CLINICAL ENDOSCOPIC PRACTICE 1

CLINICAL ENDOSCOPIC PRACTICE 1

FRIDAY, MAY 21, 2021Clinical Endoscopic Practice 1Poster

ID: 3522594SAFETY AND FEASIBILITY OF SAME DAY DISCHARGEAFTER PER ORAL ENDOSCOPIC PYLOROMYOTOMY INREFRACTORY GASTROPARESIS: A PILOT STUDYRushikesh Shah*, Lucie Calderon, Xiaoyu Li, Kara Alceguire, Mengdan Xie,Ahmed Messallam, Steven Keilin, Qiang CaiBackground: Gastroparesis is a debilitating medical condition with limited treatmentoptions. Gastric per-oral pyloromyotomy has emerged as a promising treatmentoptions with remarkable short-term clinical success shown in multiple studies. Whilethe post procedure protocol is not standardized across many centers, majority of thecenters observe these patients in the hospital after the procedure for monitoring. Inthis single center prospective study, we evaluated safety and feasibility of same daydischarge after G-POEM procedure. Methods: All the patients with refractory gas-troparesis undergoing G-POEM from 10/2019 to 3/2020 were enrolled. A total of 25patients were enrolled in the procedure. Based on pre-defined criteria, patients wereeither discharged on the same day after the procedure vs. admitted to the hospitalfor further observation. The patient and procedure related data were extracted fromthe chart review. Univariate analysis was performed (chi-square) on categoricalvariables after organizing categorical variables as numeric counts or percentage.Student’s T test was performed on continues variables after reporting as mean andstandard deviation. For analysis with smaller sample size, fisher exact test and MannWhitney tests were used. Results: A total of 25 patients were enrolled. The technicalsuccess of G-POEM was 100% and clinical success was 80% at 1 month follow up.Out of 25 patients, 9 patients (36%) were able to be discharged the same day of theprocedure from recovery unit. Out remaining 16 patients who were admitted to thehospital post-procedure, a total of 10 (40%) were admitted due to procedure relatedcauses while other admissions were either pre-planned vs. due to social reasons. Theaverage charlson comorbidity index was lower in same day discharge group (P <0.05). The number of patients with double myotomy were higher in same daydischarge group (P < 0.05). Overall complication rate of G-POEM in study cohortwas 12% with all complications being mild without any severe AEs. Conclusion: G-POEM is safe and effective method of treatment for refractory GP with higher clinicalsuccess in short term follow up. Same day discharge after G-POEM is safe andfeasible in carefully selected patients with close periprocedural monitoring.

Algorithm of post procedure disposition after GPOEM in patients with re-fractory gastroparesis

Table – 1. Comparison of Same day discharge group to post procedureadmission group.


ID: 3524289IMPACT OF COVID-19 ON THE MANAGEMENT ANDOUTCOMES OF SEVERE ACUTE CHOLANGITIS:FINDINGS FROM A NATIONWIDE CLINICAL DATARESEARCH NETWORKHemant Goyal*, Abhilash Perisetti, Mahesh Gajendran, Gregory Enders,Jiannis Anastasiou, Sumant Inamdar, Benjamin Tharian, Neil R. SharmaIntroduction: It is well known that the number of endoscopic procedures during theCOVID-19 pandemic has decreased substantially. Severe acute cholangitis (SAC)requires biliary decompression with ERCP urgently. However, data regarding theeffects of the COVID-19 on the endoscopic management and outcomes of SAC-related hospitalizations are non-existence. Methods: We used a federated cloud-based network named TriNetX, which comprises 50 healthcare organizations(HCOs) across the United States to identify all hospitalized patients with SAC.Patients were defined to have SAC if they had involvement of one or more of thefollowing concomitant clinical manifestations: hypotension (systolic blood pressure<90 or diastolic BP <60 mm of Hg), altered mental status, hypoxemia(PaO2<80 mmHg), acute kidney injury or serum creatinine of 2 or higher, hepatic failure (INR 1.5or higher) and hematological abnormalities (platelets <100,000/mm). SAC patientswith any of the above clinical characteristics alone or in combination admitted fromJanuary 1 to September 1, 2020, were identified as the 2020-SAC group, and be-tween January 1 to September 1, 2019, as the 2019-SAC group.The primary outcomes were the utilization of ERCP and MRCP in the management ofSAC. Secondary outcomes were the need for percutaneous transhepatic cholangi-ography (PTC) and mortality rate. The outcomes were measured after 1:1 propensitymatching of the groups based on the baseline demographics and comorbidities.Results: A total of 1933 patients were in the SAC-2020 group compared to 7522 inthe SAC-2019 group. Rate of SAC hospitalizations in 2020 was 0.15% (1933/1,320,222 hospitalizations) as compared to 0.22% (7522/3,367,411 hospitalizations)in 2019. Clinical manifestations of these patients at presentation (Table 1), laboratoryfindings, and clinical outcomes (Table 2) are noted in the tables. 2020-SAC grouphad a lower rate of utilization of ERCP (risk ratio [RR] 0.68, 95% CI, 0.60 – 0.78),MRCP (RR 0.64, 95% CI, 0.53 – 0.79) compared to the 2019-SAC group. However, themortality was also lower in (RR 0.47, 95% CI, 0.39 – 0.57) in the 2020-SAC groupcompared to the 2019-SAC group. The utilization rates of ERCP, MRCP, and mortalitywere reduced by 32%, 36%, and 53%, respectively, during the pandemic comparedto a similar period in 2019. Rates of PTC did not change between the two groups.Conclusion: The rate of SAC-related hospitalizations was reduced by 0.07% in 2020.The utilization rates of ERCP and MRCP were reduced by 32% and 36%, respectively,in the 2020-SAC group. Interestingly, the mortality was also reduced by 53% in

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2020-SAC groups even after lower utilization rates of ERCP and MRCP. Furtherprospective studies are needed to evaluate the possible causes of these findings.

Table 1. Baseline characteristics in severe acute cholangitis (SAC) in 2020compared to 2019 before and after propensity score matching. Footnote:SAC- Severe acute cholangitis; EGD- Esophagogastroduodenoscopy; CT –

computed tomography; INR - international normalized ratio. A 1:1 pro-pensity score matching was done based on the following variables: age,gender, race, hypertension, diabetes mellitus, obesity, chronic kidney dis-ease (CKD), Ischemic heart diseases, chronic obstructive pulmonary dis-ease, cirrhosis.

Table 2. Imaging, laboratory data, and outcomes of patients with severeacute cholangitis (SAC) in 2020 compared to 2019 before and after pro-pensity score matching.


ID: 3521513EFFICACY AND SAFETY OF VERY LOW-VOLUME BOWELPREPARATION WITH 1L PLENVU� COMPARISON WITH2L PEG-ASC : MULTICENTER, RANDOMIZED,ENDOSCOPIST-BLINDED STUDYSung Noh Hong*, Chang Kyun Lee, Jong Pil Im, Chang Hwan Choi,Jeong-Sik Byeon, Young-Seok Cho, Sung-Ae Jung, Tae Il Kim,Yoon Tae JeenBackground: Polyethyleneglycol (PEG)-based bowel preparation is effective and safe,but required high volume intake, which reduces adherence and tolerability.Although 2L PEG- Asc enables small volume preparation, lower-volume bowelpreparation is beneficial for patients. Methods: This multicenter, randomized, en-doscopist-blinded study has randomized the patients requiring colonoscopy toreceive 1L PEG-Asc, Plenvu� versus 2L PEG-Asc at nine hospitals in Korea. Bowelcleansing was assessed using the Boston Bowel Preparation Scale (BBPS). The pri-mary endpoints were overall bowel cleansing success (each BBPS segment score�2). Results: Of 360 patients, bowel cleansing was analyzed in 346 (1L PEG-Asc, nZ174; 2L PEG-Asc, n Z172). 1L PEG-Asc showed non-inferiority in successful bowelcleansing compared with 2L PEG-Asc (93.10% [162/174] vs. 91.86% [158/172], dif-ference,1.24%; one-sided 97.5% lower confidence limit, -4.31%; non-inferiority p<0.0001).Right colon BBPS score was significantly higher in 1L PEG-Asc than 2L PEG-Asc group(2.56�0.60 vs. 2.43�0.60, p Z0.029), although the differences of trans-verse and left colon BBPS scores were not significant between the groups. Polypdetection rate (PDR) of 1L PEG-Asc group was significantly higher than that of 2LPEG-Asc group (48.85% vs. 37.79%, p Z 0.0379) and adenoma detection rate (ADR)of 1L PEG-Asc group was numerically higher than that of 2L PEG-Asc group (24.71%vs. 20.35%, p Z0.3314). The mean numbers of polyps and adenomas per patient of1L PEG-Asc group were tended to be higher than those of 2L PEG-Asc group (0.33 �0.49 vs. 0.27 � 0.48, p Z0.0606; 0.14 �0.31 vs. 0.12 � 0.31, p Z0.3427). 1L PEG-Ascwas well tolerated, with more mild adverse events compared with 2L PEG-Asc(65.71% [115/175] vs. 52.91% [91/172], p Z0.0152). Conclusion: Plenvu�was as

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AB10 GASTROINTESTINAL ENDOSCOPY Volume 93, No. 6S : 2021 www.giejournal.org


effective in overall bowel cleansing as 2L PEG-Asc, with improved right coloncleansing and PDR.


ID: 3526378COMPARISON OF RESECTION METHODS OFCARCINOID TUMORS OF THE DUODENUM ANDRECTUM: A MULTICENTER EXPERIENCERobert Tamai, Varun Angajala, Uzma D. Siddiqui, Harry R. Aslanian,Thiruvengadam Muniraj, Irving Waxman, Christopher G. Chapman,Jessica D. Serna, Lee Helen, Fares Ayoub, Namrata Setia, Christina Rose,Sergei Tatishchev, James L. Buxbaum, Ara B. Sahakian*Background: Historically, surgical resection has been the mainstay for treatment ofduodenal and rectal carcinoid lesions. Recently, endoscopic therapy has emerged asa minimally invasive alternative. The aim of our study was to determine and comparethe safety and efficacy of endoscopic and surgical resection of duodenal and rectalcarcinoids. Methods: Amulticenter retrospective chart review studywas conducted onpatients with a pathological diagnosis of neuroendocrine tumor (NET) and tumor sizeof 15mm or less at three academic medical centers (Keck Medical Center of USC,University of Chicago Medical Center, Yale-New Haven Hospital) from 2015 to 2020.The primary outcome was R0 complete histological resection of the tumor and clinicalsuccess rate (i.e. no recurrence). Other study parameters included peri-proceduraland post-procedural complications. Fisher exact test was used for statistical analysiswith significance level of p<0.05. Results: A total of 55 patients underwent resectionof NET < 15mm of the duodenum or the rectum using endoscopic approaches. TheR0 resection rate was 47% (23 of 49, 6 band-and-leave cases not included) in patientswho underwent endoscopic resection. Surveillance endoscopy with biopsy at theresection site demonstrated no clinical recurrence in 92% (37 of 40). There were 2post-procedural adverse events in the endoscopy group (2 of 55; 4%).During the same time frame, 12 patients with NET <15mm underwent surgicalresection. In these patients, the rate of R0 resection rate was 58%. Of the 5 patientsthat had endoscopic follow-up, there was no evidence of local recurrence in 80% (4of 5). Of a total of 12 surgical cases, there was an adverse event rate of 8%. Therewere no statistically significant differences in any of these outcomes whencomparing endoscopic resection to surgical resection. Discussion: Endoscopicresection represents a less invasive modality for small carcinoid tumors of the du-odenum and rectum, with comparable rates of en-bloc resection and clinical tumorrecurrence. Given the known morbidities associated with surgery, endoscopic ap-proaches to small NETs may be considered as first-line therapy.


ID: 3524501DIRECT VERSUS CATHETER-ASSISTED FLUIDINSTILLATION TECHNIQUES FOR ENDOSCOPICULTRASOUND-GUIDED GASTROJEJUNOSTOMY(EUS-GJ)Donevan R. Westerveld*, Qais M. Dawod, Enad Dawod,Kaveh Hajifathalian, David L. Carr-Locke, Kartik Sampath,Reem Z. Sharaiha, Srihari MahadevIntroduction: Endoscopic ultrasound-guided gastrojejunostomy (EUG-GJ) offers asafe and effective minimally-invasive approach for palliation of gastric outletobstruction (GOO). Despite advances, EUS-GJ remains technically challenging witha steep learning curve [1] and the optimal technique is not yet standardized. Onlyone study has compared EUS-GJ techniques, studying direct infusion via the endo-scope channel against use of balloon catheter as the target, with the latter takinglonger without greater efficacy or safety [2]. We aimed to compare the efficacy,safety, and procedure duration for direct infusion and a simplified catheter-assistedinfusion technique. Methods: We report a single-center retrospective analysis of aprospectively held database of patients who underwent EUS-GJ from 2016-2020.Catheter technique: A 10 Fr enteric feeding catheter (NJFT-10,Cook Medical) wasleft in place distal to the site of obstruction and used to instil fluid while theechoendoscope was introduced. Direct technique: Fluid was instilled via a gastro-scope channel prior to echoendoscope introduction. Technical success was definedas successful stent deployment; clinical success was defined as relief of GOO.Adverse events (intra and post-procedure) and procedure duration were analyzedand compared between the techniques. Results: A total of 37 patients (67.5 male;mean age 67.5 � 12.8 years) underwent EUS-GJ for GOO, including 18 direct(48.7%) and 19 catheter-assisted (51.3%). Technical success and clinical successwere both achieved in 36 (97.3%) cases and did not differ between techniques(Table 1). Intraprocedure complications included 7 cases (4 direct; 3 catheter-as-sisted) where the stent was initially misdeployed, then removed, the gastric defectclipped closed, and a second stent successfully placed thereafter during the samesession. In the 1 clinical failure (direct), an enterotomy was created that requiredlaparoscopic repair and the patient underwent uncomplicated laparoscopic GJbypass. Procedure duration did not differ significantly between techniques.Conclusion: In this study we compared the efficacy of catheter-assisted with thedirect approach for EUS-GJ. The techniques appear to have similar efficacy, safety,and procedure duration. The catheter-assisted technique may allow endoscopistsearly in the learning curve more time to select a target.References:1. Jovani, M., Ichkhanian, Y., Parsa, N., Singh, S., Gutierrez, O. I. B., Keane, G., ... &

Khashab, M. A. (2020). An assessment of the learning curve for EUS-guidedgastroenterostomy for a single operator. GIE; in press.

2. Chen, Y. I., Kunda, R., Storm, A. C., Aridi, H. D., Thompson, C. C., Nieto, J., ... &Khashab, M. (2018). EUS-guided gastroenterostomy: a multicenter studycomparing the direct and balloon-assisted techniques. GIE, 87(5), 1215-1221.


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Table 1

Figure 1. (A) Catheter-assisted (red arrow) instillation of contrast andmethylene blue medium; (B) echoendoscope visualization of the contrastmedium; (C) Direct instillation of contrast and methylene blue; (D)echoendoscope visualization of contrast medium


ID: 3524559LONG TERM OUTCOMES OF RENDEZVOUSTECHNIQUES USED TO RESOLVE EXTERNALPANCREATIC FISTULAS IN PATIENTS WITHDISCONNECTED PANCREATIC DUCT SYNDROMENavroop Nagra*, Richard A. Kozarek, Danielle La Selva,Shivanand Bomman, Rajesh Krishnamoorthi, Joanna K. Law,Michael Larsen, Andrew Ross, Shayan S. Irani

Background: Walled off pancreatic necrosis (WOPN) and disconnected pancreaticduct syndrome (DPDS) are known complications of necrotizing pancreatitis. Surgi-cal or percutaneous drainage of WOPN in patients with DPDS can lead to persistentexternal pancreatic fistula (EPF). Conventionally, these patients were treated surgi-cally with distal pancreatectomy, which carries significant morbidity and mortality. Ithas been shown that a combined endoscopic and percutaneous rendezvousapproach shows promise in resolving EPF with good short-term outcomes, howeverlong-term data remain limited. This study was undertaken to define the long-termoutcomes of this approach. Methods: This retrospective, single-center studyincluded patients aged � 18 years with DPDS whounderwent rendezvous proced-ures to resolve EPF from October 2002 to October 2020. Follow up data were ob-tained via chart review and an IRB approved telephone survey with either the patientor their referring Gastroenterologist/Primary care provider. Patients with a follow upinterval of less than 12 months and those with pancreatic fluid collection (PFC) atthe time of the initial rendezvous procedure were excluded from analysis. Results:During the study period, 26 patients met the criteria for inclusion (mean age 54.2 �13.8 years, 76.9% male). The most common etiology of pancreatitis was gallstones(35%). Patients underwent rendezvous procedure via transgastric (88%), transpa-pillary (8%) or transduodenal (4%) approach. One patient had brisk bleeding duringthe procedure from known gastric varices, managed with cyanoacrylate injection andno procedure-related deaths occurred. Median duration to fistula closure was 29days. During the long-term follow up interval (median 62.5, range 19 – 137 months),3 patients had recurrence of EPF, all managed endoscopically. Five patients had earlystent migration and were treated with new stents. Recurrence of a PFC occurred in 9patients (1/3rd due to stent migration), also managed endoscopically, with 1 patientrequiring repeat rendezvous procedure. Five patients had one or more attacks ofrecurrent pancreatitis which resolved with supportive care. A significant percentageof nondiabetic patients (44%, p Z 0.05) developed diabetes subsequent to theirprocedure. One patient underwent surgical intervention (distal pancreatectomy andsplenectomy) due to recurrent chronic pancreatitis and 9 patients requiredpancreatic enzyme supplementation. Two patients in the study population weredeceased at the time of follow up, 30 and 87 months after their respective pro-cedures. Conclusions: Rendezvous techniques of internalizing EPF in patients withDPDS are effective and safe with mild peri-procedural morbidity and no proceduralmortality. Satisfactory long-term outcomes are seen when performed by a team ofexpert endoscopists and interventional radiologists.


ID: 3522211SAFETY OF ENDOSCOPIC MUCOSAL RESECTION OFLARGE COLONIC POLYPS IN ELDERLY PATIENTS: ASYSTEMATIC REVIEW AND META-ANALYSISUmair Iqbal*, Christopher A. Pluskota, Muhammad A. Karim, Hafsa Anwar,Zarak H. Khan, Faisal Kamal, Muhammad Ali Khan, Bradley Confer,Harshit S. KharaIntroduction: Colorectal cancer is the second most common cause of cancer-relateddeaths in the United States. Endoscopic mucosal resection (EMR) is the most uti-lized technique for the removal of large sessile and flat lesions but can be associatedwith adverse events such as bleeding, perforation, and complications related toanesthesia. There is limited data available on the safety and efficacy of EMR in elderlypatients. We performed a systematic review and meta-analysis to evaluate the safetyof EMR in the elderly population. Methods: We performed a systematic literaturesearch in Embase, Medline, and google scholar to identify all studies that evaluatethe safety and efficacy of EMR for large colorectal lesions (>20 mm) in elderly pa-tients.. Our primary outcome is to evaluate the risk of polypectomy bleeding andperforation. All analyses were conducted utilizing comprehensive meta-analysissoftware. Results: Our initial search identified 115 articles, out of which 5 observa-tional retrospective studies with 2840 patients were included in the meta-analysis.There were 2 studies that compared outcomes of EMR between octogenarians andpatients younger than 80 years of age. One study reported the outcomes of EMR inpatients over 75 years of age and one reported outcomes in octogenarians without acomparative group. Lastly, one study compared outcomes in patients over 75 yearsof age and younger than 75 years of age. In patients over 75 years of age, pooled riskfor post polypectomy bleeding is 3% (1.2%-7.1%), I2Z69.2%, and perforation is1.3% (0.5%-3.7%), I2Z27.4%. In octogenarians, pooled risk of post polypectomybleeding is 2.4% (1.2%-4.8%), I2Z0, and perforation is 2.1% (0.7%-5.8%), I2Z18.6%.There is no statistically significant difference between the risk of post polypectomybleeding [ORZ0.922, (0.359-2.367), I2Z0] and perforation [ORZ1.066 (0.188-6.031), I2Z0] between octogenarians compared to younger patients. Conclusion:EMR is safe in elderly patients and is not associated with an increased risk ofbleeding or perforation compared to the younger population. Efforts should bemade to do adequate surveillance of polyps with colonoscopy in these elderly pa-tients to decrease the morbidity and mortality associated with colorectal cancer asthe life expectancy increases.


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ID: 3520827WATER EXCHANGE IS SUPERIOR TO ENDOCUFF, CAPAND AIR INSUFFLATION IN DETECTING SESSILESERRATED ADENOMA/POLYP – A META-ANALYSISPaul P. Shao*, Changhan Shao, Tamineh Romero, Felix W. LeungIntroduction: Sessile serrated adenoma/polyps (SSA/P) account for up to 30% ofcolorectal cancers (CRC) that are particularly located in the proximal colon. SSA/Pare difficult to detect due to their indistinct border and flat morphology and aretherefore implicated in the development of interval cancers. Moreover, detection ofSSA/P at baseline screening is associated with an increased risk of interval neoplasiaon surveillance colonoscopy. Adenoma detection rate (ADR) is positively correlatedwith SSA/P detection rate (SSA/PDR). A recent meta-analysis demonstrated thatwater exchange (WE) had higher ADR than Endocuff and cap colonoscopy. We hy-pothesized that WE may significantly increase SSA/PDR to a greater extent thanEndocuff and cap compared with air insufflation as the common comparator.Methods: EMBASE, Medline and Cochrane Library were searched systematically forall randomized controlled trials (RCTs) that reported SSA/PDR as an outcome andincluded the keywords: water exchange, Endocuff or cap colonoscopy. We per-formed traditional network meta-analysis with random effect models comparingSSA/PDR of each colonoscopy method using air insufflation (AI) as the control andreported the unadjusted and adjusted odds ratios with 95% confidence interval.Performance of the different methods were ranked based on P-score, which isanalogous to the surface under the cumulative ranking curve (SUCRA) and measuresthe extent of certainty that a study group is better than another averaged over allcompeting groups. Results: A total of 531 articles resulted from initial keywordssearch. 38 articles were identified based on titles and abstracts alone. After thoroughreview of full texts, 11 RCTs were included in the analysis. A total of 7856 patientsunderwent AI, WE, Endocuff or cap colonoscopy. Compared to AI as the control,only WE significantly increased SSA/PDR (OR 2.04; 95% CI 1.33 – 3.13). Endocuff(OR 1.15; 95% CI 0.92 – 1.41) and cap (OR 1.08; 95% CI 0.42 – 2.74) did notsignificantly impact SSA/PDR when compared to AI. P-scores for WE, Endocuff, capand AI were 0.96, 0.49, 0.37 and 0.17, respectively, suggesting that WE had thehighest SSA/PDR. When adjusting for possible co-variants, including percentage ofsurveillance and mean withdrawal time, the results did not change. Conclusion: Wehad the highest SSA/PDR compared to Endocuff, cap and AI colonoscopy based onP-score. Future study should elucidate the impact of WE on interval cancers.

Forest plot for the studies assessing effects of water exchange, Endocuff,and cap on sessile serrated adenoma/polyp detection rate. AI, air insuffla-tion; CI, confidence interval; OR, odds ratio; seTE, estimated error oftreatment estimate; TE, estimated treatment effect; WE, water exchange.

Meta-analysis with random effect models comparing the impacts of waterexchange, Endocuff, and cap colonoscopy on sessile serrated adenoma/polyp detection rate using air insufflation as the common comparator.The performance of each colonoscopy modality was ranked based on P-scores. AI, air insufflation; CI, confidence interval; SSP, sessile serratedpolyp; WE, water exchange.


ID: 3526546CLINICAL OUTCOMES OF GASTRIC AND DUODENALNEUROENDOCRINE TUMORS. EXPERIENCE FROM ALARGE TERTIARY CARE CANCER CENTERMartin Coronel*, Abraham Yu, Shria Kumar, Phillip S. Ge,Graciela M. Nogueras-González, Phillip Lum, Brian R. Weston,William A. Ross, Gottumukkala S. Raju, Emmanuel Coronel, Jeffrey LeeIntroduction: Gastrointestinal neuroendocrine tumors (GI-NETs) of the stomachand duodenum are slow growing tumors that have increased in incidence in thelast few decades. Most of the upper GI- NETs are non-functional. GI-NETs are clas-sified into 4 types and can be related to chronic gastritis, hypergastrinemia, geneticmutations or can be sporadic. GI-NETs are commonly detected by endoscopy andendoscopic resection can be curative in selected patients. This is a study looking atthe outcomes of gastric and duodenal NETs that have been diagnosed and treated byendoscopy. Methods: A retrospective cohort of patients who had an upper GIendoscopy and a confirmed diagnosis of NET was identified from 11/1/2006 to 7/1/2020. Data were collected including, patient demographics, endoscopic character-istics, endoscopic resection (ER) techniques, pathology, and long patient outcomessuch as surveillance, recurrence, or other type of therapeutic interventions likesurgery or chemotherapy. Results: A total of 73 patients were identified. GastricNETs were present in 50 (68.5%) and duodenal NETs in 23 (31.5%) patients. 41(56%) were female, 47 (64%) Caucasian and the median age was 60 (IQR: 51-60). Inthe stomach, the majority of lesions were localized in the body 38 /50 (76%) and inthe duodenum, at D1 17/23 (74%). The majority of the lesions were < 10 mm 46(63%) (Table 1). The majority were classified as sessile polyps 50 (68%) followed bysubepithelial lesions in 29 (40%). Endoscopic ultrasound was performed in 40(55%); in 32/40 (80%) were confined in the mucosal and submucosal layer and 8(20%) down to the MP layer. Most lesions were low grade (NET G1) 63 (86%). ERwas performed in 50 (69%). Conventional endoscopic mucosal resection (EMR) 20/50 (40%) followed by forceps resection16/50 (32%), cold/hot snare 8/50 (16%), ESD1/50 (2%) and band EMR 5/50 (10%) were the techniques for ER. En-block resectionwas performed in 39/50 (78%), and pathology results showing deep margin invasionn 13/50 (26%). One case of minor bleeding that was controlled by endoscopy wasreported, no delayed complications were reported. After ER, 20/50 (40%) were re-ported as curative with no recurrence, 11/50 (22%) had early recurrence (<6-months), 16/50 (32%) reported late recurrence (>6-months) and only 3/50 (6%) lostfollow up. Repeat ER was performed in 18/27 (66%) and surveillance in 9/27 (34%). Ifno ER was performed, most patients underwent surveillance 22/31(71%), surgicalresection 6/31 (19%), and chemotherapy 3/31 (10%) (Table 2) Conclusion: The vastmajority of gastric and duodenal NETs are low grade. While there is a significant riskof deep margin being positive after ER and recurrence of gastric and duodenal NETsis common, most NETs <2cm can be managed with continued surveillance andretreatment as needed.


Abstracts



ID: 3521776CASE-MIX ADJUSTMENT TO COMPARE COLONOSCOPYPERFORMANCE BETWEEN ENDOSCOPY SERVICES: ANATIONWIDE COHORT STUDYJ. Nass*, Manon Van Der Vlugt, A. K. E. Elfrink, A. van der Beek,C. L. van den Brand, Aura A. van Esch, Thalia Hummel, Michiel Ledeboer,Monique Van Leerdam, Rob Ouwendijk, Peter J. Van Der Schaar,Manon Spaander, Marc A. Verhagen, Janneke Wilschut, Paul Fockens,Evelien Dekker, Michel WoutersBackground: Case-mix factors for colonoscopy are defined as non-modifiable patientand endoscopy characteristics, which might influence colonoscopy performance.Differences in case-mix factors are likely to exist between endoscopy services. Thisstudy aims to examine the importance of case-mix adjustment when comparing


Abstracts


colonoscopy performance between endoscopy services. Methods: Prospectivelycollected data recorded in the Dutch Gastrointestinal Endoscopy Audit (DGEA)between 01-01-2016 and 31-12-2019 were analyzed. The DGEA is the national co-lonoscopy registry of endoscopy services in the Netherlands. Academic, non-aca-demic and private endoscopy services are participating in the DGEA. Performanceon cecal intubation rate (CIR) and rate of adequate bowel preparation (ABPR) werestudied in the total study population per endoscopy service. The polyp detectionrate (PDR) was studied in fecal immunochemical test (FIT)-positive screening co-lonoscopies. Variation in case-mix factors (age, sex, ASA score and indication) be-tween endoscopy services was assessed. Expected outcomes for the CIR, ABPR andPDR were calculated, based on the case-mix factors of all patients per endoscopyservice, using a multivariable logistic regression model. Results: During the 4-yearstudy period, 363,840 colonoscopies were recorded from 51 endoscopy services inthe DGEA. Significant differences in the mean percentage per endoscopy servicewere observed for several case-mix factors; age higher than 65 years (range (r): 33.4 -53.6%, p < 0.001), male patients (r: 46.2 - 58.2%, p < 0.001), ASA 3 or higher (r: 0.2 -24.9%, p < 0.001) and diagnostic colonoscopies (r: 18.5 - 85.8%, p < 0.001). In theFIT-positive population (n Z 77.536), the mean percentages per endoscopy servicefor the following case-mix factors were significantly different: age higher than 65years (r: 36.0 - 62.7%, p < 0.001), male patients (r: 51.8 - 67.3%, p Z 0.001) and ASA3 or higher (r: 0.3 - 30.8%, p < 0.001). The case-mix factors age, sex, ASA classifi-cation and indication for colonoscopy were significantly associated with CIR andABPR. Age, sex and ASA classification were significantly associated with PDR in theFIT-positive population. The expected CIR, ABPR and PDR per endoscopy serviceranged from 95.0% to 96.9%, from 93.5% to 96.4% and from 75.7% to 79.0%,respectively. Conclusion: Variation in case-mix factors between endoscopy servicesresults in variation in expected outcomes for colonoscopy between these endoscopyservices. Our findings emphasize that for comparison of colonoscopy performancemeasures between endoscopy services, adjustment for case-mix factors should beconsidered. Abbreviations: ABPR, adequate bowel preparation rate; CIR, cecal intu-bation rate; DGEA, Dutch Gastrointestinal Endoscopy Audit; FIT, fecal immuno-chemical test; PDR, polyp detection rate; r, range


ID: 3526077NO REDUCTION IN ENDOSCOPIC CANCER DETECTIONDESPITE A REDUCTION IN CASE VOLUME DUE TO THECOVID-19 PANDEMIC: RESULTS FROM A TERTIARYACADEMIC CENTREDaniel A. Schneider*, Timothy Phan, Kathryn Goss, Declan Connoley,Tony Long, Nicholle Sim, Winston Zheng, Elaine Koh, Michael P. Swan,Simon HewIntroduction: The SARS-CoV-2 (COVID-19) pandemic has caused worldwide disrup-tion of endoscopic services. In Melbourne, Australia, two periods of government-mandated lockdown were enacted, leading to restrictions on endoscopic volume.Early international data suggested that such restrictions led to drastic reductions inendoscopic cancer detection, with some countries reporting a 58% reduction1. Weaimed to assess the impact of the lockdown periods on endoscopic outcomes,compared to the pre-pandemic period. Methods: A retrospective analysis was con-ducted of endoscopic procedures performed at a tertiary academic centre in Mel-bourne, Australia during the two lockdown periods: 24th March to 1st May and 2ndAugust to the 28th September 2020. During lockdown, all procedures were repri-oritised by a team of gastroenterologists according to COVID-19 guidelines pub-lished by the Gastroenterological Society of Australia. Data collected includedpatient demographics, procedure type, acuity, COVID-19 status and endoscopicoutcomes such as cancer and polyp detection. This was then compared to pre-pandemic data from the exact corresponding periods in 2019. Results: In 2020, 1147procedures were performed during the two lockdown periods (461 gastroscopies,426 colonoscopies, 27 flexible sigmoidoscopies, 114 ERCPs, 116 EUSs, 2 enteros-copies and 1 per-oral endoscopic myotomy). No patients tested positive to COVID-19 and there were no known cases of COVID-19 transmission in endoscopy. Table 1details the cases volume, endoscopist demographics, acuity and outcomes for the2019 and 2020 periods. There was a 42% reduction in procedural volume in 2020compared to 2019. Overall cancer detection rate was higher in 2020 (6.7% (77/1147)in 2020 vs. 4.5% (89/1972) in 2019, p Z 0.0083). Our ‘missed’ cancer detection was13.5%. For colonoscopy, there were no significant differences in the cancer detec-tion rate (4.2% in 2020 vs. 2.6% in 2019, p Z 0.13), adenoma detection rates (44.2%in 2020 vs. 38.4% in 2019, pZ0.20) or sessile serrated polyp detection rates (5.4% in2020 vs. 6.0% in 2019, pZ0.73). There was no significant difference in the volumesof ERCP or EUS performed. Whilst trainee involvement was lower in 2020, traineesstill participated in 28.8% of procedures in 2020. Conclusions: Although the COVID-19 pandemic resulted in a large reduction in endoscopic case volume, careful triageensured the safe provision of a prioritised service that increased cancer detectionrates and maintained endoscopy quality indicators at pre-pandemic levels. The riskof missed cancers is smaller than earlier reports but is still concerning and efforts

should be directed at the prompt restoration of case volume. References:Rutter MD, Brookes M, Lee TJ, et al. Impact of the COVID-19 pandemic on UKendoscopic activity and cancer detection: a national endoscopy database analysis.Gut 2020; 0:1–7


ID: 3526722ENDOSCOPIC SUBMUCOSAL DISSECTION IN PATIENTSWITH LIVER CIRRHOSIS – A META-ANALYTIC EFFICACYAND ADVERSE EFFECT PROFILEFaisal S. Ali*, Maryam R. Hussain, Samreen Khuwaja,John Pocholo W. Tuason, Mohammed R. Gandam, Mahrukh Siddiqui,Aurelia S. Maldonado, Jeffrey LeeIntroduction: The safety of endoscopic submucosal dissection (ESD) in patients withliver cirrhosis (LC) is not well-established. Methods: A systematic literature searchwas performed of Medline(Ovid) and Embase(Ovid) from inception-October 2020.All studies were screened to identify reports of safety and efficacy of ESD in LCversus no LC (NLC). A meta-analysis of proportions, a comparative meta-analysis tocompute odds ratios (OR) and mean differences (MD) with 95% confidence intervals(CIs) was performed. Results: Overall, eight non-randomized studies enrolling 346and 1269 patients in the LC and NLC arms were found; 80% and 82% of patients inthe LC and NLC arms were male, and the mean age of the two groups was com-parable (Table 1). Most LC patients had Child Pugh Class A disease (CP-A; 78% (66-90%; I2 86.6%)), and esophageal varices (46% (27-65%; I2 65.7%)). Ascites werereported in 11% (7-15%; I2 9.5%) of cases. Most tumors were in the lower third ofstomach in the LC and NLC arms; The mean tumor size of the two groups wascomparable. En bloc resection rate was 97% (94-99%; I2 29%) in LC and 94% (90-98%; I2 80.4%) in NLC, with no significant difference in the two groups (OR 0.83(0.42, 1.63; i2 0%) Table 2). R0 resection rate was 91% (87-94%; I2 5.4%) in LC and91% (83-98%; I2 94.5%) in NLC, with no significant difference in the two groups (OR0.81 (0.50, 1.32; i2 0%)). Adverse events (AEs) rate was 9% (6-12%; I2 1.7%) in LCand 16% (0-37%; I2 98.9%) in NLC, with no significant difference in the two groups(OR 0.97 (0.29, 3.23; i2 73.15%)). Bleeding rate was 8% (5-11%; I2 0%) in LC and 15%(0-34%; I2 98.8%) in NLC, with no significant difference in the two groups (OR 0.14


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(-0.44, 0.72; I2 0%)). Perforation rate was 2% (0-4%; I2 0%) in LC and 3% (2-4%; I20%) in NLC, with no significant difference in the two groups (OR 1.86 (0.58, 5.91; I20%)). Most tumors were differentiated carcinomas on histology; 59% (52-66%; I20%) in LC and 44% (41-47%; I2 0%) in NLC arm. Post-ESD, 3% of LC (0-8%; I2 0%)and NLC (0-13%: I2 NA; 1 Study) patients had local tumor recurrence, whereas 10%of LC (0-21%; I2 0%) and NLC (4-24%; I2 NA; 1 Study) patients underwent oncologicsurgery. Over a mean follow-up of 39.41 (25.46-53.36; I2 97.4%) and 39.92 (26.31-53.54; I2 91.2%) months, 83% (76-91%; I2 51%) and 96% (94-99%; I2 0%) of LC andNLC patients were alive, respectively. LC patients had a shorter follow-up duration(Mean difference -4.10 (-6.73, -1.46; I2 0%) and a lower survival on last follow-up (OR-1.33 (-2.02, -0.58; I2 0%). Conclusion: ESD is efficacious in LC patients whencompared with NLC controls, without increased risk of AEs or bleeding. The survivalof LC patients is impacted by the underlying liver disease. Most LC patients whounderwent ESD had CP-A disease. Future studies should assess the safety of ESD inadvanced LC and for lesions with underlying varices.

Forest Plots of En Bloc Resection, Overall Adverse Events, OverallBleeding Events, and Mortality - ESD in Cirrhotic versus Non-Cirrhotic Pa-tients


ID: 3516858OUTCOMES OF HIGH-BLEEDING RISKGASTROINTESTINAL ENDOSCOPIC PROCEDURES INPATIENTS WITH CIRRHOSIS ON ANTI-THROMBOTICAGENTSScarlett Austin*, Shifa Umar, Akash GadaniIntroduction: Antiplatelet and anticoagulant agents can pose a significant bleedingrisk during gastrointestinal (GI) endoscopic procedures. In addition, patients withcirrhosis can be at higher risk for bleeding as well due to the imbalance betweenpro-coagulation and anti-coagulation. We aim to describe outcomes of high-bleedingrisk GI endoscopic procedures in patients with cirrhosis on anti-thrombotic agents.Methods: All patients with cirrhosis who underwent high bleeding risk GI endo-scopic procedures between November 2010-2020 at our two tertiary care hospitalswere included. Information was collected regarding patient demographics, proce-dural indications and use of anti-thrombotic agents. High-bleeding risk GI endo-scopic procedures were those as defined by the American Society forGastrointestinal Endoscopy. Outcomes included bleeding events, cardiovascularevents and hospital readmission rates. Results: A total of 54 patients met inclusioncriteria. The procedures included endoscopic retrograde cholangiopancreatography(ERCP) with biliary sphincterotomy (NZ29), endoscopic ultrasound (EUS) with fineneedle biopsy or aspiration (NZ15), upper GI endoscopy with balloon dilation(NZ2), esophageal variceal band ligation (NZ2), colonoscopy with polypectomy(NZ2), colonoscopy with endoscopic mucosal resection (NZ2), and percutaneousendoscopic gastrostomy (PEG) tube placement (NZ2). The average age was 71.3years and 59.2% were males. The BMI range was between 15.6 to 43.9 kg/m2. TheMELD score ranged from 7 to 33, with an average of 16.5. Etiology of cirrhosis isdescribed in figure 1. Pre and post-procedure antiplatelet and anticoagulant agentsand laboratory values are summarized in table 2. Reported adverse events included 4bleeding events, 2 episodes of new onset atrial fibrillation with rapid ventricularresponse. A total of 9 patients were re-admitted to the hospital within 30 days ofdischarge. Conclusion: Based on our data there is limited risk of adverse bleeding orthromboembolic events in patients with cirrhosis on antithrombotic therapy whoundergo GI endoscopy. Studies performed at a larger scale on patients with cirrhosison antithrombotic therapy may be helpful in developing standardized strategies tominimize adverse events in these patients who are a high risk population andfrequently undergo endoscopic evaluation for bleeding and liver transplantevaluation.


Abstracts


Table 1. Etiology of Cirrhosis

Table 2. Anticoagulant and Antiplatelet agents with associated holdingtimes, pre-procedure labs, and adverse events


ID: 3522814LUMEN-APPOSING METAL STENTS FOR BENIGNGASTROINTESTINAL TRACT STRICTURES: ASINGLE-CENTER EXPERIENCEAzizullah Beran*, Reem Matar, Veeravich Jaruvongvanich,Fateh Bazerbachi, Eric J. Vargas, Andrew C. Storm, Navtej S. Buttar,Barham K. Abu DayyehIntroduction: Lumen-apposing metal stent (LAMS) is an alternative therapeutic op-tion for benign gastrointestinal (GI) tract strictures. Our study aimed to evaluatethe safety and efficacy of LAMS for the management of benign GI strictures.Methods: Consecutive patients who underwent a LAMS placement for benignluminal GI strictures at a tertiary care center between January 2014 and May 2019were reviewed. Outcomes were technical success, early clinical success, migrationrate, and re-intervention rate after LAMS removal or migration. Results: Sixty-eightpatients undergoing 81 LAMS placements (66.2% female, mean age of 54.3 years)were included. The majority was anastomotic stricture (82.4%). The most commonstricture site was gastrojejunal anastomosis (57.1%). Of total, 70.6% had failed priorendoscopic treatments. Early clinical success was achieved in 97.5%. The migrationrate was 28.4% (23/81). Of these, five (5/23, 21.7%) stents were successfully repo-sitioned endoscopically. The median stent dwell time was 105 days [interquartilerange (IQR) 60-150 days], and the median follow-up duration was 363 days [IQR152.2-773.5 days]. The overall stent-related adverse event rate was 30.9%. The re-intervention rate after LAMS removal or migration was 58.3%. Conclusions: LAMS isan effective therapeutic option for benign GI strictures, offering high technical andearly clinical success. However, the re-intervention rate after LAMS removal ormigration was relatively high. In selected cases of difficult-to-treat benign GI stric-tures, it may be considered a destination therapy.

Table 1. Patient characteristics prior treatment.

Table 2. Procedure-oriented adverse events and outcomes.


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ID: 3519982FACTORS ASSOCIATED WITH EARLY AND LATEMORTALITY AFTER ENDOSCOPIC RESECTION FORESOPHAGEAL SQUAMOUS CELL CARCINOMAYohei Ogata*, Waku Hatta, Tomoyuki Koike, Masahiro Saito, Xiaoyi Jin,Kenichiro Nakagawa, Takeshi Kanno, Kaname Uno, Naoki Asano,Akira Imatani, Atsushi MasamuneBackground and aims: Additional treatment is recommended for patients withesophageal squamous cell carcinoma (ESCC) that do not meet the curability criteriafor endoscopic resection due to the risk of lymph node metastasis, but the maincause of death in such patients is not ESCC itself. To date, many reports haveinvestigated ESCC-related mortality; however, few studies evaluated factorsassociated with all-cause mortality. In addition, these factors might be differentbetween early and late mortality. We aimed to investigate factors associated withearly and late mortality after endoscopic resection for ESCC. Methods: This studywas a single-center, retrospective cohort study. Patients who underwent endoscopicresection for ESCC between 2005 and 2018 at our institution were enrolled. First, weevaluated the overall and disease-specific survivals. Subsequently, we investigatedfactors associated with early and late mortality, separately, the cut-off value of whichwas defined at 3 years. The factors included age, gender, smoking and drinkinghistory, histopathological factors, additional treatment, and 9 candidate prognosticindices; Eastern Cooperative Oncology Group performance status (ECOG-PS),American Society of Anesthesiologists physical status, Charlson comorbidity index(CCI), prognostic nutritional index, modified Glasgow prognostic score, C-reactiveprotein/albumin ratio, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, andpsoas muscle mass index for evaluating sarcopenia. Multivariate Cox analyses wereperformed for variables whose P values were <0.05 in the univariate analyses.Results: We enrolled 407 patients in this study. Among 106 patients who died duringthe median follow-up period of 69 months, 6 patients died of ESCC. Two of 6 pa-tients met the endoscopic curability criteria; one was due to the metachronousadvanced ESCC, the other died of metastases from the primary ESCC. Among 22patients who received additional therapy, 2 patients died of chemoradiation therapy-related adverse event. The 5-year overall and disease-specific survivals were 83.4%and 98.4%, respectively. Multivariate Cox analysis revealed that ECOG-PS �2 (hazardratio, 7.21; P Z0.007) and CCI �2 (hazard ratio, 2.97; P Z0.017) were independentrisk factors for early mortality (Figure 1). Those for late mortality were age �85 years(hazard ratio, 8.38; P <0.001) and age of 80–84 years (hazard ratio, 3.08; P Z0.010),as well as ECOG-PS �2 (hazard ratio, 15.62; P Z0.021) and CCI �2 (hazard ratio,1.90; P Z0.019) (Figure 2). Conclusions: ECOG-PS and CCI were associated withboth mortality after endoscopic resection for ESCC, while age was associated withonly late mortality. ECOG-PS and CCI, rather than age, should be regarded as indicesfor a relatively shorter life expectancy.

Figure 1

Figure 2


ID: 3523741SURGICAL AND DEVICE-RELATED COMPLICATIONSRELATED TO PEG-J PLACEMENT FOR MANAGEMENT OFADVANCED PARKINSON’S DISEASE: A SINGLE CENTERREAL WORLD EXPERIENCEJoel Joseph*, Molly Wiggins, Mustafa Siddiqui, Michael M. GaspariBackground: Levodopa-carbidopa intestinal gel (LCIG) infusion delivered via a pro-prietary percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J)is a relatively new FDA approved treatment for patients with advanced Parkinson’sdisease (PD) who are experiencing motor fluctuations due to unpredictable oraldrug absorption. However, there is a paucity of studies on real world experiences ofits use. OBJECTIVE: This study seeks to evaluate surgical and device related com-plications over the course of LCIG therapy at a large US tertiary care academiccenter. Methods: A retrospective chart review was performed. All patients withadvanced PD treated with LCIG therapy were included. In addition to baseline de-mographics, data on adverse events connected to PEG-J placement and LCIG devicerelated complications both in the perioperative period (within 30 days) and over thelifetime of treatment was collected. Additionally, serious adverse events (SAEs) re-sulting in death or hospitalization >24 hours were monitored. Results: A total of 36patients were included in the study. Over the course of treatment, 80.5% of patientshad at least one device-related complication (102 total), most commonly deviceocclusion or inner jejunal tube dislocation/replacement. 44.4% patients also had aPEG-J related adverse effect (38 total) usually due to localized infection, abdominalpain, or leakage from the stoma site. Only 7.8% AEs occurred during the perioper-ative period. 16 (44.4%) patients experienced at least one SAE including 6 deaths,however none were related to PEG-J placement. Conclusions: Therapy is challengingin patients with advanced Parkinson’s disease, often complicated by advanced ageand multiple comorbidities. Compared to prior studies on LCIG therapy, we report alow rate of adverse events related to PEG-J placement. This procedure should beconsidered as a useful and safe option in collaborative multi-specialty managementof patients with advanced PD.

Table 1. Baseline characteristics


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Table 2. Adverse events


ID: 3522228COMPARATIVE EFFICACY OF ENDOSCOPIC ASSISTDEVICES ON COLONIC ADENOMA DETECTION: ASYSTEMATIC REVIEW WITH NETWORK META-ANALYSISSimcha Weissman*, Tej I. Mehta, Kartikeya Tripathi, Muhammad Aziz,Daniel J. Stein, Nathan Rosenwald, Sindhura Kolli, Joseph FeuersteinBackground & Aims: Numerous endoscopic assist devices exist for increased colonicadenoma detection, yet there is a lack of knowledge surrounding their comparativeefficacy. Hence, we conducted a systematic review and network meta-analysis todetermine the comparative efficacy of endoscopic assist devices on colonicadenoma detection. Methods: A comprehensive search analysis was performed us-ing multiple electronic databases from inception through July 1, 2020, to identify allrandomized controlled trials (RCTs) and dual-arm observational studies comparingendoscopic assist devices to themselves and/or standard high definition (HD) co-lonoscopy. The primary outcome was the adenoma detection rate (ADR). Secondaryoutcomes included the polyp detection rate (PDR), serrated adenoma detection rate(SADR), right-sided adenoma detection rate (RADR), and proximal adenomadetection rate (PADR). Statistical analysis was conducted using R version 3.6.1.Results: From 1305 studies identified by our search, 56 (including 30,481 patients)met inclusion criteria and were analyzed. Network meta-analysis identified anenhanced ADR among all assist-devices (ECA: OR 2.63, 95% CI 1.41-4.91, ER: OR3.69, 95% CI 1.47-9.22, and ECU: OR 5.02, 95% CI 3.19-7.90)dwith no significantdifference amongst any particular device (Figures 1, 2). Enhanced PDR was identi-fied for Endocuff (ECU) and Endoring (ER) compared to standard colonoscopy, withECU comparatively demonstrating the greatest PDR (OR 5.60, 95% CI 3.09-10.14).Enhanced SADR was identified for ECU and ER compared to standard HD colo-noscopydwith ECU comparatively demonstrating the greatest SADR (OR 9.43, 95%CI 3.71-23.95). Enhanced RADR and PADR was only identified for ECU with OR 5.36[95% CI 2.32-12.36] and OR 3.78 [95% CI 1.61-8.86] respectively, as compared tostandard colonoscopy. Upon subgroup analysis of randomized controlled trials,enhanced PDR was identified for Endocap (ECA), ECU, and ER, while enhanced ADRwas identified for ECA and ECUdall compared to standard colonoscopy.Conclusions: Endsocopic assist devices were found to increase ADR, as compared tostandard HD colonoscopy. Hence, their routine use should be more widespread. AsEndocuff appears to have the greatest comparative efficacy on PDR, SADR, RADR,and PADRdthey should be the preferred modality in gastrointestinal endoscopy.Nevertheless, further prospective investigation is warranted to directly compareeach device head-to-head.

Figure 1. Forest plot depicting endoscopic assist devices effect on ade-noma detection rate (ADR)

Figure 2. Netsplit analysis comparing assist-device effect on adenomadetection rate (ADR)

FRIDAY, MAY 21, 2021Endoscopic Practice 1Poster

ID: 3524317ENDOSCOPIC STENT PLACEMENT IN THEMANAGEMENT OF STRICTURES IN CROHN’S DISEASE: AMETA-ANALYSIS OF OBSERVATIONAL STUDIESYaniuska Lescaille*, Le-Chu Su, Garrett Lawlor, Ravi P. Kiran, Bo ShenBackground and Aims: Endoscopic balloon dilation and electroincision have beenused for the treatment of Crohn’s disease-associated strictures. Data on the role ofstents in the management of stricture in Crohn’s disease remain scarce. Weperformed this meta-analysis to evaluate efficacy of stent placement for Crohn’sstrictures. Methods: Ovid MEDLINE, PubMed, and Google Scholar were searchedfrom inception through July 2020 to identify studies that reported use of self-expandable metallic stents (SEMS) for the management of de novo or anastomoticstrictures in Crohn’s disease. Outcome data from these studies were pooled to es-timate the efficacy and safety of metal stents for the treatment of the stricture.Results: Six studies with a total of 99 patients and 108 SEMS were eligible for andincluded in the analysis. Fifty-two patients (52.5 %) were male. The mean age ofthe participants ranged from 38.0 to 49.8 years. The mean or median duration ofCrohn’s disease was reported in 4 out of 6 studies. The mean or median duration ofCrohn’s disease was greater than 10 years in those studies where such an estimatewas reported. Seventy-six percent of the strictures treated were anastomotic. Thereported maximum stricture length ranged from 4.9 to 6.0 cm. The mean technicalsuccess rate was reported in 5 out of 6 studies and it was 96% (range: 91-100%).Similarly, the mean clinical success rate was reported in 5 out of 6 studies and it was73% (range: 60-81%). The time to programmed stent removal was different acrossthe studies ranging from 1 week to 9 years and 1 month. Thirty-six percent of stentplacements were associated with complications. Stent migration (both symptomaticand asymptomatic) was the most common complication occurring in 24% of thestent placements and accounting for 67% of all complications. The pooled


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proportion of overall complications was 43% (95% confidence interval [CI] 9-76%)(Figure 2A). During a mean follow up of 11 to 49 months among 5 studies, 15% ofthe patients required surgery related to immediate stent complication or stent fail-ure and 56% remained symptom-free without any additional intervention. Thepooled proportion of patients who remained symptom-free and those who hadsymptom-recurrence after stent placement were 60% (CI 95% 29-91%) and 39%(95% CI 4-74%) respectively (Figure 1 and 2B). Conclusion: Treatment of strictureswith SEMS in patients with Crohn’s disease appears to be a feasible therapeuticoption in experienced hands. However, stent migration and reintervention arecommon.


ID: 3523009PRECLINICAL EFFICACY AND CLINICAL FEASIBILITY OFA NOVEL AEROSOL-EXPOSURE PROTECTION MASK FORESOPHAGOGASTRODUODENOSCOPY(EGD)Mai Ego*, Seiichiro Abe, Yutaka Okagawa, Satoru Nonaka,Haruhisa Suzuki, Shigetaka Yoshinaga, Ichiro Oda, Yutaka Saito

Background and Aims: To prevent health care professionals (HCP) from COVID-19infection during the endoscopy procedure, prevention from the patient’s standpointhas not been standardized yet. This study aimed to assess the preclinical efficacy of anovel aerosol-exposure protection mask (AP mask) and evaluate the clinicalfeasibility of the AP mask. Methods: The AP mask was made of an A4-sized plastic filefolder, two gauzes and an elastic string. In study 1, first, volunteers laid down on ahospital bed in the left lateral position in a cleanroom. Second, as a preclinicalsimulation, a standard gastroscope was inserted into the volunteer’s mouth throughan endoscopic mouthpiece with and without the AP mask. Third, volunteers voli-tionally coughed 12 times every 20 seconds interval with and without the AP mask,and the microparticles were visualized during the endoscopy simulation. A shortwavelength visible light source was illuminated from a light-emitting diode (LED)source (Parallel Eye D, Shin Nippon Air Technologies, Tokyo, Japan) and directed toa video camera (Eye Scope; Shin Nippon Air Technologies), which captured themicroparticles in the cleanroom. The videos of microparticles visualization, mostlyaerosol, were recorded and edited using an image processing system software(Particle Eye viewer; Shin Nippon Air Technologies). The numbers of microparticlesas small as 0.5mm during volitional coughs were counted from the image data with30 frames per second from the video using a portable particle visualization system(Type-S; Shin Nippon Air Technologies), which allows for real-time visualization andmeasurement of microparticles. We compared the number of microparticles withand without AP mask. In addition, the scatter microparticle distance was measuredfrom the videos based on the 0.128cm/pixel length. The study 1 assessed theeffectiveness of aerosol-exposure protection with and without the AP mask in theaerosol particle visualization analysis. In study 2, 30 patients underwent upper GIendoscopic resection wearing the AP mask and the saturation level of percutaneousoxygen was measured throughout the procedure. Results: In study 1, the mean(�SD) number of microparticles (counts) with and without the AP mask were19.8�6.9/ 117.4�17.5, 8.8�1.5/ 68�11.4, 8.6�1.5/ 208.3�71.0 in volunteer1, 2, 3,respectively. There was significant difference between the two groups. The mean(�SD) distances of microparticle scattering without the AP mask were 60�0, 0,68�0 in volunteer 1, 2, 3, respectively. The mean (�SD) distance of microparticlescattering with the AP mask were 0, 0, 9.6�21.5, respectively. In study 2, duringsedation, minimum SpO2 was 96.3 � 0.7, and SpO2 lower than 94% occurred in 3patients. Conclusion: The AP mask could contribute to the protection of aerosol-exposure and be safely used for upper GI endoscopy in real clinical practice.


ID: 3524458EFFECT OF THE PANDEMIC ON THE ACUTEESOPHAGEAL OBSTRUCTION MANAGEMENT IN THEEMERGENCY DEPARTMENTAbhilash Perisetti*, Hemant Goyal, Mahesh Gajendran, Adnan Malik,Sonali Sachdeva, Ritu R. Singh, Jiannis Anastasiou, Ragesh B. Thandassery,Shashank Garg, Neil R. Sharma, Sumant Inamdar, Benjamin TharianIntroduction: The Coronavirus Disease-2019 (COVID-19) caused by the novel severeacute respiratory syndrome coronavirus-2 (SARS-CoV-2) led to significant strain onthe Emergency Department (ED) visits around the world. Multiple stay-at-homeorders were issued during the pandemic unless medical treatment is urgentlyneeded. Acute esophageal obstruction (AEO) due to food/ foreign body impactionusually present to the ED given its severe symptoms. It is unclear if ED visits fromAEO changed due to the COVID-19 pandemic in the United States (US). Methods:We utilized a federated cloud-based network (TriNetX), which provides access toelectronic medical records (EMR) from 92 healthcare organizations (HCOs) from theUS. The AEO patients hospitalized from January 1, 2020, to December 1, 2020, werecompared to a similar timeline in 2019 from the TriNetX database. We used ICD-10codes for food/foreign body in esophagus, causing other injury acute food impaction(T18.128 A, T18.12), foreign body esophagus (T18.198, T18.1, T18.19, T18.108,


Abstracts


T18.108A). Outcomes of the study include utilization rates of esophagogastroduo-denoscopy (EGD), esophageal perforation, inpatient hospitalization, and mortality.The outcomes were measured before and after 1:1 propensity matching of thegroups based on the baseline demographics and comorbidities. Results: Prevalenceof AEO among all ED visits in 2020 were 0.12% (5890 AEO ED visits among 4,672,024total ED visits), compared to 0.17% (23,478 AEO ED visits among 14,199,648 totalED visits) in 2019. There was a small but significant decrease (0.05%) in the numberof AEO ED visits from pre-pandemic compared to pandemic times (P<0.01). Beforepropensity score matching Patient with AEO had higher prevalence of eosinophilicesophagitis (mean 270 [4.6%] vs. 885 [3.8%], pZ0.004) and alcohol-related disor-ders (mean 465 [7.9%] vs. 1659 [7.1%], pZ0.03) in 2020 group vs. 2019 group.Patients in the 2020-group had lower mortality rate (RR 0.23, 95% CI: 0.17–0.31,p<0.001), EGD utilization (RR 0.63, 95% CI: 0.58–0.67, p<0.001) but esophagealperforation (RR 0.87, 95% CI: 0.41–1.82) and inpatient hospitalization rates (RR 1)did not differ between two groups. Conclusion: A small reduction (0.05%) of AEOED visits were noted in 2020 compared to 2019. However, EGD utilization reducedto 63% for the AEO visits during the pandemic in the US. Despite this, the mortalityrate reduced significantly. If this is due to spontaneous resolution of the foodimpaction or reduced presentations to the ED needs to be studied prospectively.Keywords: Acute esophageal obstruction; food impaction; foreign body esophagus,EGD; COVID-19; SARS-CoV-2; outcomes; mortality; TriNetX.

Table 1. Baseline characteristics of the patients with Acute EsophagealObstruction (AEO) ingestion during the COVID-19 pandemic (2020)when compared with pre-COVID time (2019). Propensity score matchingwas done based on the following variables: age, gender, race, hyperten-sion, diabetes mellitus, chronic lower respiratory disease, chronic kidneydisease (CKD), obesity, ischemic heart disease, alcohol-related disorders,eosinophilic esophagitis, and psychotic disorders.

Table 2. Laboratory findings and clinical outcomes of the patients withAcute Esophageal Obstruction (AEO) ingestion during the COVID-19pandemic (2020) when compared with pre-COVID time (2019) V


ID: 3495973METOCLOPRAMIDE INTRAVENOUS FOR INCREASEENDOSCOPIC VISUALIZATION SCORE IN PATIENTWITH ACUTE UPPER GASTROINTESTINAL BLEEDING :DOUBLE-BLIND, CONTROLLED TRIALPanuwat Promsorn*Background & Aims: Endoscopy in patient with acute upper gastrointestinalbleeding may be difficult to identify lesion and therapeutic intervention whenblood or gastric content obscures the visibility. Metoclopramide, prokinetics agent,induces gastric emptying. We investigated wether an intravenous metoclopramidewould improve the yield of endoscopy in these patients. Methods: Patients withhistory of hematemesis or melena that suspected acute upper gastrointestinalbleeding within 24 hours were randomly assigned to metoclopramide 10 mg orplacebo for intravenous 30-120 minutes before endoscopy. The primary outcomewas endoscopic yield, as assessed by endoscopic visualization score. Secondaryoutcome were the need for second-look endoscope, endoscopic time, length ofhospital stay and number of blood units transfused. Results: 164 patients wereincluded and devided to two group equally (eighty two per group). Patient charac-teristics were similar in both groups. Mean endoscopic visualization score for thecontrol patients in fundus, body, antrum, pylorus and total were 1.52 � 0.69, 1.71 �0.6, 1.77 � 0.53, 1.71 � 0.6 and 6.71 � 1.98 respectively; scores for the metoclo-pramide injected patients were 1.76 � 0.51, 1.8 � 0.46, 1.9 � 0.34, 1.93 � 0.31 and7.39 � 1.23 (p-value Z 0.016, 0.242, 0.055, 0.004 and 0.009 respectively). Second-look endoscope were 8 patients (9.8%) in control group and 4 patients (4.9%) inmetoclopramide group. The mean duration of endoscopic time was 32.01 � 20.78minutes in the control group; 31.04 � 14.49 minutes in the metoclopramide group(p-value Z 0.728). The mean length of hospital stay was 14.91 � 32.79 days incontrol group; 10.43 � 9.51 days in the metoclopramide group (p-value Z 0.236).The mean number of RBC units transfused was 1.41 � 1.5 units in the control group;1.54 � 1.77 units in the metoclopramide group (p-value Z 0.634). Conclusions:Intravenous metoclopramide is effective increase visualization for endoscopy bystatistically significant but does not translate into better clinical outcome with


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respect to need to second-look endoscope, endoscopic time, length of hospital stayand blood transfusion requirement.


ID: 3520322PAN-ENTERIC CAPSULE ENDOSCOPY TO ASSESSMUCOSAL HEALING IN CROHN’S DISEASE; SENSITIVITYTO CHANGE (STOC) STUDYAdriaan Volkers*, Geert R. D’Haens, Peter Bossuyt, Jitteke de Jong,Mark LöwenbergIntroduction: Pan-enteric capsule endoscopy (pan-CE) visualizes the entire gastroin-testinal tract and therefore provides an attractive alternative to conventional ileo-colonoscopy to evaluate mucosal changes in Crohn’s disease (CD). An earlier studyshowed that pan-CE is feasible, safe and well tolerated by CD patients. In the STOCstudy we aimed to study the Sensitivity TO measure Change (STOC) in mucosaldisease severity using pan-CE. Methods: Patients with CD and active disease basedon symptoms (i.e. Crohn’s disease activity index (CDAI) >150) and biomarkers (i.e.C-reactive protein (CRP) >5 mg/L and/or fecal calprotectin (fCal) levels >250 mg/kg)underwent pan-CE, using the second-generation Pillcam colon capsule, before and8-12 weeks after treatment initiation with infliximab, adalimumab or vedolizumab.Luminal disease activity was assessed using the Crohn’s disease endoscopic index ofseverity (CDEIS) and the simple endoscopic index for Crohn’s disease (SES-CD),expanded with two segments for the jejunum and pre-terminal ileum. Pan-CE wasconsidered sensitive to detect mucosal change if there was a significant decreasebetween CDEIS and SES-CD before and after treatment initiation in addition of astandard effect size >0.8. Correlations with clinical and biochemical markers werecalculated. Results: Twenty-eight patients underwent pan-CE of whom 2 withdrewconsent and 4 did not start biologic therapy. Twenty-two patients (78.6%) startedbiologic treatment, median duration between treatment initiation and pan-CE was11 weeks (IQR: 9.8-12 weeks). Eleven out of 22 patients (50%) were female andmedian age was 24 years (IQRZ22-38 years). Mean CDEIS decreased from 7.6(SDZ3.7) to 3.7 (SDZ3.3, pZ0.001) and mean SES-CD went from 16.0 (SDZ7.4)to 7.3 (SDZ5.4, P<0.001). This was considered a large difference since the standardeffect size was 1.11 for CDEIS and 1.36 for SES-CD. CDAI correlated poorly withCDEIS (0.36, pZ0.009, nZ50) and SES-CD (rZ0.41, pZ0.003, nZ50). BaselineCDEIS and SES-CD scores did not correlate with CRP (rZ0.24, pZ0.22, nZ28 andrZ0.21, pZ0.28, nZ28, respectively) and fCal levels (rZ0.27, pZ0.17, nZ28 andrZ0.17, pZ0.40, nZ28, respectively). Gastroscopy was performed in 4 out of 50procedures (8%) because of capsule retention within the stomach. In 39/50 (78%)procedures the rectum was visualized, covering the entire gastro-intestinal tract.Thus, procedures were incomplete in the remaining 11/50 (22%). All capsules wereevacuated spontaneously and no patient reported adverse events related to pan-CEprocedure. Conclusion: Pan-CE is useful to assess endoscopic disease severity andmucosal healing in patients with CD who embark on biological treatment since it ishighly sensitive to detect changes in endoscopic inflammation. Pan-CE mighttherefore replace ileocolonoscopy to evaluate luminal treatment responses in CD.

FRIDAY, MAY 21, 2021Clinical Endoscopic Practice 1Lecture

ID: 3527209PAYER STATUS INFLUENCES DISPARITIES ININPATIENT CARE FOR ACUTE CHOLECYSTITISJonah Poster*, Venu Gopal Bangla, Celia M. DivinoIntroduction: Patients covered by Medicaid insurance are consistently shown to havereduced access to appropriate medical care as compared to private insurance car-riers. Greenstein et al. (2012) found that patients presenting with acute cholecystitis(AC) covered by Medicaid insurance receive lower rates of laparoscopic cholecys-tectomy, the gold standard cholecystectomy approach. In addition to updating ratesof laparoscopic approach, we investigated disparities in time to surgery, length ofstay, and mortality between Medicaid and private insurance carriers. Methods: Re-cords were selected from the Nationwide Inpatient Sample (NIS) database from2010-2014. Sample criteria was based on an AC primary diagnosis (ICD9: 575.0,574.0), 18 years or older, emergency department admission, no abdominal cancerdiagnosis, and a primary payer status of Medicaid or private insurance. We analyzedpropensity score-matched cohorts based on payer status for procedure relatedvariables and mortality. We used survey procedures for national estimates, consid-ering clusters, strata, and weights. Student’s T-test for continuous variables and Rao-Scott chi square test for categorical variables were used to find differences by payerstatus prior to matching; paired t-test for continuous variables and McNemar’s testfor categorical variables were used after the match. Results: A total of 376,823weighted records met our inclusion criteria of which 322,393 (86%) received sur-gery. Records were well matched (Standardized Difference <0.06). The median ageof matched patients who received surgery was 38.5 years, where 77.3% were female,

and 77.1% of patients had an Elixhauser Comorbidity Score of 0 or less. While 87.2%of the private insurance carriers underwent a cholecystectomy, only 79.6% of theMedicaid carriers received equivalent care (P<0.01). In the subset of patients whoreceived surgery, the Medicaid cohort underwent less laparoscopic cholecystec-tomies as compared to the private insurance cohort (93.5% vs. 95.1%; P<0.01).Medicaid carriers had an increased rate of conversion to open surgery (4.6% vs.3.6%; P<0.01), longer time from admission to surgery (1.20 vs. 0.96 days; P<0.01),and a longer length of stay (3.13 vs. 2.58 days; P<0.01) as compared to the privateinsurance carriers. Moreover, Medicaid carriers had a greater rate of mortality (0.11%vs. 0.02%; p<0.007). Conclusions: Rates of laparoscopic cholecystectomy for ACremain lower for Medicaid insurance carriers as compared to private insurance.Medicaid insurance carriers also received delayed time to cholecystectomy, a longerlength of stay, and higher mortality rates as compared to private insurance carriers.


ID: 3521872LONG-TERM OUTCOMES OF JAPANESE MULTICENTERPROSPECTIVE COHORT STUDY OF ENDOSCOPICRESECTION FOR EARLY GASTRIC CANCER USING WEBREGISTRY (J-WEB/EGC)Hirasawa*, Haruhisa Suzuki, Hiroyuki Ono, Yoji Takeuchi, Kenji Ishido,Shu Hoteya, Tomonori Yano, Shinji Tanaka, Masaki Endo,Masahiro Nakagawa, Takashi Toyonaga, Hisashi Doyama, Kingo Hirasawa,Taichi Shimazu, Kohei Takizawa, Satoshi Tanabe, Hitoshi Kondo,Hiroyasu Iishi, Ichiro OdaBackground and Aims: Limited data from multicenter prospective studies is availableregarding the long-term outcomes of endoscopic resection (ER) for gastric cancer,particularly for EGC lesions fulfilling differentiated-type, pT1b (SM1), �3 cm. A


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Japanese multicenter prospective cohort study of ER for early gastric cancer (EGC)using a Web registry system (J-WEB/EGC) has been conducted to determine thelong-term outcomes (Clinical Trial Registration: UMIN000005871). We aimed toclarify the long-term outcomes of ER for EGCs based on pathological curability ofgastric ER to determine the effectiveness of ER for EGC. Methods: We analyzed thelong-term outcomes of 9054 patients with 10,021 EGCs undergoing ER between July2010 and June 2012. The primary endpoint was the 5-year overall survival (OS). Thehazard ratio (HR) for all-cause mortality was calculated using the Cox proportionalhazards model. In addition, we compared the 5-year OS with the expected 5-year OScalculated for the general population. If the lower limit of the 95% confidence in-terval (CI) of the 5-year OS exceeded the expected 5-year OS minus a margin of 5%(threshold 5-year OS), it was considered equal to or greater than the expected one.The pathological curability was categorized into en bloc resection, negative margins,and negative lymphovascular invasion: differentiated-type, pT1a, ulcer negative, �2cm (CategoryA1); differentiated-type, pT1a, ulcer negative, >2 cm or ulcer positive,�3 cm (CategoryA2); undifferentiated-type, pT1a, ulcer negative, �2 cm (Cate-goryA3); differentiated-type, pT1b (SM1), �3 cm (CategoryB); or noncurative re-sections (CategoryC). For patients with multiple EGCs, the curability wasdetermined based on the highest of the five categories of the pathological curabilityof ER (CategoryC > CategoryB > CategoryA3 > CategoryA2 > CategoryA1). Results:Over 90% of the analyzed patients were successfully collected survival data at 5 yearafter treatment. The 5-year OS rates of CategoryA1, CategoryA2, CategoryA3, Cate-goryB, CategoryC, and overall patients were 90.2%, 89.4%, 94.2%, 88.3%, 85.1%, and89.0%, respectively (Table 1). In the univariate, age and sex-adjusted and multivar-iate analysis, no significant differences were observed when the HR (95% CI) ofCategoryA2, CategoryA3 and CategoryB were compared to that of CategoryA1 (Table2). In addition, in all the pathological curability categories, the lower limit of the 95%CI for the 5-year OS exceeded the threshold 5-year OS (Table 1). Conclusions: Thisnationwide multicenter prospective cohort study of ER for gastric cancer in “real-world” settings demonstrated that ER can be recommended as a standard treatmentfor EGC patients fulfilling CategoryA2, CategoryA3 and CategoryB as well asCategoryA1.


ID: 3524394ENDOSCOPIC ULTRASOUND-GUIDED HEPATIC SHEARWAVE ELASTOGRAPHY AND ITS ASSOCIATION WITHHEPATIC FIBROSIS STAGE: A PILOT STUDYAlyssa Y. Choi, Jason Samarasena, Kenneth J. Chang, Ke-Qin Hu*Background: Endoscopic ultrasound (EUS) has been used for liver biopsy (EUS-bx)and portal pressure gradient (EUS-PPG) measurement. Hepatic EUS-shear waveelastography (EUS-SWE) can now be performed during EUS-bx and/or EUS-PPG, butits feasibility and clinical value have not yet been reported.AIMS: To assess the feasibility, safety, and clinical value of EUS-SWE in predictinghistological hepatic stage � 3 fibrosis by liver bx (Lbx). Methods: A retrospectivepilot study in patients with various chronic liver diseases, followed at UCI Med. Ctr.Liver Clinic from 5/2019 to 10/2020. EUS-SWE was performed in the same endo-scopic session as EUS-bx and EUS-PPG. Given that elastography reading � 12.5 kPais well associated with stage 3-4 hepatic fibrosis, we used 12.5 kPa to assess EUS-SWEaccuracy in predicting hepatic fibrosis stage by Lbx. Chi-square test and 2 x 2 tablewere used to associate the EUS-SWE reading with hepatic fibrosis staging and itsperformance. Results: Twenty-seven subjects were included in this study. The meanage was 56.1 (27-79); 18 (66.7%), male. Fifteen (55.6%) had clinical cirrhosis (by Lbx,percutaneous SWE, abdominal ultrasound, EGD, or hepatic decompensation); 9(33.3%), esophageal/gastric varices (EV/GV) on esophagogastroduodenoscopy(EGD); 15 (55.6%), histological stage � 3 fibrosis by Lbx. Mean Child score was 6 (5-11); mean MELD, 11.7 (7-26). All 27 (100%) subjects had successful EUS-SWE andEUS-bx; 22 (81.5%), both left (LL) and right lobe (RL) EUS-SWE measurements.Mean EUS-SWE LL measurement was 17.3 (2.4-47.2) kPa; mean RL, 21.8 (4.4-54.5)


Abstracts


kPa. There were no complications associated with EUS-SWE. EUS-SWE LL � 12.5 kPa(compared to < 12.5 kPa) was significantly associated with fibrosis stage � 3 on Lbx(85.7% vs. 20%, pZ0.001), clinical cirrhosis (78.6% vs. 30%, pZ0.017), INR � 1.05(61.5% vs. 20%, pZ0.046), EV/GV (53.8% vs. 10%, pZ0.029) on EGD, AST to plateletratio index (APRI) score > 2 (62.5% vs. 10%, pZ0.019), Fibrosis-4 (Fib-4) score> 3.25 (62.5% vs. 10%, pZ0.066). EUS-SWE RL � 12.5 kPa was also significantlyassociated with fibrosis stage � 3 on liver biopsy (83.3% vs. 40%, pZ0.035). Overall,EUS-SWE LL measurements were superior, but comparable to RL measurements.EUS-SWE LL � 12.5 kPa had the highest combined sensitivity and specificity (85.7%,80%) in predicting histological stage � 3 fibrosis, compared to EUS-SWE RL � 12.5kPa (83.3%, 69%), clinical cirrhosis (80%, 66.7%), INR � 1.05 (80%, 50%), EV/GV onEGD (87.5%, 46.2%), APRI > 2 (83.3%, 50%), and Fib-4 > 3.25 (71.4%, 44.4%).Conclusions: This pilot study demonstrated the feasibility, safety of EUS-SWE, andits superiority to several other non-invasive clinical assessments in predictinghepatic fibrosis stage. Once confirmed by prospective studies, EUS-SWE could be anaddition to Endo-hepatology for a broader clinical application of EUS-guided diag-nosis.


ID: 3523940LONG TERM TRANSMURAL DRAINAGE OF PANCREATICFLUID COLLECTIONS IMPROVES SURVIVAL INPATIENTS WITH DISCONNECTED DUCT SYNDROMERobert Dorrell*, Swati Pawa, Kelly Hammoudi, Gregory B. Russell,Chloe Tom, John H. Gilliam, Rishi PawaBackground: Disconnected duct syndrome (DDS) is a complication of acute pancre-atitis (AP) in which the upstream pancreatic duct becomes completely discontin-uous with the downstream pancreatic duct. This presents a challenge toendoscopists as pancreatic fluid collections (PFC) frequently recur in such patients.Endoscopic approaches including permanent indwelling transmural stents havebeen advocated to decrease recurrences. Our study aims to assess the outcomes ofendoscopic management of PFC in patients with DDS. Methods: This is a retro-spective study of patients undergoing endoscopic management of PFCs from April2015-September 2020. Collected data included: patient demographics, proceduredetails, characteristics of PFCs, adverse events, and clinical outcomes. All patientswere evaluated for the presence of DDS. A subset of patients with DDS underwentplacement of 10 French double pigtail stents (DPS) after LAMS removal. The Kaplan-Meier method was used to estimate recurrence-free rates; the chi-square approxi-mation of the log-rank test assessed statistical significance. Cox Proportional Hazardsregression was used to assess the effect of independent measures on recurrence-free survival. Results: A total of 96 patients underwent endoscopic therapy for PFCs:53 were diagnosed with DDS, 34 had no DDS, and imaging was non-diagnostic in 9patients. The estimated recurrence-free rate at 2 years was 96.2% (standard error of3.8%) in patients without DDS and 66.7% (8.8%) in patients with DDS (pZ0.0097).The median follow-up was comparable in both groups (19 months vs. 20.1 months,respectively, pZ0.31). Of the 53 patients with DDS, 48 subjects had adequate followup data. Twenty-one patients (44%) were treated with DPS post LAMS removal, andin 27 patients (56%) no DPS were placed once LAMS were removed. Of the 21 pa-tients treated with DPS, there was 1 recurrence. The recurrence-free rate was 100%at 1 year and 92.3% (7.4%) at 2 years. Of the 27 patients not treated with DPS,recurrence was seen in 10 patients, with a median time to recurrence of 24.4months. The recurrence-free rate was 68.8% (10.0%) at 1 year and 57.4% (11.2%) at 2years. The p-value comparing the recurrence-free data was 0.011. In a multivariablemodel, the presence of DDS was significantly negatively associated with recurrence-free survival [HRZ24.4, 95% CI (2.77, 215), pZ0.004] while LAMS replacement withDPS in DDS was significantly associated with increased survival [HRZ0.09, 95% CI(0.01, 0.83), pZ0.033]. Conclusions: DDS is a common complication of AP and ischallenging to manage endoscopically. The presence of DDS on imaging is animportant predictor of PFC recurrence. All patients with PFCs should be evaluatedfor the presence of DDS due to its implications on definitive endoscopic manage-ment and increased survival with DPS placement post LAMS removal for long-termdrainage.


ID: 3523267OUTCOMES OF PER-ORAL ENDOSCOPIC MYOTOMYBEYOND FIVE YEARS IN ESOPHAGEAL MOTILITYDISORDERS: A LARGE, SINGLE CENTRE STUDYZaheer Nabi*, Arun Karyampudi, Mohan K. Ramchandani,Nageshwar R. DuvvurBackground: Per-oral endoscopic myotomy (POEM) is an established modality oftreatment in achalasia and non-achalasia spastic motility disorders of esophagus.However, there is limited data on the long-term outcomes of POEM. In this study,we aim to evaluate the efficacy of POEM in patients with a minimum follow-up offive-years. Methods: The data of patients who underwent POEM and completed atleast five-years follow-up were analyzed from a prospectively maintained database.The primary outcome of the study was clinical success (Eckardt�3) at �5-years afterPOEM. The secondary outcomes included the prevalence of dysphagia and symp-toms of gastroesophageal reflux disease (GERD). Multivariate analysis was per-formed to analyze the predictors of dysphagia and symptomatic GERD on long-termfollow-up. Results: 225 patients (males 129, mean age 40.7�14.3 years) completed aminimum of 5-years follow-up. The spectrum of motility disorders included idio-pathic achalasia (type I 28.4%, type II 60%, type III 6.2%) and Jackhammer esoph-agus or distal esophageal spasm (3.1%). POEM was technically successful in 217(96.4%) patients. The data for long-term follow-up was available in 201 (89.3%) pa-tients. The median follow-up was 69 months (range 60-81). In intention to treatanalysis (considering technical failures and lost to follow-up as failures), the overalllong-term success was 87.5%, 84.3% (type I), 91.8% (type II), 78.6% (type III) and85.7% (Jackhammer esophagus/ distal esophageal spasm). Clinical success was lowerin type III achalasia (pZ0.002). Young age was an independent risk factor for thedevelopment of dysphagia on follow-up (pZ0.002). Clinical GERD was detected in30.6% patients. On multivariate analysis, female sex, high Eckardt score at 5-yearsand dysphagia of any degree were independent predictors of symptomatic GERDafter POEM. Conclusion: POEM is an effective and durable treatment modality forachalasia and other non-achalasia spastic motility disorders. Clinical GERD is de-tected in nearly one-third patients.


ID: 3520196COMPARISON OF ENDOSCOPIC GUIDEDGASTROENTEROSTOMY WITH ENTERAL STENTING ANDSURGICAL GASTROJEJUNOSTOMY: A SYSTEMATICREVIEW AND META-ANALYSISUmair Iqbal*, Hafsa Anwar, Khwaja F. Haq, Ammara Khalid,Muhammad Ali Khan, Faisal Kamal, Bradley Confer, Harshit S. KharaIntroduction: Gastric outlet obstruction (GOO) presents with nausea, vomiting, andweight loss, with majority being secondary to malignant causes. Surgical gastroje-junostomy (SGJ) was considered the treatment of choice for palliation of GOO, butwith the evolution of self-expandable metal stents (SEMS), enteral stenting (ES) hasbecome more prevalent. However, studies showed an increased risk of re-inter-vention with ES due to tissue ingrowth. Endoscopic ultrasound-guided gastroen-terostomy (EUS-GE) is a novel procedure that has been utilized for the palliation ofsymptoms in patients with both benign and malignant GOO. Data is limited to smallobservational studies and only a few comparative trials are available to compare itsutility with ES and SGJ. We conducted a systematic review and meta-analysis tocompare the outcomes of EUS-GE with ES and SGJ in patients with GOO. Methods:A systematic literature search was performed up to November 2020 in Embase,MEDLINE, Web of , and Cochrane Review library to evaluate for studies thatcompare outcomes of EUS-GE with ES or SGJ in patients with malignant or benignGOO. We only included comparative trials and exclude studies which only report theoutcomes of one of these modalities. Our primary outcomes were pooled technicalsuccess and clinical success rates. Our secondary outcomes were pooled risk ofadverse events and rate of re-intervention. All analysis was performed using Revman5.4 software. Results: The initial search revealed 239 studies. Of these, 8 studiesincluding 829 patients met our inclusion criteria, of which 335 underwent ES, 315underwent EUS-GE, and 179 underwent SGJ. There was no statistically significantdifference in the technical and clinical success rates comparing EUS-GE with ES[RRZ0.98 (0.96-1.00) and RRZ1.14 (0.96-1.34)]. The rate of re-intervention wassignificantly lower with EUS-GE compare to ES with RRZ0.17 (0.07-0.40). The rateof adverse events also trended lower with EUS-GE compare to ES but did not reachstatistical significance [RRZ0.69 (0.30-1.58)]. There was also no significant differ-ence in technical and clinical success rates between EUS-GE with SGJ [RRZ0.95(0.89-1.02) and RRZ1.06 (0.97-1.17)]. The rate of adverse events was significantly


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lower in patients who underwent EUS-GE [RRZ0.40 (0.24-0.64)] compared to SGJ.The rate of re-intervention was trended lower in the EUS-GE group compare to SGJbut did not reach statistical significance [RRZ0.36 (0.08-1.62)]. Conclusion: There isno significant difference in the technical and clinical success of EUS-GE compare toES or SGJ. EUS-GE has a significantly lower rate of re-intervention compare to ES,and significantly lower rate of adverse events compared to SGJ. Thus EUS-GE shouldbe considered as a first-line modality for treatment of patients with malignant orbenign GOO in centers with available technical expertise.


ID: 3521859OPTIMAL DIAGNOSTIC IMAGING STRATEGY FORPATIENTS WITH INTERMEDIATE PROBABILITY FORCHOLEDOCHOLITHIASIS: A COST-EFFECTIVENESSANALYSISFaisal S. Ali*, Maryam R. Hussain, Shahrooz Rashtak, Srinivas Ramireddy,Ricardo Badillo, Sushovan Guha, Nirav Thosani, Tomas DaVeeIntroduction: For patients with cholelithiasis with intermediate probability for chol-edocholithiasis, various confirmatory imaging studies including endoscopic ultra-sound (EUS), magnetic resonance cholangiopancreatography (MRCP), andintraoperative cholangiogram (IOC) are advocated by the American Society forGastrointestinal Endoscopy, instead of diagnostic endoscopic retrograde cholan-giopancreatography (ERCP). While local expertise will affect the choice of oneconfirmatory imaging study over another, there is limited information availableregarding the most cost-effective approach. Methods: We developed a decision treeto identify a cost-effective strategy for patients with cholelithiasis with intermediateprobability of choledocholithiasis (Figure 1). A positive diagnostic test was modeledto lead to a therapeutic ERCP. The testing strategies were as follows: 1) EUS followedby ERCP, 2) EUS and ERCP in a single session, 3) MRCP followed by ERCP, and 4)Laparoscopic cholecystectomy (LC) with intra-operative cholangiogram (IOC) fol-lowed by ERCP. Intermediate probability was defined to range between 10-70%.Data on diagnostic test accuracy, probabilities of adverse event(s), and cost(s) ofintervention(s) and hospitalization(s) were extracted from previously publishedsystematic reviews and inpatient hospital data audit studies. Cost-effectiveness wereassessed by extrapolating an incremental cost-effectiveness ratio (ICER), a net-monetary benefit (NMB), and cost/effect. Results: LC-IOC was the most cost-effectivestrategy to diagnose choledocholithiasis, incurring $4842/utility and a NMB of$42577 (Table 1). LC-IOC remained the dominant strategy on sensitivity analysis ofvarying probabilities of choledocholithiasis (10-70%; Figure 2A & 2B). LC-IOC wasfollowed by MRCP, which incurred $7259/utility and a NMB $39928, and an ICER of-255513. EUS and ERCP, in a single session or separate sessions, incurred $17907/utility and $17906/utility, respectively, with a NMB of $33079 and $30080, respec-tively, and an ICER of -2177906 and -2178110, respectively. Conclusion: For patientswith cholelithiasis with intermediate probability for choledocholithiasis, LC-IOC isthe most cost-effective approach followed by MRCP. Our findings may be used toguide further hypothesis generation and to design institutional and organizationalmanagement protocols.

Figure 1. Schematic of Decision Tree for The Diagnosis of IntermediateProbability Choledocholithiasis

Table 1. Cost-Effectiveness of Diagnostic Strategies for IntermediateProbability CholedocholethiasisFigure 2A & 2B. Sensitivity Analyses

SUNDAY, MAY 23, 2021jSATURDAY, MAY 22, 2021Clinical Endoscopic Practice 1LecturejLecture

ID: 3524989DOES FORMAL POLYP HISTOLOGY ALTERSURVEILLANCE INTERVALS PREDICTED AT THE TIMEOF COLONOSCOPY / POLYPECTOMY WITH HIGHDEFINITION ENDOSCOPES? A PROSPECTIVE COHORTSTUDYReynauld*, Khalid N. Rasouli, Cameron Gofton, David GilbertBackground: With high definition endoscopes, narrow band imaging (NBI) andimproved bowel preparation, adenoma detection rates and lesion characterisationat the time of colonoscopy have improved. Endoscopists are better equipped to notonly detect polyps but predict histology using validated criteria such as the Paris(morphology) and Kudo / NICE (NBI International Colorectal Endoscopic) classifi-cations (pit pattern). Histology of resected polyps is a major determinant of sur-veillance intervals. However, it is costly and not available to patients at the time oftheir colonoscopy. We hypothesise that in patients undergoing colonoscopy andpolypectomy by an experienced “high detector” colonoscopist, that formal polyphistology seldom changes the surveillance interval (determined by the Australiansurveillance guidelines) predicted at the time of colonoscopy, when optimal splitpreparations and enhanced imaging with application of the classification systemsabove are used. Aim: To determine the accuracy of surveillance interval predicted atthe time of colonoscopy, dictated by number, size and predicted histology in pa-tients with polyps resected, as confirmed by formal histologic diagnosis. Methods:759 consecutive patients who underwent colonoscopy performed by a singleexperienced endoscopist from January to October 2020 in both the public (319patients) and private (438 patients) sectors on the Central Coast, New South Wales,Australia were prospectively analysed and included. 347 patients who had either nopolyps or distal hyperplastic lesions only were excluded. Patient demographics,number and size of adenomas per patient, method of polyp resection, predictedsurveillance interval and degree of confidence (high or low) of this interval based onendoscopic prediction of histology, and formal histology of polyp(s) were recordedprospectively. The primary endpoint was accuracy of the predicted surveillance in-terval based upon endoscopic characterization of polyp(s). Results: The surveillanceinterval was predicted with high confidence in 93.9% and low confidence in 6.1%.The predicted interval was accurate in 390 (94.7%) of patients. Of these, 382 (97.9%)of patients were predicted with high confidence. Of the 22 patients (5.3%) wherethe surveillance interval changed with histology, 17 (77.3%) were predicted with lowconfidence and only 5 (22.7%) with high confidence. Conclusion: This study dem-onstrates that in the vast majority of patients, formal histology does not alter thesurveillance interval predicted at the time of colonoscopy when optimal techniquesare employed by an experienced endoscopist with a high ADR. This has potentialimplications for “resect and discard” strategies in future. Where polyp histologycannot be predicted with a high degree of confidence at the time of colonoscopy,formal histology remains invaluable.


Abstracts


SATURDAY, MAY 22, 2021Clinical Endoscopic Practice 1Poster

ID: 3520052FACTORS AFFECTING OUTCOMES OF ENDOSCOPY INPATIENTS WITH GASTROINTESTINAL BLEEDING ANDCONCURRENT ACUTE MYOCARDIAL INFARCTION: ATEN YEAR STUDYHarrison R. Malcolm*, Ruchit N. Shah, Pooja D. Patel, Andrea L. Berger,Shikhar Agarwal, Harshit S. KharaBackground: Gastrointestinal (GI) bleeding in the setting of acute myocardial infarc-tion (MI) is clinically challenging as the GI bleed complicates the decision to anti-coagulate, while the presence of MI increases the risk of sedation for endoscopy.There is lack of quality evidence on the pre-procedure safety thresholds in thesepatients. Our aim was to study the impact of various hemoglobin levels at the time ofendoscopy, and sedation strategies on 30-day mortality and length of stay (LOS) inpatients with concurrent GI bleeding and MI. Methods: We retrospectively analyzeddata for patients admitted from 2010-2020 with acute MI who underwent anendoscopy for GI bleeding during the same hospitalization. ICD-9 and 10 codes forMI and CPT codes for endoscopic procedures were used. Patients who did not haveMI predating or concurrent with GI bleeding, had only historical MI, or had anendoscopy for another indication were excluded (Table 1). Three subsets of he-moglobin values were compared. Patients who received conscious sedation werecompared to those who received general anesthesia, with subsets grouped by ASAclass. The primary outcome was 30-day mortality. A logistic regression model wasused to estimate the odds ratio, 95% confidence interval, and AUC for the rela-tionship between hemoglobin as a continuous variable, and 30-day mortality andLOS. Pearson’s chi-square or Fisher’s exact tests were used to compare categoricalvariables. Results: A total of 274 patient charts were analyzed. The mean age was72.7, and 61.7% were male. Patients were less likely to die within 30 days as he-moglobin values at time of procedure increased, even when adjusted for effects ofage, sex, and anesthesia type (ORZ0.743; PZ0.0159). 30-day mortality was similarbetween patients with hemoglobin less than 7 and between 7 and 7.9 (20% v 20.5%;PZ1), and hemoglobin less than 8 and between 8 and 8.9 (20.3% v 18.3%;PZ0.7701). However, there was a significant difference in 30-day mortality betweenpatients with hemoglobin <9 and those with hemoglobin between 9 and 10.9 (19.2%v 8.4%; PZ0.018, AUCZ0.61) There was no difference in 30-day mortality betweenconscious sedation and general anesthesia groups (18.9% v 11.2%; PZ0.0764); evenwith subgroup analysis comparing high risk and low risk ASA class. There was nosignificant difference in LOS for any hemoglobin subgroup or sedation method(Table 2). Conclusion: Higher pre-procedure hemoglobin level in patients withconcurrent GI bleed and MI requiring endoscopy had lower 30-day mortality, andthis effect seems to become significant around 9 g/dL; although no hemoglobin levelindependently shows good ability to predict mortality. Our data suggests thatconscious sedation is a safe alternative even in high risk patients in this setting whengeneral anesthesia is unavailable, without increasing 30-day mortality or LOS.

Table 1. Inclusion and exclusion criteria for final analysis

Table 2. Outcomes for hemoglobin subgroups and sedation methods


ID: 3527200USE OF PRE-PROCEDURAL MRI STAGING FOR RECTALENDOSCOPIC RESECTION PLANNING: A TERTIARYREFERRAL CENTER REVIEW OF PRACTICESophie Williams*, Andrew Emmanuel, Shraddha Gulati, Margaret Burt,Mehul Patel, Bu Hayee, Amyn HajiBackground: King’s College Hospital (KCH) London is a tertiary referral center deliv-ering advanced endoscopic resection (ER) for complex polyps. Endoscopic Sub-mucosal Dissection (ESD) is a treatment modality offered increasingly for complexrectal polyps including early rectal cancer which can provide curative, organ pre-serving treatment in the majority of patients. All patients referred to our center withcomplex rectal polyps undergo MRI rectum prior to endoscopic resection to aidprocedural planning. We compare pre-procedural MRI findings and endoscopicdiagnosis to post-procedure histology. Results: In this cohort, we reviewed 148 pa-tients who underwent ESD for a rectal polyp between 2012 and 2020 at our center.Histological diagnosis demonstrated 14 tubular adenomas, 7 villous adenomas, 92tubulovillous adenomas, 3 sessile serrated adenomas, 26 adenocarcinomas, 1 squa-mous cell carcinoma and 4 neuroendocrine tumours. In one patient histology re-vealed fibrous tissue only. Of this cohort, 139 patients underwent MRI rectum,tumour staging was as follows: T0 Z 16, T1 Z 45, T1/T2 Z 28, T2 Z 34, T2/3 Z 4,T3/4 Z 11, T3/4 Z 1. Pre-procedural MRI staging was not significantly correlatedwith, or predictive of post-procedural histology. Endoscopic diagnosis was stronglypredictive of histopathogical diagnosis. Conclusion: Although the use of MRI forcomplex polyps plays a role in identifying patients for which organ preserving


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endoscopic resection is appropriate, it is not predictive of post-procedural histologyand over-stages some polyps. In expert hands, endoscopic diagnosis is stronglypredictive of histological outcomes. Therefore, a combined approach is crucial inthese complex cases.


ID: 3526875COPD IS AN INDEPENDENT RISK FACTOR FORPANCREATITIS, MORTALITY IN PATIENTSUNDERGOING ERCPEric O. Then*, Jamil M. Shah, Tagore Sunkara, Derrick Cheung,Madhavi Reddy, Vinaya GaduputiIntroduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a widelyaccepted therapeutic procedure used to alleviate many pathologic conditions ofpancreatobiliary origin. Little is known however on what impact respiratory disor-ders such as chronic obstructive pulmonary disease (COPD) have on patients un-dergoing ERCP. The aim of our study was to evaluate outcomes in COPD patientsundergoing ERCP. Methods: We retrospectively analyzed hospitalized patients whounderwent ERCP (via ICD-10 codes) in 2017 using the National Inpatient Sample(NIS) database. Our primary endpoint was to elucidate if the presence of COPDworsened outcomes in patients undergoing ERCP. We accomplished this by ex-tracting baseline demographic data and admission outcomes including length ofhospital stay (LOS), total hospital charges, and mortality. Additionally we examinedthe odds of developing PEP in patients with COPD (study group) and patientswithout COPD (control group). Categorical variables were compared using the chi-square test, and continuous variables were compared using t-test. Multivariate re-gressions models and all statistical analysis were performed using STATA 16 soft-ware. Results: A total of 160,895 hospitalized patients who underwent ERCP wereidentified in our study. Of these 4,485 had carried a secondary diagnosis of COPD,and 156,410 did not. We found that patients with COPD who underwent ERCP had astatistically significant higher mortality rate when compared to patients withoutCOPD (3% vs 1.3%; p-value: <0.01) and statistically significant higher rates ofdeveloping PEP (3.4% vs 2.7%; p-value: <0.01). Additionally, patients with COPD hada longer LOS (7.2 days vs 6.0 days; p-value: <0.01) and total hospital charges($91,301 vs $81,541; p-value: 0.02). On multivariate analysis when adjusting for age,gender, race and co-morbid conditions, we found that the presence of COPD wasindependently associated with higher mortality (OR: 1.69; 95% CI: 1.33 – 2.14; p-value: <0.01) and development of PEP (OR: 1.23; 95% CI: 1.002 – 1.530; p-value:0.04). Discussion: We conclude that the presence of COPD results in worse out-comes in patients undergoing ERCP. An increased length of hospital stay, highertotal hospital charges, increased odds of mortality and increased odds of developingpost-ERCP pancreatitis evidenced this. This should prompt closer monitoring in thissubset of patients and consideration of pre-procedure intubation.


ID: 3520910A SURVEY OF TRAINING PATHWAYS AND PRACTICETRENDS OF ENDOSCOPIC SUBMUCOSAL DISSECTIONIN CANADASuqing Li*, Jeffrey D. Mosko, Gary R. May, Christopher TeshimaBackground: Endoscopic submucosal dissection (ESD) has become the establishedstandard for endoscopic removal of large gastrointestinal (GI) lesions and early GImalignancies, with improved outcomes compared to traditional endoscopic tech-niques and offers an alternative to surgery. However, ESD is technically challengingand requires significant healthcare infrastructure. As such, its adoption in Canadawas slow relative to Asia and Europe. Thus far, the practice of ESD has been limitedto a small number of tertiary centers. The availability and practice of ESD acrossCanada remains unclear. Aim: To provide a descriptive overview of training pathwaysand practice trends of endoscopists performing ESD in Canada. Methods: ESDpractitioners across Canada were identified from internal networks and by contact-ing respective endoscopy units. All endoscopists currently accepting ESD referralswere invited to participate in a cross-sectional survey that was distributed via Sur-veyMonkey. Results: 27 ESD practitioners were identified; current survey responserate was 56% although is expected to increase. Current respondents were from 11different institutions. Median years of independent ESD practice was 4 (IQR 2). Allpractitioners underwent international ESD training of some type. 93% attendedshort-term training courses. 53% pursued international ESD fellowships. 93%received training on animal models. 53% and 33% performed hands-on human up-per and lower GI ESD respectively prior to independent practice. In practice, 67%saw an increase in number of ESD procedures performed per year from 2015 to2019. 87% felt referral providers were only “somewhat aware” of the availability ofESD in their region. 67% found referring physicians were not so aware of appro-priate ESD indications. 67% report a patient wait time of 1-3 months. 93% feltdissatisfied with renumeration for ESD. 67% and 73% felt it was difficult to secureendoscopy time and anesthesia support for ESD respectively. 80% were “dissatis-fied” or “very dissatisfied” with their institution’s healthcare infrastructure to supportESD. 20% perceived their institution as supportive in expanding the practice of ESD.Conclusions: A number of challenges exist for the adoption of ESD in Canada.Training pathways are highly variable, with no set standards. In practice, the ma-jority of practitioners express dissatisfaction with their access to necessary infra-structure for performing ESD and feel poorly supported by their centers inexpanding its practice. Additionally, the awareness of referral providers for theavailability and indications for ESD is limited. As ESD is becoming the acceptedstandard for minimally invasive treatment of indicated GI lesions; greater collabo-ration between practitioners, institutions, and healthcare systems is crucial to stan-dardize ESD training and to ensure improved patient access.


Abstracts



ID: 3523419EFFICACY AND SAFETY OF LUMEN-APPOSING METALSTENT IN THE TREATMENT OF BENIGNGASTROINTESTINAL STRICTURES: A SYSTEMATICREVIEW AND META-ANALYSISAzizullah Beran*, Sami Ghazaleh, Mohammed Mhanna, Yasir Alabboodi,Omar Srour, Ahmed M. Elzanaty, Dana Ghazaleh, Ali NawrasBackground: Lumen-apposing metal stent (LAMS) is a promising alternative thera-peutic option for benign gastrointestinal (GI) tract strictures. Our study aimed toevaluate the safety and efficacy of LAMS in the management of benign GI strictures.Methods: We performed a comprehensive literature search, using PubMed and Em-base databases from database inception through October 2020, for all the studiesthat evaluated the clinical outcomes of LAMS use for benign GI strictures. The pri-mary outcomes of interest were technical and clinical success rates. The secondaryoutcomes were overall adverse events, migration, and re-intervention rates. All meta-analyses were conducted using a random-effect model. The publication bias wasassessed by Egger’s test. Results: A total of 12 studies, including 277 patients whounderwent 293 LAMS placements, met our inclusion criteria, and were included inthe final analysis. Overall, the pooled technical success rate was 98.4% (95% confi-dence interval (CI): 0.969-0.998), and the clinical success rate was 82.9% (95% CI:0.752-0.905) (Figure 1). Ten studies reported the overall adverse events rate, whichwas 29.2% (95% CI: 0.192-0.391) (Figure 2). The most common adverse event wasmigration, and the pooled migration rate was 9.7% (95% CI: 0.41-0.152) (Figure 2).Four studies (comprising 102 patients) reported a re-intervention rate of 28.4% (95%CI: 0.148-0.420) following LAMS removal or migration. The most common re-inter-vention was replacement with another stent (15, 46.9%), followed by balloon dila-tion (9, 28.1%). According to sites of stricture, subgroup analysis was performed interms of clinical success [Esophagogastric: 94.2% (95% CI: 0.879-1.005); Gastrodu-odenal: 75.5% (95% CI: 0.961-0.949); Gastrojejunal: 78% (95% CI: 0.638-0.922); Py-lorus: 77.6% (95% CI: 0.551-1.002); Colonic: 90.2% (95% CI: 0.745-1.059)]. Noevidence of publication bias was found (Egger’s test: PZ0.193). Conclusions: Ourmeta-analysis demonstrated that LAMS offers high technical and clinical success inthe management of benign GI strictures, with a low migration rate. However, it isassociated with relatively high re-intervention rates. Further studies are needed toevaluate the efficacy and safety of LAMS in those patients.


ID: 3516691BLUE LIGHT ENDOSCOPY IN DIAGNOSIS OFHISTOLOGICAL GRADE OF GASTRIC MUCOSAYing Zhu*, Wei GongObjective: To evaluate the clinical value of blue light endoscopy in the diagnosis ofhistological changes and grading of gastric mucosa. Methods From July 2019 toSeptember 2020, blue light imaging magnifying endoscopy was performed in ourEndoscopic Center for physical examination, 160 patients with intestinal metaplasiaand atrophy of gastric mucosa confirmed by pathological examination were selectedas research objects. In the process of blue light imaging endoscopy, the appearanceof the whole gastric mucosa was observed in the normal white light mode, the brightblue light imaging mode and the blue light imaging mode in turn. Under the whitelight mode, the samples were taken according to the pathological diagnosisconsensus of chronic gastritis biopsy.Under the bright blue light imaging mode andblue light imaging mode, the samples were taken at the abnormal part of mucosalcolor. Paired chi-square test was used to analyze the diagnostic rate of biopsypathology for intestinal metaplasia and atrophy of gastric mucosa under differentobservation model.Wilcoxon signed rank test was used to analyze the auxiliaryrecognition ability of CG histological change grades (0, +, + +, + + +) underdifferent observation modes. Results: The diagnostic accuracy of gastric mucosalatrophy was 6.9% (11/160), 49.4% (79/160) and 20.6% (33/160) in white light mode,bright blue light mode and blue light mode, respectively. The diagnostic rates ofintestinal metaplasia were 3.75% (6/160), 22.5% (36/160), 55.0% (88/160) respec-tively. Compared with the white light mode, the diagnosis rate of gastric mucosalatrophy was the highest under bright blue light imaging mode (P < 0.01)，thediagnosis rate of intestinal metaplasia of gastric mucosa was the highest in blue lightimaging mode (P < 0.01).the diagnosis rate of intestinal metaplasia of gastric mucosawas the highest in the blue light imaging mode (P < 0.01).In that aspect of theauxiliary identification ability in the CG histological grade, compared with the whitelight mode, bright blue light imaging mode was the best auxiliary recognition abilityfor grading gastric mucosal atrophy (ZZ-7.685, P < 0.01), blue light imaging was thebest auxiliary recognition ability for grading intestinal metaplasia (ZZ-8.272, P <0.01). Conclusion: Blue light imaging endoscopy has a good clinical value in thediagnosis of intestinal metaplasia and atrophy of gastric mucosa in CG. Bright bluelight imaging mode is more suitable for biopsy pathology and auxiliary histologicalgrading of gastric mucosa atrophy. Blue light imaging mode is more suitable forbiopsy pathology and auxiliary histological grading of intestinal metaplasia of gastricmucosa. Objective To evaluate the clinical value of blue light endoscopy in thediagnosis of histological changes and grading of gastric mucosa.


Abstracts


SATURDAY, MAY 22, 2021Clinical Endoscopic Practice 1Lecture

ID: 3526786COMPARING THE IMPACT OF REUSABLE ANDSINGLE-USE DUODENOSCOPES USING LIFE CYCLEASSESSMENTLyndon V. Hernandez*, Nguyen Nhat Thu Le, Casey Patnode,Omar Siddiqui, Olivier JollietComparing the Impact of Reusable and Single-Use Duodenoscopes Using Life CycleAssessment. Introduction: Multidrug-resistant infections have been linked tocontaminated duodenoscopes, prompting post-market surveillance investigations bythe FDA. Although economic models have been demonstrated for single-use duo-denoscopes, its large-scale effects on the environment and public health are notknown. Our aim was to perform a Life Cycle Assessment (LCA) comparing “cradle-to-grave” environmental effects of reusable and single-use duodenoscopes. Methods:Our LCA model included granular quantitative environmental effects of production,transportation, disposal, and high-level disinfection of reusable duodenoscopes,using SimaPro 9.1.0 and the IMPACT 2002+ life cycle impact assessment method.We evaluated 3 duodenoscopes: 1) reusable duodenoscope (Olympus TJF-Q180V);2) duodenoscope with disposable endcaps (Olympus TJF-Q190V); and 3) single-useduodenoscope (Boston Scientific Exalt Model D). We assumed an infection rate of0.02% and also considered ICU stay to treat infections from contaminated duode-noscopes, with sensitivity analysis. The primary outcome was carbon dioxide emis-sions (kg). Results: Performing ERCP with a single-use duodenoscope consumes 467MJ and releases 29.3 kg of CO2, which is 20 times more than using a reusable du-odenoscope (26.8 MJ and 1.55 kg CO2) or a duodenoscope with disposable endcaps(23.4 MJ and 1.37 kg CO2). Figure 1 compares the CO2 emission of the 3 types ofduodenoscopes. When analyzing effects on human health (not counting directimpact from infections due to insufficient data), ecosystems, and resource con-sumption are considered, the single-use duodenoscope still performs 18 to 65 timesworse than the other two duodenoscopes (Figure 2). Most of the impact of thesingle-use duodenoscope effects comes from the duodenoscope’s production,which accounts for 96% of the energy consumption and greenhouse gas emission.On the other hand, duodenoscopes with disposable endcaps perform slightly betterthan the reusable duodenoscope in all categories. Limitations: Our exploratorymodeling will require further refinement, integration with economic metrics, andvalidation. Conclusion: In our preliminary analysis, single-use duodenoscopes maycome at a higher environmental cost compared to reusable duodenoscopes.

CO2 Emission

Normalized Impact

SUNDAY, MAY 23, 2021Clinical Endoscopic Practice 1Poster

ID: 3526578PREDICTORS OF POOR OUTCOMES IN PATIENTS WITHNON-VARICEAL UPPER GASTROINTESTINAL BLEEDINGUNDERGOING UPPER ENDOSCOPYChristopher Nguyen*, Alexander Dang, Michelle Baliss, Mohammad Bilal,Ronak Gandhi, Benjamin Greiner, Milee Patel, Shifa Umar, Paul T. Kröner,Saurabh Chandan, Ishani Shah, Shailendra SinghBackground: Guidelines recommend that patients presenting with non-variceal up-per gastrointestinal bleeding (NVUGIB) should undergo esophagogastroduodeno-scopy (EGD) within 24 hours of presentation. While there is consensus regardingtiming of EGD, there is limited information regarding predictors of poor outcomesin patients who undergo EGD. We sought to determine the independent predictorsof poor outcomes (mortality, acute kidney injury, shock) in patients with NVUGIBwho underwent EGD. Methods: We conducted a retrospective cohort study usingthe Nationwide Inpatient Sample (NIS) from 2015-2017. Inclusion criteria were: i) aprincipal diagnosis of NVUGIB ii) admission in 2015-2017 iii) patients who under-went EGD during the admission. Exclusion criteria were age < 18 years and electiveadmission. The primary outcomes were the rates of mortality, shock and acutekidney injury (AKI) in NVUGIB patients who underwent EGD. Secondary outcomeswere independent predictors of developing mortality, AKI and shock. Unadjustedodds ratio for the outcomes were calculated using univariate analysis and subse-quent multivariate analysis was used to adjust the results for potential confounders.Results: A total of 310,735 patients were admitted with NVUGIB and underwent EGDfrom 2015-2017. The mean age was 67 years and 44.3% were female (Table 1). Theall-cause in-hospital mortality rate was 1.2%, while 20.1% and 3.7% of patientsdeveloped AKI and shock, respectively. The mean length of stay was 4.15 (� 0.016)days incurring $43,541.44 (� 204.78) in mean total hospitalization charges (Table 2).Independent predictors of mortality (Table 3) were age, Charlson comorbidity in-dex, and medium to large hospital bed size. Protective factors included femalegender, black and Hispanic ethnicity, and median income in the second to fourthquartiles. Independent predictors for AKI (Table 4) were age, Charlson comorbidityindex, black ethnicity, Medicare, and urban teaching/non-teaching hospitals. Inde-pendent predictors of shock (Table 5) included Charlson comorbidity index, to-bacco use, urban teaching/non-teaching hospitals, and medium to large hospital bedsize. Conclusions: Our analysis shows that Charlson co-morbidity index (CCI) is anindependent predictor for poor outcomes in patients undergoing EGD for NVUGIB.While several scoring criteria exist for triaging patients with NVUGIB, there iscurrently no clear consensus regarding which one to use for routine clinical practice.CCI can be easily calculated based on a patient’s history alone and can provide usefulinformation suggesting that patients with high CCI might benefit from moreaggressive management.


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TABLE 3. Univariate and multivariable analysis of mortality during hospi-talization of patients with NVUGIB + EGDTABLE 4. Univariate and multivariable analysis of AKI during hospitaliza-tion of patients with NVUGIB + EGDTABLE 5. Univariate and multivariable analysis of shock during hospitali-zation of patients with NVUGIB + EGD


ID: 3526419THE ADDITION OF FLEXIBLE ENDOSCOPIC SUTURINGTO STENTING IN THE MANAGEMENT OF ESOPHAGEALWALL DEFECTS: A SINGLE TERTIARY CENTEREXPERIENCEItegbemie Obaitan*, John M. Dewitt, Benjamin L. Bick, Gerardo Calderon,Feenalie Patel, Adil Ghafoor, Shanker Kundumadam, Aditya Gutta,Mark A. Gromski, Mohammad A. Al-HaddadBackground: Endoscopic stenting has replaced classic surgical management foresophageal wall defects such as tracheoesophageal fistulas, perforations, and post-operative leaks. The advent of flexible endoscopic suturing tools has led to furtherenhancements of defect closures. The aim of this study is to evaluate outcomes ofesophageal closure of wall defects using stenting with and without endoscopic su-turing. Methods: This is a single-center retrospective cohort study of prospectivelyaccrued data on patients with esophageal wall defects who underwent endoscopicinterventions. The impact of stenting with and without endoscopic suturing of thedefect was assessed. Univariate and multivariate logistic regression models wereused to examine factors associated with successful defect closure. Results: Onehundred and fourteen patients underwent 254 endoscopies with an overall closurerate of 75.8%. Twenty-three (20.2%) patients underwent primary closure using endo-scopic suturing and esophageal stenting (dual modality group) while ninety-one(79.8%) underwent esophageal stenting only (with or without suturing of the stent toprevent migration). Compared to the stent-only group, the dual modality group hadsimilar defect closure rate (84.2 vs 73.8%, pZ 0.55) and time to stent migration (37 vs12.5 days, pZ0.07) but was associated with longer procedure times (60 vs 36minutes,p<0.01) and fewer additional endoscopic procedures (13.6 vs 43.2%, p Z0.01).Chronic defects (� fourweeks old)were 83% less likely to close compared to acute (<4weeks) defects (OR 0.17, CI 0.05-0.6, pZ0.01) and larger diameter stents were asso-ciated with higher odds of defect closure (OR 2.84, CI 1.08 – 7.4, p Z 0.04). Stentsuturing significantly decreased migration rates (35.5% vs 58.5%, p Z 0.04), wasassociated with fewer additional endoscopies (15.4% vs 50%, p<0.01) and reducedneed for additional stents (7.7% vs 34.3%, p<0.01). Conclusion: Endoscopic treatmentof esophageal wall defects is safe and effective and our results suggest that defectsare more likely to close if treated within four weeks of initial esophageal wall injuryand if larger diameter stents are used. Stent suturing reduces migration and theneed for additional procedures and stent exchanges. Further comparative studieswith larger cohorts are needed to validate our results.

Analysis results


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Results for subgroup analyses and regression modelling


ID: 3526745COMPUTED TOMOGRAPHY APPEARANCE HELPS GUIDECLINICAL SUSPICION FOR PANCREATIC CANCERWITHIN THE CONTEXT OF EUS-FNA "ATYPICAL CELL"BIOPSY RESULTSJin A. Moon, Patrick R. Mayock, Karl Kwok*, Sathima Natarajan,Rex A. Parker, Bechien U. WuBackground: Almost 10% of endoscopic biopsies (EUS-FNA) for suspected pancre-atic cancers (PDAC) may be read as atypical diagnostic category (ADC), which isclinically inconclusive. Not only does this delay patient care, but also it is concerningthat some of these individuals may already have radiographic evidence of cancer onindex CT scan. Thus, our aim is threefold. 1. We aim to describe the natural historyof patients with ADC, specifically those which are ultimately diagnosed with PDAC.2. We aim to compare the survival times among a) ADC -> PDAC on repeat biopsy,b) ADC -> no PDAC, c) PDAC on index biopsy. 3. We aim to identify high risk CTfeatures concerning for PDAC at index study (in patients with ADC). Methods: In thisretrospective case series, we manually chart abstracted pancreatic EUS-FNAs per-formed from 11/08–12/16 at a tertiary referral center in Southern California. Weexcluded patients with active primary malignancies & those with prior biliarymanipulation. A subset of ADC patients underwent imaging review (contrastenhanced CT imaging 2 mo. prior to index EUS-FNA & biopsy of area of concern).The films were reviewed for presence of high-risk features (table 1). Next, we wereinterested in 3 survival times: 1) ADC -> PDAC on repeat biopsy, 2) ADC -> noPDAC, 3) PDAC on index biopsy. Pts were followed until date of censorship (12/1/20). Survival time was defined from date of index EUS-FNA to date of death based onchart review. Results: Of the 250 pts with pancreatic EUS-FNAs during the timeperiod, 44/250 (17.6%) were atypical (ADC). Natural history: In the ADC cohort,there were 19 M/25 F; median age of the cohort was 69.5 YO. Ultimately 25/44(56.8%) were diagnosed w/ PDAC after a median of 1.8 procedures (table 2). Survivaltime: The mean survival time in patients with ADC -> PDAC diagnosis was 20.3 mo.,while patients with ADC without PDAC was 55.8 months. The mean survival time ofa representative sample of 44 patients with first procedure diagnosis of PDAC was13.1 months. Imaging features: CT scans were reviewed in 24/44 ADC patients. 19were diagnosed with PDAC (repeat biopsy or surgery). Excluding 2 simple cysticlesions on CT, 21/22 lesions (>95%) had malignant pathology (p<0.038, 2 tail). Ofnote, 5/24 (21%) had no discrete lesion on CT, yet all these had malignancy onfurther workup. Conclusions: 1. >50% with ADC were diagnosed with PDAC,emphasizing the need for continued vigilance. 2. The mean survival time of ADC ->PDAC was 7 mo. longer than PDAC on index biopsy. 3. Re-read of index CT scansrevealed that unless a lesion was purely cystic (i.e. no obvious PDAC features), 83%had PDAC and >95% of patients had malignancy requiring surgery (p<0.038, 2 tail).

This highlights the importance of precise nomenclature on index CT scan to facili-tate timely clinical management.


ID: 3517591THE SAFETY AND EFFICACY OF THROMBIN FORBLEEDING GASTRIC VARICES - A SYSTEMATIC REVIEWAND META-ANALYSISAbhishek Bhurwal*, Michael Makar, Hemant R. Mutneja, Puru Rattan,Aruj Choudhry, Mihajlo Gjeorgjievski, Anish V. Patel, Michael J. Bartel,Haroon M. Shahid, Vinod K. Rustgi, Avik Sarkar, Savan KabariaIntroduction: Gastric varices (GV) are an uncommon but significant cause of gastro-intestinal (GI) bleeding associated morbidity and mortality. The optimal therapy forbleeding related gastric varices is still a controversial topic. There is a paucity ofliterature that comprehensively summarizes the available literature regarding safetyand efficacy of thrombin in bleeding gastric varices. Methods: Three independentreviewers performed a comprehensive review of all original articles published frominception to October 2020, describing the use of thrombin for management ofbleeding gastric varices. Primary outcomes were (1) the pooled immediate hemo-stasis rate, (2) pooled rebleeding rate (3) pooled gastric variceal related mortalityrate within 30 days (4) pooled rescue therapy rate and (5) pooled adverse event ratewith the use of thrombin in bleeding gastric varices. The meta-analysis was per-formed and the statistics were 2-tailed. Finally, probability of publication bias was


Abstracts


assessed using funnel plots and with Egger’s test. Results: Eleven studies reportedimmediate hemostasis after injecting thrombin in bleeding gastric varices. Thisyielded a pooled immediate hemostasis rate of 91.4 (95% CI 85-95.2; I2Z25.15). Apooled rebleeding rate of 15% (95% CI 9.8-22.3) was noticed with the use ofthrombin for bleeding gastric varices (I2Z26.05). Pooled rescue therapy rate afterinjecting thrombin in bleeding gastric varices was 10.2% (95% CI 5.9-17.1, I2Z9.68).The Pooled gastric variceal related mortality rate after injecting thrombin in bleedinggastric varices was 8.4% (95% CI 4.8-14.4). There was a total of 3 adverse events outof a total of 222 patients (1 was abdominal pain whereas 2 were febrile episodes).Pooled adverse event rate after injecting thrombin in bleeding gastric varices was4.6% (95% CI 2.3-9.1). Conclusion: In summary, the first systematic review and meta-analysis on the use of thrombin for bleeding gastric varices suggest high rates ofimmediate hemostasis, low rates of rebleeding and minimal rate of adverse events.While, the immediate hemostasis, rebleeding rate and rescue therapy rate are similarto cyanoacrylate-based therapy, the minimal rate of adverse events is perhaps themost important benefit of thrombin. Thus, the current data suggest that thrombin isa very promising therapeutic alternative with low risk of adverse events for bleedinggastric varices.


ID: 3519531COMPARING ADENOMA DETECTION RATE INAMPLIFEYE�-ASSISTED VS. STANDARD SURVEILLANCECOLONOSCOPYMichael Kalinowski*, Shana Kothari, Rogelio G. SilvaBackground: Colonoscopy is the gold standard in detection of malignant and prema-lignant colon polyps. It is estimated that missed adenomas account for 50% ofcolorectal cancers. Different modalities and devices have been tried, includingexternal caps on the tip of the endoscope to flatten the colonic folds and improvefields of view. The evidence of cap-assisted colonoscopy and benefit of adenomadetection among the average risk population has been conflicting, specifically

among patients undergoing surveillance colonoscopy. Given the lack of consensusregarding the overall benefit of cap-assisted colonoscopy, our study aimed tocompare the adenoma detection rate with AmplifEYE�-assisted colonoscopy versusstandard colonoscopy in high-risk patients that require surveillance colonoscopy.Methods: This was a single-center, prospective, randomized controlled study testingadenoma detection of the AmplifEYE� Endoscopy Device among high-risk patientsundergoing surveillance colonoscopy. Informed written consent was obtained priorto randomization and colonoscopy. Patients were randomized to either theAmplifEYE� or the standard colonoscopy control group. Two patients were unableto complete their colonoscopy with the AmplifEYE� Device secondary to anal ste-nosis and were switched to the control group. Demographic data, colonoscopyprocedure and pathology reports, and colonoscopy preparation data were collectedand analyzed from October 2019 to October 2020. Univariate analysis was per-formed. Results: We have a total of 54 patients; 27 patients were randomized to thecontrol group and 27 patients were randomized to the AmplifEYE� group. Thecontrol group and AmplifEYE� group had a median age of 62 and 68 years of age,respectively (pZ0.0303). No significant sex or race differences were detected. Nocolonoscopy timing differences were found relating to insertion time to cecum,withdrawal time, or total procedure time among either group. The polyp detectionrate was the same between both groups (59%; pZ1.000). The standard group had ahigher detection of diminutive polyps (32% vs 7%) and the AmplifEYE-assistedgroup had a higher detection of small polyps (29% vs 47%) No correlation wasobserved between polyp location or pathology among the two groups (Table 1).Conclusion: The AmplifEYE�-assisted colonoscopy did not show superiority to astandard colonoscopy in regards to polyp detection. The AmplifEYE� devicegroup detected far less diminutive polyps which raises concerns about polypdetection effectiveness. The study sample size was a limiting factor. Larger long-termstudies incorporating additional endoscopists is warranted to verify if such devicesimprove adenoma detection rate and decrease occurrence of interval cancers.Additionally, economic analysis would be useful to measure the cost-benefit ratio,especially in comparison with other techniques.


ID: 3519617COMPARISON OF NO STENT FIXATION,FULL-THICKNESS ENDOSCOPIC SUTURING, ANDOVER-THE-SCOPE CLIP (OTSC) IN PREVENTINGMIGRATION OF FULLY COVERED SELF EXPANDINGMETAL STENTS (FCSEMS)Daniel Lew*, Sarvanand Patel, Quin Liu, Srinivas Gaddam, Kapil Gupta,Laith H. Jamil, Simon K. Lo, Kenneth H. ParkIntroduction: Fully covered self-expandable metal stents (FCSEMS) are used both inbenign and malignant luminal diseases. The benefit of FCSEMS is that it iscompletely removable; however, stent migration is a major limitation to duration oftherapy and poses risk for downstream obstruction or perforation. Endoscopic su-turing with OverStitch (Apollo Endosurgery), and over-the-scope clips (OTSC) havebeen used to prevent migration. More recently, a dedicated OTSC devicedstentfix(Ovesco)d has been developed for securing stents. Currently, there is very limiteddata on its use. Aims:The primary aim was comparing the frequency of stentmigration with no stent fixation and suturing, and stentfix. Secondary aims wereevaluating clinical success, and comparing procedure duration and adverse events.Methods: A retrospective cohort study between January 2013 to October 2020 of allpatients with FCSEMS placement were included. Stent migration was determined asstent displacement from the top of the stent by � 1cm as determined endoscopicallyor radiographically. Clinical success was defined by resolution of indication afterstent removal. Results: The study included 199 patients. Multiple patients requiredrepeat procedures for stent adjustment and/or fixation and were counted as aseparate event. In all, 438 procedures were performed with 264 (60%) without fix-ation, 150 (34%) with suturing, and 23 (5%) with stentfix. Indications for stentplacement included 44% benign stricture, 35% fistula/perforation, and 20% malig-nant stricture. Majority of stents (53%) were placed in the esophagus (Table 1). Stentmigration rates at all weeks assessed were not significantly different between stentfixand suturing (p>0.05). Migration rate was significantly lower when comparingstentfix and suturing to no fixation up to 8 weeks (pZ0.02, Figure 1). Beyond 8weeks, there was no significant differences in all groups (p>0.05). Median time tostent migration for no fixation was 3 weeks compared to stentfix and suturing at 5weeks (pZ0.005). Clinical success rate for the cohort occurred in 121 patients(61%). Total median procedure time for stentfix was significantly shorter comparedto suturing (44 vs 68 minutes, pZ0.002). Rates of adverse events were not signifi-cantly different, but trended towards being lowest in the stentfix group at 9%,compared to 21% with no fixation, and 18% with suturing (p>0.05). Adverse eventsincluded chest/abdominal pain and nausea/vomiting. There were no perforations.Discussion: Stentfix and endoscopic suturing seem to be equally effective in prevent-ing stent migration when compared to no fixation. Moreover, stentfix was associatedwith decreased overall procedure time and adverse events, and therefore may be


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preferred over endoscopic suturing especially given its lower costs. Future studieswith larger sample size may help further assess the differences.

Table 1. Baseline patient characteristics based on index procedure.

Figure 1. Cumulative stent migration (percentage) from time of stentplacement. Shown are p-values comparing OTSC and sutures to no stentfixation. (OTSC and sutures were not significantly different at all weeks,p>0.05, not shown in figure).


ID: 3524448THE CLINICAL OUTCOMES OF ENDOSCOPIC CLOSUREOF GASTROINTESTINAL TRACT LEAKS, AND FISTULASUSING THE OVERSTITCH DEVICE: A SYSTEMATICREVIEW AND META-ANALYSISAzizullah Beran*, Sami Ghazaleh, Yasir Alabboodi, Mohammed Mhanna,Hazem Ayesh, Muhammad Aziz, Reem Matar, Ali NawrasBackground: Endoscopic treatment modalities for gastrointestinal (GI) leaks and fis-tulas have become a promising alternative therapeutic option to surgical repair.Several studies have studied endoscopic closure of leaks and fistulas using theoverstitch device. This meta-analysis aimed to determine the clinical outcomes andsuccess rate of endoscopic closure of GI leaks and fistulas using the over-stitchdevice. Methods: We performed a comprehensive search in the literature, usingMedline and Embase databases from inception through October 2020, for all studiesthat assessed the clinical outcomes of endoscopic closure of GI leaks and fistulasusing the overstitch device. The primary outcome was the clinical success rate.Clinical success was defined as radiologic or clinical evidence of complete closure ofleaks or fistulas at the conclusion of the follow-up period. All meta-analyses wereconducted using a random-effect model. The publication bias was assessed by Eg-ger’s test. Results: Ten studies with a total of 268 patients were included in thepooled analysis. In these studies, the pooled overall clinical success rate was 75.8%(95% confidence interval (CI): 0.655-0.862, Figure 1). In a subgroup analysis of leaks,nine studies with 105 patients were included; the clinical success rate was 80.4%(95% CI: 0.681-0.928, Figure 2). In a subgroup analysis of fistulas, six studies with 100patients were included; the clinical success rate was 64.8% (95% CI: 0.465-0.831,Figure 2). Of note, one study reported only the total number of both leaks andfistulas. No evidence of publication bias was found (Egger’s test: PZ0.381).Conclusions: Our meta-analysis demonstrated that endoscopic closure of GI leaksand fistulas using the overstitch device is a promising endoscopic therapeutic

option with a relatively high clinical success rate, especially in leaks. However,further studies with larger sample sizes are warranted to determine the long-termclinical success of endoscopic closure of GI leaks and fistulas using the overstitchdevice.

SUNDAY, MAY 23, 2021Clinical Endoscopic Practice 1Lecture

ID: 3525605THE LOCATION-BASED RESECT AND DISCARDSTRATEGY FOR DIMINUTIVE COLORECTAL POLYPS: APROSPECTIVE CLINICAL STUDYMahsa Taghiakbari*, Heiko Pohl, Roupen Djinbachian, Alan N. Barkun,Paola Marques, Mickael Bouin, Erik Deslandres, Benoit Panzini,Simon Bouchard, Audrey Weber, Daniel Von RentelnBackground: Replacing histopathology evaluation of diminutive polyps with opticalpolyp diagnosis is considered a cost-effective approach. However, the widespreaduse of optical diagnosis is limited due to concerns about making incorrect opticaldiagnoses and the requirements of training, credentialing and auditing of perfor-mance. Aims: This prospective study aimed to evaluate a simplified resect anddiscard strategy that is not operator dependent. Methods: The study evaluated aresect and discard strategy that uses anatomical polyp location to classify colonpolyps into non-neoplastic or low-risk neoplastic. All rectosigmoid diminutive polypswere considered hyperplastic and all polyps located proximally to the sigmoid colonwere considered neoplastic. Surveillance interval assignments based on these apriori assumptions were compared with those based on actual pathology results andoptical diagnosis, respectively. The primary outcome was �90% agreement withpathology in surveillance interval assignment. Results: Overall, 1117 patients un-dergoing complete colonoscopy were included and 482 (43.1%) had at least onediminutive polyp. Surveillance interval agreement between the location-based resectand discard strategy and pathological findings using the 2020 US Multi-Society TaskForce guideline was 97.0% (95% CI Z 0.96 - 0.98), surpassing the �90% benchmark.Optical diagnoses using NICE and Sano classifications reached 89.1% and 90.01%agreement, respectively (p <0.0001), and were inferior to the location-based strat-egy. The location-based resect and discard strategy allowed a 69.7% (95% CIZ 0.67 -0.72) reduction in pathology examinations compared with 55.3% (95% CI Z 0.52 -0.58) (NICE and Sano) and 41.9% (95% CI Z 0.39 - 0.45) (WASP) with opticaldiagnosis. Conclusions: The location-based resect and discard strategy achieved very


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high surveillance interval agreement with pathology-based surveillance intervalassignment, surpassing the �90% quality benchmark and outperforming opticaldiagnosis in surveillance interval agreement and the number of pathology exami-nations avoided.


ID: 3526093THE VALUE OF QUANTITATIVE FAECALIMMUNOCHEMICAL TEST (QFIT) AS A PRIORITISATIONTOOL FOR PATIENTS WITH IRON DEFICIENCYREQUIRING URGENT OUTPATIENT INVESTIGATIONWilliam Clackett*, Aidan CahillDifficulty in providing endoscopy for patients with iron deficiency anaemia (IDA)during the COVID-19 pandemic has highlighted the requirement for a prioritisationtool. Currently qFIT has a role in colorectal cancer screening and in identifying pa-tient cohorts with colorectal symptoms who may benefit from more urgent endos-copy. We aimed to test the validity of qFIT as a prioritisation tool in patients withiron deficiency and its ability to identify patients with neoplasia, defined as upper GIcancer, colonic adenoma over 1cm or colorectal cancer. Data collected from patientsreferred with biochemically proven iron deficiency and synchronous qFIT who un-derwent full gastrointestinal investigation within NHS Greater Glasgow and Clydewas analysed retrospectively. Biochemically proven iron deficiency was defined as aferritin � 15 micrograms/L. Patients who did not undergo full investigation, definedas gastroscopy and colonoscopy or CT colonography, were excluded. Outcomesfrom these investigations were linked to qFIT results. Area under the curve (AUC)analysis was performed on qFIT results and outcome, defined as the presence ofneoplasia. Sensitivity and specificity from AUC analysis guided cut-off scores forqFIT. Patients with a qFIT of <9, 10-200, >200, were allocated a score of 1, 2 and 3respectively. A total of 575 patient met criteria for inclusion into the study. Withinthe patient cohort, 50 patients had a confirmed neoplasm. Overall, qFIT resultsstrongly predicted the presence of GI neoplasms (AUC 0.866, 0.812-0.921; P<0.001). The prevalence of neoplasm in patients with scores 1 to 3 was 1.2%, 13.5%and 38.9% respectfully. When controlled for other significant variables, patients witha higher qFIT score were statistically more likely to have a GI neoplasm (qFIT scoreZ 2; OR 12.8; P<0.001, qFIT score Z 3, OR 50.0; P<0.001). qFIT was highly sen-sitive for the presence of neoplasia (92.0% (84.4%-99.5%), with moderate specificity(63.2% (59.1%-67.4%)). A negative qFIT had a high negative predictive value for thepresence of neoplasia (98.5% 97.5%-100.0%). These results strongly suggest thatqFIT has validity as a prognostic tool in patients with iron deficiency; both allowingfor a more informed decision of investigation of patients with very low risk of ma-lignancy, and in identifying higher risk patients who may benefit from more urgentendoscopy.


ID: 3517867COMPARISON OF COLONOSCOPY FINDINGS INPATIENTS WITH PRECEDING FIT POSITIVE AND MT-SDNA POSITIVE TESTS TO PATIENTS HAVING ACOLONOSCOPY ONLY: DATA FROM THE NEWHAMPSHIRE COLONOSCOPY REGISTRYJoseph C. Anderson*, Paul Limburg, Christina Robinson, William Hisey,Lynn ButterlyBackground: There are few comparisons of fecal immunochemical test (FIT) andmulti-target stool DNA (mt-sDNA) screening test outcomes in clinical practice. Wecompared the yield of colorectal neoplasia in colonoscopies of patients with pre-ceding FIT+ or mt-sDNA+ tests to findings for those presenting for screening co-lonoscopy without a preceding positive stool test in the New HampshireColonoscopy Registry (NHCR), a comprehensive statewide population-based colo-noscopy database. Methods: Using an IRB-approved protocol, data from Exact Sci-ences Laboratories were used to identify patients in the NHCR catchment area (NH,VT, ME & MA) with a positive mt-sDNA as part of their usual care (8/2015-6/2019).From this group we identified average-risk patients with a subsequent colonoscopyin the NHCR within 1 year of their mt-sDNA+ test. Average-risk patients who hadfollow-up colonoscopy after FIT+ tests (1/2011-7/2019) or who had screening co-lonoscopies with no prior positive stool test were also investigated. Outcomes wereany colorectal neoplasia and an ordered outcome: adenocarcinoma/CRC, advancedprecancerous neoplasia (adenoma or serrated polyp �1 cm, or with �25% villouselements and/or high-grade dysplasia of any size), non-advanced neoplasia andnormal (including rectosigmoid hyperplastic polyps (HPs) <5 mm). We alsocompared yield for conventional advanced neoplasia versus clinically relevantserrated polyps (all Traditional Serrated Adenomas (TSAs), Sessile Serrated Polyps(SSPs), & HPs >Z10 mm), including TSAs/SSPs of all sizes. Co-variates includeddemographics (age, sex, race) and health (smoking, BMI, overall health status), andaspirin, NSAID, or anticoagulant use. Results: Our sample included 52,876 averagerisk adults: 240 mt-sDNA+ (average age (66.5), 426 FIT+ (65.3) and 52,210screening colonoscopy patients (58.9). Mt-sDNA+ patients had a substantiallyhigher yield at follow-up colonoscopy for any neoplasia (67.1%) as compared toFIT+ (43.9%, p < 0.001) or colonoscopy only (37.5%, p < 0.001) patients. Whenexamining the findings as an ordered outcome (most to least advanced pathology),we had similar results; patients with mt-sDNA+ tests had a higher yield than theother two groups (p < 0.001 for both comparisons; see Table 1). Logistic regressionshowed that positive FIT (ORZ1.34; 95%CI:1.08-1.67) and mt-sDNA (ORZ3.72;


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95%CI:2.75-5.02) testing were more likely to predict neoplasia than screening co-lonoscopy alone. When we examined the results by histology, we observed that mt-sDNA+ tests were significantly more likely to predict serrated lesions than FIT+(Table 2). Conclusions: At follow-up colonoscopy, mt-sDNA+ tests were more likelyto predict neoplasia than FIT+ as compared to colonoscopy alone, largely due to anincreased yield of serrated polyps.


ID: 3523942ENDOCUFF ASSISTED PUSH ENTEROSCOPY INCREASESTHE DIAGNOSIS OF GASTROINTESTINALANGIODYSPLASIAChristian S. Jackson, Chandrasekhar Kesavan, Anjali Das, Erick Imbertson,Richard M. Strong*Gastrointestinal angiodysplasias (GIADs) are the most common cause for suspectedsmall bowel bleeding. Approximately 50% of GIADs do not need treatment sec-ondary to bleeding cessations, while 45% have high re-bleeding rates, causing asignificant impact on patient health and VA Healthcare resources. This is likely dueto undetected lesions by the current endoscopic methods. Therefore, in this studywe evaluated whether endoscopy assisted Endocuff (a device with two rows of softprojections that remain flattened during insertion but spreads out mucosal foldsupon withdrawal with push enteroscopy (PE)) could improve GIAD detection. Aretrospective chart review of a prospective data collection was performed fromJanuary 2006 to December 2018 at VA Loma Linda Healthcare System (VALLHCS) onboth inpatients and outpatients with symptomatic GIADs initially detected via videocapsule endoscopy (VCE). GIADs observed between 0%-40% small bowel transittime (SBTT) were referred for PE with and without (+/-) the Endocuff device (EC).25 consecutive patients underwent PE +/- EC. Using PE-EC, GIADs were detected in9 of 25 (36%) patients. PE+EC detected 23 of 25 (92%) patients with GIADs. Thesum of GIADs detected without EC was 26 � 0.06 vs. 112 � 0.2 using EC (Figure 1).The average detection rate for PE without EC was significantly lower (1.04 � 0.06,mean � SE) when compared to PE with EC (4.48 � 0.23, mean � SE, p<0.0005). Wefound a positive correlation (rZ0.25) between CE location of GIADs and SBTT(Figure 2). There were no complications. In conclusion, the EC increases thedetection of GIADs and that we reconfirm the location of bleeding GIADs are withinthe reach of PE. Finally, PE+EC may reduce miss rates of GIADs, which may play arole in the reduction of rebleeding episodes.


ID: 3519259BEYOND THE RECENT MODIFIED DELPHI CONSENSUSSTATEMENTS ON WATER EXCHANGE (WE) - MORENOVEL BENEFITS OF WE.Yu-Hsi Hsieh*, Chih Wei Tseng, Malcolm Koo, Felix W. LeungIntroduction: In 2020, we presented the main results of a randomized controlledtrial (RCT) in Chinese patients. We confirmed the result of a previous RCT in Eu-ropean patients (Endoscopy. 2017;49:456) that water exchange (WE) significantlyincreased right colon adenoma detection rate (rADR). We reproduced the finding ofan RCT in Chinese patients in Taiwan (JCG 2020, in press) that WE significantlyreduced right colon adenoma miss rate (rAMR). We assessed additional findings toidentify previously unreported benefits of WE. Method: We conducted an RCTcomparing rADR (primary outcome) between WE and air insufflation using tech-niques similar to those in our previous report (GIE 2017;86:192). After cecal intu-bation, a second blinded colonoscopist examined the right colon. Then, the firstcolonoscopist reinserted the scope to the cecum using WE in both groups andcompleted the withdrawal to the anus. Data on rADR, rAMR, and right colon serratedlesion detection rate (rSLDR) published by members of the IWATERS (InternationalWater Aided Techniques for Endoscopy and Research Society) were tabulated forcomparison (Table 1). Results: The novel findings (Table 2) showed the meannumber of adenomas per colonoscopy was significantly higher in the WE group [0.9(1.1) vs. 0.5 (1.0), pZ0.005]. The significance in the rADR between WE and airinsufflation was notable in diminutive polyps (34.0% vs. 16.4%, pZ0.001) and non-polypoid adenomas (30.6% vs. 18.6%, pZ0.020). Analysis based on the indicationsfor colonoscopy showed a significantly higher rADR for WE than air insufflation insurveillance patients (40.4% vs. 17.2%, pZ0.008). In patients fully sedated withpropofol, the rADR was significantly higher in WE group than the air insufflationgroup (41.8% vs. 16.9%, pZ0.001). Adenoma per positive colonoscopy was com-parable between the two groups [1.7 (1.0)] vs. [1.7 (1.1)]. The blinded colono-scopist also detected a higher rSLDR with WE than with air insufflation (18.1% vs.7.1%, pZ0.007). The Boston Bowel Preparation Scale (BBPS) score was significantlyhigher in the WE group [2.8 (0.4) vs. 2.7 (0.5), pZ0.006]. Conclusion: The currentreport provided a comprehensive set of observations confirming the significantlybetter rADR, BBPS score, and lower rAMR previously reported in separated studieson WE (Table 1). The significantly higher rSLDR advanced earlier post hoc analysis.The significantly higher number of adenomas per colonoscopy and non-polypoidADR in the right colon also were unique discoveries. The novel data filled the gap in


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our knowledge unaddressed in the recent modified Delphi consensus statements onWE (GIE 2020, in press). The impact of the significant findings in this report on theoccurrence of interval cancers deserves to be studied, as earlier reports linkedmissed right colon lesions with the development of interval cancers.


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CLINICAL ENDOSCOPIC PRACTICE 1

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