Low delayed bleeding and high complete closure rate of mucosal defects with the novel through-the-scope dual-action tissue clip after endoscopic resection of large nonpedunculated colorectal lesions (with video)

BACKGROUND AND AIMS

Complete closure after endoscopic resection of large nonpedunculated colorectal lesions (LNPCLs) can reduce delayed bleeding but is challenging with conventional through-the-scope (TTS) clips alone. The novel dual-action tissue (DAT) clip has clip arms that open and close independently of each other, facilitating tissue approximation. We aimed to evaluate the rate of complete closure and delayed bleeding with the DAT clip after endoscopic resection of LNPCLs.

METHODS

This was a multicenter prospective cohort study of all patients who underwent defect closure with the DAT clip after EMR or endoscopic submucosal dissection (ESD) of LNPCLs ≥20 mm from July 2022 to May 2023. Delayed bleeding was defined as a bleeding event requiring hospitalization, blood transfusion, or any intervention within 30 days after the procedure. Complete closure was defined as apposition of mucosal defect margins without visible submucosal areas <3 mm along the closure line.

RESULTS

One hundred seven patients (median age, 64 years; 42.5% women) underwent EMR (n = 63) or ESD (n = 44) of LNPCLs (median size, 40 mm; 74.8% right-sided colon) followed by defect closure. Complete closure was achieved in 96.3% (n = 103) with a mean of 1.4 ± .6 DAT clips and 2.9 ± 1.8 TTS clips. Delayed bleeding occurred in 1 patient (.9%) without requiring additional interventions.

CONCLUSIONS

The use of the DAT clip in conjunction with TTS clips achieved high complete defect closure after endoscopic resection of large LNPCLs and was associated with a .9% delayed bleeding rate. Future comparative trials and formal cost-analyses are needed to validate these findings. (Clinical trial registration number: NCT05852457.).

Patient- and provider-level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis

BACKGROUND

Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration.

METHODS

Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1-year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ-2) from the electronic health record.

RESULTS

The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n = 162), hepatology (n = 45), or both (n = 41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co-occurring bipolar disorder (OR 2.94, p = 0.03) or depression (1.50, p = 0.05) or who were younger (0.97, p = 0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p = 0.05), prior AUD treatment (9.92, p < 0.0001), and a higher PHQ-2 depression score (2.85, p = 0.004).

CONCLUSIONS

We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

Epidermoid Cyst in the Appendix: A Rare Entity

Epidermoid cysts are benign cystic lesions that are usually found in the skin. They can also be found in the organs of the gastrointestinal system. Here, we report a rare case of epidermoid cyst of the appendix which has been published in only three cases in the literature. They can be either congenital or acquired. Congenital epidermoid cysts are related to the inclusion of ectodermal elements at the time of neural groove closure. Acquired cysts are thought to be due to trauma or iatrogenic implantation of the epidermis in locations favorable to growth during surgery. Diagnosis is mainly by histopathological examination of the tissue sample. Complete excision of the cyst with the walls intact is considered curative. 

452. Correlation of Charleston Comorbidity Index Score as the COVID-19 Pandemic Surged Throughout HCA Healthcare Facilities and Patient Outcomes

Background

As the COVID-19 pandemic raged throughout the United States, the healthcare system was strained due to a sudden increase in demand. Testing was initially limited, and the perception was that patients with high comorbidity burden were at higher risk for poor outcomes. The Charleston Comorbidity Index (CCI) is widely used as a predictor of prognosis and one-year mortality for a wide range of pathologies. This study aims to assess whether a correlation exists between CCI score, COVID-19 incidence throughout the pandemic and patient outcomes.

Charleston Comorbidity Index Score

Scoring system for Charleston Comorbidity Index (CCI). Plus 1 point for every decade age 50 years and over, maximum 4 points. Higher scores indicate a more severe condition and consequently, a worse prognosis.

Methods

Multicenter, retrospective review of patients diagnosed with COVID-19 from January 2020 to September 2020 throughout the HCA Healthcare system. The percent of total encounters that were COVID-19 positive by state was calculated along with the average CCI score for COVID-19 patients in 2-month increments. Patient outcomes were obtained across the entire population.

Results

A clear surge of infected patients was seen in almost all states in the dataset from May 2020 onward except in Colorado and Louisiana where the percentage of COVID-19 positive encounters decreased until July 2020. As summer 2020 progressed, the highest percentage of COVID-19 positive encounters among HCA Healthcare facilities was in Florida and Texas. However, despite the fact that more patients were COVID-19 positive in these states, the CCI score was the lowest (Figure 1). The highest average CCI throughout the 9-month period was 7.66 in Colorado. In the first two months of the pandemic, patients who tested positive for COVID-19 had higher CCI scores on average than those who became COVID-19 positive later in the pandemic. Missouri had the lowest CCI average but the highest ICU admissions and in-hospital mortality. Indiana had the lowest average CCI score, and lowest admission rate (Figure 2).

COVID-19 Encounters and Average CCI score by State from January 2020 to September 2020

Graph 1: Percentage of COVID-19 Encounters in 9 Months at an HCA Healthcare Facility by State: Graph presents data obtained for the total of 92,800 patient encounters from January to September 2020 and recorded in 2-month increments. The rate of positive encounters throughout 18 states increased on average from May to September. From January to March 2020, the facilities with the highest rate of COVID-19 encounters were in Colorado, Louisiana and Texas. The states with the highest increment increase of COVID-19 positive patients were Texas, Florida and South Carolina and were trending up as the pandemic wore on through the summer of 2020. Graph 2: Average Charleston Comorbidity Index of COVID-19 Patient Seen at an HCA Healthcare Facility by State in 9 Months: In winter 2020 (January to March 2020) the average CCI score for patients seen with COVDI-19 was higher than in the Spring and Summer 2020 in all states except in Montana and Kentucky. Summer 2020 (May to July 2020) demonstrated some of the lowest average CCI scores for COVID-19 positive patients seen at an HCA Healthcare Facility.

Rate of Positive COVID-19, Patient Outcomes and Average Charleston Comorbidity Index Score by State

Graph 3: Outcomes of COVID-19 Positive Patients Seen at an HCA Healthcare Facility: Mortality and ICU admission was the highest in Missouri, however, the state had the least COVID-19 patients admitted. The rate of positive test per encounter was the highest in Florida and Texas. Texas had a higher mortality among admitted COVID-19 patients than Florida, however, Florida had a higher percentage of COVID-19 patients admitted. Graph 4: Average Charleston Comorbidity Index Score of COVID-19 Positive Patients Seen at an HCA Healthcare Facility: Average CCI was the lowest in Missouri. The states with the highest CCI score were Indiana, California, New Hampshire and Nevada.

Conclusion

We observed an inverse correlation between CCI score and COVID-19 incidence while seeing that, on average, COVID-19 positive patients had higher CCI score in the first few months of the pandemic when incidence rate was lower. CCI score did not correlate to ICU admission, but a higher CCI score correlated to higher admission rate.

Disclosures

All Authors: No reported disclosures

28. Utilizing the Charleston Comorbidity Index as an Independent Predictor for Outcomes in SARS-Cov-2 Positive Patients

Background

Since COVID-19 was declared a pandemic, it has seemed that the virus is nondiscriminatory causing 3.73 million deaths worldwide. The Charleston Comorbidity Index (CCI) is a scoring system predicting the one-year mortality for patients with a range of comorbid conditions and is widely used as a predictor of prognosis and survival for a range of pathologies. This study aims to assess if there is an impact of comorbidity burden on COVID-19 patients by utilizing their CCI score.

Charleston Comorbidity Index Score

Scoring system for Charleston Comorbidity Index (CCI). Plus 1 point for every decade age 50 years and over, maximum 4 points. Higher scores indicate a more severe condition and consequently, a worse prognosis.

Methods

Multicenter, retrospective review of patients diagnosed with COVID-19 from January 2020 to September 2020 throughout the HCA Healthcare system. CCI scores for all COVID-19 positive patients were calculated and logistic regression analysis was performed to predict hospitalization and ICU admission by CCI controlling for age, sex and race. A multinomial regression model was also performed to predict discharge status by CCI controlling for age, sex and race. ROC curves to indicate the CCI cut-off point for each outcome (hospitalization, ICU admission and mortality) was performed, and Youden’s Index was used to identify the optimal point.

Results

In the study timeframe, 92,800 patients were diagnosed with COVID-19 and of those, 48,270 were hospitalized. A one-point increase in CCI was associated with higher odds of hospitalization [OR 1.718; 95% CI 1.696-1.74]. The threshold for significance to predict hospitalization was a CCI of 1.5 (AUC 0.804, Youden Index 0.48) with a specificity (73%) and sensitivity (75%). A one-point increase in CCI was associated with 1.444 higher odds of an ICU admission (95% CI 1.134-1.155). A one-point increase in CCI significantly increased the odds of discharge to hospice compared to any discharge other than hospice [OR 1.162; 95% CI 1.142-1.182]). A one-point increase in CCI score was associated with 1.188 higher odds of in-hospital mortality (95% CI, 1.173-1.203) with a CCI threshold of 3.5 having the highest specificity (50.9%) and sensitivity (79.9%) to predict mortality outcome (AUC 0.704, Youden Index 0.31).

Conclusion

In conclusion CCI score is an adequate predictor of hospitalization and in-hospital mortality but less so in predicting ICU admission in COVID-19 positive patients.

Disclosures

All Authors: No reported disclosures

Prospective evaluation of an assessment tool for technical performance of duodenoscopes

OBJECTIVE

While single-use and detachable-tip duodenoscopes have been recently developed to overcome risks of infection transmission, there are no reliable tools to objectively assess their technical performance. We evaluated the reliability and validity of a newly developed tool to assess the technical performance of reusable duodenoscopes.

METHODS

An assessment tool was developed to measure duodenoscope performance based on three distinct criteria: maneuverability, mechanical/imaging characteristics and ability to perform requisite interventions. The assessment tool was tested prospectively on duodenoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures at nine academic medical centers over a 6-month period. The main outcome was reliability of the duodenoscope assessment tool, which was estimated using Cronbach's coefficient alpha (α). The secondary outcome was validity of the assessment tool.

RESULTS

The assessment tool evaluated technical performance of reusable duodenoscopes in 1080 ERCP procedures. Indications were biliary in 92.8% and pancreatic in 7.2% procedures. The overall Cronbach's coefficient α for maneuverability was 0.81, assessment of mechanical/imaging characteristics was 0.92, and ability to perform requisite interventions was 0.87. On multiple linear regression analysis, prolonged procedure duration, older patient age and pancreatic interventions were significantly positively associated with higher (worse) scores.

CONCLUSIONS

The newly developed assessment tool appears reliable and valid for evaluating the technical performance of duodenoscopes. Registration: ClinicalTrials.gov Identifier: NCT04004533.