Prior Endoscopy Research Articles

Efficacy of Expansion Pharyngoplasty without Drug-induced Sleep Endoscopy Screening in Obstructive Sleep Apnea.

Introduction Expansion sphincter pharyngoplasty has been shown to be a good alternative to continuous pressure devices in patients with moderate to severe obstructive sleep apnea. On the other hand, drug-induced sleep endoscopy provides information on the pattern of collapse in obstructive sleep apnea, although it is unclear whether this information improves the surgical outcomes. Objective To evaluate the success rate obtained when performing expansion sphincter pharyngoplasty on a group of patients diagnosed with moderate to severe obstructive sleep apnea who were not previously selected by drug-induced sleep endoscopy. Methods We present a series of patients with moderate to severe obstructive sleep apnea who underwent surgery. Pre- and postoperative home sleep apnea tests were performed. The success rate was calculated, and we assessed whether there were statistically significant pre- and postoperative differences in the apnea-hypopnea index and oximetry values. Results In total, 20 patients were included, and the surgical success rate was of 80%. Statistically significant improvements were demonstrated in the mean apnea-hypopnea index (from 40.25 ± 15.18 events/hour to 13.14 ± 13.82 events/hour; p < 0. 0001), the mean oximetric data (from 26.3 ± 12.97 desaturations/hour to 13.57 ± 15.02 desaturations/hour; p = 0.034), and in the mean percentage of total sleep time in which the patient had less than 90% of saturation (from 8.64 ± 9.25% to 4.4 ± 7.76%; p = 0.028). Conclusion The results showed significant improvements in the apnea-hypopnea index and in the oximetric data, with a surgical success rate of 80%, despite the lack of prior drug-induced sleep endoscopy screening.

Esophageal cancers missed at upper endoscopy in Central Norway 2004 to 2021 – A population-based study

IntroductionThe incidence of esophageal cancers is increasing in many Western countries and the rate of missed esophageal cancers (MEC) at upper endoscopy is of concern. We aimed to calculate the MEC rate and identify factors associated with MEC.MethodsThis was a retrospective population-based cohort study including 613 patients diagnosed with esophageal cancer in Central Norway 2004–2021. MEC was defined as esophageal cancer diagnosed 6–36 months after a non-diagnostic upper endoscopy. Patient characteristics, tumor localization, histological type and cTNM stage were recorded. Symptoms, endoscopic findings, use of sedation and endoscopists experience at the endoscopy prior to esophageal cancer diagnosis and at the time of diagnosis were recorded. The association between these factors and MEC was assessed.ResultsForty-nine (8.0%) of 613 cancers were MEC. There was a significant increase in annual numbers of esophageal cancer (p < 0.001) as well as of MEC (p = 0.009), but MEC rate did not change significantly (p = 0.382). The median time from prior upper endoscopy to MEC diagnosis was 22.9 (12.1–28.6) months. MEC patients were older and were diagnosed with disease with a lower cTNM stage and cT category than non-missed cancers, whereas tumor localization and histological type were similar between the groups. The use of sedation or endoscopist experience did not differ between the endoscopy prior to esophageal cancer diagnosis and at the time of diagnosis. High proportions of MEC patients had Barrett’s esophagus (n = 25, 51.0%), hiatus hernia (n = 26, 53.1%), esophagitis (n = 10, 20.4%) or ulceration (n = 4, 8.2%). Significant proportions of MECs were diagnosed after inappropriate follow-up of endoscopic Barrett’s esophagus, histological dysplasia or ulcerations.ConclusionsThe annual number of MEC increased during the study period, while the MEC rate remained unchanged. Endoscopic findings related to gastroesophageal reflux disease such as esophagitis and Barrett’s esophagus were identified in a high proportion of patients with subsequent MECs. Cautious follow-up of these patients could potentially reduce MEC-rate.

Double balloon enteroscopy versus single balloon enteroscopy: A comparative study.

Device assisted enteroscopy (DAE) like the double balloon enteroscopy (DBE) and single balloon enteroscopy (SBE) are postulated to ease small bowel examination and performance of therapy. However, studies comparing the effectiveness of these 2 modalities have yielded varying results. The aim of this study is to compare the efficacy and safety of SBE and DBE. We retrospectively reviewed records of patients who underwent DBE (n = 82) or SBE (n = 45) for small bowel exam in our unit from January 2014 to January 2022. Our primary outcomes were to compare the technical success and diagnostic success rates between DBE and SBE. Our secondary outcomes were to compare the therapeutic success, and complication rates. The main indications were suspected GI bleeding (DBE 41.5% vs SBE 48.9%), iron deficiency anemia (DBE 9.8% vs SBE 4.4%) and small bowel lesions (DBE 28.0% vs SBE 44.4%) detected either from prior capsule endoscopy or radiological imaging. Majority of the enteroscopy exam was by antegrade approach (DBE 67.1% vs SBE 77.8%). We found no significant difference in the technical success (DBE 95.1% vs SBE 97.8%, P = .46), diagnostic success (DBE 69.5% vs SBE 77.8%, P = .36) and the therapeutic success rate (DBE 63.2% vs SBE 54.3%, P = .09) between the groups. Complications occurred in 1 case from each group (mucosal tear). None of the complications were major. In patients who underwent enteroscopy, the diagnostic and therapeutic performance of SBE is similar to DBE. Both procedures were safe with low complication rates.

Screening for exclusion of high-risk bleeding features of esophageal varices in cirrhosis through CT and MRI

Background & aimEsophageal varices (EV) screening guidelines have evolved with improved risk stratification to avoid unnecessary esophagogastroduodenoscopy (EGD) in individuals with low bleeding risks. However, uncertainties persist in the recommendations for certain patient groups, particularly those with hepatocellular carcinoma (HCC) and/or receiving non-selective beta-blockers (NSBB) without prior endoscopy. This study assessed the efficacy of imaging in ruling out EVs and their high-risk features associated with bleeding in patients with cirrhosis and with HCC. We also evaluated the impact of NSBB on the detection of these characteristics. MethodsA total of 119 patients undergoing EGD with CT and/or MRI within 90 days of the procedure were included. 87 patients had HCC. A new imaging grading system was developed utilizing the size of EVs and the extent of their protrusion into the esophagus lumen. The negative predictive value (NPV) of EVimaging(−) versus EVimaging (+) (grades 1–3) in ruling out the presence of EV and/or high-risk features by EGD was calculated. The predictive performance of imaging was determined by logistic regression. ResultsThe NPV of imaging for detecting EV and high-risk features was 81 % and 92 %, respectively. Among HCC patients, the NPV for EV and high-risk features was 80 % and 64 %, respectively. Being on NSBB didn't statistically impact the imaging detection of EV. Imaging was a better predictor of high-risk EGD findings than Child-Turcotte-Pugh scores. ConclusionsOur results suggest that imaging can effectively rule out the presence of EV and high-risk features during EGD, even in patients with HCC and/or receiving NSBB.

Abstract 4794: Impact of prior upper endoscopy on gastric cancer stage and survival

Abstract Background: While gastric cancer (GC) incidence in the US has decreased, 5-year survival remains at 34.5%. Early diagnosis offers curative or treatable options, yet many cases are detected at an advanced stage with poor prognosis. In high-incidence East Asian countries with established screening programs, endoscopic screening demonstrates stage shift towards early GC diagnosis and reduced GC-related mortality. Analyses of these programs have reported benefit of endoscopic screening up to 36 months prior to diagnosis. This study explores the impact of esophagogastroduodenoscopy (EGD) in this timeframe on GC stage at diagnosis and survival in an older US population. Methods: The SEER-Medicare database was queried from 2000 to 2017 for patients 68 years of age or older with histologically confirmed GC with continuous Medicare enrollment for at least 36 months prior to GC diagnosis. We excluded patients with prior cancer history and those diagnosed by autopsy or death certificate. Medicare claims files were searched for EGD claims 6-36 months prior to GC diagnosis. We excluded claims in the 6 months prior to diagnosis to avoid capturing potential diagnostic EGD. We defined the exposed group as patients with an EGD claim 6-36 months prior to GC diagnosis (Prior EGD) and the unexposed group as patients with no EGD claim in this period (No Prior EGD). Propensity score analysis balanced baseline differences for patients with and without Prior EGD using covariates sex, age and year of diagnosis, race and ethnicity, rural/urban, comorbidity, SES, and marital status. The primary outcome was in situ/local-stage GC (early) at diagnosis compared to regional/distant-stage (advanced). Secondary outcomes were 5-year overall and GC-specific survival. The adjusted odds of having in situ/local-stage GC diagnosis compared to regional/distant-stage was estimated using logistic regression, and survival analysis was done using the Kaplan-Meier method. Results: In 10,572 patients with GC (57.5% male, mean age 78.8 years), 16.4% had Prior EGD (n=1,736). Patients with Prior EGD had a significantly higher proportion of GC diagnosed in local stage compared to patients with No Prior EGD (45.7% vs. 30.2%, p &amp;lt; 0.001). After controlling for confounders, Prior EGD group had two-fold increased odds of GC diagnosis at early-stage compared with No Prior EGD (OR=1.99, 95% CI: 1.88-2.10). Compared with No Prior EGD, Prior EGD was associated with higher overall survival (5-year survival 32.1% vs. 22.7%, p&amp;lt;0.001) and GC-specific survival (5-year survival 46.0% vs. 31.1%, p&amp;lt;0.001), both driven by early-stage disease. Conclusions: Our analysis demonstrates that EGD up to 36 months prior to the diagnosis of GC is associated with earlier stage at diagnosis and improved overall and GC-specific survival. This study of an older population suggests that endoscopic screening may be beneficial even in a low-incidence country such as the US and warrants further study. Citation Format: Sophie Wagner, Jennifer S. Ferris, Josephine Soddano, Ji Yoon Yoon, Sheila D. Rustgi, Haley Zylberberg, Jeong Yun Yang, Yongmei Huang, Ling Chen, Chin Hur. Impact of prior upper endoscopy on gastric cancer stage and survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4794.

Low prevalence of gastric intestinal metaplasia and Helicobacter pylori on surveillance upper endoscopy in Lynch syndrome.

Lynch syndrome (LS) increases the risk of numerous different cancers including gastric cancer. While some current guidelines recommend empiric gastric biopsies be performed during upper gastrointestinal cancer surveillance in Lynch syndrome (LS), the yield of these biopsies and the prevalence of gastric intestinal metaplasia (GIM) and Helicobacter pylori (HP) in LS remains unknown. Herein we analyze 165 consecutive individuals with LS who underwent upper endoscopic surveillance with biopsies of the gastric antrum and body being performed universally in all individuals. Of the study cohort, 6.7% of universally biopsied individuals with LS had GIM and/or HP (5.5% GIM, 3.6% HP). Biopsies of the gastric body did not increase rates of GIM/HP identification compared to antral biopsies alone. GIM was detected on subsequent surveillance in 2.2% of individuals without prior GIM, which may represent either newly developed GIM or GIM that was missed on a prior upper endoscopy due to sampling error. These findings support inclusion of at least baseline gastric antrum biopsies as a routine component of all standard surveillance upper endoscopies performed in LS.

(490) The Ins and Outs of Peyronie’s Disease: An Evaluation of Endoscopic Associations

Abstract Introduction Peyronie’s disease (PD) is a fibroproliferative disorder of the tunica albuginea of the penis. Though the etiologies and potential mechanisms for PD remain understudied, known PD risk factors include family history, Dupuytren disease, diabetes mellitus, smoking, hypertension, and penile trauma. Endoscopic procedures have also been reported as a cause of PD. Although often referenced, current literature contains little evidence describing the potential association of endoscopic procedures with the development of PD. Objective To evaluate the association of endoscopic procedures and patient demographics in men with the development of Peyronie’s disease Methods Institutional review board approval was obtained, and a retrospective review was performed at a tertiary referral center of all patients with history of urologic endoscopy who were subsequently diagnosed with PD from January 2010 to January 2022. Electronic medical records were searched for ICD-9 and ICD-10 codes to identify unique records with a diagnosis of PD. Records were also identified by CPT codes for transurethral and percutaneous urologic endoscopic procedures. Endoscopic procedures were evaluated for the type of instrumentation and divided into 4 broad categories: diagnostic cystoscopy, urethral stricture manipulation, transurethral resection, and endoscopic treatment for urinary lithiasis. Records were evaluated for time to PD diagnosis following their procedure, presence of a post-operative urethral catheter, and demographic data. Results A total of 19,383 unique patients with endoscopy procedures and 629 unique patients with PD diagnosis were identified. 121 patients had a diagnosis of PD and history of endoscopy, of whom 50 patients (7.9%) were confirmed to have had endoscopy prior to PD diagnosis. The median age of PD diagnosis was 62. There was no increased association between PD and endoscopy in men with a diagnosis of diabetes (p = 0.5261), hypertension (p = 0.2256), or a history of smoking (p = 0.9398). The majority of PD diagnoses (54%, 27/50) were associated with cystoscopy performed supine (48.1%, p=0.0011), in a clinic (40.7%, p = 0.0001), and with flexible instrumentation (55.6%, p&amp;lt;0.0001). Postoperative urethral catheter use was not associated with PD (p = &amp;lt; 0001. There was no association between the time to presentation of PD and the procedure performed (p=0.73). Conclusions Men with a diagnosis of PD and a history of prior urologic endoscopy are more likely to have undergone a simple, flexible cystoscopy in the clinic setting. There does not appear to be an association between the time to presentation of PD and the endoscopic procedure performed. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Pharmaceuticals

S695 Factors Affecting Likelihood of Peptic Ulcer Disease as the Etiology of Suspected Upper Gastrointestinal Bleeding

Introduction: Patients presenting with suspected upper gastrointestinal bleeding (UGIB) have a broad differential diagnosis. Any process which affects mucosal integrity must be considered when developing a management plan. When treating UGIB a patient’s medical history may provide clues that prioritize consideration of certain diagnoses. This study aims to assess components of the medical history that affect the likelihood of finding a peptic ulcer during endoscopic evaluation. Methods: An IRB-approved retrospective study was performed to evaluate all adult patients who underwent endoscopy for suspected UGIB within five days of presentation, at two affiliated academic hospitals, between 2018 and 2022. Patients were excluded if they had prior endoscopy within 90 days of presentation. Demographic, procedural, and clinical data were obtained via electronic record. Descriptive statistics included t-tests and Chi-square tests. Multivariate analysis was conducted using logistic regression. (Table) Results: A total of 1392 charts were reviewed and 874 patients were included in the analysis. Average age was 64 years, and 525 (60%) were male. The most common symptoms were melena (68%), abdominal pain (32%) and hematemesis (28%). Peptic ulcer disease (PUD) was diagnosed in 397 patients (45%), with 97 patients (11%) classified as high-risk Forrest class 1a/1b/2a/2b lesions where endoscopic intervention is indicated. Another 300 patients (34%) had low risk PUD with Forrest class 2c/3 lesions, and 477 patients (55%) had no PUD. PPI-naïve patients were found to have PUD in 47% of endoscopies, compared to 36% in active PPI users. Multivariate analysis revealed PPI users were 37% less likely to have any ulcer (p< 0.0001). The risk of finding an ulcer increased by 2.0% for every year of age (p< 0.0001). High risk ulcers were more likely to be seen in males (OR 1.73, 95% CI 1.05-2.82), and a history of hepatic disease decreased the likelihood of finding these lesions (OR 0.56, 95% CI 0.37-0.85). Conclusion: Active outpatient PPI use leads to a significant decrease in the likelihood of finding PUD in patients with suspected UGIB. This result underscores the importance of considering other etiologies of bleeding in order to prevent a missed diagnosis and delay in care. The “protective” effect of hepatic disease likely stems from liver-related sources of UGIB present in this population. Even when PUD is suspected in these patients, the data suggest timely empiric treatment with antibiotics and vasoactive agents is warranted. Table 1. - Univariate & Multivariate Analysis of Factors Associated with Upper Gastrointestinal Bleed Presentations Any Ulcer High Risk Ulcer (Forrest 1a/1b/2a/2b) Low Risk Ulcer (Forrest 2c/3) No Ulcer Subjects (N=874) PPI Naïve (N=732) 346 (47%) 84 (11%) 262 (36%) 386 (53%) PPI Use (N=142) 51 (36%) 13 (9%) 38 (27%) 91 (64%) Active PPI Use OR 0.63 0.64 0.65 N/A (95% CI) (0.43-0.93) (0.33-1.23) (0.43-0.99) Age OR 1.02 1.04 1.01 N/A (95% CI) (1.01-1.03) (1.02-1.05) (1.01-1.02) Male Gender OR 1.29 1.73 1.21 N/A (95% CI) (0.97-1.72) (1.05-2.82) (0.88-1.64) Hepatic Disease History OR 0.56 0.86 0.46 N/A (95% CI) (0.37-0.85) (0.46-1.60) (0.28-0.73)

S3622 Idiopathic Culture-Negative Suppurative Gastritis With Gastric Abscess

Introduction: Suppurative gastritis is an uncommon infectious process involving the gastric wall from direct mucosal injury caused by a foreign object, reflux of proximal intestinal bacteria, and hematogenic or lymphatic spread from a distant infection. Intramural gastric abscess is rare with high mortality and morbidity if left untreated. Immediate management is required once there is clinical suspicion. Case Description/Methods: A 23-year-old female with unremarkable medical history presented to the emergency department with epigastric pain for 1-week. She endorsed chills, nausea, and non-bilious vomiting. There was no history of foreign body ingestion, prior endoscopy, proton pump inhibitor, tobacco, or recreational drug use. Patient reported drinking two bottles of wine a week over the month before her illness due to stress and constant use of non-steroidal anti-inflammatory drugs (NSAIDs) for relieving menstrual pain. On exam, she had mild epigastric tenderness. Laboratory work was significant for mild leukocytosis. Computed tomography revealed a lobulated mural thickening and submucosal edema involving distal gastric body & antrum, with a 4.3 cm rim-enhancing intramural collection suggestive of an abscess (a) The patient was started on empiric broad-spectrum antibiotics & Pantoprazole and intravenous fluids. Endoscopy showed a cratered ulcer in the antrum with a central sinus tract leading to the gastric wall. There was no pus exuding, and the abscess appeared to have drained spontaneously (b) Mucosal biopsies were negative for Helicobacter pylori. On endosonography, there was wall thickening of the distal stomach, measuring 20 x 35 mm, with a central hypoechoic sinus tract. The lesion originated from the deep mucosal layer (c) Fine needle biopsy revealed acute inflammation with pus in the gastric wall compatible with abscess. Cytology was negative for malignant cells. The patient was discharged on oral amoxicillin-clavulanate to complete ten days of therapy. Upon repeating endoscopy, two months later, the distal gastric ulcer healed completely, and the patient was doing very well (d). Discussion: Intramural gastric abscess is rare. Foreign body ingestion, systematic spread of infection, or prior endoscopic intervention have been described as etiologic factors. NSAIDs could be a potential contributing factor. Prompt recognition, endoscopic drainage, and antibiotic therapy are essential to improve the outcome.Figure 1.: EUS Finding of gastric mural abscess with a visualized sinus tract inside the thick antral wall.

S1477 Effect of a Detailed Educational Intervention on Pre-Endoscopy Anxiety Levels in Children and Young Adults

Introduction: Invasive medical procedures such as endoscopy are a significant source of anxiety for patients. Published data show that higher levels of pre-endoscopy anxiety are associated with worse clinical outcomes. Studies in adults have shown that pre-endoscopy interventions such as educational videos or brochures are associated with decreased pre-endoscopy anxiety. Similar literature in pediatrics is limited. We sought to evaluate whether an educational video effectively reduces pre-endoscopy anxiety in a pediatric cohort of patients and to identify the most common concerns surrounding endoscopy. Methods: This is a prospective randomized controlled trial of patients ages 8-21 years requiring gastrointestinal endoscopy with their parents participating when appropriate. The intervention group was shown an educational video created by the study investigators. Subjects were asked to report anxiety using a Numerical Rating Scale (NRS) and the State-Trait Anxiety Inventory (STAI, STAI-C). They also reported their anxiety levels surrounding specific components of the procedure. Results: 160 subjects have been recruited and the study remains open. 82 (51%) and 78 (49%) subjects were randomized to the intervention and control group, respectively. Most subjects identified as Hispanic (26%) or African American (15%) and 28% had Medicaid. 35% of subjects had a history of prior endoscopy. Baseline anxiety trait was not significantly different between control and intervention groups. NRS and STAI/STAI-C scores were comparable in intervention and control groups amongst all-comers. However, for the cohort of patients recruited prior to the day of endoscopy, NRS scores were lower in the intervention group (mean score of 3.4 vs 5.6, P = 0.01). Subjects receiving the intervention prior to the day of endoscopy had lower STAI-C state scores than those receiving the intervention the day of endoscopy. Regarding concerns surrounding endoscopy, patients and parents were most worried that some disease might be found, followed by the need for anesthesia. Conclusion: Our results suggest that an educational intervention may attenuate pre-endoscopy anxiety, but that this may be contingent on the timing of delivery. Our results also highlight the factors surrounding endoscopy that are most anxiety-provoking for patients and parents, providing valuable information which may help further define topics that should be addressed not only by educational interventions but also in physician-patient discussions regarding endoscopy.

S2078 Multicentric, Synchronous Colon Cancer in the Rectum, Sigmoid and Cecum in an Elderly Female

Introduction: Multicentric tumors are more common in genetically-linked cancers. In most instances, tumor occurrence in a different location is due to recurrence of the malignancy. Our case illustrates a rare endoscopic finding of 3 distinct and synchronous adenocarcinomas of the rectum, sigmoid colon, and cecum in an otherwise healthy elderly female at an average risk for colorectal cancer. Case Description/Methods: An 81-year-old female with no medical history presented to the hospital with constipation and diffuse intermittent abdominal pain for 4 months. She had been self-medicating at home with over-the-counter laxatives but recently reported that she was not experiencing relief. She denied any prior endoscopy or family history of colorectal cancer. On admission, her vital signs were normal and her physical exam was significant for diffuse abdominal tenderness to palpation. Digital rectal examination revealed a non-tender, hard mass in the left lateral wall of the rectum. Her complete blood count and comprehensive metabolic panels were normal. Iron studies were also unremarkable. A computed tomography (CT) scan of the abdomen and pelvis showed thickening in the sigmoid colon and the rectum with scattered subcentimeter lymph nodes. On colonoscopy, she was found to have 3 partially-obstructing, malignant-appearing lesions located in the rectum, proximal sigmoid, and cecum. Biopsies of all 3 sites revealed adenocarcinoma. Immunohistochemistry for DNA mismatch repair proteins (MMR) showed intact MLH1, MSH2, MSH6, PMS2 genes. She underwent a laparoscopic total colectomy with end ileostomy, with pathological staging revealing pT3 N0 for the sigmoid tumor and pT4a N2b for the cecal tumor. She was planned for neoadjuvant chemoradiation therapy in anticipation for future robotic proctectomy for treatment of the rectal tumor (Figure 1). Discussion: Synchronous colorectal cancers pose a distinct challenge in terms of management and treatment. The extent of surgical resection and the use of chemoradiation depends on the location, number of lesions, and lymph node involvement. Our patient was an interesting case as she presented later in life and her only symptom was constipation. She was an average risk patient, had otherwise normal labs, and HNPCC/lynch syndrome-related cancers were excluded on the basis of normal immunohistochemistry testing.Figure 1.: Partially-obstructing malignant lesions in the (A) rectum, (B) proximal sigmoid, and (C) cecum.

"Into the fire" approach to teaching endoscopic foreign body removal using a modular simulation curriculum.

As flexible endoscopy becomes an increasingly valuable minimally invasive approach to surgical challenges, an efficient and comprehensive training curriculum is needed to train surgeons in therapeutic endoscopy. We developed a modular curriculum utilizing a simulation-based, "into the fire" approach to endoscopic foreign body removal for practicing physicians with task performance pre- and post-testing. From 2020 to 2021, two sessions of our advanced flexible endoscopy course were taught by two expert surgical endoscopists using ex-vivo porcine models. The course focused on safe removal techniques for various foreign bodies as part of an overall endoscopy curriculum that uses hands-on simulation-based pre-testing, didactics, and mentored practice sessions, followed by post-course examination. Pre- and post-course assessments and surveys were used to evaluate knowledge, performance, and confidence of participants, and subsequently analyzed using the Wilcoxon-signed rank test. Of the 16 practicing physicians who participated in the course, 43.8% were certified in Fundamentals of Endoscopic Surgery, and 62.5% had completed > 200 prior upper endoscopies. Upon course completion, scoring on knowledge-based written examinations improved from 3.4 ± 1.9 to 5.8 ± 2.0 (p < 0.001). Technical facility of each participant demonstrated significant overall improvement with post-course score increased from 15.8 ± 2.5 to 23.6 ± 1.6 (p < 0.001), with skill refinement noted in technical subcategories of appropriate instrument use (p < 0.001), foreign body manipulation (p < 0.001), and successful foreign body removal (p < 0.001). Confidence surveys likewise demonstrated significant increase in confidence after completion of the curriculum 11.6 ± 3.4 to 23.0 ± 5.5 (p < 0.001). The "into the fire" approach to teaching endoscopic foreign body removal utilizing our simulation module provides an effective curriculum to improve knowledge, confidence, and overall technical performance. Our methodology utilizes hands-on, simulation-based pre-testing prior to instruction. This introduces clinical scenarios and technical challenges, while accounting for and tailoring to provider-specific variation in knowledge and experience, facilitating training efficiency.

Missed Opportunities for Screening or Surveillance Among Patients with Newly Diagnosed Non-cardia Gastric Adenocarcinoma.

Screening for gastric cancer is not recommended despite rising rates in certain U.S. We determined possible missed opportunities for the detection and surveillance of preneoplastic lesions among gastric cancer patients in a VA hospital. This retrospective cohort study included consecutive, newly diagnosed non-cardia gastric adenocarcinoma patients from 11/2007 to 10/2018 at the Houston VA Hospital. We identified missed opportunities for screening based on risk factors (non-White race, smoking, alcohol, Helicobacter pylori infection, gastric ulcers, family history of gastric cancer). We additionally determined missed opportunities for surveillance of known high-risk lesions. Associations between receipt of prior endoscopy for screening or surveillance and cancer-related outcomes (stage, treatment, survival) were determined using logistic regression models. Among 91 gastric cancer patients, 95.6% were men, 51.6% were black, 12.1% were Hispanic, with mean age of 68.0years (standard deviation 10.8years). The most common risk factors included non-white race (68.1%), smoking (76.9%), alcohol use (59.3%) and prior H. pylori (12.1%). Most patients had ≥ 1 risk factor for gastric cancer (92.6%), and 76.9% had ≥ 2 risk factors. Only 25 patients (27.5%) had undergone endoscopy prior to cancer diagnosis. Of 14 with known high-risk lesions (i.e., gastric intestinal metaplasia, dysplasia, ulcer), only 2 (14.3%) underwent surveillance endoscopy. Receipt of prior endoscopy was not associated with differences in cancer outcomes. Most patients with newly diagnosed gastric cancer had ≥ 2 known risk factors for gastric cancer but never received prior screening endoscopy. Among the few with known prior preneoplastic lesions, endoscopic surveillance was not consistently performed.

IMPACT OF RACE AND GENDER ON OUTPATIENT ENDOSCOPY PROCEDURES DURING COVID: RESULTS FROM A LARGE POPULATION-BASED SURVEY

Sachin Srinivasan: NO financial relationship with a commercial interest | Sravanthi Parasa: NO financial relationship with a commercial interest | Kevin Kennedy: NO financial relationship with a commercial interest | Paul Sinclair: NO financial relationship with a commercial interest | Gary Falk: NO financial relationship with a commercial interest | David Armstrong: YES financial relationship with a commercial interest;Takeda:Speaking and Teaching;Takeda:Advisory Committees or Review Panels;Viatris:Speaking and Teaching;Nestlé Health Sciences:Grant/Research Support;Fresenius Kabi:Speaking and Teaching;AI VALI Inc:Advisory Committees or Review Panels;AI VALI Inc:Patent Held/Filed;Cinclus Pharma:Advisory Committees or Review Panels;Phathom Pharma:Consulting | Prateek Sharma: YES financial relationship with a commercial interest;Bausch:Consulting;Boston Scientific:Consulting;CDx Labs:Consulting;Cosmo Pharmaceuticals :Grant/Research Support;Covidien:Grant/Research Support;Covidien LP:Consulting;Docbot:Grant/Research Support;ERBE USA, Inc.:Grant/Research Support;Fujifilm Medical Systems USA,Inc.:Consulting;Fujifilm Holdings America Corporation:Grant/Research Support;Ironwood Pharmaceuticals:Grant/Research Support;Lucid:Consulting;Lumendi:Consulting;Medtronic:Consulting;Medtronic USA,Inc.:Grant/Research Support;Olympus:Grant/Research Support;Olympus America, Inc.:Consulting;Salix:Grant/Research Support;Salix:Consulting;US Endoscopy:Grant/Research Support The COVID-19 pandemic has caused significant changes in access and patient reluctance for endoscopy procedures, specifically screening colonoscopy. However, patient opinion and willingness to undergo outpatient endoscopy procedures are largely unexplored. We conducted a large population-based survey of adults (ages 18-85 years) using an online platform to collect participants’ deidentified demographics, attitudes, and opinions regarding the COVID-19 pandemic and outpatient endoscopy procedures. We utilized descriptive statistics and multivariate logistic regression for data analysis. Of a total of 29,449 respondents (mean age: 43.3 (SD: 17.3) years, female: 72%), 21,703 (74%) reported having no concerns about undergoing endoscopy during the current pandemic. Of these respondents, 15,382 (71%) were female; mean age of 42.4 years (SD: 17.1); 5,033 (65%) were married; 5,517 (71%) were Caucasians, 5,522 (71%) had a college degree, and 7,059 (91%) relied on physicians or news for information related to COVID-19. Of those participants concerned about an endoscopy procedure (n=7,746; 26%, mean age:42.4 years (SD:17.1), 71% female), 28% did not want to schedule an endoscopy procedure at all during the pandemic, whereas 38% wanted to reschedule endoscopic procedures 3-4 months out and 19% after being vaccinated. Furthermore, of these individuals concerned about undergoing outpatient endoscopy, 36%) of those who were concerned to undergo endoscopy responded that nothing could make them comfortable, 34% (n=2661) would feel more comfortable with the procedure if the endoscopy staff were wearing masks and protective gear, and 17% (n=1,320) would prefer the endoscopy staff to be tested for COVID-19. However, 36% (n=2783) would not be reassured by COIVD testing or PPE use measures. A multivariate model suggested that increased age (1.07; 95%CI:1.05-1.09), female gender (1.16;95%CI: 1.09-1.23), black ethnicity (1.45; 95%CI: 1.34-1.57); married individuals (1.07; 95%CI: 1-1.14), and those who had prior endoscopy (1.88; 95%CI: 1.78-2) were all more likely to be concerned about undergoing an endoscopy during the pandemic. Results from this large population-based survey demonstrate that most of the respondents (70%) would not have any concerns about undergoing an outpatient endoscopy procedure during the pandemic. However, 1 in 4 of the surveyed general population expressed concerns about undergoing endoscopy: women and black respondents were significantly more likely NOT to undergo a procedure. These data can better inform health care systems and endoscopy practices when deciding on outpatient procedures for their patients.

Impact of Barrett oesophagus diagnoses and endoscopies on oesophageal cancer survival in the UK: A cohort study

BackgroundCurrent guidelines recommend endoscopic surveillance for Barrett oesophagus (BE), but the value of surveillance is still debated. Using a combination of primary care, secondary care and cancer registry datasets, we examined the impact of a prior BE diagnosis, clinical and risk factors on survival from oesophageal cancer and adenocarcinoma.MethodsRetrospective cohort study of patients aged 50 and above diagnosed with malignant oesophageal cancer between 1993 and 2014 using Clinical Practice Research Datalink (CPRD). All prior BE diagnoses and endoscopies were identified from CPRD and Hospital Episode Statistics. Histology information was obtained from linked cancer registry data. We used flexible parametric models to estimate excess hazard ratios (EHRs) for relative survival. We simulated the potential impact of lead‐time by adding random lead‐times from a variety of distributions to all those with prior BE.ResultsAmong our oesophageal cancer (n = 7503) and adenocarcinoma (n = 1476) cohorts only small percentages, 3.4% and 5.3%, respectively, had a prior BE diagnosis. Two‐year relative survival was better among patients with BE: 48.0% (95% CI 41.9–54.9) compared to 25.2% (24.3–26.2) without. Patients with BE had a better prognosis (EHR = 0.53, 0.41–0.68). Survival was higher even if patients with BE had fewer than two endoscopies (50.0%; 43.6–57.3). A survival benefit was still observed after lead‐time adjustment, with a 20% absolute difference in 2‐year survival using a 5 year mean sojourn time.ConclusionsPatients with a prior BE diagnosis had a survival advantage. This was not fully explained by surveillance endoscopies.

Post-endoscopy Esophageal Neoplasia in Barrett’s Esophagus: Consensus Statements From an International Expert Panel

Post-endoscopy Esophageal Neoplasia in Barrett’s Esophagus: Consensus Statements From an International Expert Panel

S2104 Acquired Tracheoesophageal Fistula in Diffuse B Cell Lymphoma Associated With Persistent COVID-19

Introduction: Acquired tracheoesophageal fistula (TEF) is rare and commonly occurs due to tracheal or esophageal trauma, malignancy, infection, and as sequelae of intubation. Symptoms typically involve aspiration. We present an elderly patient with relapsed Diffuse Large B-Cell Lymphoma (DLBCL) complicated by persistent COVID-19 infection who develops acute onset aspiration and productive cough. After workup, she is found to have an acquired TEF. Case Description/Methods:: Our patient is a 76-year-old woman who presents with acute onset cough and recurrent aspiration of solids and liquids. Past medical history includes COVID-19 infection diagnosed 2-3 months prior, and relapsed DLBCL undergoing chemotherapy with Monjuvi/Revlimid (held for 4 months due to COVID-19 infection). She denies prior dysphagia, odynophagia, intubation, or endoscopy. Physical exam is notable for expiratory wheeze. Chest XRay shows diffuse interstitial opacities bilaterally. Barium esophagram shows contrast extravasation into the left bronchus (Figures 1 & 2). Esophagogastroduodenoscopy (EGD) shows 30 mm fistula in the proximal esophagus (Figure 2A). A 20 mm x 100 mm through-the-scope esophageal stent was placed over the fistula site and anchored with endo sutures (Figure 2B). The patient had persistent aspiration and was found to have left vocal cord paralysis likely from recurrent laryngeal nerve damage. Her course was complicated by respiratory failure and she was transitioned to comfort measures. Discussion: Acquired TEF is a rare finding with several different etiologies. Diagnosis is made via esophagram and treatment is typically esophageal stenting. Large TEFs serve as incubators for recurrent respiratory infections. There are no known cases of persistent COVID pneumonia due to TEF. Therefore, TEF should be considered in any immunosuppressed patient with history of persistent pneumonia and aspiration of unexplained cause. (Figure Presented).

High Prevalence of Transjugular Intrahepatic Portosystemic Shunt Creation Without Prior Endoscopy During Acute Variceal Bleeding Hospitalization in the United States.

Current clinical guidelines by both American Association for the Study of Liver Disease and European Association for the Study of the Liver recommend endoscopy in all patients admitted with acute variceal bleeding within 12 hours of admission. Transjugular intrahepatic portosystemic shunt (TIPS) creation may be considered in patients at high risk if hemorrhage cannot be controlled endoscopically. We conducted a cross‐sectional observational study to assess how frequently TIPS is created for acute variceal bleeding in the United States without preceding endoscopy. Adult patients undergoing TIPS creation for acute variceal bleeding in the United States (n = 6,297) were identified in the last 10 available years (2007‐2016) of the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between endoscopy nonutilization and hospital characteristics, controlling for patient demographics, income level, insurance type, and disease severity. Of 6,297 discharges following TIPS creation for acute variceal bleeding in the United States, 31% (n = 1,924) did not receive first‐line endoscopy during the same encounter. Rates of “no endoscopy” decreased with increasing population density of the hospital county (nonmicropolitan counties 43%, n = 114; mid‐size metropolitan county 35%, n = 513; and central county with >1 million population 23%, n = 527) but not by hospital teaching status (n = 1,465, 32% teaching vs. n = 430, 26% nonteaching; P = 0.10). Higher disease mortality risk (odds ratio, 0.42; 95% confidence interval, 0.22‐0.80; P = 0.02) was associated with lower odds of noncompliance. Conclusion: One third of all patients undergoing TIPS creation for acute variceal bleeding in the United States do not receive first‐line endoscopy during the same encounter. Patients admitted to urban hospitals are more likely to receive guideline‐concordant care.

Effect of COVID-19 pandemic on workflows and infection prevention strategies of endoscopy units in Hungary: a cross-sectional survey

BackgroundHealth care professionals in endoscopic labs have an elevated risk for COVID-19 infection, therefore, we aimed to determine the effect of current pandemic on the workflow and infection prevention and control strategies of endoscopy units in real-life setting.MethodsAll members of Hungarian Society of Gastroenterology were invited between 7 and 17 April 2020 to participate in this cross-section survey study and to complete an online, anonymous questionnaire.ResultsTotal of 120 endoscopists from 83 institutes were enrolled of which 35.83% worked in regions with high cumulative incidence of COVID-19. Only 33.33% of them had undergone training about infection prevention in their workplace. 95.83% of endoscopists regularly used risk stratification of patients for infection prior endoscopy. While indications of examinations in low risk patients varied widely, in high-risk or positive patients endoscopy was limited to gastrointestinal bleeding (95.00%), removal of foreign body from esophagus (87.50%), management of obstructive jaundice (72.50%) and biliary pancreatitis (67.50%). Appropriate amount of personal protective equipment was available in 60.85% of endoscopy units. In high-risk or positive patients, surgical mask, filtering facepiece mask, protective eyewear and two pairs of gloves were applied in 30.83%, 76.67%, 90.00% and 87.50% of cases, respectively. Personal protective equipment fully complied with European guideline only in 67.50% of cases.ConclusionsSurvey found large variability in indications of endoscopy and relative weak compliance to national and international practical recommendations in terms of protective equipment. This could be improved by adequate training about infection prevention.

S2298 Gastrointestinal Amyloidosis in the Setting of IBD: A Diagnostic Challenge

INTRODUCTION: Amyloidosis is a clinical entity characterized by abnormal deposition of protein that impair organ function and is associated with a high morbidity and mortality. Secondary amyloidosis is a rare complication that occurs with infectious or inflammatory conditions, such as inflammatory bowel disease (IBD). We present a patient with gastrointestinal bleeding and increased ostomy output found to have secondary amyloidosis in the setting of long-standing IBD. CASE DESCRIPTION/METHODS: An 81-year-old male with a history of ulcerative colitis (UC) s/p total colectomy and ileostomy presented with increased ostomy output. The patient had multiple previous admissions for high ostomy output for which he underwent prior upper endoscopy and ileoscopy (Figure 1). Biopsies revealed chronic ileitis associated with neutrophilic cryptitis and focal crypt abscesses. Given concern for Crohn’s disease, he received oral steroids. During his recent hospitalization, he had increased ileostomy output and fecal calprotectin of 211 (4x ULN). Ileoscopy revealed erythematous mucosa with submucosal punctate hemorrhages, friability, and erosions throughout the distal ileum (Figure 2). Pathology revealed active ileitis with ulcerations. He received high dose steroids and IV octreotide for two weeks, but continued to have increased output and developed acute kidney injury. Repeat fecal calprotectin was 893. Given the lack of response to treatment, congo red staining was added to prior biopsies revealing amyloid deposition in both the gastric and duodenal specimens (Figure 3). Given there was no plasma cell dyscrasias, the amyloid deposition was felt secondary to his chronic inflammation from his IBD. Course was further complicated by small bowel bleeding requiring embolization. Unfortunately, his clinical status continued to deteriorate and the patient eventually died from hypoxic respiratory failure. DISCUSSION: Gastrointestinal amyloidosis (GIA) in the setting of IBD is exceedingly rare. While patients with UC can have extraintestinal disease following total colectomy, we have not found any reports in the literature of post-total colectomy GIA. Treatment of GIA is focused on the underlying etiology; however, given the non-specific signs and symptoms this can often delay the diagnosis. In severe cases, high dose steroids and somatostatin analogues may be used; although, some patients may be refractory as in this case. In conclusion, a high index of suspicion is needed to establish an early diagnosis, thus decreasing complications.Figure 1.: Ileoscopy revealing punctate submucosal hemorrhages and erosions within the distal ileum.Figure 2.: Ileoscopy revealing erythematous mucosa with submucosal punctate hemorrhages, friability, and erosions throughout the middle and distal portions of the ileum.Figure 3.: Congo red stain of the duodenal biopsy revealing vascular amyloid deposition (blue arrow). The waxy orange material represents the amyloid which deposits into the wall of a blood vessel.