Xiaobo Liu

Grading of gastric foveolar-type dysplasia in Barrett's esophagus

Dysplasia is the gold standard biomarker of cancer risk in Barretts esophagus, but its diagnosis remains difficult. This is due in part to its multitude of histological appearances. One aspect receiving little attention concerns gastric-type Barretts dysplasia, which is distinctly different from the well-established intestinal variant. Recognition of gastric-type dysplasia and development of separate grading criteria are required. The prevalence, diagnostic criteria, and natural history of gastric-type Barretts dysplasia were systematically evaluated in 1854 endoscopic biopsies from a cohort of 200 consecutive Barretts dysplasia patients. Goblet cells were present in all cases, confirming the utility of this defining feature of Barretts esophagus. The prevalence of Barretts gastric-type dysplasia was 15% at the patient level (30 of 200 patients) and 20% at the biopsy level (166 of 852 dysplastic biopsies). Gastric-type dysplasia uniformly showed non-stratified, basally oriented nuclei as the major criterion for distinguishing it from intestinal-type Barretts dysplasia. As such, loss of nuclear polarity, as the most objective criterion to distinguish intestinal-type low- and high-grade dysplasia, cannot be applied to gastric-type dysplasia. Rather, discriminatory features included increased nuclear size with a high-grade dysplasia cutoff by receiver operating characteristic (ROC) analysis approximating 3–4 times the size of a mature lymphocyte, providing an optimal sensitivity, specificity, and area under the curve of 0.78, 0.90, and 0.90 (95% CI: (0.87, 0.93)), respectively. Crowded, irregular glandular architecture (P<0.001) was more common in high-grade lesions (P<0.001), as was eosinophilic and oncocytic cytoplasm relative to the mucinous cytoplasm (P<0.001), prominent nucleoli (P<0.001), mild nuclear pleomorphism (P<0.001), and villiform architecture (P<0.001). During follow-up, 64% (7 of 11) of patients with pure gastric and 26% (5 of 19) with mixed gastric and intestinal dysplasia underwent neoplastic progression. The recognition of Barretts gastric-type dysplasia and use of the proposed grading criteria should promote better diagnostic classification of the Barretts neoplastic spectrum.

Pilot study to assess the frequency of fibromyalgia, depression, and sleep disorders in patients with granulomatosis with polyangiitis (Wegener's)

To assess the frequency of fibromyalgia syndrome (FMS), depression, and sleep disorders in patients with granulomatosis with polyangiitis (Wegeners) (GPA).

Prediction of need for surgery after endoscopic balloon dilation of ileocolic anastomotic stricture in patients with Crohn's disease.

BACKGROUND: Endoscopic balloon dilation is used to treat ileocolic anastomotic stricture attributed to recurrent Crohn’s disease. OBJECTIVE: The purpose of this work was to investigate long-term outcomes after dilation of ileocolic anastomotic stricture and to identify risk factors associated with the need for subsequent surgical intervention. DESIGN: This was a retrospective study based on chart review of an electronic medical chart system. SETTINGS: The study was conducted at a tertiary care center. PATIENTS: All of the eligible patients with ileocolic anastomotic stricture attributed to recurrent Crohn’s disease treated with endoscopic dilation between December 1998 and May 2013 were evaluated. Patients with concurrent enterocutaneous fistula or abdominal or pelvic abscess were excluded. MAIN OUTCOME MEASURES: The main outcome measure was the need for subsequent salvage surgery because of stricture-related symptoms. RESULTS: A total of 185 patients with Crohn’s disease (45.9% women; mean age, 43.1 years; symptomatic strictures in 80%) underwent 462 endoscopic dilations of ileocolic anastomosis (median per-patient dilations, 2; range, 1–3). During a mean follow-up of 3.9 years, 27 patients (14.6%) required hospitalization without surgery for stricture-related symptoms, and 66 patients (35.7%) required subsequent salvage surgery. Specific medical management, type of anastomosis, and endoscopic intralesional steroid injection had no impact on the risk of needing surgery. Significant factors associated with the need for surgery on multivariable analysis were symptomatic disease (HR, 3.54 [95% CI, 1.41–8.93]), longer time interval from last surgery (HR, 1.05 [95% CI, 1.01–1.10]), and radiographic proximal bowel dilation (HR, 2.36 [95% CI, 1.38–4.03]). A nomogram estimating the need for surgery was created with a concordance index of 0.67. LIMITATIONS: The study was limited by its retrospective design. CONCLUSIONS: Although endoscopic dilation is a valid option for ileocolic anastomotic stricture attributed to recurrent Crohn’s disease, the need for surgery is common. The nomogram can identify patients who might benefit from upfront surgery.

Impact of Transfusion Threshold on Infectious Complications After Ileal Pouch-Anal Anastomosis

BackgroundThis study was conducted to investigate the impact of different hemoglobin level-based transfusion practices on infectious complications after surgery for ulcerative colitis.MethodsPatients who underwent ileal pouch-anal anastomosis for ulcerative colitis between January 2008 and December 2013 were identified and divided into four groups: group 1 with hemoglobinu2009≥u200910 and group 2 with hemoglobinu2009≥u20097 and <10xa0g/dL who did not receive transfusion and group 3 with hemoglobinu2009≥u20097 and <10 and group 4 with hemoglobinu2009<u20097xa0g/dL who received transfusion. Clinical characteristics and septic complications within postoperative 30xa0days were compared.ResultsThere were 237, 341, 40, and 20 patients in groups 1, 2, 3, and 4, respectively. All the groups were comparable regarding perioperative characteristics except for age, gender, preoperative albumin and hemoglobin levels, and operative blood loss. The rates of overall septic complications were 18.6, 26.7, 47.5, and 40xa0% in the groups 1, 2, 3 and 4, respectively. In multivariate analysis, compared to group 2, group 3 was associated with an increased likelihood of developing organ/space (odds ratio (OR)u2009=u20094.34, pu2009=u20090.004) and overall surgical site infections (SSIs) (ORu2009=u20092.81, pu2009=u20090.01).ConclusionBlood transfusion decided based on a perioperative hemoglobin (Hgb) level above 7xa0mg/dL is associated with higher overall and organ/space SSIs.

Association of Preoperative Narcotic Use With Postoperative Complications and Prolonged Length of Hospital Stay in Patients With Crohn Disease

IMPORTANCEnThe use of narcotics among patients with Crohn disease (CD) is endemic.nnnOBJECTIVEnTo evaluate the association between preoperative use of narcotics and postoperative outcomes in patients with CD.nnnDESIGN, SETTING, AND PARTICIPANTSnPatients undergoing abdominal surgery for CD at a tertiary referral center between January 1998 and June 2014 were identified from an institutional prospectively maintained CD database.nnnMAIN OUTCOMES AND MEASURESnPrimary end points were overall morbidity, postoperative hospital length of stay, and readmission. Univariate and multivariate analyses were used to assess possible associations between postoperative outcomes and demographic and clinical variables, including preoperative narcotic use.nnnRESULTSnOf the 1331 patients included, the mean age for patients who had at least 1 pharmacy claim for narcotics within 1 month before surgery was 41.5 years and 41.1 years for patients without a pharmacy claim. Of 1461 abdominal operations for CD, 267 (18.3%) were performed on patients receiving preoperative narcotics. Patients receiving narcotics were more likely to have a current smoking habit (Pu2009<u2009.001) with perianal disease (Pu2009=u2009.046) and undergoing treatment with biologics (Pu2009=u2009.04). Patients with preoperative narcotic use had a longer mean (SD) length of stay (11.2u2009[8.9] vs 7.7u2009[5.5]; Pu2009<u2009.001) and were more likely to develop postoperative complications (52.8% vs 40.8%; Pu2009<u2009.001). Multivariable analysis indicated that preoperative narcotic use was the only independent risk factor associated with both postoperative morbidity (odds ratiou2009=u20091.36; 95% CIu2009=u20091.02-1.82; Pu2009=u2009.04) and prolonged hospital stay (estimateu2009=u20092.91; SEu2009=u20090.44; Pu2009<u2009.001). Subgroup analysis indicated that outpatient narcotic users had increased incidence of adverse postoperative outcomes compared with inpatient-only narcotic users.nnnCONCLUSIONS AND RELEVANCEnPreoperative use of narcotics in patients undergoing abdominal surgery for CD is associated with worse postoperative outcomes. Before starting regular narcotic use, patients with CD should be considered for surgical intervention.

525 Development of a Prognostic Nomogram for the Need for Surgery After Endoscopic Balloon Dilatation of Ileocolic Anastomotic Stricture for Crohn's Disease

Introduction: Accurate and complete identification of patients with symptoms secondary to gastroesophageal reflux disease has been a clinical challenge. This has led to the classification, perhaps erroneously, of some patients as functional heartburn. 48-hour wireless pH monitoring has been shown to increase the diagnostic yield of reflux detection. We hypothesize that 96-hour monitoring would further increase reflux detection rate. Methods: The study population consisted of 31 patients who underwent 96-hour wireless pHmonitoring between February 2012 and October 2013.Patients with incomplete studies due to capsule dislodgement or failed signal transmission, achalasia, previous antireflux or gastric bypass surgery were excluded. Patient demographics, presenting symptoms, manometric and pHmonitoring parameters were collected and compared. Patients were divided into pH negative, single day positive or multiple day positive groups for comparison. All studies were done off PPI medications for at least 7 days. A positive study was defined by DeMeester score >14.72 on any day. Results: Eighteen (58%) of the 31 patients were negative on all 4 days, 7 (23%) were positive on a single day and 6 (19%) were positive on multiple days. Thirteen percent of the patients (4/31) were only positive on day 3 or day 4 and would have been considered normal on a 48 hour study. Lower esophageal sphincter (LES) parameters correlated with the number of pH positive days including LES overall length ( σ=-0.43, p=0.02), IBP (σ=0.41, p=0.02) and IRP (σ=-0.54, p=0.003). Mean axial separation between the LES and CD, 0.16cm in pH negative, 0.66cm in patients with one day positive and 0.26 in patients with multiple days positive (p=0.1506). Conclusions: 96 hour wireless pH monitoring identified pathologic esophageal acid exposure in 13% of patients who would have been considered normal on 48 hour study. These patients are more likely to have less profound alteration in characteristics of the gastroesopahgeal barrier including LES length and axial crural diaphragm separation. Prolonged 96-hour pH monitoring may be necessary before classifying patients as GERD negative or functional heartburn.

Impact of omentoplasty on anastomotic leak and septic complications after low pelvic anastomosis: a study from the NSQIP database

PurposeThe role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.MethodsThe ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30xa0days were compared between the groups.ResultsA total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2u2009±u200913.0xa0years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (pu2009=u20090.83; ORu2009=u20090.88, 95% CI, 0.21–2.44) nor organ/space SSIs (pu2009=u20090.08; ORu2009=u20092.14, 95% CI, 0.91–4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, pu2009=u20090.04). No differences were detected between the groups with respect to the management strategies for AL (pu2009=u20090.22).ConclusionsOmentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.

Su1117 Practice Pattern and Detection of Neoplasia by Surveillance Pouch Endoscopy After IPAA for IBD Colitis in Academic Centers in the US

Background: There are still no standard endoscopic surveillance guidelines to detect neoplasia (dysplasia and/or cancer) following IPAA for IBD colitis. The aim of this survey study is to investigate the practice pattern of surveillance pouchoscopy for neoplasia in academic settings. Methods: Physicians who potentially take care of patients undergoing IPAA for IBD colitis were identified by searching literatures in MEDLINE. A questionnaire including practice pattern and opinions on ileal pouch surveillance was sent by email through REDcap. Univariable and multivariable analyses were performed. Results: A total of 118 physicians (86 gastroenterologists and 32 colorectal surgeons) were surveyed and 58 (49%) of them responded. One incomplete questionnaire and 5 physicians who do not routinely followup IBD patients with ileal pouch were excluded. Of the 52 eligible participants from 32 institutions, 6 (11%) were general gastroenterologists, 31(60%) were gastroenterologists specialized in IBD and 15 (29%) were colorectal surgeons. Forty-one physicians (79%) agree that it is necessary to perform routine pouch surveillance for neoplasia arising from ileal pouch or anal transitional zone/rectal cuff in all IBD patients undergoing IPAA and 22 (55%) think that the pouchoacopy solely for neoplasia should be performed every 2-3 years. Thirtysix physicians (69%) feel that pouchoscopy with biopsy is effective for the detection of neoplasia. Altogether 41 dysplasias and 15 cancers arising from ileal pouch or anal transitional zone/rectal cuff were reported to have been found within the past 5 years by 18 physicians (35%). There were no differences in the locations of pouch observation and biopsy during pouchocsopy examination between neoplasia detection and non-detection group. Colorectal surgeons found more pouch neoplasias than both gastroenterologists specialized in IBD and general gastroenterologists (61% vs 28% vs 11%, p 3 biopsies per location, 44% vs 82%, p=0.005). The median follow-up number of IBD pouch per year was significantly higher in neoplasia detection group (50 vs 25, p=0.041).