Endoscopic bariatrics: current therapies and future directions

Endoscopic bariatric therapies (EBTs) are endoscopic procedures indicated for weight loss in the obese population. They are shown to be safe and effective for patients who do not quality for bariatric surgery. There are currently no randomized controlled studies comparing bariatric surgery with EBTs. However, EBTs are more cost effective and have fewer complications. This review will examine currently available EBTs with published data.

Gastric per-oral endoscopic myotomy versus pyloromyotomy for gastroparesis: An international comparative study

BACKGROUND AND AIM

Gastroparesis is a potentially debilitating gastric motility disorder with limited treatment options. Highest efficacy treatments include gastric per-oral endoscopic myotomy (GPOEM) and surgical pyloromyotomy. This study compares the efficacy and safety of GPOEM versus laparoscopic pyloromyotomy for refractory gastroparesis.

METHODS

Patients who underwent GPOEM or laparoscopic pyloromyotomy for refractory gastroparesis from four centers across the USA and Latin America were included in a dedicated registry. Data collected included patient demographics, imaging, laboratory values, clinical success, gastroparesis cardinal symptom index, procedure time, pre-op and post-op gastric emptying times, adverse events, and hospital length of stay.

RESULTS

A total of 102 patients were included (mean age 47; 32.4% male): GPOEM n = 39, surgical pyloromyotomy n = 63.Technical success was 100% in both groups. Clinical success was 92.3% in the GPOEM group and 82.5% in the surgery group (P = 0.164). The GPOEM group had a significantly higher post-op GSCI score reduction by 1.3 units (P < 0.00001), post-op retention reduction at 2 h by 18% (P < 0.00001), post-op retention reduction at 4 h by 25% (P < 0.00001) and a lower procedure time by 20 min (P < 0.00001) as compared with surgery. GPOEM also had a lower hospital length of stay by 2.8 days (P < 0.00001). Adverse events were significantly fewer in the GPOEM group (13%) compared with surgery group (33.3%; P = 0.021). Mean blood loss in the GPOEM group was only 3.6 mL compared with 866 mL in the surgery group.

CONCLUSIONS

The GPOEM may be a less invasive, safer, and more efficacious procedural treatment for refractory gastroparesis as compared with surgical pyloromyotomy.

Blood lead level is associated with advanced liver fibrosis in patients with non-alcoholic fatty liver disease: A nationwide survey (NHANES 2011-2016)

INTRODUCTION AND OBJECTIVES

Non-Alcoholic Fatty Liver Disease (NAFLD) is linked to obesity and metabolic syndrome, but increasing evidence also implicates environmental toxins. In this study, we aim to show that in elevated blood Lead levels in NAFLD patients result in worsening liver fibrosis.

MATERIALS AND METHODS

30,172 patients from NHANES 2011-2016 met inclusion criteria. 2499 patients ages 20-74 were identified with NAFLD as determined by the Fatty Liver Index score, and 425 with advanced liver fibrosis were identified using the NAFLD Fibrosis Score. Simple linear regression, Student's T-test, and Rao-Scott Chi-Square test was used for continuous and categorical variables. Multivariate regression analysis was used to adjust for confounders to determine odds of Advanced Fibrosis.

RESULTS

Increased serum Lead level was independently associated with increased risk of Advanced Fibrosis (OR 5.93, 95% CI 2.88-12.24) in the highest Lead quartile (Q4). In subgroup analysis stratified by BMI, a significant association between advanced liver fibrosis and blood Lead levels was consistently present, Q4 (OR 5.78, 95% CI 0.97-33.63) and Q4 (OR 6.04, 95% CI 2.92-12.48) in BMI <30 and >30, respectively. Increased Lead exposure was also evident in patients who were older, less educated, male, and drank alcohol and smoked tobacco.

CONCLUSIONS

Our findings show that advanced liver fibrosis is up to six times more likely in NAFLD patients with increased Lead exposure.

The impact of acute kidney injury on mortality and clinical outcomes in patients with alcoholic cirrhosis in the USA

INTRODUCTION

Acute kidney injury (AKI) is associated with increased morbidity and mortality in patients with chronic liver disease. Although the impact of AKI on patients with liver disease has been established, its impact on alcoholic cirrhosis has not been studied.

METHODS

Our study utilized data from the National Inpatient Sample for the year 2016 for all patients with a diagnosis of alcoholic cirrhosis and AKI. Primary outcomes were mortality, length of stay (LOS) and hospitalization cost were compared. Secondary outcomes were complications of cirrhosis and its impact on mortality. Multivariate logistic regression analysis and propensity-score matching were used to compare the two groups.

RESULTS

A total of 29 906 patients were included and 6733 (22.5%) had AKI. Propensity-matched multivariate analysis demonstrates that AKI was associated with a significant increase risk of mortality [odds ratio (OR): 8.09; 95% confidence interval (CI), 6.68-9.79; P < 0.0001]. AKI prolonged the hospital stay by 3.68 days (95% CI, 3.42-3.93; P < 0.0001) and increased total hospital charges by $50 284 (95% CI, 45 829-54 739; P < 0.0001). AKI increased the risk of complications of cirrhosis, including hepatorenal syndrome (OR: 19.15; 95% CI, 16.1-22.76), ascites (OR: 2.27; 95% CI, 2.11-2.44), hepatic encephalopathy (OR: 2.54; 95% CI, 1.87-3.47) and portal hypertension (OR: 1.08; 95% CI, 1.01-1.16).

CONCLUSION

AKI in alcoholic cirrhosis significantly increases the risk of mortality, hospitalizations costs and LOS. Further studies are needed on addressing renal failure and treatment options for patients with alcoholic cirrhosis.

Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization.

METHODS

This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay.

RESULTS

A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001).

DISCUSSION

Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.

An Extremely Rare Presentation of an Alpha-Fetoprotein-Producing Esophageal Adenocarcinoma

Alpha-fetoprotein (AFP)-producing esophageal adenocarcinoma (EAC) is an extremely rare occurrence with very few cases reported in the literature. We report the case of a 76-year-old female who presented with progressive weakness, fatigue, and a decrease in appetite for weeks and who was found to have an AFP-producing EAC with an extraordinarily high AFP level of 46,135 ng/mL. CT angiography revealed abnormal thickening of the esophagus and multiple metastatic masses throughout the liver. Upper endoscopy revealed a large mass in the distal esophagus with extension into the stomach. Biopsy confirmed the EAC. Most cases are unsuccessfully treated with surgery and chemotherapy. Serial measurement of serum AFP may be useful for monitoring clinical status and treatment response.

In-Hospital Outcomes of Patients with Acute Decompensated Heart Failure and Cirrhosis: An Analysis of the National Inpatient Sample

INTRODUCTION

Heart failure increases morbidity and mortality in patients admitted for cirrhosis. Our objective was to determine if patients with acute decompensated heart failure (ADHF) and cirrhosis would have increased mortality, hospital length of stay (LOS), and total hospital charges compared to patients with only ADHF. There is also a paucity of data regarding the influence of gender, race, ethnicity, insurance, and cirrhosis-related complications on mortality, hospital length of stay, and total hospitalization charges. In this study, we aim to identify risk factors in a national population cohort from 2016.

METHODS

All patients above 18 years old with cirrhosis and ADHF admitted in 2016 were identified from the Nationwide Inpatient Sample (NIS). Multivariate regression analysis was used to estimate the odds ratio of in-hospital mortality, average length of stay (LOS), and total hospital charges after adjusting for the following factors: age, gender, race, Charlson and Elixhauser scores, primary insurance payer status, hospital type, hospital bed size, hospital region, and hospital teaching status. Statistical analysis was performed by using the survey procedures function in the statistical analysis system (SAS) software. Statistical significance was defined by the two-sided t-test with a p value < 0.05.

RESULTS

The overall sample contained 363,050 patients. A total of 355,455 patients were admitted with ADHF and 2% of these patients had concomitant cirrhosis (n = 7595) in 2016. The total mortality rate was 3.4%, hospital LOS was 6.6 days (with a median of 6.5 days), and the mean total hospital charge was $63,120.20. Patients with both ADHF and cirrhosis compared to patients without ADHF had increased mortality, hospital LOS, and cirrhosis-related complications.

CONCLUSIONS

As the incidence and prevalence of ADHF and cirrhosis increases worldwide, we urge the medical community to increase surveillance of patients with both diseases and perform rigorous cardiovascular risk assessments as well to improve patient outcomes.

Increased cardiovascular events and mortality in females with NAFLD: a meta-analysis

Non-alcoholic fatty liver disease (NAFLD) and cardiovascular diseases (CVD) share similar risk factors. Recent studies have focused on obesity and insulin resistance, but the link between NAFLD and CVD persists regardless of traditional risk factors. Despite the increased incidence and prevalence of NAFLD worldwide, there has been no thorough investigation of gender disparities nor a closer look taken into investigating the role gender may play in increased cardiovascular (CV) mortality in people with NAFLD. We assessed the incidence and prevalence of CV events and mortality based on gender in people with NAFLD, at any stage of fibrosis. A meta-regression was conducted to further analyze the impact of age on both genders. An aggregate analysis was performed on ten studies with NAFLD people. A random-effects model was used to pool the overall incidence and prevalence rates of CV events and mortality as well as all-cause mortality to examine any gender disparity. We also performed a meta-regression analysis to evaluate the effect of age on mortality for men versus women with NAFLD and CV events and mortality. Summary odds ratios (OR) and 95% confidence intervals (CI) were estimated using a random-effects model. In 108,711 people with NAFLD, of which 44% were females and 56% were males, all-cause mortality was 1.5x higher in women compared to men (OR 1.65, 95% CI 1.12-2.43, P<0.012). CV events and mortality were also 2x higher in women compared to men (OR 2.12 95% CI 1.65-2.73, P<0.001)). On meta-regression, females had higher mortality with advancing age starting at age 42 (coefficient =0.0518, P=0.00001). For people with NAFLD, women had a markedly higher incidence and prevalence of CV events, CV mortality, and all-cause mortality when compared to men. As the incidence and prevalence of NAFLD and concomitant CV events increase worldwide, we urge the medical community to increase surveillance and perform rigorous cardiovascular risk assessments for women, especially beginning at age 42. Additionally, we recommend heterogeneous surveys of gender disparities, increased focus on gender as a decisive factor for downstream CV events, the relationship between NAFLD severity and gender-based mortality differences, and larger studies representing equivalent male and female populations.

Portal Hypertension and Chronic Kidney Disease Significantly Increase the Risk of Early Unplanned Readmissions in GAVE- Related Admissions

BACKGROUND AND AIMS

Gastric antral vascular ectasia (GAVE) is an uncommon cause of non-variceal upper gastrointestinal bleeding that is characterized by dilation of blood vessels in the antrum of the stomach. Various co-morbidities are associated with the development of GAVE, but the impact of co-morbidities on unplanned GAVE readmissions is unclear. The aim of this study was to assess the national incidence, 30-day mortality rate, and 30-day readmissions related to GAVE. Secondary outcomes were evaluation of predictors of early readmission, hospital length of stay (LOS) and total hospitalization charges.

METHODS

Using the 2016 National Readmission Database, we analyzed discharges for GAVE. ICD-10 CM codes were utilized to identify associated comorbidities and inpatient procedures during the index admission. 30-day readmissions were identified for GAVE. Secondary measures of outcomes including LOS and hospitalization charges were also calculated. Risk factors for early readmission were also evaluated using multivariate analysis to adjust for confounders.

RESULTS

A total of 18,375 index admissions for GAVE were identified. 20.49% (n=3,720) of the discharged patients were readmitted within 30 days. 30-day mortality of GAVE-related admissions was 1.82% (n=335). Early readmissions accounted for 20,157 hospital days along with $189 million in hospitalization costs. Multivariate analysis revealed that the presence of portal hypertension (OR 1.63; 95% CI 1.37-1.93; p=0.0001) and chronic kidney disease (CKD) (OR 1.62, 95% CI 1.44-1.82; p<0.0001) significantly increased the odds of early readmission.

CONCLUSIONS

Our analysis demonstrates that the overall 30-day mortality rate of GAVE-related admissions is relatively low, but the 30-day readmission rate is significantly high. Patients with comorbid CKD and portal hypertension have a significantly higher risk of readmission. Further studies are required to determine if therapeutic interventions such as argon plasma coagulation or radiofrequency ablation during the index admission may prevent readmissions in these specific subgroups.