Efficacy of endoscopic vacuum therapy in esophageal luminal defects: a systematic review and meta-analysis

Background/Aims Endoscopic vacuum-assisted closure (EVAC) is a novel technique used to repair esophageal perforation and leaks. Varying data have been reported on the overall success rate of EVAC. We aimed to conduct a meta-analysis of the available data on the clinical success rate of EVAC. Methods Electronic databases were searched for publications addressing the efficacy of EVAC in esophageal luminal defects. Pooling was conducted using both fixed and random-effects models. The overall clinical success of EVAC therapy was considered the primary outcome, whereas, overall complication rates, need for adjunct therapy, and mortality were considered secondary outcomes. Results In total, 366 patients were included in the study. On pooled analysis, the mean age was 66 years with 68.32% of patients being men. Overall pooled clinical success rate of EVAC therapy was 87.95%. Upon subgroup analysis, the pooled clinical success rate of postsurgical anastomotic leak and transmural esophageal perforation were found to be 86.57% and 88.89%, respectively. The all-cause hospital mortality was 14% and 4.2% in patients with esophageal perforation and EVAC, respectively. Conclusions This study demonstrates that EVAC therapy has a high overall clinical success rate, with low mortality. EVAC therapy seems to be a promising procedure with excellent outcomes in patients with luminal esophageal defects

P132 OUTCOMES AND REASONS FOR ADMISSION IN CROHN’S DISEASE. AN ANALYSIS OF NATIONWIDE INPATIENT SAMPLE 2016

Abstract Objective Recent research suggests increasing nationwide admission for Crohn’s disease (CD), but the most common reasons for admission are not well known. We sought to enumerate the most common presentations of Crohn’s disease requiring admission in Nationwide Inpatient Sample (NIS) 2016 using ICD-10 codes. Methods We identified all adults aged greater than or equal to 18 years with a primary diagnosis of CD, using ICD 10 in Nationwide inpatient database. We analyzed inpatient demographics via chi-square. Inpatient mortality,Length of stay (LOS) and Total Charge (TOTCHG) was calculated using univariate and multivariable linear models. Results 60,244 patients with CD required inpatient admission. Majority of patients were females (53%), white (69%), with private insurance (46%) admitted to large bed sized (53.3%) teaching hospitals (68%). The common reasons for admission in CD patients included bowel obstruction at 24.6% (14,850) of which 57.8% (8,590) presented with small bowel obstruction (SBO). 42.1% (6260) were admitted with both SBO and LBO. Other reasons for admission were GI bleeding (6.5%) and fistulizing CD (2.4%). The inpatient mortality was 0.5%. Age was an independent predictor of mortality in these patients. (aOR 1.08, 95% CI 1.04–1.12; p=0.000). Protein energy malnutrition (PEM) (aOR 2.45, p=0.348), patients requiring pressor support (aOR 4.2, p=1.06) and those with bowel obstruction (aOR 1.1.9 p=0.84) had higher odds of mortality on multivariate analysis model, but couldn’t reach statistical significance. The mean LOS was 4.9 days and patients admitted over weekend had a longer LOS (coeff 0.22, 95% CI 0.08–0.37, p=0.002) as compared to weekdays on multivariate linear regression. The total cost attributable to Crohn’s disease was 706$ million. Independent predictors of increased total charge were Large bed sized hospitals, African-American, protein energy malnutrition, patients requiring pressor support and bowel obstruction in multivariate linear analysis. Conclusions The common reasons for inpatient admission in patients with CD include bowel obstruction, GI bleeding and fistulizing CD. Age was an independent predictor of mortality. The economic burden was highest amongst African-Americans, malnourished, patients requiring pressor support and those with bowel obstruction. </jats:sec

Comparison of clinical characteristics and survival outcomes in patients with malignant peritoneal and pleural mesothelioma.

460 Background: Malignant peritoneal mesothelioma (MPeM) is an aggressive tumor strongly associated with asbestos exposure. We analyzed a large nationwide database to better understand the differences in the demographic and clinical patterns of MPeM and pleural mesothelioma (MPlM). Methods: The National Cancer Database (NCDB) 2010-15 was queried to identify all patients diagnosed with MpeM and MPlM. The demographic and clinical characteristics were compared using Pearson’s chi-square test. Kaplan-Meier method and associated log-rank test were used to compare the unadjusted overall survival of the two malignant mesothelioma (MM) sites. A multivariate Cox regression analysis was done to determine survival difference between the 2 groups. Results: Of the 8,668 patients included in the study, 1,081 (12.5%) had MPeM and 7,587 (87.5%) had MPlM. The MPeM cohort was younger (median age at diagnosis 61 vs 73 years), predominantly females (45.7% vs 23.5%), had a lower Charlson Deyo Comorbidity Score ( &gt; = 1: 24.5% vs 32.1%), had higher percentage of uninsured patients (4% vs 2.2%), was less likely to be treated at a community or comprehensive community center (36.1% vs 47.3%) and had lower proportion of sarcomatous or biphasic histology (9.3% vs 22.4%) compared to MPlM cohort. The MPeM cohort was more likely to receive surgery (56.5% vs 28%) and chemotherapy (68.4% vs 54.5%) but less likely to receive radiation (0.8% vs 11%). The p-value was &lt; 0.001 for all comparisons. The median OS was 19.7 and 9.7 months for patients with MPeM and MPlM, respectively (log-rank p value &lt; 0.001). On multivariate Cox proportional hazards analysis, OS was significantly worse for MPlP compared to MPeP [HR adj: 1.19, 95% confidence interval (CI): 1.09-1.30 (p &lt; 0.001)]. Conclusions: There is paucity of data about clinical characteristics and outcomes of MPeM. Much of our current knowledge about MPeM is extrapolated from MPlM. Our study suggests significant differences in prognostic factors and survival outcomes between the two sites. </jats:p

Impact of malnutrition on postoperative outcomes of patients undergoing gastrectomy for gastric cancer: A nationwide analysis between 2012 and 2017.

315 Background: Gastrectomy offers a curative treatment option for non-metastatic gastric cancers (GC). Unfortunately, cancer associated malnutrition is a common and potentially actionable problem in GC patients. In this nationwide study, we analyzed the impact of malnutrition on outcomes of patients undergoing gastrectomy for GC. Methods: The Nationwide inpatient Sample database (NIS) was used to identify patients who underwent gastrectomy for gastric cancer from 2012-2017 using ICD 9 and ICD 10 codes. The population was then divided into patients with or without PEM (Protein energy malnutrition) to compare their outcomes. Univariate and Multivariable logistic and linear regression models were used to analyze mortality and healthcare resource utilization. Results: Of the 6,620 patients identified, 4,607 (69.6%) patients were ≥ 60 years old and 3,972 (60%) were males. Majority were White (49.1%) followed by Asians (20.3%). 2,052 (31%) patients were malnourished. Patients with PEM had higher rates of sepsis [adjusted Odds ratio (aOR) 3.6(2.4-5.4), p =0.000], shock [aOR 2.9(1.9-4.5), p =0.000], acute kidney injury [aOR 2.1(1.5-2.9), P&lt;0.001], ICU admissions [ aOR 1.9(1.3-2.9), p =0.001], and higher post operative mortality [aOR 2.5 (1.5-4.3), p =0.001]. Mean Length of stay was longer in PEM patients as compared to non-PEM patients (16.2 vs 9.4 days). On survival analysis, overall survival (OS) was significantly worse for patients with PEM undergoing gastrectomy [HR adj: 1.14 (p=0.04)]. A comparison of these outcomes has been detailed in the table. Conclusions: In this analysis, we highlight the importance of nutrition for gastric cancer patients undergoing gastrectomy. Ensuring adequate nutritional status prior to surgery can improve patient outcomes and decrease health care costs.[Table: see text] </jats:p

Safety and Efficacy of Primary EUS-Guided Choledochoduodenostomy for Malignant Distal Biliary Obstruction: A Systematic Review and Meta-Analysis

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for biliary drainage in malignant distal biliary obstruction (MDBO). Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is considered a rescue therapy for failed ERCP. This study aims to evaluate the safety and efficacy of this technique as the primary modality for MDBO biliary drainage. Methods: An electronic database search was conducted following PRISMA guidelines to identify studies on EUS-CDS for primary biliary drainage in MDBO. A meta-analysis was performed using random and fixed effects models. Results: We extracted data from 10 eligible studies comprising 519 patients. The mean age for the study was 70 years &plusmn; SD 2.66. The pooled technical success rate was 92.36% (95% CI = 88.39&ndash;95.56), and the clinical success rate was 88.91% (95% CI = 85.22&ndash;92.13). The pooled stent dysfunction rate was 13.66% (95% CI = 7.47&ndash;21.35), and the reintervention rate was 15.91% (95% CI = 11.00&ndash;21.54) of patients. The mean stent patency duration was 229.20 days &plusmn; SD 113.9. The total pooled adverse events rate was 17.50% (95% CI = 12.90&ndash;22.64), and 9.03% (95% CI = 4.43&ndash;15.05) was considered moderate to severe. Procedure-related pancreatitis had a pooled rate of 0%. The pooled adverse event rate of acute cholangitis was 6.84% (95% CI = 3.69&ndash;10.88), and for acute cholecystitis it was 2.61% (95% CI = 1.06&ndash;4.83). Conclusions: EUS-CDS demonstrates favorable outcomes when used as a primary approach in MDBO. With a long stent patency duration and no procedure-related acute pancreatitis, it may be considered the primary technique when expertise is available

P123 THIRTY DAY READMISSIONS AMONG PATIENTS WITH COMPLICATED INFLAMMATORY BOWEL DISEASE AND EFFECTS ON OUTCOMES: RESULTS OF ANALYSIS OF 2016 NATIONWIDE READMISSION DATABASE

Abstract Objective To determine the rate of hospital readmissions within 30 days of discharge in patients with complicated Inflammatory Bowel Disease (IBD) and its impact on mortality, morbidity, and health care cost in the United States. Methods We performed a retrospective study using the Nationwide Readmission Database(NRD) for the year 2016 (Data on 35.6 million discharges). We collected data on hospital readmissions of 29,356 adults who were hospitalized for complicated Inflammatory Bowel Disease(Crohn’s disease and Ulcerative Colitis) and discharged. Complications were defined using ICD 10 codes. Patients with age less than 18, elective admission and admission during December month were excluded. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity and resource use. Multivariate regression analysis was used to determine the independent predictors of 30-day readmission. Results Among patients admitted to US hospitals with complicated IBD, the total time at risk was 407,983 days, with the first readmission occurring at day 1 and the last readmission at day 30. The 30-day rate of readmission was 17.6%, with the most common cause of readmission being Crohn’s disease of small intestine with intestinal obstruction (9%). The mortality rate among patients readmitted to the hospital (0.6%), was higher than that for index admissions (0.3%) (P &amp;lt; .01). Mean length of stay was 5.5 days for index admission and 5.9 days for readmission (p=0.01). Mean total charge for index admission was $44,768 compared to$48,766 for readmission (p&amp;lt;0.01). Mean total cost for index admission was $11,491 compared to$12,704 for readmission (p&amp;lt;0.01). A total of 30,943 hospital days were associated with readmission, and the total health care in-hospital economic burden was $65 million (in costs) and$251 million (in charges). Independent predictors of readmission were age, insurance status, higher Charlson comorbidity score, lower income, teaching status of hospital and longer stays in the hospital. Older age, private insurance, median income more than $48,000 were associated with lower odds for readmission, whereas higher comorbidities and admission to teaching hospital were associated with increased odds for readmission. Conclusions In a retrospective study of patients hospitalized for complicated IBD in 2016, 17.6% were readmitted to the hospital within 30 days of discharge. Readmission was associated with higher mortality, morbidity, and resource use. Age, insurance status, higher comorbidity score, lower income and admission to teaching hospital were independent predictors of readmission. </jats:sec