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Kang G, Ang LS, Teo WHL, Huang YWC, Narayan V, Kwek ABE, Ang TL, Wong YJ. Clinical outcomes of variceal and non-variceal upper gastrointestinal bleeding in cirrhosis patients in Singapore. Singapore Med J 2024:00077293-990000000-00099. [PMID: 38444185 DOI: 10.4103/singaporemedj.smj-2023-046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 11/09/2023] [Indexed: 03/07/2024]
Affiliation(s)
- Garrett Kang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Le Shaun Ang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wen Hui Leia Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yu Wei Cheryl Huang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Medical School, SingHealth, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-NUS Medical School, SingHealth, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Duke-NUS Medical School, SingHealth, Singapore
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2
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Li JW, Ngu JCY, Lim KR, Tay SW, Jiang B, Wijaya R, Yusof S, Ong CJ, Kwek ABE, Ang TL. Colonic stenting in acute malignant large bowel obstruction: audit of efficacy and safety in a Singapore tertiary referral centre. Singapore Med J 2023; 64:603-608. [PMID: 34600451 PMCID: PMC10645007 DOI: 10.11622/smedj.2021127] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 01/30/2021] [Indexed: 01/10/2023]
Abstract
Introduction Acute malignant large bowel obstruction (MBO) occurs in 8%-15% of colorectal cancer patients. Self-expandable metal stents (SEMS) have progressed from a palliative modality to use as bridge to surgery (BTS). We aimed to assess the safety and efficacy of SEMS for MBO in our institution. Methods The data of patients undergoing SEMS insertion for MBO were reviewed. Technical success was defined as successful SEMS deployment across tumour without complications. Clinical success was defined as colonic decompression without requiring further surgical intervention. Rates of complications, median time to surgery, types of surgery and rates of recurrence were studied. Results Seventy-nine patients underwent emergent SEMS placement from September 2013 to February 2020. Their mean age was 68.8 ± 13.8 years and 43 (54%) patients were male. Mean tumour length was 4.2 cm ± 2.2 cm; 89.9% of malignant strictures were located distal to the splenic flexure. Technical and clinical success was 94.9% and 98.7%, respectively. Perforation occurred in 5.1% of patients, with none having stent migration or bleeding. Fifty (63.3%) patients underwent SEMS insertion as BTS. Median time to surgery was 20 (range 6-57) days. Most (82%) patients underwent minimally invasive surgery. Primary anastomosis rate was 98%. Thirty-nine patients had follow-up beyond 1-year posttreatment (median 34 months). Local recurrence and distant metastasis were observed in 4 (10.3%) and 5 (12.8%) patients, respectively. Conclusion Insertion of SEMS for acute MBO has high success rates and a good safety profile. Most patients in this audit underwent minimally invasive surgery and primary anastomosis after successful BTS.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore
| | - James Chi-Yong Ngu
- Department of General Surgery, Changi General Hospital, Singapore Health Services, Singapore
| | - Kok Ren Lim
- Department of General Surgery, Changi General Hospital, Singapore Health Services, Singapore
| | - Shu Wen Tay
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore
| | - Bochao Jiang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore
| | - Ramesh Wijaya
- Department of General Surgery, Changi General Hospital, Singapore Health Services, Singapore
| | - Sulaiman Yusof
- Department of General Surgery, Changi General Hospital, Singapore Health Services, Singapore
| | - Calvin Jianming Ong
- Department of General Surgery, Changi General Hospital, Singapore Health Services, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore Health Services, Singapore
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Kwek ABE, Ang TL. Post-papillectomy bleeding: Hemostatic powder to the rescue? J Gastroenterol Hepatol 2022; 37:2025-2026. [PMID: 36396132 DOI: 10.1111/jgh.16030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, SingHealth, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, SingHealth, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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4
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Balasundaram B, Ang WST, Stewart R, Bishara D, Ooi CH, Li F, Akram F, Eu Kwek AB. Improving quantification of anticholinergic burden using the Anticholinergic Effect on Cognition Scale - a healthcare improvement study in a geriatric ward setting. Australas Psychiatry 2022; 30:535-540. [PMID: 35726508 PMCID: PMC9379386 DOI: 10.1177/10398562221103117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Anticholinergic burden refers to the cumulative effects of taking multiple medications with anticholinergic effects. This study was carried out in a public hospital in Singapore, aimed to improve and achieve a 100% comprehensive identification and review of measured, anticholinergic burden in a geriatric psychiatry liaison service to geriatric wards. We evaluated changes in pre-to post-assessment anticholinergic burden scores and trainee feedback. METHOD Plan Do Study Act methodology was employed, and Anticholinergic Effect on Cognition scale (AEC) was implemented as the study intervention. A survey instrument evaluated trainee feedback. RESULTS There was no measured anticholinergic burden in a baseline of 170 assessments. 75 liaison psychiatry assessments were conducted between June and November 2021 in two cycles. 94.7% of pre-assessments (at the time of assessment) and 71.1% of post-assessments (following assessment) had a record of AEC scores in clinical documentation in cycle one, improving in the second cycle to 100%, 94.6%, respectively. A high post-assessment AEC score of 3 and over reduced from 15.8% in cycle one to 5.4% in cycle two. The trainee feedback suggested an enriching educational experience. CONCLUSIONS Using the AEC scale, the findings support the feasibility of comprehensive identification and review of measured anticholinergic burden in older people with neurocognitive disorders.
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Affiliation(s)
| | | | - Robert Stewart
- Department of Psychological Medicine, 34426Kings College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Delia Bishara
- Department of Psychological Medicine, Kings College London, Institute of Psychiatry, Psychology and Neuroscience, Mental Health of Older Adults & Dementia, 4958South London & Maudsley NHS Foundation Trust, London, UK
| | - Chun How Ooi
- Department of Geriatric Medicine, 26674Changi General Hospital, Singapore
| | - Fuyin Li
- Advanced Practice Nurse Development, Department of Nursing, 26674Changi General Hospital, Singapore
| | - Farooq Akram
- Department of Internal Medicine, 26674Changi General Hospital, Singapore
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5
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Pei Y, Ang D, Kwek ABE, Ang TL. The changing profile of Helicobacter pylori primary antibiotic resistance in Singapore over two decades. J Dig Dis 2022; 23:295-301. [PMID: 35849105 DOI: 10.1111/1751-2980.13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 12/11/2022]
Abstract
ObjectivesAntibiotic resistance is a key reason for Helicobacter pylori (H. pylori) treatment failure and updated local data are important to guide the choice of empiric first‐line therapy. Clarithromycin‐based triple therapy (TT) is currently the first‐line treatment in Singapore. Our primary aim was to determine the change in pattern of primary antibiotic resistance of H. pylori in Singapore as well as TT success rate.MethodsA registry of H. pylori isolates was tested for primary antibiotic resistance and were analyzed from year 2001 to 2020. Treatment outcome data based on 13C‐urea breath test (13C‐UBT) results of empiric first‐line 2‐week TT from 2019 to 2020 were also analyzed retrospectively.ResultsA total of 387 H. pylori isolates were included. Rates of resistance to clarithromycin as well as tetracycline showed a downtrend in the last 5 years (clarithromycin: 2001–2002: 8.57%; 2007–2008: 14.14%; 2013–2014: 18.09%; 2019–2020: 13.71%; tetracycline: 2001–2002: 5.71%; 2007–2008: 7.07%; 2013–2014: 7.45%; 2019–2020: 0%). The resistance rate for amoxicillin remained low (2001–2002: 2.86%; 2007–2008: 5.05%; 2013–2014: 4.26%; 2019–2020: 7.26%). There was a steady increase in the rate of levofloxacin resistance (2001–2002: 5.71%; 2007–2008: 11.11%; 2013–2014: 15.96%; 2019–2020: 16.94%). From 2019 to 2020, the rate of successful TT was 91.67% (891/972).ConclusionThe latest rate of clarithromycin resistance in 2019 to 2020 remained below the threshold of 15% and eradication rates remain high; thus, TT remains appropriate as an empiric first‐line treatment in Singapore.
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Affiliation(s)
- Yiying Pei
- Department of Gastroenterology and Hepatology, Changi General Hospital, SingHealth, Singapore
| | - Daphne Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, SingHealth, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, SingHealth, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, SingHealth, Singapore
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Tan EC, Chia SY, Rafi'ee K, Lee SX, Kwek ABE, Tan SH, Ng VWL, Wei H, Koo S, Koh AL, Koh MJA. A novel NSDHL variant in CHILD syndrome with gastrointestinal manifestations and localized skin involvement. Mol Genet Genomic Med 2021; 10:e1848. [PMID: 34957706 PMCID: PMC8801147 DOI: 10.1002/mgg3.1848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/14/2021] [Indexed: 11/11/2022] Open
Abstract
Background CHILD syndrome is an X‐linked dominant disorder associated with pathogenic mutations in the NSDHL gene. The condition is predominantly found in females as it is lethal in males. Most cases present at birth with extensive unilateral ichthyosiform erythroderma involving the trunk and limbs. Milder and less extensive presentations have been reported, leading to misdiagnosis especially during early childhood. Methods and Results We report an adult female of Malay ancestry who presented with minimal skin and limb involvement. She was only diagnosed in adulthood when she presented with gastrointestinal symptoms and worsening of skin manifestations. The clinical diagnosis was suspected after a combination of clinical, pathological and immunohistochemistry correlation, and molecularly confirmed with the discovery of a frameshift variant in NSDHL. The novel variant was inherited from her mother who had some linear hypopigmented patches over the medial aspects of both her arms and right forearm. Conclusion We uncovered a novel frameshift variant associated with presentations that cast a new light on the clinical features of CHILD syndrome.
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Affiliation(s)
- Ene-Choo Tan
- Research Laboratory, KK Women's & Children's Hospital, Singapore, Singapore.,Paediatrics Academic Clinical Programme, SingHealth Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Shi Yun Chia
- Paediatrics Academic Clinical Programme, SingHealth Duke-NUS Graduate Medical School, Singapore, Singapore.,Dermatology Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Khadijah Rafi'ee
- Research Laboratory, KK Women's & Children's Hospital, Singapore, Singapore
| | - Shan Xian Lee
- Department of Dermatology, Changi General Hospital, Singapore, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Sze Hwa Tan
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Victor Weng Leong Ng
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Heming Wei
- Research Laboratory, KK Women's & Children's Hospital, Singapore, Singapore
| | - Stephanie Koo
- Research Laboratory, KK Women's & Children's Hospital, Singapore, Singapore
| | - Ai Ling Koh
- Paediatrics Academic Clinical Programme, SingHealth Duke-NUS Graduate Medical School, Singapore, Singapore.,Genetics Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Mark Jean-Aan Koh
- Paediatrics Academic Clinical Programme, SingHealth Duke-NUS Graduate Medical School, Singapore, Singapore.,Dermatology Service, KK Women's and Children's Hospital, Singapore, Singapore
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Tan YY, Tay GSK, Wong YJ, Li JW, Kwek ABE, Ang TL, Wang LM, Tan MTK. Clinical Features and Predictors of Dysplasia in Proximal Sessile Serrated Lesions. Clin Endosc 2021; 54:578-588. [PMID: 33915614 PMCID: PMC8357591 DOI: 10.5946/ce.2020.198] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/11/2020] [Indexed: 02/05/2023] Open
Abstract
Background/Aims Proximal colorectal cancers (CRCs) account for up to half of CRCs. Sessile serrated lesions (SSLs) are precursors to CRC. Proximal location and presence of dysplasia in SSLs predict higher risks of progression to cancer. The prevalence of dysplasia in proximal SSLs (pSSLs) and clinical characteristics of dysplastic pSSLs are not well studied.
Methods Endoscopically resected colonic polyps at our center between January 2016 and December 2017 were screened for pSSLs. Data of patients with at least one pSSL were retrieved and clinicopathological features of pSSLs were analysed. pSSLs with and without dysplasia were compared for associations.
Results Ninety pSSLs were identified, 45 of which had dysplasia giving a prevalence of 50.0%. Older age (65.9 years vs. 60.1 years, p=0.034) was associated with the presence of dysplasia. Twelve pSSLs were 10 mm or larger. After adjusting for age, pSSLs ≥10 mm had an adjusted odds ratio of 5.98 (95% confidence interval, 1.21–29.6) of having dysplasia compared with smaller pSSLs.
Conclusions In our cohort of pSSLs, the prevalence of dysplasia is high at 50.0% and is associated with lesion size ≥10 mm. Endoscopic resection for all proximal serrated lesions should be en bloc to facilitate accurate histopathological examination for dysplasia as its presence warrants shorter surveillance intervals.
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Affiliation(s)
- Yi Yuan Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Gary Sei Kiat Tay
- Department of Pathology, Changi General Hospital, Singapore, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lai Mun Wang
- Department of Pathology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Pathology Academic Clinical Programme, SingHealth Duke-NUS Medical School, Singapore, Singapore
| | - Malcolm Teck Kiang Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Teh KKJ, Tay SW, Chen K, Koh SJ, Wong YJ, Kwek ABE, Li JW, Fock KM, Teo EK, Ang TL, Tan MTK. Impact of enhanced personal protective equipment on colonoscopy performance during the COVID-19 pandemic. Endosc Int Open 2020; 8:E809-E814. [PMID: 32523979 PMCID: PMC7274840 DOI: 10.1055/a-1167-1703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Using personal protective equipment (PPE) can reduce risk of disease transmission. During the COVID-19 pandemic, enhanced PPE (EPPE) is recommended when performing endoscopy. We aimed to evaluate the impact of EPPE on colonoscopy performance when compared to standard PPE (SPPE). Patients and methods A review of electronic medical records and endoscopy reports of consecutive patients who underwent colonoscopy during two similar one-month time periods (in 2019 and during the COVID-19 pandemic in 2020) was performed. SPPE was used in 2019 and EPPE was used in 2020. Patient clinical data and procedure-related information were captured and analyzed. The primary outcomes were time to cecum (TTC) and total procedure time. Secondary outcomes were adenoma detection rate (ADR), polyp detection rate (PDR) and cecal intubation rate (CIR). Statistical analysis was performed using STATA v16.1. Results Two hundred and forty-seven colonoscopy procedures were analyzed. Baseline demographics and indications for colonoscopy of patients in both groups were similar. There were no significant differences in median TTC (10.0 vs 10.0 min, P = 0.524) or total procedure time (22.5 vs 23.0 min, P = 0.946) between colonoscopy performed in SPPE and EPPE. The ADR, PDR and CIR were also similar. Conclusion Our findings suggest that use of EPPE does not affect colonoscopy performance.
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Affiliation(s)
- Kevin Kim Jun Teh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Shu Wen Tay
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kaina Chen
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Samantha Jingyun Koh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Ang TL, Li JW, Wong YJ, Tan YLJ, Fock KM, Tan MTK, Kwek ABE, Teo EK, Ang DSW, Wang LM. A prospective randomized study of colonoscopy using blue laser imaging and white light imaging in detection and differentiation of colonic polyps. Endosc Int Open 2019; 7:E1207-E1213. [PMID: 31579701 PMCID: PMC6773574 DOI: 10.1055/a-0982-3111] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/26/2019] [Indexed: 12/14/2022] Open
Abstract
Background and study aims Published data on blue laser imaging (BLI) for detection and differentiation of colonic polyps are limited compared to narrow band imaging (NBI). This study investigated whether BLI can increase the detection rate of colonic polyps and adenomas when compared to white light imaging (WLI), and examined use of NICE (NBI International Colorectal Endoscopic) and JNET (Japan NBI Expert Team) classifications with BLI. Patients and methods Patients aged 50 years and above referred for colonoscopy were randomized to BLI or WLI on withdrawal. Detected polyps were characterized using NICE and JNET classifications under BLI mode and correlated with histology. Primary outcome was adenoma detection rate. Secondary outcomes were utility of NICE and JNET classifications to predict histology using BLI. Results A total of 182 patients were randomized to BLI (92) or WLI (90). Comparing BLI with WLI, the polyp detection rate was 59.8 % vs 40.0 %, P = 0.008, and the adenoma detection rate was 46.2 % vs 27.8 %, P = 0.010. NICE 1 and JNET 1 diagnosed hyperplastic polyps with sensitivity of 87.18 % and specificity of 84.35 %. NICE 2 diagnosed low- (LGD) or high-grade dysplasia (HGD) with sensitivity of 92.31 % and specificity of 77.45 %. JNET 2A diagnosed LGD with sensitivity of 91.95 %, and specificity of 74.53 %. Four cases of focal HGD all had JNET 2A morphology. Conclusion BLI increased adenoma detection rate compared to WLI. NICE and JNET classifications can be applied when using BLI for endoscopic diagnosis of HP and LGD but histological confirmation remains crucial.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital,Corresponding author Tiing Leong Ang Department of Gastroenterology and HepatologyChangi General Hospital2 Simei Street 3Singapore 529889+6562830402
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | - Yu Jen Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | | | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | | | | | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital
| | | | - Lai Mun Wang
- Department of Laboratory Medicine, Changi General Hospital
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Li JW, Ang TL, Wang LM, Kwek ABE, Tan MTK, Fock KM, Teo EK. Endoscopic submucosal dissection of colorectal neoplasms: an audit of its safety and efficacy in a single tertiary centre in Singapore. Singapore Med J 2019; 60:526-531. [PMID: 30773601 DOI: 10.11622/smedj.2019022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) provides a higher en bloc and R0 resection rate than endoscopic mucosal resection. Colorectal ESD is not widely used because of its technical difficulty and risk of complications, especially for right-sided colonic lesions. We audited the clinical outcomes of our initial experience with colorectal ESD. METHODS We reviewed data collected from a prospective registry of patients who underwent colorectal ESD from December 2014 to March 2018. Therapeutic outcomes and procedure-related complications were analysed. RESULTS A total of 41 patients (mean age 67.4 years, 21 male) underwent colorectal ESD. The distribution of the lesions was as follows: rectum (n = 9), sigmoid colon (n = 8), descending colon (n = 6), splenic flexure (n = 1), transverse colon (n = 5), ascending colon (n = 8) and caecum (n = 4). The mean size was 23 (range 12-50) mm. En bloc resection was achieved in 35 (85.4%) out of 41 patients, and R0 resection or clear resection margins was achieved in 33 (94.3%) of the en bloc resection patients. The lesion was upstaged in 14 (34.1%) patients after ESD. Colonic perforation occurred in 3 (7.3%) patients during ESD and was successfully treated with endoscopic clips. There was no procedure-related bleeding. No patient required surgery for management of complications. The median duration of hospitalisation was 1 (range 0-7) day. Four patients with lesions that were upstaged after ESD, from high-grade dysplasia to intramucosal carcinoma with deep submucosal invasion, were referred for colectomy. CONCLUSION Our early outcome data was comparable to that from large published series. ESD is an effective and feasible treatment for colorectal lesions.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Lai Mun Wang
- Department of Laboratory Medicine, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Ang TL, Kwek ABE, Wang LM. Diagnostic Endoscopic Ultrasound: Technique, Current Status and Future Directions. Gut Liver 2019; 12:483-496. [PMID: 29291601 PMCID: PMC6143442 DOI: 10.5009/gnl17348] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/03/2017] [Accepted: 10/10/2017] [Indexed: 12/12/2022] Open
Abstract
Endoscopic ultrasound (EUS) is now well established as an important tool in clinical practice. From purely diagnostic imaging, it has progressed to include tissue acquisition, which provided the basis for therapeutic procedures. Even as interventional EUS developed, there has been ongoing progress in EUS diagnostic capabilities due to improved imaging systems, better needles for tissue acquisition and development of enhanced imaging functions such as contrast harmonic EUS (CHEUS) and EUS elastography. EUS is well established for differentiation of subepithelial lesions, for T-staging of luminal gastrointestinal and pancreaticobiliary malignancies, for differentiation of benign pancreaticobiliary disorders and for diagnostic tissue acquisition, which can be achieved by EUS-guided fine needle aspiration or by EUS-guided fine needle biopsy using dedicated biopsy needles. This review briefly describes the technique of performing EUS and then discusses its clinical utility in terms of gastrointestinal cancer staging, the evaluation of pancreaticobiliary disorders and tissue acquisition. Enhanced imaging techniques such as CHEUS and EUS elastography are briefly reviewed.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Lai Mun Wang
- Section of Histopathology, Department of Laboratory Medicine, Changi General Hospital, Singapore
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Abstract
Background and Objective: EUS-guided fine-needle biopsy (EUS-FNB) with acquisition of tissue core is possible with the use of 19G fine-needle aspiration (FNA) and dedicated biopsy needles. Published data of direct comparisons between biopsy needles are more limited compared to the abundant data comparing EUS-FNA with EUS-FNB. We performed a retrospective study to determine the difference in histologic yield between 19G FNA needle and EUS-FNB needles in patients with solid masses. Materials and Methods: Consecutive patients who underwent EUS-FNB of solid masses from January 2014 to July 2018 were identified from a database. The difference in histologic yield between needles was analyzed. Results: A total of 159 patients underwent 179 EUS-FNB procedures (median of 2 needle passes [range: 1–4]). The use of 19G FNA, 19G, 20G, and 22G FNB needles allowed acquisition of a histologic core in 67.4% (29/43), 72.5% (29/40), 82.1% (46/56), and 75.9% (22/29), respectively (P = 0.368). A significant difference in the yield of histologic core was detected when 19G FNA needle was compared with 22G Acquire™ FNB needle (67.4% [29/43] vs. 94.1% [16/17], P = 0.032). The presence of histologic core was significantly associated with a positive diagnosis (95.6% vs. 30.2%, P < 0.0001). Conclusion: EUS-FNB with acquisition of histologic core improved the diagnostic yield. Dedicated FNB needles appeared to achieve a higher yield of histologic core compared to 19G FNA needles.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Lai Mun Wang
- Department of Laboratory Medicine, Changi General Hospital, Singapore
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Abstract
INTRODUCTION This study examined the efficacy and safety of cholangiopancreatoscopy via the SpyGlass™ system in routine clinical practice. METHODS The clinical data of endoscopic retrograde cholangiopancreatography (ERCP) performed in a regional hospital from January 2013 to November 2016 was retrieved from an electronic database and reviewed. All patients who had undergone SpyGlass cholangiopancreatoscopy were enrolled. Patient demographics, procedure indication, technical success rates, clinical success rates and complication rates were analysed. A subanalysis of clinical outcomes was performed comparing the SpyGlass legacy (fibreoptic) and digital systems. RESULTS Out of 2,050 ERCP procedures performed, 47 patients underwent 50 cholangiopancreatoscopy procedures. Clinical indications were difficult common bile duct (CBD) stones (59.6%, n = 28), indeterminate CBD stricture (36.2%, n = 17), indeterminate pancreatic duct stricture (2.1%, n = 1) and proximally migrated CBD stent (2.1%, n = 1). Complete stone extraction was achieved in 26 (92.9%) out of 28 patients. Among patients with strictures, a correct diagnosis of malignancy based on image visualisation was achieved in all 11 cases. The sensitivity and specificity for SpyBite™ biopsies were 81.8% (95% confidence interval [CI] 48.2%-97.7%) and 100.0% (95% CI 15.8%-100.0%), respectively. The proximally migrated CBD stent was successfully extracted. Complications included pancreatitis (2.1%, n = 1), suspected sealed perforation after laser lithotripsy treated conservatively (2.1%, n = 1) and cholangitis (10.6%, n = 5). There was no difference in clinical outcomes between the SpyGlass legacy (n = 20) and digital (n = 30) systems. CONCLUSION SpyGlass cholangiopancreatoscopy is a safe and effective tool in routine clinical practice.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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14
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Lai Mun Wang
- Department of Laboratory Medicine, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - June Lee
- Department of General Surgery, Changi General Hospital, Singapore
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Li JW, Ang TL, Kam JW, Kwek ABE, Teo EK. The learning curve for needle knife precut sphincterotomy revisited. United European Gastroenterol J 2017; 5:1116-1122. [PMID: 29238590 DOI: 10.1177/2050640617701808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/26/2017] [Indexed: 12/22/2022] Open
Abstract
Background There is no consensus on what constitutes adequate training for needle knife precut sphincterotomy. Objective The purpose of this study was to determine the number of procedures required before effective and safe precut sphincterotomy can be achieved. Methods This retrospective study examined the cumulative experience of a single endoscopist from January 2006-December 2015. Precut sphincterotomy success and complication rates were analyzed as a function of number of procedures performed. Acceptable success and complication rates were defined as 85% and 10% respectively. A one-sided binomial test was used to test success and complication rates of every 25 precut sphincterotomies performed. Results The index endoscopic retrograde cholangiopancreatography was successful in 141/158 (89.2%) patients who underwent precut sphincterotomy. This increased to 148/158 (93.7%) when endoscopic retrograde cholangiopancreatography was repeated on another day. Six precut sphincterotomies were required to achieve an 85% success probability. This was maintained consistently above 85% after 13 precuts, and was significantly higher (91.2%; p = 0.029) than 85% at the 125th precut. Bleeding and pancreatitis developed in 2/158 (1.3%) and 5/158 (3.2%). Probability of either complications remained below 5% after 50 precuts. No perforation occurred. Conclusion At least 13 precut sphincterotomies were required to achieve a sustained success rate greater than 85%. The probability of bleeding or pancreatitis was less than 5% after 50 precut sphincterotomies.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jia Wen Kam
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Ang TL, Kwek ABE, Poh WT. An unusual case of recurrent hepatocellular carcinoma presenting as an indeterminate right intrahepatic duct stricture. Endoscopy 2017; 48 Suppl 1:E121-2. [PMID: 27008563 DOI: 10.1055/s-0042-104280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Wee Teng Poh
- Department of Laboratory Medicine, Changi General Hospital, Singapore
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Song M, Kwek ABE, Law NM, Ong JPL, Tan JYL, Harichander Thurairajah P, Ang DSW, Ang TL. Efficacy of small-volume simethicone given at least 30 min before gastroscopy. World J Gastrointest Pharmacol Ther 2016; 7:572-578. [PMID: 27867691 PMCID: PMC5095577 DOI: 10.4292/wjgpt.v7.i4.572] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/16/2016] [Accepted: 10/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the efficacy of 5 mL simethicone solution in decreasing gastric foam if given at least 30 min before gastroscopy.
METHODS This was a randomized, placebo controlled, endoscopist blinded study performed at Changi General Hospital. Patients were at least 21 years old, had no prior surgical resection of the upper gastrointestinal tract, and scheduled for elective diagnostic gastroscopies. The primary outcome was the total mucosal visibility score (TMVS) which was evaluated using McNally score. The sample size was calculated to be 24 per group (SD 2.4, 80% power, P < 0.05, 2-sample t test).
RESULTS Fifty-four patients were randomised to receive either simethicone [1 mL liquid simethicone (100 mg) in 5 mL of water] or placebo (5 mL of water) at least 30 min before their gastroscopy. Six accredited consultants conducted the gastroscopy, and the interobserver agreement of scoring TMVS was good with a Kappa statistic of 0.73. The simethicone group had significantly better mean TMVS compared to placebo (5.78 ± SD 1.65 vs 8.89 ± SD 1.97, P < 0.001). The improvement was statistically significant for the duodenum and the gastric antrum, angularis, body, and fundus. Percent 51.9 of patients in the simethicone group had a TMVS of 4 (no bubbles at all) to 5 (only 1 area with minimal bubbles), while in the placebo group 3.7% of patients had TMVS of 4 or 5. The number needed to treat was 2.1 to avoid a TMVS of 6 and more. The simethicone group also had a significantly shorter procedure time with less volume of additional flushes required during gastroscopy to clear away obscuring gastric foam.
CONCLUSION With a premedication time of at least 30 min, 5 mL simethicone can significantly decrease gastric foam, decrease the volume of additional flushes, and shorten gastroscopy time.
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Ang TL, Kwek ABE, Song M, Li JW, Thurairajah PH. Comparative study of strategies for preventing post-ERCP pancreatitis after early precut sphincterotomy for biliary access. J Dig Dis 2016; 17:692-696. [PMID: 27556283 DOI: 10.1111/1751-2980.12401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/14/2016] [Accepted: 08/21/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Needle knife precut sphincterotomy (PS) during endoscopic retrograde cholangiopancreatography (ERCP) has been associated with a high risk of post-ERCP pancreatitis (PEP). This study aimed to examine the effect of no prophylaxis, somatostatin, rectal diclofenac and pancreatic duct (PD) stenting in reducing rates of PEP in patients who underwent early PS. METHODS This was a retrospective comparative study and the study period was from January 2006 to December 2015. A standardized approach to early PS was used: (i) inadvertent guidewire cannulation of the PD > thrice; (ii) impacted bile duct stone; (iii) inability to achieve deep cannulation within 10 min. PEP prophylactic measures included: (i) none when there was minimal papilla trauma; (ii) somatostatin infusion; (iii) rectal diclofenac; (iv) PD stent. The difference in rates of PEP between the different strategies was analysed. RESULTS During the study period, PS was performed in 191 ERCP patients (mean age 66 years; 56.5% males). The ERCP success rate after PS was 93.2% (178/191). Overall the PEP rate was 3.1% (6/191) and the severity in all cases was mild. PEP occurred in 6.1% of patients with PD cannulation but not in those without (P = 0.016). PEP rates were 1.8%, 7.3%, 1.8% and 0% in control, somatostatin, diclofenac and PD stenting groups, respectively (P = 0.209). CONCLUSIONS There was no significant difference in PEP rates after early PS whether or not prophylactic measures were adopted if there was minimal papilla trauma. A trend towards lower PEP rates was observed in patients who had either rectal diclofenac or PD stenting, compared to somatostatin.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Mingjun Song
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Abstract
BACKGROUND Antibiotic resistance is an important cause of H. pylori treatment failure. This study aimed to examine the change in H. pylori antibiotic resistance profile in Singapore over the course of 15 years. MATERIALS AND METHODS The study period was from 2000 to 2014. Gastric mucosal biopsies obtained from H. pylori-positive patients were cultured. Antibiotic susceptibility to metronidazole, clarithromycin, levofloxacin, tetracycline, and amoxicillin was tested. The change in resistance rates over time was analyzed. RESULTS A total of 708 H. pylori isolates were cultured. There was a significant increase in resistance rates for metronidazole (2000-2002: 24.8%; 2012-2014: 48.2%; p < .001), clarithromycin (2000-2002: 7.9%; 2012-2014: 17.1%; p = .022), and levofloxacin (2000-2002: 5%; 2012-2014: 14.7%; p = .007). The resistance rates for tetracycline (2000-2002: 5%; 2012-2014: 7.6%) and amoxicillin (2000-2002: 3%; 2012-2014: 4.4%) remained stable. Increase in dual (2000-2002: 6.9%; 2012-2014: 9.4%; p = .479) and triple antibiotic resistance rates (2000-2002: 0; 2012-2014: 7.6%; p < .001) were observed. Overall, the most common dual and triple resistance patterns were metronidazole/clarithromycin (4.4%) and metronidazole/clarithromycin/levofloxacin (1.8%), respectively. CONCLUSIONS Over 15 years, H. pylori resistance rates to metronidazole, clarithromycin and levofloxacin had increased. There was increased resistance to multiple antibiotics.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Daphne Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Subbiah Dhamodaran
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
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Ang TL, Kongkam P, Kwek ABE, Orkoonsawat P, Rerknimitr R, Fock KM. A two-center comparative study of plastic and lumen-apposing large diameter self-expandable metallic stents in endoscopic ultrasound-guided drainage of pancreatic fluid collections. Endosc Ultrasound 2016; 5:320-327. [PMID: 27803905 PMCID: PMC5070290 DOI: 10.4103/2303-9027.191659] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Objectives: Endoscopic ultrasound-guided drainage of walled-off pancreatic fluid collections (PFCs) (pseudocyst [PC]; walled-off necrosis [WON]) utilizes double pigtail plastic stents (PS) and the newer large diameter fully covered self-expandable stents (FCSEMS) customized for PFC drainage. This study examined the impact of type of stent on clinical outcomes and costs. Patients and Methods: Retrospective two-center study. Outcome variables were technical and clinical success, need for repeat procedures, need for direct endoscopic necrosectomy (DEN), and procedure-related costs. Results: A total of 49 (PC: 31, WON: 18) patients were analyzed. Initially, PS was used in 37 and FCSEMS in 12. Repeat transmural drainage was required in 14 (PS: 13 [9 treated with PS, 4 treated with FCSEMS]; FCSEMS: 1 [treated with PS]) due to stent migration (PS: 3; FCSEMS: 1) or inadequate drainage (PS: 10). Technical success was 100%. Initial clinical success was 64.9% (25/38) for PS versus 91.7% (11/12) for FCSEMS (P = 0.074). With repeat transmural stenting, final clinical success was achieved in 94.6% and 100%, respectively (P = 0.411). Compared to FCSEMS, PS was associated with greater need for repeat drainage (34.2% vs. 6.3%, P = 0.032). The need for and frequency of DEN was similar between both groups, but PS required more frequent balloon dilatation. PS was significantly cheaper for noninfected PC. Costs were similar for infected PC and WON. Conclusion: PS was associated with a higher need for a second drainage procedure to achieve clinical success. The use of FCSEMS did not increase procedural costs for infected PC and WON.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Simei, Singapore
| | - Pradermchai Kongkam
- Department of Medicine, Faculty of Medicine, Gastrointestinal Endoscopy Excellent Center, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Simei, Singapore
| | - Piyachai Orkoonsawat
- Department of Medicine, Faculty of Medicine, Gastrointestinal Endoscopy Excellent Center, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of Medicine, Gastrointestinal Endoscopy Excellent Center, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Simei, Singapore
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Abstract
Chronic pancreatitis is associated with varied morphological complications, including intraductal stones, main pancreatic ductal strictures, distal biliary strictures and pseudocysts. Endoscopic therapy provides a less invasive alternative to surgery. In addition, extracorporeal shockwave lithotripsy improves the success rate of endoscopic clearance of intraductal stones. However, recent data from randomised trials have shown better long-term outcomes with surgical drainage for obstructive pancreatic ductal disease. In patients with distal biliary strictures, stent insertion leads to good immediate drainage, but after stent removal, recurrent narrowing is common. Endoscopic drainage of pancreatic pseudocysts has excellent outcome and should be accompanied by pancreatic ductal stenting when a ductal communication is evident. In those who remain symptomatic, endoscopic ultrasonography-guided coeliac plexus block may provide effective but short-term pain relief. In this review, we present the current evidence for the role of endotherapy in the management of patients with chronic pancreatitis.
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Affiliation(s)
- Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
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Ang TL, Kwek ABE, Seo DW, Paik WH, Cheng TY, Wang HP, Lau J. A prospective randomized study of the difference in diagnostic yield between endoscopic ultrasound-guided fine-needle aspiration (EUSFNA) needles with and without a side port in pancreatic masses. Endosc Int Open 2015; 3:E329-33. [PMID: 26356802 PMCID: PMC4554507 DOI: 10.1055/s-0034-1391964] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/04/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Two 22G needles with similar designs, apart from the absence (A) or presence of a side port (B), are available for endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). The side port was designed to increase diagnostic yield but this advantage was unproven. This study evaluated the difference in diagnostic yield between both needles in pancreatic masses. PATIENTS AND METHODS This was a prospective multicenter randomized cross-over study. Patients with pancreatic masses were randomized to one needle for the first two passes, followed by the other for the next two passes. A pathologist blinded to the needle assessed each puncture for cellularity and morphology. The diagnostic yield between both needles was compared. RESULTS In total, 30 patients were recruited (mean lesion size: 3.5 cm, range: 1.2 - 6.3). Comparison of cellularity adequacy: first pass: A vs. B: 26/30 vs. 24/30 (P = 0.488): 2nd pass: A vs. B: 25/30 vs. 26/30 (P = 0.718). Comparison of diagnostic accuracy: first pass: A vs. B: 22/30 vs. 23/30 (P = 0.766); after two passes: A vs. B: 26/30 vs. 26/30 (P = 1.0). When all four passes were assessed, adequate cellularity was obtained in 29/30 and the correct diagnosis was obtained in 28/30 patients. There were no procedural complications. CONCLUSIONS There was no significant difference in diagnostic yield between EUSFNA needles with or without a side port for pancreatic masses. STUDY REGISTRATION NCT02092519.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore,Corresponding author Tiing Leong Ang Department of Gastroenterology and HepatologyChangi General Hospital2 Simei Street 3Singapore 529889+65-67816202
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Dong Wan Seo
- Division of Gastroenterology, Asan Medical Centre, Seoul, Korea
| | - Woo Hyun Paik
- Division of Gastroenterology, Asan Medical Centre, Seoul, Korea
| | - Tsu-Yao Cheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - James Lau
- Department of Surgery, Chinese University of Hong Kong, Hong Kong, China
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Ang TL, Fock KM, Song M, Ang D, Kwek ABE, Ong J, Tan J, Teo EK, Dhamodaran S. Ten-day triple therapy versus sequential therapy versus concomitant therapy as first-line treatment for Helicobacter pylori infection. J Gastroenterol Hepatol 2015; 30:1134-9. [PMID: 25639278 DOI: 10.1111/jgh.12892] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/02/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Clarithromycin-based triple therapy (TT) is the first-line treatment for Helicobacter pylori infection in Singapore. There is awareness that TT may no longer be effective due to increased clarithromycin resistance rates. Sequential therapy (ST) and concomitant therapy (CT) are alternative treatment regimens. This study aimed to compare the efficacy of 10-day TT, ST, and CT as first-line treatment for H. pylori infection. METHODS A randomized study conducted in a teaching hospital. Patients aged 21 years and older with newly diagnosed H. pylori infection were randomized to 10-day TT, ST, or CT. Treatment outcome was assessed by 13-carbon urea breath test at least 4 weeks after therapy. Intention to treat (ITT), modified ITT (MITT), and per protocol (PP) analyses of the eradication rates were performed. RESULTS A total of 462 patients were enrolled (ST: 154; TT 155; CT 153). Patient demographics were similar. Eradication rates for ST versus TT versus CT: ITT analysis: 84.4% versus 83.2% versus 81.7% (P = not significant [NS]); MITT analysis: 90.3% versus 92.1% versus 94.7% (P = NS); PP analysis: 94.1% versus 92.8% versus 95.4% (P = NS). Antibiotic resistance rates for amoxicillin, clarithromycin, and metronidazole were 4.7%, 17.9%, and 48.1%, respectively. Dual clarithromycin and metronidazole resistance occurred in 7.5%. Dual resistance and lack of compliance were predictors of treatment failure. CONCLUSIONS TT, ST, and CT all achieved eradication rates above 80% on ITT and above 90% on MITT and PP analyses. Dual resistance and lack of compliance were predictors of treatment failure (clinicaltrials.gov: NCT02092506).
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Mingjun Song
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Daphne Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jeannie Ong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Subbiah Dhamodaran
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Ang TL, Eu Kwek AB, Fock KM, Teo EK. Endoscopic ultrasound-guided insertion of a large diameter fully covered self-expandable metallic stent as rescue therapy for recurrent infected walled off pancreatic necrosis after surgical necrosectomy. Endosc Ultrasound 2014; 3:245-8. [PMID: 25485273 PMCID: PMC4247533 DOI: 10.4103/2303-9027.144544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/16/2014] [Indexed: 01/10/2023] Open
Abstract
A 39-year-old man developed severe necrotizing gallstone pancreatitis complicated by infected pancreatic necrosis. Surgical necrosectomy was performed to control the on-going sepsis. Subsequently, there was a recurrence of an infected necrotic collection at the site of surgical necrosectomy, in the region of the pancreatic body and tail. He did not respond to conservative treatment with intravenous antibiotics. Pancreatic duct stenting was performed to treat pancreatic duct leak, followed by endoscopic ultrasound guided insertion of a large diameter fully covered self-expandable metallic stent to drain the infected collection. There was rapid and complete clinical recovery.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Ang TL, Kwek ABE, Tan SS, Ibrahim S, Fock KM, Teo EK. Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. Singapore Med J 2013; 54:206-11. [PMID: 23624447 DOI: 10.11622/smedj.2013074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. METHODS This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates. RESULTS Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered. CONCLUSION DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore.
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Ang TL, Teo EK, Ang D, Kwek ABE, Fock KM. A pilot study of contrast harmonic endosonography using DEFINITY™ in the evaluation of suspected pancreatic and peri-ampullary malignancies. J Interv Gastroenterol 2011; 1:160-165. [PMID: 22586529 DOI: 10.4161/jig.19958] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 07/04/2011] [Accepted: 11/10/2011] [Indexed: 12/18/2022]
Abstract
AIM: Contrast harmonic endosonography (CHEUS) is not widely available. This study assessed the utility of CHEUS using DEFINITY™, a second generation ultrasonic contrast agent, in the evaluation of suspected pancreatic and peri-ampullary malignancies. METHODS: Prospectively enrolled patients with suspected pancreatic and peri-ampullary malignancies underwent EUS followed by CHEUS. The incremental yield of CHEUS over EUS was analyzed. The gold standard for diagnosis of malignancy was positive cytology or histology; a negative diagnosis for malignancy was based on negative cytology or histology and benign clinical course. RESULTS: Twenty-nine patients were enrolled and underwent CHEUS. The final diagnoses were: pancreatic adenocarcinoma (16/29); metastases to pancreas (4/29); pancreatitis with inflammatory mass (4/29); normal pancreas with focal fat sparing (1/29); ampulla adenocarcinoma (2/29); serous cystic neoplasm (1/29); peri-pancreatic lymph node due to lymphoma (1/29). One bengin case of chronic pancreatitis had calcification casting artifacts that prevented accurate EUS examination and was excluded, leaving 28 cases for comparative analysis between EUS and CHEUS. CHEUS enhanced tumor margins. CHEUS detected vascular invasion missed by EUS in 2/16 patients with pancreatic adenocarcinoma. Masses appeared hypoechoic with EUS. With CHEUS malignant masses had an inhomogeneous hypoechoic pattern associated with abnormal vessels while lesions due to focal pancreatitis or fat sparing were characterized by diffuse enhancement (p<0.001). CONCLUSION: CHEUS improved the visualization of tumor margins and vascular invasion, and differentiated benign from malignant masses.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, Singapore
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Ang TL, Kwek ABE, Lim KBL, Teo EK, Fock KM. An analysis of the efficacy and safety of a strategy of early precut for biliary access during difficult endoscopic retrograde cholangiopancreatography in a general hospital. J Dig Dis 2010; 11:306-12. [PMID: 20883427 DOI: 10.1111/j.1751-2980.2010.00454.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The use of early precut during endoscopic retrograde cholangiopancreatography (ERCP) is controversial because of its association with a higher risk of complications. This study examined the efficacy and safety of a strategy of early precut for biliary access during difficult ERCP in a general hospital. METHODS Data from January 2007 to June 2009 were reviewed. Criteria for performing early precut were: (i) inadvertent guidewire cannulation of pancreatic duct on three occasions; (ii) biliary stone impacted at papilla; (iii) inability to achieve deep cannulation within 10 min. Study exclusion criteria were: (i) the inability to visualize the papilla because of anatomical distortions; (ii) complete tumour occlusion of distal bile duct; (iii) failure to adhere to inclusion criteria. The efficacy and safety of this strategy of early precut for biliary access was analyzed. RESULTS A total of 765 ERCP cases were analyzed. A precut was performed in 55 out of 765 cases (7.2%). There were no significant differences in terms of age, gender and diagnoses between the precut and no precut groups. After precut immediate biliary cannulation was achieved in 89% of patients and this increased to 98.2% with a repeat ERCP. The overall complication rate after ERCP was 2.1% (bleeding: 0.7%; pancreatitis: 1.3%; perforation: 0.3%). The only complication after the precut was pancreatitis, and this was not significantly different from the group without a precut (1.8 vs 1.3%). CONCLUSION The strategy of early precut for biliary access was safe and effective.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, Singapore.
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Kwek ABE, Tan EK, Luman W. Dysphagia as a side effect of botulinum toxin injection. Med J Malaysia 2004; 59:544-6. [PMID: 15779592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Dysphagia is a known adverse effect of botulinum toxin injection into the cervical region for dystonia. We present an unusual case of dysphagia arising from injection into the orbicularis oculi muscle, which has hitherto not been described. We postulate that her dysphagia was caused by distant side effects of botulinum toxin due to repeated injections. We recommend that clinicians should restrict the frequency of injections to as few life-time doses of the toxin as possible for adequate management of spasm. The practice of re-injecting patients routinely every three months, or at the first return of mild spasms should be discouraged.
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Affiliation(s)
- A B E Kwek
- Department of Gastroenterology, Singapore General Hospital
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