bluuebunny/crossref_metadata_2025_split huggingface dataset:
377 Histologic Response to Steroids in Eosinophilic Esophagitis Is Dependent on Dose and Delivery Compound
Authors: Schupack Daniel A. , Johnson Kimberly , Akambase Joseph A. , Geno Debra , Lavey Crystal , Ravi Karthik , Katzka David A. , Alexander Jeffrey A. 
Published: October 2019

INTRODUCTION:
Histologic response rates to steroids for eosinophilic esophagitis (EoE) vary from < 50% to >90% in controlled trials. We have used varied steroid preparations and higher doses than typically used and aimed to study if steroid dose and delivery vehicle might explain the wide variation in response.

METHODS:
A database of patients with EoE created in our esophageal clinic was reviewed and patients treated with at least an 8 week course of topical steroid therapy and undergoing pre and post-steroid histologic evaluation were included. Histologic remission was defined as eosinophil count < 15/hpf. Symptomatic remission was defined as complete resolution of symptoms and eating an unlimited diet. Endoscopy reports were reviewed.

RESULTS:
94 patients were included, 45 on 3 mg budesonide-Rincinol gel twice daily (HBRG), 29 on 3 mg budesonide capsules BID (BC), and 20 on lower doses of BRG (1.5 mg daily to 2 mg BID) (LBRG). 88.5% had dysphagia at time of steroid initiation. Mean eosinophil count before steroids was 58.6/hpf. 38.3% had esophageal dilation just prior to steroids. Average EFERS prior to steroid treatment was 1.8. There were not significant differences between the groups in terms of demographics, initial eosinophil counts, symptoms, visual EoE assessment (EREFS) or dilation rates. Histologic remission rate for HBRG was 82.2% vs 55.1% for all others combined (P < 0.001), 51.7% for BC (P = 0.005 vs 3 mg BRG BID), and 60.0% for LBRG (P = 0.06 vs 3 mg BRG BID). Symptomatic remission was similar between groups, as was change in EREFS and change in eosinophil counts. Non-responders to HBRG had mean decrease in eosinophil count of only 0.3/hpf (vs 53.2/hpf for responders, P < 0.003) and mean change in EREFS of +1.6 (vs −1.1 for responders, P < 0.001). 62.5% of non-responders to HBRG actually had increase in eosinophil count after steroids. Response rate to HBRG at < 5 eos/hpf was 77.8% overall and 94.6% in those achieving remission.

CONCLUSION:
A higher remission rate achieved with a more viscous steroid preparation compared to other formulations suggests the importance of both dose and esophageal delivery in treatment of EoE. Further, with adequate mucosal delivery and dosing of topical steroids, steroid refractory EoE appears to be uncommon. On the other hand, these results suggest the existence of a small truly steroid refractory group of EoE patients with negligible histologic, symptomatic and endoscopic response to high dose steroids that warrant further investigation.
379 Safety and Efficacy of Peroral Endoscopic Myotomy (POEM) in Patients ≥ 65 Years at a Single Academic Tertiary Care Center
Authors: Klair Jagpal S. , Hasan Yazan , Masadeh Maen , Gerke Henning , Murali Arvind , Parekh Kalpaj , Keech John , Nau Peter , El Abiad Rami 
Published: October 2019

INTRODUCTION:
Peroral endoscopic myotomy (POEM) has been proven to be effective for treating esophageal dysmotility disorders. Herein is a report of the safety and efficacy of POEM in patients aged ≥65 years at an academic US tertiary care center.

METHODS:
Medical charts of all patients aged ≥65 years that underwent POEM between December 2014 and October 2018 were retrospectively reviewed. Demographic data, clinical data and treatment outcomes were obtained. POEMs were performed by multidisciplinary teams each including 1 of 2 endoscopists (HG, RE) and 1 of 3 surgeons (KP, PN, JK). Clinical success was defined as Eckardt score ≤ 3 and improvement of symptoms.

RESULTS:
During the study period, 62 patients were included. The mean age of patients was 72.3 ± 5.7 years (range 65-89 years; 42% women). Mean BMI was 29.8 kg/m2. Indications for POEM included Achalasia 88.7%, diffuse esophageal spasm (DES) 6.5%, Jackhammer esophagus 3.2% and esophagogastric junction outflow obstruction (EGJOO) 1.6%. There were 2 intraoperative complications documented (pneumothorax and anaphylaxis to medication). Mean pretreatment IRP was 24.1. Pretreatment Eckardt score was 6.98 ± 2.2 compared with posttreatment Eckardt score of 1.25 ± 2 (P < 0.05). Clinical success (Eckardt score ≤3) was achieved in 88.7% of patients. Mean myotomy length 13.8 cm (posterior orientation of myotomy 75.8%). Median hospitalization duration was 1.9 days. Postoperative complications included 1 patient with esophageal leak on postoperative esophagram, 1 patient with esophageal stricture, and 1 patient with both stricture and leak. No deaths occurred. Six patients with persistent symptoms post POEM required through-the-scope dilation to achieve improvement in symptoms.

CONCLUSION:
POEM can be safely carried out in symptomatic elderly patients ≥ with esophageal dysmotility disorders. An excellent clinical response (88.7%) was noted in this patient cohort.
382 Esophageal Mucosal Impedance Measurement During Endoscopy: A New Approach to Diagnosis and Confirmation of Complete Remission of Intestinal Metaplasia Following Radiofrequency Ablation in Barrett’s Esophagus
Authors: Schnoll-Sussman Felice , Katz Philip 
Published: October 2019

INTRODUCTION:
Mucosal impedance (MI), measured with a specialized balloon catheter at the time of upper endoscopy reveals a distinct pattern within the esophagus in patients with eosinophilic esophagitis and GERD. This novel technology may also be able to identify a unique profile in Barrett’s esophagus (BE) and confirm Endoscopic Complete Remission of Intestinal Metaplasia (ECRIM) following Radiofrequency energy ablation (RFA).

AIM:
Explore utility of MI in identification of BE and confirmation of ECRIM following RFA.

METHODS:
Patients (pts) with endoscopic and biopsy proven BE, most dysplasia undergoing RFA were prospectively enrolled. All were maintained on BID PPI. EGD noted top of gastric folds, SCJ, Prague criteria, hernia size and presence of nodules. Pts with nodular disease were excluded. RFA was performed per standard protocol and repeated until ECRIM achieved. Measurements were obtained with an MI balloon (Diversatek Healthcare, CO) 10 cm x 5 mm with two axial arrays of 10 sensors, throughout the entire BE segment and 5 cm above at pre-ablation EGD and following achieving ECRIM. At ECRIM endoscopic surveillance biopsies (q 1 cm; 4 quadrant) and WATS brushings were obtained to confirm CRIM.

RESULTS:
16 pts 11M/5F, ages 26-71 years, all Caucasian were enrolled. BE length from 1-15 cm. (adenoca 1, LGD 5, HGD 5, indefinite1, Non dysplastic 4. To date, 7 pts have been studied prior to the initial RFA ablation and at ECRIM. 2 pts were studied only at end of RFA with ECRIM. 7 are in active treatment. MI measured within the BE segment ranged from 350-980 ohms pre RFA. (Normal >2500, EoE, GERD >1000). Post RFA MI measurements ranged from 1800- >5000 ohms. 5/7 pts that achieved ECRIM had normalization of the MI pattern visualized (all values >2500). The 2 pts that did not achieve normalization of the MI pattern demonstrated MI values consistent with inflammation in squamous tissue but no values suggestive of BE. Pathology confirmed absence of IM in all 9 pts.

CONCLUSION/SUMMARY:
1) BE exhibits MI consistently < 500 ohms and always below 1000 ohms, a unique MI profile not evident in GERD or EoE. 2) In pts who achieved ECRIM and biopsy and WATS proven CRIM following RFA ablation, the neosquamous esophageal mucosa exhibits a MI pattern similar to normal native squamous epithelium. Balloon catheter MI measurements can reliably identify BE epithelium and may be a valuable tool in assessment of post-RFA reversion to neosquamous epithielium and therefore successful BE ablation.
384 High Accuracy and Effectiveness With Deep Neural Networks and Artificial Intelligence in Detection of Early Esophageal Neoplasia in Barrett's Esophagus
Authors: Hashimoto Rintaro , El Hage Chehade Nabil , Chang Kenneth J. , Dao Tyler , Ninh Andrew , Requa James , Karnes William , Samarasena Jason 
Published: October 2019

INTRODUCTION:
The visual detection of early esophageal neoplasia (high grade dysplasia and T1 cancer) in BE with white light and virtual chromoendoscopy is still difficult. The aim of this study is to assess if a convolutional neural artificial intelligence network can aid in the recognition of early esophageal neoplasia in BE.

METHODS:
Over 800 images from 65 patients were retrospectively collected of histology-proven early esophageal neoplasia in BE containing high grade dysplasia or T1 cancer (Dysplasia Group). Within each image, the area of neoplasia was masked using image annotation software by two experts in BE imaging. Over 800 control images were collected of either histology-proven or confocal endomicroscopy-proven BE without high grade dysplasia (Non -Dysplastic Group). A training set with ∼1200 images split 50/50 Dysplasia/Non-Dysplasia was used to train the algorithm. We used a convolutional neural network (CNN) and hybrid algorithm design including Inception blocks to deepen the neural net and maximize efficiency and accuracy. The algorithm was pre-trained on ImageNet and then fine-tuned with the goal to provide the correct binary classification: “Dysplastic” (1) or “Non-dysplastic” (0). Adam optimizer performed stochastic optimization of a binary cross-entropy loss function to produce a probability value between 0 and 1. A set 458 images unique of the training set was used for algorithm validation. We additionally developed an object detection algorithm which drew localization boxes in real-time around regions classified as dysplasia. Testing was performed for near-focus images, non-near focus (far) images, white light and NBI images.

RESULTS:
The CNN analyzed 458 test images (225 dysplasia/233 non-dysplasia) and correctly detected early neoplasia in BE cases with sensitivity of 95.6% and specificity of 91.8%. The accuracy was 93.7% and the AUC was 0.94 (Figure 3). With regards to the object detection algorithm for all images in the validation set, the system was able to achieve a mean-average-precision (mAP) of 0.7533 at an intersection over union (IOU) of 0.3, Sensitivity 96.7% and Specificity 87.6% (Figure 1).

CONCLUSION:
Our AI model was able to detect early esophageal neoplasia in Barrett’s Esophagus images with 93.7% accuracy. In addition, the object detection algorithm was able to draw a localization box around the areas of dysplasia with high precision.
388 Endoscopic Intrapyloric Botulinum Toxin Injection With Pyloric Balloon Dilation for Delayed Gastric Emptying After Distal Esophagectomy for Esophageal Cancer: A 10-Year Experience
Authors: Bhutani Manoop S. , Ejaz Shamim , Cazacu Irina M. , Singh Ben S. , Shafi Mehnaz A. , Stroehlein John , Mehran Reza , Walsh Garrett , Vaporciyan Ara A. , Swisher Stephen , Hofstetter Wayne 
Published: October 2019

INTRODUCTION:
As patients with esophageal cancer undergoing esophagectomy have an improved survival over time, complications associated with the use of a gastric conduit are increasingly being reported. Delayed gastric emptying (DGE) is an esophagectomy-related adverse event which may cause debilitating symptoms, malnutrition and decreased quality of life. The aim of our study was to evaluate the effect of endoscopic intrapyloric BT injection combined associated with pyloric balloon dilation in patients with DGE after distal esophagectomy treated at a tertiary cancer center.

METHODS:
Patients with a prior history of esophageal cancer and distal esophagectomy who had undergone endoscopic BT injection with pyloric balloon dilation by a single endoscopist between 2007 and 2017 were included in the study.100 units of BT were injected endoscopically into the pylorus in four quadrants using a standard needle. Following BT injection, a standard through-the-scope balloon was passed to the pylorus and inflated to a maximum diameter of 12-20 mm. For patients who underwent repeat procedures, the symptomatic outcomes were assessed and documented by the endoscopist; for the other patients, the electronic medical records were reviewed.

RESULTS:
A total of 21 patients undergoing 44 endoscopic intrapyloric botox injections combined with balloon dilatations were identified. Baseline characteristics are summarized in Table 1. The patients underwent the procedures at a median of 22 months (range, 1-108 months) after esophagectomy. The procedures were performed only once in 43% of the patients; 43% patients underwent the procedure twice, while 14% had it multiple times.Overall, intrapyloric BT injection coupled with balloon dilation was a safe procedure, without any major immediate or delayed (1 month) procedure-related adverse events. 18 patients (85%) reported a significant overall improvement in symptoms from the initial presentation. One patient (5%) had shown no improvement, whereas in two (10%) patients responses were not available.

CONCLUSION:
In our particular cohort of patients, the interventions of endoscopic intrapyloric BT injection with pyloric balloon dilation proved to be very beneficial, leading to significant symptomatic improvement. The balloon dilation after BT injection might have resulted in better diffusion of the BT into the pyloric sphincter complex and possibly increasing its therapeutic effects. Further prospective studies are needed to validate these results.
393 7 Patterns of Esophageal Motility Disorders Detected by Multiple Rapid Swallows
Authors: Tran Victoria , Averbukh Leon D. , Tadros Micheal 
Published: October 2019

INTRODUCTION:
High resolution manometry (HRM) has improved the ability to detect esophageal motility abnormalities. In conjunction with HRM, the Chicago Classification has been widely used to classify these disorders. Provocative tests, such as multiple rapid swallows, are used as a preoperative assessment for GERD and hiatal hernia. Our study assesses the utility of MRS beyond its use as a preoperative assessment.

METHODS:
After completion of the standard protocol, patients perform multiple rapid swallows under the instruction and supervision of a trained RN. MRS consists of a series of rapid 2-mL swallows at 2-3 second intervals. Patient repeats MRS with the goal of 3-4 MRS.

RESULTS:
In this cohort, we had a total of 90 patient: 3 patients were excluded from MRS due to high suspicion of achalasia. 5 patients did not complete MRS protocol. 2 cases only tolerated 1 MRS. MRS aided in the diagnosis of 16 patients, with a diagnostic utility of 20%. We identified the following 7 patterns: 1) loss of peristaltic reserve, 2) presence of good reserve, 3) repetitive spasm pattern, 4) unmasking hypercontractility, 5) paradoxical LES contractions, 6) loss of deglutition inhibition, 7) distal esophageal pressurization.

CONCLUSION:
Currently, HRM studies involve a series of single swallows, which do not represent normal swallowing physiology. In contrast, MRS comprises series of wet swallows, which may better represent deglutition pathophysiology as it inhibits esophageal smooth muscles contraction and relaxes the lower esophageal sphincter (LES). Thus, MRS is hypothesized to serve as a non-invasive substitute to evaluate esophagus integrity. In our study, MRS had a high diagnostic yield in assessing peristaltic reserve, unmasking underlying hypercontractility and esophageal spasm, and confirming true outflow obstruction with pressurization pattern. Pathophysiology was also detected such as paradoxical LES contraction and loss of deglutition inhibition, which helped with diagnosing cases of achalasia variant and esophageal spasm. MRS is an effective, simple, and inexpensive technique to identify esophageal disorders. It was very well tolerated by majority of patients and did not add cost to the procedure. We recommend standardizing MRS in HRM protocol as it provides a better understanding of esophageal disorders. Stoikes, Nathaniel et al. “The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery.” 2012: 3401-7.
398 Identification of Varicella Zoster by Novel Salivary and Esophageal Muscle Tissue Assay in Patients With Achalasia: A Two Center Prospective Study
Authors: Naik Rishi , Gershon Anne , Higginbotham Tina , Gershon Michael , Chen Jason , Flores Elizabeth , Holzman Mike , Vaezi Michael 
Published: October 2019

INTRODUCTION:
Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) but the etiology of this neuronal damage is unknown. Varicella zoster virus (VZV) is an exclusively human neurotrophic alpha herpes virus that becomes latent in ganglionic neurons after initial infection. We tested the hypothesis that reactivation of latent VZV within esophageal enteric neurons initiates an inflammatory cascade that damages the innervation of the smooth muscle of the LES giving rise to achalasia. We aimed to determine whether VZV DNA, transcripts, and proteins are present in tissue and saliva of patients with achalasia and controls.

METHODS:
Fifteen patients with achalasia (60% Male, average age 60 years and BMI 28 kg/m2) diagnosed with high resolution manometry (7/15 with Type II Achalasia) who underwent surgical myotomy had prospective collection of saliva and LES muscle tissue with IRB approval. Salivary samples were collected by passive drool, DNA was extracted with the DNeasy Blood and Tissue Kit, and VZV DNA was amplified with PCR. All methods examined the presence of transcripts (cDNA) and DNA encoding VZV open reading frames (ORFs) 29, 40, and 67. Immunofluorescence (IMF) was used to demonstrate the neuronal markers, beta-3 tubulin or peripherin simultaneously with the VZV late protein, gE. Antigen retrieval at 100°C in citrate buffer (pH 6.0) was employed.

RESULTS:
VZV DNA was detected in the saliva in 12/15 (80%) of achalasia cases (Table 1). Transcripts encoding at least one ORF were found in esophageal myotomy samples 12/15 (80%), while DNA was detected in 7/15 (47%). All 15 patients had active VZV infection by salivary VZV DNA and/or VZV transcription in esophageal tissue (Figure 1). Detection of transcripts was more sensitive and specific indicator of tissue infection than DNA. IMF revealed the presence of gE within the cell bodies of enteric neurons (when present) (Figure 2). VZV DNA was not detected in the saliva of 20 controls.

CONCLUSION:
Direct ex-vivo examination of saliva and tissue from patients with achalasia revealed the presence of active VZV infection of the esophagus. Transcripts encoding VZV gene products, and DNA, support actively replicating virus, not just latent VZV. Immunocytochemistry suggested that enteric neurons were the site of VZV infection. These findings support VZV is a potential esophageal pathogen that reactivates from latency in enteric neurons to give rise to achalasia, which may be a therapeutic target.
404 Functional Outcomes of Gastric Conduit Post-Esophagectomy
Authors: Lewis Justin , Yip Benjamin , Siemens Kyla , Borzy Charlie , Diamond Sarah , Dolan James , Otaki Fouad 
Published: October 2019

INTRODUCTION:
Esophagectomy and gastric conduit formation is the standard of care for most esophageal cancers. Studies have evaluated different surgical techniques to reduce complications of delayed gastric emptying (DGE), reflux, and dumping syndrome, but few studies have assessed the functional outcomes of dysphagia, nausea, or vomiting post-esophagectomy. Our study evaluated the rate of functional conduit malfunction in patients who underwent an esophagectomy, and the response to medical, endoscopic, and surgical treatments. We hope this data will ultimately help standardize pre- and post-surgical management for such patients.

METHODS:
We performed a single-center retrospective review of patients with esophageal cancer treated with esophagectomy and gastric conduit formation from 2016 - 2018. Patients with prior esophagogastric surgery, underlying dysmotility disorders, and recurrence of disease were excluded. Data was case matched with asymptomatic patients post-esophagectomy. Our primary endpoint was the development of conduit malfunction symptoms (defined as patients who underwent upper endoscopy or esophagram for symptoms, as well as patients who received medical treatment for dysphagia, nausea, vomiting, and DGE). Secondary endpoints included medical, endoscopic, and surgical treatments for esophageal symptoms.

RESULTS:
50/75 patients who underwent esophagectomy in the 2-year study period were symptomatic. Symptomatic patients had greater BMI, but had comparable demographics, tumor biology, treatment, and histological features (Table 1). Initial treatment for the majority of patients was adjustment of prokinetics; some received endoscopy and few underwent revision surgery (Figure 1). Partial and complete response to medical therapy was 64% and 14%, respectively. The most common endoscopic intervention was pyloric balloon dilation, followed by stent placement; 62.5% had partial response, and only 8% full response. Only 1 out of 4 patients who underwent revision surgery had complete resolution of symptoms. There were no significant predictors of symptoms on univariate analysis.

CONCLUSION:
The majority of patients who underwent esophagectomy with gastric conduit formation for esophageal cancer developed nausea, vomiting, dysphagia, or DGE. A minority of patients had complete response to endoscopic or surgical treatment for these symptoms. Future studies should identify predictors of symptoms to help risk stratify patients with high morbidity post-esophagectomy.
406 Lymphocytic and Eosinophilic Esophagitis: A Comparative Study
Authors: Avila Meera , Khurana Shruti , Ambelil Manju , Tong Yi , Abraham Fiyinfoluwa , Ertan Atilla , Thosani Nirav , DuPont Andrew , Cash Brooks D. , Younes Mamoun 
Published: October 2019

INTRODUCTION:
While the histopathologic criteria for the diagnosis of eosinophilic esophagitis (EoE) and the related clinical and endoscopic manifestations are well established, little is known about lymphocytic esophagitis (LyE). The aim of this study was to determine whether significant correlations exist between the numbers of intraepithelial lymphocytes (IEL) in esophageal biopsies and clinical and endoscopic manifestations usually associated with EoE.

METHODS:
H&E slides from esophageal biopsies from 331 conscutive patients were reviewed. The number of IEL and intraepithelial eosinophils (IEE) per mm2 was counted in the area with highest concentration in each biopsy. The numbers were then correlated with clinical and endoscopic findings.

RESULTS:
As expected, the mean number of IEE was significantly higher in patients with complaints of food impaction (149 vs 38, P < 0.001) and dysphagia (91 vs 38, P = 0.002) and with rings (161 vs 39, P < 0.001), furrows (207 vs 48, P < 0.001) or strictures (136 vs 51, P = 0.008) typical with EoE seen on endoscopy compared to those without these complaints or findings. By contrast, there were no significant increase in mean IEL in patients complaining of food impaction (136 vs 153, P = 0.554) or dysphagia (152 vs 154, P = 0.902) or with rings (131 vs 154, P = 0.357), furrows (130 vs 152, P = 0.569) or strictures (118 vs 153, P = 0.0332) seen on endoscopy. Mean IEL was higher in smokers (180 vs 139, P = 0.029) and high IEL showed positive correlation with rings on endoscopy (P = 0.013, Spearman’s Rank), history of alcohol use (P = 0.015) and almost correlated with food impaction (P = 0.059). Interestingly, there was weak but significant negative correlation between IEL and IEE (r = -0.299, P < 0.001).

CONCLUSION:
In contrast to IEE in EoE, our study failed to show significant correlation between IEL and major clinical and endoscopic findings usually associated with EoE.