Endoscopic Palliation for Biliary and Pancreatic Malignancies: Recent Advances

Zaheer Nabi,D Nageshwar Reddy 대한소화기내시경학회 2019 Clinical Endoscopy Vol.52 No.3

Malignancies of the pancreatobiliary system are usually unresectable at the time of diagnosis. As a consequence, a majority of thesecases are candidates for palliative care. With advances in chemotherapeutic agents and multidisciplinary care, the survival rate inpancreatobiliary malignancies has improved. Therefore, there is a need to provide an effective and long-lasting palliative care for thesepatients. Endoscopic palliation is preferred to surgery as the former is associated with equal effcacy and reduced morbidity. The mainrole of endoscopic palliation in the vast majority of pancreatobiliary malignancies includes biliary and enteral stenting for malignantobstructive jaundice and gastric outlet obstruction, respectively. Recent advances in endoscopic palliation appear promising inimparting long-lasting relief of symptoms. Use of radiofrequency ablation and photodynamic therapy in malignant biliary obstructionhas been shown to improve the survival rates as well as the patency of biliary stents. The emergence of endoscopic ultrasound (EUS) asa therapeutic tool has enhanced the capability of minimally invasive palliation in pancreatobiliary cancers. EUS is a valuable alternativeto endoscopic retrograde cholangiopancreatography for the palliation of obstructive jaundice. More recently, EUS is emerging as aneffective primary modality for biliary and gastric bypass.

Can Achalasia Subtyping by High-Resolution Manometry Predict the Therapeutic Outcome of Pneumatic Balloon Dilatation?: Author`s Reply

( Nitesh Pratap ),( D Nageshwar Reddy ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2011 Journal of Neurogastroenterology and Motility (JNM Vol.17 No.2

Quantification of Esophageal Angulation in Sigmoid Achalasia: Are We There Yet?

( Zaheer Nabi ),( D Nageshwar Reddy ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2020 Journal of Neurogastroenterology and Motility (JNM Vol.26 No.4

Endoscopic Management of Gastroesophageal Reflux Disease: Revisited

Zaheer Nabi,D Nageshwar Reddy 대한소화기내시경학회 2016 Clinical Endoscopy Vol.49 No.5

Gastroesophageal reflux disease (GERD) is defined by the presence of troublesome symptoms resulting from the reflux of gastric contents. The prevalence of GERD is increasing globally. An incompetent lower esophageal sphincter underlies the pathogenesis of GERD. Proton pump inhibitors (PPIs) form the core of GERD management. However, a substantial number of patients do not respond well to PPIs. The next option is anti-reflux surgery, which is efficacious, but it has its own limitations, such as gas bloating, inability to belch or vomit, and dysphagia. Laparoscopic placement of magnetic augmentation device is emerging as a useful alternative to conventional anti-reflux surgery. However, invasiveness of a surgical procedure remains a concern for the patients. The proportion of PPI non-responders or partial responders who do not wish for anti-reflux surgery defines the ‘treatment gap’ and needs to be addressed. The last decade has witnessed the fall and rise of many endoscopic devices for GERD. Major endoscopic strategies include radiofrequency ablation and endoscopic fundoplication devices. Current endoscopic devices score high on subjective improvement, but have been unimpressive in objective improvement like esophageal acid exposure. In this review, we discuss the current endoscopic anti-reflux therapies and available evidence for their role in the management of GERD.

Endoscopic management of Combined Biliary and Duodenal Obstruction

Zaheer Nabi,D. Nageshwar Reddy 대한소화기내시경학회 2019 Clinical Endoscopy Vol.52 No.1

Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction ofgastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combinedobstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associatedwith surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenalmetal stents. Biliary cannulation is diffcult in type II bilioduodenal strictures where the duodenal stenosis is located at the level ofthe papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenalstrictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopicultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and effcacy ofendoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories andstandardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.

Endoscopic Management of Pancreatic Fluid Collections in Children

( Zaheer Nabi ),( Rupjyoti Talukdar ),( D. Nageshwar Reddy ) 대한간학회 2017 Gut and Liver Vol.11 No.4

The incidence of acute pancreatitis in children has increased over the last few decades. The development of pancreatic fluid collection is not uncommon after severe acute pancreatitis, although its natural course in children and adolescents is poorly understood. Asymptomatic fluid collections can be safely observed without any intervention. However, the presence of clinically significant symptoms warrants the drainage of these fluid collections. Endoscopic management of pancreatic fluid collection is safe and effective in adults. The use of endoscopic ultrasound (EUS)-guided procedure has improved the efficacy and safety of drainage of pancreatic fluid collections, which have not been well studied in pediatric populations, barring a scant volume of small case series. Excellent results of EUS-guided drainage in adult patients also need to be verified in children and adolescents. Endoprostheses used to drain pancreatic fluid collections include plastic and metal stents. Metal stents have wider lumens and become clogged less often than plastic stents. Fully covered metal stents specifically designed for pancreatic fluid collection are available, and initial studies have shown encouraging results in adult patients. The future of endoscopic management of pancreatic fluid collection in children appears promising. Prospective studies with larger sample sizes are required to establish their definitive role in the pediatric age group. (Gut Liver 2017;11:474-480)

Assessment of Pyloric Sphincter Physiology Using Functional Luminal Imaging Probe in Healthy Volunteers

( Nitin Jagtap ),( Rakesh Kalapala ),( D Nageshwar Reddy ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2020 Journal of Neurogastroenterology and Motility (JNM Vol.26 No.3

Background/Aims The functional luminal imaging probe (FLIP) can measure tissue distensibility and geometric changes through volumetric distention. The esophagogastric junction has been well studied using EndoFLIP, studies on pylorus are lacking. We aim to study biomechanical properties of pylorus using EndoFLIP to create normative data. Methods We performed a prospective study of 20 healthy volunteers (ages, 18-54 years; 10 men) who underwent pylorus evaluation using 12- cm FLIP placed across the pyloric sphincter. FLIP data were analyzed using FLIP planimetry plots at baseline and after administration of hyoscine butyl bromide injection. Results The median pylorus distensibility index (P-DI) was 8.37 mm2/mmHg (interquartile range, 4.22-13.04 mm2/mmHg) at 40 mL balloon volume. The 90th percentile at 40 mL balloon for P-DI was 14.89 mm2/mmHg, for cross-sectional area was 244.20 mm2/mmHg, and diameter and pressure were 17.58 mm and 48.84 mmHg, respectively. There was significant increase in P-DI after administration of hyoscine butyl bromide injection (P < 0.05). Conclusion The normative values can be used as reference values for pyloric distensibility. This reference can be used in studies of related to pyloric diseases such as gastroparesis. (J Neurogastroenterol Motil 2020;26:391-396)

Per Oral Endoscopic Myotomy in Children with Achalasia Cardia

( Zaheer Nabi ),( Mohan Ramchandani ),( D Nageshwar Reddy ),( Santosh Darisetty ),( Rama Kotla ),( Rakesh Kalapala ),( Radhika Chavan ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2016 Journal of Neurogastroenterology and Motility (JNM Vol.22 No.4

Background/Aims Achalasia cardia (AC) is a motility disorder, characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis. AC is rare in children with unclear optimum management strategies. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with encouraging results in adult patients. The efficacy and safety of POEM is not known for pediatric AC. The aim of our study was to evaluate the safety and efficacy of POEM in children with achalasia cardia Methods The data of all children (< 18 years) who underwent POEM at our center was retrospectively analysed. Symptoms were analysed using a validated score (Eckardt score) at regular predefined intervals. Objective parameters including high-resolution manometry, timed barium swallow and esophagogastroduodenoscopy were assessed before the procedure and at 1-year follow-up. Clinical success was defined as an Eckardt score ≤ 3. Results A total of 15 children underwent POEM during the specified period. Ten out of 15 (10/15) completed 1-year follow-up. Median operative time was 100 (38-240) minutes. Mean pre and post procedure LES pressure were 36.64 ± 11.08 mmHg and 15.65 ± 5.73 mmHg, respectively (P = 0.001). Mean Eckardt score before and after the POEM was 7.32 ± 1.42 and 1.74 ± 0.67, respectively (P = 0.001). Mean percentage improvement in barium emptying at 5 minutes was 63.70 ± 4.46%. All children had complete resolution of symptoms at 1 year. Median weight gain of children at 1 year was 0.65 kg (range, 0.0-4.6). Conclusions POEM is safe and effective for children and adolescents with achalasia. Future trials with larger sample size are warranted to establish its efficacy in pediatric AC.

Outcomes of Endoscopic Drainage in Children with Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis

Zaheer Nabi,Rupjyoti Talukdar,Sundeep Lakhtakia,D. Nageshwar Reddy 대한소아소화기영양학회 2022 Pediatric gastroenterology, hepatology & nutrition Vol.25 No.3

Purpose: Endoscopic drainage is an established treatment modality for adult patients with pancreatic fluid collections (PFCs). Available data regarding the efficacy and safety of endoscopic drainage in pediatric patients are limited. In this systematic review and meta-analysis, we aimed to analyze the outcomes of endoscopic drainage in children with PFCs. Methods: A literature search was performed in Embase, PubMed, and Google Scholar for studies on the outcomes of endoscopic drainage with or without endoscopic ultrasonography (EUS) guidance in pediatric patients with PFCs from inception to May 2021. The study’s primary objective was clinical success, defined as resolution of PFCs. The secondary outcomes included technical success, adverse events, and recurrence rates. Results: Fourteen studies (187 children, 70.3% male) were included in this review. The subtypes of fluid collection included pseudocysts (60.3%) and walled-off necrosis (39.7%). The pooled technical success rates in studies where drainage of PFCs were performed with and without EUS guidance were 95.3% (95% confidence interval [CI], 89.6–98%; I2=0) and 93.9% (95% CI, 82.6–98%; I2=0), respectively. The pooled clinical success after one and two endoscopic interventions were 88.7% (95% CI, 82.7–92.9%; I2=0) and 92.3% (95% CI, 87.4–95.4%; I2=0), respectively. The pooled rate of major adverse events was 6.3% (95% CI, 3.3–11.4%; I2=0). The pooled rate of recurrent PFCs after endoscopic drainage was 10.4% (95% CI, 6.1–17.1%; I2=0). Conclusion: Endoscopic drainage is safe and effective in children with PFCs. However, future studies are required to compare endoscopic and EUS-guided drainage of PFCs in children.

Familial aggregation of inflammatory bowel disease in India: prevalence, risks and impact on disease behavior

Rupa Banerjee,Partha Pal,Susan Hutfless,B Girish Ganesh,D Nageshwar Reddy 대한장연구학회 2019 Intestinal Research Vol.17 No.4

Background/Aims: Information about familial aggregation of inflammatory bowel disease (IBD) in Asia is limited. We aimed to analyze the prevalence and risk of familial IBD in an Indian cohort and compare familial and sporadic cases. Methods: Familial IBD cases were identified from a large prospectively maintained IBD registry. The prevalence of IBD in first- and seconddegree relatives of index cases was evaluated. The disease behavior was compared to that of sporadic cases. Results: Total 3,553 patients (ulcerative colitis [UC], 2,053; Crohn’s disease [CD], 1,500) were included. Familial IBD was noted in 4.13% of CD and 4.34% of UC patients. Family history was commoner in pediatric group (<18 years) (P=0.0002; odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6–4.8). Majority had paternal transmission (UC, 67.42%; CD, 70.97%). Concordance of disease type was higher in UC (79.7%) compared to CD (37.1%). Familial IBD was associated with higher cumulative relapse rate (CD, P<0.001; UC, P<0.001), higher cumulative rate of surgery (CD, P<0.001; UC, P<0.001) and higher rate of biologic use (CD, P=0.010; UC, P=0.015). Pan-colitis was higher in familial UC (P=0.003; OR, 1.935; 95% CI, 1.248–3.000). Fistulizing disease was commoner in familial CD (P=0.041; OR, 2.044; 95% CI, 1.030–4.056). Conclusions: The prevalence of familial IBD in India appears comparable to rest of Asia but lower than the West. It is associated with a younger age of onset, higher incidence of pan-colitis in UC and fistulizing complications in CD. Familial IBD has higher cumulative relapse, surgery and biologic use rates. Hence, family history of IBD could have important prognostic implications.