BACKGROUND:Our aim was to describe the clinical outcomes of surgical interventions performed for the management of colonoscopy-related perforations and to compare these outcomes with those of matched colorectal surgeries performed in elective and emergency settings.METHODS:We included patients with endoscopic colonic perforation who underwent surgical intervention from the 2014-2017 National Surgery Quality Improvement Program participant use data colorectal targeted procedure file. The primary outcome in this study was short term surgical morbidity and mortality. Patients (group 1) were matched with 1:2 ratio to control patients undergoing same surgical interventions for other indications on an elective (group 2) or emergency basis (group 3). Bivariate analysis was conducted to compare categorical variables between the three groups, and multivariate logistic regression was used to evaluate the association between the surgical indication and 30-day postoperative outcomes.RESULTS:A total of 590 patients were included. The average age of the patients was 66.5±13.6 with female gender predominance (381, 64.6%) The majority of patients underwent open colectomy (365, 61.9%) while the rest had suturing (140, 23.7%) and laparoscopic colectomy (85, 14.4%). Overall mortality occurred in 4.1% and no statistically significant difference in mortality was found between the three techniques (P=0.468). Composite morbidity occurred in 163 patients (27.6%). It was significantly lower in laparoscopic colectomy (14.1%) compared to 30.2% and 29.4% in open colectomy and suturing approaches (P=0.014). Patients undergoing colectomy for iatrogenic colonic perforation had less mortality, infection rates and sepsis, as well as bleeding episodes compared to those who had colectomy on an emergent basis. Outcomes were comparable between the former group and patients undergoing elective colectomy for other indications.CONCLUSIONS:Surgical management of colonoscopy related perforations is safe and effective with outcomes that are similar to that of patients undergoing elective colectomy.

Goals and Background: We aimed to develop a novel 1-year mortality risk-scoring system that includes use of antithrombotic (AT) drugs and to validate it against other scoring systems in patients with acute gastrointestinal bleeding (GIB). Study: We developed a risk-scoring system from prospectively collected data on patients admitted with GIB between January 2013 and August 2020, who had at least 1- year of follow-up. Independent predictors of 1-year mortality were determined after adjusting for the following confounders: the age-adjusted Charlson Comorbidity Index (CCI) (divided into 4 groups: CCI-0=0, CCI-1=1 to 3, CCI-2=4 to 6, CCI-3 ≥7), need for blood transfusion, GIB severity, need for endoscopic therapy, and type of AT. The risk score was based on independent predictors. Results: Five hundred seventy-six patients were included and 123 (21%) died at 1-year follow-up. Our risk -score was based on the following: CCI-2 (2 points), CCI-3 (4 points), need for blood transfusion (1 point), and no use of aspirin (1 point), as aspirin use was protective (maximum score=6). Patients with higher risk scores had higher mortality. The model had a better predictive accuracy [AUC=0.82, 95% confidence interval (0.78-0.86), P <0.0001] than the Rockall score for upper GIB (Area Under the Curve (AUC)=0.68, P <<0.0001), the Oakland score for lower GIB (AUC=0.69, p =0.004), or the Shock Index for all (AUC=0.54, P <0.0001). Conclusion: A simple and novel score that includes use of AT upon admission accurately predicts 1-year mortality in patients with GIB. This scoring system may help guide follow-up decisions and inform the prognosis of patients with GIB.

Aims Endoscopic detection of polyps and adenomas decreases the incidence and mortality of colorectal cancer. The available data concerning the relationship between the sedation type and adenoma detection rate (ADR) or polyp detection rate (PDR) is inconclusive. The aim of our study was to evaluate the impact of conscious vs. deep (propofol) sedation on the ADR/PDR in diagnostic and screening colonoscopies.

Background:Serum protein reflects albumin and globulin levels, both of which can be altered in inflammatory bowel disease (IBD). The implications of a high globulin fraction in IBD are unknown. We hypothesized that a high globulin fraction may function independently of albumin as a biomarker of disease severity in IBD patients over a multiyear period.Methods:This was an observational study from a prospective IBD registry of a tertiary care center. High globulin fraction was defined as an elevated globulin level >4 g/dL. Data collected included patient demographics, medication exposures, quality-of-life scores, disease activity, emergency department visits, telephone calls, hospitalizations, and IBD-related surgeries over a 4-year period. Comparisons between patients with a high globulin fraction and those without were performed using Pearson's chi-squared, Student's and Mann-Whitney tests. Multivariate analyses were used to assess the relationship between high globulin fraction and healthcare utilization.Results:A total of 1767 IBD patients with a 4-year follow up were included: 53.5% female, mean age 48.4±15.1 years, and 65.4% with Crohn's disease. Of these patients, 446 (25.2%) presented with elevated globulin fraction. Patients with a high globulin fraction were more likely to be hospitalized during the study period. This result remained significant after multivariate analysis for both Crohn's disease patients and those with ulcerative colitis.Conclusion:A high globulin fraction is independently associated with greater disease severity and healthcare utilization in IBD patients, and may function as a routinely available biomarker of a more severe future disease trajectory.

Background & Aims: Endoscopic detection of polyps and adenomas decreases the incidence and mortality of colorectal cancer. The available data concerning the relationship between the sedation type and adenoma detection rate (ADR) or polyp detection rate (PDR) is inconclusive. The aim of our study was to evaluate the impact of conscious vs. deep (propofol) sedation on the ADR/PDR in diagnostic and screening colonoscopies. Methods: This was a retrospective cohort study. Patients aged 50-75 years old presenting for a first screening or diagnostic colonoscopy were included. Baseline demographic characteristics were collected, as well as PDR and ADR. Endoscopic withdrawal time and quality of bowel preparation rated in a binary fashion were also collected. Two multivariate logistic regression models were used to evaluate the independent predictors of endoscopic detection of polyps and adenomas. Results: 574 patients met our inclusion criteria. Mean age was 59.26 +/- 7.21 with 52.4% females and an average BMI of 28.08 +/- 4.89. 374 patients (65.2%) underwent screening colonoscopies, and deep sedation was performed in 200 patients (34.8%). Only 4.7% had bad bowel preparation. PDR was 70% and ADR was 52%. On bivariate analysis, no significant difference was shown in PDR and ADR between conscious and deep sedation groups (0.70, 0.71; p = 0.712 and 0.50, 0.54; p = 0.394, respectively). On multivariate analysis for PDR, age and withdrawal time were independent predictors. For ADR, age, female sex, and withdrawal time were independent predictors. Sedation type and the indication did not reach statistical significance in both models. Conclusion: The use of deep sedation didn't influence the ADR/PDR quality metrics in our mixed cohort of screening and diagnostic colonoscopies. (c) 2022 Elsevier Masson SAS. All rights reserved.

Background The presence of granulomas in the gastrointestinal (GI) tract is one of the characteristic histologic features of Crohn’s disease (CD). The clinical significance of granulomas remains unclear. In this study, we aimed to determine whether the presence of granulomas on endoscopic pinch biopsy or surgical resection from the upper or lower GI tract is associated with worse outcomes among patients with CD. Methods This was a retrospective chart review of patients with CD evaluated at a tertiary care center between 1996 and 2019. Patients were divided into 2 groups based on the presence or absence of granulomas on GI histology. Clinical and laboratory data, and outcomes of interest, were obtained from the electronic medical records. Patients’ characteristics and outcomes were compared between the 2 groups. Results A total of 237 patients were included in our study; 41 (17.3%) had granulomas on their biopsy/resection specimen. The presence of granulomas in the GI tract was significantly associated with the development of intra-abdominal abscesses and/or fistulas (P=0.037), greater utilization of immunomodulators (P=0.029), and greater use of immunosuppressive medications (immunomodulator and/or biologic therapy) (P=0.015). No significant differences were found between the 2 groups in terms of number of hospitalizations, presence of perianal disease, intestinal resection, mean age, mean age at initial diagnosis of CD, duration of disease, sex, or smoking history. Conclusions The presence of granulomas in the GI tract of CD patients may serve as a prognostic biomarker of worse disease severity. Larger studies are needed to better validate this finding.

The aim of this study is to identify the optimal timing for cholecystectomy for acute cholecystitis. Patients undergoing cholecystectomy for acute cholecystitis from the National Surgery Quality Improvement Program database between 2014 and 2016 were included. The patients were divided into 4 groups, those who underwent surgery at days 0, 1, 2, or 3+ days. The primary outcome was short-term surgical morbidity and mortality. A total of 21,392 patients were included. After adjusting for confounders, compared to day 0 patients, those who underwent surgery at day 1 and day 2 had lower composite morbidity rate, while day 3+ patients had significantly higher bleeding and mortality rate. Subgroup analysis shows this trend to be more significant in the elderly and in diabetic patients who were delayed. Delay in cholecystectomy for over 72 h from admission is associated with statistically significant increase in bleeding and mortality.

Background/Aim We determined the effect of antiplatelet and anticoagulant agents on rebleeding and mortality in patients with gastrointestinal bleeding. Methods This was a prospective study of patients admitted with gastrointestinal bleeding between 2013 and 2018. Outcomes were compared among patients on antiplatelet agents only, anticoagulant drugs only, combination therapy, and none. The association between mortality, rebleeding, and type of antithrombotic medication on admission and discharge was determined using multivariate analysis. Results A total of 509 patients were followed up for a median of 19 months. End of follow-up rebleeding and mortality rates were 19.4% and 23.0%, respectively. Independent predictors of mortality were age [hazard ratio (HR) = 1.025 per year increase, P = 0.002], higher Charlson Comorbidity Index (HR = 1.4, P < 0.0001), severe bleeding (HR = 2.1, P < 0.0001), and being on anticoagulants (HR = 2.3, P = 0.002). Being on antiplatelets was protective against rebleeding (HR = 0.6, P = 0.047). Those on anticoagulants were more likely to die (HR = 2.5, P < 0.0001) and to rebleed (HR = 2.1, P = 0.01) than those on antiplatelets. Antithrombotic drug discontinuation upon discharge was associated with increased mortality in patients with cardiovascular disease. Conclusion In gastrointestinal bleeding, rebleeding and mortality were associated with being on anticoagulant drugs, while being on antiplatelet agents was protective against rebleeding. Discontinuation of antithrombotics upon discharge increased the risk of death. The findings inform risk stratification and decisions regarding continuation or discontinuation of antithrombotics.

The use of biological agents for the treatment of chronic inflammatory conditions such as inflammatory bowel diseases (IBD) has been on the rise.1,2 Current biological therapies include antitumor necrosis factor-α (anti-TNF-α), anti-interleukin-12/23, and anti-integrin agents. Before initiation of biological drugs, screening for Mycobacterium tuberculosis infection is required to avoid reactivation or worsening of disease after immunosuppression. It has been shown that anti-TNF-α treated patients have a 14-fold increased risk of tuberculosis (TB) infection/reactivation compared with healthy controls.3 The methods for screening for TB have evolved over time and vary from region to region.

BACKGROUND AND STUDY AIMS:Bowel wall thickening (BWT) on computed tomography (CT) has been frequently reported by radiologists. There are no clear guidelines regarding the level of thickening that is correlated with definite pathology. Radiologists usually rely on their overall subjective impression, and studies on inter-observer agreement (IOA) are lacking. This study evaluated IOA concerning BWT found on abdominal CT and identified the corresponding findings on endoscopy.PATIENTS AND METHODS:Reports of abdominal CTs performed between January 2000 and December 2015 containing the term 'thickening' were retrieved from the radiology department database. Corresponding patients who later underwent endoscopy were included. IOA concerning BWT was evaluated using a randomly mixed sample of 80 patients with normal findings or pathological BWT on endoscopy. A search for predictive factors for the subsequent finding of malignancy on endoscopy was performed using multivariate analysis.RESULTS:During the study period, 6142 CT scans described thickening, equivalent to a BWT prevalence of 13.7%. Ninety-one patients (mean age, 58 years) were included in the analysis. Thickening was found most commonly in the stomach (38.5%), followed by the rectum (22%) and small intestine (14%). Twenty-seven patients (29.7%) exhibited diffuse BWT, whereas 64 patients showed localised BWT (70.3%). Biopsy was performed for 64 of 91 patients with endoscopies. Among these patients, 8.8% exhibited normal findings, whereas inflammation and malignancy were discovered in 25 and 51.6% of patients, respectively, with a positive predictive value for malignancy of 0.36. The IOA concerning CT for predicting significantly pathological BWT was moderate (mean κ = 0.6). A strong association was evident between the presence of lymph nodes on CT and the presence of neoplastic lesions.CONCLUSION:Our study strongly recommends endoscopic follow-up of patients exhibiting BWT irrespective of the thickening location, especially if it is associated with lymphadenopathy. IOA between radiologists was moderate.

Background: Hepatitis B virus (HBV) reactivation can be asymptomatic or manifest as fatal fulminant hepatitis. Most international guidelines recommend screening patients prior to immunosuppressive therapy. Aims: To determine HBV screening rates and modalities in patients receiving chemotherapy at the American University of Beirut Medical Center. Methods: A retrospective cohort review of electronic health records of adult patients who received chemotherapeutic agents, between June 2015 and June 2016. Patients clinical characteristics were documented. Adequate screening was defined as performing all: HBsAg, HBs Abs, and anti HBc Abs(total). Results: A total of 1547 patients were initially assessed. 45.6% were males with a mean age of 56. 382(30%) had hematologic malignancies, of whom 111 underwent HSCT. Of those included, 303(24%) patients were screened by at least one test for HBV and 42(3.3%) for HBsAg, anti HBc Abs and HBs Abs. Patients who were appropriately screened were significantly younger(p=0.008) and more likely to have hematologic malignancies (n=35, 83.3%, p<0.0001). Among patients with hematologic malignancies, appropriately screened patients (n=35) were younger (p=0.042) and had a history of HSCT(n=19, 54.3%, p=0.001). Conclusion: Rates of screening for HBV prior to chemotherapy at our medical center are low, and not always complete or adequate. There is an urgent need to implement a better screening policy.

BACKGROUND: The Inflammatory Bowel Diseases (IBD) are chronic conditions with a relapsing and remitting clinical course. As IBD symptoms manifest unpredictably over time, the present study aimed to evaluate if and how associated morbidity affected Health-related Quality of Life (HRQoL) and social interaction through Facebook (FB) among patients. METHODS: This was a cross-sectional study enrolling 100 IBD outpatients from Botucatu Clinic Hospital (Botucatu group) and 185 patients with IBD who are followed at other institutions in Brazil (Online group). The online group completed the same questionnaires as the Botucatu group but did so through a web link made available on patient groups on FB. Patients were excluded if they did not use FB. Disease activity was measured using the Mayo Score for Ulcerative Colitis (UC), Crohn´s Disease Activity Index (CDAI) and Harvey-Bradshaw Simple Index for Crohn’s Disease (CD) among Botucatu and Online patients respectively. FB use was measured using the questionnaire Psycho-Social Aspects of Facebook Use (PSAFU), which comprises 5 domains: compensatory use, self-presentation, socialization, addiction and virtual identity. The Inflammatory Bowel Disease Questionnaire (IBDQ) was used to measure Health-related Quality of Life. Statistical analysis: association tests, P < 0.05 and Pearson correlations. RESULTS: The Online group had more people with CD (P = 0.006) and its patients had longer duration of IBD in years (9.94 ± 8.98 vs 7.73 ± 6.81). Patients followed in the Botucatu reference center had a greater remission rate (P < 0.0001 and P = 0.09, for UC and CD respectively) while the Online group had had more consultations (P < 0.0001), hospitalizations (P < 0.0001) and surgeries (P = 0.01) per year. The Online group used more biologic medications (P = 0.03). Botucatu patients had better HRQoL in the following IBDQ domains: intestinal (P = 0.0003), systemic (P = 0.002) and emotional (P < 0.0001). They also socialized less (P < 0.0001) on FB and presented with the lowest FB addiction rate (P < 0.0001), fewer anxious (P = 0.007) and depressive (P = 0.05) symptoms and a better body image (P = 0.02) although they had fewer patients treated with psychotherapy (P = 0.0004). Considering the Online group only, patients with longer duration of IBD spent more time? on self-presentation through social media (FB) (P = 0.005). Those with worse systemic IBDQ scores presented with more intense compensatory use of FB (P = 0.03). Worse emotional health was inversely associated with compensatory use of FB (P = 0.02) and addiction (P = 0.03). Among these patients, larger number of surgeries was related to FB addiction (P = 0.04). CD Online patients were younger at the time of diagnosis (P = 0.0003), used more biologic therapy (P < 0.0001) and had had more consultations (P = 0.01), hospitalizations (P < 0.0001) and previous surgeries (P < 0.0001). Their systemic HRQoL was negatively associated with compensatory use of FB (P = 0.0006) and the emotional aspect, with compensatory use (P = 0.008) and FB addiction (P = 0.03), while these correlations were not observed among UC Online patients. CONCLUSION: Patients with longer duration of IBD had worse HRQoL and interacted more through social media as disease related morbidity may affect their ability for in person social interaction. HRQoL was inversely related to compensatory use and FB addiction among patients with longer duration of IBD. These patients also underwent consultations and medical interventions more frequently.

Background/aim Distal pancreatectomy (DP) accounts for 25% of all pancreatic resections. Complications following DP occur in around 40% of the cases. Our aim is to analyze short-term surgical outcomes of DP based on whether the indication for resection was benign or malignant pathology, as well as the effect of the surgical approach, open versus laparoscopic on morbidity and mortality. Methods We studied all patients undergoing DP from the National Surgery Quality Improvement Program (NSQIP) targeted pancreatectomy participant use file from 2014 to 2016. The patients were divided into 2 groups, those who underwent DP for benign diseases (DP-B) and those who underwent DP for malignant diseases (DP-M). We performed multivariate logistic regression to evaluate the association between benign or malignant distal pancreatectomies and 30-day outcomes. We included clinically and/or statistically significant confounders into the models. We also conducted the same analysis in the subgroups of open and laparoscopic DP. Results Three thousand five hundred and seventy-nine patients underwent distal pancreatectomy. The most common indication for surgery was malignant disease in 1894 (53%). Thirty-day mortality occurred in 0.4% of DP-B compared to 1.3% DP-M. On multivariate analysis, no significant difference was found in mortality or in the risk of pancreatic fistula between the 2 groups. Bleeding (p = 0.002) and composite morbidity (p = 0.01) were significantly higher in the DP-M group. Among composite morbidities, thromboembolism was significantly associated with DP-M (OR 2.1,p = 0.0004) only when performed with an open approach. Conclusion DP-M is associated with a significantly higher risk of post-operative bleeding, thromboembolism, and sepsis compared to DP-B but no significant increase in mortality. When further analyzing the impact of the operative approach on morbidity, there was an increased rate of post-operative thromboembolic in the DP-M group when the surgery was performed in an open manner and this increased risk was no longer statistically significant if the DP-M was performed using a minimally invasive approach.

BACKGROUND: Disease specific knowledge amongst inflammatory bowel disease (IBD) patients remains lacking. Our study aims to (1) determine the extent of disease specific knowledge amongst IBD patients in Lebanon and (2) determine the impact of patient knowledge on anxiety, depression, and quality life while controlling for disease activity. METHODS: We prospectively recruited adult IBD patients from the GI clinic at a tertiary referral center in Beirut, Lebanon. Demographic data was collected and patients were asked to fill the following questionnaires: (1) Short IBD Questionnaire (SIBDQ) as a measure of quality of life (QoL), (2) Harvey-Bradshaw Index (HBI) for Crohn’s disease (CD) or Ulcerative Colitis (UC) Activity Index (UCAI) for UC patients as a measure of disease activity, (3) Hospital Anxiety and Depression Scale (HADS), as a measure for anxiety and depression, and (4) the Crohn’s and Colitis Knowledge (CCKnow) questionnaire as a measure of IBD-specific patient knowledge. Pearson Chi-square, student’s t-test and multivariate analysis was used for statistical analyses. RESULTS: A total of 95 patients were included; 55.8% males, 18–65 years of age, mean age 34.5 years ± 12.0. Over half (53.7%) of patients had CD, 44.2% UC, and 2.1% IBD-unclassified. The majority of patients (51.6%) were unmarried and had a university degree (77.9%). The mean CCKnow score amongst patients was 8 ± 4, with 53.7% scoring ≥8. Of all patients, 43.2% had anxiety, 22.1% had depression, mean SIBDQ score was 49 ± 15, with 49.5% having a poor QoL. The 51 CD patients had a mean CCKnow of 8 ± 4, with 45.1% scoring ≥8. These patients had a mean HBI of 5 ± 4. The 29 UC patients had a mean CCKnow of 9 ± 4, with 61.9% scoring ≥8. The mean UCAI for these patients was 5 ± 4. Patients with a university degree had more disease specific knowledge (CCKnow score ≥8). Comparing patients with CCKNOW ≥ 8 to those who lack disease specific knowledge, there was no significant difference in anxiety, depression or quality of life. When analyzing per IBD subtype, CD patients who had more disease specific knowledge had a tendency to be more anxious and depressed. After controlling for disease activity, gender, level of education, age, and years of disease, patients who were considered knowledgeable regarding their disease had no association with any of the following outcomes in the UC population: anxiety, depression, or quality of life; however, being female with CD was associated with increased levels of anxiety. CONCLUSION(S): IBD patients in Lebanon knew less about their IBD compared to values reported in the literature. There were no differences between patients who knew about their disease compared to those who do not except for a trend towards significance in anxiety amongst CD patients who knew more about their disease.