bluuebunny/crossref_metadata_2025_split huggingface dataset:
898 Antireflux Valve Metal Stent vs. Conventional Self Expandable Metal Stent in Distal Malignant Biliary Obstruction: A Systemic Review and Meta-Analysis
Authors: Renno Anas , Abdel-Aziz Yousef , Ahmed Tamer , Alastal Yaseen , Toseef Javaid , Al-Aboodi Yasir , Nawras Ali 
Published: October 2019

INTRODUCTION:
In patients with distal malignant biliary obstruction (MBO), endoscopic biliary drainage by using the conventional self-expandable metal stent (cSEMS) is the gold standard established method for palliative treatment. However, there are limited data on the role of the antireflux valve metal stent (ARVMS). The aim of this study is to compare the efficacy and safety of ARVMS and cSEMS.

METHODS:
We performed an electronic search including PubMed, MEDLINE, EMBASE and Cochrane Library following the Preferred Reporting Items for Systemic Review and Meta-analysis (PRISMA) from inception until April 2019. We included randomized controlled trials (RCTs) that studied the efficacy and safety of ARVMS vs cSEMS deployment in distal malignant biliary obstruction. The selected studies provided data regarding technical and clinical success rates. Adverse events and stent dysfunction were also analyzed. We assessed the risk of biases using Cochrane Collaboration tool to assess the risk of bias.

RESULTS:
A total of 3 RCT’s were selected, enrolling 293 patients (147 ARVMS and 146 cSEMS). The rate of technical success between the ARVMS and cSEMS groups was 95.23% and 99.31% [odds ratio (OR) 0.13; 95% Confidence Interval (95% CI) 0.01-1.06, P = 0.06]. The clinical success rate was 91.57% and 89.36% (OR: 1.30; 95% CI: 0.48-3.51, P = 0.61). There was no significant difference in terms of adverse events between ARVMS and cSEMS (OR: 0.61; 95% CI: 0.35-1.05, P = 0.07). Overall, there was no statistical significance in stent dysfunction (OR: 0.77; 95% CI: 0.48-1.24, P = 0.29), however; after performing sub analysis stent migration was significantly higher in ARVMS (OR: 2.76; 95% CI: 1.24-6.17, P = 0.01). Stent occlusion was significantly lower in ARVMS (OR: 0.44; 95% CI: 0.26-0.76, P = 0.003).

CONCLUSION:
Our study showed that ARVMS and cSEMS technical and clinical success rates were similar. Adverse events were comparable between two arms. ARVMS was associated with lower risk of stent occlusion. Further randomized controlled trials are required with a higher number of patient population to verify the benefit of ARVMS.
899 POEM Perceptions: A Survey of Gastroenterologists and the Treatment of Achalasia in the Philadelphia Region
Authors: Loh Rebecca , Schlachterman Alexander 
Published: October 2019

INTRODUCTION:
Peroral endoscopic myotomy (POEM) is a relatively new innovate technique that has been shown to be an effective treatment for achalasia. Despite studies demonstrating its effectiveness as a less invasive therapy, POEM is still not as widely implemented as the traditional Heller myotomy for the treatment of achalasia. We aimed to explore the barriers that may impact implementation of POEM and to assess the regional perception of POEM amongst gastroenterologists in an urban setting.

METHODS:
An Internal Review Board (IRB) approved our 21-question multiple-choice survey that was developed by a panel of specialists that included a POEM trained advanced endoscopist. This was sent via email to 208 physicians practicing in the Philadelphia area. Some questions allowed for responders to select all answers that applied.

RESULTS:
Forty-five physicians (45/208, 21.6%) completed our online survey. Of the total 45 responders, 82.2% were male and 68.9% were practicing at an academic medical center. Approximately 73% of responders had treated anywhere from 5 to 50 patients diagnosed with achalasia during their career. Only 11% have treated over 50 patients with achalasia. In assessing what therapies these gastroenterologists have prescribed in the treatment of achalasia, the majority of responders prescribed botulinum toxin injections (86.4%) and endoscopic dilation (standard and pneumatic) (70%). In addition, 72.7% recommended surgical myotomy (laproscopic or open) while only 27.3% prescribed POEM. In fact, 69.8% of responders had never prescribed POEM even though 95.6% would consider POEM for the treatment of achalasia and 78.6% of responders believed POEM will gain acceptance as a main form of therapy. Nearly a quarter (24.4%) of responders were unaware of a program that performed POEM in the area.

CONCLUSION:
Although the vast majority of gastroenterologists surveyed considered POEM an acceptable therapy for the treatment of achalasia (95.6%), a significantly smaller portion of physicians had actually recommended it themselves (27.3%). A fairly significant percentage of responders were unaware of a local POEM program, which may have served as a barrier to their implementation of this therapy. Future studies will be to compare our current data to that in 18 months after establishment of a POEM program at a local academic hospital.
921 Efficacy and Safety of Endoscopic Ultrasound-Directed Transgastric ERCP in Gastric Bypass Patients: A Systematic Review and Meta-Analysis
Authors: Khan Ali T. , Zhang Xiaocen , Herman Michael , Lung Edward 
Published: October 2019

INTRODUCTION:
Treating pancreaticobiliary disorders in Roux-En-Y gastric bypass patients poses a technical challenge for physicians. The traditional laparoscopic or device assisted enteroscopic techniques has high post procedural complications and failure rates. EUS directed transgastric ERCP (EDGE), which accesses the ampulla by creating a temporary fistula through the remnant stomach for standard ERCP, has shown promising results. We conducted a systematic review and meta-analysis to evaluate and compare the efficacy and safety of EDGE.

METHODS:
MEDLINE, EMBASE, and SCOPUS databases were utilized to search for eligible studies that reported on efficacy and safety from 2012-2019. Efficacy was defined as the ability to create a temporary fistula through a lumen apposing metal stent (LAMS) and conduct an ERCP. Safety included assessing adverse events. The studies included were retrospective studies and were assessed with the NHBLI tool. Figure 1 depicts the flow chart used for study screening.

RESULTS:
A total of 4 studies (n = 88 patients) were included in the analysis. The mean age of patients undergoing EDGE was 56 years with 86% females. All patients evaluated were status post roux-en-y gastric bypass and the most common indication for the procedure was choledocholithiasis. Pooled technical success was 98.8% (95% CI 0.96-1.0) although 13 cases involved either LAMS misdeployment or LAMS migration during ERCP requiring rescue or repositioning. A total of 8 adverse events (8% 95% CI 0.03-0.16) occurred including intra-procedural bleeding, pancreatitis, persistent fistula formation or perforation. Figures 2,3 highlight the clinical success and adverse events of the EDGE technique.

CONCLUSION:
EUS directed transgastric ERCP (EDGE) appears to be an effective and safe procedure for Roux-EN-Y gastric bypass patients to undergo ERCP. Further studies are needed to address optimal procedural techniques, including access tract closure and to assess long term adverse events such as post procedural weight gain.
922 Hemospray Experience in Indonesia: The Application of Hemospray During Emergency Endoscopy: Single Tertiary Center Hospital
Authors: Bestari Muhammad Begawan , Girawan Dolvy , Tahari Jefry , Abdurachman Siti Aminah 
Published: October 2019

INTRODUCTION:
Gastrointestinal bleeding (GIB) is one of the main indication to perform endoscopy, GIB can also be potentially life threatening. In some cases Emergency Endoscopy (EE) is necessary, to identify the source and to stop the bleeding. Recently, hemostatic spray powder was introduced and one of the example is Hemospray (Cook Medical, Winston-Salem, NC, USA) that shows promising results as rapid hemostasis in primary treatment and salvage when bleeding persists after conventional methods.

METHODS:
The samples were taken in retrospective manner for the duration of three years since Hemospray first introduced in Indonesia from January 2016 – January 2019. This paper has obtained ethical clearance from hospital ethic committee.

RESULTS:
For both upper and lower GI endoscopy, we conducted a total of 2,990 procedures among which 37 procedures for 37 patients, consisted of 21 (56.8%) males and 16 (43.2%) females with average age of 67.8 years old, were EE using Hemospray. It was used in 30 (81.1%) for upper GI and 7 (18.9%) for lower GI. Hemospray was used as monotherapy for 24 (64.9%) and 13 (35.1%) as secondary modality, in which the primary treatment was argon plasma coagulation (APC) 8 (21.6%), adrenaline 4 (10.8%), histoacryl 1 (2.7%). In all cases Hemospray achieved hemostasis, with no event of rebleeding occur. Mortality rate is 37.8% (n = 14), with most deaths occur within 30 (42.9%) days after EE was done. However, none of the deaths was related to endoscopy or GIB.

CONCLUSION:
In all cases, Hemospray was able to achieve hemostasis and furthermore there was no event of rebleeding. When conventional modalities alone were inadequate, the combination with Hemospray appeared to be able to control the bleeding. The use of Hemospray in endoscopy is a novel technique in the management of GIB, especially the difficult cases. The advantage of Hemospray is the simplicity of the technique, thus require lower endoscopic skills compared to coagulation, injection, and clipping, the powder spray also allows easier access where source of bleeding is technically hard to access. Studies covering the efficacy, safety, combination with other techniques are still expanding with promising results, although a larger number of subject study is necessary.
927 Traction-Assisted Endoscopic Submucosal Dissection Reduces Procedure Time and Risk of Adverse Events: A Meta-Analysis
Authors: Lopimpisuth Chawin , Simons Malorie , Prasongdee Klaorat , Ngamruengphong Saowanee 
Published: October 2019

INTRODUCTION:
Endoscopic submucosal dissection (ESD) is superior to endoscopic mucosal resection (EMR) for treatment of superficial gastrointestinal neoplasia because it is associated with increased en bloc resection and lower rates of local recurrence. However, ESD is a technically demanding procedure with increased procedure time and has potential for serious adverse events. To overcome the procedural difficulty of ESD, Various traction methods such as clip-line method, clip and snare method and internal traction method, have been developed to provide countertraction to expose the dissection plane and allow safe and effective submucosal dissection. A number of studies have compared efficacy of traction-assisted ESD (T-ESD) and conventional ESD (C-ESD) but results are conflicting. We conducted a meta-analysis to assess the efficacy of T-ESD.

METHODS:
All clinical studies published up to April 2019 comparing the efficacy and safety of T-ESD and C-ESD were identified using electronic bibliographic searches of PubMed, Medline, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), and Web of Science (Science and Social Science Citation Index). Outcomes of interests included procedure time (minutes), rate of en bloc and R0 resections, and rates of adverse events (bleeding and perforation). Random effect model was used to calculate pooled mean difference (MD) for continuous variables and Odds ratios (ORs) for categorical variables.

RESULTS:
Of 621 articles identified, 18 studies [939 T-ESD and 963 C-ESD procedures] met inclusion criteria for final analysis [6 randomized controlled trials and 12 observational studies]. Overall, T-ESD significantly reduced procedure time (MD = - 16.63 min, 95% CI - 24.65 to - 8.60, P < 0.0001, I

2
= 68) and complication rates (OR = 0.56, 95% CI 0.36 - 0.87, P = 0.009, I

2
= 0) compared to C-ESD. En bloc resection and R0 resection rates were similar in both groups (OR = 2.36; 95% CI 0.58 - 9.55; P = 0.23, I

2
= 0 and OR = 1.45; 95% CI 0.76 - 2.77; P = 0.25, I

2
= 0; respectively). No publication bias was detected by funnel plot.

CONCLUSION:
Traction techniques facilitate submucosal dissection, reduce procedure time and improve its safety. These techniques are simple and can be performed using readily available accessories in the endoscopy unit. Application of traction method improves feasibility of ESD and may enable the widespread use of ESD in the West.
929 A Prospective Evaluation of a Novel Ultra-Slim Echoendoscope for EUS-Guided FNA, FNB and Celiac Plexus Neurolysis
Authors: Green J. Alvin , Eloubeidi Mohamad A. 
Published: October 2019

INTRODUCTION:
Safe and successful EUS and EUS-guided interventions rely on the ability to reach the intended organ reliably and safely. Possible barriers include altered anatomy, stenosis in the GI tract, or low BMI, making the current echoendoscopes hazardous to use. Therefore, we prospectively evaluated the utility of a novel Ultra-Slim echoendoscope in these challenging scenarios.

METHODS:
We prospectively enrolled 25 patients in this study. Criteria for inclusion were as follows: Weight less than 120 lbs, children, mediastinal lymph nodes with severe lung disease or sleep apnea, altered anatomy, and esophageal stenosis precluding the passage of the standard echoendoscope. The Ultra-Slim echoendoscope (EG-3270UK: Pentax, Montvale, NJ USA) was utilized in all cases. A 22-gauge FNA or FNB needle were utilized. A fenestrated 20-gauge needle was used for CPN. Complications were assessed at 30 days as we previously described.

RESULTS:
A total of 25 patients were included in this study with a mean age of 69.16 years (standard deviation of 13.5). Females accounted for 64% of the study population. Indications for EUS use were: 64% (n = 16) had an abnormal CT or PET scan, 4% (n = 1) had MLN, 24% (n = 6) had a pancreatic mass, 8% (n = 2) had other indications. Reasons for using the Ultra-slim echoendoscope were: 28% of patients (n = 7) had low body weight defined as less than or equal to 120 lbs, 12% (n = 3) had MLN, 32% (n = 8) had altered anatomy and 28% (n = 7) had esophageal stenosis. Of the 25 Ultra-slim procedures performed, an FNA biopsy was taken 68% of the time (n = 17) while in 32% (n = 8) a biopsy was not performed. Of those 17 biopsies taken, a 22G FNA needle was used 87.5% (n = 14) of the time, and the FNB 19G needle was used 12.5 % (n = 2). Targets for biopsy were MLN 56.25% (n = 9), Adrenal Gland 6.25% or (n = 1), Liver 18.75% (n = 3), Pancreas 12.5% (n = 2) or Other 6.25% (n = 1). CPN was performed 3 times or 12% of procedures. Of the 17 samples taken, 65 % (n = 11) were malignant while 35% (n = 6) were benign. The average size of target biopsied was 32.8 mm × 25.2 mm (standard deviation 14.18 × 12.9) with a range of 11-73 mm and 8-65 mm. No immediate or long-term complications occurred.

CONCLUSION:
An ultra-slim echoendoscope is very useful and may be better tolerated in individuals with low body weight, altered anatomy and stenosis in the GI track and in patients with lung cancer. Further modifications are warranted to allow more therapeutic interventions with this important addition to the endosonographer daily armamentarium.
934 Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections Using AXIOS Electrocautery Enhanced Delivery System a Retrospective Experience at a Large Quaternary Care Center
Authors: Kloska Michal , Hrad Valery , Aggarwal Soorya , Shah Shashin , Zator Zachary , Shah Hiral 
Published: October 2019

INTRODUCTION:
Pancreatic fluid collections (PFC) are common complications of acute pancreatitis, surgery, or trauma. Many PFC reabsorb spontaneously but the remainder create cystic structures filled with fluid and/or with necrotic debris. Since the development of lumen apposing metal stents (LAMS) first line treatment of PFCs are with EUS guided drainage. However, despite the high technical and clinical success of the commonly used Electrocautery Enhanced AXIOS LAMS (EEAL), outcome data is still scarce.

METHODS:
An IRB approved, retrospective chart review, was performed on EUS-guided drainage of PFC using EEAL at a large quaternary care, teaching hospital. Specific procedural data including technical success rate, adverse events, and length of stay were collected. Descriptive statistics were then used to report outcomes.

RESULTS:
A total of 43 EEAL were used in the treatment of pancreatic pseudocysts (41.9%) and walled off pancreatic necrosis (65.1%). LAMS were placed successfully in 100% of procedures and required revisions in 28.6% of patients. Adverse events occurred in 16.3% of interventions: 2 bleeding events (4.7%), 3 stent migrations (7%), 1 pigtail stent occlusion (2.4%) and 1 spontaneous pancreatic fistula formation (2.4%). Only 2 patients (4.8%) required subsequent surgical resection. The average hospital stay after the procedure was 6.79 days (median of 3 days) and stents were ultimately removed on average at 24.68 days.

CONCLUSION:
This study demonstrated 100% technical success rate. Of the recorded adverse events after EEAL use in drainage of PFC most were subclinical and minor. Importantly, only two patients required further surgical intervention to obtain desired outcome. Furthermore, length of stay was particularly low with median hospital stay of 3 days. Ultimately, this study highlights how EEAL provides high value care by providing an efficient intervention in a cost-feasible length of time. Further ongoing prospective studies will help determine the utility of EEAL in the practice setting.
939 B-Type Natriuretic Peptide Predicts 90-Day Mortality and Need for Paracentesis in Patients With Cirrhosis and Without Systolic Heart Failure
Authors: Palacios Pedro , Araujo Tiago , Vohra Ishaan , Omar Yazan Abu , Flores Estefania , Kedar Mukthinuthalapati V. V. Pavan , Randhawa Tejinder , Wang Yuchen , Patel Sanjay A. 
Published: October 2019

INTRODUCTION:
Fluid overload is the most frequent complication of end-stage liver disease, regardless of its etiology. Levels of brain natriuretic peptide (BNP) have been shown to be elevated in cirrhotic patients when matched to healthy subjects. There are only small observational studies done in Asian and European populations evaluating the role of BNP in predicting mortality of patients with liver disease. The use of BNP to predict 90-day requirement of paracentesis has not been studied.

METHODS:
Retrospective analysis of medical records of patients with a diagnosis of cirrhosis without heart failure, arrhythmia, coronary artery disease or pulmonary hypertension from John H. Stroger Hospital of Cook County Medical Record's database from 2008 to 2018. IRB approval was obtained. All analysis was done using STATAv14.

RESULTS:
The cohort included 430 patients with clinical and radiological diagnosis of cirrhosis without systolic dysfunction of which 12% had BNP ≥ 300 pg/mL. Patients with BNP ≥ 300 pg/mL were younger (53.3 vs 55.6 years, P = 0.027), had less proportion of hepatitis B (0% vs 100%, P = 0.013), hepatitis C (7.4% vs 92.6%, P = 0.036), higher mean number of paracentesis (1.60 vs 2.52, P = 0.005), creatinine (2.66 vs 1.03 mg/dL, P=< 0.001), bilirubin (5.36 vs 2.84 mg/dL, P=< 0.001) and INR levels (1.75 vs 1.50, P = 0.003). There was no significant difference in Child-Pugh class between the two groups and MELDNa scores were significantly higher in the BNP ≥ 300 pg/mL group. Kaplan-Meier survival estimates for death within 90 days show increased significant mortality [HR 3.49, P = 0.037] and significantly higher requirement for paracentesis in 90 days [HR 2.26, P = 0.020] with levels of BNP ≥ 300 pg/mL.

CONCLUSION:
This is, to our knowledge, the largest study done to assess BNP as a prognostication tool in cirrhotic patients. Despite excluding patients with overt cardiac dysfunction, we found that higher BNP levels are significantly associated with higher medium-term mortality, paracentesis requirements and higher MELDNa scores, suggesting high BNP values as an indicator of severity. The presence of hepatitis B and C seem to be a protective factor, most likely due to possible less indolent disease and more accessible treatment methods. In conclusion, BNP seems to be a reliable predictor of severity in this cohort of patients.
940 Pregnancy Outcomes After Liver Transplantation
Authors: Sobotka Lindsay , Hinton Alice , Mumtaz Khalid , Conteh Lanla 
Published: October 2019

INTRODUCTION:
Liver transplantation is a safe and effective intervention for patients with acute liver failure and cirrhosis. Given that the number of liver transplantations in women of childbearing age is increasing, it is important to recognize complications during pregnancy in these patients. Previous studies have noted an increased risk of complications, specifically hypertension and preeclampsia. This study aims to evaluate complications during pregnancy in patients after liver transplantation and the effect these complications have on patient and hospital outcomes.

METHODS:
Utilizing the Nationwide Inpatient Sample, a retrospective database analysis was performed on pregnant patients aged greater than 18 between 2005 and 2013. Patients were selected with the use of ICD-9 codes. Multivariable and propensity weighted analyses were used to evaluate the impact of liver transplantation on pregnancy complications and hospital outcomes including hospital length of stay and costs.

RESULTS:
A total of 38,449,030 pregnant patients were included in this study including 1,469 patients with a history of liver transplantation. Patients with a history of liver transplant were more likely to undergo a caesarean delivery and have a pregnancy related complication including miscarriage, intrauterine growth restriction, postpartum hemorrhage, hypertension during pregnancy, preeclampsia and venous thromboembolism (P < 0.001). Propensity weighted analysis revealed higher rates of pregnancy complications (OR 2.11, 95% CI 1.63, 2.73), higher cost of admission ($3,023, 95% CI 850, 5,197) and longer length of stay (1.52 days, 95% CI 0.62, 2.41) among those with a liver transplant. A subset analysis among pregnant patients with a history of liver transplantation revealed 823 (56%) of these patients suffer from at least one pregnancy related complication. On multivariable analysis, patients that experienced a pregnancy related complication had a longer length of stay (2.45 days, 95% CI 1.44, 3.45) and higher cost of admission (5,205, 95% CI 2,848, 7,561).

CONCLUSION:
Pregnancy after liver transplant is associated with higher rates of pregnancy complications and worse patient and hospital outcomes. Further studies should be completed in order to improve outcomes in these patients.