Jose Nieto

Costs and clinical outcomes of primary prophylaxis of variceal bleeding in patients with hepatic cirrhosis: A decision analytic model

OBJECTIVE:Current guidelines recommend upper endoscopic screening for patients with hepatic cirrhosis and primary prophylaxis with a nonselective β-blocker for those with large varices. However, only 25% of cirrhotics develop large varices. Thus, the aim of this study is to evaluate the most cost-effective approach for primary prophylaxis of variceal hemorrhage.METHODS:Using a Markov model, we compared the costs and clinical outcomes of three strategies for primary prophylaxis of variceal bleeding. In the first strategy, patients were given a β-blocker without undergoing upper endoscopy. In the second strategy, patients underwent upper endoscopic screening; those found to have large varices were treated with a β-blocker. In the third strategy, no prophylaxis was used. Selected sensitivity analyses were performed to validate outcomes.RESULTS:Our results show screening prophylaxis was associated with a cost of

Similar Efficacies of Endoscopic Ultrasound Gallbladder Drainage With a Lumen-Apposing Metal Stent Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis

37,300 and 5.72 quality-adjusted life yr (QALYs). Universal prophylaxis was associated with a cost of

Nonalcoholic Fatty Liver Disease in Latinos

34,100 and 6.65 QALYs. The no prophylaxis strategy was associated with a cost of

International multicenter comparative trial of endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for the treatment of malignant gastric outlet obstruction

36,600 and 4.84 QALYs. The incremental cost-effectiveness ratio was

Hepatocellular carcinoma screening in patients waiting for liver transplantation: A decision analytic model

800/QALY for the endoscopic strategy relative to the no prophylaxis strategy. Screening endoscopy was cost saving when the compliance, bleed risk without β-blocker, and variceal bleed costs were increased, and when the discount rate, bleed risk on β-blockers, and cost of upper endoscopy were decreased. In contrast, the universal prophylaxis strategy was persistently cost saving relative to the no prophylaxis strategy. In comparing the strategies, sensitivity analysis on the death rates from variceal hemorrhage did not alter outcomes.CONCLUSIONS:Our results provide economic and clinical support for primary prophylaxis of esophageal variceal bleeding in patients with hepatic cirrhosis. Universal prophylaxis with β-blocker is preferred because it is consistently associated with the lowest costs and highest QALYs.

Tu1202 Interim Results From a Multi-Center Post-Marketing Surveillance Registry Study for Endoscopic Anterior Fundoplication

Background & Aims Acute cholecystitis in patients who are not candidates for surgery is often managed with percutaneous transhepatic gallbladder drainage (PT‐GBD). Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) with a lumen‐apposing metal stent (LAMS) is an effective alternative to PT‐GBD. We compared the technical success of EUS‐GBD versus PT‐GBD, and patient outcomes, numbers of adverse events (AEs), length of hospital stay, pain scores, and repeat interventions. Methods We performed a retrospective study to compare EUS‐GBD versus PT‐GBD at 7 centers (5 in the United States, 1 in Europe, and 1 in Asia), from 2013 through 2015, in management of acute cholecystitis in patients who are not candidates for surgery. A total of 90 patients (56 men) with acute cholecystitis (61 calculous, 29 acalculous) underwent EUS‐GBD (n = 45) or PT‐GBD (n = 45). Data were collected on technical success, clinical success (resolution of symptoms or laboratory and/or radiologic abnormalities within 3 days of intervention), and need for repeat intervention. Characteristics were compared using Student t tests for continuous variables and the chi‐square test, or the Fisher exact test, when appropriate, for categorical variables. Adverse events were graded according to American Society for Gastrointestinal Endoscopy definitions and compared using the Fisher exact test. Postprocedure pain scores were compared using the Mann‐Whitney U test. Results Baseline characteristics, type, and clinical severity of cholecystitis were comparable between groups. In the EUS‐GBD group, noncautery LAMS were used in 30 patients and cautery‐enhanced LAMS were used in 15. Technical success was achieved for 98% of patients in the EUS‐GBD and 100% of the patients in the PT‐GBD group (P = .88). Clinical success was achieved by 96% of patients in the EUS‐GBD group and 91% in the PT‐GBD group (P = .20). There was a nonsignificant trend toward fewer AEs in the EUS‐GBD group (5 patients; 11%) than in the PT‐GBD group (14 patients; 32%) (P = .065). There were no significant differences in the severity of the AEs: mild, 2 in the EUS‐GBD group versus 5 in the PT‐GBD group (P = .27); moderate, 4 versus 3 (P = .98); severe, 1 versus 3 (P = .62); or deaths, 1 versus 3 (P = .61). The mean postprocedure pain score was lower in the EUS‐GBD group than in the PT‐GBD group (2.5 vs 6.5; P < .05). The EUS‐GBD group had a shorter average length of stay in the hospital (3 days) than the PT‐GBD group (9 days) (P < .05) and fewer repeat interventions (11 vs 112) (P < .05). The average number of repeat interventions per patients was 0.2 ± 0.4 EUS‐GBD group versus 2.5 ± 2.8 in the PT‐GBD group (P < .05). Median follow‐up after drainage was comparable in EUS‐GBD group (215 days; range, 1–621 days) versus the PT‐GBD group (265 days; range, 1–1638 days). Conclusions EUS‐GBD has similar technical and clinical success compared with PT‐GBD and should be considered an alternative for patients who are not candidates for surgery. Patients who undergo EUS‐GBD seem to have shorter hospital stays, lower pain scores, and fewer repeated interventions, with a trend toward fewer AEs. A prospective, comparative study is needed to confirm these results.

Mo2001 Safety and Efficacy of Coaxial Lumen Apposing Metal Stents in the Management of Gastrointestinal Strictures: A Multicenter Study

Nonalcoholic fatty liver disease (NAFLD) is a serious public health concern that affects almost one third of the US population. The prevalence of NAFLD varies among ethnic/racial groups, with the Latin American population being affected disproportionately. The severity of NAFLD also may be greater in the Latino population. The increased prevalence and severity of NAFLD in Latino Americans likely is related to the interplay between issues such as genetic factors, access to health care, or the prevalence of chronic diseases such as metabolic syndrome or diabetes. In this review, we summarize the current literature on the prevalence and risk factors of NAFLD that are seen to be more common in the Latino population in the United States. Finally, we discuss available treatment options, medical and surgical, that are available for NAFLD and how they affect the Latino population. Health care providers need to address modifiable risk factors that impact the natural history as well as treatment outcomes for NAFLD among Latinos. Additional efforts are needed to improve awareness and health care utilization for Latinos.

Su1298 Plastic Stents Are Comparable to Lumen Apposing Metal Stents in the Management of Pancreatic Pseudocysts: A Large International Multicenter Study

Background and study aimsu2002EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers long-lasting luminal patency without the risk of tumor ingrowth/overgrowth. This study compared the clinical success, technical success, adverse events (AEs), length of hospital stay (LOHS) and symptom recurrence in EUS-GE versus SGJ. Methodsu2002This was a multicenter international retrospective comparative study of EUS-GE and SGJ in patients with malignant gastric outlet obstruction (GOO) who underwent either EUS-GE or SGJ. EUS-GE was performed using lumen apposing metal stents. Resultsu2002A total of 93 patients with malignant GOO treated with either EUS-GE (nu200a=u200a30) or SGJ (nu200a=u200a63) were identified. Peritoneal carcinomatosis was present in 13 (43u200a%) patients in the EUS-GE group and 7 (11u200a%) patients in the SGJ group (Pu200a<u200a0.001). Although the technical success rate was significantly higher in the SGJ group as compared to the EUS-GE group (100u200a% vs. 87u200a%, Pu200a=u200a0.009), the clinical success rate was not different (90u200a% vs. 87u200a%, Pu200a=u200a0.18, OR 0.8, 95u200a%CI 0.44u200a–u200a7.07). The rate of AEs was lower in the EUS-GE group, but the difference was not statistically significant (16u200a% vs 25u200a%, Pu200a=u200a0.3). The mean LOHS was similar in the EUS-GE group compared to SGJ (Pu200a=u200a0.35). The rate of recurrent GOO was not different between the two groups (3u200a% vs. 14u200a%, Pu200a=u200a0.08). Similarly, the mean time to reintervention was similar (88 days vs. 121 days, Pu200a=u200a0.83). Conclusionsu2002EUS-GE is associated with equivalent efficacy and safety as compared to surgical GJ. This is the first comparative trial between both techniques and suggests EUS-GE as a non-inferior but less invasive alter to surgery.