Comparison of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography outcomes using various technical approaches.

Background and study aims Roux-en-Y gastric bypass presents an anatomic challenge for patients needing ERCP. EUS-directed transgastric ERCP (EDGE) offers high clinical success but carries considerable risk of adverse events (AEs) with no standardized technical approach. In our study, we review the safety and efficacy of our various EDGE technical approaches. Patients and methods A retrospective single-center study of all patients who underwent EDGE procedures between February 2018 and November 2019. Primary outcomes included comparing the technical and clinical success, AEs, and lumen-apposing metal stent (LAMS) migration rates per access route (gastrogastric vs jejuno-gastric), number of procedure stages (single-stage vs two-stage), and stent size (15 mm vs 20 mm). Secondary outcomes included LAMS migration characteristics and management. Results Thirty-two EDGE procedures were performed in 29 patients, including 17 single-stage and 15 two-stage procedures, 23 gastrogastric, and nine jejuno-gastric routes, fourteen 15-mm and 17 20-mm LAMS. Overall technical and clinical success rates were 96.9 % and 87.1 %, respectively, without any significant difference between groups. The overall AE rate was (34.4 %) and was significantly lower in the 20-mm LAMS group compared to the 15-mm group (17.6 % vs 57.1 %, P  = 0.03). Compared to two-stage procedures, there was no significant difference in AEs with single-stage procedures (35.3 % vs 33.3 %, P  = 0.33). The LAMS migration rate was (25 %) with no significant difference between groups. Most migrations were around the index procedure and managed endoscopically (62.5 %). Conclusions EDGE offers high clinical success rates but AE rates remain significant. In our series, a 20-mm LAMS resulted in a significantly lower AE rate than the 15-mm LAMS. Large multicenter studies are recommended to identify technical factors leading to an optimal EDGE procedure.

External validation of a model determining risk of neoplastic progression of Barrett's esophagus in a cohort of U.S. veterans.

BACKGROUND AND AIMS: Risk of esophageal adenocarcinoma (EAC) in those with Barrett's esophagus (BE) is 11-fold greater than the general population. It remains unclear which BE patients are at highest risk of progression to EAC. We aimed to validate a predictive model risk-stratifying BE patients. METHODS: We conducted a retrospective cohort study at the Houston Veteran Affairs Medical Center of consecutive patients with a new diagnosis of BE from November 1990 to January 2019. Study follow-up was through February 2020. Patients were excluded if they had no follow-up EGD with esophageal biopsy sampling after the initial BE-diagnosing EGD or evidence of high-grade dysplasia (HGD) or EAC on initial EGD. We performed an external validation study of a risk model containing sex, smoking, BE length, and low-grade dysplasia (LGD) status and assessed discriminatory ability using the area under the receiver operating characteristic curve (AUROC). RESULTS: Among 608 BE patients, 24 progressed to HGD/EAC. The points-based model discriminated well with an AUROC of .72 (95% confidence interval [CI], .63-.82). When categorized into low-, intermediate-, and high-risk groups according to published cutoffs, the AUROC was poor at .57. Restructured into low-risk versus high-risk groups, the AUROC was .72 (95% CI, .64-.80). Excluding baseline LGD did not reduce discriminatory ability (AUROC, .73; 95% CI, .64-.82). CONCLUSIONS: This external validation provides further evidence that the model including sex, LGD status, smoking status, and BE length may help to risk stratify BE patients. A simplified version excluding LGD status and/or reducing the number of risk groups has increased utility in clinical practice without loss of discriminatory ability.

Prevalence and Predictors of Missed Dysplasia on Index Barrett's Esophagus Diagnosing Endoscopy in a Veteran Population.

BACKGROUND & AIMS: Limitations of endoscopic sampling may result in missed dysplasia at the diagnosis of Barrett's esophagus (BE). However, the role of close follow-up endoscopy is unclear. The aim was to evaluate the proportion of patients diagnosed with "missed" dysplasia within 18 months of their index nondysplastic BE (NDBE) diagnosis. METHODS: This was a retrospective analysis of a cohort of BE patients diagnosed during 1990-2019 at the Houston VA. Patients with BE on index esophagogastroduodenoscopy (EGD) were classified as NDBE, indefinite dysplasia, or dysplastic (low- or high-grade dysplasia) based on initial biopsies. We identified NDBE patients who had follow-up EGD within 3-18 months after index EGD. We used logistic regression models to estimate odds ratios and 95% confidence intervals for risk factors of dysplasia on follow-up EGD. RESULTS: We identified 614 patients who had BE on index EGD. Among those with NDBE and follow-up EGD within 3-18 months (n = 271), 4.1% had definite dysplasia on follow-up, and an additional 14.0% had indefinite dysplasia. Proportions of definite or indefinite dysplasia at follow-up within 3-18 months significantly decreased from 32.6% among patients with index EGD before 2009 to 11.7% among patients with index EGD after 2013 (P for trend = .068). Those with any indefinite or definite dysplastic BE at follow-up within 3-18 months after index EGD (n = 49) were more likely to have BE length ≥3 cm on index EGD (odds ratio, 3.39; 95% confidence interval, 1.63-7.08) than those with persistent NDBE or no BE on follow-up. CONCLUSIONS: The occurrence of missed dysplasia on an index EGD has decreased over time. However, those with long segment BE were more than 3 times as likely to have missed dysplasia, and this group could benefit from dysplasia surveillance within 18 months of BE diagnosis.

Conservative management of severe serotonin syndrome with coma, myoclonus, and crossed-extensor reflex complicated by hepatic encephalopathy.

Serotonin syndrome (SS) is an underrecognized and potentially fatal disorder that occurs secondary to combinational use or overdose of a single serotonergic medication. The presentation may be complicated by hepatic encephalopathy in cirrhotic patients, which may also affect metabolism of these serotonergic agents. The authors report a rare case of severe SS complicated by hepatic encephalopathy secondary to cirrhosis in a 52-year-old woman after an increase in her home dosage of fluoxetine and addition of other psychiatric medications.

An Investigation into the Recent Increase in Gastric Cancer in the USA.

BACKGROUND: The USA has among the lowest gastric cancer incidence rates worldwide. AIM: To investigate whether increasing immigration from high cancer incidence countries has altered the GC incidence in a large US metropolitan area. METHODS: This was a retrospective cohort study among an underprivileged, multiethnic population in Texas. Gastric cancer cases diagnosed during 2005-2015 were identified using the cancer registry of the public medical care system for Harris County. All cases were histologically confirmed; demographic and clinical data were obtained from review of electronic medical records. Census data were used to determine the distribution of the adult county population by race/ethnicity and age. Two time periods (2005-2009 and 2010-2015) were studied to correspond with census reporting intervals. RESULTS: In total, 299 cases were included: average age 55 years, 59% males and 63% Hispanics (predominantly recent immigrants of Central-American origin). The gastric cancer incidence remained stable among non-Hispanic Whites and Blacks but increased significantly among Hispanics (from 10 to 17 cases/100,000 persons/year, RR = 2.0, 95% CI 1.4-2.5, p = 0.001). Among Hispanics, gastric cancer incidence rose significantly among persons aged 40-59 years and ≥ 60 years and was likely to be at advanced stage at the time of diagnosis even in the younger age population. CONCLUSION: Gastric cancer incidence significantly increased among Hispanics residing in Houston resulting in changes in gastric cancer incidence becoming more unevenly experienced across the US population. Consideration should be given to gastric cancer preventive efforts, especially among immigrant populations from high gastric cancer risk countries.

Changing Trends in Stomach Cancer Throughout the World.

PURPOSE OF REVIEW: The paper aims to discuss the global trends in gastric cancer incidence in relation to important factors involved in the pathogenesis of gastric cancer. RECENT FINDINGS: Despite a significant worldwide decline, gastric cancer remains a common cause of cancer death. The decline has been multifactorial and preceded the fall in Helicobacter pylori prevalence. The initial decline was associated with changes in food preservation and availability, especially of fresh fruits and vegetables, followed by a decline in the primary etiologic factor, H. pylori. Gastric cancer incidence remains high in East Asia, intermediate in Latin America, and low in developed countries. Significant racial/ethnic variability exists. The rapid decline in incidence in East Asia will continue as primary and secondary prevention strategies are implemented. The incidence in Latin America is unlikely to decline significantly over the next few decades given high H. pylori prevalence in the young. Ultimately, global H. pylori eradication will be needed to largely eliminate gastric cancer.