bluuebunny/crossref_metadata_2025 huggingface dataset:
847 Real World Experience of Ustekinumab for Induction and Maintenance of Remission in Crohn’s Disease: A U.K. Single Center Experience
Authors: Bhandare Anirudh P. , Crooks Benjamin J. , Taylor J , Limdi Jimmy K.
Published: October 2019

INTRODUCTION:

Ustekinumab(UST),an IgG1 monoclonal antibody targeting IL12/IL23(p40 sub-unit)has been licensed in UK for use in moderate to severe Crohn’s disease(CD) since 2017.We present a real -world experience from our center.

METHODS:

A retrospective analysis of patients commenced on UST was conducted using electronic medical records to evaluate efficacy. Patients were assessed at baseline, induction (week 8) and at 1 year. Our primary end point was reduction in Physicians global assessment (PGA). Secondary endpoints were improvement in CRP (>10 at baseline), Fecal Calprotectin (>250 at baseline) and albumin (<35 at baseline). Concomitant medication and surgical history were also recorded.

RESULTS:

62 patients received UST (42 female; mean age 44.74). Mean age at diagnosis was 33.61 years and average duration of disease was 135 months (median 180, IQR 135.25). Sixteen patients had previous surgery for CD. At baseline 95% patients had PGA of moderate to severe disease with 54 (87%) achieving primary endpoint at induction. 16 patients had annual follow up and 81.25% achieved the primary endpoint. The Harvey Bradshaw index at follow up appointments correlated with the PGA values to account for clinical remission. From baseline to induction, 24 had CRP >10. Of these, 20 (83.3%) patients achieved the secondary endpoint for CRP at induction. At annual follow up 15 patients had CRP recorded, 7 out of them had CRP >10 at baseline and all achieved the secondary endpoint. Albumin was < 35 in 21 patients at baseline and 71.5% showed improvement at induction. At 12 months eight of the above 21 had albumin recorded and 5 achieved the secondary endpoint of improvement in albumin. Fecal calprotectin was elevated in 19 out 47 patients recorded at baseline. Of whom 58% achieved the secondary endpoint. 53 patients (85.5%) had received a previous biologic with 20 receiving Infliximab (IFX), adalimumab (ADA) and vedolizumab (VDZ) prior to UST.15 received only IFX, 11 only ADA and 20 both anti-TNF’s. One patient received IFX and VDZ. Four adverse reactions were noted, 2 had rash after infusion and 1 headache. One patient reported epidydimo-orchitis 7 days post infusion and required hospitalisation. Twelve patients discontinued UST with 6 having surgery and 6 from loss of response (5 secondary and 1 primary loss of response).

CONCLUSION:

UST is effective in induction well as maintenance of remission in CD for biologic experienced and naive patients as also in those with previous surgical resection.There were no significant safety concerns.
848 Comparison of Patient Preferences Between Stool Tests and Colonoscopy for Assessment of Disease Activity in Inflammatory Bowel Diseases
Authors: Barsky Maria , Meserve Joseph , Collins Angelina , Singh Siddharth , Boland Brigid , Sandborn William J. , Dulai Parambir
Published: October 2019

INTRODUCTION:

Fecal biomarkers are being increasingly suggested as alternatives to colonoscopy for disease activity assessments. We aimed to assess patient preferences between fecal testing and colonoscopy for disease activity assessments.

METHODS:

Prospective interview of UC and CD patients from a single tertiary referral center. A hierarchy matrix survey was built to understand patient preferences around decision making when choosing between approaches (fecal testing or colonoscopy) for achieving a specific goal (monitoring disease activity) based on pre-set criteria (accuracy, preparation, pain, complications). Presumed accuracy of fecal biomarkers was set to 80-90%, and rates of colonoscopy related complication were set to 1 in 100 or 1 in 1,000. Pair wise analyses were used to identify determinants of patient preference and thresholds of acceptability to change preferences.

RESULTS:

N = 100, median age of 44 years (IQR 27-63) with median disease duration of 9 years (IQR 5-21). Disease activity at the time of survey was well distributed with 47% in clinical remission, 24% with mild and 29% with moderate-severe activity. Colonoscopy was the initial preference for 40% of patients and more often being preferred by CD patients (49% vs. 31%, P = 0.069). When choosing between fecal testing or colonoscopy for disease activity assessment, accuracy was significantly more important than preparation, pain, or complications (P < 0.05), but preparation and pain were comparable to complications (P > 0.20). After understanding the limitations in accuracy with fecal testing, 25 patients who initially chose fecal testing changed their preference to colonoscopy (P < 0.001) and at the completion of the survey a total of 65% chose colonoscopy over fecal testing. If the fecal test was wrong at most 1 in 20 times (5%), 40% of patients who ultimately chose colonoscopy were willing to undergo fecal testing. If the fecal test was wrong at most 1 in 50 times (2%), 66% of patients who ultimately chose colonoscopy were willing to undergo fecal testing.

CONCLUSION:

Accuracy appears to be the most important criteria for IBD patients when choosing monitoring strategies, followed by pain/preparation and risk of complications. A significant number of patients changed their preferences to colonoscopy after learning more about the diagnostic accuracy of current fecal testing for disease monitoring. A high degree of confidence is required of fecal test results for patients to choose this strategy.
851 Targeted Intracecal anti-α4β7 Integrin Antibody Results in Reduce Accumulation of α4β7 Memory T-cells in Gut Tissue in DSS-induced Colitis Mice
Authors: Jones Mitchell L. , Lee Shaoying N. , Singh Sharat , Luo Allison , Sandborn William J. , Chuang Emil , Wahl Chris
Published: October 2019

INTRODUCTION:

Systemically administered anti-α4β7 integrin antibodies such as Vedolizumab have been approved for the treatment of Crohn's disease and ulcerative colitis. The objective of this study was to assess whether intracecally (IC) delivered anti-mouse α4β7 integrin antibody (DATK32) might penetrate the mucosa and confer efficacy compared with systemic intraperitoneal (IP) injection in DSS-induced colitis mice.

METHODS:

Animals underwent implantation of a cecal cannula for topical bolus delivery in the IC groups. Acute colitis was induced by exposure to 3% DSS drinking water from Day 0-5. DATK32 was administrated via IP (25 mg/kg) every 3 days (Q3D), IC (25 mg/kg) Q3D, or IC (25 or 5 mg/kg) every day (QD) from Day 0 to 14. At Day 14, plasma, colon content and tissue were collected for DATK32 measurement; and Peyer’s patches (PP), mesenteric lymph nodes (mLN), and whole blood were collected for α4β7 memory T-cell counts.

RESULTS:

Significantly higher colon content and tissue exposure but limited blood exposure of DATK32 were found in IC QD groups compared to IP Q3D group. Immunohistochemistry staining of DATK32 was found in all layers of colon tissue, and as deep as tunica muscularis when delivered IC. The α4β7 memory T-cell count was significantly reduced in mLN in all IC groups compared to vehicle control and IP groups. Similar findings were observed in PP with IC QD treatment. Finally, the α4β7 memory T-cell count in blood was significantly increased in IC QD but not IC Q3D groups compared to vehicle control and IP group.

CONCLUSION:

In this study, we demonstrated that targeted IC anti-α4β7 integrin antibody lead to significantly higher drug exposure in colon contents and tissues with limited blood exposure compared to IP. Targeted IC QD treatment showed a significantly reduced α4β7 memory T-cell counts in PP and mLN representing populations within inflamed jejunal and colon tissues. Additionaly, an increased number of α4β7 memory T-cells was found in blood with targeted IC DATK32 compared to IP, suggesting T cells that have trafficked from blood to tissue can undergo reverse trafficking. Recent publications have reported a dose dependent increase in efficacy with systemically delivered anti-α4β7 despite full T-cell receptor occupancy in blood. Results of this study point to the potential for increased efficacy with high concentrations in local inflamed tissues. Although the mechanism of action is unclear, results suggest topically delivered anti-α4β7 may be an efficacious treatment in IBD.
853 Use of Day Care and Infectious Complications in Children Born to Mothers With Inflammatory Bowel Disease: A Nested Prospective Cohort in the PIANO Registry
Authors: Long Millie D. , Siegel Corey A. , Abraham Bincy , Chiorean Michael , Mahadevan Uma
Published: October 2019

INTRODUCTION:

Children attending day care have an increased risk of infection. It is unknown whether day care attendance among children of mothers with inflammatory bowel disease (IBD) is associated with an increased risk of infection and whether maternal exposure to biologics potentiates this risk.

METHODS:

The Pregnancy in IBD and Neonatal Outcomes (PIANO) registry is a prospective cohort of over 1500 pregnant women with IBD and their children. Data are collected at each trimester, delivery and at 4, 9 and 12 months postpartum. A sub-set of this cohort completed data on day care exposure. Outcomes of interest included any infection or serious infection (infection requiring hospitalization) in the first year of life. Bivariate analyses were used to compare various clinical characteristics and infectious outcomes by day care use. Logistic regression models were used 1) to determine whether day care independently increased the risk of infections and 2) to determine whether biologic or immunosuppressive medications independently increased the risk of infections among those attending day care.

RESULTS:

A total of 310 pregnant women with IBD and their children were included. Of these, 39% of children attended day care in the first year of life. Clinical characteristics were similar in those that attended day care vs. not, including maternal medication use. Slightly greater numbers of children of non-smokers attended day care (P = 0.007) (Table 1). Children attending day care had a higher rate of any infection in the first year of life than those not attending day care (65% vs. 54%, P = 0.05). However, there were no differences in serious infection rates (6% vs. 8%, P = 0.65) (Table 2). Use of daycare was not significantly associated with any infection after controlling for vaccine use, breastfeeding and preterm birth (OR 1.2, 95% CI 0.71-2.05). Among those attending day care, neither biologic (OR 0.47, 95% CI 0.05-4.86), immunomodulator (OR 0.76, 95% CI 0.04-16.42), nor combination therapy use (OR 0.78, 95% CI 0.06-9.34) was significantly associated with any infection.

CONCLUSION:

Approximately 1/3 of children born to women with IBD in this cohort attended day care in the first year of life. Day care was associated with higher overall infection rates, but not differences in serious infections. There was no further increased risk of infection among children in day care whose mothers were exposed to biologic medications, suggesting that childcare options should not be limited by in utero medication exposure.
857 Oral Mesalamine Use in Crohn's Disease After Implementation of the American College of Gastroenterology Guidelines: A TARGET-IBD Cohort Study
Authors: Gupta Nitin , Sands Bruce E. , Regueiro Miguel , Dubinsky Marla C. , Rubin David T. , Hanson John , Aberra Faten , Weiss Michael , Watkins Stephanie , Gazis Derek R. , Long Millie D.
Published: October 2019

INTRODUCTION:

American College of Gastroenterology (ACG) guidelines for the management of adults with Crohn's disease (CD) in March 2018 state that oral mesalamine, "should not be used...to treat CD". This abstract estimates the prevalence of any use of mesalamine among patients with CD before and after the implementation of the guideline. It also aims to describe current utilization patterns of mesalamine in CD by disease phenotype, location and concomitant use of biologic agents.

METHODS:

TARGET-IBD is a longitudinal cohort of IBD patients receiving usual care in the US; this abstract includes CD patients enrolled between March 2017 and December 2018. Medication use was captured as any use in the follow up period. Use of mesalamine was stratified into patients who were on mesalamine alone or patients on mesalamine and a biologic. The proportion of patients on mesalamine was estimated in time windows after the policy change to discern penetration into usual practice.

RESULTS:

732 patients from TARGET-IBD who had baseline data prior to the new recommendation were included. Of these, 14% used mesalamine only, 8% used mesalamine plus a biologic and 78% did not use mesalamine. A total of 65% received care in academic centers and the median duration of disease at enrollment was 12 years. The distribution of patient characteristics was similar after the policy change. Six months after the ACG recommendation, 11% of patients used mesalamine only, 7% were on mesalamine plus a biologic and 82% did not use mesalamine. Prevalence of use for the 3 and 6 month time windows were similar. Subsequent therapy changes and additions in patients on mesalamine are shown in Figure 1. Location (colon vs ileum) and type of CD (inflammatory vs fistulizing) were statistically significant predictors of the odds of any mesalamine use both before and after the policy change (OR 3.233 (CI 1.725-6.061) and 3.334 (CI 1.931-5.755, respectively)).

CONCLUSION:

Mesalamine use remained stable in the TARGET-IBD CD population, despite the release of the ACG guideline. Individuals with colonic, inflammatory disease were more likely to receive mesalamine, as were Medicare recipients. There was little difference between academic and community practice in implementation of the new standards. Given that the guidelines are relatively new, it is important to follow these participants over a longer period and to monitor practice differences and ways to reinforce the practice recommendations to improve quality and cost of care.
860 A Novel Quality Improvement Initiative to Reduce Inpatient Opioid Analgesic Use in Inflammatory Bowel Disease: The “IBD Pain Ladder”
Authors: Kaimakliotis Pavlos , Ramadugu Ajit , Kang Jennifer , Trivedi Itishree
Published: October 2019

INTRODUCTION:

Opioid analgesic use is associated with increased mortality, higher readmission rates, and reduced quality of life among patients with inflammatory bowel disease (IBD). Evidence-based strategies to reduce inpatient opioid use in this population have been lacking.

METHODS:

We have initiated a quality improvement study using an educational intervention, targeting internal medicine (IM) and emergency medicine (EM) house staff with a goal to reduce in-hospital opioid use among IBD patients admitted to the gastroenterology (GI) service at our tertiary institution. This educational tool, the “IBD Pain Ladder” (Figure 1), was created using exhaustive literature review and with multi-disciplinary expert opinion. The tool is meant to help guide decisions regarding analgesia in this patient population while sparing opioid use. Pre-intervention data was collected from IBD patients admitted during a nine-month period (5/2018-2/2019). Educational intervention and prospective follow-up data for another 4 months was collected. The primary outcome was reduction in total inpatient opioid use in oral morphine equivalents per patient. Secondary outcomes included length of stay, types of opioid, 90-day readmission rates, outpatient opioid prescriptions provided upon discharge, Clostridium difficiledetection rates, fecal calprotectin, and C-reactive protein (CRP) levels. t tests for continuous variables and Fisher’s exact test for categorical variables were used; a P value < 0.05 was considered significant.

RESULTS:

A total of 51 patients with 69 hospitalizations were analyzed (Table 2). Hospitalizations before and after our intervention were compared. There was no statistically significant difference in baseline admission characteristics between the two groups (Table 1). Our primary outcome was achieved with a statistically significant reduction in opioid use (39.1 vs 12.4 mg; P < 0.037). Patients were also less likely to receive any opioid during hospitalizations after our intervention (71% vs 43%; P < 0.034.) Length of hospitalization (5.2 vs 3.9 days; P < 0.11) and readmission rates (41% vs 23.5%; P < 0.55) were decreased post-intervention but did not reach statistical significance.

CONCLUSION:

We believe this intervention, aimed at housestaff education and providing a roadmap for pain management in this patient population, is a cost-effective, readily reproducible strategy that can be widely applied to improve IBD patient care. Results will be published and used for quality improvement in inpatient IBD care.
865 Endoscopic Stricturotomy in the Treatment of Anal Stricture in Patients With Fecal Diversion
Authors: Lan Nan , Shen Bo
Published: October 2019

INTRODUCTION:

Fecal diversion has been used as a protective measure for newly constructed intestinal anastomoses or to settle chronic refractory inflammation. Fecal diversion had been associated with complications such as diversion-related anal stricture. The aim of this study is to exam the significance and the endoscopic treatment for diversion-related stricture.

METHODS:

All consecutive patients with diversion-associated anal stricture that were treated with endoscopic stricturotomy (ESt) in our interventional IBD center (i-IBD) were extracted from patient medical charts from 2010 to 2018. The primary outcome was surgery-free survival.

RESULTS:

A total of 33 patients underwent ESt for their diversion associated strictures. Patients were mostly Caucasian (N = 27, 81.8%) and 18 patients (54.5%) were female. Most of the patients included in this study were diagnosed with ulcerative colitis (N = 22, 66.7%) and most underwent ileal pouch-anal anastomosis (IPAA) with J configuration (N = 24, 72.7%). The most prevalent reason for diversion included anastomotic leaks/sinus/fistula (N = 11, 33.3%), refractory pouchitis (N = 8, 24.2%) and stricturing disease (N = 8, 24.2%). Patients were diagnosed with their stricture at the average age of 43.9 ± 16.1 years. The length of the stricture treated was 2.7 ± 2.2 cm and 32 (97.0%) strictures were nontraversable to endoscope. These patients underwent 2.5 ± 1.9 sessions of ESt in a follow-up of 2.2 ± 1.5 years. Symptomatic improvement was seen in 15/25 (60.0) patients. Subsequent surgery was needed in 4 (12.1%) and 10 (30.3%) had their stoma reversed. No post-ESt complication was reported.

CONCLUSION:

ESt is an effective safe way of treating diversion-related anal strictures. More than half of patients experienced symptomatic improvement and a third of patients had their stoma reversed successfully.
867 Efficacy and Safety of Transoral Incisionless Fundoplication (TIF) in Refractory Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis
Authors: Gopalakrishnan Ravikumar Naveen Prasad , Sannapaneni Shilpa , Arora Amita , Sanaka Madhusudhan R.
Published: October 2019

INTRODUCTION:

Refractory gastroesophageal reflux disease (GERD) is common and can affect up to 40% of patients who are on proton pump inhibitor therapy. Surgical fundoplication (Nissen fundoplication) has proven to be an effective treatment option for these patients but it remains an invasive procedure in this era of minimally invasive surgery. Several endoluminal approaches to GERD management have been developed as a potential bridge between medical management and surgical fundoplication. Transoral incisionless fundoplication (TIF) is a novel endoscopic technique which has shown some promise in early studies; however, its safety profile and efficacy remain uncertain. We aimed to assess the efficacy and safety of TIF in refractory GERD through a systematic review and meta-analysis.

METHODS:

We performed a thorough literature search using PubMed, EMBASE, Cochrane library, Medline, Google Scholar and Science citation index between January 2010 to January 2018. Search terms included MeSH and non-MeSH terms relating to gastroesophageal reflux disease, refractory gastroesophageal reflux disease, endoscopic techniques in gastroesophageal reflux disease and transoral incisionless fundoplication. Additional case-reports, case series, and abstracts were retrieved by searching from references of relevant studies. Primary outcomes measured were cumulative technical success rate and adverse events. Secondary outcomes measured were the improvement in Gastroesophageal Reflux Symptom Score (GERSS), DeMeester score and Reflux symptom index (RSI).

RESULTS:

Based on our search criteria, 41 studies were identified and 6 were excluded after careful review. 35 studies which included 1586 patients (49.4% males) were analyzed. The overall technical success rate of TIF was 98.4% (95% confidence interval [CI] 96 to 99, P < 0.001) and had an adverse event rate of 3.2% (95% CI 1 to 4, P < 0.001). Post TIF, there was a significant improvement in GERSS score (mean difference 17.29, 95% CI 17.26 to 18.28, P < 0.001), RSI (mean difference 14.37, 95% CI 13.39 to 15.19, P < 0.001) and DeMeester score (mean difference 9.78, 95 % CI 8.12 to 11.89, P < 0.001).

CONCLUSION:

TIF is a technically feasible and effective endoscopic therapeutic option for refractory GERD with good clinical responses. However, more controlled trials are required in future to compare the efficacy and safety between TIF and Nissen fundoplication.
868 Coils and Dermabond: A Large County Hospital Experience With Gastric Varices
Authors: Glass Jason , Suarez Jorge , Tavakkoli Anna , Agrawal Deepak
Published: October 2019

INTRODUCTION:

Bleeding from gastric varices (GV) is associated with high mortality and morbidity. EUS-guided injection of coils, cyanoacrylate glue or both is an emerging modality for treatment of gastric varics. We present our experience using EUS injection of coils (Nester Embolization Coil; Cook Medical) and 2-Octyl-cyanoacrylate (Dermabond) glue in the treatment of bleeding gastric varices in a large county hospital setting.

METHODS:

Medical records of consecutivepatients undergoing EUS guided treatment of gastric varices with glue and coils between mth/yer to mth/year were reviewed.Patient characteristics were recorded including presence of cirrhosis, variceal characteristics (size, location), and intervention type. Outcomes included technical success (defined as deployment of glue and coils inside the varix with cessation of blood flow on Doppler evaluation), rebleeding events, and subsequent one month follow up were recorded.

RESULTS:

Total of 16 patients were treated with EUS guided injection of coils and/or glue. Three (18.8%) had active bleeding and four (25%) had stigmata of recent bleeding at the index endoscopy. The remaining 9 (46.2%) had history of bleeding from gastric varices. 15/16 patients were treated with both coils and glue injection. One patient with small varices was treated with glue injection alone. Technical success was achieved in all 16 (100%) patients. None of the patients had active bleeding at the end of the procedure. The mean number of coils inserted was 3.9 and the mean volume of glue injected was 2.1 mL. Rebleeding, defined as having repeat endoscopy for gross gastrointestinal bleeding, occurred in 3 patients within one month of the initial EUS. In one patient, rebleeding was from gastric varices and was again treated with coils and glue injection. There were no significant adverse events including pain or embolization of glue or coils. One patient had extrusion of coils into the lumen of the stomach with no active bleeding identified.

CONCLUSION:

In this series, we demonstrate the high technical success and efficacy of EUS guided coil and glue injection in treatment of bleeding or secondary prophylaxis of gastric varices.
871 Impact of Patient Screening Process on Diagnostic and Therapeutic Yield of Double Balloon Enteroscopy
Authors: Wang Xiao Jing , Liu Mengfei , Anderson Bradley , Chakraborty Subhankar , Garg Sushil , Kane Sunanda , Sanchez William
Published: October 2019

INTRODUCTION:

Double balloon enteroscopy (DBE) is an important tool for evaluation of obscure GI bleeding but is a limited resource given time and expertise required. Patient selection is important to help optimize diagnostic yield and subsequent successful management of small bowel bleeding. To maximize the efficiency of DBE performed, our endoscopy group established a screening protocol (Figure) prior to approval of any procedure. We developed a quality improvement project to assess the efficacy of this screening protocol and to evaluate which components of screening were most predictive for procedural success.

METHODS:

A retrospective chart review was performed on all patients who underwent anterograde or retrograde double balloon enteroscopy for suspected GI bleeding from January 2016 to December 2017. Our screening protocol was implemented on February 1st, 2017. Data was obtained on patient demographics, clinical presentation, laboratory evaluation, and prior investigation for bleeding evaluation. Endoscopy outcomes were separated into procedural success, defined as lesion identified, and clinical success, defined as resolution of bleeding. Success rates were compared pre and post intervention. Regression analysis was performed to evaluate which components best predicted a successful procedure.

RESULTS:

We reviewed 114 DBE procedures in 89 patients, 53.5% male (n = 61) with a mean age of 62.8 + 13.3 years. Of these, 86% (n = 98) were performed prior to initiation of the screening protocol. Overall, there was no significant difference in procedural success pre and post intervention as defined by presence of recurrent bleeding, persistent anemia, or transfusion need (Table 1). On univariate analysis of clinical success, defined as lack of recurrent bleeding, gender, anticoagulation use, and presence of lesion on CE were significant (Table 2). Identification and intervention on a lesion during the balloon endoscopy did not impact future anemia, bleeding, or transfusion requirements.

CONCLUSION:

The patient screening protocol was successful in decreasing the number of procedures performed but did not improve our lesion detection rate on endoscopy and did not improve clinical outcomes as measured by rebleeding. Patients on anticoagulation and those who had prior lesions identified on capsule endoscopy had higher odds of rebleeding, indicating clinical failure. This data may help modify patient selection to maximize success of DBE procedures in the future.
877 Impact of Prior Myocardial Infarction or Revascularization on Outcomes of Adult Patients Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP): An 8-year Nationwide Inpatient Outlook
Authors: Patel Harsh K. , Desai Rupak , Doshi Shreyans , Lakhani Neet , Chudasama Jay , Singh Sandeep , Vyas Ankit , Vyas Manan , Varma Yash , Goyal Hemant
Published: October 2019

INTRODUCTION:

Considering its inflammatory potential Endoscopic retrograde cholangiopancreatography (ERCP) can prompt myocardial infarction in patients with preexisting coronary artery disease (CAD). However, the data regarding the impact of previous MI/revascularization procedures are non-existent. We aimed to compare the outcomes of adult patients undergoing ERCP with vs. without any such prior history.

METHODS:

Using the ICD-9 CM codes in the National Inpatient Sample (2007 -2014) we identified adult patients undergoing ERCP who had a prior history of MI, PCI or CABG. Primary endpoints- inpatient mortality and post-ERCP complications. Secondary endpoints- discharge disposition, mean length of stay and total hospital charges. SPSS version 22 (IBM Corp, NY, USA) was used for all analyses. Categorical and continuous variables were compared using the Chi-square test and Student’s t-test, respectively. A two-tailed P value ≤ 0.05 was set as the cutoff for the statistical significance.

RESULTS:

Of total 1,374,773 ERCP procedures performed between 2007 to 2014, 120,418 (8.8%) were performed in patients who had a prior history of MI, PCI or CABG (study cohort) and the rest were considered the control cohort. The study-cohort had older (mean age 74y vs. 58y) population and more males (63.9% vs. 37.6%), who were admitted non-electively (88.1% vs. 87.3%) as compared to the control cohort (P < 0.001) Figure 1. compares baseline characteristics between both cohorts. There is an increasing trend of performing ERCP in study group between 2007 to 2014 (7.5% to 9.5%; P
trend = 0.022) with a decrease in inpatient mortality from 1.8 to 1.4% (Figure 1). All-cause inpatient mortality was also higher (1.7% vs. 1.5%, P < 0.001) in the study cohort (Figure 1). Post-ERCP cardiopulmonary complications, sepsis, and haemorrhage were all higher in the study group (P < 0.001) (Table 2). However, post-ERCP pancreatitis (14.1% vs. 15.4%, P < 0.001) was lower in the study group without any difference in cholecystitis (0.4% vs. 0.4%, P = 0.180). The mean length of stay (6.8 days vs 6.6 days) was marginally higher in the study cohort without any difference in the hospitalization charges.

CONCLUSION:

In this nationwide retrospective study, we determined higher inpatient mortality and cardiopulmonary complications, sepsis, and haemorrhage in adult patients undergoing ERCP with a prior history of MI, PCI or CABG. Future prospective studies are warranted to delineate the impact of prior infarction or revascularization on the outcomes of ERCP.
878 Prophylactic Antibiotic Administration in EUS-Guided Aspiration of Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis
Authors: Elkafrawy Ahmed A. , Nehme Fredy , Elkhouly Mohamed A. , Zafar Yousaf
Published: October 2019

INTRODUCTION:

EUS guided fine needle aspiration (FNA) of pancreatic cystic lesions (PCL) has become the standard diagnostic modality for pancreatic cysts. Current American Society of Gastrointestinal Endoscopy (ASGE) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommended the use of periprocedural prophylactic antibiotics (PA), although data is equivocal. Our aim was to perform a systematic review and meta-analysis to evaluate the efficacy of PA in preventing cyst infection during EUS-guided aspiration of PCL and assess the rate of complications related to antibiotic use.

METHODS:

We included studies evaluating the outcomes of using PA in EUS-guided FNA of PCL. We searched PubMed, Embase, and Google Scholar through April 2019. Eligible studies were searched for variables of interest including infection of PCL and antibiotic-related complications. All statistical analyses were performed using the R Programming Language. Pooled rates of variables were reported as Relative risks (RR) with 95% confidence interval and heterogeneity was reported as I2 statistics.

RESULTS:

A total of 9 retrospective studies were eligible and included in the analysis. 6 studies compared the use of PA to no antibiotics while the other 3 did not have a comparison group. There were 1183 subjects in the antibiotic group and 579 subjects in the non-antibiotic group. Duration of antibiotics varied from a single intraprocedural dose to 3-5 days following the procedure. Multiple antibiotic regimens were used including ceftriaxone, quinolones, amoxicillin, and piperacillin/tazobactam. There was no statistically significant difference in the rate of cyst infection between patients receiving PA and those who did not (RR = 0.6, 0.21-1.75; I2 = 0%) (Figure 1). 1.2% of patients receiving PA developed adverse events related to antibiotic use. In addition, there was no difference among subgroups when stratifying subjects by single dose and 3-5 days of antibiotics (P = 0.619) (Figure 2).

CONCLUSION:

The incidence of infectious complications after EUS-guided FNA of PCL appears very low and the use of PA did not substantially reduce the risk. Antibiotic use is not free of adverse events. Further randomized controlled trials are needed to evaluate the appropriateness of current recommendations.
879 Post-ERCP Pancreatitis in Solid Organ Transplant Recipients
Authors: Elangovan Abbinaya , Sandhu Dalbir S. , Kochhar Gursimran S.
Published: October 2019

INTRODUCTION:

Post-ERCP pancreatitis (PEP) is the most common post-procedure complication of ERCP with an incidence of 3.5-15%. The prevalence of PEP and the role of immunosuppression in PEP among solid organ transplant (SOT) recipients is not well established. We aimed to study the prevalence of PEP and the effect of immunosuppressants in SOT recipients.

METHODS:

A retrospective analysis of 55 million individuals was performed using a cloud-based database, IBM Explorys. Explorys aggregates de-identified electronic health record data from 26 health care systems across the US and rounds to the closest 10 for statistical de-identification. PEP was defined as the elevation of lipase level > 500 U/L along with SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) diagnosis code of acute pancreatitis within 72 hours of ERCP procedure. The prevalence of PEP and the all-cause 30-day re-admission rate after an episode of PEP were calculated for SOT recipients (lung/kidney/heart/liver). Characteristics were compared using univariate chi-square test between SOT and non-transplant patients as well as liver transplant (LT) recipients and non-transplant patients. P < 0.05 was determined as statistically significant.

RESULTS:

There was no significant difference in the prevalence of PEP (8.03% vs 8.4%, P = 0.676) and re-admission rate (22.2% vs 20.3%, P = 0.645) between SOT recipients and non-transplant patients. Subgroup analysis of liver transplant (LT) recipients revealed a significantly lower rates of PEP (5.66% vs 8.4%, P = 0.002). Compared to the general population, transplant recipients were less likely to be women [Odds ratio OR 0.567, 95% confidence interval CI (0.375 – 0.866), P = 0.008] (Table 1). Among the transplant recipients, individuals with PEP were more likely to be under 50 years [OR 3.179, CI (1.980 - 5.102), P < 0.001]. PEP rates were lower with SOT recipients on steroids [OR 0.240 CI (0.113 - 0.509), P < 0.001] and calcineurin inhibitors [OR 0.078 CI (0.0317 - 0.194), P < 0.001] (Table 2).

CONCLUSION:

In this population-based study, the prevalence of PEP was not elevated in SOT recipients. Steroids and calcineurin inhibitors were associated with a protective effect against PEP. To our knowledge, this is the largest cohort to report on PEP in SOT recipients. Since population level database limits access to patients’ charts, studies with details on anatomical and peri-operative risk factors of PEP will further enhance our understanding in this specific subset of population.
882 EUS-Guided Gastroenterostomy (GE) versus Surgical Gastroenterostomy for Patients With Malignant Gastric Outlet Obstruction: A Systematic Review and Meta-Analysis
Authors: Jayaraj Mahendran , Singh Dhruv P. , Gopalakrishnan Ravikumar Naveen Prasad , Narala Sai , Krishnamoorthi Rajesh
Published: October 2019

INTRODUCTION:

Surgical gastroenterostomy has been the traditional approach to manage malignant gastric outlet obstruction (GOO). With advances in Endoscopic Ultrasound (EUS) technology and availability of dedicated devices and stents for EUS scopes, EUS guided gastroenterostomy (GE) is emerging as an alternative to surgical gastroenterostomy. Recently studies have been published comparing the outcomes between these two approaches. We performed a systematic review and meta-analysis of studies that compare the outcomes between the two approaches (EUS-GE vs Surgical GE).

METHODS:

We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GE vs surgical GE in management of malignant gastric outlet obstruction. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GE and surgical GE groups were calculated.

RESULTS:

Three comparative studies with a total of 171 patients; were included in the analysis. The pooled OR for technical success of EUS-GE in comparison to surgical GE was 0.16 (95% CI: 0.03-0.86; P = 0.033; I2 = 2%). The pooled OR for clinical success (EUS-GE vs surgical GE) was 0.98 (95% CI: 0.13-7.48; P = 0.984; I2 = 25%) The pooled OR for overall adverse events (EUS-GE vs surgical GE) was 0.35 (95% CI: 0.15-0.81; P = 0.014, I2 = 0%). There was minimal heterogeneity in the analysis.

CONCLUSION:

While EUS-GE is associated with similar rates of clinical success compared to surgical GE, the rate of overall adverse events is statistically lower. Hence in centers with expertise in EUS, EUS-GE could be considered as an effective alternate option.
883 EUS-Guided Gallbladder Drainage versus Endoscopic Trans-Papillary Gallbladder Drainage for High Risk Surgical Patients With Acute Cholecystitis: A Systematic Review and Meta-Analysis
Authors: Jayaraj Mahendran , Sandeep Vivek , Singh Dhruv , Law Joanna , Larsen Michael , Ross Andrew , Kozarek Richard , Irani Shyan , Krishnamoorthi Rajesh
Published: October 2019

INTRODUCTION:

In patients with acute cholecystitis who were deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for decompression of the gallbladder. There are several limitations associated with PC. Endoscopic gallbladder drainage [Endoscopic trans-papillary gallbladder drainage (ET-GBD) via ERCP and EUS-guided gallbladder drainage (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the outcomes between the two endoscopic techniques (EUS-GBD vs ET-GBD).

METHODS:

We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in management of acute cholecystitis in high risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated.

RESULTS:

Five comparative studies with a total of 861 patients; were included in the analysis. The pooled OR for technical success of EUS-GBD in comparison to ET-GBD was 5.22 (95% CI: 2.03-13.44; P = 0.01; I2 = 20%). The pooled OR for clinical success (EUS-GBD vs ET-GBD) in intention-to-treat analysis was 4.16 (95% CI: 2.00-8.66; P = 0.001; I2 = 19%) and per-protocol analysis was 1.81 (95% CI: 0.80-4.09; P = 0.15; I2 =0%). The pooled OR for overall acute adverse events (EUS-GBD vs ET-GBD) was 1.32 (95% CI: 0.78 -2.25; P = 0.31, I2 = 0%). The pooled OR for perforation and pancreatitis (EUS-GBD vs ETGBD) were 1.98 (95% CI: 0.32-12.29) and 0.19 (95% CI: 0.03-0.99) respectively. The pooled OR for recurrent cholecystitis (EUS-GBD vs ETGBD) was 0.33 (95% CI: 0.13-0.82). There was minimal heterogeneity in the analysis.

CONCLUSION:

EUS-GBD is associated with higher rate of technical and clinical success compared to ET-GBD. While the rate of overall acute adverse events are statistically similar between the two techniques, EUS-GBD is associated with lower rate of recurrent cholecystitis. In centers with expertise in EUS, EUS-GBD could be considered as first-line treatment in carefully selected patients.
884 Endoscopic Intervention of Pancreatic Acute Necrotic Collections: A Retrospective Review
Authors: Oblizajek Nicholas , Agayeva Sevda , Takahashi Naoki , Topazian Mark D.
Published: October 2019

INTRODUCTION:

Early endoscopic intervention of pancreatitis with acute necrotic collection is conflicting with standard practice except in extenuating circumstances. The Atlanta criteria define necrotic collections based on the age from onset of disease as either acute necrotic collections (ANC ≤ 4 weeks) or walled-off necrosis (WON > 4 weeks). Some patients with ANCs will have clinically apparent infection of necrosis potentially necessitating infectious source control via endoscopic intervention where percutaneous drainage is technically challenging or inadequate. At present, data regarding early endoscopic intervention for acute necrotic collections is lacking.

METHODS:

A retrospective review of patients undergoing endoscopic intervention for pancreatic necrosis between 2008 and 2018 was performed. Included patients had definitive pancreatic/peri-pancreatic necrosis on contrast-enhanced computed tomography, signs/symptoms and laboratory evidence of pancreatitis in relation to hospital presentation, and endoscopic intervention within 28 days of symptom onset. Patients with prior percutaneous or surgical intervention were excluded. ANC cases were matched and compared to WON controls for analyzed parameters via conditional logistic regression.

RESULTS:

Twenty four patients were identified to have attempted drainage within 28 days of symptom onset, three of which were excluded (imaging limitations, spontaneous drainage/fistulization, unclear date of symptom onset). Demographic and clinical characteristic data are summarized in Table 1, with procedure and outcome characteristics shown in Table 2 for the 21 ANC cases in comparison to WON controls. Overall, ANC cases had slightly larger collections, with statistically significantly longer hospital stays as compared to matched WON controls (P < 0.01); otherwise measured variables were not statistically significant between the groups.

CONCLUSION:

There is a paucity of data regarding the safety and efficacy of intervention of ANCs complication pancreatitis. We found in this study that there was reasonable success in clinically indicated endoscopic drainage of ANCs without significant sequelae from the procedures undertaken as compared to matched WON controls. This study demonstrates the safety of intervening on ANCs as early as 15 days if clinically indicated. Further research in regards to efficacy/safety of intervention and prognostic indicators of early intervention is required to further discern whether this applies to general practice of ANC management.
887 Clinical Efficacy of Endoscopic Vacuum-Assisted Closure Therapy (EVAC) in Gastroesophageal Defects: A Systematic Review and Comparative Meta-Analysis With Endoscopic Stent Therapy (EST)
Authors: Chandan Saurabh , Mohan Babu P. , Khan Shahab R. , Malik Sarah , Bhogal Neil , Chandan Ojasvini Choudhry , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Treatment of gastroesophageal leaks and perforations after upper gastrointestinal surgery remains clinically challenging. Advanced endoscopic interventions have traditionally included placement of self-expanding metal or plastic stents i.e. endoscopic stent therapy (EST) and endoscopic vacuum-assisted closure therapy (EVAC). The aim of our study was to evaluate the overall clinical efficacy of EVAC when compared to EST in the treatment of gastroesophageal defects.

METHODS:

Our primary goals were to analyze the pooled rates of clinical success and overall mortality with EVAC therapy in gastroesophageal defects. Using EST as a comparator group, we analyzed clinical outcomes and predictors of clinical success.

RESULTS:

6 cohort studies compared EVAC (109 patients) to EST (197 patients). These included 313 cases of esophageal anastomotic leaks. The pooled odds ratio of clinical success with EVAC was 2.9 (95% CI 1.4-5.8, P = 0.003, I2 = 13) when compared to EST in the treatment of esophageal leaks secondary to surgical anastomosis. The pooled odds ratio of mortality was 0.43 (95% CI 0.19-0.95, P = 0.04, I2 = 0). When all studies that evaluated EVAC alone were analyzed (14 studies - 89 perforations and 136 anastomotic leaks), the pooled rate of clinical success was 87.5% (95% CI 81.6-91.7, I2 = 0, P = 0.001). For studies evaluating EST (12 studies, 349 patients), the pooled rate of clinical success was 75.4% (95% CI 75.6-84.1, P = 0.001, I2 = 30). EVAC performed significantly better than EST (P = 0.004). The pooled mortality rate with EVAC was 9.1% (95% CI 4.5-17.5, P = 0.01, I2 = 0) and with EST was 17.2% (95% CI 11.2-20.2, P = 0.001, I2 = 38). Based on univariate meta-regression analysis, anastomotic leaks demonstrated statistical significance as a predictive factor of clinical success with EVAC (2-sided P-value 0.05, R2 analog = 1), whereas perforation almost reached statistical significance (2-sided P-value 0.06, R2 analog = 0). On multivariate meta-regression, neither of the etiologies showed statistical significance as a possible predictor of clinical success. We performed meta-regression analysis on mortality data and found no significant predictive effect of etiology in EVAC and EST groups, except for anastomotic leaks that almost reached statistical significance as a predictor of mortality with EST (2-sided P-value 0.06, R2 analog = 1).

CONCLUSION:

EST performed favorably when compared to EST in the treatment of gastroesophageal defects with higher clinical success and lesser mortality.
893 Endoscopic Ultrasound-Guided Sampling of Solid Pancreatic Lesions: A Comparative Analysis of 25 vs. 22 Gauge Core Biopsy Needles
Authors: Siddique Daanish , Trevino Karen , Rahal Mahmoud A. , Wu Howard , Al-Haddad Mohammad
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound guided fine needle biopsy (EUS-FNB) is increasingly replacing fine needle aspiration (FNA) for sampling of solid pancreatic lesions. In FNA, 25G needles appear to outperform 22G needles in sampling pancreatic lesions, but data comparing 22G and 25G FNB platforms is lacking. We aimed to prospectively assess the performance of 22G and 25G Franseen tip core biopsy needles in the sampling of solid pancreatic lesions.

METHODS:

Consecutive patients were enrolled between 2017 and 2018 and underwent EUS-FNB sampling of solid pancreatic lesions at Indiana University Hospital using 2 needle sizes: 25G (Study group) and 22G (Control group) Acquire needles (Boston Scientific Co., Natick, MA, USA). The endosonographer chose the needle size based on lesion location and characteristics. Tissue specimens were handled in a standardized fashion using onsite evaluation, touch and smear preparation, and cell block tissue collection. Specimens were independently evaluated by 2 expert cytopathologists blinded to the diagnosis in each case. They assessed cytological yield (on smears) and histologic yield (on cellblock) using a previously validated standard scoring system reached by a consensus among our cytopathologists.

RESULTS:

A total of 75 patients (42 males, median age = 65 years) with solid pancreatic lesions underwent EUS-FNB during the study period: 50 using a 25G and 25 using 22G needle. There was no significant difference in the size or final cytopathological diagnosis of the lesions between the 2 groups (Table 1). Similarly, cytological scores of smears were comparable between the 2 groups. Due to the 25G needle’s increased flexibility in locations that entailed excessive scope angulation, it was utilized more for lesion sampling in the pancreatic head and uncinate process (70% vs 52%, P = 0.012). There was a statistically significant increase in diagnostic yield seen in the 25G group compared to the 22G (98% vs 88%. P = 0.013). The number of passes for cytological smears between both groups were similar; however, the 25G group required additional passes to obtain an adequate cell-block (1.6 vs 0.4, P = 0.001).

CONCLUSION:

We found the 25G FNB needle to be associated with superior diagnostic adequacy over 22G needles. This is consistent with FNA literature comparing these two common needle sizes. We noted an increased number of passes required in the 25G group to develop a cell block. This is likely due to the smaller size needle requiring more passes to build up an adequate cell block.