: -7.8 (-10.7 - -4.9) mm Hg; MD in diastolic blood pressure: -5.1 (-7.0 - 3.2) mm Hg; MD in triglycerides: -15.8 (-24.0 - -7.6) mg/dL; MD in high-density lipoprotein: 3.6 (0.7-6.6) mg/dL; MD in hemoglobin A1c (HbA1c): -1.3 (-1.8 - -0.8) %; MD in aspartate transaminase: -2.7 (-4.1 - -1.3) U/L; MD in alanine transaminase: -7.5 (-9.8 - -5.2) U/L. At 1 (n=218), 2 (n=125), 3 (n=46), and 4 (n=27) years, the patients experienced 17.8%, 18.3%, 19.1%, and 18.6% total weight loss (TWL), corresponding to 46.3%, 46.2%, 48.0%, and 48.7% excess weight loss (EWL) (p<0.0001 for all). Subgroup analysis of 2 randomized controlled trials (n=225) showed that AT patients lost more weight than did controls by 11.6 (6.5-16.7) %TWL and 25.6 (16.0-35.3) %EWL and experienced greater improvement in HbA1c and alanine transaminase by 1.3 (0.8-1.8) % and 9.0 (3.9-14.0) U/L. The pooled SAE rate was 4.1%.

Conclusion: Obesity-related comorbidities significantly improved at 1 year following AT. Additionally, a subgroup of patients who continued to use AT appeared to experience significant weight loss that persisted up to at least 4 years.
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http://dx.doi.org/10.5946/ce.2019.181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719414PMC
November 2020

EUS-guided fine-needle biopsy sampling versus FNA in the diagnosis of subepithelial lesions: a large multicenter study.

Gastrointest Endosc 2020 07 25;92(1):108-119.e3. Epub 2020 Feb 25.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts, USA; Division of Gastroenterology, Hepatology, and Endoscopy, Harvard Medical School, Boston, Massachusetts, USA.

Background And Aims: Although conventional EUS-guided FNA (EUS-FNA) has previously been considered first-line for sampling subepithelial lesions (SELs), variable accuracy has resulted in increased use of fine-needle biopsy (FNB) sampling to improve diagnostic yield. The primary aim of this study was to compare FNA versus FNB sampling for the diagnosis of SELs.

Methods: This was a multicenter, retrospective study to evaluate the outcomes of EUS-FNA and EUS-guided FNB sampling (EUS-FNB) of SELs over a 3-year period. Demographics, lesion characteristics, sensitivity, specificity, accuracy, number of needle passes, diagnostic adequacy of rapid on-site evaluation (ROSE), cell block accuracy, and adverse events were analyzed. Subgroup analyses were performed comparing FNA versus FNB sampling by location and diagnostic yield with or without ROSE. Multivariable logistic regression was also performed.

Results: Two hundred twenty-nine patients with SELs (115 FNA and 114 FNB sampling) underwent EUS-guided sampling. Mean patient age was 60.86 ± 12.84 years. Most lesions were gastric in location (75.55%) and from the fourth layer (71.18%). Cell block for FNB sampling required fewer passes to achieve conclusive diagnosis (2.94 ± 1.09 vs 3.55 ± 1.55; P = .003). The number of passes was not different for ROSE adequacy (P = .167). Immunohistochemistry was more able to be successfully performed in more FNB sampling samples (69.30% vs 40.00%; P < .001). Overall, sensitivity and accuracy were superior for FNB sampling versus FNA (79.41% vs 51.92% [P = .001] and 88.03% vs 77.19% [P = .030], respectively). On subgroup analysis, sensitivity and accuracy of FNB sampling alone was superior to FNA + ROSE (79.03% vs 46.67% [P = .001] and 87.25% vs 68.00% [P = .024], respectively). There was no significant difference in diagnostic yield of FNB sampling alone versus FNB sampling + ROSE (P > .05). Multivariate analysis showed no predictors associated with accuracy. One minor adverse event was reported in the FNA group.

Conclusions: EUS-FNB was superior to EUS-FNA in the diagnosis of SELs. EUS-FNB was also superior to EUS-FNA alone and EUS-FNA + ROSE. These results suggest EUS-FNB should be considered a first-line modality and may suggest a reduced role for ROSE in the diagnosis of SELs. However, a large randomized controlled trial is required to confirm our findings.
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http://dx.doi.org/10.1016/j.gie.2020.02.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340004PMC
July 2020

Validation of a Novel Endoscopic Retrograde Cholangiopancreatography Cannulation Simulator.

Clin Endosc 2020 May 17;53(3):346-354. Epub 2020 Feb 17.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA.

Background/aims: Endoscopic retrograde cholangiopancreatography (ERCP) requires a unique skill set. Currently, there is no objective methodology to assess and train a professional to perform ERCP. This study aimed to develop and validate a novel ERCP simulator.

Methods: The simulator consists of papillae presenting different anatomy and positioned in varied locations. Deep cannulation of the pancreatic duct, followed by the bile duct, was performed. The time allotted was 5 minutes. The content validity indexes (CVIs) for realism, relevance, and representativeness were calculated. Correlation between ERCP experience and simulator score was determined.

Results: Twenty-three participants completed the simulation. The CVIs for realism were orientation of duodenoscope to papilla (1.00), angulation of papillotome to achieve cannulation (0.71), and haptic feedback during cannulation (0.80). The CVIs for relevance were use of elevator (1.00), wheels to achieve en face orientation (1.00), and papillotome for selective cannulation (1.00). Regarding CVI for representativeness, the results were as follows: basic cannulation (0.83), papilla locations (0.83), and papilla anatomies (0.80). The novice, intermediate, and experienced groups scored 6.7±8.7, 30.0±16.3, and 74.4±43.9, respectively (p<0.0001). There was a strong correlation between the ERCP experience level and the individual's simulator score (Pearson value of 0.77, R2 of 0.60).

Conclusion: This simulator appears to be realistic, relevant, and representative of ERCP cannulation techniques. Additionally, it is effective at objectively assessing basic ERCP skills by differentiating scores based on clinical experience.
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http://dx.doi.org/10.5946/ce.2019.105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280851PMC
May 2020

Endoscopic submucosal dissection with suturing for the treatment of weight regain after gastric bypass: outcomes and comparison with traditional transoral outlet reduction (with video).

Gastrointest Endosc 2020 06 31;91(6):1282-1288. Epub 2020 Jan 31.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.

Background And Aims: Although traditional transoral outlet reduction (TORe) involves argon plasma coagulation (APC) before endoscopic suturing, modified endoscopic submucosal dissection (ESD) has also been used. This study aims to evaluate the safety and efficacy of modified ESD-TORe in comparison with traditional APC-TORe.

Methods: This was a retrospective study of prospectively collected data from patients who underwent modified ESD-TORe and APC-TORe for weight regain after Roux-en-Y gastric bypass (RYGB). Our outcomes were technical success, adverse events as categorized by the American Society for Gastrointestinal Endoscopy lexicon, and percent total weight loss (TWL) at 6 and 12 months and patients who underwent ESD-TORe were matched 1:3 based on gastrojejunal anastomosis (GJA) and pouch sizes to those who underwent APC-TORe. TWL between groups was compared. A linear regression was performed to control for any confounders.

Results: Nineteen RYGB patients underwent ESD-TORe. Technical success rate was 100%, with no severe adverse events. At 6 and 12 months, patients experienced 13.4% ± 6.6% and 12.1% ± 9.3% TWL, respectively (P < .05 for both). Nineteen ESD-TORe patients were also matched with 57 APC-TORe patients based on GJA and pouch sizes. At 12 months, the ESD-TORe group experienced greater weight loss compared with the APC-TORe group (12.1% ± 9.3% vs 7.5% ± 3.3% TWL, respectively; P = .036). On regression analysis, ESD remained a significant predictor of percent of TWL at 12 months after controlling for age, sex, body mass index, weight regain, and years from RYGB (β = 5.99, P = .02).

Conclusions: Combining endoscopic tissue dissection with suturing provides greater and more durable weight loss for patients with weight regain after RYGB.
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http://dx.doi.org/10.1016/j.gie.2020.01.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245570PMC
June 2020

Endoscopic gastric body plication for the treatment of obesity: technical success and safety of a novel technique (with video).

Gastrointest Endosc 2020 06 28;91(6):1388-1394. Epub 2020 Jan 28.

Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background And Aims: Primary obesity surgery endoluminal (POSE) is a primary endoscopic bariatric therapy focusing on gastric remodeling. The original POSE procedure involved placement of full-thickness plications in the fundus. Here we aim to assess the feasibility, safety, and efficacy of a novel POSE procedure that involves plications of only the gastric body to reduce the width and length of the stomach.

Methods: This was a pilot study of patients who underwent a distal POSE procedure with gastric body plications for the treatment of obesity. Outcomes included technical success rate, serious adverse event (AE) rate, and efficacy of this novel POSE procedure at inducing weight loss and improving obesity-related comorbidities.

Results: Ten patients (6 women, age 52 ± 20 years) underwent a distal POSE procedure. Baseline body mass index was 38.1 ± 6.2 kg/m. The technical success rate was 100%. An average of 21 ± 4 plications were placed per case (6 ± 2 for distal belt, 10 ± 3 for suspenders, 4 ± 2 for proximal belt, and 3 ± 1 for fillers). The gastroesophageal junction was pulled distally by 3.0 ± 1.6 cm. The gastric body was shortened by 11.0 ± 5.1 cm, representing a 59% reduction. The serious AE rate was 0%. At 6 months, patients experienced 15.0% ± 7.1% total weight loss (TWL). All patients achieved at least 5% TWL, and 8 patients (80%) achieved at least 25% excess weight loss. Hypertension, diabetes, GERD, and obstructive sleep apnea improved after the procedure.

Conclusions: This novel POSE procedure, focusing on gastric body plication and sparing the fundus, is technically feasible and appears to be safe and effective for the treatment of obesity.
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http://dx.doi.org/10.1016/j.gie.2020.01.030DOI Listing
June 2020

Incremental Cost-Effectiveness of Aspiration Therapy vs Bariatric Surgery and No Treatment for Morbid Obesity.

Am J Gastroenterol 2020 03;115(3):481-482

Brigham and Women's Hospital, Boston, Massachusetts, USA.

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http://dx.doi.org/10.14309/ajg.0000000000000494DOI Listing
March 2020

Comparative Study Evaluating Lumen Apposing Metal Stents Versus Double Pigtail Plastic Stents for Treatment of Walled-Off Necrosis.

Pancreas 2020 02;49(2):236-241

From the Developmental Endoscopy Lab, Harvard Medical School.

Objectives: Lumen-apposing metal stents (LAMSs) are increasingly used for direct endoscopic necrosectomy (DEN) in the management of walled-off necrosis (WON). We compared LAMS and traditional cystoenterostomy in the management of WON.

Methods: Retrospective analysis of patients who underwent DEN for management of WON was performed. Primary outcome was rate of WON resolution. Secondary outcomes included technical and clinical success, time and number of procedures until resolution, requirement for alternative therapy, recurrence, and adverse events.

Results: One hundred twelve patients underwent DEN with LAMS (n = 34) or traditional cystoenterostomy (n = 78). Mean WON size was 90.2 × 60.1 mm, and 61.8% had infected necrosis. Overall WON resolution was similar between LAMS and traditional cystoenterostomy (94.1% vs 92.1%, P = 0.510), with similar number of procedures until resolution (1.5 vs 1.5, P = 0.871). The LAMSs were associated with faster resolution (86.9 vs 133.6 days, P = 0.038), lower recurrence (6.3% vs 23.1%, P = 0.032), and decreased requirement for surgery (0% vs 12.8%, P = 0.031) compared with traditional cystoenterostomy, but higher adverse event rates (41.2% vs 7.7%, P < 0.001).

Conclusions: Despite higher adverse event rates, initial LAMS cystoenterostomy for management of WON results in faster resolution, lower recurrence, and decreased requirement for surgery.
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http://dx.doi.org/10.1097/MPA.0000000000001476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7018618PMC
February 2020

Endoscopic sleeve gastroplasty in the management of weight regain after sleeve gastrectomy.

Endoscopy 2020 03 15;52(3):202-210. Epub 2020 Jan 15.

Division of Gastroenterology, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts, United States.

Background: Sleeve gastrectomy is a well-standardized surgical treatment for obesity. However, rates of weight regain after sleeve gastrectomy in long-term follow-up are relatively high. This multicenter study is the first to evaluate the use of an endoscopic sleeve gastroplasty (ESG) technique for the management of this population.

Methods: This was a multicenter retrospective study, including patients with weight regain following sleeve gastrectomy who underwent ESG for weight loss. Primary outcomes included absolute weight loss, percent total weight loss (%TWL), change in body mass index (BMI), percent excess weight loss (%EWL) at 6 and 12 months, and safety profile. Clinical success was defined as achieving ≥ 25 % EWL at 1 year, ≤ 5 % serious adverse event (SAE) rate following society-recommended thresholds, and %TWL ≥ 10 %.

Results: 34 patients underwent ESG after sleeve gastrectomy. Technical success was 100 %. At 1 year, 82.4 % and 100 % of patients achieved ≥ 10 %TWL and ≥ 25 % EWL, respectively. Mean (SD) %TWL was 13.2 % (3.9) and 18.3 % (5.5), and %EWL was 51.9 % (19.1) and 69.9 % (29.9) at 6 months and 1 year, respectively. Mean (SD) %TWL was 14.2 % (12.5), 19.3 % (5.3), 17.5 % (5.2), and 20.4 % (3.3), and %EWL was 88.5 % (52.8), 84.4 % (22.4), 55.4 % (14.8), and 47.8 % (11.2) for BMI categories of overweight and obesity class I, II, and III, respectively, at 1 year. No predictors of success were identified in the multivariable regression analysis. No SAEs were reported.

Conclusion: ESG appears to be safe and effective in the management of weight regain following sleeve gastrectomy.
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http://dx.doi.org/10.1055/a-1086-0627DOI Listing
March 2020

Dysphagia predicts greater weight regain after Roux-en-Y gastric bypass: a longitudinal case-matched study.

Surg Obes Relat Dis 2019 Dec 9;15(12):2045-2051. Epub 2019 Jul 9.

Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: Weight regain (WR) after gastric bypass is thought to be multifactorial in etiology with behavioral, neurohormonal, and anatomic features playing a role. A significant proportion of patients complain of dysphagia after Roux-en-Y gastric bypass (RYGB) and may have difficulty tolerating solid foods. Our observations suggest that this subgroup of patients compensate for esophageal symptoms by increasing their intake of calorie-dense liquid and soft foods, which can precipitate WR.

Objectives: We hypothesize that dysphagia predisposes to greater WR than seen in individuals without swallowing symptoms.

Setting: Single tertiary care referral center.

Methods: This was a matched-cohort study analysis of prospectively collected data on RYGB patients. All individuals who underwent high-resolution manometry after RYGB were enrolled. Controls were identified via a retrospective analysis of a prospective institutional database. Patients who developed dysphagia were matched with controls, from a subset of 450 eligible controls. Each patient with dysphagia was matched with 4 control patients based on age, body mass index, and time since surgery. WR was defined as an increase of ≥15% from nadir. Χ and t test (or Wilcoxon rank sum, if applicable) were used for bivariable analysis. Multiple logistic and linear regression were used for multivariable calculations.

Results: Forty-nine patients with dysphagia were included. After matching, there were 196 RYGB controls that did not have swallowing or esophageal symptoms. Controls had similar baseline demographic characteristics and initial weight loss compared with dysphagia cases. WR was common in both groups; however, total WR in those with dysphagia was greater than controls (15.7 versus 11.4 kg, respectively; P = .02). In addition, percent WR in those with dysphagia exceeded that seen in controls (mean 37% versus 25%, P = .003), and more individuals regained 15% of nadir weight (55% of dysphagia cases versus 38% of controls, P = .03) when adjusting for baseline body mass index, age at surgery, and race. Dietary histories suggested that, among those with dysphagia, patients with partial or complete conversion to soft or liquid calories had greater WR than those who adhered to the solid food diet.

Conclusions: Dysphagia is a risk factor for WR post-RYGB. This is likely due to increased intake of soft or liquid foods that are tolerable in these patients but lead to a positive energy balance and accelerated WR. More than half of patients with dysphagia after RYGB regain significant weight. Screening for and aggressively managing dysphagia in patients before or after RYGB may be warranted to prevent significant WR.
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http://dx.doi.org/10.1016/j.soard.2019.06.041DOI Listing
December 2019
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