Faculty Bibliography

Introduction: Endoscopic bariatric therapies have emerged as a potential treatment option for metabolic disease. Duodenal mucosal resurfacing (DMR) is an endoscopic procedure that aims to ablate the hypertrophic duodenal mucosa noted to be associated with diabetes mellitus type 2 (DM2).
Aim(s): To assess the effect of DMR on metabolic outcomes associated with DM2.
Method(s): MEDLINE, Embase, and Cochrane Database were searched from inception through November 2019. Data extraction was performed independently by two authors. Inclusion criteria were metabolic parameters data before and after DMR treatment in studies with greater than 5 adult patients. Primary outcomes included the mean difference (MD) in hemoglobin A1C (HbA1c), fasting blood glucose (FBG), fasting insulin, HOMA-IR, liver transaminases (ALT), weight (kg) between the baseline and final values in patients undergoing DMR in RCT and observational studies; secondary outcomes were adverse events and co-variate predictors. Random effects model was used for all primary outcomes. Heterogeneity was assessed by the I² statistic, with I²> 50% considered substantial.
Result(s): Eighty-one citations were identified; 9 observational studies including 179 subjects were analyzed (4 primary studies, with 5 overlapping studies providing additional missing data). The majority of studies included only subjects with DM2 (HbA1c 7.5-10% on stable oral medications), average age was 56 years. DMR lead to a decrease in HbA1c by 1.1% (95% CI -1.2, -0.9) in subjects followed up to 6 months after DMR (Figure 1). By meta-regression, baseline HbA1c and ALT predicted changes in HbA1c, with respective R² values of 0.95 and 0.98, with slightly worse outcomes in patients with higher ALT. Additionally, in subjects followed up to 6 months, DMR was associated with decrease in FBG by 30.8 mg/dL (95% CI -35.3, -26.3); fasting insulin by 2.8 mIU/L (95% CI -6.1, 0.5); weight by 3.7 kg (95% CI -5.4, -2.0); ALT by -8 U/L (95% CI -10.5, -5.5); HOMA-IR by -2.6 (95% CI -3.7, -1.5), as shown in Table 1. The rate of serious adverse was 4.13%. Two studies reported limited follow-up data after 6 months, reporting a decrease in HbA1c of 1.5% (SD 0.7, N=22) and 1.4% (SD 0.8, N=21) at 12 months and 24 months follow-up respectively. One study reported decrease in liver fat by 30% from baseline to three months after DMR. There was insufficient data to investigate heterogeneity, with the exception of HbA1c.
Conclusion(s): DMR therapy led to significant improvements in several metabolic parameters including HbA1c, fasting insulin, FBG and ALT. These improvements were independent of weight loss, suggesting a direct metabolic effect that could offer a new treatment option for patients with DM2 and steatosis. More long-term data are needed to confirm durability of results. [Formula presented] [Formula presented]
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Introduction: Women remain underrepresented in gastroenterology (GI), especially interventional endoscopy. Women represented 32% of first year GI fellows in 2017/2018, yet in 2019, only 12.8% of fellows who matched into interventional endoscopy were women.
Aim(s): To assess perceived barriers toward women pursuing interventional endoscopy training, Methods: We administered a 21-question web-based survey to program directors of interventional endoscopy fellowships participating in the 2018-2019 ASGE match. We assessed program director and program characteristics and asked program directors to rank barriers and facilitators (Scale 1-5, 5= most important) that may influence women pursuing interventional endoscopy training. Program characteristics affecting female interventional fellow graduation rates were assessed.
Result(s): We received 38 (59%) responses from 64 program directors. Program director and program characteristics are summarized in Table1. Only 16% (6/38) of programs had a woman as interventional endoscopy program director and 13.2% (5/38) had a woman as endoscopy chief. The mean (+/-SD) percentage of interventional faculty who were women was 15% (+/-17%). 47.4% (18/38) programs reported no women interventional faculty. Only 12% of interventional fellowship graduates from each program over the past 10 years were women, and 32% (12/38) of programs have never had a woman graduate. The percentage of female interventional fellowship graduates was strongly associated with percentage of female interventional faculty (s= 0.43, p< 0.001). Percentage of female interventional endoscopy graduates was higher in programs with female leadership, with highest association with programs with female endoscopy chiefs (20% vs 11%, p=0.09). There was no significant association between percentage of female interventional fellowship graduates and call structure or parental leave policy. Difficult or inflexible hours and call (mean rank 3.3+/- SD 1.1), exposure to fluoroscopy during childbearing age (2.9+/-1.1), lack of women endoscopists at national conferences and courses (2.9+/-1.1), and lack of mentorship to female trainees (2.9+/-1.0) were cited as the most important barriers regarding recruitment. Figure 1 summarizes potential facilitators for women pursuing a career in interventional endoscopy.
Discussion(s): We utilized a survey of program directors from interventional endoscopy fellowships participating in the ASGE match to determine program characteristics and identify contributors to gender disparity. We found women represent a minority of interventional endoscopy program directors, endoscopy chiefs, interventional endoscopy faculty and interventional fellowship graduates. Our study highlights barriers and facilitators to recruitment, and emphasizes the importance of having female representation in faculty and leadership positions in endoscopy. [Formula presented] [Formula presented]
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BACKGROUND AND AIMS/OBJECTIVE:Gastric stenosis is a rare but potentially serious adverse event after sleeve gastrectomy. Despite current suboptimal treatments, endoscopic balloon dilatation (EBD) has emerged as a safe and efficacious approach. The purpose of this study is to assess the overall success of EBD for sleeve gastrectomy stenosis (SGS) as first-line therapy. METHODS:MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane Database were searched from inception to July 2018, whereas OPUS, LILACS, BVS, CINAHL were not searched. The primary outcome was defined as overall success rate of clinical resolution of SGS obstructive symptoms with EBD, expressed as pooled event rate and 95% confidence interval (95% CI). The secondary predefined outcomes include EBD success rates for SGS in proximal (cardia) location or mid-distal location (antrum/incisura), in early SGS (up to 3 months after LSG) and late SGS (3 months or longer after LSG), and success rate of cases requiring stents or salvage surgery. RESULTS:Eighteen studies encompassing 426 patients were analyzed. The average age and BMI were 41.7 and 40.1, respectively, and average number of dilations for all cases was 1.8 per person. Overall EBD success rate was 76% (95% CI, 0.67-0.86). EBD success rates were as follows: proximal SGS was 90% (95% CI, 63%-98%); distal SGS was 70% (95% CI, 47%-86%); early SGS within 3 months was 59% (95% CI, 34%-79%); and late SGS after 3 months was 61% (95% CI, 41%-78%). Seventeen percent of patients underwent secondary salvage surgery, with a success rate of 91% (95% CI, 80%-96%). CONCLUSION/CONCLUSIONS:EBS appears to be a safe and effective minimally invasive alternative to surgical revision and should be used as first-line therapy for SGS.

INTRODUCTION: There is a wealth of epidemiologic evidence supporting the association between weight parameters and colorectal cancer incidence. However, how these variables affect colorectal cancer (CRC) recurrence is still a topic of debate. In our study, we hypothesized that there would be increased risk of recurrence of colorectal cancer with obesity and higher visceral fat.
METHOD(S): A systematic review of electronic databases was performed through April 2019, including NCBI, Embase, Cochrane, and Web of Science. Screening was performed using Covidence and each article was screened independently by two authors. Included were retrospective and prospective studies reporting CRC outcomes of at least 2 months after cancer diagnosis. The primary outcome was CRC recurrence in obese compared to normal weight subjects, and high vs. normal visceral fat. Weight parameters tested were body mass index (BMI) categories of underweight, normal, overweight, and obese; visceral fat as measured by CT scan into categories of normal and high visceral fat. Odds ratios (OR), risk ratios (RR), and 95% confidence intervals (95% CI) are reported. Random effects analysis was performed for all outcomes, with heterogeneity assessed by the I2 statistic.
RESULT(S): 484 citations were reviewed of which 9 were included in the final analysis. In total, 7 studies analyzed CRC recurrence data in terms of BMI, and 2 in terms of visceral adiposity. Most were retrospective cohort studies. These studies comprised 5777 patients, with an average age of 61.4 years and with mean follow-up time of 58.4 months, range (52 months-77 months). Both overweight and obese BMI were associated with significantly increased risk of cancer recurrence compared to normal BMI individuals (Figure 1), OR 1.41 (95% CI 1.18-1.69), P=0.00, I²=0%, N=4295, and OR 1.47 (95% CI 1.02-2.12), P=0.04, I²=45%, N=3637, respectively. There was no association between being underweight and colorectal cancer recurrence compared to normal BMI or overweight BMI. High visceral adiposity was also not associated with increased CRC recurrence, although only two studies were included in our meta-analysis (Table 1).
CONCLUSION(S): Obese and overweight BMI are both associated with increased risk of CRC recurrence compared to normal weight. However, being underweight was not associated with CRC recurrence compared to being normal weight. Patients with CRC would likely benefit from active interventions to prevent obesity. (Table Presented)

INTRODUCTION: Metabolic risk factors have been implicated in the incidence of colorectal cancer (CRC); however, less is known about the relationship between obesity and CRC outcomes. We hypothesized that obesity would be associated with worse outcomes compared to normal weight, but with better outcomes compared to underweight individuals.
METHOD(S): A systematic review of electronic databases was performed through May 2019, including NCBI, Embase, Cochrane, and Web of Science. Screening was performed independently by two authors using Covidence. Inclusion criteria were retrospective and prospective cohort studies reporting CRC outcomes at least 60 months after CRC diagnosis. The primary outcome analyzed was CRC mortality in obese compared to normal body mass index (BMI). Secondary outcomes included overall mortality, disease free survival (DFS) and CRC mortality by BMI category (underweight, normal, overweight, and obese), and high vs. normal waist circumference (WC). Odds ratios (OR) and 95% confidence intervals (95% CI) are reported. Random effects analysis was performed for all outcomes, with heterogeneity assessed by the I2 statistic and metaregression by area of origin (East vs. West).
RESULT(S): 484 relevant citations were identified and 17 were included in the final analysis. Fifteen studies analyzed CRC outcome data in terms of BMI, and 2 in terms of WC. These studies comprised 251,347 patients, with a median age range of 61.8-71 years and follow-up time range of 60-192 months. Obesity was associated with significantly increased CRCspecific mortality compared to normal BMI (Figure 1). Interestingly, study origin (East vs. West) explained 53% of the heterogeneity in these results, R2 = 0.53 (Figure 2). Underweight patients had increased CRC mortality compared to both normal and overweight patients, but not significantly different from obese patients. High WC was also associated with increased CRC mortality compared to normal WC (Table 1). Obese and underweight patients both had increased OM compared to normal weight patients; underweight patients had increased OM compared to obese patients. Significant effects of BMI on DFS were only observed in Eastern studies, where underweight patients had worse DFS than normal weight and obese.
CONCLUSION(S): Overweight and obesity as well as underweight are risk factors for CRC-specific mortality. Underweight patients had poorer prognosis than overweight patients, but not significantly different from obese patients

INTRODUCTION: The prevalence of obesity and the medical costs associated with it are steadily rising, both among the adult and adolescent populations. New procedures such as the intragastric balloon (IGB), can provide rapid improvement in overall health to help manage and maintain weight loss with few adverse events. CASE DESCRIPTION/METHODS: A 61-year-old male patient with class III-IV obesity and multiple comorbidities had been in discussion with his gastroenterologist for over a year to undergo an IGB procedure. Peak weight was 302 lbs, with BMI of 43 kg/m2. He underwent intensive lifestyle and medical therapy, was started on Liraglutide 1.8 mg daily, with 15 lbs weight loss that plateaued. On his pre-procedure visit, hemoglobin A1C was 9.4, with a weight of 275 lbs and BMI 40.7 kg/m2. An intragastric OrberaTM IGB System (Apollo Endosurgery Inc, Austin, TX, United States) was placed and inflated with 600 ml of saline. On 2-month follow-up, the patient had lost 34 pounds. A number of his chronic medications, including those for hypertension and diabetes mellitus, were held due to improvement in lab and exam findings. The IGB was removed after 6 months. The patient continued to lose weight and has maintained daily exercise and dietary guidelines. Most recently, the patient's A1C level has trended down to 6.4%, with a weight of 202 lbs and a BMI of 29.9 kg/m2. Since starting the program, he has lost a total of 101 lbs. DISCUSSION: This case highlights the dramatic weight loss after a minimally invasive weight loss procedure in conjunction with proper diet and, exercise. The patient lost 27% of his body weight (275 lbs to 202 lbs) and went from class III obesity (>40 BMI), to an overweight range (25.0-29.9 BMI) with the IGB. Overall, he has lost over 100 lbs with 34.4% total weight loss, making him the ?biggest loser' in our program. The effect on the patient's overall well-being has been extraordinary; over time, he has been able to start a regular exercise and dietary regimen, use less medication or experience remission of his chronic conditions. The typical weight loss expected with a gastric balloon is 10-12%. This patient's results have far exceeded the expected trajectory. Given the chronicity of obesity, and improvements in health seen with even 5-10% weight loss, a relatively safe endoscopic procedure such as the gastric balloon can significantly improve the health status of patients with obesity and should be considered before more invasive interventions. (Figure Presented)

INTRODUCTION: Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal (GI) tract, present in 2-4% of the population. Typically, it presents as GI bleeding and is usually diagnosed in childhood. However, some patients may remain asymptomatic through adulthood or present later in life with complications. We describe an unusual case of an adult male presenting with abdominal pain and maroon stools, who underwent an extensive workup and was eventually diagnosed with MD only after a double-balloon enteroscopy (

INTRODUCTION: Bariatric surgery has become a common therapeutic approach to obesity. However, bariatric procedures may affect bowel habits due to changes in dietary intake as well as altered anatomy. To date, few studies have evaluated the impact of bariatric surgery on post-operative constipation. The aim of this study is to determine if patients experience a greater rate of constipation after bariatric surgery compared to non-bariatric controls.
METHOD(S): A retrospective chart review at New York Langone Hospital (NYU) was performed on 160 bariatric surgery patients who had surgery in the year 2012 and 160 control patients with BMI < 30 kg/m2 seen in primary care in 2012. Reports of constipation were recorded up until November 2018. Exclusion criteria included those with inflammatory bowel disease or hereditary colorectal cancer syndromes prior to age 50. The primary outcome was diagnosis of post-operative constipation. Secondary outcomes included rates of constipation according to surgical procedure. Presence of constipation was recorded if listed on the problem list or if medications for constipation were prescribed. Logistic regression and chi-squared testing was used to assess differences in groups.
RESULT(S): Table 1 shows patient characteristics of the study population. The average age of bariatric surgery patients was 64.1 years compared to 69.8 in the control group. Overall, 20% of bariatric patients were diagnosed with constipation compared to 15% of controls (P = 0.239). Constipation rates post-bariatric surgery were 17.9% in lap band, 20.6% in sleeve gastrectomy, and 7.1% in gastric bypass patients (P = 0.256). A logistic regression controlling for age, sex, and Charlson co-morbidity index was performed between controls and post-surgery subjects. This revealed no significant difference in rates of constipation between the two groups (OR 1.158, 95% CI 0.790 - 1.696 P-value = 0.45). There was, however, a significant difference in constipation rates between the bariatric group pre-surgery (13.8%) and post-surgery (17.5%) (P = < 0.001) (Table 2).
CONCLUSION(S): Bariatric surgery patients experience significantly higher rates of constipation after surgery compared to prior to surgery, but similar rates to controls without obesity. Constipation impairs quality of life and is associated with significant health care costs. Further studies investigating the mechanisms underlying this increase in constipation after bariatric surgery and effective measures to treat it are warranted. (Figure Presented)

INTRODUCTION: Anastomotic gastric adenocarcinoma (GAC) following distal gastrectomy Billroth II for peptic ulcer disease (PUD) has long been recognized but remains poorly studied. CASE DESCRIPTION/METHODS: A 65-year-old male with history of PUD status post Billroth II in 1991 presented with multiple episodes of melena and abdominal pain. EGD revealed friable gastric mucosa with oozing ulcers on the gastric side of the gastrojejunal anastomosis (GJA) (Figure 1a-c) and severe bile reflux. Stomach biopsies were negative for H. pylori or other pathology. Patient was subsequently admitted four more times that year for similar symptoms, each time presenting with symptomatic anemia that resolves with therapy, and EGD showing superficial erosions near the GJA. It was suspected however, that the initial biopsies were likely taken from areas far from the actively bleeding sites. Therefore, the GI team insisted on an outpatient EGD when the patient was asymptomatic to accurately investigate the GJA. After multiple missed appointments, he had an outpatient EGD (Figure 1d) with biopsies of the friable mucosa positive for GAC, and eventually underwent Roux-en-Y gastrectomy with esophagojejunostomy. Biopsy of the mesenteric nodules confirmed the diagnosis of moderately differentiated Stage IIIA GAC. Chemoradiation therapy was initiated, but patient left against medical advice and ended up in hospice care eight months later. DISCUSSION: We present a patient with persistent bleeding ulcers and symptomatic anemia 25 years after a Billroth II procedure, who despite multiple endoscopic evaluations with stomach biopsies, was not diagnosed on time. Eventually, the correct diagnosis of Stage III primary GAC was made after an outpatient EGD with targeted biopsies of the area associated with recurrent bleeding. Given the negative biopsies, the persistent gastric ulcers were thought to be complications of Billroth II with a short limb leading to bile reflux, or due to patient's poor compliance and follow up. However, it was recognized that the patient had a higher risk of GAC as he was 15-20 years after Billroth II, and more importantly, that the inpatient EGD biopsies were not of the actively bleeding area of interest. Our patient presented after a long asymptomatic interval with symptoms initially misinterpreted as benign. It is therefore imperative to maintain a high suspicion of gastric malignancy for these patients to encourage earlier diagnosis. (Figure Presented)