Brahmbhatt, Bhaumik

INTRODUCTION: Aberrant subclavian artery (ASA) is a rare anatomic variant and frequently asymptomaticcondition. We present a case of a young patient with progressive dysphagia who underwent extensive workup and repetitive endoscopic procedures until diagnosed. CASE DESCRIPTION/METHODS: 35-year-old female with history of systemic lupus erythematous, presented with progressive dysphagia for several weeks. No preceding trauma, procedures or infections. She had anunremarkable upper endoscopy, but an empiric esophageal dilation was performed. However, in few months her symptoms recurred; another dilation was pursued along with proton pump inhibitor therapy and dietary changes. Three years later, she had worsening dysphagia, leading to an 8-pound weight loss. An esophagram raised suspicion for an extrinsic esophageal compression (Figure 1). A computed tomography (CT) angiogram confirmed the presence of a right ASA (Figure 2). Patient was referred to thoracic surgery and underwent operative repair of right ASA (Figure 3). A repeated esophagram on the 5th day after surgery, showing no delay in the passage of the barium pill. Upon discharge, she was tolerating soft diet and in one month she was able to eat normally. DISCUSSION: ASA is characterized by a vascular ring structure due to aberrant arising of one of the subclavian arteries (arteria lusoria) from the aortic arch. Although ASA is the most common congenital aortic arch anomaly, it occurs in less than 2.5% of overall population. Its management depends on symptoms: if mild and intermittent, dietary and behavioral modifications are appropriate; if severe dysphagia, surgery should be considered. During adulthood, 30% of patients are symptomatic with intermittent dysphagia being the most prominent symptom. Late presentation is probably related with atherosclerosis and aneurismal formation due to advancing age. Even though ASA is found mostly in women and its possible relation with atherosclerosis, we could not find any data in literature linking ASA to SLE. Dysphagia lusoria can be easily diagnosed by barium esophagogram, an inexpensive test which would typically show an impression defect at the level of the third or fourth vertebra. Esophageal manometry and upper endoscopy usually are unrevealing but a CT angiogram can confirm the diagnosis. Because of its rarity, ASA is not commonly suspected upon evaluation of dysphagia in adults, often times causing recurrent endoscopies and other non-revealing tests to be repeated.

INTRODUCTION: Mucosal healing is a widely accepted target for ulcerative colitis (UC) treatment. Linked color imaging (LCI) is a novel endoscopic enhancement system that utilizes Light Emitting Diode (LED) sources to spectrally enhance subtle erythema and mucosal surface patterns which may improve endoscopic classification of IBD associated inflammation. We aimed to assess the accuracy of LCI in classifying UC-associated mucosal healing compared to a validated histological reference standard (Geboes score). METHODS: 22 patients with ulcerative colitis were prospectively enrolled and evaluated by LCI colonoscopy using the Fujifilm’s digital video Processor VP-7000 and LED light source BL-7000 (Fujifilm, Tokyo Japan). Interobserver agreement was reported as kappa values. Geboes score was reported as score range of 0 to 5.4. A Geboes score of ≥3.1 (presence of surface intraepithelial neutrophils or < 5% crypts) was used to define histologic activity and a score of < 2B (no increase in neutrophils in the lamina propria) was used to define histologic remission. Geboes score has been previously validated to predict clinical recurrence. We calculated the overall accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the LCI classification identifying mucosal healing against the Geboes score using the Fisher’s exact test. RESULTS: Total of 62 endoscopic images were obtained for different parts of the colon, 43 of which were matched to a corresponding biopsy. Endoscopic images were scored by 2 endoscopists into LCI-A (no redness), LCI-B (redness with visible vessels) and LCI-C (redness without visible vessels). A final LCI score was given for images with discrepant scores based on a consensus vote from both endoscopists. The interobserver agreement between the two endoscopists was 81%, kappa of 0.71 (95% confidence interval [CI] 0.57- 0.86). Among regions scored ≥3.1 on Geboes score, 9.5%, 28.6% and 61.9 % were classified as LCI-A, LCI-B and LCI-C, respectively ( P < 0.0001). Among images scored < 2B on Geboes score, 81.8%, 13.6% and 4.6% were classified as LCI-A, LCI-B and LCI-C, respectively ( P < 0.0001). Analyzing data against histology with LCI-A representing mucosal healing and LCI-B and C representing active mucosal disease, the overall accuracy becomes 86%, with NPV of 82.6% and PPV of 90% for identifying UC patients with histological and endoscopic evidence of mucosal healing. CONCLUSION: LCI technology has a potential role in assessing mucosal healing in UC.

40 Background: Gastroesophageal junction (GEJ) cancer can be endoscopically resected and/or ablated in its early tumor stage. Despite significant effort to address the epidemiology and populations at risk for distal esoaphgeal cancer, very limited effort has been undertaken to assess such in GEJ cancer. Methods: A SEER database analysis was performed for the study period 1973 – 2013. Inclusion criteria were GEJ cancer (microscopically confirmed primary site of malignancy with ICD-O-3 histology of adenocarcinoma). Data was stratified by years 1973-82, 1983-92, 1993-2002 and 2003-2012, patient age, gender, and race. A Kaplan-Meier curve for the 5-year survival analysis of GEJ cancer was calculation. Further, GEJ cancer data was compared with the epidemiology of distal esophageal cancer (ICD-10). Results: 32,073 patients with GEJ cancer were included in the SEER database between 1973 and 2015 (female 19%, Caucasian race 88.7%). The incidence of GEJ cancer increased significantly over the four decades between 1973 and 2013, 15.7%, 25.3%, 26.9% and 32% (p = 0.001). The rising prevalence was particularly accounted in the patient age cohorts 65-74 years and 75+ years and in white male patients followed by black male patients. The 5-year survival analysis showed a median survival during the four analyzed decades of 8, 10, 11, and 14 months, respectively (Log rank test p < 0.001). During the last decades (1993-2002 and 2003-2012) GEJ cancer and distal esophageal cancer had comparable incidences. Conclusions: GEJ cancer incidence is rising over the last four decades and is in fact comparable with the incidence of distal esophageal cancer. This is particularly true for white male patients and patients older than 65 years. Given that early GEJ cancer is endoscopically treatable, more effort is warranted to address its risk factors and to identify populations at risk who could benefit from early cancer detection programs.

Abstract Background Proximal esophageal stents are poorly tolerated and have a high risk of complications. We report our experience using fully covered, biliary, self-expandable metal stents (B-SEMS) and narrow-diameter, esophageal, self-expandable metal stents (NDE-SEMS) for this group of patients. Methods 24 patients underwent placement of B-SEMS or NDE-SEMS for proximal esophageal lesions between 1 January 2011 and 31 July 2016. The outcomes included improvement of dysphagia, healing of fistulas, and adverse events. Results 10 patients received B-SEMS and 14 had NDE-SEMS. Median follow-up time was 11.5 months (range 0.5 – 62 months). In both cohorts, stents were left in place for a mean of 6 weeks. The dysphagia score decreased in 7 (70 %) and 10 (71.4 %) patients, and fistulas resolved in 3/5 (60.0 %) and 5/8 (62.5 %) patients with B-SEMS and NDE-SEMS, respectively. Stent migration occurred in three patients (30.0 %) with B-SEMS and five patients (35.7 %) with NDE-SEMS. Conclusions Both stents were well tolerated and resulted in overall improvement of dysphagia in 70.8 % of patients. B-SEMS appeared to be more favorable for cervical esophageal lesions with narrower diameters, while NDE-SEMS may be better for more distal lesions.

Objectives. Surgery is the most effective treatment for pancreatic cancer. However, present literature varies on outcomes of curative pancreatic resection in the elderly. The objective of the study was to evaluate age as an independent risk factor for 90-day mortality and complications after pancreatic resection. Methods. Nine hundred twenty-nine consecutive patients underwent 934 pancreatic resections between March 1995 and July 2014 in a tertiary care center. Primary analyses focused on outcomes in terms of 90-day mortality and postoperative complications after pancreatic resection in these two age groups. Results. Even though patients aged 75 years or older had significantly more postoperative morbidities compared with the younger patient group, the age group was not associated with increased risk of 90-day mortality after pancreatic resection. Discussion. The study suggests that age alone should not preclude patients from undergoing curative pancreatic resection.