Broder, Arkady

Abstract EUS-guided hepaticogastrostomy (EUS-HGS) is one of the preferred methods in biliary drainage where ERCP fails or is contraindicated. The clinical outcomes of EUS-HGS are not well studied because of variability in procedure technique. We conducted a search of multiple electronic databases and conference proceedings from inception through January 2023. The clinical outcomes studied were pooled technical success, clinical success, and adverse events. Standard meta-analysis methods were used using the random-effects model, and heterogeneity was studied by I 2 statistics. We analyzed 44 studies, which included 19 prospective and 25 retrospective studies. The pooled technical success rate of EUS-HGS was 94.4% (confidence interval [CI], 92.4%–95.9%; I 2 = 0%), and the pooled clinical success rate was 88.6% (CI, 83.7%–92.2%; I 2 = 0%). The pooled adverse outcomes with EUS-HGS were 23.8% (CI, 19.6%–28.5%; I 2 = 0%). The mild adverse event rate associated with HGS was 5.8% (4.2%–8.1%; I 2 = 0%), moderate adverse event rate was 12.1% (9.1%–15.8%; I 2 = 16%), and severe adverse event rate was 4.2% (3.0%–5.7%; I 2 = 61%), whereas fatal adverse event rate was 3.2% (1.9%–5.4%; I 2 = 62%). On subgroup analysis, the pooled rate of adverse events of EUS-guided hepaticogastrostomy with antegrade stenting was 13.3% (95% CI, 8.2%–21.0%). The pooled technical success with EUS-guided hepaticogastrostomy with antegrade stenting was 89.7% (95% CI, 82.6%–94.2%), and clinical success was 92.5% (95% CI, 77.9%–97.7%). On the basis of our analysis of EUS-HGS, the overall technical success was 94.4%, and the clinical success rate was 88.6%, and the overall adverse events were reported to be 23.8%. These data can also help improve the clinical benefits of EUS-HGS in the selected patients in whom it is performed.

Abstract Background and Aim Data are lacking on predicting inpatient mortality (IM) in patients admitted for inflammatory bowel disease (IBD). IM is a critical outcome; however, difficulty in its prediction exists due to infrequent occurrence. We assessed IM predictors and developed a predictive model for IM using machine‐learning (ML). Methods Using the National Inpatient Sample (NIS) database (2005–2017), we extracted adults admitted for IBD. After ML‐guided predictor selection, we trained and internally validated multiple algorithms, targeting minimum sensitivity and positive likelihood ratio (+LR) ≥ 80% and ≥ 3, respectively. Diagnostic odds ratio (DOR) compared algorithm performance. The best performing algorithm was additionally trained and validated for an IBD‐related surgery sub‐cohort. External validation was done using NIS 2018. Results In 398 426 adult IBD admissions, IM was 0.32% overall, and 0.87% among the surgical cohort ( n = 40 784). Increasing age, ulcerative colitis, IBD‐related surgery, pneumonia, chronic lung disease, acute kidney injury, malnutrition, frailty, heart failure, blood transfusion, sepsis/septic shock and thromboembolism were associated with increased IM. The QLattice algorithm, provided the highest performance model (+LR: 3.2, 95% CI 3.0–3.3; area‐under‐curve [AUC]:0.87, 85% sensitivity, 73% specificity), distinguishing IM patients by 15.6‐fold when comparing high to low‐risk patients. The surgical cohort model (+LR: 8.5, AUC: 0.94, 85% sensitivity, 90% specificity), distinguished IM patients by 49‐fold. Both models performed excellently in external validation. An online calculator ( https://clinicalc.ai/im‐ibd/ ) was developed allowing bedside model predictions. Conclusions An online prediction‐model calculator captured > 80% IM cases during IBD‐related admissions, with high discriminatory effectiveness. This allows for risk stratification and provides a basis for assessing interventions to reduce mortality in high‐risk patients.

Abstract Purpose: Little is known about the outcomes of endoscopic resection (ER) for patients with colorectal adenomas (CRAs) with high-grade dysplasia (HGD) or intramucosal cancer (IMCA). This study aimed to estimate the rate of local/malignant recurrence, identify the predictive factors for local recurrence (LR) and evaluate the treatment outcomes of recurrence after ER for HGD/IMCA. Methods: A retrospective review was performed to identify patients who underwent ER for HGD/IMCA in two academic medical centers. Risk factors for LR were determined by Cox regression analysis. Results: Overall, 188 lesions with HGD/IMCA were included; 61 lesions were removed by en-bloc ER (e-ER), whereas 127 lesions were removed in a piecemeal ER (p-ER). The mean lesion size was 20.3 mm. Of the 125 patients who underwent follow-up, local adenoma recurrence occurred in 31 (23%), and malignant recurrence occurred in 2 (1.6%) patients at a median follow-up of 8 months. HGD/IMCA ≥ 4 cm removed by p-ER have the greatest hazard ratio (HR=21.5, 95% CI: 2.5-180.5; p=0.005) for LR, compared to the HGD/IMCA < 4 cm removed by e-ER. Surgery was performed in 3.2% of patients after a complete ER, all after p-ER. Of all patients who had LR, 22.6% (7/31 patients) had recurrent/residual adenomas despite repeat ER attempts after a mean of 1.9±0.79 procedures from the index ER. Conclusions: Our study demonstrates high rate of LR (23%) after ER of CRAs with HGD/IMCA with rate of malignant recurrence of 1.6% especially after p-ER. Thus, e-ER should be preferred for these lesions whenever technically feasible.