Search

Background and Aims EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. Methods We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. Results Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. Conclusions Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.

ObjectiveAlthough gastric per-oral endoscopic myotomy (G-POEM) is considered a promising technique for the management of refractory gastroparesis, high-quality evidence is limited. We prospectively investigated the efficacy and safety of G-POEM in unselected patients with refractory gastroparesis.DesignIn five tertiary centres, patients with symptomatic gastroparesis refractory to standard medical therapy and confirmed by impaired gastric emptying were included. The primary endpoint was clinical success, defined as at least one score decrease in Gastroparesis Cardinal Symptom Index (GCSI) with ≥25% decrease in two subscales, at 12 months. GCSI Score and subscales, adverse events (AEs) and 36-Item Short Form questionnaire of quality of life were evaluated at baseline and 1, 3, 6 and 12 months after G-POEM. Gastric emptying study was performed before and 3 months after the procedure.ResultsOf 80 enrolled patients, 75 patients (94%) completed 12-month follow-up. Clinical success at 12 months was 56% (95% CI, 44.8 to 66.7). GCSI Score (including subscales) improved moderately after G-POEM (p2.6 (OR=3.23, p=0.04) and baseline gastric retention >20% at 4 hours (OR=3.65, p=0.03) were independent predictors of clinical success at 12 months, as was early response to G-POEM at 1 month after therapy (OR 8.75, pConclusionG-POEM is a safe procedure, but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged.Trial registration numberClinicalTrials.gov Registry NCT02732821.

The incidence of eosinophilic esophagitis (EoE) has been rapidly increasing. EoE affects both children and adults and can present with a variety of symptoms depending on age. Multiple studies have found that EoE is more common in Caucasian men compared with other genders or racial or ethnic groups; however, the basis for that predominance is still unknown. The varied clinical illness presentation and persistence in various ethnic groups begs the question of whether genetic or environmental factors might be contributors behind EoE. This paper will review the literature regarding epidemiology, risk factors, and genetic and ethnic differences in EoE.

Predictive models for key outcomes of coronavirus disease 2019 (COVID-19) can optimize resource utilization and patient outcome. We aimed to design and internally validate a web-based calculator predictive of hospitalization and length of stay (LOS) in a large cohort of COVID-19-positive patients presenting to the Emergency Department (ED) in a New York City health system. The study cohort consisted of consecutive adult ( 18 years) patients presenting to the ED of Mount Sinai Health System hospitals between March 2020 and April 2020, diagnosed with COVID-19. Logistic regression was utilized to construct predictive models for hospitalization and prolonged ( 3 days) LOS. Discrimination was evaluated using area under the receiver operating curve (AUC). Internal validation with bootstrapping was performed, and a web-based calculator was implemented. From 5859 patients, 65% were hospitalized. Independent predictors of hospitalization and extended LOS included older age, chronic kidney disease, elevated maximum temperature, and low minimum oxygen saturation (p 0.001). Additional predictors of hospitalization included male sex, chronic obstructive pulmonary disease, hypertension, and diabetes. AUCs of 0.881 and 0.770 were achieved for hospitalization and LOS, respectively. Elevated levels of CRP, creatinine, and ferritin were key determinants of hospitalization and LOS (p 0.05). A calculator was made available under the following URL: https://covid19-outcome-prediction.shinyapps.io/COVID19_Hospitalization_Calculator/ . This study yielded internally validated models that predict hospitalization risk in COVID-19-positive patients, which can be used to optimize resource allocation. Predictors of hospitalization and extended LOS included older age, CKD, fever, oxygen desaturation, elevated C-reactive protein, creatinine, and ferritin.

Aim To determine the aetiology, hospital course, and outcome of patients diagnosed with acute pancreatitis (AP) presenting to the Emergency Department (ED) of a tertiary care center in Lebanon. Patients and Methods Using a retrospective cross-sectional study design, records of all patients presenting to the ED with elevated lipase over one calendar year (2016) were reviewed. Patients diagnosed with AP according to the revised Atlanta classification were identified. Results Over one year, a total of 24,133 adult patients visited the ED and 4,976 had serum lipase determination. Of those, 75 patients (mean age 59.4 ± 16.1; range 20–95; M:F 2.1) had confirmed AP accounting for 0.3% of adult ED visits. The most common etiologies were biliary (36%), idiopathic (16%), drugs (13%), and alcohol (11%). Intake of drugs known to be associated with AP was identified in 26% of patients. Alcoholic pancreatitis was more common in males, while biliary pancreatitis was more common in females (p less than 0.05 in both). 63 patients (84%) required regular hospital admission and only 1 (1.3%) required intensive care unit admission and passed away after multiorgan failure. Mean hospital stay was 4.0 ± 4.0 days (range 0–23) with mean hospital charges of $6,637 ± 8,496. Conclusion Acute pancreatitis accounts for a relatively small number of emergency visits in Lebanon. Leading etiologies are biliary and drugs, with a low contribution of alcohol compared to the West. The economic burden of AP is important, but outcomes appear largely favorable with an overall mortality of less than 2%.

Background Endoscopic resection of lesions involving the appendiceal orifice remains a challenge. We aimed to report outcomes with the full-thickness resection device (FTRD) for the resection of appendiceal lesions and identify factors associated with the occurrence of appendicitis. Methods This was a retrospective study at 18 tertiary-care centers (USA 12, Canada 1, Europe 5) between November 2016 and August 2020. Consecutive patients who underwent resection of an appendiceal orifice lesion using the FTRD were included. The primary outcome was the rate of R0 resection in neoplastic lesions, defined as negative lateral and deep margins on post-resection histologic evaluation. Secondary outcomes included the rates of: technical success (en bloc resection), clinical success (technical success without need for further surgical intervention), post-resection appendicitis, and polyp recurrence. Results 66 patients (32 women; mean age 64) underwent resection of colonic lesions involving the appendiceal orifice (mean [standard deviation] size, 14.5 (6.2) mm), with 40 (61 %) being deep, extending into the appendiceal lumen. Technical success was achieved in 59/66 patients (89 %), of which, 56 were found to be neoplastic lesions on post-resection pathology. Clinical success was achieved in 53/66 (80 %). R0 resection was achieved in 52/56 (93 %). Of the 58 patients in whom EFTR was completed who had no prior history of appendectomy, appendicitis was reported in 10 (17 %), with six (60 %) requiring surgical appendectomy. Follow-up colonoscopy was completed in 41 patients, with evidence of recurrence in five (12 %). Conclusions The FTRD is a promising non-surgical alternative for resecting appendiceal lesions, but appendicitis occurs in 1/6 cases.

BACKGROUND: Gastric cancer (GC) is a leading cause of cancer-related death in the world and most patients have advanced disease upon presentation. The effect of age on prognosis in GC is controversial. We aimed to determine the impact of age on survival in patients with GC. METHODS: This was a retrospective study of the medical records of Lebanese patients diagnosed with GC at the American University of Beirut Medical Center (AUBMC) between 2005 and 2014. Patients were divided into young (

Background Serum lipase is a rapid and reliable laboratory test central to diagnosing acute pancreatitis (AP). Routine use in the emergency department (ED) setting for all cases of abdominal pain or as part of a standard laboratory biochemical profile may lead to unnecessary expenses. Aim To examine the utility of serum lipase determination at a tertiary care centre ED. Methods Retrospective cross-sectional study of ED patients having serum lipase determination over a 12-month period. Electronic medical records were reviewed for indication and interpretation leading to additional diagnostic imaging, specialist consultation, interventions or hospital admission. Results A total of 24 133 adult patients visited the ED during the study period: 4976 (20.6%) had serum lipase determination, 614 (12.4%) had abnormal lipase, 130 of which (21.1%) were above the diagnostic threshold for acutre pancreatitis (AP) (>3× ULN). A total of 75 patients had confirmed AP (0.3% of all adult ED visits). The positive and negative predictive values of serum lipase (>3× ULN) for AP were 43.6% and 99.6%, respectively. One thousand eight hundred and ninety patients (38.0%) had no abdominal pain on history or physical examination. In this group, the total charge associated with lipase determination was $51 030 with 251 (13.3%) elevated lipase values triggering cross-sectional abdominal imaging in 61 (24.3%) patients and unwarranted gastroenterology consultation in three (1.2%) for an additional charge of $28 975. Conclusions Serum lipase is widely overutilised in the emergency setting resulting in unnecessary expenses and investigations. Evidence-based review of clinical guidelines and more restrictive testing can result in substantial cost savings and improved patient care.