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.

SECONDARY SALVAGE INTRAVENOUS CHEMOTHERAPY FOR REFRACTORY/RECURRENT RETINOBLASTOMA: A Study of 41 Eyes.

PURPOSE: To determine the efficacy of secondary salvage intravenous chemotherapy (IVC) for refractory/recurrent retinoblastoma. METHODS: Retrospective, nonrandomized interventional case series of 41 eyes of 33 patients with recurrent retinoblastoma. RESULTS: Of the 33 patients, mean age at the time of commencement of salvage IVC was 5 years (median, 5 years; range, 2-8 years). At presentation, recurrent retinoblastoma in 41 eyes of 33 patients was classified by the International Classification of Retinoblastoma as Group B (n = 7; 17%), Group C (n = 3; 7%), Group D (n = 16; 39%), and Group E (n = 15; 37%). All patients received 6 cycles of IVC as primary treatment. The indication for secondary salvage IVC with focal treatment included recurrent solid tumor (n = 36; 88%), subretinal seeds (n = 22; 54%), or persistent solid tumor (n = 2; 5%). Mean number of cycles of salvage IVC were 8 (median, 6; range, 6-18). Over a mean follow-up period of 43 months (median, 43 months; range, 12-96 months) after completion of salvage IVC, globe salvage was achieved in 22 (54%) eyes, 1 (3%) patient had histopathology-proven bone metastasis, and 1 (3%) patient died because of presumed metastasis. CONCLUSION: Secondary salvage IVC with appropriate focal treatment allows globe salvage in 54% eyes with refractory/recurrent retinoblastoma and thus serves as an alternative to intraarterial chemotherapy or enucleation.

Design of quetiapine fumarate loaded polyethylene glycol decorated graphene oxide nanosheets: Invitro-exvivo characterization.

Quetiapine Fumarate (QF) is an atypical antipsychotic with poor oral bioavailability (9%) due to its low permeability and pH-dependent solubility. Therefore, this study aims to design QF-loaded polyethylene glycol (PEG) functionalized graphene oxide nanosheets (GON) for nasal delivery of QF. In brief, GO was synthesized using a modified Hummers process, followed by ultra-sonication to produce GON. Subsequently, PEG-functionalized GON was prepared using carbodiimide chemistry (PEG-GON). QF was then decorated onto the cage of PEG-GON using the π-π stacking phenomenon (QF@PEG-GON). The QF@PEG-GON nanocomposite underwent several spectral characterizations, in vitro drug release, mucoadhesion study, ex vivo diffusion study, etc. The surface morphology of QF@PEG-GON nanocomposite validates the cracked nature of the nanocomposite, whereas the diffractograms and thermogram of nanocomposite confirm the conversion of QF into an amorphous form with uniform distribution in PEG-GON. Moreover, an ex vivo study of PEG-GON demonstrates superior mucoadhesion capacity due to its surface functional groups and hydrophilicity. The percent drug loading content and percent entrapment efficiency of the nanocomposite were found to be 9.2±0.62% and 92.3±1.02%, respectively. The developed nanocomposite exhibited 43.82±1.65% drug release within 24h, with the Korsemeyer-Peppas model providing the best-fit release kinetics (R2: 0.8614). Here, the interlayer spacing of PEG-GON prevented prompt diffusion of the buffer, leading to a delayed release pattern. In conclusion, the anticipated QF@PEG-GON nanocomposite shows promise as a nanocarrier platform for nasal delivery of QF.

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.

Advances in the Management of Pain in Chronic Pancreatitis.

PURPOSE OF REVIEW: The data on recent advances in managing chronic pancreatitis (CP) pain is limited. This review highlights the role of endotherapy and the advances in the overall management of pain in CP. RECENT FINDINGS: Of late, pancreatic biodegradable stents have been used in endotherapy with appreciable success. These include slow, medium, and fast degrading stents, which optimize the overall management of CP and could prevent the need for multiple procedures. Endoscopic ultrasound-guided celiac plexus block is reserved in selected patients to treat debilitating pain. Total pancreatectomy with islet autotransplantation in small duct disease has shown promising results. The indications for treating pain in CP with endoscopy and surgery need to be better defined. The complexity of pain control due to the incomplete understanding of pathomorphology makes the management of CP challenging. The current treatment methods are still evolving. Therapy aims to reduce pain, optimize recovery, maintain quality of life, and meet postoperative needs. Initial management includes lifestyle modification, nutrition optimization, risk factor reduction with abstinence from alcohol, cessation of tobacco and smoking. Supportive medical management involves the judicial use of analgesics, neuromodulators, antioxidants, pancreatic enzyme replacement for insufficiency, and diabetes management. Patients with intractable pain are ideal for therapeutic intervention. Being less invasive with an acceptable complication rate makes endotherapy the preferred first-line treatment. If found to be cost-effective, biodegradable stents can reduce the overall cost. Unfortunately, if patients remain symptomatic, surgery is preferred in case of failure or recurrence. For optimal results, appropriate patient selection is vital to maximizing outcomes.

Early outcomes of peroral endoscopic myotomy with fundoplication for achalasia cardia - Is it here to stay?

BACKGROUND: Peroral endoscopic myotomy with fundoplication (POEM-F) has garnered widespread attention since it tries to achieve an appropriate antireflux procedure during the same setting. The outcomes of POEM-F are currently unexplored. METHODS: Patients who underwent POEM-F at our center were retrospectively studied to assess its safety and early outcomes. RESULTS: Twenty patients [70% male; median age 32 years (range 25-41)], with a median symptom duration of 2.1 years (range 1.5-3.7) with achalasia were included. POEM-F procedure was completed in a median of 118 min (range 90-160), with 17/20 (85%) technical success. The median hospitalization was 4 days (range 2-7). Capnothorax (n = 3), resolved spontaneously (n = 2) in 4-6 h, while in one patient (n = 1) the endoscope inadvertently entered into the thoracic cavity for which prophylactic intercostal drain was required. Capnoperitoneum was seen in 17/17 (100%) patients who underwent fundoplication, subcutaneous emphysema in 8/17 (47%) patients. At 1-month follow-up endoscopy, 5/17 (29.4%) patients had loosening of the fundal wrap, 3/17 (17.6%) patients had ulceration in fundus and in gastroesophageal junction due to underlying hemoclips. At 3 months, loosening of the fundal wrap was seen in 7/17 (41.2%) patients. A 24-h pH-metry revealed abnormal esophageal acid exposure in 7/17 (41.2%) patients, while it was normal in those patients in whom the fundal wrap was maintained. 10/17 (58.8%) patients were off proton pump inhibitors. CONCLUSION: POEM-F is technically feasible with reasonable short term success. However, the durability, early success and safety of POEM-F need reassessment in long-term studies before being applied in clinical practice.

Six-year retrospective analysis of endoscopic ultrasonography-guided pancreatic ductal interventions at a tertiary referral center.

BACKGROUND AND AIM: Endoscopic ultrasonography-guided pancreatic ductal intervention (EUS-PDI) serves as a rescue therapy in patients with failure of retrograde access to the pancreatic duct (PD) at the time of endoscopic retrograde pancreatography (ERP). We review our experience of this procedure. METHODS: This is a retrospective study of patients who underwent EUS-PDI for an unsuccessful ERP and altered anatomy. RESULTS: A total of 44 (65.9% male) patients underwent EUS-PDI with a mean age of 43.5 years, (range: 23-67). Transgastric rendezvous technique was carried out in 23/44 (52.3%), transgastric pancreaticogastrostomy in 18/44 (40.9%) and transduodenal pancreaticobulbostomy in 3/44 (6.8%). Overall technical and clinical success was seen in 88.6% (39/44) and 81.8% (36/44), respectively. Technical success of transgastric rendezvous was 95.6% and that of transgastric pancreaticogastrostomy was 77.8%. Two of seven patients with failure to access the PD had successfully undergone EUS-PD stenting at subsequent attempt. Ten immediate adverse events (AE) were noted which included abdominal pain (n = 4), pancreatitis (n = 2), fever (n = 2), minor bleeding (n = 1), and stripping of wire (n = 1). Delayed AE included stent blockage in 12/39 (30.8%) and spontaneous stent migration in 5/39 (12.8%) which were managed with stent exchange at follow up. The rendezvous technique was associated with fewer AE than transgastric pancreaticogastrostomy. CONCLUSIONS: Endoscopic ultrasonography-PDI is an effective treatment modality and salvage therapy in patients with unsuccessful ERP. Technical and clinical success seen with this study is comparable to studies conducted across the world. EUS-PDI needs to show cost-effectiveness in future studies.

Feasibility and outcomes of anti-reflux mucosectomy for proton pump inhibitor dependent gastroesophageal reflux disease: First Indian study (with video).

BACKGROUND: Anti-reflux mucosectomy (ARMS) is a newfangled minimally invasive technique, with successful outcomes for the management of gastroesophageal reflux (GER). We present our initial experience (success rate) and safety profile for this procedure. METHODS: Consecutive patients with daily dependence on proton pump inhibitor (PPI) for GER were prospectively enrolled from September 2016 to August 2019 and underwent ARMS using a cap assisted endoscopic mucosal resection. Severity was assessed by gastroesophageal reflux disease questionnaire. Gastroscopy and 24-h pH-metry was done pre and post procedure. Patient characteristics, PPI requirement, adverse events and follow-up were documented. RESULTS: Sixty-two patients [44 (71%) male] underwent successful ARMS with a mean age (SD) of 36 (9.9) years. Technical success was achieved in 100 % of patients. Intraoperative bleeding was noted in 62 (100%) patients, endoscopic hemostasis was successfully achieved. At follow-up dysphagia was seen in 5 (8%) patients which needed a single session of endoscopic dilation. At 2 months, mean (SD) DeMeester score normalized in 45 (72.5%) patients from 76.8 (18.3) to 14.3 (6.1) (P < 0.001). PPI could be stopped in 43 (69.4%) patients. The mean (SD) GERD-Q score reduced from 10.6 (1.9) to 3.4 (1.5) (P < 0.001). However, in 12 (19.3%) patients low dose of PPIs was continued, while 7 (11.3%) patients continued full dose. Thirty-eight (61.3%) patients telephonically reported symptomatic improvement and were off PPIs at 12 months. CONCLUSIONS: Anti-reflux mucosectomy is safe and effective for treatment of GER. The long term outcomes are favorable, response is durable and promising at our center. Appropriate patient selection still remains primal to the overall success of ARMS.

An Indian Experience of Endoscopic Treatment of Obesity by Using a Novel Technique of Endoscopic Sleeve Gastroplasty (Accordion Procedure).

INTRODUCTION: Endoscopic Sleeve gastroplasty (ESG) is a novel minimally invasive endoscopic restrictive bariatric procedure. We studied the safety, effectiveness, 6-month weight loss outcomes of ESG. METHODS: We prospectively collected data for patients undergoing ESG at a tertiary care referral center. Laboratory investigations were performed preoperatively, and at 6 months post-operatively. Anthropometric measurements were noted pre and post-operatively at a frequency of 3 months for a 6-month follow-up. Patients with BMI ≥28 kg/m2 who were ready for multidisciplinary follow up for at least 6 months were part of the study. Weight was evaluated at 1, 3 and 6 months' post procedure, and percent of total weight loss (%TWL) and percent of extra weight loss (% EWL) was calculated. Adverse events and new-onset symptoms were recorded. RESULTS: This prospective study included 58 patients, [55(94.8%)females] who underwent ESG (Jun 2018 - July 2019) using the Over Stitch device (Apollo Endosurgery, Inc., Austin, Texas, US). Mean age was 42.1 years (range 23-53) and mean BMI (kg/m2) was 37.88 (range 28.4-42.9). A median of 5 plications (range 4-6) were used to provide a tubular restriction to the gastric cavity. Mean procedural time (min) was 55 (Range 45 - 86). The mean (±SD) weight reduced significantly from baseline of 98.3±20.4 to 81.8±19.1 at 6 months (p<0.001). The mean BMI reduced significantly from baseline of 37.88±5.76 to 31.37±5.23 at 6months (p<0.001). The mean % of TWL was 8.8 (5.6-16.1), 12.6(10.4-19.1) and 17.1 (11.2-24.1) at 1, 3 and 6 months respectively. The % of EWL was 21.3(12.3-34.3), 30.5(17.7-45.6) and 42.8 (24.5-61.9) at 1, 3 and 6 months respectively. No major complications developed, and patients were discharged on postoperative day 2 (+4 days). Nausea 29 (50%) and moderate to severe abdominal pain 14 (24.1%) were the most common adverse events, treated conservatively. Stitch loosening was noted in 1(1.7%) patient at third month who underwent resuturing. CONCLUSIONS: ESG appears safe and effective in treating obesity at our center. Mindfulness to reduction in %TWL, %EWL and BMI are critical in evaluating the initial success of ESG. Long term follow-up is required to assess for its sustained effect. Further research into dietary and behavioral modifications with ESG is warranted.

Operative technical tricks and 12-month outcomes of diverticular peroral endoscopic myotomy (D-POEM) in patients with symptomatic esophageal diverticula.

BACKGROUND: Submucosal tunneling diverticular septotomy by diverticular peroral endoscopic myotomy (D-POEM) has emerged as an alternative to surgery for symptomatic esophageal diverticula, but its medium to long-term outcomes are currently unexplored. METHODS: D-POEM for patients with symptomatic esophageal diverticula was prospectively studied to assess its safety and the 12-month outcomes. RESULTS: 25 patients (72 % male; median age 61 years [range 48 - 88]) with a Zenker's diverticulum (n = 20) or epiphrenic diverticulum (n = 5) were included. Major indications were dysphagia, recurrent bronchoaspiration, and foreign body sensation in 20 patients (80 %), with a mean symptom duration of 2.5 years (range 1 - : 4). Complete submucosal tunneling septotomy was achieved in a mean of 36 minutes (range 25 - : 45), with 100 % technical success. The median hospitalization was 5 days (range 4 - : 10). The mean (standard deviation) Eckardt Score improved significantly from 13.2 (1.0) at baseline to 3.2 (1.4) at 12 months (P < 0.001) with clinical success in 19/22 patients (86 %) and no long-term adverse events. CONCLUSIONS: D-POEM appears safe and durable in patients with esophageal diverticula. Further multicenter studies with a larger patient cohort are warranted.

Antireflux mucosectomy for managing reflux symptoms in an obese patient post laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment modality for obesity. Commonest delayed complication post LSG is gastroesophageal reflux disease (GER). The prevalence of GER among obese patients is higher than normal individuals. Such patients need long term Proton pump inhibitors (PPI) or antireflux procedures to manage reflux. Antireflux mucosectomy (ARMS) uses techniques of endoscopic mucosal resection to treat reflux for PPI refractory GER. However, it can be technically challenging to perform ARMS with a restricted stomach in patients who have undergone LSG. A 40-year-old female, hypertensive who had previously undergone LSG was treated for GER by a multidimensional approach with ARMS utilizing hypotensive anesthesia. The patient underwent the procedure successfully without any complication. She was discharged and at follow up visit, her reflux symptoms had improved and endoscopy was unremarkable. We describe this unusual case which was treated effectively with ARMS.

Plummer-Vinson Syndrome with Simultaneous Mid-esophageal Growth.

Patterson Brown Kelly or Plummer-Vinson syndrome is characterized by dysphagia, iron deficiency anemia and post-cricoidal esophageal web. Waldenstorm introduced the term 'sideropenic dysphagia' because of absence of stainable iron in the bone marrow. There is increased incidence of upper aero-digestive tract carcinoma in patients with Plummer-Vinson syndrome has been well established. The reported rates range from 4% to 16%, with almost all cases occurring at the postcricoid location.We have reported here a case of a 48-year-old woman with dysphagia , upper esophageal web and iron deficiency anemia . Dilatation of esophageal web with subsequent endoscopy showed mid- esophageal growth which on biopsy showed squamous cell carcinoma.

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.