Sunil Dacha

Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes.

Gastroparesis is a poorly understood, chronic, debilitating motility disorder with very limited medical therapeutic options. Gastric peroral endoscopic pyloromyotomy (G‐POEM) is an emerging novel endoscopic technique as an incisionless pyloroplasty for refractory cases. Effective information of G‐POEM on different types of gastroparesis is sparse.

Treatment allocation in patients with early-stage esophageal adenocarcinoma: Prevalence and predictors of lymph node involvement

In considering treatment allocation for patients with early esophageal adenocarcinoma, the incidence of lymph node metastasis is a critical determinant; however, this has not been well defined or stratified by the relevant clinical predictors of lymph node spread.

Fluoroscopy-guided gastric peroral endoscopic pyloromyotomy (G-POEM): a more reliable and efficient method for treatment of refractory gastroparesis.

IntroductionPrior studies show promising results of the gastric peroral endoscopic pyloromyotomy (G-POEM) procedure for treatment of refractory gastroparesis. One major technical challenge involved in this procedure is identifying the pyloric muscular ring (PMR). The aim of this study is to establish a reliable method for identification of the PMR during G-POEM.MethodsFluoroscopy-guided G-POEM was performed by placing an endoclip at the 9 to 11’o clock position at the pylorus for identification of PMR. Conventional G-POEM was performed by observation of blue colored mucosa at the pylorus area as an indirect marker for PMR. The degree of the PMR identification was graded into well identified, identified, and not identified based on the appearance of the PMR. Procedure times were accurately documented. Gastroparesis cardinal symptoms index and gastric emptying scintigraphy were evaluated before and after the procedure.ResultsFourteen patients were studied, seven underwent fluoroscopy-guided G-POEM, and seven patients underwent conventional G-POEM. All procedures achieved technical success and no adverse events occurred. In the seven patients who underwent fluoroscopy-guided G-POEM, the PMR was well identified in four patients and identified in three patients. In the seven patients who underwent conventional G-POEM, the PMR was identified in four patients and not identified in three patients. The average time to complete the fluoroscopy-guided G-POEM was significantly shorter than that of the conventional G-POEM.ConclusionsFluoroscopy-guided G-POEM by placement of an endoclip at the pylorus was a reliable and safe method to direct the orientation of the submucosal tunnel, to facilitate the location of the PMR, and to shorten the procedure time.

Concurrent myotomy and tunneling after establishment of a half tunnel instead of myotomy after establishment of a full tunnel: a more efficient method of peroral endoscopic myotomy

Background and study aims: Peroral endoscopic myotomy (POEM) is a time-consuming and challenging procedure. Traditionally, the myotomy is done after the submucosal tunnel has been completed. Starting the myotomy earlier, after submucosal tunneling is half completed (concurrent myotomy and tunneling), may be more efficient. This study aims to assess if the method of concurrent myotomy and tunneling may decrease the procedural time and be efficacious. Patients and methods: This is a retrospective case series of patients who underwent modified POEM (concurrent myotomy and tunneling) or traditional POEM at a tertiary care medical center. Modified POEM or traditional POEM was performed at the discretion of the endoscopist in patients presenting with achalasia. The total procedural duration, myotomy duration, myotomy length, and time per unit length of myotomy were recorded for both modified and traditional POEM. Results: Modified POEM was performed in 6 patients whose mean age (± standard deviation [SD]) was 58 ± 13.3 years. Of these, 5 patients had type II achalasia and 1 patient had esophageal dysmotility. The mean Eckardt score (± SD) before the procedure was 8.8 ± 1.3. The modified technique was performed in 47 ± 8 minutes, with 6 ± 1 minutes required per centimeter of myotomy and 3 ± 1 minutes required per centimeter of submucosal space. The Eckardt score was 3 ± 1.1 at 1 month and 3 ± 2.5 at 3 months. The procedure time for modified POEM was significantly shorter than that for traditional POEM. Conclusions: Modified POEM with short submucosal tunneling may be more efficient than traditional POEM with long submucosal tunneling, and outcomes may be equivalent over short-term follow-up. Long-term data and randomized controlled studies are needed to compare the clinical efficacy of modified POEM with that of the traditional method.

Fluoroscopic gastric peroral endoscopic pyloromyotomy (G-POEM) in patients with a failed gastric electrical stimulator

Abstract Background Gastric electrical stimulators (GESs) have been used to treat refractory gastroparesis in patients who fail initial therapies such as dietary modifications, control of psychological stressors and pharmacologic treatment. More recently, gastric peroral endoscopic pyloromyotomy (G-POEM) has emerged as a novel endoscopic technique to treat refractory gastroparesis. We present a case series of patients with refractory gastroparesis who failed treatment with an implanted GES that were safely treated with G-POEM performed under fluoroscopy as a salvage therapy. Methods Cases of G-POEM performed on patients with refractory gastroparesis who failed treatment with a GES were retrospectively reviewed. All G-POEM procedures were performed under fluoroscopic guidance with the GES still in place. Gastroparesis Cardinal Symptoms Index (GCSI) and gastric emptying scintigraphy were assessed before and after the procedure. Patients were followed up for up to 18 months post procedure. Results Five patients underwent G-POEM after failing treatment with a GES. Under fluoroscopy, the GES and their leads were visualized in different parts of the stomach. One GES lead was observed at the antrum near the myotomy site. All procedures were successfully completed without complications. Patients’ GCSI decreased by an average of 62% 1 month post procedure. Patients also had notable improvements in gastric emptying 2 months post procedure. Conclusion In patients with refractory gastroparesis who have failed treatment with a GES, G-POEM can be safe and effective without removing the GES. To visualize the GES and avoid cutting GES leads during myotomy, the procedure should be performed under fluoroscopy.

Gastric Peroral Endoscopic Pyloromyotomy Reduces Symptoms, Increases Quality of Life, and Reduces Health Care Use For Patients With Gastroparesis

BACKGROUND & AIMS: Gastric peroral endoscopic pyloromyotomy (GPOEM) is becoming a promising treatment option for patients with refractory gastroparesis. We aimed to systematically assess the efficacy of GPOEM and its effects on health care use. METHODS: We performed a retrospective study on 30 patients with refractory gastroparesis who underwent GPOEM from June 2015 through July 2017 at a tertiary center. We compared outcomes with those of 7 patients with refractory gastroparesis who did not undergo the procedure (controls). The primary outcomes were patient‐reported reductions in symptoms, based on the gastroparesis cardinal symptom index (GCSI), and increases in 8 aspects of quality of life, based on Short Form 36 (SF‐36) scores. Data were collected on the day of the procedure (baseline) and at 1 month, 6 months, 12 months, and 18 months afterward. Secondary outcomes included visits to the emergency department or hospitalization for gastroparesis‐related symptoms. RESULTS: GPOEM was technically successful in all patients and significantly reduced GCSI scores in repeated‐measure analysis of variance (F2.044, 38.838 = 22.319; P < .0005). The mean score at baseline was 3.5 ± 0.6, at 1 month after GPOEM was 1.8 ± 1.0 (P < .0005), at 6 months after was 1.9 ± 1.2 (P < .0005), at 12 months after was 2.6 ± 1.5 (P < .026), and at 18 months after was 2.1 ± 1.3 (P < .016). GPOEM was associated with improved quality of life: 77.8%, 76.5%, and 70% of patients had significant increases in SF‐36 scores, compared with baseline, at 1 month, 6 months, and 12 months after GPOEM, respectively (F1.71,18.83 = 14.16; P < .0005). Compared with controls, patients who underwent GPOEM had significant reductions in GCSI, after we controlled for baseline score and duration of the disease (F1,31 = 9.001; P = .005). Patients who received GPOEM had significant reductions in number of emergency department visits (from 2.2 ± 3.1 times/mo at baseline to 0.3 ± 0.8 times/mo; P = .003) and hospitalizations (from 1.7 ± 2 times/mo at baseline to 0.2 ± 0.4 times/mo; P = .0002). CONCLUSIONS: In a retrospective study of patients who underwent GPOEM for refractory gastroparesis, we found the procedure significantly improved symptoms, increased quality of life, and reduced health care use related to gastroparesis.

Endoscopic retrograde cholangiopancreatography with ampullary biopsy vs ERCP alone: a matched-pairs controlled evaluation of outcomes and complications.

Abstract Background and aims Biopsy of the ampulla of Vater may be performed to evaluate for ampullary adenomas, suspected ampullary tumors and immunohistological staining for autoimmune pancreatitis. Ampullary biopsies are commonly performed at the time of endoscopic retrograde cholangiopancreatography (ERCP). Due to the well-established complication rate following ERCP, the contribution of ampullary biopsy as a potential independent risk factor would require a controlled comparison. Methods A matched-pairs, case-control analysis was performed for patients undergoing ERCP with or without ampullary biopsy. The analysis involved a retrospective review of adult patients at a tertiary-care center who underwent ampullary biopsies during ERCP compared (via procedural complexity) with a matched control group who underwent ERCP without ampullary biopsies. Results Of 159 procedures involving ampullary biopsy, 54 ERCPs that met the inclusion criteria were performed with ampullary biopsy and included in the analysis cohort. This cohort was compared with 54 patients undergoing ERCP without ampullary biopsy, matched by American Society for Gastrointestinal Endoscopy (ASGE) grade of procedural complexity. There were no patients with sphincter of Oddi dysfunction. Ampullary biopsies suggested a diagnosis in 75.9% of the procedures including 12 adenomas, 5 adenocarcinomas and 1 intraductal papillary mucinous neoplasm. Including major and minor complications, the overall complication rate with biopsy (9.3%) was equivalent to the complication rate in the control group without ampullary biopsy (9.3%, P>0.99). The incidence of post-procedure pancreatitis was not significantly different between the two groups (5.6% vs 3.7%, P=0.6). Age and pancreatic duct manipulation, but not ampullary biopsy, were associated with complications on multivariate analysis in the study population. Conclusions Ampullary biopsy performed during ERCP had a high diagnostic yield and was not associated with an increased rate of post-procedure complications or pancreatitis when compared with ERCP alone.

Sa2041 Predictors of Lymph Nodal Metastases With Resectable Pancreatic Adenocarcinoma

Background: Pancreatic ductal adenocarcinoma (PDAC) is frequently diagnosed at an advanced stage. Breath testing is a non-invasive method that detects volatile organic compounds (VOCs). The aim was to identify VOCs that discriminate patients with PDAC from those with chronic pancreatitis (CP) and healthy controls. Methods: Blood was obtained from healthy controls (screening colonoscopy), severe CP (SCP, imaging demonstrating pancreatic calcifications), minimal change CP (MCCP, ≥4 standard endoscopic ultrasound (EUS) criteria and endoscopic pancreatic function testing peak bicarbonate <80 mEq), and PDAC (positive cytology obtained by EUS guided fine needle aspiration).Twenty milliliters of headspace was removed from the samples and analyzed for 22 VOCs by selected ion flow tube mass spectrometry. Analysis of variance was used to assess differences in VOC levels and receiver operating characteristic (ROC) analysis was performed to assess the role of VOCs in distinguishing PDAC from severe CP, MCCP and healthy controls. Results: 73 patients were included (20 healthy controls, 19 MCCP, 18 SCP and 16 PDAC). Adjusting for tobacco and alcohol usage, acetonitrile, ethanol, isoprene, 1-heptene, ammonia, ethane and triethyl amine were found to be associated with PDAC compared to all groups. ROC

Critical Care Management in Cirrhosis

The critical care management of cirrhotic patients involves a multidisciplinary team approach, including the hepatologist and intensivist, to address life-threatening complications and to provide comprehensive care for multi-organ failure commonly seen in these patients. A systematic approach to the diagnosis and therapy of multi-organ system dysfunction is essential to optimize the intensive care management of these complex patients, with a goal to stabilize them for possible liver transplantation. This review provides a system-based approach for the intensive care management of critically ill cirrhotic patients.

Mo1042 Incidence and Predictors of Lymph Nodal Metastases in Patients With Cholangiocarcinoma in the United States

A S L D A b st ra ct s Multivariate logistic regression analyses showed that younger age, African-American race, scirrhous, spindle cell or pleomorphic histology and severe fibrosis score were independent factors associated with AFP-elevated HCC. Conclusions: Elevated pretreatment serum AFP level (i.e. A-stage) is an AJCC-stage independent poor prognostic factor in HCC. We recommend the incorporation of A-stage within the current TNM-based AJCC staging system to enhance estimates of survival and aid therapeutic decision-making, especially in earlier stage HCC.