Medicine and Health Sciences Commons^™

Endoscopic Ultrasound-Guided Transluminal Gallbladder Drainage In Patients With Acute Cholecystitis: A Prospective Multicenter Trial., Shayan S Irani, Neil R. Sharma Md, Andrew C Storm, Raj J Shah, Prabhleen Chahal, Field F Willingham, Lee Swanstrom, Todd H Baron, Eran Shlomovitz, Richard A Kozarek, Joyce A Peetermans, Edmund Mcmullen, Evelyne Ho, Schalk W Van Der Merwe

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OBJECTIVE: To evaluate the safety and efficacy of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS).

BACKGROUND: For patients with acute cholecystitis who are poor surgical candidates, EUS-GBD using a LAMS is an important treatment alternative to percutaneous gallbladder drainage.

METHODS: We conducted a regulatory-compliant, prospective multicenter trial at 7 tertiary referral centers in the United States of America and Belgium. Thirty consecutive patients with mild or moderate acute cholecystitis who were not candidates for cholecystectomy were enrolled between September 2019 and August 2021. Eligible patients had a LAMS placed transmurally with 30 to 60-day indwell if …

Endoscopic Management Of Complex Colorectal Polyps: Current Insights And Future Trends, Rupinder Mann, Mahesh Gajendran, Chandraprakash Umapathy, Abhilash Perisetti Md, Hermant Goyal, Shreyas Saligram, Juan Echavarria

PCI Publications and Projects

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to …

The Evolution Of Device-Assisted Enteroscopy: From Sonde Enteroscopy To Motorized Spiral Enteroscopy, Freddy Nehme, Hermant Goyal, Abhilash Perisetti Md, Ben Tharian, Neil Sharma Md, Tony C. Tham, Rajiv Chhabra

PCI Publications and Projects

THIS ARTICLE IS PART OF THE RESEARCH TOPIC: Recent Updates in Advanced Gastrointestinal Endoscopy

The introduction of capsule endoscopy in 2001 opened the last “black box” of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral …

Scope Of Artificial Intelligence In Gastrointestinal Oncology, Hermant Goyal Md, Syed A.A. Sheraz, Rupinder Mann, Zainab Gandhi, Abhilash Perisetti Md, Muhammad Aziz, Saurabh Chandan, Jonathan Kopel, Benjamin Tharian Md, Neil Sharma Md, Nirav Thosani

PCI Publications and Projects

Simple Summary

Endoscopic Ultrasound-Guided Vascular Interventions: Current Insights And Emerging Techniques, Rupinder Mann Md, Hermant Goyal Md, Abhilash Perisetti Md, Saurabh Chandan Md, Sumant Inamdar Md, Benjamin Tharian Md

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Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration …

Effect Of Pandemic On Endoscopic Utilization In Colonic Volvulus: A Global Multicentric Study, Abhilash Perisetti Md, Hermant Goyal Md, Syed Mahanazuddin Phd, Saurabh Chandan Md, Ruthvik Allala Ba, Mariajose Rojas Md, Jonathan Kopel Phd, Sonali Sachdeva Mbbs, Mark M. Aloysius Md, Phd, Benjamin Tharian, Neil Sharma Md

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Introduction- Acute colonic volvulus (ACV) is a gastrointestinal emergency that results from the torsion of a segment of the colon either at the level of the sigmoid colon or cecum. It can lead to severe complications such as bowel infarction and peritonitis which can increase mortality. The COVID-19 pandemic has led to a significant reduction in endoscopic utilization globally. However, the data about endoscopy utilization in a gastrointestinal emergency such as ACV is not non-existent. Hence, we attempted to evaluate the rates of endoscopy utilization in 2020 compared to 2019 for ACV patients.

Methods- We used TriNetX, a federated cloud-based …

Don't Blame The Duodenoscope Elevator, The Channels Are Contaminated As Well: A Systematic Review And Meta-Analysis, Hermant Goyal Md, Sara Larsen Ms, Abhilash Perisetti Md, Aman Ali Md, Jiannis Anastasiou Md, Nikolaj B. Larsen Ms, Lotte Ockert, Sven Adamsen Md, Benjamin Tharian Md, Nirav Thosani Md

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Introduction:

The elevator mechanism has been suggested as the main reason for multiple outbreaks associated with contaminated reusable patient-ready duodenoscopes. The elevator is difficult to clean even with all precautions, and specially designed brushes are recommended for proper cleaning. However, the narrow channels of the duodenoscope might pose a risk of contamination since they are prone to scratches by the insertion of various accessories creating space for microbes to hide. Our aim is to estimate the contamination rate beyond the elevator of duodenoscopes based on currently available literature.

Methods:

We searched PubMed, Web of Science, and Embase from January 1, …

Spontaneous Bacterial Empyema In Cirrhosis Patients - A Systematic Review And Meta-Analysis, Saurabh Chandan Md, William Reiche Do, Shahab R. Khan Mbbs, Smit Deliwala Md, Banreet Dhindsa Md, Daryl Ramai Md, Abhilash Perisetti Md, Rajani Rangray Md, Sandeep Mukherjee Md

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Introduction:

Spontaneous bacterial empyema (SBE), defined as spontaneous infection of the pleural fluid, represents a distinct and often underdiagnosed complication of hepatic hydrothorax in patients with cirrhosis. Although the transudative nature of hepatic hydrothorax is well established, the characteristics and risk factors for SBE have not been well investigated. We performed a systematic review and meta-analysis on the incidence and risk factors for this elusive entity.

Methods:

A systematic and detailed search was run in June 2021 with the assistance of a medical librarian for studies reporting on the incidence, associations, and outcomes of SBE in cirrhosis patients. Meta-analysis was …

1-Day Vs 3-Day Low Residue Diet For Colonoscopy Bowel Cleansing: A Systematic Review, Hermant Goyal Md, Syed Ali Amir Sherazi Md, Shweta Gupta Md, Smit Deliwala Md, Pardeep Bansal Md, Abhilash Perisetti Md, Benjamin Tharian Md, Nirav Thosani

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Introduction:

Colonoscopy is the best method for colon cancer screening and to evaluate bowel abnormalities, including cancer. However, good bowel preparation is essential for a successful colonoscopy. Several studies have shown Low Residue Diet (LRD) to be better tolerated without any negative effects on bowel cleansing compared to Clear Liquid Diet. Several studies have compared 1-day vs. 3-day LRD for bowel cleansing. This study aims to compare the impact of the duration of LRD for colonoscopy bowel cleansing in adult patients.

Methods:

We studied the Cochrane and MEDLINE/Ovid databases from inception to November 2020 with keywords “colonoscopy,” “bowel preparation,” “bowel …

Working With Fellows Improves Adenoma Detection Rate During Screening Colonoscopies., Mark M Aloysius, Hemant Goyal, Niraj James Shah, Abhilash Perisetti Md, Benjamin Tharian

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No abstract provided.

Peptic Ulcer With Adherent Clot—Treat It Or Leave It: A Systematic Review And Metanalysis Of Randomized Trials, Hermant Goyal Md, Sonali Sachdeva Mbbs, Abhilash Perisetti Md, Syed Ali Amir Sherazi Md, Mark M. Aloysius Md, Phd, Aman Ali Md, Greg Enders Md, Benjamin Tharian Md, Nirav Thosani Md

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Introduction:

Peptic ulcer diseases (PUD) remain the most common cause of hospitalized upper GI bleeding patients (30%-60%). Upper endoscopy is needed for diagnosis, stratification, and endoscopic hemostatic therapy of these ulcers depending on the presence of stigmata of increased risk of rebleeding. PUDs with adherent clot (Forrest classification IIb) are at 20-30% risk of rebleeding with a 7% mortality rate. Recent ACG guidelines could not reach a recommendation for or against endoscopic interventions for ulcers with adherent clot resistant to vigorous irrigation. This systematic review and meta-analysis aims to analyze the randomized studies for the treatment of PUD with adherent …

Continued Aspirin Use And Bleeding Risk After Endoscopic Submucosal Dissection Of Gastric Neoplasms: A Meta-Analysis, Hermant Goyal Md, Sonali Sachdeva Mbbs, Abhilash Perisetti Md, Mark M. Aloysius Md, Saurabh Chandan Md, Benjamin Tharian Md, Nirav Thosani Md

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Introduction:

With the development of endoscopic technologies, the detection rate of early gastric cancer (EGC) and precancerous lesions is gradually increasing. As an effective minimally invasive therapy, endoscopic submucosal dissection (ESD) has been accepted as a standard treatment for EGC and dysplasia. However, postprocedural bleeding is one of the most common complications of ESD, with a reported incidence of 5.1%. Moreover, the effect of continued low-dose aspirin (LDA) on bleeding during the peri-ESD period is not clear.

Methods:

We searched the OVID/Medline and Google Scholar databases through June 2021 to find studies relating to continued LDA use in patients undergoing …

Safety Of Glucagon Use During Endoscopic Retrograde Cholangiopancreatography: A Retrospective Multicentric Study, Abhilash Perisetti Md, Hermant Goyal Md, Syed Mahanazuddin Phd, Rupinder Mann Md, Saurabh Chandan Md, Benjamin Tharian Md, Neil Sharma Md

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Introduction- Injectable glucagon inhibits gastrointestinal (GI) and duodenal motility by relaxing smooth muscles, decreasing the frequency and amplitude of phasic activity of the sphincter of Oddi. This enables endoscopists to enhance biliary cannulation and extract small bile duct stone. Additionally, glucagon can potentially worsen underlying hyperglycemia and hyperkalemia especially in patients with diabetes. It is unclear if glucagon impacts the adverse events of Endoscopic Retrograde Cholangiopancreatography (ERCP) such as rates of GI bleeding, GI perforation, post-ERCP pancreatitis (PEP) and in patient hospitalizations.

Methods We used TriNetX, a federated cloud-based network comprising of 92 healthcare organizations (HCOs) across the US. All …

How “Dirty” Are The Endoscope Channels? A Systematic Review And Meta-Analysis Of Reprocessed Endoscopes, Hermant Goyal Md, Sara Larsen Ms, Abhilash Perisetti Md, Pardeep Bansal Md, Aman Ali Md, Nikolaj B. Larsen Ms, Lotte Ockert, Sven Adamsen Md, Benjamin Tharian Md, Nirav Thosani Md

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Introduction:

The duodenoscope elevator mechanism has been considered a culprit for multiple outbreaks from contaminated reusable patient-ready duodenoscopes. These outbreaks necessitated FDA to issue various Safety Communications and recommend endoscopy units to transition to duodenoscopes with innovative designs that ease or eliminate reprocessing. However, numerous studies have documented microbes in the channels of reprocessed gastrointestinal (GI) endoscopes, including duodenoscopes and linear echoendoscopes. Our aim is to estimate the channel contamination rate of patient-ready reprocessed GI endoscopes based on the currently available data.

Methods:

We searched PubMed, Web of Science, and Embase from January 1, 2010, until October 10, 2020, for …

National Trends In The Incidence Of Sporadic Malignant Colorectal Polyps In Young Patients (20-49 Years): An 18-Year Seer Database Analysis, Mark M. Aloysius Md, Hermant Goyal Md, Aman Ali Md, Niraj Shah Nd, Mahesh Gajendran Md, Abhilash Perisetti Md, Patrick Basu Md, Rajiv Chhabra Md, Benjamin Tharian Md

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Introduction:

Recent changes in the USPSTF guidelines recommend that CRC (Colorectal Cancer) screening in average-risk patients should commence at 45 years with the intent of finding sporadic premalignant or malignant polyps, allowing early endoscopic interventions to improve clinical outcomes. This study aims to find the incidence of sporadic malignant polyps in adult patients < 50 years of age) from the National Cancer Institute's SEER (Surveillance Epidemiology and End Results) database over a period of 18 years.

Methods:

We interrogated the SEER database (2000-2017) on patients aged 20-49 years diagnosed with at least a single malignant sporadic colorectal polyp. Data extraction was performed through a case listing session using SEER*Stat v8.3.9 on combined SEER 18 incidence registries using specific codes for CRC polyps with …

Impact Of Pandemic On Epidemiology And Management Of Acute Colonic Pseudo Obstruction: Nationwide Clinical Data Research Network, Abhilash Perisetti Md, Hermant Goyal Md, Syed Mahanazuddin Phd, Mariajose Rojas Md, Mahesh Gajendran Md, Syed Ali Amir Sherazi Md, Shweta Gupta Md, Mbs, Ragesh Thandassery Md, Benjamin Tharian Md, Mrcp, Fracp, Neil Sharma Md

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Introduction Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie’s syndrome, is characterized by massive acute dilatation of the large intestine without a mechanical cause. Early recognition to identify serious adverse events such as ischemia/ perforation is critical to reducing mortality rates. COVID-19 pandemic led to a significant shift of resources for the treatment of patients with reduced utilization of endoscopy and imaging, which could have impacted outcomes in patients with ACPO. In this study, we aim to identify the change in the clinical outcomes in ACPO patients in 2020.

Methods All adult patients with a new diagnosis of intestinal obstruction …

Improved Resection Rates In Locally Advanced Pancreatic Cancer (Lapc) Following Eus-Fni Of Large Surface Area Microparticle Paclitaxel (Lsam Pac), Neil Sharma Md, C Max Schmidt Md, Sushil Jain Md, Joseph Mccollom Do, Holly Maulhardt Bs, Shelagh Verco Bsc, Phd, Mariajose Rojas Md, Saurabh Gupta Md, Chetan Mittal Md, Christina Zelt, Ashley Rumple Rn, Bsn, James Verco Bs, Ccra, Abhilash Perisetti Md, Gere S. Dizerega Md

PCI Publications and Projects

Introduction:

LAPC is generally defined as unresectable disease without evidence of metastatic spread, and reports suggest between 8-25% of these patients may become resectable following current standard of care (SOC) therapy. EUS-FNI allows for the delivery of drug therapies directly into the tumor, which led to the development of LSAM pac currently being evaluated in LAPC and other solid tumors by means of direct injection, where the particles of pure drug act as a depot releasing paclitaxel over several weeks.

Methods:

Clinical study [NCT # 03077685] enrolled patients with LAPC, confirmed non-surgical despite SOC therapy, to additionally receive LSAM pac …

Reduced Incidence Of New Gastrointestinal Cancers Diagnosis During Covid-19 Pandemic, Abhilash Perisetti Md, Syed Mahanazuddin Phd, Rachana Yendala Md, Hermant Goyal Md, Benjamin Tharian Md, Mariajose Rojas Md, Neil Sharma Md

PCI Publications and Projects

Introduction- Gastrointestinal cancers such as esophageal, gastric, colon, liver, and pancreas cancers present a significant global challenge. The burden of these cancers depends mainly on early recognition and treatment initiation. COVID-19 pandemic led to a strain on multiple healthcare systems resulting in stay-at-home restraints, which might have impacted early recognition of these cancers. The data about the the incidence of GI cancers during the pandemic is scarce.

Methods- All adult patients with a new diagnosis of GI cancers in 2020 were compared with the patients in 2019. ICD-10 codes were utilized to identify these patient from TriNetX, a federated cloud-based …

'Scope' Of Acute Esophageal Obstruction In The Era Of Covid-19., Hemant Goyal, Abhilash Perisetti, Mahesh Gajendran, Aman Ali, Neil Sharma Md

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No abstract provided.

Management Of Gastrointestinal Bleeding During Covid-19: Less Is More!, Hemant Goyal, Sonali Sachdeva, Abhilash Perisetti Md, Rupinder Mann, Saurabh Chandan, Sumant Inamdar, Benjamin Tharian

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No abstract provided.

Direct-Acting Oral Anticoagulants Versus Warfarin In Relation To Risk Of Gastrointestinal Bleeding: A Systematic Review And Meta-Analysis Of Randomized Controlled Trials., Mark M Aloysius, Abhilash Perisetti Md, Hemant Goyal, Umesha Boregowda, Mladen Jecmenica, Mahesh Cheryala, Anurag Bajaj, Bojana Milekic, Milos Babic, Pardeep Bansal, Greg H Enders

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Background: Direct-acting oral anticoagulants (DOACs) are increasingly used, with studies showing a lower risk of gastrointestinal bleeding (GIB), but overall data for GIB risk remains debatable. The objective was to assess non-fatal and fatal GIB risk in patients on DOACs compared with warfarin from randomized clinical trials (RCTs).

Methods: RCTs comparing warfarin and DOACs for various indications (atrial fibrillation, thromboembolism, insertion of mechanical heart valves) were included. The primary endpoint was any GIB event. Other clinical events, such as fatal GIB, and effects of age (≤60 years or older), time in therapeutic range for warfarin, and choice of individual DOACs …

Short Versus Standard Esophageal Myotomy In Achalasia Patients: A Systematic Review And Meta-Analysis Of Comparative Studies., Saurabh Chandan, Antonio Facciorusso, Shahab R Khan, Daryl Ramai, Babu P Mohan, Mohammad Bilal, Banreet Dhindsa, Lena L Kassab, Hemant Goyal, Abhilash Perisetti Md, Ishfaq Bhat, Shailender Singh, Stephanie Mcdonough, Douglas G Adler

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Background and study aims Despite the clinical efficacy of peroral endoscopic myotomy (POEM), postoperative symptomatic gastroesophageal reflux disease (GERD) remains a major concern. While it is known that length of the gastric myotomy affects postoperative GERD, the clinical relevance of variation in esophageal myotomy length is not well known. We performed a systematic review and meta-analysis of studies comparing outcomes of short versus standard myotomy length in patients with achalasia. Patients and methods We searched multiple databases from inception through November 2020 to identify studies that reported on outcomes of achalasia patients who underwent short compared with standard esophageal myotomy. …

Impact Of Race And Socioeconomics Disparities On Survival In Young-Onset Colorectal Adenocarcinoma-A Seer Registry Analysis., Mark M Aloysius, Hemant Goyal, Niraj J Shah, Kumar Pallav, Nimy John, Mahesh Gajendran, Abhilash Perisetti Md, Benjamin Tharian

PCI Publications and Projects

INTRODUCTION: We aimed to assess the impact of socio-economic determinants of health (SEDH) on survival disparities within and between the ethnic groups of young-onset (age) colorectal adenocarcinoma patients.

PATIENTS AND METHODS: Surveillance, epidemiology, and end results (SEER) registry was used to identify colorectal adenocarcinoma patients aged between 25-49 years from 2012 and 2016. Survival analysis was performed using the Kaplan-Meir method. Cox proportional hazards model was used to determine the hazard effect of SEDH. American community survey (ACS) data 2012-2016 were used to analyze the impact of high school education, immigration status, poverty, household income, employment, marital status, and insurance …

Endoscopic Resection Of Multiple Large Gastric Polyps., Abhilash Perisetti Md, Hemant Goyal, Benjamin Tharian, Sumant Inamdar, Shashank Garg

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No abstract provided.

Fr247 Budesonide Vs. Mesalamine In Microscopic Colitis: A Systematic Review And Meta-Analysis Of Efficacy And Adverse Events, Adnan Malik Md, Hermant Goyal Md, Abhilash Perisetti Md, Mahum Nadeem, Mahesh Gajendran, Gregory Enders, Aman Ali, Benjamin Tharian

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Poster Presentation: BUDESONIDE VS. MESALAMINE IN MICROSCOPIC COLITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF EFFICACY AND ADVERSE EVENTS

Emerging Role Of Fascin-1 In The Pathogenesis, Diagnosis, And Treatment Of The Gastrointestinal Cancers., Bojana Ristic, Jonathan Kopel, Syed A A Sherazi, Shweta Gupta, Sonali Sachdeva, Pardeep Bansal, Aman Ali, Abhilash Perisetti Md, Hemant Goyal

PCI Publications and Projects

Gastrointestinal (GI) cancers, including esophageal, gastric, colorectal, liver, and pancreatic cancers, remain as one of the leading causes of death worldwide, with a large proportion accounting for fatalities related to metastatic disease. Invasion of primary cancer occurs by the actin cytoskeleton remodeling, including the formation of the filopodia, stereocilia, and other finger-like membrane protrusions. The crucial step of actin remodeling in the malignant cells is mediated by the fascin protein family, with fascin-1 being the most active. Fascin-1 is an actin-binding protein that cross-links filamentous actin into tightly packed parallel bundles, giving rise to finger-like cell protrusions, thus equipping the …

Successful Distancing: Telemedicine In Gastroenterology And Hepatology During The Covid-19 Pandemic., Abhilash Perisetti M.B.B.S, M.D., Hemant Goyal

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Telemedicine involves delivering healthcare and preventative care services to patients without the need for in-person encounters. Traditionally, telemedicine has been used for acute events (e.g., stroke, used to relay essential information to the emergency department) and chronic disease management (e.g., diabetes and chronic kidney disease management). Though the utilization of telemedicine in gastroenterology and hepatology has been modest at best, especially for inflammatory bowel diseases and chronic liver disease management, since the onset of coronavirus disease 2019 (COVID-19) pandemic, utilization of telemedicine in gastroenterology increased by 4000% in the first two weeks, equivalent to the last six years of growth …

Hyperlipasemia And Potential Pancreatic Injury Patterns In Covid-19: A Marker Of Severity Or Innocent Bystander?, Hemant Goyal, Sonali Sachdeva, Abhilash Perisetti Md, Rupinder Mann, Sumant Inamdar, Benjamin Tharian

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No abstract provided.

Covid-19 And Acute Esophageal Obstruction Management In The Emergency Department: An U.S. Multicenter Research Network Propensity-Matched Analysis, Hemant Goyal Md Facp, Abhilash Perisetti Md Facp, Mahesh Gajendran Md Mph Facp, Aman Ali Md, Neil Sharma Md

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Introduction- The Coronavirus Disease-2019 (COVID-19) caused by the novel SARS-CoV-2 led to significant strain on the Emergency Department (ED) visits worldwide. Multiple stay-at-home orders were issued during the pandemic unless medical treatment was urgently needed1 . Acute esophageal obstruction (AEO) due to food/ foreign body impaction usually present to the ED, given its severe symptoms. Most esophageal foreign bodies pass through the gastrointestinal (GI) tract uneventfully, and related mortality is very low. Still, most of these patients receive endoscopic interventions (up to 76%)2 . The number of non-urgent endoscopies plummeted sharply during the pandemic to reduce exposure and preserve personal …

Endobariatric Procedures For Obesity: Clinical Indications And Available Options., Hemant Goyal, Jonathan Kopel, Abhilash Perisetti Md, Rupinder Mann, Aman Ali, Benjamin Tharian, Shreyas Saligram, Sumant Inamdar

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Obesity remains a growing public health epidemic that has increased healthcare costs and related comorbidities. Current treatment guidelines encourage a multidisciplinary approach starting from patient selection, interventions, and long-term follow-up to maintain weight loss. However, these conservative interventions are largely ineffective at reducing body weight due to low adherence to the treatment regimen. Recently, endoscopic bariatric therapies have become an attractive alternative to traditional invasive bariatric surgeries due to their improved efficacy, safety, and cost-effectiveness. Endoscopic bariatric therapies include intragastric balloon placement, endoscopic sleeve gastroplasty, gastric bypass revision, and aspiration therapy. These procedures fall into two separate categories depending on …