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Article ; Online: Peroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review.

North, Adam / Tewari, Nilanjana

Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus

2023 Volume 37, Issue 1

Abstract: Peroral endoscopic myotomy (POEM) is an intervention for the treatment of achalasia which has gained popularity over the last decade. It's efficacy and invasiveness are comparable to laparoscopic Heller myotomy (LHM). The purpose of this systematic ... ...

Abstract	Peroral endoscopic myotomy (POEM) is an intervention for the treatment of achalasia which has gained popularity over the last decade. It's efficacy and invasiveness are comparable to laparoscopic Heller myotomy (LHM). The purpose of this systematic review is to compare POEM to existing therapies. The systematic review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. MEDLINE, EMBASE, Web of Science and Cochrane Libraries were searched using keywords: esophageal achalasia, POEM, LHM, pneumatic dilation (PD), and related terms. The studied outcomes were Eckardt score, clinical success, hospital stay, cost-utility analysis, complications, and post-treatment gastro-esophageal reflux disease. Articles were reviewed by one researcher and uncertainty was resolved by a second researcher. The search strategy retrieved 1948 citations. After removing duplicates and applying the exclusion criteria, 91 studies were selected for full-text review of which a total of 31 studies were considered eligible for further analysis, including two studies which were found through manual searching. POEM has improved efficacy compared to PD with similar cost-effectiveness. POEM results showed comparable patient outcomes when compared with laparoscopic myotomy. Overall, POEM is a feasible first-line treatment for achalasia.
MeSH term(s)	Humans ; Esophageal Achalasia/surgery ; Esophageal Sphincter, Lower/surgery ; Heller Myotomy/methods ; Dilatation ; Treatment Outcome ; Myotomy/methods ; Natural Orifice Endoscopic Surgery/methods
Language	English
Publishing date	2023-07-28
Publishing country	United States
Document type	Systematic Review ; Journal Article
ZDB-ID	639470-x
ISSN	1442-2050 ; 1120-8694
ISSN (online)	1442-2050
ISSN	1120-8694
DOI	10.1093/dote/doad055
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Article ; Online: A comparison of three methods to assess body composition.

Tewari, Nilanjana / Awad, Sherif / Macdonald, Ian A / Lobo, Dileep N

Nutrition (Burbank, Los Angeles County, Calif.)

2017 Volume 47, Page(s) 1–5

Abstract: Objective: The aim of this study was to compare the accuracy of measurements of body composition made using dual x-ray absorptiometry (DXA), analysis of computed tomography (CT) scans at the L3 vertebral level, and bioelectrical impedance analysis (BIA). ...

Abstract	Objective: The aim of this study was to compare the accuracy of measurements of body composition made using dual x-ray absorptiometry (DXA), analysis of computed tomography (CT) scans at the L3 vertebral level, and bioelectrical impedance analysis (BIA). Methods: DXA, CT, and BIA were performed in 47 patients recruited from two clinical trials investigating metabolic changes associated with major abdominal surgery or neoadjuvant chemotherapy for esophagogastric cancer. DXA was performed the week before surgery and before and after commencement of neoadjuvant chemotherapy. BIA was performed at the same time points and used with standard equations to calculate fat-free mass (FFM). Analysis of CT scans performed within 3 mo of the study was used to estimate FFM and fat mass (FM). Results: There was good correlation between FM on DXA and CT (r Conclusion: Although a systematic error underestimating FFM was demonstrated with BIA, it may be a useful modality to quantify body composition in the clinical situation.
MeSH term(s)	Absorptiometry, Photon/statistics & numerical data ; Aged ; Anthropometry/methods ; Body Composition ; Clinical Trials as Topic ; Cohort Studies ; Electric Impedance ; Female ; Humans ; Male ; Middle Aged ; Reproducibility of Results ; Tomography, X-Ray Computed/statistics & numerical data
Language	English
Publishing date	2017-09-25
Publishing country	United States
Document type	Comparative Study ; Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	639259-3
ISSN	1873-1244 ; 0899-9007
ISSN (online)	1873-1244
ISSN	0899-9007
DOI	10.1016/j.nut.2017.09.005
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Article ; Online: Early outcomes following EndoFLIP-tailored peroral endoscopic myotomy (POEM): the establishment of POEM services in two UK centers.

Knight, William / Kandiah, Kaveetha / Vrakopoulou, Zoi / White, Annabel / Barbieri, Lavinia / Tewari, Nilanjana / Couch, Jennifer / DiMaggio, Francesco / Barley, Mark / Ragunath, Krish / Catton, James / Botha, Abraham

Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus

2022 Volume 36, Issue 8

Abstract: Peroral endoscopic myotomy (POEM) is a safe and effective minimally invasive treatment for achalasia. Postoperative reflux rates remain high. The functional luminal imaging probe (FLIP) allows intraoperative measurement of lower esophageal distensibility ...

Abstract	Peroral endoscopic myotomy (POEM) is a safe and effective minimally invasive treatment for achalasia. Postoperative reflux rates remain high. The functional luminal imaging probe (FLIP) allows intraoperative measurement of lower esophageal distensibility during POEM. In theory, this enables a tailoring of myotomies to ensure adequate distensibility while minimizing postoperative reflux risk. Two prospectively collected POEM databases were analyzed from two UK tertiary upper GI centers. The operators in each center used FLIP measurements to ensure adequate myotomy. Outcome measures included Eckardt score (where <3 indicated clinical success) and proton-pump inhibitor use (PPI), collected at the first postoperative appointment. Length of stay was recorded as were complications. In all, 142 patients underwent POEM between 2015 and 2019. Overall, 90% (128/142) had postoperative Eckardt scores of <3 at 6 weeks. Clinical success improved to 93% (66/71) in the latter half of each series with a significantly higher rate of complete symptom resolution (53 versus 26%, P = 0.003). In all, 79% of the poor responders had previous interventions compared with 55% of responders (P = 0.09). Median post-myotomy distensibility index was 4.0 mm2/mmHg in responders and 2.9 in nonresponders (P = 0.16). Myotomy length of <7 cm was associated with 93% clinical success and 40% post op PPI use compared with 60% PPI use with longer myotomies. There were two type IIIa, two type IIIb, and one IV Clavien-Dindo complications. This is the largest series of endoluminal functional lumen imaging probe (EndoFLIP)-tailored POEM in the UK to date. The shorter myotomies, allowed through EndoFLIP tailoring, remained clinically effective at 6 weeks. Complete symptom response rates improved in the latter half of each series. More data will be needed from high-volume collaborations to decipher optimal myotomy profiles based on EndoFLIP parameters.
MeSH term(s)	Humans ; Natural Orifice Endoscopic Surgery/methods ; Esophageal Achalasia/surgery ; Treatment Outcome ; Gastroesophageal Reflux ; Myotomy/methods ; United Kingdom ; Esophageal Sphincter, Lower ; Esophagoscopy/methods
Language	English
Publishing date	2022-12-22
Publishing country	United States
Document type	Journal Article
ZDB-ID	639470-x
ISSN	1442-2050 ; 1120-8694
ISSN (online)	1442-2050
ISSN	1120-8694
DOI	10.1093/dote/doac110
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Article: Postoperative inflammation and insulin resistance in relation to body composition, adiposity and carbohydrate treatment: A randomised controlled study

Tewari, Nilanjana / Awad, Sherif / Duška, František / Williams, Julian P / Bennett, Andrew / Macdonald, Ian A / Lobo, Dileep N

Clinical nutrition. 2019 Feb., v. 38, no. 1

2019

Abstract: The aims of this study were to identify whether differences in distribution of adipose tissue and skeletal muscle in obese and non-obese individuals contribute to the magnitude of the postoperative inflammatory response and insulin resistance, with and ... ...

Abstract	The aims of this study were to identify whether differences in distribution of adipose tissue and skeletal muscle in obese and non-obese individuals contribute to the magnitude of the postoperative inflammatory response and insulin resistance, with and without preoperative treatment with carbohydrate drinks.Thirty-two adults (16 obese/16 non-obese) undergoing elective major open abdominal surgery participated in this 2 × 2 factorial, randomised, double-blind, placebo-controlled study. Participants received Nutricia preOp® or placebo (800 ml on the night before surgery/400 ml 2–3 h preoperatively) after stratifying for obesity. Insulin sensitivity was measured using the hyperinsulinaemic-euglycaemic clamp preoperatively and on the 1st postoperative day. Vastus lateralis, omental and subcutaneous fat biopsies were taken pre- and postoperatively and analysed after RNA extraction. The primary endpoint was within subject differences in insulin sensitivity.Major abdominal surgery was associated with a 42% reduction in insulin sensitivity from mean(SD) M value of 37.3(11.8) μmol kg−1 fat free mass (FFM) to 21.7(7.4) μmol kg−1 FFM, but this was not influenced by obesity or preoperative carbohydrate treatment. Activation of the triggering receptor expressed on myeloid cells (TREM1) pathway was seen in response to surgery in omental fat samples. In postoperative muscle samples, gene expression differences indicated activation of the peroxisome proliferator-activated receptor (PPAR-α)/retinoid X-receptor (RXR-α) pathway in obese but not in non-obese participants. There were no significant changes in gene expression pathways associated with carbohydrate treatment.The reduction in insulin sensitivity associated with major abdominal surgery was confirmed but there were no differences associated with preoperative carbohydrates or obesity.
Keywords	RNA ; adipose tissue ; adiposity ; adults ; biopsy ; carbohydrates ; gene expression ; gene expression regulation ; inflammation ; insulin ; insulin resistance ; lean body mass ; muscles ; obesity ; peroxisome proliferator-activated receptor alpha ; placebos ; skeletal muscle ; subcutaneous fat
Language	English
Dates of publication	2019-02
Size	p. 204-212.
Publishing place	Elsevier Ltd
Document type	Article
ZDB-ID	604812-2
ISSN	1532-1983 ; 0261-5614
ISSN (online)	1532-1983
ISSN	0261-5614
DOI	10.1016/j.clnu.2018.01.032
Database	NAL-Catalogue (AGRICOLA)

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Zs.A 1774: Show issues

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Article ; Online: Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis following Esophagectomy.

Yanni, Fady / Singh, Pritam / Tewari, Nilanjana / Parsons, Simon L / Catton, James A / Duffy, John / Welch, Neil T / Vohra, Ravinder S

World journal of surgery

2019 Volume 43, Issue 10, Page(s) 2483–2489

Abstract: Background: Several techniques have been described for esophagogastric anastomosis following esophagectomy. This study compared the outcomes of circular stapled anastomoses with semi-mechanical technique using a linear stapler.: Methods: ... ...

Abstract	Background: Several techniques have been described for esophagogastric anastomosis following esophagectomy. This study compared the outcomes of circular stapled anastomoses with semi-mechanical technique using a linear stapler. Methods: Perioperative data were extracted from a contemporaneously collected database of all consecutive esophagectomies for cancer with intrathoracic anastomoses performed in the Trent Oesophago-Gastric Unit between January 2015 and April 2018. Anastomotic techniques: circular stapled versus semi-mechanical, were evaluated and outcomes were compared. The primary outcome was anastomotic leak rate. Secondary outcomes included anastomotic stricture, overall complication rates, length of stay (LOS) and 30 day all-cause mortality. Results: One hundred and fifty-nine consecutive esophagectomies with intrathoracic anastomosis were performed during the study period. There were no significant differences between the two groups in terms of age, American Society of Anaesthesiologists score, Charlson comorbidity index and neoadjuvant therapies received. Circular stapled anastomoses were performed in 85 patients, while 74 patients received a semi-mechanical anastomosis. Clavien-Dindo complications II or more were higher in the circular stapled group (p = 0.02). There were 16 (10%) anastomotic leaks overall, three (4%) in semi-mechanical group versus 13 (15%) in the circular stapled group (p < 0.019). There was no statistically significant difference between the two groups in terms of LOS, 30-day mortality or the need for endoscopic dilatation of the anastomosis at 3 months follow-up. Conclusion: The move from a circular stapled to a semi-mechanical intrathoracic anastomosis has been associated with a reduced postoperative anastomotic leak rate following esophagectomy for esophageal cancer.
MeSH term(s)	Aged ; Anastomosis, Surgical/adverse effects ; Anastomosis, Surgical/methods ; Anastomotic Leak/epidemiology ; Databases, Factual ; Esophageal Neoplasms/surgery ; Esophagectomy/instrumentation ; Esophagectomy/methods ; Esophagectomy/mortality ; Female ; Follow-Up Studies ; Humans ; Length of Stay ; Male ; Middle Aged ; Postoperative Complications/epidemiology ; Surgical Stapling/methods ; Suture Techniques ; Treatment Outcome
Keywords	covid19
Language	English
Publishing date	2019-06-05
Publishing country	United States
Document type	Comparative Study ; Journal Article
ZDB-ID	224043-9
ISSN	1432-2323 ; 0364-2313
ISSN (online)	1432-2323
ISSN	0364-2313
DOI	10.1007/s00268-019-05057-0
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Zs.A 1336: Show issues

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Article ; Online: Regulation of food intake after surgery and the gut brain axis.

Tewari, Nilanjana / Awad, Sherif / Lobo, Dileep N

Current opinion in clinical nutrition and metabolic care

2013 Volume 16, Issue 5, Page(s) 569–575

Abstract: Purpose of review: To highlight recent developments relating control of food intake after surgery and the gut-brain axis by reviewing clinically relevant English language articles mainly from January 2011 to March 2013.: Recent findings: The gut- ... ...

Abstract	Purpose of review: To highlight recent developments relating control of food intake after surgery and the gut-brain axis by reviewing clinically relevant English language articles mainly from January 2011 to March 2013. Recent findings: The gut-brain axis involves a number of complex interactions between hypothalamic nuclei and the gastrointestinal tract. In the postoperative period, release of cytokines and neuromodulators are involved in the control of food intake. Analogues of neuromodulators have been developed and tested in animal studies. The emerging field of metabolic surgery has allowed study of these mechanisms in greater detail. Summary: The current epidemic of worldwide obesity demands further research into the mechanisms underlying control of food intake.
MeSH term(s)	Animals ; Appetite/physiology ; Bariatric Surgery ; Cytokines/metabolism ; Eating/physiology ; Gastrointestinal Tract/metabolism ; Ghrelin/metabolism ; Humans ; Hypothalamus/metabolism ; Insulin/metabolism ; Leptin/metabolism ; Neurotransmitter Agents/metabolism ; Obesity/surgery ; Postoperative Period
Chemical Substances	Cytokines ; Ghrelin ; Insulin ; Leptin ; Neurotransmitter Agents
Language	English
Publishing date	2013-09
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Review
ZDB-ID	1460178-3
ISSN	1473-6519 ; 1363-1950
ISSN (online)	1473-6519
ISSN	1363-1950
DOI	10.1097/MCO.0b013e3283638e97
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Zs.A 5586: Show issues

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Article ; Online: Postoperative inflammation and insulin resistance in relation to body composition, adiposity and carbohydrate treatment: A randomised controlled study.

Tewari, Nilanjana / Awad, Sherif / Duška, František / Williams, Julian P / Bennett, Andrew / Macdonald, Ian A / Lobo, Dileep N

Clinical nutrition (Edinburgh, Scotland)

2018 Volume 38, Issue 1, Page(s) 204–212

Abstract: Background & aims: The aims of this study were to identify whether differences in distribution of adipose tissue and skeletal muscle in obese and non-obese individuals contribute to the magnitude of the postoperative inflammatory response and insulin ... ...

Abstract	Background & aims: The aims of this study were to identify whether differences in distribution of adipose tissue and skeletal muscle in obese and non-obese individuals contribute to the magnitude of the postoperative inflammatory response and insulin resistance, with and without preoperative treatment with carbohydrate drinks. Methods: Thirty-two adults (16 obese/16 non-obese) undergoing elective major open abdominal surgery participated in this 2 × 2 factorial, randomised, double-blind, placebo-controlled study. Participants received Nutricia preOp Results: Major abdominal surgery was associated with a 42% reduction in insulin sensitivity from mean(SD) M value of 37.3(11.8) μmol kg Conclusion: The reduction in insulin sensitivity associated with major abdominal surgery was confirmed but there were no differences associated with preoperative carbohydrates or obesity.
MeSH term(s)	Abdomen/surgery ; Adipose Tissue/physiopathology ; Adiposity/physiology ; Adult ; Aged ; Body Composition/physiology ; Dietary Carbohydrates/administration & dosage ; Double-Blind Method ; Elective Surgical Procedures ; Female ; Humans ; Inflammation/physiopathology ; Insulin Resistance/physiology ; Male ; Middle Aged ; Muscle, Skeletal/physiology ; Obesity/physiopathology ; Postoperative Complications/physiopathology ; Preoperative Care/methods
Chemical Substances	Dietary Carbohydrates
Language	English
Publishing date	2018-02-15
Publishing country	England
Document type	Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't
ZDB-ID	604812-2
ISSN	1532-1983 ; 0261-5614
ISSN (online)	1532-1983
ISSN	0261-5614
DOI	10.1016/j.clnu.2018.01.032
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Article: The utilisation of the MUST nutritional screening tool on vascular surgical wards.

Tewari, Nilanjana / Rodrigues, Jeremy / Bothamley, Lydia / Altaf, Nishath / Awad, Sherif

BMJ quality improvement reports

2013 Volume 2, Issue 1

Abstract: Whilst malnutrition is prevalent in approximately 40% of general surgical patients, the prevalence of malnutrition and nutritional screening practices amongst vascular patients remain unknown. The Malnutrition Universal Screening Tool (MUST) is ... ...

Abstract	Whilst malnutrition is prevalent in approximately 40% of general surgical patients, the prevalence of malnutrition and nutritional screening practices amongst vascular patients remain unknown. The Malnutrition Universal Screening Tool (MUST) is recommended for risk screening and provides 3 scores for risk classification: 0=low risk, 1=intermediate risk, 2=high risk. The aim of this preliminary study was to evaluate the use of MUST on vascular wards. This prospective study was undertaken in a tertiary referral vascular unit in the UK. Patient demographics, utilisation of MUST by nursing staff (N-MUST) and referral to nutritional support teams (NST) were studied. When MUST was not completed by nursing staff, the study team (S-MUST) performed it. Fifty-three patients, median (interquartile range, IQR) age 67 (59-75) years were initially studied. For N-MUST: Overall MUST score was recorded in 18/25 (72%) patients, of whom 1 (4%) scored 2, whilst the remainder scored 0. For S-MUST: Overall MUST scores were recorded in 28 patients, MUST=0 in 75% and ≥2 in 21%. An educational session on use of MUST was delivered to nursing staff, as well as a Trust-wide educational initiative to improve assessment of nutritional status and, after a 2-month period, the study was repeated. The second cohort comprised forty-two patients, median (IQR) age 72 (64-79) years. For N-MUST: Overall MUST score was recorded in 37/40 (93%) patients, of whom 3 (8%) scored ≥2. For S-MUST: Overall MUST scores were recorded in 2 patients, MUST = 0 in 67% and ≥2 in 33%. Despite the ease of use of MUST, it was under-utilised on vascular wards. However, following provision of a dedicated educational programme to ward nursing staff, utilisation of MUST for risk scoring patients on admission increased to over 90%.
Language	English
Publishing date	2013-09-12
Publishing country	England
Document type	Journal Article
ZDB-ID	2677829-4
ISSN	2050-1315
ISSN	2050-1315
DOI	10.1136/bmjquality.u201374.w1122
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Article ; Online: Mixed periampullary adenocarcinoma and somatostatinoma with small bowel gastrointestinal stromal tumour in neurofibromatosis type 1.

Tewari, Nilanjana / Rollins, Katie / Gandhi, Nirav / Kaye, Phillip / Lobo, Dileep N

JOP : Journal of the pancreas

2014 Volume 15, Issue 6, Page(s) 600–603

Abstract: Context: Gastrointestinal (GI) involvement is present in about one quarter of cases of neurofibromatosis type 1 (NF1). Adenocarcinomas have been reported in several organs. Gastrointestinal stromal tumors are the most common GI lesion seen in NFI. GISTs ...

Abstract	Context: Gastrointestinal (GI) involvement is present in about one quarter of cases of neurofibromatosis type 1 (NF1). Adenocarcinomas have been reported in several organs. Gastrointestinal stromal tumors are the most common GI lesion seen in NFI. GISTs in combination with ampullary neuroendocrine tumors in NF-1 have been reported rarely. Case report: We present the case of a 44-year-old man who presented with a history of obstructive jaundice and weight loss. Investigations revealed a pancreatic tumor associated with a common bile duct (CBD) stricture. At operation, an ampullary adenocarcinoma that infiltrated into the head of pancreas with an adjacent somatostatinoma was found. In addition, a small bowel GIST was present. Conclusions: Mixed periampullary adenocarcinoma and somatostatinoma in a patient with NF1 has only been previously reported once. The current case highlights the spectrum of associated tumor types which can be seen in association with NF1. Patients with NF1 who present with jaundice and weight loss should be investigated in the usual manner with increased suspicion for duodenal and ampullary tumors.
Language	English
Publishing date	2014-11
Publishing country	Italy
Document type	Journal Article
ISSN	1590-8577
ISSN (online)	1590-8577
DOI	10.6092/1590-8577/2844
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Article ; Online: Lymphoepithelial cyst of the pancreas and elevated cyst fluid carcinoembryonic antigen: a diagnostic challenge.

Tewari, Nilanjana / Rollins, Katie / Wu, Jessie / Kaye, Phillip / Lobo, Dileep N

JOP : Journal of the pancreas

2014 Volume 15, Issue 5, Page(s) 504–507

Abstract: Context: Pancreatic lymphoepithelial cysts are rare, benign cysts which can present diagnostic difficulties. Non-invasive imaging alone is unreliable in distinguishing between benign and malignant cysts. Endoscopic ultrasound (EUS) and fine needle ... ...

Abstract	Context: Pancreatic lymphoepithelial cysts are rare, benign cysts which can present diagnostic difficulties. Non-invasive imaging alone is unreliable in distinguishing between benign and malignant cysts. Endoscopic ultrasound (EUS) and fine needle aspiration (FNA) with analysis of cyst fluid is more reliable, but invasive. In addition, tumor markers such as carcinoembryonic antigen (CEA) can be grossly elevated in cyst fluid of benign cysts. Case report: We present the case of a 67 year old man with an incidental finding of a pancreatic cyst. EUS and FNA-guided aspiration of cyst fluid was performed. Fluid CEA was grossly elevated and resectional surgery was performed. On histological examination the diagnosis was confirmed as lymphoepithelial cyst of the pancreas. Conclusion: Tumor markers such as CEA can be elevated in the cyst fluid of benign pancreatic conditions such as lymphoepithelial cyst. Although the diagnosis is challenging preoperatively, if a systematic algorithm is followed, these conditions can be managed safely and efficiently.
Language	English
Publishing date	2014-09-28
Publishing country	Italy
Document type	Journal Article
ZDB-ID	2039637-5
ISSN	1590-8577 ; 1590-8577
ISSN (online)	1590-8577
ISSN	1590-8577
DOI	10.6092/1590-8577/2799
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