bluuebunny/crossref_metadata_2025_split huggingface dataset:
439 Risk of Air Leak and Mucosal Injury in Esophageal POEM After Prior Myotomy
Authors: Samo Salih , Jain Anand , Hamo Falak , Abdelfatah Mohamed Magdy , Xia Liang , Chen Huimin , Patel Vaishali , Mekaroonkamol Parit , Keilin Steven , Cai Qiang 
Published: October 2019

INTRODUCTION:
Peroral endoscopic myotomy (POEM) is deemed to be more challenging with more periprocedural adverse events. We aimed to assess the risk of air leak and mucosal injury in POEM after prior myotomy (Heller’s myotomy [HM] or POEM), the Redo POEM, in addition to extubation time when air leak occurs.

METHODS:
A retrospective study comparing Redo POEM to an index POEM at a tertiary center from March 2016 to August 2018. Table 1 summarizes the data collected. Air leak was defined by subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, and/or pneumothorax documented by physical exam and/or imaging. Difficult procedures were determined by endoscopist impression as challenging or based on difficulty creating submucosal tunnel and/or difficulty performing myotomy.

RESULTS:
We identified 21 cases of Redo (1st myotomy: HM in 8/21, POEM in 13/21) and 56 cases of index POEM. One case had two prior HMs and two cases had HM and POEM each before Redo POEM. The results are summarized in Table 1. The Redo group was younger with more difficult procedures encountered, shorter myotomy length (due to difficulty with myotomy) and longer procedure time. There were more mucosal injuries with more clips used to close them in the Redo group. Short myotomy (≤5 cm) was performed in 5 cases in the Redo group (23.8%) and 5 cases in the index POEM (8.9%). There was a trend toward more air leak in the Redo group, but it was not statistically significant. Air leak was seen in 14/77 (18.2%) cases in the study. Extubation time was longer in cases with air leak (Table 2). Postprocedural symptoms did not predict air leak. Procedure difficulty did not predict air leak or mucosal injury. No intervention was required for air decompression and there was no ICU admission pertinent to air leak or mucosal injury in either group.

CONCLUSION:
Redo POEM appears to be more challenging, takes longer time to perform with a shorter than intended myotomy. Mucosal injuries are more common and more clips are used to close them. Air leak tends to be higher in Redo POEM, but not statistically significant. The incidence of air leak was likely underestimated as imaging was not routinely obtained for all procedures. Air leak is associated with a slight delay in postprocedural extubation time, but it does not appear to affect the overall procedural outcomes or prolong hospitalization. Postprocedural symptoms and procedure difficulty did not predict air leak or mucosal injury.
448 Wide Area Transepithelial Sampling (WATS) Augments Detection of Barrett’s Esophagus and Associated Dysplasia in Patients With a Hiatal Hernia
Authors: Smith Michael S. , Odze Robert 
Published: October 2019

INTRODUCTION:
Detection of BE and associated dysplasia is important prior to referral for endoscopic surveillance or treatment. Use of WATS with computer-assisted analysis, as an adjunct to forceps biopsy (FB), has been shown to markedly improve detection of both BE and dysplasia in both screening and surveillance cohorts (CDx Diagnostics, Suffern NY). Our aim was to assess the effect of a hiatal hernia (HH), a condition that leads to difficulty in performing routine forceps biopsies, on the utility of WATS in detection of BE and dysplasia.

METHODS:
Patients enrolled in IRB-approved trials where both FB and WATS were performed in the same endoscopy were eligible for inclusion. Cases were excluded if prior endoscopic ablation was documented. Data, including length of salmon-colored mucosa (SCM), HH size, FB and WATS results were aggregated and de-identified prior to analysis.

RESULTS:
A total of 4677 patients met study criteria (Table 1). For the entire cohort, the adjunctive yield for WATS in addition to FB was 111% for detection of any BE as well as associated dysplasia. Additional BE detection was less in the presence of a clinically significant hiatal hernia (HH) measuring at least 2 cm in axial length (116% vs 79% for any BE, P < 0.0001). However, augmented dysplasia detection remained constant at 111%. There was no significant change in detection of additional BE as hernia size increased in length (87% for HH< 2 cm, 81% for HH 2-4 cm, 72% for HH >4 cm). Of note, dysplasia detection rates increased with the length of SCM regardless of HH size (80% for < 1 cm, 120% for 1-3 cm, and 133% for 3+ cm), though there were insufficient dysplastic cases to reach statistical significance. Upstaging of non-dysplastic to dysplastic BE occurred when WATS was used regardless of HH size, with significantly higher rates for BE segments at least 3 cm in length (2% vs 14%, P = 0.0012). Similarly, the rate at which NDBE was upstaged to dysplastic BE by WATS was significantly higher when a HH was 2 cm or greater in length (2.17% vs 9.47%, P = 0.013).

CONCLUSION:
WATS improves the diagnostic yield of both BE and associated dysplasia above that achieved with FB, regardless of the presence or absence of a HH. Sampling the distal esophagus with FB above a HH can be technically challenging. WATS may provide the endoscopist with an easier and more effective means of confirming a BE diagnosis and identifying associated dysplasia.
451 Lower Basal Esophagogastric Junction Pressures Associated With Regurgitation Severity
Authors: Lalehzari Mona , Chaudhuri Subhajyoti , Gaeta Marina , Nguyen Mytien , Ryabtsev Roman , Masoud Amir , Sanchez Mayra 
Published: October 2019

INTRODUCTION:
It is thought that regurgitation is brought on by changes in esophageal pressure ultimately causing a transient relaxation in the lower esophageal sphincter (LES) with resultant regurgitation. However, it is unknown if the severity of regurgitation symptoms experienced by a patient are related to the basal LES pressure. Our hypothesis is that patients with more severe regurgitation symptoms have lower basal LES pressures.

METHODS:
A retrospective chart review was completed on all patients referred to our tertiary care hospital for esophageal manometry testing with impedance in 2016. Basal LES pressure (as measured on manometry), regurgitation severity (as reported on pre-manometry patient questionnaire), age, and sex were recorded for each patient. Only patients who reported both regurgitation symptoms and specified severity were included in the final analyses. Mean LES pressures were compared between regurgitation severities and P-values were calculated for all pairwise comparisons.

RESULTS:
Of the 354 patients referred for manometry, 167 patients (41 males, mean age 54.6; 126 females, mean age 55.6) endorsed regurgitation. Of those 167 patients, 62 reported their symptoms as “mild”, 61 as “moderate”, 29 as “severe”, and 15 as “very severe”. The average LES pressure was 33.22 mmHg for those with mild regurgitation, 27.98 for moderate, 23.94 for severe, and 19.02 for very severe (P = 0.03). There was also a statistically significant difference in LES pressures between mild and severe regurgitation (P=0.03) and mild and very severe regurgitation (P = 0.01).

CONCLUSION:
Overall, it is known that transient relaxations in LES pressure lead to regurgitation. However, we aimed to assess if there is a difference in basal LES pressures amongst patients who experience regurgitation symptoms, as perhaps a lower basal pressure makes a patient more prone to experiencing more severe regurgitation. There was a statistically significant difference in basal LES pressures amongst patients with varying severities of regurgitation. Future studies should look at pH testing to note if there is an actual increase in proximal acid exposure in patients with lower basal LES pressures and more severe regurgitation.
455 Esophageal Granular Cell Tumors: A Retrospective Institutional Analysis
Authors: Baba Tilak R. , Woo Stephanie , Shafa Shervin , Rastogi Pawan 
Published: October 2019

INTRODUCTION:
Granular Cell Tumor (GCT) is generally a benign neoplasm derived from Schwann cells. Less than ten percent of GCTs are found in the gastrointestinal (GI) tract and most common site in the GI tract has been reported to be the esophagus. The current existing literature is limited. Given the rarity of these lesions, the management of GCTs remain a clinical challenge for gastroenterologists. Here we present a case series of thirteen esophageal GCTs and their characteristics, diagnosis and management.

METHODS:
We conducted a retrospective review of all cases of pathologically confirmed GCTs from 2010 to 2018 at our institution from our endoscopic pathology database. Data were collected regarding demographics, endoscopic, endosonographic appearance and presence of any malignant transformation.

RESULTS:
Thirteen total patients were identified. Mean age was 43.6 years. Six patients were females. All esophageal lesions were noted to be in the mid-distal esophagus. Majority of the lesions were subcentimeter. Mean size of the lesions was 8.2 mm. Most common endoscopic features were nodularity (11/13 cases) and white-yellow appearance (8/13). Endoscopic ultrasound (EUS) was conducted in 11/13 cases and the lesions appeared hypoechoic in the majority of cases (6/11). Extension of the lesion was limited to the submucosa in all except one case. Endoscopic mucosal resection (EMR) was performed in 8/13 cases. Pathologic diagnosis of GCT was confirmed using immunohistochemical stain of S100 in 8/13 cases. None of the cases showed any evidence of malignancy from the initial endoscopic resection or biopsies.

CONCLUSION:
Our institutional review of esophageal cases of GCTs not only highlights the rarity of GCTs, but provides endoscopic and endosonographic features of esophageal GCT. Based on our cohort of patients, GCTs most commonly present in mid-distal esophagus with a white-yellowish hue. Patients are generally asymptomatic. EUS findings suggest lesions are hypoechoic and arise from the submucosal layer. Given this location, lesions can be removed in entirety through EMR, which will also allow for greater depth of resection. Overall, mucosectomy may serve as an adequate modality for removal of these apparent benign lesions. Our preliminary finding delineates the success of en bloc resectability of esophageal GCTs less than 2 cm in size. Additional studies would be needed to better establish a more definitive management algorithm of esophageal GCTs and the role of endoscopic mucosal resection.
456 Impact of Endoscopic Surveillance on Detection of Dysplasia Progression in Patients With Barrett's Esophagus Who Have Undergone Complete Eradication of Intestinal Metaplasia
Authors: Um Phoebe S. , Chan Megan Q. , Walker Jon P. , Perry Kyle A. 
Published: October 2019

INTRODUCTION:
Barrett's esophagus (BE) affects up to 15% of patients with gastroesophageal reflux disease and poses high risk of progression to esophageal adenocarcinoma (EAC). While radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR) are effective treatments for dysplastic BE, risk of recurrence remains even after complete eradication of intestinal metaplasia (CEIM). Currently, endoscopic surveillance intervals after RFA ± EMR are informed only by expert opinion and weak evidence. It is unclear if current guidelines are cost-effective or suitable for all patients. The purpose of this study is to assess for variation in surveillance intervals and rates of recurrence in BE patients with high grade dysplasia (HGD).

METHODS:
A retrospective review of medical records was performed for 70 BE patients who underwent RFA ± EMR for biopsy-proven HGD between January 1, 2010 until November 30, 2018 and received at least 1 surveillance endoscopy with biopsies at 1 year after completion of treatment. These patients were analyzed for adherence to the ACG guidelines of an endoscopy every 3 months for the first year after treatment and for recurrence of dysplasia or development of EAC.

RESULTS:
At 1 year post treatment completion, CEIM was achieved in 48.6% of patients and non-dysplastic BE was achieved in 32.9% of patients. The average time between the first 4 surveillance intervals was 5.5 months. 14 of 70 patients were adherent to ACG guidelines, and 56 received endoscopies less frequently than recommended. Of the 14 patients who were adherent, 6 developed recurrent dysplasia (1 low grade dysplasia (LGD), 4 HGD) and 1 developed T1b carcinoma at one year. Of the 56 patients who received surveillance endoscopies less frequently than recommended, 7 developed recurrent dysplasia (4 LGD, 3 HGD) at one year.

CONCLUSION::
Adhering to ACG surveillance guidelines following RFA±EMR treatment for HGD is difficult and requires close attention to the scheduling of these BE patients. Although our sample size is small, our study showed that the recurrence of dysplasia was not significantly reduced in individuals that were adherent to the ACG guidelines when compared to those that received surveillance less frequently than recommended. Further studies are needed to inform the development of evidence-based guidelines that identify recurrence or progression of dysplastic BE early, while minimizing the costs of over-surveillance.
461 Obstructive Sleep Apnea Is Associated With an Increased Risk of Barrett's Esophagus
Authors: Hadi Yousaf , Naqvi Syeda Fatima , Khan Adnan Aman , Kupec Justin T. 
Published: October 2019

INTRODUCTION:
Current guidelines suggest screening at-risk groups of patients for Barrett's esophagus (BE), a precursor to esophageal cancer. Although BE and obstructive sleep apnea (OSA) have common risk factors, including elevated body mass index (BMI) and gastroesophageal reflux disease (GERD), the relationship between these two conditions has not been well established.

METHODS:
Retrospectively, all patients who had undergone a polysomnography and esophagogastroduodenoscopy (EGD) at West Virginia University Hospital from 2013 to 2018 were identified and divided into groups based on the presence or absence of OSA. Clinical course and procedure reports were reviewed to identify relevant variables.

RESULTS:
1091 patients met inclusion criteria. 60.9% were female, and mean age of participants was 53.5 years. Univariate analysis revealed that male gender, age, diagnosis of OSA, severity of OSA, and a clinical diagnosis of GERD were associated with Barrett's esophagus (P values < 0.05). Multiple logistic regression incorporating age, sex, clinical diagnosis of GERD, smoking history, BMI, Helicobacter pylori status, and presence of hiatal hernia was utilized. Patients with OSA had an increased risk of Barrett's esophagus when compared with those without OSA [P < 0.001, Odds Ratio 3.26 (1.72-6.85)]. The risk increased with increasing severity of OSA, categorized in apnea-hyponea index increments of 10. In a separate multivariable regression model where OSA was graded in AHI increments of 10, an increased risk for Barrett's esophagus with every 10 point increase in AHI was found (OR 1.10, 95% CI: 1.02 – 1.19). BMI, evaluated in increments of 5, was not associated with BE. The association of OSA with BE remained unchanged in a separate model incorporating a binary variable with BMI of greater than 30 used as a surrogate for central adiposity.

CONCLUSION:
OSA is associated with Barrett's esophagus, a relationship that is independent of other known risk factors. Additionally, this risk increases with increasing severity of OSA. Future efforts should determine if patients with severe OSA need to be screened for Barrett's esophagus due to its potential for causing esophageal cancer.
464 The Burden of Chronic Gastrointestinal Diseases Among the Uninsured: A Free Clinic Study
Authors: Song Ethan , Aponte Alexandra , Swanson Justin , Patel Artish , Shah Nirav , Segarra Daniel , MacDonald Madeline , Mirza Abu-Sayeef 
Published: October 2019

INTRODUCTION:
Uninsured and under-insured patients with high comorbidity burden are associated with high costs and high needs. GI diseases make up a significant portion of comorbidity burden and annual health expenditures. There is limited data on GI illnesses among the uninsured. The objective of this study is to do a preliminary evaluation of the burden of chronic GI illness in the uninsured community of Tampa Bay, Florida.

METHODS:
A retrospective query of an IRB approved database of 5076 patients seen across nine free clinics in the Tampa Bay area in 2017 revealed 760 patients with GI illness. Demographics, substance abuse, prevalence of GI illnesses including GERD, metabolic syndrome, irritable bowel syndrome, inflammatory bowel disease, ulcers, hemorrhoids, hepatitis, chronic liver disease, gallstones, and pancreatitis, were analyzed. Statistical analysis was performed with R 3.5.3.

RESULTS:
GI patients had a preponderance to be female (62.5%) and Hispanic (57.0%). GERD was the most prevalent condition (13.5%) followed by chronic liver disease (3.6%), GI ulcer (3.2%), hemorrhoids (2.2%), hepatitis C (1.6%), metabolic syndrome (1.5%), gallstones (1.2%), inflammatory bowel syndrome (1.0%), pancreatitis (0.6%), hepatitis B (0.4%), Crohn's disease (0.1%), and hepatitis A (0.1%). Most patients with GI illness have had a history of smoking (34.4% vs. 21.9%, P < .001) or alcohol consumption (30.2% vs. 24.1%, P < .001). Patients with chronic GI illness had more average visits per year than those who did not have chronic GI illness (3.7 vs 2.2 visits per year, P < 0.001). Compared to patients without GI illness, patients with GI illness were older (Mean: 48.7 vs. 39.8 years, SD: 13.1 vs. 17.1, P < .001).

CONCLUSION:
Patients with chronic GI illness tended have more clinic visits, were more likely to have a comorbid history of smoking and alcohol consumption, and were older than those without GI illness. More education and preventative resources should be directed toward the most common GI illnesses such as GERD, chronic liver disease, and ulcers. Further evaluation of the low-income community is required to identify community level solutions and management strategies for chronic GI illness.
467 Human Milk Oligosaccharides Improve All the Central Symptoms of Irritable Bowel Syndrome: A Multi-Center, Open Label Trial
Authors: Palsson Olafur S. , Peery Anne , Seitzberg Dorthe , Amundsen Ingvild D. , McConnell Bruce , Simrén Magnus 
Published: October 2019

INTRODUCTION:
Altered gut microbiota is increasingly seen as a potential factor in irritable bowel syndrome (IBS) pathophysiology. Human milk oligosaccharides (HMOs) have been shown in healthy adults to increase the abundance of bifidobacteria, which are reported to be depleted in IBS. HMOs may also have beneficial impact on gut motility and visceral pain. We conducted a multi-center, open label trial in patients with IBS (Rome IV criteria plus physician diagnosis) to assess the potential for HMOs to support normal bowel habits and improve other bowel symptoms of IBS.

METHODS:
Subjects were recruited from 17 sites across the United States. The subjects took 5 grams of the HMOs 2'fucosyllactose (2'FL) and lacto-N-neotetraose (LNnT) in a 4:1 mix daily by mouth for 12 weeks. Bowel habits, IBS symptoms and quality of life were assessed at baseline and every 4 weeks during the intervention. Results were analyzed with Intention-to-Treat (ITT) methodology (last observation carried forward for non-completers), using repeated measures Analysis of Variance.

RESULTS:
A total of 317 subjects (70.7% females; mean age 44.0 years, range 18-93 years) received the study product; 136 with constipation predominant, 85 with diarrhea predominant, 95 with mixed, and 1 with unspecified IBS. The full 12-week intervention was completed by 245 subjects. In the ITT analyses, the subjects showed a significant reduction from baseline to 12 weeks in total percentage of abnormal bowel movements (Bristol Stool Form Scale types 1, 2, 6, or 7), overall IBS Symptom Severity Score, abdominal pain severity and bloating severity, as well as improvement in health-related quality of life (see Table 1 and Figures 1 and 2). Most of the symptom improvement occurred in the first 4 weeks of intervention. Younger age was predictive of greater improvement in stool consistency and abdominal pain severity. The study product was well tolerated by most patients. The only common side effects were mild GI symptoms such as abdominal discomfort, distension and flatulence.

CONCLUSION:
Our findings suggest that oral supplementation with 2'FL and LNnT can provide nutritional support that significantly reduces abnormal stool consistency, abdominal pain and bloating and improves health-related quality of life in IBS sufferers of all subtypes. However, the results from this open label trial need to be followed up by a randomized controlled trial.
472 Impact of Plecanatide on Symptoms and Quality of Life for Patients With Chronic Idiopathic Constipation: Analysis of PAC-SYM and PAC-QOL From Two Phase III Clinical Trials
Authors: Brenner Darren M. , Franklin Howard , Sayuk Gregory S. 
Published: October 2019

INTRODUCTION:
Plecanatide, a 16-amino acid analog of human uroguanylin, activates guanylate cyclase-C receptors in the small intestine in a pH-sensitive manner to induce fluid secretion and peristalsis. This analysis looks at whether plecanatide improved global symptoms and health-related quality of life (HRQOL) in patients with chronic idiopathic constipation (CIC) from 2 large-scale, randomized, double-blind, placebo-controlled, phase 3 studies.

METHODS:
Patients (N = 2683) who met modified Rome III criteria were randomized to placebo, plecanatide 3mg, or 6mg QD for 12 weeks and included in the phase 3 intention-to-treat populations. Baseline characteristics were comparable between groups and across studies. CIC symptoms and HRQOL were evaluated using the Patient Assessment of Constipation–Symptoms (PAC-SYM) and Patient Assessment of Constipation–Quality of Life (PAC-QOL) scales, respectively. The PAC-SYM measured patients' constipation symptom experience and severity over time, including abdominal, rectal, and stool symptoms of constipation. The PAC-QOL evaluated patients' HRQOL perceptions with constipation and rated patients' worries and concerns, physical discomfort, psychosocial discomfort, satisfaction, and overall effects on HRQOL. Scales were rated from 0 to 4 with reductions in scores indicating improvement. Efficacy analyses evaluated each plecanatide dose vs placebo.

RESULTS:
Statistically and clinically significant improvements in PAC-SYM (∼ −0.75-point changes; Table 1) and PAC-QOL (∼ −1.0-point change; Table 2) were observed at Weeks 4, 8, and 12 for both plecanatide 3 mg and 6 mg vs placebo across both studies. Plecanatide-treated patients reported significant improvements vs placebo in all PAC-SYM domain scores, except in Study 2 for abdominal symptoms. Significant improvements in plecanatide arms vs placebo were seen in 3 of 4 PAC-QOL domain scores (worries and concerns, physical discomfort, satisfaction). The most common adverse event (AE) was diarrhea (3 mg, 4.6%; 6 mg, 5.1%; placebo, 1.3%). Discontinuation rates due to AEs were 4.1% (3 mg), 4.5% (6 mg), and 2.2% (placebo), with low discontinuation due to diarrhea (3 mg, 1.9%; 6 mg, 1.8%; placebo, 0.4%).

CONCLUSION:
Patients who received plecanatide 3mg and 6mg had statistically and clinically significant improvements in global constipation symptoms and HRQOL at all measured time points. Plecanatide treatment was associated with a low incidence of AEs and was well tolerated.