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Background The factors associated with maximizing the cytological adequacy of EUS-guided FNA (EUS-FNA) in pancreatic tumor evaluation are not well-known. Objective To examine associations of physician and procedural factors with the endpoint: the presence of an adequate cytological specimen found by using EUS-FNA in patients with pancreatic tumors and lymph nodes. Design Retrospective cohort study. Setting A U.S. tertiary care center. Patients Patients undergoing EUS-FNA of pancreatic masses and lymph nodes. Interventions Analysis of EUS-FNA procedures performed in our institution from 1997 to 2007. Main Outcome Measurements Associations were evaluated between the primary endpoint of cytological adequacy and factors including the endoscopist, needle gauge, the number of needle passes attempted, the pathologist, and the presence of an onsite cytotechnologist to confirm an adequate specimen. EUS-FNA adequacy was determined by a pathologist based on the presence of definite benign or malignant tissue. Results EUS-FNA was performed in 247 pancreatic masses and 276 lymph nodes. An adequate cytological sample was obtained in 240 (97%) pancreatic tumors (95% CI, 94%-99%) and 252 (91%) lymph nodes (95% CI, 87%-94%). For pancreatic tumors, there was no evidence of any associations between factors and cytological adequacy. For lymph nodes, cytological adequacy was improved when an onsite cytotechnologist was present (96% vs 84%, P = .002); no other factors showed statistically significant associations with cytological adequacy. Limitations Retrospective study, low power to detect associations. Conclusions The presence of an onsite cytotechnologist is an important factor in achieving successful EUS-FNA of suspicious lymph nodes in patients with pancreatic masses.

As limited as are the studies regarding peritoneal Natural Orifice Trans-Luminal Endoscopic Surgery, mediastinal transluminal experiments are certainly in their infancy. The authors evaluate the parallel development of minimally invasive thoracic surgery with regard to its counterpart in peritoneal laparoscopy to NOTES. Transesophageal interventions by both endosonographic and direct visualization are examined in the context of minimally invasive surgery and mediastinal NOTES. Techniques of viscerotomy creation, visualization, and closure are examined with particular emphasis on mediastinal structures. The state of current interventions is examined. Finally, current morbidity (including infectious complications) and survival outcomes are examined in those animals that have undergone transesophageal exploration.

BACKGROUND AND STUDY AIMS: Cystic pancreatic lesions (CPLs) are increasingly detected by various imaging studies. Mucinous CPLs carry a risk of malignant transformation but this is often difficult to diagnose preoperatively. In a previous report of 10 suspected mucinous CPLs, the cellular yield of endoscopic ultrasonography (EUS)-guided cytology brushings was found to be superior to the yield from standard fine-needle aspiration (FNA). The aim of this prospective and blinded study was to compare the cytology yield of mucinous epithelium from brushing with FNA in suspected mucinous CPLs. PATIENTS AND METHODS: In total, 37 patients with 39 CPLs measuring at least 20 mm were enrolled between June 2006 and July 2008 for EUS-cytobrushing and EUS-FNA of CPLs. Demographic, clinical, EUS, cytopathologic, and surgical data were recorded whenever available. Yield of cytology brushings was compared with that of FNA. Procedure morbidity was evaluated after 30 days. The main outcome assessed was yield of intracellular mucin (ICM) on cytobrushing specimens compared with EUS-FNA for the diagnosis of suspected mucinous CPL. RESULTS: Cytobrushings were more likely to detect ICM than the EUS-FNA method ( P = 0.001). In three patients with hypocellular FNA, dysplasia was found on cytology brushing and later confirmed by surgical pathology. Significant complications occurred in three patients (8 %): one postbrushing bleeding and two acute pancreatitis. CONCLUSIONS: Cytology brushings are more likely to provide an adequate mucinous epithelium specimen than standard FNA and could aid the diagnosis of CPLs in a selective group of patients.

To evaluate the natural course of3-cm upper gastrointestinal subepithelial tumors by endoscopic ultrasound (EUS) and to determine the appropriate timing for EUS follow-up.Subepithelial tumors (SETs) can range from benign lesions to tumors with malignant behavior or potential to become malignant such as gastrointestinal stromal tumors (GISTs). EUS is considered a valuable tool for their evaluation as it estimates the exact size and layer of origin, and also additional morphologic features that can suggest the diagnosis. For high surgical risk patients and when no worrisome EUS features are seen, EUS surveillance of subepithelial tumors is often used.Fifty-one patients (mean age, 61.2+/-11.8 y; median, 63 y) with asymptomatic3-cm SETs of second and fourth echolayer were followed for a mean period of 29.7 months (range, 3 to 84; median, 23 mo) in 3 tertiary care institutions. Evaluation included location, echolayer, tumor diameter, internal echo pattern, and outer margin of lesions by EUS. EUS was performed by using miniprobes, radial and linear echoendoscopes.Follow-up revealed increase in size and/or change in echogenic features in 7/51 (13.7%) patients. Surgical follow-up was available for 3 of 7 of these patients. Two of the fourth layer SETs, which had both increase in size and change in echogenicity were found to be GISTs (+c-kit).The majority of3-cm SETs does not change during a median of 23 months. The change in echogenicity and increase in size may indicate a GIST.

Introduction Total pancreatectomy (TP) is associated with significant metabolic abnormalities leading to considerable morbidity. With the availability of modern pancreatic enzyme formulations and improvements in control of diabetes mellitus, the metabolic drawbacks of TP have diminished. As indications for TP have expanded, we examine our results in patients undergoing TP. Materials and methods Retrospective study of 47 patients undergoing TP from January 2002 to January 2008 was performed. Patient data and clinical outcomes were collected and entered into a database. Disease-free survival and overall survival were estimated using the Kaplan–Meier method. Results Fifteen males and 32 females with a median age of 70 years underwent TP for non-invasive intraductal papillary mucinous neoplasms (IPMN) (21), pancreatic adenocarcinoma (20), other neoplasm (3), chronic pancreatitis (2) and trauma (1). Median hospital stay and intensive care stay were 11 days and 1 day, respectively. Thirty-day major morbidity and mortality was 19% and 2%, respectively. With a median follow-up length of 23 months, 33 patients were alive at last follow-up. Estimated overall survival at 1, 2 and 3 years for the entire cohort was 80%, 72% and 65%, and for those with pancreatic adenocarcinoma was 63%, 43% and 34%, respectively. Median weight loss at 3, 6 and 12 months after surgery was 6.8 kg, 8.5 kg and 8.8 kg, respectively. Median HbA1c values at 6, 12 and 24 months after surgery were 7.3, 7.5 and 7.7, respectively. Over one-half of the patients required re-hospitalization within 12 months post-operatively. Conclusion TP results in significant metabolic derangements and exocrine insufficiency, diabetic control and weight maintenance remain a challenge and readmission rates are high. Survival in those with malignant disease remains poor. However, the mortality appears to be decreasing and the morbidities associated with TP appear acceptable compared with the benefits of resection in selected patients.

Background An American Society for Gastrointestinal Endoscopy–American College of Gastroenterology (ASGE-ACG) task force recently developed quality indicators for the preprocedure, intraprocedure, and postprocedure phases of each endoscopic procedure. Benchmark rates and clinical significance of compliance have not been determined. Objectives To establish baseline compliance rates to the preprocedure and intraprocedure quality indicators in our EUS cases, identify indicators with the lowest compliance rates, and establish change in compliance rates with a targeted performance improvement plan. Methods We measured baseline compliance to each of the preprocedure and intraprocedure EUS quality indicators in the EUS procedures performed at Mayo Clinic Jacksonville from March 1996 through August 2006. We developed a performance improvement plan that targeted the 4 indicators with the lowest compliance over the entire time period. Compliance rates in the year after plan implementation were compared with those from January 2004 to August 2006, when adjusting for endoscopist and direct access. Results We demonstrated areas of high quality as well as areas for improvement in compliance with the ASGE-ACG quality metrics in a large cohort of EUS cases. We achieved improvement in all 4 areas targeted for quality improvement, statistically significant at the 5% level for two of the quality indicators. Limitations Limitations included our retrospective design and the use of unstructured procedure dictations that may limit application of our results. It is also unclear whether compliance was truly synonymous with performance. Conclusions We established reference levels of compliance rate within our practice and showed that a targeted performance improvement plan that consisted of awareness, individual accountability, and documentation can result in improvement.

Esophageal cancer staging continues to evolve, especially for advanced cases. Computer tomography (CT) scan of the thorax and abdomen to detect metastatic disease, and endoscopic ultrasound with fine needle aspiration (EUS-FNA) remain the preferred methods. Several recent studies have evaluated alternative methods for locoregional and distant disease detection and staging.There seems to be emerging roles for fluorine-18 fluorodeoxyglucose (FDG)-PET, laparoscopic staging, and high-resolution T2-weighted MRI in esophageal cancer staging. Perfusion CT and FDG-PET and FDG-PET/CT may have an emerging role in assessing response to neoadjuvant therapy. Restaging following neoadjuvant therapy remains suboptimal. A 50% or more reduction of tumor thickness by EUS postchemotherapy continues to be the best measure for tumor downstaging survival, while FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy. Potential methylation analysis, digital image analysis, and fluorescence in-situ hybridization on EUS-FNA samples may increase the yield and prove to be better than routine cytology.For advanced esophageal cancer, locoregional staging is best performed with EUS-FNA, with CT scan of the thorax and abdomen and FDG-PET, to detect metastatic disease. The role of EUS in restaging following neoadjuvant therapy remains controversial, with recent studies showing that FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy.

Upper gastrointestinal hemorrhage (UGIH) is an infrequent complication (1-3.8%) following laparoscopic Roux-en-Y gastric bypass (LRYGB). The safety and efficacy of endoscopic management of immediate postoperative bleeding is unknown. We sought to determine how frequently UGIH complicates LRYGB and whether endoscopic management is successful in controlling hemorrhage.Retrospective chart review of all patients who developed UGIH following LRYGB from November 2001 to July 2005 at a large suburban teaching hospital.Of 933 patients who underwent LRYGB, 30 (3.2%) developed postoperative UGIH. An endoscopic esophagogastroduodenoscopy (EGD) was performed in 27/30 patients (90%). All were found to have bleeding emanating from the gastrojejunostomy (GJ) staple line. Endoscopic intervention was performed in 24/30 (80%) with epinephrine injection and heater probe cautery being used most commonly. Endoscopic therapy was ultimately successful in controlling all hemorrhage, with 5 patients (17%) requiring a second EGD for rebleeding. No patient required surgery to control hemorrhage. One patient aspirated during the endoscopic procedure with subsequent anoxic encephalopathy and died 5 days postoperatively. Twenty-one patients (70%) developed UGIH in the intraoperative or immediate postoperative period (4 h postoperative). The mean length of stay was significantly longer in these patients (2.84 vs 4.1, P= 0.001).(a) UGIH complicates LRYGB in a small but significant number of patients. (b) Bleeding usually occurs at the GJ site. (c) EGD is safe and effective in controlling hemorrhage with standard endoscopic techniques. (d) UGIH occurs most commonly in the immediate postoperative period and may be best managed in the operating room with the patient intubated to prevent aspiration.

Prospective randomized controlled trials (RCTs) comparing phlebotomy and interferon (IFN) treatment to IFN alone in patients with chronic hepatitis C (CHC) have suggested a benefit for the phlebotomy group. However, statistical significance was achieved in only one of these trials. We performed a meta-analysis of RCTs comparing phlebotomy and IFN to IFN alone for the treatment of CHC. The MEDLINE database and Cochrane registry of controlled trials were searched using the key words "phlebotomy" and "treatment of hepatitis C." Reference lists of review articles discussing the interaction between iron and CHC, and prospective RCTs comparing phlebotomy plus IFN therapy to IFN alone were searched to identify additional RCTs that compared phlebotomy plus IFN to IFN alone. Peto odds ratios with their 95% confidence intervals and Forrest plots were generated for each variable to assess the relationships among the studies that had provided that information. Statistical analysis was performed using Comprehensive META-Analysis version 2.0. Six prospective RCTs were identified: all used sustained viral response (SVR) as an endpoint. The three largest RCTs excluded patients with cirrhosis. Two RCTs specifically included only patients with either high ferritin or high hepatic iron content. IFN treatment regimes varied. Length of treatment varied between 6 and 12 months. The phlebotomy plus IFN group and the IFN group did not differ with respect to the percentage of patients with cirrhosis or genotype 1. SVR was attained in 50/182 (27%) patients in the phlebotomy plus IFN group, compared to 22/185 (12%) patients in the IFN group. Peto odds ratio for SVR in phlebotomy plus IFN group was 2.7; 95% CI 1.6-4.5, P < 0.0001. All five RCTs published in manuscript form showed a trend towards a benefit from the phlebotomy plus IFN in attaining SVR, and the results of the meta-analysis were not dependent on any single RCT, since excluding any single RCT did not change the results. Phlebotomy improves the SVR in response to IFN treatment in patients with CHC. Confirmation of this will require RCT with detailed pre-treatment iron studies and appropriately powered to demonstrate a statistically significant benefit.

Prior reports have linked patient transmission of carbapenem-resistant Enterobacteriaceae (CRE, or "superbug") to endoscopes used during endoscopic retrograde cholangiopancreatography (ERCP). We performed a decision analysis to measure the cost-effectiveness of four competing strategies for CRE risk management.We used decision analysis to calculate the cost-effectiveness of four approaches to reduce the risk of CRE transmission among patients presenting to the hospital for symptomatic common bile duct stones. The strategies included the following: (1) perform ERCP followed by US Food and Drug Administration (FDA)-recommended endoscope reprocessing procedures; (2) perform ERCP followed by "endoscope culture and hold"; (3) perform ERCP followed by ethylene oxide (EtO) sterilization of the endoscope; and (4) stop performing ERCP in lieu of laparoscopic cholecystectomy (LC) with common bile duct exploration (CBDE). Our outcome was incremental cost per quality-adjusted life year (QALY) gained.In the base-case scenario, ERCP with FDA-recommended endoscope reprocessing was the most cost-effective strategy. Both the ERCP with culture and hold ($4,228,170/QALY) and ERCP with EtO sterilization ($50,572,348/QALY) strategies had unacceptable incremental costs per QALY gained. LC with CBDE was dominated, being both more costly and marginally less effective vs. the alternatives. In sensitivity analysis, ERCP with culture and hold became the most cost-effective approach when the pretest probability of CRE exceeded 24%.In institutions with a low CRE prevalence, ERCP with FDA-recommended reprocessing is the most cost-effective approach for mitigating CRE transmission risk. Only in settings with an extremely high CRE prevalence did ERCP with culture and hold become cost-effective.

Performing ERCP in patients with previous pancreaticoduodenectomy (PD) is technically challenging. Balloon-assisted ERCP has recently been recognized as a useful tool in patients with surgically altered anatomies. However, there are few studies that focus on ERCP in post-PD patients. This study aimed to evaluate the outcome of ERCP in patients in post-PD and the patterns for type of endoscopes used. Patients with previous PD who had undergone ERCP were included in this retrospective study. One hundred and thirty ERCP procedures were performed on 47 post-PD patients. The overall success of ERCP was 82.3 % (107/130). Endoscope insertion to the pancreaticobiliary anastomoses was accomplished in 93.8 % (122/130), which resulted in successful completion of ERCP in 87.7 % (107/122) of the procedures: 89.5 % (94/105) in biliary indications and 76.5 % (13/17) in pancreas indications. Using the conventional endoscopes (CEs) led to ERCP success in 66.4 % (71/107) of attempts versus 78.3 % (36/46) with balloon-assisted enteroscopes (BAEs). Among 105 cases in which CEs were initially tried, ERCP was successful in 69 (65.7 %) cases with CEs alone. When CEs failed to reach the pancreaticobiliary anastomoses, the subsequent use of BAEs resulted in a successful ERCP in 16/19 (84.2 %) of attempts. ERCP in post-PD patients can be performed with a high success rate. We recommend that CEs should be used initially for ERCP in patients with PD and that BAEs be reserved for situation in which CEs have failed to reach the pancreaticobiliary anastomoses.

Periampullary tumors constitute a number of diverse neoplastic lesions located within 2 cm of the major duodenal papilla; among these, metastatic lesions account for only a small proportion of the periampullary tumors. To our knowledge, a metastatic periampullary tumor from hepatocellular carcinoma has never been reported. A 62-year-old male reported to our institute for fatigue and low hemoglobin. His medical history was remarkable for multifocal hepatocellular carcinoma (HCC) treated with selective transcatheter arterial chemoembolization (TACE). An esophagogastroduodenoscopy (EGD) was performed which revealed a periampullary mass. Histopathology was consistent with metastatic moderately differentiated HCC. Two endoloops were deployed around the base of the mass one month apart. The mass eventually sloughed off and patient’s hemoglobin level stabilized. We postulated that periampullary metastasis in this patient was the result of tumor fragments migration through the biliary tracts and that TACE which increases tumor fragments burden might have played a contributory role. Metastasis of HCC to the gastrointestinal (GI) tract should be considered as a cause of GI bleeding.

Veterans of the Gulf War present various symptoms and maladies. Reports by governmental and private entities have yielded mixed results and have been fraught with criticisms of biased research design. The vast majority of these studies have focused on U.S. veterans, with a much smaller number focusing upon British veterans. Very few have examined Iraqi Gulf War veterans. Our study involves administering a health issues questionnaire to a sample of Iraqi Gulf War veteran refugees in the U.S. Results indicate relationships between Post-Traumatic Stress Disorder (PTSD) scores and health outcome measures of chronic fatigue, fibromyalgia, functional status, quality of life, and health care utilization in terms of frequency and level of intensity. Implications for further inquiry are presented.

Background & Aims: Distinguishing an alcohol basis from a nonalcoholic basis for the clinical and histologic spectrum of steatohepatitic liver disease is difficult because of unreliability of alcohol consumption history. Unfortunately, various biomarkers have had limited utility in distinguishing alcoholic liver disease (ALD) from nonalcoholic fatty liver disease (NAFLD). Thus, the aim of our study was to create and validate a model to diagnose ALD in patients with steatohepatitis. Methods: A cross-sectional cohort study was performed at the Mayo Clinic, Rochester, Minnesota, to create a model using multivariable logistic regression analysis. This model was validated in 3 independent data sets comprising patients of varying severity of steatohepatitis spanning over 10 years. Results: Logistic regression identified mean corpuscular volume, aspartate aminotransferase (AST)/alanine aminotransfersase (ALT) ratio, body mass index, and gender as the most important variables that separated patients with ALD from NAFLD. These variables were used to generate the ALD/NAFLD Index (ANI), with ANI of greater than zero incrementally favoring ALD and ANI of less than zero incrementally favoring a diagnosis of NAFLD, thus making ALD unlikely. ANI had a c-statistic of 0.989 in the derivation sample, and 0.974, 0.989, 0.767 in the 3 validation samples. ANI performance characteristics were significantly better than several conventional and recently proposed biomarkers used to differentiate ALD from NAFLD, including the histopathologic marker protein tyrosine phosphatase 1b, AST/ALT ratio, γ-glutamyl transferase, and carbohydrate-deficient transferrin. Conclusions: ANI, derived from easily available objective variables, accurately differentiates ALD from NAFLD in hospitalized, ambulatory, and pretransplantation patients and compares favorably with other traditional and proposed biomarkers.

The purpose of this study was to clarify the mental health needs of Iraqi immigrants who arrived in the United States in the 1990s after the Persian Gulf War. The records of 375 clients were examined at a clinic that serves Arab Americans. More posttraumatic stress disorder and health problems were found in Iraqi refugees than in other clients. Results suggest the need for further research on immigrants with traumatic histories to facilitate effective treatments.

Lymph nodes (LNs) echofeatures on endoscopic ultrasound (EUS) and concurrent fine needle aspiration (FNA) are alternatives to highly invasive approaches for etiologic diagnosis of mediastinal lymphadenopathy (MLAD). To evaluate the efficacy of LNs echofeatures and FNA via EUS to distinguish benign LNs from LNs involved by sarcoidosis, lymphoma, and metastasis in non-lung cancer patients. A retrospective review of patients who underwent EUS–FNA for MLAD was performed. Echofeatures of LNs including echogenicity, margins, shape, and LN size were recorded. Final diagnosis was made based on surgical sampling or clinical diagnosis with long-term follow-up. Only patients diagnosed as benign MLAD, sarcoidosis, lymphoma, and metastasis included. Diagnostic value of echofeatures and FNA was evaluated. Included were 162 patients with final diagnosis of benign (68), sarcoidosis (33), lymphoma (20), and metastasis (41). The median LN along axis in the benign group [20.5 mm (6–76)] was significantly shorter than in the metastasis [28 mm (9–82)] and sarcoidosis [27 mm (17–50)] groups (p

The prevalence of antibodies to the hepatitis C virus (anti-HCV) in the United States is estimated to be 1.6%. There are no published studies on the prevalence of anti-HCV among the Arab/Chaldean American population in the United States.Retrospective review of data collected during an HCV public awareness program conducted by the Arab American and Chaldean Council. Inclusion criteria were that subjects had to be of Arab/Chaldean descent, born in an Arab country, and test positive or negative for anti-HCV using the "Home Access Hepatitis C Test."The overall estimated prevalence of anti-bodies to HCV was 5.4% among Arab/Chaldean Americans residing in southeast Michigan.Four hundred and eighty four participants were tested for anti-HCV. The estimated prevalence among Chaldeans was 2% vs 5.9% among Arabs, which varied according to their country of origin. Anti-HCV positive results were more common in participants with a history of hepatitis (30.4%), jaundice (21.1%), blood transfusion (14.6%), treatment by nonsterile injection (13.6%), and tattoo/body piercing (10%). On binary logistic regression analysis, significant predictors for positive anti-HCV included history of hepatitis (OR: 19, 95% CI 2.58-139.93), blood transfusion (OR: 4.7, 95% CI 1.09-20.56), tattoo or body piercingTo our knowledge, this is the first study to report the estimated prevalence of anti-HCV and risk factors among the Arab and Chaldean Americans in the United States. The estimated prevalence of anti-bodies to HCV is 5.4% in this population, a rate that is more than triple the national average. Because of the relatively small sample size and limited geographic region, more studies are needed to evaluate the true prevalence of HCV antibodies in this and other ethnic minority population.

GOALS To evaluate the usefulness of repeat double balloon endoscopy (DBE) in obscure gastrointestinal bleeding (OGIB). BACKGROUND OGIB recurs in 11% to 42% of patients after DBE. Little is known about the outcome of repeat DBE in recurrent OGIB after DBE. STUDY We reviewed clinical course of patients who underwent repeat DBE for recurrent OGIB in the same direction as in previous DBE. Diagnostic yield and therapeutic intervention of repeat DBE were analyzed. RESULTS Thirty-five repeat DBEs were performed in 32 patients (M:F=15:17; age range, 36 to 85 y). The first DBE identified a probable bleeding source in 21 (65.6%) patients. Angiodysplasia was the most common and was found in 16 patients. The second DBEs were performed after a median of 30 weeks (range, 1 to 204 wk). Oral approach only was performed in 28 patients and anal approach only in 4. Probable bleeding sources were detected in 17 (53.1%) patients. Sixteen (94.1%) cases were angiodysplasia, of which 14 patients had angiodysplasia also at the first DBE. All detected bleeding sources were managed with endoscopic interventions such as argon plasma coagulation. Seventeen of 21 patients with positive first DBE showed bleeding source at the repeat DBE, whereas none of the 11 patients with negative first DBE did (81.0% vs. 0%; P

Background. OTSCs are now available in the US for various indications. Methods. Retrospective review of OTSCs used from January 2011 to April 2012. Results. Twenty-four patients underwent placement of 28 OTSCs. Indications included postsurgical fistula, perforations, anastomotic leak, prophylactic closure after EMR, postpolypectomy bleeding, tracheoesophageal fistula, and jejunostomy site leak. Instruments used to grasp the tissue were dedicated (bidirectional forceps or tripronged device) and nondedicated devices (rat/alligator forceps or suction). Success was higher with nondedicated devices (12.5% versus 86.5%, P=0.0004). Overall, OTSC was effective in 15/27 procedures. Defect closure was complete in 12/21. Mean followup was 2.9 months (1–8 m). Mean defect size was 10 mm (5–25 mm). A trend towards higher success was noted in defects 10 mm (90% versus 60%; P=0.36). No difference was noted in closure of fresh (1 month) (75% versus 67%). There were no complications. Conclusion. The OTSC provides a safe alternative to manage fistula, perforation, and bleeding. No significant difference was seen for closure of early fistula or perforations as compared to chronic fistula. Rat-tooth forceps or suction was superior to the dedicated devices.

TPS487 Background: Targeted inhibition of PARP1/2 is one way to further exploit the well-known synergy between gemcitabine (G) and radiotherapy (RT) in locally advanced pancreatic cancer (LAPC). PARP1/2 inhibitors, such as veliparib (V), have shown excellent anti-tumor activity when used with other cytotoxic therapies. This synergy may be further exploited in pancreatic cancer by targeting tumors with pre-existing defects in double- strand DNA repair. Extrapolating from our own laboratory findings (Tuli et al, Transl Oncol, 2014) and based on our hypothesis that PARP1/2 inhibition with G and RT will result in enhanced tumor control, we are conducting an IRB- approved phase I study in patients with borderline resectable and LAPC. Methods: The primary objective of this study is to determine the maximum tolerated dose (MTD) of V, which is defined as the dose level resulting in a probability (θ = 0.4) that a dose limiting toxicity (DLT) will occur within six weeks. Treatment cycle is 3 weeks followed by weekly evaluation for an additional 3 weeks. G (1000 mg/m2) is administered on days 1, 8, 15. RT (36 Gy) is given in 15 fractions (2.4 Gy/day). V is administered BID in 20 mg increments beginning at a dose of 20 mg. Inclusion criteria: histolopathological diagnosis of borderline resectable or LAPC, age > 18 years, KPS > 70%, life expectancy > 6 months, normal organ and marrow function, and negative pregnancy test. Dose escalation follows a Bayesian escalation without control (EWOC) design, where time to DLT is modeled using a proportional hazards model with constant baseline hazard rate. Secondary objectives: 1) measure clinical activity using RECIST 1.1 for PFS, OS; 2) evaluate pre-treatment tumor biopsy specimen and longitudinal blood samples for baseline levels of DNA repair proteins (ERCC1, XRCC1, PAR, etc.) as potential prognostic, predictive and correlative biomarkers; and 3) assess BRCA1/2, PALB2, PTEN germline and somatic mutations using validated gene sequencing, immunohistochemical and quantitative PCR methods. Since December 2013, 26 patients have consented with 22 enrolled. Clinical trial information: NCT01908478.

Goals: To measure esophageal wall thickness (EWT) with endoscopic ultrasound (EUS) in patients with and without Barrett's esophagus (BE). Background: Segment length and histology are used to evaluate BE. The development of varying depths of ablation therapy has renewed interest in using EUS for BE. Study: In this prospective study, EWT measurements were taken from the balloon-mucosal interface to the outer most hyper-echoic line. These measurements were correlated with the highest grade of BE dysplasia and segment length, and then compared with the measurements from control group. Results: Between 2004 to 2007, 76 BE patients (69 men, mean age 68y, 4 ND, 14 low-grade dysplasia, 52 high-grade dysplasia, 6 carcinoma in situ) and 53 normal controls (18 men, mean age 60 y) underwent EUS. The mean EWT was 2.4 mm for controls, 3.1 mm for nondysplastic BE, 3.2mm for low-grade dysplasia, 3.4mm for high-grade dysplasia, and 3.9mm for carcinoma in situ. In the control group of 53 patients, the mean EWT was 2.4mm. Compared with normal controls, the mean EWT was significantly greater in all histologic subgroups of BE patients (P < 0.001). No statistically significant correlation was seen between EWT and BE histology grade. There were no correlations between age, gender, or BE segment length and EWT (P = 0.55). Conclusions: EWT is greater among patients with BE compared with control patients; however, there were no systematic differences in EWT were found among BE patients, based on histology and segment length.

Intraductal papillary mucinous neoplasms (IPMNs) are being recognized with increased frequency and are the most common indication of pancreatic surgery at specialized centers. Many IPMN patients are found to have non-IPMN related pancreatic tumors like pancreatic neuroendocrine tumors (PNTs).To study the prevalence of PNTs among patients with IPMN.Patients who underwent surgical resection for IPMN were retrospectively reviewed for presence of histologically proven PNTs. The PNTs were evaluated for the patient demographics, imaging characteristics, histology, and surgical staging.Between January 2002 and October 2007, 104 patients underwent surgery for pancreatic IPMN. Among these, 4 patients (3.8%) were diagnosed with concomitant PNTs (1 male, 3 females; median age 72 years). Three patients had branch duct type-IPMN (cyst size: 19 mm, 15 mm and 27 mm), and one had main duct type-IPMN. Only one branch duct IPMN had adenocarcinoma, other three had low grade/borderline dysplasia. The median size of PNT was 10 mm (range 8-16 mm) and all were missed on the cross sectional imaging. Three patients were recognized by endoscopic ultrasound (EUS) and the fine needle aspiration confirmed the diagnosis in 1/3. Only one patient had metastatic PNT to lymph node, the other three were low grade lesions.IPMN and PNT can coexist. The prevalence of PNT among IPMN patients is low (3.8%). Our study is limited by small sample size. Large studies with large number of patients are needed to further explore this association.

Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis ($18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA ($18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was

Mo1403 Gastrojejunal Tube Feeding: a Potential New Treatment for Sphincter of Oddi Dysfunction Type III (SODPPP) Patients With Severe Post-Prandial Pain Tae Joo Jeon*, Byung Kyu Park, Laith H. Jamil, Simon K. Lo Cedars-Sinai Medical Center, Los Angeles, CA; Division of Gastroenterology, Inje University Sanggye Paik Hospital, Seoul, Korea (the Republic of); Division of Gastroenterology, National Health Insurance Service Ilsan Hospital, Goyang-si, Korea (the Republic of) Background: ERCP and Sphincterotomy had been widely used to evaluate and treat the Sphincter of Oddi dysfunction (SOD) type III condition until their benefit was disputed by the recent EPISOD study. Unfortunately, there is no proposed alternative to manometry-directed sphincterotomy at the present moment. Aim: To determine if gastrojejunal tube (PEGJ) feeding may have therapeutic benefits for SODPPP patients. Method: All SODPPP patients without sustained improvement after bi-ductal sphincterotomies were offered percutaneous endoscopic gastrostomy-jejunostomy tube (PEGJ) feeding. SOD III was defined by pancreatic or biliary type pain without a dilated duct or abnormal pancreatic or liver tests. PEGJ was placed in the usual fashion and inserted into the proximal antrum. PEGJ’s tip location in the proximal jejunum was confirmed with fluoroscopy. Strict NPO was kept within the first 4-6 weeks. PEGJ feeding was maintained as long as these patients needed feeding to provide nutrition or pain relief. Results: Nine highly symptomatic SODPPP patients underwent PEGJ tube insertion for feeding. All were female. Median age was 41 years old (25-53). Median duration of SOD symptoms was 27 months (22-96). All but one patient had elevated pancreatic or biliary sphincter pressure. Only one patient did not have a prior cholecystectomy. Eight patients had sphincterotomy and experienced pain improvement for a short duration (median; 8 weeks) before recurrence of symptoms. The mean duration of tube feeding was 5.08 months (S.E 1.83). Seven patients reported dramatic pain improvement. Six had less number of hospitalizations or ER visits after PEGJ feeding. Five patients were satisfied with the procedure and could return to normal daily activities while on tube feeding. Only 1 patient was not satisfied because of the lack of effectiveness. The demand of analgesics was decreased in 5 patients. Complications included prolonged tube insertion site pain-2, pinkish drainage-1, and nausea-1. Persistent insertion site pain was the reason for tube removal on day 7 in on patient. There were 4 tube malfunctions (J-tube dislodgement-2, tube coiling-1, broken tube-1). PEGJ had since been removed in 5 patients (no benefit-1, dramatic clinical improvement-1, husband’s disagreement-1, unsightly catheter-1, insertion site pain1). Interestingly, those 2 patients who had tube removal due to personal issues eventually requested PEGJ re-insertion. Conclusion: PEGJ feeding may have therapeutic benefits for the subset of highly symptomatic SOD III patients with postprandial pain exacerbations. It may represent a breakthrough in the management of these patients and should be confirmed by a larger, prospective clinical study.

patient’s upper GI anatomy was the following: gastric bypass (nZ4), Whipple’s (nZ4), Billroth II (nZ5), Ivor-Lewis (nZ3), gastric sleeve with leak (nZ3), several anastomosis-undefined post-surgical status (nZ2). The technical success was 90%. In two patients transillumination was not obtainable and placement failed. The mean distance of DPEJ was 70 cm (range 45 to 110 cm) past the gastrojejunal anastomosis. The mean procedure time was 35 minutes (range 20-110). There were no major adverse events associated with the procedure. Conclusions: To the best of our knowledge this is the largest study using DPEJ in patients with complex surgically altered upper GI tract anatomy. The novel technique using overtubeand fluoroscopy was efficacious, safe and successful. Future comparative studies are now warranted

The Gulf War in 1991 resulted in an influx of refugees from Iraq to the United States and to other regions of the world. The purpose of this study was to describe the self-reported medical complaints of Iraqi American refugees who were seeking mental health services in southeastern Michigan. We anticipated that the frequency and pattern of medical symptoms would differ from that reported in the literature on United States Gulf War veterans or other Arab Americans who immigrated to the U.S. in the 1990s. Potential reasons for such differences include indirect effects, such as neglect of general health prior to and during the war, or direct effects, such as the impact of environmental changes from the war itself. As part of a larger study on the health of refugees from Iraq, self-reported medical conditions and symptoms were analyzed in a sample of 116 adult Iraqi immigrants (46 male, 70 female) who were seeking or already receiving outpatient mental health services (n = 87) or treatment in a partial hospitalization program (n = 29). Measures were translated into Arabic and administered in an interview format by one of two bilingual mental health workers. The results were consistent with other studies on refugees in which the number of medical complaints reported was relatively high. Discussion centers on the importance of addressing the specific medical needs of refugees in general, and of the Iraqi refugees in particular, and on how they may be better served within our primary health care systems.

Assessing severity of disease in patients with alcoholic hepatitis (AH) is useful for predicting mortality, guiding treatment decisions, and stratifying patients for therapeutic trials. The traditional disease-specific prognostic model used for this purpose is the Maddrey discriminant function (DF). The model for end-stage liver disease (MELD) is a more recently developed scoring system that has been validated as an independent predictor of patient survival in candidates for liver transplantation. The aim of the present study was to examine the ability of MELD to predict mortality in patients with AH. A retrospective cohort study of 73 patients diagnosed with AH between 1995 and 2001 was performed at the Mayo Clinic in Rochester, Minnesota. MELD was the only independent predictor of mortality in patients with AH. MELD was comparable to DF in predicting 30-day mortality (c-statistic and 95% CI: 0.83 [0.71-0.96] and 0.74 [0.62-0.87] for MELD and DF, respectively, not significant) and 90-day mortality (c-statistic and 95% CI: 0.86 [0.77-0.96] and 0.83 [0.74-0.92] for MELD and DF, respectively, not significant). A MELD score of 21 had a sensitivity of 75% and a specificity of 75% in predicting 90-day mortality in AH. In conclusion, MELD is useful for predicting 30-day and 90-day mortality in patients with AH and maintains some practical and statistical advantages over DF in predicting mortality rate in these patients. MELD is a useful clinical tool for gauging mortality and guiding treatment decisions in patients with AH, particularly those complicated by ascites and/or encephalopathy.