bluuebunny/crossref_metadata_2025 huggingface dataset:
805 Improving Chromoendoscopy Utilization in Dysplasia Surveillance of Patients With Inflammatory Bowel Disease
Authors: Fan Katherine , Greeff Yesenia , Browne Alexander , Rich Harlan
Published: October 2019

INTRODUCTION:

Given the increased risk of colon cancer, patients with longstanding inflammatory bowel disease (IBD) of at least 8 years are recommended to undergo screening every 1-2 years. Chromoendoscopy has been shown to provide up to 9-fold detection of dysplastic lesions versus standard-definition endoscopy. However, it has not yet been widely adopted. A background needs assessment at our institution suggested that lack of familiarity and comfort with chromoendoscopy in our endoscopy ancillary staff had contributed to its low implementation rate. Our baseline data also showed that a majority of endoscopy ancillary staff preferred in-person, small group educational sessions to learn more about chromoendoscopy, as opposed to mandatory online training. We aim to improve the implementation of chromoendoscopy at our institution via in-person, small group education of endoscopy ancillary staff.

METHODS:

Two in-service small group sessions with endoscopy nurses at Rhode Island Hospital (RIH) focusing on chromoendoscopy were held in December 2016 and January 2017. A pre-intervention survey was sent to the staff. Staff were asked whether they had ever heard of/personally participated in chromoendoscopy and how comfortable they were with it. Possible concerns, including safety, time constraint, and cost of procedure, were also evaluated in the pre-intervention assessment. A post-intervention survey, consisting of the same questions, was sent after the two education sessions. The number of chromoendoscopy performed over a 22-month period prior to the sessions and following the sessions were evaluated.

RESULTS:

Prior to the intervention, 31% staff had never heard of chromoendoscopy and 22% reported feeling very uncomfortable with it. Post-intervention, less than 10% reported never having heard of chromoendoscopy or feeling very uncomfortable with it. While less than half of the staff reported they would want a physician to use chromoendoscopy for dysplasia surveillance if they themselves had IBD prior to the educational sessions, more than two-thirds after the sessions reported they would. Three cases of chromoendoscopy were done in the 22 months prior to the sessions, compared to 16 cases in the 22 months following.

CONCLUSION:

In-person, small group education of endoscopy ancillary staff on chromoendoscopy decreased their unfamiliarity and discomfort with assisting physicians in chromoendoscopy procedures. The number of chromoendoscopies done at our institution was also higher post-intervention.
821 Presence of Obstructive Symptoms and Absence of Perianal Crohn’s Disease Is Predictive of Surgery After Endoscopic Balloon Dilation
Authors: Sivasailam Barathi , Manski Scott , Wentz Alicia , Cross Raymond K.
Published: October 2019

INTRODUCTION:

Patients with Crohn’s disease (CD) often develop strictures that require surgery. Endoscopic balloon dilation (EBD) is an alternative treatment which can be safe and effective. The objective of this study was to assess factors associated with need for repeat EBD and surgery after initial EBD for stricturing CD.

METHODS:

Patients with stricturing CD who underwent EBD from 2007-2017 were identified. Demographic and clinical information was obtained from a review of electronic medical records. Outcomes of interest included adverse events, repeat EBD, and surgery. Cox proportional hazards regression model and Kaplan Meier curves were generated for variables associated with repeat EBD and surgical resection.

RESULTS:

99 patients underwent a total of 240 EBD; 63% were women, 75% were Caucasian, and 20% were active smokers. 54% had ileocolonic disease, 35% had a history of perianal disease, and 63% were on a biologic at time of initial EBD. 51% of patients had obstructive symptoms at the time of initial EBD. The stricture location varied but anastomotic (52%) and ileal were most common (17%). 48% of strictures had an inflammatory component. 75% of EBD were successful. Complications occurred in 13 EBD (5%) and included abdominal pain (n = 5), bleeding (n = 3) and perforation (n = 2). 51 patients underwent repeat EBD. Repeat intervention after EBD was more likely in patients on biologics at baseline EBD (76% vs. 54%, P = 0.029). 33% of patients had surgical resection a median of 5 months (IQR 2.0-13.0) after initial EBD. The presence of obstructive symptoms at time of EBD was associated with surgical resection [HR = 3.18, 95% CI 1.28-7.86] (Figure 1). Conversely, a history of perianal disease was negatively associated with surgical resection [HR = 0.27 95% CI 0.10-0.68] (Figure 2).

CONCLUSION:

EBD is an alternative to surgery with good short-term response rates. With experienced gastroenterologists, EBD is safe with perforation rates of < 1%. Patients on biologic treatment at the time of EBD are more likely to need an intervention in the future, either EBD or surgery. One third of patients are referred to surgery after initial EBD; patients with obstructive symptoms at time of initial EBD and those without a history of perianal involvement are more likely to undergo surgical intervention. Gastroenterologists can consider these factors when offering EBD or surgery for treatment of stricturing CD.
834 Early Symptom Improvement With Risankizumab Treatment in Patients With Moderately to Severely Active Crohn’s Disease: Analysis From a Phase 2 Study
Authors: Feagan Brian G. , Sandborn William J. , D'Haens Geert R. , Panés Julian , Kaser Arthur , Ferrante Marc , Louis Edouard , Dewit Olivier , Seidler Ursula , Kim Kyung-Jo , Kligys Kristina , Wallace Kori , Liao Xiaomei , Lee Wan-Ju , Neurath Markus F.
Published: October 2019

INTRODUCTION:

Risankizumab (RZB), an IL-23 p19 inhibitor, has shown safety and efficacy in inducing clinical remission in patients with Crohn’s disease (CD) in a Phase 2 study.1 Here we assessed early symptom improvement during the randomized, double-blind, placebo-controlled induction phase of the trial.

METHODS:

This Phase 2 study enrolled adult patients with moderate-to-severe CD with a Crohn’s Disease Activity Index (CDAI) of 220–450, ulcers in the ileum and/or colon, and a Crohn’s Disease Endoscopic Index of Severity (CDEIS) ≥7 (≥4 for patients with isolated ileitis) assessed by ileocolonoscopy confirmed by a blinded central reader. Patients were randomized 1:1:1 to receive intravenous RZB (200 mg or 600 mg) or placebo at Weeks 0, 4, and 8. Endpoints examined in this post hoc analysis included changes from baseline at Weeks 2, 4, 8, and 12 in CDAI, average daily stool frequency (SF) and average daily abdominal pain score (AP) for all patients with available data, and newly defined clinical remission at Week 12, based on symptom improvement, defined as SF ≤ 2.8 and AP ≤1, both not worse than baseline, in patients with baseline SF ≥ 4 or AP ≥2. Continuous endpoints were analyzed using observed case; non-responder imputation was used for missing data of binary endpoints. Statistical comparisons of median change were based on Wilcoxon rank sum test.

RESULTS:

121 patients were randomized in the induction phase. Baseline characteristics were similar among treatment arms.1 Mean (SD) disease duration at baseline was 13.4 (9.4) years; 94.2% of patients received previous anti-TNF therapy. Significant improvements in CDAI and AP were observed with RZB (600 mg) versus placebo as early as Week 2 and in SF at Week 8 (Table 1). The proportion of patients with clinical remission based on symptom improvement was significantly higher in the 600 mg RZB group versus placebo at Week 12 (23.7% versus 6.1%; P < 0.05), supporting the previously reported superiority of RZB versus placebo for inducing CDAI remission at Week 12 (36.6% of 600 mg RZB versus 15% of placebo; P < 0.05).

CONCLUSION:

RZB induction treatment was associated with significant early improvements in clinical symptoms and disease activity in a highly refractory patient population with moderately to severely active CD.
844 Improvement of Osteoporosis Screening Among IBD Patients at GI Fellows’ Clinics
Authors: Wehbeh Antonios , Phatharacharukul Parkpoom , Fayad Nabil F.
Published: October 2019

INTRODUCTION:

Individuals with IBD have an increased risk of osteoporosis compared to the general population. Gastroenterologists should screen at-risk IBD patients for osteoporosis, since those patients often consider their gastroenterologist to be their primary provider. We aimed to improve the osteoporosis screening rate in the IBD patient population of the GI fellows’ continuity clinics.

METHODS:

Baseline pre-intervention data were collected on patients seen over a 12-week period. Simplified criteria for osteoporosis screening were extrapolated from 3 guidelines (ACG 2017, USPSTF 2018 and NOF 2014) and included: females ≥65 years, males ≥70 years, use of oral corticosteroid therapy for >3 consecutive months in a dose ≥ 7.5 mg/day, and a previous bone fracture in adult life occurring spontaneously or from minor trauma. Among patients who met any of these criteria, we determined the baseline screening rate (proportion of patients who had a bone DEXA scan in the past 2 years). Fellows were then educated with a didactic session and handout material, and a standardized template was incorporated into clinic notes. Following this intervention, screening rates were reassessed over another 12-week period (by charts’ reviews performed after those 12 weeks).

RESULTS:

During the pre-intervention phase, fellows saw 743 patients, 80 of whom had IBD. DEXA scan was obtained in 44% of IBD patients who qualify for screening at the County hospital clinic, compared to only 21% of Veterans’ clinic IBD patients. The most common indications for screening were age criteria and steroid use. In the post-intervention period, 81 patients with IBD were seen. Screening rates (DEXA scans performed within past 2 years, or ordered in clinic during intervention) remarkably improved to 100% in the County hospital clinic and to 75% in the Veterans’ clinic. Overall, the screening rate increased by 56% (Table 1).

CONCLUSION:

A large percentage of IBD patients at risk for osteoporosis did not have appropriate bone mass density testing. Educating GI fellows and adding a template to clinic notes was effective in significantly improving the number of patients at risk of osteoporosis to receive appropriate screening test, a DEXA scan. This potentially could lead to identifying more patients with osteoporosis and referring them early for pharmacotherapy. The rate in the County clinic was higher, possibly because of a higher proportion of female patients compared to the Veterans’ clinic.
854 Comparison of Injection Site Pain With Citrate Free and Original Formulation Adalimumab in Pediatric IBD Patients
Authors: Patel Ashish S. , Luu Phuong
Published: October 2019

INTRODUCTION:

Adalimumab is a fully-humanized anti-tumor necrosis factor antibody FDA approved in 2014 for the treatment of pediatric patients between 6 and 17 years of age with moderately to severely active Crohn's disease. Across all indications, the most commonly reported adverse event was injection site reaction. Citrate free adalimumab was specifically designed to reduce injection pain by removing the citrate acid monohydrate from the formula, using less volume and a smaller needle. The study supporting decreased perception of pain was conducted in adult rheumatological disease patients. The perception of pain in children is very complex and involves psychological, physiological, behavioral and developmental factors. Complications associated with sub-optimally controlled disease is more detrimental for children because the impact on their growth potential. For those patients on dose intensification with adalimumab, the implications of compliance is even more important and the experience with injection site reaction is even more impactful.

METHODS:

Patients with pediatric inflammatory bowel disease were asked to rate their injection site pain comparing the original adalimumab formulation verses the citrate free adalimumab formulation. We collected patient’s specific inflammatory bowel disease type, gender, and age. We evaluated changes in pain between the original formulation verses the citrate free adalimumab using a pediatric visual analog scale (VAS) pain scale.

RESULTS:

The pain score deviated significantly from normal distribution by both Shapiro-Wilk and Kolmogorov Smirnov tests (P < 0.05). Therefore, Wilcoxon Signed Rank test was used to test the difference in pain score between the two types of injection medication. The median pain score was 7.5 in the original formulation injection group and 1 in the citrate free formulation injection group. The median pain reduction was 6 scales when switching from original formulation to citrate free injection. Wilcoxon Signed Rank test showed significant difference in pain score between the two types of the injections (P < 0.0001).

CONCLUSION:

The citrate free adalimumab formulation is associated with statistically significant less injection site pain which provided an overall improved experience for pediatric IBD patients and their families. Alleviating the burden of treatment may improve the quality of adherence for pediatric patients and positively influence treatment outcomes for patients with IBD.
855 Validating the Accuracy of Linked Color Imaging (LCI) in Assessing Mucosal Healing in Ulcerative Colitis Patients Using the Geboes Score
Authors: Ghoz Hassan , Picco Michael , Abader Peter , Krishna Murli , Brahmbhatt Bhaumik , Uchiyama Kazuhiko , Naito Yuji , Takagi Tomohisa , Wallace Michael
Published: October 2019

INTRODUCTION:

Mucosal healing is a widely accepted target for ulcerative colitis (UC) treatment. Linked color imaging (LCI) is a novel endoscopic enhancement system that utilizes Light Emitting Diode (LED) sources to spectrally enhance subtle erythema and mucosal surface patterns which may improve endoscopic classification of IBD associated inflammation. We aimed to assess the accuracy of LCI in classifying UC-associated mucosal healing compared to a validated histological reference standard (Geboes score).

METHODS:

22 patients with ulcerative colitis were prospectively enrolled and evaluated by LCI colonoscopy using the Fujifilm’s digital video Processor VP-7000 and LED light source BL-7000 (Fujifilm, Tokyo Japan). Interobserver agreement was reported as kappa values. Geboes score was reported as score range of 0 to 5.4. A Geboes score of ≥3.1 (presence of surface intraepithelial neutrophils or < 5% crypts) was used to define histologic activity and a score of < 2B (no increase in neutrophils in the lamina propria) was used to define histologic remission. Geboes score has been previously validated to predict clinical recurrence. We calculated the overall accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the LCI classification identifying mucosal healing against the Geboes score using the Fisher’s exact test.

RESULTS:

Total of 62 endoscopic images were obtained for different parts of the colon, 43 of which were matched to a corresponding biopsy. Endoscopic images were scored by 2 endoscopists into LCI-A (no redness), LCI-B (redness with visible vessels) and LCI-C (redness without visible vessels). A final LCI score was given for images with discrepant scores based on a consensus vote from both endoscopists. The interobserver agreement between the two endoscopists was 81%, kappa of 0.71 (95% confidence interval [CI] 0.57- 0.86). Among regions scored ≥3.1 on Geboes score, 9.5%, 28.6% and 61.9 % were classified as LCI-A, LCI-B and LCI-C, respectively (P < 0.0001). Among images scored < 2B on Geboes score, 81.8%, 13.6% and 4.6% were classified as LCI-A, LCI-B and LCI-C, respectively (P < 0.0001). Analyzing data against histology with LCI-A representing mucosal healing and LCI-B and C representing active mucosal disease, the overall accuracy becomes 86%, with NPV of 82.6% and PPV of 90% for identifying UC patients with histological and endoscopic evidence of mucosal healing.

CONCLUSION:

LCI technology has a potential role in assessing mucosal healing in UC.
858 Reversal of Anti-Drug Antibodies Against Tumor Necrosis Factor Inhibitors With Addition of Immunomodulators: A Systematic Review and Meta-Analysis
Authors: Dhindsa Banreet , Mashiana Harmeet , Dhaliwal Amaninder , Shafi Amaan , Sayles Harlan , Ohning Gordon , Young Renee , Hewlett Alexander , Eichele Derrick
Published: October 2019

INTRODUCTION:

The presence of anti-drug antibodies (ADA) to tumor necrosis factor (TNF) inhibitors (infliximab or adalimumab) is one of the reasons for the diminished clinical response in patients with inflammatory bowel disease (IBD). To overcome the loss of response, dose escalation of TNF inhibitors or addition of immunomodulators (methotrexate or thiopurines) is considered before switching to other drugs due to limited therapeutic options. We conducted a systematic review and meta-analysis to assess the overall efficacy of immunomodulators (methotrexate or thiopurines) to reverse the loss of clinical response in IBD patients with TNF inhibitors antibodies.

METHODS:

We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through October 2018) to identify studies that reported the clinical response in patients with IBD on TNF inhibitors after the addition of immunomodulators (methotrexate or thiopurines). Clinical response was defined as improvement of symptoms, with either decrease or complete elimination of ADA against TNF inhibitors. The meta-analysis was performed using Der Simonian and Laird random effect model.

RESULTS:

A total of 4 studies reporting on 72 patients receiving either infliximab (27) or adalimumab (45) were included in our final meta-analysis. 49/72 (68%) patients received either thiopurines (30) or methotrexate (19). Total no of males: females were 32: 40. The mean age and follow up were 37.1 years and 13.5 months respectively. The overall pooled clinical response (Table 1) was 73.86% (95% CI = 47.36-94.38, I2 = 60.77%). Significant heterogeneity was noted in the studies included in our meta-analysis.

CONCLUSION:

In our limited meta-analysis, addition of immunomodulators to TNF inhibitors were shown to restore the clinical response in 74% of the patients by either decreasing or completely eliminating anti-drug antibody levels. Further long term multicenter studies are needed to further validate these findings
872 Clip It and Forget It? A Natural History of 358 Over-the-Scope Clips
Authors: Wang Xiao Jing , Gonzalez Izundegui Daniel , Singh Sneha , Calderon Gerardo , Valencia Oscar Garcia , Storm Andrew C.
Published: October 2019

INTRODUCTION:

Over-the-scope clips (OTSC) are used for closure of fistulas, leaks, and acute perforations, and for GI bleeding. Adverse events include perforation, migration, and ulceration. Little is know about the natural history of OTSCs and no data addressing the longevity of clips is available. We present an interim analysis of our center’s experience with OTSC focusing on natural history.

METHODS:

OTSCs used from 1/1/2011 to 1/1/2019 were compiled and retrospective chart review undertaken. Primary endpoint was clip retention time (time when the clip was placed to time the clip was last seen or was physically removed). Secondary endpoints were rate of complications and factors that influence clip retention time and clinical success. Cox proportional hazards were used to evaluate variables impacting clip retention. Univariate regression was used to assess potential risk factors for adverse events.

RESULTS:

A total of 358 OTSC were placed in 299 patients (55.8% male, n = 184) with mean age 64 + 15.3 years. Procedures and indications presented in Table 1. Clip placement was clinically successful in 81% of cases (N = 265). Median time to clip loss as assessed by Kaplan-Meier curve was 267 days (95% CI 196-406) (Figure 1). Adverse events occurred in 34 clip placements (10.7%) and included bleeding (n = 8, 24.2%), perforation (n = 5, 15.2%), ulceration (n = 3, 9.1%), migration (n = 15, 45.5%), and infection (n = 1, 3.0%). Univariate analysis (Table 2) revealed that age, gender, type of clip used (there are 3 types of OTSC), and performing endoscopist did not impact clip retention rate. A size 14 clip had marginally higher rates of retention compared to others. Clips placed in the rectum or esophagus were lost earlier compared to those in the small/large intestine and stomach. Clips placed for fistulas and those associated with adverse event were associated with earlier clip loss. In evaluation of clinical success, clips placed for fistulas had a relative risk of clinical failure of 2.08 (95% CI 1.29-3.36) compared to all other indications.

CONCLUSION:

OTSCs are retained for a median of 8.9 months with clip location and indication for placement being key factors in time to clip loss. Clips used for fistula closure were more likely to be lost compared to those placed for other indications, less likely to be clinically successful, and more likely to cause a complication. These data help guide decision-making when considering OTSC use across clinical indications.
873 Gastric Findings During Endoscopic Ultrasound (EUS)-Guided Liver Biopsy
Authors: Gulati Rishabh , Sánchez-Luna Sergio A. , Paleti Swathi , Rustagi Tarun
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound (EUS)-guided liver biopsy has recently emerged as an alternative approach to obtain liver biopsy with a low adverse event profile. With the new dedicated 19-gauge EUS core biopsy needle, it is shown that the procedure is safe and provides excellent diagnostic yield with a minimal number of passes. This is of particular importance, given the rise in the metabolic syndrome paralleling the increase in the diagnosis of non-alcoholic fatty liver disease (NAFLD). EUS-guided liver biopsy requires transgastric or transduodenal needle passage to obtain core needle biopsies from left and right lobes of the liver, respectively. However, given the nature of its transmural path, unexpected histopathological results can be seen from gastric tissue acquired during transgastric needle passage. Here we describe incidental and interesting gastric findings obtained during transgastric EUS-guided liver biopsies.

METHODS:

A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-guided liver biopsy from 01/2017 to 11/2018 was performed. Transgastric liver biopsies were obtained using a 19-gauge core biopsy needle with application of 10 ml suction. The syringe piston was locked into this position for continuous suction. The needle was moved to and fro 2-3 times inside the liver parenchyma under complete endosonographic control. All specimens were recovered, fixed in formalin, and processed for histological analysis. Additional non-hepatic tissue findings were analyzed for any clinically relevant histopathologic diagnosis.

RESULTS:

A total of 28 patients (mean age 48 ± 14 years; 57% females) were included. The median number of passes was 2 (range 1-3, mean 2). The mean total sample length was 24.5 ± 8.32 mm. Biopsy specimen was adequate for liver histology in all patients. Six patients had additional unexpected histopathological results from gastric tissue acquired during the transgastric needle passage. Four patients were found to have chronic active gastritis with Helicobacter pylori as a “gastric contaminant” on the liver biopsy specimens. One patient had atrophic gastritis and one patient was noted to have autoimmune gastritis further confirmed on serology. There were no reported complications from the procedures. All patients were then subsequently managed for incidentally noted findings.

CONCLUSION:

This study shows that transgastric EUS-guided liver biopsies can result in incidental bystander gastric diagnoses with clinical importance.
885 Outcomes of ERCP in Patients With Acute Myocardial Infarction: A National Study
Authors: Patel Pavan , Ahlawat Sushil , Patel Kalpesh
Published: October 2019

INTRODUCTION:

There is limited data on the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with recent myocardial infarction. The objective of this study is to better assess safety and outcomes in patients with admission for acute myocardial infarction (MI) that undergo ERCP for a variety of reasons during the same admission in a national inpatient database.

METHODS:

The National Inpatient Sample (NIS) is the largest all-payer inpatient database in the United States. Data from the years 2008 to 2014 were collected. Patients older than 18 years with an admission diagnosis of myocardial infarction and who underwent ERCP were included (n = 259). Case-control matching (3:1) based on age and race were selected (n = 762). Mortality, length of stay, cost of hospitalization, and complications were measured against case controls.

RESULTS:

Between 2008 and 2014, there were 259 patients older than 18 years with acute myocardial infarction who underwent inpatient ERCP. Baseline patient demographics and hospital characteristics is available in Table 1. Complications related to ERCP were infrequent though the rate of post-ERCP bleeding was higher in patients with recent MI compared to controls (4.2% vs. 1.6%; P = 0.012). Rates of cholecystitis, post-ERCP pancreatitis and perforation were not different between groups. There was no significant difference in mortality between patients that had recent MI vs those who did not (4.6% vs. 2.5%, P = 0.083). Length of stay was higher in patients with recent MI (median 9 days vs. 5 days, P < 0.001). Cost of hospitalization was also significantly higher in the MI group ($22,197.86 vs. $25,937, P < 0.001). The primary indication for ERCP in patients with acute MI was choledocholithiasis while that in the control group was cholangitis. Furthermore, the time to ERCP (emergent, urgent or delayed) did not significantly affect the risk of mortality and post-ERCP hemorrhage.

CONCLUSION:

Patients with acute MI that undergo ERCP during the same admission have a higher risk of post-ERCP hemorrhage with longer LOS and cost of hospitalization. However, the mortality and other ERCP-related complications are not significantly different when compared to patients undergoing ERCP without recent MI. Therefore, in general it would be considered safe to perform ERCP in patients with recent MI with precautions to monitor or prevent post-ERCP bleeding.
886 Underwater Endoscopic Mucosal Resection May Only Be Superior to Conventional Endoscopic Mucosal Resection for the Treatment of Colorectal Polyps 4 CM or Larger
Authors: Douglas Scott R. , Stratton Leland , Buerlein Ross C. , Patrie James , Shami Vanessa M. , Sauer Bryan , Yoshida Cynthia , Copland Andrew , Scheiman James , Uppal Dushant , Strand Daniel , Wang Andrew Y.
Published: October 2019

INTRODUCTION:

Underwater endoscopic mucosal resection (UEMR) is an alternative to conventional submucosal-lift EMR (CEMR) for removal of large non-pedunculated colorectal polyps. Retrospective studies have suggested that UEMR may be more effective at reducing lesion recurrence than CEMR, when performed by experts in this technique. The aim of this study was to compare the generalized safety and effectiveness of UEMR to CEMR for removal of large colorectal polyps when performed by expert endoscopists at a tertiary referral center.

METHODS:

Patients who had UEMR or CEMR performed by one of 7 experienced endoscopists (>50 large polyp resections/year) at a single university-based health system between 3/2015 and 7/2018 were included. Each of the 7 endoscopists regularly performed CEMR but adopted UEMR before or during this study. Patients were identified retrospectively using CPT codes and data was collected from our electronic medical record.

RESULTS:

186 patients who underwent 142 UEMR and 98 CEMR procedures were included (Table 1). Mean size of polyps removed was 30.7 mm (range: 15-120 mm) for UEMR and 25.3 mm (range: 15- 50 mm) for CEMR (P = 0.001). There were a significantly greater number of tubulovillous adenomas in the UEMR group (22% vs. 37%, P = 0.02). For polyps ≥4 cm, the residual polyp rate on the first follow-up colonoscopy was 26% for UEMR and 60% for CEMR (OR 4.2, P = 0.05), as confirmed by biopsies. However, there was no statistically significant difference between UEMR vs. CEMR for lesion recurrence for polyps < 4 cm in size. For all polyp sizes, there was no difference in rates of complete macroscopic resection, en bloc resection, number of colonoscopies to reach clearance, and need for adjunctive resection techniques (i.e., argon plasma coagulation, hot biopsy avulsion) between the groups (Table 2). There were no instances of perforation. No significant differences in rates of intra-procedural or delayed procedural bleeding were found between groups (Table 3).

CONCLUSION:

When generalized across multiple endoscopists at a university-based health system, there was no observed benefit of UEMR compared to CEMR for colorectal polyps under 4 cm in size. However, for lesions 4 cm and greater, UEMR was superior in terms of reduced rates of residual lesion at the first follow-up colonoscopy. Prospective trials are required to further delineate the comparative impact of UEMR vs. CEMR with respect to rates of residual neoplasia.
904 EUS-Guided Treatment of Gastric Varices: A Systematic Review and Meta-Analysis With Indirect Comparison to Endoscopic Therapy
Authors: Mohan Babu P. , Chandan Saurabh , Khan Shahab R. , Dosala Sushanth , Trakroo Sushruth , Ponnada Suresh , Asokkumar Ravishankar , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Gastric variceal (GV) bleeding carries a significant mortality in the setting of portal hypertension. Emergency band ligation and/ or transjugular intrahepatic portosystemic shunt is the current recommended treatment. Other treatment options include direct endoscopic (END) glue injection and endoscopic ultrasound (EUS) guided glue and/ or coil injection. The role of EUS in the treatment of GV is not established and remains an active area of investigation. The aim of this study was to describe the performance of EUS in the treatment of GV.

METHODS:

We conducted a comprehensive search of several databases (inception to Dec 2018) to identify studies that evaluated END-glue and EUS in the treatment of GV. Our goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, early re-bleeding, late re-bleeding and adverse events with EUS guided therapy in GV. The pooled outcomes of END-glue was used as a comparator group.

RESULTS:

Total of 35 studies (2777 patients) were included. Mean age range was between 40 and 65 years, with 68% males. N-butyl-2-cyanoacrylate was the most commonly used glue. Use of lipiodol varied among the studies. 28% had GOV1, 48% had GOV2, and 24% had IGV1 (Sarin classification of GV). 63% of the patients had cirrhosis. 30% were due to alcohol and 31% due to viral hepatitis. 11% of the included patients had concomitant hepatocellular carcinoma. GV obliteration with EUS-guided therapy was 84.7% (95% CI 66.8-93.8, I2 = 84.2), and with END-glue was 57.1% (38.2-74.1, I2 = 94.3), P = 0.03. GV recurrence with EUS was 6.1% (95% CI 2.6-13.7, I2 = 51.4, and with END-glue was 22.6% (13.8-34.9, I2 = 77.1), P = 0.006. Late re-bleeding with EUS was 10.6% (95% CI 6.3-17.3, I2 = 45.7), and with END-glue was 20% (14.7-26.6, I2 = 89.30), P = 0.03. The pooled rates of immediate treatment efficacy and early re-bleeding were comparable. On subgroup analysis, EUS-coil/glue combination showed superior outcomes when compared to END-glue (Table 1). The pooled rate of overall adverse events with EUS-glue was 16.5% (9.7-26.9). The rates of adverse event subtypes, and how it compared to END-glue is given in Table 2.

CONCLUSION:

Based on our meta-analysis, EUS-guided therapies seems to demonstrate benefit in terms of GV obliteration, GV recurrence and late GV re-bleeding. They were significantly superior when indirectly compared to END therapy. The immediate treatment efficacy and early re-bleeding rates were comparable. EUS-coil/glue, in particular, seems to be the best modality.
905 Endoscopic Ultrasound vs. Endoscopic Trans-Papillary vs. Percutaneous Gallbladder Drainage in High-Risk Acute Cholecystitis Patients: A Systematic Review and Indirect Comparative Meta-Analysis
Authors: Mohan Babu P. , Khan Shahab R. , Trakroo Sushrut , Chandan Saurabh , Ponnada Suresh , Jayaraj Mahendran , Asokkumar Ravishankar , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound guided gallbladder drainage (EUSGBD) are alternative to percutaneous gallbladder drainage (PCGBD) in the management of acute cholecystitis in patients deemed unfit for surgery. The role of endoscopy in the treatment algorithm has not been confirmed due to limited data and conflicting results.

METHODS:

We searched multiple databases from inception through May2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients high-risk for surgery. Our goals were to indirectly compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence with ETGBD, EUSGBD, and PCGBD by meta-analysis methods.

RESULTS:

15131 patients from 72 studies were analyzed. 22 studies (1223 patients), 14 studies (557 patients), and 46 studies (13351 patients) were treated by ETGBD, EUSGBD, and PCGBD respectively. The pooled technical and clinical successes of EUSGBD were statistically superior to ETGBD [95.3% (95%CI 92.8-96.9, I2 = 0) vs 83% (95%CI 80.1-85.5, I2 = 29), P = 0.001] and [96.7% (95% CI 94-98.2, I2 = 0) vs 88.1% (95%CI 83.6-91.4, I2 = 50), P = 0.001], respectively. Pooled clinical success with EUSGBD was statistically superior to PCGBD [89.3% (95%CI 86.6-91.5, I2 = 84), P = 0.001]. The pooled rate of disease recurrence was comparable between ETGBD and EUSGBD, but more with PCGBD (10.8%, 95%CI 8.4-13.9, P = 0.001). The pooled rate of all adverse events were comparable between the groups (Table 1). Bleeding and perforation was statistically more with EUSGBD [4.3% (95%CI 2.7-6.8), P = 0.03; 3.7% (95%CI 2.3-6), P = 0.004; respectively], pancreatitis was statistically more with ETGBD [5.1% (95%CI 3.5-7.3, P = 0.003], and stent-migration was more with PCGBD 7.4% (95%CI 5.5-10, P = 0.01) (Table 2). All cause mortality was 9.8% (7.7-12.4) with PCGBD and was statistically significant when compared to EUSGBD (3.8%, 2-7, P = 0.006).

CONCLUSION:

This is the largest and most comprehensive meta-analysis indirectly comparing ETGBD, EUSGBD and PCGBD in the treatment of acute cholecystitis in surgically unfit patients. Based on our analysis, EUSGBD demonstrates superior clinical success when compared to ETGBD and/ or PCGBD, albeit with increased risk to perforation and bleeding. Given the low heterogeneity and the strength of the data, EUSGBD should be considered the first line approach in this patient population.
906 To Cut or Not to Cut – Clinical Efficacy of Endoscopic Sphincterotomy in Recurrent Acute Pancreatitis From Functional Biliary Sphincter of Oddi Disorder: A Systematic Review and Meta-Analysis
Authors: Chandan Saurabh , Mohan Babu P. , Mashiana Harmeet , Dhindsa Banreet , Braseth Annie , Sayles Harlan , Jha Lokesh , Singh Shailender , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Functional biliary Sphincter of Oddi disorder, previously referred to as Sphincter of Oddi Dysfunction, is an established cause of recurrent acute pancreatitis which is defined as two or more episodes of documented acute pancreatitis per year. Data on the efficacy of endoscopic sphincterotomy in preventing future episodes of pancreatitis is limited. We performed a systematic review and meta-analysis to evaluate the clinical efficacy of index endoscopic sphincterotomy in patients with Recurrent Acute Pancreatitis secondary to manometrically proven functional biliary Sphincter of Oddi disorder. Our goal was to assess reduction in episodes of pancreatitis following sphincterotomy, and not to assess chronic pain in these patients.

METHODS:

We conducted a search of several databases including PubMed, EMBASE, Google-Scholar, Scopus and Cochrane Review (from 1960 to October 2018). Random-effects model was used for analysis. Heterogeneity between study-specific estimates was calculated using Cochran Q statistical test, 95% confidence interval (CI) and I2 statistics. Publication bias was ascertained, qualitatively, by visual inspection of funnel plot and quantitatively, by the Egger test.

RESULTS:

Our initial search yielded 3201 results. Of 1936 studies screened, 12 met inclusion criteria. A total of 396 patients with recurrent acute pancreatitis and abnormal manometry findings were included from these studies in the final analysis. The interventions performed were as follows: Endoscopic biliary sphincterotomy in 212 (53.5%), endoscopic pancreatic sphincterotomy in 19 (4.8%) and dual biliary and pancreatic sphincterotomy in 165 (41.6%) patients. Technical success ranged from 99 to 100%.The pooled estimate for clinical success following index sphincterotomy was 68.4% (95% CI 57.6-77.4; I2 = 71.4%). Lone endoscopic biliary sphincterotomy was successful in 43/60 (71.6%) patients. The pooled estimate for proportion of patients with post-ERCP pancreatitis was 23.2% (95% CI 16.6-31.4; I2 = 44.4%). The follow up duration ranged from 6 to 120 months. There was no evidence of publication bias, based on funnel plot analysis and Egger’s test.

CONCLUSION:

Our study highlights the utility and clinical efficacy of endoscopic sphincterotomy in patients with recurrent acute pancreatitis secondary to Functional biliary Sphincter of Oddi disorder. We conclude that 68.4% of patients improved after endoscopic sphincterotomy and that it can be considered in patients with recurrent acute pancreatitis.
910 Comparison of Safety and Efficacy Between Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in the Treatment of Superficial Esophageal Cancers - A Meta-Analysis Update
Authors: Rajabalan Ajai , Suresh Kumar Vishnu Charan , Patthipati Venkata Suresh , Mani Vishnu
Published: October 2019

INTRODUCTION:

From radical esophagectomy, we have advanced towards endoscopic procedures for the treatment of esophageal cancers without lymph node involvement, superficial esophageal cancers (SEC). Endoscopic mucosal resection (EMR) is a widely accepted treatment modality for SEC due to its minimal invasive nature, low cost and excellent patient tolerance but has limitations. Endoscopic submucosal dissection (ESD) was developed to overcome these limitations. However, ESD has several disadvantages owing to longer procedural times and higher complication rates. The use of ESD is still being debated in the United States. We did a systematic review and meta-analysis to compare the efficacy and safety of EMR and ESD for the treatment of superficial esophageal cancers.

METHODS:

Literature search was done from electronic databases including PubMed, Cochrane, and Embase from inception until November 2018. Data from 9 relevant studies were extracted and meta-analysis with Random effects model was done using RevMan 5.3.

RESULTS:

There were 692 lesions in the EMR group and 468 lesions in the ESD group. Patient characteristics were available for only 3 out of 9 studies which showed a mean age of 65.66 years [Male-86.3%, Female-13.7%] in the EMR group and a mean age of 65.66 years [Male-83%, Female-17%] in the ESD group. Our primary outcomes were En-bloc resection rate (EBR) and curative resection rate (CRR) which were analyzed in all 9 studies. Bleeding and perforation rates were our secondary outcomes. EBR was achieved in 319 out of 692 lesions by EMR and 455 out of 468 lesions by ESD [OR 50.93, 95%CI (23.29, 111.37), P < 0.00001, I2 = 23%], favoring ESD over EMR. The CRR was significantly better with ESD when compared to EMR [OR 10.96, 95%CI (3.78, 31.74), P < 0.0001, I2 = 72%]. There was no significant difference in the occurrence of bleeding [OR 1.48, 95%CI (0.37, 5.87), P = 0.58, I2 = 0%] but the rate of perforation was higher with ESD [OR 0.40, 95%CI (0.18, 0.91), P = 0.03, I2 = 6%]

CONCLUSION:

Our Study shows that the EBR and CRR are better achieved with ESD than EMR. Although there was no significant difference in bleeding, the risk of perforation was higher in ESD. ESD is a complex time consuming procedure that requires great technical expertise and is performer dependent. With careful selection of patients and advanced endoscopic skills, ESD might give better overall outcomes than EMR. Non-randomization and usage of data from heterogeneous practice settings are the limitations of our study data.
912 Comparison of Diagnostic Yield of Cytology versus Histology on Samples Obtained During Endoscopic Ultrasound-Guided Fine-Needle Biopsy (EUS-FNB)
Authors: Plafsky Liza , Diaz Liege , Satiya Jinendra , Girotra Mohit
Published: October 2019

INTRODUCTION:

The advent of endoscopic ultrasound (EUS) has vastly improved access to several gastrointestinal lesions, thereby leading to increased diagnostic capability. Moreover, improved core tissue sampling is now possible with fine needle biopsy (EUS-FNB) needle, as opposed to aspiration (FNA) alone. However, the practice of sample handling is highly individualized due to lack of standardization as to whether core sample should be sent only in histology (in formalin), or cytology (in cytolyte) or both. This study was abstracted to compare the diagnostic yield of cytology versus histology on core tissue obtained from the same lesion, using the same EUS-FNB needle.

METHODS:

Single endoscopist at a large tertiary referral center conceptualized a prospective EUS database between October 2017 and February 2019, where a 22-gauge FNB needle was used to obtain core tissue samples, which were sent for cytology and histology. After IRB approval, retrospective analysis of this database was performed. Patient’s demographics, medical history, imaging, indication for EUS, EUS findings, and cytology/histology results were analyzed.

RESULTS:

Out of 226 therapeutic EUS' performed by single endoscopist during study period, 103 samples were collected using 22-gauge FNB needle [solid masses (62), lymph nodes (18) & solid-cystic lesions (23)]. 28 samples were sent for cytology, 29 for histology, and 46 for both (passes equally divided). Out of these 46 samples, 42 were consistent between cytology and histology, but 4 were discordant; in all 4 cases, histology provided the conclusive information. In 3 cases, histology provided the diagnosis of cancer while cytology was reported negative. In the fourth case, cytology was inconclusive while histology was definitely negative for carcinoma. These samples were obtained from 2 pancreatic masses, one gastric subepithelial lesion, and one lymph node, and pathology showed pancreatic adenocarcinoma, GIST, and persistent follicular lymphoma, respectively. 22-gauge needles were used for all these procedures, and no complications were noted.

CONCLUSION:

Our study demonstrates 8% inconsistency between cytology and histology on core samples obtained using EUS-FNB. In all discordant cases, histology provided more accurate information than cytology. Larger, multi-centric and prospective studies are needed to ascertain the best practice to make the diagnostic process more efficient, accurate, and cost-effective.
920 Efficacy and Safety of EUS-Guided Gastroenterostomy for Gastric Outlet Obstruction: A Systematic Review and Meta-Analysis
Authors: Khan Ali T. , Zhang Xiaocen , Herman Michael , Lung Edward
Published: October 2019

INTRODUCTION:

For symptomatic gastric outlet obstruction (GOO), enteral stents or surgical gastroenterostomy (GE) are treatment options that are limited by short term efficacy or high procedural complication rates. With the advent of lumen apposing metal stents (LAMS) it is possible to use a minimally invasive EUS guided approach to create a gastro-enteric fistula. We conducted a systematic review and meta-analysis to evaluate and compare the efficacy and safety of EUS-guided gastroenterostomy for GOO.

METHODS:

MEDLINE, EMBASE, and SCOPUS were utilized to search for eligible studies that reported on technical success, clinical success and adverse events of this procedure from 2012-2019. Technical success was defined as the ability to create a GE with a LAMS and clinical success was defined as the ability to tolerate an oral diet. Patients with benign and malignant GOO were included. All studies were retrospective and the quality of eligible studies was assessed by the NHBLI tool. A sub-analysis was done to analyze the direct and balloon assisted techniques and procedural times. Figure 1 depicts the flow chart used for study screening.

RESULTS:

A total of 5 studies (n = 147 patients) were included in the analysis. The mean age of patients undergoing EUS guided GE was 64 years with 50% females. Most common etiology for GOO was malignancy with 77% of cases. Pooled technical success was 96% (95% CI 0.91-0.99) although 5 cases initially involved LAMS misdeployment requiring repositioning. Clinical success was 80% (95% CI 0.58-0.96) and a total of 6 adverse events (2% 95% CI 0.00 – 0.08) occurred including intra-procedural bleeding, peritonitis and perforation requiring surgery. Figures 2a–c highlights the technical success, clinical success and adverse events of EUS guided GE. On procedural sub-analysis, a total of 74 cases were done with the direct GE technique while 27 cases underwent balloon-assisted GE. Stent misdeployments occurred in 6.7% of cases of the direct technique and 9.1% of balloon assisted cases. Procedural time was comparatively lower with the direct technique averaging 35.6 mins compared to 84 mins for the balloon assisted technique.

CONCLUSION:

EUS guided gastroenterostomy is an efficacious and safe procedure for patients with gastric outlet obstruction. Although the direct GE technique appears to require less procedural time, more studies need to be done to assess the optimal procedural technique.