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  • The changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-24
    Megan Q. Chan; Gokulakishnan Balasubramanian; Rohan M. Modi; Georgios I. Papachristou; Sebastian G. Strobel; Jeffery. Groce; Alice Hinton; Somashekar G. Krishna

    Background and Aims In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia. Methods The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time-periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed. Results A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003, 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time-period (2010-2013: OR, 2.09; 95% CI, 1.40- 3.13). Multivariable analysis of hospital outcomes revealed that there were no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications. Conclusion In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.

  • Association between improved adenoma detection rate and interval colorectal cancer rates after a quality improvement program
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-21
    Angela Y. Lam; Yan Li; Dyanna L. Gregory; Joanne Prinz; Jacqueline O’Reilly; Michael Manka; John E. Pandolfino; Rajesh N. Keswani

    Background and Aims Although colonoscopy reduces colorectal cancer (CRC) risk, interval CRCs (iCRCs) still occur. We aimed to determine iCRC incidence, assess the relationship between adenoma detection rates (ADRs) and iCRC rates, and evaluate iCRC rates over time concomitant with initiation of an institutional colonoscopy QI program. Methods We performed a retrospective cohort study of patients who underwent colonoscopy at an academic medical center (January 2003 to December 2015). We identified iCRCs through our data warehouse, and reviewed charts to confirm appropriateness for study inclusion. An iCRC was defined as a cancer diagnosed 6 to 60 months and an early iCRC diagnosed 6 to 36 months after index colonoscopy. We measured the relationship between provider ADRs and iCRC rates, and assessed iCRC rates over time with initiation of a QI program that started in 2010. Results A total of 193,939 colonoscopies were performed over the study period. We identified 186 patients with iCRC. The overall iCRC rate was 0.12% and the early iCRC rate was 0.06%. Average-risk patients undergoing colonoscopy by highest ADR quartile (34%-52%) endoscopists had a 4-fold lower iCRC risk (RR, 0.23; 95% CI, 0.11-0.48) than those undergoing colonoscopy by a lowest quartile (12%-21%) endoscopist. After QI program initiation, overall iCRC rates improved from 0.15% to 0.08% (p<0.001) and early iCRC rates improved from 0.07% to 0.04% (p=0.004). Conclusions We confirmed that iCRC rate is inversely correlated with provider ADR. ADR increased and iCRC rates decreased over time, concomitant with a QI program focused on split-dose bowel preparation, quality metric measurement, provider education and feedback. iCRC rate measurement should be considered a feasible, outcomes-driven institutional metric of colonoscopy quality.

  • Feasibility of a new ligation using the double-loop clips technique without an adhesive agent for ulceration after endoscopic submucosal dissection of the colon (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-20
    Satoshi Abiko; Sonoe Yoshida; Ayumu Yoshikawa; Kazuaki Harada; Naoki Kawagishi; Itsuki Sano; Hisashi Oda; Takuto Miyagishima

    Background and Aims Several ligation techniques for ulceration after endoscopic submucosal dissection (ESD) have been reported but none have been established for clinical use because of technical complexity and requirement for expensive equipment. Therefore, the technical feasibility of a new ligation using the double-loop clips (D-L clips) technique without an adhesive agent for ulceration after ESD of the colon was assessed. Methods Among 35 patients who underwent ESD of the colon in Kushiro Rosai Hospital between April 2019 and September 2019, 26 patients who underwent ligation using D-L clips technique for the post-ESD ulcer bed were included in this retrospective study. Continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment. Results The rate of en bloc R0 resection was 97.1%, the median length of the resected specimen was 3.2 (interquartile range [IQR], 2.8–3.8) cm, and the complete ligation rate was 88.5% (23/26). Excluding patients with lesion sites in the rectum below the peritoneal reflection, the complete ligation rate was 95.5% (21/22). The median duration of ligation procedure was 20 (IQR, 16–24) minutes. The only delayed procedural adverse event was post-ESD coagulation syndrome in 1 patient. Incomplete ligation was significantly more frequent in patients with lesion sites in the inferior rectal valve/anal verge area (p = 0.0269). Conclusions Ligation using the D-L clips technique without an adhesive agent is feasible for closing ulceration after ESD of the colon, whereas other techniques may be necessary for lesions in the rectum below the peritoneal reflection.

  • Tolerability and safety of EUS-injected adenovirus-mediated double-suicide gene therapy with chemotherapy in locally advanced pancreatic cancer: Phase I Trial
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-19
    Jong-chan Lee; Dong Woo Shin; Haeseong Park; Jinkuk Kim; Yuna Youn; Jae Hyeong Kim; Jaihwan Kim; Jin-Hyeok Hwang
  • Automatic detection and classification of protruding lesions in wireless capsule endoscopy images based on a deep convolutional neural network
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-19
    Hiroaki Saito; Tomonori Aoki; Kazuharu Aoyama; Yusuke Kato; Akiyoshi Tsuboi; Atsuo Yamada; Mitsuhiro Fujishiro; Shiro Oka; Soichiro Ishihara; Tomoki Matsuda; Masato Nakahori; Shinji Tanaka; Kazuhiko Koike; Tomohiro Tada

    Background and Aims Protruding lesions of the small bowel vary in wireless capsule endoscopy (WCE) images, and their automatic detection may be difficult. We aimed to develop and test a deep learning-based system to automatically detect protruding lesions of various types in WCE images. Methods We trained a deep convolutional neural network (CNN), using 30,584 WCE images of protruding lesions from 292 patients. We evaluated CNN performance by calculating the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity, using an independent set of 17,507 test images from 93 patients, including 7,507 images of protruding lesions from 73 patients. Results The developed CNN analyzed 17,507 images in 530.462 seconds. The AUC for detection of protruding lesions was 0.911 (95% confidence interval [Cl], 0.9069 – 0.9155). The sensitivity and specificity of the CNN were 90.7% (95% CI, 90.0% - 91.4%) and 79.8% (95% CI, 79.0% - 80.6%), respectively, at the optimal cut-off value of 0.317 for probability score. In subgroup analysis of the category of protruding lesions, the sensitivities were 86.5%, 92.0%, 95.8%, 77.0%, and 94.4% for the detection of polyps, nodules, epithelial tumors, submucosal tumors, and venous structures, respectively. In individual patient analysis (n = 73), the detection rate of protruding lesions was 98.6%. Conclusion We developed and tested a new computer-aided system based on a CNN to automatically detect various protruding lesions in WCE images. Patient-level analyses with larger cohorts and efforts to achieve better diagnostic performance are necessary in further studies.

  • EUS-guided choledochoduodenostomy using electrocautery-enhanced lumen-apposing metal stents: a French multicenter study after implementation of the technique (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-19
    Jérémie Jacques; Jocelyn Privat; Fabien Pinard; Fabien Fumex; Ulriika Chaput; Jean-Christophe Valats; Franck Cholet; Julien Jezequel; Philippe Grandval; Romain Legros; Hugo Lepetit; Jeremie Albouys; Bertrand Napoleon
  • Therapeutic Resolution of Focal, Predominantly Anastomotic Crohn’s Disease Strictures Using Removable Stents: Outcomes from a Single-Center United Kingdom Case Series
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-18
    Ronit Das; Rajeev Singh; Said Din; Jonathan Lund; Rajesh Krishnamoorthy; Stephen Hearing; Bernard Norton; Jessica Williams; Catherine Fraser; Andrew Goddard; Andrew Cole
  • Dutch Gastrointestinal Endoscopy Audit: Automated extraction of colonoscopy data for quality assessment and improvement
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-11
    Michael P.M. de Neree tot Babberich; Michiel Ledeboer; Monique E. van Leerdam; Manon C.W. Spaander; AuraA.J. van Esch; Rob J. Ouwendijk; Peter J. van der Schaar; Sander van der Beek; Miangela M. Lacle; Paul A. Seegers; Michel W.J.M. Wouters; Paul Fockens; Evelien Dekker

    Background and Aims The importance of having quality assessment, assurance, and improvement tools in healthcare is increasingly recognized. However, the additional administration burden, which is still often associated therewith, progressively interferes with the structural implementation and adoption of such tools, especially when it concerns high-volume procedures such as colonoscopies. The development of the Dutch Gastrointestinal Endoscopy Audit (DGEA), a registry with automated extraction of colonoscopy quality data, and its first results, are described. Methods In close cooperation with commercial endoscopy reporting systems and a national histopathology database, healthcare professionals performing colonoscopies initiated a quality registry that extracts data from its core hospital resource or histology database without manual interference of the healthcare providers. Data extracted consisted of patients’ age, gender, indication of the colonoscopy, ASA-score, Boston Bowel Preparation Score, Cecal intubation, and for the colonoscopy after a positive FIT in the colorectal cancer screening program also the polyp detection rate, which was available for all 48 hospitals or endoscopy centers, and adenoma detection rate, which was available for 26 hospitals or endoscopy centers. Results Between 1 January 2016 and 31 March 2019, 48 hospitals or endoscopy centers voluntarily participated in the DGEA and 275,017 unique patients with 313,511 colonoscopies were registered. Overall missing values were limited to <1%. Conclusions The results of this study demonstrate that it is feasible to deploy a quality registry collecting uniform data without additional administration burden for the healthcare professionals.

  • ASGE guideline on minimum staffing requirements for the performance of GI endoscopy
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-06
    Laith H. Jamil; Mariam Naveed; Deepak Agrawal; Larissa L. Fujii-Lau; Mohammad Al-Haddad; James L. Buxbaum; Douglas S. Fishman; Terry L. Jue; Joanna K. Law; Jeffrey K. Lee; Bashar J. Qumseya; Mandeep S. Sawhney; Nirav Thosani; Andrew C. Storm; Audrey H. Calderwood; Suryakanth R. Gurudu; Mouen A. Khashab; Julie Yang; Sachin B. Wani

    Efforts to increase patient safety and satisfaction, a critical concern for health providers, require periodic evaluation of all factors involved in the provision of GI endoscopy services. We aimed to develop guidelines on minimum staffing requirements and scope of practice of available staff for the safe and efficient performance of GI endoscopy. The recommendations in this guideline were based on a systematic review of published literature, results from a nationwide survey of endoscopy directors, along with the expert guidance of the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee members, ASGE Practice Operation Committee members, and the ASGE Governing Board.

  • Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-06
    Kia Vosoughi; Yervant Ichkhanian; Jérémie Jacques; A. Aziz Aadam; Petros C. Benias; Ryan Law; William L. Hasler; Andrew Canakis; Olivier Ragi; Joseph Triggs; Nicole Bowers; Olaya I. Brewer Gutierrez; Vivek Kumbhari; Anthony N. Kalloo; Robert S. Bulat; John E. Pandolfino; Mouen A. Khashab

    Background and Aims Endoluminal functional luminal imaging probe (EndoFLIP) is an imaging tool that measures physiological characteristics of gastrointestinal sphincters. In this study we used EndoFLIP to evaluate the association between the pyloric physiological measurements with clinical outcomes of gastric peroral endoscopic myotomy (G-POEM) in patients with refractory gastroparesis. Methods Thirty-seven patients who underwent G-POEM for management of refractory gastroparesis and had EndoFLIP measurements from five centers were evaluated. Cross-sectional area (CSA), balloon pressure (BP), and distensibility index (DI) of the pylorus were evaluated by EndoFLIP at 40 mL and 50 mL balloon fills before and after G-POEM. One-year clinical success and change in gastric emptying study (GES) 3 months after the G-POEM procedure were compared with EndoFLIP measurements. Results Clinical success was achieved in 26 (70%) patients. Post–G-POEM CSA and DI were significantly higher in the clinical success group with both 40 mL (CSA: 89.9 ± 64.8 vs 172.5 ± 71.9 mm2, p=0.003; DI: 5.8 ± 4.4 vs 8.8 ± 6.1 mm2/mm Hg, p=0.043) and 50 mL volume distention (CSA: 140.1 ± 89.9 vs 237.5 ± 80.3 mm2, p=0.003; DI: 5.6 ± 3.3 vs 9.9 ± 6.6 mm2/mm Hg, p=0.049). CSA using 40 mL volume distention, with an area under the curve (AUC) of 0.83 yielded specificity of 91% and sensitivity of 71% at a cut-off point of 154 mm2. Conclusions Post–G-POEM CSA of the pylorus associates with clinical success and improvement of GES after G-POEM. EndoFLIP measurements of pylorus have the potential to be used as a predicting tool of the G-POEM clinical outcome.

  • Performance of radiographic imaging after incomplete colonoscopy for nonmalignant causes in clinical practice
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-04
    Nasim Parsa; Krishna C. Vemulapalli; Douglas K. Rex

    Background and aims CT colonography (CTC) or barium enema (BE) are commonly ordered to complete colorectal imaging after an incomplete colonoscopy. We evaluated the sensitivity of radiographic studies performed for this purpose in clinical practice outside of clinical trials. Methods Adult patients referred to an expert endoscopist for incomplete colonoscopy because of a redundant colon or a difficult sigmoid and who underwent prior radiographic imaging between July 2001 and July 2019 were identified. None of the patients had a malignant obstruction as the cause of incomplete colonoscopy. Data on polyp size, location and pathology were obtained from colonoscopy and radiology reports. Identified polyps on imaging and colonoscopy were matched based on polyp size and location. Results Among 769 patients referred for incomplete colonoscopy, we identified 65 with a radiographic examination performed within 36 months of colonoscopy at our center. Per-patient sensitivity for CTC was suboptimal (70%) and was very low for BE (26.7%). Per-polyp sensitivity for both CTC and BE was poor (23.8% and 7.6%). Quality of the examination did not seem to affect procedure sensitivity. Conclusions Radiographic imaging after incomplete colonoscopy for reasons other than malignant obstruction had poor sensitivity for polyps. Patients with incomplete colonoscopies should be considered for repeat colonoscopy by an expert.

  • Diagnostic yield of EUS-guided through-the-needle biopsy in pancreatic cysts: a meta-analysis
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-01
    Antonio Facciorusso; Valentina Del Prete; Matteo Antonino; Vincenzo Rosario Buccino; Sachin Wani

    Background and Aims There is currently limited evidence supporting the use of endoscopic ultrasound-guided through-the-needle biopsy for sampling pancreatic cystic lesions. The aim of this meta-analysis was to provide a pooled estimate of the diagnostic performance of through-the-needle biopsy for sampling of pancreatic cysts. Methods A bibliographic search on the main databases was performed through September 2019. Pooled effects were calculated using a random-effects model by means of DerSimonian and Laird test. The primary outcome was sample adequacy. Additional endpoints were diagnostic accuracy, optimal histological core procurement, mean number of needle passes, pooled specificity, and sensitivity. Adverse event rates were also analyzed. Results Eleven studies enrolling 490 patients were included. Eight articles compared through-the-needle biopsy to cytology/cystic fluid analysis. Most patients were female, and body/tail was the most frequent location of cystic lesions. Sample adequacy with through-the-needle biopsy was 85.3% (78.2%-92.5%) and subanalysis was performed according to cyst morphology, size, and location confirmed the above reported result. Through-the-needle biopsy clearly outperformed fine-needle aspiration both in terms of sample adequacy (odds ratio, 4.83; 95% CI, 1.63-14.31; p=0.004) and diagnostic accuracy (odds ratio, 3.44; 95% CI, 1.32-8.96; p=0.01). Pooled diagnostic accuracy rate, sensitivity and specificity of through-the-needle biopsy were 78.8%, 82.2%, and 96.8%, respectively. A mean of 3.121 (2.98-3.25) passes through the cyst was needed to obtain adequate histological samples. The incidence rates of mild bleeding and pancreatitis were 4% and 2%, respectively. Conclusion Our meta-analysis speaks in favor of the use of through-the-needle biopsy as a safe and effective tool in EUS-guided tissue acquisition of pancreatic cysts.

  • Nonvariceal upper GI hemorrhage after percutaneous coronary intervention for acute myocardial infarction: a national analysis over 11 months
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-02-01
    Mohammad Bilal; Ronald Samuel; Mazen K. Khalil; Shailendra Singh; Sreeram Parupdui; Marwan S. Abougergi

    Background and Aims Nonvariceal upper GI hemorrhage (NVUGIH) is a feared adverse event after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We aimed to determine the incidence of NVUGIH after PCI for AMI and its impact on mortality, morbidity, and healthcare resource utilization over 11 months. Methods We used the Nationwide Readmission Database 2014. Inclusion criteria were (1) a principal diagnosis of ST or non-ST elevation myocardial infarction, (2) in-hospital PCI, and (3) admission in January. Exclusion criteria were age less than 18 years and elective admission. The primary outcome was 11-month incidence of NVUGIH. Secondary outcomes were 11-month mortality rate, prolonged mechanical ventilation (PMV), shock, upper endoscopy, length of stay (LOS), and total hospitalization costs and charges. Independent risk factors for NVUGIH were identified using multivariate logistic regression analysis. Results A total of 22,669 patients were included in the study. The mean age was 63.8 (63.4-64.1) years and 31.7% of patients were female. The 11-month incidence of NVUGIH was 1.6%. The onset of NVUGIH was associated with an increase in 11-months mortality rate (adjusted odds ratio [aOR], 1.94; 95% CI, 1.01-3.72; p=0.04). The upper endoscopy, shock and PMV rates were 72%, 6.2%, and 1.9%, respectively. In total, 26,532 days were associated with NVUGIH, with a total healthcare in-hospital economic burden of $17.6 million. Independent predictors of NVUGIH were female gender, Charlson comorbidity score, and length of stay. Conclusions The 11-month incidence of NVUGIH among patients who undergo PCI for AMI is 1.6%. NVUGIH has a substantial impact on mortality, morbidity, and in-hospital healthcare resource utilization.

  • Endoscopic submucosal dissection with suturing for the treatment of weight regain after gastric bypass: outcomes and comparison with traditional transoral outlet reduction (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-31
    Pichamol Jirapinyo; Diogo T.H. de Moura; Christopher C. Thompson

    Background and Aims Although traditional transoral outlet reduction (TORe) involves argon plasma coagulation (APC) before endoscopic suturing, modified endoscopic submucosal dissection (ESD) has also been used. This study aims to evaluate the safety and efficacy of modified ESD-TORe in comparison with traditional APC-TORe. Methods This was a retrospective study of prospectively collected data of patients who underwent modified ESD-TORe and APC-TORe for weight regain after Roux-en-Y gastric bypass (RYGB). Our outcomes were (1) technical success, adverse events as categorized by the ASGE lexicon, and percent total weight loss (TWL) at 6 and 12 months, and (2) patients who underwent ESD-TORe were matched 1:3 based on gastrojejunal anastomosis (GJA) and pouch sizes to those who underwent APC-TORe. TWLs were compared. A linear regression was performed to control for any confounders. Results Nineteen RYGB patients underwent ESD-TORe. Technical success rate was 100%. There were no severe adverse events. At 6 and 12 months, patients experienced 13.4±6.6 % and 12.1±9.3% TWL, respectively (p<0.05 for both). Nineteen ESD-TORe patients were also matched to 57 APC-TORe patients based on GJA and pouch sizes. At 12 months, the ESD-TORe group experienced greater weight loss compared with the APC-TORe group (12.1±9.3% TWL versus 7.5±3.3 TWL (p=0.036)). On regression analysis, ESD remained a significant predictor of %TWL at 12 months after controlling for age, sex, BMI, weight regain and years from RYGB (β=5.99, p=0.02). Conclusion Combining endoscopic tissue dissection with suturing providers greater and more durable weight loss for patients with weight regain after RYGB.

  • Surgical and endoscopic management options for patients with GERD based on proton pump inhibitor symptom response: recommendations from an expert U.S. panel
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-31
    Andrew J. Gawron; Reginald Bell; Barham K. Abu Dayyeh; F.P. Buckley; Kenneth Chang; Christy M. Dunst; Steven A. Edmundowicz; Blair Jobe; John C. Lipham; Dan Lister; Marcia Irene Canto; Michael S. Smith; Anthony A. Starpoli; George Triadafilopoulos; Thomas J. Watson; Erik Wilson; John E. Pandolfino; Alexander Kaizer; Rena Yadlapati

    Background and Aims The objective of this study was to examine expert opinion and agreement on the treatment of distinct GERD profiles, from a surgical and therapeutic endoscopy perspective. Methods We used the RAND/University of California, Los Angeles Appropriateness Method over 6 months (July 2018 to January 2019) to assess the appropriateness of antireflux interventions among foregut surgeons and therapeutic gastroenterologists. Patients with primary atypical or extraesophageal symptoms were not considered. Patient scenarios were grouped according to their symptom response to PPI therapy. The primary outcome was appropriateness of an intervention. Results Antireflux surgery with laparoscopic fundoplication (LF) and magnetic sphincter augmentation (MSA) were ranked as appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication (TIF) was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. Radiofrequency energy was not ranked as appropriate for complete or partial responders. There was lack of agreement between surgery and interventional gastroenterology groups on the appropriateness of LF and MSA for PPI nonresponders. Rankings for PPI nonresponders were similar when results from impedance-pH testing on PPI therapy were available, except that LF and MSA were not ranked as appropriate for PPI nonresponders if the impedance-pH study was negative. Conclusions This work highlights areas of agreement for invasive therapeutic approaches for GERD and provides impetus for further interdisciplinary collaboration and trials to compare and generate novel and effective treatment approaches and care pathways, including the role of impedance-pH testing in PPI nonresponders.

  • Repeated EUS-FNA of pancreatic masses after nondiagnostic or inconclusive results: systematic review and meta-analysis
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-30
    Andrea Lisotti; Leonardo Frazzoni; Lorenzo Fuccio; Marta Serrani; Anna Cominardi; Franco Bazzoli; Pietro Fusaroli

    Background and Aims EUS-guided fine-needle aspiration (EUS-FNA) is the criterion standard for the diagnosis of solid pancreatic lesions. Several studies assessed the role of repeat EUS-FNA (rEUS-FNA) after an inconclusive examination. Our aim was to evaluate the pooled diagnostic accuracy of rEUS-FNA after nondiagnostic result. Methods We conducted systematic research on electronic databases (MEDLINE, PubMed, EMBASE) and meta-analysis to obtain pooled sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio. Summary ROC curve was used to calculate area under the curve. Subgroup analysis was used to assess the role of rapid on-site evaluation (ROSE). Results Twelve studies (505 patients) were included. Sensitivity was 77% (66%–86%) and specificity 98% (78%–100%); positive and negative predictive values were 99% (98%-100%) and 61 (60%-63%), respectively. At 73% of disease prevalence (pre-test probability), positive rEUS-FNA increased the disease probability to 99%, whereas negative result decreased the disease probability to 39%. The sensitivity was 83% (64%-93%) and specificity 98% (80%-100%) when ROSE was available and 65% (57%-73%) and 94% (31%-100%) when not available. The number-needed-to-diagnose was 1.2 (1.1-2.3) and 1.7 (1.4-8.3) in ROSE+ and ROSE- cases, respectively. The number of correctly diagnosed cases increased from 6 (1-7) to 8 (4-9) out of 10 patients without and with ROSE, respectively. Conclusions This study objectively substantiated the added value of rEUS-FNA for the diagnosis of solid pancreatic masses, in case of a previous nondiagnostic or inconclusive result. Moreover, our data suggested that ROSE may be beneficial in this setting, as it increased the proportion of definitive diagnoses.

  • Family history of colorectal cancer and prevalence of advanced colorectal neoplasia in asymptomatic screened populations in different age groups
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-29
    Masau Sekiguchi; Yasuo Kakugawa; Keiko Nakamura; Minori Matsumoto; Yutaka Tomizawa; Yoshitaka Murakami; Yutaka Saito; Takahisa Matsuda

    Background and Aims The clinical significance of a family history (FH) of colorectal cancer (CRC) in first-degree relatives (FDRs) in CRC screening stratified by different age groups of screened individuals is not fully understood. We investigated the relationship between FH and the presence of advanced colorectal neoplasia (ACN) in screened individuals in different age groups. Methods Data from screened individuals aged 40 to 54 years (n=2,263) and 55 to 69 years (n=2,621) who underwent their first-ever screening colonoscopy were analyzed. The relationship between FH and ACN was examined, and a multivariate logistic regression analysis incorporating other baseline characteristics was performed. Results Among individuals aged 40 to 54 years, the prevalence of ACN was significantly higher in 249 individuals with affected FDRs than in those without (5.6% vs 1.6%; P<0.01), with an adjusted OR of 3.7 (95% confidence interval, 1.9–7.0; P<0.01), and the prevalence was particularly high in those having FDRs with CRC mortality (7.3%). Among individuals aged 55 to 69 years, the prevalence of ACN was not significantly different between 291 individuals with affected FDRs and those without (5.8% vs 5.8%; P=0.95); however, individuals with 2 FDRs with CRC affection and mortality showed a high prevalence of ACN (17.4% and 42.9%, respectively). Conclusions An FH of CRC in FDRs was associated with a higher prevalence of ACN in younger individuals with a particularly high impact of the FH of CRC mortality. In contrast, the impact of FH was weaker in older individuals except those having 2 FDRs with CRC affection or mortality.

  • Endoscopic gastric body plication for the treatment of obesity: technical success and safety of a novel technique (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-28
    Pichamol Jirapinyo; Christopher C. Thompson

    Background and Aims Primary obesity surgery endoluminal (POSE) is a primary endoscopic bariatric therapy focusing on gastric remodeling. The original POSE procedure involves placement of full-thickness plications in the fundus. Here we aim to assess the feasibility, safety, and efficacy of a novel POSE procedure that involves plications of only the gastric body to reduce the width and length of the stomach. Methods This was a pilot study of patients who underwent a distal POSE procedure with gastric body plications for the treatment of obesity. Outcomes included technical success rate, serious adverse event (SAE) rate and efficacy of this novel POSE procedure at inducing weight loss and improving obesity-related comorbidities. Results Ten patients (6 female, age 52±20) underwent a distal POSE procedure. Baseline BMI was 38.1±6.2 kg/m2. The technical success rate was 100%. An average of 21±4 plications were placed per case (6±2 for distal belt, 10±3 for suspenders, 4±2 for proximal belt, and 3±1 for fillers). The gastroesophageal junction (GEJ) was pulled distally by 3.0±1.6 cm. The gastric body was shortened by 11.0±5.1 cm, representing a 59% reduction. The SAE rate was 0%. At 6 months, the patients experienced 15.0±7.1% total weight loss (TWL), respectively. All patients (100%) achieved at least 5% TWL, and 8 patients (80%) achieved at least 25% excess weight loss. Hypertension, diabetes, GERD, and obstructive sleep apnea improved after the procedure. Conclusion This novel POSE procedure, focusing on gastric body plication and sparing the fundus, is technically feasible and appears to be safe and effective for the treatment of obesity.

  • The use of rapid reading software to reduce capsule endoscopy reading times while maintaining accuracy
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-22
    Sabina Beg; Ewa Wronska; Isis Araujo; Begona González Suárez; Ekaterina Ivanova; Evgeny Fedorov; Lars Aabakken; Uwe Seitz; Jean-Francois Rey; Jean-Christophe Saurin; Roberto Tari; Tim Card; Krish Ragunath

    Backgrounds and Aims A typical capsule endoscopy case generates tens of thousands of images, with abnormalities often confined to a just few frames. Omni Mode is a novel EndoCapsule software algorithm (Olympus), which proposes to intelligently remove duplicate images while maintaining accuracy in lesion detection. Methods This prospective multicenter study took place across 9 European centers. Consecutive, unselected capsule endoscopy cases were read conventionally in normal mode, with every captured frame reviewed. Cases were subsequently anonymized and randomly allocated to another center where these were read using Omni Mode. Detected lesions and reading time were recorded, with findings compared between both viewing modes. The clinical significance of lesions was described according to the P-classification (P0, P1, and P2). Where a discrepancy in lesion detection in either mode was found, expert blinded review at a consensus meeting was undertaken. Results The patient population undergoing capsule endoscopy had a mean age of 49.5 years (range 18 - 91), with the investigation of anemia or gastrointestinal bleeding accounting for 71.8% of cases. The average small-bowel transit time was 4 hours and 26 minutes. The mean reading time in normal mode was 42.5 minutes. The use of Omni Mode was significantly faster (P<0.0001), with an average time saving of 24.6 minutes (95% CI, 22.8 - 26.9).A total of 2172 lesions were identified, which were classified according to the P-classification as P0 (1234), P1 (656), and P2 (237). Lesions were identified using both reading modes in 40% (n=936). 1186 lesions were identified by either normal or Omni Mode alone. Normal mode interpretation was associated with 647 lesions being missed, giving an accuracy of 0.70. Omni Mode interpretation led to 539 lesions being missed, with an accuracy of 0.75. There was no significant difference in clinical conclusions made between either reading mode. Conclusion This study shows that capsule endoscopy reading times can be reduced by an average of 40%, without any reduction in clinical accuracy.

  • Second-generation magnetically controlled capsule gastroscopy with improved image resolution and frame rate: a randomized controlled clinical trial (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-22
    Bin Jiang; Yang-Yang Qian; Jun Pan; Xi Jiang; Yuan-Chen Wang; Jia-Hui Zhu; Wen-Bin Zou; Wei Zhou; Zhao-Shen Li; Zhuan Liao

    Background and Aims Compared with conventional endoscopy, magnetically controlled capsule gastroscopy (MCCG) can be further optimized in gastric examination time and complete visualization of upper gastrointestinal (UGI) mucosa. The second-generation MCCG (MCCG-2) was developed with higher image resolution and adaptive frame rate, and we aimed to evaluate its clinical availability for UGI examination in this study. Methods Consecutive patients undergoing MCCG examination between May to June 2019 were prospectively enrolled and randomized to swallow the first-generation MCCG (MCCG-1) or MCCG-2 in a 1:1 ratio. The main outcomes included visualization of the esophagus and duodenum, operation related parameters, image quality, maneuverability, detection of lesions, as well as safety evaluation. Results Eighty patients were enrolled. In MCCG-2 group, frames captured for esophageal mucosa and Z-line were 171.00 and 2.00, significantly increased from those in MCCG-1 group with 97.00 and 0.00 (P=0.002 and 0.028). The gastric examination time was shortened from 7.78±0.97 min to 5.27±0.74 min (P<0.001), with the total running time of capsule extended from 702.83 min to 1001.99 min (P<0.001). MCCG-2 also greatly improved the image quality (P<0.001) and maneuverability (P<0.01). No statistical difference existed in the detection of lesions between the 2 groups, and no adverse events occurred. Conclusions MCCG-2 showed better performance in mucosal visualization, examination duration and maneuverability, making better diagnosis of UGI diseases a possibility.

  • Valuing Innovative Endoscopic Techniques: Prophylactic Clip Closure After Endoscopic Resection of Large Colon Polyps
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-19
    Eric D. Shah; Heiko Pohl; Douglas K. Rex; Michael B. Wallace; Seth D. Crockett; Shannon J. Morales; Linda A. Feagins; Ryan Law

    Background And Aims Clip closure of the mucosal defect after resecting large (≥20 mm) nonpedunculated colorectal polyps reduces postprocedure bleeding and is cost-saving to payers. Clip costs are not reimbursed by payers, posing a major barrier to adoption of this technique in the community. We aimed to determine appropriate clip costs to support broader use of this procedure in practice. Methods We performed budget impact analysis using our recent decision analytic model, comparing prophylactic clip closure to no clip closure on national cost and outcomes data, to determine the maximum feasible clip price while maintaining cost-savings in practice. Sensitivity analyses were performed on important clinical factors. Results In the original model, the baseline postprocedure bleeding risk was 6.8%, increasing cost-of-care by $614.11 averaged among all patients undergoing large polyp resection without clip closure. Prophylactic clip closure of only large right-sided polyps reduced postprocedure bleeding risk by 70.7% but resulted in cost-saving only if price of clips was $100 or less. Comparatively, prophylactic clip closure of large left-sided polyps had no clinical benefit and was not cost-saving. Clip closure strategies focused on only extra-large polyps (≥40 mm), or patients taking antithrombotics regardless of polyp characteristics, were only minimally cost-saving. Cost-savings and maximum tolerated clip prices depended on medical comorbidity, which directly influences the costs-of-care to manage postprocedure bleeding. Conclusions Prophylactic clip closure after endoscopic resection of large colon polyps, particular those in the right colon segment, is cost-saving, but requires clip costs less than $100. Translating these findings into practice requires gastroenterology practices to obtain reimbursement from payers for improved clinical outcomes and to align commercial clip prices with this clinical indication.

  • Outcomes of early endoscopic intervention for pancreatic necrotic collections: a matched case-control study
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-18
    Nicholas Oblizajek; Naoki Takahashi; Sevda Agayeva; Fateh Bazerbachi; Vinay Chandrasekhara; Michael Levy; Andrew Storm; Todd Baron; Suresh Chari; Ferga C. Gleeson; Randall Pearson; Bret T. Petersen; Santhi Swaroop Vege; Ryan Lennon; Mark Topazian; Barham K. Abu Dayyeh

    Background and Aims Pancreatic necrosis (PN) may be categorized as an acute necrotic collection (ANC) or walled-off necrosis (WON) based on complete encapsulation by a wall and collection age (≤ or > 4 weeks). Endoscopic intervention of WON has become the standard of care, but little is known regarding the safety and efficacy of endoscopic intervention of PN ≤4 weeks from disease onset. Methods Retrospective review of medical records and imaging studies of all patients undergoing early endoscopic intervention of PN between 2008 and 2018 at one referral center. Patients who underwent previous interventional treatment were excluded. Control WON patients were matched to early intervention cases. Primary outcome was defined as resolution of the collection after endoscopic treatment, without surgery. Results Nineteen patients with early intervention were identified. The most common indication for intervention was infection. Median age of these collections at the time of initial endoscopic intervention was 23 days (range 15-27), and all collections had a partial or complete wall discernable on contrast-enhanced CT. Eleven patients underwent concurrent endoscopic necrosectomy. Primary outcome was achieved in all of the early intervention group. Total duration of therapy was longer for early intervention compared with controls (103 vs 69 days, p=0.042), with no mortality and similar adverse event rates compared with controls. Conclusions Endoscopic intervention of PN in the third and fourth weeks of illness appears effective and safe when a partial collection wall is present on cross-sectional imaging studies, with outcomes paralleling those reported for intervention of WON.

  • Short-term outcomes of double pyloromyotomy versus single pyloromyotomy at peroral endoscopic pyloromyotomy in treatment of gastroparesis (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-17
    Mohamed M. Abdelfatah; Baiwen Li; Neil Kapil; Alan Noll; Lianyong Li; Hui Luo; Huimin Chen; Liang Xia; Xiangbo Chen; Vailshali Patel; Parit Mekaroonkamol; Julia Massaad; Steven Keilin; Qiang Cai

    Background and Aims Gastroparesis (Gp) is a chronic debilitating disorder rising in prevalence and hospitalizations. Gastric peroral endoscopic pyloromyotomy (POP or GPOEM) is a novel technique in the treatment of refractory Gp. Despite the initial promising results of GPOEM, one-third of patients do not exhibit any clinical response. Furthermore, loss of clinical response was reported in several studies. No response or loss of response after GPOEM may be related to inadequate myotomy. The aim of our study is to examine whether double pyloromyotomy at GPOEM is superior to single pyloromyotomy. Method A retrospective case-controlled study of patients who underwent GPOEM for refractory Gp at our tertiary care institution between June 2015 and March 2018 was performed. Because the follow-up time for the single myotomy group was much longer than that of the double-myotomy group, we matched the length of follow-up for the single myotomy group to that of the double myotomy group. The outcomes were measured by the changes in Gp cardinal symptom index (GCSI) before and 3 to 6 months after the procedure. Adverse events and other procedural and clinical parameters were also compared. Results Ninety patients underwent GPOEM (55 single and 35 double pyloromyotomy) Mean age was 47 ±14 years old, mean duration of symptoms was 5.3 ± 4.4 years. Average GCSI was 3.8 before the GPOEM and the average GCSI 6 months after procedure was 1.8 37 out of 55 (67%) patients underwent single pyloromyotomy achieved clinical response compared with 30 out of 35 (86%) patients receiving double pyloromyotomy. There were no significant differences among procedure time, postoperative pain or length of hospital stay between the 2 groups. There was no difference in adverse events in the 2 pyloromyotomy groups. Conclusion Double pyloromyotomy is a safe and feasible technique during GPOEM. Clinical success was higher in patients undergoing double pyloromyotomy compared with single pyloromyotomy in this nonrandomized, short-term follow-up study. Long-term studies are needed to further confirm our results.

  • Clinical outcomes of adults with eosinophilic esophagitis with severe stricture
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-16
    Jooho P. Kim; Gabriel Weingart; Brent Hiramoto; Dyanna L. Gregory; Nirmala Gonsalves; Ikuo Hirano

    Background & Aims Eosinophilic esophagitis (EoE) is an inflammatory disease of the esophagus that has been steadily increasing in prevalence over the past three decades. The prognosis of EoE patients presenting with severe esophageal strictures is poorly understood. The aim of this study is to describe the clinical outcomes of EoE patients with severe stricture and identify factors associated with a greater likelihood of improvement in esophageal diameter. Methods This study is a retrospective chart review of patients with EoE with severe stricture, defined as an esophageal diameter of 10 millimeters (mm) or less at one point in their disease course. Each patient’s clinical course was followed during standard of care follow-up with medical or dietary therapy in conjunction with repeated esophageal dilations. Multivariate regression analysis was performed to determine which variables are associated with endoscopic response, defined by an improvement in esophageal diameter to 13 mm and to 15 mm. Results From a cohort of 1091 adults with EoE, severe strictures were identified in 66 patients (7%). Of the 66 patients, 59 (89%) achieved an esophageal diameter of ≥13 mm, and 43 (65%) to ≥15 mm. Initial diameter (OR, 1.58; 95% CI, 1.06-2.35; P=0.025) and histologic remission (OR, 34.97; 95% CI, 6.45-189.49; P<0.0001) were significantly associated with achieving a ≥15 mm diameter. Age at diagnosis, gender, and number of months to maximum esophageal diameter were not associated with achieving either diameter. Conclusions The majority of patients with EoE with severe stricture experienced improvement in esophageal diameter to ≥15 mm with treatment, suggesting that the currently available treatment options are effective for patients with severe strictures. The most significant factors associated with disease reversibility are initial esophageal diameter and histologic remission.

  • Cold snare piecemeal endoscopic mucosal resection of large sessile colonic polyps ≥20 mm (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-15
    Dileep Mangira; Karla Cameron; Koen Simons; Simon Zanati; Richard LaNauze; Spiro Raftopoulos; Gregor Brown; Alan Moss

    Background and Aims Conventional endoscopic mucosal resection (EMR) using hot snare is the standard of care for resection of large (≥20 mm) nonmalignant sessile colonic polyps. Serious adverse events are predominantly due to electrocautery. This could potentially be avoided by cold snare piecemeal EMR (CSP-EMR). The study aimed to evaluate the safety and efficacy of CSP-EMR of sessile colonic polyps sized ≥20 mm. Methods All cases of CSP-EMR at 5 Australian academic hospitals for sessile polyps ≥20 mm over a 2-year period, from January 2016 to December 2017 were identified retrospectively. Efficacy was defined as the absence of residual or recurrent polyp tissue during the first surveillance colonoscopy (SC1) and second surveillance colonoscopy (SC2). Clinically significant intraprocedural or delayed adverse events and surveillance colonoscopy findings were assessed by reviewing medical records. Results CSP-EMR was performed on 204 polyps sized ≥20 mm in 186 patients (men 33.8%; median age 68 years). SC1 for 164 (80.4%) polyps at a median interval of 150 days showed residual or recurrent polyp in 9 cases (5.5%; 95% CI, 3%-11%). SC2 for 113 (72.9%) polyps at a median interval of 18 months showed late residual or recurrent polyp in 4 cases (3.5%; 95% CI, 0.9%-8.5%) after a normal SC1. Intra-procedural bleeding was successfully treated in 4 (2.2%) patients, 7 (3.8%) patients experienced self-limiting clinically significant post-EMR bleeding (CSPEB) and 1 patient (0.5%) required overnight observation for nonspecific abdominal pain that resolved spontaneously. None experienced other adverse events. Conclusion CSP-EMR of sessile colonic polyps ≥20 mm is technically feasible, effective, and safe. The adverse event rate and polyp recurrence rate were low. Randomized or large prospective trials are required to confirm the noninferiority and improved safety of CSP-EMR compared with conventional EMR, and to further determine the polyp morphologies that are best suited for CSP-EMR.

  • High-definition colonoscopy for improving adenoma detection: a systematic review and meta-analysis of randomized controlled studies
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-15
    Georgios Tziatzios; Paraskevas Gkolfakis; Lazaros Dimitrios Lazaridis; Antonio Facciorusso; Giulio Antonelli; Cesare Hassan; Alessandro Repici; Prateek Sharma; Douglas K. Rex; Konstantinos Triantafyllou

    Background and Aims Previous meta-analysis showed marginal benefit of high-definition white-light endoscopy (HD-WLE) over standard-definition (SDC) colonoscopy for adenoma detection, but with residual uncertainty due to inclusion of nonrandomized studies. We aimed to further assess the effect of HD-WLE on adenoma detection by including only randomized controlled trials (RCTs). Methods A literature search was performed for RCTs evaluating HD-WLE versus SDC in terms of adenoma, advanced adenoma, and serrated sessile adenoma detection rates as well as mean number of adenomas (MAC), advanced adenomas (MAAC), and sessile serrated adenomas per colonoscopy (MSSAC). The effect size on study outcomes is presented as risk ratio (RR; 95% CI) or mean difference (MD; 95% CI). We assessed the strength of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Six RCTs involving 4594 individuals (HD-WLE 2323; SDC 2271) were included. Clinical indications were screening (1 study), positive FOBT and personal/family history of colorectal cancer (1 study), and mixed indications (4 studies). Withdrawal time was similar between the 2 arms (MD, -0.06; 95% CI, -0.25 to 0.12; p=0.50). Adenoma detection rate was significantly higher in the HD-WLE compared with SDC arm (40% vs 35%; RR, 1.13; 95% CI, 1.05-1.22; p=0.001; I2=0%; GRADE: low). This effect was consistent for advanced and sessile serrated adenoma detection rates (RR, 1.33; 95% CI, 1.03-1.72; p=0.03; I2=0%; GRADE: low and RR, 1.55; 95% CI, 1.05-2.28; p=0.03; I2=0%; GRADE: low, respectively). On the contrary, the difference was not significant for MAC, MAAC, and MSSAC. Conclusions Meta-analysis of RCT data support the use of HD-WLE in clinical practice, although the additional benefit is limited.

  • Efficacy of EUS-guided celiac plexus neurolysis compared with medication alone for unresectable pancreatic cancer in the oxycodone/fentanyl era: A prospective randomized control study
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-15
    Yoshihide Kanno; Shinsuke Koshita; Kaori Masu; Takahisa Ogawa; Hiroaki Kusunose; Toji Murabayashi; Toshitaka Sakai; Fumisato Kozakai; Kei Ito

    Background and aims The efficacy of celiac plexus neurolysis (CPN) with EUS guidance has not been confirmed in the era of developed opioids. The aim of this study was to evaluate the efficacy of EUS-guided CPN (EUS-CPN) for patients with pancreatic cancer-associated pain to compare medication using oxycodone and/or fentanyl with and without EUS-CPN. Methods In this randomized control study involving patients who underwent EUS-CPN and those who did not, pain, quality of life (QOL), and opioid consumption were compared. Standard medicinal treatment using oxycodone and/or fentanyl was performed for both groups. The primary endpoint was defined as the pain evaluated by using a 0 to10 visual analogue scale (VAS) 4 weeks after the baseline. Results For 48 registered patients, the outcomes of 24 patients in the EUS-CPN group and 22 patients in the control group were analyzed. EUS-CPN was successfully performed and did not induce severe procedure-related adverse events for all patients in the EUS-CPN group. Although the average pain VAS scores for both groups significantly decreased in comparison with the baseline, they were not statistically different between the groups at week 4 (1.3 ± 1.3 for the EUS-CPN group vs 2.3 ± 2.3 for the control group, P = 0.10). There was no statistical difference nor tendency in favor of EUS-CPN at evaluation points of weeks 1, 2, 8, and 12. Moreover, the average VAS scores for QOL and the average opioid consumption between the groups were not different at all evaluation points. Conclusions EUS-CPN for patients with pancreatic cancer-associated pain did not appear to improve pain, QOL, nor opioid consumption in comparison to those who did not undergo EUS-CPN being medicated with oxycodone/fentanyl. Although EUS-CPN can be an option, it was not found to have a large enough impact to be routinely performed for all patients with pain.

  • Outcomes of patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-15
    Fouad Otaki; Gene K. Ma; Anna Krigel; Ross A. Dierkhising; Jason T. Lewis; Christopher H. Blevins; Naveen P. Gopalakrishnan; Adharsh Ravindran; Michele L. Johnson; Cadman L. Leggett; Denis Wigle; Kenneth K. Wang; Gary W. Falk; Julian A. Abrams; Hiroshi Nakagawa; Anil K. Rustgi; Timothy C. Wang; Charles J. Lightdale; Prasad G. Iyer

    Background and Aims The treatment of submucosal (T1b) esophageal adenocarcinoma (EAC) remains in evolution with some evidence supporting endoscopic management of low-risk lesions. Using a multicenter cohort, we evaluated outcomes of patients with T1b EAC and predictors of survival. Methods Patients diagnosed between 2001 and 2016 with T1b EAC were identified from 3 academic medical centers in the United States. Demographic, clinical and outcome data were collected. Outcomes studied included overall and cancer-free survival. Cox proportional hazards models were constructed to assess independent predictors of survival. Results One hundred forty-one patients were included, of whom 68 (48%) underwent esophagectomy and 73 (52%) were treated endoscopically. Most (85.8%) patients had high-risk histological features. Thirty-day operative mortality was 2.9%. Median follow-up in the esophagectomy and endoscopic cohorts was 49.4 and 43.4 months, respectively. Patients treated endoscopically were older with higher comorbidity scores. 46 (63%) patients treated endoscopically achieved histologic remission. Nineteen (26.0%) patients also received chemoradiation. Five-year overall survival rates in the surgical and endoscopic cohorts were 89% and 59% respectively whereas 5-year cancer free survival rates were 92 and 69%. Presence of high-risk histological features was associated with reduced overall survival. Conclusions In this large multicenter study of patients with T1b EAC, esophagectomy was associated with improved overall but not cancer-free survival. High-risk histological features were associated with poorer survival.

  • Results of duodenoscope culture and quarantine after manufacturer-recommended cleaning process
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-13
    Jacob Mark; Karin Underberg; Robert Kramer

    Background and Aims Outbreaks of infections transmitted by duodenoscopes have prompted changes to duodenoscope cleaning protocols. However, little is known about effectiveness of clinical cleaning practices. We present culture data after duodenoscope manufacturer-recommended high-level disinfection (HLD) and quarantine. Methods Our institution adopted a combination of manufacturer-recommended cleaning with the CDC-recommended culture and quarantine in 2015. Duodenoscopes (Olympus models TJF-Q180V, TJF-160, PJF-160) underwent HLD according to the manufacturer’s reprocessing manual protocols after use. Two culture specimens were then obtained using a sterile brush from the distal tip, including elevator mechanism, and by flushing sterile water through the working channel. Duodenoscopes were quarantined until cultures resulted. Positive cultures were defined as >10 colony-forming units (CFUs) of low-concern organisms, or any CFUs of high-concern organisms according to CDC recommendations. If either culture specimen was positive, the process was repeated until cultures were negative. Data were collected from December 2015 to July 2018. Results There were 140 instances of duodenoscope cleaning with 280 specimens. Twenty-eight of 234 (12%) initial culture specimens (18% of cultured duodenoscopes) were positive. Five of 36 (14%) second cultures were positive. Two of 8 (25%) third cultures were positive. Ninety-eight percent of organisms cultured were gram positive. There were 8 instances when both culture methods (brushing and flush) were positive; otherwise only one method was positive. There were 11 instances (8%) of duodenoscope removals from quarantine before final culture results. No patients had infections related to ERCP. Conclusions 18% of duodenoscopes had a positive culture after initial HLD. Only 3% were gram negative bacteria. Repeated HLD was 86% and 75% effective at eliminating initial and repeat positive cultures respectively. Initial HLD per manufacturer recommendations is not always effective at eliminating bacterial contamination. Additional steps are necessary to decrease risks of duodenoscope-transmitted infections.

  • Artificial intelligence using convolutional neural networks for real-time detection of early esophageal neoplasia in Barrett’s esophagus (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-11
    Rintaro Hashimoto; James Requa; Dao Tyler; Andrew Ninh; Elise Tran; Daniel Mai; Michael Lugo; Nabil El-Hage Chehade; Kenneth J. Chang; Williams E. Karnes; Jason Samarasena

    Background and Aims The visual detection of early esophageal neoplasia (high-grade dysplasia and T1 cancer) in Barrett’s esophagus (BE) with white-light and virtual chromoendoscopy still remains challenging. The aim of this study was to assess whether a convolutional neural artificial intelligence network can aid in the recognition of early esophageal neoplasia in BE. Methods Nine hundred sixteen images from 65 patients were collected of histology-proven early esophageal neoplasia in BE containing high-grade dysplasia or T1 cancer. The area of neoplasia was masked using image annotation software. Nine hundred nineteen control images were collected of BE without high-grade dysplasia. A convolutional neural network (CNN) algorithm was pretrained on ImageNet and then fine-tuned with the goal to provide the correct binary classification of “dysplastic” or “nondysplastic.” We developed an object detection algorithm that drew localization boxes around regions classified as dysplasia. Results The CNN analyzed 458 test images (225 dysplasia/233 nondysplasia) and correctly detected early neoplasia with sensitivity of 96.4%, specificity of 94.2% and accuracy of 95.4%. With regard to the object detection algorithm for all images in the validation set, the system was able to achieve a mean-average-precision (mAP) of 0.7533 at an intersection over union (IOU) of 0.3 Conclusion In this pilot study, our AI model was able to detect early esophageal neoplasia in Barrett’s esophagus images with high accuracy. In addition, the object detection algorithm was able to draw a localization box around the areas of dysplasia with high precision and at a speed that allows for real-time implementation.

  • Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: A systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-10
    Fahima Dossa; Braeden Medeiros; Christine Keng; Sergio A. Acuna; Nancy N. Baxter

    Background and Aims Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (+/- short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (+/- short-acting opioids) in patients undergoing colonoscopy. Methods We systematically searched MEDLINE, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (+/- short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMD) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models. Results Nine studies of 1,427 patients met inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (+/- short-acting opioids) (SMD, 0.54; 95% CI, 0.30-0.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, 0.15; 95% CI, 0.04-0.27). Recovery time was shorter in the propofol group (SMD, 0.41; 95% CI, 0.08-0.74). The median difference in recovery time was 3 minutes 6 seconds shorter in patients sedated with propofol. Conclusions Both propofol and midazolam (+/- short-acting opioids) result in high patient satisfaction and appear safe for use in colonoscopy. There are marginal benefits to propofol, including improvements in satisfaction and recovery time.

  • Deep learning algorithm detection of Barrett’s neoplasia with high accuracy during live endoscopic procedures: a pilot study (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-10
    Albert J. de Groof; Maarten R. Struyvenberg; Kiki N. Fockens; Joost van der Putten; Fons van der Sommen; Tim G. Boers; Sveta Zinger; Raf Bisschops; Peter H. de With; Roos E. Pouw; Wouter L. Curvers; Erik J. Schoon; Jacques J.G.H.M. Bergman

    Background & Aims We assessed the preliminary diagnostic accuracy of a recently developed computer aided detection (CAD) system for detection of Barrett’s neoplasia during live endoscopic procedures. Methods The CAD system was tested during endoscopic procedures of 10 patients with nondysplastic Barrett’s esophagus (NDBE), and 10 patients with confirmed Barrett’s neoplasia. White-light endoscopy images were obtained at every 2-centimeter level of the Barrett’s segment, and immediately analyzed by the CAD system, providing instant feedback to the endoscopist. At every level, 3 images were evaluated by the CAD system. Outcome measures were as follows: (1) diagnostic performance of the CAD system per-level and per-patient, defined as accuracy, sensitivity, and specificity. Ground truth was established by expert assessment and corresponding histopathology; and (2) concordance of 3 sequential CAD predictions per-level. Results Accuracy, sensitivity, and specificity of the CAD system in a per-level analyses were 90%, 91%, and 89%, respectively. In total, 9 out of 10 neoplastic patients were correctly diagnosed. The single lesion not detected by CAD, showed NDBE in the endoscopic resection specimen. In only 1 NDBE patient, the CAD system produced false positive predictions. In 75% of all levels, the CAD system produced 3 concordant predictions. Conclusion This is one of the first studies to evaluate a CAD system for Barrett’s neoplasia during live endoscopic procedures. The system detected neoplasia with high accuracy, with only a small number of false-positive predictions, and with a high concordance rate between separate predictions. The CAD system is thereby ready for testing in larger, multicenter trials.

  • Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-08
    Jennifer Siu; Kaitlin Fuller; Ashlie Nadler; Robyn Pugash; Lawrence Cohen; Konrado Deutsch; Danny Enepekides; Irene Karam; Zain Husain; Kelvin Chan; Simron Singh; Ian Poon; Kevin Higgins; Bin Xu; Antoine Eskander

    Background and Aims Metastasis to the gastrostomy site in patients with upper aerodigestive tract (UADT) malignancies is a rare but devastating adverse event that has been poorly described. Our aim was to determine the overall incidence and clinicopathological characteristics observed with development of gastrostomy site metastasis in patients with UADT cancers. Methods Systematic review and meta-analysis of 6,138 studies retrieved from MEDLINE, EMBASE, CINAHL, and the Cochrane Register after being queried for studies including gastrostomy site metastasis in patients with UADT malignancies. Results The final analysis included 121 studies. Pooled analysis showed overall event rate gastrostomy site metastasis to be 0.5% (95% CI, 0.4%-0.7%). Subgroup analysis showed an event rate of 0.56% (95% CI, 0.40%-0.79%) with the pull technique and 0.29% (95% CI, 0.15%-0.55%) with the push technique. Clinicopathological characteristics observed with gastrostomy site metastasis included: late stage disease (T3/T4) (57.8%), positive lymph node status (51.2%), and no evidence of systemic disease (M0) (62.8%) at initial presentation. Average time from gastrostomy placement to diagnosis of metastasis was 7.78 ± 4.9 months, average tumor size on detection was 4.65 (SD, 2.02) cm, and average length of survival was 7.26 (SD, 6.23) months. Conclusions Gastrostomy site metastasis is a rare, but serious adverse event that occurs at an overall rate of 0.5%, particularly in patients with advanced stage disease, and is observed with a very poor prognosis. These findings emphasize a need for clinical practice guidelines to include a regular assessment of the PEG site and highlight the importance of detection and management of gastrostomy site metastasis by the multidisciplinary care oncology team.

  • Endoscopic hand-suturing is feasible, safe, and might contribute in reducing bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-07
    Osamu Goto; Tsuneo Oyama; Hiroyuki Ono; Akiko Takahashi; Mitsuhiro Fujishiro; Yukata Saito; Seiichiro Abe; Mitsuru Kaise; Katsuhiko Iwakiri; Naohisa Yahagi

    Background and Aims Endoscopic hand-suturing (EHS) provides secure intraluminal mucosal closure and should decrease the risk of adverse events after gastric endoscopic submucosal dissection (ESD). We prospectively investigated the feasibility and safety of EHS after gastric ESD, particularly for preventing post-ESD bleeding. Methods Patients scheduled for gastric ESD at 3 institutions were prospectively recruited. Just after ESD, the mucosal defect was closed by EHS. The primary outcome was endoscopic assessment of adequately sustained closure of the defect on postoperative day (POD) 3. Endoscopy was performed to assess maintenance of the closure for the primary outcome. During postoperative week 3 to 4, the patients were interviewed as outpatients about any occurrence of delayed bleeding. Results Data from 30 patients (15 each who did or did not take antithrombotic agents [ATAs]) were analyzed. Mucosal closure by EHS was completed in 29 of 30 cases (97%) and was well maintained on POD 3 in 25 cases (84%). Emergency endoscopy was required for major postoperative bleeding in 3 cases (10%), including the one in which suturing had been incomplete. Excluding one patient with a remnant stomach, the other 24 with sustained closure had no bleeding, regardless of whether they did or did not take ATAs (0/11 and 0/13, respectively). No serious adverse events occurred during EHS. Conclusions The results show that EHS is feasible and safe with favorable outcomes. Provided that mucosal suturing is successfully completed and sustained, post-ESD bleeding can be decreased even in patients undergoing antithrombotic therapy.

  • The use of small-bowel capsule endoscopy in cases of equivocal celiac disease
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-07
    Stefania Chetcuti Zammit; Annalisa Schiepatti; Imran Aziz; Matthew Kurien; David S. Sanders; Reena Sidhu

    Background and aims Seronegative villous atrophy (SNVA), raised intraepithelial lymphocytes (IELs) and crypt hyperplasia on duodenal histology can be secondary to celiac disease (CD) or other causes such as medications or infections. Our aims were to assess the role of small-bowel capsule endoscopy (SBCE) in these patients and to ascertain whether findings on SBCE at diagnosis can predict disease outcome. Methods Patients (177) with SNVA, IELs +/-crypt hyperplasia on duodenal histology were studied. These patients all had an equivocal diagnosis of CD. Results Overall, 56 (31.6%) patients had a positive SBCE. Most patients had disease affecting the proximal third of the small bowel (SB) (33, 58.9%). The diagnostic yield of SBCE was 40.0% (22 patients), 51.4% (18 patients), 27.0% (10 patients), and 14.0% (7 patients) in patients with an unknown cause for SNVA (SNVA-UO), patients with SNVA who responded to a gluten-free diet (SNVA-CD), SNVA-KNOWN CAUSE, patients with railed intraepithelial lymphocytes +/- crypt hyperplasia respectively. In SNVA-UO, SBCE at diagnosis was more likely to be positive in patients with persistent SNVA (10, 90.9%) and persistent SNVA with lymphoproliferative features (4, 80.4%) than patients with spontaneous resolution of SNVA (8, 20.5%) (p=0.0001). All patients in the SNVA-CD group who eventually developed adverse events had a positive SBCE (p=0.022). They also had more extensive SB disease than those without adverse events (50% vs 1% p=0.002). More-extensive SB disease on SBCE correlated with a higher SNVA-related mortality in patients with SNVA-UO and SNVA-CD (p=0.019). Severity of histology did not correlate with mortality (p=0.793). Conclusions A positive SBCE at diagnosis predicts a worse outcome. More importantly, more extensive disease in these patients is associated with poor survival. Targeting patients with extensive disease at diagnosis with more aggressive therapy can help to improve prognosis.

  • EUS-directed transenteric ERCP in non–Roux-en-Y gastric bypass surgical anatomy patients (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-07
    Yervant Ichkhanian; Juliana Yang; Theodore W. James; Todd H. Baron; Shayan Irani; John Nasr; Reem Z. Sharaiha; Ryan Law; Andreas Wannhoff; Mouen A. Khashab

    Background And Aims Enteroscopy-assisted ERCP is challenging in patients with surgically altered upper gastrointestinal anatomy. This study evaluated a novel procedure, EUS-directed transenteric ERCP (EDEE), in de novo creation of enteroenteric (EE) anastomosis for the performance of ERCP in non-RYGB patients. Patients And Methods This was a multicenter retrospective study involving 7 centers between January 2014 and October 2018. Primary outcome was clinical success (completion of EDEE and ERCP with intended interventions). Secondary outcomes included technical success and rate/severity of adverse events (AEs). Results A total of 18 patients (mean age 63 years, 13 female) were included. The most common type of surgical anatomy was Whipple (10/18) and Roux-en-Y hepaticojejunostomy (RYHJ) (6/18). Technical success rate of EUS-guided lumen-apposing metal stent (LAMS) placement was 100%. Technical success rate of ERCP was 94.44% (17/18). A total of 14 patients underwent separate session EDEE with a median of 21 (IQR 11.5-36) days between the 2 procedures. Median total procedure time was 111 (IQR 81-192) minutes. Clinical success and AEs occurred in 17 (94.4%) and 1 (5.6%; abdominal pain) patients, respectively, during a median follow-up of 88 (IQR 54-142) days. Conclusion This study suggests that EDEE using LAMSs is feasible and safe in patients with non-RYGB surgical anatomy and complex pancreaticobiliary pathologies.

  • Increased risk of high-grade dysplasia and colorectal cancer in inflammatory bowel disease patients with recurrent low-grade dysplasia
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-07
    Michiel E. de Jong; Heleen Kanne; Loes H.C. Nissen; Joost P.H. Drenth; Lauranne A.A.P. Derikx; Frank Hoentjen

    Background and Aims The impact of recurrent low-grade dysplasia (LGD) on the risk of advanced neoplasia (high-grade dysplasia and colorectal cancer) in inflammatory bowel disease (IBD) patients is unknown. In addition, it is unclear how a neoplasia-free period after index LGD impacts this risk. We aimed (1) to determine whether recurrent LGD is a risk factor for advanced neoplasia development and (2) to evaluate the impact of a neoplasia-free time period after initial LGD diagnosis on the advanced neoplasia risk. Methods This is a nationwide cohort study using data from the Dutch National Pathology Registry (PALGA) to identify all IBD patients with LGD and ≥1 follow-up colonoscopy between 1991 and 2010 in the Netherlands. Follow-up data were collected until January 2016. We compared the cumulative advanced neoplasia incidence between patients with and without recurrent LGD at first follow-up colonoscopy using log-rank analysis. We subsequently studied the impact of a neoplasia-free period after initial LGD on the advanced neoplasia incidence. Results We identified 4,284 IBD patients with colonic LGD with a median follow-up of 6.4 years. Recurrent low-grade dysplasia was a risk factor for advanced neoplasia (HR, 1.66; 95% CI, 1.22-2.25; p=0.001). A neoplasia-free period of >3 years after LGD protected against advanced neoplasia. Conclusions Recurrent LGD at follow-up colonoscopy after initial LGD was a risk factor for advanced neoplasia. A neoplasia-free period of >3 years after initial LGD was associated with a reduced subsequent risk of advanced neoplasia.

  • Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-07
    Bram D. Vermeulen; Merle de Zwart; Jasmijn Sijben; Elsa Soons; Lucie van der Weerd; Daniele Arese; Daan W. von den Hoff; Vincenzo Craviotto; Adriaan C.I.T.L. Tan; Marcel J.M. Groenen; Auke Bogte; Alessandro Repici; Manon C.W. Spaander; Peter D. Siersema

    Background and Aims Endoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BES). This study aimed to establish risk factors for refractory BES and assess long-term clinical outcomes of ED. Methods We performed a retrospective study in 891 patients who underwent ED from 2003 to 2018 for BES. We searched electronic medical records in 6 tertiary care centers in the Netherlands for data on clinical outcome of ED. Median follow-up was 39 months. The primary endpoint was risk factors for refractory BES, defined as factors associated with an increased number of ED sessions during follow-up. Secondary endpoints included time from first to last ED session and adverse events. Results Dilation up to 13-15 mm was associated with a higher number of ED sessions than 16-18 mm (5.0 vs 4.1; hazard rate [HR]=1.4; p=0.001). Compared with peptic strictures, anastomotic (4.9 vs 3.6; HR=2.1; p<0.001), radiation (5.0 vs 3.6; HR=3.0; p<0.001), caustic (7.2 vs 3.6; HR=2.7; p<0.001) and postendotherapy (3.9 vs 3.6; HR=1.8; p=0.005) strictures were associated with a higher number of ED sessions. After 1 year of follow-up, the proportions of patients who remained free of ED was 75% in anastomotic, 71% in radiation, 70% in peptic, 83% in postendotherapy and 62% in caustic strictures. Esophageal perforation occurred in 23 (0.4%) ED sessions, in 22 (2.4%) patients. Conclusions More than 60% of patients with BES remain free of ED after 1 year of follow-up. Because dilation up to 16 to 18 mm diameter was associated with fewer ED sessions during follow-up, we suggest that clinicians should consider dilation up to at least 16 mm to reduce the number of ED sessions in these patients.

  • Diagnostic findings and long-term prognosis in children with anemia undergoing GI endoscopies
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-07
    Marleena Repo; Teemu Rajalahti; Pauliina Hiltunen; Antti Sotka; Laura Kivelä; Heini Huhtala; Katri Kaukinen; Katri Lindfors; Kalle Kurppa
  • Dose response for argon plasma coagulation in the treatment of weight regain after Roux-en-Y gastric bypass
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-03
    Pichamol Jirapinyo; Diogo T.H. de Moura; William Y. Dong; Galileu Farias; Christopher C. Thompson

    Background and Aims Argon plasma coagulation (APC) of the gastrojejunal anastomosis (GJA) is effective in treating weight regain after Roux-en-Y gastric bypass (RYGB). This study aims to compare efficacy of different APC settings at treating weight regain. Methods This was a single-center retrospective study of RYGB patients who underwent APC from 2014 to 2018 for weight regain. Patients receiving only low-dose APC (45-55 watts) or high-dose APC (70-80 watts) were compared. Primary outcome was the difference in percent total weight loss (%TWL) between groups at 6 and 12 months after the last treatment. Secondary outcomes were technical success, adverse events (AEs) and predictors of weight loss at 12 months. Results Two hundred seventeen patients met inclusion criteria and underwent 411 APC sessions. Of these, 116 (53.5%) patients underwent 267 low-dose APC (2.4±1.5 sessions/patient) and 101 (46.5%) patients underwent 144 high-dose APC (1.4±0.7 sessions/patient). Follow-up rates were 82.9% and 75.3% at 6 and 12 months. At 6 months, the low- and high-dose groups experienced 7.3±6.6% and 8.1±7.4% TWL, respectively (p=0.41). At 12 months, the low- and high-dose groups experienced 5.1±8.5% and 9.7±10.0% TWL, respectively (p=0.008). Technical success was 100%. The overall AE rate was 8.0%, with the most common one being GJA stenosis (4.6%). The GJA stenosis rate was similar between the low- and high-dose groups (3.0% vs 7.6%, p=0.06). High-dose APC remained a significant predictor of greater weight loss at 1 year after controlling for confounders. Conclusion APC is effective at treating weight regain after RYGB, with higher-watt APC being associated with greater weight loss.

  • Blue-light imaging and linked-color imaging improve visualization of Barrett’s neoplasia by nonexpert endoscopists
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-03
    Albert J. de Groof; Kiki N. Fockens; Maarten R. Struyvenberg; Roos E. Pouw; Bas L.A.M. Weusten; Erik J. Schoon; Nahid Mostafavi; Raf Bisschops; Wouter L. Curvers; Jacques J. Bergman

    Background and Aims Endoscopic recognition of early Barrett’s neoplasia is challenging. Blue-light imaging (BLI) and linked-color imaging (LCI) may assist endoscopists in appreciation of neoplasia. Our aim was to evaluate BLI and LCI for visualization of Barrett’s neoplasia in comparison with WLE alone, when assessed by nonexpert endoscopists. Methods In this web-based assessment, corresponding white-light endoscopy (WLE), BLI, and LCI images of 30 neoplastic Barrett’s lesions were delineated by 3 expert endoscopists to establish ground truth. These images were then scored and delineated by 76 nonexpert endoscopists from 3 countries and with different levels of expertise, in 4 separate assessment phases with a washout period of 2 weeks. Assessments were as follows: Assessment 1: WLE only; Assessment 2: WLE+BLI; Assessment 3: WLE+LCI; Assessment 4: WLE+BLI+LCI. The outcomes were (1) appreciation of macroscopic appearance and ability to delineate lesions (VAS-scores); (2) preferred technique (ordinal scores); and (3) assessors’ delineation performance in terms of overlap with expert ground truth. Results Median VAS scores for phases 2 to 4 were significantly higher than in phase 1 (P < 0.001). Assessors preferred BLI and LCI over WLE for appreciation of macroscopic appearance (P < 0.001) and delineation (P < 0.001). Linear mixed-effect models showed that delineation performance increased significantly in phase 4. Conclusions The use of BLI and LCI has significant additional value for the visualization of Barrett’s neoplasia, when used by nonexpert endoscopists. Assessors appreciated the addition of BLI and LCI better than the use of WLE alone. This addition furthermore led to improved delineation performance, thereby allowing for better targeted biopsy acquisition.

  • Comparison of underwater endoscopic mucosal resection and endoscopic submucosal dissection of rectal neuroendocrine tumors (with videos)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-03
    Sung Sil Park; Kyung Su Han; Bun Kim; Byung Chang Kim; Chang Won Hong; Dae Kyung Sohn; Hee Jin Chang

    Background and Aims For rectal neuroendocrine tumors (NETs) with size ≤10 mm, endoscopic resection is the first choice of treatment. However, because rectal NETs usually invade the submucosal layer, achieving R0 resection is difficult. Endoscopic submucosal dissection (ESD) has a high R0 resection rate, and underwater endoscopic mucosal resection (UEMR) was recently introduced to secure a negative resection margin easily and safely. The aim of this study was to evaluate the efficacy and safety of UEMR versus ESD for rectal NETs ≤10 mm in size. Methods This retrospective observational study enrolled 115 patients with rectal NETs sized ≤10 mm who underwent ESD or UEMR between January 2015 and July 2019 at the National Cancer Center, Korea. The differences in R0 resection rate, adverse event rate, and procedure time between the ESD and UEMR groups were evaluated. Results Of the included 115 patients, 36 underwent UEMR and 79 underwent ESD. R0 resection rate was not different between the UEMR and ESD groups (UEMR vs ESD, 86.1% vs 86.1%, p=0.996). Procedure time was significantly shorter with UEMR (UEMR vs ESD, 5.8 ± 2.9 vs 26.6 ±13.4 minutes, p< 0.001). Two patients (2.5%, 2/79) and none experienced adverse events in the ESD and UEMR groups, respectively; however, this difference was not statistically significant. Conclusion UEMR is a safe and effective technique that should be considered when removing small rectal NETs. Further studies are warranted to define its role when compared with ESD.

  • A clinical model predicting the risk of esophageal high-grade lesions in opportunistic screening: a multicenter real-world study in China
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-03
    Zhen Liu; Chuanhai Guo; Yujie He; Yun Chen; Ping Ji; Zhengyu Fang; Fenglei Li; Yuefei Tang; Xiujian Chen; Ping Xiao; Chengwen Wang; Weihua Yin; Hai Guo; Mengfei Liu; Yaqi Pan; Fangfang Liu; Ying Liu; Zhonghu He; Yang Ke

    Background and Aims Prediction models for esophageal squamous cell carcinoma are not common, and no model, which targets a clinical population, has previously been developed and validated. We aimed to develop a prediction model for estimating the risk of high-grade esophageal lesions for application in clinical settings, and to validate the performance of this model in an external population. Methods This model was developed based on results of endoscopic evaluation of 5,624 outpatients in one hospital in a high-risk region in northern China, and was validated using 5,765 outpatients who had undergone endoscopy in another hospital in a non-high-risk region in southern China. Predictors were selected with unconditional logistic regression analysis. The Akaike information criterion was used to determine the final model structure. Discrimination was estimated using the area under the receiver operating characteristic curve (AUC). Calibration was assessed using a calibration plot with an intercept and slope. Results The final prediction model contained 5 variables, including age, smoking, BMI, dysphagia, and retrosternal pain. This model generated an AUC of 0.871 (95%CI, 0.842-0.946) in the development set, with an AUC of 0.862 after bootstrapping. The 5-variable model was superior to a single age model. In the validation population, the AUC was 0.843 (95% CI, 0.793-0.894). This model successfully stratified the clinical population into 3 risk groups and showed high ability for identifying concentrated groups of cases. Conclusions Our model for esophageal high-grade lesions has a high predictive value. It has the potential for application in clinical opportunistic screening to aid decision-making for both healthcare professionals and individuals.

  • Endoscopic suturing promotes healing of mucosal defects after gastric endoscopic submucosal dissection: endoscopic and histological analyses in in vivo porcine models (with video)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-03
    Teppei Akimoto; Osamu Goto; Motoki Sasaki; Mari Mizutani; Koshiro Tsutsumi; Yoshiyuki Kiguchi; Atsushi Nakayama; Motohiko Kato; Ai Fujimoto; Yasutoshi Ochiai; Tadateru Maehata; Mitsuru Kaise; Katsuhiko Iwakiri; Naohisa Yahagi
  • Multitarget stool DNA testing for the prevention of colon cancer: outcomes in a large integrated healthcare system
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2020-01-02
    Nimish Vakil; Kristin Ciezki; Nadia Huq; Maharaj Singh
  • Impact of en bloc resection on long-term outcomes after endoscopic mucosal resection: a matched cohort study
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-28
    David J. Tate; Mayenaaz Sidhu; Iddo Bar-Yishay; Lobke Desomer; Gregor Brown; Luke F. Hourigan; Eric YT. Lee; Alan Moss; Spiro Raftopoulos; Rajvinder Singh; Stephen J. Williams; Simon Zanati; Nicholas Burgess; Michael J. Bourke

    Background and Aims Residual or recurrent adenoma (RRA) is the major limitation of piecemeal endoscopic mucosal resection (p-EMR) for large colonic laterally spreading lesions (LSLs) ≥20 mm. En bloc EMR (e-EMR) has been shown to achieve low rates of RRA but specific procedural and long-term outcomes are unknown. Our aim was to compare long-term outcomes of size-matched LSLs stratified by whether they were resected e-EMR or p-EMR. Methods Data from a prospective tertiary referral multicenter cohort of large LSLs referred for EMR over a 10-year period were analyzed. Outcomes were compared between sized-matched LSLs (20-25 mm) resected by p-EMR or e-EMR. Results Five hundred seventy LSLs met the inclusion criteria of which 259 (45.4%) were resected by e-EMR. The risk of major deep mural injury (DMI) was significantly higher in the e-EMR group (3.5% vs 1.0%, p=0.05), whereas rates of other intraprocedural adverse events did not differ significantly. Five out of 9 (56%) LSLs, with endoscopic features of submucosal invasion (SMI), resected by e-EMR were saved from surgery. RRA at first surveillance was lower in the e-EMR group (2.0% vs 5.7%, p=0.04) but this difference was negated at subsequent surveillance. Rates of surgical referral were not significantly different between the groups at either surveillance interval. Conclusion In a large prospective multicentre cohort when comparing e-EMR against p-EMR for lesions ≤25 mm in size of similar morphology, e-EMR offered no additional advantage for predicted-benign LSLs. It was however associated with an increased risk of major DMI. Thus, en bloc resection techniques should be reserved for lesions suspicious for invasive disease.

  • Prospective Multicenter Study to Evaluate Capsule Endoscopy Competency using a Validated Assessment Tool
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-26
    Elizabeth Rajan; Manuel Martinez; Emmanuel Gorospe; Badr Al Bawardy; Akira Dobashi; Kristin C. Mara; Stephanie L. Hansel; David H. Bruining; Joseph A. Murray; Cadman L. Leggett; Vandana Nehra; Prasad G. Iyer; Shabana F. Pasha; Jonathan A. Leighton; Arthur D. Shiff; Suryakanth R. Gurudu; Laura E. Raffals; Crystal Lavey; Chien-Huan H. Chen

    Background and Aims Capsule endoscopy (CE) is an established, noninvasive modality for examining the small bowel. Minimum training requirements are primarily based on guidelines and expert opinion. A validated assessment tool of CE competence is lacking. In this prospective, multicenter study we determined the minimum number of CE procedures required to achieve competence during gastroenterology fellowship; validated a capsule competency test (CapCT); and evaluated any correlation between CE competence and endoscopy experience. Methods We included second- and third-year gastroenterology fellows from 3 institutions between 2013 and 2018 to participate in a structured CE training program with supervised CE interpretation. Fellows completed the CapCT with a maximal score of 100. For comparison, expert faculty completed the same CapCT. Trainee competence was defined as a score >90% compared with the mean expert score. Fellows were tested after 15, 25, and 35 supervised CE interpretations. CapCT was validated using expert consensus and item analysis. Data were collected on number of prior endoscopies. Results A total of 68 trainees completed 102 CapCTs. Fourteen CE experts completed the CapCT with a mean score of 94. Mean scores for fellows after 15, 25, and 35 cases were 83, 86, and 87, respectively. Fellows with at least 25 interpretations achieved a mean score >84 in all 3 institutions. CapCT item analysis showed high interobserver agreement among expert faculty (k=0.85). There was no correlation between scores and number of endoscopies performed. Conclusion After a structured CE training program, gastroenterology fellows should complete a minimum of 25 supervised CE interpretations before assessing competence using the validated CapCT, regardless of endoscopy experience.

  • Impact of EUS-guided microforceps biopsy and needle-based confocal laser endomicroscopy on the diagnostic yield and clinical management of pancreatic cystic lesions
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-25
    Antonio R. Cheesman; Hongfa Zhu; Xiaoyan Liao; Arnold H. Szporn; Nikhil A. Kumta; Satish Nagula; Christopher J. DiMaio

    Background and Aims EUS-guided microforceps biopsy (MFB) and needle-based confocal laser endomicroscopy (nCLE) are emerging diagnostic tools for pancreatic cystic lesions (PCLs). There is a paucity of data regarding their performance and impact. The aim of this study was to compare diagnostic outcomes and changes in clinical management resulting from MFB and nCLE use in PCLs. Methods Single-center retrospective study of patients with PCLs who underwent combined EUS-guided FNA, MFB, and nCLE. Primary outcomes included diagnostic yield (specific PCL type) and change in clinical management for each modality compared with the current "composite standard" (CS) obtained by combining clinical, morphologic, cyst fluid cytology, and chemical analysis. Results A total of 44 cysts were studied in 44 patients. Technical success: EUS-FNA 100%, MFB 88.6%, nCLE 97.7%. Adverse events: 1 out of 44 (2.3%, one infected pseudocyst). Diagnostic yield for each individual modality: CS 34.1%, MFB 75.0% (p<0.05 vs CS), nCLE, 84.1% (p<0.05 vs CS). Diagnostic yield for combined tests: CS/MFB 79.5%, CS/nCLE, 88.6%, CS/MFB/nCLE, 93.2% (p=NS). Compared with the CS, the use of MFB, nCLE, and their combination, led to overall change in clinical management in 38.6%, 43.2%, and 52.3% of cases. MFB and nCLE led to an overall increase in discontinuation of surveillance (MFB 34.1% p<0.05, nCLE 31.8%, p<0.05), led by a reduction in the indication for follow-up radiologic or endoscopic studies (MFB 34.1%, p<0.05, nCLE 38.6%, p<0.05). Based on MFB and nCLE, 2 out of 28 (7.1%) and 3 out of 28 (10.7%) patients who would have undergone further surveillance were referred for surgery. Conclusion In the evaluation of PCLs, the use of combined EUS-guided FNA, MFB and nCLE is safe. MFB and nCLE lead to significant improvements in specific PCL diagnosis, which in turn has major impact in clinical management.

  • Optimal stent placement strategy for malignant hilar biliary obstruction: a large multicenter parallel study
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-25
    Ming-Xing Xia; Xiao-Bo Cai; Yang-Lin Pan; Jun Wu; Dao-Jian Gao; Xin Ye; Tian-Tian Wang; Bing Hu

    Background and Aims The endoscopic management of malignant hilar biliary obstruction (MHBO) remains extremely challenging without a universal consensus. We compared, for the first time, 4 major modalities aiming to determine the optimal strategy. Methods We reviewed 1239 patients with advanced MHBO who underwent endoscopic stent placement as the primary treatment in 4 tertiary centers. Among them, 633 eligible patients were identified and classified into 4 groups: bilateral metal stent placement (BMS), unilateral metal stent placement (UMS), bilateral plastic stent placement (BPS), and unilateral plastic stent placement (UPS). The outcomes were compared before and after propensity score matching (PSM). Results After PSM, 87, 97, 91, and 81 patients in the BMS, UMS, BPS, and UPS groups, respectively, were matched. The clinical success rates were 98.9%, 83.5%, 71.4%, and 65.4% in the BMS, UMS, BPS, and UPS groups (p<0.001), respectively. The postprocedural cholangitis rates were 8.0%, 17.5%, 26.4%, and 29.6% (p=0.002), respectively. The median symptom-free stent patency was 9.6, 6.8, 4.6, and 4.2 months (p<0.001), respectively. The mean total interventions required was 1.2±0.5, 1.7±0.8, 2.0±1.4, and 1.9±1.3 (p<0.001), respectively. The median (95% confidence interval) overall survival (OS) was 7.1 (6.0-8.2), 4.4 (3.8-4.9), 4.1 (2.9-5.2), and 2.7 (1.8-3.7) months (p=0.001), respectively. Compared with plastic stent placement, metal stent placement achieved higher success in all outcome parameters (p≤0.001). Bilateral stent placement was superior to unilateral stent placement in terms of clinical success (p=0.024), stent patency (p=0.018), and OS (p=0.040). Conclusions If technically possible, dual metal stent placement could be a preferred palliation for inoperable MHBO, and unilateral metal stent placement be the second option.

  • Clinical importance of cold polypectomy during the insertion phase in the left side of the colon and rectum: a multicenter randomized controlled trial (PRESECT STUDY)
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-24
    Akira Teramoto; Nobuo Aoyama; Chikara Ebisutani; Tsuguhiro Matsumoto; Hirohisa Machida; Shiei Yoshida; Nobufumi Uchima; Takahiro Utsumi; Tomomasa Tochio; Daizen Hirata; Mineo Iwatate; Santa Hattori; Mikio Fujita; Wataru Sano; Yasushi Sano

    Background and Aims Colorectal polyps are often detected during insertion phase of colonoscopy, but they are commonly removed during withdrawal phase. We aimed to investigate the clinical advantages of instant removal of colorectal polyps during insertion phase to determine the appropriate strategy for polyps detected upon insertion. Methods This prospective multicenter randomized trial targeted patients with at least one left-sided polyp <10 mm in size detected unintentionally upon endoscope insertion from April 2018 to March 2019. Patients were allocated to the following 2 groups: the Study group consisted of patients who had polyp removal instantly upon insertion, and the Control group comprised patients who had the endoscope inserted to the cecum first and the polyps were removed subsequently upon withdrawal. Carbon dioxide gas insufflation and cold polypectomy were applied to minimize the influences of polypectomy on endoscope insertion. Twenty advanced endoscopists from 7 community-based institutions participated in this trial. Results Out of 1451 patients enrolled, 220 patients were eligible for full assessment. Mean total procedure time was significantly shorter in the study group (18.9 vs 22.3 min, p<0.001). Mean pure cecal intubation time and number of polyps per patient were similar between the 2 groups. In the control group, among 107 polyps found during insertion, 48 polyps (45.8%) required reinspection, and 7 (6.5%) polyps were completely missed with an average reinspection time of approximately 3 minutes. Conclusion Polypectomy during the insertion phase in the colon and rectum significantly shortens the total procedure time and eliminates all missed polyps without experiencing any disadvantages.

  • Outcomes of Delayed Endoscopic Management for Esophageal Soft Food Impactions
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-24
    Timothy Krill; Ronald Samuel; Andrew Vela; Felippe Marcondes; Jenine Zaibaq; Praveen Guturu; Sreeram Parupudi

    Background and Aims Food impactions are a common reason for emergent upper endoscopy. Current guidelines call for urgent upper endoscopy (within 24 hours) for food impactions without complete esophageal obstruction and emergent endoscopy (within 6 hours) for those with complete esophageal obstruction. Multiple adverse events can arise from esophageal foreign bodies. Cases with longer delays from symptom onset to presentation have been associated with higher rates of surgical intervention. However, data on esophageal soft food impactions are scant. We set out to determine differences in outcomes for food impactions intervened on within 12 hours versus over 12 hours of symptom onset. Methods A retrospective review of medical records was conducted to identify patients who presented to our hospital with an esophageal soft food impaction and underwent an esophagogastroduodenoscopy (EGD) between January 2010 and January 2018. Patients were divided into 2 groups based on the timing from symptom onset to EGD. An EGD within 12 hours was considered an early intervention and over 12 hours was considered a delayed intervention. Patients who had ingested bones or hard objects were not included. Primary outcomes studied were rates of aspiration, admission, local esophageal adverse events, and 30-day all-cause mortality. Results We identified 110 patients with a soft food impaction who underwent an EGD. Forty- two patients had an early intervention and 68 a delayed intervention. There were no differences in basic demographics and comorbidities. Additionally, it was found that there were no differences in rates of local esophageal adverse events, aspiration, admission, or 30-day mortality. Multivariate analysis revealed endoscopic accessory use was associated with increased odds of local esophageal adverse events (OR = 6.37; p=0.01). Conclusion The overall rates of serious adverse events in esophageal soft food impactions is low. Delayed intervention is not associated with increased adverse events or 30-day mortality compared with early intervention. However, accessory use is associated with higher adverse event rates.

  • A new staining method using methionyl-tRNA synthetase 1 antibody for brushing cytology of bile duct cancer
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-24
    Sung Ill Jang; Nam Hoon Kwon; Beom Jin Lim; Ji Hae Nahm; Joon Seong Park; Chang Moo Kang; So Ra Park; Su Yun Lee SD; Beom Sik Kang; Sunghoon Kim; Dong Ki Lee
  • Safety and Histologic Outcomes of Endoscopic Submucosal Dissection with a Novel Articulating Knife for Esophageal Neoplasia
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-20
    Juan Reyes Genere; Harshith Priyan; Tarek Sawas; Yuri Hanada; Kavel Visrodia; Liam Zakko; Prasad G. Iyer; Louis Michel Wong Kee Song; Kenneth K. Wang

    Background and Aims Treatment of large esophageal neoplasia is gradually evolving from piecemeal to en bloc resections. Endoscopic submucosal dissection (ESD) is known to achieve more complete resections than piecemeal endoscopic mucosal resection (EMR) for large lesions, yet it remains underused in the West due to technical and safety concerns with traditional electrosurgical knives. We aimed to evaluate a novel endoscopic articulating knife (ESD-AR) to determine its safety and efficacy for large esophageal neoplasms in comparison with EMR. Method We retrospectively studied clinically indicated cases of ESD-AR and EMR for esophageal lesions that were 15 mm or greater. All EMR cases had at least 3 simultaneous EMRs to adequately compare resection area. Rates of perforation, gastrointestinal bleeding, technical performance, and pre- and postendoscopic resection diagnoses were evaluated. Results A total of 72 ESD-AR and 72 widespread EMR cases were evaluated for the following indications: Barrett’s esophagus (56%), adenocarcinoma (36%), squamous nodularity (2%), and squamous cell carcinoma (6%). There were no statistical differences in age, sex, Barrett’s esophagus length, and lesion or resection size between the 2 groups. No perforations occurred. Two adverse events were recorded with ESD-AR and none occurred with EMR (3% vs 0%, P=0.50); these were associated with anticoagulation use (P=0.04) and greater resection area (P=0.02). There were more upgraded diagnoses post-ESD versus EMR (27% vs 12%, P=0.05). Conclusion ESD performed with an articulating knife by an experienced endoscopist has a comparable safety profile to widespread EMR for large esophageal neoplasia and may have advantages for diagnostic staging.

  • Comparison between fine-needle biopsy and fine-needle aspiration for EUS-guided sampling of subepithelial lesions: a meta-analysis
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-07-30
    Antonio Facciorusso; Sumsum P. Sunny; Valentina Del Prete; Matteo Antonino; Nicola Muscatiello
  • Endotherapy of postcholecystectomy biliary strictures with multiple plastic stents: long-term results in a large cohort of patients
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-06-05
    Guido Costamagna; Andrea Tringali; Vincenzo Perri; Pietro Familiari; Ivo Boškoski; Federico Barbaro; Rosario Landi
  • Linked color imaging versus narrow-band imaging for colorectal polyp detection: a prospective randomized tandem colonoscopy study
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-07-02
    Wai K. Leung; Chuan-guo Guo; Michael K.L. Ko; Elvis W.P. To; Lung Yi Mak; Teresa S.M. Tong; Li-Jia Chen; David Y.K. But; Siu Yin Wong; Kevin S.H. Liu; Vivian Tsui; Frank Y.F. Lam; Thomas K.L. Lui; Ka Shing Cheung; Siu Hung Lo; Ivan F.N. Hung

    Background and Aims Linked color imaging (LCI) is a newly available image-enhanced endoscopy (IEE) system that emphasizes the red mucosal color. No study has yet compared LCI with other available IEE systems. Our aim was to investigate polyp detection rates using LCI compared with narrow-band imaging (NBI). Methods This is a prospective randomized tandem colonoscopy study. Eligible patients who underwent colonoscopy for symptoms or screening/surveillance were randomized in a 1:1 ratio to receive tandem colonoscopy with both colonoscope withdrawals using LCI or NBI. The primary outcome was the polyp detection rate. Results Two hundred seventy-two patients were randomized (mean age, 62 years; 48.2% male; colonoscopy for symptoms, 72.8%) with 136 in each arm. During the first colonoscopy, the polyp detection rate (71.3% vs 55.9%; P = .008), serrated lesion detection rate (34.6% vs 22.1%; P = .02), and mean number of polyps detected (2.04 vs 1.35; P = .02) were significantly higher in the NBI group than in the LCI group. There was also a trend of higher adenoma detection rate in the NBI group compared with the LCI group (51.5% vs 39.7%, respectively; P = .05). Multivariable analysis confirmed that use of NBI (adjusted odds ratio, 1.99; 95% confidence interval, 1.09-3.68) and withdrawal time >8 minutes (adjusted odds ratio, 5.11; 95% confidence interval, 2.79-9.67) were associated with polyp detection. Overall, 20.5% of polyps and 18.1% of adenomas were missed by the first colonoscopy, but there was no significant difference in the miss rates between the 2 groups. Conclusion NBI was significantly better than LCI for colorectal polyp detection. However, both LCI and NBI missed 20.5% of polyps. (Clinical trial registration number: NCT03336359.)

  • Impact of a ring-fitted cap on insertion time and adenoma detection: a randomized controlled trial
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-07-09
    Douglas K. Rex; William R. Kessler; Sashidhar V. Sagi; Nicholas A. Rogers; Monika Fischer; Matthew E. Bohm; John M. Wo; John M. Dewitt; Lee McHenry; Rachel E. Lahr; Meghan P. Searight; Margaret MacPhail; Andrew W. Sullivan; Connor D. McWhinney; Krishna C. Vemulapalli

    Background and Aims Devices for flattening colon folds can improve polyp detection at colonoscopy. However, there are few data on the endoscopic ring-fitted cap (EndoRings; EndoAid, Caesarea, Israel). We sought to compare adenoma detection with EndoRings with that of standard high-definition colonoscopy. Methods This was a single-center, randomized controlled trial of 562 patients (284 randomized to EndoRings and 278 to standard colonoscopy) at 2 outpatient endoscopy units in the Indiana University Hospital system. Adenoma detection was the primary outcome measured as adenoma detection rate (ADR) and adenomas per colonoscopy (APC). We also compared sessile serrated polyp detection rate, insertion times, withdrawal times, and ease of passage through the sigmoid colon. Results EndoRings was superior to standard colonoscopy in terms of APC (1.46 vs 1.06, P = .025), but there were no statistically significant differences in ADR or sessile serrated polyp detection rate. Mean withdrawal time (in patients with no polyps) was shorter and insertion time (all patients) was longer in the EndoRings arm by 1.8 minutes and 0.75 minutes, respectively. One provider had significantly higher detection with Endo-Rings and contributed substantially to the overall results. Conclusions EndoRings can increase adenoma detection without a significant increase in procedure time, but the effect varies between operators. The use of EndoRings slows colonoscope insertion. (Clinical trial registration number: NCT03418662.)

  • An international study on the use of peroral endoscopic myotomy in the management of Zenker’s diverticulum
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-05-10
    Juliana Yang; Stephanie Novak; Michael Ujiki; Óscar Hernández; Pankaj Desai; Petros Benias; David Lee; Kenneth Chang; Bertrand Brieau; Maximilien Barret; Nikhil Kumta; Xianhui Zeng; Bing Hu; Konstantinos Delis; Mouen A. Khashab
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-13
    Andrew C. Storm; Michael J. Levy; Karan Kaura; Barham K. Abu Dayyeh; Sean P. Cleary; Michael L. Kendrick; Mark J. Truty; Eric J. Vargas; Mark Topazian; Vinay Chandrasekhara
  • ASGE guideline on the management of achalasia
    Gastrointest. Endosc. (IF 7.229) Pub Date : 2019-12-13
    Mouen A. Khashab; Marcelo F. Vela; Nirav Thosani; Deepak Agrawal; James L. Buxbaum; Syed M. Abbas Fehmi; Douglas S. Fishman; Suryakanth R. Gurudu; Laith H. Jamil; Terry L. Jue; Bijun Sai Kannadath; Joanna K. Law; Jeffrey K. Lee; Mariam Naveed; Bashar J. Qumseya; Mandeep S. Sawhney; Julie Yang; Sachin Wani

    Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.

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