bluuebunny/crossref_metadata_2025_split huggingface dataset:
437 Peroral Endoscopic Myotomy Is a Safe and Effective Treatment Modality for Geriatric Patients With Achalasia
Authors: Sanaka Madhusudhan R. , Parikh Malav P. , Tang Andrew , Chadalavada Pravallika , Khoudari George , Gupta Niyati M. , Thota Prashanthi N. , Gabbard Scott , Murthy Sudish , Raja Siva 
Published: October 2019

INTRODUCTION:
Peroral endoscopic myotomy (POEM) is an emerging treatment modality for achalasia. It is a particularly appealing treatment option in older patients, as it is minimally invasive like an endoscopic procedure and highly effective as surgical myotomy. However, there is lack of a systematic study analyzing and comparing POEM outcomes in young (< 65 years) and geriatric patients (≥65 years). Hence, our study aims were to assess and compare the safety and efficacy of POEM in young versus geriatric patients.

METHODS:
Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution manometry (HREM) prior to POEM along with two-month post-POEM esophageal pH study, TBE and HREM were included. Patients were categorized into two groups as: young (<65 years) and old (≥65 years). Demographic and procedural details, TBE, HREM, pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤3 was considered as successful palliation of symptoms.

RESULTS:
148 patients met the study criteria (<65 years = 93; ≥65 years = 55). Younger patients were more likely to have higher BMI, but fewer comorbidities and lower TBE height at 1 minute but wider TBE width at 5 minutes. Rest of the TBE parameters, pre-operative Eckardt's score and lower esophageal sphincter-integrated relaxation pressure (LES-IRP) were similar between the two groups. Young patients were more likely to have undergone prior Heller myotomy, where as Botox injections were more common in older group. The operative time, total myotomy length, complications, length of stay and 30-day readmission rates were similar in the two groups (Table 1). POEM was successful in 94.5% young and 96% old patients. At two-month follow up, both groups showed significant improvements in Eckhardt scores (Figure 1a) and HREM parameters, however older patients showed greater improvement in TBE height at 1 and 5 minutes (Figure 1b,c). The rates of symptomatic GERD and abnormal esophageal pH study findings were not significantly different between the two groups (Table 2).

CONCLUSION:
POEM is a safe and effective treatment option for geriatric patients with achalasia similar to younger patients. POEM might emerge as the preferred approach for myotomy in this patient population, because of its low morbidity compared to surgical myotomy.
440 Long-Term Outcomes of POEM in Achalasia With a Minimum Follow-Up of 3, 4, and 5 Years: A Meta-Analysis
Authors: Barakat Mohamed , Aloreidi Khalil , Aamar Ali , Tsipotis Evangelos , Quintero Eduardo , Abdelfatah Mohamed Magdy 
Published: October 2019

INTRODUCTION:
Per-oral endoscopic myotomy (POEM) has promising safety and efficacy outcomes in short-term studies. However, long-term follow-up data are limited. The aims of this study was to review and analyze the clinical outcomes and failure rates of of studies that reported a minimum post-POEM follow-up of 3, 4 and 5 years.

METHODS:
A systematic review of POEM performed for the treatment of achalasia was performed. We searched major medical databases (Pubmed, Medline, Ovid, Cochrane and EBSCO databases) from inception till May 2019. Major conference abstracts and presentations were searched. Statistical analysis was performed using Med Calc Software (Ostend, Belgium). Clinical success was defined as Eckardt score ≤3 and failure was defined as Eckardt score >3 on follow up.

RESULTS:
A total of 8 retrospective and prospective studies fulfilled inclusion criteria (Table 1). The studies originated from China, Czech Republic, Japan and USA. The total number of patients included in this study was 671. Eight studies (671 patients) with follow up data post-POEM of a minimum of 3 years were included in the 3 year analysis. Four studies (407 patients) with 4 year follow up data post-POEM were included in the 4 year analysis. Three studies (97 patients) with 5 year follow up data post-POEM were included in the 5 year analysis. There was no heterogeneity between studies. The overall clinical success rate at the 3, 4 and 5 year follow up was 88% (95% CI 85-91%), 87% (95% CI 83-90%), 84% (95% CI 76-90%) respectively (Figure 1). The overall failure rates at 3, 4 and 5 year follow up were 11.7% (95% CI 9-15%), 13% (95% CI 10-17%) and 16% (95% CI 10-24%) respectively. There was no significant difference in clinical success or failure rates.

CONCLUSION:
Our study demonstrates that POEM is effective and safe for treating achalasia during the long term follow up to 5 years. Randomized controlled trials are needed to validate these findings.
442 Strength of Peristalsis and Its Association With Bolus Clearance in Esophageal Motility Disorders
Authors: Al-Jashaami Layth , Alani Mustafa , Kannadath Bijun Sai , Ahmed Shifat , Mann Sarabdeep , Guha Sushovan , Mills Michael , Ratuapli Shiva 
Published: October 2019

INTRODUCTION:
High resolution manometry (HRM) is a valuable tool increasingly used in clinical practice for diagnosis of esophageal disorders. Impedance measurement was recently added to the manometry catheter to assess bolus clearance. However, clinical utility of this metric and its association with esophageal motility disorders are currently unknown. The aims of this study are to a) evaluate the association between strength of peristalsis and bolus clearance and b) compare the strength of peristalsis and bolus clearance between normal patients and patients with various esophageal motility disorders.

METHODS:
A retrospective review of patients referred for HRM at our tertiary academic center from January 2016 to October 2018 was performed. All studies were interpreted by two HRM-trained GI specialists and reported in accordance with the Chicago classification of esophageal motility disorders, version 3.0. Distal Contractile Integral (DCI) was used to measure strength of peristalsis. Bolus clearance was measured by visual assessment of color topography clearance of bolus in each swallow. Greater than 50% complete bolus clearance was considered as effective peristalsis. Demographic and manometry data were analyzed using STATA 15.1.

RESULTS:
1,323 consecutive studies were included in the analysis. The mean age was 59.6± 14.5 years. Of these 898 (67.9%) were women. Women were overall older with an average of 60.1 ± 0.5 years compared to men (58.5 ± 0.8 Years, P = 0.0332). The most commonly diagnosed motility disorder was ineffective esophageal motility (IEM) (284, 21.5%). There was moderate correlation between DCI and intrabolus pressure (r = 0.29, P < 0.001). Patients with normal esophageal motility had higher DCI (1875.9 vs 551.8, P < 0.0001) and complete bolus clearance (85.8% vs 56.8%, P < 0.0001) compared to patients with IEM. In contrast, patients with spastic motility disorders (Achalasia and Esophagogastric Junction Outflow Obstruction) had lower bolus clearance (43.2% vs 85.2%, P < 0.0001) despite higher DCI than normal patients (4661 vs 1875, P < 0.0001). ROC analysis showed that a DCI of 320 mmHgcm2 had greater accuracy in predicting complete clearance of bolus in >50% of swallows (96.5% sensitivity, 24.8% specificity) compared to 450 mmHgcm2 (accuracy 83.1% vs 79.3%, P < 0.0001).

CONCLUSION:
In our large cohort of patients, HRM peristaltic metrics suggest that a DCI cut-off value of 320 mmHgcm2 had greater accuracy for predicting complete bolus clearance.
444 Unmet Need for Additional Resources to Support Successful Transition of Care From Pediatric to Adult Providers for the Management of Eosinophilic Gastrointestinal Diseases
Authors: Falk Gary W. , Gehman Lauren , Strobel Mary Jo 
Published: October 2019

INTRODUCTION:
Eosinophilic gastrointestinal diseases (EGIDs), including eosinophilic esophagitis (EoE), are chronic conditions characterized by eosinophil infiltration into the gastrointestinal mucosa. Children and adolescents diagnosed with EGIDs typically continue to experience symptoms and require lifelong disease management. Therefore, transition to adulthood necessitates a transition from pediatric to adult healthcare providers. The aim of this study is to better understand perceived challenges, unmet needs, and utility of resources to aid in successful transition of care (TOC) for EGID patients.

METHODS:
An online survey of adolescents and young adults with EGIDs, ages 15-26 years, or their parents/caregivers, was conducted from Dec 2018 to Jan 2019. Participants were recruited through the online platforms of the American Partnership for Eosinophilic Disorders (APFED). There were no prespecified statistical analyses, as this study was intended to be descriptive only.

RESULTS:
Forty-one participants completed the survey: 7 patients and 34 parents/caregivers. Survey participants were primarily diagnosed with EoE (81%), diagnosed by a pediatric gastroenterologist (95%), and diagnosed at 5 years of age or younger (44%). Most patients (93%) planned to transition to an adult provider at some point, with ages 18-21 years the most common ages of planned TOC (51%); the remaining 7% stated they did not intend to ever transition and instead remain with their pediatric gastroenterologist indefinitely. All patients perceived potential challenges associated with TOC, with “inability to locate an adult provider” and “new provider changing my current treatment plan” cited most frequently as concerns (Table 1). All patients indicated a need for additional TOC resources, such as a list of local adult providers familiar with treating EGIDs, a designated care coordinator, and a checklist of steps to ensure smooth TOC (Table 2).

CONCLUSION:
This study identified several potential barriers to successful TOC and highlights the need for additional resources to ensure a smooth transition from pediatric to adult providers for the management of EGIDs. To alleviate concerns that TOC may result in change in treatment plan, implementation of tools that enable efficient transfer of relevant medical history and current management plan may help optimize continuity of care as patients transition into adulthood.
447 Clinical Characteristics of Secondary Achalasia Associated With a Malignancy: A 20-Year Review From a Cancer Hospital
Authors: Shafi Mehnaz A. , Bokhari Raza , Lum Phillip , Stroehlein John 
Published: October 2019

INTRODUCTION:
Achalasia is an uncommon neurodegenerative disorder of esophageal motor function with an annual incidence of 1.6:100, 000. Most cases are idiopathic. Achalasia secondary to neoplasia is extremely rare, with an incidence of 1: 750,000.

AIM:
To evaluate the incidence and characteristics of achalasia in patients with a malignancy at our institution between 1999-2019.

METHODS:
Electronic medical records were retrospectively reviewed from January 1999 to May 2019 to identify patients with a diagnosis of achalasia and a malignancy. Patiets with direct tumor invasion of the distal esophagus were excluded. We identified 28 patients who had a malignancy and a diagnosis of achalasia.

RESULTS:
The median age at diagnosis of achalasia was 58 years (19-85). There were 14 (50%) male and 14 (50%) female patients. The most common associated cancer was a hematologic malignancy (N = 9, 32%: lymphoma N = 4, leukemia N = 4, myeloma N = 1), followed by breast cancer, (N = 7, 25%). Other cancers included lung, (N = 3, 11%), carcinoid tumor, (N = 2, 7%), and one each of thymoma, sarcoma, esophagus, stomach, thyroid, larynx, and prostate. The median interval between the diagnosis of cancer and achalasia was 78 months (range 2- 364). In 21 patients, the cancer preceded the diagnosis of achalasia. All patients underwent endoscopy to rule out psuedoachalasia. Where high resolution manometry was done (N = 10/28, 36%), type 2 achalasia was seen in 8/10 patients and type 1 achalasia in 2/10 patients. In seven patients, achalasia was diagnosed before the cancer. The median time interval between diagnosis of achalasia and diagnosis of a primary malignancy in these patients was 72 months (range 12-354 months). Anti-Hu antibodies were present in 2/8 patients who were checked for it, suggestive of a paraneoplastic process. Eight patients underwent endoscopic dilatations, 12 had Botulinum Toxin A injection into the lower esophageal sphincter and 6 had both procedures. 7 patients underwent a Heller myotomy. One is awaiting surgery. Response to treatment was favorable when assessed for improvement in dysphagia and eating ability for 6 months after diagnosis in 24/ 28 patients (85%).

CONCLUSION:
Malignancy associated secondary achalasia is very rare. In our population heme associated malignancy and breast cancer were the 2 cancers most commonly associated with achalasia. Patients with cancer who develop dysphagia should be screened for achalasia, as response to treatment is favorable.
450 Esophageal Motility Disorders and GERD in Patients With Pulmonary Nontuberculous Mycobacterial Infection: A Growing Medical Problem
Authors: Fass Ofer , Khan Abraham , Kamelhar David , Addrizzo-Harris Doreen , Segal Leopoldo , Knotts Rita 
Published: October 2019

INTRODUCTION:
The prevalence of pulmonary infections by nontuberculous mycobacteria (NTM) is increasing worldwide. The etiology of this increase is unclear. There is evidence that gastroesophageal reflux disease (GERD) is associated with NTM infections and can increase the severity of pulmonary disease. Data regarding esophageal motility in this population is sparse. We aimed to characterize esophageal motility disturbances and GERD in patients with bronchiectatic NTM and explore its associations with pulmonary pathology and lung function.

METHODS:
We conducted a retrospective review of all patients with a confirmed diagnosis of bronchiectatic NTM at a single center who underwent high resolution esophageal manometry (HRM) between November 2014 and March 2018. Chicago Classification 3.0 was used to characterize HRM findings. Combined multichannel intraluminal impedance-pH (pH-MII) was utilized to assess reflux burden. Statistical relationships between proportions and percentages were evaluated by Fisher’s exact test. Linear regression was utilized to assess associations with pulmonary function testing.

RESULTS:
A total of 32 patients underwent HRM, of which 27 underwent pH-MII. The mean age of all was 70 (SD 10), mean body mass index was 23.4 (SD 6.1), 78% were female, and 44% had a smoking history. The mean lower esophageal sphincter (LES) resting and residual pressures (mmHg) were 36.12 (SD 17.12) and 11 (SD 8.37), respectively. HRM motility disorders included 38% ineffective esophageal motility, 38% normal esophageal motility, 19% esophagogastric outflow obstruction, and 6% jackhammer esophagus. Significant evidence of GERD on pH testing was seen in 12 patients (44%). pH testing showed similar upright and supine reflux burdens of 7.6% and 7.4% respectively. On endoscopy, 2 patients (6.25%) had Barrett’s esophagus. No statistically-significant correlations were found between BMI, gender, mycobacterial organism, imaging characteristics, pulmonary function, HRM diagnosis or presence of significant reflux.

CONCLUSION:
Esophageal motility is frequently abnormal among patients with NTM. NTM patients also have a high prevalence of GERD, including supine GERD, and Barrett’s esophagus, which is far greater than the general population. Consideration should be given to screening for BE among patients with NTM related bronchiectasis. Larger studies are warranted to further characterize esophageal physiology in these patients and the potential impact on pulmonary pathology.
454 Usefulness of Linked Color Imaging in Reflux Esophagitis
Authors: Takeda Tsutomu , Asaoka Daisuke , Nagahara Akihito 
Published: October 2019

INTRODUCTION:
Barrett's esophagus and esophageal adenocarcinoma are increasing because of rising prevalence of gastro esophageal reflux disease. Accurate diagnosis of reflux esophagitis is important in daily clinical practice. Linked Color Imaging (LCI) was newly developed for image-enhanced endoscopy that makes easy to recognize differences in mucosal color. Therefore, we investigated the visibility of LCI in reflux esophagitis compared with white light imaging (WLI).

METHODS:
Consecutive patients who underwent esophagogastroduodenoscopy using WLI, LCI between April 2017 and March 2018 in our hospital were selected retrospectively. 5 endoscopists compared WLI images with LCI of 109 images obtained from 109 patients. Physicians assessed visibility as follows: 5 (improved), 4 (somewhat improved), 3 (equivalent), 2 (somewhat decreased), 1 (decreased). Scores were totaled and defined more than 20 points as improved visibility, 10-20 points as equivalent to white light, less than 10 points as decreased visibility. Inter-rater reliability (Intra-class Correlation Coefficient: ICC) was also evaluated. Images were objectively evaluated based on L* a* b* color values and color differences (ΔE*) between normal esophageal mucosa and reflux esophagitis in a CIELAB color space system.

RESULTS:
Improved visibility compared with WLI achieved for All: 29.4% (32/109), LA-M: 21.3% (13/61), LA-A: 41.2% (14/34), LA-B: 50.0% (5/10), LA-C: 0%, LA-D: 0%. Decreased visibility was not detected in LCI. ICC of LCI compared with WLI was 0.470 and inter-rater reliability is moderate. The color difference (ΔE*) revealed WLI: 22.8 ± 7.0, LCI: 33.5 ± 8.4 and statistically significant difference between WLI and LCI was observed (P < 0.001).

CONCLUSION:
LCI improves visibility of reflux esophagitis compared with WLI especially for LA-M, A, B when evaluated both subjectively and objectively. LCI enables the clear visualization of reflux esophagitis and provides better contrasting images between normal esophageal mucosa and reflux esophagitis.
459 The Effect of Rebamipide in Patients With Gastroesophageal Reflux Disease, Including Non-Erosive Reflux Disease: A Multi-Center, Randomized, Single-Blind, Placebo-Controlled Study (RENERD Study)
Authors: Lee Jun Su , Kwon Hyeonwoo , Kim Seongmin , Cho Byungha , Choi Jongwook , Yoon Soon Man , Kim Hyoung Woo , Kim Ki Bae 
Published: October 2019

INTRODUCTION:
Gastroesophageal reflux disease (GERD) is a chronic and frequently relapsing disease. The etiology of non-erosive reflux disease (NERD) remains unclear, but it has been reported to manifest histologic changes such as dilated intercellular spaces (DIS) and inflammatory cells infiltration in the esophageal mucosa. In this study, we investigated the effect of rebamipide, a mucosal protective agent, in the recurrence of symptoms in GERD patients during proton pump inhibitor (PPI) and also examined histologic changes in the esophageal mucosa of NERD patients.

METHODS:
A total of 139 patients with GERD including 50 patients with NERD were enrolled in this study and were treated randomly with either PPI plus rebamipide (rebamipide group) or PPI plus placebo (placebo group) during 8 weeks. We compared the change of symptom score at 8 weeks in both groups using a GERD questionnaire. In addition, we analyzed histologic findings such as DIS, inflammatory cells infiltration, and basal cell hyperplasia in the esophageal mucosa of NERD patients, and we compared the histologic changes at 8 weeks in both groups.

RESULTS:
After 8 weeks, the mean decreases in the total symptom score in the rebamipide group were greater than those in the placebo group in GERD patients, but not statistically significant (-4.4 ± 2.7 vs. -3.9 ± 3.1, P = 0.382). However, the proportion of at least a 50% decrease in the total symptom score in the rebamipide group was significantly higher than that in the placebo group (74.1% vs. 51.7%, P = 0.020). With regard to histologic changes in NERD patients, the severity of DIS in the rebamipide group was significantly improved compared to that in the placebo group after 8 weeks (P = 0.024), and also the lymphocytes counts were more decreased in the rebamipide group compared to the placebo group (P = 0.026).

CONCLUSION:
Rebamipide, a mucosal protective agent, might be helpful in attenuating the recurrence of symptoms in GERD patients. It could also improve histologic abnormalities in the esophageal mucosa of NERD patients.
463 The Prevalence and Epidemiology of Achalasia in the USA: A Population-Based Study
Authors: Khoudari George , Saleh Mohannad Abou , Sarmini Muhammad Talal , Parikh Malav P. , Vega Kenneth J. , Sanaka Madhusudhan R. 
Published: October 2019

INTRODUCTION:
Achalasia is a rare and benign neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and loss of peristalsis in the distal esophagus. A substantial increase has been reported in the number of hospitalizations for achalasia and its associated costs over the last few decades and the etiology is still unknown. Epidemiological studies of this disease have been limited by small sample size. We aim to investigate further the epidemiology of achalasia using a large database.

METHODS:
We used a commercial database (Explorys Inc, Cleveland, OH), which includes electronic health record data from 26 major integrated US healthcare systems. We identified all patients aged 18 and older who were diagnosed with achalasia, over the last five years based on Systematized Nomenclature Of Medicine – Clinical Terms (SNOMED-CT) and evaluated the prevalence of Achalasia among all the patients in this database. We also performed univariate analysis to describe age-, race-, and gender-based distributions and to identify potential risk factors.

RESULTS:
Of the 36,750,450 individuals in the database, we identified 19,840 individuals with achalasia with an overall prevalence of 0.05%. Individuals with achalasia were more likely to be females, senior adults (age > 65), Caucasians, (P < 0.0001 to all) compared to patients without achalasia. Similarly, patients with achalasia were more likely to have gastroesophageal reflux disease (GERD), Barrett's esophagus, eosinophilic esophagitis, esophageal neoplasms, autoimmune disease, diabetes mellitus type 2, amyloidosis, sarcoidosis, and hypoadrenalism, (P < 0.0001 to all). Additionally, patients with achalasia were more likely to be obese, smokers, and drink alcohol (P < 0.0001 to all). Table 1 represents the odds ratio (OR) for all factors.

CONCLUSION:
This is one of the largest epidemiological studies investigating the prevalence and epidemiology of achalasia. The estimated prevalence rate of achalasia was 0.05%. Patients with achalasia were more likely to be females, senior adults (age >65), Caucasians, smokers, and obese. Further studies are needed to confirm these findings.