bluuebunny/crossref_metadata_2025_split huggingface dataset:
923 Endoscopic Ultrasound-Guided Fiducial Placement for Stereotactic Body Radiation Therapy in Patients With Pancreatic Adenocarcinoma
Authors: Cazacu Irina M. , Singh Ben S. , Martin Rachael , Slagowski Jordan , Beddar Sam , Koay Eugene , Taniguchi Cullen , Herman Joseph , Bhutani Manoop S. 
Published: October 2019

INTRODUCTION:
Stereotactic body radiotherapy (SBRT) has emerged as a novel therapeutic option in pancreatic cancer care. In the absence of diagnostic quality CT-on-rails or on-board MRI, accurate delivery of SBRT relies on fiducial markers. Endoscopic ultrasound (EUS) has become the preferred method for fiducial markers placement. The aim of this study is to report the technical feasibility and safety of EUS-guided fiducial placement and to evaluate the technical benefit and SBRT outcomes in a cohort of patients with pancreatic cancer (PC).

METHODS:
A retrospective chart review was performed for all (n = 67) PC patients referred for EUS-guided fiducial placement by a single endosonographer (MSB) at a tertiary cancer center between 2016 and 2019. Data regarding EUS-related technical details and adverse events were recorded. The continuous visibility of the fiducial markers was assessed by an experienced medical physicist on simulation CT and during the final treatment fraction on cone beam CT.

RESULTS:
During the study period, 67 PC patients underwent placement of 174 fiducial markers under EUS guidance (Table 1). Technical success rate of fiducial placement was 97%. Technical difficulty due to intervening blood vessels was noted in 2 (3%) patients. EUS evaluation showed duodenal invasion in one case and fiducial placement was canceled. All patients received periprocedural antibiotics and no immediate or delayed adverse events were reported. The average time to simulation CT after marker placement was 4.6 days (range, 1-53). 64 (96%) patients received SBRT after fiducial placement (Table 2). Of the total 174 fiducials placed, 165 (95%) fiducial markers were clearly visible on both the CT simulation and cone beam CT scan acquired on the last day of SBRT delivery. 9 (5%) fiducial were not useful for SBRT delivery most likely due to migration or poor visibility. No major SBRT-related toxicity was reported.

CONCLUSION:
Our results demonstrate that EUS-guided fiducial placement is safe and effective in target volume delineation, facilitating SBRT delivery in PC patients. Further clinical trials are needed to determine the optimal type of fiducial to place under EUS-guidance and the survival benefits in patients with pancreatic cancer.
924 How Successful Is Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction Post-Pancreaticoduodenectomy?
Authors: Ahmed Osman , Angsuwatcharakon Phonthep , Yu Abraham , Hakim Seifeldin , Coronel Emmanuel , Wolff Robert , Katz Matthew , Weston Brian , Ross William , Lee Jeffrey H. 
Published: October 2019

INTRODUCTION:
Endoscopic retrograde cholangiopancreatography (ERCP) is the accepted therapy for the management of biliary obstructions, however, in patients who have had previous pancreaticoduodenectomy (PD) (i.e. Whipple’s procedure), due to the altered surgical anatomy, the ability to perform ERCP is challenging. In this study, we examine our experience at a large tertiary cancer-center in performing ERCPs for biliary obstructions in patients who are post-PD.

METHODS:
This was a retrospective review from 2006 to 2018 of all patients referred for the management of biliary obstructions post-PD. Outcomes included technical success (ability to treat the stricture, e.g. dilation or placement of a stent) and clinical success (decrease in bilirubin to normal or 50% of peak value within 2 weeks) rates.

RESULTS:
A total of 66 patients were included in the study. The mean age was 67.7 years (SD +/- 11.6) and 58 patients (87.9%) were male. The most common indications for PD were duodenal adenocarcinoma (20 patients, 30.3%) followed by pancreatic adenocarcinoma (16, 24.4%). In terms of surgery, the mean length of the afferent limb was 45.7 cm (SD +/- 6.34). The most common indications for ERCP were cholangitis (31 patients, 49%), followed by a biliary obstruction without cholangitis (11, 16.7%). The mean length of procedure was 66.7 minutes (SD +/- 34.8). The hepaticojejunostomy (and/or choledochojejunostomy) was reached in 56 patients (84.8%). The most common endoscope used was a therapeutic upper endoscope (31 patients, 47%), followed by a regular upper endoscope (11, 16.7%) and a pediatric colonoscope (10, 15.2%). Cannulation of the biliary tree was successful in 55 patients (83.3%). The most common location for the stricture was at the anastomosis (41 patients, 80.4%), followed by distal extra-hepatic (8, 15.7%). Successful stents were placed in 31 patients (47%). There were no episodes of bleeding, perforation or pancreatitis post-ERCP. Four patients developed self-resolving fever post-procedure. The technical success rate was 75.8% (50 patients) while the clinical success rate was 71.2% (47 patients).

CONCLUSION:
ERCP post-PD can be challenging due to the surgical anatomy and inability to use common endoscopes and instruments. Our study demonstrates that nevertheless, endoscopic biliary decompression can still be successful by experienced endoscopists in the majority of patients post-PD, with minimal adverse events.
932 Efficacy and Outcomes of Endoscopic Gastrointestinal Fistula Closure: A Single Center Study
Authors: Mbih Irene , Bergenstock Marika , Mehta Minesh , Berger Andrea , Confer Bradley , Diehl David L. , Khara Harshit S. 
Published: October 2019

INTRODUCTION:
Historically, patients with gastrointestinal fistulas who have failed conservative management required surgical intervention. The advent of novel endoscopic devices has revolutionized endoscopic closure of gastrointestinal fistulas presenting a promising and less invasive alternative to surgery. Our study aims to evaluate the efficacy and outcomes of endoscopic closure of gastrointestinal fistulas from a single center database.

METHODS:
We performed a retrospective review of all patients from 2009 to 2019 undergoing endoscopic closure of gastrointestinal fistulas at our tertiary referral center. Demographics, nutritional status, type of fistula, modality of endoscopic repair, number of attempts at closure, technical and clinical success rates, and adverse events were collected.

RESULTS:
A total of 130 procedures were reviewed from 75 patients undergoing endoscopic fistula repair over a 10 year period, 40 males / 35 females, with a median age of 56.5 years. Mean BMI was 26.4 (kg/m2) with a mean albumin of 3.4 (normal > 4). Upper GI closures accounted for 85.3% of cases (64/75) vs lower GI was 14.7% (11/75). The median number of attempts for endoscopic closure was 1 (range 1-5). Technical success rate was 97.7% (127/130). Single modality closure techniques were used in 63% (82/130) of procedures. The most frequently used modality of closure was endoscopic stenting (51/130, 39.2%), followed by endosuture (39/130, 30%), over-the-scope-clips (28/130, 21.5%), endoclip (24/130, 18.5%), APC (20/130, 15.4%), fibrin glue (7/130, 5.4%), and others (3/130, 2.3%). Multimodality closure using a combination above devices was used in 37% (48/130). Clinical success rate for documented complete endoscopic fistula closure was seen in 45.3% (34/75) of cases, while 28% (21/75) needed surgical intervention, and the remaining were managed conservatively. The adverse event rate was 3% (4 cases of stent migration).

CONCLUSION:
Endoscopic intervention of gastrointestinal fistula closure has a high technical success rate and can avoid almost half the cases going to surgical repair. New endoscopic techniques, along with the use of multimodality closure, can be used to increase overall clinical success rate, especially in post-surgical anatomy. Endoscopic therapies of gastrointestinal fistulas are efficacious and offer a safe alternative to surgery for high risk patients.
933 Females Are Associated With an Increased Excess Weight Loss Reduction in Obese Patients Following Intragastric Balloon Placement
Authors: Marrero-Torres Ricardo , Gregory-Gonzalez Federico , Micames-Caceres Carlos 
Published: October 2019

INTRODUCTION:
Obesity is an expanding public health problem, resulting in more than half a billion adults worldwide who were considered obese in 2016. Similarly, in Puerto Rico, as stated by the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention there was a prevalence of 32.9% in 2017. Intragastric balloon (IGB) placement is a weight loss alternative for obese patients with an inadequate weight loss response to diet and exercise. The aim of this study is to examine the efficacy and safety of the single-chamber fluid-filled IGB for weight loss and compare its results across different age groups.

METHODS:
We performed a database review of all consecutive patients from two outpatient GI clinics who underwent placement of an IGB. Our final analysis comprised of 239 IGB placements in 232 patients (mean age, 44.5 ± 10.3 years; 67% female; baseline BMI 42.1 ± 9.0). Efficacy outcomes included: the percentage of the total (%TWL) and excess weight loss (%EWL), and Body Mass Index (BMI) reduction at 3 and 6 months. Safety outcomes was measured as the number of patients who required early IGB removal (before 6 months).

RESULTS:
%TWL at 3 months was 10.4%, and 14.5% at 6 months. Overall, 92%, 74%, and 46% of patients lost 5%, 10%, and 15% of total weight at 6 months, respectively. %EWL was 22.1% and 30.3% at 3 and 6 months post-IGB placement, respectively. We observed a BMI reduction of 4.4 kg/m2 at three months and 6.3 kg/m2 at six months overall. Subgroup analysis revealed that females %EWL significantly higher than males (31.9% vs 25.9%, P-value < 0.05). Similarly, patients between ages 51-60 had the highest %EWL (37.3%, P-value < 0.05) among all studied age groups. Likewise, patients grouped by BMI ranges showed a significant weight loss compared to baseline (BMI 30-40 kg/m2 %TWL: 14.6%, BMI 40-50 kg/m2 %TWL: 15.0% and BMI ≥ 50 kg/m2 %TWL: 14.4%), yet there was no significant statistical difference between them. The balloon was safely removed at six months after placement in most patients, whereas in 13.0% of cases early removal was performed at an average of 11.7 weeks after placement (range, 2 days-23 weeks).

CONCLUSION:
Patients among ages 51- 60 showed a significant decrease in %EWL in comparison with other age groups. Women achieved a greater weight loss than men. Subgroup analysis revealed no statistical differences in weight loss percentage among different BMI ranges.
935 Salvage Hybrid APC After Failed Radiofrequency Ablation and Cryotherapy for Barrett’s Esophagus
Authors: Nieto Jose , Casas Daniel 
Published: October 2019

INTRODUCTION:
The frequency of Barrett’s esophagus (BE) has increased by a factor of more than 7 during the past four decades in the United States. It has been estimated that 5.6 percent of adults in the United States have Barrett's esophagus, although the large majority of cases go unrecognized. Endoscopic resection of visible lesions, followed by ablation of the rest of the BE epithelium is the current standard of care for management of BE with confirmed dysplasia and IMC. Today, the most readily use treatment for Barret’s esophagus is RFA and APC. None of the current methods are able to guarantee a complete ablation success of 100 %. Cryotherapy has become a salvage technique for patient that have failed RFA. There is limited data available to determine the efficacy and safety of this technique. For patients who failed RFA and Cryotherapy, there are limited options available. The aim of this study is to assess the efficacy and safety of hybrid APC in patients with BE dysplasia who failed RFA and cryotherapy.Hybrid APC can be an effective alternative adjunctive salvage tool to RFA and cryotherapy for patients in whom both of these techniques have failed.

METHODS:
This is a single center, retrospective cohort study at a tertiary medical center between 2010 and 2019 in patients with BE low-grade dysplasia (LGD) and high grade dysplasia (HGD) who failed RFA and cryotherapy treatment. Six patients with an average age of 63, and five out of six are males (84%) and five have persistent LGD (84%). Response was determined by complete eradication (CE). Six patients with persistent dysplasia and with incomplete response to RFA and cryotherapy were offered hybrid APC. The primary endpoint was CE after hybrid APC.

RESULTS:
A total of 6 patients underwent RFA and Cryotherapy for BE dysplasia. After an average of 4.5 RFA sessions and 2.7 Cryotherapy session none of the patient were able to reach CE. 5 patients with BE with LGD and 1 with HGD were offered H-APC after failure of reaching CE (average of 2.3 H-APC treatment). CE was reached in 100% of the patients who underwent H-APC. 6 months endoscopic surveillance has not shown any recurrence of BE or dysplasia.

CONCLUSION:
Patient with refractory dysplasia or recurrent dysplasia after failed eradication of salvage cryotherapy and radiofrequency ablation were offered hybrid APC. The data demonstrate a complete eradication in those patients who failed treatment with RFA and cryotherapy. Furthermore, there were no alternative outcome reported as of to date.
936 Endoscopic Submucosal Dissection as a Salvage Therapy After Failed Endoscopic Mucosal Resection for Colorectal Lesions: A Single Center Experience
Authors: Shah Rushikesh , Abdelfatah Mohamed Magdy , Mekaroonkamol Parit , Yu Michael , Xue Yue , Keilin Steven , Willingham Field , Cai Qiang 
Published: October 2019

INTRODUCTION:
There is limited data in efficacy of Endoscopic Submucosal Dissection (ESD) as a salvage therapy after failed Endoscopic Mucosal Resection (EMR) attempt leading to scar tissue formation. We present a single center experience of ESD in evaluating safety and efficacy of ESD in treatment of colorectal lesions with failed prior attempt of EMR.

METHODS:
All patients who had ESD for colorectal lesions after prior unsuccessful attempt of removal by EMR, from 1/2013 to 12/2018 were included. Patient and procedure related data points were collected. Technical success was defined as successful completion of ESD to remove colonic lesions and clinical success was defined as complete removal of colonic lesions with negative margins.

RESULTS:
A total of 19 patients were included. The average age was 68.3 ± 7.5 years, 53% (10/19) patients were female. 10 patients had right sided, 2 patients had left sided and 7 patients had rectal lesions. The average size of the lesion was 3.9 ± 2.5 cm. 10 patients (53%) had en bloc resection and 9 patients (47%) had piecemeal resection despite ESD due to scar tissue formation from prior EMR attempt. Technical success of ESD was 100%. The average duration of the procedure was 103.5 ± 48 minutes. Complications occurred in 2 cases (10.5%), both had En bloc resection. One patient developed bleeding requiring endoscopic treatment and another patient developed microperforation managed conservatively. Of resected lesions, there were 9 tubular adenomas, 5 sessile serrated adenoma, 1 Tubulovillous adenoma, 1 neuroendocrine tumor and 3 samples with histology showing tubular adenoma but with positive margins for adenocarcinoma. ESD specimen added the diagnosis of carcinoma. All of the patients with en bloc resection had negative peripheral margins while of 9 patients who had piecemeal resection, 3 patients had positive margins for carcinoma. Thus clinical success of ESD was 84%. 2 of these patients required surgery while 1 was lost to follow up. Out of 16 patients with initial successful ESD, 13 patients had follow up for average 24 months without any recurrence (3 patients were lost to follow up). A trainee was involved in 60% of the procedures.

CONCLUSION:
ESD is a safe and effective method of diagnosis and treatment for colorectal lesions as a salvage therapy after failed EMR with overall low complication rates and low recurrence rates. ESD should be considered in centers of expertise prior to referring patients for surgical approach.
937 Statin Use Reduces the Risk of Hepatocellular Carcinoma: An Updated Meta-analysis and Systematic Review
Authors: Sarmini Muhammad Talal , Alomari Mohammad , Al Momani Laith , Asfari Mohammad Maysara , Romero-Marrero Carlos 
Published: October 2019

INTRODUCTION:
Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver resulting in approximately 800,000 deaths around the world every year. A growing body of research investigating statin use and HCC risk has shown conflicting results. We examined the association between statin use and risk of HCC utilizing all the available high-quality literature, aiming to provide a quality synthesis of current evidence of statin impact on HCC risk.

METHODS:
We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May of 2019 to identify all studies that evaluated the association between statin use and new HCC development. We included studies that presented an odds ratio (OR) with a 95% confidence interval (CI) or presented data sufficient to calculate the OR with a 95% CI. Statistical analysis was performed using the Comprehensive Meta-Analysis (CMA), Version 3 software and a Forrest plot was generated. Publication bias was assisted for using conventional techniques.

RESULTS:
Twenty studies (3 randomized controlled trials, 7 cohorts and 11 case–controls) with a total of 2,668,497 patients including 24,341 cases of HCC. Studies and patients’ characteristics are summarized in tables 1 and 2, respectively. Our findings indicate a significant risk reduction of HCC among all statin users with a pooled OR of 0.57 (95% CI: 0.49 – 0.66, P < 0.05, I2 = 86.57%) compared to non-users. (Figure 1a) No publication bias was found using Egger’s regression test or on visual inspection of the generated Funnel plot (Figure 1b).

CONCLUSION:
Our results indicate that statin use was associated with 43% lower risk of HCC compared to those who did not use statin. Further prospective randomized research is needed to confirm this association.
941 Sex-Specific and Ethnicity-Specific Disparities in Successful Linkage to Care Among Chronic Hepatitis C Virus Infection Patients at a Under-Served Safety Net Hospital
Authors: Gomes Chantal , Ginzberg Dina , Liu Benny , Bhuket Taft , Wong Robert 
Published: October 2019

INTRODUCTION:
Despite availability of highly effective therapies for chronic hepatitis C virus (HCV), sub-optimal linkage to care (LTC) after HCV diagnosis remains a major barrier to achieving eradication. We aim to identify sex- and ethnicity-specific disparities in HCV LTC among an ethnically diverse safety-net population.

METHODS:
We retrospectively evaluated all adults who underwent HCV antibody (Ab) testing at a single-center safety-net hospital from 2014 to 2018. Among adults with positive HCV Ab, we evaluated overall rates and trends in proportion of patients with positive HCV RNA. Rates of chronic HCV infection were compared by sex and race/ethnicity using chi-squared methods. Among patients with confirmed chronic HCV infection, we evaluated overall rates and trends in successful LTC (defined as successful completion of first medical encounter with a HCV provider following diagnosis). Comparisons of successful LTC between groups were evaluated with chi-squared testing and adjusted multivariate logistic regression models.

RESULTS:
From 2014 to 2018, 54,173 HCV Ab tests were performed, among which 7.03% were HCV Ab positive. Among patients with HCV Ab positive, prevalence of positive HCV RNA was 52.5%. From 2014 to 2018, proportion of HCV Ab positive patients with positive HCV RNA declined from 74.3% in 2014 to 44.2% in 2018. The prevalence of HCV RNA positive among HCV Ab positive patients was significantly higher in men compared to women (58.0% vs. 43.7%, P < 0.001), significantly higher in African Americans compared to whites (58.8% vs. 52.7%, P < 0.001), and significantly lower in Asians compared to whites (30.4% vs. 52.7%, P < 0.001). Overall LTC among patients with confirmed chronic HCV infection was 33.2%. Women with chronic HCV had significantly higher LTC compared to men (38.3% vs. 30.6%, P < 0.04). Compared to whites with chronic HCV, significantly higher LTC rates were observed for African Americans (33.3% vs. 27.4%, P < 0.01) and Asians (66.7% vs. 27.4%, P < 0.01). On multivariate regression, there was a trend towards lower LTC rates among men compared to women (OR 0.73, 95% CI 0.52-1.02, P = 0.06). Asians were significantly more likely to achieve successful LTC compared to whites (OR 3.80, 95% CI 1.40-10.32, P < 0.01).

CONCLUSION:
Among safety-net populations with HCV, sex-specific and ethnicity-specific disparities in successful LTC were observed. Successful LTC following HCV diagnosis was highest among women, African Americans, and Asians.
945 Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma in the U.S.: Exploring Trends Since 2001
Authors: Raed Anas , Bhagatwala Jigar , Hudgi Amit , Sherid Muhammed , Sifuentes Humberto , Sharma Amol , Sridhar Subbaramiah 
Published: October 2019

INTRODUCTION:
The combined mortality from hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) is rising worldwide and expected to uptrend. We aimed to evaluate incidence trends of these two cancers over last 15 years in the US population.

METHODS:
Data was extracted from National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology and End Results (SEER) for the period 2001-2015. Age-adjusted incidence and annual percent change (APC) were calculated to examine trends based on type of LC, gender, and race. SEER Stat software was used to analyze this data.

RESULTS:
There were 334,617 cases of both types of cancers from 2001 to 2015, of which 89.2% had hepatocellular carcinoma. Total of 71.4% were males, 76% Caucasians, 14.2% African Americans and 9.8% were others. There was significant uptrend in the incidence rates of these cancers for period of 2001-2015 with APC 3.6 (CI: 3.2, 4.0) (Figure 1). The rise in incidence of ICC were higher than HCC with APC of 7.1 (CI: 6.1, 8.2), 3.2 (2.6, 3.8), respectively (Table 1). Males had higher increase in HCC with APC of 3.2 (CI: 2.6, 3.8), and females had higher risk for ICC with APC 7.6 (CI: 6.4, 88.) (Table 2). Caucasians had the highest APC of combined cancers 3.9 (3.5, 4.3). The APCs were trending up for HCC & ICC among all races except in other race, that showing APC was trending down -0.5 (CI: -1.0, -0.1).

CONCLUSION:
Our data reveal alarming rise in the incidence rates, for both HCC and ICC, separately and combined. Males and females differ in the rising trends of these cancers and all races appear to harbor rise in the cancer incidence. Identifying and treating risk factors are crucial to prevent this fatal disease.