July effect in clinical outcomes of esophagogastroduodenoscopy performed at teaching hospitals in the United States.

Background: Esophagogastroduodenoscopy (EGD) is a common procedure used for both diagnosis and treatment, but carries risks such as bleeding and perforation. The "July effect"-described as increased complication rates during the transition of new trainees-has been studied in other procedures, but has not been thoroughly evaluated for EGD. Methods: We used the National Inpatient Sample database for 2016 to 2018 to compare outcomes in EGD performed between July to September and April to June. Results: Approximately 0.91 million patients in the study received EGD between July to September (49.35%) and April to June (50.65%), with no significant differences between the two groups in terms of age, gender, race, income, or insurance status. Of the 911,235 patients, 19,280 died during the study period following EGD, 2.14% (July-September) vs 1.95% (April-June), with an adjusted odds ratio of 1.09 (P < 0.01). The adjusted total hospitalization charge was $2052 higher in July-September ($81,597) vs April to June ($79,023) (P < 0.005). The mean length of stay was 6.8 days (July-September) vs 6.6 days (April-June) (P < 0.001). Conclusions: The results of this study are reassuring as the July effect on inpatient outcomes for EGDs was not significantly different according to our study. We recommend seeking prompt treatment and improving new trainee training and interspecialty communication for better patient outcomes.

Differential to Terminal Ileitis: Terminal Ileum Neuroendocrine Tumor Identified on Screening Colonoscopy.

Background: Asymptomatic patients at average risk of developing colorectal cancer are encouraged to undergo screening colonoscopy beginning at age 45 years. While ileal intubation is often considered the gold standard for a complete colonoscopy, the relatively low diagnostic yield has prevented widespread adoption. Small bowel cancers, including neuroendocrine tumors, may present incidentally as terminal ileitis on routine colonoscopy with terminal ileum intubation. Neuroendocrine tumors, the most common primary neoplasm of the small intestine, are often asymptomatic or present as nonspecific abdominal pain in the sixth or seventh decade of life. Case Report: A 51-year-old asymptomatic male with unremarkable physical examination underwent screening colonoscopy that revealed scattered ulcerations of the terminal ileum. Immunohistochemistry of the lesion was consistent with well-differentiated neuroendocrine tumor, World Health Organization Grade I. DOTATATE positron emission tomography/computed tomography demonstrated avid adjacent right mesenteric lymph node and avid focal pancreatic body lesion. Fine-needle biopsy and immunohistochemistry of the pancreatic lesion confirmed neuroendocrine tumor, while the mesenteric lymph node was found to be benign. The patient underwent robotic-assisted ileocolic resection and has ongoing surveillance of the pancreatic lesion. Conclusion: Terminal ileitis encompasses a host of pathologic processes, including inflammatory states, infectious disease, malignancy, and vasculitis. Importantly, small bowel cancer is an increasing cause of terminal ileitis. Screening colonoscopy with ileal intubation can be a valuable tool for early detection of these lesions.

COVID-19 Alcoholic Cirrhosis and Non-Alcoholic Steatohepatitis Cirrhosis Outcomes among Hospitalized Patients in the United States: Insight from National Inpatient Sample Database.

Patients with co-morbidities like cirrhosis are at risk of worse outcome from COVID-19 infection. Given limited prior studies, we evaluated outcomes associated with COVID-19 infection in alcoholic and non-alcoholic steatohepatitis cirrhotic (CC+) versus cirrhotic without COVID-19 (CC−). We performed retrospective analysis of 822,604 patients including 28,610 COVID-19 patients from the National Inpatient Sample database with alcoholic and NASH cirrhosis enrolled between 1 January 2020 to 31 December 2020, with univariate and multivariate regression analyses. Primary outcome was mortality and secondary outcomes was mechanical ventilation, vasopressor use, length of stay, hospitalization expense and predictors of mortality. In-hospital mortality was three time higher in the CC+ group compared to those in the CC− group(18.6% vs. 5.96%, p < 0.001, adjusted odds ratio (OR)3.39 (95% 3.08−3.74 CI). Hospitalization was more likely for underrepresented racial and ethnic groups with COVID-19 and cirrhosis. CC+ group had over twice the rates of mechanical ventilation (19.92% vs. 9.07%, adjusted OR 2.71 2.71 (95% 2.51−2.93 CI)),1.7 times likelihood of receiving vasopressors (4.12% vs. 2.45%, p < 0.001, adjusted OR 1.71 (95% CI 1.46−2.01). COVID-19 is associated with increased mortality in patients with alcoholic and NASH cirrhosis, and patients with alcoholic cirrhosis and COVID-19 have a slightly higher mortality compared to NASH cirrhosis.

Metastatic Renal Cell Carcinoma Presenting as a Bleeding Gastric Polyp.

BACKGROUND: Renal cell carcinoma (RCC) is responsible for nearly 13,000 deaths in the United States every year, predominantly because of metastasis to other bodily organs. However, metastasis of RCC to the stomach occurs rarely; it presents as solitary or multiple polyps or as ulcers concerning for primary gastric carcinoma. Bleeding from metastasis to the stomach is a rare and underrecognized cause of gastrointestinal bleeding. We describe a case of gastrointestinal bleeding in an elderly female who was found to have a gastric polyp of RCC origin. CASE REPORT: An 83-year-old female presented to our hospital for evaluation of an acute right basal ganglia hemorrhage after falling at her nursing home. Her hospital course was notable for melenic stool and anemia. Upper endoscopy revealed a single 40-mm pedunculated polyp and active bleeding on the lesser curvature of the stomach. Polypectomy and clipping were performed. Pathology was consistent with metastatic clear cell RCC. The patient's family declined a referral to oncology for evaluation of the newly diagnosed malignancy and opted for hospice care. CONCLUSION: This case illustrates the potential for metastatic RCC to involve the stomach and cause gastrointestinal bleeding and anemia. The case also illustrates the role of upper gastrointestinal endoscopy in diagnosing and treating metastatic causes of gastrointestinal bleeding.

Endoscopic submucosal resection of gastric subepithelial lesions smaller than 20 mm: a comparison of saline solution-assisted snare and cap band mucosectomy techniques.

BACKGROUND AND AIMS: Application of endoscopic submucosal resection (ESMR) in the management of gastric subepithelial lesions (GSLs) less than 20 mm is gradually increasing because it allows diagnosis and treatment at the same operative session. In this study, we compare and evaluate the benefits of ESMR with an endoscopic cap band mucosectomy technique or saline solution-assisted snare technique in GSLs smaller than 20 mm. METHODS: This was a retrospective analysis of a prospectively maintained database used at 2 academic tertiary care centers. A total of 63 patients (34 females, mean age 52 years) with endoscopically resected GSLs were included in this study. RESULTS: The mean tumor size determined by EUS was 12.3 mm (range, 5-20 mm). Sixty-seven percent of the GSLs were localized in the antrum in all groups. The endoscopic cap band mucosectomy technique was used to resect 32 (50.8%) GSLs, whereas 31 (49.2%) were resected with the saline solution-assisted snare technique. The en bloc resection rates were 97% for the saline solution-assisted snare technique and 100% for the endoscopic cap band mucosectomy. Intraoperative bleeding occurred in 1 of 31 patients (3.2%) when ESMR was performed with the saline solution-assisted snare technique. Postoperative bleeding was seen in 1 of 32 patients (3.1%) who underwent the endoscopic cap band mucosectomy technique. CONCLUSIONS: In GSLs smaller than 20 mm, ESMR with saline solution-assisted snare or endoscopic cap band mucosectomy techniques is safe, the adverse event rate is low, accurate diagnosis is achieved, and treatment with en bloc resection is provided in a single session. Given similar success and adverse event rates, saline solution-assisted ESMR may be the preferred technique because of its lower cost advantages.

Evaluation of radiofrequency ablation using the 1-Fr wire electrode in the porcine pancreas, liver, gallbladder, spleen, kidney, stomach, and lymph nodes: A pilot study.

OBJECTIVES: The frequency of detecting asymptomatic incidental lesions of the pancreas is increasing. A substantial number of these lesions are either malignant or premalignant, thus mandating pancreatic resection. A less invasive treatment option may be feasible for selected patients. Endoscopic ultrasound-guided radiofrequency ablation (RFA) may be offered as a treatment option for these patients. The objective of this study was to evaluate the performance characteristics of monopolar RFA using a 1-Fr wire electrode in the porcine pancreas, liver, gallbladder, spleen, kidney, stomach, and lymph nodes. METHODS: Six Yorkshire pigs were used for this study. The internal organs were accessed after a midline laparotomy. Manual monopolar RFAs were performed over a 90-second period using a wide range of power settings (3, 4, 5, 10, 15, and 25 W). The pancreas was exposed at all power settings; the other organs were exposed at power settings of 3, 4, 5, and 10 W. The maximum diameter of coagulative necrosis was measured. RESULTS: In all study animals, RFA was performed in the target organs without difficulty. Only the pancreas showed definite coagulative necrosis. The maximum diameter of coagulative necrosis (8.0±1.7 mm) was achieved at 5 W. No definite coagulative necrosis was noted in the other organs. CONCLUSIONS: Monopolar RFA using a 1-Fr wire electrode resulted in coagulative necrosis in the porcine pancreas. RFA in higher power settings resulted in relatively homogeneous necrosis. At a given power setting, the RFA effect is likely to be differ according to electrical properties of the target tissue. This article is protected by copyright. All rights reserved.

Evaluation of bipolar radiofrequency ablation for occluded self-expandable metal stents in the bile duct: in vivo and in vitro study.

BACKGROUND AND AIMS: Endobiliary radiofrequency ablation (RFA) has been used to treat occluded self-expandable metal stents (SEMSs). The aim of this study was to determine the characteristics of bipolar RFA in occluded SEMSs using both in vivo and in vitro models. METHODS: For the in vivo study, uncovered SEMSs were deployed in the bile ducts of three pigs; another pig was used as the control. RFA was performed at 10 W for 90 seconds. The bile duct was examined for histological changes. For the in vitro simulation of tissue ingrowth in SEMSs, RFA at 10 W for 30 seconds was performed on SEMS-occlusion polyacrylamide-gel phantoms. RESULTS: The ablation depth was markedly reduced in the stented porcine bile duct. RFA of uncovered SEMS-occlusion gel phantoms resulted in early termination of RFA when the coagulated area contacted the SEMS. This phenomenon was not observed in RFA of the covered SEMS-occlusion gel phantoms. CONCLUSIONS: The presence of SEMSs attenuated the effect of bipolar endobiliary RFA. Tumorous tissue outside the SEMS is unlikely to be affected.

The Presence of Genetic Mutations at Key Loci Predicts Progression to Esophageal Adenocarcinoma in Barrett's Esophagus.

OBJECTIVES: Risk stratification in Barrett's esophagus (BE) is challenging. We evaluated the ability of a panel of genetic markers to predict progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). METHODS: In this case-control study, we assessed a measure of genetic instability, the mutational load (ML), in predicting progression to HGD or EAC. Cases had nondysplastic BE or low-grade dysplasia (LGD) at baseline and developed HGD/EAC ≥1 year later. Controls were matched 2:1, had nondysplastic BE or LGD, and no progression at follow-up. Formalin-fixed, paraffin-embedded tissue was microdissected for the epithelium. Loss of heterozygosity (LOH) and microsatellite instability (MSI) were assessed. ML was calculated from derangements in 10 genomic loci. High-clonality LOH mutations were assigned a value of 1, low-clonality mutations were assigned a value of 0.5, and MSI 0.75 at the first loci, and 0.5 for additional loci. These values were summed to the ML. Receiver operator characteristic (ROC) curves were created. RESULTS: There were 69 patients (46 controls and 23 cases). Groups were similar in age, follow-up time, baseline histology, and the number of microdissected targets. Mean ML in pre-progression biopsies was higher in cases (2.21) than in controls (0.42; P<0.0001). Sensitivity was 100% at ML ≥0.5 and specificity was 96% at ML ≥1.5. Accuracy was highest at 89.9% for ML ≥1. ROC curves for ML ≥1 demonstrated an area under the curve (AUC) of 0.95. CONCLUSIONS: ML in pre-progression BE tissue predicts progression to HGD or EAC. Although further validation is necessary, ML may have utility as a biomarker in endoscopic surveillance of BE.

Outcome of patients with positive heparin-platelet factor-4 antibodies: A retrospective multi-institutional observational study.

Studies show increased mortality with positive heparin-platelet factor-4 (H-PF4) antibodies, especially in hemodialysis patients. We aimed to compare mortality and thrombosis in hospitalized patients with positive, equivocal and negative H-PF4 antibody results. Information was collected on these patients using a multi-institutional retrospective electronic medical record review. Patients tested for H-PF4 antibodies by commercial ELISA during the years 2006 to 2010 were identified. We compared 30-day, 90-day and 1-year mortality in patients with negative, equivocal and positive H-PF4 test and evaluated the relationship between H-PF4 status and rate of thrombosis. Four hundred and seventeen patients had ELISA testing for H-PF4 antibodies. Forty-four patients had equivocal (optical density value 0.4-0.9) and 21 had positive (value 1) H-PF4 antibody test. There were no statistically significant differences in mortality between patients with negative, equivocal and positive results at all three time points (p = 0.22, 0.27 and 0.38, respectively) even after excluding patients with thrombosis (p = 0.22, 0.24 and 0.31, respectively). Age and Charlson score were associated with increased 30-day, 90-day and 1 year mortality. Odds ratio of having thrombosis was 23.1 for positive vs. equivocal results (p < 0.001); however, there was no statistically significant difference between equivocal vs. negative results (p = 0.22). Our results revealed no association between H-PF4 status and mortality, as well as no difference in 1-year survival between the positive and negative groups.

Characterization of epithelial subtypes of intraductal papillary mucinous neoplasm of the pancreas with endoscopic ultrasound and cyst fluid analysis.

BACKGROUND AND STUDY AIMS: Intraductal papillary mucinous neoplasm (IPMN) consists of four epithelial subtypes. There are limited data on the endoscopic ultrasound (EUS) findings and/or cyst fluid analysis of the epithelial subtypes. The objective of this study was to determine whether there are differences in EUS and cyst fluid characteristics (carcinoembryonic antigen [CEA] concentration and cytology) among the subtypes. PATIENTS AND METHODS: The study cohort consisted of 85 patients (median age 68 years, 40 men) with resected and histologically confirmed branch-duct or mixed-type IPMNs who underwent preoperative EUS-guided fine-needle aspiration between 1999 and 2010 for the evaluation of pancreatic cysts. EUS and cyst fluid characteristics were analyzed retrospectively and correlated with the subtypes. RESULTS: The numbers of evaluated cystic lesions were 1 in 79 patients, 2 in 5 patients, and 3 in 1 patient. Of 92 IPMNs analyzed, gastric-type IPMNs were the most common (n = 68, 73.9 %), followed by intestinal (n = 17, 18.5 %), oncocytic (n = 5, 5.4 %), and pancreatobiliary subtypes (n = 2, 2.2 %). Gastric-type IPMNs were significantly smaller (cutoff 30 mm; P = 0.002), and less likely than other subtypes to have a mass lesion or mural nodule (P = 0.046) on EUS. Cyst fluid CEA concentration varied among the subtypes (median concentrations for gastric, intestinal, oncocytic, and pancreatobiliary types 619.8, 83.0, 5.1, and 270.0 ng/mL, respectively; P = 0.012). The presence of neoplastic epithelial cells (P = 0.624) and extracellular mucin (P = 0.208) on cytology had no association with subtypes. CONCLUSIONS: Gastric-type IPMNs, the most common subtype, are characterized by high concentrations of cyst fluid CEA, small cyst diameter, and low risk EUS imaging features.

Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: the PIPE Study.

BACKGROUND AND STUDY AIMS: There have been concerns about peritoneal seeding after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mucinous pancreatic cystic lesions. The aims of this study were to determine the frequency of postoperative peritoneal seeding in patients with intraductal papillary mucinous neoplasm (IPMN) who had undergone pre-operative EUS-FNA and to compare it with that of patients with IPMN who had surgery with no pre-operative tissue sampling. PATIENTS AND METHODS: A total of 175 patients who had undergone resection of IPMNs with pre-operative EUS-FNA (EUS-FNA group) were analyzed and compared with 68 patients who had undergone resection with no pre-operative tissue sampling (No Sampling group). Patient characteristics, pathology, and frequency of peritoneal seeding after surgery were analyzed and compared. Peritoneal seeding was diagnosed based on pathology or image findings. RESULTS: The two groups were comparable with respect to sex, age, follow-up duration, involvement of the pancreatic head, involvement of the main duct, grade of dysplasia, and size of histologically proven branch-duct IPMNs. Four patients (2.3 %) with invasive IPMN developed peritoneal seeding in the EUS-FNA group, whereas three (4.4 %, two with invasive IPMN and one with high-grade dysplasia) developed peritoneal seeding in the No Sampling group (P  = 0.403). No peritoneal seeding was noted during surgery in these cases. Except for one patient in the EUS-FNA group, no spillage occurred during resection in these patients. CONCLUSIONS: In this cohort of patients undergoing resection of IPMN, the difference in the frequency of peritoneal seeding in the EUS-FNA group and the No Sampling group was not significant.

Cytological criteria of high-grade epithelial atypia in the cyst fluid of pancreatic intraductal papillary mucinous neoplasms.

BACKGROUND: The recognition of epithelial cells with high-grade atypia (HGA) in the cyst fluid of an intraductal papillary mucinous neoplasm (IPMN) identifies a cyst at high risk of invasive carcinoma. To the best of the authors' knowledge, the cytological features of HGA have not been systematically analyzed to define diagnostic criteria. METHODS: Cell groups from patients with histologically confirmed branch-duct IPMNs were evaluated by 2 cytopathologists with expertise in pancreatic cytology. A consensus interpretation categorized the cell groups as having either low-grade (LG) or high-grade (HG) morphology. Characteristics regarding cell size and architecture, nuclear and cytoplasmic features, and background necrosis were analyzed. Performance characteristics were assessed using the Fisher exact test at 95% confidence intervals. RESULTS: Sixty cell groups yielded 27 LG and 25 HG morphological groups. No consensus was reached for 8 groups, which were excluded from statistical analysis. Five features that were found to be significantly different between the LG and HG groups included: 1) cell size < a 12-µm duodenal enterocyte for HG and size equal for LG; 2) an increased nuclear-to-cytoplasmic (N/C) ratio; 3) marked nuclear membrane abnormalities; 4) abnormal chromatin pattern; and 5) background necrosis. The 3 most accurate features for the identification of HGA were background necrosis (88%), abnormal chromatin pattern (84%), and an increased N/C ratio (82%). CONCLUSIONS: IPMN cyst fluid at high-risk of malignancy can be recognized most accurately by the presence of epithelial cells with HGA showing an increased N/C ratio, an abnormal chromatin pattern, and background necrosis.

Controlled swine bile duct ablation with a bipolar radiofrequency catheter.

BACKGROUND: Radiofrequency (RF) power is capable of ablation of neoplastic tissue arising from Barrett's esophagus. Endoscopic catheter bipolar RF ablation is a new technique for ablation of neoplastic tissue in the bile duct. OBJECTIVE: To determine the effect of RF power on bile duct and solid organ histology. DESIGN: Nonsurvival animal study. SETTING: Academic center. PATIENTS: This study involved 4 Yorkshire farm swine. INTERVENTION: After we made a midline laparotomy incision, a bipolar RF catheter was placed with 3 power (5, 7, 10 W) and voltage settings (66, 132, 190 V) in the bile duct and solid organs (liver, spleen, kidney, and pancreas). Gross and histologic examinations were performed. MAIN OUTCOME MEASUREMENTS: Depth of ablation in the bile duct wall, characteristics of the ablation in the solid organs. RESULTS: An endoscopic bipolar RF catheter produced incomplete (bile duct), patchy ablation (pancreas) with 5 watts, intramural (bile duct) or confluent ablation with 7 watts, and transmural (bile duct) ablation at 10 W. The depth of ablation in the bile duct was 0.9 ± 0.3, 1.5 ± 0.2, 2.3 ± 0.6 mm at 5, 7, and 10 W, respectively (analysis of variance; P = .02). Histologic ablation was not achieved in the liver, although gross changes were seen. LIMITATIONS: Animal study, normal bile duct. CONCLUSION: RF energy applied to the bile duct or solid organs resulted in controlled ablation with a linear relationship between the depth of ablation in the bile duct and RF power.