bluuebunny/crossref_metadata_2025_split huggingface dataset:
892 A Retrospective Study of the Influencing Factors on Fluoroscopy Time (FT) and Patient Radiation Dose (DAP) During ERCP in a Setting of 12 Large Tertiary Academic Hospitals
Authors: Patil Prithvi , Subramanian Sruthi K. , Ramireddy Srinivas , Badillo Ricardo , Davee Tomas , Thosani Nirav 
Published: October 2019

INTRODUCTION:
ERCP uses endoscopic and radiological guidance to accomplish diagnosis and therapy of biliary and pancreatic disorders. During ERCP, the patients are exposed to a higher amount of radiation dose compared to endoscopy staff and over the years both the number and the complexity of the procedure associated has increased significantly resulting in longer procedural and fluoroscopy times. This increasing exposure of patients to such medical radiation is concerning. The primary aim of this study was to get familiar and better understand the various factors influencing patient radiation dose to be able to optimize radiation exposure in fluoroscopy procedures, thereby, minimizing the risk of any radiation-induced injury.

METHODS:
Retrospective analysis of a prospectively collected database over a study period of 3.5 years (January 2015 to May 2018) was performed. Data related to patient demographics, ERCP indication and radiation exposure in ERCP procedures (n = 7400) in a setting of 12 large tertiary academic hospitals was reviewed and analyzed. Statistical significance, increased Fluoroscopy Time (FT) and Dose area product (DAP) were identified. All ERCPs were graded on their procedural complexity with scores from 1 to 4 signifying simple to the most complex ERCPs.

RESULTS:
Factors independently associated with an increased FT and DAP included age, level of complexity and the volume of the hospitals performing ERCPs (High volume hospital – more than 450 ERCPs a year). The average Fluoroscopy time (FT) and DAP for different ages (Patients under 35 years old, 35-65 years old and over 65 years old). The average FT was 45.8% higher in patients with higher complexity score and also had a higher DAP of about 13.5%. Also, ERCPs performed in a lower volume hospital had a higher FT (2.93 vs 2.78) and a higher dose area product (12.5 vs 10.1) compared to the higher volume hospitals.

CONCLUSION:
A number of factors were found to affect the FT and DAP in ERCP. The awareness about the risks of radiation exposure to patients, specific settings of the fluoroscopy machine used and various fluoroscopy modifications that can decrease radiation exposure will help to predict prolonged procedures thereby facilitating the use of appropriate precautions.
894 Ulcer Formation in Patients With GAVE and Gastric AVMs After Endoscopic Ablation
Authors: Stratton Leland , Henry Zachary , Wynter Javelle , Reutemann Bethany , Shah Neeral 
Published: October 2019

INTRODUCTION:
Gastric antral vascular ectasia (GAVE) is a cause of chronic gastrointestinal bleeding and is often managed with upper endoscopic ablation. At our institution, ablation for GAVE or other gastric arterio-venous malformation (AVM) is carried out using either argon plasma coagulation (APC) or bipolar electrocautery. No prior study exists comparing the safety profiles of these two modalities. The aim of this study was to determine the rate of ulcer development following ablation therapy for GAVE or gastric AVM and compare the rate of ulcer formation in patients treated by APC versus electrocautery.

METHODS:
Retrospective chart review of patients who underwent endoscopic ablation of GAVE or gastric AVM with subsequent upper endoscopy between 2007-2017. The primary outcome was presence of ulcers on follow up endoscopy in the region previously ablated. Sub-group analysis of demographics, comorbidities, prescriptions and laboratory data at time of therapy was also completed to determine other risk factors. Statistical analysis of ulcer rates between groups were compared using the Chi-square model.

RESULTS:
Of the 139 patients treated for bleeding GAVE or gastric AVM, 81 (58%) received APC and 58 (42%) bipolar electrocautery. In total, 26 (19%) patients were noted to have ulcer on follow-up endoscopy. Eighteen (22%) of patients treated with APC developed ulcers compared to eight (14%) with electrocautery (P = 0.2). There were no significant differences in co-morbidities, medications or age between the groups. Notably, 76 (55%) patients had cirrhosis, of whom 16 (21%) developed ulcer compared with 10 (16%) patients without cirrhosis (P = 0.44). Among cirrhotic patients there was no significant difference in ulcer rates between APC and electrocautery (P = 0.7).

CONCLUSION:
Ulcer development after endoscopic ablation for treatment of GAVE or gastric AVM is not uncommon, occurring in 19% of patients. Difference in ulcer rates between APC and electrocautery was not statistically significant, indicating that the two endoscopic modalities carry equal risk of ulcer formation. Of the demographic, diagnostic, medication and lab variables analyzed, none were found to significantly increase risk of ulcer development. Only cirrhosis and thrombocytopenia, which are inherently coupled, showed any trend towards significance. We propose that APC and electrocautery are equally safe and may be employed to treat bleeding from GAVE or gastric AVM.
895 Comparison of Endosonographic Pancreatic Abnormalities Between Diabetics and High Risk Individuals for PDAC
Authors: Schwartz Ingrid , Vankawala Preksha , Satiya Jinendra 
Published: October 2019

INTRODUCTION:
Several predisposing factors for pancreatic ductal adenocarcinoma (PDAC) have been described. High risk individuals (HRIs) are defined by presence of significant family history (FH) or predisposing genetic mutations/syndromes. Studies have postulated that Diabetes Mellitus (DM) could also play a role in PDAC; however, this relationship is not yet fully elucidated. We aimed to identify the prevalence and distribution of pancreatic parenchymal and ductal changes during EUS of DM patients compared to HRIs.

METHODS:
We retrospectively reviewed EUS findings of patients with DM or with a significant FH of PDAC and/or a predisposing high-risk genetic mutation/syndrome (BRCA2, PALB2, CDKN2A, ATM, Lynch and Peutz-Jeghers Syndrome). Significant FH was defined as (1): 2 or more relatives with PDAC, including at least one first-degree relative (FDR); (2) 3 or more non-FDR with PDAC.

RESULTS:
100 patients were included: 78 in diabetes and 22 in HRI group (12 = significant FH, 7 = high-risk genetic mutations, 3 = Lynch Syndrome). Patient demographics are presented in Table 1. The mean number of EUS procedures was 1.25 ± 0.62 and mean interval between procedures was 299.3 ± 299 days. Pancreatic abnormalities on EUS were found in 47% of patients (Table 2). In HRI group, cysts was the commonest finding (9), out of which 7 had significant FH for PDAC. Cysts were consistent with Intraductal Papillary Mucinous Neoplasm (IPMN) in 8 patients. Pancreatic mass was evidenced in 3 cases, out of which 1 was found to be malignant. In DM group, the most frequent finding was lobularity (20), followed by main pancreatic duct (PD) dilation (8). Cysts were present in 4, with 1 malignant outcome. Mass was present in 4, with 2 diagnosed as PDAC and one as neuroendocrine tumor. When defined using the Rosemont classification, 3 patients had findings consistent with chronic pancreatitis, 2 in the DM group and 1 in the HRIs group. In the HRIs group, 8 patients underwent interval EUS, and new/additional pancreatic abnormality was seen in 1 patient. Nine patients in the DM group underwent interval EUS and 1 patient showed progression of changes.

CONCLUSION:
There is a clear difference in the most prevalent endosonographic findings in DM and HRI patient groups. Whereas cysts appear to be more prevalent in HRI for PDAC, diabetics have higher prevalence of lobularity on EUS examination. When available, repeat EUS examination demonstrated stable findings in almost all cases.
900 Efficacy and Safety of Endoscopic Full-Thickness Resection Device (FTRD) for Gastrointestinal Lesions Full-Thickness Resection: A Meta-Analysis Study
Authors: Fahmawi Yazan , Kumar Manoj , Shapira Gilad , Ludvik Nicholas , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Endoscopic full-thickness resection (EFTR) is an emerging minimally invasive resection procedure for GI lesions not amenable to conventional resection methods. Endoscopic full-thickness resection device (FTRD) is an over-the-scope single-step device that has been developed recently for EFTR. In this meta-analysis, we aim to assess efficacy and safety of FTRD for EFTR of GI lesions.

METHODS:
Methods: A comprehensive literature review was performed. Studies with < 5 cases were excluded. Rates of histologic complete resection (R0), technical success, and complications were extracted. Pooled estimates and the 95% CI were calculated depending on heterogenicity. Heterogenicity was assessed using I2 statistics.

RESULTS:
Nine studies (5 retrospective and 4 prospective) including 480 patients with 489 lesions were included. Indications were difficult adenomas (355), early carcinoma (82), and subepithelial lesions (SEL) (47). Locations of the lesions: stomach (5), duodenum (20), proximal colon (220), distal colon (98), and rectum (141). 57% of patients were male with median of age 66.5 years (range 20-92). Mean size of the lesions was 15.36 mm (range 1-40). Median procedure time was 46.56 minutes (range 3-190). Mean hospital stay was 3.23 days (range 0-11). Pooled overall R0 resection rate and technical success rate were 81.12% (95% CI: 77.63-84.6; I2 56.7%) and 90.39% (95% CI: 87.76-93.00; I2 10.2%), respectively. The pooled R0 resection rate was 81.59% (95% CI: 76.96-85.63) for difficult adenomas, 83.47% (95% CI: 73.19-91.00) for early carcinomas, and 81.59% (95% CI:68.25-91.05) for SELs. For locations; R0 resection rate were 78.42% (95% CI: 72.17-85.50), 76.97% (95% CI: 62.56-87.88), and 80.59% (95% CI: 67.56-90.09) for proximal, distal colon, and rectum, respectively. The complications were as follows: minor bleeding 2.89 (95% CI: 1.60-4.76), major bleeding 0.88 (95% CI: 0.26-2.15), perforation 2.23% (95% CI: 1.12-3.95), postpolypectomy syndrome 1.26% (95% CI: 0.48-2.68), local trauma 0.9% (95% CI: 0.27-2.19), and other complications 1.91% (95% CI: 0.90-3.54). Of 50 patients with peri-appendicular lesion, the rate of appendicitis was 14.29% (95% CI: 6.38-26.23). The rate of complications that required surgery was 1.55 (95% CI: 0.66-3.06). No procedural death related was found. There was no correlation between mean lesion’s size and complications rates

CONCLUSION/DISCUSSION:
FTRD is a safe and effective procedure for lesions not suitable for conventional resection.
908 Diagnostic Value of Semi-Quantitative Endoscopic Ultrasound Elastography in the Evaluation of Mediastinal and Abdominal Lymph Nodes
Authors: Cazacu Irina M. , Singh Ben S. , Gonzalez Graciela Nogueras , Luzuriaga Chavez Adriana A. , Saftoiu Adrian , Bhutani Manoop S. 
Published: October 2019

INTRODUCTION:
An accurate differentiation between benign and malignant lymph nodes (LN) is crucial for staging, risk stratification and treatment selection in patients with gastrointestinal malignancies. Endoscopic ultrasound (EUS) elastography can offer additional information that enables a better tissue characterization, enhancing the diagnostic power of EUS. The aim of this study was to evaluate the accuracy of the qualitative elasticity scores (ES) and semi-quantitative strain ratio (SR) for the diagnosis of abdominal and mediastinal LNs.

METHODS:
Consecutive patients referred for EUS evaluation of a mediastinal or abdominal LN by a single endosonographer (MSB) at a tertiary cancer center between January 2018 and May 2019 were included in the study. Elasticity scores (Table 1) and SR were determined during EUS exam. The final diagnosis was obtained by EUS-FNA cytology evaluation, surgical pathologic examination or clinical follow up.

RESULTS:
A total of 45 patients undergoing EUS evaluation of 70 LNs (40 benign, 30 malignant) were included in the analysis. According to the qualitative ES, the elastography images were interpreted as benign in 18 cases, malignant in 33 cases and indeterminate in 19. ES alone had a sensitivity of 100% and a specificity of 60% (Table 1). Based on the ROC curve analysis results, the best cut-off of SR to obtain the maximum area under the curve was 18.9, with a sensitivity of 47% and specificity of 85%. When both ES and SR were considered, the sensitivity was 100% with a specificity of 60% and negative predictive value of 100%.

CONCLUSION:
EUS elastography represents a promising method that allows the differential diagnosis of benign and malignant LN and it is complimentary to EUS-FNA. Given the high negative predictive value, EUS-elastography can decrease the number of unnecessary biopsies. The elasticity score and SR may be useful in patients with negative EUS-FNA results or in case in which a biopsy is not feasible.
915 A Comparison of Endoscopic Submucosal Resection (EMR) vs. Endoscopic Submucosal Dissection (ESD) on Histologic Margins and Pathologic Evaluation for Endoscopically Managed Early Esophageal Adenocarcinoma
Authors: Mehta Neal , Robertson Scott , Young Andrew , Bahdi Firas , Li Feng , Cruise Michael , Vargo John , Jang Sunguk , Murthy Sudish , Bhatt Amit 
Published: October 2019

INTRODUCTION:
Accurate histologic determination is important to determine the completeness of endoscopic resection for esophageal adenocarcinoma (EAC) and gauge risk of recurrence. EMR and ESD are both endoscopic resection techniques used for the treatment of early EAC. ESD advocates believe ESD specimens allow for more precise histopathologic analysis than EMR, but this has never been proven. We aim to determine the effect of EMR vs ESD techniques on histologic analysis in endoscopically treated early EAC.

METHODS:
This is a retrospective, single center study of EMR and ESD resection specimens with pathologic confirmation of HGD or T1 EAC between 1/15-12/18. Lesions with suspected invasion into the muscularis mucosa or beyond (T2 carcinoma or higher) were excluded. Endoscopic and histologic characteristics were collected. Pathology slides were re-analyzed by a blinded GI pathologist for typical pathologic features.

RESULTS:
52 patients with early EAC were analyzed (23 ESD;29 EMR) [Table 1]. ESD-resected tumors were larger compared to those resected by EMR (20 mm [20.0, 28.0] vs 11 mm [9.0, 13.0], P < 0.001) [Table 2]. As per Table 3, EMR specimens were more likely to have positive lateral margins compared to ESD (38% vs 13%, P < 0.005) and have lower confidence in determining lateral margins. Reasons for lower confidence in the EMR group included cautery artifact (37.9%) and difficulty in orientation (20.7%). When accounting for differences in specimen thickness, EMR had a higher percentage of cauterized tissue per total tissue thickness (11.8% vs 3.9%, P < 0.001). EMR specimens had cautery effect abutting the lesion while ESD did not (0 μm vs 2259 μm distance of lesion from nearest cautery, P = 0.001). Cautery effect was more likely to interfere with margin evaluation in EMR (38% vs 13%, P = 0.04). ESD specimens were well-oriented compared to EMR (P = 0.011). EMR and ESD had no difference in positive vertical margins (7% vs 9%, P = 0.33), lymphovascular invasion (P = 0.11), or submucosal invasion (P = 0.62).

CONCLUSION:
Cautery effect and the inability to orient the specimens appropriately play a role in limiting the evaluation of EMR specimens. EMR and ESD had similar rates of positive vertical margins but rates of positive lateral margins were significantly higher in EMR, despite a smaller lesion size resected with EMR. We postulate that this is a limitation of EMR technique and there is a certain lateral size that is unsuitable for EMR as it may not be able to resect enough of a “normal” margin to the tumor compared to ESD.
919 Outcomes of Endoscopic Ultrasound Directed Trans-Gastric ERCP (EDGE): A Single Center Experience
Authors: Gutta Aditya , Patel Harsh K. , Watkins James L. , Sherman Stuart , DeWitt John , Lehman Glen , Fogel Evan L. , Easler Jeffrey J. , Gromski Mark A. , Bick Benjamin L. , Al-Haddad Mohammad 
Published: October 2019

INTRODUCTION:
ERCP can be difficult in patients with Roux-En-Y foregut anatomy due to difficulty accessing the papilla, where balloon-assisted enteroscopy or laparoscopy based access has been used. Endoscopic ultrasound directed trans-gastric ERCP (EDGE) allows access to the excluded stomach via a lumen apposing metal stent (LAMS) from the gastric pouch, and passage of the duodenoscope in standard anatomical fashion. Early studies demonstrated high technical and clinical success rates of EDGE with few major adverse events (AEs). We aimed at describing rates of technical and clinical success and AEs of EDGE, impact on patients’ weight and incidence of persistent gastro-gastric fistulae (GGF).

METHODS:
This is a single center retrospective analysis of a prospectively collected database. All patients who underwent EDGE from 06/2018 to 05/2019 were included. AEs were defined per ASGE lexicon. Descriptive statistical analysis was used to assess outcomes.

RESULTS:
Nineteen patients were included in the study [mean age 59.4 years (SD = 10.7); 79% females, Table 1]. Two additional patients with spontaneous GGF noted at planned EDGE had no LAMS placed and were excluded. Choledocholithiasis was the most common indication (7/19, 37%), with three associated with cholangitis. Technical success for EUS guided LAMS placement/GGF creation was 100% (Hot AXIOS, 15 mm × 10 mm) with a mean procedure time of 26.8 (SD = 10) minutes and no major AEs. Same session ERCP was done in 2/19 (10%) with LAMS anchoring and 17/29 ERCPs (90%) performed a mean 5.5 (SD = 4.9) days after LAMS placement with a diagnostic duodenoscope (18/19, 95%) most commonly used. Mean ERCP time was 38.7 (SD = 4.9) min with a technical and clinical success of 95% (18/19). Two ERCP-related moderate adverse events occurred managed endoscopically and conservatively. LAMS were removed within 4 weeks of last ERCP, with APC +/- endoscopic suturing in 13/16 (81%) with 100% technical success of endoscopic closure. There was no weight gain noted on a mean follow up of 11.3(SD = 9) weeks. GGF resolution was confirmed in 5/16 with CT (1/5), Upper GI Series (2/5) or upper endoscopy (2/5) done in 6 months of GGF closure with other patients yet to reach the 6-month time-frame (Table 2).

CONCLUSION:
EDGE is an effective procedure for patients with Roux-en-Y foregut anatomy, with acceptable safety profile and low risk of persistent GGF or weight gain in this series. Further prospective studies are needed to assess the long-term safety, in regards to weight gain and persistence of GGF.
930 Same Day Discharge After Peroral Endoscopic Myotomy versus Overnight Observation
Authors: DiJoseph Kara , Manzo Carl , Mathew Abraham 
Published: October 2019

INTRODUCTION:
Achalasia is a spastic motility disease of the esophagus, characterized by aperistalsis and a nonrelaxing lower esophageal sphincter. Since this disorder impacts individual’s quality of life drastically, more treatment modalities have emerged to help relieve patients’ discomfort; the most recent palliative treatment discovered being the Peroral Endoscopic Myotomy, a non-invasive procedure to alleviate hypertonicity at with the lower esophageal sphincter. With any new procedure, there is a high risk of complications including perforations and pneumothoraces that could lead to a lengthy post-operative stay. As time goes on, we are learning that this method maybe safer than we originally thought.1,2

METHODS:
Utilizing the electronic medical record and with IRB approval, we analyzed 149 patients who underwent POEM procedure. Readmission rates were compared between patients who were discharged to those who were kept overnight.

RESULTS:
149 patients underwent POEM in the study periodbetween September 23, 2013 and March 1, 2019. Same day discharge was standard in February 2017; 59 of those patients were discharged after the POEM the same day.

CONCLUSION:
POEM has been established as a very successful alternative treatment for severe achalasia that is minimally invasive compared to a surgical myotomy. It comes with many risks including pneumoperitoneum and esophageal perforation as seen in the early studies. This study effectively demonstrated the safety of same day discharge with zero people requiring readmission. In conclusion, same day discharge after a POEM is relatively safe to the general population and does not require post-operative admission for surveillance.2,3
931 Surveillance of Duodenal Carcinoids and the Importance of Tumor Margins: A Single Center Retrospective Study at the Moffit Cancer Center
Authors: Mony Shruti , Klapman Jason 
Published: October 2019

INTRODUCTION:
The incidence of gastrointestinal neuroendocrine tumors (GI-NETs) is increasing in recent times reflecting the widespread use of endoscopy, and an increased awareness among clinicians. Duodenal carcinoids are rare and accounting for 1%-3% of primary duodenal tumors. Duodenal carcinoids < 10 mm in size and limited to the submucosal layer are amenable for endoscopic resection. Despite the increase in incidence, the natural history of duodenal carcinoid tumors has not yet been well defined. The aim of our study was to evaluate the recurrence rate following endoscopic resection of well differentiated duodenal carcinoid tumors from 2006-2016 at our institution.

METHODS:
We performed a retrospective analysis on 39 patients who underwent endoscopic resection of duodenal carcinoids from 2006-2016 at the Moffitt Cancer Institute. The indications for endoscopic resection were lesions ≤ 10 mm in diameter, confined to the submucosal layer, and without lymph node or distant metastasis. Endoscopic resection was accomplished using endoscopic mucosal resection (EMR) and biopsy forceps. The patients were followed for a mean of 3 years.

RESULTS:
Among the 39 patients meeting criteria for endoscopic resection, 28 patients underwent surveillance endoscopies post EMR and were included in final analysis . EMR was performed in 12 tumors while biopsy forceps resection in 11 patients. Pathological complete resection(R0) was achieved in 20 patients (71%), without evidence of recurrence in 9 (45%) patients followed for at least 3 years and in the 11(55%) patients followed for lesser than 3 years. On the contrary, in the 8 patients (28%) had recurrence in the 3 year follow up period of which that was recurrence,6 (75%) had either positive lateral or deep margins on initial resection (Table 1). There were no post procedural complications in any of the patients in the follow up period.

CONCLUSION:
Endoscopic resection appears to be a safe and effective treatment for duodenal carcinoid tumors measuring ≤ 10 mm in diameter and confined to the submucosal layer. This retrospective study showed that the main predictor of recurrence is the presence of positive tumor margins at initial resection. Patients with negative and margins had no recurrences in the 3 year follow up period, thus alleviating the need for long term surveillance in this patient population. Larger multicenter studies are required to determine the optimal surveillance stragey in patients undergoing endoscopic resection of duodenal carcinoid tumors.