Mohammad H. Shakhatreh

Use of a novel through-the-needle biopsy forceps in endoscopic ultrasound.

Background and aims: Pancreatic cysts are becoming more common. Their differential diagnosis includes benign, premalignant, and malignant lesions. Distinguishing the type of cyst helps in the management decision making. We report on a novel tissue acquisition device for pancreatic cysts. Methods: Data on two patients who underwent endoscopic ultrasound (EUS) – guided fine-needle aspiration with a new micro forceps device are presented. Results: Two patients had large pancreatic cystic lesions in the pancreatic head. Linear EUS was performed, and tissue samples were obtained with the Moray micro forceps through a 19-gauge needle. In both patients, mucinous columnar epithelium lined the cystic walls. One patient underwent surgical resection, and the other elected surveillance. Examination of the surgical specimen from the first patient confirmed the cyst was a side-branch intraductal papillary mucinous neoplasm (IPMN), gastric type. Conclusions: The Moray micro forceps is a new tool that can be used to help determine the nature of pancreatic cysts and aid in their risk stratification and management.

The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus.

OBJECTIVES:The increasing incidence of esophageal adenocarcinoma (EA) in the United States may have leveled off in recent years. The risk of EA among patients with Barrett’s esophagus (BE) seems to be decreasing in several European cohorts, but these estimates are unknown in the United States. We aimed to determine the risk of developing EA in a national cohort of BE patients in the US Veterans Health Administration and to account for the use of endoscopic ablation and esophagectomy.METHODS:This was a retrospective cohort study from a total of 121 facilities in the Veterans Health Administration. Veteran patients with BE diagnosed between 1 October 2003 and 30 September 2009 were included and followed until esophageal cancer diagnosis, death or 30 September 2011. All EA diagnoses were verified in detailed structured reviews of medical records.RESULTS:We identified 29,536 patients with BE who met our eligibility criteria. Most were men (96.9%) and White (83.2%), with a mean age of 61.8 years. During 144,949 person-years of follow-up, 466 patients developed EA, yielding an incidence rate of 3.21 per 1,000 person-years (95% confidence interval (CI) 2.94–3.52). Excluding those who developed EA within 1 year of their index BE date lowered the incidence rate to 1.75 per 1,000 person-years. However, including additional patients who underwent endoscopic ablation or esophagectomy for HGD or EA increased the incidence rate to 4.79 (95% CI 4.44–5.16).CONCLUSIONS:The incidence of EA in a US national cohort of mostly male veterans may be lower than previous estimates. Almost half of the EA cases were diagnosed within 1 year of their BE index date.

Incidence and Determinants of Hepatocellular Carcinoma in Autoimmune Hepatitis: A Systematic Review and Meta-analysis

Background & Aims The risk of hepatocellular carcinoma (HCC) in patients with autoimmune hepatitis (AIH) is unclear. We conducted a systematic review and meta‐analysis of the incidence of HCC and associated risk factors among patients with AIH. Methods We searched PubMed, Embase, and reference lists from relevant articles through June 2016 to identify cohort studies that examined the incidence of HCC in patients with AIH. We used random effects models to estimate pooled incidence rates overall and in subgroup of patients with cirrhosis. The between‐study heterogeneity was assessed using I2 statistic. Results A total of 25 studies (20 papers and 5 abstracts), including 6528 patients, met the eligibility criteria. The median cohort size was 170 patients with AIH (range, 25–1721 patients), followed for a median of 8.0 years (range, 3.3–16.0 years). The pooled incidence rate for HCC in patients with AIH was 3.06 per 1000 patient‐years (95% confidence interval, 2.22–4.23; I2 = 51.5%; P = .002). The pooled incidence of HCC in patients with cirrhosis at AIH diagnosis was 10.07 per 1000 patient‐years (95% confidence interval, 6.89–14.70; I2 = 48.8%; P = .015). In addition, 92 of 93 patients who had HCC had evidence of cirrhosis before or at the time of their HCC diagnosis. The risk of HCC seems to be lower in patients with AIH and cirrhosis than that reported for patients with cirrhosis from hepatitis B, hepatitis C, or primary biliary cholangitis. Conclusions Based on the increased risked of HCC shown in this meta‐analysis, there may be a role for HCC surveillance in patients with AIH and cirrhosis.

Lumen-apposing metal stents for benign gastrointestinal tract strictures: An international multicenter experience

AIM To investigate technical feasibility, outcomes and adverse events of the lumen-apposing metal stent (LAMS) for benign gastrointestinal (GI) tract strictures. METHODS Between July 2015 and January 2017, patients undergoing treatment by LAMS for benign GI strictures at three tertiary referral centers were included in this study. Primary outcomes included technical success, short-term clinical success, long-term clinical success, and adverse events. Short-term clinical success was defined as symptom resolution at 30 d after stent placement. Long-term clinical success was defined by symptom resolution at 60 d in patients who continued to have indwelling stent, or continued symptom resolution at 30 d after elective stent removal. RESULTS A total of 21 patients (mean age 62.6 years, 47.6% males) underwent placement of LAMS for benign GI strictures. A 15 mm × 10 mm LAMS was placed in 16 patients, a 10 mm × 10 mm LAMS was placed in 2 patients, and a 16 mm × 30 mm LAMS was placed in 3 patients. Technical success was obtained in all cases. Short-term clinical success was achieved in 19 out of 21 cases (90.5%), and long-term clinical success was achieved in 12 out of 18 (66.7%). Mean (range) stent indwell time was 107.2 (28-370) d. After a mean (range) dwell time of 104.3 (28-306) d, 9 LAMSs were removed due to the following complications: ulceration at stent site (n = 1), angulation (n = 2), migration (n = 4) and stricture overgrowth (n = 2). Migration occurred in 4 cases (19.0%), and it was associated with stricture resolution in one case. Median (range) follow-up period was 119 (31-422) d. CONCLUSION Utilization of LAMS for benign strictures has shown to be technically feasible and safe, but adverse events highlight the need for further study of its indications.

Use of a cardiac septal occluder for the closure of a benign bronchoesophageal fistula

re 1. A, Chest radiograph demonstrating contrast material in the right lung. B, Upper endoscopic view of the diverticulum in the mid-esophagus. per endoscopic view showing a fistula at the end of the diverticulum. D, Chest radiograph of an incompletely expanded septal occluder device after scopic placement (arrow). E, Barium esophagram demonstrating the septal occluder device in a mid-intrathoracic esophageal diverticulum (arrow). e is no extravasation of contrast material.

A comparison of endoscopic and non-endoscopic biliary intervention outcomes in patients with prior bariatric surgery

Background and study aims  Endoscopic biliary intervention (BI) is often difficult to perform in patients with prior bariatric surgery (BRS). We sought to analyze outcomes of patients with prior BRS undergoing endoscopic and non-endoscopic BI. Patients and methods  The Nationwide Inpatient Sample (2007 - 2011) was reviewed to identify all adult inpatients (≥ 18 years) with a history of BRS undergoing BI. The clinical outcomes of interest were in-patient mortality, length of stay (LOS), and total hospital charges. Results  There were 7,343 patients with prior BRS who underwent BIs where a majority were endoscopic (4,482 vs. 2,861, P  < 0.01). The mean age was 50±30.8 years and the majority were females (80.5 %). Gallstone-related disease was the most common indication for BI and managed more often with primary endoscopic management (2,146 vs. 1,132, P  < 0.01). Inpatient mortality was not significantly different between patients undergoing primary endoscopic versus non-endoscopic BI (0.2 % vs. 0.7 %, P  = 0.2). Patients with sepsis were significantly more likely to incur failed primary endoscopic BI (OR 2.74, 95 % CI 1.15, 6.53) and were more likely to be managed with non-endoscopic BI (OR 2.13, 95 % CI 1.3, 3.5). Primary non-endoscopic BI and failed endoscopic BI were both associated with longer LOS (by 1.77 days, P  < 0.01 and by 2.17 days, P  < 0.01, respectively) and higher hospitals charges (by

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

11,400, P  < 0.01 and by

ERCP through a gastrojejunal lumen-apposing stent

 14,200, P  < 0.01, respectively). Conclusion  Primary endoscopic management may be a safe and cost-effective approach for patients with prior BRS who need BI. While primary endoscopic biliary intervention is more common, primary non-endoscopic intervention may be used more often for sepsis.

Endoscopic removal of over-the-scope clip with cold saline solution technique.

BACKGROUND AND AIMS The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Sa1313 MULTIPLE PLASTIC STENTS VERSUS FULLY COVERED SELF-EXPANDING METAL STENTS FOR BENIGN BILIARY STRICTURE: META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Figure 2. Fluoroscopic view showing passage of guidewire into the distal duodenum. We present a case of an 84-year-old man who had received a diagnosis of pancreatic head adenocarcinoma 2 years earlier. At that time, he had received bile and pancreatic duct stents with resolution of jaundice and improvement in diarrhea. Over the past month, the patient started experiencing epigastric pain, nausea, and vomiting. Cross-sectional imaging demonstrated no significant change in pancreatic mass size, with intact stents and stable pneumobilia. An upper endoscopy was then performed, demonstrating narrowing of the second portion of the duodenum with inability of the endoscope to traverse this segment. Contrast medium was injected into the duodenal bulb and showed evidence of severe narrowing of the second portion of the duodenum (Fig. 1). A long ERCP guidewire was advanced through the upper endoscope past the duodenal narrowing and looped in the distal duodenum (Fig. 2). The endoscope was then withdrawn while the guidewire was maintained in place. A dilation balloon was advanced over the guidewire into the distal duodenum and inflated to 18 mm (Fig. 3). A linear echoendoscope was then advanced into the stomach. The dilated balloon was identified and punctured with a 19-gauge needle and immediate dissipation of contrast medium into the small intestine was observed (Fig. 4). Another guidewire was advanced through the 19-gauge needle into the small intestine. A Boston-Scientific (Marlborough, Mass) electrocautery-enhanced Axios stent was then deployed over the guidewire into the lumen of the small intestine (Fig. 5). The stent was then dilated with a 13.5-mm dilation balloon (Fig. 6). The final endoscopic and fluoroscopic appearance appeared satisfactory. The patient did well after the procedure, with resolution of symptoms, and was discharged the next day after tolerating a regular diet. However, the patient presented about 2 weeks later with right upper-quadrant pain, fever, and an increase in bilirubin from 0.4 to 2.6 mg/dL. A transabdominal US showed worsening intrahepatic biliary dilatation. Intravenous antibiotics were started, with improvement in symptoms but persistence of laboratory abnormalities. We then discussed with the patient the options of percutaneous drainage, EUS-guided hepaticogastrostomy, or an attempt at exchanging the stent through the newly placed Axios stent. The patient opted for an endoscopic