Faculty Bibliography

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)

BACKGROUND:Intragastric balloons are anatomy-preserving, minimally invasive obesity therapies. Enhanced tolerance and durability could help broaden clinical adoption. We investigated the safety and efficacy of an adjustable intragastric balloon (aIGB) in adults with obesity. METHODS:In this prospective, multicentre, open-label, randomised clinical trial done at seven US sites, adults aged 22-65 years with obesity were randomly assigned (2:1) to aIGB with lifestyle intervention or lifestyle intervention alone (control) for 32 weeks. Balloon volume could be increased to facilitate weight loss or decreased for tolerability. Coprimary endpoints included mean percentage total bodyweight loss and responder rate (≥5% total bodyweight loss) at 32 weeks. We used a multiple imputed intention-to-treat population analysis. This study was registered with ClinicalTrials.gov, NCT02812160. FINDINGS/RESULTS:Between Aug 9, 2016, and Dec 7, 2018, we randomly assigned 288 patients to aIGB (n=187 [65%]) or control (n=101 [35%]) groups. Mean total bodyweight loss at 32 weeks was 15·0% (95% CI 13·9-16·1) in the aIGB group versus 3·3% (2·0-4·6) in the control group (p<0·0001). Clinical response was observed in 171 (92%) patients in the aIGB group. Adjustments to the aIGB occurred in 145 (80%) patients for weight loss plateau or intolerance. Upward volume adjustment facilitated an additional mean 5·2% total bodyweight loss. Downward volume adjustment allowed 21 (75%) patients in the aIGB group to complete the full duration of therapy. Intolerance caused early removal of the device in 31 (17%) patients. No micronutrient deficiencies were observed in the aIGB cohort. Device-related serious adverse events were observed in seven (4%) patients, without any deaths. INTERPRETATION/CONCLUSIONS:When aIGB was combined with lifestyle modification, significant weight loss was achieved and maintained for 6 months following removal. Balloon volume adjustability permitted individualised therapy, maximising weight loss and tolerance. FUNDING/BACKGROUND:Spatz Medical.

Introduction: Non-alcoholic fatty liver disease (NAFLD) is present in 36-70% of women with polycystic ovary syndrome (PCOS). Both are highly prevalent in subjects with obesity. Androgen overproduction in PCOS promotes a pro-apoptotic environment and may contribute to NAFLD. Our objective was to examine the association between PCOS and NAFLD diagnosis and if PCOS is an independent predictor of advanced fibrosis in patients with NAFLD.
Method(s): In a single-center retrospective analysis of electronic medical records, 625 adult patients ( .18 years old) with a diagnosis of NAFLD from 2018-2019 were divided into 3 cohorts: a female study group with PCOS, female control group without PCOS, and a male control cohort, age-matched to the study group. PCOS diagnosis was based on established PCOS society criteria. Our primary outcome was to assess the stage of liver fibrosis, as defined by histology, Fibroscan, MR elastography, NAFLD fibrosis score (NFS), by the age of initial diagnosis. Additionally, demographic, laboratory and clinical parameters were analyzed to compare the three cohorts. Demographics were analyzed using ANOVA, Pearson's chi-squared, and Kruskal-Wallis methods. Linear regression modeling NAFLD score as a function of age of diagnosis was performed.
Result(s): A total of 625 subjects with NAFLD were seen. Of these, 21 met criteria for the female NAFLD/PCOS study group, 525 in the female NAFLD only control group, and 79 age-matched male subjects with NAFLD. The NAFLD/PCOS females study group were significantly younger than the other two cohorts at time of diagnosis of NAFLD, had the highest BMI of 38.4, highest AST/ALT ratio of 0.92, lowest albumin value of 4.03, highest percentage of patients with physical signs of the male cohort was associated with a 0.7 reduction in NFS compared to women with NAFLD only. Females with NAFLD demonstrate significant difference in the mean NFS and mean age of diagnosis compared to the other 2 groups, while females with both versus males with NAFLD did not (Image 1).
Conclusion(s): Females with PCOS significantly demonstrated NAFLD at an earlier age supported by positive physical and radiological signs, and worse NFS vs. males at the time of initial NAFLD diagnosis.

Introduction: Digestive laboratory abnormalities related to COVID-19 have been previously described, but most reports came from single centers and findings have been conflicting. We conducted a multi-center study using data from three large urban VA centers (New York Harbor VA, New Orleans VA and Detroit VA) to examine the association between demographics and digestive laboratory values with mortality on index hospitalization among individuals diagnosed with COVID-19.
Method(s): We manually extracted data on individuals hospitalized for COVID-19 between December 2019 and June 2020 at the three facilities. For this analysis, data on demographics and seven digestive laboratory values (highest AST, ALT, alkaline phosphatase, total bilirubin, and INR during admission, as well as lowest hemoglobin and platelets) were analyzed in relation to index hospitalization mortality. We performed descriptive statistics and conducted a multivariable logistic regression model.
Result(s): Out of a total of 390 individuals who were hospitalized with COVID-19, 168 (43%) died and 222 survived. The median age of patients who died was higher than those who survived (75 vs. 69 years). The vast majority (94%) of patients were male. Black patients accounted for a higher proportion of those who died than those who survived (61% vs. 55%), whereas the opposite was true for Whites (26% vs. 31%) and Hispanics (9% vs. 12%). In the multivariable model (Table), mortality was associated with older age (OR 1.07, 95% CI 1.03-1.10), higher BMI (OR 1.05, 95% CI 1.01-1.10), higher AST (OR 1.01, 95% CI 1.004-1.02), lower ALT (OR 0.99, 95% CI 0.98-0.996), higher alkaline phosphatase (OR 1.02, 95% CI 1.01-1.02), and lower hemoglobin (OR 0.83, 95% CI 0.72-0.97).
Conclusion(s): In this multicenter VA study of patients hospitalized with COVID-19 during the first half of 2020, overall mortality was 43%. For mortality during index hospitalization, we observed a positive association with age, BMI, AST, and alkaline phosphatase, and an inverse association with ALT and hemoglobin. Every 1 unit increase in hemoglobin was associated with 17% decreased odds of death. These findings suggest that commonly used digestive laboratory tests have prognostic significance for COVID-related survival

BACKGROUND:Competency in endoscopy has traditionally been based on number of procedures performed. With movement towards milestone-based accreditation, new standards of establishing competency are required. The Thompson Endoscopic Skills Trainer (TEST) is a training device previously shown to differentiate between novice and expert endoscopists. This study aims to correlate TEST scores to other markers of performance in endoscopy. METHODS:Trainees of a gastroenterology fellowship program were guided through the TEST. Their scores and sub-scores were correlated to their endoscopic metrics of performance, including adenoma detection rate, cecal intubation rate, cecal intubation time, withdrawal time, fentanyl usage, midazolam usage, pain score, overall procedure time, and performance on the ASGE Assessment of Competency in Endoscopy Tool (ACE Tool). RESULTS:The Overall Score positively correlated with the ACE Tool Total Score (r = 0.707, p = 0.010) and sub-scores (Cognitive Skills Score: r = 0.624, p = 0.030; Motor Skills Score: r = 0.756, p = 0.004), and negatively correlated with cecal intubation time (r = - 0.591, p = 0.043). The Gross Motor Score positively correlated with cecal intubation rate (r = 0.593, p = 0.042), ACE Tool Total Score (r = 0.594, p = 0.042) and Motor Skills Score (r = 0.623, p = 0.031), and negatively correlated with cecal intubation time (r = - 0.695, p = 0.012). The Fine Motor Score positively correlated with the ACE Tool Polypectomy Score (r = 0.601, p = 0.039), and negatively correlated with procedure time (r = - 0.640, p = 0.025), cecal intubation time (r = - 0.645, p = 0.024), and withdrawal time (r = - 0.629, p = 0.028). CONCLUSION/CONCLUSIONS:This study demonstrates that performance on the TEST correlate to endoscopic measures. Given these results, the TEST may be used in conjunction with existing assessment tools for demonstrating competency in endoscopy.