Peroral endoscopic myotomy for spastic esophageal dysmotility among opioid users: a multicenter propensity score matching study.

BACKGROUND AND AIMS: Opioid-induced esophageal dysfunction (OIED) often presents as spastic esophageal disorders (SEDs) and esophagogastric junction outflow obstruction (EGJOO). The aim of this study was to evaluate and compare clinical outcomes of peroral endoscopic myotomy (POEM) for SEDs and EGJOO among opioid users and nonusers. METHODS: This propensity score (PS) matching study included consecutive opioid users and nonusers who underwent POEM for SEDs and EGJOO between January 2018 and September 2022. The following covariates were used for the PS calculation: age, sex, duration of symptoms, Eckardt score, type of motility disorder, and length of myotomy during POEM. Clinical response was defined as a post-POEM Eckardt score ≤3. RESULTS: A total of 277 consecutive patients underwent POEM during the study period. PS matching resulted in the selection of 64 pairs of patients strictly matched 1:1 (n = 128) with no statistically significant differences in demographic, baseline, or procedural characteristics or in the parameters considered for the PS between the 2 groups. Clinical response to POEM was significantly lower among opioid users (51 of 64 [79.7%]) versus nonusers (60 of 64 [93.8%]) (P = .03) at a median follow-up of 18 months. Among opioid users, higher opioid dose (>60 morphine milligram equivalents per day) was associated with a higher likelihood of failure to respond to POEM (odds ratio, 4.59; 95% confidence interval, 1.31-3.98; P = .02). CONCLUSIONS: Clinical response to POEM for SEDs and EGJOO is significantly lower among opioid users versus nonusers. There was a dose-relationship between opioids and response to POEM, with higher daily opioid usage associated with a higher likelihood of treatment failure.

Favorable Survival with Non-curative Treatments for Patients with Early-Stage Hepatocellular Carcinoma After Liver Transplant Denial.

BACKGROUND: Many patients are not candidates for liver transplant for non-tumor-related reasons including medical comorbidities and non-adherence. The prognosis of patients with hepatocellular carcinoma (HCC) who are not liver transplant candidates in the era of locoregional therapy (LRT) including y90 is not well defined. AIMS: This study seeks to evaluate outcomes and the natural history of early-stage HCC in patients who were denied liver transplant listing due to non-tumor reasons and instead were treated with LRT. METHODS: A retrospective evaluation was performed for all patients who completed liver transplant evaluation with their tumor within Milan criteria but were denied due to non-tumor reasons and were treated with LRT at a single tertiary referral center. RESULTS: The 61 patients included had a favorable overall survival, with a median survival 60.3 months (86.9% at 1 year and 52.7% at 5 years). Patients with Child-Pugh A cirrhosis (n = 34) had significantly longer overall survival compared to those with Child-Pugh B/C cirrhosis (median survival of 70.3 months versus 26.1 months, p = 0.005). Survival in patients with Child-Pugh A at 1, 3, and 5 years was 97%, 80%, and 73%, respectively, compared to 74%, 41%, and 31% in patients with Child-Pugh B/C. CONCLUSIONS: In a small single-center cohort, patients with HCC who were denied liver transplant due to non-tumor reasons and underwent LRT and had Child-Pugh A cirrhosis had survival approaching the national average for patients who undergo liver transplantation. Patients with Child-Pugh B/C cirrhosis had significantly worse outcomes than those with Child-Pugh A.

Discrepancy between self-reported and actual colonoscopy polypectomy practices for the removal of small polyps.

BACKGROUND AND AIMS: Cold snare polypectomy (CSP) is associated with higher rates of complete resection compared with cold biopsy forceps (CBF) for the removal of small polyps (4-9 mm). This study aimed to evaluate self-reported polypectomy preferences and actual practice patterns among endoscopists at an academic center and to identify factors associated with the use of CSP for small polyps. METHODS: In phase A, endoscopists completed a survey evaluating preferences for polypectomy techniques. In phase B, we performed a retrospective analysis of all consecutive colonoscopies with polypectomy (January 2016 to September 2018). Uni- and multivariate analysis were performed to identify factors associated with CSP for small polyps. RESULTS: Nineteen of 26 (73%) endoscopists completed the survey (phase A); 3 (15.8%) were interventional endoscopists. Most respondents indicated that they use CSP (89.5%) for small polyps and identified no reasons for choosing CBF over CSP (73.7%). In phase B, we identified 1118 colonoscopies with 2625 polypectomies for polyps ≤9 mm. Most diminutive polyps (≤3 mm) were removed with CBF (819 of 912; 90%). CBF (46.2%) was also preferentially used for removal of small polyps (n = 1713), followed by hot snare polypectomy (27.2%), and CSP (26.6%). On multivariate analysis, interventional endoscopists were associated with a higher likelihood of using CSP for small polyps (odds ratio, 1.38; 95% confidence interval, 1.07-1.79; P = .01). CONCLUSIONS: Significant discrepancy exists between self-reported preferences and actual polypectomy practices. CBF is still preferentially used over CSP for the removal of polyps sized 4-9 mm; further strategies are needed to monitor and implement adequate polypectomy techniques.

Survey Study on the Practice Patterns of the Evaluation and Management of Incidental Pancreatic Cysts.

BACKGROUND AND AIMS: Various gastrointestinal societies have released guidelines on the evaluation of asymptomatic pancreatic cysts (PCs). These guidelines differ on several aspects, which create a conundrum for clinicians. The aim of this study was to evaluate preferences and practice patterns in the management of incidental PCs in light of these societal recommendations. METHODS: An electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). Main outcomes included practice setting (academic vs. community), preferences for evaluation, management, and surveillance strategies for PCs. RESULTS: A total of 172 subjects completed the study (52% academic-based endoscopists). Eighty-six (50%) and 138 (80%) of the participants responded that they would recommend EUS surveillance of incidental PCs measuring less than 2 cm and 3 cm, respectively. Nearly half of the endosonographers (42.5% community and 44% academic; p = 1.0) would routinely perform FNA on PCs without any high-risk features. More academic-based endoscopists (57% academic vs. 32% community; p = 0.001) would continue incidental PC surveillance indefinitely. CONCLUSIONS: There is significant variability in the approach of incidental PCs among clinicians, with practice patterns often diverging from the various GI societal guideline recommendations. Most survey respondents would routinely recommend EUS-FNA and indefinite surveillance for incidental PCs without high-risk features. The indiscriminate use of EUS-FNA and indefinite surveillance of all incidental PCs is not cost-effective, exposes the patient to unnecessary testing, and can further perpetuate diagnostic uncertainty. Well-designed studies are needed to improve our diagnostic and risk stratification accuracy in order to formulate a consensus on the management of these incidental PCs.

Endoscopic submucosal dissection for early Barrett's neoplasia: a meta-analysis.

BACKGROUND AND AIMS: The role of endoscopic submucosal dissection (ESD) in Barrett's esophagus (BE) is not well established. This meta-analysis aimed to evaluate the safety and efficacy of ESD for the management of early BE neoplasia. METHODS: Three online databases were searched. The Cochran Q test and I2 were used to test for heterogeneity. Pooling was conducted using either fixed- or random-effects models depending on heterogeneity across studies. For the main outcomes, potential sources of heterogeneity were evaluated via linear regression analysis. RESULTS: Eleven studies (501 patients, 524 lesions) were included. Mean lesion size was 27 mm (95% confidence interval [CI], 20.9-33.1). Pooled estimate for en bloc resection was 92.9% (95% CI, 90.3%-95.2%). The pooled R0 (complete) and curative resection rates were 74.5% (95% CI, 66.3%-81.9%) and 64.9% (95% CI, 55.7%-73.6%), respectively. There was no association between R0 or curative resection rates and study setting (Asia vs West), length of BE, lesion characteristics, procedural time, or length of follow-up. The pooled estimates for perforation and bleeding were 1.5% (95% CI, .4%-3.0%) and 1.7% (95% CI, .6%-3.4%), respectively. Esophageal stricture rate was 11.6% (95% CI, .9%-29.6%). Incidence of recurrence after curative resection was .17% (95% CI, 0%-.3%) at a mean follow-up 22.9 months (95% CI, 17.5-28.3). CONCLUSIONS: ESD for early BE neoplasia is associated with a high en bloc resection rate, acceptable safety profile, and low recurrence after curative resection. ESD should be considered as part of the armamentarium for the management of BE neoplasia.

See Something, Say Something: Global Positioning System Tracker Foreign Body Ingestion as a Unique Presentation of Human Trafficking.

In 2021, there were about 17,000 victims of human trafficking in the United States. We present a case of a 28-year-old sex trafficking victim who was forced to swallow 2 global positioning system trackers by her perpetrator. The gastroenterology team performed an upper endoscopy and retrieved 2 global positioning system devices from her antrum. Most of these victims do not disclose any history of abuse because of fear of their perpetrators. Further training and research can help to allow for recognition of these victims and potentially help them.

Novel single-operator through-the-scope traction device for endoscopic submucosal dissection: Outcomes of a multicenter randomized pilot ex-vivo study in trainees with limited endoscopic submucosal dissection experience (with video).

Objectives: Endoscopic submucosal dissection is a technically demanding procedure. The pilot study aimed to prospectively evaluate the efficacy and safety of a novel single-operator through-the-scope dynamic traction device among trainees with limited endoscopic submucosal dissection (ESD) experience. Methods: Randomized, controlled, pilot study comparing traction-assisted ESD (T-ESD) versus conventional ESD (C-ESD) in an ex-vivo porcine stomach model. Trainees were randomized to group 1 (T-ESD followed by C-ESD) and group 2 (C-ESD followed by T-ESD). Lesions were created on the gravity-dependent area of the stomachs. The primary outcome was submucosal dissection speed. Secondary outcomes included differences in en-bloc resection, adverse events, and workload, assessed by the National Aeronautical and Space Administration Task Load Index (NASA-TLX). Results: Five trainees performed two T-ESD and two C-ESD each, for a total of 20 procedures. Submucosal dissection speed was significantly faster in the T-ESD group compared to the C-ESD group (43.32 ± 22.61 vs. 24.19 ± 15.86 mm2/min; p = 0.042). En-bloc resection was achieved in 60% with T-ESD and 70% with C-ESD (p = 1.00). The muscle injury rate was higher in the C-ESD group (50% vs. 10%; p = 0.21) with 1 perforation reported with C-ESD and none with T-ESD. NASA-TLX physical demand was lower with T-ESD compared to C-ESD (4.5 ± 2.17 vs. 6.9 ± 2.50; p = 0.03). Conclusion: T-ESD resulted in faster submucosal dissection and less physical demand when compared to C-ESD, as performed by trainees in an ex-vivo gravity-dependent model. Future studies are needed to assess its role in human ESD cases.

Management of Biliary Complications in Liver Transplant Recipients.

Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.

Sporadic Neurofibroma of the Peritoneal Cavity.

Neurofibromas are peripheral nerve sheath tumors that are typically seen in syndromic conditions such as neurofibromatosis 1. We present the case of a 26-year-old woman suffering from chronic abdominal pain for over 5 years. Prior workup showed a large retroperitoneal mass extending into the abdomen and encasing multiple major vessels. She underwent endoscopic ultrasound (EUS)-guided biopsy, which was histologically consistent with a solitary neurofibroma. There is no prior report of solitary neurofibroma of the abdomen diagnosed with the use of EUS-guided biopsy. This case highlights the utility of EUS-guided biopsy in the evaluation of intra-abdominal pathology.

Utility of Inflammatory Markers in Predicting Hepatocellular Carcinoma Survival after Liver Transplantation.

Inflammatory markers have been studied in cancers and chronic states of inflammation. They are thought to correlate with tumor pathology through disruption of normal homeostasis. Markers such as neutrophil to lymphocyte ratio (NLR) among others have shown promise as prognostic tools in various cancers. In this study, we evaluate complete blood count based inflammatory markers in hepatocellular carcinoma (HCC) to predict overall and recurrence-free survival of patients after liver transplant. Between 2001 and 2017, all HCC indicated liver transplants were retrospectively reviewed. Inclusion criteria included presence of complete blood cell counts with differential within three months prior to transplantation. Exclusion criteria included retransplantation and inadequate posttransplant followup. A total of 160 patients with HCC were included in the study. Of those, 74.4% had hepatitis C virus as the underlying cause of HCC. Calculated Model for End stage Liver Disease (MELD) scores were statistically worse in patients with elevated NLR (≥5), derived NLR (≥3), and low lymphocyte to monocyte ratio (LMR) (<3.45), whereas elevated platelet to lymphocyte ratio (PLR) (≥150) did not correlate with MELD. Of the tumor characteristics, low LMR was associated with tumor presence and microvascular invasion on explant. Though overall survival trended towards better outcomes with low NLR and dNLR and high LMR, these did not reach statistical significance. High LMR also trended towards better recurrence-free survival without statistical significance. Low PLR was associated with statistically significant overall and recurrence-free survival. In conclusion, while prior studies in HCC have identified NLR as surrogate for tumor burden and survival, in this study we highlight that PLR is a good surrogate of mortality and recurrence-free survival in HCC transplant patients. Further, future study of PLR, NLR, and LMR in larger HCC populations before and after interventions may help clarify their clinical utility as a simple and noninvasive clinical tool as prognostic markers.

Effect of prophylactic clip placement following endoscopic mucosal resection of large colorectal lesions on delayed polypectomy bleeding: A meta-analysis.

BACKGROUND: The role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes. AIM: To conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection (EMR) of colorectal lesions ≥ 20 mm. METHODS: We performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I 2 were used to test for heterogeneity. Pooling was conducted using a random-effects model. RESULTS: Thirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB (1.4%) when compared to no clipping (5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm. There was no significant heterogeneity among the studies (I 2 = 0%, P = 0.67). CONLUSION: Prophylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.

Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus: a retrospective analysis.

BACKGROUND: Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE). METHODS: This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval. RESULTS: In total, 397 patients (66.5 % male; mean age 60.1 ±â€Š12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 - 6.82; P  < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 - 1.12; P  < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 - 0.97; P  < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 - 29 months) than the recommended interval. CONCLUSION: Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Intractable Fasting Hypoglycemia as a Manifestation of Hepatocellular Carcinoma.

Non-islet cell tumor hypoglycemia (NICTH) is a rare and serious paraneoplastic complication of both malignant and benign tumors to consider when evaluating fasting hypoglycemia, especially in the setting of liver diseases. We present a case of NICTH in a 54-year-old male with hepatocellular carcinoma (HCC) who presented with symptomatic intractable hypoglycemia (IH) after bowel preparation and fasting for screening upper endoscopy and colonoscopy.

Primary gastric Burkitt lymphoma: a rare cause of life-threatening haematemesis.

Lymphomas are the second most common gastric malignancy following gastric adenocarcinoma. The majority of gastric lymphomas are either mucosa-associated lymphoid tissue lymphomas or diffuse large B-cell lymphomas. Primary gastric Burkitt lymphoma is a subtype of non-Hodgkin's lymphoma and represents an aggressive and rare malignancy with only a small number of cases reported worldwide. Clinical and radiological presentation is non-specific and mimics other gastric lymphomas. Diagnosis is established with pathological evaluation. Due to the paucity of cases, treatment of this condition is not well studied and is extrapolated from paediatric and adult literature of Burkitt lymphoma not isolated to the stomach. We present the case of a male patient with primary gastric Burkitt lymphoma who initially presented with life-threatening haematemesis, later achieving complete remission with treatment. We discuss the epidemiology, presentation and management of gastric Burkitt lymphoma.