bluuebunny/crossref_metadata_2025_split huggingface dataset:
A130 RETROGRADE ENDOSCOPIC ULTRASOUND-GUIDED ENTERO-ENTEROSTOMY USING A LUMEN-APPOSING METAL STENT FOR THE MANAGEMENT OF A HIGH-OUTPUT ENTEROCUTANEOUS FISTULA AND ILEAL STRICTURE IN A COMPLEX SURGICAL ABDOMEN
Authors: Gupta S , Gupta S , Pawlak K , De Rezende-Neto J , May G , Mosko J , Calo N 
Published: February 2024

Abstract

Background
A 26-year-old male sustained significant traumatic thoracoabdominal injuries following a gunshot. He underwent several laparotomies, small bowel resections, an extended left hemicolectomy with end-colostomy formation, and a flap to close the abdomen. He subsequently developed a high-output enterocutaneous fistula (ECF) and loss of colostomy output. CT imaging confirmed an ECF from the ileum to the anterior abdominal wall and a severe ileal stricture distal to the fistula.

Aims
In the context of his complex surgical abdomen and proximity of the ECF to the abdominal flap, surgical re-intervention was deemed high-risk. He was placed on total parenteral nutrition and referred for endoscopic management.

Methods
Under fluoroscopic guidance, we injected methylene blue & contrast dye from the skin side of the ECF. A dilated segment of small bowel was filled, with no downstream passage of contrast (Fig 1A). Retrograde ileoscopy was performed with an Olympus pediatric colonoscope via the patient’s colostomy. 90 cm from the ileocecal valve (ICV), we encountered a benign enteric stenosis that could not be traversed. Contrast was injected, with fluoroscopy revealing a 10 cm long tortuous stenosis (Fig 1B), extending to the previously filled loop of small bowel. Given the length and characterof the stricture, endoscopic balloon dilation and enteral stenting were technically infeasible.

Results
We proceeded to retrograde endoscopic ultrasound (EUS)-guided entero-enterostomy creation. With the aid of a guidewire, and under endoscopic, fluoroscopic and endosonographic guidance, a linear echoendoscope was advanced into the ileum via the colostomy, cecum and ICV. 50 cm from the ICV, we identified an adjacent dilated loop of small bowel (Fig. 1C). Water was instilled through the ECF, with the endosonographic view demonstrating filling, thus indicating this location to be upstream from the ECF. A 19-gauge needle was punctured through, with subsequent aspiration of methylene blue (Fig. 1D). We then created an EUS-guided entero-enterostomy using a 15mm lumen-apposing metal stent (Hot-AXIOS; Boston Scientific, Massachusetts, USA; Fig. 1E). Passage of methylene blue & contrast through the stent confirmed accurate deployment (Fig. 1F&G). With both the ECF & stricture bypassed, the patient’s colostomy output returned and ECF output diminished.

Conclusions
Electrocautery-enhanced lumen apposition with metal stenting is well established. It can facilitate the formation of an anchored anastomosis across non-adherent luminal structures in a single-step fashion. Herein, we have reported a novel application of this technique in the management of a complex post-surgical trauma patient with a high-output ECF and deep enteric stenosis.

Figure 1: Retrograde EUS-guided entero-enterostomy

Funding Agencies
None
A132 A COLON-SPECIFIC SELECTIVE RESECTION ALGORITHM FOR LARGE NON-PEDUNCULATED POLYPS OPTIMIZES EFFICIENCY WITH HIGH TECHNICAL AND CLINICAL SUCCESS: A PROSPECTIVE COHORT STUDY
Authors: Jiang S X , Zarrin A , Walia A , Galorport C , Enns R , Lam E , Shahidi N 
Published: February 2024

Abstract

Background
Endoscopic resection is now the first line treatment strategy for most large (≥20 mm) non-pedunculated colonic polyps (LNPCPs); which includes endoscopic mucosal resection (EMR), cold snare resection (CSR), and endoscopic submucosal dissection (ESD). A selective resection algorithm incorporating EMR and ESD is cost effective and optimizes oncologic outcomes in the rectum. However, a focused evaluation for colonic lesions has not been described.

Aims
Assess the performance of a colon-specific selective resection algorithm for LNPCPs.

Methods
Consecutive patients ampersand:003E 18 years of age who underwent endoscopic resection for a LNPCP were enrolled in a prospective single center observation cohort study (clinicaltrials.gov ID: NCT05402696). Modality selection was determined by optical evaluation using the Paris and the Japan NBI Expert Team (JNET) classifications: 1) JNET I – CSR; 2) JNET IIA – EMR; 3) JNET IIB or Paris 0-IIC morphology – en bloc resection (EMR/ESD); 4) JNET III – referral to surgery/multi-disciplinary team review. Algorithm performance was evaluated by technical success (all neoplastic tissue removed at index procedure), procedure-related adverse events, referral to surgery, and recurrence at first surveillance colonoscopy (SC1).

Results
From 06/2022-09/2023, 230 patients underwent 244 procedures for 295 lesions. Median age was 67 years (IQR 61-74 years) and 127 (55.2%) were male. Median lesion size was 30mm (IQR 20-40mm). Cancer was identified in 12 (4.1%) LNPCPs. Based on pre-resection optical evaluation, 204 (69.2%), 86 (29.2%) and 5 (1.7%) LNPCPs underwent EMR, CSR and ESD, respectively. Technical success was 97.1%, 100.0% and 100.0% for EMR, CSR and ESD, respectively (p=0.245). Procedure duration was significantly shorter for CSR (10 min; IQR 8-15 min) compared to EMR (15 min; IQR 10-25 min) and ESD (30 min; IQR 30-60 min) (P ampersand:003C 0.001). There was no significant difference in intra-procedural perforation, clinically significant post-endoscopic resection bleeding, delayed perforation or serositis, with overall frequencies of 3.4%, 5.2%, 0% and 0.4% respectively. Surgery was performed for 15 lesions (11 submucosal invasive cancer (SMIC); 3 synchronous SMIC; 1 technical failure). Of LNPCPs completing SC1, there was 1 recurrence (1.2%) in the CSR group (p=0.366), which was successfully managed endoscopically.

Conclusions
A colon-specific selective resection algorithm optimizes procedural efficiency and the risk-benefit profiles of EMR, CSR and ESD for LNPCPs.

Funding Agencies
None
A133 MARGIN THERMAL ABLATION WITH SNARE-TIP SOFT COAGULATION EFFECTIVELY MITIGATES RECURRENCE AFTER ENDOSCOPIC MUCOSAL RESECTION OF LARGE NON-PEDUNCULATED COLORECTAL POLYPS
Authors: Jiang S X , Zarrin A , Walia A , Galorport C , Xiong W , Enns R , Lam E , Shahidi N 
Published: February 2024

Abstract

Background
Recurrence following endoscopic mucosal resection (EMR) historically occurs in approximately 15-20% of large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs). Margin thermal ablation with snare-tip soft coagulation (STSC) of the post-EMR defect is an evidence-based modality to mitigate recurrence. However, international validation of margin thermal ablation outcomes is needed.

Aims
To evaluate the frequencies of endoscopic and histologic recurrence following margin thermal ablation with STSC for LNPCPs managed by EMR.

Methods
Consecutive patients ampersand:003E 18 years of age who underwent endoscopic resection for a LNPCP were enrolled in a prospective single center observation cohort study (clinicaltrials.gov ID: NCT05402696). Of those lesions which underwent successful EMR, margin STSC was applied systematically aiming to create at least a 2-3mm rim of completed ablated tissue (complete whitening). Recurrence was evaluated both endoscopically, using a standardized protocol for the post-EMR scar, and histologically.

Results
From 06/2022-09/2023, 335 LNPCPs were endoscopically resected, including 209 by EMR. Following successful EMR, 182 (87.1%) underwent margin STSC. Of these lesions, 49 LNPCPs in 46 patients were assessed at first surveillance colonoscopy. Margin STSC was complete for 44 (89.8%) lesions and incomplete for 5 (10.2%) due to difficult angulation/positioning (n=3) and ileocecal valve location (n=2). Median interval to first surveillance colonoscopy was 6 (IQR 6-7) months. There was no evidence of recurrence noted on endoscopy. Biopsy was performed in 44 (89.8%) with no evidence of histologic recurrence.

Conclusions
Thermal ablation of the defect margin with STSC effectively negates recurrence and should be considered standard of care following EMR.

Funding Agencies
None
A137 BALLOON-ASSISTED ENDOSCOPY FOR SMALL BOWEL BLEEDING – A REVIEW
Authors: Malik G , Guo J Y , Halloran B , Zepeda-Gomez S 
Published: February 2024

Abstract

Background
Gastrointestinal (GI) bleeding is a potentially life-threatening medical emergency requiring immediate medical attention. Obscure GI bleeding (OGIB) Is defined as GI bleeding with no obvious culprit lesion found on initial upper or lower endoscopy. Further investigations are needed as 75% of those cases originate in the small bowel. The advent of small bowel endoscopy, consisting of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE) has allowed clinicians to endoscopically visualize the entire GI tract and perform therapeutic interventions. These devices include balloon assisted endoscopy (BAE) and Spiral Endoscopy (SPE).

Aims
The objectives of this review are to analyze the definitions, etiologies, and risk factors of OGIB. Furthermore, we reviewed the diagnostic and therapeutic yields of DAE and its safety profile. Due to the adverse effects and recall of SPE, we only report here on BAE.

Methods
A literature review was conducted using PubMed and OvidSP (Medline) to identify articles on the use of VCE and DAE for OGIB. Keywords included a combination of gastrointestinal bleeding with occult, obscure, active and inactive, small bowel bleed, diagnostic yield, therapeutic yield, and rebleeding rate. The information was obtained via systematic review and meta-analysis, retrospective studies, and case reports.

Results
A total of 32 papers were reviewed. The most common causes of OGIB reported were vascular lesions (23-47%), inflammatory lesions (12-16%), and tumors (5-16%). The risk factors associated with OGIB include age, cardiac disease, liver cirrhosis, chronic kidney disease, and hereditary vascular diseases. The overall diagnostic and therapeutic yields of BAE in OGIB were 76.3% and 49.5%, respectively. Factors that increased the yield included performing an initial VCE (increase by 7%) and performing the procedure within the first 10 days after the initial bleeding episode (87.5%) as compared to after 10 days (11.1%). Recurrent bleeding can occur in up to 46% of patients. Risk factors for rebleeding include cirrhosis, overt bleeding symptoms, and presence of multiple vascular lesions. Associated adverse effects in DAE were minor in 9.1% of patients and severe in less than 2%. These include bleeding (0.8%), perforation (0.3%), and pancreatitis (0.3%).

Conclusions
OGIB is a challenging clinical entity. BAE now allows clinicians to diagnose and treat culprit lesions in the small bowel with reasonable success and a strong safety profile, however timing and prior VCE can further optimize this. Clinical decisions and follow up should be made based around existing risk stratification tools and scores. Further prospective research is needed to determine optimal timing of DAE from presentation of OGIB that would increase diagnostic and therapeutic yields.

Figure 1. A and B) Endoscopic images of small bowel vascular lesion. C) Bleeding vascular lesion treated with hemostatic clips.

Funding Agencies
None
A146 UNDERWATER EMR WITHOUT SUBMUCOSAL INJECTION FOR COLONIC ANGIODYSPLASIA
Authors: Yu R , Barclay R 
Published: February 2024

Abstract

Background
Angiodysplasia is a common source of overt or occult colonic bleeding. Lesions are amenable to endoscopic thermal treatment such as APC, which requires a dedicated device and carries a small risk of perforation. Underwater EMR without submucosal injection (UEMR) is safe and effective for colorectal polyps, and requires no special equipment.

Aims
This study explores the use of UEMR to treat colonic angiodysplasia. We endeavoured to assess the effectiveness of treatment with UEMR in patients with this unique condition and further quantify the safety and adequacy of the obtained sample to achieve diagnosis. Further analyses were undertaken to determine the cost-burden of this method compared to comparable methods of treatment.

Methods
Retrospective review of clinical database for patients who underwent UEMR for colonic angiodysplasia between 2021 and 2023.
Indications for treatment were iron deficiency anemia (N=4), Hematochezia (N=2), and melena (N=1).
Lesions were excised en bloc using standard UEMR technique without submucosal injection and soft-coagulation electrosurgical settings.

Results
Six patients (5 females, mean age 76 ± 10) underwent colonoscopy with UEMR for treatment of angiodysplasia. One patient with extensive lesions required two endoscopic sessions; the others were treated during a single procedure. The median number of lesions was two; range, 1 to 13). A total of 24 lesions (size 7 ± 2 mm) were treated with UEMR. All lesions were located in the proximal colon (cecum, 14; ascending colon, 10). Histology of excised specimens confirmed a diagnosis of angiodysplasia.
There were no procedural complications. Overt bleeding and anemia resolved in all patients.

Conclusions
In this series of patients, UEMR without submucosal injection was simple, safe and effective for treatment of proximal colon angiodysplasia. Advantages of this approach over conventional therapy with APC include reduced equipment needs, lower cost and histologic diagnosis. Further study comparing UEMR to conventional thermal modalities is warranted.

Funding Agencies
None
A147 FACTORS ASSOCIATED WITH PATIENT COMFORT DURING ENDOSCOPIC RESECTION OF LARGE NON-PEDUNCULATED COLORECTAL POLYPS
Authors: Zarrin A , Jiang S X , Walia A , Galorport C , Xiong W , Telford J , Enns R , Lam E , Shahidi N 
Published: February 2024

Abstract

Background
Patient comfort is an important quality indicator in endoscopy, as it relates to patient satisfaction and adherence with endoscopic surveillance recommendations. Endoscopic resection techniques are now the primary treatment strategy for LNPCPs. However, factors associated with patient comfort are unknown.

Aims
To assess patient comfort during endoscopic resection of LNPCPs and factors associated with discomfort.

Methods
Consecutive patients ampersand:003E 18 years of age who underwent endoscopic resection for a LNPCP were enrolled in a prospective single center observation cohort study (clinicaltrials.gov ID: NCT05402696). The St. Paul’s Endoscopic Comfort Scale (SPECS) was used to assess patient comfort (total score; vocalization, body language, anxiety sub-scores). Patient discomfort was defined as a SPECS total or sub-score above 0.

Results
Between 06/2022 - 07/2023, 258 patients underwent 276 procedures to remove 318 LNPCPs. Median age was 67.0 years and 126 (48.9%) were female. Most patients were ASA II (168, 57.3%) and 268 (97.1%) received conscious sedation with midazolam and/or fentanyl. Median SPECS score was 0 (IQR 1) with a range of 0 (145, 56.6%) to 5 (2, 0.8%). Challenging access and proximal LNPCP location were associated with overall discomfort and vocalization respectively (both p ampersand:003C 0.03). Highest rate of discomfort corresponded to lesions with difficult reach and easy positioning (70.6% of patients with these lesions had SPECSampersand:003E0). Lesion size, resection technique or resection duration were not associated with discomfort.

Conclusions
Minimally invasive endoscopic resection techniques can be performed without patient discomfort in most patients with LNPCPs. Challenging access and proximal location should be taken into consideration when administering sedation.

Funding Agencies
None
Gastrointestinal Oncology
A153 IMPLEMENTATION OF THE CHAMPLAIN REGION GASTROINTESTINAL ENDOSCOPY CENTRAL INTAKE (GICI) PROGRAM
Authors: Monod A , Jarrar M , Coates S , Burns H , Prihar R , Dubé C 
Published: February 2024

Abstract

Background
The Champlain region of Ontario is implementing a regional central intake triage program for screening colonoscopy services (FIT+, screening and surveillance indications). The aim of this program is to improve the delivery of regional endoscopy services, so that access to resource-intensive endoscopy procedures can be equitable, timely and evidence-based. We characterized the first phase of implementation of the Champlain Regional GI Central Intake (GICI).

Aims
The primary objective of this study is to identify program strengths and opportunities for quality improvement.

Methods
Prospective data was collected from August 1, 2022 to August 31, 2023. Descriptive statistics were analyzed. Discrete data were presented in terms of counts, percentages and means where appropriate.

Results
1942 CIP referrals were received during the period of study. 1478(76.1%) referrals were submitted by fax, and 571(29.4%) were for positive FITs. 703(36.2%) referrals were declined, with 374(19.3%) not meeting Cancer Care Ontario (CCO) referral indications, 84(4.3%) being duplicates and 56(2.9%) being symptomatic. Prior to a policy change in March 2023, 23(1.2%) referrals were declined due to incomplete referral forms. 581(29.9%) referrals indicated a preferred physician or hospital site. On average, triage decisions were made within 11.4 hours of receipt of referrals for positive FIT, and 6.8 days for other indications. The average time from FIT positivity to referral receipt at CIP was 20.0 days. In the first quarter of 2023, 75th percentile wait times for colonoscopy were 35 days for FIT positivity, 150 days for symptoms, and 346 days for other screening indications.

Conclusions
GICI and the use of CCO evidence-based guidance reduces the need for colonoscopy in nearly 20% of referrals. It also decreases physician administrative burdens by eliminating duplicate referrals. Referrals should not be declined due to incomplete forms. Measures to improve timely access to colonoscopy for symptomatic patients should be explored. Most referred patients do not have a preferred physician or hospital site. Further primary care support and engagement is needed to encourage the use of the GICI as well as immediate referral for FIT+ colonoscopy.

Funding Agencies
None
A154 PRIMARY APPENDICEAL GASTROINTESTINAL STROMAL TUMOR (GIST) IN A PATIENT WITH DELAYED APPENDICITIS: CASE PRESENTATION AND LITERATURE REVIEW
Authors: Pacheco Blandino I I , Naser K 
Published: February 2024

Abstract

Background
Gastrointestinal stromal tumors (GISTs) are uncommon neoplasias, arising from mesenchymal tissue in the gastrointestinal tract. However, primary appendiceal GISTs (PA-GISTs) are rare, with less than 27 cases reported to date. Although treatable with neoadjuvant chemotherapy and subsequent resection, GISTs of the appendix can initially present with appendicitis-like symptoms, and are often treated as acute appendicitis (AA) due to initial misdiagnosis. A 75-year-old man presented to the emergency department of Brightshores Health System (BSHS) with right upper abdominal pain progressing to the right lower quadrant. He was referred to our surgical service, and his condition was treated as delayed appendicitis.

Aims
1. To raise awareness of GIST as a distinct diagnostic possibility in patients presenting with acute appendicitis (AA)-like symptoms.
2. To assess whether delayed appendectomy has an impact in the overall disease outcome for PA-GIST.

Methods
A rare case of PA-GIST was found after a retrospective review of all appendectomies performed at BSHS for appendicitis with or without neoplasia in the last 11 years. To our surprise, we uncovered a rare case PA-GIST. Comprehensive chart review was performed.

Results
A 75-year-old man presenting with a 5-day history of right upper and lower abdominal pain was clinically diagnosed with AA. CT abdomen and ultrasound showed probable appendicitis with phlegmon, distal tip inflammation, no abcess and mild left hydronephrosis. After initial antibiotics and colonoscopy, the patient underwent interval appendectomy. Pathology revealed no AA, a low-grade GIST with focal interstitial cell of Cajal hyperplasia of the distal appendix and positive margin. Six weeks later, cecectomy showed no clinicopathologic evidence of residual PA-GIST. Literature review revealed 27 other PA-GIST tumors to date. Twenty three were found incidentally through imaging, colonoscopy, or surgery. Four cases involved patients presenting with AA symptoms. Our patient was among those presenting with AA symptoms, but with no histological evidence of appendicitis in the delayed appendectomy specimen. Consistent with 25/27 cases, our patient’s GIST displayed spindle morphology, ampersand:003C5cm in size, and without atypia, mitosis, or necrosis.

Conclusions
PA-GISTs tumors are rare, with only 28 cases reported to date, including ours. Some PA-GIST tumors are found incidentally in patients that present with symptoms of AA. Although there is no concensus opinion for optimal treatment of PA-GIST, delayed appendectomy followed by cecectomy have proven to be an acceptable treatment for our patient with no evidence of recurrent or metastatic disease after 6.5 years on follow up by clinical and endoscopic surveilance.

Funding Agencies
None
A156 INCIDENCE OF MALIGNANT GASTRIC OUTLET OBSTRUCTION IN PATIENTS WITH PANCREATIC CANCER UNDERGOING FOLFIRINOX THERAPY
Authors: Rostamianmoghaddam Y , Barkun J , Qatomah A , Long C , Chen Y 
Published: February 2024

Abstract

Background
Malignant gastric outlet obstruction is a morbid complication of pancreatic cancer. There is currently a lack of epidemiology data characterizing its incidence and outcomes in patients with unresectable pancreatic head cancer undergoing chemotherapy with leucovorin, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX). Determining the incidence of MGOO in this context is crucial for developing effective management strategies.

Aims
We aim to ascertain the incidence of MGOO in patients with pancreatic cancer treated with FOLFIRINOX. Secondary objectives include evaluating the clinical outcomes of MGOO. The primary endpoint was the rate of malignant gastric outlet obstruction, defined as clinical evidence of MGOO confirmed with axial imaging and/or endoscopy. Secondary endpoints included the length of hospitalization for MGOO and the rate of successful endoscopic or surgical management.

Methods
This was a retrospective, single-center study including patients with pancreatic head cancer treated with FOLFIRINOX between January 1, 2017, and December 31, 2022, who did not undergo surgical resection. Patients were excluded if they had pancreatic cancer located in the neck, body, and/or tail of the pancreas, had predominantly cystic cancer, had an oncological resection, had a prophylactic surgical gastrojejunostomy, or had metastatic cancer to the pancreas.

Results
Overall, 44 patients with pancreatic head cancer (40.90% female, mean age 59.3 ± 8.5 years) were included. There was no statistically significant difference in tumor staging between MGOO and No-MGOO patients: overall, 6.8% borderline, 40.9% metastatic, and 52.3% locally advanced. The incidence of MGOO in patients with pancreatic head cancer was 36.36%. Patients who never developed MGOO experienced significantly shorter unplanned hospitalizations (mean ± SD: 20.8 ± 18.30 days) compared to those with MGOO (mean ± SD: 50.33 ± 41.22 days; p = 0.0175). The mean number of FOLFIRINOX cycles received was 7.2 (±5.43) for patients without MGOO and 8.1 (±5.81) for patients with MGOO (p = 0.6152). Among patients with MGOO (n=12), management strategies included EUS-guided gastrojejunostomy (43.75%), duodenal stent placement (31.25%), and medical management (25%).

Conclusions
Our contemporary data suggest a high rate of MGOO (36%) in patients with advanced pancreatic head cancer undergoing FOLFIRINOX treatment. The development of MGOO was associated with longer total hospitalization when compared to patients who never developed MGOO. Our study underscores the significant negative impact of MGOO with further research needed to elucidate better management strategies including better endoscopic or surgical prophylactic measures.

Funding Agencies
CIHR