bluuebunny/crossref_metadata_2025 huggingface dataset:
850 Long-Term Consequences of Surgery in Patients With Ulcerative Colitis: A Study Using German Claims Data
Authors: Ghiani Marco , Naessens Dominik , Takacs Peter , Myers David , Maywald Ulf , Bokemeyer Bernd , Wilke Thomas
Published: October 2019

INTRODUCTION:

Proctocolectomy in patients with ulcerative colitis (UC) is traditionally considered curative. However, little is known on the long-term complications and costs of surgery in UC and previous literature mostly relied on hospital registry data. Using German claims data, this study explored long-term healthcare resource utilization (HCRU) and costs among UC patients who had surgery and patients who did not.

METHODS:

Patients from a German health insurance with a UC diagnosis between 01/01/2010-31/12/2017 were included. Patients who had proctocolectomy or colectomy after first UC diagnosis and between 01/07/2010-31/12/2014 were identified and surgery date was set as index. Non-surgery patients were given a random index date in the inclusion period after first UC diagnosis, and were required to have received a corticosteroid or biologic in the six months before index. A 1:2 nearest-neighbor propensity score matching (PSM) with replacement was used and UC-related hospital stays and costs, as well as outpatient visits, were studied in the three years after index.

RESULTS:

Of 21,392 UC patients, 76 were included in the surgery group (34 proctocolectomy, 37 colectomy, 5 other) and 114 in the non-surgery group. Matched cohorts did not differ significantly in the baseline characteristics and mortality rates where high in both groups (21.1% and 29.0%, respectively). Patients who had surgery relied less on biologics compared to patients who did not (10.5% vs 23.7%, P = 0.022), but the number of UC-related hospitalizations per-patient-year (PPY) was twice as large in the surgery group than in the non-surgery group (0.4 vs 0.2, P < 0.001), and no significant difference in the number of UC-related outpatient visits PPY was observed (7.2 vs 7.0, P = 0.364). This resulted in higher UC-related hospitalization costs for patients who had surgery (cost-ratio = 4.3, 95% CI: 2.0, 6.7). Costs of UC-related medications were lower for patients who had surgery (cost-ratio = 0.2, 95% CI: 0.0, 0.4), but they increased over the follow-up period for patients in the surgery group and approached costs in the non-surgery group.

CONCLUSION:

While PSM does not account for unobservable confounders and further research on patients who had proctocolectomy is required, this work is the first to study long-term HCRU and costs among UC patients who had surgery and patients who did not, based on claims data. Results show that surgical options may be not curative and result in high hospitalization costs.
861 Mind the Gap: A Comparison of the Randomized Clinical Trial Efficacy and Real World Effectiveness of Tofacitinib for the Treatment of Inflammatory Bowel Disease
Authors: Rudrapatna Vivek A. , Butte Atul J.
Published: October 2019

INTRODUCTION:

Randomized clinical trials (RCTs) represent the gold standard for clinical evidence. However, they have also raised concerns over generalizability due to unrealistic patient selection and endpoints. Real-world data (RWD) is receiving growing interest from the FDA as a complementary source of evidence. However, the suitability of these data for RCT-grade evidence and best practices in their use remain unclear. Here we compare the real-world effectiveness of Tofacitinib with efficacy assessed by RCTs of Inflammatory Bowel Disease (IBD).

METHODS:

Electronic health records (EHR) at the University of California San Francisco (UCSF) were reviewed for IBD patients prescribed Tofacitinib following a pre-protocol. The primary outcome was drug effectiveness measured by continued use and by RCT endpoints. Secondary outcomes assessed the completeness of RWD to measure RCT endpoints and the number of patients meeting RCT inclusion criteria.

RESULTS:

68 Ulcerative Colitis (UC) and 18 Crohn’s Disease (CD) patients received Tofacitinib (Figure 1). Most of the data needed to calculate the RCT endpoints was available in the EHR (77% and 91%) with the remainder imputed. The baseline characteristics of the UCSF and trial cohorts were similar, except for greater disease duration and 100% TNFi failure in UCSF patients (Table 1). However, 0% of the real-world UC cohort met the RCT inclusion criteria (Table 2). The rate of continued treatment at 1 year was greater than 50% irrespective of disease subtype. Time-to-treatment-failure curves were nearly identical for UC and CD, with all drop-off occurring within the first 6 months. This rate of continued treatment in practice was significantly greater than the RCT primary endpoint and least stringent secondary endpoint (P-values 0.003 and 0.08) for UC, and for CD (P-value 0.02). However, the rates of meeting the primary endpoint for both subtypes using the Mayo score and CDAI were identical (P-values 0.5 and 1.0).

CONCLUSION:

Routinely collected data is sufficiently detailed to measure IBD trial endpoints. Analysis of RWD reproduced Tofacitinib efficacy measured by RCTs, despite trial selection criteria excluding most UCSF patients. However, real-world use patterns indicate much greater treatment durability than that suggested by trial endpoints, likely related to different treatment failure thresholds used in clinical care. These results support a role for JAK inhibition in CD, and overall highlight the value of real-world evidence to complement that obtained by RCTs.
862 Patient Attitudes Towards Pre-Procedure Telehealth Visits Prior to Advanced Endoscopic Procedures: Results of a Pilot Survey
Authors: Suresh Suraj , Menees Stacy , Saini Sameer D. , Prabhu Anoop
Published: October 2019

INTRODUCTION:

Telehealth is an emerging technology that enables remote video visits between providers and their patients. The role of a telehealth visit prior to high-risk endoscopy has not been evaluated. The purpose of this study was to pilot a patient survey to assess experiences and preferences for different visit types including telehealth (TH), face-to-face (F2F), and direct access (DA) (i.e., without meeting with a GI physician) prior to undergoing advanced endoscopic procedures.

METHODS:

We developed a survey instrument to assess patient knowledge and preference regarding visit types prior to advanced endoscopic procedures. The survey was refined through input from an expert survey working group. The questionnaire was then administered immediately prior to informed consent to patients undergoing advanced endoscopy procedures at a tertiary referral academic VA medical center. Exclusion criteria included inability to consent and prior exposure to advanced endoscopic procedures. Data were collected on demographics, computer and health literacy, knowledge of procedural risks, benefits, and alternatives, comfort with the proceduralist, visit satisfaction, and overall preference of pre-procedural visit modality. Differences between groups were analyzed using a Chi-Square test.

RESULTS:

A total of 40 patients completed the pilot questionnaire (Table 1). 20 patients were in the DA group, 11 in the F2F group, and 9 in the TH group. Most respondents in the TH and F2F visit groups (78% and 82%, respectively) were satisfied with their visit types and would choose the same visit modality in the future (Table 2, Figure 1). In contrast, significantly fewer (30%, P = 0.003) in the DA group were satisfied with their visit type. Patients with transportation difficulties were more likely to choose a TH visit (P = 0.018).

CONCLUSION:

In this pilot survey, a telehealth visit prior to advanced endoscopic procedures appears to be an acceptable alternative to a F2F visit in terms of patient satisfaction. Most respondents preferred a pre-procedural clinic visit with GI (via either telehealth or F2F) over DA, underscoring the importance of a measured discussion about risks and alternatives for high-risk endoscopic procedures. In the future, telehealth could be considered the visit modality of choice for patients referred for advanced endoscopic procedures who live a significant distance from the procedure site. These results will be confirmed with a larger sample in a future study.
863 Single-Use Duodenoscope for Endoscopic Retrograde Cholangiopancreatography: Performance Ratings From a Case Series of 60 Patients
Authors: Muthusamy V. Raman , Bruno Marco , Kozarek Richard , Petersen Bret , Pleskow Douglas , Sejpal Divyesh , Slivka Adam , Peetermans Joyce , Rousseau Matthew , Tirrell Gregory , Ross Andrew
Published: October 2019

INTRODUCTION:

Exogenous transmission of infection via duodenoscope cross-contamination after failed disinfection is a preventable risk. Inadequate reprocessing of reusable duodenoscopes can occur. Given this possibility, a new single-use duodenoscope was recently developed. It had comparable performance to reusable duodenoscopes when tested by expert endoscopists in a comparative bench model for endoscopic retrograde cholangiopancreatography (ERCP). We subsequently aimed to assess the performance of this disposable duodenoscope in a series of human cases.

METHODS:

Six academic medical centers enrolled consecutive adults 18 years or older without altered pancreaticobiliary anatomy scheduled for an ERCP. Seven ERCP experts rated the new EXALT single-use Model D duodenoscope (Boston Scientific, Marlborough, MA; ClinicalTrials.gov NCT03701958) in ERCP procedures for Overall Satisfaction on a scale of 1 (unsatisfied) to 10 (very satisfied), “Not preferred/Neutral/Preferred” compared to reusable duodenoscopes on 23 ERCP maneuvers, and Qualitative Comparison of 17 performance characteristics on a scale of 1 (not preferred) to 5 (comparable to reusable duodenoscopes).

RESULTS:

Sixty consecutive patients had an ERCP using the first-generation single-use duodenoscope in April and May 2019. Thirty-seven (61.7%) were male, mean age was 64.4 years, and 44 (73.3%) had a prior ERCP at baseline. All 60 ERCP procedures were successfully performed, 58 (96.7%) with the single-use duodenoscope alone and 2 (3.3%) with crossover to a reusable duodenoscope. Median overall satisfaction with the single-use duodenoscope was rated 9.0 (range 1-10). The overall satisfaction rating was ≥ 7 in 56 (93.3%) ERCPs. All three ratings were at or above midpoint (Overall satisfaction ≥ 5, Comparative ERCP maneuver “Neutral/Preferred,” Qualitative Comparative rating of performance characteristic 3-5) in 47 (78.3%) cases. Four ERCPs had low (≤4) overall satisfaction ratings attributed to inadequate pushability of instruments due to suboptimal positioning of the duodenoscope in front of the papilla; these ERCPs were a subset in which biliary or pancreatic duct strictures were dilated and/or stented.

CONCLUSION:

Expert endoscopists reported good overall performance of a new single-use duodenoscope in a broad array of cases. Low ratings occurred rarely and were associated with particular ERCP maneuvers. Detailed design improvements to the single-use duodenoscope are underway.
881 Is There a "July Effect" for Endoscopic Variceal Band Ligation in Teaching Hospitals?
Authors: Rodgers Brandon , Patel Pavan , Ahlawat Sushil
Published: October 2019

INTRODUCTION:

The July effect describes the increased morbidity and mortality that studies have shown when new trainees begin in teaching hospitals in the United States. The July effect has not been shown to impact outcomes of screening colonoscopy or ERCP, but to our knowledge no study has assessed the July effect in endoscopic variceal band ligation. Our study aimed to assess whether there was a July effect associated with endoscopic variceal band ligations for patients with variceal hemorrhage in teaching hospitals.

METHODS:

The National Inpatient Sampl (NIS) is the largest all-payer inpatient database in the United States, consisting of approximately seven million hospital stays. We collected data from 2008 to 2012. International Classification of Disease, Ninth Edition codes were used to identify patients with a diagnosis code of variceal hemorrhage and procedure code for ligation of esophageal varices, endoscopic excision or destruction of lesion or tissue of esophagus, or ligation of gastric varices. Patients that were included were admitted in the “early” months of July, August or September, or those in the “late” months of April, May or June.

RESULTS:

A total of 477 (weighted = 2378) patients with variceal hemorrhage and endoscopic band ligation were identified. 231 (weighted = 1148) patients were admitted in the early period, and 246 (weighted = 1230) in the late period. There was a significant difference in length of stay (days) (7.11 ± 7.38 vs. 8.69 ± 13.01 P = 0.0003) and incidence of post procedure infection (.04% vs. 1.3% P = 0.024). There was no significant difference between the early and late groups in all-cause mortality (11.1% vs. 8.8% P = 0.107). When controlled for cofounding factors including demographics, number of medical comorbidities and hospital characteristics in regression analysis, incidence of post procedure infection remained significant (OR = 0.098, 95% CI: 0.015, .650, P = 0.016). There remained no significant difference in mortality (OR = 0.697, 95% CI: 0.423-1.147, P = 0.156). After controlling for cofounders using regression, LOS also remained significant (β = -0.59, P = 0.0003).

CONCLUSION:

Our analysis shows increased length of stay and post procedure infections in the later academic months, with no difference in mortality. These differences found in our analysis could possibly be attributed to less experienced trainees having more opportunities to perform band ligation procedures in the later academic months compared to earlier months.
898 Antireflux Valve Metal Stent vs. Conventional Self Expandable Metal Stent in Distal Malignant Biliary Obstruction: A Systemic Review and Meta-Analysis
Authors: Renno Anas , Abdel-Aziz Yousef , Ahmed Tamer , Alastal Yaseen , Toseef Javaid , Al-Aboodi Yasir , Nawras Ali
Published: October 2019

INTRODUCTION:

In patients with distal malignant biliary obstruction (MBO), endoscopic biliary drainage by using the conventional self-expandable metal stent (cSEMS) is the gold standard established method for palliative treatment. However, there are limited data on the role of the antireflux valve metal stent (ARVMS). The aim of this study is to compare the efficacy and safety of ARVMS and cSEMS.

METHODS:

We performed an electronic search including PubMed, MEDLINE, EMBASE and Cochrane Library following the Preferred Reporting Items for Systemic Review and Meta-analysis (PRISMA) from inception until April 2019. We included randomized controlled trials (RCTs) that studied the efficacy and safety of ARVMS vs cSEMS deployment in distal malignant biliary obstruction. The selected studies provided data regarding technical and clinical success rates. Adverse events and stent dysfunction were also analyzed. We assessed the risk of biases using Cochrane Collaboration tool to assess the risk of bias.

RESULTS:

A total of 3 RCT’s were selected, enrolling 293 patients (147 ARVMS and 146 cSEMS). The rate of technical success between the ARVMS and cSEMS groups was 95.23% and 99.31% [odds ratio (OR) 0.13; 95% Confidence Interval (95% CI) 0.01-1.06, P = 0.06]. The clinical success rate was 91.57% and 89.36% (OR: 1.30; 95% CI: 0.48-3.51, P = 0.61). There was no significant difference in terms of adverse events between ARVMS and cSEMS (OR: 0.61; 95% CI: 0.35-1.05, P = 0.07). Overall, there was no statistical significance in stent dysfunction (OR: 0.77; 95% CI: 0.48-1.24, P = 0.29), however; after performing sub analysis stent migration was significantly higher in ARVMS (OR: 2.76; 95% CI: 1.24-6.17, P = 0.01). Stent occlusion was significantly lower in ARVMS (OR: 0.44; 95% CI: 0.26-0.76, P = 0.003).

CONCLUSION:

Our study showed that ARVMS and cSEMS technical and clinical success rates were similar. Adverse events were comparable between two arms. ARVMS was associated with lower risk of stent occlusion. Further randomized controlled trials are required with a higher number of patient population to verify the benefit of ARVMS.
899 POEM Perceptions: A Survey of Gastroenterologists and the Treatment of Achalasia in the Philadelphia Region
Authors: Loh Rebecca , Schlachterman Alexander
Published: October 2019

INTRODUCTION:

Peroral endoscopic myotomy (POEM) is a relatively new innovate technique that has been shown to be an effective treatment for achalasia. Despite studies demonstrating its effectiveness as a less invasive therapy, POEM is still not as widely implemented as the traditional Heller myotomy for the treatment of achalasia. We aimed to explore the barriers that may impact implementation of POEM and to assess the regional perception of POEM amongst gastroenterologists in an urban setting.

METHODS:

An Internal Review Board (IRB) approved our 21-question multiple-choice survey that was developed by a panel of specialists that included a POEM trained advanced endoscopist. This was sent via email to 208 physicians practicing in the Philadelphia area. Some questions allowed for responders to select all answers that applied.

RESULTS:

Forty-five physicians (45/208, 21.6%) completed our online survey. Of the total 45 responders, 82.2% were male and 68.9% were practicing at an academic medical center. Approximately 73% of responders had treated anywhere from 5 to 50 patients diagnosed with achalasia during their career. Only 11% have treated over 50 patients with achalasia. In assessing what therapies these gastroenterologists have prescribed in the treatment of achalasia, the majority of responders prescribed botulinum toxin injections (86.4%) and endoscopic dilation (standard and pneumatic) (70%). In addition, 72.7% recommended surgical myotomy (laproscopic or open) while only 27.3% prescribed POEM. In fact, 69.8% of responders had never prescribed POEM even though 95.6% would consider POEM for the treatment of achalasia and 78.6% of responders believed POEM will gain acceptance as a main form of therapy. Nearly a quarter (24.4%) of responders were unaware of a program that performed POEM in the area.

CONCLUSION:

Although the vast majority of gastroenterologists surveyed considered POEM an acceptable therapy for the treatment of achalasia (95.6%), a significantly smaller portion of physicians had actually recommended it themselves (27.3%). A fairly significant percentage of responders were unaware of a local POEM program, which may have served as a barrier to their implementation of this therapy. Future studies will be to compare our current data to that in 18 months after establishment of a POEM program at a local academic hospital.
921 Efficacy and Safety of Endoscopic Ultrasound-Directed Transgastric ERCP in Gastric Bypass Patients: A Systematic Review and Meta-Analysis
Authors: Khan Ali T. , Zhang Xiaocen , Herman Michael , Lung Edward
Published: October 2019

INTRODUCTION:

Treating pancreaticobiliary disorders in Roux-En-Y gastric bypass patients poses a technical challenge for physicians. The traditional laparoscopic or device assisted enteroscopic techniques has high post procedural complications and failure rates. EUS directed transgastric ERCP (EDGE), which accesses the ampulla by creating a temporary fistula through the remnant stomach for standard ERCP, has shown promising results. We conducted a systematic review and meta-analysis to evaluate and compare the efficacy and safety of EDGE.

METHODS:

MEDLINE, EMBASE, and SCOPUS databases were utilized to search for eligible studies that reported on efficacy and safety from 2012-2019. Efficacy was defined as the ability to create a temporary fistula through a lumen apposing metal stent (LAMS) and conduct an ERCP. Safety included assessing adverse events. The studies included were retrospective studies and were assessed with the NHBLI tool. Figure 1 depicts the flow chart used for study screening.

RESULTS:

A total of 4 studies (n = 88 patients) were included in the analysis. The mean age of patients undergoing EDGE was 56 years with 86% females. All patients evaluated were status post roux-en-y gastric bypass and the most common indication for the procedure was choledocholithiasis. Pooled technical success was 98.8% (95% CI 0.96-1.0) although 13 cases involved either LAMS misdeployment or LAMS migration during ERCP requiring rescue or repositioning. A total of 8 adverse events (8% 95% CI 0.03-0.16) occurred including intra-procedural bleeding, pancreatitis, persistent fistula formation or perforation. Figures 2,3 highlight the clinical success and adverse events of the EDGE technique.

CONCLUSION:

EUS directed transgastric ERCP (EDGE) appears to be an effective and safe procedure for Roux-EN-Y gastric bypass patients to undergo ERCP. Further studies are needed to address optimal procedural techniques, including access tract closure and to assess long term adverse events such as post procedural weight gain.
922 Hemospray Experience in Indonesia: The Application of Hemospray During Emergency Endoscopy: Single Tertiary Center Hospital
Authors: Bestari Muhammad Begawan , Girawan Dolvy , Tahari Jefry , Abdurachman Siti Aminah
Published: October 2019

INTRODUCTION:

Gastrointestinal bleeding (GIB) is one of the main indication to perform endoscopy, GIB can also be potentially life threatening. In some cases Emergency Endoscopy (EE) is necessary, to identify the source and to stop the bleeding. Recently, hemostatic spray powder was introduced and one of the example is Hemospray (Cook Medical, Winston-Salem, NC, USA) that shows promising results as rapid hemostasis in primary treatment and salvage when bleeding persists after conventional methods.

METHODS:

The samples were taken in retrospective manner for the duration of three years since Hemospray first introduced in Indonesia from January 2016 – January 2019. This paper has obtained ethical clearance from hospital ethic committee.

RESULTS:

For both upper and lower GI endoscopy, we conducted a total of 2,990 procedures among which 37 procedures for 37 patients, consisted of 21 (56.8%) males and 16 (43.2%) females with average age of 67.8 years old, were EE using Hemospray. It was used in 30 (81.1%) for upper GI and 7 (18.9%) for lower GI. Hemospray was used as monotherapy for 24 (64.9%) and 13 (35.1%) as secondary modality, in which the primary treatment was argon plasma coagulation (APC) 8 (21.6%), adrenaline 4 (10.8%), histoacryl 1 (2.7%). In all cases Hemospray achieved hemostasis, with no event of rebleeding occur. Mortality rate is 37.8% (n = 14), with most deaths occur within 30 (42.9%) days after EE was done. However, none of the deaths was related to endoscopy or GIB.

CONCLUSION:

In all cases, Hemospray was able to achieve hemostasis and furthermore there was no event of rebleeding. When conventional modalities alone were inadequate, the combination with Hemospray appeared to be able to control the bleeding. The use of Hemospray in endoscopy is a novel technique in the management of GIB, especially the difficult cases. The advantage of Hemospray is the simplicity of the technique, thus require lower endoscopic skills compared to coagulation, injection, and clipping, the powder spray also allows easier access where source of bleeding is technically hard to access. Studies covering the efficacy, safety, combination with other techniques are still expanding with promising results, although a larger number of subject study is necessary.
927 Traction-Assisted Endoscopic Submucosal Dissection Reduces Procedure Time and Risk of Adverse Events: A Meta-Analysis
Authors: Lopimpisuth Chawin , Simons Malorie , Prasongdee Klaorat , Ngamruengphong Saowanee
Published: October 2019

INTRODUCTION:

Endoscopic submucosal dissection (ESD) is superior to endoscopic mucosal resection (EMR) for treatment of superficial gastrointestinal neoplasia because it is associated with increased en bloc resection and lower rates of local recurrence. However, ESD is a technically demanding procedure with increased procedure time and has potential for serious adverse events. To overcome the procedural difficulty of ESD, Various traction methods such as clip-line method, clip and snare method and internal traction method, have been developed to provide countertraction to expose the dissection plane and allow safe and effective submucosal dissection. A number of studies have compared efficacy of traction-assisted ESD (T-ESD) and conventional ESD (C-ESD) but results are conflicting. We conducted a meta-analysis to assess the efficacy of T-ESD.

METHODS:

All clinical studies published up to April 2019 comparing the efficacy and safety of T-ESD and C-ESD were identified using electronic bibliographic searches of PubMed, Medline, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), and Web of Science (Science and Social Science Citation Index). Outcomes of interests included procedure time (minutes), rate of en bloc and R0 resections, and rates of adverse events (bleeding and perforation). Random effect model was used to calculate pooled mean difference (MD) for continuous variables and Odds ratios (ORs) for categorical variables.

RESULTS:

Of 621 articles identified, 18 studies [939 T-ESD and 963 C-ESD procedures] met inclusion criteria for final analysis [6 randomized controlled trials and 12 observational studies]. Overall, T-ESD significantly reduced procedure time (MD = - 16.63 min, 95% CI - 24.65 to - 8.60, P < 0.0001, I

2
= 68) and complication rates (OR = 0.56, 95% CI 0.36 - 0.87, P = 0.009, I

2
= 0) compared to C-ESD. En bloc resection and R0 resection rates were similar in both groups (OR = 2.36; 95% CI 0.58 - 9.55; P = 0.23, I

2
= 0 and OR = 1.45; 95% CI 0.76 - 2.77; P = 0.25, I

2
= 0; respectively). No publication bias was detected by funnel plot.

CONCLUSION:

Traction techniques facilitate submucosal dissection, reduce procedure time and improve its safety. These techniques are simple and can be performed using readily available accessories in the endoscopy unit. Application of traction method improves feasibility of ESD and may enable the widespread use of ESD in the West.
929 A Prospective Evaluation of a Novel Ultra-Slim Echoendoscope for EUS-Guided FNA, FNB and Celiac Plexus Neurolysis
Authors: Green J. Alvin , Eloubeidi Mohamad A.
Published: October 2019

INTRODUCTION:

Safe and successful EUS and EUS-guided interventions rely on the ability to reach the intended organ reliably and safely. Possible barriers include altered anatomy, stenosis in the GI tract, or low BMI, making the current echoendoscopes hazardous to use. Therefore, we prospectively evaluated the utility of a novel Ultra-Slim echoendoscope in these challenging scenarios.

METHODS:

We prospectively enrolled 25 patients in this study. Criteria for inclusion were as follows: Weight less than 120 lbs, children, mediastinal lymph nodes with severe lung disease or sleep apnea, altered anatomy, and esophageal stenosis precluding the passage of the standard echoendoscope. The Ultra-Slim echoendoscope (EG-3270UK: Pentax, Montvale, NJ USA) was utilized in all cases. A 22-gauge FNA or FNB needle were utilized. A fenestrated 20-gauge needle was used for CPN. Complications were assessed at 30 days as we previously described.

RESULTS:

A total of 25 patients were included in this study with a mean age of 69.16 years (standard deviation of 13.5). Females accounted for 64% of the study population. Indications for EUS use were: 64% (n = 16) had an abnormal CT or PET scan, 4% (n = 1) had MLN, 24% (n = 6) had a pancreatic mass, 8% (n = 2) had other indications. Reasons for using the Ultra-slim echoendoscope were: 28% of patients (n = 7) had low body weight defined as less than or equal to 120 lbs, 12% (n = 3) had MLN, 32% (n = 8) had altered anatomy and 28% (n = 7) had esophageal stenosis. Of the 25 Ultra-slim procedures performed, an FNA biopsy was taken 68% of the time (n = 17) while in 32% (n = 8) a biopsy was not performed. Of those 17 biopsies taken, a 22G FNA needle was used 87.5% (n = 14) of the time, and the FNB 19G needle was used 12.5 % (n = 2). Targets for biopsy were MLN 56.25% (n = 9), Adrenal Gland 6.25% or (n = 1), Liver 18.75% (n = 3), Pancreas 12.5% (n = 2) or Other 6.25% (n = 1). CPN was performed 3 times or 12% of procedures. Of the 17 samples taken, 65 % (n = 11) were malignant while 35% (n = 6) were benign. The average size of target biopsied was 32.8 mm × 25.2 mm (standard deviation 14.18 × 12.9) with a range of 11-73 mm and 8-65 mm. No immediate or long-term complications occurred.

CONCLUSION:

An ultra-slim echoendoscope is very useful and may be better tolerated in individuals with low body weight, altered anatomy and stenosis in the GI track and in patients with lung cancer. Further modifications are warranted to allow more therapeutic interventions with this important addition to the endosonographer daily armamentarium.
934 Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections Using AXIOS Electrocautery Enhanced Delivery System a Retrospective Experience at a Large Quaternary Care Center
Authors: Kloska Michal , Hrad Valery , Aggarwal Soorya , Shah Shashin , Zator Zachary , Shah Hiral
Published: October 2019

INTRODUCTION:

Pancreatic fluid collections (PFC) are common complications of acute pancreatitis, surgery, or trauma. Many PFC reabsorb spontaneously but the remainder create cystic structures filled with fluid and/or with necrotic debris. Since the development of lumen apposing metal stents (LAMS) first line treatment of PFCs are with EUS guided drainage. However, despite the high technical and clinical success of the commonly used Electrocautery Enhanced AXIOS LAMS (EEAL), outcome data is still scarce.

METHODS:

An IRB approved, retrospective chart review, was performed on EUS-guided drainage of PFC using EEAL at a large quaternary care, teaching hospital. Specific procedural data including technical success rate, adverse events, and length of stay were collected. Descriptive statistics were then used to report outcomes.

RESULTS:

A total of 43 EEAL were used in the treatment of pancreatic pseudocysts (41.9%) and walled off pancreatic necrosis (65.1%). LAMS were placed successfully in 100% of procedures and required revisions in 28.6% of patients. Adverse events occurred in 16.3% of interventions: 2 bleeding events (4.7%), 3 stent migrations (7%), 1 pigtail stent occlusion (2.4%) and 1 spontaneous pancreatic fistula formation (2.4%). Only 2 patients (4.8%) required subsequent surgical resection. The average hospital stay after the procedure was 6.79 days (median of 3 days) and stents were ultimately removed on average at 24.68 days.

CONCLUSION:

This study demonstrated 100% technical success rate. Of the recorded adverse events after EEAL use in drainage of PFC most were subclinical and minor. Importantly, only two patients required further surgical intervention to obtain desired outcome. Furthermore, length of stay was particularly low with median hospital stay of 3 days. Ultimately, this study highlights how EEAL provides high value care by providing an efficient intervention in a cost-feasible length of time. Further ongoing prospective studies will help determine the utility of EEAL in the practice setting.
939 B-Type Natriuretic Peptide Predicts 90-Day Mortality and Need for Paracentesis in Patients With Cirrhosis and Without Systolic Heart Failure
Authors: Palacios Pedro , Araujo Tiago , Vohra Ishaan , Omar Yazan Abu , Flores Estefania , Kedar Mukthinuthalapati V. V. Pavan , Randhawa Tejinder , Wang Yuchen , Patel Sanjay A.
Published: October 2019

INTRODUCTION:

Fluid overload is the most frequent complication of end-stage liver disease, regardless of its etiology. Levels of brain natriuretic peptide (BNP) have been shown to be elevated in cirrhotic patients when matched to healthy subjects. There are only small observational studies done in Asian and European populations evaluating the role of BNP in predicting mortality of patients with liver disease. The use of BNP to predict 90-day requirement of paracentesis has not been studied.

METHODS:

Retrospective analysis of medical records of patients with a diagnosis of cirrhosis without heart failure, arrhythmia, coronary artery disease or pulmonary hypertension from John H. Stroger Hospital of Cook County Medical Record's database from 2008 to 2018. IRB approval was obtained. All analysis was done using STATAv14.

RESULTS:

The cohort included 430 patients with clinical and radiological diagnosis of cirrhosis without systolic dysfunction of which 12% had BNP ≥ 300 pg/mL. Patients with BNP ≥ 300 pg/mL were younger (53.3 vs 55.6 years, P = 0.027), had less proportion of hepatitis B (0% vs 100%, P = 0.013), hepatitis C (7.4% vs 92.6%, P = 0.036), higher mean number of paracentesis (1.60 vs 2.52, P = 0.005), creatinine (2.66 vs 1.03 mg/dL, P=< 0.001), bilirubin (5.36 vs 2.84 mg/dL, P=< 0.001) and INR levels (1.75 vs 1.50, P = 0.003). There was no significant difference in Child-Pugh class between the two groups and MELDNa scores were significantly higher in the BNP ≥ 300 pg/mL group. Kaplan-Meier survival estimates for death within 90 days show increased significant mortality [HR 3.49, P = 0.037] and significantly higher requirement for paracentesis in 90 days [HR 2.26, P = 0.020] with levels of BNP ≥ 300 pg/mL.

CONCLUSION:

This is, to our knowledge, the largest study done to assess BNP as a prognostication tool in cirrhotic patients. Despite excluding patients with overt cardiac dysfunction, we found that higher BNP levels are significantly associated with higher medium-term mortality, paracentesis requirements and higher MELDNa scores, suggesting high BNP values as an indicator of severity. The presence of hepatitis B and C seem to be a protective factor, most likely due to possible less indolent disease and more accessible treatment methods. In conclusion, BNP seems to be a reliable predictor of severity in this cohort of patients.
940 Pregnancy Outcomes After Liver Transplantation
Authors: Sobotka Lindsay , Hinton Alice , Mumtaz Khalid , Conteh Lanla
Published: October 2019

INTRODUCTION:

Liver transplantation is a safe and effective intervention for patients with acute liver failure and cirrhosis. Given that the number of liver transplantations in women of childbearing age is increasing, it is important to recognize complications during pregnancy in these patients. Previous studies have noted an increased risk of complications, specifically hypertension and preeclampsia. This study aims to evaluate complications during pregnancy in patients after liver transplantation and the effect these complications have on patient and hospital outcomes.

METHODS:

Utilizing the Nationwide Inpatient Sample, a retrospective database analysis was performed on pregnant patients aged greater than 18 between 2005 and 2013. Patients were selected with the use of ICD-9 codes. Multivariable and propensity weighted analyses were used to evaluate the impact of liver transplantation on pregnancy complications and hospital outcomes including hospital length of stay and costs.

RESULTS:

A total of 38,449,030 pregnant patients were included in this study including 1,469 patients with a history of liver transplantation. Patients with a history of liver transplant were more likely to undergo a caesarean delivery and have a pregnancy related complication including miscarriage, intrauterine growth restriction, postpartum hemorrhage, hypertension during pregnancy, preeclampsia and venous thromboembolism (P < 0.001). Propensity weighted analysis revealed higher rates of pregnancy complications (OR 2.11, 95% CI 1.63, 2.73), higher cost of admission ($3,023, 95% CI 850, 5,197) and longer length of stay (1.52 days, 95% CI 0.62, 2.41) among those with a liver transplant. A subset analysis among pregnant patients with a history of liver transplantation revealed 823 (56%) of these patients suffer from at least one pregnancy related complication. On multivariable analysis, patients that experienced a pregnancy related complication had a longer length of stay (2.45 days, 95% CI 1.44, 3.45) and higher cost of admission (5,205, 95% CI 2,848, 7,561).

CONCLUSION:

Pregnancy after liver transplant is associated with higher rates of pregnancy complications and worse patient and hospital outcomes. Further studies should be completed in order to improve outcomes in these patients.
944 Prevalence Rate of Colorectal Cancer in Various Chronic Liver Disease Groups in the United States Between 2014 and 2019: A Population-Based Study
Authors: Lindsey Adrian , Jit Patel
Published: October 2019

INTRODUCTION:

Prior studies have suggested that the risk of colorectal cancer (CRC) may be increased in individuals with cirrhosis and chronic liver disease (CLD). It is well known that a diagnosis of PSC has increased risk of CRC, but there is little date as to whether other causes of CLD have increased CRC risk as well. Some prior studies have been limited by small sample sizes, and to our knowledge no large study has been performed comparing CRC risk between the different causes of chronic liver disease.

METHODS:

We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of Electronic Health Record data from 26 major integrated healthcare systems in the United States from 1999 to 2019. We identified an aggregated patient cohort of eligible patients with “Diagnosis: Alcoholic liver cirrhosis”, “Diagnosis: Chronic Viral hepatitis”, “Diagnosis: Autoimmune hepatitis”, and “Diagnosis: PBC” followed by a diagnosis of “Primary malignant neoplasm of colon and/or rectum” between May 2014 and May 2019, based on Systematized Nomenclature Of Medicine – Clinical Terms (SNOMED-CT).

RESULTS:

Of the 36,813,060 individuals active in the database between May 2014 and 2019, we identified 7,350 individuals with PBC with an overall prevalence rate of 20.0 per 100,000 persons; 66,160 individuals with alcoholic cirrhosis (AC) with overall prevalence rate of 180 per 100,000 persons; 186,840 individuals with chronic viral hepatitis (CVH) with overall prevalence rate of 508 per 100,000 persons; and 13,540 individuals with autoimmune hepatitis (AH) with overall prevalence rate of 36.8 per 100,00 persons. In the PBC group, 60 were found to have CRC with overall prevalence rate of 816/100,000, OR 2.1 [95%CI (1.62 to 2.64) P < 0.0001]. In the AC group 400 were found to have CRC with overall prevalence rate of 605/100,000, OR 1.54 [95%CI (1.40 to 1.70) P < 0.0001]. In the CVH group 890 were found to have CRC with overall prevalence of 473/100,000, OR 1.21 [95%CI (1.41 to 1.30) P < 0.0001]. In the AH group 50 were found to have CRC with overall prevalence of 369/100,000, OR 0.94 [95%CI (0.712 to 1.24) P = 0.6647].

CONCLUSION:

To our knowledge, this is one of the first large studies to describe the epidemiology of CRC in chronic alcoholic, viral, and autoimmune diseases. We found that the estimated prevalence of CRC to be the highest in the PBC group at 816/100,000 and that CRC in the PBC and AC groups had increased risk compared to non liver disease with ORs of 2.1 and 1.54 respectively.
954 Evaluation of Reasons for Admission in Patients With Decompensated Cirrhosis and Their Burden on Health Care Costs and Mortality Over the Years: Nationwide Analysis
Authors: Patel Kalpesh , Kabaria Savan , Patel Pavan , Shulik Oleg , Pyrsopoulos Nikolaos T.
Published: October 2019

INTRODUCTION:

Cirrhosis is considered the late stage irreversible sequela of progressive fibrosis and distortion of hepatic architecture. Patients with decompensated cirrhosis have significant morbidity and mortality and may present with signs of upper GI bleeding, ascites, confusion, and kidney injury. The aim of our study was to evaluate and report the trends for the most common causes of decompensation in patients with cirrhosis.

METHODS:

A retrospective cohort analysis was performed using the Nationwide Inpatient Sample (NIS) from 2007–2014. All patients with a diagnosis of cirrhosis, elective admission, and age greater than 18 years were included in our analysis. We evaluated those who had primary admission diagnosis for ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, esophageal variceal bleeding, and hepatorenal syndrome (HRS). We evaluated the trends of mortality, the length of stay, and cost of hospitalization.

RESULTS:

Ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, esophageal variceal bleeding, and HRS accounted for 44,614 admissions from 2007–2014 as a primary diagnosis. Mortality for HRS decreased from 36.59% to 24.05% (P < 0.001) from 2007 to 2014, representing average overall mortality of 30.32%. Furthermore, average length of stay (LOS) for spontaneous bacterial peritonitis went from 7.22 days to 6.42 days (P < 0.05). Average LOS went from 9.07 days to 7.88 days (P < 0.05) for hepatic encephalopathy. Average total charges of hospitalization went from $51,665 to $71,779 (P < 0.001) from 2007 to 2014 for hepatic encephalopathy. Average total charges of hospitalization went from $19,692 to $32,336 (P < 0.001) from 2007 to 2014 for ascites. Mortality for bleeding from esophageal varices increased from 5.21% to 6.11% (P < 0.001) from 2007 to 2014, representing average overall mortality of 5.59%. Average total charges of hospitalization went from $34,107 to $51,424 (P < 0.001) from 2007 to 2014 for hepatic encephalopathy.

CONCLUSION:

Admission for HRS represents approximately 30% overall mortality in patients with decompensated cirrhosis in our study. On the contrary, while the total mean charge for hospitalization increases, spontaneous bacterial peritonitis and hepatic encephalopathy has had significant decrease in LOS from 2007–2014. Clinicians should be vigilant for patients admitted for HRS as it represents high mortality. Further prospective studies are warranted to evaluate the causes for high mortality in decompensated cirrhosis.
957 Awareness and Utilization of the Baveno VI Criteria to Predict Gastroesophageal Varices in Compensated Cirrhotic Patients
Authors: Shah Samip , Hung Chun Kit , Bernstein David , Lee Tai-Ping
Published: October 2019

INTRODUCTION:

The Baveno VI criteria states that patients with a platelet count greater than 150,000/µl and liver stiffness less than 20 kPa on transient elastography (TE) are at low risk for gastroesophageal varices in compensated cirrhosis and can safely forego screening endoscopy (EGD). Despite being validated in multiple studies, the familiarity with this criteria and degree of utilization is unclear among gastroenterologists.

METHODS:

An 11-question multiple choice survey was distributed to gastroenterologists including fellows in training. Questions pertained to clinicians’ approach to compensated cirrhotic patients. Baseline data was obtained from all respondents regarding years in practice, practice setting, state of practice, volume of EGDs performed annually for screening varices, rates of diagnosis of varices, and frequency of ordering TE in compensated cirrhotics. Respondents were then asked about their familiarity and use of the Baveno VI criteria, their willingness to adopt it in their practice, and their reservations with the criteria. Responses were anonymous and recorded from 4/24/19 to 6/9/19.

RESULTS:

One hundred twenty-two completed surveys were analyzed. The experience of the respondents ranged from being in fellowship to being in practice over 20 years, Graph 1. The most common practice setting was within an academic teaching hospital (n = 77, 63.1%), and 115 respondents (94.3%) reported adherence to screening EGD at time of diagnosis of cirrhosis at least 75% of the time. Most respondents (n = 75, 61.5%) endorsed ordering TE less than 25% of the time. Furthermore, the majority of respondents (n = 106, 86.9%) either were unfamiliar with the criteria or did not use them in clinical practice despite familiarity, Graph 2. Reservations about adopting the criteria centered on a perceived lack of substantiated data regarding TE (n = 44, 36.1%) and its absence from guidelines by predominant GI societies (n = 27, 22.1%), Table 1.

CONCLUSION:

Our survey showed that a majority of gastroenterologists are unaware of the existence and potential use of the Baveno VI criteria. As in any invasive procedure, EGD has an inherent risk of complications. Additionally, the costs associated with screening EGDs may pose an unnecessary economic burden to the healthcare system. Provision of validated data, education of the criteria, availability of non-invasive TE, and incorporation of the criteria into GI societies’ guidelines may increase the awareness and implementation of the criteria into clinical practice.
974 One, Three, and Five Years Post Transplant Outcomes in Diabetic Patients After Liver Transplant for NASH Cirrhosis: A Single Centre Study
Authors: Fahad Hamna , Singh Amandeep , Lan Nan , Singh Kevin , Wakim-Fleming Jamile
Published: October 2019

INTRODUCTION:

Beside immunosuppression, patients undergoing liver transplantation (LT) for non-alcoholic steatohepatitis (NASH) cirrhosis are at additional risk of complications due to a myriad of comorbidities that accompany the metabolic syndrome. We aimed to assess post-LT outcomes at one, three and five year intervals for patients with type-2 diabetes mellitus who underwent LT for NASH cirrhosis.

METHODS:

Using ICD-9 codes all type diabetics with the diagnosis of non-alcoholic fatty liver disease (NAFLD) were identified between January 2000 and Decemeber 2015. Of these, those who had biopsy-proven NAFLD and underwent LT for NASH cirrhosis were recognized and subsequently followed to assess outcomes at one-, three- and five-years. A P-value of < 0.05 was considered significant.

RESULTS:

60 out of 1300 patients underwent LT for NASH-cirrhosis. Mean age was 59.6 ± 7.6 years; mean BMI was 31.2 ± 6.3 kg/m2. Mean MELD score at listing was 17.9 ± 9.1 and on the day of LT was 20.1 ± 9.3. Median post-LT follow-up was 66.5 months (IQR 59.5). Follow-up was available for 57, 50 and 34 patients at 1, 3 and 5 years, respectively. Infection was the most common complication within the first year (35%). Cardiovascular (CV) events were most common overall, effecting 25.3% patients in year 1, 32 % in 3 years and 23.5 % in a 5-year period. Post-LT biliary complications were seen in 22.8%, 12.9% and 8%, respiratory complications in 4%, 2% and 0%; gastrointestinal complications in 1%, 2%, 1% and renal complications in 9%, 5%, and 1% within one, three and five years, respectively. 29.6% patients had an episode of rejection within one year of transplant, 7 % within 3 years and 3.3% in 5 years (P = 0.02). A worsening trend was seen in steatosis of the graft across the years 20%, 39.3%, 42.9 % for year 1, 3 and 5 ((P = 0.02). Rates of complications were not statistically different for patients who had normal versus those with elevated gylcated hemoglobin post LT, or for those who lost weight ( >5 lbs), except at year 3 (P < 0.05) (Figure 1).

CONCLUSION:

Patients undergoing LT for NASH-cirrhosis are at a high risk of developing post-LT infectious and cardiovascular complications. Risk of developing steatosis in the graft also increases every year. These patients need to continue dietary and lifestyle modifications to reduce the risk of future complications, even after LT.