Faculty Bibliography

Remdesivir has been the mainstay of coronavirus disease 2019 treatment since the start of the severe acute respiratory syndrome coronavirus 2 pandemic. Despite its growing use, safety data are limited. We present the case of an elderly man with obesity and coronavirus disease 2019 who developed acute liver failure after initiation of remdesivir. This report broadens our knowledge of the side effect profile of remdesivir and discusses potential risk factors and an approach to remdesivir-induced liver failure. Our case also highlights the importance of monitoring hepatic function after initiation of therapy with remdesivir.

Introduction: Esophageal food impactions (EFI) contribute significantly to morbidity and health expenditures. Professional recommendations for endoscopic management have advised a pull or bolus extraction method, noting a risk of perforation with the alternative push or gastric advancement method. Recent studies have suggested non-inferior safety of the push method compared to traditional piecemeal extraction. We sought to systematically compare the rate of significant adverse events of the push and pull from inception to September 2021. Studies with over five adult participants that reported endoscopic outcomes for EFI were selected. The primary outcomes were success and adverse event rates of endoscopic foreign body removal (FBR) via the pull vs push method. All outcomes were assessed with pooled event rates (ER) and 95% confidence intervals (CI) using a random-effects model, and groups were compared in a mixed-analysis model, with p < 0.05 considered significant.
Result(s): After reviewing 1567 publications, 17 studies with 3296 patients were included. Of these, 1522 cases were treated with the push method and 983 with the pull method. There were no significant differences in demographic data between the two groups. Our analysis of overall adverse events showed that the pull method had ER of 0.046 (95% CI 0.032-0.067), and push ER of 0.058 (95% CI 0.044-0.076), p= 0.798 for the difference. There was a trend towards increased success rates with the push method [pull 0.860 (95% CI 0.749-0.927), push 0.933 (95% CI 0.982-0.997), p= 0.185]. ER of perforation was 0.009 in the pull group (95% CI 0.004-0.019) and 0.012 in the push group (95% CI 0.007-0.023), p= 0.507. ER of bleeding after pull was 0.039 (95% CI 0.024-0.062) and push 0.057 (95% CI 0.040-0.079). For aspiration, the pull ER was 0.024 (95% CI 0.013-0.042) and push 0.014 (95% CI 0.008-0.025), p= 0.536. Overall success rate for all studies for endoscopic treatment of EFI was 0.985 (95% CI 0.935 - 0.996). (Table)
Conclusion(s): Endoscopic therapy for relieving EFI is effective with low rates of adverse events overall. Based on limited data available, there was a trend for increased success rates with the push technique, and a trend for lower adverse events with the pull method. To our knowledge, this is the first meta-analysis to demonstrate that the push method for treatment of EFI is non-inferior to the pull method with respect to both success rates and safety profile. (Table Presented)

Introduction: Bariatric endoscopic (BE) procedures are an important bridge to address the unmet need of curbing the obesity epidemic. Endoscopic sleeve gastroplasty (ESG) has gained popularity over the past few years as studies have shown promising results. However, there are no practice guidelines or consensus on its implementation in practice. We aimed to perform a survey to inquire about ESG practice patterns across the globe.
Method(s): A survey evaluating ESG practice patterns was distributed online via a digital platform to BE practitioners, participants in virtual international seminars in BE and in-person to participants of the annual Association for Bariatric Endoscopy and Flexible Endoscopic Surgery meetings. The survey consisted of 3 parts. 1- physician demographics (practicing specialty, type and location of practice), 2- types of bariatric procedures offered 3- practice patterns of each procedure offered. The main comparisons were among geographic areas (Western, Middle East and Asia, South America), private vs academic, and surgical vs gastroenterology practice, using Pearson chi-square test, with P< 0.05 considered significant.
Result(s): In total, 110 participants responded to our survey: 37% from South America, 35.4% from the Middle East and Asia, and 30% from the US and Europe (Western). From the total cohort, 79 (73.8%) were gastroenterologists, 25 (23.3%) were surgeons, and 3 (2.6%) participants were obesity medicine specialists. The majority were practicing in academic centers (62.8%) and performing procedures in ambulatory surgical center (ASC) settings (50%) with a median multidisciplinary team size of 4 providers (Table). The use of perioperative antibiotics was significantly higher in those practicing in South America when compared to those in the Middle East/Asia (84.6% vs 40%; 0.022). There was a trend for a shorter duration of post-operative liquid diet in private compared to academic practices (P=0.05). Otherwise, there was no difference in number of ESG procedures performed, type of sedation, setting (ASC vs hospital), and adverse events among the different groups (Figure).
Conclusion(s): Across the globe, most ESG procedures are currently performed by gastroenterologists in academic centers. Practice patterns of ESG are consistent across the globe in regard to use of general anesthesia, peri-procedural antibiotics and post-operative liquid diet, with some variations across regions and practices. Larger studies are needed to inform best practice recommendations. (Figure Presented)

Introduction: Intragastric balloons (IGB) have been used for over 30 years to treat obesity and have been approved in the US since 2015. Our objective was to globally survey IGB placement and management patterns.
Method(s): A survey evaluating bariatric endoscopy (BE) practice patterns was distributed online via a digital platform to practitioners, participants in virtual international seminars in BE and in-person at the annual Association for Bariatric Endoscopy and Flexible Endoscopic Surgery meetings. The survey consisted of 3 parts. 1- physician demographics (practicing specialty, type and location of practice), 2- types of bariatric procedures offered 3- practice patterns for IGB placement/removal. The main comparisons were among geographic areas (Western, Middle East and Asia, South America), private vs academic, and surgical vs gastroenterology practice, using Pearson chi-square test, with P< 0.05 considered significant.
Result(s): In total, 110 participants responded to the survey. 79 (73.8%) were gastroenterologists, 25 (23.3%) were surgeons, and 3 (2.6%) participants were obesity medicine specialists. 62.8% were practicing in academic centers and performing procedures in ambulatory surgical center(ASC) settings (50%) (Table). Orbera (Apollo Endosurgery; Austin, TX, USA) was the most common IGB placed in South America and Western countries, while Spatz (Spatz FGIA; Great Neck, NY, USA); was more commonly placed in the Middle East/Asia (Figure). Gastroenterologists were more likely to place and remove IGB under monitored anesthesia care while surgeons were more likely to use general anesthesia with endotracheal intubation (52% vs 25% and 17.9% vs 1 %, P=0.0013; respectively). Private practitioners were more likely to use conscious sedation and start a liquid diet sooner (1 week) compared to those in academic centers, 60% vs 40%, P=0.03 & 56% vs 40% P 0.0041, respectively. Providers in the South America and Western countries were more likely to use ET for placement/removal compared to those in the Middle East/Asia.
Conclusion(s): Based on this global survey, most IGB procedures are performed by gastroenterologists practicing in academic centers. Variation exists in the type of anesthesia and timing of diet initiation following IGB placement, with no significant difference in adverse events. Larger survey/registries and data are needed to inform best practice recommendations. (Figure Presented)

Introduction: As rates of obesity rise, the incidence of bariatric surgery (BaS) has increased. Included amongst these patients are women with plans for pregnancy and labor and delivery (L&D). Bariatric surgery has been shown to improve menstrual irregularities and conception rates; but there is limited data on its effects on pregnancy and L&D outcomes.
Method(s): A retrospective cohort analysis of the 2012 Nationwide Inpatient Sample (NIS) database. Inclusion criteria were ICD-9 codes for pregnancy and L&D. Exposure of interest was ICD-9 code for history of BaS. Primary outcomes were pregnancy and L&D complications in women with BaS compared to women without BaS with and without obesity. Secondary outcomes were length of stay (LOS) and hospitalization cost. Differences between cases and controls were compared with student t-test and chi-square tests; multivariable logistic regression was used to control for confounders.
Result(s): A total of 8,185 inpatient admissions of pregnant subjects with BaS were captured in the 2012 NIS with 212,945 admissions of pregnant women with obesity without BaS and 211,155 admissions of pregnant women without obesity or BaS. A total of 3,608,876 deliveries were captured in the United States in 2012 with 9,159 with history of BaS. Patients with prior BaS were older (33 vs 28 years, P< 0.01), had longer mean LOS (3.3 vs 2.6/2.8 days, P< 0.01), and higher cost (18,945 vs 15,071 USD, P< 0.01; 19,107 vs 14,971 USD, P< 0.01). Pregnancy complications like gestational diabetes, hypertension, pre-eclampsia were more common in the BaS cohort than the general cohort, but lower than the cohort with obesity. Alcohol and mental health disorders, hyperemesis, spontaneous abortions, and thromboembolism were more common in pregnant women with BaS compared with both other cohorts (Table A). The rate of cesarean and breech delivery, fetal distress, anesthesia complication, ectopic pregnancy, and infection was higher in women with BaS compared to those without (Table B). Bariatric surgery remained a significant predictor for cesarean delivery and longer LOS after controlling for age.
Conclusion(s): Pregnant women with history of bariatric surgery have increased risk of pregnancy and L&D complications and should be considered high-risk pregnancies and deliveries as the rate of potential complications is higher compared to those without prior bariatric surgery, including when compared to pregnant women with obesity. (Table Presented)