Training in Bariatric and Metabolic Endoscopic Therapies

Pichamol Jirapinyo,Christopher C. Thompson 대한소화기내시경학회 2018 Clinical Endoscopy Vol.51 No.5

Bariatric endoscopy is an emerging subspecialty for gastroenterologists encompassing a broad array of procedures including primaryendoscopic bariatric and metabolic therapies and the treatment of complications of bariatric surgery. In addition, comprehensiveunderstanding of lifestyle intervention and pharmacotherapy are essential to successful outcomes. This review summarizes goals andsteps of training for this emerging field.

Validation of a Novel Endoscopic Retrograde Cholangiopancreatography Cannulation Simulator

Pichamol Jirapinyo,Andrew C. Thompson,Hiroyuki Aihara,Marvin Ryou,Christopher C. Thompson 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.3

Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) requires a unique skill set. Currently, there is noobjective methodology to assess and train a professional to perform ERCP. This study aimed to develop and validate a novel ERCPsimulator. Methods: The simulator consists of papillae presenting different anatomy and positioned in varied locations. Deep cannulation of thepancreatic duct, followed by the bile duct, was performed. The time allotted was 5 minutes. The content validity indexes (CVIs) forrealism, relevance, and representativeness were calculated. Correlation between ERCP experience and simulator score was determined. Results: Twenty-three participants completed the simulation. The CVIs for realism were orientation of duodenoscope to papilla (1.00),angulation of papillotome to achieve cannulation (0.71), and haptic feedback during cannulation (0.80). The CVIs for relevance wereuse of elevator (1.00), wheels to achieve en face orientation (1.00), and papillotome for selective cannulation (1.00). Regarding CVI forrepresentativeness, the results were as follows: basic cannulation (0.83), papilla locations (0.83), and papilla anatomies (0.80). The novice,intermediate, and experienced groups scored 6.7±8.7, 30.0±16.3, and 74.4±43.9, respectively (p<0.0001). There was a strong correlationbetween the ERCP experience level and the individual’s simulator score (Pearson value of 0.77, R2 of 0.60). Conclusions: This simulator appears to be realistic, relevant, and representative of ERCP cannulation techniques. Additionally, it iseffective at objectively assessing basic ERCP skills by differentiating scores based on clinical experience.

Effect of Aspiration Therapy on Obesity-Related Comorbidities: Systematic Review and Meta-Analysis

Pichamol Jirapinyo,Diogo T. H. de Moura,Laura C. Horton,Christopher C. Thompson 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.6

Background/Aims: Aspiration therapy (AT) involves endoscopic placement of a gastrostomy tube with an external device that allows patients to drain 30% of ingested calories after meals. Its efficacy for inducing weight loss has been shown. This study aimed to assess the effect of AT on obesity-related comorbidities. Methods: A meta-analysis of studies that assessed AT outcomes was conducted through December 2018. Primary outcomes were changes in comorbidities at 1 year following AT. Secondary outcomes were the amount of weight loss at up to 4 years and pooled serious adverse events (SAEs). Results: Five studies with 590 patients were included. At 1 year, there were improvements in metabolic conditions: mean difference (MD) in systolic blood pressure: -7.8 (-10.7 – -4.9) mm Hg; MD in diastolic blood pressure: -5.1 (-7.0 – 3.2) mm Hg; MD in triglycerides: -15.8 (-24.0 – -7.6) mg/dL; MD in high-density lipoprotein: 3.6 (0.7–6.6) mg/dL; MD in hemoglobin A1c (HbA1c): -1.3 (-1.8 – -0.8) %; MD in aspartate transaminase: -2.7 (-4.1 – -1.3) U/L; MD in alanine transaminase: -7.5 (-9.8 – -5.2) U/L. At 1 (n=218), 2 (n=125), 3 (n=46), and 4 (n=27) years, the patients experienced 17.8%, 18.3%, 19.1%, and 18.6% total weight loss (TWL), corresponding to 46.3%, 46.2%, 48.0%, and 48.7% excess weight loss (EWL) (p<0.0001 for all). Subgroup analysis of 2 randomized controlled trials (n=225) showed that AT patients lost more weight than did controls by 11.6 (6.5–16.7) %TWL and 25.6 (16.0–35.3) %EWL and experienced greater improvement in HbA1c and alanine transaminase by 1.3 (0.8–1.8) % and 9.0 (3.9–14.0) U/L. The pooled SAE rate was 4.1%. Conclusions: Obesity-related comorbidities significantly improved at 1 year following AT. Additionally, a subgroup of patients who continued to use AT appeared to experience significant weight loss that persisted up to at least 4 years.

Endoscopic Ultrasound-Guided Pancreatobiliary Endoscopy in Surgically Altered Anatomy

Pichamol Jirapinyo,Linda S. Lee 대한소화기내시경학회 2016 Clinical Endoscopy Vol.49 No.6

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of therapy for pancreatobiliary diseases. WhileERCP is safe and highly effective in the general population, the procedure remains challenging or impossible in patients with surgicallyaltered anatomy (SAA). Endoscopic ultrasound (EUS) allows transmural access to the bile or pancreatic duct (PD) prior to ductaldrainage using ERCP-based techniques. Also known as endosonography-guided cholangiopancreatography (ESCP), the procedureprovides multiple advantages over overtube-assisted enteroscopy ERCP or percutaneous or surgical approaches. However, the procedureshould only be performed by endoscopists experienced in both EUS and ERCP and with the proper tools. In this review, variousEUS-guided diagnostic and therapeutic drainage techniques in patients with SAA are examined. Detailed step-by-step proceduraldescriptions, technical tips, feasibility, and safety data are also discussed.

Role of Cardiac Septal Occluders in the Treatment of Gastrointestinal Fistulas: A Systematic Review

Diogo Turiani Hourneaux De Moura,Alberto Baptista,Pichamol Jirapinyo,Eduardo Guimarães Hourneaux De Moura,Christopher Thompson 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.1

Treating gastrointestinal (GI) fistulas endoscopically is challenging owing to an established epithelial tract. The variety of endoscopicapproaches is transforming endoscopy into a first-line therapy. However, many sessions are often required, with variable success rates. Owing to these limitations, the off-label use of cardiac septal occluders (CSOs) has been reported. We searched for articles related to CSOs in the MEDLINE, EMBASE, Cochrane Library, and LILACS databases and gray literature. Theprimary outcomes included technical success, clinical success, and safety of CSOs in GI fistula management. A total of 25,574 records were identified, and 19 studies ultimately satisfied the inclusion criteria. Technical success was achieved inall cases. Of the 22 fistulas, 77.27% had successful closure, with a mean follow-up period of 32.02 weeks. The adverse event rate was22.72%, with no associated mortality. Univariable and multivariable regression analyses showed no significant difference in the successof closure and adverse events in relation to several variables among the subgroups. The use of CSOs appeared to be technically feasible, effective, and safe in the treatment of GI fistulas. The satisfactory results derived fromthis sparse literature suggest that it can be an option in the management of GI fistulas.

Endoscopic Ultrasound Fine-Needle Aspiration versus Fine-Needle Biopsy for Lymph Node Diagnosis: A Large Multicenter Comparative Analysis

Diogo Turiani Hourneaux de Moura,Thomas R. McCarty,Pichamol Jirapinyo,Igor Braga Ribeiro,Galileu Ferreira Ayala Farias,Marvin Ryou,Linda S. Lee,Christopher C. Thompson 대한소화기내시경학회 2020 Clinical Endoscopy Vol.53 No.5

Background/Aims: Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is preferred for sampling of lymph nodes (LNs) adjacentto the gastrointestinal wall; however, fine-needle biopsy (FNB) may provide improved diagnostic outcomes. This study aimed toevaluate the comparative effcacy and safety of FNA versus FNB for LN sampling. Methods: This was a multicenter retrospective study of prospectively collected data to evaluate outcomes of EUS-FNA and EUS-FNBfor LN sampling. Characteristics analyzed included sensitivity, specificity, accuracy, the number of needle passes, diagnostic adequacyof rapid on-site evaluation (ROSE), cell-block analysis, and adverse events. Results: A total of 209 patients underwent EUS-guided LN sampling. The mean lesion size was 16.22±8.03 mm, with similar sensitivityand accuracy between FNA and FNB ([67.21% vs. 75.00%, respectively, p=0.216] and [78.80% vs. 83.17%, respectively, p=0.423]). Thespecificity of FNB was better than that of FNA (100.00% vs. 93.62%, p=0.01). The number of passes required for diagnosis was notdifferent. Abdominal and peri-hepatic LN location demonstrated FNB to have a higher sensitivity (81.08% vs. 64.71%, p=0.031 and80.95% vs. 58.33%, p=0.023) and accuracy (88.14% vs. 75.29%, p=0.053 and 88.89% vs. 70.49%, p=0.038), respectively. ROSE was asignificant predictor for accuracy (odds ratio, 5.16; 95% confidence interval, 1.15–23.08; p=0.032). No adverse events were reported ineither cohort. Conclusions: Both EUS-FNA and EUS-FNB are safe for the diagnosis of LNs. EUS-FNB is preferred for abdominal LN sampling. EUS-FNA+ROSE was similar to EUS-FNB alone, showing better diagnosis for EUS-FNB than traditional FNA. While ROSE remained asignificant predictor for accuracy, due to its poor availability in most centers, its use may be limited to cases with previous inconclusivediagnoses.