Sandeep Lakhtakia

Achalasia Cardia Subtyping by High-Resolution Manometry Predicts the Therapeutic Outcome of Pneumatic Balloon Dilatation

Background/Aims High-resolution manometry (HRM) with pressure topography is used to subtype achalasia cardia, which has therapeutic implications. The aim of this study was to compare the clinical characteristics, manometric variables and treatment outcomes among the achalasia subtypes based on the HRM findings. Methods The patients who underwent HRM at the Asian Institute of Gastroenterology, Hyderabad between January 2008 and January 2009 were enrolled. The patients with achalasia were categorized into 3 subtypes: type I - achalasia with minimum esophageal pressurization, type II - achalasia with esophageal compression and type III - achalasia with spasm. The clinical and manometric variables and treatment outcomes were compared. Results Eighty-nine out of the 900 patients who underwent HRM were diagnosed as achalasia cardia. Fifty-one patients with a minimum follow-up period of 6 months were included. Types I and II achalasia were diagnosed in 24 patients each and 3 patients were diagnosed as type III achalasia. Dysphagia and regurgitation were the main presenting symptoms in patients with types I and II achalasia. Patients with type III achalasia had high basal lower esophageal sphincter pressure and maximal esophageal pressurization when compared to types I and II. Most patients underwent pneumatic dilatation (type I, 22/24; type II, 20/24; type III, 3/3). Patients with type II had the best response to pneumatic dilatation (18/20, 90.0%) compared to types I (14/22, 63.3%) and III (1/3, 33.3%). Conclusions The type II achalasia cardia showed the best response to pneumatic dilatation.

Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a single-center, prospective study.

BACKGROUND Currently available techniques to diagnose indeterminate biliary lesions have many limitations. OBJECTIVE To assess the accuracy of single-operator peroral cholangioscopy by using the SpyGlass system to differentiate malignant from benign disease in patients with indeterminate biliary lesions. DESIGN Prospective, single-arm, single-center study. SETTING Tertiary referral center. PATIENTS Thirty-six patients with indeterminate biliary strictures and filling defects who had inconclusive results on previous biliary ductal tissue sampling. INTERVENTIONS SpyGlass cholangioscopy with cholangioscopically guided intraductal biopsies. MAIN OUTCOME MEASUREMENTS Accuracy of SpyGlass visual impression and SpyBite biopsies for differentiating malignant from benign ductal lesions. RESULTS Thirty-six patients (22 men, mean age 48.3 years [range 27-68 years]) with indeterminate stricture and/or filling defects underwent SpyGlass cholangioscopy. Of the 22 patients with a final diagnosis of malignant lesion, cholangioscopic impression was malignant in 21 patients (95%) and benign in 1 patient (5%). Of the 14 patients with a final diagnosis of benign disease, including the 3 patients with common bile duct stones and no stricture, cholangioscopic impression was malignant in 3 patients (21%) and benign in 11 patients (79%). The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis. LIMITATIONS No randomized comparison with alternative diagnostic modalities for the nature of biliary strictures. CONCLUSIONS SpyGlass cholangioscopy with SpyBite biopsies has a high accuracy with regard to confirming or excluding malignancy in patients with indeterminate biliary lesions.

Diagnostic yield and therapeutic impact of single-balloon enteroscopy: series of 106 cases.

Background and Aim:  Single‐balloon enteroscopy (SBE) is a novel method of balloon assisted enteroscopy which allows deep intubation of intestine and has therapeutic potential. This prospective study was done in a tertiary care center to evaluate the feasibility, complications, diagnostic and therapeutic yield of SBE in patients with suspected small bowel disorders.

Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: Efficacy and analysis of factors that favor stone fragmentation

Background and Aim:  Difficult common bile duct stones (CBD) are those not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon. The role of extracorporeal shock wave lithotripsy (ESWL) in stone fragmentation and clearance of difficult CBD stones and the factors which favor fragmentation were prospectively evaluated in the present study.

Safety and efficacy of the M2A patency capsule for diagnosis of critical intestinal patency: Results of a prospective clinical trial

Background and Aim:  The presence of a critical intestinal stricture is a contraindication for conventional capsule endoscopy for the risk of impaction. Prior assessment of intestinal patency can substantially minimize this risk. The aim of the present study was to assess the safety and efficacy of the M2A patency capsule (PC) for verification of intestinal strictures.

Endoscopic ultrasound guided fine-needle aspiration of lymph nodes and solid masses: factors influencing the cellularity and adequacy of the aspirate.

Goals: To study the factors that influence the cellularity and adequacy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). Background: An on-site cytopathology service is preferred during EUS-guided FNA. However, this is not always available. Factors that influence the aspirate cellularity and adequacy have not been well defined in the absence of on-site cytopathology. Study: EUS-guided FNA procedures without an on-site cytopathologist from a single center were retrospectively studied. FNA of solid masses and lymph nodes (LN) were included. The FNA cellularity, hemorrhagic content, and endoscopists’ assessment of adequacy were analyzed. Results: A total of 166 patients from January 2009 to October 2010 were included. A total of 520 FNA passes were performed. Of the 166 lesions, 70 (42.2%) were solid masses and 96 (57.8%) were LNs. A 22-G needle was used in 72.3% and 25 G in 27.7% of the patients. The median (range) number of FNA passes was 3 (1 to 7) for LNs and 3 (1 to 5) for solid masses. With this, the endoscopists had an accuracy of 92.2% (153/166) for obtaining an adequate aspirate. Of the 166 samples, 4 (2.4%) were acellular, 20 (12.0%) sparsely cellular, 52 (31.4%) moderately cellular, and 90 (54.2%) highly cellular. The 25-G needle had significantly more adequate aspirates than the 22-G needle for solid masses (P=0.011). Also, increasing passes correlated with higher cellularity (P=0.002) and an adequate aspirate (P=0.021). No correlation was found for LN FNA. Lesion size did not influence the cellularity or adequacy (P>0.05). The degree of hemorrhage was not influenced by the needle gauge, number of passes, or lesion size. The diagnostic yield was not affected by hemorrhage in the sample (P>0.05). Conclusions: EUS-guided FNA obtains a high proportion of adequate aspirates for LNs and solid masses, even without an on-site cytopathologist. Small proportions of inadequate samples still occur. For solid masses, a 25-G needle with at least 3 passes is more likely to provide an adequate aspirate than a 22-G needle and fewer passes. Hemorrhage did not affect the cytopathology’s ability to make a diagnosis.

Use of a novel transluminal balloon accessotome in transmural drainage of pancreatic pseudocyst (with video)

BACKGROUND Endoscopic transmural pseudocyst drainage is a multistep procedure. OBJECTIVE Our purpose was evaluation of a new device, the transluminal balloon accessotome (TBA) in transmural drainage of pancreatic pseudocysts. DESIGN Case series. SETTING Subspecialty tertiary care center. PATIENTS AND INTERVENTIONS Between September and October 2007, all consecutive patients with symptomatic pancreatic pseudocysts in whom TBA was used for pseudocyst drainage were included. Through a therapeutic duodenoscope, the pseudocyst was punctured with the needle-knife of the TBA at the point of maximal bulge. After the cyst cavity was entered, the needle-knife and the handle of the TBA device were withdrawn and a 0.035-inch guidewire was passed into the cavity. The tract was dilated with the inflatable balloon of the TBA device, and a 10F double-pigtail was inserted. RESULTS Six patients, all male, median age 35 years, underwent transmural pancreatic pseudocyst drainage with TBA during this period. All procedures were completed successfully. There were no major complications during or after the procedure except for fever in 1 patient, which responded to parenteral antibiotics. At 6-week follow-up, the pseudocyst cavity had completely collapsed, and stents could be extracted in all patients. LIMITATIONS Single-center experience, small sample size. CONCLUSIONS TBA is a safe, useful, and easy-to-use device for transmural drainage of pancreatic pseudocysts.

Epidural anesthesia is effective for extracorporeal shock wave lithotripsy of pancreatic and biliary calculi.

AIM To evaluate the efficacy of thoracic epidural analgesia for extracorporeal shock wave lithotripsy (ESWL). METHODS ESWL is an effective, non-invasive technique for the treatment of difficult pancreatic and large bile duct calculi. The procedure is often painful and requires large doses of analgesics. Many different anesthetic techniques have been used. Patients with either large bile duct calculi or pancreatic duct calculi which could not be extracted by routine endoscopic methods were selected. Thoracic epidural anesthesia (TEA) was routinely used in all the subjects unless contraindicated. Bupivacaine 0.25% with or without clonidine was used to block the segments D6 to D12. The dose was calculated depending on the age, height and weight of the patient. It was usually 1-2 mL per segment blocked. RESULTS Ninety eight percent of the 1509 patients underwent ESWL under TEA. The subjects selected were within American Society of Anesthesiologists grade I to III. ESWL using EA permitted successful elimination of bile duct or pancreatic calculi with minimal morbidity. The procedure time was shorter in patients with TEA than in those who underwent ESWL under total intravenous anesthesia. CONCLUSION Almost all patients undergoing ESWL with EA had effective blocks with a single catheter insertion and local anesthetic injection.

Spiral enteroscopy: A preliminary experience in Asian population

Background and Aim:  In spite of recent developments in the field of enteroscopy the small bowel remains the challenging organ to access. The spiral enteroscopy is a novel technique using a special over‐tube (Endo‐Ease Discovery SB) system for deep intubation of the small bowel. The aim of the present study was to evaluate the efficacy of spiral enteroscopy with an Olympus enteroscope (SIF Q 180) in an Asian subset of patients.

Achalasia cardia with esophageal varix managed with endoscopic ultrasound-guided botulinum toxin injection.

Achalasia cardia is a motility disorder of the esophagus characterized by failure of relaxation of the lower esophageal sphincter. Nitrates and calcium channel blockers, pneumatic dilatation, botulinum toxin injection and surgical myotomy have been described in literature as possible management options. We present a patient who presented with achalasia and was co-incidentally diagnosed to have cryptogenic cirrhosis with portal hypertension and had esophageal varices. This clinical combination precluded the use of pneumatic dilatation and surgical myotomy. We injected botulinum toxin into the lower esophageal sphincter using a celiac plexus neurolysis needle under endoscopic ultrasound guidance; the clinical response was good.