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.

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.

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 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 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.

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

Submucosal endoscopy: the present and future

Zaheer Nabi,Duvvur Nageshwar Reddy 대한소화기내시경학회 2023 Clinical Endoscopy Vol.56 No.1

Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinaltract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosalspace has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomyin patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resectsubepithelial tumors and to manage refractory gastroparesis and Zenker’s diverticulum. While the utility of submucosal endoscopyhas stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditionssuch as Zenker’s diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophagealepiphrenic diverticulum, Hirschsprung’s disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors tonovel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This reviewfocuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.

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.