Comparison of the Efficacy and Safety of the FDA-approved Intragastric Balloon Systems in a Clinical Setting.

BACKGROUND AND AIMS: The gas-filled intragastric balloon (IGB) system (Obalon) and the fluid-filled IGB system (Orbera) are the current FDA-approved IGB systems to treat obesity; however, they have not been previously compared in clinical practice. The aims of this study were to compare their efficacy, tolerance, and safety in a clinical setting. MATERIALS AND METHODS: This is a retrospective cohort study of consecutive patients treated with the gas-filled IGB or fluid-filled IGB between October 2015 and May 2020 at 2 academic centers. The primary endpoints included percent total body weight loss at balloon removal in patients who completed at least 20 weeks of therapy, the difference in adverse events that required urgent evaluation or hospitalization, and early removal in the 2 groups. RESULTS: A total of 87 patients underwent successful IGB placement (gas-filled IGB n=57, age 48.9±8.8, body mass index 35.5±5 kg/m 2 ; fluid-filled IGB n=30, age 49.2±14.3, body mass index 38.8±6 kg/m 2 ). Eleven patients underwent early device removal. There were no differences in percent total body weight loss at balloon removal and 12 months between the balloon systems ( P =0.39). Patients who received the fluid-filled IGB were more likely to require urgent evaluation or treatment, require hospital stay >24 hours, and need early balloon system removal compared with patients treated with the gas-filled IGB. CONCLUSION: In this 2-center cohort, both FDA-approved gastric balloon systems had the same effectiveness, but the gas-filled IGB had fewer serious adverse events and better tolerability than the fluid-filled IGB.

Validation of choledocholithiasis predictors from the "2019 ASGE Guideline for the role of endoscopy in the evaluation and management of choledocholithiasis."

BACKGROUND AND AIMS: Identifying patients likely to have CDL is an important clinical dilemma because endoscopic retrograde cholangiopancreatography (ERCP), carries a 5-7% risk of adverse events. The purpose of this study was to compare the diagnostic test performance of the 2010 and 2019 ASGE criteria used to help risk stratify patients with suspected CDL. METHODS: Consecutive patients evaluated for possible CDL from 2013 to 2019 were identified from surgical, endoscopic, and radiologic databases at a single academic center. Inclusion criteria included all patients who underwent ERCP and/or cholecystectomy with intraoperative cholangiogram (IOC) for suspected CDL. We calculated the diagnostic test performance of criteria from both guidelines and compared their discrimination using the receiver operator curve. Univariate and multivariate analysis was used to identify the strongest component predictors. RESULTS: 1098 patients [age 57.9 ± 19.0 years, 62.8% (690) F] were included. 66.3% (728) were found to have CDL on ERCP and/or IOC. When using the 2019 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 65.8, 78.9, 86.3, 54.1, and 70.4%, respectively. Using the 2010 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 50.5, 78.9, 82.5, 44.8, and 60.1%, respectively. The AUC for high-risk criteria using the 2019 guidelines [0.726 (0.695, 0.758)] was greater than for the 2010 guidelines [0.647 (0.614, 0.681)]. The key difference providing the increased discrimination was the inclusion of stones on any imaging modality, which increased the sensitivity to 55.0% from 29.1%. Not including CDL on imaging or cholangitis, a dilated CBD was the strongest individual predictor of CDL on multivariate analysis (OR 3.70, CI 2.80, 4.89). CONCLUSION: Compared to 2010, the 2019 high-risk criterion improves diagnostic test performance, but still performs suboptimally. Less invasive tests, such as EUS or MRCP, should be considered in patients with suspected CDL prior to ERCP.

Advancements in Endoscopic Biliary Interventions by Gastroenterology.

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.

Postsurgical Presentation of Zollinger-Ellison Syndrome After Resection of Endometrioid Neuroendocrine Tumor.

Zollinger-Ellison syndrome is a functional neuroendocrine tumor with inappropriate gastrin secretion and hyperchlorhydria causing severe peptic ulcer disease and chronic diarrhea. Although 70% of primary gastrinomas occur in the region of the duodenum, the diagnosis and localization of gastrinomas can be challenging because of small lesions that may arise functionally as lymph node metastases at initial presentation. We report a 76-year-old woman presenting with Zollinger-Ellison syndrome several months after surgical resection of endometrioid small cell neuroendocrine carcinoma and endometrioid adenocarcinoma.

Patient Engagement with Interactive Text Message System Improves Successful Colonoscopy Rates in an Outpatient Endoscopy Center.

INTRODUCTION: Text message-based interventions reduce colonoscopy no-show rates and improve bowel preparation scores. In this non-randomized study, we assessed whether an interactive text messaging system could improve colonoscopy outcomes. METHODS: Colonoscopy pre-procedural instructions were programmed into a dedicated software platform created for this study. In the intervention arm, text messages were sent to veterans during a 4-week study period. Validated pre-procedural satisfaction questionnaires were completed by patients during standard protocol and intervention periods. Demographics and colonoscopy outcomes data were compared between the standard protocol and intervention arms, including procedure completion rate on scheduled date, Boston bowel preparation score (BPPS), adenoma detection rate, and satisfaction. RESULTS: Of 241 patients, 128 were in the standard protocol arm and 113 in the intervention arm. Higher proportions of patients receiving text messages underwent colonoscopy on their scheduled date (69.9%) compared to the ones in the standard protocol (50.8%, p = 0.015). Patients with ≥3 interactions with the system had 80.6% likelihood of completing colonoscopy on the scheduled date compared to 56.9% with <3 interactions and 50.8% with standard protocol (p < 0.001). Frequency of interaction with the system was similar between older (>65 years) and younger patients (p = 1.0). Among older patients, colonoscopy was completed successfully in 84.2% when alert-based human interactions occurred compared to 65.6% in those without and 47.9% with standard protocol (p = 0.018). More than 90% indicated they would recommend the system to patients undergoing future colonoscopy. CONCLUSION: An interactive text messaging system improves successful colonoscopy rates in a VA setting, with greatest impact in older patients.

Appropriateness and Safety of Direct Access Endoscopy in Hospitalized Patients.

Background and objective Direct access endoscopy (DAE) allows hospitalists to refer patients for endoscopy without a gastroenterologist (GI) evaluation, potentially decreasing wait time and facilitating earlier discharge from the hospital. This study aimed to evaluate the efficacy and safety of DAE for average-risk endoscopic procedures. Methods A retrospective chart review was performed by comparing patients who underwent a DAE with patients who underwent an endoscopy ordered by GI physicians at a tertiary care hospital. The procedure indications were obtained from the endoscopy reports and hospitalist progress notes. Appropriateness of each procedure was determined based on the guidelines from the American Society for Gastrointestinal Endoscopy (ASGE). Findings, procedure-related complications, and clinical significance were recorded. Results A total of 110 patients were included in this study; 40 were DAE and 70 were ordered by GI. The mean age of the patients was 55.5 years with 69 males and 41 females. In the DAE group, there were 31 esophagogastroduodenoscopies (EGD) and nine colonoscopies performed, while in the GI group, there were 58 EGDs, 11 colonoscopies, and one push enteroscopy. All procedures fulfilled ASGE criteria; 20/40 DAE and 53/70 GI-ordered procedures had clinically significant findings. There was one complication in each group. Conclusion DAE allows a hospitalist to order an endoscopy without consultation with a GI physician. This study showed that all DAE procedures had met ASGE criteria for appropriateness, with 50% having clinically significant findings and no difference in adverse events. These results suggest that DAE is safe and effective in evaluating hospitalized patients for average-risk endoscopy.