Extracorporeal membrane oxygenation can provide cardiopulmonary support during bronchoscopic clearance of airways after sand aspiration.

BACKGROUND: Sand aspiration occurs in situations of cave-in burial and near-drowning. Sand in the tracheobronchial airways adheres to the mucosa and can cause tracheal and bronchial obstruction, which can be life-threatening even with intensive management. In previous case reports of airway obstruction caused by sand aspiration, fiber optic or rigid bronchoscopy has been effective in removing loose sand, but removal of sand particles lodged in smaller airways has proven challenging and time-consuming. CASE REPORT: In this case report of sand aspiration with acute pulmonary failure, the use of extracorporeal membrane oxygenation for respiratory support allowed more effective removal of sand particles by rigid bronchoscopy and lavage with less patient compromise. CONCLUSION: Our case of sand aspiration is unique in that the patient presents with complex medical problems (mixed respiratory and metabolic acidosis), hypothermia, hypoxemia, and neoplastic conditions. The fact that she survived the sand aspiration and a long inter-hospital transport time (90 min) with inadequate ventilation and oxygenation without apparent ill effects suggests that the measures we took to resuscitate her and extract the sand from her airways were reasonable and appropriate.

Successful resuscitation after multiple injuries in the wilderness.

BACKGROUND: Survival of blunt trauma associated with hypothermic and hemorrhagic cardiac arrest in wilderness areas is extremely rare. CASE REPORT: We describe a case of a 19-year-old female college sophomore who, while glissading down Mt. Adams, had a 400-pound boulder strike her back and left pelvis, propelling her 40 feet down the mountain to land face down in the snow at 7000 feet. It took 4 h from the time of injury until the arrival of the helicopter at our Emergency Department and Trauma Center. The patient lost vital signs en route and had no CO(2) production. A cardiothoracic surgeon was the trauma surgeon on call. The patient was taken directly from the helipad to the operating room, where cutdowns enabled initial intravenous access, median sternotomy and pericardiotomy open heart massage, massive transfusion, chest and abdominal cavity irrigations with warm saline, correction of acid base imbalances and coagulopathies, and epicardial pacing that led to a successful reanimation of the patient. The patient was rewarmed without extracorporeal membrane oxygenation or heat exchangers. The ensuing multiple organ failures (heart, lungs, kidneys, intestines, brain, and immune system) and rhabdomyolysis led to a 2-month intensive care unit stay. She received over 120 units of blood and blood products. The patient regained cognitive function, mobility, and overcame multiple organ failure. CONCLUSION: This report is presented to increase awareness of the potential survivability in hypothermia, and to recognize the heroic efforts of the emergency services personnel whose efforts saved the patient's life.

Poor discriminatory function for endoscopic skills on a computer-based simulator.

BACKGROUND: Computer-based endoscopy simulators may enable trainees to learn and develop technical skills before performing on patients. Simulators require validation as adequate models of live endoscopy before being used for training or assessment purposes. OBJECTIVE: To evaluate content and criterion validity of the CAE EndoscopyVR Simulator colonoscopy and EGD modules as predictors of clinical endoscopic skills. DESIGN: Prospective, observational, non-randomized, parallel cohort study. SETTING: Single academic center with accredited gastroenterology training program. PARTICIPANTS: Five novice first-year gastroenterology fellows and 6 expert gastroenterology attending physicians. INTERVENTION: Participants performed 18 simulated colonoscopies and 6 simulated EGDs. The simulator recorded objective performance parameters. Participants then completed feedback surveys. MAIN OUTCOME MEASUREMENTS: The 57 objective performance parameters measured by the endoscopy simulator were compared between the two study groups. Novice and expert survey responses were analyzed. RESULTS: Significant differences between novice and expert performance were detected in only 19 of 57 (33%) performance metrics. Eight of these 19 (42%) were time-related metrics, such as total procedure time, time to anatomic landmarks, and time spent in contact with GI mucosa. Of 49 non-time related measures, the few additional statistically significant differences between novices and experts involved air insufflation, sedation management, endoscope force, and patient comfort. These findings are of uncertain clinical significance. Survey data found multiple aspects of the simulation to be unrealistic compared with human endoscopy. LIMITATIONS: Small sample size. CONCLUSION: The CAE EndoscopyVR Simulator displays poor content and criterion validity and is thereby incapable of predicting skill during in vivo endoscopy.

Endovascular repair compared with operative repair of traumatic rupture of the thoracic aorta: a nonsystematic review and a plea for trauma-specific reporting guidelines.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become the preferred intervention for managing traumatic thoracic aortic injury. The literature suggests that TEVAR is associated with reduced mortality and paraplegia compared with open repair (OR). The lack of guidelines for reporting results and the paucity of patient follow-up make interpretation of the literature difficult. METHODS: A literature review of English language papers on thoracic aortic trauma published between 2005 and 2010 was performed. Papers were analyzed to determine how many commented on injury data known to affect outcome (age, hemodynamic stability, injury severity, degree of aortic injury, etc.). RESULTS: Sixty-two retrospective reviews and six meta-analysis papers were identified. Of the review papers, only 6.4% described aortic anatomy using standard criteria, only 25.8% reported the degree of aortic injury, only 19.4% defined early or emergent intervention, only 32.3% provided details regarding hemodynamic stability, and only 56.5% described injury severity by Injury Severity Score. In a subset analysis of papers containing trauma relevant data, comparing TEVAR with OR, the TEVAR population was older, whereas the OR group was more often unstable. TEVAR had a significantly lower mortality, a trend to reduction in paralysis, but a significantly increased stroke rate. Follow-up was minimal in both groups. CONCLUSION: The lack of reporting guidelines coupled with a paucity of follow-up data weakens any recommendation regarding the optimal choice of intervention. To address these deficiencies, we recommend reporting guidelines specific to the trauma population that will allow better risk adjustment and improve the quality of the evidence base.

Revolutionary advances in enhancing patient comfort on patients transported on a backboard.

BACKGROUND: Patients with suspected spinal cord injuries are immobilized to a backboard during ambulance and helicopter air transport. It has been well documented that patients who are immobilized to a backboard experience discomfort and eventually become susceptible to pressure ulcer formation. Because the patient lying on a backboard is subjected to high skin interface pressures, it is imperative to improve patient comfort and prevent pressure ulcer formation. OBJECTIVE: Realizing the dangers of the potentially preventable pressure ulcers, our team of scientists, surgeons, and trauma nurses performed a comprehensive study of the Back Raft system that was designed to reduce patient discomfort and skin interface pressure. METHODS: Pressure under the occipital, scapula, and sacral regions of the back was measured using the Tactilus pressure analyzer of 10 healthy volunteers immobilized on a backboard and a backboard with a Back Raft air mattress system. Discomfort levels of each volunteer were measured using a Visual Analog Scale. RESULTS: Data from this study indicated that the Back Raft significantly reduces discomfort as well as tissue interface pressure in the occipital, scapula, and sacral regions of the back. CONCLUSIONS: The implementation of an air mattress system analogous to the Back Raft would facilitate the prevention of pressure ulcer formation during prehospital care and transportation. In 2008, The Centers for Medicare and Medicaid Services enacted a policy in which the Centers for Medicare and Medicaid Services can refuse payment for hospital-acquired conditions. Pressure ulcers were among the hospital-acquired conditions within the final rule.

Advances in the treatment of peanut allergy: a case report.

BACKGROUND: Peanut allergies affect 1.5% of children. The majority of reactions to peanuts are mild, but peanut allergy is also the most common cause of fatal anaphylactic reactions to food. CASE REPORT: The purpose of this case report was to describe a 1-year old boy who developed difficulty breathing after eating a peanut food product. The boy was taken immediately by his mother to an Emergency Department, exhibiting severe respiratory distress. After speaking to the child's mother, the emergency physician (EP) realized that the wheezing was due to a peanut food allergy. The child's respiratory symptoms responded within 10 min to bronchodilatator inhalation. The EP gave the mother educational information regarding the management of asthma and the proper use of metered dose inhalers with spacer devices. The EP referred the child to a clinical allergist who specializes in the management of food allergies. The diagnosis was made by skin prick testing as well as in vitro measurement of peanut-specific immunoglobulin E. CONCLUSION: The allergist explained that the mainstay of management of peanut allergy is avoidance of the allergenic food. Patient education involved teaching the mother to avoid high-risk situations such as dinner with family members who are not informed about the child's allergy to peanuts, encouraging the child to wear a Medic Alert Bracelet, and teaching the family and child to recognize early symptoms of allergic reactions and to manage an anaphylactic reaction, including the use of self-injectable epinephrine, as well as activating emergency services.

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles.

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

Choosing wisely: A prospective study of direct to operating room trauma resuscitation including real-time trauma surgeon after-action review.

INTRODUCTION: Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments. METHODS: Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion. RESULTS: There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact. CONCLUSION: Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups. LEVEL OF EVIDENCE: Prospective observational study, level III.

Anatomically contoured plates for fixation of rib fractures.

BACKGROUND: : Intraoperative contouring of long bridging plates for stabilization of flail chest injuries is difficult and time consuming. This study implemented for the first time biometric parameters to derive anatomically contoured rib plates. These plates were tested on a range of cadaveric ribs to quantify plate fit and to extract a best-fit plating configuration. METHODS: : Three left and three right rib plates were designed, which accounted for anatomic parameters required when conforming a plate to the rib surface. The length lP over which each plate could trace the rib surface was evaluated on 109 cadaveric ribs. For each rib level 3-9, the plate design with the highest lP value was extracted to determine a best-fit plating configuration. Furthermore, the characteristic twist of rib surfaces was measured on 49 ribs to determine the surface congruency of anatomic plates with a constant twist. RESULTS: : The tracing length lP of the best-fit plating configuration ranged from 12.5 cm to 14.7 cm for ribs 3-9. The corresponding range for standard plates was 7.1-13.7 cm. The average twist of ribs over 8-cm, 12-cm, and 16-cm segments was 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constant twist of anatomic rib plates was not significantly different from the average rib twist. CONCLUSIONS: : A small set of anatomic rib plates can minimize the need for intraoperative plate contouring for fixation of ribs 3-9. Anatomic rib plates can therefore reduce the time and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates.

Modern concepts of the diagnosis and treatment of necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. OBJECTIVES: The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. DISCUSSION: Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Gram's staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. CONCLUSION: Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.

Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part I.

BACKGROUND AND OBJECTIVES: This report provides an overview of advances in wound repair devised by our research team during the last four decades. This collective review is presented in two parts. DISCUSSION: The following components are included in Part I: 1) search and treat life-threatening trauma; 2) conduct a thorough history; 3) examine the wound using aseptic technique; 4) anesthetize the wound before cleansing; 5) hair removal, skin disinfection, hemostasis, surgical debridement, and mechanical cleansing; 6) antibiotics, drains, and open wound management. CONCLUSION: On the basis of these comprehensive research studies, we have noted a marked reduction in the incidence of wound infection in traumatic wounds.

Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part II.

BACKGROUND AND OBJECTIVES: During the last four decades, our research team has devised advances in wound repair that are highlighted in Part II of this collective review. DISCUSSION: There are several different methods to provide an accurate and secure approximation of the skin edges-sutures, tapes, staples, and tissue adhesives. Ideally, the selection of the wound closure technique will be based on the biologic interaction of the materials employed, tissue configuration, and biomechanical properties of the trauma wound. Selection of the appropriate wound dressing is another important consideration in the management of the trauma wound. CONCLUSION: On the basis of the comprehensive research and clinical studies, we have individualized the wound closure techniques for traumatic wounds so that healing can be achieved with more aesthetically pleasing scars.

A case report of a severe musculoskeletal injury in a wheelchair user caused by an incorrect wheelchair ramp design.

The Americans with Disabilities Act (ADA) gives all Americans with disabilities a chance to achieve the same quality of life that individuals without disabilities enjoy. In this case report, we will be discussing the consequences of having inaccessible ramps to persons with disabilities that can result in severe musculoskeletal injuries in a wheelchair user. While going down an inaccessible ramp in the garage of a hospital, a wheelchair tipped over, causing a fracture to the user's right femur. The injured patient was taken to the Emergency Department, where the diagnosis of a fracture of the right femur was made. The fracture then had to be repaired with an intramedullary rod under general anesthesia in the hospital. It was discovered that the ramps in the hospital garage did not comply with the guidelines of the ADA. The wheelchair ramps had a ramp run with a rise > 6 inches (150 mm) and a horizontal projection > 72 inches (1830 mm). This led to the redesign and construction of safe ramps for individuals using wheelchairs as well as for pedestrians using canes, within 1 month after the patient's injury, making it safe for wheelchair users as well as pedestrians using the parking facilities. The ADA specifies guidelines for safe ramps for patients with disabilities. It is important to ensure that hospital ramps comply with these guidelines.

Rotational thromboelastometry predicts transfusion and disability in pediatric trauma.

BACKGROUND: Trauma-induced coagulopathy seen on rotational thromboelastometry (ROTEM) is associated with poor outcomes in adults; however, this relationship is poorly understood in the pediatric population. We sought to define thresholds for product-specific transfusion and evaluate the prognostic efficacy of ROTEM in injured children. METHODS: Demographics, ROTEM, and clinical outcomes from severely injured children (age, < 18 years) admitted to a Level I trauma center between 2014 and 2018 were retrospectively analyzed. Receiver operating characteristic curves were plotted and Youden indexes were calculated against the endpoint of packed red blood cell transfusion to identify thresholds for intervention. The ROTEM parameters were compared against the clinical outcomes of mortality or disability at discharge. RESULTS: Ninety subjects were reviewed. Increased tissue factor-triggered extrinsic pathway (EXTEM) clotting time (CT) >84.5 sec (p = 0.049), decreased EXTEM amplitude at 10 minutes (A10) <43.5 mm (p = 0.025), and decreased EXTEM maximal clot firmness (MCF) <64.5 mm (p = 0.026) were associated with need for blood product transfusion. Additionally, EXTEM CT longer than 68.5 seconds was associated with mortality or disability at discharge. CONCLUSION: Coagulation dysregulation on thromboelastometry is associated with disability and mortality in children. Based on our findings, we propose ROTEM thresholds: plasma transfusion for EXTEM CT longer than 84.5 seconds, fibrinogen replacement for EXTEM A10 less than 43.5 mm, and platelet transfusion for EXTEM MCF less than 64.5 mm. LEVEL OF EVIDENCE: Prognostic, Level III; Therapeutic, Level IV.

Modern concepts in the diagnosis and treatment of vitamin D deficiency and its clinical consequences.

It is the purpose of this comprehensive report to outline a revolutionary strategy to prevent vitamin D deficiency in our nation. Vitamin D is a unique vitamin. Its metabolic product, calcitriol, is a profound secosteroid hormone that has impact on over 1000 genes in the human body. Recent clinical research has implicated vitamin D deficiency as a major factor in the etiology of rickets, a wide variety of cancers, as well as hypertension, stroke, heart attack, diabetes, bone fractures, periodontal disease, and even multiple sclerosis. There are two forms of vitamin D utilized in the human body: D2 and D3. Measurement of 25(OH)D is the most reliable method of detecting vitamin D deficiency. Several methods, including high-performance liquid chromatography (HPLC), chemoluminescence, and radioimmunoassay (RIA), have been developed for the measurement of total 25(OH)D levels. Prevention and treatment of vitamin D deficiency is accomplished by regulated sun exposure as well as vitamin D, supplementation. This information describing our plan to prevent vitamin D deficiency in the patients and employees of Legacy Health System is a landmark accomplishment that should be replicated in every healthcare setting in our country to prevent vitamin D deficiency.

Revolutionary advances in the diagnosis and treatment of Familial Adenomatous Polyposis.

During the last 25 years, there have been revolutionary advances in the treatment of Familial Adenomatous Polyposis (FAP). The purpose of this article is to describe the pathophysiology, genetic testing, surveillance, surgical interventions, and psychosocial issues. The genetic defect in FAP is germline mutation in the adenomatous polyposis coli (APC) gene. Syndromes once thought to be distinct from FAP are now recognized to be part of the phenotypic spectrum of FAP. Syndromes with a germline mutation in the APC gene include FAP, Gardner syndrome, Turcot syndrome, and Attenuated Adenomatous Polyposis Coli (AAPC). FAP is a germline mutation in the APC gene with onset of florid polyposis in childhood and development of colorectal cancer by age 30. Colectomy is advised because of the high risk of developing colorectal cancer. AAPC is a variant of this condition with later age of onset and milder clinical phenotype. However, colectomy is advised once polyposis develops and polyps cannot be managed endoscopically. Despite the unique advances in genetic testing, psychosocial management of these syndromes remains to be a challenging problem.

Delusions of parasitosis.

BACKGROUND: Delusions of parasitosis (DP) is a rare psychiatric disorder in which the patient has a firm belief that she or he is infected by parasites. Although it is a psychiatric disorder, these patients often present to an emergency physician because they are convinced that they have a severe skin problem. TREATMENT: Patients with DP often reject psychiatric referral. The diagnosis of DP can usually be made based on history alone. However, it is important that the patient does not have an organic skin disorder and that the delusion is not secondary to another mental or physical illness. The current treatments of choice are the antipsychotic medications risperidone and olanzapine. CONCLUSIONS: In our experience, patients with DP seen in the emergency department who are suspected of having this condition can be a challenging diagnostic and treatment problem because they usually do not have health insurance. Consequently, we find it difficult to get dermatologic and psychiatric consultation to treat their illness.

Citizen's Petition to Food and Drug Administration to ban cornstarch powder on medical gloves: Maltese cross birefringence.

BACKGROUND: During the last 25 years, scientific experimental and clinical studies have documented the dangers of cornstarch powder on examination and surgical gloves because the cornstarch promotes wound infection, causes serious peritoneal adhesions and granulomatous peritonitis, and is a well-documented vector of the latex allergy epidemic in the world. Realizing the dangers of cornstarch on examination and surgical gloves, Germany's regulations of personal protective equipment banned the use of surgical glove powder cornstarch in 1997. In 2000, the Purchasing and Supply agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch. DISCUSSION: Realizing the dangers of cornstarch-powdered gloves, many hospitals and clinics in the United States have banned the use of cornstarch-powdered examination and surgical gloves. Hospitals that have banned cornstarch in their examination and surgical gloves have noted a marked reduction in the latex allergy epidemic in their facilities. Realizing the dangers of cornstarch-powdered examination and surgical gloves, Dr Sheila A. Murphey, branch chief, Infection Control Devices Branch, Division of Anesthesiology, General Hospital, Infection Control, and Dental Devices Office of Device Evaluation, Center for Devices and Radiological Health of the Food and Drug Administration (FDA), recommended that a Citizen's Petition be filed to the FDA to ban cornstarch on surgical and examination gloves. CONCLUSION: The 12 authors of this report have attached the enclosed petition to the FDA to ban the use of cornstarch on all synthetic and latex examination and surgical gloves used in the United States.

Dangers of cornstarch powder on medical gloves: seeking a solution.

This article reviews information on the hazards of cornstarch powder on medical gloves. Dusting powders were first applied to latex gloves to facilitate donning. After 1980, manufacturers devised innovative techniques without dusting powder. It has been well documented that these powders on gloves present a health hazard to patients and health care workers by 5 different mechanisms. First, the glove cornstarch has documented detrimental effects on wound closure techniques. Second, this powder potentiates wound infection. Third, cornstarch induces peritoneal adhesion formation and granulomatous peritonitis. Finally, these powders serve as carriers as latex allergen and they precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powder have caused the United Kingdom and Germany to ban cornstarch powder on medical gloves over 10 years ago.

Endoluminal resection for sessile neoplasia in the GI tract is associated with a low recurrence rate and a high 5-year survival rate.

BACKGROUND: Endoluminal resection (ELR) is an alternative to surgery for the removal of superficial neoplastic lesions of the GI tract. We previously reported a complete resection (CR) rate of 89% when using ELR techniques. However, the long-term efficacy of ELR for the eradication of sessile lesions, as well as patient survival after ELR, is not known. OBJECTIVES: To assess the long-term recurrence rate of GI lesions that were completely resected by ELR and to determine the long-term (5-year) survival rate of patients who had ELR for GI lesions that contained high-grade dysplasia (HGD) or adenocarcinoma (AdCa). DESIGN: From a larger cohort of 92 consecutive patients who had undergone ELR of sessile lesions from 1997 to 2000, long-term follow-up was obtained. Patient survival rates were considered in terms of disease-specific mortality. RESULTS: Endoscopic follow-up was possible in 44 patients (48%) and 46 lesions (46%). At the time of the initial ELR, the median age was 68.5 years. The median duration of follow-up was 3.8 years after ELR (range 7 months to 8.1 years). Resected lesions were located in the esophagus (25%), stomach (11%), duodenum (25%), colon (27%), and rectum (11%). Post-ELR histopathology consisted of adenomas (46%), HGD (16%), AdCa (11%), lymphoma (2%), leiomyoma (2%), carcinoid (2%), lesions indeterminate for dysplasia (2%), and nondysplastic lesions (18%). CR was achieved in 42 patients and 44 lesions (96%) after initial ELR procedures (range 1-3). Thirty-seven of 39 neoplastic lesions (95%) in this cohort achieved initial CR. Two lesions (found in 2 patients) that did not achieve initial CR were excluded from analysis. Four of 37 neoplastic lesions (10.8%) that underwent successful ELR had local recurrence of neoplasia (median time to recurrence was 1.9 years). Two of the 4 neoplastic recurrences were successfully eradicated by subsequent endoscopic techniques (95% overall eradication rate). Long-term endoscopic follow-up was possible in 12 of 20 patients (60%) with HGD or AdCa who achieved initial CR. These 12 patients had HGD (n = 7) or AdCa (n = 5) and were observed for an average of 4.9 years (range 1.4-7.9 years) after an ELR. Two of these patients died during follow-up, but only 1 death (8%) was lesion related. When comparing post-ELR pathology, HGD and AdCa trended toward an increased risk of recurrence compared with other neoplastic lesions (hazard ratio 4.75 [95% CI, 0.49-46.35], P = .18). LIMITATIONS: A retrospective study with 52% of patients lost to long-term endoscopic follow-up, which limited the sample size and the number of events. CONCLUSIONS: ELR effectively eradicates sessile neoplastic lesions from the GI tract, with a low recurrence rate (10.8%) at long-term follow-up. Post-ELR surveillance is important, because local recurrences may be amenable to endoscopic eradication. HGD and cancers may carry an increased risk for a local recurrence, with a 5-year disease-specific survival of 92%. This study suggests that ELR is associated with a low recurrence rate for neoplastic lesions and appreciable long-term survival in patients with highly dysplastic lesions. Additional, long-term follow-up studies are necessary to investigate the role of ELR in the treatment of highly dysplastic lesions of the GI tract.