A257 ASSOCIATION OF DIETITIAN CONSULTATION WITH INFECTION RATES IN PATIENTS WITH SEVERE ALCOHOLIC HEPATITIS

Background

Patients with alcoholic hepatitis have significant morbidity and mortality, frequently infection related. They are often malnourished from increased nutritional demands. Studies show conflicting results on whether nutritional therapy reduces infections.

Purpose

To examine if dietitian consultation is associated with lower infection rates in patients with alcoholic hepatitis.

Method

Retrospective chart review of adults aged 18-75 admitted to The Ottawa Hospital for severe alcoholic hepatitis between January 1, 2016 and December 31, 2018. Patients with co-existing liver diseases were excluded. Descriptive statistics compared those with and without dietitian consultation during admission. The primary exposure was dietitian consultation over 48 hours before infection. The primary outcome was infection over 48 hours after admission.

Result(s)

64 patients were assessed (mean age 52.3+/-10.9 years; mean Maddrey Discriminant Function 53.6+/-33.2). Those with dietitian consultation (N=17, 26.6%) had greater Charlson (p=0.016) and Model for End Stage Liver Disease (p=0.048) scores, with no difference in steroid use (p=0.60). Among 53 patients without infection on admission, 10 had infection in hospital, of whom 4 had dietitian consultation before infection. Dietitian consultation was associated with increased infection risk (OR 6.5, 95%CI=1.3-33.2).

Conclusion(s)

Only the sickest patients received dietitian consultation, which likely explains the observed increased infection risk. Given high malnutrition rates in this population, our results suggest a significant care gap.

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Disclosure of Interest

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A285 CHANGE IN ALT DURING MODIFIED OPTIFAST WEIGHT LOSS PROGRAM IN INDIVIDUALS AT RISK FOR NON-ALCOHOLIC FATTY LIVER DISEASE

Background

Obesity is linked to various health complications, including diabetes, metabolic syndrome, cardiovascular disease, and non-alcoholic fatty liver disease (NAFLD). NAFLD is the most frequent cause of abnormally high alanine aminotransferase (ALT) levels. ALT is released at higher levels during hepatocellular injury and represents a simple, low cost and non-invasive method of assessing liver damage. There are conflicting data on ALT response to weight loss between men and women, with some evidence of transient increase in ALT levels in women.

Purpose

The aim of this study was to assess the impact of a dietary weight loss intervention with Optifast on ALT in patients with obesity who have baseline elevated ALT levels.

Method

This was a retrospective cohort study of Ontario adults who participated in a 26 week weight loss program, including 6 or 12 weeks of low-calorie liquid diet meal replacement with Optifast 900^® (Nestlé, Canada), between 1992 and 2015. We included patients with elevated baseline ALT levels, defined by > 40 U/L, who had at least one follow-up ALT between week 15 and 26. We excluded patients with nonadherence to dietary intervention, established liver disease or using hepatotoxic drugs, excessive alcohol intake (>11U/wk for females and >14U/wk for males), and insufficient data to calculate FIB-4. The primary outcome was change in ALT levels, measured by normalization (post-intervention ALT < 40 U/L), percentage decrease and absolute decrease. Multiple linear regressions were obtained for the relationship between ALT changes and age, sex, body mass index (BMI) and FIB-4. All analyses were conducted in SPSS. P value of ≤0.05 was considered statistically significant.

Result(s)

444 patients met study criteria. Mean age was 47.1 years +/- 10.9, 49 % of patients were female, and mean BMI was 43.5 kg/m² +/- 7.9. All patients lost weight, with mean weight loss 27.3 kg +/- 11.5 and a mean 20.7% decrease from baseline weight. Mean ALT at baseline was 58.9 U/L +/- 25.4 and mean ALT post intervention was 32.3 U/L +/- 28.1 (p <0.01). 85.1% of patients had normalization of ALT. Mean % decrease in ALT was 41.9% and mean absolute decrease in ALT was 26.6 U/L +/- 25.4. Younger age and higher baseline FIB-4 were significantly associated with a larger decrease in ALT levels, while sex and initial BMI were not significantly associated with changes in ALT.

Conclusion(s)

In patients with obesity and baseline elevated ALT, dietary weight loss intervention with Optifast leads to ALT normalization in most patients, regardless of sex. Younger age at baseline and higher baseline FIB-4 are significantly associated with greater decrease in ALT.

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A reliable and safe gastrotomy closure technique assessed in a porcine survival model pilot study: success of the Queen's closure

BACKGROUND AND STUDY AIMS

The evolution of NOTES to clinical implementation has been hampered by lack of a reliable, safe, and easy-to-implement technique for closure of the opening created in accessing the peritoneum. The Queen's closure uses a combination of endoscopic clips and loop devices to seal such defects in the stomach wall. This study aimed to assess the Queen's closure in a porcine survival model.

METHODS

Five 30-kg pigs underwent endoscopic transgastric surgery with exploration of the peritoneum. The endoscope was then withdrawn back into the stomach and the closure performed. The animals were recovered, monitored closely, and underwent endoscopy 1 week after surgery. They were then euthanized at 2 (n = 2) and 3 (n = 3) weeks after surgery with subsequent necropsy.

RESULTS

The mean procedure time (from intubation of the esophagus to withdrawal of the endoscope) was 79 minutes (range 45-105 minutes) with a mean time of exploration of the peritoneum of 14 minutes (range 8-25 minutes). All animals recovered well with no apparent pain, distress, or signs of infection. Endoscopic examination 1 week after surgery revealed all the closures to be intact and only identifiable by a small ulcer. At necropsy, the gastrotomy site was identifiable only by minor serosal adhesions. Histological study demonstrated full-thickness closure with minimal inflammation.

CONCLUSIONS

The Queen's closure is a reliable and safe technique that provides full-thickness gastrotomy closure without any observed complications. The technique has proven to be transferable knowledge that holds promise for clinical implementation.

The Queen's closure: a novel technique for closure of endoscopic gastrotomy for natural-orifice transluminal endoscopic surgery

BACKGROUND AND AIMS

Finding a reliable, safe, adaptable method of closing gastrotomies for natural-orifice transluminal endoscopic surgery (NOTES) procedures has been a major challenge facing this new clinical area. The Queen's NOTES Group has designed a novel endoscopic method of closing gastrotomies which involved using PolyLoop polyp ligature devices and endoscopic clips. The current study describes the technique and a pilot study of leak testing it versus hand-sewn suture closure.

METHODS

Ten fresh pig stomachs were used, five for each technique. A 16-mm endoscopic gastrotomy was performed on the anterior wall of each. Five stomachs were then closed using the Queen's closure technique, and five with a hand-sewn double-layer suture technique. The stomachs were then connected to a water infusion device with sensitive pressure monitoring and were filled until leakage was detected at the closure site.

RESULTS

The closures were all technically successful. The mean time for each gastrotomy and closure using the Queen's closure technique was 1.2 hours. The mean leak pressure for the Queen's closure was 51.8 mmHg and for the hand-sewn suture technique it was 80.8 mmHg ( P < 0.001).

CONCLUSIONS

The Queen's closure technique holds promise as a reliable transferable technique for closing gastrotomies. Further study is necessary to evaluate its effects in live models.

Implantation and follow-up of ICD leads implanted in the right ventricular outflow tract

Unipolar ICD electrodes are routinely implanted at the right ventricular apex (RVA). However, inappropriate pacing/sensing parameters and/or high DFT may limit the appropriateness of the lead's implantation at the RVA. This study examined the effects on DFT of ICD leads implanted in the RVOT, attached to the high interventricular septum as an alternate location. DFT, defibrillation impedance, and sensing and pacing characteristics were measured at the time of implantation in 28 consecutive patients. Group A consisted of 12 patients in whom the ICD implantation criteria in the RVA were not satisfied, and whose lead was placed in the RVOT. Group B consisted of 16 patients with ICD electrodes implanted at the RVA. Mean DFT in group A was 11 +/- 4 J (4.5-20 J) versus 12 +/- 6 J (4-20 J) in the group B (P = 0.58). Defibrillation impedance was 81 +/- 9 omega (69-92 omega) in group A versus 77 +/- 15 omega) (46-93 omega) in group B (P = 0.43). R wave amplitude, slew rate, pacing threshold, and pacing impedance were comparable in both groups. In the perioperative period, the electrode needed to be repositioned in two patients from group A. There was no further dislodgment of RVOT defibrillation leads or other lead related complications during a follow-up of 23 +/- 9 months. The placement of ICD leads in the RVOT is an alternative to the RVA position. However, active-fixation ICD leads should be considered to limit the risk of electrode dislodgment.