L1 24 (44%), L2 8 (14%), L3 23 (42%),L4 2 (4%).In CD, 19 (35%) were smokers, 5 (9%)had familiar history ofIBD.Among the 93 IBD pts with arthralgias, rheumatologic assessmentdiagnosed rheumatologic diseases in 33 (88%) UC and in 44 (80%) CD pts. In particular,a diagnosis of SpAewas made in 50 (54%) IBD pts(54% peripheral SpA, 24%, axial SpA,22% both), 24 (26%)Osteoarthritis, 6 (7%)Fybromialgia,3 (3%), Gout, 3 (3%)RheumatoidArthritis, 2 (2%) Psoriatic Arthritis, while diagnosis was inconclusive in 5 (6%) pts. Afterrheumatological assessment, a higher percentage of IBD pts were treated with disease-modifying anti-rheumatic drugs (including anti-TNFs)(5.3% vs 15%, p=0.03, RR 1.6)and/or with anti-COX2 (6.4% vs 27%; p<0.0001; RR 2.3). Anti-TNFs use also significantlyincreased (19% vs 34%, p=0.009;RR 1.8).Conclusions. Multidisciplinary IBD care includingrheumatologists may facilitate the diagnosis and management of arthralgias in IBD. A com-bined multidisciplinary approach may also lead to an early diagnosis and proper treatmentof chronic and debilitating inflammatory arthritis.

Su1136

Cost Minimization Analysis of Onsite Cytopathologist (CyP) EvaluationDuring EUS-FNA of Solid Pancreatic Lesions: Results From a MulticenterProspective Randomized Controlled TrialSachin Wani, Amit Rastogi, Dayna S. Early, Daniel Mullady, Brian T. Collins, Jeff F. Wang,Roy D. Yen, Sharon B. Sams, Carrie Marshall, Srinivas Gaddam, Brian C. Brauer, StuartK. Amateau, Vladimir M. Kushnir, Mona Rizeq, Thomas G. Hollander, Lindsay Hosford,Sydney S. Johnson, Riad R. Azar, Ozlem Ulusarac, Maria M. Romanas, Norio Fukami, RajJ. Shah, Steven A. Edmundowicz, Ananya Das

Background: Results of a recent RCT showed that onsite CyP evaluation during EUS-FNAof solid pancreatic lesions (SPL) reduces the overall number of FNA passes without impactingthe overall diagnostic yield of malignancy. However, considerable additional resources arerequired to have onsite CyP in the endoscopy room and it is not clear if such a strategyleads to overall cost-savings. Aim: To perform a cost-minimization analysis of a strategyusing onsite CyP evaluation during EUS-FNA of SPL compared to one without onsite CyP.Methods: A decision analysis tree was constructed using decision analysis software and 2competing strategies were compared in patients with SPL undergoing EUS-FNA. Understrategy I, slides from each EUS-FNA pass were prepared by a cytotechnician and a CyPinterpreted slides during the procedure to asses for adequacy and a preliminary diagnosis.In strategy II, endosonographers performed a number of passes at their discretion until itwas felt that adequate samples have been obtained. Aspirate was put into a preservativesolution and transported to the cytology laboratory. Slides were assessed by CyP after theprocedure was completed. Under both strategies, repeat EUS was performed if clinicallyindicated (non-diagnostic 1st procedure). The model did not consider any cost associatedwith further work-up beyond 2 non-diagnostic EUS procedures. Data on parameters: diagnos-tic yield and adequacy of sampling with and without onsite CyP, incremental diagnosticyield with second EUS procedures were obtained from a recent multi-center RCT (Table),primary results comparing diagnostic yield of malignancy between the 2 arms are presentedelsewhere. The analysis was performed from a third party payor perspective, and CMS dataon EUS-FNA procedural reimbursement, reimbursement for sedation and interpretation ofonsite and offsite cytology slides was used. Cost parameters in terms of utilization and salaryof cytotechnician were obtained from local institutional data. Results: In the baseline analysis,cost per patient with onsite CyP evaluation at US$ 2,053 compared to US$ 2,090 withoutonsite CyP. Sensitivity analysis revealed the following factors as determinants of cost indescending order of magnitude of impact: cost of procedure (including sedation cost),probability of diagnostic yield with offsite CyP, probability of adequate sampling with off-site cytology, probability of incremental adequacy of sampling with onsite cytology, number ofslides required for adequate sampling with on-site pathology, and probability of incrementaldiagnostic yield with onsite pathology (Figure - Tornado diagram). Conclusion: Within thereported range of parameters, with need for additional resources, availability of onsite CyPevaluation does not increase costs and actually adds minimal cost saving in patients withSPL undergoing EUS-FNA.Table: Estimate of Clinical and cost variables used in the model

RCT*: Wani et al, 2014 abstract submitted to DDW

S-385 AGA Abstracts

Su1137

Significant Increase in Pancreatectomy Rates in the United States: A 19-Year(1993-2011) Population Based StudyNirav C. Thosani, Alka Sehgal, Ann M. Chen, Shai Friedland, Gurkirpal Singh, SubhasBanerjee

Background: The number of CT scans performed annually in the U.S. has increased from<3 million/yr in 1980 to > 80 million/yr at present. A consequence of this dramatic increasein utilization of CT and MRI scans, is that asymptomatic pancreatic lesions (APLs) areincreasingly being identified. Over the last 2 decades, endoscopic ultrasound has also beenincreasingly used for the diagnosis and characterization of asymptomatic and symptomaticpancreatic lesions. In a recent single center study, 23% of pancreatic surgeries were performedfor APLs identified incidentally, following imaging studies performed for other reasons.Whether a similar trend is seen across the United States remains an important public healthquestion. Aim: To evaluate the US national trends in pancreatectomy rates in the contextof known national trends of increasing utilization of diagnostic imaging studies includingCT scans, MRI scans and Endoscopic Ultrasound. Methods: We used hospitalization datafrom the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care databasein the United States to estimate the rate of pancreatectomies from 1993 to 2011. We studiedall inpatient hospitalizations in the NIS with primary or secondary procedure codes ofpancreatectomy. Results: The rate of partial pancreatectomy (proximal, distal or ‘other')increased by 73%, from 1.62 per 100,000 persons (95% CI, 1.57-1.67) to 2.81 per 100,000persons (95% CI, 2.75-2.87) from 1993 to 2011 (p < 0.001). Of partial pancreatectomies,the most dramatic increase was seen in the rate of distal pancreatectomy, which increasedby 97%, from 1.15 per 100,000 persons (95% CI, 1.11-1.20) in 1993 to 2.27 per 100,000persons (95% CI, 2.22-2.32) in 2011 (p < 0.001). Rates of proximal pancreatectomy didnot increase significantly. A dramatic increase was also seen in the rate of radical pancreatico-duodenectomy, which increased by 110%, from 1.75 per 100,000 persons (95% CI, 1.69-1.80) in 1993 to 3.68 per 100,000 persons (95% CI, 3.62-3.75) in 2011 (p < 0.001). Therate of total pancreatectomy increased by a smaller but significant amount (25%), from 0.24per 100,000 persons (95% CI, 0.22-0.26) in 1993 to 0.30 per 100,000 persons (95% CI,0.28-0.32) in 2011 (p < 0.001). Table 1 highlights the results of rates of pancreatectomyper 100,000 hospitalizations and 100,000 US populations. Figure 1 highlights the temporaltrends of pancreatic surgeries from 1993 to 2011. Conclusion: Our results indicate anoverall marked increase in the rate of pancreatectomies between 1993 and 2011, perhapscorrelating with the detection of asymptomatic pancreatic lesions due to due to increasedutilization of abdominal diagnostic imaging techniques including CT/MRI scans and Endo-scopic Ultrasound.Pancreatectomy rates per 100,000 US Resident Population & per 100,000 Hospitaliza-tion

AG

AA

bst

ract

s

AG

AA

bst

ract

s

Figure 1: Temporal trends of pancreatectomies from 1993 to 2011 per 100,000 Hospital-izations

Su1138

Dramatic Decline in Bile Duct Surgery Rates With Increased Utilization ofTherapeutic ERCP in the United States: Population-Based National Data Over19 Years (1993-2011)Nirav C. Thosani, Alka Sehgal, Shai Friedland, Ann M. Chen, Gurkirpal Singh, SubhasBanerjee

Background: Biliary diseases account for substantial clinical and economic burdens onmedical services. Gallstone disease alone accounted for 1.8 million ambulatory care visits,700,000 surgeries, & 622,000 hospitalizations in the U.S. in 2004. Over the last few decades,ERCP has become the mainstay for the diagnosis and management of biliary disease. ERCPhas also evolved from a largely diagnostic to a predominantly therapeutic procedure. Theimpact of widespread availability of ERCP and associated endoscopic interventions for biliarystrictures and stones, on the need for biliary surgery remains unknown, and is an importantpublic health question. Aim: To evaluate U.S. national trends in bile duct surgery rates, inthe context of known national trends in utilization of therapeutic ERCP. Methods: Weused hospitalization data from the Nationwide Inpatient Sample (NIS), the largest all-payerinpatient care database in the United States to estimate rates of bile duct surgery from 1993through 2011. We studied all inpatient hospitalizations with primary or secondary procedurecodes of bile duct surgeries/procedures. Results: The rate of inpatient ERCP with sphinctero-tomy increased by 171%, from 15 per 100,000 persons (95% CI, 14.99-15.29) in 1993 to41 per 100,000 persons (95% CI, 40.84-41.29) in 2011 (p < 0.001). The rates of inpatientERCP with stent placement and ERCP with stone removal also increased by 198% and200%, respectively from 1993 to 2011(p<0.001) (Table 1). Along with the rising rates oftherapeutic ERCP, we noted concurrently falling rates of biliary surgery. Rates of anastomosisof the bile duct or gall bladder to the small bowel decreased by 81%, from 3.0 per 100,000persons (95% CI, 2.9-3.1) to 0.57 per 100,000 persons (95% CI, 0.54-0.60) from 1993 to2011 (p < 0.001). Similarly, the rate of incision of bile duct for relief of obstruction (commonbile duct exploration) decreased by 82%, from 10.6 per 100,000 persons (95% CI, 10.5-10.7) to 1.94 per 100,000 persons (95% CI, 0.19-0.20) from 1993 to 2011 (p < 0.001).The rate of percutaneous extraction of common duct stones declined by 79%, from 0.53per 100,000 persons (95% CI, 0.50-0.55) to 0.11 per 100,000 persons (95% CI, 0.10-0.12)from 1993 to 2011 (p < 0.001). The rate of repair of bile ducts decreasedby 29%, from0.83 per 100,000 persons (95% CI, 0.8-0.9) to 0.59 per 100,000 persons (95% CI, 0.56-0.62) from 1993 to 2011 (p < 0.001) (Table 1). Figure 1 highlights the temporal trendsfor inpatient therapeutic ERCPs and bile duct surgeries from 1993 to 2011. Conclusion:Our results indicate a marked overall increase in therapeutic ERCP and a concurrent markedreduction in rates of bile duct surgeries in the U.S. between 1993 and 2011. These findingshighlight the significant impact of therapeutic ERCP on the management of biliary diseases.Table 1: Inpatient therapeutic ERCP & Bile duct surgery rates per 100,000 US Resi-dent Population

S-386AGA Abstracts

Figure 1: Temporal trends for inpatient therapeutic ERCPs and bile duct surgeriesfrom 1993 to 2011

Su1139

New Technology Therapy Using High-Intensity Focused Ultrasound (HIFU)for Pancreatic CancerAtsushi Sofuni, Fuminori Moriyasu, Takatomo Sano, Fumihide Itokawa, TakayoshiTsuchiya, Toshio Kurihara, Shujiro Tsuji, Kentaro Ishii, Nobuhito Ikeuchi, Junko Umeda,Reina Tanaka, Ryoske Tonozuka, Mitsuyoshi Honjo, Shuntaro Mukai, Takao Itoi

INTRODUCTION: Recently, High-intensity focused ultrasound (HIFU) is most expected asnew advanced therapy for pancreatic cancer (PC). HIFU therapy with chemotherapy is beingpromoted as new method to control local advance by cauterizing tumor and achieve reliefof pain caused by PC. AIMS & METHODS: We have evaluated the therapeutic effect andapplicability of HIFU therapy in locally advanced and metastatic PC. We treated PC patientsusing HIFU therapy as optional local therapy as well as systemic chemo / chemo-radiotherapy,with whom an agreement was obtained in adequate IC, from the end of 2008 in our hospital.This study took approval of member of ethic society of our hospital. HIFU device used isFEP-BY02 (China Medical Technologies Co.LTD., China). The subjects were 54 PC patients,i.e. 35 cases in stage III, 19 cases in stage IV. RESULTS: All tumors were visualized by HIFUmonitor system. Treatment data in Stage III and IV were followed; mean tumor size was34.4 vs 30.8 mm, mean treatment sessions: 3.0 vs 2.5 times, mean total treatment time:2.6 vs 2.1 hours, mean total number of irradiation: 3024 vs 1838 shots, respectively. Therewas no significant difference in treatment data between two groups. The effects of HIFUtherapy in Stage III and IV were the following; the rate of complete tumor ablation was85.7 vs 63.2%, the rate of symptom relief effect was 65 vs 58%, the effectiveness of primarylesion was CR:0, PR:4, SD:29, PD:2 vs CR:0, PR:3, SD:14, PD:2, primary disease controlrate (DCR) more than SD was 94.3% vs 89.5%. Comparison of mean survival time (MST)after diagnosis in Stage III and IV was 35.0 vs 15.2 months, respectively (p<0.05, p =0.021).MST after diagnosis in HIFU with chemotherapy and chemotherapy alone (38 patients inour hospital) was 29.3 vs 12.2 months, respectively (p<0.001). Combination therapy ofHIFU with chemotherapy was better result than common chemotherapy alone. CONCLU-SION: This study suggested that HIFU therapy has the potential of new method of combina-tion therapy for PC.