Faculty Bibliography

Introduction: Many patients who undergo Roux-en-Y gastric bypass (RYGB)surgery experience weight regain after initial weight loss, particularly patients who develop dilation of the gastrojejunal (GJ)anastomosis. Transoral outlet reduction (TORe)is a minimally invasive endoscopic procedure which has demonstrated efficacy in inducing weight loss in patients who have experienced weight regain after RYGB. Prior literature has described total weight loss of 8.4-8.6kg or 25% excess weight loss. However, there is limited published information on patient reported experiences with the TORe procedure. We aimed to evaluate clinical and patient-reported experience outcomes in patients who have undergone TORe.
Result(s): A total of 18 patients who underwent TORe procedure within the last 1.5 years at a large, urban medical center were requested to participate in a survey-based study. A total of 7 subjects agreed to participate. All were older than age 18, had undergone RYGB, and had a mean GJ diameter prior to TORe of 27mm. All patients underwent TORe with reduction of the GJ to a diameter of 8mm sized by a CRE balloon, and 5 out of 7 received supporting sutures to reduce the gastric pouch. The average weight loss was 6.8kg, with average excess weight loss of 7.5% with median follow-up of 4 months after TORe. Metabolic parameters including hemoglobin A1c and lipid panels were evaluated pre- and post-TORe, and all were reduced, however the differences were not statistically significant (table 1). Survey results indicated that 4 out of 7 subjects were satisfied with their weight loss after TORe, and were notable for a higher perceived than actual weight loss after TORe (self-reported average 8.6kg or 9.6% excess weight loss). Only 1 patient reported significant adverse event following TORe, with epigastric pain requiring hospitalization for two days for pain control. Subjects, on average, reported high quality of life following TORe with use of Moorehead-Ardelt Quality of Life Questionnaire. 6 of 7 subjects stated they were willing to undergo repeat TORe for further weight loss.
Conclusion(s): Our study demonstrates that patients who have undergone TORe tolerated the procedure well and experienced excess weight loss. Most patients reported satisfaction with their weight loss following TORe, and we found that patients reported a higher perceived weight loss than objectively measured. Clinically our cohort demonstrated a reduction in metabolic parameters, but this was not statistically significant, likely given small sample size. Most patients reported high quality of life scores following TORe and were willing to undergo repeat TORe based on their experiences. These findings support the use of TORe given general positive patient-reported outcomes, however further evaluation is needed to predict which patients are most likely to clinically benefit from this procedure. [Figure presented]
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Background: Prior data from Asian countries showed comparable outcomes of endoscopic submucosal dissection (ESD)vs surgery in patients with early gastric cancer (EGC)meeting standard and expanded criteria. Data from comparative studies using strict criteria in North American population are lacking.
Method(s): We conducted a multicenter retrospective study from 16 North American centers. All patient underwent ESD and/or gastrectomy for EGC between 12/2004 and 2/2018, with follow-up until 10/2018. Patients who did not meet either standard or expanded criteria, those with evidence of lymph node or distant metastasis at time of diagnosis, those without curative resection, and those with follow-up time of less than 6 months were excluded. Primary outcomes were overall survival (OS), cancer-specific survival (CSS)and recurrence-free survival (RFS). Kaplan-Meier using log-rank analysis was used to compare outcomes between ESD and surgery groups. Factors associated with outcomes were analyzed using Cox hazards regression and linear regression analyses.
Result(s): There were 393 patients with EGC who underwent ESD or gastrectomy from 14 US and 2 Canadian centers. Of these, 318 patients were excluded due to unfulfilled standard or expanded criteria (n=254), evidence of lymph node metastasis (n=1), no data on lymphovascular invasion (n=1), non-R0 resection (n=17)and follow-up time of less than 6 months (n=45). A total of 75 patients were analyzed (38 treated with ESD and 37 treated with surgery). Patients treated with surgery had a higher proportion of pedunculated lesions (P=0.02), undifferentiated tumors (P =0.01), EGCs fulfilling expanded criteria (P <0.0001)and longer follow-up time (P=0.0004)(Table 1). OS (P= 1.00), CSS (P=1.00)and RFS (P=1.00)were not statistically different between ESD vs surgery groups. There was no subsequent nodal or distant metastasis in either group. A single patient in the surgery group died of an etiology not related to gastric cancer at 7.9 years after gastrectomy. There were no deaths in the ESD group. One patient with moderately differentiated adenocarcinoma in the gastric antrum, treated with curative ESD, developed a gastric cardiac neuroendocrine tumor at 7.2 years (Table 2). The metachronous lesion was treated with a repeat curative endoscopic resection. There was no demographic, procedural or histological factor associated with OS, CSS or RFS.
Conclusion(s): The standard and expanded criteria for gastric ESD are clinically applicable to a North American population. ESD provides comparable oncologic outcomes and is thus an alternative treatment option to surgery. Recurrence after ESD is uncommon, and can be managed successfully using follow-up and repeat endoscopic treatment. [Figure presented][Figure presented]
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Despite the small bowel comprising 90% of the mucosal surface area of the gastrointestinal tract, it is a rare site for neoplasia and only accounts for a little over 3% of the tumors that arise in the digestive tract. Benign small bowel lesions include lipomas, lymphangiomas, leiomyomas, neurofibromas, nodular lymphoid hyperplasia and adenomas, many of which are precursors to malignant lesions. Several polyposis syndromes are associated with small bowel polyps as well, including familial adenomatous polyposis syndrome, lynch syndrome, Peutz-Jeghers syndrome, Cowden syndrome and juvenile polyposis syndrome. Our aim was to review non-malignant small bowel polyps and discuss the prevalence, typical location, clinical presentation, diagnosis, endoscopic and histologic description and lastly management of each of these lesions.