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Introduction: Clinical significance and long-term impacts of Fatty pancreas (FP) on pancreatic parenchyma are not well-recognized. The aim of this study is to assess parenchymal alterations over time in patients with FP. Methods: This is a retrospective study (2014-2021) of patients with diffuse echogenicity of the pancreas, suggestive of FP, on endoscopic ultrasound (EUS). Subjects with subsequent EUS, Magnetic Resonance Imaging (MRI), or Computed Tomography (CT) scan at least two years after the initial EUS were included. Incidence of parenchymal changes and development of chronic pancreatitis (CP) overtime were recorded.Results: A total of 39 patients with a mean age of 51.24 6 12.31 years were enrolled. Mean initial weight was 80.17617.75kg. Diabetes mellitus (DM), fatty liver, and exocrine pancreatic insufficiency (EPI) were present in 15%, 46% and 33% of the patients at baseline, respectively. Patients were followed by EUS (n525), CT scan (n59), and MRI (n55) over an average follow up period of 2.38 6 0.94 years. In 25 patients with available follow up EUS, 16% (n54) progressed to CP and 24% (n56) had additional parenchymal changes without meeting the criteria for CP. Only one patient from the latter group developed new onset DM during the follow up period. No major parenchymal changes were noted in 52% (n513). Of the two remaining patients, one had progressed to diffuse echogenicity of the entire pancreas rather than the body alone, while the other patient was noted to have resolution of FP with minimal hyperechoic strands after weight loss. Average weight was statistically higher at baseline and follow-up in patients with progressive parenchymal changes (92.6 6 5.2 kg[baseline] and 96.26 6.09 kg [follow-up]) in comparison to those with parenchymal appearance (78.43 6 4.6 kg [baseline] and 82.17 6 4.4 kg [follow-up]); p-value 0.032. In multivariate analysis, progressive parenchymal changes on EUS were associated with an increase in weight over time, independent of the effects of gender, alcohol, or tobacco (p-value 5 0.04). (Table ) (Figure) Conclusion: Progressive parenchymal changes was noted in 44%. FP is a potential precursor for chronic pancreatitis and further parenchymal changes. Weight gain may be an independent contributor to the development of further parenchymal changes in patients with FP. Our results suggest that FP is a dynamic process with the possibility of progression or regression over time.

Introduction: Transoral incisionless fundoplication (TIF) is a minimally invasive procedure for treatment of gastroesophageal reflux disease (GERD). Although studies have reported long-term durability and resolution of symptoms, the procedure carries a wide range of adverse events from mild to life-threatening. This study aims to evaluate the short-term outcomes of consecutive TIF procedures in a tertiary academic center. Methods: This is a retrospective study of patients who underwent TIF procedure by a single experienced gastroenterologist at a tertiary center in the United States from January 2018 to December 2021. Clinical success was defined as the ability to create a .5270°partial wrap with estimated longitudinal length of .52cm. Short-term outcomes including patient symptoms or procedure related adverse events immediately to two months post-op were collected retrospectively. Results: Overall, 68 patients underwent 77 consecutive TIF procedures. The average age of patients was 52.35 6 15.74 years (67.6% female). Technical success was achieved in 100% of the patients. 10.3% of the patients had a history of prior anti-reflux surgery. Chronic GERD was the main indication for TIF procedure. The majority of patients underwent TIF for Hill grade II and III flap valves, present in 62.5% and 25%, respectively. 50.6% of patients had post-procedure symptoms up to 2 months post-procedure including abdominal pain (28%), nausea/vomiting (14.3%), chest pain (10.4%), dysphagia/odynophagia (6.5%). There was a positive correlation between number of fasteners used and immediate abdominal pain (p50.003), sore throat (p50.024), and nausea/vomiting (p50.046). Two patients developed major adverse events: one developed pneumoperitoneum and the second aspiration pneumonia complicated by flash pulmonary edema. Of the 29 patients with follow-up EGDs, 62.1% had an intact wrap (Hill I). There was no significant difference in the average number of fasteners in those with intact or loose wrap on follow up EGD (21.67 6 5.1 vs. 22.8 6 5.2, p50.57). 9 patients (13.2%) underwent redo TIF and 2 (2.9%) proceeded with surgical fundoplication for persistent symptoms. (Table ) Conclusion: Outcomes of TIF performed on a heterogeneous population in a tertiary academic center are comparable to outcomes reported from original randomized trials of TIF. Immediate adverse effects are common after TIF, but typically improve on long-term follow-up.

Introduction: Transoral incisionless fundoplication (TIF) is a minimally invasive endoscopic procedure for treatment of gastroesophageal reflux disease. Performing TIF requires unique training to achieve proficiency. This study aims to evaluate the learning curve of performing TIF in relation to patient and procedure-specific characteristics. Methods: This is a retrospective study of consecutive TIF procedures performed by a single experienced gastroenterologist to assess the procedure learning curve. Historical and procedural characteristics were recorded, and the learning curve was estimated by cumulative sum of means (CUSUM) analysis. Proficiency was defined as reliably achieving a procedure length less than 45 minutes. Results: 77 consecutive TIF procedures (68 patients) were included. The average age of patients was 52.35 6 15.74 years (32.4% male). The estimated learning plateaus for procedure time and number of fasteners were 41 minutes and 24 fasteners, respectively. Twelve procedures were required to reliably achieve a procedure length of 45 minutes or less. There was no significant correlation between the length of the TIF procedure and number of fasteners (p50.091) or Hill classification (I vs II/III) (p50.483). There was no relationship between the Hill classification (I vs. II/III) and number of fasteners (p50.475). We observed a significant increase in average number of fasteners used over time from 18.5 6 2.28 during the first quartile of procedures to 29.82 6 4.61 in the last quartile (p50.01). There was no relationship between procedure length, ASA score, number of fasteners, and hospital length of stay. Conclusion: Proficiency in performing TIF in less than 45 minutes can be achieved after independently performing 12 procedures.

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