Background and Aims Endoscopic transmural drainage/debridement of pancreatic walled-off necrosis (WON) has been performed using double-pigtail plastic (DP), fully covered self-expanding metal stents ...(FCSEMSs), or the novel lumen-apposing fully covered self-expanding metal stent (LAMS). Our aim was to perform a retrospective cohort study to compare the clinical outcomes and adverse events of EUS-guided drainage/debridement of WON with DP stents, FCSEMSs, and LAMSs. Methods Consecutive patients in 2 centers with WON managed by EUS-guided debridement were divided into 3 groups: (1) those who underwent debridement using DP stents, (2) debridement using FCSEMSs, (3) debridement using LAMSs. Technical success (ability to access and drain a WON by placement of transmural stents), early adverse events, number of procedures performed per patient to achieve WON resolution, and long-term success (complete resolution of the WON without need for further reintervention at 6 months after treatment) were evaluated. Results From 2010 to 2015, 313 patients (23.3% female; mean age, 53 years) underwent WON debridement, including 106 who were drained using DP stents, 121 using FCSEMSs, and 86 using LAMSs. The 3 groups were matched for age, cause of the pancreatitis, WON size, and location. The cause of the patients' pancreatitis was gallstones (40.6%), alcohol (30.7%), idiopathic (13.1%), and other causes (15.6%). The mean cyst size was 102 mm (range, 20-510 mm). The mean number of endoscopy sessions was 2.5 (range, 1-13). The technical success rate of stent placement was 99%. Early adverse events were noted in 27 of 313 (8.6%) patients (perforation in 6, bleeding in 8, suprainfection in 9, other in 7). Successful endoscopic therapy was noted in 277 of 313 (89.6%) patients. When comparing the 3 groups, there was no difference in the technical success ( P = .37). Early adverse events were significantly lower in the FCSEMS group compared with the DP and LAMS groups (1.6%, 7.5%, and 9.3%; P < .01). At 6-month follow-up, the rate of complete resolution of WON was lower with DP stents compared with FCSEMSs and LAMSs (81% vs 95% vs 90%; P = .001). The mean number of procedures required for WON resolution was significantly lower in the LAMS group compared with the FCSEMS and DP groups (2.2 vs 3 vs 3.6, respectively; P = .04). On multivariable analysis, DP stents remain the sole negative predictor for successful resolution of WON (odds ratio OR, 0.18; 95% confidence interval, 0.06-0.53; P = .002) after adjusting for age, sex, and WON size. Although there was no significant difference between FCSEMSs and LAMSs for WON resolution, the LAMS was more likely to have early adverse events (OR, 6.6; P = .02). Conclusions EUS-guided drainage/debridement of WON using FCSEMSs and LAMSs is superior to DP stents in terms of overall treatment efficacy. The number of procedures required for WON resolution was significantly lower with LAMSs compared with FCSEMSs and DP stents.
Background and Aims EUS-guided biliary drainage (EUS-BD) is increasingly used as an alternate therapeutic modality to percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction in ...patients who fail ERCP. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures. Methods We searched several databases from inception to September 4, 2016 to identify comparative studies evaluating the efficacy and safety of EUS-BD and PTBD. Primary outcomes of interest were the differences in technical success and postprocedure adverse events. Secondary outcomes of interest included clinical success, rate of reintervention, length of hospital stay, and cost comparison for these 2 procedures. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. These were analyzed using random effects model of meta-analysis. Results Nine studies with 483 patients were included in the final analysis. There was no difference in technical success between 2 procedures (OR, 1.78; 95% CI, .69-4.59; I2 = 22%) but EUS-BD was associated with better clinical success (OR, .45; 95% CI, .23-.89; I2 = 0%), fewer postprocedure adverse events (OR, .23; 95% CI, .12-.47; I2 = 57%), and lower rate of reintervention (OR, .13; 95% CI, .07-.24; I2 = 0%). There was no difference in length of hospital stay after the procedures, with a pooled standard mean difference of –.48 (95% CI, –1.13 to .16), but EUS-BD was more cost-effective, with a pooled standard mean difference of –.63 (95% CI, –1.06 to –.20). However, the latter 2 analyses were limited by considerable heterogeneity. Conclusions When ERCP fails to achieve biliary drainage, EUS-guided interventions may be preferred over PTBD if adequate advanced endoscopy expertise and logistics are available. EUS-BD is associated with significantly better clinical success, lower rate of postprocedure adverse events, and fewer reinterventions.
There are marked racial and ethnic differences in non-cardia gastric cancer prevalence within the United States. Although gastric cancer screening is recommended in some regions of high prevalence, ...screening is not routinely performed in the United States. Our objective was to determine whether selected non-cardia gastric cancer screening for high-risk races and ethnicities within the United States is cost effective.
We developed a decision analytic Markov model with the base case of a 50-year-old person of non-Hispanic white, non-Hispanic black, Hispanic, or Asian race or ethnicity. The cost effectiveness of a no-screening strategy (current standard) for non-cardia gastric cancer was compared with that of 2 endoscopic screening modalities initiated at the time of screening colonoscopy for colorectal cancer: upper esophagogastroduodenoscopy with biopsy examinations and continued surveillance only if intestinal metaplasia or more severe pathology is identified or esophagogastroduodenoscopy with biopsy examinations continued every 2 years even in the absence of identified pathology. We used prevalence rates, transition probabilities, costs, and quality-adjusted life years (QALYs) from publications and public data sources. Outcome measures were reported in incremental cost-effectiveness ratios, with a willingness-to-pay threshold of $100,000/QALY.
Compared with biennial and no screening, screening esophagogastroduodenoscopy with continued surveillance only when indicated was cost effective for non-Hispanic blacks ($80,278/QALY), Hispanics ($76,070/QALY), and Asians ($71,451/QALY), but not for non-Hispanic whites ($122,428/QALY). The model was sensitive to intestinal metaplasia prevalence, transition rates from intestinal metaplasia to dysplasia to local and regional cancer, cost of endoscopy, and cost of resection (endoscopic or surgical).
Based on a decision analytic Markov model, endoscopic non-cardia gastric cancer screening for high-risk races and ethnicities could be cost effective in the United States.
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Objective
The 2019 novel coronavirus disease (COVID‐19) has triggered a rapidly expanding global pandemic in which patients exhibit a wide spectrum of disease severity. Given the high prevalence of ...obesity in the United States, we hypothesized that the presence of obesity may play a role in the clinical course of patients with COVID‐19.
Methods
This is a retrospective review of adult patients admitted with confirmed severe acute respiratory syndrome coronavirus 2. Demographics, clinical characteristics, laboratory data, and clinical outcomes were ed. BMI (kilograms per meter squared) was analyzed with regard to a composite outcome of intensive care unit (ICU) admission or death and intubation rate.
Results
About 770 patients were included (61% male, mean age 63.5 years). Patients with obesity were more likely to present with fever, cough, and shortness of breath. Obesity was also associated with a significantly higher rate of ICU admission or death (RR = 1.58, P = 0.002) even after adjusting for age, race, and troponin level.
Conclusions
Patients with obesity had an increased risk for critical illness leading to ICU admission or death compared with normal weight individuals. This study confirms that obesity is a major risk factor for COVID‐19 disease severity, significantly impacting disease presentation and critical care requirements.
Non‐alcoholic fatty liver disease (NAFLD) has become the most common liver disease in industrialized countries because of the worldwide epidemic of obesity. Beyond metabolic complications, a subset ...of patients with NAFLD develop non‐alcoholic steatohepatitis (NASH) with fibrosis, which is emerging as a leading cause of liver transplantation due to progression to cirrhosis and cancer. For these reasons, NAFLD is considered a public health burden. In recent years endoscopic bariatric and metabolic therapies (EBMT) have emerged as safe and effective for the treatment of obesity and type 2 diabetes mellitus. EBMT include gastric and duodenal devices and techniques such as intragastric balloons, endoscopic sleeve gastroplasty, endoscopic small bowel by‐pass and duodenal mucosal resurfacing. Observational studies and pilot trials have revealed beneficial effects of EBMT on NAFLD as assessed by non‐invasive parameters or histology. In this review we summarise current evidence for the efficacy and safety of EBMT in obese patients with NAFLD and examine future clinical applications.
Background and Aims Endoscopic retrograde pancreatography (ERP) is considered first-line therapy for management of symptomatic pancreatic duct obstruction. Technical failure with ERP occurs when the ...main pancreatic duct cannot be cannulated. EUS-guided drainage of the pancreatic duct is a minimally invasive alternative to surgery for failed conventional ERP. We present an international, multicenter study on the safety and efficacy of EUS-guided pancreatic drainage (EUS-PD) for patients who fail conventional endoscopic therapy. Methods Between January 2006 and December 2015, 80 patients underwent EUS-PD at 4 academic centers in 3 countries. Patient demographics, medical history, procedure data, and follow-up clinical data were collected. Technical success was defined as successful pancreatic duct drainage with stent placement. Clinical success was defined as resolution or improvement of symptoms or improvement on postprocedure imaging. Results Eighty patients (62.5% men; mean age, 58.2 ± 15.5 years) were included. All patients had attempted ERP and/or extracorporeal lithotripsy if needed before EUS-PD. Technical success was achieved in 89% of patients (n = 71). Clinical success was achieved in 81% of patients overall (65/80) and in 92% of patients who achieved technical success (65/71). Immediate adverse events occurred in 20% of patients (n = 16) and delayed adverse events occurred in 11% of patients (n = 9). Conclusions With appropriate endoscopic expertise, EUS-PD offers a minimally invasive, more effective, and safer alternative to some surgical PD procedures. Prospective studies are needed to evaluate long-term outcomes. (Clinical trial registration number: NCT01522573 .)
The 2019 novel coronavirus disease (COVID-19) has created unprecedented medical challenges. There remains a need for validated risk prediction models to assess short-term mortality risk among ...hospitalized patients with COVID-19. The objective of this study was to develop and validate a 7-day and 14-day mortality risk prediction model for patients hospitalized with COVID-19.
We performed a multicenter retrospective cohort study with a separate multicenter cohort for external validation using two hospitals in New York, NY, and 9 hospitals in Massachusetts, respectively. A total of 664 patients in NY and 265 patients with COVID-19 in Massachusetts, hospitalized from March to April 2020.
We developed a risk model consisting of patient age, hypoxia severity, mean arterial pressure and presence of kidney dysfunction at hospital presentation. Multivariable regression model was based on risk factors selected from univariable and Chi-squared automatic interaction detection analyses. Validation was by receiver operating characteristic curve (discrimination) and Hosmer-Lemeshow goodness of fit (GOF) test (calibration). In internal cross-validation, prediction of 7-day mortality had an AUC of 0.86 (95%CI 0.74-0.98; GOF p = 0.744); while 14-day had an AUC of 0.83 (95%CI 0.69-0.97; GOF p = 0.588). External validation was achieved using 265 patients from an outside cohort and confirmed 7- and 14-day mortality prediction performance with an AUC of 0.85 (95%CI 0.78-0.92; GOF p = 0.340) and 0.83 (95%CI 0.76-0.89; GOF p = 0.471) respectively, along with excellent calibration. Retrospective data collection, short follow-up time, and development in COVID-19 epicenter may limit model generalizability.
The COVID-AID risk tool is a well-calibrated model that demonstrates accuracy in the prediction of both 7-day and 14-day mortality risk among patients hospitalized with COVID-19. This prediction score could assist with resource utilization, patient and caregiver education, and provide a risk stratification instrument for future research trials.
Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or ...chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.
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