bluuebunny/crossref_metadata_2025 huggingface dataset:
A33 MEALTIME SUPPORT: A PILOT COHORT STUDY OF AN EFFECTIVE, COST-SAVING OUTPATIENT HUNGER-BASED FEEDING PROGRAM FOR TUBE DEPENDENCY
Authors: Huynh G , Vishram A , Graham-Parker C , Blatz D , Carroll M W , Turner J
Published: March 2021

Background

Tube dependency is an under recognized complication of long-term enteral feeding in young children. Many children struggle to progress to full oral feeds even with sufficient oral motor skills and swallowing ability. Tube dependency greatly impacts the quality of life of children and families and is a significant burden to the health care system. Economic challenges, increased burden of care and psychosocial issues all reinforce the need for timely tube removal.

Aims

We aimed to examine the efficacy of a multidisciplinary child-led, hunger-based approach called “Mealtime Support” at the Stollery Children’s Hospital in Edmonton. Nutritional outcomes, parental satisfaction and cost implications were evaluated. As a secondary aim we sought to determine the rates of gastrostomy tube insertions in the pediatric age range across Canada as a potential indicator of increasing need for long term tube feeding, hence the need for cost effective tube weaning programs to be developed in Canada.

Methods

The ambulatory program was delivered 2–3 times a day, for 2 weeks, by an occupational therapist and dietitian, under medical supervision. Hunger was promoted by reducing tube fed calories by 80% prior to commencement. Top-up tube feeds were given immediately after feeding sessions if needed. Caregivers completed 12-question subjective surveys pre and post intervention. Micro-costing methods compared costs between the program and ongoing tube feeding. The number of pediatric hospital admissions and gastrostomy tube insertions from 2008–2019, per province, was collected from the Canadian Institute for Health Information (CIHI).

Results

From 2016 - 2017, 6 children who had been tube fed from 7 to 21 months in total were enrolled and 5 completed the program. At 1-month post intervention, 4/5 of the children were 100% orally fed. Parents reported improvement in mealtime struggles (p-value = 0.005), reduction in worry about their child’s eating (p-value = 0.005) and improvement in their child’s appetite/variety foods eaten (p-value = 0.004). Over a year the potential cost savings were estimated at $42,471.24. By 6-months, all feeding tubes were removed. Based on the CIHI data, the number of gastrostomy tubes inserted per 100,000 children varied significantly between provinces, but highest in Nova Scotia, Saskatchewan and Alberta with increases seen from 2008–2018.

Conclusions

The transition from tube feeding to oral feeding is difficult for children who are tube dependent and poses several economic and psychosocial challenges. Mealtime Support was safe and successful in reducing tube dependency and cost-effective compared to no intervention or hospital based programs. There is a need to develop and fund Canadian outpatient feeding programs.

Funding Agencies

The Stollery Children’s Foundation
A39 CULTURE-ENRICHED METAGENOMICS REVEALED MICROBIAL ENGRAFTMENT FOLLOWING FMT IN PATIENTS WITH ULCERATIVE COLITIS
Authors: Shekarriz S , Whelan F , Lau J , Libertucci J , Moayyedi P , Surette M
Published: March 2021

NOT PUBLISHED AT AUTHOR’S REQUEST

Funding Agencies: CIHRImagine SPOR
A46 LOSS OF BMP-SIGNALING IN MESENCHYMAL TELOCYTES TRIGGERS MODIFICATION OF THE GLYCOSYLATION PROFILE OF COLONIC MUCINS.
Authors: Reyes-Nicolas V , Pomerleau V , Gómez D Pupo , Cofino G Marrero , Menendez A , Perreault N
Published: March 2021

NOT PUBLISHED AT AUTHOR’S REQUEST

Funding Agencies: CIHR
A54 THE CIRCADIAN CLOCK INFLUENCES JAK/STAT SIGNALING AND GUT PERMEABILITY
Authors: Parasram K , Bachetti D , Karpowicz P
Published: March 2021

Background

The circadian clock is a 24-hour feedback loop that drives rhythms in behaviours and physiological processes. This molecular timekeeper consists of the transcription factors, Clock-Cycle, that drive expression of thousands of clock-controlled genes, with two of these, Period and Timeless, acting as negative regulators of Clock-Cycle. This fundamental mechanism was initially characterized in the fruit fly, Drosophila melanogaster (Nobel Prize in Physiology & Medicine, 2017), and is highly conserved in humans. The intestine, or midgut, of Drosophila, is also similar to the human small intestine consisting of similar cellular lineage, signaling pathways, and physiological functions. The lineage of the Drosophila intestine contains the same four cell types as humans: intestinal stem cells (ISCs), progenitors called enteroblasts, enterocytes and enteroendocrine cells. This simplified lineage as well as the genetic tools available, make Drosophila an ideal model for intestinal regeneration in health and disease. We have previously shown that the circadian clock is active in ISCs, EBs and ECs during both homeostatic and regenerating conditions. Furthermore, the circadian clock regulates the mitosis of ISCs under regenerating conditions.

Aims

We sought to uncover if Jak/STAT signaling, one of the key pathways involved in ISC proliferation in the Drosophila intestine, shows a circadian rhythm and if there is a time-of-day difference in the regenerative response.

Methods

To test whether the clock regulates Jak/STAT during acute injury, we developed an irradiation assay that does not affect survival but acutely disrupts intestinal barrier function.

Results

Using a dynamic reporter of Jak/STAT activity we show that Period circadian clock mutants have low Jak/STAT signaling and a leaky gut phenotype. Wildtype controls show time-dependent gut leakiness upon irradiation, which is higher and time-independent in Period mutants. The level of Jak/STAT response differs depending on the time of irradiation in the controls, but is higher at all times in the mutants.

Conclusions

The Jak/Stat pathway regulates intestinal immunity and epithelial cell proliferation in humans, thus playing a role in colorectal cancer and inflammatory bowel disease. Our results suggest Jak/Stat is controlled by the circadian clock, which has implications for intestinal recovery following medical treatments, including radiation therapy.

Funding Agencies

NRC
A56 CLINICAL AND BIOCHEMICAL EFFICACY ARE NOT AFFECTED BY SWITCH FROM INFLIXIMAB ORIGINATOR TO RENFLEXIS IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS.
Authors: Rosborough K , Yu G , Barker C , Jacobson K , Lawrence S
Published: March 2021

Background

Increased infliximab (IFX) utilization has generated higher drug expenditures and cost burden to the healthcare system. The expiration of the IFX originator Remicade patent led to the addition of biosimilar agents to the drug market that may reduce drug expenditures. In British Columbia, Pharmacare’s 2019 biosimilar initiative mandated all pediatric inflammatory bowel disease (IBD) patients on Remicade to switch to the biosimilar Renflexis. To date, there is limited pediatric IBD data demonstrating that switching from IFX originator to IFX biosimilar CT-P13 is safe and effective, and no data on switching to Renflexis.

Aims

To determine the proportion of patients remaining on Renflexis 6 months after switch from originator IFX. The secondary aims are to determine the proportion of patients remaining in clinical and biochemical remission after switch.

Methods

In this prospective, longitudinal observation single-center study, all children with Crohn’s disease and ulcerative colitis receiving maintenance IFX originator therapy were switched to Renflexis by May 15th 2020. Baseline demographics, concomitant therapy, clinical disease indices (wPCDAI, PUCAI), growth data, blood work, fecal calprotectin and IFX drug levels were collected at baseline and prospectively from 6 months after the switch. All data are presented as median and interquartile range.

Results

A total of 139 children (110 CD, 25 UC and 4 IBDU; Median age 16.2 (3.7) years) with a median IFX originator duration of 42.7 (35.1) months before switching to Renflexis were included. 137/139 (99%) of patients remained on Renflexis at study end. The proportion of children in clinical remission from baseline to 6 months post switch was unchanged (133/139 (95.7%) vs. 130/132 (98.5%), p=0.17). There was no significant change pre and post switch in median CRP (<5 (0) mg/L vs <5 (0) mg/L, p=0.26) or fecal calprotectin (72.5 (144.2) ug/g vs. 65.5 (140.0) ug/g, p=0.87). There was no significant change pre and post switch in the proportion of patients with normal CRP (<5 mg/L) (89/103 (86.4%) vs 89/98 (90.8%), p=0.33) or normal fecal calprotectin (<250 ug/g)(91/112 (81.2%) vs 51/63 (80.9%), p=0.60). There was no significant change pre and post switch in IFX trough level (15.5 (12.3) ug/mL vs 17.5 (12.9) ug/mL, p=0.42). 2 patients had antibodies to IFX after switching. Safety profile is improved with adverse events in 38/139 (27.3%) children on IFX originator vs. 11/139 (7.91%) children on Renflexis for 6 months.

Conclusions

Pediatric IBD patients can be successfully switched from IFX originator to biosimilar Renflexis during maintenance without affecting efficacy, immunogenicity or safety in the short term.

Funding Agencies

None
A59 SEVERE CHEMOTHERAPY-INDUCED SECRETORY DIARRHEA
Authors: Emmerick M , Eindor A , Jacobson K , Schreiber R
Published: March 2021

Background

Diarrhea is one of the most common side effects of chemotherapy, estimated to occur in up to 40% of all patients undergoing cancer therapy. Non-complicated chemotherapy-induced diarrhea (CID) can be managed with loperamide, whereas complicated CID should be treated with continuous infusion of octreotide. Octreotide is usually effective within 48hs of administration. Options for patients that do not respond to loperamide or octreotide include atropine, oral budesonide and cholestyramine.

Aims

To describe the case of an 18 yo girl with acute myeloid leukemia (AML) who developed severe secretory diarrhea during her treatment course.

Methods

Retrospective case report.

Results

The patient was initially treated with Cytarabine, Daunorubicin and Etoposide, and on her third cycle, Gemtuzumab was added. Four weeks later she presented with watery diarrhea up to 6 L/day. She continued with high output despite no oral intake, which was consistent with secretory diarrhea. Infectious workup was negative, and she received Loperamide. Her output decreased to 1 L for 2 days but then increased again to 6 L. She deteriorated and loperamide was switched to octreotide 0.8mcg/Kg/h. The dose was increased to 1.2mcg/Kg/h and she presented blood in the stools. Her stool output was still 4 L/day and octreotide was stopped after one week. Flex sigmoidoscopy showed proctocolitis with friability. Biopsy showed architectural distortion with loss of the superficial epithelium. She was emotionally distressed due to many days of no oral intake, hence Pediasure peptide was introduced, with no changes in the output. Rice was introduced but her diarrhea worsened, and oral intake was stopped again. Four weeks after the onset of diarrhea, her stool output was still above 2 L/day, and cholestyramine 4g once daily was started. Four days later her output decreased and diet was slowly introduced. Two weeks later she had a normal stool output. Cholestyramine was stopped and she was discharged home.

Finding the culprit for this case is a challenge, but important to avoid this drug in the future as prior history of CID is a risk factor for a new-onset. Gemtuzumab is a relatively new anti-CD33 antibody used in AML, and results from a meta-analysis showed that adding it to induction chemotherapy may increase the incidence of diarrhea. Her diarrhea started four weeks after the dose of Gemtuzumab, and we believe this new agent might have played an important role in her case. To our knowledge, there are no cases in the literature associating Gemtzumab with such prolonged and severe diarrhea.

Conclusions

This was a challenging case of CID that did not respond to Loperamide or octreotide and caused a lot of emotional distress for the patient and her providers. Since she responded well to cholestyramine, we recommend its use when the loperamide and octreotide have failed, or in addition to octreotide in severe cases.

Funding Agencies

None
A64 REVIEW OF PATIENTS REFERRED TO THE DIVISION OF DIGESTIVE CARE AND ENDOSCOPY AT DALHOUSIE UNIVERSITY FOR COLORECTAL CANCER SCREENING BASED ON A FAMILY HISTORY OF COLORECTAL CANCER: HOW MANY UNDERWENT COLONOSCOPY?
Authors: Miles M
Published: March 2021

Background

Nova Scotia has provincial colorectal cancer (CRC) screening for asymptomatic, average risk individuals age 50–74 using fecal immunochemical testing (FIT) every 2 years. However, individuals with 1 or more first degree relatives (FDR) diagnosed with CRC by age 60 have a 2–4 fold increased risk for developing CRC. For these high risk individuals, current guidelines recommend CRC screening with colonoscopy rather than FIT testing. Annually, the Division of Digestive Care & Endoscopy (DCE) at Dalhousie University receives many referrals for patients with a family history of CRC but the percentage of patients who require this procedure is unclear.

Aims

The objectives of this quality assessment study were to review patients referred to DCE for a family history of CRC to (1) better understand the indication for referral; and (2) determine the percentage of patients undergoing colonoscopy

Methods

This was a retrospective cross sectional review of a prospectively updated database. The study population was patients referred to DCE from 2012–2019 based on a family history of CRC, as indicated on the referral. Family history of CRC was defined as 1 or more FDRs diagnosed with CRC. High risk patients were those with 2 or more FDRs with CRC or 1 FDR diagnosed by age 60. All patients were reviewed by a single gastroenterologist in clinic.

Results

A total of 107 referrals from 2012–2019 were reviewed. Of patients age 50 or older, 51/78 (65.4%) had performed at least 1 FIT. The indications for referral were 2 or more FDR diagnosed with CRC for 6/107 (5.6%) patients, 1 FDR diagnosed with CRC by age 60 for 37/107 patients (34.6%) and 1 FDR diagnosed with CRC over age 60 for 33/107 patients (30.8%). The remaining 31/107 patients (29.0%) had no FDR with CRC. Of the 43/107 patients (40.2%) considered high risk based on family history alone, 34/43 (79.1%) underwent colonoscopy and 8/43 (18.6%) opted for FIT testing. Of the 64/107 patients (59.8%) considered average risk based on family history alone, 26/64 (40.6%) had another indication for colonoscopy and 35/64 (54.7%) resumed FIT testing.

Conclusions

The majority of patients (71.0%) referred to the DCE for a family history of CRC had at least 1 FDR with CRC. Just over half of patients (55.1%) referred to the DCE for a family history of CRC underwent colonoscopy. Strategies to improve the referral process by better capturing high risk individuals are needed.

Funding Agencies

None
A71 RECOMMENDATION REVERSALS IN GASTROENTEROLOGY CLINICAL PRACTICE GUIDELINES
Authors: Gholami R , Gimpaya N , Khan R , Scaffidi M A , Bansal R , Ramkissoon A , Alabdulqader A , Grover S C
Published: March 2021

Background

Clinical practice guidelines are evidence-based resources designed to inform clinical decision making. Often, superior evidence will support the inclusion of novel procedures and practices to replace older recommendations. Recommendation reversals occur when (a) superior quality evidence emerges to suggest the harm or non-beneficence of prior recommendations, and (b) that recommendation is not supplanted by a newer one.

Aims

The primary objective of this study was to describe the content, frequency and rationale for recommendation reversals in CPGs published by gastroenterological societies.

Methods

For this meta-epidemiologic study, we considered two criteria to define a recommendation reversal: (a) the more recent CPG makes a recommendation that contradicts a previously accepted practice; and (b) the prior recommendation is not replaced by any novel intervention. We searched CPGs published by 20 major GI societies from 1991- 2019. Guidelines were included if had at least two iterations with the same title and used a valid evidence rating system (such as GRADE). Explicit recommendations which reported definite levels of evidence and strength of recommendation were extracted.

Results

We identified 1022 clinical guidelines from GI societies over 28 years. 292 CPGs were included for data synthesis. 5985 explicit statements were extracted. 12 reversals were confirmed and are summarized in the Table. Six reversals (50.0%) occurred due to studies reporting non-beneficence and 3 (25.0%) occrred due to studies reporting harm. Three recommendations (25.0%) were reversed due to new clinical trials; 3 (25.0%) due to systematic reviews or meta-analyses; and 2 to conform with CPGs of other societies (16.7%).

Conclusions

We describe recommendation reversals made in gastroenterology CPGs, and the reasons thereof. Investigation of recommendation reversals allows for the identification of low-value medical practices. This reinforces the need for GI CPG committees to (1) iteratively review guidelines to re-evaluate recommendations made on low-quality evidence and; (2) refrain from making recommendations when evidence for the same is weak.

Funding Agencies

None
A73 PERFORMANCE OF ASGE AND ESGE CRITERIA FOR RISK STRATIFICATION FOR CHOLEDOCHOLITHIASIS IN A REAL-WORLD SETTING
Authors: Lei Y , Wishart E , Mohamed R , Forbes N
Published: March 2021

Background

Choledocholithiasis (CDL) is a common clinical entity and can lead to serious complications, such as pancreatitis or ascending cholangitis. Endoscopic retrograde cholangio-pancreatography (ERCP) is generally the first-line procedure for definitive management of CDL. ERCP has well-established adverse events. Given the risks, patients can be stratified by likelihood of finding CDL on ERCP, thus potentially avoiding an unnecessary procedure in low probability patients. There are three commonly used criteria for this – the American Society for Gastrointestinal Endoscopy (ASGE) 2010 criteria, the ASGE 2019 criteria, and the European Society of Gastrointestinal Endoscopy (ESGE) 2019 criteria. These criteria use a mixture of biliary imaging, clinical condition, and liver biochemistry to stratify patients into low, intermediate, and high probability for CDL.

Aims

To test the performance characteristics of the ASGE 2010, ASGE 2019, and ESGE 2019 criteria for probability of CDL on a real-world sample.

Methods

We identified all adult patients who had ERCP done at our local centre for suspected CDL between 2012/01/01 and 2018/10/07. A sample of 1000 cases were chosen. We obtained the patients’ pre-procedural liver biochemistries, pre-procedural imaging in the preceding 6 months, and their ERCP reports. We used a semi-automated algorithm to determine confirmation of CDL. We inferred clinical gallstone pancreatitis using the surrogate of serum lipase at or greater than three times upper limit of normal. We could not capture clinical ascending cholangitis from the collected data. We stratified each patient according to the three guidelines and calculated their performance characteristics.

Results

After manually reviewing visits with incomplete ERCP or repeat ERCP, we analyzed 879 ERCP visits. There were 622 with stone or sludge found on ERCP. The performance characteristics of the high-probability and intermediate-probability criteria of the three guidelines are listed in the table below.

Conclusions

Our results for the 2010 ASGE guidelines high probability patients are in keeping with previous validation studies. There have been only one validation study each of the 2019 ASGE guidelines and the 2019 ESGE guidelines, and our results are different in sensitivity and negative predictive value. Future directions in refining these risk stratification tools are needed, and our project in ongoing in assessing the additional value of trends in liver biochemistry.

Funding Agencies

None
A82 A SURVEY OF TRAINING PATHWAYS AND PRACTICE TRENDS OF ENDOSCOPIC SUBMUCOSAL DISSECTION IN CANADA
Authors: Li S , Mosko J , May G , Teshima C
Published: March 2021

Background

Endoscopic submucosal dissection (ESD) has become the established standard for endoscopic removal of large gastrointestinal (GI) lesions and early GI malignancies, with improved outcomes compared to traditional endoscopic techniques and offers an alternative to surgery. However, ESD is technically challenging and requires significant healthcare infrastructure. As such, its adoption in Canada was slow relative to Asia and Europe. Thus far, the practice of ESD has been limited to a small number of tertiary centers. Currently, the availability and practice of ESD across Canada remains unclear.

Aims

To provide a descriptive overview of the training pathways and practice trends of endoscopists performing ESD in Canada.

Methods

ESD practitioners across Canada were identified from internal networks and by contacting respective endoscopy units. All endoscopists currently accepting ESD referrals were invited to participate in a cross-sectional survey that was distributed via SurveyMonkey.

Results

27 ESD practitioners were identified; current survey response rate was 44% although is expected to increase. Median years of independent ESD practice was 5 (IQR 2.75). All practitioners underwent international ESD training of some type. 92% attended short-term training courses. 50% pursued international ESD fellowship training. 92% received training on animal models. 58% and 33% performed hands-on human upper and lower GI ESD respectively prior to independent practice. In practice, 67% of practitioners noted an increase in number of ESD procedures performed per year from 2015 to 2019. 67% rated the awareness of appropriate ESD indications by referring physicians to be “not so aware” or lower. 75% of practitioners report a patient wait time for ESD of 1–3 months. 67% and 75% rated the difficulty of securing endoscopy time and anesthesia support for ESD respectively to be “difficult” or “very difficult”. 75% were “dissatisfied” or “very dissatisfied” with their institution’s healthcare infrastructure to support ESD. 25% perceived their institution as supportive in expanding the practice of ESD.

Conclusions

A number of challenges exist for the adoption of ESD in Canada. Training pathways are highly variable, with no set standards and most practitioners pursue international training. In practice, the majority of practitioners express dissatisfaction with their access to necessary infrastructure for performing ESD and feel poorly supported by their centers in expanding its practice. As ESD is becoming the accepted standard in allowing for the minimally invasive treatment of indicated GI lesions; greater collaboration between practitioners, institutions, and healthcare systems is crucial to standardize ESD training and to ensure improved patient access.

Funding Agencies

None
A108 ARE INPATIENTS STILL MORE LIKELY TO FAIL BOWEL PREPARATION IN THE SPLIT-DOSE ERA? FINDINGS FROM 47, 292 COLONOSCOPIES IN THE SOUTHWEST ONTARIO COLONOSCOPY COHORT
Authors: Sey M , Wong A , McDonald C , Liu E Y , Yan B
Published: March 2021

Background

Prior studies before the widespread use of split-dose bowel preparation have shown a high rate of inadequate bowel preparation in hospitalized patients. Whether this is still true in the era of split-dose bowel preparation is unknown.

Aims

To determine the impact of inpatient status on bowel preparation quality in the contemporary era of split-dose bowel preparation.

Methods

The Southwest Ontario Colonoscopy cohort consists of all inpatient and outpatient colonoscopies performed between April 2017 and Oct 2018 at 21 hospitals serving a large geographic health region. Procedures done in patients < 18 years of age or by an endoscopist performing <50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed. The primary outcome was adequate bowel preparation, defined on an ordinal scale as “good” or “fair” rather than “poor”. Secondary outcomes included adenoma detection rate (ADR), sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), and cecal intubation rate (CIR).

Results

A total of 47,292 colonoscopies were performed by 75 physicians (36.2% by gastroenterologists, 60% by general surgeons, 4% others), of which 1,690 were inpatients (3.6%). Inpatients were older (mean 66.8 years vs 60.2 years, p<0.0001), more co-morbid (≥ASA grade 3, 53.6% vs 23.7%, p<0.0001), performed for symptomatic indications (95.7% vs 48.6%, p< 0.0001), have trainee involvement (47% vs 11.6% p<0.001), and less likely to receive split-dose bowel preparation (71.7% vs 91.6% p<0.001). On crude analysis, inpatients were less likely to have adequate bowel preparation (86.2% vs 97.6% p<0.001). On multi-variable analysis, inpatients had lower odds of achieving adequate bowel preparation (OR=0.41, 95% CI 0.33 - 0.50, p<0.001), lower ADR (OR=0.47, 95% CI 0.40 - 0.55, p<0.001), lower PDR (OR=0.54, 95% CI 0.47 - 0.61 p<0.001) and lower CIR (OR = 0.43, 95% CI 0.35 - 0.54, p<0.001).

Conclusions

In the era of split-dose bowel preparation, inpatient status is still an important predictor of inadequate bowel preparation with resultant lower quality outcome metrics.

Funding Agencies

None
A109 LINKING PRIMARY AND SPECIALTY CARE FOR THE MANAGEMENT OF DIGESTIVE HEALTH CONDITIONS: AN EVALUATION OF GUT LINK IMPLEMENTATION
Authors: Stewart M J , Heisler C , Kohansal A R , Patel S , Williams G , Williams S , Miles M , Zhu J , Kulai T , Peltekian K , Gruchy S E , Epstein I , Farina D , Jones J
Published: March 2021

Background

Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions.

Aims

To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service.

Methods

This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%).

Results

A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%).

To date, 21 PHCP agreed to be contacted for the post-consultation survey and 10 have been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI.

Conclusions

The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways.

Funding Agencies

CAG
A117 PROPOFOL SEDATION DOES NOT IMPROVE MEASURES OF COLONOSCOPY QUALITY – FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT
Authors: Sey M , Yan B , Hindi Z , Brahmania M , Gregor J C , Jairath V , Wilson A , Khanna N , McDonald C , cocco S , Chakraborti D , French K , ALasseger M , Siddiqi O , Blier M , makandey b , Al-obaid S , wong A , Siebring V , Brackstone M , Teriaky A , Vinden C , Guizzetti L
Published: March 2021

Background

The use of propofol during colonoscopy has gained increased popularity due to deeper anesthesia compared to conscious sedation. Prior studies examining the use of propofol sedation during colonoscopy have primarily focused on anesthesia outcomes. Whether propofol sedation is associated with improvements in colonoscopy outcomes is uncertain.

Aims

The primary outcome was adenoma detection rate (ADR). Secondary outcomes were the detection of any adenoma (conventional adenoma, sessile serrated polyp, and traditional serrated adenoma), sessile serrated polyp detection rate, polyp detection rate, cecal intubation rate, and perforation rate.

Methods

The Southwest Ontario Colonoscopy cohort consists of all patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 hospitals serving a large geographic area in Southwest Ontario. Procedures performed in patients less than 18 years of age or by endoscopist who perform <50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed.

Results

A total of 46,634 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others) of which 16,408 (35.2%) received propofol and 30,226 (64.8%) received conscious sedation (e.g. combination of a benzodiazepine and a narcotic). Patients who received propofol were likely to have a screening indication (49.2% vs 45.5%, p<0.0001), not have a trainee endoscopist present and be performed at a non-academic centre (32.2% vs 44.6%, p<0.0001). Compared to conscious sedation, use of propofol was associated with a lower ADR (24.6% vs. 27.0%, p<0.0001) and detection of any adenoma (27.7% vs. 29.8%, p<0.0001); no difference was observed in the detection ofsessile serrated polyps (5.0% vs. 4.7%, p=0.26), polyp detection rate (41.2% vs 41.2%, p=0.978), cecal intubation rate (97.1% vs. 96.8%, p=0.15) or perforation rate (0.04% vs. 0.06%,p=0.45). On multi-variable analysis, the use of propofol was not significantly associated with any improvement in ADR (RR=0.90, 95% CI 0.74–1.10, p=0.30), detection of any adenoma (RR=0.93, 95% CI 0.75–1.14, p=0.47), sessile serrated polyp detection rate (RR=1.20, 95%CI 0.90–1.60, p=0.22), polyp detection rate (RR=1.00, 95% CI 0.90–1.11, p=0.99), or cecal intubation rate (RR=1.00, 95%CI 0.80–1.26, p=0.99).

Conclusions

The use of propofol sedation does not improve colonoscopy quality metrics.

Funding Agencies

None
A125 SNARE TIP SPRAY COAGULATION FOR NON-CONTACT HEMOSTASIS: A SINGLE OPERATOR RETROSPECTIVE STUDY OF CLINICAL OUTCOMES.
Authors: Fetz A , Gan S
Published: March 2021

Background

An emerging non-contact endoscopic method for hemostasis is the use of spray coagulation (SC) using a polypectomy snare tip. Other non-contact options, such as argon plasma coagulation (APC), can be inconvenient and costly. Our current practice includes using SC where APC would be traditionally indicated.

Aims

The aim of this study was to characterize the clinical outcomes, including rates of successful hemostasis, rebleeding, and complications, for snare tip SC in hemostasis.

Methods

We conducted a retrospective chart review of all patients who underwent therapeutic endoscopy for hemostasis using snare tip SC by a single operator at a large Canadian tertiary care centre between January 2018 and September 2020.

Results

14 patients, including 10 males and 4 females, were included. 5 (35%) patients received SC during an EGD, 5 (35%) patients during a colonoscopy, and 4 (29%) patients during a small bowel enteroscopy. Mean age was 74.4 (±11). All patients were referred for work-up of gastrointestinal bleeding or anemia. 5 (35%) patients were treated for vascular lesions including AVMs or angioectasias, 4 (29%) patients for GAVE, 3 (21%) patients for radiation proctitis, and 2 (14%) patients for bleeding ulcers. Adequate hemostasis, defined by cessation of bleeding symptoms, lack of a 10g/L or more decrease in hemoglobin post-procedure, and no further endoscopic therapies in the subsequent 28 days, was achieved in 11 patients (79%). 2 of the 3 patients in which adequate hemostasis was not achieved had additional investigations in which a second source of bleeding was found and treated. 1 patient with colonic AVMs and 1 patient with radiation proctitis required a repeat treatment in 2 weeks and 6 months, respectively. There were no incidence of prolonged abdominal pain, perforations or deaths.

Conclusions

Snare tip spray coagulation appears to be a safe and effective modality for non-contact hemostasis. Larger studies will help solidify its use in daily practice.

Funding Agencies

None
A131 POINT OF CARE ULTRASOUND CHANGES THE NEEDLE INSERTION LOCATION FROM AN ANATOMICALLY LANDMARKED SITE DURING BEDSIDE PARACENTESIS.
Authors: Rodrigues D , Kundra A , Hookey L , Montague S
Published: March 2021

Background

Paracentesis is a bedside procedure to obtain ascitic fluid from the peritoneum. It is traditionally performed using anatomic landmarking and percussion to ascertain a safe drainage site. The serious complication rate has been reported as less than 2%. Point-of-care ultrasound (POCUS) has been adopted into education and clinical use and has been shown to improve the safety of certain procedures such as central line insertion and thoracentesis. However, the evidence supporting its use is limited.

Aims

We aimed to assess if POCUS would yield a user-preferred site for needle insertion compared to conventional landmarking, defined as a >5cm change in location.

Methods

Adult patients under the care of gastroenterology or general internal medicine at Kingston Health Sciences Centre undergoing paracentesis were consecutively enrolled between January and September of 2020. Physicians performing the procedure were enrolled based on availability. An anatomic site was selected 4cm superiorly and 2-4cm medially to the anterior superior ileac spine and confirmed with dullness to percussion. POCUS was then employed to determine if there was an alternative user-preferred site. Patient and operator demographic data and procedure-related information were collected.

Results

A total of 30 individual patients and 24 operators were enrolled, comprising 45 unique procedure combinations. Operators were primarily in their PGY 1 and 2 years of training (33% and 31% respectively). Per procedure, patients mean age was 61, and most of the ascites was due to cirrhosis (84%) predominantly due to EtOH (47%) and NAFLD (34%). As per indication, 29% of procedures were for diagnostic purposes alone. In total, users primarily preferred the POCUS site which resulted in a change in needle insertion site >5cm from the anatomic site in 69% of cases. The average depth of fluid was greater at the POCUS site vs. the anatomic site (5.4cm+/-2.8 vs 3.0cm+/-2.5, p<0.005). On average, POCUS deflected the needle insertion site superiorly and laterally to the anatomic site. Operators listed that per procedure the POCUS site was chosen to avoid adjacent organs (38%), optimize fluid pocket (61%) and due to abdominal wall issues (primarily issues with pannus; 11.5%). Importantly 6 cases were aborted due to a lack of an appropriate fluid pocket, despite clinical and/or prior radiographic evidence of ascites.

Conclusions

Overall, POCUS changes the needle insertion site from the conventional anatomic site for most procedures, due to user-perceived safety concerns. POCUS also prevented an attempt at paracentesis in 6 cases that were deemed unsafe. Therefore, POCUS plays an important role in bedside paracentesis. This research supports the use of POCUS in paracentesis and argues for continued training with POCUS throughout medical school and residency.

Funding Agencies

None
A135 ASSESSING THE HISTOLOGICAL QUALITY OF ENDOSCOPIC BIOPSY SAMPLES OBTAINED USING NOVEL MULTIBITE FORCEPS FROM A PORCINE GASTRIC SPECIMEN
Authors: Anvari H , Rai M , Hussey A , Hurlbut D , Grin A , Hookey L
Published: March 2021

Background

Tissue sampling is often limited to acquisition of one to two biopsy samples during a single pass. The ability to obtain more than two biopsies during a single pass can improve diagnostic yield however is potentially limited by poor specimen quality and loss of specimens. The multibite forceps used in this study have a unique geometry with the ability to store up to six biopsy samples taken consecutively with easy removal of the samples when shaken in solution. If multiple biopsies can be taken during a single pass with preserved specimen quality then we can reduce procedure time, improve efficiency and sensitivity of biopsies.

Aims

To evaluate the histological quality of the first biopsy sample compared to the last (sixth) biopsy sample acquired consecutively with the multibite forcep during a single act.

Methods

A porcine stomach was coloured with surgical dye to create six separate segments. An experienced endoscopist used single use disposable MultiCROC multi-sampling biopsy forceps to acquire six consecutive biopsies. Biopsies were manually separated into the order of which they were acquired (biopsy one through six) and each sample was placed in formalin solution. A total of 35 sets of 6 biopsies were obtained producing a total of 210 samples. Samples were randomized and two independent pathologists who were blinded to the biopsy order assessed the histological quality of specimens. Specimens were evaluated for presence of full thickness mucosa, absence of fragmentation, crush artifact and diagnostic utility. Each pathologist then scored each specimen and the mean scores were used to compare the histological quality of the first biopsy vs. the sixth biopsy for each set.

Results

Our preliminary results include 12 of the 35 sets of biopsies. Using a paired sample t test, there was no significant difference between the mean score given to biopsy one and biopsy six for all twelve pairs [3.62 (SD 1.46) vs. 3.67 (SD 1.15), correlation factor=0.498 and p=.10). There was no significant difference between the first and sixth biopsy when comparing the presence of full thickness mucosa [0.59 (SD 0.49) vs. 0.59 (SD 0.44), p=.086], absence of fragmentation [0.50 (SD 0.50) vs. 0.73 (SD 0.34), p=0.06], absence of crush artifact [0.96 (SD 0.15) vs. 0.91 (SD 0.30), p=0.77), and specimen size [1.64 (SD 0.92) vs. 1.70 (SD 0.65), p=0.56).

Conclusions

No significant differences were found between the histological quality of the first biopsy and the sixth biopsy. Additional parameters such as specimen size, full thickness mucosa, absence of fragmentation and absence of crush artifact revealed no significant differences between the first and sixth biopsy. This preliminary data thus far shows that there is no difference between the histological quality when multiple biopsies are retrieved consecutively.

Funding Agencies

NoneNone
A137 LAPAROSCOPIC ENDOSCOPIC COOPERATIVE SURGERY FOR GASTROINTESTINAL STROMAL TUMOURS: EARLY EXPERIENCE IN A CANADIAN ACADEMIC CENTRE
Authors: Low D J , Fecso A , Chesney T , Mosko J
Published: March 2021

Background

Surgical resection with laparoscopic gastric wedge resection is commonly conducted for local management of gastrointestinal stromal tumours (GIST). However, resection margins are often difficult to appreciate for lesions with larger endophytic components. As a result, tumour margins may be compromised or excess tissue resected. Laparoscopic endoscopic cooperative surgery (LECS) was developed in Japan to overcome these technical challenges in the resection of subepithelial lesions, including GISTs. Here, we present a case report of an early Canadian experience utilizing LECS in the management of gastric GIST.

Aims

To describe a case report of an early Canadian experience of LECS for the resection of a gastric GIST.

Methods

We performed a review of the literature and describe a case of LECS.

Results

We present a 70-year-old female referred to our centre for endoscopic resection of a 2.5x2.5cm histologically confirmed gastric GIST (low mitotic index and no known metastases). Repeat endoscopic evaluation at our centre confirmed a 25-30mm subepithelial lesion with both exophytic (small) and endophytic (large) components. After tumour board review, we opted for a LECS approach. In the OR, the lesion was identified endoscopically and marked with a Dual J-Knife (Olympus). The margins were injected with a combination of Voluven, methylene blue, and dilute epinephrine. A circumferential incision was then completed using standard ESD technique. The lesion was subsequently identified laparoscopically, with endoscopic guidance, along the lesser curvature. The lesser omentum was mobilized for clear visualization of the serosa around the lesion. A full thickness incision was made endoscopically along the distal aspect of lesion. Full thickness resection was continued endoscopically for one third of the circumference of the lesion until gastric insufflation became compromised. Full thickness resection was completed laparoscopically under endoscopic guidance with grossly negative margins. The defect was closed with running laparoscopic sutures. Endoscopic leak test was performed which was negative. The specimen was retrieved and follow up pathology demonstrated a GIST with low mitotic index and negative margins without tumour rupture.

Conclusions

In a review of the literature, LECS appears to minimize tissue resection while maintaining R0 resection rates. This technique is especially useful for subepithelial lesions with larger endophytic and transmural components. It has an excellent safety profile with a less than 5% anastomotic leak rate. As such, the literature supports LECS as a suitable procedure for gastric subepithelial lesions <50 mm. However, further studies are needed to compare it systematically to conventional laparoscopic wedge resection in addition to other innovative endoscopic techniques such as STER and EFTR.

Funding Agencies

None
A141 SPONTANEOUS ESOPHAGEAL PERFORATION: AN UNREPORTED COMPLICATION OF LYMPHOCYTIC ESOPHAGITIS
Authors: LAGROTTERIA A , Collins A W , Someili A , Narula N
Published: March 2021

Background

Lymphocytic esophagitis is a new and rare clinicopathological entity. It is a histological pattern characterized by lymphocytic infiltrate without granulocytes. Its etiology and clinical significance remains unclear. The clinical manifestations are typically mild, with reflux and dysphagia the most commonly reported symptoms.

Aims

We describe a case report of spontaneous esophageal perforation associated with lymphocytic esophagitis.

Methods

Case report

Results

A previously well 31-year-old male presented to the emergency department with acute food impaction. His antecedent symptoms were acute chest discomfort and continuous odynophagia following his most recent meal, with persistent globus sensation. The patient had no reported history of allergies, atopy, rhinitis, or asthma. A previous history of non-progressive dysphagia was noted after resuscitation. Emergent endoscopy revealed no food bolus, but a deep 6 cm mucosal tear in the upper-mid esophagus extending 24 to 30 cm from the incisors. Chest computed tomography observed small volume pneumoperitoneum consistent with esophageal perforation. The patient’s recovery was uneventful; he was managed conservatively with broad-spectrum antibiotics, proton pump inhibitor therapy, and a soft-textured diet. Endoscopy was repeated 48 hours later and revealed considerable healing with only a residual 3-4cm linear laceration. Histology of biopsies taken from the mid and distal esophagus demonstrated marked infiltration of intraepithelial lymphocytes. There were no eosinophils or neutrophils identified, consistent with a diagnosis of lymphocytic esophagitis.

Autoimmune indices including anti-nuclear antibodies and immunoglobulins were normal, ruling out a contributory autoimmune or connective tissue process. The patient was maintained on a proton pump inhibitor (pantoprazole 40 mg once daily) following discharge.

Nearly six months following his presentation, the patient had a recurrence of symptoms prompting representation to the emergency department. He described acute onset chest discomfort while eating turkey. Computed tomography of the chest redemonstrated circumferential intramural gas in the distal esophagus and proximal stomach.

Conclusions

Esophageal perforation is a potentially life-threatening manifestation of what had been considered and described as a relatively benign condition. From isolated dysphagia to transmural perforation, this case significantly expands our current understanding of the clinical spectrum of lymphocytic esophagitis.

Funding Agencies

None