Faculty Bibliography

BACKGROUND: Endotherapy is a treatment modality that can be used to manage the pain associated with chronic pancreatitis. The aim of this systematic review and meta-analysis is to evaluate the efficacy of endotherapy in the management of pain associated with chronic pancreatitis. METHODS: A search of Medline, Pubmed, and Embase databases between 1988 to December 2014 was conducted to evaluate the use of endotherapy for pain relief in patients with chronic pancreatitis. We included large prospective studies, randomized controlled trials and retrospective analyses. Exclusion criteria included studies not written in the English language, small studies with less than 10 patients, case series/case reports and studies that enrolled patients treated with dual therapies including surgery or celiac plexus neurolysis. In addition, a subgroup analysis was conducted to evaluate studies that included patients with pancreatic duct strictures. A meta-analysis was performed and the data on pain relief was subsequently extracted, pooled, and analyzed. I2 index estimates were calculated to test for variability and heterogeneity across the included studies. RESULTS: Our final analysis included sixteen studies, comprising 1498 patients. Eleven studies presented data on immediate pain relief after endotherapy and twelve studies presented data on both immediate and long term pain relief (mean follow up was 47.4 months). The compiled result of the sixteen studies for immediate pain relief demonstrated 88% efficacy (95% NT CI [81.0%, 94%]) of endotherapy. Similarly, analysis of pain relief on long term follow-up showed a 67% efficacy of endotherapy (95% NT CI [58%, 76%]). The compiled complication rate for endotherapy in this review was 7.85% per ERCP/endotherapeutic procedure and the most common complications were acute pancreatitis, stent occlusion and stent migration. CONCLUSIONS: Endotherapy is beneficial for both immediate and long term management of pain associated with chronic pancreatitis. The efficacy of endotherapy decreases over time as assessed by evaluating pain relief on long term follow up. Given the considerable heterogeneity of reported data, additional prospective and standardized multicenter studies need to be conducted to evaluate the efficacy of this modality in controlling pain associated with chronic pancreatitis.

Background and study aims Data on clinical outcomes of endoscopic drainage of debris-free pseudocysts (PDF) versus pseudocysts containing solid debris (PSD) are very limited. The aims of this study were to compare treatment outcomes between patients with PDF vs. PSD undergoing endoscopic ultrasound (EUS)-guided drainage via transmural stents. Patients and methods Retrospective review of 142 consecutive patients with pseudocysts who underwent EUS-guided transmural drainage (TM) from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TM technical success, treatment outcomes (symptomatic and radiologic resolution), need for endoscopic re-intervention at follow-up, and adverse events (AEs). Results TM was performed in 90 patients with PDF and 52 with PSD. Technical success: PDF 87 (96.7 %) vs. PSD 51 (98.1 %). There was no difference in the rates for endoscopic re-intervention (5.5 % in PDF vs. 11.5 % in PSD; P = 0.33) or AEs (12.2 % in PDF vs. 19.2 % in PSD; P = 0.33). Median long-term follow-up after stent removal was 297 days (interquartile range [IQR]: 59 - 424 days) for PDF and 326 days (IQR: 180 - 448 days) for PSD (P = 0.88). There was a higher rate of short-term radiologic resolution of PDF (45; 66.2 %) vs. PSD (21; 51.2 %) (OR = 0.30; 95 % CI: 0.13 - 0.72; P = 0.009). There was no difference in long-term symptomatic resolution (PDF: 70.4 % vs. PSD: 66.7 %; P = 0.72) or radiologic resolution (PDF: 68.9 % vs. PSD: 78.6 %; P = 0.72) Conclusions There was no difference in need for endoscopic re-intervention, AEs or long-term treatment outcomes in patients with PDF vs. PSD undergoing EUS-guided drainage with transmural stents. Based on these results, the presence of solid debris in pancreatic fluid collections does not appear to be associated with a poorer outcome.

BACKGROUND: There is debate regarding preoperative endoscopy (EGD) in patients undergoing bariatric surgery. Some centers perform EGD routinely in all patients; others perform EGD selectively. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to estimate how frequently preoperative EGD changes management. METHODS: Our review yielded 28 studies encompassing 6616 patients. Baseline characteristics including age and body mass index (BMI) were included. Patients were grouped based on EGD findings into two groups: Group 1-findings which did not significantly change management (e.g., mild/moderate duodenitis, Grade A/B esophagitis, mild/moderate gastritis, H. pylori infection, hiatal hernia <2 cm); Group 2-findings which delayed, altered, or cancelled surgery (e.g., severe duodenitis, Grade C/D esophagitis, gastric varices, hiatal hernia >2 cm, mass/carcinoma). A general estimating equation (GEE) model accounting for the correlated data within each study was used to calculate confidence intervals around the estimate of how frequently surgery was delayed or altered. RESULTS: Mean age was 41.4 +/- 2.9 years, the majority was women, and mean preoperative BMI was 47 +/- 3.2 kg/m2. Overall 92.4 % (n = 6112) had a normal EGD or findings that did not change clinical management and 7.6 % (n = 504); 95 % CI [4.6, 12.4 %] had findings that delayed/altered surgery. The revised estimate was 20.6 %; 95%CI [14.5, 28.2 %] if all esophagitis (regardless of grade) were categorized into Group 2. The approximate incidence of Barrett's esophagus and carcinoma were 0.1 and 0.08 %, respectively. CONCLUSION: A selective approach to preoperative EGD may be considered, based on the patients' symptoms, risk factors, and type of procedure planned.

GOAL: The purpose of this study was to assess the effect of decreased colonoscopy reimbursement on gastroenterologist practice behavior, including time to retirement and procedure volume. BACKGROUND: In 2015, the Centers for Medicare and Medicaid Services proposed reductions in colonoscopy reimbursements. With new initiatives for increased colorectal cancer screening, it is crucial to understand how reimbursement changes could affect these efforts. STUDY: Randomly selected respondents from the American College of Gastroenterology membership database were surveyed on incremental changes in practice behavior if colonoscopy reimbursement were to decrease by 10, 20, 30, or 40 %. Data were analyzed using both Pearson's Chi-square and analysis of variance. RESULTS: Two thousand and nine gastroenterologists received the survey with a 16.3 % response rate. Procedure volume significantly decreased with degree of reimbursement reductions (p < 0.001). With a 10 % decrease, 72 % of respondents reported no change in the number of colonoscopies performed. With a 20 % decrease, 39 % would decrease their procedure volume, while 21 % of respondents would increase their procedure volume. With a 30 and 40 % decrease, procedure volume decreased by 48 and 50 %, respectively. In terms of retirement, current plans predict a cumulative retirement rate of 29.4 % at 10 years. More than 42 % of respondents plan to retire after 2030. In the 2014-2023 retirement subgroup (N = 74 responses), there was a significant hastening of retirement year at 20 % (p = 0.016), 30 % (p < 0.001), and 40 % (p < 0.001) reimbursement reductions as compared to baseline responses. CONCLUSION: Decreasing colonoscopy reimbursements may have a significant effect on the effective gastroenterology work force.

BACKGROUND AND AIMS: The need for transpapillary drainage (TP) in patients undergoing transmural drainage (TM) of pancreatic fluid collections (PFC) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TM versus combined (TM and TP) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS: Retrospective review of 375 consecutive patients with PFC who underwent endoscopic ultrasound (EUS)-guided TM from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TM and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS: A total of 375 patients underwent EUS-guided TM drainage of a PFC, of which 174 were pseudocysts. TM alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success: TM 92(97%) versus CD 35(44%) (P=0.0001). There was no difference in adverse events between the TM (15%) and CD (14%) cohorts (P=0.23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TM and 201 days (interquartile range: 150-493 days) (P=0.37). There was no difference in LT symptomatic resolution (TM: 69% vs CD: 62%, P=0.61) or LT radiologic resolution (TM: 71% vs CD: 67%, P=0.79). TP attempt was negatively associated with LT radiologic resolution of pseudocyst (OR, 0.11; 95% CI, 0.02-0.8; P=0.03). CONCLUSIONS: TP has no benefit on treatment outcomes in patients undergoing EUS-guided TM of pancreatic pseudocysts and negatively impacts long-term resolution of PFC.

Introduction: EUS-guided transmural drainage (TM) of pancreatic pseudocysts is well established. It . remains unclear if TM alone is sufficient treatment in pseudocysts containing solid debris. Aim: To compare clinical outcomes in patients who undergo TM of pancreatic pseudocysts that are debris-free (PDF) vs those that contain solid debris (PSD). Methods: Multi-center retrospective cohort study across 15 centers of patients who underwent TM of pancreatic pseudocysts during a 6-year period (2008-2014). Outcome measures included technical success, symptom resolution, radiologic resolution, endoscopic re-intervention and adverse events (AE). PSD was defined as a pseudocyst containing solid material at time of index EUS TM drainage. Patients with obvious walled-offnecrosis on index imaging were excluded. Technical success was defined as drainage with successful placement of > of 1 transmural stent. Short-term (ST) followup was designated as > 2 weeks following TM, but before stent removal. Long-term (LT) follow-up was defined as > 2 weeks following stent removal. Symptom resolution was defined as the complete absence of symptoms at follow-up. Radiologic resolution was defined as the absence of the pseudocyst on repeat imaging. Re-intervention was defined as the need to repeat endoscopic drainage within a 4-week period. Results: A total of 142 patients underwent TM: 90 PDF and 52 PSD. There were no differences in patient characteristics, indication for drainage, size and location of pseudocyst between the two groups (Table 1). Technical success: PDF 87/90 (97%) vs PSD 51/52 (98%, p=1.00). Endoscopic re-intervention rate was similar between the two groups: PDF 5/90 (6%) vs PSD 6/52 (12%, p=0.21). One patient with PSD underwent endoscopic necrosectomy following initial TM. Median ST and LT follow-up were similar between the two cohorts (Table 2). There was no statistically significant difference in ST symptom resolution rate and LT outcomes in the two groups. ST radiologic resolution was higher in PDF 45/68(66%) compared to PSD 21/41(51%; p=0.009). Overall, procedure-related AE occurred in 13 (14%) in the PDF and 9 (17%) in the PSD group (P=0.64). Conclusion: There is no difference in technical success, ST or LT clinical outcomes in performing TM of PSD, when compared to patients with PDF. Thus, TM alone can be considered a suitable initial intervention in patients with PSD, without increased risk of infectious complications or need for endoscopic debridement. (Table Presented)