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Adverse events (AEs) are commonly seen at endoscopic retrograde cholangiopancreatography (ERCP) during difficult biliary cannulation (DBC). Therefore, attaining the right technique is essential to have improved outcomes.Patients who had DBC over a 3-year period were assessed for outcomes. The protocol included double guidewire (DGW) technique, wire-guided cannulation (WGC) after pancreatic stent, precut sphincterotomy/fistulotomy, and EUS-guided rendezvous (RV). The success of various techniques and AE was studied.As per available case analysis, a total of 3680 patient details were assessed out of which DBC was noted in 471 (12.8%) patients with a mean (SD) age of 51.5 (17.4) years; majority being 330 (70.1%) males. Most patients underwent precut sphincterotomy 230 (48.8%); however, it was not successful in the first attempt in 10 (2.1%) patients with the success rate of 220 (95.6%). The success rate of DGW cannulation was 120 (95.2%), WGC after pancreatic stent was 64 (94.1%), EUS-RV was 34 (97.1%), and wire-guided repeat ERCP after 48 h was 10 (98.3%). AEs were noted in 52 (11.1%) patients. After precut, 32 (13.9%) patients developed AE out of which post-ERCP pancreatitis was noted in 20 (8.7%). Twenty-three patients had failed biliary access after all methods and 20 (86.9%) of those received successful percutaneous transhepatic biliary drainage.Repeat ERCP after 48 h and EUS-RV appear prudent for DBC. Precut remains one of the preferred choices for most endoscopists when there is no entrance to PD. Further utilizing an algorithmic approach can contribute to higher success rates without compromising safety.

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) Results 60 patients were randomized (30 in each group). At 3 months, a significantly higher proportion of patients achieved improvement in AET Conclusion EFTP improved post-POEM GERD symptoms, 24-hour pH impedance findings with normalization in one-third, and reduced PPI usage at 6 months.

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is considered a safe therapeutic modality even in pregnant women; however, adequate care needs to be taken. The utility of the SpyGlassTM DS II system in choledocholithiasis among pregnant women is unexplored. Methods: We retrospectively analyzed patients who underwentERCP for choledocholithiasis in the absence of fluoroscopy using the SpyGlass DS II system from October 2019 to November 2020. Depending on the size and location of the stones, we used laser lithotripsy (LL) for large impacted stones, the balloon extraction technique for multiple stones, and the SpyGlass retrieval basket for single solitary stones. Results: A total of 10 (100% female) patients with a mean (±SD) age of 29.5 (±2.5) years underwent ERCP. Abdominal pain was the commonest presenting symptom in all patients. Four (40%) patients had cholangitis and 3 (30%) had pancreatitis. The majority of the patients (9; 90%) were in the second trimester. MRCP was the commonest radiological entity, used in 9 (90%) patients. ERCP was technically successful and the stones were removed from all of the patients in a mean (±SD) time of 30 (±3.5) min. LL was used successfully in 4 (40%) patients, balloon extraction in 3 (30%) patients, and the SpyGlass retrieval basket in 3 (30%) patients. There were no pre- or post-procedural complications. All of the patients had an uneventful childbirth, after which they underwent cholecystectomy and subsequent stent removal 2 weeks later. Conclusions: Use of the SpyGlass DS II system and LL during ERCP appears safe and effective for the treatment of choledocholithiasis among pregnant women.

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is considered a safe therapeutic modality even in pregnant women; however, adequate care needs to be taken. The utility of the SpyGlassTM DS II system in choledocholithiasis among pregnant women is unexplored. Methods: We retrospectively analyzed patients who underwentERCP for choledocholithiasis in the absence of fluoroscopy using the SpyGlass DS II system from October 2019 to November 2020. Depending on the size and location of the stones, we used laser lithotripsy (LL) for large impacted stones, the balloon extraction technique for multiple stones, and the SpyGlass retrieval basket for single solitary stones. Results: A total of 10 (100% female) patients with a mean (±SD) age of 29.5 (±2.5) years underwent ERCP. Abdominal pain was the commonest presenting symptom in all patients. Four (40%) patients had cholangitis and 3 (30%) had pancreatitis. The majority of the patients (9; 90%) were in the second trimester. MRCP was the commonest radiological entity, used in 9 (90%) patients. ERCP was technically successful and the stones were removed from all of the patients in a mean (±SD) time of 30 (±3.5) min. LL was used successfully in 4 (40%) patients, balloon extraction in 3 (30%) patients, and the SpyGlass retrieval basket in 3 (30%) patients. There were no pre- or post-procedural complications. All of the patients had an uneventful childbirth, after which they underwent cholecystectomy and subsequent stent removal 2 weeks later. Conclusions: Use of the SpyGlass DS II system and LL during ERCP appears safe and effective for the treatment of choledocholithiasis among pregnant women.

Infliximab (IFX) or adalimumab (ADA) use in patients with inflammatory bowel disease (IBD) leads to increased risk of tuberculosis (TB). This meta-analysis evaluated the factors which determine this risk, with special focus on local TB incidence.All studies until January 31, 2019, which reported the development of TB in patients with IBD on IFX/ADA, were included after searching PubMed and Embase. Data regarding disease type, number of patients on IFX/ADA, number of patients who developed TB, mean age at IFX/ADA initiation, median duration of development of TB, and latent TB (LTB) were extracted. The details on local TB incidence were obtained from the World Health Organization database, and the studies were stratified into low (10/100,000), intermediate (10-40/100,000), and high TB burden countries (40/100,000). Random effect meta-analysis was performed to calculate the overall pooled prevalence and prevalence based on local TB burden.Of 130,114 patients (128 studies), 373 developed TB (pooled prevalence: 0.08% [95% confidence interval {CI}: 0.05%-0.10%]). The risk increased with increasing TB burden, pooled prevalence being 0.02% (95% CI: 0.02%-0.03%), 0.21% (95% CI: -0.02% to 0.43%), and 1.59% (95% CI: 1.19%-2.00%) for low, intermediate, and high TB burden countries, respectively. Seventy-three percent of patients who developed TB had no evidence of LTB on screening, the proportion being independent of TB burden. There was no effect of disease or treatment type, study type, gender, age at IFX/ADA initiation, and follow-up duration on TB prevalence.TB risk in patients with IBD on IFX/ADA depends on the local TB burden and is independent of disease/treatment type.

Adalimumab has emerged as a useful drug for treating patients with Crohn's disease (CD) and ulcerative colitis (UC), not responding to conventional therapy. There is limited data on effectiveness and safety of adalimumab biosimilar in patients with inflammatory bowel disease (IBD).Patients with IBD who received at least one dose of adalimumab biosimilar from October 2015 to February 2018 were retrospectively included in this multicenter data analysis. Its effectiveness in inducing and maintaining clinical remission at 8, 26, and 52 weeks for CD and UC and safety profile of the drug was studied.Seventy patients (49 CD; 21 UC) with a median age of 39 (range 13-73) years, male predominance (64.3%), and median (IQR) disease duration of 72 (33-104) months were included. Adalimumab biosimilar was effective in inducing remission (at 8 weeks) in 46.9% and 52.4% patients with CD and UC, respectively, of whom 32.7% and 33.3% (three fourths of remitters) maintained remission over 1 year, respectively. Twenty (28.6%) patients experienced adverse events; seven (10%) were serious of whom three had developed tuberculosis.Adalimumab biosimilar in usual clinical practice is safe and effective in inducing and maintaining remission in Indian patients with IBD. Steroid-free clinical remission was observed in one third of patients with UC and CD at 1 year of therapy. Graphical Abstract.

OBJECTIVES Patients with inflammatory bowel diseases (IBD) have to deal with a poor quality of life (QOL) and psychomorbidity resulting from an incurable illness. We aimed to study the effect of patient education on QOL, compliance, anxiety and depression in IBD. METHODS Patients were prospectively enrolled over two years beginning July 2014 and divided into an interventional and usual care group. Both received the standard of care, but the former in addition received an 8 min session of video-assisted education. Compliance to drugs was defined as drug intake of > 80% of the prescribed dose, and adherence to scheduled follow up visits were also compared. Self-administered questionnaires namely Short IBD questionnaire (SIBDQ), Beck Anxiety and Depression Inventory (BAI, BDI-II), Hospital Anxiety and Depression Scale (HADS) were used to assess QOL, anxiety and depression respectively at baseline, 6 months and 1 year. RESULTS Of the 91 patients enrolled, 84 [92.3%; male = 66 (78.57%)] completed the follow up. Significantly more patients were compliant to follow up visits in the intervention and usual care groups respectively at 6 months (88.4% versus 65.8% respectively; p

Background: Chronic pancreatitis (CP) is a leading cause of hospitalization among gastrointestinal diseases resulting in considerable financial burden to patients. However the direct costs for nonsurgical management in CP remains unexplored. Methods: A cross sectional study was carried out (2011–14) in the Department of Gastroenterology, Kasturba Hospital, Manipal, India. Demographic and clinical data on laboratory investigations, interventions and follow up were obtained from the medical records department. Item costs were derived from the hospital electronic billing section. Cost was expressed as median annual cost per patient. Results: 65 (male 48; 73.8%) patients were included. Their median age was 31 (range 12–68) years. The annual median (IQR) total cost per patient was INR 88,892 (70,550.5–116,004); [USD 1410(1119–1841); € 1155(916–1507)], comprising of INR 61,089 (39,102.5–90,360.5) [USD 970 (621–1434); € 793(508–1174)] for outpatient management and INR 32,450 (11,016–46,958) [USD 515 (175–745); €421(143–610)] for hospitalization. 69.5% of the treatment cost was attributed to outpatient treatment. Drugs contributed to 54%, hospitalization incurred 30.5%, investigations 12% and professional fees (3.5%) of the total cost. Pancreatic enzyme replacement therapy (PERT) cost contributed to three-quarters of drug therapy. Use of rabeprazole as against pantoprazole reduced the overall annual cost of therapy by 4%. Conclusions: This study depicts the first nonsurgical management of accrued direct costs associated with CP due to expensive medications. Due to the high cost for PERT, its usefulness needs proper validation by cost benefit analysis.

Frequent relapses sometimes necessitating hospitalization and the absence of pharmacological cure contribute to substantial healthcare costs in inflammatory bowel diseases (IBDs). The costs of health care in Indian patients with IBD are unknown. To evaluate the annual costs for treating Crohn’s disease and ulcerative colitis. A prevalence-based, micro-costing method was used to assess the components of annual costs in a prospective, observational study conducted in a tertiary healthcare center enrolled over a 24-month period beginning of July 2014. At enrollment, 43/59 (72.88%) patients with UC and 18/25 (72%) with CD were in remission. The annual median (IQR) cost per UC and CD patient in remission was INR 43,140 (34,357–51,031) [USD $707 (563–836)] and INR 43,763.5 (32,202–57,372) [USD $717 (527–940)], respectively, and in active disease was INR 52,436.5 (49,229–67,567.75) [$859 (807–1107)] and INR 72,145 (49,447–92,212) [USD $1182 (811–1512)], respectively. Compared with remission, active disease had a 1.4-fold higher cost for CD as compared to UC. In both groups, the greatest component of direct costs was drugs. Thirteen (22%) and 7 (28%) patients with UC and CD needed hospitalization accounting for 23.1 and 20.4% of the total costs, respectively. At one year, direct costs surmounted indirect costs in UC and CD (p

Background Laparoscopic management of colorectal cancer (CRC) has been gaining popularity at a rapid pace across the world. Proponents argue for better short term outcomes including shorter hospital stay, acceptable safety profile and better outcomes of laporoscopic versus open surgery. However, the direct inpatient cost for laparoscopic management of CRC remains unexplored. This assumes even more importance in resource-strapped economies like India. Methods A cross-sectional study was carried out with a hospital discharge diagnosis of CRC (ICD-10 C18-C19) from 2015–2018. Patient details on surgery, investigations, days of hospitalization, and drugs from hospital admission to discharge were obtained precisely from the medical records department. Item costs were obtained from the hospital electronic billing section. Economic evaluation included a prevalence-based approach with a societal perspective utilizing the bottom-up technique; cost was expressed as median cost per patient. Results 391 (male 288; 73.6%) patients were included. Their median age was 59 (range 49–69) years. The median time for hospitalization was 6 (range 5–11 days). The median inpatient cost was INR 1,86,564, with a wide range of (1,69,514 – 4,51,529); [USD 2743(2492–6640); € 2332(2118–5644)]. Surgical procedure with operation theatre contributed to 30% and was the highest among all the cost components. Consumables incurred (25%), bed charges (16%), anesthesia (8%), investigations (7%), drugs and professional fees of 6% each and miscellaneous charges (2%) contributed to the total cost. Conclusions The first pharmacoeconomic study for inpatients with CRC managed laparoscopically incurred modest cost. This study acts as a reference to future pharmacoeconomic studies in CRC. Its usefulness and advantages might lead to increased cost savings but needs justification by cost-benefit analysis in addition to long term outcome post-laparoscopic resection.

Background Proton Pump Inhibitor (PPI) is the commonest prescribed drug in gastroenterology practice due to its proven effectiveness for a variety of indications. Long-term use contributes to adverse events. There is a large unmet need to evaluate the appropriateness of prescribing PPI therapy. Methods A cross-sectional study was conducted over three months at a Gastroenterology outpatient department of a tertiary care teaching hospital. Adult patients who were prescribed PPI were interviewed. Patient medication charts were reviewed and demographic details, PPI use, dose, regimen and valid indication for PPI prescription was noted in accordance with international guidelines and best evidence. Results Three forty-one (male 240; 70.4%) patients were included. Their median age was 35 (range 18–78) years. 191(56%), 84(24.6%) and 56 (16.4%) of the patients received oral Rabeprazole, Pantoprazole and Esomeprazole respectively. Rest were prescribed a combination of PPI with prokinetic (Domperidone/Itopride). The commonest indication was Gastroesophageal Reflux Disease followed by Pancreatitis. Overall, 10(2.9%) of the patients were receiving PPIs without an appropriate indication out of which 3 were on self-medication. 85(24.9%) patients had a previous PPI prescription, and 256(75.1%) were initiated on PPI therapy during their current visit. The median duration of therapy was 4.5 weeks. Conclusions Majority of the patients (97.1%) had an identifiable and appropriate PPI indication. Accurate PPI prescribing can reduce the incidence of adverse events and contribute to overall cost savings. Nevertheless, patients should be educated and warned regarding self-medication and inappropriate use. Meanwhile, doctors need to reevaluate drugs at follow up, reduce dose and stop accordingly.

Objective: Patient education is important in irritable bowel syndrome (IBS), but its effects on outcomes have not been studied extensively. Methods: Patients were enrolled and prospectively divided into an interventional and usual care group. Both received standard of care, but the former additionally received video-assisted patient education. Self-administered questionnaires IBS-quality of life (QOL), Beck Anxiety-Depression Inventory II (BAI, BDI), and Hospital Anxiety and Depression Scale (HADS) were administered at baseline, 3 months, and 6 months. Compliance was defined as drug intake of >80% of the prescribed dose. COI included prospective, prevalence-based, societal perspective. Results: Of the 107 patients included, 84 [78.5%; male = 66 (78.57%); median age = 44 (range 20–77 years)] completed the follow up. While the median (inter-quartile range; IQR) QOL scores decreased significantly in both the groups (p < 0.001 for either group), the final scores were significantly better in the interventional group [49 (44–52.5) versus 80 (76–103), respectively; p < 0.005]. There was a significant improvement in the BDI; p < 0.001]. However, the rest did not achieve statistical significance. At 6 months, total median (IQR) semi-annual cost per patient was INR 14,639 (8253–17,909) [US $240 (135–294]. Conclusion: Video-assisted patient education should be a part of the treatment of IBS since it improves the QOL and depression scores.

Background Vaccination is the most cost-effective strategy in disease prevention but remains an ambiguous area in Inflammatory Bowel Disease (IBD). Most patients will require immunomodulators/biologics at some time point; hence there exists a large unmet need for vaccination. Guidelines are not strict around the world while western guidelines are not pragmatic in Indian population; extrapolating may not be cost-effective. However, certain diseases are uncommon in Asia-Pacific countries including India. We gathered details on the recommendation for vaccination in IBD around the world, explored the appropriateness, and calculated the probable cost of implementing them. Methods A computer-assisted publication search of MEDLINE was performed on August 9, 2017, to identify guidelines and/or recommendations (in English) from the year 1980–2017 for vaccination in IBD which were later critiqued. Current Index of Medical Specialties (August 2017) was used for costing, expressed in Indian Rupee (INR) and UK pound sterling (£). Results This narrative review included nine articles, all highlighting the need to assess immunosuppressed state prior to administering live vaccines, while inactivated can be used safely. Hepatitis A, Meningococcal, Japanese encephalitis and Yellow fever vaccine (for travellers) could perhaps be withheld in Indian patients with IBD since their occurrence is low. Hepatitis B, Varicella Zoster (VZ), pneumococcal, HPV and yearly influenza shots look appropriate; rest should be decided on clinical wisdom based on the type of flare (MMR, DPT if unvaccinated). Majority of the vaccines have been available after 1980, patients born prior might need additional protection. The total cost of vaccinating per patient with IBD in the Indian context is INR 48016 (£ 534). Conclusions The timing of vaccination is crucial; patients with IBD need it regardless of age. Screening is necessary, but some can be excluded, rest decided on local disease prevalence. The disease should be in remission, medication optimised and health care maintenance updated. The need for specific vaccines should currently follow national guidelines. Proposed strategy preferably would be the development of Indian guidelines for vaccination in IBD. The cost of VZ, pneumococcal and Hepatitis A/B combination vaccine is colossally highlighting the need for prescribing cost-effective alternate vaccine brands when available.

Background and Aim The literature on medication adherence in patients with inflammatory bowel disease (IBD) is heterogeneous. The present study aimed to identify the rates and predictors of nonadherence to medications in IBD. Methods This cross‐sectional study included patients of IBD (ulcerative colitis [UC] and Crohn's disease [CD]) recruited between November 2016 and March 2017. Adherence was assessed with a questionnaire (interview based) that evaluated patients' sociodemographic and disease profile and rates and predictors of medication adherence. Results A total of 266 patients (204 UC, 62 CD) were included (mean age: 38.5 ± 12.7 years, males: 142 [53.4%], mean disease duration: 6.4 ± 5.2 years). The overall adherence rate was 82.3%, with the lowest for topical therapy (67.3%) and the highest for steroids (95.9%). Predominant reasons for nonadherence were forgetting dose (18.8%), unavailability of medications (13.2%), felt better (11.7%), adverse effects (6.8%), and cost of treatment (6.0%). Patients' education (P

In extensive disease or injury to the ureter, the options are autotransplantation or ileal ureteral substitution [1]. The metabolic and physiological effects of ileal ureter must be kept in mind prior to embarking on the procedure. The general contra indications are renal impairment when the serum creatinine is greater than 2 mg/dl, bladder dysfunction, bladder outlet obstruction, inflammatory bowel disease or radiation enteritis.

We report the first laparoscopy-assisted replacement of the ureter with an ileal segment reconfigured by using the Yang Monti principle. We performed this surgery in a patient with a long segment right lower ureteral stricture from a nonspecific cause. The initial dissection of the colon and the ureter was done laparoscopically. The bowel was identified and delivered through a 3.5 cm midline infraumbilical incision. The bowel segment was isolated and reconfigured extracorporeally. The bowel was placed back in the peritoneal cavity, and the ureteroileal and the ileovesical anastomosis were performed using the laparoscopic intracorporeal suturing technique. The patient had an uneventful postoperative recovery. The ileal segment showed good patency on early follow-up.

We describe in detail the technique of laparoscopy-assisted ileal ureter creation for multiple tuberculous ureteral strictures in two patients. The proximal anastomosis included an ileocalicostomy in the first patient and an ileopyelostomy in the second patient. The first patient had bowel entrapment behind the mesentery of the ileal loop, but the second patient had an uneventful postoperative recovery. Short-term follow-up showed good patency of the ileal loop. The variations in the technique that can cause postoperative problems are discussed, and the future of this technique is postulated.

Bladder calculi associated with benign prostatic hyperplasia are fairly common, and a popular treatment is transurethral resection of the prostate (TURP) with endoscopic lithotripsy as a combined procedure. We have been routinely using a Reuter's suprapubic trocar and cannula for continuous irrigation during TURP for medium-size and large glands. Rather than performing the vesicolithotripsy per urethra, we have found it easier and faster to use the suprapubic route, especially because the suprapubic tract was already partly made by the Reuter's trocar and half sheath. We describe the technique in detail and explain why we find it easier to extract the stone by the suprapubic rather than the urethral route.

Naturally available fruits and vegetables along with a healthy diet does provide all required nutrients to the body. Then why do people go behind the so-called “health supplements” - vitamins, minerals, herbal immune booster, probiotics, tonics, etc? Do you really need them? Patients in India are desperate to grab the shortcut to good health. They buy products which are unnecessary and which do not have any beneficial effect. On the other hand, health of the patient is undermined as he skips essential drugs which doctors would have prescribed according to the health of a patient. Misconceptions that herbal medicines are safe and without side effects need to be addressed. Patients need to be educated regarding health supplements, its consequences, costs and its implications, and nonadherence. The need of the hour is educating patients to be the guardian of their own health. Numerous reviews exist on health supplementation; however, many facts remain unexplored. This review focuses on what needs to be done for optimal health care.

Perineal urethrostomy stenosis can be a difficult problem to treat, especially in patients with balanitis xerotica obliterans. We have devised a technique of using the buccal mucosa, with the idea of forming a composite stoma comprising skin and buccal mucosa. We describe the technique and short-term results in 4 patients.

Laparoscopic extravesical neoureterocystostomy is an infrequently described technique in adults. It is a technically demanding procedure, especially when the intracorporeal freehand suturing technique is used. Our aim is to describe two cases where we used the intracorporeal freehand suturing technique successfully for performing laparoscopic extravesical transperitoneal ureteral reimplantation. We describe the preliminary results of these cases.We performed this surgery in two female patients. The first patient had a low ureterovaginal fistula after abdominal hysterectomy. We performed a laparoscopic extravesical neoureterocystostomy by the refluxing technique. The second patient had a lower-third ureteral stricture. We performed a laparoscopic extravesical neoureterocystostomy with detrusorrhaphy and supported it with a psoas hitch.The average surgical time was 235 minutes. The average blood loss was 50 mL. The average stay was 48 hours, and the average time to starting oral intake was 12 hours. The average requirement for postoperative analgesia was one injection of diclofenac sodium, followed by oral ibuprofen. Follow-up urography showed good clearance of the kidney and ureter. The second patient, in whom the detrusorrhaphy was performed, did not show any reflux on the postoperative cystogram.Laparoscopic extravesical neoureterocystostomy using intracorporeal freehand suturing technique, combining detrusorrhaphy and psoas hitch, is a feasible procedure in adults for various indications. The detrusorrhaphy was effective in preventing reflux, but the long-term results need to be evaluated.

We present our preliminary experience with the technique of laparoscopic pyelolithotomy for ectopic pelvic kidney calculi. This surgery has low morbidity and is ideally suited for the ectopic pelvic kidney with a laterally or anteriorly directed pelvis.