Endoscopic submucosal dissection with versus without traction for pathologically staged T1B esophageal cancer: a multicenter retrospective study.

BACKGROUND AND AIMS: Positive vertical margins (VMs) are common after endoscopic submucosal dissection (ESD) of T1b esophageal cancer (EC) and are associated with an increased risk of recurrence. Traction during ESD provides better exposure of the submucosa and may allow deeper dissection, potentially reducing the risk of positive VMs. We conducted a retrospective multicenter study to compare the proportion of resections with positive VMs in ESD performed with versus without traction in pathologically staged T1b EC. METHODS: Patients who underwent ESD revealing T1b EC (squamous or adenocarcinoma) at 10 academic tertiary referral centers in the United States (n = 9) and Brazil (n = 1) were included. Demographic and clinical data were abstracted. ESD using either traction techniques (tunneling, pocket) or traction devices (clip line, traction wire) were classified as ESD with traction (Tr-ESD) and those without were classified as conventional ESD without traction. The primary outcome was a negative VM. Multivariable logistic regression was used to assess associations with negative VMs. RESULTS: A total of 166 patients with pathologically staged T1b EC underwent Tr-ESD (n = 63; 38%) or conventional ESD without traction (n = 103; 62%). Baseline factors were comparable between both groups. On multivariable analysis, Tr-ESD was found to be independently associated with negative VMs (odds ratio, 2.25; 95% confidence interval, 1.06-4.91; P = .037) and R0 resection (odds ratio, 2.83; 95% confidence interval, 1.33-6.23; P = .008). CONCLUSION: Tr-ESD seems to be associated with higher odds of negative VMs than ESD without traction for pathologically staged T1b EC, and future well-conducted prospective studies are warranted to establish the findings of the current study.

Is it enough to observe less than 2 cm sized gastric SET?

BACKGROUND AND AIMS: The recent surge in demand for screening endoscopy has led to an increased detection of gastric subepithelial tumors (SETs). According to current guideline, SETs less than 2 cm in size are recommended for periodic surveillance. In light of recent advancement in therapeutic endoscopy in resection of small SET, we analyzed the histopathological features and the effectiveness of endoscopic resection for these small SETs. METHODS: Retrospectively study was performed on 74 patients who underwent endoscopic resection of gastric small (≤ 2 cm) upper gastrointestinal tract SETs. The outcomes including histopathology and en bloc resection were analyzed. RESULTS: The mean SET size was 11.69 ± 5.11 mm. The mean procedure time was 81.26 ± 42.53 min. Of the 74 patients, 28 patients had leiomyomas, 26 had gastrointestinal stromal tumors (GISTs), 14 had ectopic pancreas, 4 had lipomas, and 2 had neuroendocrine tumors. Among those with GIST, two patients exhibited high-risk histology. All patients underwent successful and uneventful endoscopy. CONCLUSIONS: Endoscopic resection can be recommended even for the small gastric SETs. In our study, we found that SETs with a size of less than 2 cm have significant proportion of GISTs which harbor malignant transformation potential.

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.

Superiority of Self-Expandable Metallic Stents Over Plastic Stents in Treatment of Malignant Distal Biliary Strictures.

BACKGROUND & AIMS: Treatment of malignant biliary strictures with endoscopic retrograde cholangiopancreatography (ERCP) guided stent placement is highly effective. Our objective was to compare the efficacy and adverse outcomes between plastic stents (PS) and self-expandable metallic stents (SEMS). METHODS: A cohort study was performed of all consecutive patients who underwent ERCP with stent placement for the management of malignant biliary stricture. Comparisons on clinical success, patency duration, stent dysfunction, unplanned reintervention and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with clinical success, need for reintervention, and stent dysfunction. RESULTS: From 2012 to 2019, 1139 patients underwent ERCP with PS placement while 1008 patients received SEMS for the management of malignant biliary stricture. In distal strictures, SEMS reported a significantly higher rate of clinical success compared with PS (94.1% vs 87.4%, P < 0.001) and a lower rate of unplanned reintervention (17.1% vs 27.4%, P < 0.001). In hilar strictures, the rates of clinical success and unplanned intervention were comparable. The patency duration and time to unplanned reintervention were significantly longer with SEMS than PS, irrespective of stricture location. In distal stricture, PS was associated with a significantly higher rate of cholangitis than SEMS (6.9% vs 2.4%; P < .001) but a lower rate of pancreatitis (3.6% vs 6%; P = 0.021). CONCLUSION: Given superior efficacy, durability and lower rates of cholangitis, SEMS should be offered as the first line endoscopic treatment option for malignant distal biliary stricture. For malignant hilar stricture, SEMS is an attractive alternative to PS in some cases by offering a comparable efficacy with a superior durability.

Outcomes for endoscopic submucosal dissection of pathologically staged T1b esophageal cancer: a multicenter study.

BACKGROUND AND AIMS: The outcomes of endoscopic submucosal dissection (ESD) for T1b esophageal cancer (EC) and its recurrence rates remain unclear in the West. Using a multicenter cohort, we evaluated technical outcomes and recurrence rates of ESD in the treatment of pathologically staged T1b EC. METHODS: We included patients who underwent ESD of T1b EC at 7 academic tertiary referral centers in the United States (n = 6) and Brazil (n = 1). We analyzed demographic, procedural, and histopathologic characteristics and follow-up data. Time-to-event analysis was performed to evaluate recurrence rates. RESULTS: Sixty-six patients with pathologically staged T1b EC after ESD were included in the study. A preprocedure staging EUS was available in 54 patients and was Tis/T1a in 27 patients (50%) and T1b in 27 patients (50%). En-bloc resection rate was 92.4% (61/66) and R0 resection rate was 54.5% (36/66). Forty-nine of 66 patients (74.2%) did not undergo surgery immediately after resection and went on to surveillance. Ten patients had ESD resection within the curative criteria, and no recurrences were seen in a 13-month (range, 3-18.5) follow-up period in these patients. Ten of 39 patients (25.6%) with noncurative resections had residual/recurrent disease. Of the 10 patients with noncurative resection, local recurrence alone was seen in 5 patients (12.8%) and metastatic recurrence in 5 patients (12.8%). On univariate analysis, R1 resection had a higher risk of recurrent disease (hazard ratio, 6.25; 95% confidence interval, 1.29-30.36; P = .023). CONCLUSIONS: EUS staging of T1b EC has poor accuracy, and a staging ESD should be considered in these patients. ESD R0 resection rates were low in T1b EC, and R1 resection was associated with recurrent disease. Patients with noncurative ESD resection of T1b EC who cannot undergo surgery should be surveyed closely, because recurrent disease was seen in 25% of these patients.

Endoscopic submucosal dissection vs. endoscopic mucosal resection for early Barrett's neoplasia in the West: a retrospective study.

BACKGROUND: The difference in clinical outcomes after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for early Barrett's esophagus (BE) neoplasia remains unclear. We compared the recurrence/residual tissue rates, resection outcomes, and adverse events after ESD and EMR for early BE neoplasia. METHODS: We included patients who underwent EMR or ESD for BE-associated high grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC) at eight academic hospitals. We compared demographic, procedural, and histologic characteristics, and follow-up data. A time-to-event analysis was performed to evaluate recurrence/residual disease and a Kaplan-Meier curve was used to compare the groups. RESULTS: 243 patients (150 EMR; 93 ESD) were included. EMR had lower en bloc (43 % vs. 89 %; P < 0.001) and R0 (56 % vs. 73 %; P = 0.01) rates than ESD. There was no difference in the rates of perforation (0.7 % vs. 0; P > 0.99), early bleeding (0.7 % vs. 1 %; P > 0.99), delayed bleeding (3.3 % vs. 2.1 %; P = 0.71), and stricture (10 % vs. 16 %; P = 0.16) between EMR and ESD. Patients with non-curative resections who underwent further therapy were excluded from the recurrence analysis. Recurrent/residual disease was 31.4 % [44/140] for EMR and 3.5 % [3/85] for ESD during a median (interquartile range) follow-up of 15.5 (6.75-30) and 8 (2-18) months, respectively. Recurrence-/residual disease-free survival was significantly higher in the ESD group. More patients required additional endoscopic resection procedures to treat recurrent/residual disease after EMR (EMR 24.2 % vs. ESD 3.5 %; P < 0.001). CONCLUSIONS: ESD is safe and results in more definitive treatment of early BE neoplasia, with significantly lower recurrence/residual disease rates and less need for repeat endoscopic treatments than with EMR.

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.

Clinical Outcomes of Acute Pancreatitis in Patients with Cirrhosis According to Liver Disease Severity Scores.

BACKGROUND: Literature on acute pancreatitis (AP) outcomes in patients with cirrhosis is limited. We aim to investigate the mortality and morbidity of AP in patients with cirrhosis. METHODS: We conducted a retrospective cohort study, and propensity score matching was done to match cirrhotic with non-cirrhotic patients on a 1:2 basis. Outcomes included inpatient mortality, organs failure, systemic inflammatory response syndrome, and length of hospital stay. We performed subgroup analysis of cirrhotics according to Child-Pugh and MELD scores. Multivariable logistic regression models were tested. RESULTS: From 819 AP patients, cirrhosis prevalence was 4.9% (40). There was no significant difference between cirrhotics and non-cirrhotics for inpatient mortality (7.5% vs. 1.3%, p = 0.1), severe AP (17.5% vs. 7.5%), shock (7.9% vs. 3%), respiratory failure (10% vs. 3.8%), need for intensive care unit (15% vs. 6.3%), systemic inflammatory response syndrome (SIRS) on admission (22.5% vs. 32.5%), and SIRS on day 2 (25% vs. 15%). Cirrhotics had similar rates of pancreatic necrosis, ileus, BISAP score, Marshall score, admission hematocrit, BUN, and hospital length of stay. Finally, cirrhotics who had severe AP, required ICU, and/or die in-hospital appeared to have more severe liver diseases (Child-C, higher MELD score > 17) and had lower AP severity scores (BISAP < 3, Marshall scores < 2). CONCLUSION: In our study, cirrhotics hospitalized with AP had similar morbidity and mortality when compared to non-cirrhotics.

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.

Clinical outcomes of acute pancreatitis in patients with cirrhosis.

BACKGROUND: AP outcomes in cirrhotic patients have not yet been studied. We aim to investigate the outcomes of cirrhotics patients with acute pancreatitis. METHODS: The National Inpatient Sample (NIS) database (2003-2013) was queried for patients with a discharge diagnosis of AP and liver cirrhosis. Cirrhosis was further classified as compensated and decompensated using the validated Baveno IV criteria. Primary outcome was inpatient mortality. The analysis was adjusted for age, gender, race, Charlson comorbidity index (CCI), median income quartile, and hospital characteristics. RESULTS: Over 2.8 million patients with acute pancreatitis were analyzed. Cirrhosis prevalence was 2.8% (80,093). Both compensated and decompensated cirrhosis subjects had significantly higher mortality. Highest odds ratios (OR) were: inpatient mortality (OR 3.4, P < 0.001), Shock (OR 1.5, P = 0.02), Ileus (OR: 1.3, p = 0.02, ARDS (OR 1.2, p = 0.03), upper endoscopy performed (OR 2.0, p < 0.001), blood transfusions (OR 3.1, p < 0.001), gastrointestinal bleed (OR 5.5, p < 0.001), sepsis (OR 1.3, p = 0.005), portal vein thrombosis (PVT) (OR 7.2, p < 0.001), acute cholecystitis (OR 1.3, p < 0.001). Interestingly, cirrhosis patients had lower hospital length of stay, (OR 0.16, p < 0.001), AKI (OR 0.93, p = 0.06), myocardial infarction (OR 0.31, p < 0.001), SIRS (OR 0.62, p < 0.001), parenteral nutrition requirement (OR 0.84, p = 0.002). Decompensated cirrhosis had higher inflation-adjusted hospital charges (+$3896.60; p < 0.001). CONCLUSION: AP patients with cirrhosis have higher inpatient mortality, but it is unlikely to be due to AP severity as patients had lower incidence of SIRS and AKI. Higher mortality is possibly related to complications of cirrhosis and portal hypertension itself such as GI bleed, shock, PVT, AC and sepsis.

The utility of intracystic glucose levels in differentiating mucinous from non-mucinous pancreatic cysts.

BACKGROUND: Differentiating benign non-mucinous from potentially malignant mucinous pancreatic cysts is still a challenge. This study aims to improve this distinction with cyst fluid analysis. METHODS: A cohort study of pancreatic cyst undergoing EUS/FNA was performed from a prospectively maintained database between 2014 and 2018 was performed. RESULTS: 113 patients were analyzed (40 non-mucinous and 73 mucinous). For differentiating mucinous from non-mucinous cyst: intracyst glucose ≤41 mg/dl had a sensitivity of 92% and a specificity of 92%; positive predictive value (PPV) of 96 and negative predictive value (NPV) of 86. Glucose ≤21 mg/dl had a sensitivity of 88%, specificity of 97%, PPV of 98 and NPV of 81. CEA ≥192 ng/mL had a sensitivity of 50% and a specificity of 92%; PPV of 92 and NPV of 50. Glucose ≤21 mg/dl or CEA ≥192 ng/mL combined had a sensitivity of 93%, specificity of 92%, PPV of 96 and NPV of 87 (Fig. 1, Table 1). CONCLUSION: Intra-cyst glucose levels (≤41 mg/dl) outperforms classic CEA testing for differentiation of mucinous from non-mucinous pancreatic cysts. It was found to be an excellent diagnostic test with an AUC of 0.95 (95% CI: 0.81, 0.97).

Efficacy of digital single-operator cholangioscopy and factors affecting its accuracy in the evaluation of indeterminate biliary stricture.

BACKGROUND AND AIMS: Indeterminate biliary stricture remains a significant diagnostic challenge. The current method of ERCP with bile duct brush cytology has substantial room for improvement. We aimed to determine the efficacy of a digital single-operator cholangioscopy (DSOC) in evaluation of indeterminate biliary stricture. METHODS: An observational cohort study was conducted among the patients who underwent DSOC for the indication of indeterminate biliary stricture at a tertiary academic medical center. The outcomes of interests were the accuracy of DSOC in visual interpretation and bile duct sample and identification of any factor(s) that could influence its effectiveness. RESULTS: One hundred five patients were included. The overall accuracy of DSOC in visual interpretation was 89.5%, whereas the accuracy of bile duct sample was 83.2%. The sensitivities of visual impression and bile duct sample were 89.1% and 69.8% and their specificities were 90% and 97.9%, respectively. The degree of endoscopists' experience with fewer than 25 cases and the severity of hyperbilirubinemia negatively impacted the accuracy of DSOC. Among 55 patients with definitive diagnosis of malignant stricture, the sensitivity of combined intraductal forceps biopsy sampling and brush cytology was 80.6%, whereas the sensitivity of brush cytology alone was 47.1%. CONCLUSIONS: DSOC augments ERCP in evaluating indeterminate biliary stricture. The acquisition of intraductal forceps biopsy samples should be a requisite in evaluation of indeterminate biliary stricture with DSOC. Discovery of modifiable factors such as the degree of endoscopists' expertise and the severity of hyperbilirubinemia, which can influence the accuracy of DSOC, warrants further studies on patient preprocedure optimization and an endoscopic training program that will cultivate procedural competency.

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.

Self-Expandable Metallic Stent Is More Cost Efficient Than Plastic Stent in Treating Anastomotic Biliary Stricture.

BACKGROUND: Anastomotic bile duct stricture (ABS) is one of the most common complications after liver transplantation. Current practice of endoscopic retrograde cholangiopancreatography (ERCP) with multiple plastic stent (MPS) insertion often requires multiple sessions before achieving stricture resolution. We aimed to compare the efficacy of fully covered self-expandable metallic stent (FCSEMS) with MPS method while simultaneously analyzing the relative healthcare cost between the two methods in the management of ABS. METHODS: Liver transplant patients with ABS who received ERCP with stent placement were identified by query of our endoscopic database. Comparative analyses between the group of patients treated with ERCP with MPS and the group treated with FCSEMS were performed. The costs to achieve stricture resolution, and the rates of stricture resolution, recurrence and complications were also compared. RESULTS: A total of 158 patients underwent ERCP with stent insertion for the management of ABS. Of those, 49 patient received FCSEMS for their ABS while 109 patients were treated with MPS only. Our cost analysis showed early utilization of FCSEMS can deliver up to 25% savings in the total procedure cost while providing comparable rates of stricture resolution. The rates of technical success, stricture recurrence and adverse outcomes, and stricture free durations were also comparable between the two groups. CONCLUSION: While providing efficacy and safety rates comparable to ERCP-MPS, the incorporation of FCSEMS at early stage of ABS management could provide a substantial savings by reducing the number of ERCP session to achieve stricture resolution. Optimization of the timing and duration of FCSEMS indwelling time needs further validation.

Superiority of Gastrojejunostomy Over Endoscopic Stenting for Palliation of Malignant Gastric Outlet Obstruction.

BACKGROUND & AIMS: Gastric outlet obstruction (GOO) in patients with malignancies causes nausea, vomiting, abdominal pain, malnutrition, and dehydration. Endoscopic placement of self-expandable metallic stent (SEMS) and gastrojejunostomy are the 2 main palliative options. We aimed to compare the outcomes of endoscopic SEMS placement with gastrojejunostomy in a propensity score matched study and identified factors associated with clinical success. METHODS: We performed a retrospective analysis of patients with malignant GOO who underwent endoscopic SEMS placement (n = 183) or gastrojejunostomy (n = 127) from 2011 through 2017 at a tertiary academic medical center. Clinical success was defined as successful resumption of oral intake and relief of obstructive symptoms after either procedure. A propensity score matched analysis was conducted to compare clinical success rate, luminal patency duration, survival length, and adverse outcomes. We performed multivariable analyses to identify factors associated with clinical success. RESULTS: Proportions of patients with clinical success did not differ significantly between the SMES group (79.4%) and the gastrojejunostomy group (80.1%) (P = .83). The mean patency duration and survival lengths were significantly longer in the gastrojejunostomy group (169.2 and 193.4 days respectively), compared to the endoscopic stenting group (96.5 and 119.9 days respectively). Poor performance status, presence of ascites and low albumin were independent risk factors for failure of enteral stenting and gastrojejunostomy. CONCLUSIONS: In a retrospective analysis of patients with GOO, due to cancer, who underwent endoscopic SEMS placement or gastrojejunostomy, we found gastrojejunostomy to provide significant increases in patency duration and survival time. Gastrojejunostomy should therefore be considered the primary treatment option for patients with good performance status and reasonable survival expectancy. Nutritional status, the absence of ascites, and pre-procedure performance status are associated with clinical success.

EUS-Guided Biliary Drainage Versus ERCP for the Primary Palliation of Malignant Biliary Obstruction: A Multicenter Randomized Clinical Trial.

OBJECTIVES: The goal of the study was to determine whether endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is comparable to conventional transpapillary stenting with endoscopic retrograde cholangiopancreatography (ERCP) in palliation of malignant distal biliary obstruction. Although ERCP for the palliation of malignant biliary obstruction is the standard of care, post-procedure pancreatitis and stent dysfunctions are not uncommon. While EUS-BD has garnered interest as a viable alternative when ERCP is impossible, its role as a primary palliation of malignant distal biliary obstruction is yet to be proven. METHODS: We performed random allocation to EUS-BD or ERCP in 125 patients with unresectable malignant distal biliary obstruction at four tertiary academic referral centers in South Korea. RESULTS: Technical success rates were 93.8% (60/64) for EUS-BD and 90.2% (55/61) for ERCP (difference 3.6%, 95% 1-sided confidence interval lower limit -4.4%, P = 0.003 for noninferiority margin of 10%). Clinical success rates were 90.0% (54/60) in EUS-BD and 94.5% (52/55) in ERCP (P = 0.49). Lower rates of overall adverse events (6.3% vs 19.7%, P = 0.03) including post-procedure pancreatitis (0 vs 14.8%), reintervention (15.6% vs 42.6%), and higher rate of stent patency (85.1% vs 48.9%) were observed with EUS-BD. EUS-BD was also associated with more preserved quality of life (QOL) than transpapillary stenting after 12 weeks of the procedure. CONCLUSIONS: This study demonstrated comparable technical and clinical success rates between EUS-BD and ERCP in relief malignant distal biliary obstruction. Substantially longer duration of patency coupled with lower rates of adverse events and reintervention, and more preserved QOL were observed with EUS-BD (cris.nih.go.kr, Identifier: KCT0001396, https://cris.nih.go.kr/cris/search/search_result_st01_en.jsp?seq=9716<ype=&rtype= ).

Association of covered metallic stents with cholecystitis and stent migration in malignant biliary stricture.

BACKGROUND AND AIMS: ERCP with self-expandable metallic stent (SEMS) placement provides reliable and durable relief of malignant biliary obstruction. Our objective was to compare efficacy and adverse outcomes between uncovered SEMSs (USEMSs) and covered SEMSs (CSEMSs). METHODS: A retrospective cohort study was performed of all consecutive patients who underwent ERCP with SEMS placement for the management of a malignant bile duct stricture. Comparative analyses on clinical success, patency duration, stent dysfunction, and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with stent dysfunction. RESULTS: Six hundred forty-five patients underwent SEMS placement for the management of malignant bile duct stricture from 2008 to 2016. CSEMSs and USEMSs had similar rates of clinical success in relief of bile duct obstruction (93.0% vs 92.1%, respectively; P = .69) and patency duration (546.7 vs 557.9 days, P = .14). Among those with an intact gallbladder, the incidence of acute cholecystitis was higher in the CSEMS group compared with the USEMS group (7.8% vs 1.2%; P < .001). In the multivariable analysis, CSEMS use was associated with increased risk of stent migration (hazard ratio, 10.7; 95% confidence interval, 4.1-27.7). CONCLUSIONS: CSEMSs and USEMSs have similar clinical success rates and patency durations in management of malignant bile duct stricture. CSEMSs, however, are associated with increased rates of migration and cholecystitis. Comparable efficacy and superior safety profile of USEMSs render a compelling argument for its place as the preferred choice of SEMSs in the management of malignant biliary stricture.

Cryotherapy and Radiofrequency Ablation for Eradication of Barrett's Esophagus with Dysplasia or Intramucosal Cancer.

BACKGROUND AND AIMS: Endoscopic ablation therapy has become the mainstay of treatment of Barrett's associated dysplasia and intramucosal cancer (IMC). The widely available techniques for ablation are radiofrequency ablation (RFA) and cryotherapy. Our aim was to compare eradication rates of metaplasia and dysplasia with both these modalities. PATIENTS AND METHODS: Retrospective review of prospectively collected database of patients who underwent endoscopic therapy for Barrett's dysplasia or IMC from 2006 to 2011 was performed. Demographic features, comorbidities, and endoscopic data including length of Barrett's segment, hiatal hernia size, interventions during the endoscopy and histological results were reviewed. RESULTS: Among 154 patients included, 73 patients were in the RFA and 81 patients were in the cryotherapy group. There was complete eradication of intestinal metaplasia (CE-IM) in 81 (52.6%), complete eradication of dysplasia (CE-D) in 133 (86.4%), and persistent dysplasia or cancer in 19 patients (12.3%). Compared to RFA, cryotherapy patients were found to be older and less likely to have undergone endoscopic mucosal resection. On multivariate analysis, patients who underwent RFA had a threefold higher odds of having CE-IM than those who underwent cryotherapy (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.4-6.0, p = 0.004), but CE-D were similar between the two groups (OR 1.7, 95% CI 0.66-4.3, p = 0.28). CONCLUSIONS: Endoscopic therapy is highly effective in eradication of Barrett's associated neoplasia. Patients who underwent cryotherapy were equally likely to achieve CE-D but not CE-IM than patients who underwent RFA. Patient characteristics and preferences may effect choice of treatment selection and outcomes.

Optimal injection solution for endoscopic submucosal dissection: A randomized controlled trial of Western solutions in a porcine model.

BACKGROUND AND AIM: When carrying out endoscopic submucosal dissection (ESD), procedural safety increases with greater tissue elevation and efficiency increases with longer-lasting submucosal cushion. Fluids specifically developed for ESD in Asia are not commercially available in the West, leaving endoscopists to use a variety of injectable fluids off-label. To determine the optimal fluid available in the West, we compared commonly used fluids for Western ESD. METHODS: All phases were carried out in an ex vivo porcine stomach model. Phase 1 compared tissue elevation and duration of submucosal cushions produced by various standard volumes of various injectable solutions used for ESD. The two best-performing solutions used off-label were tested head-to-head in ESD in Phase 2. Phase 3 compared the best solution from Phase 2 to Eleview® , currently the only submucosal injection fluid approved in the USA. In Phases 2 and 3, five ESD were carried out with each solution. The solutions were randomized and the endoscopist blinded to the solution. RESULTS: The best-performing solutions in Phase 1 were 0.4% hyaluronic acid, 6% hydroxyethyl starch (HES), and Eleview® . Phase 2 compared 6% HES and hydroxypropyl methylcellulose (HPMC), showing that ESD with 6% HES was easier (P = 0.007), faster (P = 0.041) and required less injection volume (P = 0.003). In Phase 3, resection speed, ease of ESD and total volume per area resected were comparable between 6% HES and Eleview® . CONCLUSIONS: Of the submucosal injection fluids currently available in the West, Eleview® and 6% HES are the best-performing solutions for ESD in a porcine model.

Efficacy and Optimal Duration of Metallic Stent in the Management of Refractory Anastomotic Stricture After Liver Transplantation.

BACKGROUND & AIMS: Anastomotic bile duct stricture (ABS) remains as one of the most common complications in liver transplant patients. Current practice of endoscopic retrograde cholangiopancreatography (ERCP) with insertion of plastic stent often requires multiple procedures before achieving stricture resolution. To date, studies using covered self-expandable metallic stent (cSEMS) in ABS management reported varying degrees of efficacy. The aim of this study was to analyze long-term efficacy of cSEMS in patients with ABS and identify factor(s) influencing the probability of stricture resolution. METHODS: Liver transplant patients with ABS who received cSEMS were identified by query of our endoscopic database. The rate of stricture resolution, duration of stricture-free interval, factors associated with stricture resolution, and adverse outcomes were analyzed. RESULTS: Among 44 liver transplant patients with refractory ABS who underwent ERCP-cSEMS, stricture resolution was observed in 33 patients (75%). Longer duration of cSEMS insertion was the only variable associated with increasing probability of stricture resolution. There was 20% increase in odds of stricture resolution for every additional week cSEMS was in place. Among 33 patients with initial stricture resolution, 26 patients (78.8%) maintained bile duct patency throughout the follow-up period. The most common adverse outcome was internal migration of cSEMS, which occurred in 11 patients (25%). CONCLUSIONS: The rate of ABS resolution observed with cSEMS placement in a single ERCP session appears to be comparable with that of multiple ERCPs with plastic stent placement reported previously. Longer stent insertion period is associated with higher likelihood of ABS resolution.