Faculty Bibliography

Intraductal papillary neoplasm of the bile duct is a rare bile duct tumor that displays a range of cytoarchitectural atypia and is recognized as a precursor of invasive carcinoma. We present a 71-year-old woman with a recent diagnosis of lung adenocarcinoma, who presented with acute cholangitis secondary to an obstructive intraductal papillary neoplasm of the bile duct. The patient underwent endoscopic retrograde cholangiopancreatography, which identified the lesion, and on biliary sweep, the polyp presented externally and she underwent successful polypectomy with resolution of the infection.

BACKGROUND AND AIMS/OBJECTIVE:Simulation refers to educational tools that allow for repetitive instruction in a nonpatient care environment that is risk-free. In GI endoscopy, simulators include ex vivo animal tissue models, live animal models, mechanical models, and virtual reality (VR) computer simulators. METHODS:After a structured search of the peer-reviewed medical literature, this document reviews commercially available GI endoscopy simulation systems and clinical outcomes of simulation in endoscopy. RESULTS:Mechanical simulators and VR simulators are frequently used early in training, whereas ex vivo and in vivo animal models are more commonly used for advanced endoscopy training. Multiple studies and systematic reviews show that simulation-based training appears to provide novice endoscopists with some advantage over untrained peers with regard to endpoints such as independent procedure completion and performance time, among others. Data also suggest that simulation training may accelerate the acquisition of specific technical skills in colonoscopy and upper endoscopy early in training. However, the available literature suggests that the benefits of simulator training appear to attenuate and cease after a finite period. Further studies are needed to determine if meeting competency metrics using simulation will predict actual clinical competency. CONCLUSIONS:Simulation training is a promising modality that may aid in endoscopic education. However, for widespread incorporation of simulators into gastroenterology training programs to occur, simulators must show a sustained advantage over traditional mentored teaching in a cost-effective manner. Because most studies evaluating simulation have focused on novice learners, the role of simulation training in helping practicing endoscopists gain proficiency using new techniques and devices should be further explored.

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 & AIMS: Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the GI tract. Fine needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB. METHODS: This is a multicenter, prospective randomized clinical trial from six large tertiary care centers. Patients referred for tissue sampling of solid lesions were randomized to either FNA or FNB of the target lesion. Demographics, size, location, number of needle passes, and final diagnosis were recorded. RESULTS: After enrollment, 135 patients were randomized to FNA (49.3%) and 139 patients were randomized to FNB (50.7%).The following lesions were sampled: mass (n=210; 76.6%), lymph nodes (n=46, 16.8%), submucosal tumors (n=18, 6.6%). Final diagnosis was malignancy (n=192, 70.1%), reactive lymphadenopathy (n=30, 11.0%), and spindle cell tumors (n=24, 8.8%). FNA had a diagnostic yield of 91.1% compared to 88.5% for FNB (p=0.48). There was no difference between FNA and FNB when stratified by the presence of on-site cytopathology or by type of lesion sampled A median of 1 needle pass was needed to obtain a diagnostic sample for both needles. CONCLUSION: FNA and FNB obtained a similar diagnostic yield with a comparable number of needle passes. Based on these results, there is no significant difference in the performance of FNA compared to FNB in the cytological diagnosis of solid lesions adjacent to the GI tract. (ClincalTrials.gov identifier: NCT01698190).

Background/UNASSIGNED:This study was performed to compare patient-reported tolerability and its barriers in single- vs. split-dose 4-L polyethylene glycol (PEG) bowel preparation for colonoscopy in a large multiethnic, safety-net patient population. Methods/UNASSIGNED:A cross-sectional, dual-center study using a multi-language survey was used to collect patient-reported demographic, medical, socioeconomic, and tolerability data from patients undergoing outpatient colonoscopy. Univariate and multivariate analyses were used to identify demographic and clinical factors significantly associated with patient-reported bowel preparation tolerability. Results/UNASSIGNED:A total of 1023 complete surveys were included, of which 342 (33.4%) completed single-dose and 681 (66.6%) split-dose bowel preparation. Thirty-nine percent of the patients were Hispanic, 50% had Medicaid or no insurance, and 34% had limited English proficiency. Patients who underwent split-dose preparation were significantly more likely to report a tolerable preparation, with less severe symptoms, than were patients who underwent single-dose preparation. Multiple logistic regression revealed that male sex and instructions in the preferred language were associated with tolerability of the single-dose preparation, while male sex and concerns about medications were associated with tolerability of the split-dose preparation. Conclusions/UNASSIGNED:In a large multiethnic safety-net population, split-dose bowel preparation was significantly more tolerable and associated with less severe gastrointestinal symptoms than single-dose preparation. The tolerability of split-dose bowel preparation was associated with social barriers, including concerns about interfering with other medications.

Double aortic arch is a rare congenital anomaly usually recognized in infancy or childhood. We present an unusual case of massive gastrointestinal hemorrhage resulting from aortoesophageal fistula complicating previously unrecognized double aortic arch in an adult. A 52 year-old man with a prior history of mild intermittent asthma was admitted to the hospital with a severe asthma exacerbation requiring endotracheal intubation. His course was complicated by prolonged respiratory failure and lower extremity deep venous thrombosis. He received enteral feeding via nasogastric tube throughout the period of mechanical ventilation. Several days after initiation of anticoagulation with enoxaparin, he developed melena, hypotension, and acute blood loss anemia. Urgent upper endoscopy revealed an actively bleeding ulcer in the mid esophagus, thought to have been caused by nasogastric tube trauma. Endoscopic hemostasis was achieved with epinephrine injection and clip placement. The patient recovered from this episode and anticoagulation was resumed after 72 hours. Four days later, the patient developed large volume hematemesis and hemodynamic shock requiring massive transfusion. Upper endoscopy revealed active hemorrhage at the same site in the mid esophagus, and hemostasis was again achieved with clip placement. Due to repeat massive esophageal bleeding of uncertain etiology, the patient underwent computed tomography of the chest, which revealed a right-dominant double aortic arch and aortoesophageal fistula. He underwent emergent surgery with ligation of the left-sided arch and repair of the fistula. He recovered from surgery and bleeding has not recurred. Double aortic arch (DAA), or vascular ring, is a rare developmental anomaly which usually presents in infancy or childhood. Aortoesophageal fistula due to a tight vascular ring is exceedingly rare and usually fatal. It has been reported in a handful of cases to have been precipitated by the use of a nasogastric tube. To our knowledge, this is the first case of aortoesophageal complicating DAA in a patient over 40 years old. Due to the high risk of massive hemorrhage and circulatory collapse, this case illustrates that vascular anomalies should be considered in adults with presenting with significant nonvariceal esophageal hemorrhage, prompting early consideration of cross sectional imaging. (Figure Presented)

Introduction: Efficacy of colonoscopy is limited by inadequate preparation. A high social deprivation index has been identified as a risk factor for failure to repeat a colonoscopy when indicated. It is unknown whether or not split dose preparation increases adherence to recommendation for repeat colonoscopy. Few studies to date have evaluated the potential barriers to likelihood of repeating a bowel preparation in an underserved population. The purpose of this study was to identify factors associated with an increased likelihood of repeating a bowel preparation in a population with a high social deprivation index in a split-dose versus a single dose cohort Methods: Demographic, socioeconomic, medical, education and tolerability data were collected prospectively using a multi-language questionnaire. Descriptive statistics and multivariate analyses were performed on all variables assessed by our questionnaire to evaluate for differences in patients who were likely and unlikely to repeat the preparation. Results: Demographics are presented in table 1 (N=990). 336 (34%) completed single dose and 654 (66%) completed split dose colon preparation. Split dose patients were equally willing-to-repeat colonoscopy preparation compared to single dose patients (69.0% vs. 71.6%; P=0.45) (Table 2). Patients who were not willing to repeat split preparation complained of significantly more adverse gastrointestinal symptoms and difficulty completing dosing instructions due to social barriers and tolerability issues compared to single-dose cohort. Multivariable analysis revealed that concerns with time off work (OR: 0.48; 95% CI: 0.29-0.80), availability of appropriate food/drinks (OR: 0.59; CI: 0.36-0.97), tolerability (OR: 0.72; CI: 0.57-0.92), and colonoscopy scheduling (OR: 0.77; CI: 0.63- 0.94) were all factors independently associated with decreased willingness to repeat in the split dose cohort. Nurse's instruction in preferred language (OR: 2.69; CI: 1.22-5.91) and tolerability (OR: 0.71; CI: 0.55-0.92) were independently associated with patient willingness-to-repeat in the single-dose cohort. Conclusion: This study highlights that tolerability significantly effects repeatability in both single and split dose cohorts. It should be noted that patients with a high social deprivation index identify different barriers to single and split dose preparations. This observation could impact choice of preparation as it affects adherence to physician recommendations. (Figure Presented)

Introduction: Effectiveness of colonoscopy is limited by inadequate bowel preparation. Failure of proper cleansing is multifactorial, but includes the inability of patients to tolerate the bowel preparation due to side effects. It is unknown whether or not the experience with split dose preparation increases adherence to recommendation for repeat colonoscopy. Few studies to date have evaluated potential barriers to bowel preparation in underserved populations. The purpose of this study was to identify whether adverse effects of bowel preparation affect the likelihood of repeating a colonoscopy in a split-dose versus a single dose cohort Methods: Demographic, socioeconomic, medical, education and tolerability data were collected prospectively using a multi-language questionnaire. Descriptive statistics and multivariate analyses were performed on all variables assessed by our questionnaire to evaluate for differences in patients who were likely or unlikely to repeat the preparation. Results: A total of 990 patients satisfied the study criteria (Figure 1). 54.6% of the patients were male, 39.7% Hispanic, 41.2% with less than a high school education, and 38.9% without medical insurance. 336 (34%) completed single dose and 654 (66%) completed split dose colon preparation. In the single dose cohort there were no statistically significant differences in the side effects experienced between patients who would and would not repeat the bowel preparation (Table 1). In contrast, in the split-dose cohorts, complaints of bad taste in mouth, nausea/vomiting and headache were statistically significant causes of a patient being unlikely to repeat the bowel preparation (p < .05) (Table 2). Despite the difference in the role of symptoms in willingness to repeat colon preparation between split dose versus single does preparation groups, there was no significant difference in overall willingness to repeat colon preparation between groups (69.0% versus 71.6%, p = 0.45). Conclusion: This study highlights differences in side effects experienced by patients taking a split dose compared to a single dose preparation. Despite these differences, patients in both groups were likely to repeat a colonoscopy. These results should give a provider confidence in prescribing a split dose preparation to a diverse patient population