Procedure-related Parameters Research Articles

Efficacy of Epinephrine Injection in Preventing Post-ERCP Pancreatitis.

Rectal indomethacin or a topical spray of epinephrine to the papilla of Vater has each shown efficacy alone in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We supposed that a submucosal epinephrine injection would be more effective and longer acting than a topical epinephrine spray and therefore would further reduce the incidence of PEP. A retrospective analysis was conducted of 412 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2017 and December 2019. These patients were divided into 2 groups: the indomethacin group and the indomethacin plus the submucosal epinephrine injection group. The incidence rates and severity of PEP, post-ERCP hyperamylasemia, other outcomes, and any other adverse events were compared between the groups. Baseline demographic and clinical characteristics and procedure-related parameters were similar between the 2 groups. The incidence of PEP was 0.4% in the epinephrine group compared with 5.1% in the indomethacin group (P<0.001). Post-ERCP hyperamylasemia occurred in 24.6% of patients in the indomethacin group, whereas 7.6% of patients in the epinephrine group developed this condition; the difference was significant (P<0.001). Postsphincterotomy bleeding occurred in 5 patients, all of whom were in the indomethacin group (P<0.001). Other adverse events, including arrhythmias, acute coronary events, stroke, or hypertension were not significantly different between the 2 groups. Addition of a submucosal epinephrine injection in conjunction with rectal indomethacin significantly reduced the incidence of PEP, post-ERCP hyperamylasemia, and postsphincterotomy bleeding.

S1226 Impact of Fellowship Training Level on Quality Metrics in Veterans Undergoing Screening Colonoscopy

INTRODUCTION: Colonoscopy is the recommended modality for colorectal cancer (CRC) screening. Adenoma detection rate (ADR) has emerged as a leading quality metric for screening colonoscopy. The rates of interval CRC and mortality decrease when ADR is improved. The cognitive and fine motor skills required for identification of polyps is a learned skill, which may differ between early and advanced trainees. This could have an impact on the quality of the procedure, even when supervised by faculty. The aim of this study is to compare metrics of screening colonoscopies performed at a teaching hospitals involving early (first year) and advanced (second and third year) gastroenterology fellowship trainees. METHODS: A retrospective review was performed of patients between age 50 and 75 years, with average familial cancer risk, who underwent a first-time screening colonoscopy by a gastroenterology fellowship trainee at Clement J. Zablocki Veterans Affairs Medical Center between January 2018 and June 2019. Patients with inadequate bowel preparation were excluded. Data were analyzed using Chi Square, Fishers' Exact Test, and One-Way ANOVA, as appropriate. A binomial test was used to compare rates of polyp identification against the minimum standard of 25%. All analyses were conducted using SAS 9.4. RESULTS: 280 patients were included in the study. Patient demographics are outlined in Table 1. Procedure-related parameters are outlined in Table 2. When early trainees were involved in a procedure, the time to reach cecum (12.2 vs. 7.1 minutes, P < 0.0001), and the total procedure time (35.8 vs 28.8 minutes, P < 0.0001) were longer. The overall withdrawal time was not different (23.5 vs 21.8 minutes, P = 0.168), however, a second exam of the right colon was less likely to be performed when an early trainee was involved (81.8% vs 96.8%, P < 0.0001). A statistically significant high ADR was achieved by both groups (46.8% vs 50.6%, P = 0.078). There were no emergency room visits, hospital admissions, or deaths attributable to colonoscopy. There were more unrelated 30 day emergency room visits in the early trainee group (8.7% vs. 3.9%, P = 0.0498). CONCLUSION: A high ADR was achieved irrespective of level of trainee involved in the procedure. Trainee level did not adversely affect key quality metrics in screening colonoscopy when performed under supervision. Extra time should be allotted when first year fellowship trainees are involved in the procedure.Table 1.: DemographicsTable 2.: Procedure CharacteristicsTable 3.: Polyp Characteristics

Impact of class III obesity on outcomes and complications of transvaginal ultrasound-guided oocyte pickup

ObjectiveTo assess the impact of class III obesity on outcomes and complications of transvaginal ultrasound-guided oocyte pickup (OPU).DesignRetrospective cohort study.SettingHospital-based fertility clinic.Patient(s)All women undergoing OPU procedures during autologous in vitro fertilization (IVF) and oocyte banking cycles, grouped by patient body mass index (BMI: <25, 25–29.9, 30–34.9, 35–39.9, ≥40 kg/m2).Intervention(s)Transvaginal OPU under conscious sedation.Main Outcome Measure(s)Sedation and procedure-related parameters and complications.Result(s)A total of 2,141 OPU procedures in 1,579 patients were analyzed, including 121 OPU procedures in 94 patients with BMI ≥40 kg/m2. There was a statistically significant increase in total fentanyl and midazolam doses and procedure duration as BMI increased. Compared with patients with BMI <25 kg/m2, those with BMI ≥40 kg/m2 were more likely to require additional sedation during the procedure (adjusted odds ratio [aOR] 1.99; 95% confidence interval [CI], 1.14–3.49). The rate of difficult access was 28.9% for procedures with BMI ≥40 kg/m2 compared with 5.2% with BMI <25 kg/m2 (aOR 7.57; 95% CI, 4.66–12.29). The OPU was incomplete due to inaccessible follicles through a transvaginal approach in 18.2% of procedures with BMI ≥40 kg/m2 compared with 1.3% with BMI <25 kg/m2 (aOR 16.94; 95% CI, 8.24–34.84). The rates of sedation and procedure-related complications were low, and none occurred in patients with BMI ≥40 kg/m2.Conclusion(s)There was no increased risk of complications for women with class III obesity undergoing OPU with conscious sedation. However, the operator was more likely to encounter difficult access and to incompletely aspirate follicles through a transvaginal approach.

Factors associated with silent cerebral events during atrial fibrillation ablation in patients on uninterrupted oral anticoagulation.

Silent cerebral events (SCEs) are related to the potential thromboembolic risk in atrial fibrillation (AF) ablation. Periprocedural uninterrupted oral anticoagulation (OAC) reportedly reduced the risk of SCEs, but the incidence still remains. AF patients undergoing catheter ablation were eligible. All patients took non-vitamin K antagonist oral anticoagulants (NOACs; n = 248) or vitamin K antagonist (VKA; n = 37) for periprocedural OAC (>4 weeks) without interruption during the procedure. Brain magnetic resonance imaging was performed within 2 days after the procedure to detect SCEs. Clinical characteristics and procedure-related parameters were compared between patients with and without SCEs. SCEs were detected in 66 patients (23.1%; SCE[+]) but were not detected in 219 patients (SCE[-]). Age was higher in SCE[+] than in SCE[-] (66 ± 10 vs. 62 ± 12 years; p < .05). Persistent AF prevalence, CHADS2 /CHA2 DS2 -VASc scores, serum NT-ProBNP levels, left atrial dimension (LAD), and spontaneous echo contrast prevalence in transesophageal echocardiography significantly increased in SCE[+] versus SCE[-]. SCE[+] had lower baseline activated clotting time (ACT) before heparin injection and longer time to reach optimal ACT (>300 s) than SCE[-] (146 ± 27 vs. 156 ± 29 s and 44 ± 30 vs. 35 ± 25 min; p < .05, respectively). In multivariate analysis, age, LAD, baseline ACT, and time to reach the optimal ACT were predictors for SCEs. The average values of the ACT parameters were significantly different among NOACs/VKA. Age, LAD, and intraprocedural ACT kinetics significantly affect SCEs during AF ablation. Different anticoagulants have different impacts on ACT during the procedure, which should be considered when estimating the risk of SCEs.

Comparison of Middle and Lower Calyceal Access for Renal Pelvis Stone in Percutaneous Nephrolithotomy: A Prospective Randomized Study

Objective: The aim of the study was to evaluate the possible effects of calyceal choice for renal puncture under sonographic guidance on the outcomes of percutaneous nephrolithotomy (PNL). Materials and Methods: A total of 70 patients for whom ultrasound-guided PNL was planned for 20–30-mm single renal pelvic stones were prospectively allocated to group 1 (n:35) with middle calyx entry or group 2 (n:35) with lower calyx entry. Procedure-related parameters such as duration of operation, stone-free rates, complication rates, and radiation exposure time were analyzed in detail. Results: The mean age of the patients was 45.67 ± 1.50 years and the mean stone size was 316.4 ± 17.95 mm². There was no significant difference regarding the age, BMI, stone burden, and the grade of hydronephrosis between the groups. Skin to collecting system distance was significantly shorter in the middle calyx entrance (p = 0.021). Total duration of the procedure was again significantly shorter in group 1 cases (74.69 ± 2.94 min) than in group 2 (84.29 ± 4.25 min) (p = 0.003). Regarding the success rates, the postoperative stone-free rate was higher in group 1 (91.4% in group 1, 80.0% in group 2, p = 0.305). Last, there was no statistically significant difference in hemoglobin reduction rates, blood transfusion requirements, and complication rates between the 2 groups. Conclusion: Getting access to the renal pelvis through the middle calyx during ultrasonic guided PNL procedure is more advantageous to lower the calyceal approach by reducing both the duration of the PNL procedure with significantly higher stone-free and comparable complication rates.

Sa1262 A LARGE SINGLE-CENTER STUDY ON THE CLINICAL OUTCOMES OF PER-ORAL ENDOSCOPIC MYOTOMY FOR SIGMOID TYPE 2 ACHALASIA

Per-oral endoscopic myotomy (POEM) has been recognized as a safe and effective minimally-invasive endoscopic treatment for achalasia. Good clinical outcomes have been reported on the application of POEM in straight type achalasia. On the other hand, results of POEM in sigmoid type achalasia, especially sigmoid type 2, are limited. This study aims to report the clinical outcomes of POEM for sigmoid type 2 achalasia. A single-center retrospective study was conducted. A prospectively collected database of 2000 patients who underwent POEM in Showa University between September 2008 to June 2019 has been reviewed. Patients who were diagnosed as sigmoid type 2 achalasia and underwent POEM were included in this study. Sigmoid type 2 achalasia was defined as an enormously dilated and tortuous esophagus in barium esophagram and double esophageal lumen in some CT slices. The primary outcome was the success rate, defined as an Eckardt Symptom Score(ESS) of less than 3 without additional treatments such as balloon dilation or redo POEM. The secondary outcomes were integrated relaxation pressure(IRP), mean lower esophageal sphincter(LES) pressure, and GERD after POEM. Patient’s characteristics: A total of 108 patients (age: 58.4±14.7 y/o, 51 females(47%), BMI: 21.7±4.6kg/m2) were included. Based on Chicago Classification, the type of achalasia seen were as follows: Type I/II/III= 28/8/1, and there were 71 unidentified cases due to the difficulty of inserting catheters. Diameter of esophagus was 48.1±17.5mm. Duration of symptoms was 17.4(7.7-29)years. ESS was 5(3-7). As pre-treatment, 49 patients had balloon dilation, Hellor-Dor in 8 patients, and Heller myotomy in 2 patients. Procedure-related parameters: Operation time was 95.9±32.1min. Myotomy length was 7(5-9)cm at the esophageal side, and 3(2-3)cm at the gastric side. Post-operative hospital stay was 4(4-5) days. The following complications were noted: mucosal perforation in 3 patients, submucosal hematoma or bleeding in 3 patients. Treatment outcomes: Success rate after 2 months was 89.1%(82/92). Pre- and 2-months post-POEM ESS were 5.0±2.5 and 1.1±1.0 (p<0.0001), respectively. Pre- and 2-months post-POEM IRP were 15.7±9.9 and 8.6±5.5 mmHg (p=0.0012), respectively. Pre- and 2-months post-POEM mean LES pressure were 19.9±13.9 and 14.6±7.7 mmHg (p=0.066), respectively. GERD 2-months post-POEM were as follows: Grade(N/A/B/C/D=37/29/13/7/1). Patients with GERD symptoms were 11.3%(10/88). PPI usage rate was 16.1%(13/81). Success rate after 1 year was 87.8%(43/49). Since good results of the short- and mid-term success rate and significant improvement of ESS and IRP value were achieved, POEM shows to be an effective procedure for sigmoid type 2 achalasia. Long-term results are expected in future studies.CT slice showing double esophageal lumenView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Peroral endoscopic myotomy (POEM): a comparative study between Chagasic and idiopathic achalasia.

Background and study aims Achalasia can be classified as either primary (idiopathic) achalasia or secondary achalasia, which is a consequence of another systemic disease. Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia. We evaluated the efficacy and safety of POEM in patients with Chagasic achalasia compared to idiopathic achalasia. Patients and methods We evaluated POEM procedures performed at a single institution from November 2016 to January 2018. Demographic data, Eckardt score, lower esophageal sphincter (LES) pressure, body mass index, post-operative erosive esophagitis, adverse events, length of hospital stay, and procedure-related parameters were analyzed. Results Fifty-one patients underwent POEM as a treatment for achalasia in this period (20 patients with Chagasic and 31 with Idiopathic etiology). The overall clinical success rate was 92.1 %, with no statistical difference between groups (90 % in the Chagasic group vs. 93.5 % in the Idiopathic group, P = 0.640). Both groups had significant reduction in Eckardt score and in LES pressure, and increase in bodey mass index (BMI) at 1-year follow-up. There was no statistical difference between groups regarding Eckardt score ( P = 0.439), LES pressure (p = 0.507), BMI ( P = 0.254), post erosive esophagitis (35 % vs. 38.7 %, P = 0.789), adverse events (30 % vs. 12 %, P = 0.163,) length of hospital stay (3.75 days vs. 3.58 days, P = 0.622), and operative time (101.3 min vs. 99.1 min, P = 0.840). Conclusion POEM is an effective and safe treatment for patients with achalasia. There is no difference in POEM outcomes for those patients with Chagasic or Idiopathic achalasia.

P6020His bundle pacing in patients with abnormal versus intact atrioventricular conduction: from the IMAGE-HBP Study

Abstract Background Frequent right ventricular pacing causes ventricular dyssynchrony and adverse outcomes. His bundle pacing (HBP) offers a physiological alternative. HBP electrical performance characteristics with cardiac conduction system abnormalities are not well established. Purpose To compare HBP implant procedure related parameters in patients with abnormal atrioventricular (AV) conduction versus those with intact AV conduction. Methods Patients prospectively enrolled in the IMAGE-HBP study undergoing implant attempt with a SelectSecure 3830 lead placed at the putative His-bundle location were included in the analysis. Patients were divided into groups based on AV conduction status. Implant characteristics and electrical performance of the pacemaker were tabulated and compared between the two groups with formal statistical tests. Results Among 60 patients (age 74.7 years old and 60% male), 29 patients (48%) had abnormal AV conduction at or below the AV node (18 with AV block of which 5 also had bundle branch block (BBB), 6 with SND and BBB, and 5 with AV node ablation). The remaining 31 patients (52%) had intact AV conduction. Procedure times were not significantly different between the groups (P=0.26). Selective HBP was achieved in 20.7% of abnormal AV conduction patients and 45.2% of intact AV conduction patients (P=0.06); the remaining patients had non-selective HBP. There were no differences detected in pacing characteristics at implant and paced QRS durations by AV conduction status. Patient with intact AV conduction (N=31) Patients with abnormal AV conduction at or below AV node (N=29) Procedure time in minutes (mean ± SD, Median, IQR) 99±38; 87 [43, 180] 108±32; 108 [65, 182] Fluoroscopy time in minutes (mean ± SD, Median, IQR) 15±12; 11 [3, 50] 16±9; 13 [4, 36] Number of fixation attempts 3.0±2.2 2.2±2.0 sHBP PCT N=14 N=6 V at 0.5ms 1.8±0.9 1.7±1.2 V at 1.0ms 1.6±1.2 1.2±0.8 nsHBP PCT N=17 N=22 V at 0.5ms 2.2±1.9 1.7±1.3 V at 1.0ms 1.5±1.1 1.3±1.1 His signal recorded, number 30 (96.8%) 28 (96.6%) H-QRS interval, ms 46±7 48±13 His Injury of Current, N (%) 23 (74.2%) 18 (62.1%) Baseline Intrinsic QRS, ms 96±16 107±22 Paced QRS duration, ms (from HBP at 1.0ms) 119±23 121±19 Conclusions Selective and non-selective HBP are achievable in bradycardic patients with abnormal and intact AV conduction, including those with BBB. There were no major differences in HBP implant parameters between patients with abnormal AV conduction and those with intact AV conduction.

Could ureteral wall thickness have an impact on the operative and post-operative parameters in ureteroscopic management of proximal ureteral stones?

AimTo evaluate the possible impact of stone impaction in terms of ureteral wall thickness (UWT) on the success and procedure related parameters of ureteroscopic management in proximal ureteral calculi. Patients and methods82 patients with proximal ureteric stones were included and were divided into two subgroups where UWT was >5 mm in 38 cases; and <5 mm in 44 cases. Stone size, degree of hydronehrosis, diameter of proximal ureteral lumen, UWT and patient's demographics were evaluated. Semi-rigid ureteroscopy with Ho-YAG laser was performed and the possible impact of UWT as an objective parameter for stone impaction on the success rates and procedure related parameters was evaluated. ResultsMean patient age and stone size values were 47.55 ± 1.78 years and 8.17 ± 0.29 mm respectively. Regarding the impact of UWT value at the stone site for the parameters mentioned above stone free rates particularly at 1-week after the procedure was higher in group 2 and the rate of residual fragments as well as the need for double J stent placement was higher in group 1. Additionally, mean duration of the procedures was significantly longer in Group 1 during which pathologic alterations were significantly higher in ureteral wall at stone site were observed in these cases (p:0.0243). ConclusionsUWT may be used to predict the success of ureteroscopic management and other procedure related parameters for proximal ureteral stones in an effective manner. With this approach a more rational operative plan with higher success rates, limited complications and auxiliary procedures could be made.

Preliminary Experience With Proximal Flow Reversal During Intracranial Balloon Angioplasty and Stenting for Symptomatic, Severe Intracranial Stenosis

Abstract INTRODUCTION The frequency of balloon-angioplasty and stenting for symptomatic intracranial stenosis was drastically reduced after publication of the negative SAMMPRIS trial. In part, this was due to a higher than expected periprocedural complication rate (14.7% 30-d stroke or death) compared to maximal medical therapy (5.8%). Although the cause of periprocedural stroke was not defined, intraprocedural artery-to-artery embolism is a likely contributor. The Silk Road ENROUTE Transcarotid Neuroprotection System (TCNS) was designed as an alternative revascularization strategy for carotid bifurcation disease. It provides direct transcarotid access and proximal protection through flow reversal. We adapted this system as a proximal protection strategy for balloon angioplasty and stenting of severe, symptomatic intracranial stenosis. METHODS From May-2017 to May-2019, 7 patients underwent intracranial balloon angioplasty and stenting for symptomatic intracranial stenosis using the TCNS. Baseline demographics, comorbidities, procedure-related parameters, and outcomes were assessed. RESULTS A total of 7 patients (mean age 63, SEM 4.7 yr, 57% female) with severe (84% +/− 5%) supraclinoid internal carotid artery (ICA) and/or M1 stenosis presented with recurrent strokes (86% left sided) despite dual antiplatelet therapy (DAPT). Angiographically, cessation or reversal of flow was seen in the supraclinoid ICA in all patients, with confirmation by transcranial doppler in selected cases, after the institution of flow reversal by the TCNS. A noncompliant balloon was used to perform submaximal angioplasty, followed by stenting with intracranial stents. All procedures were technically successful with no evidence of periprocedural thromboembolic complications. Follow-up ranged from 6 to 12 mo. One patient suffered a fatal reperfusion hemorrhage on POD 3. One patient suffered from a minor recurrent stroke at 7 mo (after the cessation of DAPT) and was restarted on DAPT. CONCLUSION Traditional methods of intracranial balloon angioplasty and stenting suffer from high periprocedural ischemic stroke rates. TCNS can be adapted to provide a means of proximal protection during the treatment of these high-risk lesions. This procedural innovation warrants further investigation.

Submucosal tunneling endoscopic resection of large submucosal tumors originating from the muscularis propria layer in the esophagus and gastric cardia.

The aim of this study was to evaluate the short-term complications of submucosal tunneling endoscopic resection (STER) for large submucosal tumors (SMTs) originating from the muscularis propria (MP) layer in the esophagus and gastric cardia. We performed 286 cases of STER from September 2012 to December 2017. The clinical data of patients with SMTs originating from the MP layer of 3.0-7.0 cm, who underwent STER procedure at the endoscopy center of Tianjin Medical University General Hospital, were collected retrospectively. Epidemiological data, tumor location, tumor size, procedure-related parameters, complications, and follow-up were included. A total of 27 (9.4 % [27/286]) patients were large-size SMTs, with a mean age of 51.9 ± 9.4 years. The male/female ratio was 19:8. Of the 27 SMTs, 23 were located in the esophagus and 4 in the gastric cardia. The mean tumor size was 4.0 ± 1.1 cm. The en bloc resection rate was 85.2 % (23/27), and the complete resection rate was 100 % (27/27). Intra-operative perforation occurred in 2 patients (7.4 %) and post-operative perforation occurred in 2 patients (7.4 %). No other complications were observed. The average cost of the procedure was $3357.99 ± $1171.60 per inpatient stay (including both the procedure and an additional inpatient stay). The mean follow-up time was 15 ± 10.1 months. No recurrence and metastasis occurred during the follow-up period. There is low risk of STER for the large-sized SMTs in the esophagus and gastric cardia, and the most common complication occurred during or after the procedure is perforation.

¿Podría el espesor de la pared ureteral afectar a los parámetros intra y postoperatorios de la ureteroscopia para el tratamiento de piedras ureterales proximales?

AimTo evaluate the possible impact of stone impaction in terms of ureteral wall thickness (UWT) on the success and procedure related parameters of ureteroscopic management in proximal ureteral calculi. Patients and methods82 patients with proximal ureteric stones were included and were divided into 2subgroups where UWT was> 5mm in 38 cases; and <5mm in 44 cases. Stone size, degree of hydronehrosis, diameter of proximal ureteral luz, UWT and patient's demographics were evaluated. Semi-rigid ureteroscopy with Ho-YAG laser was performed and the possible impact of UWT as an objective parameter for stone impaction on the success rates and procedure related parameters was evaluated. ResultsMean patient age and stone size values were 47.55±1.78 years and 8.17±0.29mm respectively. Regarding the impact of UWT value at the stone site for the parameters mentioned above stone free rates particularly at 1-week after the procedure was higher in group 2 and the rate of residual fragments as well as the need for double J stent placement was higher in group 1. Additionally, mean duration of the procedures was significantly longer in Group 1 during which pathologic alterations were significantly higher in ureteral wall at stone site were observed in these cases (P=.0243). ConclusionsUWT may be used to predict the success of ureteroscopic management and other procedure related parameters for proximal ureteral stones in an effective manner. With this approach a more rational operative plan with higher success rates, limited complications and auxiliary procedures could be made.

Submucosal Tunneling Endoscopic Resection for Gastric Submucosal Tumors: a Comparison Between Cardia and Non-cardia Location

Background and PurposeSubmucosal tunneling endoscopic resection (STER) was initially used to remove submucosal tumors (SMTs) located at the esophagus and cardia; only few researchers have reported the feasibility of STER for gastric SMTs beyond cardia due to the technical difficulty, and little is known about the comparison of STER for cardia and non-cardia gastric SMTs. The purpose was to compare the feasibility and efficacy of STER for cardia and non-cardia gastric SMTs, as well as to explore the risk factors for failure of en bloc resection. MethodsWe retrospectively collected the clinical data about patients with gastric SMTs who received STER at our hospital from June 2012 to June 2018. Demographics, tumor size, procedure-related parameters, complications, hospital stay, and follow-up data were compared between cardia and non-cardia SMTs. And multivariate analyses were conducted to look for the risk factors for failure of en bloc resection. ResultsA total of 46 SMTs were removed, and 25 of them were located at cardia, while the other 21 at non-cardia position. There was no significant difference between the two groups in terms of gender, age, tumor size, en bloc resection rate, operation time, complications, and hospital stay (p > 0.05). No recurrence was noticed in all the cases. Multivariate analyses revealed that irregular shape was an independent risk factor for failure of en bloc resection. ConclusionSTER is feasible for both cardia and non-cardia gastric SMTs, and the efficacy between cardia and non-cardia location is comparable. Irregular shape was an independent risk factor for failure of en bloc resection.

Anterior versus posterior myotomy during poem for the treatment of achalasia: systematic review and meta-analysis of randomized clinical trials.

The optimal orientation of the myotomy during peroral endoscopic myotomy (POEM) is unknown. This meta-analysis aims to compare anterior and posterior myotomy regarding clinical success and safety. PubMed, Embase, Cochrane Library, WOK, and clinicaltrials.gov were searched to identify randomized clinical trials (RCTs) comparing anterior and posterior myotomy during POEM for the treatment of achalasia. The primary outcome was clinical success. Secondary outcomes included postprocedural gastroesophageal reflux disease (GERD), adverse events (AEs), manometric findings, and procedure-related parameters. Random-effects models were used for the primary analysis. Four RCTs enrolling 488 patients were included. Overall clinical success 3-12 months after POEM was 97% (95% confidence interval [CI] 93-100%) and did not differ between anterior and posterior myotomy (Relative risk [RR] 0.98, 95%CI: 0.96-1.01; I2: 0%). Incidence of GERD after POEM based on 24-hour pH monitoring (RR 0.98, 95%CI: 0.75-1.28), endoscopy (RR 1.04, 95%CI: 0.78-1.38), and symptoms (RR 0.89, 95%CI: 0.55-1.42) was similar. Posterior myotomy was associated with fewer AEs (RR 0.63, 95%CI: 0.42-0.94), lower risk of mucosotomy (RR 0.42, 95%CI: 0.27-0.66) and shorter incision closure time (mean difference: -2.28 minutes, 95%CI: -3.46 to -1.10). Anterior myotomy was associated with a shorter length of hospitalization (mean difference: 0.31 days, 95%CI: 0.05-0.57), although the clinical relevance of this finding is negligible. No significant differences were found regarding manometric outcomes, total operation and myotomy time. Anterior and posterior myotomy are equally effective for the treatment of achalasia, without significant differences in postprocedural GERD. Posterior POEM was associated with fewer AEs and a shorter incision closure time.

Cardiac resynchronisation therapy: current benefits and pitfalls.

Cardiac resynchronisation therapy (CRT) has been shown to reduce all-cause mortality, heart failure events, and symptoms while improving exercise capacity and quality of life. Nevertheless, despite a large number of multicentre randomised trials and clear evidence confirming the above, there is still a higher number of patients who fail to develop reverse remodelling. In order to select the optimal patient population, the current European Society of Cardiology guidelines recommend a simultaneous evaluation of QRS morphology and width. However, based on recent data, QRS width itself is a less accurate parameter in the prediction of the outcome, as compared to QRS morphology. Furthermore, the baseline left ventricular (LV) ejection fraction (LVEF), which is also an known criterion for selecting CRT candidates (partly applied due to cost-benefit reasons), can be misleading. Data showed that patients with LVEF > 35% might also benefit from this type of treatment. Thus, LVEF should be evaluated less rigorously when screening patients for resynchronisation therapy. While the subsequent beneficial response to CRT is multifactorial, procedure-related parameters, such as LV lead position, are also crucial. The first data released recently confirmed the previous empiric clinical experience indicating that the LV lead should be implanted into the lateral or posterior coronary sinus side branch. This location was associated with a better long-term clinical outcome in terms of death and heart failure events. Some issues related to CRT are awaiting further clarification, such as the choice of the type of the implanted device (pacemaker or defibrillator) or the decision about CRT device upgrade. This review discusses the current evidence regarding the above, focusing on the questions that should be handled with caution or require clarification.

Real World Utilization of a Mobile Application-Based Bowel Preparation on Quality Indicators in Colonoscopy

Introduction: Adequate bowel preparation for colorectal cancer (CRC) screening can be challenging in direct-to-procedure colonoscopy due to barriers with patient engagement and communication, which can negatively impact colonoscopy quality indicators. With widespread use of smart phones, mobile delivery of prep instructions has potential to improve the patient experience and colonoscopy outcomes. Our study aimed to assess whether the use of a mobile application to disseminate bowel prep instructions influenced patient satisfaction and quality indicators for colonoscopy. Methods: An IRB-approved prospective pilot study of Twistle mobile application was conducted at our outpatient surgical center from October 2017 to January 2018. Patients scheduled to undergo a direct-to-procedure colonoscopy for CRC screening were eligible for enrollment. Patient demographics and procedural outcomes were collected including quality of prep, cecal intubation time, scope withdrawal time, and number of polyps or adenomas detected. Patients were matched 1:1 to historical controls that received standard mailed prep instructions as a comparison group. Patients that used Twistle were asked to complete a 5-question telephone survey after their colonoscopy to assess satisfaction. Results: 133 eligible patients were contacted by phone call (n = 80; 60.2%) or invitational letter (n = 53, 39.8%) to receive bowel prep instructions via Twistle (Figure 1). 12 patients, mean age 55.2 years, completed colonoscopy prep utilizing Twistle and a post-procedure satisfaction survey (response rate = 9.0%). No statistically significant differences were demonstrated on any procedure-related parameters between those using Twistle or mailed bowel prep instructions (Table 1). A post-procedure telephone survey revealed 91.7% (n = 11) of patients considered the Twistle application easy to follow, and 83.3% (n = 10) indicated they were “very satisfied” and would be very likely to utilize again for a future colonoscopy procedure (Table 2).253_A Figure 1 No Caption available.Conclusion: In this pilot study, we have demonstrated real-world challenges of implementing a mobile application-based bowel prep program for direct colonoscopy referrals in a large academic setting. Despite a low utilization rate, patients who completed bowel prep using Twistle reported high satisfaction. Further studies are needed to evaluate the role of a mobile application-based bowel prep and to develop improved processes to successfully integrate these tools into routine practice.253_B Figure 2 No Caption available.253_C Figure 3 No Caption available.

What are the risk factors for surgical site infection after spinal fusion? A meta-analysis.

Although many risk factors for surgical site infection (SSI) following spinal fusion have been described in the literature, methodologies and study cohorts vary widely. Patient- and procedure-specific risk factors for (SSI) can be identified via a meta-analysis. We sought to review the existing data and isolate significant risk factors for SSI in patients undergoing thoracolumbar spinal fusion. The literature was searched through December of 2016. Studies including adult patients undergoing thoracolumbar spinal fusion surgery (single or multilevel, anterior, posterior or combined approach) were identified. Only studies that included an odds ratio (OR) for SSI or sufficient data to calculate it were included. A meta-analysis was performed using RevMan 5.1. Depending on heterogeneity (I2), OR with 95% confidence intervals was calculated using either the fixed-effects model (when I2 < 60%) or the random-effects model (when I2 > 60%). 6482 manuscripts were identified and reviewed. 29 manuscripts with 374,488 patients met the criteria for inclusion. Twelve risk factors were assessed by the meta-analysis and grouped into two categories (patient related and procedure related). Significant patient-related factors for SSI included obesity, diabetes, ASA score, tobacco use and revision status. Procedure-related risk factors included operative time, use of osteotomy, fusion length and extension of fusion to the sacrum or pelvis. This meta-analysis identified significant risk factors for SSI following spine arthrodesis. These included potentially modifiable factors such as obesity, diabetes, smoking status and procedure-related parameters. Non-modifiable risk factors were identified, including ASA score and age. These factors may prove useful for patient counseling as well as surgical planning. Level III (Meta-analysis including studies with a level of evidence of III or higher). These slides can be retrieved under Electronic Supplementary Material.

Comparison of combined laparoscopic ureterolithotomy and flexible ureteroscopy with percutaneous nephrolithotomy for removing large impacted upper ureteral stones with concurrent renal stones

ObjectivesThe present study compared the safety and efficacy of combined laparoscopic ureterolithotomy (LU) and flexible ureteroscopy with percutaneous nephrolithotomy (PCNL) for removing large impacted upper ureteral stones with concurrent renal stones. MethodsThis study included 52 patients who underwent combined LU and retrograde flexible ureteroscopy for removing renal stones (group A) or PCNL (group B) for removing large upper impacted ureteral stones and concurrent renal stones at our department from January 2014 to December 2016. Patient demographics, stone characteristics, and procedure-related parameters including stone-free rate, operation time, hospital stay after surgery, mean decrease in hemoglobin levels, visual analog scale (VAS) score, auxiliary procedure rate, and complication rate were compared between groups A and B. ResultsResults of this study showed that both procedures were effective for removing large impacted upper ureteral stones with concurrent renal stones. The stone-free rate after a single procedure was 95.7% in group A and 89.7% in group B (p = 0.62). The operation time was longer in group A than in group B (112.2 ± 23.3 min versus 96.2 ± 16.4 min, p = 0.006). However, no significant difference was observed between the two groups with respect to the length of hospital stay after the surgery (5 days versus 6 days, p = 0.06). The decrease in hemoglobin levels was significantly higher in group B than in group A (−0.64 ± 0.36 g/dL versus −1.44 ± 0.65 g/dL, p < 0.0001). The mean VAS scores obtained at 24 hours (2.91 ± 1.08 versus 5.10 ± 1.01, p < 0.0001) and 48 hours after the surgery (1.09 ± 0.73 versus 2.28 ± 0.96, p < 0.0001) were significantly higher for group B than for group A. Moreover, the auxiliary procedure rate was higher in group B than in group A (6.9% versus 0%). ConclusionThese results indicate that both combined LU and flexible ureteroscopy and PCNL are suitable for removing large impacted upper ureteral stones with concurrent renal stones and are associated with a high rate of patients being stone free afterwards. Despite the longer operation time, the combined laparoscopic and endourological procedure may be associated with less postoperative pain and fewer major complications. However, the choice of treatment depends on the preferences of surgeons and patients.

Tu1033 RISK FACTORS FOR INADEQUATE BOWEL PREPARATION IN PATIENTS WITH FUNCTIONAL CONSTIPATION

Constipation is a common reason of poor bowel preparation, which negatively influences the quality of colonoscopy. The risk factors associated with inadequate bowel preparation in constipated patients remains unclear. The aim of this study was to investigate the high-risk factors which might influence the quality of bowel preparation in patients with functional constipation. In this multicenter, prospective cohort study, consecutive patients with functional constipation who underwent colonoscopy between May 2016 and April 2017 were enrolled. Standard split-dose of 4 Liter (L) polyethylene glycol (PEG) was used for bowel preparation. Patient-related and procedure-related parameters were recorded. The primary outcome was adequate rate of bowel preparation, defined as Boston Bowel Preparation Scale (BBPS) ≥6 with each segment ≥2. Risk factors for inadequate bowel preparation were screened by multivariate logistic regression analysis. A total of 199 patients with functional constipation were included. 78.4% of them were female. Adequate bowel preparation was found in 62.8% (125/199) of patients. At multivariate analysis, Bristol stool form scale (BSFS) 1 (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.11-4.56; P = 0.008), no or mild pain during defecation (OR 4.14, 95% CI 1.22-13.97; P=0.022), and starting-to-defecation interval more than 4h (OR 3.10, 95% CI 1.17-8.22; P=0.023) were independent risk factors for inadequate bowel preparation in patients with constipation. For patients with non-, 1, 2 or 3 risk factors, the rates of inadequate bowel preparation were 11%, 23%, 49%, and 65% respectively (P＜0.001). With standard preparation regime, more than 1/3 of patients with functional constipation had inadequate bowel cleansing. BSFS 1, no or mild pain during defecation, and starting-to-defecation interval more than 4h were identified as independent risk factors for inadequate bowel preparation in constipated patients.Tabled 1Multivariate analysis of the association between potentially significant factors and inadequate bowel preparationInadequate rate, n (%)OR (95% CI)P valueUnmarried6/9 (66.7%)4.24 (0.87-20.81)0.075Past alcohol intake1/11 (9.1%)0.17 (0.02-1.52)0.113Duration of constipation ≥4 years44/130 (33.8%)0.55 (0.26-1.16)0.119BSFS score 150/110 (45.5%)2.25 (1.11-4.56)0.024No or mild pain during defecation70/174 (40.2%)4.14 (1.22-13.97)0.022Stools ≤3 times per week31/104 (29.8%)1.31 (0.65-2.64)0.45Using purgatives ≥2 times per week22/77 (28.6%)0.87 (0.42-1.78)0.695Starting-to-defecation interval ≥4h20/32 (62.5%)3.10 (1.17-8.22)0.023Vomiting19/36 (52.8%)2.89 (0.91-14.32)0.113Nausea41/84 (48.8%)1.56 (0.79-3.05)0.199Stools ≤2 times after 1st PEG23/45 (51.1%)1.37 (0.60-3.13)0.454BSFS, Bristol stool form scale; PEG, polyethylene glycol; OR, odds ratio; CI, confidence interval. Open table in a new tab

Recurrence after pulmonary vein isolation is associated with low contact force

Objectives. Recurrent arrhythmia after pulmonary vein isolation (PVI) by radiofrequency (RF) ablation in patients with atrial fibrillation (AFIB) remains a significant challenge. Using contact force (CF) sensing ablation catheters, we aimed to identify procedure related parameters associated with recurrence after de-novo PVI in patients with AFIB. Methods. Consecutive patients undergoing a de-novo PVI procedure (n = 120, 63% paroxysmal and 37% persistent AFIB) employing a force-sensing ablation catheter were included. A clinical control including electrocardiogram and 120 hour of Holter-recording at 12-months was performed in all patients. Recurrence was defined as any documented AFIB or atrial flutter more than 30 seconds on Holter-recording after an initial blanking period of three months. Results. Recurrence occurred in 44 patients (37%). Mean CF was lower in patients with recurrent arrhythmia (22.2 ± 9.5 vs. 28.8 ± 9.3 g, p < .001). In multi-variable analyses lower mean CF (OR 0.9 (95% CI 0.8–1.0), p = .03), and higher percentage of ablation time with a CF <10 grams (OR 1.1 (95% CI 1.0–1.1), p = .004) were both associated with recurrence in two distinct models. Dragging during ablation compared with point-by-point ablation technique was associated with recurrence in both models (OR 19.2 (95% CI 2.9–130.0), p = .002, and OR 21.7 (95% CI 2.7–176.2), p = .004). Conclusions. Low CF and dragging during ablation as compared with point-by-point ablation technique were associated with recurrent arrhythmia in patients with AFIB undergoing de-novo PVI by RF ablation.