Double Balloon Enteroscopy in a North American Setting: A Large Single Center 5-year Experience

( Gulseren Seven ),( Richard A. Kozarek ),( Andrew Ross ),( Shayan Irani ),( Michael Gluck ),( Drew Schembre ),( Johannes Koch ),( S. Ian Gan ) 대한장연구학회 2013 Intestinal Research Vol.11 No.1

Background/Aims: Double balloon enteroscopy (DBE) allows both diagnosis and therapeutic maneuvers in the small bowel. Its use was pioneered in Europe and Asia but there remains a relative paucity of literature from North America. Our aim in this study was to determine diagnostic and therapeutic yield in a North American setting. Methods: A five-year retrospective analysis of all patients undergoing DBE at a single tertiary care North American hospital was performed. Results: Four-hundred fifty-seven procedures, 265 anterograde and 192 retrograde, were performed on 335 patients. The most common indications were obscure gastrointestinal bleeding, small bowel obstruction, and suspected masses and mucosal abnormalities. Total enteroscopy was achieved in 19 of the 89 patients who had both anterograde and retrograde procedures. Overall diagnostic yield in the determination of cause of symptoms or previous imaging was 52%. The most common causes of obscure bleeding were small bowel ulcers (10%), vascular lesions (25%) and neoplasms (10%). The most common causes of small bowel obstruction were strictures, some of which underwent dilation. Other therapeutic interventions included polypectomy, retrieval of retained capsules, stent retrievals and percutaneous enteral jejunostomy tube placement. Overall complication rates were very low (0.6%) and included medication reaction (n=1), scope dysfunction (n=1) and perforation (n=1). Conclusions: DBE can be performed safely and with good diagnostic yield in a single referral center in North America. (Intest Res 2013;11:34-40)

Review : The Society for Gastrointestinal Intervention. Are We, as an Organization of Disparate Disciplines, Cooperative or Competitive?

( Richard A. Kozarek ) The Editorial Office of Gut and Liver 2010 Gut and Liver Vol.4 No.s1

Efficacy and safety of sofosbuvir-based regimens for treatment in chronic hepatitis C genotype 1 patients with moderately impaired renal function

신현필,박지애,Blaire Burman,Richard A. Kozarek,Asma Siddique 대한간학회 2017 Clinical and Molecular Hepatology(대한간학회지) Vol.23 No.4

Background/Aims: Treatment of chronic hepatitis C virus (HCV) infection in patients with chronic kidney disease (CKD) is essential. The availability of sofosbuvir (SOF) has dramatically improved overall HCV cure rates, however there is insufficient data regarding its use in patients with CKD. We evaluated SOF in patients with hepatitis C genotype 1 (G1) and moderately impaired renal function. Methods: We retrospectively reviewed all patients treated with a SOF-based regimen from December 2013 through September 2015 at Virginia Mason Medical Center. Data was then collected for HCV G1 patients with stage 3 CKD. Results: A total of 28 patients with HCV G1 and stage 3 CKD were treated with a SOF-based regimen. Twenty-one patients had stage 3A CKD (estimated glomerular filtration rate [eGFR] 45–60 mL/min/1.73m2) and 7 patients had stage 3B CKD (eGFR 30–45 mL/min/1.73m2). The overall rate of sustained virologic response (SVR) 12 weeks after completion of therapy (SVR12) was 85.7% (24/28). SVR12 in stage 3A CKD patients was 81.0% (17/21) and in stage 3B CKD patients, SVR12 was 100% (7/7). Based on the treatment regimen used, the SVR12 was 81.8% (9/11), 92.3% (12/13), and 75.0% (3/4) for SOF/ledipasvir (LDV), SOF/simeprevir (SIM), and SOF/pegylated interferon (PEG)/ribavirin (RBV), respectively. Greater than 30% reduction eGFR was observed in 4 out of 28 patients. Conclusions: SOF-based regimens resulted in high SVR12 rates in patients with moderately impaired renal function. During therapy, HCV patients with CKD should be carefully monitored for worsening renal function.

REVIEW : Impact of Sigmoidoscopy and Colonoscopy on Colorectal Cancer Incidence and Mortality: An Evidence-Based Review of Published Prospective and Retrospective Studies

( Otto S. Lin ),( Richard A. Kozarek ),( Jae Myung Cha ) 대한장연구학회 2014 Intestinal Research Vol.12 No.4

Screening for colorectal cancer (CRC) using sigmoidoscopy or colonoscopy is now common in many developed countries. This concise, evidence-based review looks at the impact of sigmoidoscopy or colonoscopy screening on CRC incidence, CRC mortality and overall mortality. Data from controlled retrospective and prospective (observational or randomized) studies have generally shown that sigmoidoscopy and colonoscopy, whether for diagnostic, screening or surveillance purposes, are associated with a significant reduction in CRC incidence and CRC mortality. The data on their impact on overall mortality is much more limited, with most studies unable to report a reduction in overall mortality. The results of three meta-analyses have confirmed these conclusions. As expected, sigmoidoscopy has a predominant effect on left-sided CRC, although some studies have shown modest effects on right-sided colon cancer as well. Most studies on colonoscopy have demonstrated that the protective effect applies to both right and left-sided cancer, although the protection seemed better on the left side. Despite the introduction of other screening and diagnostic modalities for the colon, such as computed tomography colonography and colonic capsule endoscopy, lower endoscopy will continue to be an important mode of screening for CRC and evaluating the colon. (Intest Res 2014;12:268-274)

Safe implementation of transoral incisionless fundoplication as a new technique in a tertiary care center

Shivanand Bomman,Sofya Malashanka,Adil Ghafoor,David J. Sanders,Shayan Irani,Richard A. Kozarek,Andrew Ross,Michal Hubka,Rajesh Krishnamoorthi 대한소화기내시경학회 2022 Clinical Endoscopy Vol.55 No.5

Background/Aims: Transoral incisionless fundoplication (TIF) is an accepted anatomic treatment for gastroesophageal reflux disease in selected patients. In this report, we analyze our institution’s programmatic allocation of resources during the safe implementation of TIF as a new procedure. Methods: A retrospective analysis of all patients who underwent TIF from January 2020 to February 2021 at our institution was per- formed. The process of initially allocating the operating room (OR) with overnight admission and postoperative esophagram for added safety, and subsequently transitioning TIF to the endoscopy suite (ES) as an outpatient procedure was described. Patient safety and out- comes were evaluated during transition. Results: Thirty patients who underwent TIF were identified. The mean age was 51.2±16.0 years. TIF was performed in an OR in nine patients (30%) and 21 (70%) in the ES. All the OR patients were admitted overnight and had routine esophagogram. In contrast, four (19%) from the ES group required clinically-indicated admission and three (14.2%) required esophagram. The mean procedure dura- tion was significantly lower in the ES group (65.7 min vs. 84 min, p=0.02). Conclusions: A stepwise, resource-efficient process was described that allowed safe initiation of TIF as a new technique and its effec- tive transition to a fully outpatient procedure.

Real-World Single-Center Experience with Sofosbuvir-Based Regimens for the Treatment of Chronic Hepatitis C Genotype 1 Patients

( Hyun Phil Shin ),( Blaire Burman ),( Richard A. Kozarek ),( Amy Zeigler ),( Chia Wang ),( Houghton Lee ),( Troy Zehr ),( Alicia M. Edwards ),( Asma Siddique ) 대한간학회 2017 Gut and Liver Vol.11 No.5

Background/Aims: The approval of sofosbuvir (SOF), a direct- acting antiviral, has revolutionized the treatment of chronic hepatitis C virus (HCV). Methods: We assessed the sustained virological response (SVR) of SOF-based regimens in a real- world single-center setting for the treatment of chronic HCV genotype 1 (G1) patients. This was a retrospective review of chronic HCV G1 adult patients treated with a SOF-based regi-men at Virginia Mason Medical Center between December 2013 and August 2015. Results: The cohort comprised 343 patients. Patients received SOF+ledipasvir (LDV) (n=155), SOF+simeprevir (SIM) (n=154), or SOF+peginterferon (PEG)+ribavirin (RBV) (n=34). Of the patients, 50.1% (n=172) had cirrhosis. The SVR rate was 92.2% for SOF/LDV, 87.0% for SOF/SIM, and 82.4% for SOF/PEG/RBV. Compared with the cirrhotic patients, the patients without cirrhosis had a higher SVR (96.8% vs 85.5%, p=0.01, SOF/LDV; 98.2% vs 80.6%, p=0.002, SOF/SIM; 86.4% vs 75.0%, p=0.41, SOF/ PEG/RBV). In this study, prior treatment experience adversely affected the response rate in subjects treated with SOF/ PEG/RBV. Conclusions: In this single-center, real-world set-ting, the treatment of chronic HCV G1 resulted in a high rate of SVR, especially in patients without cirrhosis. (Gut Liver 2017;11:711-720)

Contamination Rates in Duodenoscopes Reprocessed Using Enhanced Surveillance and Reprocessing Techniques: A Systematic Review and Meta-Analysis

Shivanand Bomman,Munish Ashat,Navroop Nagra,Mahendran Jayaraj,Shruti Chandra,Richard A Kozarek,Andrew Ross,Rajesh Krishnamoorthi 대한소화기내시경학회 2022 Clinical Endoscopy Vol.55 No.1

Background/Aims: Multiple outbreaks of multidrug-resistant organisms have been reported worldwide due to contaminatedduodenoscopes. In 2015, the United States Food and Drug Administration recommended the following supplemental enhancedsurveillance and reprocessing techniques (ESRT) to improve duodenoscope disinfection: (1) microbiological culture, (2) ethyleneoxide sterilization, (3) liquid chemical sterilant processing system, and (4) double high-level disinfection. A systematic review andmeta-analysis was performed to assess the impact of ESRT on the contamination rates. Methods: A thorough and systematic search was performed across several databases and conference proceedings from inceptionuntil January 2021, and all studies reporting the effectiveness of various ESRTs were identified. The pooled contamination rates ofpost-ESRT duodenoscopes were estimated using the random effects model. Results: A total of seven studies using various ESRTs were incorporated in the analysis, which included a total of 9,084 post-ESRTduodenoscope cultures. The pooled contamination rate of the post-ESRT duodenoscope was 5% (95% confidence interval [CI]:2.3%–10.8%, inconsistency index [I2]=97.97%). Pooled contamination rates for high-risk organisms were 0.8% (95% CI: 0.2%–2.7%,I2=94.96). Conclusions: While ESRT may improve the disinfection process, a post-ESRT contamination rate of 5% is not negligible. Ongoingefforts to mitigate the rate of contamination by improving disinfection techniques and innovations in duodenoscope design toimprove safety are warranted.

Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones

( Jong Jin Hyun ),( Shayan S. Irani ),( Andrew S. Ross ),( Michael C. Larsen ),( Michael Gluck ),( Richard A. Kozarek ) 대한소화기학회 2021 Gut and Liver Vol.15 No.1

Background/Aims: This study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi. Methods: A total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records. Results: Biliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8). Conclusions: Although periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase. (Gut Liver 2021;15:128-134)