INTRODUCTION:Endoscopic submucosal dissection (ESD) is a promising technique for early-stage gastrointestinal neoplasms; however, its use for periappendiceal lesions poses challenges because of anatomical complexities and the potential risk of appendicitis or perforation. As a result, these lesions are often managed surgically. This systematic review and meta-analysis evaluate the safety and efficacy of ESD for periappendiceal lesions. METHODOLOGY:A systematic search across multiple databases was conducted, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies focused on adult populations undergoing ESD for periappendiceal lesions. The primary outcome was a technical success, and secondary outcomes included R0 resection, en-bloc resection, adverse events, and need for surgery. Data were reported using percentages with associated confidence intervals (CIs) and heterogeneity ( I ²). RESULTS:Six studies comprising 298 patients were included. Technical success was achieved in 98% (95% CI: 97-100%, I2  : 4.63%), with R0 resection and en-bloc resection rates of 84% (95% CI: 77-91%, I2  : 61.86%) and 92% (95% CI: 86-97%, I2  : 66.11%), respectively. The overall rates of polyp recurrence, appendicitis, and bleeding were 0.1% (95% CI: 0-2%, I2  : 0%), 3% (95% CI: 0-4%, I2  : 0%), and 1% (95% CI: 0-3%, I2  : 0%), respectively. Conversely, perforation exhibited a relatively high incidence of 11% (95% CI: 3-19%, I2  : 84.55%); however, the need for surgical intervention was 6% (95% CI: 1-10%, I2  : 74.12%). CONCLUSION:ESD provides a safe and effective alternative to surgical resection for managing periappendiceal lesions.

BACKGROUND:Type I achalasia comprises 20% of achalasia and has nearly absent esophageal motor activity. Concerns that fundoplication decreases the effectiveness of Heller myotomy in these patients has increased adoption of peroral endoscopic myotomy (POEM). Hence, we compared outcomes after Heller myotomy with Dor fundoplication vs POEM.METHODS:From 2005 to 2020, 150 patients with type I achalasia underwent primary surgical myotomy (117 Heller myotomy, 33 POEM). Patient demographics, prior treatments, timed barium esophagrams, Eckardt scores, and reinterventions were assessed between the 2 groups. Median follow-up was 5 years for Heller myotomy and 2.5 years for POEM.RESULTS:The Heller myotomy group was younger, had fewer comorbidities, and lower body mass index vs POEM. Risk-adjusted models demonstrated clinical success (Eckardt ≤3) in 83% of Heller myotomies and 87% of POEMs at 3 years; longitudinal complete timed barium esophagram emptying and reintervention were also similar. An abnormal pH test result was documented in 10% (6 of 60) after Heller myotomy and in 45% (10 of 22) after POEM (P < .001).CONCLUSIONS:Despite nearly absent esophageal contractility, Heller myotomy with Dor fundoplication and POEM result in similar long-term symptom relief, esophageal emptying, and occurrence of reintervention in patients with type I achalasia. There is decreased esophageal acid exposure with the addition of a fundoplication, without compromised esophageal drainage, allaying fears of a detrimental effect of a fundoplication. Hence, choice of procedure may be personalized based on patient characteristics and esophageal morphology and not solely on manometric subtype.

Current classification of achalasia does not account for variability in esophageal tortuosity. The esophageal length-to-height ratio (LHR) was developed to objectively quantify tortuosity, based on the premise that the esophagus must elongate to become tortuous. Hence, we assess the relationship of esophageal tortuosity, measured by LHR, to preoperative patient characteristics and post-myotomy outcomes, including longitudinal symptom relief and esophageal emptying. From 01/2014 to 01/2020, 420 eligible adult patients underwent myotomy for achalasia at our institution, 216 (51

St Joseph Mercy Ann Arbor Hospital, USA; Central Michigan University College of Medicine, USA; Creighton University School of Medicine, USA; University of Toledo College of Medicine and Life Sciences, USA; University of Maryland School of Medicine, USA; Rochester General Hospital, USA; University of Utah Health, USA; University of Arkansas for Medical Sciences, USA; Cleveland Clinic, USA; Parkview Health, USA; Indiana University School of Medicine, USA.

BACKGROUND Peptic ulcer disease (PUD) is frequently seen in patients with liver cirrhosis. However, current literature lacks data on PUD in non-alcoholic fatty liver disease (NAFLD) hospitalizations. AIM To identify trends and clinical outcomes of PUD in NAFLD hospitalizations in the United States. METHODS The National Inpatient Sample was utilized to identify all adult (≥ 18 years old) NAFLD hospitalizations with PUD in the United States from 2009-2019. Hospitalization trends and outcomes were highlighted. Furthermore, a control group of adult PUD hospitalizations without NAFLD was also identified for a comparative analysis to assess the influence of NAFLD on PUD. RESULTS The total number of NAFLD hospitalizations with PUD increased from 3745 in 2009 to 3805 in 2019. We noted an increase in the mean age for the study population from 56 years in 2009 to 63 years in 2019 (P < 0.001). Racial differences were also prevalent as NAFLD hospitalizations with PUD increased for Whites and Hispanics, while a decline was observed for Blacks and Asians. The all-cause inpatient mortality for NAFLD hospitalizations with PUD increased from 2% in 2009 to 5% in 2019 (P < 0.001). However, rates of Helicobacter pylori (H. pylori) infection and upper endoscopy decreased from 5% in 2009 to 1% in 2019 (P < 0.001) and from 60% in 2009 to 19% in 2019 (P < 0.001), respectively. Interestingly, despite a significantly higher comorbidity burden, we observed lower inpatient mortality (2% vs 3%, P = 0.0004), mean length of stay (LOS) (11.6 vs 12.1 d, P < 0.001), and mean total healthcare cost (THC) ($178598 vs $184727, P < 0.001) for NAFLD hospitalizations with PUD compared to non-NAFLD PUD hospitalizations. Perforation of the gastrointestinal tract, coagulopathy, alcohol abuse, malnutrition, and fluid and electrolyte disorders were identified to be independent predictors of inpatient mortality for NAFLD hospitalizations with PUD. CONCLUSION Inpatient mortality for NAFLD hospitalizations with PUD increased for the study period. However, there was a significant decline in the rates of H. pylori infection and upper endoscopy for NAFLD hospitalizations with PUD. After a comparative analysis, NAFLD hospitalizations with PUD had lower inpatient mortality, mean LOS, and mean THC compared to the non-NAFLD cohort.

St Joseph Mercy Ann Arbor Hospital, USA; Central Michigan University, USA; Creighton University School of Medicine, USA; University of Toledo College of Medicine and Life Sciences, USA; University of Maryland School of Medicine, USA; Rochester General Hospital, USA; University of Utah Health, USA; University of Arkansas for Medical Sciences, USA; Cleveland Clinic, USA; Parkview Health, USA; Indiana University School of Medicine, USA.

A 59-year-old woman presented to the gastroenterology clinic in 2012 for evaluation of epigastric pain for several months. She also reported heartburn for several years which was well controlled with acid suppression therapy. She denied any smoking or excessive alcohol intake. An esophagogastroduodenoscopy revealed a dark discolored area about 1 × 1 cm at 32 cm (Figure A) with a Z-line at 39 cm from the incisors. Biopsies from the area showed squamous mucosa with scattered melanotic cells (Figure B hematoxylin and eosin stain and Figure C HMB45 stain) and no evidence of dysplasia or malignancy which was consistent with esophageal melanocytosis. Since then, she had periodic surveillance endoscopies which showed a lack of any neoplastic progression based on the endoscopic appearance and histology in the past ten years. Esophageal melanocytosis is a rare condition characterized by melanocytic proliferation in the esophageal squamous epithelium and increased deposition of melanin in the esophageal mucosa. The etiology is not known but chronic irritation from gastroesophageal reflux disease is thought to be an inciting factor. It is generally considered as a benign incidental finding; however, cases progressing to malignant melanoma have been reported. Therefore, endoscopic surveillance or in selected cases, endoscopic resection can be considered.

Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) has evolved into a vital endoscopic technique for managing numerous pancreaticobiliary disorders. Studies have reported higher rates of adverse outcomes and post-ERCP complications in ethnic minorities, making race an important risk factor for ERCP utilization. In this study, we aimed to identify the influence of race on clinical outcomes of all-cause inpatient ERCPs in the United States (US). Methods: We used the National Inpatient Sample (NIS) to identify all adult (≥18 years) hospitalizations that underwent ERCP in the US from 2007–2019. The study population was further subdivided into 3 groups based on race (Whites, Blacks, and Hispanics). Hospitalization characteristics and clinical outcomes were highlighted and compared. P-values ≤0.05 were considered statistically significant. Results: Between 2007–2019, there were 1,515,516 White, 205,338 Black and 348,269 Hispanic hospitalizations that underwent inpatient ERCP in the US. Whites had a higher mean age (62.5 vs 54.8 vs 50.7 years, P< 0.0001) and higher proportion of patients ≥65 years of age compared to Blacks and Hispanics, respectively. Overall, a female predominance was noted for all-cause inpatient ERCPs (Table 1). The household income for a higher proportion of Blacks and Hispanics was in the first (low-income) Quartile, while most White hospitalizations had household incomes in the second, third and fourth Quartiles (Table 1). A higher proportion of Black hospitalizations that underwent inpatient ERCP had a higher Charlson Comorbidity Index (CCI) ≥3 (32.37% vs 26.76% vs 18.36%, P< 0.0001) compared to Whites and Hispanics, respectively. All-cause inpatient mortality (2.03% vs 1.51% vs 0.99%, P< 0.0001) and longer mean length of stay [LOS] (7.62 vs 6.23 vs 6.04 days, P< 0.0001) was higher for Black hospitalizations that underwent inpatient ERCPs compared to Whites and Hispanics, respectively. However, Hispanic hospitalizations had the highest mean total healthcare charge at $80,569 (Table 1). Conclusion: Our study demonstrates the influence of race on hospitalization characteristics and clinical outcomes for hospitalizations that underwent inpatient ERCP. Black hospitalizations had a significant comorbidity burden, higher all-cause inpatient mortality, and longer mean LOS. Ethnic minorities i.e. Hispanics and Blacks also had a higher total healthcare charge compare to White hospitalizations. There is an urgent need for large, prospective studies to investigate these findings. Table 1. - Comparative analysis for racial distribution of all-cause inpatient endoscopic retrograde cholangiopancreatography (ERCP) in the United States from 2007 – 2019 Variable Whites Blacks Hispanics P-value Total number of Hospitalizations 1,9777,674 527,843 300,516 Mean Age (years)± Standard Error 67.91 ( 0.05) 62.92 (0.08) 61.91 (0.18) P< 0.0001 Age groups (years) P< 0.0001 18-34 3.77% 5.20% 7.02% 34-49 9.65% 14.71% 17.18% 50-64 23.41% 31.30% 27.46% 65-79 35.80% 32.79% 30.19% ≥80 27.37% 16.00% 17.54% Gender P< 0.0001 Male 46.24% 43.93% 47.40% Female 53.76% 56.07% 52.60% Charlson Comorbidity Index (CCI) P< 0.0001 CCI = 0 25.83% 21.72% 26.07% CCI = 1 22.60% 20.74% 21.55% CCI = 2 17.38% 16.51% 15.06% CCI ≥ 3 34.19% 41.04% 37.32% Hospital Region P< 0.0001 Northeast 21.55% 18.18% 15.85% Midwest 23.50% 20.62% 6.43% South 38.63% 52.68% 40.03% West 16.32% 8.51% 37.69% Hospital Bed-Size P< 0.0001 Small 15.63% 12.86% 12.81% Medium 27.43% 28.47% 29.35% Large 56.93% 58.67% 57.84% Hospital Location and Teaching status P< 0.0001 Rural 11.22% 6.33% 3.72% Urban Non-teaching 37.76% 28.04% 39.62% Urban teaching 51.03% 65.63% 56.66% Median Household Income (Quartile) P< 0.0001 1st (0-25th) 24.34% 53.29% 39.26% 2nd (26th -50th) 27.31% 21.35% 24.61% 3rd (51st - 75th) 25.46% 15.46% 23.03% 4th ( 76th - 100th) 22.89% 9.90% 13.10% Discharge Home 65.68% 66.97% 73.28% P< 0.0001 Inpatient Mortality 1.55% 1.38% 1.57% P = 0.0006 Length of Stay (days) 6.66 7.58 6.99 P< 0.0001 Total Healthcare Charge ($) 60,024 65,825 78,781 P< 0.0001

Background and aims:Idiopathic or functional esophagogastric junction outflow obstruction (EGJOO) is characterized by preserved peristalsis and an elevated integrated relaxation pressure of the lower esophageal sphincter (LES) without mechanical obstruction. Data on efficacy of peroral endoscopic myotomy (POEM) in EGJOO are limited. Prior studies included heterogeneous patients and those with prior LES interventions such as pneumatic dilation and Heller myotomy. The aim of this study was to determine outcomes of POEM in EGJOO without prior pneumatic dilation or Heller myotomy. Methods:We reviewed medical records of patients who had POEM for EGJOO between 2014 and 2022 at our institution. The primary outcome was clinical success, defined as a reduction in Eckardt score to ≤3. Secondary outcomes were technical success, adverse events, reduction in LES pressure on high-resolution esophageal manometry (HREM), improvement in timed barium esophagram (TBE), and esophageal pH study findings. Results:Seventeen patients (9 female subjects; mean age 57.8 ± 14.4 years) met study criteria. POEM was technically successful in all patients, with no significant adverse events. Clinical success was achieved in 94.1% (16 of 17) of patients. There was a significant improvement in barium column height on TBE at 1 and 5 minutes (9.5 ± 6.2 cm vs 2.6 ± 2.6 cm [P < .004] and 4.1 ± 5.6 cm vs 1.0 ± 1.6 cm [P = .05]) and integrated relaxation pressure of the lower esophageal sphincter on HREM (26.5 ± 9.4 mm Hg vs 6.1 ± 3.6 mm Hg, P < .002). The esophageal pH study was abnormal in 5 (41.6%) of 12 patients. Conclusions:POEM seems to provide high clinical success along with improvement in TBE and HREM in EGJOO; however, GERD is very common after POEM.