Arvind J. Trindade

A survey of current practice of venous thromboembolism prophylaxis in hospitalized inflammatory bowel disease patients in the United States.

Background: Inflammatory bowel disease (IBD) patients are at an increased risk of thrombosis, particularly when hospitalized. Several clinical practice guidelines now recommend pharmacologic prophylaxis for hospitalized ulcerative colitis and Crohn’s disease patients. It is unclear to what extent gastroenterologists are aware of these recommendations and whether they are administering pharmacologic venous thromboembolism (VTE) prophylaxis appropriately. Our aim was to explore current practice of VTE prophylaxis in hospitalized IBD patients in the United States. Methods: A survey was mailed electronically to gastroenterologists whose electronic mail address was listed in the American College of Gastroenterology (ACG) database. This survey included clinical vignettes outlining scenarios for consideration of VTE prophylaxis. Results: A total of 6227 surveys were sent to gastroenterologists nationwide, and 591 physicians chose to participate (response rate 9.5%). Respondents (80.6%) believed that hospitalized IBD patients have a higher risk of VTE than other inpatients. A total of 29.1% were unaware of any recommendations addressing pharmacologic prophylaxis included in ACG IBD guidelines and 34.6% would give pharmacologic VTE prophylaxis to a hospitalized patient with severe ulcerative colitis. Heparin VTE prophylaxis use was associated with gastroenterologists who indicated that their practices comprised more than 50% of patients with IBD (P=0.0001), being a physician at an academic hospital (P=0.0001) and providers having less than 5 years practice experience (P=0.003). Conclusions: Despite reasonable awareness of the increased risk of thrombosis in hospitalized IBD patients, many US gastroenterologists may not follow clinical practice guidelines and use pharmacologic VTE prophylaxis.

Current practice and perception of screening for medication adherence in inflammatory bowel disease.

Background Adherence to medication in inflammatory bowel disease (IBD) improves outcomes. Current practices of screening for adherence to IBD medications are unknown. The goal of this study was to determine current practice and perception of screening for medication adherence among US-based gastroenterologists. Methods A survey was mailed electronically to gastroenterologists whose electronic-mail address was listed in the American College of Gastroenterology database. Physicians who cared for IBD patients were invited to answer. Results About 6830 surveys were sent to gastroenterologists nationwide, and 395 physicians who cared for IBD patients completed the survey. The true response rate is unknown, as the number of physicians caring for IBD patients in the database is unknown. About 77% (n=303) of physicians who responded stated they screen for adherence to medication. Of the 77% of physicians who screened for adherence, only 19% (n=58) use accepted measures of screening for adherence (pill counts, prescription refill rates, or adherence surveys). The remaining 81% used patient interview to screen for adherence, a measure considered least accepted to determine adherence, as it overestimates adherence. The average number of IBD patients observed in 1 week had no statistical significance in predilection for screening (P=0.82). Private practice physicians (P=0.05), younger physicians (P=0.03), and physicians with fewer years of experience (P=0.02) all were more likely to screen. About 95% of responders thought determining a low adherer to medicine was important because an intervention can increase adherence. Conclusions The majority of gastroenterologists surveyed recognize that adherence to medication is important and improves outcomes. The majority of physicians in this study are screening for nonadherence in IBD, but are not using accepted measures for adherence detection. If this study truly reflects the majority of physicians nationwide, changing the way physicians screen for adherence, may detect more low adherers to medication.

Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort.

IMPORTANCE Nonsurgical biliary drainage in malignant biliary tract obstruction can be performed endoscopically by endoscopic retrograde cholangiopancreatography (ERCP) or by percutaneous transhepatic biliary drainage (PTBD). The published body of literature to support either approach is surprisingly sparse, is conflicting on the preferred approach, and is limited by small studies with heterogeneous groups. OBJECTIVE To evaluate the procedure-related adverse event rate with endoscopic vs percutaneous drainage in patients with malignant biliary tract obstruction. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective analysis from the National Inpatient Sample (NIS) database from 2007 through 2009. Data analysis was performed in 2015. Patients from the NIS database are representative of the US population and are included from both community and tertiary care hospitals in the United States. MAIN OUTCOMES AND MEASURES Procedure-related adverse event rates. RESULTS A total of 7445 patients were included for ERCP and 1690 for PTBD. The overall adverse event rate was 8.6% for endoscopic drainage (640 events) and 12.3% for percutaneous biliary drainage (208 events) (P < .001). When analyzed by type of malignant neoplasm, ERCP was associated with a lower rate of adverse events compared with PTBD for pancreatic cancer (2.9% vs 6.2%; odds ratio [OR], 0.46 [95% CI, 0.35-0.61]; P < .001) and cholangiocarcinoma (2.6% vs 4.2% OR, 0.62 [95% CI, 0.35-1.10]; P = .10). For pancreatic cancer, endoscopic procedures were associated with a lower rate of adverse events regardless of the volume of percutaneous procedures performed by a center. For cholangiocarcinoma, centers that performed a low volume of percutaneous biliary drainage procedures were more likely to have adverse events compared with endoscopic procedures performed at the same center (5.7% vs 2.5%; OR, 2.28 [95% CI, 1.02-5.11]; P = .04). In centers that performed a high volume of percutaneous drainage procedures, rates of adverse events were similar to those of endoscopic adverse events (3.5% vs 3.0%; OR, 1.18 [95% CI, 0.53-2.66]; P = .68). CONCLUSIONS AND RELEVANCE Our results support the finding that endoscopic biliary drainage for malignant biliary obstruction is a first-line intervention. Endoscopic drainage is superior to percutaneous drainage, in regard to adverse event rate, for patients with pancreatic cancer. For patients with cholangiocarcinoma, endoscopic drainage is superior in centers that perform a low volume of percutaneous biliary drainage procedures.

The new kid on the block for advanced imaging in Barrett’s esophagus: a review of volumetric laser endomicroscopy

Advanced imaging techniques used in the management of Barrett’s esophagus include electronic imaging enhancement (e.g. narrow band imaging, flexible spectral imaging color enhancement, and i-Scan), chromoendoscopy, and confocal laser endomicroscopy. Electronic imaging enhancement is used frequently in daily practice, but use of the other advanced technologies is not routine. High-definition white light endoscopy and random four quadrant biopsy remain the standard of care for evaluation of Barrett’s esophagus; this is largely due to the value of advanced imaging technologies not having been validated in large studies or in everyday practice. A new advanced imaging technology called volumetric laser endomicroscopy is commercially available in the United States. Its ease of use and rapid acquisition of high-resolution images make this technology very promising for widespread application. In this article we review the technology and its potential for advanced imaging in Barrett’s esophagus.

Volumetric laser endomicroscopy can target neoplasia not detected by conventional endoscopic measures in long segment Barrett's esophagus.

Methods and study aims: The incidence of esophageal cancer is rising despite increased surveillance efforts. Volumetric laser endomicroscopy (VLE) is a new endoscopic imaging tool that can allow for targeted biopsy of neoplasia in Barrett’s esophagus. We report a series of 6 patients with long-segment Barrett’s esophagus ( > 3 cm), who underwent a session of endoscopy with volumetric laser endomicroscopy, after a separate prior session of standard high-definition endoscopy with narrow band imaging (NBI) and random biopsies that did not reveal neoplasia. In all six patients, the first endoscopy was the index endoscopy diagnosing the Barrett’s esophagus. All VLE exams were performed within 6 months of the previous endoscopy. In five patients, VLE-targeted biopsy resulted in upstaged disease/diagnosed dysplasia that then qualified the patient for endoscopic ablation therapy. In one patient, VLE localized a focus of intramucosal cancer that allowed for curative endoscopic mucosal resection. This case series shows that endoscopy with VLE can target neoplasia that cannot be localized by high-definition endoscopy with NBI and random biopsies.

Use of a cap in single-balloon enteroscopy-assisted endoscopic retrograde cholangiography.

BACKGROUND AND STUDY AIM Cannulation of the native papilla in surgically altered anatomy is difficult in endoscopic retrograde cholangiography (ERC). There are limited data regarding the success of single-balloon enteroscopy-assisted ERC (SBE-ERC) in patients with a native papilla and Roux-en-Y gastric bypass. Use of a plastic cap may assist cannulation in these cases. The aim of the current study was to investigate the use of SBE-ERC with a cap (Cap-SBE-ERC) in patients with surgically altered anatomy referred for ERC. PATIENTS AND METHODS Patients with surgically altered anatomy (hepaticojejunostomy, gastric bypass surgery, and Whipples surgery) who underwent Cap-SBE-ERC were identified from a prospectively maintained database. Outcomes were diagnostic and procedural success. Patients with a native papilla were compared with those with a biliary-enteric anastomosis. RESULTS Among 56 patients with surgically altered anatomy, high rates of diagnostic and procedural success were observed (78.6 % and 71.4 %, respectively). High diagnostic and procedural success rates of 72.7 % and 65.9 %, respectively, were also observed for patients with Roux-en-Y gastric bypass anatomy with a native papilla (n = 44). CONCLUSION High rates of diagnostic and procedural success were reported for SBE-ERC with the use of a cap, including a large subgroup of patients with Roux-en-Y gastric bypass and a native papilla.

Decompensated cirrhosis may be a risk factor for adverse events in endoscopic retrograde cholangiopancreatography

There are limited data regarding the safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis. The current literature consists of small series totalling less than 225 patients.

Weekend vs. Weekday Admissions for Cholangitis Requiring an ERCP: Comparison of Outcomes in a National Cohort

OBJECTIVES:There has been increasing medical literature showing worse outcomes in patients admitted for medical and surgical conditions on the weekend. This has been termed the weekend effect. Little is known whether this weekend effect occurs for patients with cholangitis who require endoscopic retrograde cholangiopancreatography (ERCP), a procedure that requires many resources from the nursing staff, anesthesia, and the endoscopist.METHODS:Retrospective analysis from the National Inpatient Sample (NIS) database from 2009 through 2012. Patient data were abstracted from the database for patients admitted on the weekend and weekday with cholangitis who underwent ERCP. Time to ERCP, length of stay, total cost, and mortality were compared in patients admitted with cholangitis on the weekend vs. weekday who required ERCP. ERCP adverse events were recorded from the weekend vs. weekday as well.RESULTS:Twenty-three thousand six-hundred sixty-one patients were identified in the NIS database who were admitted for cholangitis who required ERCP in the study period, of which 18,106 (76.5%) patients were admitted on the weekday, whereas 5,555 (23.5%) were admitted on the weekend. By 24 h, the weekday group had undergone ERCP more frequently than the weekend group (54.6 vs. 43%; P<0.001). By 48 h, the weekday group had undergone ERCP more frequently than the weekend group (70 vs. 65.4%; P<0.001). By 72 h, both groups had undergone a similar rate of ERCP (79.7 vs. 78.9%; P=0.17). There was no statistical difference between the groups for in-hospital all-cause mortality (2.86 vs. 2.56%; P=0.24), length of stay (6.97 days vs. 6.88 days; P=0.28), or total cost of hospitalization (

Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship

71,552 vs

Targeting neoplasia using volumetric laser endomicroscopy with laser marking

71,469; P=0.94).CONCLUSIONS:Despite a delay in regard to time to ERCP for weekend admissions, there was no weekend effect observed in regard to length of stay, mortality, or total cost of hospitalization. Although biliary drainage with ERCP is important, these results suggest that other factors in the management of cholangitis (e.g., antibiotics and intravenous fluids) contribute to outcomes.