Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment
BACKGROUND AND AIMS/OBJECTIVE:Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux. METHODS:This was a single-center prospective cohort study. RESULTS:Six hundred ten consecutive patients received POEM from October 2009 to October 2019 for type I achalasia in 160 (26.2%), II in 307 (50.3%), III in 93 (15.6%), untyped achalasia in 25 (4.1%), and nonachalasia disorders in 23 (3.8%). Two hundred ninety-two (47.9%) patients had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 (10.5%) and clinically significant adverse events (csAEs) in 21 (3.4%) patients. There were no adverse events (AEs) leading to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at year 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 (2%) patients were missing follow-up assessments. One hundred twenty-five (20.5%) patients had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 (66.6%) patients and was positive in 232 (57.1%) and endoscopy in 438 (71.8%) patients and showed reflux esophagitis in 218 (49.8%), mostly mild. CONCLUSION/CONCLUSIONS:POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at â‰¥5 years.
Characterizing COVID-19 in relation to acute pancreatitis [Meeting Abstract]
Introduction: The purpose of this study is to evaluate the relationship between patients with a history acute pancreatitis and tested for COVID-19 across all of NYU Langone Health system from 2/ 28/2020 to 6/24/2020 in order to ascertain the following information in regards to the novel coronavirus (COVID-19) and to provide clinicians greater information with hope of improving clinical outcomes.
Method(s): Using billing codes, other patient demographics, and our COVID-19 Datamart we obtained a list of patients who had a history of acute pancreatitis and tested for COVID-19. Charts were reviewed manually to review various metrics. Descriptive statistics (medians [25th, 75th percentiles] for continuous variables and frequencies and percentages for categorical variables) were calculated separately for acute pancreatitis patients that were COVID positive vs COVID negative. The Mann-Whitney test was used to test for differences between the groups for continuous variables, and the chi-square or Fisher's exact test was used for categorical variables. A result was considered statistically significant at the p< 0.05 level of significance. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).
Result(s): A total of 391 patients with a history of acute pancreatitis were tested for COVID in the inpatient setting. Our study contains the largest sample of patients to date. 74 patients were COVID positive (18.9%). Weighted Elixhauser score (AHRQ) and Charlson Comorbidity Index were equivocal when comparing the past medical histories of our two patient populations. Significant data was defined as p < 0.05. A significantly greater number of COVID negative patients were current smokers. However, COVID positive patients were more likely to have a history of diabetes with complications, coagulopathy, fluid and electrolyte disorders, and other neurological disorders. COVID positive patients took a higher percentage of steroid use (hydrocortisone and methylprednisolone). Length of stay and death rates were significantly worse for COVID positive patient. Inconsistent lab draws made comparisons challenging.
Conclusion(s): Prevalence of COVID-19 among patients with prior acute pancreatitis is 18.9% which is significantly higher than the population-weighted prevalence of SARS-CoV-2 positive serology in our background population of 6.9. Need for further studies to be conducted in patients with pancreatitis and COVID to help risk stratify patients for improved clinical outcomes
Gastrostomy tubes in patients with COVID-19: Reduction of in-hospital mortality with a multidisciplinary team-based approach [Meeting Abstract]
Introduction: Critically-ill patients with COVID-19 often require long-term enteral access due to prolonged ventilator support and slow recovery from neurologic injury. The outcomes of hospitalized patients with SARS-CoV-2 who received gastrostomy tubes (GTs) are unknown and limited guidance exists on how to safely triage GT placement in this population. The Enteral Access Team (EAT) is a multidisciplinary team led by an attending gastroenterologist (GI) hospitalist with advanced practice providers who collaborate with Palliative Care, Geriatrics, Speech-Language Pathology, and Nutrition to reduce unnecessary feeding tube placements at the end-of-life. The EAT reviews the appropriateness of GT placement and triages each case to the indicated procedural service. The EAT's multidisciplinary approach was applied for patients with COVID-19.
Method(s): We performed a retrospective study of 135 hospitalized patients with positive PCR tests for SARS-CoV-2 who received GTs between 3/2020 and 4/2021. The GTs were placed by 3 services (gastroenterology, interventional radiology and surgery) at 3 hospitals within 1 health system in New York. One of the hospitals employed the multidisciplinary EAT approach to its triage of GT placement. Outcomes were compared between the EAT site and control sites where GT placement was decided through direct consultation by the primary team with one of the procedural services.
Result(s): Demographics for the two groups, including overall numbers of COVID-19 admissions, can be seen in Table 1. At the EAT site (n =43) 5% of patients expired prior to discharge following GT placement compared with 25% at the control sites (P <0.05). Patients at the EAT site were older with a mean age of 70 years compared to the control sites with a mean age of 63 years (P=0.01). There was no significant difference in the percentage of COVID-19 patients who received GTs, length-ofstay, or time from gastrostomy to discharge or death. Multivariable analysis showed the odds of in hospital mortality were 10.1 times greater with the standard workflow than with the EAT workflow (OR 10.1, [95% CI: 1.7-60.6], P <0.05).
Conclusion(s): The EAT's novel multidisciplinary team-based approach helps to appropriately select hospitalized patients with SARs-CoV-2 for long-term enteral access leading to reduced in-hospital mortality following GT placement. Additionally, this approach may help to mediate the national shortage of GTs and reduce the risk of exposure to providers involved in GT placement
Incidental finding of inflammatory fibroid polyp of the appendix in a patient with acute appendicitis
Learning Curve for Endoscopic Submucosal Dissection With an Untutored, Prevalence-Based Approach in the United States
BACKGROUND & AIMS/OBJECTIVE:Endoscopic submucosal dissection (ESD) is widely used in Asia to resect early-stage gastrointestinal neoplasms, but use of ESD in Western countries is limited. We collected data on the learning curve for ESD at a high-volume referral center in the United States to guide development of training programs in the Americas and Europe. METHODS:/hr. RESULTS:/hr in esophagus, stomach, and colon, respectively. CONCLUSIONS:In an analysis of ESDs performed at a large referral center in the United States, we found that an untutored, prevalence-based approach allowed operators to achieve all proficiency benchmarks after âˆ¼250 cases. Compared with Asia, ESD requires more time to learn in the West, where the untutored, prevalence-based approach requires resection of challenging lesions, such as colon lesions and previously manipulated lesions, in early stages of training.
PER ORAL ENDOSCOPIC MYOTOMY (POEM): 10-YEAR OUTCOME FROM A LARGE US REFERRAL CENTER [Meeting Abstract]
Impact of Institutional Enteral Feeding Tube Policy on Medical Nutrition Utilization [Meeting Abstract]
EFTR AND STER FOR GASTROINTESTINAL SUBEPITHELIAL TUMORS (SETS): LARGE SERIES FROM A LARGE US REFERRAL CENTER [Meeting Abstract]
Association of Antibiotic and Proton Pump Inhibitor Usage in Patients with Hospital Acquired Clostridium difficile Infection: A Single Center Experience [Meeting Abstract]
A Rare Case of High-Grade Dysplasia in Sporadic Fundic Gland Polyps [Meeting Abstract]