Repeat Endoscopic Procedures Research Articles

Qualitative Analysis of Patient Experiences Reaching Urethroplasty for Recurrent Urethral Stricture Disease.

Despite the inferior outcomes, urethral stricture patients often undergo multiple endoscopic procedures prior to undergoing definitive urethroplasty. We sought to qualitatively evaluate the patient experience of obtaining urethroplasty to better understand the impact of this experience on quality of life. Patients treated with urethroplasty between September 2019 and July 2021 were identified and invited to participate in our study if they had undergone ≥ 2 endoscopic procedures prior to urethroplasty. Semistructured telephone interviews were conducted, coded, and analyzed using an iterative inductive-deductive approach. Of the 105 urethroplasty patients during the study period, 50 (47.6%) had undergone ≥ 2 endoscopic procedures prior (IQR 3-5), of whom 20 participated in the study. Qualitative themes related to repeat endoscopic procedures included unmet treatment expectations, dissatisfaction with catheterization and repeat procedures, and negative impacts of recurrent stricture symptoms and treatments on quality of life. External factors associated with a delay to urethroplasty included financial constraints, surgeon access, and time off work. A trajectory of declining quality of life and unmet treatment expectations are the primary factors driving the decision to proceed with urethroplasty. However, external factors such as recovery costs and access to specialists play important roles in delaying surgery. These findings illustrate the need for improved community provider education and patient counseling to better inform expectations of both patients and providers with various treatment outcomes. Furthermore, these data highlight the need to improve access to specialized care for urethral stricture patients.

MP78-01 EFFECT OF URETHRAL STRICTURE AUA GUIDELINES ON NATIONAL TRENDS IN RECONSTRUCTIVE MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023MP78-01 EFFECT OF URETHRAL STRICTURE AUA GUIDELINES ON NATIONAL TRENDS IN RECONSTRUCTIVE MANAGEMENT Samuel Sorkhi, Sirpi Nackeeran, Michael Witthaus, Jill Buckley, and M. Raj Rajasekaran Samuel SorkhiSamuel Sorkhi More articles by this author , Sirpi NackeeranSirpi Nackeeran More articles by this author , Michael WitthausMichael Witthaus More articles by this author , Jill BuckleyJill Buckley More articles by this author , and M. Raj RajasekaranM. Raj Rajasekaran More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethral Stricture Disease (USD) is a pathological narrowing of the urethra that often results in lower urinary tract symptoms (LUTS), urinary incontinence, urinary tract infections, and ultimately progression toward acute urinary retention. In 2016, the AUA released guidelines on urethral stricture management, focusing on the importance of an earlier transition to urethroplasty rather than repeat endoscopic procedures. This study aims to analyze the recent trends in male urethral stricture treatment from 2016-2020 to determine the impact of the AUA’s most recent guidelines on male urethral stricture management. METHODS: We utilized electronic health record data stored within the TriNetX Research Network to conduct a retrospective analysis of procedures performed between 2016-2020 (a total of 78,532 procedures). Rates of direct visual internal urethrotomy (DVIU), urethral dilation, dilation+DVIU, and urethroplasty were analyzed using chi-square analysis to assess linear trends. RESULTS: The dilation+DVIU group showed a significant increase in procedure rates between 2016-2017 (p=1.269E-08), 2016-2018 (p=5.08E-07), 2016-2019 (p=2.7637E-31), and 2018-2019 (p=5.38E-13; Figure 1A-B). While 2019-2020 showed a decrease (p=4.792E-06), an analysis of the overall trend from 2016-2020 demonstrated no significant difference (p=0.07739). Urethroplasty was offered to younger patients when compared to urethral dilation/incision (Figure 1C) performed in older patients. Repeat dilation/incisions were performed at significantly (22%) higher rates when compared to urethroplasty (Figure 1D). CONCLUSIONS: Despite AUA recommendations encouraging reconstructive surgeons to offer urethroplasty instead of repeated endoscopic interventions, our results suggest no significant change in the rates of these procedures after the release of the 2016 AUA urethral stricture guidelines. The lack of clinical modification may reflect the lag-time incorporating guideline recommendations or practice barriers to implementation. Source of Funding: UCSD Academic Senate © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1131 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samuel Sorkhi More articles by this author Sirpi Nackeeran More articles by this author Michael Witthaus More articles by this author Jill Buckley More articles by this author M. Raj Rajasekaran More articles by this author Expand All Advertisement PDF downloadLoading ...

PD32-11 IMPACT OF SOCIAL DETERMINANTS OF HEALTH ON CARE OF URETHRAL STRICTURES: A PILOT EVALUATION OF THE AREA DEPRIVATION INDEX

You have accessJournal of UrologyCME1 Apr 2023PD32-11 IMPACT OF SOCIAL DETERMINANTS OF HEALTH ON CARE OF URETHRAL STRICTURES: A PILOT EVALUATION OF THE AREA DEPRIVATION INDEX Evan Watkins, Abimbola Ayangbesan, George Koch, Rohan Bhalla, Jackson Cabo, Helen Gambrah, Theresa Zwaschka, and Niels Johnsen Evan WatkinsEvan Watkins More articles by this author , Abimbola AyangbesanAbimbola Ayangbesan More articles by this author , George KochGeorge Koch More articles by this author , Rohan BhallaRohan Bhalla More articles by this author , Jackson CaboJackson Cabo More articles by this author , Helen GambrahHelen Gambrah More articles by this author , Theresa ZwaschkaTheresa Zwaschka More articles by this author , and Niels JohnsenNiels Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003325.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Living in socioeconomically disadvantaged neighborhoods affects health behaviors and outcomes. How neighborhood disadvantage impacts care of benign urologic disease has not been previously studied. In this pilot study, we sought to evaluate how patient-level social risk determinants impact care of urethral stricture patients. METHODS: Patients treated with urethroplasty between 9/4/2019 and 12/29/2021 were analyzed. Those with a history of urethroplasty and under the age of 18 were excluded. To evaluate neighborhood disadvantage, we used the area deprivation index (ADI), a 17-component index composed of education, employment, housing-quality, and poverty measures utilizing data from the American Community Survey. Patient addresses were geocoded and assigned a national ADI rank, with scores normalized to a percentile from 0 to 100, with higher numbers representing higher levels of disadvantage. For this analysis, patients were grouped into ADI quartiles. Multiple endoscopic procedures was defined as >2 procedures prior to urethroplasty. Impact of ADI on treatment and processes of care was analyzed utilizing univariate and multivariate models. RESULTS: 104 patients were included, with a median age 54.5 (IQR 38, 66) and ADI of 63.5 (IQR 38.8, 79.3). When separated into quartiles, 15.4%, 21.2%, 31.7% and 31.7% were in the first, second, third and fourth ADI quartiles, respectively, with higher quartiles representing increased levels of deprivation. There were no significant differences in race or insurance status by ADI quartile. Patients in the highest ADI quartile underwent significantly more endoscopic procedures prior to urethroplasty than those in the lowest, at 0 (0, 1) versus 2 (1, 4) (p=0.01). On multivariate analysis adjusting for age and insurance status, ADI quartile was associated with an increased likelihood of undergoing multiple endoscopic procedures, with OR 4.97 (95% CI 1.22-26.14) and OR 5.05 (95% CI 1.23 – 26.53) for third and fourth quartiles, respectively. A one-point increase in ADI was associated with a 2% increased risk of repeat endoscopic procedures prior to urethroplasty (OR 1.02 [95% CI 1.01 – 1.04]). CONCLUSIONS: This is the first analysis evaluating how a patient’s physical neighborhood can mediate processes of care for urethral stricture disease. We found that increased neighborhood deprivation, regardless of race or insurance status, can lead to increased endoscopic treatments and delays to urethroplasty. Utilization of this methodology can help further identify disparities in care and highlight the impact of social determinants on urologic care. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e911 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Evan Watkins More articles by this author Abimbola Ayangbesan More articles by this author George Koch More articles by this author Rohan Bhalla More articles by this author Jackson Cabo More articles by this author Helen Gambrah More articles by this author Theresa Zwaschka More articles by this author Niels Johnsen More articles by this author Expand All Advertisement PDF downloadLoading ...

Prevalence, Clinical Characteristics, and Treatment Response in Patients with Post Cricoid Inlet Patch—A Descriptive Retrospective Study

Abstract Objectives The aim of this study was to determine the incidence of post cricoid inlet patch (PC-IP) and to assess the clinical characteristics, pathological features, and treatment response. Materials and Methods A retrospective cross-sectional study was conducted from April 2016 to April 2021 in the tertiary gastroenterology unit of urban India. All patients with symptoms of globus sensation, chronic cough, heartburn, hoarseness, throat pain, dysphagia, and acid regurgitation after a thorough clinical examination underwent esophagogastroduodenoscopy by experienced endoscopists including biopsy. Sociodemographic data, symptoms and its duration, previous hospital visits, and chronic proton pump inhibitor (PPI) use were noted during the study. Results Three-thousand two-hundred fifty upper gastrointestinal endoscopies were performed during the study period. The prevalence of PC-IP was 2.7%, comprising 36.3% males and rest females. Mean age was 36.2 ± 17years. The most common symptom among these patients was globus sensation (81.8%) followed by acid regurgitation (75%), dyspepsia (64.7%), dysphagia (48.8%), throat pain (29.54%), chronic cough (22.72%), hoarseness (22.72%), and others (6.81%). Mean diameter of PC-IP was 1.5 ± 0.5 cm, more than one patch was found in 23.76% of patients. Histopathological examination showed heterotrophic gastric mucosa in 77.27%, out of which 38.23% had oxyntic type, 44.11% had mucoid type, and the rest had mixed cell type. On median follow-up after 20 months, 68.18% of patient had persistent symptoms, 77.27% were PPI responsive, and 22.73% were PPI refractory. On follow-up, 38.63% of patients had a repeat endoscopic procedure and biopsy (20.45%); none showed any changes in size or dysplasia. Conclusion Prevalence of PC-IP could be higher than the estimated. Careful examination of upper esophagus and use of narrow band imaging will increase the possibility of identifying IP. Those symptomatic patients need treatment with PPI, sometimes for long term. Ablative therapy with radiofrequency or argon plasma coagulation needs further clarification.

S3629 Lumen Apposing Metal Stent for Sleeve Gastrectomy Surgical Site Stricture

Introduction: The obesity pandemic has continuously increased yearly and more patients are seeking both medical and surgical treatments. Sleeve gastrectomy accounts for 60% of bariatric surgeries in the US. Stricture formation occurs in approximately 0.5% of cases and usually occurs at the incisura. Unfortunately, given the current insurance coverage in the US, some patients opt to travel overseas to obtain cheaper bariatric surgeries with limited quality assurance, no follow-ups and possible higher rates of complication. The use of Lumen Apposing Metal Stents (LAMS) for benign strictures are expanding and has been used in post Roux-en-Y gastric bypass (RYGB) strictures. Case Description/Methods: We present a 29-year-old female who underwent a laparoscopic sleeve gastrectomy for Class 3 obesity. The surgery was performed overseas due to insurance coverage issues in the US. She was seen for intractable nausea and vomiting. She had an EGD performed which identified a tight 10-12mm long angulated stricture at 42cm from the incisors requiring balloon dilatations to 20mm on two occasions with no resolution of symptoms. After a multidisciplinary discussion with Bariatric Surgery, a plan was made to place a stent at the angulated stricture area as a bridge therapy while awaiting insurance approval for a definitive surgical intervention. In view of the short length of the angulated stricture, a 20mm wide X 10mm long fully covered LAMS (Figure) was successfully deployed. A subsequent CT scan of the abdomen with oral contrast (Figure 2) showed that the stent in the appropriate position with no evidence of obstruction. The oral contrast passed through the stent beyond the angulated stricture. The patient however, had no improvement of symptoms and only tolerated some clear liquids. Given persistence of symptoms, the LAMS was successfully removed intact for an emergent laparoscopic RYGB reconstruction. Discussion: Treatment of post- sleeve gastrectomy stricture is primarily endoscopic balloon dilation but this unfortunately requires repeat endoscopic procedures. If the endoscopic therapy fails, conversion to RYGB may be required. Our case provides the first reported use of a 20mm wide LAMS as a bridge therapy for managing short surgical site stricture after a sleeve gastrectomy. More studies are needed to evaluate the effectiveness of LAMS in the management of short strictures related to gastric sleeve surgery.Figure 1.: (1.1) A 20 mm wide X 10 mm long LAMS at the narrow-angulated area in the proximal mid body stomach with patent lumen. (1.2) Gastric LAMS at the junction of proximal and mid body with 3 anchoring clips proximal to stent.

S2845 Inadvertent Treatment of a Vertical Banded Gastroplasty Stricture With a LAMS for Two Years

Introduction: Lumen-apposing metal stents (LAMS) are innovative endoscopic devices representing the next significant advancement in stent technology. LAMS have demonstrated success, most notably with improving drainage of pancreatic fluid collections. Other clinical indications for using LAMS include biliary drainage, gastroenterostomy, or the managment of luminal tract strictures. The stent has a larger lumen diameter than previously created stents as well as a unique “dumbbell” shape to limit migration. Studies have demonstrated advantages such as shorter procedure times and overall reduced repeat endoscopic procedures. As LAMS has gained notoriety, there have been increasing studies demonstrating potential complications of the device. Most common consequences of LAMS include bleeding, biliary stricture, and buried LAMS syndrome. As the anatomical design has decreased migration risk, prompt removal is recommended to prevent buried LAMS syndrome, where the stent is embedded in the wall of the gastric mucosa and can eventually not be visualized endoscopically. In this case, we will present a patient with an endoscopically placed LAMS, which was successfully removed with minimal complications after two years in place. Case Description/Methods: Our patient is a 68 year old female with a Vertical Banded Gastroplasty Stricture. She had required multiple repeat endoscopies for dilation therapy but the stricture was refractory to dilation, as a result, she underwent LAMS placement Due to the onset of the COVID pandemic, patient was lost to follow up. On a repeat EGD two years after placement, the stent remained in its original location. There were signs of mild gastric tissue overgrowth at the right lateral side of the LAMS. The stent was then removed easily with no signs of bleeding. After removal, the stricture remained dilated as the scope could be passed without difficulty. Over course of COVID she ate better than she had in years. (Figure) Discussion: LAMS have demonstrated significant success in a variety of endoscopic interventions. Their potential complications are well documented in various studies. This case is unique in regards to the length of time in which the LAMS remained in position. From a literature review, no study has demonstrated a LAMS in place as long as two years for stricture management. More remarkable is the lack of complications from the stent such as no bleeding with removal and no true buried LAMS syndrome as there was minimal tissue overgrowth.Figure 1.: LAMS on endoscopic evaluation two years after placement.

A new biodegradable stent in bilio-pancreatic diseases: a prospective multi-center feasibility study.

biodegradable stents of various designs are reportedly used in pancreato-biliary conditions with promising results. Their major advantage is the avoidance of repeat endoscopic procedure for stent removal, thereby reducing overall costs and endoscopic retrograde cholangiopancreatography (ERCP) associated adverse events. The aim of the study was to evaluate the feasibility and safety of a new biodegradable stent in patients with pancreato-biliary diseases. a prospective multicenter pilot study was performed. All consecutive patients ≥ 18 years old who underwent biliary or pancreatic stenting using the new biodegradable Archimedes stent were included in the study. There were three biodegradation profiles. Technical and clinical success and feasibility and safety were assessed during a pre-established follow-up schedule. fifty-three patients (mean age: 48.54 ± 19.29, 66 % male) with biliary (n = 29, 54.7 %) or pancreatic (n = 24, 45.3 %) indications were included. The distribution of stents used according to degradation properties were as follows: fast (n = 11, 20.8 %), medium (n = 16, 30.2 %) and slow (n = 26, 49.1 %). The technical and clinical success were 100 % and 77.8 %, respectively. Thirty-five patients were followed for a median of 26 weeks (range: 4-56, 66 %). There were nine procedure-related adverse events (17 %), all mild, including one uneventful stent-related event (external migration). the biodegradable Archimedes stent placement is feasible and safe in pancreato-biliary diseases.

EndoConf: real-time video consultation during endoscopy; telemedicine in endoscopy at its best.

Background and study aims The aim of this study was to introduce EndoConf, a reliable and easy-to-use tool capable of optimizing clinical care in endoscopy by reducing the number of repeat endoscopy procedures, providing continuous on-the-job clinical education, and allowing a smooth transition to the next level of artificial intelligence-supported systems. Patients and methods We prospectively developed and improved a real-time conference system (EndoConf). EndoConf enables endoscopists to contact on-demand and in real time experienced endoscopists across other sites. After the initial introduction period, we registered all EndoConf-assisted procedures from our unit (Surgical Department of Odense University Hospital) over a 3-month period (Autumn of 2019). Results Of 84 EndoConf-supported procedures, 58 were eligible for further analysis. Eventually, 38 calls were made, of which only four were technically of low quality (10.5 %) while three were not answered (7.9 %). Of the 35 (92.1 %) completed EndoConf calls; 24 were referred for endoscopic mucosal resection, six were referred for transanal microsurgery preceded by transrectal ultrasonography and three were referred for multidisciplinary conference, whereas in two cases, the lesion was resected during EndoConf. Conclusions We found the EndoConf system to provide support that could reduce the number of unnecessary repeat endoscopic procedures while at the same time ensuring avoidance of any hazardous attempt at polypectomy.

Does endoscopic intervention prevent subsequent gastrointestinal bleeding in patients with left ventricular assist devices? A retrospective study.

BACKGROUNDPatients with left ventricular assist devices (LVADs) are at increased risk for recurrent gastrointestinal bleeding (GIB) and repeat endoscopic procedures. We assessed the frequency of endoscopy for GIB in patients with LVADs and the impact of endoscopic intervention on preventing a subsequent GIB.AIMTo evaluate for an association between endoscopic intervention and subsequent GIB. Secondary aims were to assess the frequency of GIB in our cohort, describe GIB presentations and sources identified, and determine risk factors for recurrent GIB.METHODSWe conducted a retrospective cohort study of all patients at a large academic institution who underwent LVAD implantation from January 2011 – December 2018 and assessed all hospital encounters for GIB through December 2019. We performed a descriptive analysis of the GIB burden and the outcome of endoscopic procedures performed. We performed multivariate logistic regression to evaluate the association between endoscopic intervention and subsequent GIB.RESULTSIn the cohort of 295 patients, 97 (32.9%) had at least one GIB hospital encounter. There were 238 hospital encounters, with 55.4% (132/238) within the first year of LVAD implantation. GIB resolved on its own by discharge in 69.8% (164/235) encounters. Recurrent GIB occurred in 55.5% (54/97) of patients, accounting for 59.2% (141/238) of all encounters. Of the 85.7% (204/238) of encounters that included at least one endoscopic evaluation, an endoscopic intervention was performed in 34.8% (71/204). The adjusted odds ratio for subsequent GIB if an endoscopic intervention was performed during a GIB encounter was not significant (odds ratio 1.18, P = 0.58).CONCLUSIONPatients implanted with LVADs whom experience recurrent GIB frequently undergo repeat admissions and endoscopic procedures. In this retrospective cohort study, adherence to endoscopic guidelines for performing endoscopic interventions did not significantly decrease the odds of subsequent GIB, thus suggesting the uniqueness of the LVAD population. A prospective study is needed to identify patients with LVAD at risk of recurrent GIB and determine more effective management strategies.

National Trends in the Management of Urethral Stricture Disease.

A growing body of evidence suggests that practice patterns for the management of urethral strictures are changing. We examined national trends in urethral stricture management over time using a national data set. Individuals with a new diagnosis of urethral stricture disease between 2008 and 2016 were identified within MarketScan® to determine management strategies. Repeat endoscopic management was defined as 2 or more endoscopic procedures per patient. Recommended care was defined as primary urethroplasty, a single endoscopic procedure or a single endoscopic procedure followed by urethroplasty. Linear regression and multivariate models were fit to determine trends over time. A mean of 15,621,116 beneficiaries per year were identified with a mean prevalence of urethral stricture disease of 349 strictures per 100,000 male beneficiaries. There was no significant change in urethral stricture diagnosis over time, while urethroplasty usage per stricture diagnosis increased by 43.9% (R2=0.52, p=0.003). The ratio of recommended care to repeat endoscopic care in those who underwent treatment similarly increased by 87.4% (R2=0.87, p <0.01). On multivariate analysis later year of diagnosis was associated with an increased odds of receiving recommended care while increasing age and increasing comorbidity status were associated with decreased odds. In a large national sample a significant trend toward decreased use of repeat endoscopic procedures and increased use of urethroplasty for management of urethral stricture disease was noted. These data highlight a drastic change in practice patterns over time, favoring a more definitive evidence-based approach.

Recurrent small-bowel bleeding from a Dieulafoy's lesion after combined endoscopic treatment.

Dieulafoy's lesion of the small bowel is an uncommon cause of gastrointestinal (GI) bleeding that often recurs after endoscopic treatment. we report an observational, descriptive, retrospective, single-center study in 15 patients with small bowel bleeding who were diagnosed with a Dieulafoy's lesion by capsule endoscopy or double-balloon enteroscopy. all patients underwent combined endoscopic treatment. During a median follow-up of 33.5 months (range, 2-145), three of the 12 cases that stayed in follow-up (25 %) recurred, all within 48 hours after treatment. Two were successfully re-treated with a repeat endoscopic procedure.

2895 Recurrent Bleeding in Patients With LVADs: Endoscopic Yield and Impact of Endoscopic Intervention

INTRODUCTION: Patients with LVADs are at increased risk for gastrointestinal bleeds (GIBs) because of chronic anticoagulation and high flow states. A prior retrospective study at our institution confirmed that 22% of patients with LVADs had a GIB after implantation, consistent with prior literature. There are no evidence-based guidelines regarding the role of repeat endoscopic procedures for recurrent GIB, resulting in varying practice patterns among Cardiology and GI teams. It is unknown how often repeat inpatient endoscopic examinations during hospitalizations result in intervention or reduction in future GIB episodes. We sought to assess the proportion of endoscopic intervention and impact on recurrent GIB. METHODS: We conducted a retrospective cohort study of all patients at one academic institution who underwent LVAD implantation between March 2016 through February 2018. For each patient, we assessed post implant hospital encounters for GIBs through May 2019. The primary outcome was the odds ratio for a future GIB based on the occurrence of endoscopic intervention versus none (endoscopy with no intervention or no procedure). Secondary outcomes included endoscopic intervention based on overt versus occult GIB. RESULTS: The cohort included 105 patients who had LVADs implanted during the stated time. 34 patients (32%) presented for GIBs during the study period, with a total of 71 encounters. A third or higher encounter occurred in 26% of patients (9/34) and accounted for 27% (19/71) of encounters. 79% of all encounters (56/71) included at least one invasive endoscopic evaluation; an endoscopic intervention was performed in 41% (23/56). The odds ratio for future GIB after endoscopic intervention during the first GIB (34/71) was 0.2 (95% CI 0.04-0.97, P = 0.046) but was not statistically significant if the intervention was during a recurrent GIB (37/71) (0.33, 95% CI 0.08 - 1.41, P = 0.14). The odds ratio of performing an intervention during endoscopic procedure for overt versus occult GIB was 3.4 (95% CI 0.98-11.7231, P = 0.053), trending towards significant. CONCLUSION: Patients with LVADs who have recurrent GIBs experience repeat admissions and endoscopic procedures. In our cohort, endoscopic interventions for repeat GIB did not have an impact on future episodes of GIB. Our data suggest that the endoscopic yield is likely lower with occult GIB.There is a clinical need to identify characteristics of LVAD patients at risk and to develop guidelines for the management of patients with recurrent GIB.

355 Endoscopic Submucosal Dissection vs. Endoscopic Mucosal Resection for Treatment of Barrett’s Related Superficial Esophageal Neoplasia

INTRODUCTION: The difference in long-term outcomes of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for Barrett’s related superficial neoplasia remains unclear. We aimed to compare the rates of local and metachronous recurrence of ESD and EMR in patients with clinically staged BE-associated high-grade dysplasia (HGD) and T1a esophageal adenocarcinoma (EAC). METHODS: Multicenter study at six academic hospitals in the U.S. including patients who underwent ESD for BE-HGD or T1a EAC. Primary outcome was a composite of metastasis and local recurrence rate. A time-to-event analysis was performed to evaluate recurrence. A Kaplan-Meier plot was constructed, and a log-rank test was used to compare the groups. A Cox hazard ratio regression analysis was performed to identify predictors of recurrence. RESULTS: A total of 241 patients were included. 154 underwent EMR, while 84 underwent ESD (Table 1). ESD had higher en bloc (96% vs 33%, P &lt; 0.0001), R0 (76% vs 54%, P = 0.0009) and curative resection rates (75% vs 32%, P &lt; .0001) when compared to EMR. The 24-month local recurrence rate for EMR and ESD was 43% and 11%, respectively (P = 0.0007) (Figure 1). Significantly more endoscopic resection procedures were required to treat recurrence after EMR compared to after ESD (Table 1). EMR, piecemeal resection, positive margins, and non-curative resection were identified as predictors of recurrence on univariate analysis. En bloc resection remained significant after multivariate analysis (Table 2). CONCLUSION: This multicenter study showed that ESD results in more definitive treatment of BE-associated early neoplasia than EMR, with significant lower recurrence rates and less need for repeat endoscopic therapeutic procedures than EMR.

PD22-09 NATIONAL TRENDS IN URETHRAL STRICTURE MANAGEMENT

INTRODUCTION AND OBJECTIVES:There is a growing body of evidence that practice patterns with regards to management of urethral stricture disease are changing, with fewer repeat endoscopic procedures...

Endoscopic treatment of intraventricular ependymal cysts in children: personal experience and review of literature.

Intracranial ependymal cysts are rare neuroepithelial cysts that occur less frequently than arachnoid cysts. The cysts are most often intraparenchymal, but they are rarely reported to be intraventricular. This study evaluates the role of endoscopy in the treatment of intraventricular ependymal cysts (IVECs). Twelve pediatric patients (mean age 4.3years) with symptomatic IVECs were the subject of this study. The cyst was located inside the lateral ventricle in all cases (100%), it was present in trigone (10 patients, 83.3%), and in temporal horn (2 patients, 16.7%). Concomitant hydrocephalus was present in two patients (16.7%). All patients underwent operations through a purely endoscopic procedure. Communication of the cyst with the subarachnoid space was performed in six patients (50%); endoscopic cystocisternostomy was performed in four patients (33.3%), and endoscopic cystoventriculostomy in two patients (16.7%). Postoperative clinical improvement associated with postoperative reduction in cyst size was encountered in ten patients (83.3%). Improvement of hydrocephalus occurred in both patients who had hydrocephalus (100%). There were no deaths or permanent morbidity. Among the follow-up period (mean 44.3months), none of the patients required a repeat endoscopic procedure due to recurrence of symptoms or increase in cyst size. Intraventricular ependymal cysts can be effectively treated by endoscopy. Endoscopic fenestration of the cyst wall into subarachnoid space, basal cisterns, or ventricular system can be used in the treatment of these patients with postoperative symptomatic improvement and reduction of cyst size. The procedure is simple, effective, minimally invasive, and associated with low morbidity and mortality rates.

Guidelines of guidelines: a review of urethral stricture evaluation, management, and follow-up.

BackgroundOur objective is to report a comparative review of recently released guidelines for the evaluation, management, and follow-up of urethral stricture disease.MethodsThis is an analysis of the American Urologic Association (AUA) and Société Internationale d’Urologie (SIU) guidelines on urethral stricture. Strength of recommendations is stratified according to letter grade that corresponds to the level of evidence provided by the literature.ResultsAlthough few, the discrepancies between the recommendations offered by the two guidelines can be best explained by varying interpretations of the literature and available evidence on urethral strictures. When comparing the AUA guidelines and the SIU guidelines on urethral stricture, there are very few discrepancies. Perhaps the most notable difference is in the use of repeat DVIU or urethral dilation after an initial failed attempt. SIU guidelines state that there are instances where repeat DVIU or urethral dilation can be indicated, and they give a range of time at which stricture recurrence post procedure mandates an urethroplasty (less than 3 to 6 months). The AUA guidelines definitively state that repeat endoscopic procedures should not be offered as an alternative to urethroplasty, and they do not mention time of stricture recurrence as a factor. SIU guidelines allow for management of urethral stricture with indwelling urethral stenting.ConclusionsOverall there is a need for more high quality research in the work up, management, and follow up care of urethral stricture.

Recurrent and acquired tracheoesophageal fistulae (TEF)—Minimally invasive management

ObjectiveRecurrent and acquired fistulae are a serious complication of congenital esophageal atresia and tracheoesophageal fistula (TEF) repair and foreign body ingestion (FBI) (e.g., button battery). We report our experience with a minimally invasive approach to recurrent and acquired TEF. MethodsMedical records of patients referred for management of recurrent and acquired TEF between 2003 and 2015 were reviewed retrospectively. Patients underwent endoscopic procedures (de-epithelization of fistulous tract and fibrin tissue adhesive-TisseelR) under general anesthesia. ResultsNine children (7 male, 2 female) with age range 3months to 3years (mean 1.5year) were managed. TEF closed spontaneously in four patients, whereas in 5 patients the TEF closed after combined endoscopic procedure. Three patients required repeat endoscopic procedures. Follow-up ranged between 7months to 10years (mean 4.2years). ConclusionsActive observation and repeat combined endoscopic procedures are safe alternatives to open surgical repair of acquired and recurrent TEF. Level of evidenceLevel IV study.

Holmium:YAG Laser Ablation for the Management of Lower Urinary Tract Foreign Bodies Following Incontinence Surgery: A Case Series and Systematic Review

The objective of this study was to determine the outcomes associated with the endoscopic removal of foreign bodies (such as mesh or permanent suture) in the lower urinary tract after female stress incontinence surgery with the Holmium:YAG (Ho:YAG) laser, and to systematically review the literature on this topic. A retrospective chart review of 18 consecutive women found to have mesh or suture exposure was performed. All patients underwent Ho:YAG laser ablation. A systematic review was performed to identify literature addressing the endoscopic management of mesh/suture exposure after stress incontinence surgery. Between November 2011 and February 2016, 18 women underwent Ho:YAG laser ablation of exposed mesh or suture. Presenting symptoms included lower urinary tract symptoms, pelvic pain, incontinence, or recurrent urinary tract infections. Thirteen women had a previous synthetic midurethral sling and five had a prior retropubic suspension. The median age was 58 years (interquartile range [IQR] 50-60) and median follow-up was 2 years (IQR 1-2). Four patients (22%) had residual mesh after the first procedure, requiring a repeat endoscopic procedure. Only one patient had a small amount of asymptomatic residual mesh on cystoscopy after the final procedure. Only minor postoperative complications were observed. Eight patients had stress incontinence and four underwent operative treatment for this. In our systematic review, we identified 16 case series, which described a total of 158 patients. Women most commonly presented with voiding symptoms or incontinence. Based on the synthesis of these data, repeat procedures were necessary in 16% and vesicovaginal fistula occurred in 2%. Recurrent/persistent stress incontinence was present in 20%, and of these patients, 3/4 underwent a new stress incontinence procedure. Both our case series and the systematic review of the literature demonstrated that endoscopic treatment of lower urinary tract foreign bodies after stress incontinence surgery has good success rates and minimal morbidity.

A Review Over the Past 15 Years of the Management of the Internal Piriform Apex Sinus Tract of a Branchial Pouch Anomaly and Case Description

Literature review of treating the piriform apex sinus tract through microlaryngoscopy and a case description. Fourteen papers were identified in PubMed using the search criteria of piriform sinus fistula, microlaryngoscopic repair, and endoscopy. Institutional Review Board approval was obtained. One hundred forty-five cases including ours were available for review, with 182 procedures. Sixty-two cases were male, 73 female, and 10 genders were not reported. Multiple treatment options were used, including electrocautery, chemocautery, mass excision, fibrin glue, lasers, suture closure, or combination of stated modalities. Of the 182 procedures, 147 procedures were performed endoscopically. There were 37 recurrences (25%). These patients either underwent a repeat endoscopic procedure or an open excision. One hundred and ten (75%) endoscopic procedures were successful. Piriform sinus tract anomalies often present as a mass and recurrent neck infections. This review reveals that treating the internal piriform sinus opening alone can be successful. This procedure has low morbidity, short operative time, and high success. We advocate this approach first with a combined open/laryngoscopic approach for failed cases. To our knowledge, our technique of CO₂laser ablation of the tract followed by suture closure has not been previously described. We believe this to be the first comprehensive review of this topic and the largest series of cases included in a single report.

Mo1535 Outcomes of Fistula Closure by Endoscopic Suturing: a Multi- Center Study

Mo1534 Extreme Endoscopy: a New Paradigm in Interventional Endoscopy Monkemuller Klaus*, Paul T. Kroner, Mark C. Phillips, Helmut Neumann, Ivan Jovanovic Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama, Birmingham, AL Introduction: Extreme endoscopy is a new discipline in interventional GI endoscopy. Previous data on extreme endoscopy comes from case reports. Aims: To report on the feasibility and outcomes of extreme endoscopy. Methods: Observational, retrospective study conducted at a tertiary care hospital during an 18-months period. All procedures were performed under general anesthesia. Extreme endoscopy comprises five key components: (i) use of multiple scopes or dual endoscope technique; (ii) use of various types of overtubes (OT), (iii) utilization of modified devices, (iv) use of fluoroscopy and, (v) necessity of utilizing a tool box with: wire cutter, glue, tape, foam (Endosponge). Singleor double balloon enteroscopy (SBE, DBE) was not defined as extreme endoscopy, unless the technique was utilized to perform a) endoscopic re-anastomosis of disrupted GI tract; b) PATENT (percutaneous assisted transprosthetic endoscopic therapy); c) SBEor DBE-rendezvousERCP; d) endoluminal stenting, e) removal of migrated SEMS from the small bowel. Additional exclusions: ESD or POEM cases (nZ45) and pancreatic necrosectomies (nZ28). Success was defined as resolution of the primary luminal problem. Results: 44 patients (23 females, 21 males, mean age 57 years, age range 32-83) with various types of complex primary, secondary or post-surgical anatomy endoluminal GI defects were studied. In 20 patients (45%) previous surgical, endoscopic or radiologic attempts at solving the problem had failed. In 11 patients (25%) there were no other interventional treatment options available. Interventions performed: PATENT (nZ3), endoscopic re-anastomosis of the disrupted GI tract (nZ4), Endosponge placement for drainage of huge cavities (nZ3), OT-assisted removal of mesh (nZ2), OT-assisted removal of migrated lap bands (nZ3), OT-assisted SEMS placement of the small bowel and/or colon (nZ8), combined closure of fistula or perforation and placement of direct endoscopic jejunostomy (nZ7), SBEor DBE ERCP with exchange of scope for slim cholangioscope to perform EHL (nZ4), rendezvous-DBE ERCP to place SEMS into the bile duct (nZ3) or to place plastic stents percutaneously under direct endoscopic view (nZ2), OT-assisted endoscopy allowing for ERCP or PEG placement in patients with esophageal stenosis (nZ3). The technical success was 87.8%. The mean procedure time was 35 minutes (range 45 min to 4 hours). There were no major adverse events associated with the procedures. Conclusions: This is the largest study reporting on extreme endoscopy. Albeit time consuming extreme endoscopic interventions lead to a resolution or remediation of complex endoluminal disorders in the majority of patients. It appears that extreme endoscopy may provide hope for patients in whom no other choices exist. Now multi-center studies in this topic are warranted. Mo1535 Outcomes of Fistula Closure by Endoscopic Suturing: a MultiCenter Study Saurabh S. Mukewar*, Nitin Kumar, Marc F. Catalano, Christopher C. Thompson, Christopher J. Gostout Gastroenterology, Mayo Clinic, Rochester, MN; Gastroenterology, Brigham and Women’s hospital, Boston, MA; Gastroenterology, GI Health Associates, Milwaukee, WI Background: Endoscopic closure of fistulas is desirable but remains a challenge, especially for gastrogastric fistulas. We report a multicenter experience using endoscopic suturing to close gastrointestinal fistulas. Methods: Electronic records at two academic centers and one private clinic were reviewed to identify patients who underwent sutured fistula closure (OverStitch, Apollo Endosurgery , Inc., Austin, Texas). Demographic, clinical variables and details of endoscopic procedure were recorded. Results: A total of 56 patients underwent single session fistula closure (26: Brigham and Women’s hospital; 21: Mayo Clinic and 9: GI associates, Milwaukee, WI). Mean age was 54 +/12.7 years. Gastrogastric fistula (29 (51.8%) was the most common fistula. 16 (28.6%) had a failed previous attempt at closure of fistula. Immediate success was seen in all cases [56 (100%)] and 17 (42.5%) had successful closure of fistulas as observed on endoscopy [18(45%)], imaging [13(32.5%)] or clinical [5(12.5%)] follow up. Gastrogastric fistulas had lower rates of closure [5/19 (26.3%)] compared to other fistulas [12/21 (57.1%)]. Data on subsequent procedures and outcomes was available from Mayo cohort. Out of 21 patients, 2 underwent surgery, 3 had no follow up imaging/endoscopy. 9/15 (60%) required repeat endoscopic procedures (range: 1 to 4) with successful outcome in 4/9 (44.5%) cases. Only one patient (1.8%) had abdominal pain requiring hospital admission. Conclusion: Single session suture closures of fistulas alone are safe and can be effective especially in known challenging cases. Sequential closures for persistent fistula warrants attention. Age* 53.9 +/Type of fistula Fistula sutures^ 2