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.

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)

Advanced Therapeutic Gastrointestinal Endoscopy in Children – Today and Tomorrow

Zaheer Nabi,Duvvur Nageshwar Reddy 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.2

Gastrointestinal (GI) endoscopy plays an indispensable role in the diagnosis and management of various pediatric GI disorders. Whilethe pace of development of pediatric GI endoscopy has increased over the years, it remains sluggish compared to the advancements inGI endoscopic interventions available in adults. The predominant reasons that explain this observation include lack of formal trainingcourses in advanced pediatric GI interventions, economic constraints in establishing a pediatric endoscopy unit, and unavailability ofpediatric-specific devices and accessories. However, the situation is changing and more pediatric GI specialists are now performingcomplex GI procedures such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography for variouspancreatico-biliary diseases and more recently, per-oral endoscopic myotomy for achalasia cardia. Endoscopic procedures are associatedwith reduced morbidity and mortality compared to open surgery for GI disorders. Notable examples include chronic pancreatitis,pancreatic fluid collections, various biliary diseases, and achalasia cardia for which previously open surgery was the treatment modalityof choice. A solid body of evidence supports the safety and efficacy of endoscopic management in adults. However, additions continueto be made to literature describing the pediatric population. An important consideration in children includes size of children, which inturn determines the selection of endoscopes and type of sedation that can be used for the procedure.

Endoscopic management of Zenker’s diverticulum

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.2

Zenker’s diverticulum (ZD) is a rare condition that predominantly effects elderly population. Dysphagia and regurgitation are the common presenting symptoms in patients with ZD. Flexible endoscopic diverticulotomy (FED) of the cricopharyngeal septum is the mainstay of management in symptomatic ZD. The outcomes of FED compare favorably to open surgical and trans-oral rigid endoscopic treatment methods. Moreover, FED is associated with relatively fewer morbidities as compared to surgery. Bleeding and micro-perforation are the most commonly reported immediate adverse events. Majority of the adverse events are mild and severe adverse events are rare with FED. Recurrence of symptoms remain the most important long-term concern after FED. Nevertheless, majority of the recurrences respond to a repeat session of endoscopic treatment. Lately, new electrosurgical knives and novel endoscopic techniques of cricopharyngeal myotomy have been evaluated for the treatment of ZD. Novel techniques include double incision with snare resection and submucosal tunneling endoscopic septum division. The proposed advantage with these techniques is possible reduced incidence of recurrences after endoscopic treatment. Randomized comparison studies are required between new and conventional flexible endoscopic techniques. In addition, standardized reporting of clinical success, and adverse events is required in future studies.

Non-achalasia esophageal motility disorders: Role of per-oral endoscopic myotomy

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.2

Major disorders of esophageal peristalsis other than achalasia include Jackhammer esophagus (JHE), distal esophageal spasm (DES), and esophagogastric junction outflow obstruction (EGJOO). These disorders are rare, distinct from achalasia and characterized by high resolution manometry. Unlike achalasia, the treatment strategies are not well defined in these disorders. Therapies directed at lower esophageal sphincter may be inadequate in JHE and DES as a variable length of esophageal body is also involved in symptom generation. On the other hand, EGJOO is a more heterogenous group and the decision for endoscopic treatment is based on comprehensive evaluation of the underlying etiology. A subset of patients with EGJOO without significant stasis may improve on conservative treatment. Per-oral endoscopic myotomy (POEM) is a newer endoscopic treatment modality that has established its role in the management of achalasia. Limited studies suggest the efficacy of POEM in non-achalasia esophageal motility disorders as well. The ability to perform long esophageal myotomies with POEM makes it an attractive management tool for these patients.

Comparison of Short Versus Long Esophageal Myotomy in Cases With Idiopathic Achalasia: A Randomized Controlled Trial

( Zaheer Nabi ),( Mohan Ramchandani ),( Mahiboob Sayyed ),( Radhika Chavan ),( Santosh Darisetty ),( Rajesh Goud ),( H V V Murthy ),( D Nageshwar Reddy ) 대한소화기기능성질환·운동학회(구 대한소화관운동학회) 2021 Journal of Neurogastroenterology and Motility (JNM Vol.27 No.1

Background/Aims Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia. The technique of POEM is still evolving and the impact of length of esophageal myotomy on the outcomes of POEM is not known. In this study, we aim to compare the outcomes of short (3 cm) versus long (6 cm and above) esophageal myotomy in patients undergoing POEM for achalasia cardia. Methods Consecutive patients with idiopathic achalasia (type I and II) were randomized to receive short (3 cm) or long esophageal myotomy (≥ 6 cm). Both groups were compared for clinical success, operative time, adverse events, and gastroesophageal reflux disease (GERD). Results Seventy-one consecutive patients with type I and II achalasia underwent POEM with short (n = 34) or long (n = 37) esophageal myotomy techniques. Mean length of esophageal myotomy in short and long groups was 2.76 ± 0.41 and 7.97 ± 2.40, respectively (P < 0.001). Mean operative time was significantly shorter in short myotomy group (44.03 ± 13.78 minutes and 72.43 ± 27.28 minutes, P < 0.001). Clinical success was comparable in both arms at 1-year (Eckardt score 0.935 ± 0.929 vs 0.818 ± 0.983, P = 0.627). Improvement in objective parameters including integrated relaxation pressure and barium column height at 5 minutes was similar in both groups. GERD was detected in 50.88% patients with no significant difference in short and long myotomy groups (44.44% vs 56.67%, P = 0.431). Conclusions A short esophageal myotomy is non-inferior to long myotomy with regards to clinical success, adverse events, and GERD in cases with type I and II achalasia. Reduced operating duration favors short esophageal myotomy in these patients. (J Neurogastroenterol Motil 2021;27:63-70)

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.

Endoscopic management of Zenker’s diverticulum

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.2

Zenker’s diverticulum (ZD) is a rare condition that predominantly effects elderly population. Dysphagia and regurgitation are the common presenting symptoms in patients with ZD. Flexible endoscopic diverticulotomy (FED) of the cricopharyngeal septum is the mainstay of management in symptomatic ZD. The outcomes of FED compare favorably to open surgical and trans-oral rigid endoscopic treatment methods. Moreover, FED is associated with relatively fewer morbidities as compared to surgery. Bleeding and micro-perforation are the most commonly reported immediate adverse events. Majority of the adverse events are mild and severe adverse events are rare with FED. Recurrence of symptoms remain the most important long-term concern after FED. Nevertheless, majority of the recurrences respond to a repeat session of endoscopic treatment. Lately, new electrosurgical knives and novel endoscopic techniques of cricopharyngeal myotomy have been evaluated for the treatment of ZD. Novel techniques include double incision with snare resection and submucosal tunneling endoscopic septum division. The proposed advantage with these techniques is possible reduced incidence of recurrences after endoscopic treatment. Randomized comparison studies are required between new and conventional flexible endoscopic techniques. In addition, standardized reporting of clinical success, and adverse events is required in future studies.

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.

Non-achalasia esophageal motility disorders: Role of per-oral endoscopic myotomy

Zaheer Nabi,Duvuur Nageshwar Reddy 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.2

Major disorders of esophageal peristalsis other than achalasia include Jackhammer esophagus (JHE), distal esophageal spasm (DES), and esophagogastric junction outflow obstruction (EGJOO). These disorders are rare, distinct from achalasia and characterized by high resolution manometry. Unlike achalasia, the treatment strategies are not well defined in these disorders. Therapies directed at lower esophageal sphincter may be inadequate in JHE and DES as a variable length of esophageal body is also involved in symptom generation. On the other hand, EGJOO is a more heterogenous group and the decision for endoscopic treatment is based on comprehensive evaluation of the underlying etiology. A subset of patients with EGJOO without significant stasis may improve on conservative treatment. Per-oral endoscopic myotomy (POEM) is a newer endoscopic treatment modality that has established its role in the management of achalasia. Limited studies suggest the efficacy of POEM in non-achalasia esophageal motility disorders as well. The ability to perform long esophageal myotomies with POEM makes it an attractive management tool for these patients.