Publications by authors named "Tobias Zuchelli"

23 Publications

  • Page 1 of 1

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy.

Endosc Int Open 2022 Jun 10;10(6):E898-E904. Epub 2022 Jun 10.

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

The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.
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http://dx.doi.org/10.1055/a-1794-0331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9187392PMC
June 2022

Role of gastric per-oral endoscopic myotomy (G-POEM) in post-lung transplant patients: a multicenter experience.

Endosc Int Open 2022 Jun 10;10(6):E832-E839. Epub 2022 Jun 10.

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

Gastroparesis post-lung transplant (LTx) can lead to increased risk of gastroesophageal reflux (GER) and accelerated graft dysfunction. We aimed to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM), a promising tool in patients with refractory gastroparesis, for managing refractory gastroparesis and GER in post-LTx patients. This was a multicenter retrospective study on post-LTx patients who underwent G-POEM for management of gastroparesis and GER that were refractory to standard medical therapy. The primary outcome was clinical success post-G-POEM. Secondary outcomes included the rate of post-G-POEM objective esophageal pH exam normalization, rate of gastric emptying scintigraphy (GES) normalization, technical success, and adverse events. A total of 20 patients (mean age 54.7 ± 14.1 years, Female 50 %) underwent G-POEM at a median time of 13 months (interquartile range 6.5-13.5) post-LTx. All G-POEM procedures were technically successful. Clinical success was achieved in 17 (85 %) patients during a median follow-up time of 8.9 (IQR: 3-17) months post-G-POEM. Overall GCSI and two of its subscales (bloating and postprandial fullness/early satiety) improved significantly following G-POEM. Two patients (10 %) developed post-procedural AEs (delayed bleeding 1, pyloric stenosis 1, both moderate in severity). Post-G-POEM GES improvement was achieved in 12 of 16 patients (75 %). All 20 patients were on proton pump inhibitors pre-G-POEM, as opposed to five post-G-POEM. Post-G-POEM PH study normalization was noted in nine of 10 patients (90 %) who underwent both pre- and post-G-poem pH testing. G-POEM is a promising noninvasive therapeutic tool for management of refractory gastroparesis and GER post-LTx.
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http://dx.doi.org/10.1055/a-1797-9587DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9187381PMC
June 2022

EUS-directed transgastric interventions in Roux-En-Y Gastric Bypass anatomy: a multicenter experience.

Gastrointest Endosc 2022 May 24. Epub 2022 May 24.

Johns Hopkins Medicine, Baltimore, MD, United States.

Background And Aims: Placement of a Lumen Apposing Metal Stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS Guided Transgastric Interventions (EDGI) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS guided transgastric ERCP (EDGE) outcomes have been reported, there is a paucity of data on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGI.

Methods: This is a retrospective study involving 9 centers (8 USA, 1 Europe) and included patients with RYGB who underwent EDGI between 06/2015 and 09/2021. The primary outcome was the technical success of EDGI. Secondary outcomes included adverse events, length of hospital stay, and fistula follow-up and management.

Results: 54 EDGI procedures were performed in 47 patients (mean age 61yr, F 72%), most commonly for the evaluation of a pancreatic mass (n=16) and management of pancreatic fluid collections (n=10). A 20mm LAMS was utilized in 26 patients and a 15mm LAMS in 21, creating a gastrogastrostomy (GG) in 37 patients and jejunogastrostomy (JG) in 10. Most patients (n=30, 64%) underwent a dual-session EDGI, with a median interval of 17d between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (+/-FNA/B) (n=28) and EUS-guided cystgastrostomy (n=8). The mean procedural time was 97.6 ± 78.9 mins. Technical success was achieved in 52 (96%). AEs occurred in 5 (10.6%) patients, of which only 1 (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), while delayed spontaneous LAMS migration occurred in 2 (4.3%). 4 of the 5 LAMS migration events were managed endoscopically, and one required surgical repair. LAMS anchoring was found to be protective against LAMS migration (p=0.001). The median duration of hospital stay was 2.1 ± 3.7d. Of the 17 patients who underwent objective fistula assessment endoscopically/radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In one case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically.

Conclusion: EDGI is effective and safe for the diagnosis and management of pancreatobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems effective.
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http://dx.doi.org/10.1016/j.gie.2022.05.008DOI Listing
May 2022

Role of functional luminal imaging probe in the management of postmyotomy clinical failure.

Gastrointest Endosc 2022 07 9;96(1):9-17.e3. Epub 2022 Feb 9.

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

Background And Aims: A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment.

Methods: This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy.

Results: One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03).

Conclusions: The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.
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http://dx.doi.org/10.1016/j.gie.2022.02.002DOI Listing
July 2022

Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study.

Gastrointest Endosc 2022 06 29;95(6):1176-1182. Epub 2021 Dec 29.

Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA.

Background And Aims: Nonampullary small-bowel adenomas ≥10 mm are typically resected using cautery-based polypectomy, which is associated with significant adverse events. Studies have demonstrated the safety and efficacy of piecemeal cold snare EMR for removing large colon polyps. Our aim was to assess the safety and efficacy of cold snare EMR for removal of large adenomas in the small bowel.

Methods: A retrospective study of patients who underwent lift and piecemeal cold snare EMR of small-bowel adenomas ≥1 cm between January 2014 and March 2019 was conducted at a tertiary care medical center. Polyp characteristics at the time of index and surveillance endoscopy were collected. Primary outcomes were residual or recurrent adenoma (RRA) seen on surveillance endoscopy, polyp eradication rate, and number of endoscopic procedures required for eradication. Adverse events including immediate and delayed bleeding, perforation, stricture, pancreatitis, and postpolypectomy syndrome were assessed.

Results: Of 43 patients who underwent piecemeal cold snare EMR, 39 had follow-up endoscopy. Polyps ranged in size from 10 to 70 mm (mean, 26.5 mm). RRA was found in 18 patients (46%), with increased polyp size correlating with higher recurrence (P < .001). Polyp eradication was observed in 35 patients (89%), requiring a median of 2 (range, 1-6) endoscopic procedures. Only 1 patient (2.3%) had immediate postprocedural bleeding. No cases of perforation or postpolypectomy syndrome were seen.

Conclusions: Piecemeal cold snare EMR may be a feasible, safe, and efficacious technique for small-bowel polyps >10 mm. Prospective, randomized studies are needed to assess how outcomes compare with traditional cautery-based polypectomy.
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http://dx.doi.org/10.1016/j.gie.2021.12.018DOI Listing
June 2022

Evolving management of colorectal polyps.

Ther Adv Gastrointest Endosc 2021 Jan-Dec;14:26317745211047010. Epub 2021 Sep 28.

Section Chief-Advanced Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA.

Advances in endoscopic technology have led to increased success in colorectal cancer (CRC) screening and polyp management, with reduction of CRC incidence and mortality. Despite these advances, CRC is still one of the leading causes of cancer deaths, and half of all CRC develops from lesions that were missed during colonoscopy while one-fifth of CRC arise from prior incomplete resection. Techniques to improve polyp detection are needed, along with optimization of complete resection of any abnormal lesions that are found. This article will review the currently available endoscopic resection techniques and will discuss where they fit in the management of polyps of different sizes and types, such as pedunculated nonpedunculated, and those with or without suspected invasion.
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http://dx.doi.org/10.1177/26317745211047010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8485258PMC
September 2021

Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients With Liver Cirrhosis: Analysis of Trends and Outcomes From the National Inpatient Sample Database.

J Clin Gastroenterol 2022 Aug 9;56(7):618-626. Epub 2021 Jun 9.

Department of Gastroenterology, Henry Ford Hospital, Detroit, MI.

Goals: We aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis.

Background: ERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis.

Study: Using patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes.

Results: A total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P <0.0001) compared with noncirrhosis patients but had lower incidence of perforations (0.1% vs. 0.2%; P <0.0001) and post-ERCP pancreatitis (8.6% vs. 7%; P <0.0001). Cholecystitis was the same between groups (2.3% vs. 2.3%; P <0.0001). In patients with cirrhosis, those who received therapeutic ERCP had higher post-ERCP pancreatitis (7.9% vs. 5.1%; P <0.0001) and ERCP-associated hemorrhage (2.7% vs. 2.1%; P <0.0001) but lower incidences of perforation and cholecystitis (0.1% vs. 0.3%; P <0.0001) and cholecystitis (1.9 vs. 3.1%; P <0.0001) compared with those who received diagnostic ERCP.

Conclusions: Use of therapeutic ERCP in patients with liver cirrhosis may lead to higher risk of complications such as pancreatitis and postprocedure hemorrhage, whereas diagnostic ERCP may increase the risk of pancreatitis and cholecystitis in patients with cirrhosis. Comorbidities in cirrhosis patients may increase the risk of post-ERCP complications and mortality; therefore, use of ERCP in cirrhosis patients should be carefully considered, and further studies on this patient population are needed.
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http://dx.doi.org/10.1097/MCG.0000000000001573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9257052PMC
August 2022

Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: a retrospective chart review.

Endosc Int Open 2021 Jun 27;9(6):E867-E873. Epub 2021 May 27.

Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States.

Cold snare endoscopic mucosal resection (EMR) is being increasingly utilized for non-pedunculated polyps ≥ 20 mm due to adverse events associated with use of cautery. Larger studies evaluating adenoma recurrence rate (ARR) and risk factors for recurrence following cold snare EMR of large polyps are lacking. The aim of this study was to define ARR for polyps ≥ 20 mm removed by cold snare EMR and to identify risk factors for recurrence. A retrospective chart review of colon cold snare EMR procedures performed between January 2015 and July 2019 at a tertiary care medical center was performed. During this period, 310 non-pedunculated polyps ≥ 20 mm were excised using cold snare EMR with follow-up surveillance colonoscopy. Patient demographic data as well as polyp characteristics at the time of index and surveillance colonoscopy were collected and analyzed. A total of 108 of 310 polyps (34.8 %) demonstrated adenoma recurrence at follow-up colonoscopy. Patients with a higher ARR were older (  = 0.008), had endoscopic clips placed at index procedure (  = 0.017), and were more likely to be Asian and African American (  = 0.02). ARR was higher in larger polyps (  < 0.001), tubulovillous adenomas (  < 0.001), and polyps with high-grade dysplasia (  = 0.003). Although cold snare EMR remains a feasible alternative to hot snare polypectomy for resection of non-pedunculated polyps ≥ 20 mm, endoscopists must also carefully consider factors associated with increased ARR when utilizing this technique.
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http://dx.doi.org/10.1055/a-1399-8398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8159587PMC
June 2021

Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration.

Gastrointest Endosc 2021 10 3;94(4):727-732. Epub 2021 May 3.

Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Background And Aims: EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE.

Methods: We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation.

Results: Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding.

Conclusions: Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.
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http://dx.doi.org/10.1016/j.gie.2021.04.022DOI Listing
October 2021

Increased Morbidity and Mortality in COVID-19 Patients with Liver Injury.

Dig Dis Sci 2022 06 4;67(6):2577-2583. Epub 2021 May 4.

Department of Gastroenterology and Hepatology, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI, 48202, USA.

Background: There is a high prevalence of liver injury (LI) in patients with coronavirus disease 2019 (COVID-19); however, few large-scale studies assessing risk factors and clinical outcomes in these patients have been done.

Aims: To evaluate the risk factors and clinical outcomes associated with LI in a large inpatient cohort of COVID-19 patients.

Methods: Adult patients with COVID-19 between March 1 and April 30, 2020, were included. LI was defined as peak levels of alanine aminotransferase/aspartate aminotransferase that were 3 times the ULN or peak levels in alkaline phosphatase/total bilirubin that were 2 times the ULN. Mild elevation in liver enzymes (MEL) was defined as abnormal peak liver enzyme levels lower than the threshold for LI. Patients with MEL and LI were compared to a control group comprising patients with normal liver enzymes throughout hospitalization.

Results: Of 1935 hospitalized COVID-19 patients, 1031 (53.2%) had MEL and 396 (20.5%) had LI. Compared to control patients, MEL and LI groups contained proportionately more men. Patients in the MEL cohort were older compared to control, and African-Americans were more highly represented in the LI group. Patients with LI had an increased risk of mortality (relative risk [RR] 4.26), intensive care unit admission (RR, 5.52), intubation (RR, 11.01), 30-day readmission (RR, 1.81), length of hospitalization, and intensive care unit stay (10.49 and 10.06 days, respectively) compared to control.

Conclusion: Our study showed that patients with COVID-19 who presented with LI had a significantly increased risk of mortality and poor clinical outcomes.
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http://dx.doi.org/10.1007/s10620-021-07007-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094979PMC
June 2022

Association of obesity with illness severity in hospitalized patients with COVID-19: A retrospective cohort study.

Obes Res Clin Pract 2021 Mar-Apr;15(2):172-176. Epub 2021 Feb 25.

Division of Gastroenterology and Hepatology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, Michigan 48202, US.

Background: Although recent studies have shown an association between obesity and adverse coronavirus disease 2019 (COVID-19) patient outcomes, there is a paucity in large studies focusing on hospitalized patients. We aimed to analyze outcomes associated with obesity in a large cohort of hospitalized COVID-19 patients.

Methods: We performed a retrospective study at a tertiary care health system of adult patients with COVID-19 who were admitted between March 1 and April 30, 2020. Patients were stratified by body mass index (BMI) into obese (BMI ≥ 30 kg/m 2) and non-obese (BMI < 30 kg/m 2) cohorts. Primary outcomes were mortality, intensive care unit (ICU) admission, intubation, and 30-day readmission.

Results: A total of 1983 patients were included of whom 1031 (51.9%) had obesity and 952 (48.9%) did not have obesity. Patients with obesity were younger (P < 0.001), more likely to be female (P < 0.001) and African American (P < 0.001) compared to patients without obesity. Multivariable logistic models adjusting for differences in age, sex, race, medical comorbidities, and treatment modalities revealed no difference in 60-day mortality and 30-day readmission between obese and non-obese groups. In these models, patients with obesity had increased odds of ICU admission (adjusted OR, 1.37; 95% CI, 1.07-1.76; P = 0.012) and intubation (adjusted OR, 1.37; 95% CI, 1.04-1.80; P = 0.026).

Conclusions: Obesity in patients with COVID-19 is independently associated with increased risk for ICU admission and intubation. Recognizing that obesity impacts morbidity in this manner is crucial for appropriate management of COVID-19 patients.
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http://dx.doi.org/10.1016/j.orcp.2021.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904471PMC
March 2021

Colovaginal fistula closure using a cardiac septal defect occluder.

VideoGIE 2021 Jan 29;6(1):41-43. Epub 2020 Oct 29.

Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan.

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http://dx.doi.org/10.1016/j.vgie.2020.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805018PMC
January 2021

Cold snare endoscopic mucosal resection for the removal of large nonpedunculated colon polyps.

VideoGIE 2021 Jan 3;6(1):4-6. Epub 2020 Nov 3.

Henry Ford Hospital, Division of Gastroenterology, Detroit, Michigan.

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http://dx.doi.org/10.1016/j.vgie.2020.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805126PMC
January 2021

Post-endoscopic retrograde cholangiopancreatography pancreatitis prevention using topical epinephrine: systematic review and meta-analysis.

Endosc Int Open 2020 Aug 21;8(8):E1061-E1067. Epub 2020 Jul 21.

University of Connecticut Health Center - Gastroenterology and Hepatology, Farmington, Connecticut, United States.

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Multiple drugs and techniques have been studied for the prevention of PEP. Topical epinephrine has shown mixed results and is still not widely accepted as an alternative for prevention of PEP. We performed a systematic review and meta-analysis to evaluate the efficacy of topical epinephrine in preventing PEP. A comprehensive literature review was conducted by searching Cochrane library database, Embase and PubMed up to August 2019, to identify all studies that evaluated use of topical epinephrine alone or in conjunction with other agents for prevention of PEP. Outcomes included prevention of PEP with use of topical epinephrine and evaluation of whether addiing epinephrine provides any additional benefit in preventing PEP. All analysis was conducted using Revman 5.3. Eight studies, including six randomized controlled trials and two observational studies with 4123 patients, were included in the meta-analysis. Overall, there was no difference in incidence of PEP in patients who underwent ERCP and were treated with epinephrine spray versus those who were not, RR = 0.63 (CI 0.32-1.24) with heterogeneity (I2 = 72 %). However, on a subgroup analysis, topical epinephrine significantly decreases the risk of PEP when compared to placebo alone (means no intervention was done including no rectal indomethacin)., RR = 0.32 (0.18-0.57). In another subgroup analysis, there was no statistically significant difference in using topical epinephrine along with rectal indomethacin in preventing PEP compared to rectal indomethacin alone RR = 0.87 (0.46-1.64). Topical epinephrine does not provide any additional benefit in preventing PEP when used in conjunction with rectal indomethacin. In subgroup analysis, topical epinephrine appeared to decrease risk of PEP in the absence of rectal indomethacin, and could be considered when rectal indomethacin is unavailable or if there is a contraindication to its use.
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http://dx.doi.org/10.1055/a-1190-3777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383058PMC
August 2020

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees.

Gastrointest Endosc 2019 06 7;89(6):1160-1168.e9. Epub 2019 Feb 7.

University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Background And Aims: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs.

Methods: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees.

Results: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases.

Conclusion: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).
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http://dx.doi.org/10.1016/j.gie.2019.01.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527477PMC
June 2019

Repair of upper-GI fistulas and anastomotic leakage by the use of endoluminal vacuum-assisted closure.

VideoGIE 2019 Jan 1;4(1):40-44. Epub 2019 Jan 1.

Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA.

Background And Aims: GI perforations, leaks, and fistulas are types of full-thickness mural defects that frequently occur as adverse events from GI surgeries such as esophagectomy for malignancy and bariatric surgery. Historically, treatment has entailed a combination of reoperation, percutaneous drainage, and bowel rest. Recently, there has been a changing paradigm in the management of these defects. Endoscopic interventions, including endoclipping and placement of self-expanding metal stents (SEMSs), have been increasingly used with good success. Despite this, some defects remain refractory to these techniques. Endoscopic vacuum-assisted closure (EVAC) is a new, promising endoscopic approach to repairing these defects. EVAC works through applying continuous, controlled negative pressure at the defect with the use of an endoscopically placed polyurethane sponge connected to an electronic vacuum device. EVAC has been shown to be feasible, safe, and effective.

Methods: We present a video series of 3 cases demonstrating the successful application of EVAC for the treatment of anastomotic leakage after esophagectomy and of fistula formation after bariatric surgery.

Results: Two patients experienced anastomotic leakage after esophagectomy for esophageal adenocarcinoma, and 1 patient experienced a chronic gastric fistula after Roux-en-Y gastric bypass. The gastric bypass patient's fistula failed to resolve with over-the-scope-clip placement, and all 3 patients' defects did not heal despite SEMS placement; therefore, EVAC was performed. The bariatric surgery patient required 9 sponge exchanges over 35 days, and the 2 esophagectomy patients each required 3 sponge exchanges over 13 days. All 3 patients had resolution of their defects with EVAC. No adverse events occurred, and all patients have had no recurrence for several months.

Conclusions: These cases help to highlight the feasibility, safety, and efficacy of EVAC for the closure of full-thickness GI defects. On the basis of our experience, the use of EVAC should be considered for these complex and refractory cases.
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http://dx.doi.org/10.1016/j.vgie.2018.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318080PMC
January 2019

Many Options for Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Masses, but Any Differences?

Clin Gastroenterol Hepatol 2018 11 16;16(11):1712-1713. Epub 2018 Aug 16.

Section of Advanced Therapeutic Endoscopy, Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan.

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http://dx.doi.org/10.1016/j.cgh.2018.07.044DOI Listing
November 2018

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

Gastroenterology 2018 11 26;155(5):1483-1494.e7. Epub 2018 Jul 26.

University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background & Aims: It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence.

Methods: We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs.

Results: By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate).

Conclusions: In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.
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http://dx.doi.org/10.1053/j.gastro.2018.07.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6504935PMC
November 2018

Does an Upper Endoscopy Before Transesophageal Echocardiography Change Patient Management?

J Clin Gastroenterol 2015 Nov-Dec;49(10):848-52

*Division of Gastroenterology and Hepatology, Drexel University College of Medicine, Philadelphia, PA †Department of Internal Medicine, University of Maryland, College Park, MD.

Goal: To determine if esophagogastroduodenoscopy (EGD) before transesophageal echocardiography (TEE) will change patient management.

Background: Before TEE gastroenterologists are often consulted to evaluate patients with a history of dysphagia, known gastrointestinal (GI) disease, or GI bleed. There are no known published data on the clinical utility of EGD before TEE.

Design And Setting: Retrospective study at an inner city tertiary-care center.

Patients: A total of 134 patients were included who were at least 18 years old and underwent an EGD to evaluate the safety of the blind passage of a TEE probe.

Results: In total, 134 patients were identified. Twenty patients (15%) were not cleared for TEE due to esophageal surface abnormalities (n=3; esophagitis, ulcer, mucosal tear), esophageal structural abnormalities (n=10; varices, stricture, ring, web, hernia, Zenker), and combinations thereof (n=7). Of the 20 patients not cleared for TEE, 17 never underwent a TEE and 3 patients underwent a TEE 7 to 180 days later. Two patients undergoing EGD and 5 patients undergoing TEE experienced adverse cardiopulmonary events.

Conclusions: Our results demonstrate that an EGD before TEE can elucidate findings that may preclude the passage of a blind probe in patients with upper GI symptoms or known esophageal disease. Therefore, we propose that an EGD is clinically beneficial before TEE and can change patient management.
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http://dx.doi.org/10.1097/MCG.0000000000000332DOI Listing
July 2016

A Unique Case of Hematemesis in a 17-Year-Old Female.

ACG Case Rep J 2014 Apr 4;1(3):151-3. Epub 2014 Apr 4.

Division of Gastroenterology and Hepatology, Drexel University College of Medicine, Philadelphia, PA.

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding (GIB) that should be considered in a patient with a history of pancreatitis and GIB. A 17-year-old female presented with nausea followed by an episode of hematemesis. Fourteen weeks prior to presentation, she had 3 episodes of vomiting within a week. Six weeks prior to presentation, she developed abdominal pain and was diagnosed with acute idiopathic pancreatitis. Computed tomography (CT) revealed a cystic lesion arising in the gastroduodenal artery (GDA), and coil embolization was performed. There are no reported cases of HP in an adolescent with acute idiopathic pancreatitis.
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http://dx.doi.org/10.14309/crj.2014.34DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4435304PMC
April 2014

Gastrointestinal issues in the older female patient.

Gastroenterol Clin North Am 2011 Jun 13;40(2):449-66, x. Epub 2011 Apr 13.

Drexel University College of Medicine, 245 North 15th Street, 5th Floor New College Building, Philadelphia, PA 19107, USA.

As the body ages, it undergoes a multitude of changes. Some of these changes are visible, whereas others are not and may be elicited during the patient encounter. Some gastrointestinal issues may be more common in the elderly population and possibly in older women. These issues range from motility disorders, such as fecal incontinence and constipation, to changes in neuropeptide function and its effect on the anorexia of aging. This article comprehensively reviews gastrointestinal issues that commonly afflict the elderly female population.
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http://dx.doi.org/10.1016/j.gtc.2011.03.007DOI Listing
June 2011
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