Faculty Bibliography

BACKGROUND:Limited literature exists on labor and delivery outcomes after bariatric surgery. This study assesses the impact of prior bariatric surgery on peripartum outcomes. METHODS:We queried the National Inpatient Sample (2016-2020) for labor and delivery admissions, categorizing them into three cohorts: prior bariatric surgery (BaS), obesity without prior bariatric surgery, and controls without obesity. We used a multivariate regression model, adjusting for confounders, to compare peripartum outcomes. RESULTS:We identified 22,685 BaS cases, 2.1 million pregnant controls with obesity, and 16.37 million pregnant controls without obesity. Compared to controls with obesity, the BaS cohort had lower rates of cesarean delivery [43% vs 46.8%, adjusted odds ratio (aOR) 0.72, p < 0.001], fetal distress [aOR 0.79, p < 0.001), post-partum hemorrhage (aOR 0.67, p < 0.001), fetal disproportion (aOR 0.36, p < 0.001), and premature rupture of membranes (aOR 0.88, p = 0.04). Compared to controls without obesity, the BaS group had higher rates of cesarean delivery (43% vs 29.57%, aOR 1.43, p < 0.001), breech presentation (aOR 1.4, p < 0.001), thromboembolic events (aOR 2.47, p = 0.01), and pregnancy termination (aOR 1.59, p = 0.048), but lower rates of assisted delivery (aOR 0.54, p < 0.001), fetal disproportion (aOR 0.56, p = 0.025), PROM (aOR 0.87, p = 0.024), and placenta previa (aOR 0.63, p = 0.019). The BaS group had longer hospitalizations (3.11 vs 2.56 days, p < 0.001) and higher hospitalization charges ($25,941 vs $20,760, p < 0.001) compared to controls without obesity. CONCLUSION/CONCLUSIONS:Pregnancy after bariatric surgery is associated with lower odds of cesarean delivery and postpartum complications, relative to the general population with obesity. This underscores the positive impact of bariatric surgery on peripartum outcomes.

BACKGROUND AND AIMS/OBJECTIVE:The COVID-19 pandemic significantly decreased procedural volume in 2020, thus limiting training opportunities. First-year fellows (1YF) are particularly susceptible to reduction in endoscopic volume as they build foundational endoscopic skills. We used an objective validated tool, the Assessment of Competency in Endoscopy (ACE), to determine the effect of the pandemic on endoscopy competency in gastroenterology fellows. METHODS:This was a prospective cohort study conducted across two fellowship programs in New York City. Our primary outcome was the comparison of ACE scores of fellows starting gastroenterology fellowships in 2020 to the scores of those starting in 2016-2018. Our secondary outcome was to compare colonoscopy quality metrics and endoscopy volume between these cohorts. RESULTS:ACE scores were available from 11 pandemic and 10 pre-pandemic 1YFs, and five pandemic and 19 pre-pandemic second (2YF) and third-year fellows (3YF). ACE scores for 1YFs showed significantly higher rating in the pre-pandemic cohort for 4 domains including knowledge of indications and medical issues (p = 0.03), effective and efficient use of air, water, and suction (p = 0.04), pathology identification (p = 0.001), and overall hands-on skills (p = 0.004). 2YFs showed no significant differences. 3YFs showed significantly lower scores in the pandemic cohort in the effective and efficient use of air, water, and suction (p = 0.03), fellows' knowledge of therapeutic tools (p = 0.05), and fellows overall cognitive skills (p = 0.05). There were no significant differences in quality metrics between the cohorts, except longer procedure time for the pandemic cohort (p < 0.01). CONCLUSION/CONCLUSIONS:Following the COVID-19 pandemic, there was a decline in multiple aspects of endoscopic competency both at the beginning and the end of fellowship training. These trends are likely the result of a decrease in overall procedure volume early in training and highlight the need for supplementing trainee education with other modalities.

Sessile serrated lesions (SSLs) are a class of colon polyps challenging to detect through current screening methods but highly associated with colon cancer. To improve detection, we sought a biomarker sensitive for SSLs. Recent endoscopic and histopathologic studies suggest that SSLs are associated with alterations in intestinal mucin expression, but the frequency with which this occurs is not known. We performed a meta-analysis of available pathologic studies comparing mucin expression on SSLs to normal colonic mucosa, tubular adenomas (TAs), villous adenomas (VAs), traditional serrated adenomas (TSAs), and hyperplastic polyps (HPs). We searched Medline, Pubmed, and Embase and found 440 publications in this topic, and 18 total studies met inclusion. We found that MUC5AC expression was more common in SSLs compared to normal colonic mucosa (OR=82.9, p<0.01), TAs (OR=11, p<0.01), and TSAs (OR=3.6, p=0.04). We found no difference in MUC5AC expression between SSLs versus HPs (OR=2.1, p=0.09) and no difference in MUC5AC expression between left colon and right colon HPs, with an OR=1.8, p=0.23. We found that MUC5AC expression was found commonly on VAs, SSLs, and TSAs while the frequency on colon cancers declined. MUC5AC is also upregulated in inflammatory bowel disease and in response to intestinal infections. MUC5AC expression highlights the potential of mucins as useful biomarkers, though not specific to SSLs. Further research into the clinical utility of MUC5AC as a pathologic or fecal biomarker could enhance SSL detection.

BACKGROUND:Measurement of colorectal polyps is typically performed via visual estimation, which is prone to bias. Studies have evaluated the accuracy of visual estimation and utility of assistive tools, but results have been mixed. This study aims to clarify the accuracy of visual estimation as a measurement tool, and the benefits of artificial intelligence. METHODS:MEDLINE and Embase were searched through October 2024. Extraction and quality assessment were performed independently by two authors. The primary outcome was the pooled absolute mean difference in size between visual estimation and control. Secondary outcomes included subgroup analysis of expert vs trainee status, accuracy of artificial intelligence, study origin (East vs. West), comparator type, definition of accuracy, polyp size, direction of estimation, and image type. RESULTS:35 studies with 42,964 polyp measurements were included in our analysis. All studies were of high quality and there was no evidence of publication bias. The pooled absolute mean difference from comparator was 1.68mm (CI 1.21-2.15) with high variability explained by differences in the comparator, the direction of estimation, image type, and size of the polyp. Overall accuracy was 60% with high variability as well, with increased accuracy with video displayed over photos. Artificial intelligence improved accuracy with an odds ratio of 7.46. CONCLUSION/CONCLUSIONS:Visual estimation is an inaccurate and imprecise way to measure colorectal polyps. Further research is needed to determine the impact on clinical outcomes related to colorectal cancer. Investment in new technology to aid in polyp measurement is an important next step.

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)

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: 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)

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)