Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

BACKGROUND: We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics. METHODS: The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant. RESULTS: We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7 days in 2007 to 6 days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014. CONCLUSION: Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Mortality Trends, Outcomes, and Predictors of Portal Vein Thrombosis in Acute Pancreatitis Patients: A Propensity-Matched National Study.

BACKGROUND: Portal vein thrombosis (PVT) is a rare complication of acute pancreatitis (AP) and might be associated with worse outcomes. We aimed to study trends, outcomes, and predictors of PVT in AP patients. METHODS: The National Inpatient Sample database was utilized to identify the adult patients (≥ 18 years) with primary diagnosis of AP from 2004 to 2013 using International Classification of Disease, Ninth Revision. Patients with and without PVT were entered into propensity matching model based on baseline variables. Outcomes were compared between both groups and predictors of PVT in AP were identified. RESULTS: Among the total of 2,389,337 AP cases, 7046 (0.3%) had associated PVT. The overall mortality of AP decreased throughout the study period (p trend ≤ 0.0001), whereas mortality of AP with PVT remained stable (1-5.7%, p trend = 0.3). After propensity matching, AP patients with PVT patients had significantly higher in-hospital mortality (3.3% vs. 1.2%), AKI (13.4% vs. 7.7%), shock (6.9% vs. 2.5%), and need for mechanical ventilation (9.2% vs. 2.5%) along with mean higher cost of hospitalization and length of stay (p < 0.001 for all). Lower age (Odd ratio [OR] 0.99), female (OR 0.75), and gallstone pancreatitis (OR 0.79) were negative predictors, whereas alcoholic pancreatitis (OR 1.51), cirrhosis (OR 2.19), CCI > 2 (OR 1.81), and chronic pancreatitis (OR 2.28) were positive predictors of PVT (p < 0.001 for all) in AP patients. CONCLUSION: PVT in AP is associated with significantly higher risk of death, AKI, shock, and need for mechanical ventilation. Chronic and alcoholic pancreatitis is associated with higher risk of PVT in AP.

Prediction of neoplastic progression in Barrett's esophagus using nanoscale nuclear architecture mapping: a pilot study.

BACKGROUND AND AIMS: Nanoscale nuclear architecture mapping (nanoNAM), an optical coherence tomography-derived approach, is capable of detecting with nanoscale sensitivity structural alterations in the chromatin of epithelial cell nuclei at risk for malignant transformation. Because these alterations predate the development of dysplasia, we aimed to use nanoNAM to identify patients with Barrett's esophagus (BE) who might progress to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). METHODS: This is a nested case-control study of 46 BE patients, of which 21 progressed to HGD/EAC over 3.7 ± 2.37 years (cases/progressors) and 25 patients who did not progress over 6.3 ± 3.1 years (control subjects/nonprogressors). The archived formalin-fixed paraffin-embedded tissue blocks collected as part of standard clinical care at the index endoscopy were used. nanoNAM imaging was performed on a 5-µm formalin-fixed paraffin-embedded section, and each nucleus was mapped to a 3-dimensional (3D) depth-resolved optical path difference (drOPD) nuclear representation, quantifying nanoscale-sensitive alterations in the 3D nuclear architecture of the cell. Using 3D-drOPD representation of each nucleus, we computed 12 patient-level nanoNAM features summarizing the alterations in intrinsic nuclear architecture. A risk prediction model was built incorporating nanoNAM features and clinical features. RESULTS: A statistically significant differential shift was observed in the drOPD cumulative distributions between progressors and nonprogressors. Of the 12 nanoNAM features, 6 (mean-maximum, mean-mean, mean-median, entropy-median, entropy-entropy, entropy-skewness) showed a statistically significant difference between cases and control subjects. NanoNAM features based prediction model identified progression in independent validation sets, with an area under the receiver operating characteristic curve of 80.8% ± .35% (mean ± standard error), with an increase to 82.54% ± .46% when combined with length of the BE segment. CONCLUSIONS: NanoNAM can serve as an adjunct to histopathologic evaluation of BE patients and aid in risk stratification.

Clinical Risk Prediction Model for Neoadjuvant Therapy in Resectable Esophageal Adenocarcinoma.

GOALS AND BACKGROUND: Clinical staging with endoscopic ultrasound (EUS) and positron emission tomography (PET) is used to identify esophageal adenocarcinoma (EAC) patients with locally advanced disease and therefore, benefit from neoadjuvant therapy. However, EUS is operator dependent and subject to interobserver variability. Therefore, we aimed to identify clinical predictors of locally advanced EAC and build a predictive model that can be used as an adjunct to current staging methods. STUDY: This was a cross-sectional study of patients with EAC who underwent preoperative staging with EUS and PET scan followed by definitive therapy at our institution from January 2011 to December 2017. Demographic data, symptoms, endoscopic findings, EUS, and PET scan findings were obtained. RESULTS: Four hundred and twenty-six patients met the study criteria, of which 86 (20.2%) patients had limited stage EAC and 340 (79.8%) had locally advanced disease. The mean age was 65.4±10.3 years of which 356 (83.6%) were men and 393 (92.3%) were White. On multivariable analysis, age (above 75 or below 65 y), dysphagia [odds ratio (OR): 2.84], weight loss (OR: 2.06), protruding tumor (OR: 2.99), and tumor size >2 cm (OR: 3.3) were predictive of locally advanced disease, while gastrointestinal bleeding (OR: 0.36) and presence of visible Barrett's esophagus (OR: 0.4) were more likely to be associated with limited stage. A nomogram for predicting the risk of locally advanced EAC was constructed and internally validated. CONCLUSIONS: We constructed a nomogram to facilitate an individualized prediction of the risk of locally advanced EAC. This model can aid in decision making for neoadjuvant therapy in EAC.

Fecal Microbiota Transplantation and Medical Therapy for Clostridium difficile Infection : Meta-analysis of Randomized Controlled Trials.

GOALS: The aim was to assess the effectiveness of fecal microbiota transplantation (FMT) against medical therapy (MT). BACKGROUND: FMT has shown good outcomes in the treatment of Clostridium difficile infection (CDI). We aimed to conduct a systematic review and meta-analysis to compare the effectiveness of FMT versus MT for CDI. STUDY: We performed a comprehensive search to identify randomized controlled trials comparing FMT against MT in patients with CDI. Outcomes of interest were clinical cure as determined by the resolution of diarrhea and/or negative C. difficile testing. Primary CDI is defined as the first episode of CDI confirmed endoscopically or by laboratory analysis. Recurrent C. difficile infection (RCDI) is defined as laboratory or endoscopically confirmed episode of CDI after at least 1 course of approved antibiotic regimen. RESULTS: A total of 7 studies with 238 patients were included in meta-analysis. Compared with MT, FMT did not have a statistically significant difference for clinical cure of combined primary and RCDI after first session [risk ratio (RR): 1.52, 95% confidence interval (CI): 0.90, 2.58; P =0.12; I2 =77%] and multiple sessions of FMT (RR: 1.68; CI: 0.96, 2.94; P =0.07; I2 =82%). On subgroup analysis, FMT has statistically higher rate of response than MT (RR: 2.41; CI: 1.20, 4.83; I2 =78%) for RCDI. However, for primary CDI there is no statistically significant difference between FMT and MT (RR: 1.00; CI: 0.72, 1.39; I2 =0%). CONCLUSION: As per our analysis, FMT should not be utilized for every patient with CDI. It is more effective in RCDI, but the results were not significant in patients with primary CDI.

Pneumatic dilation for esophageal achalasia: patient selection and perspectives.

Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter. Treatment is palliative, aimed at decreasing the lower esophageal sphincter pressure. Pneumatic dilation (PD) is a safe and effective treatment for achalasia. Several other invasive and minimally invasive treatment modalities, such as Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM), also have a comparable safety and efficacy profile to PD. The current review focuses on the indications, contraindications, techniques, and outcomes of PD in various patient populations and its comparison to LHM and POEM. This review also provides relevant information to help endoscopists identify those patients who will benefit the most from PD.

Endoscopic ultrasound with combined fine needle aspiration plus biopsy improves diagnostic yield in solid pancreatic masses.

GOALS: Our aim was to compare the diagnostic yield of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) versus combined fine needle aspiration and fine needle biopsy (EUS-FNA + FNB) in the evaluation of solid pancreatic masses (SPMs). BACKGROUND: EUS-FNA and EUS-FNB are established methods to diagnose SPMs. No studies have evaluated the efficacy of combination of both (EUS-FNA + FNB). Our senior author (MRS) hypothesized that combining the two techniques by using a single FNB needle improves diagnostic yield and started combination technique in October 2016. STUDY: Patients who underwent EUS for SPMs by MRS during January 2014-September 2019 were included. They were divided into the EUS-FNA group and EUS-FNA + FNB group. EUS-FNA was performed using a 22 or 25 gauge Expect Slimline needle (Boston Scientific, Marlborough, MA) and EUS-FNA + FNB was performed using a single 22 or 25 gauge Shark-core needle (Medtronics, Minneapolis, MN, USA). Our primary outcome was to compare the diagnostic yield in the two groups. RESULTS: Among 105 patients included, 58 were in the EUS-FNA group and 47 were in the EUS-FNA + FNB group. EUS-FNA + FNB group had significantly higher diagnostic yield and required fewer needle passes compared to EUS-FNA group, 95.7% vs. 77.6%, p = .01: and 4 vs. 5, p = .002; respectively. Procedural duration was similar in both groups but the combined technique required less number of needles per procedure. There was no difference in adverse events in the two groups. CONCLUSION: Our study showed that combined EUS-FNA + FNB had higher diagnostic yield compared to EUS-FNA in SPMs along with less number of needle passes and needles required. Further prospective studies are needed to validate these findings and cost-effectiveness of this strategy.

Early readmissions of spontaneous bacterial peritonitis in the USA: Insights into an emerging challenge.

BACKGROUND AND AIM: Early readmissions of spontaneous bacterial peritonitis (SBP) are often associated with poor outcomes. We compared characteristics and outcomes for index and 30-day readmissions of SBP in the USA. METHODS: We analyzed the Nationwide Readmissions Database for 2018 to identify all adult (≥ 18 years) 30-day readmissions of SBP in the USA. Hospitalization characteristics and outcomes for index and 30-day readmissions of SBP were compared. Independent predictors of 30-day readmissions were also identified. RESULTS: In 2018, of the 5,797 index admissions for SBP, 30% (1726) were readmitted within 30 day. At the time of readmission, the most common admitting diagnosis was alcoholic cirrhosis of the liver with ascites (11.8%) followed by sepsis due to an unspecified organism (9.2%). SBP as an admitting diagnosis was identified for only 8.3% of these 30-day readmissions. Compared with index admissions, 30-day readmissions of SBP had a lower mean age (56.1 vs 58.6 years, P < 0.001) without a statistically significant difference for gender. Furthermore, 30-day readmissions of SBP were associated with significantly higher odds of inpatient mortality (10% vs 4.9%, OR: 2.15, 95% CI: 1.66-2.79, P < 0.001), and mean total hospital charge ($85,031 vs $56,000, mean difference: 29,032, 95% CI: 12,867-45,197, P < 0.001) compared with index admissions. The presence of chronic pulmonary disease, liver failure, inpatient dialysis, and discharge against medical advice were identified as independent predictors for increased 30-day readmissions of SBP. CONCLUSION: The 30-day readmission rate of SBP was 30% and these readmissions were associated with higher odds of inpatient mortality compared with index admissions.

Peroral Endoscopic Myotomy Is Safe and Highly Effective Treatment for Advanced Achalasia With Sigmoid Esophagus.

BACKGROUND AND AIMS: In advanced achalasia patients with sigmoid esophagus, peroral endoscopic myotomy (POEM) might be technically challenging and its outcomes are not well known in western population. Hence, our study aims were to assess and compare the safety and efficacy of POEM in achalasia patients with and without sigmoid esophagus. MATERIALS AND METHODS: Medical records of achalasia patients who had POEM at our institution between April 2014 and December 2019 were reviewed. Patients who underwent work-up comprising timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with 2-month post-POEM esophageal pH study, TBE and HREM were included in the final analysis. Patients were categorized as either sigmoid or no sigmoid esophagus based on the morphology of esophagus on TBE as per Japan Esophageal Society guidelines. Treatment success was defined as reduction of post-POEM Eckardt score to ≤3. RESULTS: A total of 168 patients (sigmoid esophagus=20; no sigmoid esophagus=148) were included. Esophageal width on TBE at 1 minute was significantly higher in sigmoid esophagus group compared with no sigmoid esophagus group (4.9 vs. 3.0 cm, P<0.001). Procedural outcomes and complications were similar in both groups. At 2-month follow-up, both groups had significant improvement in Eckardt scores, TBE, and HREM parameters. Treatment success was high and similar in both sigmoid and no sigmoid groups (94.4% vs. 93.2%, P=0.84). The rates of gastroesophageal reflux disease were also similar in both groups. CONCLUSIONS: Our study findings suggest that POEM is safe and highly effective treatment for achalasia patients with sigmoid esophagus similar to those without sigmoid esophagus in western population. POEM should be considered as the treatment of choice in advanced achalasia with sigmoid esophagus.

Long term outcomes of sporadic large fundic gland polyps: a single-center experience.

BACKGROUND AND STUDY AIMS: Sporadic fundic gland polyps (FGP) are the most common type of gastric polyp, reported in 0.8%-1.9% of patients undergoing Esophagogastroduodenoscopy (EGD). Data on long-term outcomes of large FGP is limited. We aim to study the natural history of sporadic large (≥ 10 mm) FGPs. PATIENTS AND METHODS: All adults who underwent EGD for any indication from April 2014 to December 2019 at a tertiary care center were retrospectively assessed, and patients with FGP (≥10mm) were identified. Data on baseline characteristics and long-term outcomes were recorded. Follow-up data were recorded for patients who underwent repeat endoscopy to evaluate for rates of dysplasia and cancer. RESULTS: A total of 4,000 patients with a diagnosis of FGP were screened and 132 large, biopsy-proven FGPs were included in the final analysis. The most common indication for EGD was gastroesophageal reflux disease (61%). During a follow-up period of 3.2 years, the rate of dysplasia, was 4.0%. Subgroup analysis based on size (10-19 mm and ≥ 20 mm) showed no significant difference in overall outcomes. CONCLUSION: Repeat EGDs for surveillance should not be routinely performed since large (≥10 mm) sporadic FGPs are mostly benign without significant malignant potential.

Peroral endoscopic myotomy is highly effective for achalasia patients with recurrent symptoms after pneumatic dilatation.

BACKGROUND: Previous interventions in achalasia such as pneumatic dilation (PD) might lead to difficulties with peroral endoscopic myotomy (POEM) along with sub-optimal outcomes. There are limited data in the literature on outcomes of POEM after PD, especially from the western hemisphere. Hence, we aimed to determine the safety and efficacy of POEM for recurrent symptoms after PD compared to treatment naïve achalasia patients. METHODS: Medical records of achalasia patients who underwent POEM at our institution between April 2014 and October 2019 were reviewed. Patients who had POEM for recurrent symptoms after prior PD were matched at 1:2 ratio with treatment naïve achalasia patients using propensity score matching. Patients who had prior Heller myotomy were excluded. Patient demographics, Eckardt scores, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), and pH study findings were compared between the two groups, pre- and 2 months post-POEM. Treatment success was defined as reduction of Eckardt score to ≤ 3. RESULTS: A total of 39 patients (prior PD = 13; treatment naïve = 26) were included. Patient demographics, procedural, and peri-procedural outcomes were similar in both groups. Treatment success was similar in both groups, 100.0% in prior PD vs 91.7% in treatment naïve group (p = 0.53). On adjusted analysis, there was no significant difference in the pre-post-POEM improvement in Eckardt scores, TBE, and HREM parameters in the two groups. Gastroesophageal reflux disease rates were also similar in both groups. CONCLUSIONS: In achalasia with recurrent symptoms after PD, POEM is a safe and highly effective treatment modality. Prior PD does not seem to influence the outcomes or efficacy of POEM.

Endoscopic mucosal incision and muscle interruption (MIMI) for the treatment of Zenker's diverticulum.

BACKGROUND: In peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the mucosal incision and muscular interruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach. METHODS: All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system. RESULTS: Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group (p = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients (p = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group (p ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients (p = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group (p = 0.094). CONCLUSIONS: MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.

Trends and risk factors for 30-day readmissions in patients with acute cholangitis: analysis from the national readmission database.

INTRODUCTION: Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC. METHODS: We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association. RESULTS: From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4-1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2-1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0-1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73-0.88) or cholecystectomy (OR 0.54, 95% CI 0.43-0.69). CONCLUSIONS: AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.

Peroral endoscopic myotomy is equally safe and highly effective treatment option in achalasia patients with both lower and higher ASA classification status.

INTRODUCTION: The American Society of Anesthesiologists (ASA) physical status classification system was developed as a simple categorization of patients' physiological status that predicts the operative risk. Peroral endoscopic myotomy (POEM) is a less invasive alternative to surgical myotomy in achalasia. As such, POEM seems to be an appealing option for high-risk patients with achalasia. However, there are no studies which systematically analyzed the outcomes of POEM among patients with different ASA classes. Hence, we aimed to compare the safety and efficacy of POEM in patients with lower and higher ASA classes. METHODS: Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized arbitrarily into two groups, lower ASA class (ASA I and II combined) and higher ASA class (ASA class III and IV combined). Demographic and procedural details, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Baseline characteristics were compared using Chi-square test and two-sample t-test for categorical and continuous variables, respectively. RESULTS: A total of 144 patients met our study criteria (lower ASA class, n = 44; and higher ASA class, n = 100). Patients in higher ASA class were significantly more obese and older. More patients in lower ASA class had prior Heller myotomy and more patients in higher ASA Class had prior botulinum toxin injections. Procedural parameters were similar in both groups. Procedural complications were infrequent and were also similar in the two groups. The length of stay, 30-day readmission rate, reflux symptoms and esophageal pH study findings were also comparable between the two groups. Treatment success was similar in both groups, 97.7% in lower ASA class versus 92% in higher ASA class (p = 0.19). At 2-month follow-up, both groups had significant improvement in HREM and TBE parameters. CONCLUSION: POEM is a very safe and highly effective treatment option for achalasia patients with advanced ASA class similar to lower ASA class patients. POEM may be considered as the preferred choice for myotomy in these high-risk achalasia patients due to its low morbidity and high efficacy.

Changes in esophageal physiology after paraesophageal hernia repair and Collis gastroplasty.

BACKGROUND: The surgical approach and technique for paraesophageal hernia (PEH) repair is much debated. The changes in the esophageal physiology after PEH repair with a concomitant Collis gastroplasty (PEH-CG) are not clearly known. The aim of this study was to determine the changes in high resolution esophageal manometry (HREM) and esophageal pH testing after PEH-CG. METHODS: Retrospective analysis of all patients who underwent PEH-CG at our institution between 2006 and 2013 was performed. Patients had esophageal pH testing, HREM, barium swallow and an upper endoscopy before and after PEH-CG. RESULTS: A total of 182 patients underwent PEH-CG during the study period. Majority of patients had Nissen fundoplication (176, 96.7%) with Toupet in 6 (3.3%). Basal lower esophageal sphincter pressure (LESP) was lower after fundoplication (20.3 mmHg ± 11.3 vs. 25.8 mmHg ± 15.6, p < 0.001), whereas residual LESP was noted to be higher after fundoplication (7.7 mmHg ± 4.9 vs. 6.1 mmHg ± 6.7, p < 0.009). There were no significant changes in the esophageal motility patterns. There was an improvement in total pH and upright pH but not supine pH post PEH-CG. Normalization of total acid exposure after fundoplication was noted in 31 (59.6%) of the 52 patients who had abnormal total acid exposure prior to fundoplication. CONCLUSIONS: Objective clinical assessment in patients undergoing PEH-CG demonstrates an effective operation for this complex problem. There was an increase in residual LESP but interestingly, decrease in basal LESP. Additionally, there was an improvement in esophageal acid exposure afterwards. These findings will facilitate future management of PEH.

Quality of Colonoscopy: A Comparison Between Gastroenterologists and Nongastroenterologists.

BACKGROUND: Colonoscopy performance by gastroenterologists has been shown to be associated with lower rates of developing interval colorectal cancer. However, it is unclear if this difference among specialists stems from a difference in meeting colonoscopy quality indicators. OBJECTIVE: The purpose of this study is to determine and compare the rates of colonoscopy quality indicators between different specialties. DESIGN: This is a cohort study of patients undergoing screening colonoscopy investigating quality metrics as compared by the proceduralist specialty. SETTING: All screening colonoscopies performed at the Cleveland Clinic between 2012 and 2014 were followed by manual chart review. PATIENTS: Average-risk patients, ≥50 years of age, who had a complete screening colonoscopy were included. MAIN OUTCOME MEASURES: Adenoma detection rate, cecal intubation rate, withdrawal time, and other nonestablished overall and segment-specific rates were calculated and compared using t tests. RESULTS: A total of 4151 patients were included in the analysis. Colonoscopies were performed by 54 (64.3%) gastroenterologists, 21 (25%) colorectal surgeons, and 9 (10.7%) general surgeons. Gastroenterologists had the highest overall adenoma detection rate (28.6 ± 1.2; p < 0.001), followed by colorectal surgeons (24.3 ± 1.5) and general surgeons (18.4 ± 2.3), as well as the highest adenoma detection rate in men (34.7 ± 1.3; p < 0.001), followed by colorectal surgeons (28.2 ± 1.6) and general surgeons (23.7 ± 2.6). Similarly, gastroenterologists had the highest adenoma detection rate in women (24.3 ± 1.1; p < 0.001), followed by colorectal surgeons (21.6 ± 1.4) and general surgeons (12.9 ± 2.0). Withdrawal time was the longest among general surgeons (11.1 ± 5.5; p = 0.041), followed by colorectal surgeons (10.94 ± 5.2) and gastroenterologists (10.16 ± 1.26). LIMITATIONS: We could not adjust for some procedure-related details such as retroflexion in the right colon and the use of end-of-scope devices. CONCLUSIONS: In this study, only gastroenterologists met the currently accepted overall and sex-specific adenoma detection rate benchmarks. They also outperformed nongastroenterologists in many other nonestablished quality metrics. See Video Abstract at http://links.lww.com/DCR/B232. CALIDAD DE LA COLONOSCOPIA: UNA COMPARACIÓN ENTRE GASTROENTERÓLOGOS Y NO GASTROENTERÓLOGOS: Se ha demostrado que el rendimiento de la colonoscopia por parte de los gastroenterólogos, se asocia con tasas más bajas de cáncer colorrectal en intervalos de desarrollo. Sin embargo, no está claro si esta diferencia entre especialistas, se deriva de una diferencia en el cumplimiento de los indicadores de calidad de la colonoscopia.El propósito del estudio, es determinar y comparar las tasas de indicadores de calidad de colonoscopia entre diferentes especialidades.Este es un estudio de cohorte de pacientes sometidos a una colonoscopia de detección, que investiga métricas de calidad en comparación con la especialidad de procesos.Todas las colonoscopias de detección realizadas en la Clínica Cleveland entre 2012 y 2014, fueron seguidas por una revisión manual del expediente.Pacientes de riesgo promedio, ≥50 años de edad que se sometieron a una colonoscopia de detección completa.La tasa de detección de adenomas, tasa de intubación cecal, tiempo de retirada y otras tasas generales y específicas de segmento no establecidas, se calcularon y compararon usando pruebas t.Un total de 4,151 pacientes fueron incluidos en el análisis. Las colonoscopias fueron realizadas por 54 (64.3%) gastroenterólogos, 21 (25%) cirujanos colorrectales y 9 (10.7%) cirujanos generales. Los gastroenterólogos tuvieron la tasa de detección más alta de adenomas en general (28.6 ± 1.2; p < 0.001), seguidos por los cirujanos colorrectales (24.3 ± 1.5) y los cirujanos generales (18.4 ± 2.3), así como la tasa de detección más alta de adenoma en hombres (34.7 ± 1.3; p < 0.001) seguido por cirujanos colorrectales (28.2 ± 1.6) y cirujanos generales (23.7 ± 2.6). Del mismo modo, los gastroenterólogos tuvieron la tasa más alta de detección de adenoma en mujeres (24.3 ± 1.1; p < 0.001), seguidos por los cirujanos colorrectales (21.6 ± 1.4) y los cirujanos generales (12.9 ± 2.0). El tiempo de extracción fue el más largo entre los cirujanos generales (11.1 ± 5.5; p = 0.041) seguido por los cirujanos colorrectales (10.94 ± 5.2) y los gastroenterólogos (10.16 ± 1.26).No pudimos ajustar algunos detalles relacionados con el procedimiento, tales como la retroflexión en el colon derecho y el uso de accesorios endoscópicos.En este estudio, solo los gastroenterólogos cumplieron con los índices de referencia actualmente aceptados, de detección de adenomas en general y específicas de género. También superaron a los no gastroenterólogos en muchas otras métricas no establecidas de calidad. Consulte Video Resumen en http://links.lww.com/DCR/B232. (Traducción-Dr. Fidel Ruiz Healy).

Clinical Outcomes Based on the Timing of Appearance of Visible Lesions in Barrett's Esophagus During Endoscopic Eradication Therapy.

BACKGROUND AND GOALS: Visible lesions (VLs) in Barrett's esophagus (BE) are seen in 70% to 90% of patients presenting for endoscopic eradication therapy (EET). It is not known if there are any differences in outcomes of patients with flat dysplasia versus patients with VL. Our aim was to assess outcomes of EET in BE patients with VL and BE patients with flat dysplasia. STUDY: This is a single center study with data drawn from a prospective registry of patients referred for EET of BE between 2011 and 2015. Demographic data, endoscopic findings, histologic findings, and response to EET were analyzed. RESULTS: There were 264 patients of which 34 had flat dysplasia, 180 had VL before initiating EET (prevalent lesions) and 50 who developed VL during EET (incident lesions). Compared with patients with flat dysplasia, patients with VL had longer segments of BE (5 vs. 4 cm, P=0.002) and greater prevalence of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) (63.6% vs. 29.4%, P<0.001). Incident lesions are less likely to harbor HGD/EAC compared with prevalent lesions (28.1% vs. 61.8%, P<0.001). There were no significant differences in eradication of metaplasia/dysplasia between the groups. No progression or recurrences were observed in flat dysplasia group. In VL group, 14 patients progressed (prevalent VL=11, incident VL=3) and 15 had recurrences (prevalent VL=11, incident VL=4). CONCLUSIONS: About 19% of BE patients developed VL during EET. There is higher prevalence of HGD/EAC in prevalent VL compared with incident VL. However, the outcomes did not differ.

Obesity Does Not Impact Outcomes or Rates of Gastroesophageal Reflux After Peroral Endoscopic Myotomy in Achalasia.

BACKGROUND: Outcomes of laparoscopic Heller myotomy in obese patients with achalasia are suboptimal along with the increased risk of gastroesophageal reflux disease (GERD). The impact of obesity on treatment success and GERD after peroral endoscopic myotomy (POEM) are not well known. Hence, our study aims were to compare the clinical outcomes and rates of GERD after POEM in nonobese versus obese patients with achalasia. METHODS: Chart review of all achalasia patients who underwent POEM at our institution between April 2014 and June 2018. Patients with timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with post-POEM TBE, HREM, and esophageal pH study were included. Patients were categorized into 2 groups, nonobese (body mass index <30 kg/m) and obese (body mass index ≥30 kg/m). Patient demographics, TBE, HREM, pH study findings, and Eckardt scores were compared between the 2 groups. RESULTS: A total of 89 patients (46 nonobese; 43 obese) met the study criteria. There were no significant differences in age, gender, achalasia subtype, operative time, length of stay and complication rates between the 2 groups. Treatment success (Eckardt score ≤3) was similar in both groups (97.7% nonobese vs. 92.7% obese, P=0.35). Abnormal DeMeester scores on pH study (>14.72) were similar in nonobese and obese patients (58.7% vs. 46.5%, P=0.25). Symptomatic GERD was also similar in both groups (17.8% in nonobese vs. 20% in obese, P=0.79). CONCLUSIONS: POEM is an equally safe and effective treatment option for both nonobese and obese patients with achalasia in the short-term. Interestingly, POEM does not lead to higher rates of GERD in obese compared with nonobese patients.

Proposal of high-risk adenoma detection rate as an impactful, complementary quality indicator of colonoscopy.

BACKGROUND AND AIMS: Adenoma detection rate (ADR), a validated quality indicator (QI) of colonoscopy, does not take into account risk stratification of adenomas. Low-risk adenomas are not associated with a significantly increased risk of future colorectal cancer (CRC). On the other hand, high-risk adenomas (HRA) are associated with up to six fold higher risk of future CRC. Therefore, HRA detection rate (HR-ADR) as a QI in addition to ADR may further enhance the efficacy of screening colonoscopy. Our aim was to calculate ADR and HR-ADR in a large cohort of average risk screening colonoscopy patients and propose HR-ADR which correlates with current threshold ADR. METHODS: This is a retrospective chart review of all colonoscopies performed in patients aged ≥ 50 years at our institution between 2012 and 2014. Average risk patients who had complete colonoscopy with good, excellent and adequate bowel preparation were included. Overall and gender-specific ADR and HR-ADR were calculated. HR-ADR was defined as proportion of colonoscopies with HRA. RESULTS: Among 4158 colonoscopies included, ADR was 26.4 ± 10.9% overall, 32.7 ± 14.5% in men, and 22.1 ± 12.6% in women. HR-ADR was 8.0 ± 5.7% overall, 10.2 ± 8.6% in men, and 6.1 ± 6% in women. There was only moderate correlation between ADR and HR-ADR [r = 0.57 (0.40-0.70)]. HR-ADR corresponding with minimum threshold ADR of 30% in men and 20% in women were calculated to be 7% in men and 4% in women. CONCLUSIONS: HR-ADR correlates only moderately with ADR. Based on the current threshold ADRs, we propose a benchmark HR-ADR of 7% in men and 4% in women as complementary QI to ADR.

National trends in healthcare outcomes and utilization of endoscopic and surgical interventions in patients hospitalized with esophageal foreign body and food impaction.

The incidence and number of emergency room visits for esophageal foreign body and food impaction (EFB) are on the rise. However, its impact on the rate of inpatient admissions, utilization of endoscopic and surgical interventions, and healthcare outcomes is poorly understood. We conducted a study to analyze these outcomes using the national inpatient sample (NIS) database. Data on all adult patients (≥18 years) admitted with EFB was extracted from the NIS database from 1998 to 2013. The temporal trends in discharge rates as well as in length of stay (LOS), hospital charges, and in-hospital mortality rates were assessed by linear and polynomial regression. Average age, gender, and race of inpatients with EFB were not significantly different between 1998 and 2013. The rate of EFB admissions increased significantly from 1998 to 2005 followed by a decline thereafter (p = 0.01). LOS and hospital charges significantly increased by 0.02 days/year (p = 0.015) and $1,547/year (p < 0.001), respectively. There was a trend towards less utilization of overall esophagogastroduodenoscopy (EGD) over the last decade with significant lower use of EGD within 24 hours in 2013 as compared to 1998 (p = 0.026). The rates of surgical intervention and inpatient mortality did not change significantly over the study period. The rate of inpatient admissions for EFB is on the decline in recent years, suggesting the modern-day practice of cost-effective medicine. Hospitalization costs for EFB have increased, whereas rates of surgical intervention and inpatient mortality have not changed significantly over the study period.