Bio


I am a gastroenterologist with a clinical focus on advanced endoscopic procedures including ERCP, endoscopic ultrasound, and techniques of advanced endoscopic resection of neoplastic and malignant lesions of the gastrointestinal tract.

My research is aimed at improving the diagnosis and management of gastrointestinal malignancies though epidemiology, clinically-impactful biomarkers, and prevention trials.

Clinical Focus


  • Gastroenterology
  • ERCP, endoscopic ultrasound, luminal stenting, small bowel endoscopy
  • gastric cancer, gastric intestinal metaplasia and premalignant lesions

Academic Appointments


Honors & Awards


  • North American International Training Grant, American College of Gastroenterology (2019)
  • Pilot Grant Award, Stanford Center for Asian Health Research and Education (2019)
  • Chief Fellow, Division of Gastroenterology, Stanford University (2016-2017)
  • Top Reviewer, Annals of Internal Medicine (2018)
  • NIH-Clinical Research Training Program (CRTP), Foundation for the NIH, Pfizer Inc. (2009-2010)
  • William G. Anlyan Scholarship, Duke University School of Medicine (2010)
  • Harvard College Scholar, Harvard College (2003-2005)
  • Weissman International Internship Program, Harvard College (2006)

Professional Education


  • Residency: Stanford University Internal Medicine Residency (2014) CA
  • Board Certification: American Board of Internal Medicine, Gastroenterology (2018)
  • Fellowship: Stanford University Gastroenterology Fellowship CA
  • Board Certification: American Board of Internal Medicine, Internal Medicine (2014)
  • Residency, Stanford Hospital and Clinics, Internal Medicine (2014)
  • Medical Education: Duke University School of Medicine (2011) NC
  • M.D., Duke University School of Medicine (2011)
  • A.B., Harvard College, Biochemical Sciences, magna cum laude (2007)

Current Research and Scholarly Interests


Epidemiology
Epidemiology of gastric cancer
Racial and ethnic disparities in gastric cancer
Gastric intestinal metaplasia and other precancerous lesions
Molecular marker development

Clinical Trials


  • The GAstric Precancerous Conditions Study Recruiting

    Gastric cancer afflicts 27,000 Americans annually and carries a dismal prognosis. One reason for poor outcomes is late diagnosis, as the majority of gastric cancers in the United States are diagnosed at a relatively advanced stage where curative resection is unlikely. Gastric intestinal metaplasia (GIM) is a precancerous change of the stomach which increases risk for subsequent gastric cancer multiple-fold. The Gastric Precancerous Conditions Study (GAPS) is an observational study with two over-arching objectives: 1) improve the non-invasive identification of patients with GIM, and 2) develop biological markers to predict the subset of GIM which will progress onto gastric cancer. To achieve Aim 1, a case-control study (N=300 pairs) matching cases of GIM with age-/gender-matched controls will be recruited form the population of subjects undergoing clinically-indicated endoscopy. Determination of gastric pathology will be made by two, independent gastrointestinal pathologists. At time of endoscopy, a detailed clinical questionnaire is administered by face-to-face interview. Saliva and blood is collected prior to endoscopy. At time of endoscopy, protocoled clinical biopsies (per Revised Sydney Protocol) as well as additional research specimens are collected. Scoring of GIM will be performed based on the Operative Link for GIM scoring system. To achieve Aim 2, patients with histologically-confirmed GIM (N=300) will be followed longitudinally. Biennial endoscopic surveillance will be performed, with repeat biopsies, specimen collection, and histologic scoring. Progression of GIM will be defined as upstaging of GIM score, or development of either dysplasia or carcinoma on any biopsy.

    View full details

Projects


  • The Stanford Gastric Precancerous Conditions Study (GAPS)

    The goal of the Stanford GPC Study is to 1) identify non-invasive markers to identify patients at high risk for advanced GPCs and 2) develop molecular risk stratification models to predict which patients with advanced GPCs will progress onto gastric cancer. We are seeking to recruit subjects between the ages of 30 to 84 with 1) a personal history of GPC (either intestinal metaplasia or gastric atrophy) 2) a family history of gastric cancer or 3) dyspepsia or abdominal pain. The research involves a brief questionnaire, blood draw, saliva specimen, and gastric biopsies. We hope that through this research we will develop molecular tests which will improve the early detection of gastric cancer.

    Location

    Stanford, CA

All Publications


  • A Summary of the 2020 Gastric Cancer Summit at Stanford University. Gastroenterology Huang, R. J., Koh, H., Hwang, J. H., Summit Leaders, Abnet, C. C., Alarid-Escudero, F., Amieva, M. R., Bruce, M. G., Camargo, M. C., Chan, A. T., Choi, I. J., Corvalan, A., Davis, J. L., Deapen, D., Epplein, M., Greenwald, D. A., Hamashima, C., Hur, C., Inadomi, J. M., Ji, H. P., Jung, H., Lee, E., Lin, B., Palaniappan, L. P., Parsonnet, J., Peek, R. M., Piazuelo, M. B., Rabkin, C. S., Shah, S. C., Smith, A., So, S., Stoffel, E. M., Umar, A., Wilson, K. T., Woo, Y., Yeoh, K. G. 2020

    View details for DOI 10.1053/j.gastro.2020.05.100

    View details for PubMedID 32707045

  • A case-control study of risk factors for advanced gastric intestinal metaplasia in a multiethnic United States population (The Stanford GAPS Study) Huang, R. J., Park, S., Chitre, T., Shen, J., Longacre, T., Ha Hwang, J. AMER ASSOC CANCER RESEARCH. 2020
  • Regional disparities in gastric cancer survival in the United States: An observational cohort study of the Surveillance Epidemiology and End Results Program, 2004-2016 Huang, R., Hsing, A., Palaniappan, L., Hwang, J. AMER ASSOC CANCER RESEARCH. 2020
  • Disaggregation of gastric cancer risk Between Asian American subgroups Huang, R. J., Hwang, J., Hsing, A., Palaniappan, L. AMER ASSOC CANCER RESEARCH. 2020
  • County Rurality and Socioeconomic Deprivation is Associated with Reduced Survival from Gastric Cancer in the United States. Gastroenterology Huang, R. J., Shah, S. C., Camargo, M. C., Palaniappan, L., Hwang, J. H. 2020

    View details for DOI 10.1053/j.gastro.2020.05.006

    View details for PubMedID 32387539

  • The Management of Gastric Intestinal Metaplasia in the United States - A Controversial Topic. Gastroenterology Huang, R. J., Hwang, J. H. 2020

    View details for DOI 10.1053/j.gastro.2020.02.066

    View details for PubMedID 32234304

  • Goff Septotomy Is a Safe and Effective Salvage Biliary Access Technique Following Failed Cannulation at ERCP. Digestive diseases and sciences Barakat, M. T., Girotra, M., Huang, R. J., Choudhary, A., Thosani, N. C., Kothari, S., Sethi, S., Banerjee, S. 2020

    Abstract

    BACKGROUND: Biliary cannulation is readily achieved in>85% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). When standard cannulation techniques fail, salvage techniques utilized include the needle knife precut, double wire technique, and Goff septotomy.METHODS: Records of patients undergoing ERCP from 2005 to 2016 were retrospectively examined using a prospectively maintained endoscopy database. Patients requiring salvage techniques for biliary access were analyzed together with a control sample of 20 randomly selected index ERCPs per study year. Demographic and clinical variables including indications for ERCP, cannulation rates, and adverse events were collected.RESULTS: A total of 7984 patients underwent ERCP from 2005 to 2016. Biliary cannulation was successful in 94.9% of control index ERCPs, 87.2% of patients who underwent Goff septotomy (significantly higher than for all other salvage techniques, p≤0.001), 74.5% of patients in the double wire group and 69.6% of patients in the needle knife precut group. Adverse event rates were similar in the Goff septotomy (4.1%) and index ERCP control sample (2.7%) groups. Adverse events were significantly higher in the needle knife group (27.2%) compared with all other groups.CONCLUSIONS: This study represents the largest study to date of Goff septotomy as a salvage biliary access technique. It confirms the efficacy of Goff septotomy and indicates a safety profile similar to standard cannulation techniques and superior to the widely employed needle knife precut sphincterotomy. Our safety and efficacy data suggest that Goff septotomy should be considered as the primary salvage approach for failed cannulation, with needle knife sphincterotomy restricted to Goff septotomy failures.

    View details for DOI 10.1007/s10620-020-06124-6

    View details for PubMedID 32052216

  • Single cell genomic characterization reveals the cellular reprogramming of the gastric tumor microenvironment. Clinical cancer research : an official journal of the American Association for Cancer Research Sathe, A., Grimes, S. M., Lau, B. T., Chen, J., Suarez, C., Huang, R. J., Poultsides, G. A., Ji, H. P. 2020

    Abstract

    The tumor microenvironment (TME) consists of a heterogenous cellular milieu that can influence cancer cell behavior. Its characteristics havean impact on treatments such as immunotherapy. These features can be revealed with single-cell RNA sequencing (scRNA-seq). We hypothesized that scRNA-seq analysis ofgastric cancer (GC) together with paired normal tissue and peripheral blood mononuclear cells (PBMCs) would identify critical elements of cellular deregulation not apparent with other approaches.scRNA-seq was conducted on seven patients with GC and one patient with intestinal metaplasia. We sequenced 56,167 cells comprising GC (32,407 cells), paired normal tissue (18,657 cells) and PBMCs (5,103 cells). Protein expression was validated by multiplex immunofluorescence.Tumor epithelium had copy number alterations, a distinct gene expression program from normal, with intra-tumor heterogeneity. GC TME was significantly enriched for stromal cells, macrophages, dendritic cells (DCs) and Tregs. TME-exclusive stromal cells expressed distinct extracellular matrix components than normal. Macrophages were transcriptionally heterogenous and did not conform to a binary M1/M2 paradigm. Tumor-DCs had a unique gene expression program compared to PBMC DCs. TME-specific cytotoxic T cells were exhausted with two heterogenous subsets. Helper, cytotoxic T, Treg and NK cells expressed multiple immune checkpoint or costimulatory molecules. Receptor-ligand analysis revealed TME-exclusive inter-cellular communication.Single-cell gene expression studies revealed widespread reprogramming across multiple cellular elements in the GC TME. Cellular remodeling was delineated by changes in cell numbers, transcriptional states and inter-cellular interactions. This characterization facilitates understanding of tumor biology and enables identification of novel targets including for immunotherapy.

    View details for DOI 10.1158/1078-0432.CCR-19-3231

    View details for PubMedID 32060101

  • One Size Does Not Fit All: Marked Heterogeneity in Incidence of and Survival from Gastric Cancer among Asian American Subgroups. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology Huang, R. J., Sharp, N., Talamoa, R. O., Ji, H. P., Hwang, J. H., Palaniappan, L. P. 2020

    Abstract

    Asian Americans are at higher risk for non-cardia gastric cancers (NCGCs) relative to non-Hispanic Whites (NHWs). Asian Americans are genetically, linguistically, and culturally heterogeneous, yet have mostly been treated as a single population in prior studies. This aggregation may obscure important subgroup-specific cancer patterns.We utilized data from 13 regional United States cancer registries from 1990-2014 to determine secular trends in incidence and survivorship from NCGC. Data were analyzed for NHWs and the six largest Asian American subgroups: Chinese, Japanese, Filipino, Korean, Vietnamese, and South Asian (Indian/Pakistani).There exists substantial heterogeneity in NCGC incidence between Asian subgroups, with Koreans (48.6 per 100,000 person-years) having seven-fold higher age-adjusted incidence than South Asians (7.4 per 100,000 person-years). Asians had generally earlier stages of diagnosis and higher rates of surgical resection compared to NHWs. All Asian subgroups also demonstrated higher five-year observed survival compared to NHWs, with Koreans (41.3%) and South Asians (42.8%) having survival double that of NHWs (20.1%, p<0.001). In multivariable regression, differences in stage of diagnosis and rates of resection partially explained the difference in survivorship between Asian subgroups.We find substantial differences in incidence, staging, histology, treatment, and survivorship from NCGC between Asian subgroups, data which challenge our traditional perceptions about gastric cancer in Asians. Both biological heterogeneity and cultural/environmental differences may underlie these findings.These data are relevant to the national discourse regarding the appropriate role of gastric cancer screening, and identifies high-risk racial/ethnic subgroups who many benefit from customized risk attenuation programs.

    View details for DOI 10.1158/1055-9965.EPI-19-1482

    View details for PubMedID 32152216

  • Risk of ambulatory colonoscopy in patients with cirrhosis: a propensity-score matched cohort study. Endoscopy international open Huang, R. J., Banerjee, S., Friedland, S., Ladabaum, U. 2020; 8 (10): E1495–E1501

    Abstract

    Background and study aims  Patients with cirrhosis demonstrate alterations in physiology, hemodynamics, and immunity which may increase procedural risk. There exist sparse data regarding the safety of performing ambulatory colonoscopy in patients with cirrhosis. Patients and methods  From a population-based sample of three North American states (California, Florida, and New York), we collected data on 3,590 patients with cirrhosis who underwent ambulatory colonoscopy from 2009 to 2014. We created a control cohort propensity score-matched for cirrhotic severity who did not undergo colonoscopy (N = 3,590) in order to calculate the attributable risk for adverse events. The primary endpoint was the rate of unplanned hospital encounters (UHEs) within 14 days of colonoscopy (or from a synthetic index date for the control cohort). Predictors for UHE were assessed in multivariable regression. Results  The attributable risk for any UHE following colonoscopy was 3.1 % (confidence interval [CI] 2.1-4.1 %, P  < 0.001). There was increased risk for infection (0.9 %, CI 0.7-1.1 %), spontaneous bacterial peritonitis (0.1 %, CI 0.0-0.3 %), decompensation of ascites (0.3 %, CI 0.2-0.4 %), and cardiovascular event (0.4 %, CI 0.3-0.5 %). There was no increased attributable risk for gastrointestinal bleeding, perforation, or development of the hepatorenal syndrome. The presence of ascites at time of procedure was the only predictor for UHE in the fully-adjusted model (OR 2.6, CI 1.9-3.5, P  < 0.001). Conclusions  There is a moderate though detectable increase in risk for adverse event following ambulatory colonoscopy in patients with cirrhosis. The presence of ascites in particular portends higher risk. These data may guide clinicians when counseling patients with cirrhosis on the choice of colorectal cancer screening modality.

    View details for DOI 10.1055/a-1242-9958

    View details for PubMedID 33043119

    View details for PubMedCentralID PMC7541192

  • Risk Factors for Advanced Gastric Intestinal Metaplasia in a Multi-Ethnic United States Cohort Huang, R., Park, S., Chitre, T., Shen, J., Longacre, T., Hwang, J. LIPPINCOTT WILLIAMS & WILKINS. 2019: S689–S690
  • Disaggregation of Gastric Cancer Risk Between Asian American Subgroups Huang, R., Hwang, J., Palaniappan, L. LIPPINCOTT WILLIAMS & WILKINS. 2019: S688–S689
  • Diagnosis and Management of Gastric Intestinal Metaplasia: Current Status and Future Directions. Gut and liver Huang, R. J., Choi, A. Y., Truong, C. D., Yeh, M. M., Hwang, J. H. 2019

    Abstract

    Gastric intestinal metaplasia (GIM) is a known premalignant condition of the human stomach along the pathway to gastric cancer (GC). Histologically, GIM represents the replacement of normal gastric mucosa by mucin-secreting intestinal mucosa. Helicobacter pylori infection is the most common etiologic agent of GIM development worldwide. The prevalence of GIM is heterogeneous among different regions of the world and correlates with the population endemicity of H. pylori carriage, among other environmental factors. GC remains the third leading cause of cancer-related mortality globally. GIM is usually diagnosed by upper endoscopy with biopsy, and histologic scoring systems have been developed to risk-stratify patients at highest risk for progression to GC. Several recent endoscopic imaging modalities may improve the optical detection of GIM and early GC. Appropriate surveillance of GIM may be cost effective and represents an opportunity for the early diagnosis and therapy of GC. Certain East Asian nations have established population-level programs for the screening and surveillance of GIM; guidelines regarding GIM surveillance have also recently been published in Europe. By contrast, few data exist regarding the appropriateness of surveillance of GIM in the United States. In this review, we discuss the pathogenesis, epidemiology, diagnosis, and management of GIM with an emphasis on the role of appropriate endoscopic surveillance.

    View details for DOI 10.5009/gnl19181

    View details for PubMedID 31394893

  • A Chance to Cut Is a Chance to Cure: Endoscopic Submucosal Dissection for Early Gastric Cancer DIGESTIVE DISEASES AND SCIENCES Huang, R. J., Charville, G. W., Hwang, J., Friedland, S. 2019; 64 (5): 1129–32
  • Unplanned Hospital Encounters After Endoscopic Retrograde Cholangiopancreatography in 3 Large North American States GASTROENTEROLOGY Huang, R. J., Barakat, M. T., Girotra, M., Lee, J. S., Banerjee, S. 2019; 156 (1): 119-+
  • ASGE review of adverse events in colonoscopy. Gastrointestinal endoscopy Kothari, S. T., Huang, R. J., Shaukat, A., Agrawal, D., Buxbaum, J. L., Abbas Fehmi, S. M., Fishman, D. S., Gurudu, S. R., Khashab, M. A., Jamil, L. H., Jue, T. L., Law, J. K., Lee, J. K., Naveed, M., Qumseya, B. J., Sawhney, M. S., Thosani, N., Yang, J., DeWitt, J. M., Wani, S. 2019

    Abstract

    Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.

    View details for DOI 10.1016/j.gie.2019.07.033

    View details for PubMedID 31563271

  • Prevalence, Risk Factors, and Surveillance Patterns for Gastric Intestinal Metaplasia Among Patients Undergoing Upper Endoscopy with Biopsy. Gastrointestinal endoscopy Huang, R. J., Ende, A. R., Singla, A., Higa, J. T., Choi, A. Y., Lee, A. B., Whang, S. G., Gravelle, K., D'Andrea, S., Bang, S. J., Schmidt, R. A., Yeh, M. M., Hwang, J. H. 2019

    Abstract

    Gastric intestinal metaplasia (GIM) is an important precursor lesion to gastric cancer (GC), the second leading cause of cancer deaths worldwide. There exist few data regarding the prevalence of, risk factors for, and clinical practice patterns regarding gastric intestinal metaplasia (GIM) in the United States. Furthermore, there are currently no U.S. guidelines regarding screening/surveillance for GIM.All consecutive upper endoscopic procedures from 2 academic medical centers in Seattle between 1999 and 2014 are reviewed. Demographic, clinical, and endoscopic covariates are recorded at time of endoscopy. Procedures with gastric biopsy are matched to final histologic diagnoses, including presence of Helicobacter pylori. Cases of GIM and dysplasia are recorded and compared with non-GIM controls using univariate and multivariable regression. Surveillance patterns for cases of GIM are recorded.Data from 36,799 upper endoscopies, 17,710 gastric biopsies, 2,073 cases of GIM, 43 cases of dysplasia, and 78 cases of GC were captured. The point prevalence of GIM is 11.7% in patients who underwent gastric biopsy. Non-white race (P<0.001), increasing age (P<0.001), and presence of H pylori (P<0.001) associated with GIM. Once GIM is present, increasing age (P<0.001) and male gender (P<0.001) associate with progression, and presence of H pylori (P<0.001) inversely associates with progression to dysplasia/GC. Few cases of GIM/dysplasia/GC are made during procedures for GIM screening/surveillance. Only 16% of patients with a diagnosis of GIM received a recommendation for surveillance.There is a high prevalence of GIM among non-white and Hispanic Americans. Risk factors for development of GIM may be distinct from risk factors for progression to GC.

    View details for DOI 10.1016/j.gie.2019.07.038

    View details for PubMedID 31425693

  • Routine gastric biopsies: Should we be doing more? Gastrointestinal endoscopy Huang, R. J., Hwang, J. H. 2019; 89 (6): 1150–51

    View details for DOI 10.1016/j.gie.2019.02.010

    View details for PubMedID 31104747

  • Recent Trends and the Impact of the Affordable Care Act on Emergency Department Visits and Hospitalizations for Gastrointestinal, Pancreatic, and Liver Diseases. Journal of clinical gastroenterology Barakat, M. T., Mithal, A., Huang, R. J., Sehgal, A., Sehgal, A., Singh, G., Banerjee, S. 2018

    Abstract

    BACKGROUND: The Affordable Care Act (ACA) with Medicaid expansion implemented in 2014, extended health insurance to >20-million previously uninsured individuals. However, it is unclear whether enhanced primary care access with Medicaid expansion decreased emergency department (ED) visits and hospitalizations for gastrointestinal (GI)/pancreatic/liver diseases.METHODS: We evaluated trends in GI/pancreatic/liver diagnosis-specific ED/hospital utilization over a 5-year period leading up to Medicaid expansion and a year following expansion, in California (a state that implemented Medicaid expansion) and compare these with Florida (a state that did not).RESULTS: From 2009 to 2013, GI/pancreatic/liver disease ED visits increased by 15.0% in California and 20.2% in Florida and hospitalizations for these conditions decreased by 2.6% in California and increased by 7.9% in Florida. Following Medicaid expansion, a shift from self-pay/uninsured to Medicaid insurance was seen California; in addition, a new decrease in ED visits for nausea/vomiting and GI infections, was evident, without associated change in overall ED/hospital utilization trends. Total hospitalization charges for abdominal pain, nausea/vomiting, constipation, and GI infection diagnoses decreased in California following Medicaid expansion, but increased over the same time-period in Florida.CONCLUSIONS: We observed a striking payer shift for GI/pancreatic/liver disease ED visits/hospitalizations after Medicaid expansion in California, indicating a shift in the reimbursement burden in self-pay/uninsured patients, from patients and hospitals to the government. ED visits and hospitalization charges decreased for some primary care-treatable GI diagnoses in California, but not for Florida, suggesting a trend toward lower cost of gastroenterology care, perhaps because of decreased hospital utilization for conditions amenable to outpatient management.

    View details for PubMedID 30285976

  • Unplanned Hospital Encounters Following Endoscopic Retrograde Cholangiopancreatography in 3 Large American States. Gastroenterology Huang, R. J., Barakat, M. T., Girotra, M., Lee, J. S., Banerjee, S. 2018

    Abstract

    BACKGROUND & AIMS: We have few population-level data on the performance of endoscopic retrograde cholangiopancreatography (ERCP) in the United States. We investigated the numbers of unplanned hospital encounters (UHEs), patient and facility factors associated with UHEs, and variation in quality and outcomes in the performance of ERCP in 3 large American states.METHODS: We collected data on 68,642 ERCPs, performed at 635 facilities in California, Florida, and New York from 2009 through 2014. The primary endpoint was number of UHEs with an ERCP-related event within 7 days of ERCP; secondary endpoints included numbers of UHE within 30 days and mortality within 30 days. Each facility was assigned a risk-standardized cohort, and variations in numbers of UHE were analyzed using multivariable analysis.RESULTS: Among all ERCPs, 5.8% resulted in an UHE within 7 days, and 10.2% by 30 days. Performance of sphincterotomy was significantly associated with a higher risk of UHE at 7 and 30 days (P<.001). Younger age, female sex, and more advanced comorbidity associated with UHE. There was substantial heterogeneity in rates of UHE among facilities: 4.2% at facilities in the lower 5th percentile and 25.2% at facilities in the 95th percentile. Increasing facility volume and ability to perform endoscopic ultrasound associated inversely with risk. The median number of ERCPs performed each year was 68.7, but 69% of facilities performed 100 or fewer ERCPs per year. Risk for UHE following sphincterotomy decreased with increasing facility volume until an inflection point of 157 ERCPs per year was reached.CONCLUSIONS: In an analysis of outcomes of 68,642 ERCPs performed in three states, we found a higher than expected number of UHEs. There is substantial unexplained variation in risk for adverse event following ERCPs among facilities-volume is the strongest predictor of risk. Annual facility volumes above approximately 150 ERCPs per year may protect against UHE.

    View details for PubMedID 30243620

  • Chronic pancreatitis changes in high-risk individuals for pancreatic ductal adenocarcinoma. Gastrointestinal endoscopy Thiruvengadam, S. S., Chuang, J., Huang, R., Girotra, M., Park, W. G. 2018

    Abstract

    BACKGROUND AND AIMS: Pancreatic intraepithelial neoplasia is associated with chronic pancreatitis (CP) changes on EUS. The objective of this study was to determine whether CP changes were more common in high-risk individuals (HRIs) than in controls and whether these changes differed among higher-risk subsets of HRIs.METHODS: HRIs and controls were identified from an endoscopy database. HRIs were defined as having predisposing mutations or a family history (FH) of pancreatic ductal adenocarcinoma. HRIs were classified as vHRIs who met cancer of the pancreas screening (CAPS) criteria for high risk and mHRIs who did not. Multivariable logistic regression was used to adjust for confounders and CP risk factors.RESULTS: 65 HRIs (44 vHRIs, 21 mHRIs) and 118 controls were included. HRIs were included for FH (25), Lynch syndrome (5), Peutz-Jeghers syndrome (2), and mutations in BRCA1/2 (26), PALB2 (3), ATM (3), and CDKN2A (1). After adjustment for relevant variables, HRIs were 16 times more likely to exhibit 3 or more CP changes than controls (95% CI, 2.6-97.0; P = .003). HRIs were also more likely to have hypoechoic foci (OR, 8.0; 95% CI, 1.9-32.9; P = .004). vHRIs and mHRIs did not differ in frequency of three or more CP changes on EUS.CONCLUSIONS: HRIs were more likely to exhibit CP changes and hypoechoic foci on EUS compared with controls. HRIs with these findings may require closer surveillance. HRIs who did or did not meet CAPS criteria did not differ with regard to CP findings, supporting a more inclusive approach to screening.

    View details for DOI 10.1016/j.gie.2018.08.029

    View details for PubMedID 30145314

  • NO INCREASED RISK OF POST-PROCEDURAL UNPLANNED HOSPITAL ENCOUNTERS FOLLOWING AMBULATORY COLONOSCOPY IN PATIENTS WITH CIRRHOSIS: A POPULATION-LEVEL, COHORT-CONTROLLED STUDY. Huang, R. J., Barakat, M. T., Friedland, S., Banerjee, S. MOSBY-ELSEVIER. 2018: AB91–AB92
  • RISK OF POST-PROCEDURAL UNPLANNED HOSPITAL ENCOUNTERS FOLLOWING ENDOSCOPIC ULTRASOUND WITH FINE-NEEDLE ASPIRATION OF THE PANCREAS: A POPULATION-LEVEL, PROPENSITY-SCORE CONTROLLED COHORT STUDY Huang, R. J., Barakat, M. T., Park, W. G., Banerjee, S. MOSBY-ELSEVIER. 2018: AB107–AB108
  • Video-based performance assessment in endoscopy: Moving beyond "see one, do one, teach one"? GASTROINTESTINAL ENDOSCOPY Huang, R. J., Limsui, D., Triadafilopoulos, G. 2018; 87 (3): 776–77

    View details for PubMedID 29454450

  • A Chance to Cut Is a Chance to Cure: Endoscopic Submucosal Dissection for Early Gastric Cancer. Digestive diseases and sciences Huang, R. J., Charville, G. W., Hwang, J. H., Friedland, S. 2018

    View details for PubMedID 30350240

  • Practice Patterns for Cholecystectomy Following Endoscopic Retrograde Cholangio-Pancreatography for Patients With Choledocholithiasis. Gastroenterology Huang, R. J., Barakat, M. T., Girotra, M., Banerjee, S. 2017

    Abstract

    Cholecystectomy (CCY) following an episode of choledocholithiasis requiring endoscopic retrograde cholangio-pancreatography (ERCP) with stone extraction reduces recurrent biliary events, compared to expectant management. We studied practice patterns for performance of CCY following ERCP for choledocholithiasis using data from 3 large states and evaluated the effects of delaying CCY.We conducted a retrospective cohort study using the ambulatory surgery, inpatient, and emergency department databases from the states of California (years 2009-2011), New York (2011-2013), and Florida (2012-2014). We collected data from 4516 patients hospitalized with choledocholithiasis who underwent ERCP. We compared outcomes of patients who underwent CCY at index admission (early CCY), elective CCY within 60 days of discharge (delayed CCY), or did not undergo CCY (no CCY), calculating rate of recurrent biliary events (defined as an emergency department visit or unplanned hospitalization due to symptomatic cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis), mortality, and cost by CCY cohort. We also evaluated risk factors for not undergoing CCY. The primary outcome measure was the rate of recurrent biliary events in the 365 days following discharge from index admission.Of the patients who underwent ERCP for choledocholithiasis, 41.2% underwent early CCY, 10.9% underwent delayed CCY, and 48.0% underwent no CCY. Early CCY reduced relative risk of recurrent biliary events within 60 days by 92%, compared with delayed or no CCY (P<.001). After 60 days following discharge from index admission, patients with early CCY had an 87% lower risk of recurrent biliary events than patients with no CCY (P<.001) and patients with delayed CCY had an 88% lower risk of recurrent biliary events than patients with no CCY (P<.001). A strategy of delayed CCY performed on an outpatient basis was least costly. Performance of early CCY was inversely associated with low facility volume. Hispanic race, Asian race, Medicaid insurance, and no insurance associated inversely with performance of delayed CCY.In a retrospective analysis of over 4500 patients hospitalized with choledocholithiasis, we found that CCY was not performed following ERCP for almost half of the cases. Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of recurrent biliary event while waiting for a delayed CCY compared with patients who underwent early CCY. Delayed CCY is a cost-effective strategy that must be balanced against the risk of loss to follow up, particularly among patients who are ethnic minorities or have little or no health insurance.

    View details for DOI 10.1053/j.gastro.2017.05.048

    View details for PubMedID 28583822

  • The Gastroenterology Fellowship Match: A Decade Later. Digestive diseases and sciences Huang, R. J., Triadafilopoulos, G., Limsui, D. 2017; 62 (6): 1412-1416

    Abstract

    Following a period of uncertainty and disorganization, the gastroenterology (GI) national leadership decided to reinstitute the fellowship match (the Match) under the auspices of the National Residency Matching Program (NRMP) in 2006. Although it has now been a decade since the rebirth of the Match, there have been limited data published regarding progress made. In this piece, we discuss reasons for the original collapse of the GI Match, including most notably a perceived oversupply of GI physicians and a poor job market. We discuss the negative impacts the absence of the Match had on programs and on applicants, as well as the impetus to reorganize the Match under the NRMP. We then utilize data published annually by the NRMP to demonstrate that in the decade since its rebirth, the GI Match has been remarkably successful in terms of attracting the participation of applicants and programs. We show that previous misguided concerns of an oversupply of GI physicians were not realized, and that GI fellowship positions remain highly competitive for internal medicine applicants. Finally, we discuss possible implications of recent changes in the healthcare landscape on the GI Match.

    View details for DOI 10.1007/s10620-017-4593-z

    View details for PubMedID 28474142

    View details for PubMedCentralID PMC5535767

  • Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013. Gastrointestinal endoscopy Huang, R. J., Thosani, N. C., Barakat, M. T., Choudhary, A., Mithal, A., Singh, G., Sethi, S., Banerjee, S. 2017

    Abstract

    Bile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States.We used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures.Total biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures has increased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals.Although therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of the increased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Large urban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.

    View details for DOI 10.1016/j.gie.2016.12.021

    View details for PubMedID 28062313

  • Adenosine triphosphate bioluminescence for bacteriological surveillance and reprocessing strategies for minimizing risk of infection transmission by duodenoscopes. Gastrointestinal endoscopy Sethi, S., Huang, R. J., Barakat, M. T., Banaei, N., Friedland, S., Banerjee, S. 2016

    Abstract

    Recent outbreaks of duodenoscope-transmitted infections underscore the importance of adequate endoscope reprocessing. Adenosine triphosphate (ATP) bioluminescence testing allows rapid evaluation of endoscopes for bacteriologic/biologic residue. In this prospective study we evaluate the utility of ATP in bacteriologic surveillance and the effects of endoscopy staff education and dual cycles of cleaning and high-level disinfection (HLD) on endoscope reprocessing.ATP bioluminescence was measured after precleaning, manual cleaning, and HLD on rinsates from suction-biopsy channels of all endoscopes and elevator channels of duodenoscopes/linear echoendoscopes after use. ATP bioluminescence was remeasured in duodenoscopes (1) after re-education and competency testing of endoscopy staff and subsequently (2) after 2 cycles of precleaning and manual cleaning and single cycle of HLD or (3) after 2 cycles of precleaning, manual cleaning, and HLD.The ideal ATP bioluminescence benchmark of <200 relative light units (RLUs) after manual cleaning was achieved from suction-biopsy channel rinsates of all endoscopes, but 9 of 10 duodenoscope elevator channel rinsates failed to meet this benchmark. Re-education reduced RLUs in duodenoscope elevator channel rinsates after precleaning (23,218.0 vs 1340.5 RLUs, P < .01) and HLD (177.0 vs 12.0 RLUs, P < .01). After 2 cycles of manual cleaning/HLD, duodenoscope elevator channel RLUs achieved levels similar to sterile water, with corresponding negative cultures.ATP testing offers a rapid, inexpensive alternative for detection of endoscope microbial residue. Re-education of endoscopy staff and 2 cycles of cleaning and HLD decreased elevator channel RLUs to levels similar to sterile water and may therefore minimize the risk of transmission of infections by duodenoscopes.

    View details for DOI 10.1016/j.gie.2016.10.035

    View details for PubMedID 27818222

  • Colonoscopy with polypectomy is associated with a low rate of complications in patients with cirrhosis. Endoscopy international open Huang, R. J., Perumpail, R. B., Thosani, N., Cheung, R., Friedland, S. 2016; 4 (9): E947-52

    Abstract

    Cirrhotic patients are at a theoretically increased risk of bleeding. The safety of polypectomy in cirrhosis is poorly defined.We performed a retrospective review of patients with cirrhosis who underwent colonoscopic polypectomy at a tertiary-care hospital. Patient characteristics and polyp data were collected. Development of complications including immediate bleeding, delayed bleeding, hospitalization, blood transfusion, perforation, and death were recorded to 30-day follow-up. Clinical characteristics between bleeders and non-bleeders were compared, and predictors of bleeding were determined.A total of 307 colonoscopies with 638 polypectomies were identified. Immediate bleeding occurred in 7.5 % (95 % CI 4.6 % - 10.4 %) and delayed bleeding occurred in 0.3 % (95 % CI 0.0 % - 0.9 %) of colonoscopies. All cases of immediate bleeding were controlled endoscopically and none resulted in serious complication. The rate of hospitalization was 0.7 % (95 % CI 0.0 % - 1.6 %) and repeat colonoscopy 0.3 % (95 % CI 0.0 % - 0.9 %); no cases of perforation, blood transfusion, or death occurred. Lower platelet count, higher INR, presence of ascites, and presence of esophageal varices were associated with increased risk of bleeding. Use of electrocautery was associated with a lower risk of immediate bleeding. There was no significant difference between bleeding and non-bleeding polyps with regard to size, morphology, and histology.Colonoscopy with polypectomy appears safe in patients with cirrhosis. There is a low risk of major complications. The risk of immediate bleeding appears higher than an average risk population; however, most bleeding is self-limited or can be controlled endoscopically. Bleeding tends to occur with more advanced liver disease. Both the sequelae of portal hypertension and coagulation abnormalities are predictive of bleeding.

    View details for DOI 10.1055/s-0042-111317

    View details for PubMedID 27652299

    View details for PubMedCentralID PMC5025305

  • Response. Gastrointestinal endoscopy Huang, R. J., Draper, K. V., Gerson, L. B. 2015; 81 (3): 777-?

    View details for DOI 10.1016/j.gie.2014.09.056

    View details for PubMedID 25708772

  • Colonic plasmacytomas: a rare complication of plasma cell leukemia. Endoscopy Hang, C. T., Perumpail, R. B., Huang, R. J., Fernandez-Pol, S., Fernandez-Becker, N. Q. 2015; 47: E77-8

    View details for DOI 10.1055/s-0034-1390722

    View details for PubMedID 25926223

  • GI bleeding in patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis GASTROINTESTINAL ENDOSCOPY Draper, K. V., Huang, R. J., Gerson, L. B. 2014; 80 (3): 435-U219

    Abstract

    Patients with left ventricular assist devices (LVADs) are at increased risk of GI bleeding (GIB), primarily from GI angiodysplastic lesions (GIAD).To perform meta-analysis of the medical literature in order to determine prevalence and risk factors for GIB.A literature search was performed to identify studies reporting GIB in LVAD patients. We extracted rates of prevalence, rebleeding, and overall mortality from each study. Pooled event rates and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.Meta-analysis of 17 case-control and cohort studies.A total of 1839 LVAD patients of whom 1697 (92%) had continuous-flow LVADs.The pooled prevalence of GIB in LVAD patients was 23% (95% CI, 20.5%-27%). Subgroup analysis demonstrated that older age (standard difference in means (SDm), 0.69; 95% CI, 0.23-1.15), and elevated creatinine (SDm, 0.65; 95% CI, 0.12-1.18, P = .02) were associated with GIB. Risk factors not associated with GIB included LVAD as destination therapy (OR 1.85; 95% CI, 0.8-4.3), prior history of GIB (OR 2.22; 95% CI, 0.83-5.96), hypertension (OR 1.6; 95% CI, 0.87-2.97), and/or the presence of a continuous-flow LVAD (OR 4.5; 95% CI, 2.1-9.5). Recurrence of GIB occurred in 9.3% (95% CI, 7%-12%), with a GIB mortality rate of 23% (95% CI, 16%-32%). The pooled event rates were 48% (95% CI, 39%-57%) for upper GIB, 22% (95% CI, 16%-31%) for lower GIB, and 15% (95% CI, 8%-25%) for small-bowel bleeding. GIAD in the proximal GI tract were the most common cause of GIB (29%).Lack of information regarding endoscopic therapy and follow-up in most studies.The prevalence of GIB is increased in patients with continuous-flow LVADs, primarily secondary to the presence of GIAD.

    View details for DOI 10.1016/j.gie.2014.03.040

    View details for Web of Science ID 000341153400013

    View details for PubMedID 24975405

  • Significantly higher rates of gastrointestinal bleeding and thromboembolic events with left ventricular assist devices. Clinical gastroenterology and hepatology Shrode, C. W., Draper, K. V., Huang, R. J., Kennedy, J. L., Godsey, A. C., Morrison, C. C., Shami, V. M., Wang, A. Y., Kern, J. A., Bergin, J. D., Ailawadi, G., Banerjee, D., Gerson, L. B., Sauer, B. G. 2014; 12 (9): 1461-1467

    Abstract

    The risk of gastrointestinal (GI) bleeding (GIB) and thromboembolic events may increase with continuous-flow left ventricular assist devices (CF-LVADs). We aimed to characterize GIB and thromboembolic events that occurred in patients with CF-LVADs and compare them with patients receiving anticoagulation therapy.We performed a retrospective analysis of 159 patients who underwent CF-LVAD placement at 2 large academic medical centers (mean age, 55 ± 13 y). We identified and characterized episodes of GIB and thromboembolic events through chart review; data were collected from a time period of 292 ± 281 days. We compared the rates of GIB and thromboembolic events between patients who underwent CF-LVAD placement and a control group of 159 patients (mean age, 64 ± 15 y) who received a cardiac valve replacement and were discharged with anticoagulation therapy.Bleeding events occurred in 29 patients on CF-LVAD support (18%; 45 events total). Sixteen rebleeding events were identified among 10 patients (range, 1-3 rebleeding episodes/patient). There were 34 thrombotic events among 27 patients (17%). The most common source of bleeding was GI angiodysplastic lesions (n = 20; 44%). GIB and thromboembolic events were more common in patients on CF-LVAD support than controls; these included initial GIB (18% vs 4%, P < .001), rebleeding (6% vs none, P = .001), and thromboembolic events (17% vs 8%, P = .01).Patients with CF-LVADS receiving anticoagulants have a significantly higher risk of GIB and thromboembolic events than patients receiving anticoagulants after cardiac valve replacement surgery. GI angiodysplastic lesions are the most common source of bleeding.

    View details for DOI 10.1016/j.cgh.2014.01.027

    View details for PubMedID 24480675

  • Locally advanced gastric cancer complicated by mesenteric invasion and intestinal malrotation. Digestive diseases and sciences Huang, R. J., Visser, B. C., Chen, A. M., Ladabaum, U. 2014; 59 (2): 267-269

    View details for DOI 10.1007/s10620-013-2869-5

    View details for PubMedID 24036993

  • Manometric abnormalities in the postural orthostatic tachycardia syndrome: a case series. Digestive diseases and sciences Huang, R. J., Chun, C. L., Friday, K., Triadafilopoulos, G. 2013; 58 (11): 3207-3211

    Abstract

    Postural orthostatic tachycardia syndrome (POTS) is a rare disease that is believed to be mediated by dysautonomia. Gastrointestinal complaints in POTS patients are common and disturbing but not well characterized.We hypothesized that gastrointestinal dysmotility may be contributory to these symptoms.We studied 12 POTS patients who presented with gastrointestinal symptoms to a tertiary referral center. Gastrointestinal symptoms were quantified using a previously validated symptom questionnaire. All patients underwent gastroduodenal manometry (GDM); select patients also underwent further testing including esophageal manometry (EM), anorectal manometry (ARM), plain abdominal radiography (AXR), abdominal computed tomography (CT), gastric emptying studies (GES), and colonic transit time (CTT) studies.The four most common symptoms were bloating, constipation, abdominal pain, and nausea/vomiting, all experienced by greater than 70 % of patients. On GDM testing, 93 % of patients demonstrated signs of neuropathy, and the most common abnormalities observed included bursts of uncoordinated phasic activity in both fasting (59 %) and post-prandial (42 %) states, low contractility in the post-prandial state (67 %), and lack of post-prandial pattern (42 %). A total of 67 % of patients undergoing EM and 86 % of those undergoing ARM demonstrated abnormalities consistent with dysmotility. On AXR or CT, 58 % demonstrated either dilated intestinal loops or air-fluid levels. On CTT 80 % demonstrated delayed colonic transit, while on GES 60 % demonstrated delayed gastric emptying.In this cohort of POTS patients with gastrointestinal symptoms, there is a high prevalence of abnormal manometric and radiographic findings suggestive of dysmotility.

    View details for DOI 10.1007/s10620-013-2865-9

    View details for PubMedID 24068608

  • Acute Fulminant Hepatic Failure Associated with Parvovirus B19 Infection in an Immunocompetent Adult DIGESTIVE DISEASES AND SCIENCES Huang, R. J., Varr, B. C., Triadafilopoulos, G. 2012; 57 (11): 2811-2813

    View details for DOI 10.1007/s10620-012-2110-y

    View details for Web of Science ID 000309867800028

    View details for PubMedID 22395961

  • De novo arteriovenous malformations following implantation of the HeartMate II left ventricular assist device. Endoscopy Huang, R. J., Wong, R. J., Draper, K. V., Winter, T. A. 2012; 44: E441-?

    View details for DOI 10.1055/s-0032-1325899

    View details for PubMedID 23258493