Paul D. James

The incremental benefit of EUS for identifying unresectable disease among adults with pancreatic adenocarcinoma: A meta-analysis

Background and study aims It is unclear to what extent EUS influences the surgical management of patients with pancreatic adenocarcinoma. This systematic review sought to determine if EUS evaluation improves the identification of unresectable disease among adults with pancreatic adenocarcinoma. Patients and methods We searched MEDLINE, EMBASE, bibliographies of included articles and conference proceedings for studies reporting original data regarding surgical management and/or survival among patients with pancreatic adenocarcinoma, from inception to January 7th 2017. Our main outcome was the incremental benefit of EUS for the identification of unresectable disease (IBEUS). The pooled IBEUS were calculated using random effects models. Heterogeneity was explored using stratified meta-analysis and meta-regression. Results Among 4,903 citations identified, we included 8 cohort studies (study periods from 1992 to 2007) that examined the identification of unresectable disease (n = 795). Random effects meta-analysis suggested that EUS alone identified unresectable disease in 19% of patients (95% confidence interval [CI], 10–33%). Among those studies that considered portal or mesenteric vein invasion as potentially resectable, EUS alone was able to identify unresectable disease in 14% of patients (95% CI 8–24%) after a CT scan was performed. Limitations The majority of the included studies were retrospective. Conclusions EUS evaluation is associated with increased identification of unresectable disease among adults with pancreatic adenocarcinoma.

Temporal trends in postcolonoscopy colorectal cancer rates in 50- to 74-year-old persons: a population-based study

BACKGROUND AND AIMS Colorectal cancers (CRCs) diagnosed between 6 and 36 months after colonoscopy, termed postcolonoscopy CRCs (PCCRCs), arise primarily due to missed or inadequately treated neoplasms during colonoscopy. Introduction of multiple quality indicators and technological advances to colonoscopy practice should have reduced the PCCRC rate over time. We assessed temporal trends in the population rate of PCCRC as a measure of changing colonoscopy quality. METHODS We conducted a population-based retrospective cohort study of persons aged 50 to 74 years without advanced risk factors for CRC who underwent complete colonoscopy in Ontario, Canada between 1996 and 2010. We defined the PCCRC rate as the proportion of individuals diagnosed with CRC within 36 months of colonoscopy that had PCCRC. We compared age-adjusted and sex-adjusted rates of PCCRC over time based on 3 periods (1996-2001, 2001-2006 and 2006-2010) and assessed the independent association between time period and PCCRC risk through multivariable regression, with respect to all PCCRCs, proximal PCCRC and distal PCCRC. RESULTS There was a marked increase in colonoscopy volumes over the study period, particularly in younger age groups and non-hospital settings. Among 1,093,658 eligible persons the PCCRC rate remained stable at approximately 8% over the 15-year study period. The adjusted odds of PCCRC, distal PCCRC and proximal PCCRC, comparing the 2006 to 2010 period with the 1996 to 2001 period, were 1.14 (95% confidence interval [CI], 1.0-1.31), 1.11 (95% CI, 0.91-1.34), and 1.14 (95% CI, 0.94-1.38), respectively. Temporal trends in PCCRC risk did not differ by endoscopist specialty or institutional setting after covariate adjustment. CONCLUSION The PCCRC rate in Ontario has remained consistently high over time. Widespread initiatives are needed to improve colonoscopy quality.

High end of life health care costs and hospitalization burden in inflammatory bowel disease patients: A population-based study

Background End of life (EOL) care is associated with greater costs, particularly for acute care services. In patients with inflammatory bowel disease (IBD), EOL costs may be accentuated due to reliance on hospital-based services and expensive diagnostic tests and treatments. We aimed to compare EOL health care use and costs between IBD and non-IBD decedents. Methods We conducted a retrospective cohort study of all decedents of Ontario, Canada between 2010 and 2013 using linked health administrative data. IBD (N = 2,214) and non-IBD (N = 262,540) decedents were compared on total direct health care costs in the last year of life and hospitalization time during the last 90 days of life. Results During the last 90 days of life, IBD patients spent an average of 16 days in hospital, equal to 2.1 greater adjusted hospital days (95% confidence interval [CI] 1.5–2.8 days) than non-IBD patients. IBD diagnosis was associated with

Increased prevalence of colonic adenomas in patients with cystic fibrosis

7,210 CAD (95% CI

Paraduodenal pancreatitis as an uncommon cause of gastric outlet obstruction: A case report and review of the literature

5,005 -

Long-Term Effectiveness, Safety and Mortality Associated with the Use of TC-325 for Malignancy-Related Upper Gastrointestinal Bleeds: A Multicentre Retrospective Study

9,464) higher adjusted per-patient cost in the last year of life, of which 76% was due to excess hospitalization costs. EOL cost of IBD care was higher than 15 of 16 studied chronic conditions. Health care costs rose sharply in the last 90 days of life, primarily due to escalating hospitalization costs. Conclusions IBD patients spend more time in hospital and incur substantially greater health care costs than other decedents as they approach the EOL. These excess costs could be curtailed through avoidance of unnecessary hospitalizations and expensive treatments in the setting of irreversible deterioration.

Regional differences in use of endoscopic ultrasonography in Ontario: a population-based retrospective cohort study

BACKGROUND Cystic fibrosis (CF) is the most common lethal genetic illness in the Caucasian population. Studies have shown that CF patients are at an elevated risk of developing colon cancer. Colonic adenomas are the precursors of colon cancer. This study aims to determine the prevalence of adenomas in patients with cystic fibrosis. METHODS All patients were recruited prospectively at The Ottawa Hospital Cystic Fibrosis Clinic from 2010 through 2015. Baseline demographic and cystic fibrosis disease characteristics were collected from the clinics CF patient database. Upon presentation at the endoscopy unit, and after a brief history and physical exam, a colonoscopy was performed. Polyps were resected if detected and sent to the pathology department for characterization. Findings were compared with a control group (pairing each CF patient with 5 age and sex-matched controls) of near-average risk patients who underwent a colonoscopy at the same center. RESULTS Of the 33 patients that provided informed consent to participate in the study, 30 patients underwent colonoscopy and 13/30 (43.3%) were found to have colonic adenomas compared to 7 (4.7%) of the 150 control patients. The relative risk ratio for adenoma detection in a CF patient as compared to a matched control patient was 9.29 (95% CI 4.04-21.31), p<0.01. CONCLUSIONS Colonic adenomas are more prevalent in CF patients compared to the general population. This study suggests the need for additional research to support recently published screening guidelines for CF patients.

Albumin May Prevent the Morbidity of Paracentesis-Induced Circulatory Dysfunction in Cirrhosis and Refractory Ascites: A Pilot Study

Highlights • Paraduodenal pancreatitis is a rare form of focal chronic or recurrent pancreatitis that can present as gastric outlet obstruction.• Endoscopic ultrasound and fine needle aspiration biopsy provides the best diagnostic modality.• Key histopathologic features include Brunner gland hyperplasia, myofibroblastic proliferation, spindle cells and foamy cells.• Cross-sectional imaging demonstrates a fibrotic, sheet-like mass with cystic change between the duodenal wall and pancreatic head.• The optimal treatment for refractory symptoms is pancreaticoduodenectomy.

892 Regular Screening With FOBT is Associated With Detection of Colorectal Cancer at an Earlier Stage: A Population-Based Study

Abstract Background and Study Aims Malignant-related upper gastrointestinal bleeding (MRUGIB) is difficult to treat by conventional endoscopic methods. We sought to determine the efficacy, safety and mortality associated with the use of TC-325 for the treatment of MUGIB. Patients and Methods This is a multicentre, retrospective study at the University of Calgary and University of Ottawa performed between January 1, 2010, and July 30, 2016. TC-325 use was identified via staff polling, product order forms and endoscopic records review. Once identified, patient charts and online records were examined to identify MRUGIB cases and to assess our primary and secondary endpoints. Outcomes The primary outcome was hemostasis at seven days. Secondary outcomes include immediate hemostasis, early hemostasis, hemostasis at 14 days, 30-day mortality, adverse events related to TC-325 therapy and the need for repeat endoscopic intervention, surgery or transarterial embolization. Results Twenty-five patients were identified. The median age was 62 years (interquartile range [IQR] 52.5–76), and most were male (64%). TC-325 was the primary treatment modality in 20 patients (80%). Hemostasis was 88%, 89%, 58% and 50% at 24 hours, 72 hours, 7 days and 14 days, respectively. Five patients underwent repeat endoscopy, two patients required surgical intervention, and transarterial embolization was not required. Twelve patients died by 30 days (48%). There were no complications directly attributed to the use of TC-325. Conclusions TC-325 is effective for achieving and maintaining hemostasis in patients with malignancy-related upper gastrointestinal bleeding, and most patients do not require additional interventions. The 30-day mortality risk in this group of patients is high.

A324 FOUR OR MORE EUS-FNA PASSES FOR PANCREATIC SOLID LESIONS IS ASSOCIATED WITH INCREASED RISK WITHOUT IMPROVING DIAGNOSTIC YIELD: RESULTS FROM THE OTTAWA HOSPITAL EUS RYSE QA INITIATIVE

BACKGROUND Endoscopic ultrasonography is a safe and accurate modality for evaluating and managing hepatobiliary and gastrointestinal conditions (malignant and nonmalignant); its use is increasing. The aim of this study was to describe regional trends in the use of endoscopic ultrasonography in Ontario. METHODS We conducted a population-based retrospective cohort study using health administrative databases. We identified all patients who underwent an endoscopic ultrasound procedure in Ontario from 2003 to 2011 using physician billing data. Patient, physician and institution characteristics were examined. The primary outcome was use of endoscopic ultrasonography. RESULTS We identified 9076 endoscopic ultrasound procedures performed in 8001 patients (3858 women [48.2%]; median patient age at first procedure 59 years). A total of 3066 procedures (33.8%) involved fine-needle aspiration. Use of endoscopic ultrasonography increased 17-fold over the study period. In 2011, people living in the health region with the highest rate of use of endoscopic ultrasonography were more than 4 times more likely to undergo the procedure than people living in the health region with the lowest rate of use (standardized rate 61.6 v. 12.9 per 100 000). About 7 in 10 endoscopic ultrasound procedures were performed in an academic institution or regional cancer centre. All 17 endoscopists performing endoscopic ultrasonography during the study period practised in urban areas. INTERPRETATION Although the use of endoscopic ultrasonography increased over time in Ontario, there were marked regional differences in use. Provincial needs- and evidence-based initiatives may be needed to narrow the regional gaps in provision of endoscopic ultrasound services in the province.