A Combined DNA/RNA-based Next-Generation Sequencing Platform to Improve the Classification of Pancreatic Cysts and Early Detection of Pancreatic Cancer Arising From Pancreatic Cysts.

OBJECTIVE: We report the development and validation of a combined DNA/RNA next-generation sequencing (NGS) platform to improve the evaluation of pancreatic cysts. BACKGROUND AND AIMS: Despite a multidisciplinary approach, pancreatic cyst classification, such as a cystic precursor neoplasm, and the detection of high-grade dysplasia and early adenocarcinoma (advanced neoplasia) can be challenging. NGS of preoperative pancreatic cyst fluid improves the clinical evaluation of pancreatic cysts, but the recent identification of novel genomic alterations necessitates the creation of a comprehensive panel and the development of a genomic classifier to integrate the complex molecular results. METHODS: An updated and unique 74-gene DNA/RNA-targeted NGS panel (PancreaSeq Genomic Classifier) was created to evaluate 5 classes of genomic alterations to include gene mutations (e.g., KRAS, GNAS, etc.), gene fusions and gene expression. Further, CEA mRNA ( CEACAM5 ) was integrated into the assay using RT-qPCR. Separate multi-institutional cohorts for training (n=108) and validation (n=77) were tested, and diagnostic performance was compared to clinical, imaging, cytopathologic, and guideline data. RESULTS: Upon creation of a genomic classifier system, PancreaSeq GC yielded a 95% sensitivity and 100% specificity for a cystic precursor neoplasm, and the sensitivity and specificity for advanced neoplasia were 82% and 100%, respectively. Associated symptoms, cyst size, duct dilatation, a mural nodule, increasing cyst size, and malignant cytopathology had lower sensitivities (41-59%) and lower specificities (56-96%) for advanced neoplasia. This test also increased the sensitivity of current pancreatic cyst guidelines (IAP/Fukuoka and AGA) by >10% and maintained their inherent specificity. CONCLUSIONS: PancreaSeq GC was not only accurate in predicting pancreatic cyst type and advanced neoplasia but also improved the sensitivity of current pancreatic cyst guidelines.

Incidence, Burden, and Predictors of 11-Month Readmission in Patients Undergoing Bariatric Surgery.

BACKGROUND: Bariatric surgery (BSx) is one of the most common surgical procedures performed in the USA. Nonetheless, data regarding 11-month period after BSx remain limited. METHODS: A retrospective cohort study using the 2016 National Readmission Database. Adult patients admitted for BSx in January were included. The follow-up period was 11 months (February-December). The primary outcome was all-cause 11-month readmission. Secondary outcomes were index admission (IA) and readmission in-hospital mortality rate and healthcare resource use associated with readmission. Multivariate regression was performed to identify independent risk factors for readmission. RESULTS: A total of 13,278 IA were included. The 11-month readmission rate was 11.1%. The mortality rate of readmission was 1.4% and 0.1% for IA (P < 0.01). The most common cause of readmission was hematemesis. Independent predictors were Charlson comorbidity index (CCI) score ≥ 3 (adjusted hazard ratio [aHR] 1.34; P = 0.05), increasing length of stay (aHR 1.01; P < 0.01), transfer to rehabilitation facilities (aHR 5.02; P < 0.01), undergoing laparoscopic Roux-en-Y gastric bypass (aHR 1.71; P = 0.02), adjustable gastric band (aHR 14.09; P < 0.01), alcohol use disorder (2.10; P = 0.01), and cannabis use disorder (aHR 3.37; P = 0.01). Private insurance as primary payer (aHR 0.65; P < 0.01) and BMI 45-49 kg/m2 (aHR 0.72; P < 0.01) were associated with less odds of readmission. The cumulative total hospitalization charges of readmission were $69.9 million. CONCLUSIONS: The 11-month readmission rate after BSx is 11.1%. Targeting modifiable predictors of readmission may help reduce the burden of readmissions on our healthcare system.

Endoscopic sleeve gastroplasty plus liraglutide versus endoscopic sleeve gastroplasty alone for weight loss.

BACKGROUND AND AIMS: Endoscopic sleeve gastroplasty (ESG) has been shown to be effective for inducing weight loss. The efficacy of liraglutide, a glucagon-like peptide-1 agonist, to augment weight loss after ESG is unknown. This study aims to evaluate the efficacy of ESG and liraglutide (ESG-L) compared with ESG alone. METHODS: This was a retrospective study of prospectively collected data from patients undergoing ESG at 3 outpatient clinics in Brazil between November 2017 and July 2018. Liraglutide was offered to all patients 5 months after ESG. Patients who opted to take liraglutide (ESG-L) were matched 1:1 to patients who declined it (ESG). The primary outcome was percent total body weight loss (%TBWL), and percent excess weight loss (%EWL) 7 months after initiation of liraglutide (12 months after ESG). The secondary outcome was change in percent body fat 12 months after ESG. ESG technique and postprocedure follow-up were identical at all 3 sites. RESULTS: Propensity score matching yielded 26 matched pairs. Adjusted comparisons between the 2 groups showed that patients who opted to take liraglutide had a superior mean %TBWL 7 months after initiation of liraglutide (ESG-L) compared with those who declined it (ESG) (24.72% ± 2.12% vs 20.51% ± 1.68%, respectively; P < .001). ESG-L had a statistically greater reduction in percent body fat compared with ESG (7.85% ± 1.26% vs 10.54% ± 1.88%, respectively; P < .001) at 12 months. CONCLUSIONS: Addition of liraglutide at 5 months results in superior weight loss and improved efficacy as demonstrated by decreased body fat 12 months after ESG. Further studies are imperative to determine optimal dose, timing, and duration of liraglutide.

Efficacy of Liraglutide to Prevent Weight Regain After Retrieval of an Adjustable Intra-gastric Balloon-a Case-Matched Study.

PURPOSE: Weight regain after balloon retrieval is a concern with all intra-gastric balloons (IGBs). The aim of this study was to evaluate the efficacy of liraglutide, a glucagon-like peptide-1 (GLP-1) agonist, to prevent weight regain following IGB retrieval. MATERIALS AND METHODS: This was a case-matched study of patients undergoing Spatz3 adjustable IGB (Spatz FGIA, Inc. NY, USA) at three outpatient clinics in Brazil between November 2015 and January 2019. Seventy-seven patients that opted to take liraglutide following IGB retrieval (IGB-L) were matched 1:1 to 198 patients that declined the medication-IGB-Alone (IGB-A). Propensity score adjustment was performed at the time of balloon retrieval on factors known to influence the choice of liraglutide. Weight and percent body fat (%BF) was measured at baseline and 9 months after IGB retrieval. % BF is defined as the total mass of fat divided by total body mass, multiplied by 100. The primary outcome was weight regain, and the secondary outcome was change in %BF 9 months after IGB retrieval. RESULTS: Propensity score matching yielded 53 matched pairs. Weight regain to the starting point was not observed in either group. There was significantly less weight regain in IGB-L compared to IGB-A, - 1.15 ± 0.94 kg versus - 0.66 ± 0.99 kg (p = 0.010) 9 months after balloon retrieval. Additionally, %BF decline in IGB-L was superior to IGB-A - 10.83 ± 1.50 versus - 7.94 ± 2.02 (p < 0.01). There was no difference in weight regain or decline in %BF based on liraglutide dose. CONCLUSION: Liraglutide has an additive benefit with respect to efficacy and a reduction in body fat when commenced after IGB retrieval. Future randomized control studies will be needed to determine the optimal dose and duration of liraglutide to achieve superior outcomes.

The Effect of the Intra-gastric Balloon on Gastric Emptying and the DeMeester Score.

BACKGROUND AND AIMS: The mechanism of weight loss with the intra-gastric balloon (IGB) is thought to be a decrease in gastric emptying (GE); however the evidence is conflicting. Nausea, abdominal pain, and gastroesophageal reflux disease (GERD) can cause intolerance resulting in early removal. This is demoralizing for the patient and costly for the healthcare system. The ability to predict which patients will have superior weight loss and tolerance is invaluable. We sought to investigate if the IGB induced weight loss by reducing GE and the effect of the IGB on the DeMeester score. METHODS: We retrospectively reviewed prospectively collected data for patients undergoing IGB placement at a single hospital. Manometry and pH studies were performed before and with the IGB in place. Weight was measured at baseline, at removal, and 6 months later. Adverse events leading to early removal were recorded. RESULTS: Twenty-four patients were evaluated. There was a statistically significant decrease in GE for solids with the IGB (117.92 ± 150.23 vs 281.48 ± 206.49 min; p = 0.0048), but not for liquids (54.44 ± 17.97 vs 56.08 ± 43.96 min; p = 0.7228). The lower esophageal sphincter (LES) pressure did not change significantly with placement of the IGB (17.76 ± 7.39 vs 14.74 ± 7.24 mmHg; p = 0.09). On multivariate analysis, increase in DeMeester score was associated with total body weight loss (p = 0.0125) and change in GE (p = 0.038) independently. CONCLUSION: The IGB delays GE for solids, but not for liquids, and increases the DeMeester score by a mechanism other than a loss of LES pressure.

Cromoscopia vital com Lugol versus cromoscopia óptica na detecção de câncer de esôfago em pacientes com estenoses cáusticas esofagianas / Lugol's iodine chromoendoscopy versus narrow band image enhanced endoscopy for the detection of esophageal cancer in patients with stenosis secondary to caustic/corrosive agent ingestion

ABSTRACT BACKGROUND The diagnosis of corrosion cancer should be suspected in patients with corrosive ingestion if after a latent period of negligible symptoms there is development of dysphagia, or poor response to dilatation, or if respiratory symptoms develop in an otherwise stable patient of esophageal stenosis. Narrow Band Imaging detects superficial squamous cell carcinoma more frequently than white-light imaging, and has significantly higher sensitivity and accuracy compared with white-light. OBJECTIVE To determinate the clinical applicability of Narrow Band Imaging versus Lugol´s solution chromendoscopy for detection of early esophageal cancer in patients with caustic/corrosive agent stenosis. METHODS Thirty-eight patients, aged between 28-84 were enrolled and examined by both Narrow Band Imaging and Lugol´s solution chromendoscopy. A 4.9mm diameter endoscope was used facilitating examination of a stenotic area without dilation. Narrow Band Imaging was performed and any lesion detected was marked for later biopsy. Then, Lugol´s solution chromoendoscopy was performed and biopsies were taken at suspicious areas. Patients who had abnormal findings at the routine, Narrow Band Imaging or Lugol´s solution chromoscopy exam had their stenotic ring biopsied. RESULTS We detected nine suspicious lesions with Narrow Band Imaging and 14 with Lugol´s solution chromendoscopy. The sensitivity and specificity of the Narrow Band Imaging was 100% and 80.6%, and with Lugol´s chromoscopy 100% and 66.67%, respectively. Five (13%) suspicious lesions were detected both with Narrow Band Imaging and Lugol's chromoscopy, two (40%) of these lesions were confirmed carcinoma on histopathological examination. CONCLUSION Narrow Band Imaging is an applicable option to detect and evaluate cancer in patients with caustic /corrosive stenosis compared to the Lugol´s solution chromoscopy.

RESUMO CONTEXTO A suspeita do câncer de esôfago na lesão cáustica ocorre quando os pacientes com estenoses previamente estáveis, após um período latente sem sintomas, apresentam disfagia, baixa resposta as dilatações ou sintomas respiratórios. A cromoscopia com luz de banda estreita detecta o câncer superficial de esôfago mais frequentemente que a luz branca, com alta sensibilidade e acurácia. OBJETIVO Determinar a aplicabilidade clínica da luz de banda estreita versus a cromoscopia vital com Lugol na detecção do câncer precoce de esôfago em pacientes com lesões cáusticas. MÉTODOS Um total de 38 pacientes, entre 28 e 84 anos, foram alocados seguidamente e submetidos à cromoscopia com luz de banda estreita e com Lugol. Um gastroscópio de 4,9 mm de diâmetro foi usado para facilitar o exame da área estenosada, sem necessidade de dilatação. A cromoscopia com luz de banda estreita era realizada primeiro e as áreas suspeitas anotadas. Depois, a cromoscopia com Lugol era realizada e as áreas suspeitas biopsiadas. RESULTADOS Detectamos nove lesões suspeitas com a luz de banda estreita e 14 com o Lugol. A sensibilidade e especificidade da cromoscopia com luz de banda estreita foi de 100% e 80,6%, e a do Lugol foi de 100% e 66,67% respectivamente. Cinco (13%) lesões suspeitas foram detectadas coincidentemente pelos dois métodos, sendo duas (40%) com diagnóstico anatomopatológico de câncer de esôfago. CONCLUSÃO A cromoscopia com luz de banda estreita é opção concreta para o diagnóstico de câncer em pacientes com estenoses esofágicas por corrosões cáusticas, comparado a cromoscopia com Lugol.

LUGOL'S IODINE CHROMOENDOSCOPY VERSUS NARROW BAND IMAGE ENHANCED ENDOSCOPY FOR THE DETECTION OF ESOPHAGEAL CANCER IN PATIENTS WITH STENOSIS SECONDARY TO CAUSTIC/CORROSIVE AGENT INGESTION.

BACKGROUND: The diagnosis of corrosion cancer should be suspected in patients with corrosive ingestion if after a latent period of negligible symptoms there is development of dysphagia, or poor response to dilatation, or if respiratory symptoms develop in an otherwise stable patient of esophageal stenosis. Narrow Band Imaging detects superficial squamous cell carcinoma more frequently than white-light imaging, and has significantly higher sensitivity and accuracy compared with white-light. OBJECTIVE: To determinate the clinical applicability of Narrow Band Imaging versus Lugol´s solution chromendoscopy for detection of early esophageal cancer in patients with caustic/corrosive agent stenosis. METHODS: Thirty-eight patients, aged between 28-84 were enrolled and examined by both Narrow Band Imaging and Lugol´s solution chromendoscopy. A 4.9mm diameter endoscope was used facilitating examination of a stenotic area without dilation. Narrow Band Imaging was performed and any lesion detected was marked for later biopsy. Then, Lugol´s solution chromoendoscopy was performed and biopsies were taken at suspicious areas. Patients who had abnormal findings at the routine, Narrow Band Imaging or Lugol´s solution chromoscopy exam had their stenotic ring biopsied. RESULTS: We detected nine suspicious lesions with Narrow Band Imaging and 14 with Lugol´s solution chromendoscopy. The sensitivity and specificity of the Narrow Band Imaging was 100% and 80.6%, and with Lugol´s chromoscopy 100% and 66.67%, respectively. Five (13%) suspicious lesions were detected both with Narrow Band Imaging and Lugol's chromoscopy, two (40%) of these lesions were confirmed carcinoma on histopathological examination. CONCLUSION: Narrow Band Imaging is an applicable option to detect and evaluate cancer in patients with caustic /corrosive stenosis compared to the Lugol´s solution chromoscopy.