Advancements in Digestive Health

By Shyam Varadarajulu, MD

The recently created Orlando Health Digestive Health Institute offers a comprehensive digestive disease program with areas of expertise including luminal gastroenterology, pancreatology, inflammatory bowel diseases, motility and hepatology. As president of the Orlando Health Digestive Health, I am excited about our new state-of-the-art facility in downtown Orlando, which will provide dedicated space to deliver care ranging from general GI procedures to subspecialized care for complex digestive disorders, as well as an opportunity to be at the leading edge of research with clinical trial that will bring innovation and treatment options not available elsewhere.

The new facility will house the Center for Advanced Endoscopy, Research and Education (CARE), featuring purpose-built space for advanced endoscopic services, together with the personnel and technical expertise needed for impactful clinical research and teaching. The dedicated area will be outfitted with the latest technologies to optimize clinical outcomes and maximize research productivity, including sophisticated endoscopic and fluoroscopic equipment, capability for artificial intelligence, and specific areas for observation and education.

Specialized Poem Procedure

One of those advanced services is peroral endoscopic myotomy (POEM). This specialized endoscopic procedure addresses swallowing disorders such as achalasia, spastic esophageal conditions and esophagogastric junction outflow obstruction. Orlando Health is one of only five hospital systems in Florida to provide POEM treatment.

This advanced, minimally invasive therapeutic procedure to treat motility disorders of the esophagus is performed orally using high-definition upper endoscopes. This allows physicians to make mucosal incisions and subsequent submucosal tunneling to permanently relax tight esophageal muscles and open narrowed parts of the esophagus. No external cuts are required.

“POEM gives us a very controlled method of cutting from inside the esophageal cavity for solving these complex disorders in a safe, effective manner,” says Ji Young Bang, MD, a board-certified gastroenterologist and director of clinical research at the Orlando Health Digestive Health Institute Center for Advanced Endoscopy, Research & Education. An internationally recognized researcher in interventional endoscopy, Dr. Bang brings extensive experience in POEM to Orlando Health, having completed 150 of these procedures since 2017.

While POEM was developed specifically for one digestive disorder, it forms a foundation for other procedures like submucosal tunneling endoscopic resection (STER), endoscopic submucosal dissection and gastric peroral endoscopic myotomy (G-POEM). Each of these procedures differ slightly, but they are all a part of our arsenal of very advanced, complex endoscopy procedures that we can now offer to patients.

A Standardized Treatment Approach

As an example of our passion for effecting meaningful contributions to research, Orlando Health Digestive Health Institute physicians are among the authors of a recently published journal article highlighting results from a study involving a new protocol to help standardize treatment options and improve clinical outcomes for patients who require endoscopic drainage of pancreatic fluid collections (PFC).1

Results from a retrospective, observational study of prospectively collected data among patients with symptomatic PFCs demonstrated significantly higher rates of endoscopic treatment success in patients treated with a combination of lumen-apposing metal stents (LAMS) and selective plastic stents (the Orlando Protocol) versus those treated with plastic stents alone. Additionally, the need for rescue surgery was significantly higher in patients treated with plastic stents alone compared with those treated using the Orlando Protocol. These results promise to bring a much-needed measure of standardization to PFC treatment.

Traditionally, transluminal plastic stents have been placed to facilitate drainage in the endoscopic management of PFC. But today, LAMS are increasingly used instead of plastic stents, largely because of three distinct advantages LAMS offer: better drainage due to their larger diameter, less risk of peritoneal leakage and perforation due to their apposing nature, and technically easier stent deployment. Despite these advantages, there has been a lack of data validating the use of LAMS over plastic stents in patients with PFCs. By introducing a measure of standardization in PFC management, the Orlando Protocol can help to improve clinical outcomes in this complex group of patients.

Evidence supporting the Orlando Protocol is further strengthened by several additional considerations. These include significantly shorter procedural duration times for index interventions, which is an important advantage given the critically ill status of most patients, who likely cannot endure longer procedures. The Orlando Protocol also appears to be particularly useful for a subset of patients suffering from disconnected pancreatic duct syndrome, who have higher PFC recurrence rates. Utilizing the protocol can facilitate better drainage and reduce PFC recurrence in these patients, thereby reducing disease morbidity.

As one of the study authors, I can confidently state that this is the first time in the medical literature where a treatment protocol was validated prospectively for index interventions, reinterventions and follow-up, thereby standardizing the management approach outside of a clinical trial setting for patients with PFCs.

These are just two examples of the elevated level of services that the Orlando Health Digestive Institute will provide as a national and international destination for care.

References available by request

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Shyam Varadarajulu, MD, is a board-certified gastroenterologist and president of the Orlando Health Digestive Health Institute. He specializes in advanced endoscopy for the treatment of complex digestive disorders at the institute’s Center for Advanced Endoscopy, R.esearch & Education. Dr. Varadarajulu is a sought-after researcher, educator and lecturer. He is widely published in peer-reviewed journals and reference textbooks, and is currently editor of the textbook ENDOSONOGRAPHY and a reviewer for more than 30 professional journals. After earning his medical degree at Madras Medical College in India, Dr. Varadarajulu completed his residency in internal medicine at St. Mary’s Hospital in Rochester, New York, followed by fellowships in gastroenterology at the University of Connecticut and advanced endoscopy at the Medical University of South Carolina.

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Dr. Bandaru, MD FACP received her medical doctorate from Loyola Medicine Macneal Hospital, Illinois. She is trained in Internal Medicine and Primary Care and has experience working in community settings, treating adult patients with diverse pathology. She is passionate about Women’s Health.

With her intriguing experiences with postmenopausal women’s issues, she is looking forward to NAMS NCMP certification. She is a Member of the American College of Physicians (Florida Chapter). Dr. Bandaru has been honored with the prestigious Fellowship of the American College of Physicians (FACP) as an acknowledgment of her ongoing individual service and contributions to the practice of medicine.