bluuebunny/crossref_metadata_2025_split huggingface dataset:
903 Clinical Efficacy of Gastric Per-Oral Endoscopic Myotomy in the Treatment of Refractory Gastroparesis and Predictors of Successful Outcomes: A Systematic Review and Meta-Analysis
Authors: Chandan Saurabh , Mohan Babu P. , Jha Lokesh K. , Khan Shahab R. , Kotagiri Rajesh , Kassab Lena , Ravikumar Naveen , Bhogal Neil , Chandan Ojasvini Choudhry , Bhat Ishfaq , Hewlett Alexander , Ponnada Suresh , Asokkumar Ravishankar , Adler Douglas G. 
Published: October 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCLUSION:
There were no differences in the technical success, clinical success and rate of adverse events of EUS-GE and ES for the treatment of GOO. Recurrence of symptoms and need for re-intervention trended higher in ES group compared to EUS-GE. Large prospective comparative trials are needed to evaluate the safety and efficacy of EUS-GE and ES.