bluuebunny/crossref_metadata_2025 huggingface dataset:
2 Hydrogen Peroxide-Assisted Endoscopic Necrosectomy vs. Standard Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis: A Multi-Center Retrospective Comparative Study
Authors: Messallam Ahmed , Adler Douglas G. , Shah Raj , Nieto Jose , Moran Robert , Elmunzer Badih , Cosgrove Natalie , Mullady Daniel , Singh Harkirat , Papachristou Georgios , Othman Mohamed , Javaid Huma , Mercado Michael Oliver M. , Tsistrakis Steven , Kumta Nikhil A. , Nagula Satish , DiMaio Christopher J. , Birch Madeleine , Taylor Linda , LaBarre Nicolas , Han Samuel , Hollander Thomas G. , Cristofaro Sarah , Keilin Steven , Cai Qiang , Willingham Field
Published: October 2019

INTRODUCTION:

Endoscopic necrosectomy has emerged as the preferred treatment modality for walled off pancreatic necrosis (WON). Standard endoscopic necrosectomy can be tedious and time consuming, employs sharp instruments in vascular cavities, and does not provide for microdebridement. Hydrogen peroxide (H2O2) lavage has been reported in small series; however, there have been no comparative studies on its safety and efficacy in the management of WON.

METHODS:

We performed a retrospective chart review of all cases undergoing endoscopic transmural management of WON at 9 major medical centers in the US from November 2011 to August 2018. Cystogastrostomies were performed using lumen apposing metal stents (LAMS). Patients who underwent cystogastrostomy without necrosectomy were excluded. Clinical success was defined as resolution of the WON by imaging within 6 months, without requiring non-endoscopic drainage procedures or surgery.

RESULTS:

A total of 296 patients underwent cystgastrostomy and 206 patients underwent one or more necrosectomies. Clinical success was achieved in 171/192 (89.1%) of those with follow-up data at 6 months. In terms of patients, 122 (59.2%) patients had at least one H2O2 necrosectomy (H2O2 group), and 84 (40.8%) patients had standard endoscopic necrosectomy. Clinical success was higher in the H2O2 group (n = 107 (95.5%) vs 63 (79.7%), P < 0.001). On multivariate logistic regression, the use of hydrogen peroxide (OR 17.4, 95% CI: 2.9–103, P = 0.002) was associated with higher clinical success rates (Table 2). During a mean follow up of 278 days, 29 complications occurred: bleeding (n = 18), perforation (n = 5), respiratory complication (n = 3), and sepsis (n = 3). One death was presumed to be procedure related (splenic pseudoaneurysm rupture day 8; standard necrosectomy group). A total of 394 necrosectomies were performed. Comparing necrosectomy procedures with and without H2O2 (n = 209 vs 185), there was no difference in procedure time (72.5 ± 39.6 vs 72 ± 44.2, P = 0.936), post-procedural bleeding (8 vs 10, P = 0.45), perforation (3 vs 2, P = 1), infection (1 vs 2, P = 0.6) or overall complication rate (n = 15 (7.1%) vs 14 (7.6%), P = 1) (Table 3).

CONCLUSION:

In this multicenter retrospective cohort study, H2O2 necrosectomy appeared to be safe and effective with a higher clinical success rate and equivalent rates of bleeding, perforation, death, and overall complications relative to standard necrosectomy.
7 Efficacy of Endoscopic Ultrasound Radiofrequency Ablation in the Treatment of Pancreatic Tumors: Is It Ready for Prime Time? A Systematic Review and Meta-Analysis
Authors: Dhaliwal Amaninder , Dhindsa Banreet , Choa Jacqueline , Jindal Robin , Sayles Harlan , Mashiana Harmeet , Kolli Sindhura , Rangray Rajani , Bhat Ishfaq , Singh Shailender , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound radiofrequency ablation (EUS-RFA) is the newer technique, which is minimally invasive, more selective and safer in patients with unresectable pancreatic ductal adenocarcinoma (PDAC). We did systematic review and meta-analysis to evaluate the efficacy of EUS-RFA in the treatment of unresectable PDAC, pancreatic neuroendocrine tumors (PNENs) and other pancreatic tumors.

METHODS:

We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through May 2019) to identify the studies reporting use of EUS-RFA for pancreatic lesions. The primary outcome was to evaluate technical and clinical success of the procedure. Technical success was defined as successful placement of the needle within the lesion. The clinical success was defined (a) decrease in size of lesion (b) improvement of symptoms (c) radiological evidence of necrosis status post RFA. The secondary outcome was to study overall adverse events. The meta-analysis was performed using Der Simonian and Laird random effect model.

RESULTS:

13 studies reporting on 127 patients with mean age of 61.3 years were included. 156 EUS-RFA procedures were performed on 127 patients. Out of 127 patients, 67% (85) had advanced PDAC, 16% (20) PNENs and 17% (22) other pancreatic tumors. The location of tumor and clinical success rate was reported in 10 out of 13 studies. The most common location of the lesion was head (54%) followed by the body of the pancreas (35%). The pooled technical success (Figure 1) rate calculated out of the total number of procedures was 98% (95% CI = 90.69–100, I2 = 50%). The pooled clinical success rate (Figure 2) calculated out of the total number of patients was 89.46% (95% CI = 69.17–100, I2 = 77.8%). The pooled overall adverse event rates (Figure 3) were 13.40% (95% CI = 4.11–25.55, I2 = 51.80%). In subgroup analysis, abdominal pain was the most common side effect (8.81%; 95% CI = 2.72–16.88, I2 = 18.87%). Bleeding and post procedure pancreatitis were noted in one patient each. No perforation or procedure related infections were noted in our patient population. Moderate heterogeneity was noted in our study.

CONCLUSION:

EUS-RFA not only has high technical (98%) and clinical success (89.46%) rates but is also a safer procedure with minimal overall adverse events (13.4%). Further multi-center trials are needed to further validate our findings.
10 Transmural Pancreatic Necrosectomy: A Systematic Review and Meta-Analysis on Different Endoscopic Approaches
Authors: Ullah Waqas , Rashid Mamoon Ur , Ammar Abdullah Hafez Muhammad , Ur Rehman FNU Asad , Bashir Muhammad H. , Hurairah Abu
Published: October 2019

INTRODUCTION:

Acute pancreatitis is complicated by necrosis of the peripancreatic tissue in about 20% of patients. Over the past few decades, endoscopic necrosectomy (EN) is increasingly gaining traction as primary management. EN techniques are subject to rapid innovations, recently fully covered self-expanding metal stents (FCSEMS), bi-flanged metal stent (BFMS), plastic and lumen-apposing metal stents (LAMS) has taken the place of direct endoscopic necrosectomy (DEN). This study sought to determine the efficacy and safety of these approaches.

METHODS:

The MedLine, Embase, and Cochrane databases were systematically searched since inception till Jan 2019 and 4678 articles were retrieved. Only 59 articles deemed relevant and were analyzed using the Meta-disc.

RESULTS:

The weighted mean number of days in the hospital for BFMS was lowest (4.1) compared to plastic (32) and LAMS (60). The pooled proportion of successful symptoms resolution after DEN was 78.27% ± 28.15% (16.70%–94%), compared to 90 and 94% for plastic and BFMS and 100% for FCSEMS and LAMS. Radiological resolution after DEN was recorded to be 84.75%, increasing to 98%, 98.85% and 100% after plastic, FCSEMS and BFMS respectively. Overall mean complications rate was significantly high 30.46% ± (18.58%, 0–71%) in the DEN group, followed by plastic stenting 23.72% (P = 0.002). FCSEMS (16%) and BFMS (7.50%) had the lowest proportion of complications. The weighted mean recurrence of disease post-FCSEMS procedure was 23.25% and 14.75% after DEN while no recurrence occurred after BFMS. For pancreatic necrosis that did not resolve, 100% of the LAMS group, more than half of plastic and FCSEMS, and only 47% of BFMS patients had a repeat procedure. The weighted mean of mortality was highest but statistically non-significant in FCSEMS 8.62% followed by direct ETN 8.07% and BFMS patients 3.20%.

CONCLUSION:

EN is emerging as an increasingly popular technique, rapidly expanding the domain of therapeutic endoscopists. The highest rate of complications with DEN can be explained by the aggressive nature of procedure devoid of stentings such as puncturing the gastric or duodenal wall. Plastic, FCSEMS, and BFMS have lower procedure-related complications, and hospital stays due to small stent size and a targeted approach. The clinical and radiological resolution with these approaches were also better than DEN, but repeat procedure for stent removal or EN revision was often required. The mortality was not significantly different for different approaches.
13 Endoscopic Ultrasound for Screening Patients With Increased Risk of Pancreatic Ductal Adenocarcinoma: Miles to Go Before We Sleep
Authors: Moutinho-Ribeiro Pedro , Morais Rui , Costa-Moreira Pedro , Baptista Manuela , Dias-da-Silva Diogo , Vilas-Boas Filipe , Lopes Susana , Macedo Guilherme
Published: October 2019

INTRODUCTION:

The incidence of pancreatic ductal adenocarcinoma (PDAC) is increasing worldwide, but early diagnosis of the disease is only possible in a minority of patients. In 2020, it is expected to be the second cause of mortality among all cancers. We aimed to access the value of endoscopic ultrasound (EUS) in screening a population with increased risk for PDAC.

METHODS:

We prospectively studied a cohort of 70patients considered to have increased risk of PDAC: chronic pancreatitis (CP), n = 30; hereditary risk (HR), n = 20; and new onset diabetes after age of 50 years (NOD), n = 20; Demographical and clinical data was collected. All patients were submitted to EUS with screening purpose, by 3 experienced endoscopists.

RESULTS:

We evaluated 70 patients with a median age of 54 years (49–61), 58.6% were male. In CP group [54 years (48–61), 76.7% male], 26.7% presented exocrine insufficiency, 30.0% endocrine insufficiency and 3.3% both. The etiology of CP was toxic (tobacco and/or alcohol) in 86.7%. In the HR group [49 years (41–56), 45.0% male], 65% presented Lynch Syndrome and 35% other hereditary syndromes with increased risk for PDAC. Fifteen percenthad already had the diagnosis of one or more digestive cancers. All of these individuals were asymptomatic for pancreatic diseases. In the NOD group [61 years (54–67), 45.0% male], all have the diagnosis in a time period inferior to 36 months, and all were under antidiabetic oral therapy. All subjects had normal CA 19.9 levels. In relation to EUS finding: in the CP group, 20.0% had mass forming disease, and all these patients were submitted to EUS-tissue acquisition that excluded malignancy. In HR group, all EUS findings were normal. In NOD group, EUS revealed a lipomatous pancreatic parenchyma in 4 (20.0%) patients, small simple cystic lesions in 2 (10.0%) and signs of incipient CP (indeterminate for CP according Rosemont criteria) in another 2 (10.0%). Overall, in the 3 groups, no suspicious solid lesion was found, nor a cystic one with worrisome features or high-risk stigmata. The median follow-up after EUS was 12 months (IQR 6–23).

CONCLUSION:

Regardless EUS is being considered one of the most accurate modalities for detection of pancreatic small/precursor lesions, our results (in accordance to the literature) do not support its use for routine screening of PDAC in the studied population.
16 Model for Predicting Severity in Acute Pancreatitis
Authors: John Elizabeth S. , Reddy Rathan , Acharya Priyanka , Kedia Prashant , Tarnasky Paul
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is severe in about 20% of cases with an associated mortality as high as 40%. Accurate prediction of AP severity is necessary to both triage patients and to identify those that might require specific early medical management (EMM). Existing AP severity scoring methods are based on retrospective data and derived from cohorts managed without standardized EMM. The aim of this study was to identify a prognostic model to predict AP severity in a prospective cohort using an evidence-based EMM protocol.

METHODS:

All patients diagnosed with AP from 1/2015–9/2018 were managed per protocol that included emergency department and admit order sets to standardize EMM, e.g., early aggressive fluid resuscitation and enteral feeding. Exclusion criteria included age less than 18 yrs, transfers from outside hospitals, post-ERCP AP, and trauma related AP. Final severity of AP was categorized as either mild or severe (severe and moderately severe) as per Revised Atlanta Classification. Univariate analysis was performed to identify variables of interest. Classification and regression tree (CART®) analysis (a non-parametric method based on the binary recursive partitioning of data) was used to identify the baseline variables most important in predicting severity, determine cutoffs, and to create a decision tree model. Class probability function was used as the splitting rule for tree building with the limit set to not split the node if sample <30 and that the terminal node not have sample <10. We used 20-fold cross validation method for validating the tree model, the overall performance of which was validated in the test sample using area under the receiver operating characteristic (ROC) curve.

RESULTS:

417 total patients were included in the cohort; 356 and 61 patients met criteria for mild and severe pancreatitis, respectively. CART analysis identified five baseline variables in order of greatest to least importance: Creatinine (Cr), procalcitonin, SIRS, age, and HCT (Figure 1). The analysis identified a prognostic algorithm using cutoffs to predict AP severity (Figure 2). ROC curves were generated for the learned (83.7%) and test (73.6%) data sets, respectively (Figure 3).

CONCLUSION:

We identified baseline variables and an algorithm to predict AP severity from a prospective cohort managed using a standardized, evidence based approach. Our results should be validated prospectively to generate a simple scoring model that can be used to appropriately care for patients with AP.
19 Outcomes of Acute Necrotizing Pancreatitis and Associated Fluid Collections in Cannabis Users
Authors: Salazar Miguel , Ramey James S. , Barkin Jodie A. , Kumapley Rudolf , Paintsil Isaac , Barkin Jamie S. , Simons-Linares C. Roberto
Published: October 2019

INTRODUCTION:

Acute Pancreatitis can be complicated by pancreatic necrosis and or pancreatic/peripancreatic fluid collections. The effects of cannabis and the incidence of necrosis and/or pancreatic/peripancreatic fluid collections have not been yet studied. We sought to investigate if cannabis users had less incidence of pancreatic necrosis and/or pancreatic/peripancreatic fluid collections and to ascertain the clinical effects cannabis use has on severity and outcomes in this group of patients.

METHODS:

We performed a retrospective cohort study of all consecutive patients admitted with a first episode of acute pancreatitis at a large tertiary referral center in Chicago, IL from 01/01/2012 to 04/30/2018. Acute pancreatitis diagnosis and severity were identified as per the Revised Atlanta Classification. Presence of pancreatic necrosis or pancreatic/peripancreatic fluid was stablished by radiologic imaging or histopathologic evaluation. Use of cannabis was identified via recorded history and/or urine toxicology. A multivariate logistic regression model was constructed using STATA software version 13 (STATA Corp LLC College Station Texas, USA).

RESULTS:

Five hundred and nineteen patients were included, from which 107 (20.6%) were cannabis users (CU). A total of 69 patients developed acute necrotizing pancreatitis; 58 (84%) were non-cannabis users (N-CU) and 11 (16%) were CU A total of 109 patients with moderate-severe acute pancreatitis developed pancreatic/peripancreatic fluid collections, 92 (84.4%) were NCU and 17 (16.6%) were CU. Acute necrotizing pancreatitis outcomes: CU were more likely to have persistent SIRS (18.2% vs. 12.1%) and to require ICU (63.6% vs. 43.1%), they were also less likely to have Infected necrosis (9.1% vs. 51.7%), bacteremia (18.2% vs. 31%), to require debridement of necrosis (9.1% vs. 32.8%). CU with any pancreatic/peripancreatic fluid collection were more likely to have AKI (47.1% vs. 26.1%).

CONCLUSION:

Cannabis users with acute necrotizing pancreatitis or fluid collection are more likely to have persistent SIRS, AKI and require ICU. However, they're less likely to have infected necrosis/fluid collections, bacteremia and to require pancreatic/peripancreatic fluid debridement. This is a pioneer study to investigate the clinical impact of cannabis use in acute pancreatitis, including outcomes and severity in patients with pancreatic necrosis and pancreatic/peripancreatic fluid collections.
20 Comparison and Outcomes of Cannabis Users With Acute Pancreatitis According to Severity Using the Revised Atlanta Classification of Acute Pancreatitis
Authors: Salazar Miguel , Barkin Jodie A. , Ramey James S. , Kumapley Rudolf , Paintsil Isaac , Barkin Jamie S. , Simons-Linares C. Roberto
Published: October 2019

INTRODUCTION:

Cannabis remains the most widely and commonly used substance in the world. There is conflicting data regarding its effects on Acute Pancreatitis. Aim with this study is to investigate the clinical effects of cannabis use and to compare outcomes in cannabis users (CU) vs. non-cannabis users according to acute pancreatitis severity.

METHODS:

Retrospective design study was conducted on a cohort of patients admitted with acute pancreatitis between January 2012 to April 2018 at a large tertiary hospital in Chicago, IL. Cannabis users were identified via recorded history, urine toxicology or both. Patients who were over 18 years of age at the time of the study and had an episode of acute pancreatitis were included, patients who were pregnant were excluded. Severity of acute pancreatitis was assessed using the revised Atlanta Classification for acute pancreatitis. Multivariate logistic regression model was constructed using STAT software version 13 (STATA Corp LLC, College Station, Texas, USA).

RESULTS:

Five hundred nineteen patients were included, from which 107 (21%) were CU. 65 (61%) had mild acute pancreatitis and 42 (39%) had moderate or severe pancreatitis. Mild acute pancreatitis outcomes: CU were more likely to have AKI (aOR 5.7, P < 0.001), to come back to the ED for recurrent acute pancreatitis after discharge (aOR 2.77, P = 0.004), more likely to require re-hospitalization (aOR 2.43, P = 0.006). Moderate or Severe acute pancreatitis outcomes: CU were more likely to have AKI (aOR 1.8, P = 0.017) and less likely to have necrosis or any pancreatic fluid collection (aOR 0.15, P = 0.018), to require debridement (aOR 0.45, P = 0.037), to have bacteremia (aOR 0.27, P = 0.066).

CONCLUSION:

This is one of the largest studies investigating the clinical effects of cannabis in patients with AP. We found significant difference in AP outcomes according to the severity. CU had higher incidence of AKI either during a mild or moderate/severe pancreatitis attack and were more likely to have recurrent pancreatitis that requires ED visit or re-hospitalization. Interestingly, CU were less likely to have pancreatic necrosis, fluid collection, and bacteremia. Further prospective studies are needed to investigate the acute and long-term factors of cannabis consumption and its impact on AP course and outcomes.
28 Clinical Outcomes of Acute Pancreatitis in Patients With Cirrhosis: 5-Years Update of the National Readmission Database in the United States
Authors: Gad Mohamed , Saad Anas , Simons-Linares Roberto , Chahal Prabhleen
Published: October 2019

INTRODUCTION:

Cirrhosis affects the outcome of non–liver-related illnesses requiring hospitalization, but its impact on acute pancreatitis (AP) patients requiring hospitalization has not yet been studied. We aim to investigate the prevalence of cirrhosis among AP patients and outcomes of mortality, morbidity and cost.

METHODS:

Data from Nationwide Readmission database from 2010 to 2015 was analyzed. All adult patients who were hospitalized for a primary diagnosis of acute pancreatitis were identified and patients who had a history of cirrhosis were compared to patients with no cirrhosis, using the appropriate ICD 9 codes. Continuous variables were expressed as means ± standard deviation or median (IQR), and categorical variables were expressed as percentages. All statistical tests were two-sided.

RESULTS:

A total of 1,575,148 patients were admitted for AP were included in this cohort, and out of those 46,904 patients (3.0%) had a history of cirrhosis. Patients in the cirrhosis group were significantly older, mean age 53.42 ± 11.885 vs. 51.55 ± 17.627 years, P-value < 0.001, mostly males 62.0% vs. 52.3%, P-value < 0.001, and admitted emergently, 97.0% vs. 95.5%, P-value < 0.001. Alcohol abuse was more common among cirrhosis patients 69.1% vs. 28.7%, P-value < 0.001 as well as drug abuse, 12.1% vs. 6.7%, P-value < 0.001. Cirrhosis patients had higher rates of in-hospital AP complications: acute kidney injury 11.7% vs. 8.2%, P-value < 0.001, pneumonia 3.6% vs. 2.8%, P-value < 0.001, acute respiratory distress syndrome and/or ventilation need, 3.0% vs. 2.2%, P-value < 0.001, transfusion requirement 8.9% vs. 2.8%, P-value < 0.001, sepsis, 2.1% vs. 1.6%, P-value < 0.001. SIRS: no difference. In-hospital mortality was higher in patients with cirrhosis 1.8% vs. 0.8%, P-value < 0.001. Median length of stay (LOS) was not significantly different 4.00 (2–6) days vs. 4.00 (2–6), P-value = 0.751. Charges of hospitalization were significantly higher in the cirrhosis group 24,819 USD vs. 20,918 USD, P-value < 0.001.

CONCLUSION:

Acute pancreatitis patients with liver cirrhosis have higher mortality, possibly related to cirrhosis-related comorbidities (sepsis, AKI, GI bleed/transfusion requirement, and ARDS) and not due to AP. Interestingly, they had lower prevalence of SIRS and LOS was not different.
31 The Relationship Between Acute Pancreatitis and Cannabis Use Before and After Recreational Legalization in Select States
Authors: Nemer Laura , Hinton Alice , Krishna Somashekar , Conwell Darwin , Lara Luis
Published: October 2019

INTRODUCTION:

Cannabis is one of the most widely used illicit drugs in the United States. Its use has steadily increased over the last decade in part due to recreational legalization in select states. Concurrently, the prevalence of acute pancreatitis (AP) has increased, yet the etiology of many cases remains unknown. With the national trend toward increased cannabis use, we sought to determine if there was an association between cannabis use and admissions for AP after recreational cannabis was legalized.

METHODS:

State Inpatient Databases for Colorado and Washington were obtained before (2011) and after (2015) recreational cannabis legalization. For comparison, data from Arizona and Florida was also obtained in matching years to represent states that have not legalized recreational cannabis. These were reviewed using ICD-9 and 10 codes for acute pancreatitis, cannabis use, and other variables. Demographics (age, gender and race), comorbidities and hospital characteristics were analyzed. Multivariate comparisons were performed for AP to determine if prevalence has increased over this time period and to assess an association between AP and cannabis use. Significance was determined with a P < 0.05.

RESULTS:

On univariate comparison, a significant increase was found for both cannabis use and admissions for AP in both legalized and non-legalized states from 2011 to 2015 (P < 0.001 for all). Multivariable adjusted analysis for AP indicated an increased odds of presentation with AP in all four states over the study period [legalized: OR 1.07 (CI 1.04, 1.10); non-legalized: OR 1.09 (CI 1.08, 1.11); P < 0.001]. However, cannabis users as a group had a lower odds of presentation with AP in Colorado [OR 0.78 (CI 0.72, 0.86); P < 0.001] and in Washington [OR 0.90 (CI 0.82, 0.98; P < 0.001].

CONCLUSION:

Both cannabis use and AP increased in all states in 2015, after legalization of recreational cannabis. Interestingly, cannabis users appeared to have a decreased odds of AP in both Colorado and Washington. This suggests that although cannabis use and AP have increased from 2011 to 2015, cannabis legalization does not appear to account for the rise in AP. Further studies are needed to better clarify the role of cannabis use and other factors that have led to a rise in AP over recent years.
44 Trends in ERCP Utilization for Sphincter of Oddi Dysfunction: The Real World Impact of EPISOD and Rome IV
Authors: Shah Raj , Smith Zachary L.
Published: October 2019

INTRODUCTION:

The widespread clinical adaptation of landmark clinical trials and practice guidelines is often unclear. The EPISOD trial, a randomized, sham-controlled trial, demonstrated that endoscopic sphincterotomy in patients with Type III Sphincter of Oddi dysfunction (SOD) did not result in clinical improvement. The results of this study were presented at the 2013 National Meeting of the American College of Gastroenterology and published in May 2014. Subsequently, the updated 2016 Rome IV criteria removed Type III SOD from the functional biliary disorder classification. Though patients with Type III SOD make up a minority of all SOD patients, we aimed to assess the utilization of ERCP for patients with SOD in a large population database from 2012–2017.

METHODS:

We searched electronic health record (EHR)-based disparate data from a cloud-based dataset which incorporates over 300 individual hospitals in the United States (Explorys Inc, Cleveland, OH). Using Systematized Nomenclature of Medicine (SNOMED) codes we identified patients with a first-ever diagnosis of “disorder of Sphincter of Oddi” or “spasm of Sphincter of Oddi” annually from 2012–2017. Because the dataset uses SNOMED codes, it was not feasible to sub-classify the types of SOD. Stratified by year, we identified the proportion of patients undergoing ERCP with sphincterotomy and those receiving tricyclic antidepressants (TCA). A Mantel-Haenszel test was used.

RESULTS:

The number of index cases of SOD and rates of ERCP utilization are outlined in Table 1. From 2013 (the presentation of EPISOD data) to 2016, there was a significant trend demonstrating lower rates of ERCP for newly-diagnosed SOD (P = 0.018). A divergent increase in TCA utilization was concomitantly seen from 2013–2015, but the trend was not statistically significant (P = 0.29). Following the publication of the ROME IV criteria, rates of ERCP utilization for newly-diagnosed SOD significantly increased (P = 0.048) (Figure 1).

CONCLUSION:

Following the presentation of the EPISOD data, there was a significant 3-year linear decrease in ERCP utilization for all-comers newly-diagnosed with SOD. Concomitantly, a divergent yet insignificant increase in TCA usage was observed. In 2016, after the Rome IV criteria narrowed the diagnosis of SOD, an expected increase in ERCP utilization was observed. These findings call for ongoing observation to see if these trends are durable.
48 An Overused Lab Test? Evaluating Repeat Lipase in the Management of Acute Pancreatitis and Its Impact on Patient Outcomes
Authors: Datta Samit K , Inaganti Anupama , Nguyen Michael T. , Singh Maharaj , Affi Aboud
Published: October 2019

INTRODUCTION:

Lipase has historically been used to diagnose acute pancreatitis. Its role in prognostication and determining illness severity has been poorly elucidated. A recent literature review demonstrated an inconclusive role of serial lipase in managing acute pancreatitis. Our aim was to evaluate the frequency of repeat lipase and its effect on outcomes.

METHODS:

Retrospective chart review on patients admitted to 3 facilities with a new diagnosis of acute pancreatitis between 2016–2018. Patients (age > 18) who presented with epigastric pain and lipase levels > 1179 (3x ULN) were included. Those with an unclear admission diagnosis or prior pancreatitis were excluded. Data collected included baseline characteristics, admission and any repeat lipase values, admission SIRS and BUN, cause of pancreatitis, length of stay (LOS), and mortality. Statistical analysis was performed using SAS Institute Statistical Analysis Program Version 9.4.

RESULTS:

203 patients met inclusion criteria. There were statistically significant differences in sex and pancreatitis etiology (Table 1). Baseline lipase was not significantly different between the repeat lipase group (RLG) and the non-repeat lipase group (NRLG) (13268.7 vs 7472.8, P = 0.059) (Table 1). LOS was significantly different (5.35 d in RLG vs 2.72 d in NRLG, P = 0.001) (Table 1). There was no difference in mortality (1.8% in RLG vs 0.0% in NRLG, P = 0.450). When done, lipase was repeated an average of 2.88 times and it dropped to <3x ULN in 81.2% of patients (Table 2). Lipase was repeated in 63.6% of patients after lipase to <3x ULN. There was no difference in LOS (5.57 d if lipase <3x ULN vs 4.22 d if lipase not <3x ULN on repeat, P = 0.095) and lipase trended down in 98.8% of patients (Table 2).

CONCLUSION:

Our study demonstrates a frequent remeasurement of lipase levels for first acute pancreatitis episodes. Patients who did not have their lipase repeated had a statistically significant shorter LOS. Age, SIRS, and BUN were used as surrogate markers of severity (BISAP unable to be calculated) and there were no statistically significant differences. Lipase trend unlikely affected discharge as there was no difference in LOS in patients whose lipase went to < 3x ULN. Lipase was repeated even after returning to <3x ULN, suggesting overuse of repeat lipase. There was no difference in mortality. Therefore, our study suggests that repeat lipase does not affect patient discharge and is being overutilized.
49 National Trends in Liver and Pancreatic Malignancy in the U.S.: Increasing Interventions yet Mortality Persists
Authors: Chkhikvadze Tamta , McNary James , Gigauri Nino , Feng Zizhen , Shi Junxin , Kwak Ye Eun
Published: October 2019

INTRODUCTION:

Although there have been recent advances in the treatment of liver and pancreatic cancer, the incidence of both has continued to rise in the USA as well as worldwide. Our aim was to analyze the most recent trends in hospital admissions for malignant liver and pancreas neoplasms and the associated interventions, as well as in-hospital mortality in the US using the largest administrative database, the National Inpatient Sample (NIS).

METHODS:

We extracted admission data of patients of all ages (0–70+) from 2006 to 2014 with associated primary ICD-9 diagnosis codes of liver (155.0) and pancreatic neoplasms (157), and queried for associated procedures (total/local excision/destruction, transplantation, Whipple procedure). Survey data analysis methods were used for national estimates and trend analysis.

RESULTS:

National estimates of admissions due to liver cancer continued to rise from 29,388 in 2006 to 54,930 in 2014. Pancreatic cancer related admissions have also been increasing from 71,479 in 2006 to 95,145 in 2014 (Figure 1). The majority of liver and pancreatic cancers manifested in patients over the age of 50 (92.5%), with the highest number of hospitalizations occuring in patients above age 70 (38%, Table 1). There were more males than females who were admitted due to liver or pancreatic cancer (59% vs. 41%), and most patients were White (67%), followed by Black (14%), Hispanic (11%), Asian/Pacific Islander (4.4%) and Native American/other (3.5%). Despite increasing numbers of cancer related hospitalizations, in-hospital mortality has been decreasing from 11% to 8% in the same 9 year period. Liver transplantation has tripled (650 in 2006 to 1940 in 2014), and the number of loco-regional interventions on liver cancer as well as partial pancreatectomy and Whipple procedures have together all increased at greater rates than hospitalizations for each malignancy (Table 1).

CONCLUSION:

Liver and pancreatic cancer related hospitalizations in the USA has risen for the last decade, and so has the intent-to-cure procedures for these malignancies. The curative liver transplant and Whipple procedure have almost tripled and doubled in number, respectively. However, in-patient mortality from both liver and pancreatic cancer has decreased only by 3% in the past decade and mortality rates remain at 8%. Future strategies to optimize liver and pancreatic cancer screening and medical/surgical treatment is urgently needed in order to decrease liver and pancreatic cancer related admissions and mortality.
55 Choice of Sedation in Endoscopic Retrograde Cholangiopancreatography: Is Monitored Anesthesia Care Safer Than General Anesthesia? Systematic Review and Meta-Analysis
Authors: Dhaliwal Amaninder , Dhindsa Banreet , Satiya Jinendra , Mashiana Harmeet , Bhogal Neil , Rangray Rajani , Ofosu Andrew , Sayles Harlan , Bhat Ishfaq , Singh Shailender , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Monitored anesthesia care (MAC) and general anesthesia (GA) are the two most common methods of sedation used for endoscopic retrograde cholangiopancreatography (ERCP). We performed systematic review and meta-analysis to compare the overall safety between MAC versus GA in ERCP.

METHODS:

We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through May 2019) to identify the studies reporting use of MAC or GA as choice of sedation for ERCP. The primary outcome was to compare the overall sedation related side effects including hypoxia, arrhythmias, hypotension and aspiration in MAC versus GA groups. The secondary outcome was to study the total duration of procedure and recovery time. The meta-analysis was performed using Der Simonian and Laird random effect model.

RESULTS:

A total of 28 studies (11 in GA group and 18 in MAC group) reporting on 12918 patients were included. One study was included in both the groups. The mean age in both the groups was 60 years. A total of 27 studies reported sedation related side effects. The overall sedation related side effects were similar in GA (12.76%; 95% CI = 5.80–21.73, I2 = 95%) versus MAC (12.08%; 95% CI = 5.38–20.89, I2 = 99%) groups with P = 0.859 (Figure 1). In sub-group analysis, hypoxia, arrhythmias, hypotension, aspiration and other sedation related side effects were similar between the two groups (Table 1). The recovery time and duration of procedure was reported in 10 and 14 studies respectively. Although, the mean duration of procedure was more in MAC group (47 min versus 33 min) but mean recovery time was less as compared to GA group (47 min versus 59 min). Only 1.7% of the MAC patients were converted to GA. Significant heterogeneity was noted in in our meta-analysis.

CONCLUSION:

In our meta-analysis, overall sedation related side effects were similar between MAC versus GA groups. The mean duration of procedure was lower in GA group but on contrary recovery (mean) was noted to be faster in MAC group. Based on our meta-analysis, monitored anesthesia care could be used as an alternative to general anesthesia when performing ERCP, although high risk patients may be better served by general anesthesia. Large multicenter randomized control trials are needed to further validate our findings.
56 Is There Association Between Pancreatic Divisum and Other Pancreatic Conditions Including Acute Pancreatitis, Chronic Pancreatitis, and Pancreatic Tumors?
Authors: Al-Aboodi Yasir , Alazzawi Yasir , Al-Chalabi Ahmed , Nawras Ali
Published: October 2019

INTRODUCTION:

Over many decades, there has been controversy about pancreatic divisum and its association with acute and or chronic pancreatitis. In this study, we used the largest national data registry to examine the relation between pancreatic divisum and the other forementioned pancreatic conditions.

METHODS:

A retrospective analysis is performed on the National Inpatient Data base (NIS) of 2014 to examine the association between pancreatic Divisum, pancreatitis (Acute and chronic) and pancreatic tumor. Case (Divisum) -control (No divisum) design is created. The no divisum (Control) is selected using the random percentage. The international code for diseases version nine (ICD9) is used to identify all variables. All ages, sex and races were included.

RESULTS:

660cases vs 5000 control encounters are identified with a mean age of 49 years. Of the 660, 35.5% (235) male, and 64.5% (426) female. 481 (72.9%) are white, 62 (9.4%) black, 71 (10.8%) Hispanic, 19 (2.9%) Asians, 9 (1.4%) Native Americans and 18 (2.7%) others. 262/660 (39.7%) in the Divisum group has been found to have a diagnosis of chronic pancreatitis vs.0.6% in the non Divisum group (control). P < 0.005, OR = 103, CI 95% (70–153). 327/660 (49%) in the pancreatic divisum group have acute pancreatitis vs 1.4% (70) in the control group. P < 0.000, OR = 70.78, 95% CI (53.081–94.398) with the adjustment to other risk factors for chronic and acute pancreatitis including smoking, alcohol, cystic fibrosis, TGD pancreatitis, and gallstones pancreatitis and idiopathic pancreatitis. Only 3 cases of pancreatic tumor were detected in the pancreatic Divisum group.

CONCLUSION:

There is strong association between Pancreatic divisum and acute and chronic pancreatitis. Yet this association might be influenced by the selection bias from inpatient population only. There is no association found between pancreatic Divisum and pancreatic tumor.
59 Pancreas Enzyme Replacement Dosing Before and After Total Pancreatectomy and Islet Autotransplantation
Authors: Lara Luis , Buss Jill , Schaefer Monica , Black Sylvester , Rajab Amer , Kuntz Kristin , Hart Phil , Conwell Darwin , Washburn Kenneth
Published: October 2019

INTRODUCTION:

Pancreas enzyme replacement therapy (PERT) is used to improve nutrient digestion, especially of lipids, in patients with exocrine pancreas insufficiency who otherwise may experience maldigestion, malabsorption, malnutrition, and steatorrhea. Although underdosage of PERT is common, adequate dosing is particularly important in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT). Current PERT dosing guidelines do not explicitly provide recommendations following TPIAT so we determined the adequacy of PERT dosing in a cohort of patients with TPIAT.

METHODS:

The TPIAT database from 2009-2018 was searched to determine PERT dosing in subjects before TPIAT (n = 14), immediately after TPIAT and at 6 and 12 months (n = 11). Adequate weight based dosing was established using Cystic Fibrosis Foundation guidelines. Average PERT dose was calculated and the ranges were reported, P < 0.05 was significant.

RESULTS:

Data was available in 14 patients, and 6 and 12 month data was available in 11 patients. Indication for TPIAT included 6 idiopathic chronic pancreatitis (CP), 4 genetic CP (4 PRSS1, 1 CFTR), 3 idiopathic recurrent AP, 1 alcohol induced CP. 3 patients were not using PERT before TPIAT, 7 were underdosed (average 62,000 U/day, range 6,000–108,000), and 4 were adequate (205,250 U/day; 125,000–228,000). At discharge 9 patients were underdosed (72,222 U/day; 6000–108,000), and 5 were adequate (248,200 U/day; 125,000–360,000). At 6 months 3/11 pts (27%) were underdosed (56,666 U/day; 30,000–80,000) and 8/11 pts (73%) were adequate (228,000 U/day; 144,000–432,000). At 12 months 2/11 pts (18%) were underdosed (108,000 U/day each) and 9/11 (82%) pts were adequate (430,222 U/day; 144,000–384,000). PERT dose increase was significant for the period post-TPIAT to 6 months (P = 0.04). The graph shows the trend of PERT during the study period.

CONCLUSION:

Underdosing of PERT was common before and immediately after TPIAT. It is possible that poor oral intake dictated the immediate low post TPIAT dose. Significant PERT dose increase was noted in the first 6 months, and was sustained at 12 months. PERT dosing needs to be monitored closely and weight based dosing should be considered to achieve optimal nutritional benefit.
64 Acute Pancreatitis Outcomes May Not Be Worse in Post-Transplant Patients
Authors: Wadhwa Vaibhav , Gonzalez Adalberto , Gupta Kapil , Castaneda Daniel , Garg Sushil , Bilal Mohammad , Lara Luis
Published: October 2019

INTRODUCTION:

The average incidence of acute pancreatitis (AP) in patients with a history of solid organ transplant ranges from 2 to 8%. Patients with a history of bone marrow transplant are reported to have an incidence of 4%. Presentations include “chemical” pancreatitis with enzymes elevation only and clinical pancreatitis according to the revised Atlanta criteria. A few previous studies have shown that multi-organ failure and death are frequent complications of AP in transplanted patients. Most of the studies individualize their findings based on a specific organ transplanted (such as kidney or heart or liver, etc.) The aim of our study was to evaluate the outcomes of patients with acute pancreatitis with a history of any solid organ or bone marrow transplant using a national database.

METHODS:

We performed a retrospective cross-sectional analysis using the National Inpatient Sample (NIS) database from 2014. We included all patients with acute pancreatitis (ICD 9 Code: 577.0). Next, we divided the AP patients into two groups - one with history of a transplant and those without a history of transplant. We compared the outcomes of both groups. Both univariable and multivariable analyses were performed to assess the risk factors and outcomes of patients with acute pancreatitis in post transplant patients.

RESULTS:

We analyzed more than 35 million US hospitalizations in 2014 out of which 279,145 were acute pancreatitis related hospitalizations. There were 1,265 hospitalizations for acute pancreatitis in previously transplanted patients, an incidence of 4.53%. The mortality rate of AP was similar in non-transplanted patients (0.66%) than in transplanted patients (0.4%). The mean length of stay (4.62 days vs. 4.61 days) and mean total charges ($35,723 vs. $31,202) were similar in acute pancreatitis for transplant and non-transplant patients. Multivariable regression analysis showed that multiorgan dysfunction risk among AP patients was significantly higher if they had a history of transplant (OR of 2.27; P < 0.01).

CONCLUSION:

Our study showed that AP generally has similar outcomes in transplant and non-transplant patients even with a higher risk of multiorgan failure. More data is needed to determine if this holds true for subjects who develop AP in the immediate post transplant period.
66 Predictors of Increased Hospital Length of Stay Among Elderly Individuals With Acute Pancreatitis
Authors: Bassi Mehak , Mohapatra Sonmoon , Charilaou Paris , Bandla Harikrishna , Pitchumoni Capecomorin
Published: October 2019

INTRODUCTION:

Acute pancreatitis (AP) is one of the most common conditions affecting the elderly. Older age is recognized as a marker of severity in most severity scoring systems. In this study, we aim to compare the demographics, clinical and laboratory variables, and outcomes between elderly (age ≥65 years) versus younger (age <65 years) patients with AP. We also aimed to determine the factors associated with increased hospital length of stay (LOS) in elderly individuals admitted with AP.

METHODS:

For this retrospective study, our hospital's inpatient database was used to identify patients with AP between January 2015 to August 2018. Group differences were tested with Chi-square for categorical variables and t-test/quantile regression analysis for continuous variables. After the univariate analysis was conducted and the clinical relevance of significant variables was assessed, the multivariate accelerated failure time model was used to determine factors affecting LOS.

RESULTS:

Among 277 subjects with AP, 64 (23%) were elderly (≥65 y, mean 74.3 ± 0.9 y). Compared to the younger population (age <65 y, mean 42.5 ± 0.9 y), elderly patients were more associated with Type 2 DM (40.6% vs 22.5% P = 0.004), hypertension (78.1% vs 29.1%, P < 0.001), congestive heart failure (10.9% vs 1.9%, P = 0.001), CKD (12.5% vs 2.8%, P = 0.002), malignancy (23.4% vs 5.6%, P < 0.001), coronary artery disease (15.6% versus 2.8%, P < 0.001), and COPD (17.2% vs 4.2%, P < 0.001) (Table 1). Elderly patients had a higher blood urea nitrogen, creatinine, amylase, and low albumin levels at the time of admission compared to the younger population. The mean LOS was higher in the elderly population (5.2 ± 0.7 vs 4.5 ± 0.2 days, P = 0.037) compared to the younger individuals. Presence of pancreatitis related complications, the performance of cholecystectomy and endoscopic interventions (EUS and ERCP) during the same admission, and higher serum creatinine at the time of admission were independently associated with increased LOS (Table 2).

CONCLUSION:

1. Older age in itself is not a cause of increased mortality or morbidity in AP. 2. Comorbid conditions are commonly associated with older age but not significantly associated with increased LOS in AP. 3. The factors associated with increased LOS in elderly AP patients include the presence of pancreatitis related complications, the performance of cholecystectomy and endoscopic interventions during the same admission, and higher serum creatinine at the time of presentation.
71 The Safety of Endoscopic Retrograde Cholangiopancreatography in Renal Transplant Patients
Authors: Alomari Mohammad , Sarmini Muhammad Talal , Asfari Mohammad Maysara , Al Momani Laith , Nehme Fredy , Aasen Tyler , Young Mark
Published: October 2019

INTRODUCTION:

Patients with renal transplant (RT) are prone to higher rates of complications after procedures and surgical interventions. The literature that evaluates the outcomes of endoscopy retrograde cholangiopancreatography (ERCP) in RT patients is scarce. Therefore, we conducted this study to evaluate the outcomes of ERCP in RT patients using a large nationwide inpatient database.

METHODS:

Using data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified all patients who underwent ERCP using appropriate ICD 9 coding. Afterwards, we divided patients who had ERCP into two groups: patients with RT (study group) and patients without RT (control group). Primary outcomes included post ERCP adverse effects (AE): post ERCP pancreatitis (PEP), bleeding, and perforation. Secondary outcomes included inpatient mortality (IM) and length of stay (LOS). AEs and mortality were compared using multivariate logistic regression analysis after adjusting for potential cofounding factors including: (age, race, gender, smoking, and Elixhauser comorbidities).

RESULTS:

A total of 108,199 patients underwent ERCP, of which 343 (0.32%) had RT. RT patients were younger (median age: 58 vs. 59), less likely to be female (48.1% vs. 59.8%), and more likely to be African American (12.1% vs. 9.1%) compared to the control group (P < 0.05). In addition, RT patients were less likely to have alcohol abuse (2% vs. 4.1%) and smoking (3.8% vs. 12.1%) compared to the control group (P < 0.05) (Table 1). Using multivariate logistic regression, individuals in the RT group had a statistically significant higher odds for PEP (OR 1.61, 95% CI: 1.05–2.47, P < 0.05) compared with the control group. On the other hand, there was no statistically significant difference between the two groups in bleeding (OR 1.32, 95% CI: 0.42–4.14, P > 0.05) and IM (OR 0.97, 95% CI: 0.31–3.06, P > 0.05). The post ERCP perforation rate was 0.04% (n = 48) in the control group while the RT group had no reported perforations. Finally, the adjusted LOS was longer in the RT group compared to the control group (6.51 vs 5.49, P < 0.05) (Figure 1).

CONCLUSION:

This is one of the largest studies that assessed the outcomes of ERCP in RT patients to date. Our analysis showed that patients with RT had increased risk for PEP, while there was no significant difference in the post ERCP bleeding rate or IM. Careful selection and close monitoring for RT patients requiring ERCP is warranted to avoid complications in this population.