Stopgap Measures for Obesity Prior to Surgery.

PURPOSE OF REVIEW: The data on preventive measures for managing obesity prior to surgery is limited. This review highlights the role of stopgap measures for managing obesity before surgery. RECENT FINDINGS: Body weight regulation to achieve sustainable weight loss is a gradual process. Regular aerobic exercises, transformative yoga and restrained eating can contribute to a calorie deficit. Behavioural strategies aim to raise awareness, set goals, manage stress, and support adherence to healthier lifestyles. Pharmacotherapy can be adjunctive in inducing weight loss but could be better at maintaining weight. Intragastric balloon and endoscopic sleeve gastroplasty are restrictive procedures for patients before surgery. Obesity is a multifaceted chronic disease with adverse health consequences. There is a need to identify contributors to weight gain and treatment should target the cause of obesity. Utilize stop-gap measures and monitor progress for step-up or more intensive treatment. Structured weight loss needs lifelong commitment.

Tips and Thought Processes to Overcome Difficult Situations in Third Space Endoscopy.

PURPOSE OF REVIEW: Third space endoscopy (TSE) offers diverse treatment options for a variety of conditions of the gastrointestinal tract and motility disorders. Accuracy and precise dissection have helped treat complex conventional surgeries with TSE. Despite over a decade of its presence, difficult situations are routinely encountered. RECENT FINDINGS: The first challenging situation is decision-making (before the procedure), the second is tackling procedure-induced pulmonary / insufflation-related adverse events and intra-operative complications (during the procedure), and the third is post-operative complications and morbidity (post-procedure). The performance of TSE procedures is not without risk. Patients should receive enough time to weigh their options, considering that attitudes toward risk impact decision-making. Continuous basic patient monitoring and the micro-movements of endoscopic and electrosurgical equipment is crucial to avoid accidental injury. Anaesthetists should be mindful of anticipated complications and closely monitor, diagnose, and treat them. Demanding situations need careful consideration, problem-solving, or persistence to overcome challenges. This brief review provides inputs on preventing and tackling difficult situations in TSE.

Oesophageal perforation by migrated Ryles tube.

A 72-year woman with a history of multiple cerebrovascular accidents presented with severe epigastric pain. An oesophageal perforation by the tip of a Ryles tube, which had migrated into the mediastinum, was diagnosed by radiography. An attempt at pushing the nasogastric tube into the stomach resulted in increasing the rupture to about 6 cm in size. Replacement by a triple-lumen nasojejunal feeding tube and subsequent feeding with c.1,400 calories per day enabled the perforation to close without further intervention.

Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy.

Background and study aims The utility of stone density at non-contrast computed tomography (NCCT) for predicting the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis (CCP) is relatively unexplored. Patients and methods This was a prospective observational study of patients with CCP. Hounsfield units (HU) were determined for the largest pancreatic ductal stone during pretreatment NCCT. All patients underwent ESWL until the largest stone was fragmented to <3mm, followed by endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The predictive factors following ESWL for successful stone extraction were studied and the receiver operating characteristic (ROC) curve determined the HU optimal cut-point. Results Eighty-two patients with a median (interquartile range) age of 36 years (range, 29-55); majority male 45 (54.9%), were included. Idiopathic CCP was noted in 78 patients (95.1%). The median stone density (SD) was 1095 HU (range, 860.7-1260.7) and the number of ESWL sessions was 2 (range, 2-3). Complete stone removal at index ERCP was achieved in 55 patients (67.1%). Those with partial clearance (n=27) needed a repeat ERCP, which was successful in 26 (96.3%); one patient (3.7%) underwent surgery. There was a significant, positive correlation between number of ESWL sessions and SD (r=0.797; P <0.001). On bivariate analysis, SD and the number of ESWL sessions revealed a significant association with complete ductal clearance. The optimal cut-point for complete stone removal by the ROC curve was 1106.5 HU (Youden index 0.726), with a sensitivity of 93% and a specificity of 80%. Conclusions The SD is a significant predictor of ESWL success followed by ductal clearance at ERCP, and <1106.5 HU is a predictor of good candidates for ESWL therapy.

Comparison of diagnostic outcomes, safety, and cost of Franseen-tip 19G versus 22G needles for endoscopic ultrasound-guided liver biopsies.

Background and study aims Favorable outcomes were noted with refinement in newer endoscopic ultrasound-guided liver biopsy (EUS-LB) needle tips. Still, the overall usefulness and benefit are yet to be well explored. Patients and methods This was a retrospective analysis of patients with EUS-LB (Franseen-tip 19G versus 22G FNB needle) over 2 years. EUS-LB was obtained in a one-pass, two-actuation, modified wet suction technique. Diagnostic yield, fragmentation rate, aggregate specimen length (AL), number of complete portal tracts (CPT), length of longest intact core (LIC), adverse events (AEs) (early), and cost of the procedure (1USD = 82 INR) were compared. Results Fifty-four patients (33 [61.1%], female) successfully underwent EUS-LB with a median age of 46 years (interquartile range [IQR] 34-54); the majority 32 (59.2%) underwent 19G biopsies. There was a significantly increased median (IQR) AL in the 19G compared with 22G (20 mm [19-21] vs. 15 [14-15], P < 0.001), respectively. Similarly, significantly lengthier median LIC and CPT were seen, respectively. A nonsignificant diagnostic yield was noted (100% vs. 90.9%, P = 0.082), respectively. The fragmentation rate was higher in 22G FNB needles (36.4% [95% CI 16-56] vs. 12.5% [95% CI 1-24], respectively; P = 0.038). Seven patients (12.9%) had mild AEs with no difference between groups. The average procedure cost with 19G was INR 63000 (768$), and with 22G needle was INR 54500 (664$). Conclusions The Franseen-tip 19G outperforms 22G with a significantly lower fragmentation rate, longer AL, LIC, and a higher number of CPT with a marginal increase in the procedure cost, without any difference in diagnostic yield and safety.

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux after peroral endoscopic myotomy: a randomized sham-controlled study.

BACKGROUND : Endoscopic full-thickness plication (EFTP) has shown promising results in gastroesophageal reflux disease (GERD), but its efficacy in GERD after peroral endoscopic myotomy (POEM) is unclear. METHODS : In a prospective, randomized trial of post-POEM patients dependent on proton pump inhibitors (PPIs) for documented GERD, patients underwent EFTP (plication to remodel the gastroesophageal flap valve) or an endoscopic sham procedure (positioning of the EFTP device, but no stapling). The primary end point was improvement in acid exposure time (AET) < 6 % (3 months). Secondary end points included improvement in esophagitis (3 months), GERD Questionnaire (GERDQ) score (3 and 6 months), and PPI usage (6 months). RESULTS : 60 patients were randomized (30 in each group). At 3 months, a significantly higher proportion of patients achieved improvement in AET < 6 % in the EFTP group compared with the sham group (69.0 % [95 %CI 52.1-85.8] vs. 10.3 % [95 %CI 0-21.4], respectively). EFTP was statistically superior to sham (within-group analysis) in improving esophageal AET, DeMeester Score, and all reflux episodes (P < 0.001). A nonsignificant improvement in esophagitis was noted in the EFTP group (P = 0.14). Median GERDQ scores (3 months) were significantly better (P < 0.001) in the EFTP group, and the same trend continued at 6 months. A higher proportion of patients in the sham group continued to use PPIs (72.4 % [95 %CI 56.1-88.7] vs. 27.6 % [95 %CI 11.3-43.8]). There were no major adverse events in either group. CONCLUSION : EFTP improved post-POEM GERD symptoms, 24-hour pH impedance findings with normalization in one-third, and reduced PPI usage at 6 months.

A rare case of intraductal tubulopapillary neoplasm of the pancreas - case report (with video).

Intraductal tubulopapillary neoplasm (ITPN) is a premalignant epithelial tumor of the pancreas. We report a case of ITPN detected incidentally during histopathology examination (HPE) from a specimen taken at the time of endosonography in a patient with pancreatitis. A 53-year-old man presented with severe recurrent epigastric pain, associated with episodic nonbilious vomiting, with a weight loss of about 7 Kg since 15 days. He underwent Magnetic resonance cholangiopancreatography which showed an ovoid soft tissue lesion in the Pancreatic duct (PD) reported as possible intraductal neoplasm. Patient underwent Endoscopic Ultrasound, whereby the PD was dilated and a large hypoechoic lesion was noted in the PD (head region) causing upstream dilatation. Lesion did not show any vascularity on Doppler. Fine needle biopsy was sent from the intraductal lesion for histopathology examination (HPE). Patient then underwent an ERCP. After performing a pancreatic sphincterotomy, pancreaticoscopy was done using SPYGLASS DS system which showed a nodular intraluminal lesion in the head region with irregular and abnormal vascularity and papillary fronds. Biopsies were taken from this lesion using SpyBite biopsy forceps. To our surprise this HPE report came out to be ITPN. Patient was then referred for surgery. There is often a difference of opinion in distinguishing and classifying such tumors when compared to the subtypes of mucinous neoplasm. Identification of this neoplasm is often challenging for pathologists as well as radiologists. We present this case since it is infrequent and atypical in routine medical practice.