bluuebunny/crossref_metadata_2025 huggingface dataset:
896 Endoscopic Ultrasound on Diabetic Patients for Unexplained Abdominal Pain: High Prevalence of Parenchymal Abnormalities
Authors: Schwartz Ingrid , Satiya Jinendra , Singh Harjit , Abraham Rtika , Girotra Mohit
Published: October 2019

INTRODUCTION:

The association between newly diagnosed Diabetes Mellitus (DM) and pancreatic ductal adenocarcinoma (PDAC) is a field of immense interest. Work up for unexplained abdominal pain (UAP) in DM patients could include endoscopic ultrasound (EUS). The aim of our study is to understand prevalence of pancreatic parenchymal and ductal changes during EUS in patients with DM being evaluated for UAP.

METHODS:

We retrospectively reviewed of charts of DM patients who underwent EUS at our center between 2010-2018 for the evaluation of UAP or other causes. Patients with known history of chronic pancreatitis (CP), pancreatic mass/PDAC or pancreatic surgery were excluded.

RESULTS:

A hundred and fourteen patients were identified (mean age = 66 ± 13.9 years; M:F = 48:66): 17 (14.9%) Blacks, 61 (53.5%) Whites, 66 (57.8%) Hispanics. Mean BMI was 31.3 ± 8.9. Eight patients (7%) had DM type 1 and 106 (93%) had type 2, with mean disease duration of 9.78 ± 6.4 years and mean HbA1c of 7.69 ± 1.8%. Eighty patients (70%) were on oral agents and 64 (55%) on insulin-based regimens. Diabetic complications were present in 60 patients (52.6%). Alcohol use was reported in 30 (26%) patients, and smoking in 44 (38.5%) patients (14.6 ± 26 mean pack/years). EUS was performed exclusively for UAP in 38 patients. Other indications included submucosal esophageal (2), gastric (13) or duodenal (3) lesion, CBD narrowing/dilation (21), abnormal hepatic panel (4), LAD on imaging (5), suspected choledocholithiasis (5), jaundice (2), and elevated CA-19-9 (3). Mean number of EUS procedures was 1.19 ± 0.5 and mean interval between procedures was 229.5 ± 203.6 days. Pancreatic abnormalities on non-EUS imaging were reported in 27 patients. On EUS, parenchymal or ductal abnormalities were present in 49 (42.9%) patients. Mean duration of disease in those noted to have EUS abnormalities was 10.6 ± 5.8 years. When defined using Rosemont classification, 2 met criteria for CP, 6 were indeterminate. In 106 patients classified as normal pancreas, lobularity was the commonest finding seen in 20 (18.8%) patients. Out of the 14 patients who underwent interval EUS, 3 patients showed progression of parenchymal and ductal changes.

CONCLUSION:

Endosonographic pancreatic abnormalities, not amounting to Rosemont definitions of CP, seem to be present in diabetic patients presenting with UAP. In our retrospective study, although 92.9% diabetic patients were classified to have normal pancreas, 38.6% of them had at least one abnormal finding on EUS.
897 Aggressive Hydration With Lactated Ringer for Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis
Authors: Paleti Swathi , Junna Shilpa , Nutalapati Venkat , Jeepalyam Sravan , Rustagi Tarun
Published: October 2019

INTRODUCTION:

Pancreatitis is the leading complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in considerable morbidity and, rarely, in death. Hydration is a mainstay of treatment for acute pancreatitis, independent of etiology. Aggressive hydration with lactated ringers (LR) has been suggested for prevention of post-ERCP pancreatitis (PEP). However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the impact of aggressive LR hydration in PEP incidence.

METHODS:

A comprehensive search of MEDLINE, EMBASE, Scopus, Cochrane Database was conducted from each database’s inception to search for comparative studies of aggressive LR vs standard therapy for prevention of PEP. Aggressive LR is defined as 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure. The primary outcome of interest was PEP rates. Secondary outcomes were other adverse events. Outcomes were reported as pooled odds ratio (OR) with 95% confidence intervals (CI) with statistical significance (P < 0.05). RevMan 5.3 software was used for statistical analysis.

RESULTS:

Eight studies (7 randomized controlled trials and one prospective study) with a total of 3248 patients were included in the meta-analysis. There were 1623 patients in the aggressive LR group and 1625 patients in the standard therapy group. There was no difference between the groups regarding age and sex. Patients in the aggressive arm received 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure compared to 1.5 ml/kg/hour during the procedure and for 8 hours after the procedure without a bolus in the standard hydration arm. The mean total fluid administered in the two groups was reported in 2 studies with a pooled mean of 3.25 L in the aggressive and 1.47 L in the standard group (P < 0.001). The PEP rate was significantly lower in the aggressive LR arm compared to standard therapy (OR 0.33, 95% CI 0.21-0.50, P < 0.0001). There was no heterogeneity between the studies (I2 = 0%). Peripheral edema as an adverse outcome of aggressive LR therapy was reported only in 2 (0.69%) patients in 2 studies and was managed conservatively. No significant adverse events were reported in any study.

CONCLUSION:

Aggressive hydration with LR is associated with a significant reduction in incidence of PEP, and therefore, should be practiced routinely.
902 Dual Modality Therapy for Endoscopic Management of Esophageal Defects
Authors: Han Andrew , Patel Feenalie , Ghafoor Adil , Siddique Daanish , Bick Benjamin L. , Al-Haddad Mohammad
Published: October 2019

INTRODUCTION:

Previously, surgical management represented the mainstay of therapy for esophageal defects such as tracheoesophageal fistulas, perforations, and post-operative leaks. As technical improvements in devices and endoscopic techniques improved, non-surgical management options increased to include clips, fibrin glue, and endoscopic suturing. Hybrid therapy involving both primary closure of the defect with endoscopic suturing and esophageal stent placement to protect the site was investigated.

METHODS:

We report a single center experience on dual modal therapy with endoscopic suturing and esophageal stenting for management of esophageal defects including tracheoesophageal fistulas, perforations, and post-operative leaks from 2013 to 2019. Factors such as etiology of defect (spontaneous perforation, iatrogenic perforation, tracheoesophageal fistula), size of defect, prior esophageal surgeries, and other factors were evaluated. Resolution was confirmed using esophagram to rule out leaks.

RESULTS:

18 patients underwent dual modality therapy with primary closure using endoscopic suturing with concurrent esophageal stenting. Mean length of defects was 14.5 mm. 2 patients were lost to followup, and 1 patient was excluded because they underwent thoracostomy for concomitant therapy. Of the 15 patients left for analysis, successful closure was achieved in 14 patients.There were no significant complications related to the procedures.

CONCLUSION:

Early data from dual modality therapy from our single center report appear positive, however, there have not been enough cases to provide sufficient statistical analysis. Still, our combined approach show promising rates of success with minimal adverse effects. Further investigation comparing dual modality therapy with standard therapy are planned to be performed.
903 Clinical Efficacy of Gastric Per-Oral Endoscopic Myotomy in the Treatment of Refractory Gastroparesis and Predictors of Successful Outcomes: A Systematic Review and Meta-Analysis
Authors: Chandan Saurabh , Mohan Babu P. , Jha Lokesh K. , Khan Shahab R. , Kotagiri Rajesh , Kassab Lena , Ravikumar Naveen , Bhogal Neil , Chandan Ojasvini Choudhry , Bhat Ishfaq , Hewlett Alexander , Ponnada Suresh , Asokkumar Ravishankar , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Options to treat medically refractory gastroparesis are limited. Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery that has shown promising results. Data is limited as to its efficacy, safety, predictive factors and its comparability to surgical pyloroplasty. The aim of our study was to synthesize and analyze the clinical outcomes of GPOEM by meta-analysis methods.

METHODS:

We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and surgical pyloroplasty in gastroparesis. Our primary outcome was to analyze the pooled rates of gastroparesis cardinal symptom index (GCSI) score and 4-hr gastric emptying study (GES) results, with G-POEM. Similar outcomes with surgical pyloroplasty was used as a comparator group.

RESULTS:

332 and 375 patients underwent G-POEM (11studies) and pyloroplasty (7studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance,P = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with GPOEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, P = 0.91. The pooled rate of mean pre-G-POEM GCSI score was 3.4 (95% CI 3.1-3.7, I2 = 89) and post-G-POEM GCSI score was 1.8 (95% CI 1.4-2.1, I2 = 89), with statistical significance (P = 0.001). The pooled pre-G-POEM 4-hr GES was 49.9% (95% CI 41.6-58.3, I2 = 94) and post-G-POEM 4-hr GES was 20.6% (95% CI 12.3-28.8, I2 = 77), with statistical significance (P = 0.001). The pre and post pyloroplasty 4-hr GES results were 36% (95% CI 32.7-39.3, I2 = 88) and 3.9% (95% CI 2.3-5.5, I2 = 43), respectively (P = 0.001). The pre and post pyloroplasty GCSI score was not analyzed due to paucity in data. The overall adverse events were comparable (11%, 5.9-19.8, I2 = 66 vs 11.4%, 5-24, I2 = 69, P = 0.95). Based on meta-regression analysis, idiopathic-gastroparesis, prior treatment with botulinum toxin and gastric-stimulator seemed to predict clinical success with G-POEM.

CONCLUSION:

G-POEM demonstrates clinical success in treating refractory gastroparesis with comparable outcomes to pyloroplasty. Idiopathic gastroparesis, prior treatment with botulinum injection and gastric stimulator appear to have positive predictive effects on the 4-hr GES results after G-POEM.
907 Endoscopic Pancreatic Necrosectomy Technique: Know Your "How" to Justify Your "Why"
Authors: Robles Alejandro , Umeanaeto Onyedika , Contreras Alberto , Conwell Darwin , Mendoza-Ladd Antonio
Published: October 2019

INTRODUCTION:

Walled-off necrosis (WON) is a feared complication of acute pancreatitis that carries significant morbidity. Direct endoscopic necrosectomy (DEN) is preferred over surgical one due to its minimally invasive nature and lower complication rates. However, no endoscopic technique and/or device has been adopted as a gold standard; and endoscopists differ significantly in their DEN preferences. The primary aim of this study was to report our DEN technique and its outcomes.

METHODS:

Medical records of patients who underwent EN from September 2016 – May 2019 were reviewed. Continuous data was described using mean and standard deviation (SD); categorical data as frequency and proportion (%); and interval data as median and (range).

RESULTS:

A total of 20 patients underwent DEN after initial drainage with a 10 × 15 mm electrocautery enhanced AXIOS lumen apposing metal stent (LAMS) (Table 1). A total of 23 LAMS were placed (22 trans-gastric and 1 trans-duodenal) Technical success (LAMS correctly deployed between the cavity and the gastric/duodenal lumen) was achieved in 100% of cases. All LAMS were dilated to 15 mm the same day of deployment, and the mean interval from drainage to first DEN was 5.4 days. DEN was repeated until the cavity was empty. A total of 66 DEN were performed. The mean number of DEN/patient was 3.3; each with a mean duration of 50 min. The most commonly used endoscope and device was the single channel gastroscope (83%) and the 27 mm snare (93.9%), respectively. The mean interval between each DEN was 7 days. All LAMS were removed after a mean of 27 days. Three patients were lost to follow up. After a median follow-up time of 14 months (1-28), clinical success (resolution of WON by imaging and patient’s symptoms on follow up visit) was achieved in 94% of cases. Only 1 subject had a major complication (cavity wall rupture with pneumoperitoneum that required surgery). Minor non-life-threatening complications occurred in 9 subjects (Table 2).

CONCLUSION:

At our center, the most commonly used endoscope and device to perform DEN is the single channel gastroscope and the 27 mm snare, respectively. An average of 3 DEN are required per patient, each one averaging 50 min. Our DEN technique is safe and effective in the management of WON, achieving clinical success in 94% of cases with minimal morbidity and no mortality.
909 Endoscopic Mucosal Resection versus Endoscopic Submucosal Dissection in the Treatment of Superficial Gastric Cancers - A Meta-Analysis Update
Authors: Rajabalan Ajai , Suresh Kumar Vishnu Charan , Patthipati Venkata Suresh , Mani Vishnu
Published: October 2019

INTRODUCTION:

Early gastric cancer (EGC) is defined as a malignant tumor confined to the mucosa or the submucosa regardless of lymph node metastases. Endoscopic Mucosal Resection (EMR) is widely accepted as the treatment modality for EGC although it has some limitations. To overcome these and to facilitate resection of difficult lesions, Endoscopic Submucosal Dissection (ESD) was developed. ESD has a higher En-bloc and histological resection rate when compared to EMR. However, when compared to EMR, ESD has a higher complication rate, longer duration and is technically challenging. Despite its wide use in Eastern countries, the application of ESD is still being debated in the United States. We conducted a meta-analysis comparing the efficacy and safety of EMR and ESD in the management of EGC.

METHODS:

A literature search was done from electronic databases including PubMed, Cochrane, and Embase from inception until November 2018. A total of 13 relevant studies were isolated and included in the study. The relevant data were extracted, and meta-analysis with Random effects model was done using RevMan 5.3.

RESULTS:

We had a total of 3807 lesions in the EMR group and 4284 lesions in the ESD group. Patient characteristics were available for only 8 studies and were age-matched with a mean age of 67.15 years [Male-76.9%, Female-23.1%] and 67.52 years [Male-76.7%, Female-23.3%] in EMR and ESD groups respectively. Our primary outcomes were en-bloc resection rate (EBR) and curative resection rate (CRR). 2171 lesions were removed en-bloc by EMR versus 3949 lesions by ESD [OR 8.14, 95%CI (6.08, 10.91), P < 0.0001, I2 = 71%], favoring ESD over EMR. The CRR was achieved in 3194 lesions with ESD as compared to 1890 lesions with EMR [OR 4.23, 95%CI (2.61, 6.85), P < 0.00001, I2 = 91%]. Complications including bleeding [OR 0.65, 95%CI (0.43, 0.98), P = 0.04, I2 = 54%] and perforation [OR 0.40, 95%CI (0.24, 0.68), P = 0.0006, I2 = 50%] were significantly higher with ESD over EMR.

CONCLUSION:

This meta-analysis shows that EBR and CRR are better achieved with ESD over EMR, with higher rates of bleeding and perforation with ESD. ESD is a complex procedure requiring a high level of expertise, training, and its success depends on the performer’s skills. With careful selection of patients and advanced endoscopic skills, outcomes could be better with ESD than EMR. Our study has limitations; the data used for the analysis were non- randomized and were conducted in heterogeneous practice settings.
911 Endoscopic Mucosal Resection versus Endoscopic Submucosal Dissection for Treatment of Superficial Colorectal Neoplasms - A Meta-Analysis Update
Authors: Rajabalan Ajai , Patthipati Venkata Suresh , Suresh Kumar Vishnu Charan , Mani Vishnu
Published: October 2019

INTRODUCTION:

Endoscopic mucosal resection (EMR) is widely accepted for the treatment of superficial colorectal tumors; however complete resection is difficult for large lesions (>20 mm) and/or sessile lesions. Endoscopic submucosal dissection (ESD) was developed to solve these problems. However, when compared to EMR, ESD has several disadvantages, such as long procedure time, complication rates and is technically challenging. We conducted a systematic review to compare the efficacy and safety of EMR and ESD for the treatment of colorectal tumors.

METHODS:

A literature search was done using PubMed, Cochrane, and Embase from inception until May 2018. Ten relevant studies were isolated and included in the study. The relevant data were extracted, and meta-analysis with Random effects model was done using RevMan 5.3.

RESULTS:

A total of 2678 lesions in the EMR group and 1934 lesions in the ESD group were included in the study. Out of the 14 studies included, patient characteristics were available only in 4 studies with a mean age of 63.97 years [Male-59.3%, Female-40.7%] in the EMR group and 65.19 years [Male-61.4%, Female-38.6%] in the ESD group. Our primary outcomes were En-bloc Resection Rate (EBR) and Curative Resection Rate (CRR). We also analyzed the adverse events – bleeding and perforation. 997 lesions were removed en-bloc by EMR and 1785 lesions by ESD [OR 8.95, 95%CI (4.13, 19.41), P < 0.00001, I 2 = 92%], favoring ESD over EMR. The curative resection rate was 359 out of 625 lesions in the EMR group and 434 out of 530 lesions in the ESD group [OR 1.70, 95%CI (0.58, 5.03), P < 0.34, I2 = 88%] indicating no significant difference between the 2 groups. There was also no significant difference in the occurrence of bleeding when comparing the 2 groups [OR 1.34, 95%CI (0.90, 1.98), P = 0.15, I2 = 0%]; however, EMR had significantly lower rates of perforation when compared to ESD [OR 0.35, 95%CI (0.23, 0.52), P = 0.00001, I2 = 1%].

CONCLUSION:

ESD has a better EBR without much difference in the CRR as compared to EMR while treating colorectal neoplasms. EMR had a lower perforation rate but there was no significant difference in bleeding between the groups. ESD is more complex and operator dependent requiring great technical expertise. With careful selection of patients and advanced endoscopic skills, ESD might give better overall outcomes than EMR. The limitations of our study were that the trials included were non-randomized and conducted in heterogeneous practice settings.
913 Predictors of Failed Index Endoscopic Retrograde Cholangiopancreatography
Authors: Kamal Ayesha , Wang Peiqi , Akshintala Venkata S. , Khashab Mouen , Makary Martin , Singh Vikesh
Published: October 2019

INTRODUCTION:

We aimed to evaluate the frequency and factors associated with failed ERCP in the Medicare population.

METHODS:

We identified patients who underwent ERCP using CPT codes from Medicare fee-for-service carrier claims from 1/10/15-6/20/18. Medicare beneficiaries comprise 15% of the total US population. Each patient’s index ERCP was defined as their first ERCP during the study period and was defined as failed if a second ERCP was performed within a week of the index ERCP. We evaluated factors associated with failed ERCP using a multivariable logistic regression model with cluster-robust standard errors calculated at the facility-level using demographics, ERCP indications, endoscopist and facility characteristics as covariates with results reported as [OR(95% CI)]. A cutoff of 50 and 200 ERCPs over the study period was used to dichotomize endoscopists and facilities into low and high volume, respectively.

RESULTS:

A total of 170,500 patients (54.3% female) underwent index ERCPs performed by 6,686 endoscopists at 2,847 facilities. The mean volume of ERCPs performed by endoscopists and at facilities was 25 ± 35 and 60 ± 103, respectively, during the study period. Indications for ERCP were gallstone disease (42%), biliary obstruction (25%), cholangitis (2.4%), abnormal imaging/laboratory findings (6.7%), bile duct (BD) injury (1.3%), pancreatitis (6.3%), malignancy (5.8%), sphincter of Oddi dysfunction (SOD) (3.2%) and others (7.3%). Approximately 95% of the index ERCPs were performed by male endoscopists; 92% performed by endoscopists with >10 years in practice; 51% performed by low-volume endoscopists; and 57% performed in low-volume facilities. A total of 9186 patients (5.4%) underwent a second ERCP within 7 days. Older age [1.05(1.01-1.11)] and male patients [1.12(1.12-1.27)] were more likely to have failed ERCP. Compared to gallstone disease, abnormal imaging /laboratory findings [1.28(1.17-1.40)], BD injury [1.54(1.29-1.83)], biliary obstruction [1.44(1.33-1.55)], cholangitis [1.74(1.52-2.00)], malignancy [2.01(1.84-2.20)], pancreatitis [1.31(1.07-1.61)] and SOD [1.29(1.14-1.46)] were more likely to result in failed ERCP. Female endoscopists [1.23(1.09-1.38)], low volume endoscopists [1.59(1.45-1.74)] and low volume facilities [1.90(1.03-1.35)] were more likely to experience failed ERCP.

CONCLUSION:

Younger age, female patients, gallstone disease, male as well as high volume endoscopists and high volume facilities are associated with lower rates of ERCP failure among Medicare beneficiaries.
914 Dissection-Enabled Scaffold-Assisted Resection (DeSCAR): A Novel Technique for Resection of Residual or Non-Lifting GI Neoplasia of the Colon, Expanded Experience and Follow-Up
Authors: Villa Edward , Stier Matthew , Donboli Kianoush , Chapman Christopher C. , Siddiqui Uzma D. , Waxman Irving
Published: October 2019

INTRODUCTION:

Colonic lesions referred for endoscopic mucosal resection (EMR) may not be amenable to conventional snare resection due to previous manipulation or submucosal invasion or because of flat lesions unable to be snared. In 2018, we initially described Dissection-enabled Scaffold Assisted Resection (DeSCAR)—a combination of circumferential endoscopic submucosal dissection (ESD) with EMR—to be safe for the endoscopic resection for removal of non-lifting or residual colonic lesions with suspected submucosal involvement or fibrosis. We describe our expanded experience and follow up of patients undergoing DeSCAR and assess the efficacy, safety, and feasibility of DeSCAR for endoscopic resection of non-lifting or residual colonic lesions.

METHODS:

Lesions referred for EMR were retrospectively reviewed. Our initial cohort of 29 patients from 2015-2017 combined with 28 additional patients from 2018-2019 were identified where the DeSCAR technique was performed for colonic lesions with incomplete lifting and/or snaring. Cases were reviewed for location, prior manipulation, rates of successful hybrid resection, adverse events, and endoscopic follow up to assess for residual lesions.

RESULTS:

57 lesions underwent DeSCAR for non-lifting or residual colonic lesions. Patients were 51% female and 49% male with an average age 69 (SD +/- 9.6 yrs). Lesions were located in the cecum (n = 16), right colon (n = 22), transverse colon (n = 5), left colon (n = 7), rectum (n = 4), or in other locations defined by distance from the anus (n = 4). Average lesion size was 27.7 mm (SD +/- 16.6 mm). Previous manipulation occurred in 54 of 57 cases (68% biopsy, 47% resection attempt, 18% intralesional tattoo). The technical success rate for resection of non-lifting lesions was 100%. There were two delayed bleeding episodes (one required endoscopic intervention) and one small perforation (managed by successful endoscopic hemoclip closure at the time of perforation). No other adverse events were observed. Endoscopic follow up was available in 27 patients (47%) with no residual adenoma noted in 25 patients (93% of those with surveillance).

CONCLUSION:

Our expanded experience with DeSCAR continues to demonstrate a high safety, feasibility, and effectiveness profile for the endoscopic management of non-lifting or residual colonic lesions, providing en-bloc resection of tissue for histologic review. Further studies are needed to demonstrate long-term eradication and direct comparison with other currently available endoscopic techniques.
917 EUS-Directed Transgastric ERCP (EDGE) versus Laparoscopy-Assisted ERCP (LAERCP) for Roux-en-Y Gastric Bypass (RYGB): A Single Center Experience
Authors: Parvataneni Swetha , Kumar Vikas , Confer Bradley , Diehl David L. , Khara Harshit S.
Published: October 2019

INTRODUCTION:

The rising obesity epidemic in the US has led to an increase in bariatric surgeries, and Roux-en-Y gastric bypass (RYGB) is a common option. These patients are at higher risk for gallstone disease, but the resulting altered anatomy presents unique challenges to accessing the bile duct. Lap-assisted ERCP (LAERCP) is the most common modality for biliary access in this setting but leads to high resource utilization and morbidity. EUS-directed trans-gastric ERCP (EDGE), is emerging as a new alternative. We present a comparison between the performances of LAERCP and EDGE in RYGB patients at our institution.

METHODS:

The protocol was approved by the institutional review board. Charts were reviewed for all RYGB cases that underwent LAERCP or EDGE at our health system between 5/2009 – 5/2019. Patient demographics, procedural and clinical information was gathered. Both groups were compared using students T test for continuous variables and Pearson’s chi square and Fisher exact test for categorical variables.

RESULTS:

A total of 76 RYGB patients (17 EDGE and 59 LAERCP) were analyzed. The mean age, gender and indication for the procedure (biliary vs pancreatic) were similar in both groups. All EDGE and LAERCP were performed in a single step setting. Technical success of obtaining access to the excluded stomach was 100% for both groups. There was no statistical difference in the technical success of therapeutic ERCP between the two groups (94% EDGE vs 100% LAERCP). There was no difference in the adverse event rates between EDGE (6%) and LAERCP (17%). The EDGE group had significantly shorter procedural time as compared to LAERCP (103 vs 208 min, P < 0.001); but there was no difference in the length of hospital stay (2.7 vs 2.6 days, P = 0.94). The median time for lumen-apposing metal stent removal was 22 days (range 0-111). There was no significant weight gain (-6.33 lbs) at median follow up of 35 days in the EDGE group.

CONCLUSION:

Overall success rate of intended therapeutic intervention and adverse event profile are similar for EDGE and LAERCP. EDGE has significantly shorter procedure time and can be done independently in the endoscopy unit, unlike LAERCP which requires operating room availability and coordination with a skilled laparoscopic surgeon. EDGE can be considered as a safe and effective first line modality for pancreaticobiliary access in RYGB patients offering the benefit of repeat ampullary access if needed on follow up procedure and without any worries of significant weight gain.
918 Endoscopic Ultrasound-Guided Gastroenterostomy vs. Enteral Stenting for Treatment of Gastric Outlet Obstruction: A Retrospective Review
Authors: Iqbal Umair , Berger Andrea , Confer Bradley , Diehl David L. , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Gastric outlet obstruction (GOO) is a potential complication of pancreatic or distal gastric malignancy. As many as 15-20% of patients with pancreatic adenocarcinoma have GOO as a presenting symptom. Benign etiologies of GOO include chronic pancreatitis, peptic ulcer disease and caustic ingestion. Enteral stenting (ES) can be done for the palliation of GOO but recently endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a novel technique. We conducted a retrospective study to compare the differences in efficacy and safety of EUS-GE and ES.

METHODS:

Patients who underwent EUS-GE or ES for benign or malignant GOO from September 2015 to December 2018 were included in the study. Our primary outcomes were technical success defined as successful deployment of the stent and clinical success defined as tolerating oral diet after the procedure. Secondary outcomes were adverse events and need for unplanned re-intervention. Statistical analysis was done using SAS 9.4.

RESULTS:

Out 428 charts reviewed, 60 patients met are our inclusion criteria. 8 patients underwent EUS-GE and 52 patients underwent ES. Pancreatic adenocarcinoma was the most common etiology of GOO (58%) followed by gastric adenocarcinoma (13%). Chronic pancreatitis was the most common benign etiology of GOO (8%) requiring intervention. Technical success was 100% in both the groups. There was no significant difference in the clinical success (87.5% in EUS-GE vs 90.4% ES; P = 1.00) and rate of adverse events (12.5% EUS-GE vs 3.8% ES; P = 0.35) between the two groups. One patient in EUS-GE group did not achieve clinical success and underwent surgical gastrojejunostomy 23 days later which was also not clinically successful. The need for reintervention in clinically successful patients was 17% in the ES group due to tumor in-growth as compared to 0% in EUS-GE. Median time for re-intervention in the ES group was 94 days, (IQR: 43, 112). Two patients in an ES group required EUS-GE for the palliation of recurrence of symptoms.

CONCLUSION:

There were no differences in the technical success, clinical success and rate of adverse events of EUS-GE and ES for the treatment of GOO. Recurrence of symptoms and need for re-intervention trended higher in ES group compared to EUS-GE. Large prospective comparative trials are needed to evaluate the safety and efficacy of EUS-GE and ES.
923 Endoscopic Ultrasound-Guided Fiducial Placement for Stereotactic Body Radiation Therapy in Patients With Pancreatic Adenocarcinoma
Authors: Cazacu Irina M. , Singh Ben S. , Martin Rachael , Slagowski Jordan , Beddar Sam , Koay Eugene , Taniguchi Cullen , Herman Joseph , Bhutani Manoop S.
Published: October 2019

INTRODUCTION:

Stereotactic body radiotherapy (SBRT) has emerged as a novel therapeutic option in pancreatic cancer care. In the absence of diagnostic quality CT-on-rails or on-board MRI, accurate delivery of SBRT relies on fiducial markers. Endoscopic ultrasound (EUS) has become the preferred method for fiducial markers placement. The aim of this study is to report the technical feasibility and safety of EUS-guided fiducial placement and to evaluate the technical benefit and SBRT outcomes in a cohort of patients with pancreatic cancer (PC).

METHODS:

A retrospective chart review was performed for all (n = 67) PC patients referred for EUS-guided fiducial placement by a single endosonographer (MSB) at a tertiary cancer center between 2016 and 2019. Data regarding EUS-related technical details and adverse events were recorded. The continuous visibility of the fiducial markers was assessed by an experienced medical physicist on simulation CT and during the final treatment fraction on cone beam CT.

RESULTS:

During the study period, 67 PC patients underwent placement of 174 fiducial markers under EUS guidance (Table 1). Technical success rate of fiducial placement was 97%. Technical difficulty due to intervening blood vessels was noted in 2 (3%) patients. EUS evaluation showed duodenal invasion in one case and fiducial placement was canceled. All patients received periprocedural antibiotics and no immediate or delayed adverse events were reported. The average time to simulation CT after marker placement was 4.6 days (range, 1-53). 64 (96%) patients received SBRT after fiducial placement (Table 2). Of the total 174 fiducials placed, 165 (95%) fiducial markers were clearly visible on both the CT simulation and cone beam CT scan acquired on the last day of SBRT delivery. 9 (5%) fiducial were not useful for SBRT delivery most likely due to migration or poor visibility. No major SBRT-related toxicity was reported.

CONCLUSION:

Our results demonstrate that EUS-guided fiducial placement is safe and effective in target volume delineation, facilitating SBRT delivery in PC patients. Further clinical trials are needed to determine the optimal type of fiducial to place under EUS-guidance and the survival benefits in patients with pancreatic cancer.
924 How Successful Is Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction Post-Pancreaticoduodenectomy?
Authors: Ahmed Osman , Angsuwatcharakon Phonthep , Yu Abraham , Hakim Seifeldin , Coronel Emmanuel , Wolff Robert , Katz Matthew , Weston Brian , Ross William , Lee Jeffrey H.
Published: October 2019

INTRODUCTION:

Endoscopic retrograde cholangiopancreatography (ERCP) is the accepted therapy for the management of biliary obstructions, however, in patients who have had previous pancreaticoduodenectomy (PD) (i.e. Whipple’s procedure), due to the altered surgical anatomy, the ability to perform ERCP is challenging. In this study, we examine our experience at a large tertiary cancer-center in performing ERCPs for biliary obstructions in patients who are post-PD.

METHODS:

This was a retrospective review from 2006 to 2018 of all patients referred for the management of biliary obstructions post-PD. Outcomes included technical success (ability to treat the stricture, e.g. dilation or placement of a stent) and clinical success (decrease in bilirubin to normal or 50% of peak value within 2 weeks) rates.

RESULTS:

A total of 66 patients were included in the study. The mean age was 67.7 years (SD +/- 11.6) and 58 patients (87.9%) were male. The most common indications for PD were duodenal adenocarcinoma (20 patients, 30.3%) followed by pancreatic adenocarcinoma (16, 24.4%). In terms of surgery, the mean length of the afferent limb was 45.7 cm (SD +/- 6.34). The most common indications for ERCP were cholangitis (31 patients, 49%), followed by a biliary obstruction without cholangitis (11, 16.7%). The mean length of procedure was 66.7 minutes (SD +/- 34.8). The hepaticojejunostomy (and/or choledochojejunostomy) was reached in 56 patients (84.8%). The most common endoscope used was a therapeutic upper endoscope (31 patients, 47%), followed by a regular upper endoscope (11, 16.7%) and a pediatric colonoscope (10, 15.2%). Cannulation of the biliary tree was successful in 55 patients (83.3%). The most common location for the stricture was at the anastomosis (41 patients, 80.4%), followed by distal extra-hepatic (8, 15.7%). Successful stents were placed in 31 patients (47%). There were no episodes of bleeding, perforation or pancreatitis post-ERCP. Four patients developed self-resolving fever post-procedure. The technical success rate was 75.8% (50 patients) while the clinical success rate was 71.2% (47 patients).

CONCLUSION:

ERCP post-PD can be challenging due to the surgical anatomy and inability to use common endoscopes and instruments. Our study demonstrates that nevertheless, endoscopic biliary decompression can still be successful by experienced endoscopists in the majority of patients post-PD, with minimal adverse events.
932 Efficacy and Outcomes of Endoscopic Gastrointestinal Fistula Closure: A Single Center Study
Authors: Mbih Irene , Bergenstock Marika , Mehta Minesh , Berger Andrea , Confer Bradley , Diehl David L. , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Historically, patients with gastrointestinal fistulas who have failed conservative management required surgical intervention. The advent of novel endoscopic devices has revolutionized endoscopic closure of gastrointestinal fistulas presenting a promising and less invasive alternative to surgery. Our study aims to evaluate the efficacy and outcomes of endoscopic closure of gastrointestinal fistulas from a single center database.

METHODS:

We performed a retrospective review of all patients from 2009 to 2019 undergoing endoscopic closure of gastrointestinal fistulas at our tertiary referral center. Demographics, nutritional status, type of fistula, modality of endoscopic repair, number of attempts at closure, technical and clinical success rates, and adverse events were collected.

RESULTS:

A total of 130 procedures were reviewed from 75 patients undergoing endoscopic fistula repair over a 10 year period, 40 males / 35 females, with a median age of 56.5 years. Mean BMI was 26.4 (kg/m2) with a mean albumin of 3.4 (normal > 4). Upper GI closures accounted for 85.3% of cases (64/75) vs lower GI was 14.7% (11/75). The median number of attempts for endoscopic closure was 1 (range 1-5). Technical success rate was 97.7% (127/130). Single modality closure techniques were used in 63% (82/130) of procedures. The most frequently used modality of closure was endoscopic stenting (51/130, 39.2%), followed by endosuture (39/130, 30%), over-the-scope-clips (28/130, 21.5%), endoclip (24/130, 18.5%), APC (20/130, 15.4%), fibrin glue (7/130, 5.4%), and others (3/130, 2.3%). Multimodality closure using a combination above devices was used in 37% (48/130). Clinical success rate for documented complete endoscopic fistula closure was seen in 45.3% (34/75) of cases, while 28% (21/75) needed surgical intervention, and the remaining were managed conservatively. The adverse event rate was 3% (4 cases of stent migration).

CONCLUSION:

Endoscopic intervention of gastrointestinal fistula closure has a high technical success rate and can avoid almost half the cases going to surgical repair. New endoscopic techniques, along with the use of multimodality closure, can be used to increase overall clinical success rate, especially in post-surgical anatomy. Endoscopic therapies of gastrointestinal fistulas are efficacious and offer a safe alternative to surgery for high risk patients.
933 Females Are Associated With an Increased Excess Weight Loss Reduction in Obese Patients Following Intragastric Balloon Placement
Authors: Marrero-Torres Ricardo , Gregory-Gonzalez Federico , Micames-Caceres Carlos
Published: October 2019

INTRODUCTION:

Obesity is an expanding public health problem, resulting in more than half a billion adults worldwide who were considered obese in 2016. Similarly, in Puerto Rico, as stated by the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention there was a prevalence of 32.9% in 2017. Intragastric balloon (IGB) placement is a weight loss alternative for obese patients with an inadequate weight loss response to diet and exercise. The aim of this study is to examine the efficacy and safety of the single-chamber fluid-filled IGB for weight loss and compare its results across different age groups.

METHODS:

We performed a database review of all consecutive patients from two outpatient GI clinics who underwent placement of an IGB. Our final analysis comprised of 239 IGB placements in 232 patients (mean age, 44.5 ± 10.3 years; 67% female; baseline BMI 42.1 ± 9.0). Efficacy outcomes included: the percentage of the total (%TWL) and excess weight loss (%EWL), and Body Mass Index (BMI) reduction at 3 and 6 months. Safety outcomes was measured as the number of patients who required early IGB removal (before 6 months).

RESULTS:

%TWL at 3 months was 10.4%, and 14.5% at 6 months. Overall, 92%, 74%, and 46% of patients lost 5%, 10%, and 15% of total weight at 6 months, respectively. %EWL was 22.1% and 30.3% at 3 and 6 months post-IGB placement, respectively. We observed a BMI reduction of 4.4 kg/m2 at three months and 6.3 kg/m2 at six months overall. Subgroup analysis revealed that females %EWL significantly higher than males (31.9% vs 25.9%, P-value < 0.05). Similarly, patients between ages 51-60 had the highest %EWL (37.3%, P-value < 0.05) among all studied age groups. Likewise, patients grouped by BMI ranges showed a significant weight loss compared to baseline (BMI 30-40 kg/m2 %TWL: 14.6%, BMI 40-50 kg/m2 %TWL: 15.0% and BMI ≥ 50 kg/m2 %TWL: 14.4%), yet there was no significant statistical difference between them. The balloon was safely removed at six months after placement in most patients, whereas in 13.0% of cases early removal was performed at an average of 11.7 weeks after placement (range, 2 days-23 weeks).

CONCLUSION:

Patients among ages 51- 60 showed a significant decrease in %EWL in comparison with other age groups. Women achieved a greater weight loss than men. Subgroup analysis revealed no statistical differences in weight loss percentage among different BMI ranges.
935 Salvage Hybrid APC After Failed Radiofrequency Ablation and Cryotherapy for Barrett’s Esophagus
Authors: Nieto Jose , Casas Daniel
Published: October 2019

INTRODUCTION:

The frequency of Barrett’s esophagus (BE) has increased by a factor of more than 7 during the past four decades in the United States. It has been estimated that 5.6 percent of adults in the United States have Barrett's esophagus, although the large majority of cases go unrecognized. Endoscopic resection of visible lesions, followed by ablation of the rest of the BE epithelium is the current standard of care for management of BE with confirmed dysplasia and IMC. Today, the most readily use treatment for Barret’s esophagus is RFA and APC. None of the current methods are able to guarantee a complete ablation success of 100 %. Cryotherapy has become a salvage technique for patient that have failed RFA. There is limited data available to determine the efficacy and safety of this technique. For patients who failed RFA and Cryotherapy, there are limited options available. The aim of this study is to assess the efficacy and safety of hybrid APC in patients with BE dysplasia who failed RFA and cryotherapy.Hybrid APC can be an effective alternative adjunctive salvage tool to RFA and cryotherapy for patients in whom both of these techniques have failed.

METHODS:

This is a single center, retrospective cohort study at a tertiary medical center between 2010 and 2019 in patients with BE low-grade dysplasia (LGD) and high grade dysplasia (HGD) who failed RFA and cryotherapy treatment. Six patients with an average age of 63, and five out of six are males (84%) and five have persistent LGD (84%). Response was determined by complete eradication (CE). Six patients with persistent dysplasia and with incomplete response to RFA and cryotherapy were offered hybrid APC. The primary endpoint was CE after hybrid APC.

RESULTS:

A total of 6 patients underwent RFA and Cryotherapy for BE dysplasia. After an average of 4.5 RFA sessions and 2.7 Cryotherapy session none of the patient were able to reach CE. 5 patients with BE with LGD and 1 with HGD were offered H-APC after failure of reaching CE (average of 2.3 H-APC treatment). CE was reached in 100% of the patients who underwent H-APC. 6 months endoscopic surveillance has not shown any recurrence of BE or dysplasia.

CONCLUSION:

Patient with refractory dysplasia or recurrent dysplasia after failed eradication of salvage cryotherapy and radiofrequency ablation were offered hybrid APC. The data demonstrate a complete eradication in those patients who failed treatment with RFA and cryotherapy. Furthermore, there were no alternative outcome reported as of to date.
936 Endoscopic Submucosal Dissection as a Salvage Therapy After Failed Endoscopic Mucosal Resection for Colorectal Lesions: A Single Center Experience
Authors: Shah Rushikesh , Abdelfatah Mohamed Magdy , Mekaroonkamol Parit , Yu Michael , Xue Yue , Keilin Steven , Willingham Field , Cai Qiang
Published: October 2019

INTRODUCTION:

There is limited data in efficacy of Endoscopic Submucosal Dissection (ESD) as a salvage therapy after failed Endoscopic Mucosal Resection (EMR) attempt leading to scar tissue formation. We present a single center experience of ESD in evaluating safety and efficacy of ESD in treatment of colorectal lesions with failed prior attempt of EMR.

METHODS:

All patients who had ESD for colorectal lesions after prior unsuccessful attempt of removal by EMR, from 1/2013 to 12/2018 were included. Patient and procedure related data points were collected. Technical success was defined as successful completion of ESD to remove colonic lesions and clinical success was defined as complete removal of colonic lesions with negative margins.

RESULTS:

A total of 19 patients were included. The average age was 68.3 ± 7.5 years, 53% (10/19) patients were female. 10 patients had right sided, 2 patients had left sided and 7 patients had rectal lesions. The average size of the lesion was 3.9 ± 2.5 cm. 10 patients (53%) had en bloc resection and 9 patients (47%) had piecemeal resection despite ESD due to scar tissue formation from prior EMR attempt. Technical success of ESD was 100%. The average duration of the procedure was 103.5 ± 48 minutes. Complications occurred in 2 cases (10.5%), both had En bloc resection. One patient developed bleeding requiring endoscopic treatment and another patient developed microperforation managed conservatively. Of resected lesions, there were 9 tubular adenomas, 5 sessile serrated adenoma, 1 Tubulovillous adenoma, 1 neuroendocrine tumor and 3 samples with histology showing tubular adenoma but with positive margins for adenocarcinoma. ESD specimen added the diagnosis of carcinoma. All of the patients with en bloc resection had negative peripheral margins while of 9 patients who had piecemeal resection, 3 patients had positive margins for carcinoma. Thus clinical success of ESD was 84%. 2 of these patients required surgery while 1 was lost to follow up. Out of 16 patients with initial successful ESD, 13 patients had follow up for average 24 months without any recurrence (3 patients were lost to follow up). A trainee was involved in 60% of the procedures.

CONCLUSION:

ESD is a safe and effective method of diagnosis and treatment for colorectal lesions as a salvage therapy after failed EMR with overall low complication rates and low recurrence rates. ESD should be considered in centers of expertise prior to referring patients for surgical approach.
937 Statin Use Reduces the Risk of Hepatocellular Carcinoma: An Updated Meta-analysis and Systematic Review
Authors: Sarmini Muhammad Talal , Alomari Mohammad , Al Momani Laith , Asfari Mohammad Maysara , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver resulting in approximately 800,000 deaths around the world every year. A growing body of research investigating statin use and HCC risk has shown conflicting results. We examined the association between statin use and risk of HCC utilizing all the available high-quality literature, aiming to provide a quality synthesis of current evidence of statin impact on HCC risk.

METHODS:

We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May of 2019 to identify all studies that evaluated the association between statin use and new HCC development. We included studies that presented an odds ratio (OR) with a 95% confidence interval (CI) or presented data sufficient to calculate the OR with a 95% CI. Statistical analysis was performed using the Comprehensive Meta-Analysis (CMA), Version 3 software and a Forrest plot was generated. Publication bias was assisted for using conventional techniques.

RESULTS:

Twenty studies (3 randomized controlled trials, 7 cohorts and 11 case–controls) with a total of 2,668,497 patients including 24,341 cases of HCC. Studies and patients’ characteristics are summarized in tables 1 and 2, respectively. Our findings indicate a significant risk reduction of HCC among all statin users with a pooled OR of 0.57 (95% CI: 0.49 – 0.66, P < 0.05, I2 = 86.57%) compared to non-users. (Figure 1a) No publication bias was found using Egger’s regression test or on visual inspection of the generated Funnel plot (Figure 1b).

CONCLUSION:

Our results indicate that statin use was associated with 43% lower risk of HCC compared to those who did not use statin. Further prospective randomized research is needed to confirm this association.