Gitanjali Vidyarthi

Comparative effectiveness of traditional chemoembolization with or without sorafenib for hepatocellular carcinoma.

AIM To compare the overall survival (OS) and progression-free survival (PFS) with associated adverse events (AE) in patients with unresectable hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE) + sorafenib vs TACE alone. METHODS In this retrospective cohort study we collected data on all consecutive patients with a diagnosis of unresectable HCC between 2007 and 2011 who had been treated with TACE + sorafenib or TACE alone. We hypothesized that the combination therapy is superior to TACE alone in improving the survival in these patients. Data extracted included patients demographics, etiology of liver disease, histology of HCC, stage of liver disease with respect to model of end stage liver disease score and Child-Turcotte-Pugh (CTP) classification and Barcelona Clinic Liver Cancer (BCLC) staging for HCC. Computed tomography scan findings, alpha fetoprotein levels, number of treatments and related AE were also recorded and analyzed. RESULTS Of the 43 patients who met inclusion criteria, 13 were treated with TACE + sorafenib and 30 with TACE alone. There was no significant difference in median survival: 20.6 mo (95%CI: 13.4-38.4) for the TACE + sorafenib and 18.3 mo (95%CI: 11.8-32.9) for the TACE alone (P = 0.72). There were also no statistically significant differences between groups in OS (HR = 0.82, 95%CI: 0.38-1.77; P = 0.61), PFS (HR = 0.93, 95%CI: 0.45-1.89; P = 0.83), and treatment-related toxicities (P = 0.554). CTP classification and BCLC staging for HCC were statistically significant (P = 0.001, P = 0.04 respectively) in predicting the survival in patients with HCC. The common AE observed were abdominal pain, nausea, vomiting and mild elevation of liver enzymes. CONCLUSION Combination therapy with TACE + sorafenib is safe and equally effective as TACE alone in patients with unresectable HCC. CTP classification and BCLC staging were the significant predictors of survival. Future trials with large number of patients are needed to further validate this observation.

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia (IDA) is common and often under recognized problem in the elderly. It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract. Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel (SB). Capsule endoscopy (CE) provides direct visualization of entire SB mucosa, which was not possible before. It is superior to push enteroscopy, enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA. Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA. The diagnostic yield of CE for IDA progressively increases with advancing age, and is highest among patients over 85 years of age. Balloon assisted enteroscopy is used to treat the lesions seen on CE. CE has some limitations mainly lack of therapeutic capability, inability to provide precise location of the lesion and false positive results. Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.

Safety of conscious sedation in patients with sleep apnea in a veteran population.

Objectives: Due to the presumed higher risk of cardiopulmonary complications in patients with obstructive sleep apnea (OSA), many endoscopy centers consider OSA a contraindication to using conscious sedation. We evaluated the safety of conscious sedation during endoscopy for patients with OSA in a veteran population, and compared this to patients without OSA. Methods: Polysomnography studies were reviewed from 2004 to 2009 to identify 200 patients with OSA who had undergone endoscopy. Controls included the last 200 consecutive endoscopies in this institution for patients without OSA. Sixty-three upper endoscopies, 136 colonoscopies, and one enteroscopy were included in the OSA group. Sixty-five upper endoscopies, 133 colonoscopies, one sigmoidoscopy, and one endoscopic ultrasound comprised the control group. Data obtained included demographics, medications prescribed, and any complication noted in the procedure report. Results: No complications occurred in the control group. In the OSA group, a patient experienced oxygen desaturation during an upper endoscopy and required oxygen supplementation. The procedure was completed and did not require an extended stay in the endoscopy suite. Conclusion: This study demonstrated that endoscopy can be safely done in OSA patients using conscious sedation, and the complication rate is not significantly different than patients without OSA.

Safety of Gastrointestinal Endoscopy With Conscious Sedation in Patients With and Without Obstructive Sleep Apnea.

Background and Study Aims: Patients with obstructive sleep apnea (OSA) undergoing endoscopy with sedation are considered by practitioners to be at a higher risk for cardiopulmonary complications. The aim of the present study was to evaluate the safety of conscious sedation in patients with OSA undergoing gastrointestinal endoscopy. Patients and Methods: This is an IRB-approved prospective cohort study performed at the James A. Haley VA. A total of 248 patients with confirmed moderate or severe OSA by polysomnography and 252 patients without OSA were enrolled. Cardiopulmonary variables such as heart rate, blood pressure, and level of blood oxygen saturation were recorded at 3-minute intervals throughout the endoscopic procedure. Results: In total, 302 colonoscopies, 119 esophagogastroduodenoscopies, 6 flexible sigmoidoscopies, and 60 esophagogastroduodenoscopy/colonoscopies were performed. None of the patients in the study required endotracheal intubation, pharmacologic reversal, or experienced an adverse outcome as a result of changes in blood pressure, heart rate, or blood oxygen saturation. There were no significant differences in the rate of tachycardia (P=0.749), bradycardia (P=0.438), hypotension (systolic/diastolic, P=0.460; mean arterial pressure, P=0.571), or hypoxia (P=0.787) between groups. The average length of time spent in each procedure and the average dose of sedation administered also did not differ significantly between the groups. Conclusions: Despite the presumed increased risk of cardiopulmonary complications, patients with OSA who undergo endoscopy with conscious sedation have clinically insignificant variations in cardiopulmonary parameters that do not differ from those without OSA. Costly preventative measures in patients with OSA are not warranted.

Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea

AIM To perform a systematic review and meta-analysis to assess the safety of conscious sedation in patients with obstructive sleep apnea (OSA). METHODS A comprehensive electronic search of MEDLINE and EMBASE was performed from inception until March 1, 2015. In an effort to include unpublished data, abstracts from prior gastroenterological society meetings as well as other reference sources were interrogated. After study selection, two authors utilizing a standardized data extraction form collected the data independently. Any disagreements between authors were resolved by consensus among four authors. The methodological quality was assessed using the Newcastle Ottawa tool for observational studies. The primary variables of interest included incidence of hypoxia, hypotension, tachycardia, and bradycardia. Continuous data were summarized as odds ratio (OR) and 95%CI and pooled using generic inverse variance under the random-effects model. Heterogeneity between pooled studies was assessed using the I2 statistic. RESULTS Initial search of MEDLINE and EMBASE identified 357 citations. A search of meeting abstracts did not yield any relevant citations. After systematic review and exclusion consensus meetings, seven studies met the a priori determined inclusion criteria. The overall methodological quality of included studies ranged from moderate to low. No significant differences between OSA patients and controls were identified among any of the study variables: Incidence of hypoxia (7 studies, 3005 patients; OR = 1.11; 95%CI: 0.73-1.11; P = 0.47; I2 = 0%), incidence of hypotension (4 studies, 2125 patients; OR = 1.10; 95%CI: 0.75-1.60; P = 0.63; I2 = 0%), incidence of tachycardia (3 studies, 2030 patients; OR = 0.94; 95%CI: 0.53-1.65; P = 0.28; I2 = 21%), and incidence of bradycardia (3 studies, 2030 patients; OR = 0.88; 95%CI: 0.63-1.22; P = 0.59; I2 = 0%). CONCLUSION OSA is not a significant risk factor for cardiopulmonary complications in patients undergoing endoscopic procedures with conscious sedation.

Colonic stasis and chronic constipation: Demystifying proposed risk factors for colon polyp formation in a spinal cord injury veteran population

Background and Aims: Patients with spinal cord injury (SCI) suffer significant morbidity from neurogenic bowel. Chronic constipation has long-been a proposed risk factor for polyp development. We performed a retrospective cohort study in veterans with SCI to assess polyp presence in the setting of colonic stasis. Methods: All consecutive patients at the James A. Haley Veterans Affairs Hospital with SCI and neurogenic bowel who completed screening colonoscopy between January 1, 2004 to June 30, 2013 were included. Colonoscopies were excluded if they were aborted, not completed to the cecum, of less than adequate preparation, or if polypectomy was precluded. Patient data included level, duration, and completeness of SCI. Polyp data included number, location, and histology. Results: 325 patients ultimately met inclusion criteria. Most were male (96%). The average age at screening colonoscopy was 62.8 years. The majority of patients had injury to the cervical spine (41.5%). Colon polyps were detected in 130 patients (40%). Adenomatous change was seen in 95 (73%) of these patients. The adenoma detection rate (ADR) across all patients was 29.2%. Polyp presence and ADR demonstrated no statistically significant correlation with level, degree, or duration of SCI. Only patient age at time of screening colonoscopy had a significant correlation with polyp and adenoma presence (P<0.05). Conclusions: SCI had no statistically significant correlation with polyp or adenoma presence. The ADR in our veteran SCI population with chronic constipation is comparable with that reported in the general population.

Precision Medicine for CRC Patients in the Veteran Population: State-of-the-Art, Challenges and Research Directions.

Colorectal cancer (CRC) accounts for ~9% of all cancers in the Veteran population, a fact which has focused a great deal of the attention of the VA’s research and development efforts. A field-based meeting of CRC experts was convened to discuss both challenges and opportunities in precision medicine for CRC. This group, designated as the VA Colorectal Cancer Cell-genomics Consortium (VA4C), discussed advances in CRC biology, biomarkers, and imaging for early detection and prevention. There was also a discussion of precision treatment involving fluorescence-guided surgery, targeted chemotherapies and immunotherapies, and personalized cancer treatment approaches. The overarching goal was to identify modalities that might ultimately lead to personalized cancer diagnosis and treatment. This review summarizes the findings of this VA field-based meeting, in which much of the current knowledge on CRC prescreening and treatment was discussed. It was concluded that there is a need and an opportunity to identify new targets for both the prevention of CRC and the development of effective therapies for advanced disease. Also, developing methods integrating genomic testing with tumoroid-based clinical drug response might lead to more accurate diagnosis and prognostication and more effective personalized treatment of CRC.

S1829 A Comparative Evaluation of Esophageal Capsule Endoscopy Versus Esophagogastroduodenoscopy for Assessing Esophageal Varices in a Veteran Population

Introduction: Screening cirrhotic patients with EGD for esophageal varices (EV) to identify those at risk for catastrophic gastrointestinal hemorrhage is the current standard of care. Esophageal capsule endoscopy (ESO) is increasingly recognized as an alternative non-invasive screening tool to detect EV. This trial was designed to determine if ESO could assess the presence and grade of EV with accuracy comparable to EGD. ESO and EGD were also compared in terms of procedural complications and their ability to detect gastric varices (GV) and stigmata of potential bleeding. Methods: 34 patients with ESLD were prospectively enrolled in an IRB-approved protocol in this study. Each underwent ESO followed by EGD on the same day. EGD and ESO were performed by separate trained Gastroenterologists who were blinded to the results of the other. Each ESO study was also evaluated by another ESO-experienced Gastroenterologist. Findings were reviewed and analyzed. Findings: Using EGD as the gold standard, detecting EV by ESO had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100%, 66.7%, 93.3%, and 100% respectively. EV grade was classified as absent, small, medium, or large. Complete agreement of EV grade occurred in 25/34 (73.5%) cases. Strength of association using the Kendall tau-b score was 0.7991. Only 1/18 patients with small EV by ESO had medium EV on EGD. Conversely, 2/12 patients with medium or large EV by ESO had small EV on EGD. Evaluation of stigmata of potential bleeding with ESO compared to EGD had a sensitivity, specificity, PPV, and NVP of 92.6%, 85.7%, 96.1% and 75% respectively. Utility of ESO in the detection of GV was limited where sensitivity was only 33.3%. Four minor adverse events occurred with EGD that included hypotension, hypoxia and possible aspiration. No complications occurred with ESO. There was no significant difference in the side effect profiles of ESO and EGD. Conclusions: Based on minimal invasiveness, lack of need for sedation, less discomfort, and fewer side effects, ESO may be a more desirable procedure for cirrhotic patients that need EV screening. This study shows good correlation between ESO and EGD in detecting EV and assessing grade for treatment purposes as noted on published studies. ESO lacks sensitivity for assessment of gastric varices. Larger studies with additional patients are needed for further evaluation.