Shawn L. Shah

Endoscopic Sleeve Gastroplasty, Laparoscopic Sleeve Gastrectomy, and Laparoscopic Band for Weight Loss: How Do They Compare?

BackgroundEndoscopic sleeve gastroplasty (ESG) is a novel endobariatric procedure. Initial studies demonstrated an association of ESG with weight loss and improvement of obesity-related comorbidities. Our aim was to compare ESG to laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB).MethodsWe included 278 obese (BMI >xa030) patients who underwent ESG (nxa0=xa091), LSG (nxa0=xa0120), or LAGB (nxa0=xa067) at our tertiary care academic center. Primary outcome was percent total body weight loss (%TBWL) at 3, 6, 9, and 12xa0months. Secondary outcome measures included adverse events (AE), length of stay (LOS), and readmission rate.ResultsAt 12-month follow-up, LSG achieved the greatest %TBWL compared to LAGB and ESG (29.28 vs 13.30 vs 17.57%, respectively; pxa0<xa00.001). However, ESG had a significantly lower rate of morbidity when compared to LSG or LAGB (pxa0=xa00.01). The LOS was significantly less for ESG compared to LSG or LAGB (0.34xa0±xa00.73 vs 3.09xa0±xa01.47 vs 1.66xa0±xa03.07xa0days, respectively; pxa0<xa00.01). Readmission rates were not significantly different between the groups (pxa0=xa00.72).ConclusionAlthough LSG is the most effective option for weight loss, ESG is a safe and feasible endobariatric option associated with low morbidity and short LOS in select patients.

Setting Up An Endobariatric Weight Loss Program

INTRODUCTIONObesity has become a national epidemic and a consequential public health problem [1, 2]. The burden of obesity is staggering, severely impacting not only the quality of life of millions of individuals across the country, but also the national healthcare budget with an estimated annual co

Double-balloon platform-assisted rectal endoscopic submucosal dissection

A 69-year-old woman with complicated diverticular disease post-partial left colectomy was referred for evaluation of hematochezia. Index colonoscopy showed a large rectal polyp, and polypectomy was incomplete. Biopsy showed a traditional serrated adenoma. The case was referred to the advanced endoscopy service for further management. The patient underwent a sigmoidoscopy that revealed a 40-mm, partially circumferential and lateral-spreading polypoid lesion, 0.5 cm from the dentate line. Endoscopic ultrasound (EUS) revealed a hypoechoic rectal mass with well-defined borders confined to the mucosa, which was amenable to endoscopic submucosal dissection (ESD). Colonoscopy was then performed with the intention of undertaking ESD. A border around the lesion was initially marked using the soft coagulation setting. High pressure injection using a hybrid knife was used around the edges of the lesion; after adequate expansion of the submucosal space, the mucosa was incised into the submucosa. After dissection had been started at the distal edge of the lesion, the double-balloon platform was deployed. The dissected edge was secured to the proximal balloon of the platform using hemoclips, and the device was used to retract the mucosa, facilitating further dissection. The submucosal space below the lesion was dissected using repeated submucosal injections followed by short bursts of dissection, and the lesion was ultimately removed en bloc (▶Fig. 1; ▶Video1). One suture was placed to close the ESD defect. The patient was discharged on day 2 and remained asymptomatic on follow-up. Pathology showed a 4.5 ×2.5 ×1-cm serrated adenoma with margins that were free of adenomatous epithelium. ESD can be safely and effectively used for en bloc excision of large colorectal tumors without submucosal invasion. However, the limitations of ESD include the currently available endoscopic accessories. Here, we demonstrate the successful application of the double-balloon platform to facilitate traction, provide stability, and allow for precise dissection of a large semi-circumferential rectal tumor.

Endoscopic removal of a proximally migrated pancreatic stent

A 64-year-old woman with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and biliary and pancreatic duct (PD) stent placement. She subsequently presented with postprandial abdominal distension of a few weeks’ duration. The patient had undergone a laparoscopic cholecystectomy following the ERCP; however, a repeat ERCP nearly 2 months after her initial endoscopy revealed a proximally migrated PD stent that could not be retrieved, prompting transfer to our center. Repeat ERCP revealed a normal-appearing PD with a retained PD stent, which had migrated towards the pancreas. The ventral PD was deeply cannulated with a short-nosed traction autotome, and a pancreatic sphincterotomy was performed. A pediatric biopsy forceps was then advanced into the duct over the wire, and closed over the pancreatic stent, but the stent appeared to be embedded. Further attempts to extract the PD stent with a rat tooth forceps and retrieval basket were also unsuccessful. The PD was then dilated with a 4-mm hurricane balloon and the pediatric biopsy forceps was again advanced over the wire, with successful extraction and complete removal of the retained PD stent (▶Fig. 1, ▶Video1). One 5 Fr ×12 cm, single-pigtail, plastic stent was placed into the ventral PD to prevent post-ERCP pancreatitis. The patient was discharged home the same day. At post-ERCP followup, the patient remained pain free and had normal liver chemistry. The removal of proximally migrated PD stents remains technically challenging owing to the small diameter, bending course, and often stricturing of the PD. Many devices have been successfully used for endoscopic removal of migrated stents, including a basket, snare, extraction balloon, and grasping forceps. Despite the lack of a standardized approach to migrated pancreatic stents, ERCP should be attempted at an experienced center for retrieval of a proximally migrated PD stent prior to considering surgical intervention [1].

A wormy surprise: ERCP for intrabiliary drainage of a hydatid cyst

A 41-year-old man with a known hepatic hydatid cyst presented with several months of abdominal pain and more recent onset of jaundice. Despite repeated courses of albendazole, he reported no clinical improvement. Upon presentation, he underwent magnetic resonance cholangiopancreatography (MRCP), which revealed a multiloculated cystic structure within hepatic segments 5 and 6, measuring approximately 7 ×4.5×6.5 cm with mildly enhancing septations, and diffuse intrahepatic biliary ductal dilatation (▶Fig. 1). The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) with the initial cholangiogram showing a hilar filling defect, a common bile duct (CBD) stricture, and dilated intrahepatic ducts in segments 5 and 8 (▶Fig. 2 a). A biliary sphincterotomy was performed and the cholangioscope was advanced over the wire into the CBD, where cyst membranes were visualized mid-duct (▶Fig. 2b, ▶Video1). The CBD was then dilated with a balloon catheter and copious amounts of cyst membranes were swept from the duct (▶Fig. 2 c). The cyst membranes were collected with a Roth Net and sent to microbiology. After multiple balloon sweeps, the cholangioscope was re-inserted into the bile duct and complete clearance of cyst membranes was confirmed. A 10-Fr ×7-cm straight plastic stent was deployed in the CBD at the end of the procedure. The patient was treated with albendazole and returned a few days later for an extended right hepatectomy. His postoperative course was complicated by a bile leak that required repeat ERCP and placement of a long plastic stent to cover the defect causing the observed leak. The patient was seen at follow-up and continues to remain free of both symptoms and cysts. While surgical resection has been the mainstay in the approach to the management of hepatic hydatid cysts, ERCP can be a useful modality both to aid in the diagnosis of hepatic cyst extension into the bile ducts and for therapeutic drainage of the tapeworm cyst and membranes.

Endoscopic ultrasound-guided transrectal pelvic abscess drainage using a lumen-apposing metal stent

A 31-year-old woman with asthma presented with 1 week of lower abdominal pain and fevers after a recent emergency room discharge for appendicitis that had been managed conservatively with antibiotics. Upon presentation, she underwent a computed tomography (CT) scan of the abdomen and pelvis, which revealed a multiloculated pelvic abscess measuring approximately 7.3 × 4.7 ×7.0 cm (▶Fig. 1). The collection was thought to be unamenable to drainage by interventional radiology. The patient underwent a lower gastrointestinal endoscopic ultrasound (EUS), which identified the pelvic abscess from the rectosigmoid colon. After color flow Doppler had been used to ensure there was no intervening vasculature, a cautery-enhanced delivery system was used to deploy a 10-mm lumen-apposing metal stent (LAMS; Axios; Boston Scientific, Marlborough, Massachusetts, USA) into the collection, with the distal flange in the collection and the proximal end in the sigmoid colon. This process was visualized under fluoroscopic, endosonographic, and endoscopic guidance. Copious amounts of purulent material were seen draining from the stent. The stent was then dilated and two doublepigtail plastic stents (10 Fr × 7 cm) were deployed into the metal stent to prevent migration (▶Video1). The patient was discharged on hospital day 4 after an uncomplicated post-operative course. A repeat CT scan of the abdomen and pelvis was performed nearly 3 weeks later and revealed resolution of the multiloculated pelvic abscess; the LAMS was endoscopically removed a few days later. The patient was subsequently seen in follow-up and has continued to remain asymptomatic. The use of LAMSs has revolutionized EUS as it creates a large conduit for drainage, as well as for passage of both the endoscope and a variety of endoscopic accessories [1]. While surgical resection has been the main approach to drainage of intra-abdominal and pelvic collections, EUS can be a useful modality to aid in the diagnosis and for therapeutic drainage of pelvic collections [2–5].