Faculty Bibliography

Background: Lumen-apposing self-expandable metal stents (LAMS) have transformed the management of pancreatic fluid collections over the last two decades. There has since been significant interest in expanding the utility of LAMS for additional therapies such as the management of benign luminal strictures. However, there remains little data on their efficacy and safety when used for this indication. The goal of this study was to define the technical success, clinical success, and complication rates of LAMS when used in the management of benign strictures Methods: This was a retrospective multicenter evaluation of the safety, efficacy, and long-term clinical durability of LAMS in the treatment of benign strictures. The study took place between June 2018 and November 2019. Data collection included demographic information, indication, stent size, use of concurrent balloon dilation including dilation diameter, stent stabilization technique, intra-procedure and post-procedure complications, clinical improvement, and post-procedure follow up outcomes.
Result(s): 30 patients underwent placement of LAMS for a benign luminal stricture, with one having two stents placed during the index procedure at separate areas of stenoses resulting in a total of 31 stents placed. In total, 19 stents were 15 x 10 mm and 12 stents were 20 x 10 mm. No intra-procedural complications were noted. The technical success of deployment was 100%. Clinical resolution of symptoms was present in 25 (83%) patients. Of the patients who experienced clinical improvement, 17 underwent stent removal after an average of 6.4 weeks, and clinical recurrence occurred in 7 (41%) patients. The mean time to recurrence of symptoms after stent removal was 7 weeks. Univariate subgroup analysis revealed 15 x 10 mm stents were associated with clinical improvement (OR 12.86, 95% CI: 1.27-130.57, p 0.031). Each patient who did not clinically improve developed pain (3) or stent migration (2). In total 11 (37%) patients developed minor post-procedure adverse event. Stent migration was seen in 5 (17%) cases. Bleeding and pain were noted in 1 (3%) and 7 (23%) patients, respectively. Ulceration was found in 4 patients.
Conclusion(s): LAMS is a durable, safe option for patients with benign luminal strictures. Overall technical success was 100% and clinical success was 83%. The data also suggests better clinical outcomes with 15 x 10 mm stents, when compared to 20 x 10 mm stents. Pain is the most common adverse event but easily managed. [Formula presented]
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INTRODUCTION: Colonoscopy is the only colorectal cancer screening modality that permits direct visualization of the entire colon and removal of polyps. Low-quality bowel preparation has been associated with lower adenoma detection rates, increased procedure time, and increased hospital cost. An inadequate preparation limits the diagnostic accuracy and overall efficacy of colonoscopy. Factors that contribute to inadequate bowel preparations include age, male sex, inpatient status, low socioeconomic status, low English proficiency, obesity, diabetes, and cirrhosis. We investigated the complex relationship between socioeconomic factors and medical comorbidities on the quality of inpatient colonoscopy preparation.
METHOD(S): We conducted a retrospective chart review of inpatient colonoscopies between October 2017 and April 2019. All patients received a single-dose preparation of polyethylene glycol. We collected data including demographics, medical history, indication, and bowel preparation. A Boston Bowel Preparation Score of 6 or above or an Aronchick score of "good" or "excellent" was used to define an adequate preparation.
RESULT(S): A total of 230 patients were included in the final analysis (Table 1). An inadequate bowel preparation was reported in 16.1% of our inpatient colonoscopies. Within the inadequate preparation group, a greater percentage of patients were male (17.3% vs. 12.3%), had low English proficiency (18.3% vs.15.3%), were not diabetic (17.7% vs.12.3%), and did not have prior bowel surgery (16.4% vs. 0.0%). Within the age, race/ethnicity, and insurance subgroups, patients who were age 80+ (21.4%), Asian-American (25%), unreported race/ethnicity (29.4%), uninsured (25%), and prisoners (22.8%) had a greater percentage of inadequate preparation (Table 2). A logistic regression was performed to assess the effects of age, sex, race/ethnicity, insurance, English fluency, diabetes, restricted mobility, and prior surgery on bowel preparation. The logistic regression model was not statistically significant.
CONCLUSION(S): No significant socioeconomic or medical predictors of bowel preparation were found in this inpatient population which is in contrast to prior literature. While less than 20% of our patient population had inadequate bowel preparation, this is still significant in the broader context of quality, safety, and healthcare costs. Identifying strategies to increase the quality of bowel preparation still remains at the forefront of our field. (Table Presented)

With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.

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.

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.

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.