bluuebunny/crossref_metadata_2025_split huggingface dataset:
879 Post-ERCP Pancreatitis in Solid Organ Transplant Recipients
Authors: Elangovan Abbinaya , Sandhu Dalbir S. , Kochhar Gursimran S. 
Published: October 2019

INTRODUCTION:
Post-ERCP pancreatitis (PEP) is the most common post-procedure complication of ERCP with an incidence of 3.5-15%. The prevalence of PEP and the role of immunosuppression in PEP among solid organ transplant (SOT) recipients is not well established. We aimed to study the prevalence of PEP and the effect of immunosuppressants in SOT recipients.

METHODS:
A retrospective analysis of 55 million individuals was performed using a cloud-based database, IBM Explorys. Explorys aggregates de-identified electronic health record data from 26 health care systems across the US and rounds to the closest 10 for statistical de-identification. PEP was defined as the elevation of lipase level > 500 U/L along with SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) diagnosis code of acute pancreatitis within 72 hours of ERCP procedure. The prevalence of PEP and the all-cause 30-day re-admission rate after an episode of PEP were calculated for SOT recipients (lung/kidney/heart/liver). Characteristics were compared using univariate chi-square test between SOT and non-transplant patients as well as liver transplant (LT) recipients and non-transplant patients. P < 0.05 was determined as statistically significant.

RESULTS:
There was no significant difference in the prevalence of PEP (8.03% vs 8.4%, P = 0.676) and re-admission rate (22.2% vs 20.3%, P = 0.645) between SOT recipients and non-transplant patients. Subgroup analysis of liver transplant (LT) recipients revealed a significantly lower rates of PEP (5.66% vs 8.4%, P = 0.002). Compared to the general population, transplant recipients were less likely to be women [Odds ratio OR 0.567, 95% confidence interval CI (0.375 – 0.866), P = 0.008] (Table 1). Among the transplant recipients, individuals with PEP were more likely to be under 50 years [OR 3.179, CI (1.980 - 5.102), P < 0.001]. PEP rates were lower with SOT recipients on steroids [OR 0.240 CI (0.113 - 0.509), P < 0.001] and calcineurin inhibitors [OR 0.078 CI (0.0317 - 0.194), P < 0.001] (Table 2).

CONCLUSION:
In this population-based study, the prevalence of PEP was not elevated in SOT recipients. Steroids and calcineurin inhibitors were associated with a protective effect against PEP. To our knowledge, this is the largest cohort to report on PEP in SOT recipients. Since population level database limits access to patients’ charts, studies with details on anatomical and peri-operative risk factors of PEP will further enhance our understanding in this specific subset of population.
882 EUS-Guided Gastroenterostomy (GE) versus Surgical Gastroenterostomy for Patients With Malignant Gastric Outlet Obstruction: A Systematic Review and Meta-Analysis
Authors: Jayaraj Mahendran , Singh Dhruv P. , Gopalakrishnan Ravikumar Naveen Prasad , Narala Sai , Krishnamoorthi Rajesh 
Published: October 2019

INTRODUCTION:
Surgical gastroenterostomy has been the traditional approach to manage malignant gastric outlet obstruction (GOO). With advances in Endoscopic Ultrasound (EUS) technology and availability of dedicated devices and stents for EUS scopes, EUS guided gastroenterostomy (GE) is emerging as an alternative to surgical gastroenterostomy. Recently studies have been published comparing the outcomes between these two approaches. We performed a systematic review and meta-analysis of studies that compare the outcomes between the two approaches (EUS-GE vs Surgical GE).

METHODS:
We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GE vs surgical GE in management of malignant gastric outlet obstruction. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GE and surgical GE groups were calculated.

RESULTS:
Three comparative studies with a total of 171 patients; were included in the analysis. The pooled OR for technical success of EUS-GE in comparison to surgical GE was 0.16 (95% CI: 0.03-0.86; P = 0.033; I2 = 2%). The pooled OR for clinical success (EUS-GE vs surgical GE) was 0.98 (95% CI: 0.13-7.48; P = 0.984; I2 = 25%) The pooled OR for overall adverse events (EUS-GE vs surgical GE) was 0.35 (95% CI: 0.15-0.81; P = 0.014, I2 = 0%). There was minimal heterogeneity in the analysis.

CONCLUSION:
While EUS-GE is associated with similar rates of clinical success compared to surgical GE, the rate of overall adverse events is statistically lower. Hence in centers with expertise in EUS, EUS-GE could be considered as an effective alternate option.
883 EUS-Guided Gallbladder Drainage versus Endoscopic Trans-Papillary Gallbladder Drainage for High Risk Surgical Patients With Acute Cholecystitis: A Systematic Review and Meta-Analysis
Authors: Jayaraj Mahendran , Sandeep Vivek , Singh Dhruv , Law Joanna , Larsen Michael , Ross Andrew , Kozarek Richard , Irani Shyan , Krishnamoorthi Rajesh 
Published: October 2019

INTRODUCTION:
In patients with acute cholecystitis who were deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for decompression of the gallbladder. There are several limitations associated with PC. Endoscopic gallbladder drainage [Endoscopic trans-papillary gallbladder drainage (ET-GBD) via ERCP and EUS-guided gallbladder drainage (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the outcomes between the two endoscopic techniques (EUS-GBD vs ET-GBD).

METHODS:
We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in management of acute cholecystitis in high risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated.

RESULTS:
Five comparative studies with a total of 861 patients; were included in the analysis. The pooled OR for technical success of EUS-GBD in comparison to ET-GBD was 5.22 (95% CI: 2.03-13.44; P = 0.01; I2 = 20%). The pooled OR for clinical success (EUS-GBD vs ET-GBD) in intention-to-treat analysis was 4.16 (95% CI: 2.00-8.66; P = 0.001; I2 = 19%) and per-protocol analysis was 1.81 (95% CI: 0.80-4.09; P = 0.15; I2 =0%). The pooled OR for overall acute adverse events (EUS-GBD vs ET-GBD) was 1.32 (95% CI: 0.78 -2.25; P = 0.31, I2 = 0%). The pooled OR for perforation and pancreatitis (EUS-GBD vs ETGBD) were 1.98 (95% CI: 0.32-12.29) and 0.19 (95% CI: 0.03-0.99) respectively. The pooled OR for recurrent cholecystitis (EUS-GBD vs ETGBD) was 0.33 (95% CI: 0.13-0.82). There was minimal heterogeneity in the analysis.

CONCLUSION:
EUS-GBD is associated with higher rate of technical and clinical success compared to ET-GBD. While the rate of overall acute adverse events are statistically similar between the two techniques, EUS-GBD is associated with lower rate of recurrent cholecystitis. In centers with expertise in EUS, EUS-GBD could be considered as first-line treatment in carefully selected patients.
884 Endoscopic Intervention of Pancreatic Acute Necrotic Collections: A Retrospective Review
Authors: Oblizajek Nicholas , Agayeva Sevda , Takahashi Naoki , Topazian Mark D. 
Published: October 2019

INTRODUCTION:
Early endoscopic intervention of pancreatitis with acute necrotic collection is conflicting with standard practice except in extenuating circumstances. The Atlanta criteria define necrotic collections based on the age from onset of disease as either acute necrotic collections (ANC ≤ 4 weeks) or walled-off necrosis (WON > 4 weeks). Some patients with ANCs will have clinically apparent infection of necrosis potentially necessitating infectious source control via endoscopic intervention where percutaneous drainage is technically challenging or inadequate. At present, data regarding early endoscopic intervention for acute necrotic collections is lacking.

METHODS:
A retrospective review of patients undergoing endoscopic intervention for pancreatic necrosis between 2008 and 2018 was performed. Included patients had definitive pancreatic/peri-pancreatic necrosis on contrast-enhanced computed tomography, signs/symptoms and laboratory evidence of pancreatitis in relation to hospital presentation, and endoscopic intervention within 28 days of symptom onset. Patients with prior percutaneous or surgical intervention were excluded. ANC cases were matched and compared to WON controls for analyzed parameters via conditional logistic regression.

RESULTS:
Twenty four patients were identified to have attempted drainage within 28 days of symptom onset, three of which were excluded (imaging limitations, spontaneous drainage/fistulization, unclear date of symptom onset). Demographic and clinical characteristic data are summarized in Table 1, with procedure and outcome characteristics shown in Table 2 for the 21 ANC cases in comparison to WON controls. Overall, ANC cases had slightly larger collections, with statistically significantly longer hospital stays as compared to matched WON controls (P < 0.01); otherwise measured variables were not statistically significant between the groups.

CONCLUSION:
There is a paucity of data regarding the safety and efficacy of intervention of ANCs complication pancreatitis. We found in this study that there was reasonable success in clinically indicated endoscopic drainage of ANCs without significant sequelae from the procedures undertaken as compared to matched WON controls. This study demonstrates the safety of intervening on ANCs as early as 15 days if clinically indicated. Further research in regards to efficacy/safety of intervention and prognostic indicators of early intervention is required to further discern whether this applies to general practice of ANC management.
887 Clinical Efficacy of Endoscopic Vacuum-Assisted Closure Therapy (EVAC) in Gastroesophageal Defects: A Systematic Review and Comparative Meta-Analysis With Endoscopic Stent Therapy (EST)
Authors: Chandan Saurabh , Mohan Babu P. , Khan Shahab R. , Malik Sarah , Bhogal Neil , Chandan Ojasvini Choudhry , Adler Douglas G. 
Published: October 2019

INTRODUCTION:
Treatment of gastroesophageal leaks and perforations after upper gastrointestinal surgery remains clinically challenging. Advanced endoscopic interventions have traditionally included placement of self-expanding metal or plastic stents i.e. endoscopic stent therapy (EST) and endoscopic vacuum-assisted closure therapy (EVAC). The aim of our study was to evaluate the overall clinical efficacy of EVAC when compared to EST in the treatment of gastroesophageal defects.

METHODS:
Our primary goals were to analyze the pooled rates of clinical success and overall mortality with EVAC therapy in gastroesophageal defects. Using EST as a comparator group, we analyzed clinical outcomes and predictors of clinical success.

RESULTS:
6 cohort studies compared EVAC (109 patients) to EST (197 patients). These included 313 cases of esophageal anastomotic leaks. The pooled odds ratio of clinical success with EVAC was 2.9 (95% CI 1.4-5.8, P = 0.003, I2 = 13) when compared to EST in the treatment of esophageal leaks secondary to surgical anastomosis. The pooled odds ratio of mortality was 0.43 (95% CI 0.19-0.95, P = 0.04, I2 = 0). When all studies that evaluated EVAC alone were analyzed (14 studies - 89 perforations and 136 anastomotic leaks), the pooled rate of clinical success was 87.5% (95% CI 81.6-91.7, I2 = 0, P = 0.001). For studies evaluating EST (12 studies, 349 patients), the pooled rate of clinical success was 75.4% (95% CI 75.6-84.1, P = 0.001, I2 = 30). EVAC performed significantly better than EST (P = 0.004). The pooled mortality rate with EVAC was 9.1% (95% CI 4.5-17.5, P = 0.01, I2 = 0) and with EST was 17.2% (95% CI 11.2-20.2, P = 0.001, I2 = 38). Based on univariate meta-regression analysis, anastomotic leaks demonstrated statistical significance as a predictive factor of clinical success with EVAC (2-sided P-value 0.05, R2 analog = 1), whereas perforation almost reached statistical significance (2-sided P-value 0.06, R2 analog = 0). On multivariate meta-regression, neither of the etiologies showed statistical significance as a possible predictor of clinical success. We performed meta-regression analysis on mortality data and found no significant predictive effect of etiology in EVAC and EST groups, except for anastomotic leaks that almost reached statistical significance as a predictor of mortality with EST (2-sided P-value 0.06, R2 analog = 1).

CONCLUSION:
EST performed favorably when compared to EST in the treatment of gastroesophageal defects with higher clinical success and lesser mortality.
893 Endoscopic Ultrasound-Guided Sampling of Solid Pancreatic Lesions: A Comparative Analysis of 25 vs. 22 Gauge Core Biopsy Needles
Authors: Siddique Daanish , Trevino Karen , Rahal Mahmoud A. , Wu Howard , Al-Haddad Mohammad 
Published: October 2019

INTRODUCTION:
Endoscopic ultrasound guided fine needle biopsy (EUS-FNB) is increasingly replacing fine needle aspiration (FNA) for sampling of solid pancreatic lesions. In FNA, 25G needles appear to outperform 22G needles in sampling pancreatic lesions, but data comparing 22G and 25G FNB platforms is lacking. We aimed to prospectively assess the performance of 22G and 25G Franseen tip core biopsy needles in the sampling of solid pancreatic lesions.

METHODS:
Consecutive patients were enrolled between 2017 and 2018 and underwent EUS-FNB sampling of solid pancreatic lesions at Indiana University Hospital using 2 needle sizes: 25G (Study group) and 22G (Control group) Acquire needles (Boston Scientific Co., Natick, MA, USA). The endosonographer chose the needle size based on lesion location and characteristics. Tissue specimens were handled in a standardized fashion using onsite evaluation, touch and smear preparation, and cell block tissue collection. Specimens were independently evaluated by 2 expert cytopathologists blinded to the diagnosis in each case. They assessed cytological yield (on smears) and histologic yield (on cellblock) using a previously validated standard scoring system reached by a consensus among our cytopathologists.

RESULTS:
A total of 75 patients (42 males, median age = 65 years) with solid pancreatic lesions underwent EUS-FNB during the study period: 50 using a 25G and 25 using 22G needle. There was no significant difference in the size or final cytopathological diagnosis of the lesions between the 2 groups (Table 1). Similarly, cytological scores of smears were comparable between the 2 groups. Due to the 25G needle’s increased flexibility in locations that entailed excessive scope angulation, it was utilized more for lesion sampling in the pancreatic head and uncinate process (70% vs 52%, P = 0.012). There was a statistically significant increase in diagnostic yield seen in the 25G group compared to the 22G (98% vs 88%. P = 0.013). The number of passes for cytological smears between both groups were similar; however, the 25G group required additional passes to obtain an adequate cell-block (1.6 vs 0.4, P = 0.001).

CONCLUSION:
We found the 25G FNB needle to be associated with superior diagnostic adequacy over 22G needles. This is consistent with FNA literature comparing these two common needle sizes. We noted an increased number of passes required in the 25G group to develop a cell block. This is likely due to the smaller size needle requiring more passes to build up an adequate cell block.
896 Endoscopic Ultrasound on Diabetic Patients for Unexplained Abdominal Pain: High Prevalence of Parenchymal Abnormalities
Authors: Schwartz Ingrid , Satiya Jinendra , Singh Harjit , Abraham Rtika , Girotra Mohit 
Published: October 2019

INTRODUCTION:
The association between newly diagnosed Diabetes Mellitus (DM) and pancreatic ductal adenocarcinoma (PDAC) is a field of immense interest. Work up for unexplained abdominal pain (UAP) in DM patients could include endoscopic ultrasound (EUS). The aim of our study is to understand prevalence of pancreatic parenchymal and ductal changes during EUS in patients with DM being evaluated for UAP.

METHODS:
We retrospectively reviewed of charts of DM patients who underwent EUS at our center between 2010-2018 for the evaluation of UAP or other causes. Patients with known history of chronic pancreatitis (CP), pancreatic mass/PDAC or pancreatic surgery were excluded.

RESULTS:
A hundred and fourteen patients were identified (mean age = 66 ± 13.9 years; M:F = 48:66): 17 (14.9%) Blacks, 61 (53.5%) Whites, 66 (57.8%) Hispanics. Mean BMI was 31.3 ± 8.9. Eight patients (7%) had DM type 1 and 106 (93%) had type 2, with mean disease duration of 9.78 ± 6.4 years and mean HbA1c of 7.69 ± 1.8%. Eighty patients (70%) were on oral agents and 64 (55%) on insulin-based regimens. Diabetic complications were present in 60 patients (52.6%). Alcohol use was reported in 30 (26%) patients, and smoking in 44 (38.5%) patients (14.6 ± 26 mean pack/years). EUS was performed exclusively for UAP in 38 patients. Other indications included submucosal esophageal (2), gastric (13) or duodenal (3) lesion, CBD narrowing/dilation (21), abnormal hepatic panel (4), LAD on imaging (5), suspected choledocholithiasis (5), jaundice (2), and elevated CA-19-9 (3). Mean number of EUS procedures was 1.19 ± 0.5 and mean interval between procedures was 229.5 ± 203.6 days. Pancreatic abnormalities on non-EUS imaging were reported in 27 patients. On EUS, parenchymal or ductal abnormalities were present in 49 (42.9%) patients. Mean duration of disease in those noted to have EUS abnormalities was 10.6 ± 5.8 years. When defined using Rosemont classification, 2 met criteria for CP, 6 were indeterminate. In 106 patients classified as normal pancreas, lobularity was the commonest finding seen in 20 (18.8%) patients. Out of the 14 patients who underwent interval EUS, 3 patients showed progression of parenchymal and ductal changes.

CONCLUSION:
Endosonographic pancreatic abnormalities, not amounting to Rosemont definitions of CP, seem to be present in diabetic patients presenting with UAP. In our retrospective study, although 92.9% diabetic patients were classified to have normal pancreas, 38.6% of them had at least one abnormal finding on EUS.
897 Aggressive Hydration With Lactated Ringer for Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis
Authors: Paleti Swathi , Junna Shilpa , Nutalapati Venkat , Jeepalyam Sravan , Rustagi Tarun 
Published: October 2019

INTRODUCTION:
Pancreatitis is the leading complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in considerable morbidity and, rarely, in death. Hydration is a mainstay of treatment for acute pancreatitis, independent of etiology. Aggressive hydration with lactated ringers (LR) has been suggested for prevention of post-ERCP pancreatitis (PEP). However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the impact of aggressive LR hydration in PEP incidence.

METHODS:
A comprehensive search of MEDLINE, EMBASE, Scopus, Cochrane Database was conducted from each database’s inception to search for comparative studies of aggressive LR vs standard therapy for prevention of PEP. Aggressive LR is defined as 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure. The primary outcome of interest was PEP rates. Secondary outcomes were other adverse events. Outcomes were reported as pooled odds ratio (OR) with 95% confidence intervals (CI) with statistical significance (P < 0.05). RevMan 5.3 software was used for statistical analysis.

RESULTS:
Eight studies (7 randomized controlled trials and one prospective study) with a total of 3248 patients were included in the meta-analysis. There were 1623 patients in the aggressive LR group and 1625 patients in the standard therapy group. There was no difference between the groups regarding age and sex. Patients in the aggressive arm received 3 ml/kg/hr during the procedure, a 20 ml/kg bolus after the procedure, and 3 ml/kg/hr for 8 hours following the procedure compared to 1.5 ml/kg/hour during the procedure and for 8 hours after the procedure without a bolus in the standard hydration arm. The mean total fluid administered in the two groups was reported in 2 studies with a pooled mean of 3.25 L in the aggressive and 1.47 L in the standard group (P < 0.001). The PEP rate was significantly lower in the aggressive LR arm compared to standard therapy (OR 0.33, 95% CI 0.21-0.50, P < 0.0001). There was no heterogeneity between the studies (I2 = 0%). Peripheral edema as an adverse outcome of aggressive LR therapy was reported only in 2 (0.69%) patients in 2 studies and was managed conservatively. No significant adverse events were reported in any study.

CONCLUSION:
Aggressive hydration with LR is associated with a significant reduction in incidence of PEP, and therefore, should be practiced routinely.
902 Dual Modality Therapy for Endoscopic Management of Esophageal Defects
Authors: Han Andrew , Patel Feenalie , Ghafoor Adil , Siddique Daanish , Bick Benjamin L. , Al-Haddad Mohammad 
Published: October 2019

INTRODUCTION:
Previously, surgical management represented the mainstay of therapy for esophageal defects such as tracheoesophageal fistulas, perforations, and post-operative leaks. As technical improvements in devices and endoscopic techniques improved, non-surgical management options increased to include clips, fibrin glue, and endoscopic suturing. Hybrid therapy involving both primary closure of the defect with endoscopic suturing and esophageal stent placement to protect the site was investigated.

METHODS:
We report a single center experience on dual modal therapy with endoscopic suturing and esophageal stenting for management of esophageal defects including tracheoesophageal fistulas, perforations, and post-operative leaks from 2013 to 2019. Factors such as etiology of defect (spontaneous perforation, iatrogenic perforation, tracheoesophageal fistula), size of defect, prior esophageal surgeries, and other factors were evaluated. Resolution was confirmed using esophagram to rule out leaks.

RESULTS:
18 patients underwent dual modality therapy with primary closure using endoscopic suturing with concurrent esophageal stenting. Mean length of defects was 14.5 mm. 2 patients were lost to followup, and 1 patient was excluded because they underwent thoracostomy for concomitant therapy. Of the 15 patients left for analysis, successful closure was achieved in 14 patients.There were no significant complications related to the procedures.

CONCLUSION:
Early data from dual modality therapy from our single center report appear positive, however, there have not been enough cases to provide sufficient statistical analysis. Still, our combined approach show promising rates of success with minimal adverse effects. Further investigation comparing dual modality therapy with standard therapy are planned to be performed.