bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.