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Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker’s diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker’s diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung’s disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.
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Purpose@#Endoscopic drainage is an established treatment modality for adult patients with pancreatic fluid collections (PFCs). Available data regarding the efficacy and safety of endoscopic drainage in pediatric patients are limited. In this systematic review and metaanalysis, we aimed to analyze the outcomes of endoscopic drainage in children with PFCs. @*Methods@#A literature search was performed in Embase, PubMed, and Google Scholar for studies on the outcomes of endoscopic drainage with or without endoscopic ultrasonography (EUS) guidance in pediatric patients with PFCs from inception to May 2021. The study’s primary objective was clinical success, defined as resolution of PFCs. The secondary outcomes included technical success, adverse events, and recurrence rates. @*Results@#Fourteen studies (187 children, 70.3% male) were included in this review. The subtypes of fluid collection included pseudocysts (60.3%) and walled-off necrosis (39.7%).The pooled technical success rates in studies where drainage of PFCs were performed with and without EUS guidance were 95.3% (95% confidence interval [CI], 89.6–98%; I2 =0) and 93.9% (95% CI, 82.6–98%; I2 =0), respectively. The pooled clinical success after one and two endoscopic interventions were 88.7% (95% CI, 82.7–92.9%; I2 =0) and 92.3% (95% CI, 87.4–95.4%; I2 =0), respectively. The pooled rate of major adverse events was 6.3% (95% CI, 3.3–11.4%; I2 =0). The pooled rate of recurrent PFCs after endoscopic drainage was 10.4% (95% CI, 6.1–17.1%; I2 =0). @*Conclusion@#Endoscopic drainage is safe and effective in children with PFCs. However, future studies are required to compare endoscopic and EUS-guided drainage of PFCs in children.
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Background: Fistula in ano is a very common perianal condition seen in outpatient departments. Fistulotomy and fistulectomy are two conventional options of surgery. The present study is designed to observe wound healing time and mean postoperative pain score in the comparison of outcome of the fistulectomy to fistulotomy with marsupialization. Methods: This prospective randomized trial was conducted in the surgical department of the Civil Hospital Karachi for a period of 12 months, in which 60 patients with low anal fistula were divided into 2 groups. Thirty patients in group A were treated with fistulectomy, and 30 in group B were treated with fistulotomy with marsupialization. The postoperative pain severity was assessed after 24 hrs through a visual analogue scale and on weekly and fortnightly follow-ups for 6 weeks. Wound healing was assessed by clinical examination on weekly and fortnightly follow-ups for 6 weeks to estimate the mean healing time. Results: The mean pain score was significantly lower in group B in comparison to group A (3.6±1.99 versus 2.40±1.52; p=0.01). The mean wound healing time was shorter in group B in comparison to group A (4.23±0.77 versus 5.80±0.41 weeks; p=0.0005). Conclusion: Fistulotomy with marsupialization is a simple, easy, and more effective method than fistulectomy for the treatment of simple perianal fistula. (AU)
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Rectal Fistula/surgery , Colorectal Surgery/methods , Rectal Fistula/therapyABSTRACT
Background/Aims@#Information on pediatric inflammatory bowel disease (PIBD) and very early onset IBD (VEOIBD) are sparse in India, where IBD is emerging. We aimed to evaluate characteristics of VEOIBD and later onset PIBD (LO-PIBD) in India. @*Methods@#We performed retrospective analysis of a large, prospectively maintained IBD registry. PIBD was divided in to VEOIBD ( 6 months) was significantly lower in VEOIBD (40.9%) than in LO-PIBD (78.8%) (P< 0.001). Compared to other Asian and Western studies, extensive UC (72.5%) and complicated CD (stricturing/penetrating: 42.7%) were relatively more common. Perianal CD was relatively less frequent (7.4%). PIBD had a significantly higher number of complicated and ileal CD and extensive UC comparison to adult cohort of the registry. @*Conclusions@#VEOIBD has more aggressive phenotype than LO-PIBD. Disease appears distinct from other Asian and Western studies and adult onset disease, with more complicated CD and extensive UC.
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Background/Aims@#Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia. The technique of POEM is still evolving and the impact of length of esophageal myotomy on the outcomes of POEM is not known. In this study, we aim to compare the outcomes of short (3 cm) versus long (6 cm and above) esophageal myotomy in patients undergoing POEM for achalasia cardia. @*Methods@#Consecutive patients with idiopathic achalasia (type I and II) were randomized to receive short (3 cm) or long esophageal myotomy (≥ 6 cm).Both groups were compared for clinical success, operative time, adverse events, and gastroesophageal reflux disease (GERD). @*Results@#Seventy-one consecutive patients with type I and II achalasia underwent POEM with short (n = 34) or long (n = 37) esophageal myotomy techniques. Mean length of esophageal myotomy in short and long groups was 2.76 ± 0.41 and 7.97 ± 2.40, respectively (P < 0.001). Mean operative time was significantly shorter in short myotomy group (44.03 ± 13.78 minutes and 72.43 ± 27.28 minutes, P < 0.001). Clinical success was comparable in both arms at 1-year (Eckardt score 0.935 ± 0.929 vs 0.818 ± 0.983, P = 0.627).Improvement in objective parameters including integrated relaxation pressure and barium column height at 5 minutes was similar in both groups. GERD was detected in 50.88% patients with no significant difference in short and long myotomy groups (44.44% vs 56.67%, P = 0.431). @*Conclusions@#A short esophageal myotomy is non-inferior to long myotomy with regards to clinical success, adverse events, and GERD in cases with type I and II achalasia. Reduced operating duration favors short esophageal myotomy in these patients.
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Traumatic brain injury (TBI) causes disability and death, accelerating the progression towards Alzheimer’s disease and Parkinson’s disease (PD). TBI causes serious motor and cognitive impairments, as seen in PD that arise during the period of the initial insult. However, this has been understudied relative to TBI induced neuroinflammation, motor and cognitive decline that progress towards PD. Neuronal ubiquitin-C-terminal hydrolase- L1 (UCHL1) is a thiol protease that breaks down ubiquitinated proteins and its level represents the severity of TBI. Previously, we demonstrated the molecular action of glia maturation factor (GMF); a proinflammatory protein in mediating neuroinflammation and neuronal loss. Here, we show that the weight drop method induced TBI neuropathology using behavioral tests, western blotting, and immunofluorescence techniques on sections from wild type (WT) and GMF-deficient (GMF-KO) mice. Results reveal a significant improvement in substantia nigral tyrosine hydroxylase and dopamine transporter expression with motor behavioral performance in GMF-KO mice following TBI. In addition, a significant reduction in neuroinflammation was manifested, as shown by activation of nuclear factor-kB, reduced levels of inducible nitric oxide synthase, and cyclooxygenase- 2 expressions. Likewise, neurotrophins including brain-derived neurotrophic factor and glial-derived neurotrophic factor were significantly improved in GMF-KO mice than WT 72 h post-TBI. Consistently, we found that TBI enhances GFAP and UCHL-1 expression and reduces the number of dopaminergic TH-positive neurons in WT compared to GMF-KO mice 72 h post-TBI. Interestingly, we observed a reduction of THpositive tanycytes in the median eminence of WT than GMF-KO mice. Overall, we found that absence of GMF significantly reversed these neuropathological events and improved behavioral outcome. This study provides evidence that PD-associated pathology progression can be initiated upon induction of TBI.
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Background@#The poultry industry in Pakistan has flourished since the 1960s; however, there are scarce data regarding the impact of occupational exposure on the pulmonary health of farm workers in terms of years working in the industry. The objective of the present study was to assess the effect of poultry environment on the health of occupationally exposed poultry farmers in countries of warm climatic regions, such as Pakistan. This study will also show the effect of exposure to poultry facilities on the health of poultry farmers in the context of low-income countries with a relatively inadequate occupational exposure risk management. @*Materials and methods@#The lung function capacity of 79 poultry workers was measured using a spirometer. Along with spirometry, a structured questionnaire was also administrated to obtain information about age, height, weight, smokersonsmokers, years of working experience, and pulmonary health of farm workers. The workers who were directly involved in the care and handling of birds in these intensive facilities were considered and divided into four groups based on their years of working experience: Group I (3-10 months), Group II (1-5 years), Group III (6-10 years), and Group IV (more than 11 years). The forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and the FEV1/FVC ratio were considered to identify lung function abnormalities. Statistical analysis was carried out using independent sample t test, Chi-square test, Pearson's correlation, and linear regression. @*Results@#Based on the performed spirometry, 68 (86 %) of workers were found normal and healthy, whereas 11 (14 %) had a mild obstruction. Of the 11 workers with mild obstruction, the highest number with respect to the total was in Group IV (more than 11 years of working experience) followed by Group III and Group II. Most of the workers were found healthy, which seems to be because of the healthy survivor effect. For the independent sample t test, a significant difference was noticed between healthy and nonhealthy farmers, whereas Chi-square test showed a significant association with height, drugs, and working experience. Linear regression that was stratified by respiratory symptoms showed for workers with symptoms, regression models for all spirometric parameters (FVC, FEV1, and FEV1/FVC) have better predictive power or R square value than those of workers without symptoms. @*Conclusion@#These findings suggest that lung function capacity was directly related to years of working experience. With increasing number of working years, symptoms of various respiratory problems enhanced in the poultry workers. It should be noted that most of the poultry workers were healthy and young, the rationale being that there is a high turnover rate in this profession. The mobility in this job and our finding of 86% of the healthy workers in the present study also proposed healthy worker survivor effect.
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The objective of the study was to evaluate different types of cancer and its chemotherapy in various ethnic groups of Pakistan. Ethnic groups includes, Pukhtoons, Punjabis, Sindhis, Muhajirs, Siraikis, Memoons, Hazaras, Hindkos, Baltis, Gilgitis, Kashmiris, and Afghanis. The data was collected from well reputed hospitals located in the different provinces of Pakistan. The collected data was taken from 15 hospitals where around 8500 patients visited during 2010 to 2017. From the visited patients, 8356 were analyzed for their ethnicity, age and sex while, 144 patients (male 77 and female 67) were excluded from analysis due to incomplete information or loss of follow-up. Among 8356 patients, 3762 were male (45%) whereas, 4594 were female (55%). The chemotherapy was carried out as per National Comprehensive Cancer Network guidelines (NCCN- guidelines). The most common five prevalent cancer among these ethnic groups were Head and Neck, Blood, Respiratory, Genito-urinary and Breast cancer. The most common cancer in female was breast cancer while, head and neck cancer was more prevalent in male. It can be concluded that the prevalence of cancer in Pakistan is very alarming, which may be due to lack of awareness, illiteracy, lack of national cancer control programs, and economics issues.
Subject(s)
Humans , Male , Female , Pakistan/ethnology , Ethnicity/classification , Prevalence , Retrospective Studies , Drug Therapy/instrumentation , Neoplasms/pathology , Breast Neoplasms/physiopathology , /classification , Head and Neck Neoplasms/physiopathologyABSTRACT
Background: The objective of the study was to evaluate analgesic activity of ethanolic extract, methanol and benzene fraction of Myristica fragrans on wistar albino rats.Methods: The present study was carried out in the department of pharmacology JNMC AMU and F.H. Medical College, Agra. The analgesic activity was evaluated by employing the Eddy’s hot plate method and tail flick response method. In both the tests, Rats of either sex weighing 150-200 g were used. The total number of animals n=36 were allocated to six groups. Each group consist of six animals each. The response noted in animals that were tested by hot plate method was reaction time for licking/biting of both the paws before and after administration of control & test drugs. However in Tail flick test, the pain threshold response was recorded before and after administration of control & test drugs. The statistical analysis was done by using one-way ANOVA. The data is expressed as Mean±SEM. P<0.05 was considered to be statistically significant.Results: Ethanolic extracts and methanol fraction of M. fragrans showed statistically significant (p<0.001) increase in reaction time for licking/biting in hot plate method. On the contrary a significant increase in pain threshold was also recorded in tail flick response test. It is interesting to note that no significant degree of analgesia related to any dose of benzene fraction was observed.Conclusions: The present study reveals the dose dependent significant analgesic activity of the extracts of M. fragrans i.e. ethanolic extracts and methanol fraction in both the test. However, the degree of analgesia was recorded significantly higher in groups received higher doses of extracts of M. fragrans.
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Objectives: To measure levels of empathy among undergraduate dental students in Pakistani Dentistry Institute and to find the difference with respect to gender and academic year in the dental college. Methods: This cross-sectional study was conducted at CMHLMC and IOD in Pakistan, from December 2018 to April 2019, and comprised dental students of all four years. A valid and reliable “The Toronto empathy questionnaire” was used for the collection of data. Responses were indicated on a four-point Likert scale and total scores ranged from 0-64, with higher values indicating higher levels of empathy. Eight out of sixteen items were positively worded and the remaining eight items were negatively worded. Comparison of empathy scores across the year of study was analyzed using one-way ANOVA whereas a t-test was utilized for gender differences. SPSS version 20 was used for data analysis. Results: Questionnaire was returned by 281 students, with a 94% response rate. First-year dentistry students scored the highest mean score of 3.0, followed by second and third-year students by scoring 2.8 whereas the final year students obtained the lowest mean empathy score of 2.7. When mean empathy scores were compared among students of all 4 years by ANOVA test, it was found to be statistically significant, F=3.22, p=0.02. No significant differences in empathy scores were found with respect to gender (p ≥ 0.05). Conclusion: The present study reported a decline of empathy mean scores among dentistry students as the years of study progressed. This study reflects the need for early exposure to clinical training, educational programs and innovative teaching strategies in the undergraduate dentistry curriculum by emphasizing on dentists-patient communication skills, which in turn could encourage dentistry students to become empathetic health professionals.
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Objective: Impacted third molars are a major problem in modern dentistry and the decision of whether to remove an impacted third molar is probably one of the most frequent treatment decisions faced by dentists. Impacted mandibular third molars are often associated with pericoronitis, periodontitis, cystic lesions, neoplasm, and pathological root resorption and can cause detrimental effects on the adjacent tooth. Therefore, the objective of the present study was to determine the frequency of different types of mandibular third molar impactions. Materials and Methods: This cross-sectional study was carried out in the outdoor patient Department of Oral and Maxillofacial Surgery, Multan Medical and Dental College, Multan during a period of 6 months from 15 December 2017 to 14 June 2018. After written informed consent, a total of 200 patients were recruited, diagnosed clinically and radiographically as having impacted mandibular 3rd molar. Angulation of impacted third molar was classified according to the long axis of the adjacent second molar on periapical and OPG radiographs. Statistical analysis was done through SPSS version 20. Results: Out of 200 patients, the frequency of mesioangular, vertical, distoangular, and horizontal impactions were 84 (42%), 60 (30%), 40 (20%), and 16 (8%) respectively. The depths of the impactions were 67 (33.5%) depth A, 92 (46%) depth B, and 41 (20.5%) depth C. Conclusion: Mesioangular impaction was more common followed by vertical. Depth B was the most common.
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Background: Extracranial head and neck schwannomas are rare tumors which are often clinically misdiagnosed. Preoperative diagnosis of these tumors is challenging but imperative for surgeons so as to avoid nerve damage during excision. Materials and Methods: Sixteen patients diagnosed with extracranial head and neck schwannomas over a period of 2 years were retrospectively analyzed. Clinical details including preoperative fine-needle aspiration cytology (FNAC) and/or computed tomography (CT)/magnetic resonance imaging (MRI) findings were retrieved. FNAC smears and formalin-fixed paraffin-embedded sections were evaluated. Results: Among these 16 tumors, 6 (37.5%) were located in the lateral aspect of neck, 4 (25%) in scalp, 2 (12.5%) in orbit, and one each (6.25%) in palate, tongue, submandibular gland and parotid gland. The mean patient age was 31.3 years. FNAC was performed in 14 cases, of which 8 cases (58.3%) showed features of benign nerve sheath tumor (BNST), two cases (14.2%) were inconclusive with possibility of mesenchymal lesion, two cases (14.2%) were inadequate, one case (8.3%) showed features suggestive of schwannoma, and a diagnosis of nerve sheath tumor inconclusive for malignancy was rendered in a single case. The sensitivity of FNAC in diagnosis of BNST was 71.4%. CT or MRI was performed in five cases, of which an accurate diagnosis was rendered only in one case of orbital schwannoma. Conclusion: Imaging has a limited role in the preoperative diagnosis of head and neck schwannomas owing to nonspecific radiological features. Cellular aspirate smears are helpful in accurate diagnosis even at unusual locations
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Diabetes mellitus is a world-widely public health issue associated with premature mortality, decreased quality of life and increased health-care expenditures. The aim of the review was to elevate the effect of apple cider vinegar on glycemic control, hyperlipidemia and obesity control in type 2 diabetes patients. Many clinical trials showed the hypoglycemic, hypolipidemic and anti-obesity effect of vinegar. Proposed mechanisms action of vinegar for the hypoglycemic, hypolipidemic effect are including slow gastric emptying, it promotes uptake of skeleton muscles glucose in the body and acetic acid may inhibit disaccharides activity in the small intestine blocking the complete digestion of starch molecules, suppression of hepatic glucose production and increased glucose utilization. Results of previous studies showed that apple cider vinegar has the potential of anti-diabetic, antihyperlipidemic and antiobesity effects in diabetes mellitus patients. Objective of review: The objective of the current review study was to investigate the effect of apple cider vinegar on glycemic control, hyperlipidemia and control on body weight in type 2 diabetes patients and other therapeutic and commercial effect of apple cider vinegar. Data sources: To collect data for relevant literature PubMed, Google Scholar, science direct and Cochrane sources were used.
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Aim: The aim of the trial was to measure the effect of apple cider vinegar on glycemic control and biochemical parameters in type 2 diabetes mellitus (DM) patients with poor glycemic control. Methods: A single-blind, randomized, placebo-controlled trial was conducted on 110 eligible types 2 DM patients who were selected and allocated into 2 groups. The interventional group was given 15 ml apple cider vinegar in 200 ml water during dinner for 3 months while the other group was placebo. Before and after HbA1C (glycosylated hemoglobin), fasting lipid profile, fasting blood sugar, anthropometrics, and dietary changes were assessed and analyzed using IBM SPSS version 20, through statistical tests. Formal ethical approval was obtained from the local institutional review board. Results: Significant mean change was found in interventional group in HbA1c (p<0.001), blood sugar fasting (p<0.001), total cholesterol (p=0.002), triglyceride (p=0.002) and hip-waist ratio (p=0.002). No significant change was observed in the mean of these statistics in the placebo group. No significant change was observed in height, weight, mid-upper arm ratio, and low density lipoprotein, high density lipoprotein and food frequency in intervention and placebo groups before and after. Conclusion: Apple cider vinegar if used regularly is effective in controlling diabetes, lowering hypercholesterolemia and hypertriglyceridemia in DM type 2 patients.
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The concept of theranostics, where individual patient-level biological information is used to choose the optimal therapy for that individual, has become more popular in the modern era of ‘personalised’ medicine. With the growth of theranostics, nuclear medicine as a specialty is uniquely poised to grow along with the ever-increasing number of concepts combining imaging and therapy. This special report summarises the status and growth of Theranostic Nuclear Medicine in Singapore.We will cover our experience with the use of radioiodine, radioiodinated metaiodobenzylguanidine, peptide receptor radionuclide therapy, prostate specific membrane antigen radioligand therapy, radium-223 and yttrium-90 selective internal radiation therapy.We also include a section on our radiopharmacy laboratory, crucial to our implementation of theranostic principles. Radionuclide theranostics has seen tremendous growth and we hope to be able to grow alongside to continue to serve the patients in Singapore and in the region.
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The concept of theranostics, where individual patient-level biological information is used to choose the optimal therapy for that individual, has become more popular in the modern era of ‘personalised’ medicine. With the growth of theranostics, nuclear medicine as a specialty is uniquely poised to grow along with the ever-increasing number of concepts combining imaging and therapy. This special report summarises the status and growth of Theranostic Nuclear Medicine in Singapore.We will cover our experience with the use of radioiodine, radioiodinated metaiodobenzylguanidine, peptide receptor radionuclide therapy, prostate specific membrane antigen radioligand therapy, radium-223 and yttrium-90 selective internal radiation therapy.We also include a section on our radiopharmacy laboratory, crucial to our implementation of theranostic principles. Radionuclide theranostics has seen tremendous growth and we hope to be able to grow alongside to continue to serve the patients in Singapore and in the region.
Subject(s)
Humans , Hope , Lutetium , Membranes , Nuclear Medicine , Prostate , Radium , Receptors, Peptide , Singapore , Theranostic Nanomedicine , YttriumABSTRACT
The antioxidant potential of leaf, stem, root and flower extracts of Quisqualis indica Linn. was assessed to verify its ethnopharmacological importance. Both polar and non-polar solvents like n-hexane, chloroform, ethanol and distilled water were used to obtain crude extracts. The chloroform extract of leaves showed the maximum %age yield, i.e. 27.3% while the n-hexane extract of stem showed the minimum yield, i.e. 0.2%. Five activities including DPPH free radical scavenging activity, ABTS+ assay, Total flavonoid components [TFC], Total phenolic components [TPC] and Metal chelating Assay [MC] were employed to evaluate the antioxidant activity of the plant. The ethanol extract of inflorescence of the plant displayed most elevated DPPH potential, i.e. 452.11%. Aqueous extract of root had highest value of TEAC i.e., 7.4515 mmol. The aqueous extract of flower displayed the highest level of phenolic contents with the value of 35 in terms of GAE mg/mL. On the other hand, the chloroform extract had the highest % bound iron value of 128 and the aqueous extract of flower showed a high concentration of Flavonoids having the value 347.65mg/l of Quercetin. It has been inferred that all parts of Quisqualis indica L. possess good antioxidant potential. Differents parts showed different antioxidant potentials hence they can be used as curative agents against human and animal ailments
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Malignancies of the pancreatobiliary system are usually unresectable at the time of diagnosis. As a consequence, a majority of these cases are candidates for palliative care. With advances in chemotherapeutic agents and multidisciplinary care, the survival rate in pancreatobiliary malignancies has improved. Therefore, there is a need to provide an effective and long-lasting palliative care for these patients. Endoscopic palliation is preferred to surgery as the former is associated with equal efficacy and reduced morbidity. The main role of endoscopic palliation in the vast majority of pancreatobiliary malignancies includes biliary and enteral stenting for malignant obstructive jaundice and gastric outlet obstruction, respectively. Recent advances in endoscopic palliation appear promising in imparting long-lasting relief of symptoms. Use of radiofrequency ablation and photodynamic therapy in malignant biliary obstruction has been shown to improve the survival rates as well as the patency of biliary stents. The emergence of endoscopic ultrasound (EUS) as a therapeutic tool has enhanced the capability of minimally invasive palliation in pancreatobiliary cancers. EUS is a valuable alternative to endoscopic retrograde cholangiopancreatography for the palliation of obstructive jaundice. More recently, EUS is emerging as an effective primary modality for biliary and gastric bypass.
Subject(s)
Humans , Catheter Ablation , Cholangiopancreatography, Endoscopic Retrograde , Diagnosis , Gastric Bypass , Gastric Outlet Obstruction , Jaundice, Obstructive , Palliative Care , Pancreatic Neoplasms , Photochemotherapy , Stents , Survival Rate , UltrasonographyABSTRACT
Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.
Subject(s)
Humans , Bile Ducts , Catheterization , Cholangiopancreatography, Endoscopic Retrograde , Constriction, Pathologic , Drainage , Duodenal Obstruction , Duodenum , Endoscopy , Gastric Outlet Obstruction , Jaundice, Obstructive , Length of Stay , Prognosis , Stents , UltrasonographyABSTRACT
Unlike North America and European Union (EU), Asian continent appears to be an ideal destination for conducting cost-effective clinical trials utilizing the pool of treatment naïve subjects. With a population approaching 4.5 billion, recruitment of subjects can be done without a fear of limited patient pool across Asia. The burden of infectious and chronic diseases is also higher in Asian countries. The emerging clinical trial markets particularly China, South Korea, and Taiwan offers genetic diversity in population group, thus promoting the quality and generalizability of clinical trial’s data. Nonetheless, several challenges also exist for the Western sponsors in majority of the Asian countries; regulatory, operational and infrastructural challenges are atthe forefront. Challenges under the heads regulatory, operational, infrastructural, language and cultural, ethics, and future challenges have been discussed. SWOT analysis of Asian clinical trial’s market exhibits enormous opportunities for study sponsorswith manageable threats.