Adam J. Goodman

Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

Strongyloidiasis: a diagnosis more common than we think.

Strongyloides stercoralis is endemic to many tropical regions; however, there is limited knowledge concerning the clinical implication of this helminth, particularly in urban medical centers. We report a case series of strongyloidiasis in our urban medical center in New York City. Patients over the age of 18 years who were examined in our institution from January 1998 to May 2011 were identified by electronic medical record search using International Classification of Diseases, 9th Revision codes. We identified 22 cases of S. stercoralis. Eleven patients were men and 11 were women, with the average age at diagnosis being 62.4 years. Fourteen patients emigrated from the Caribbean, one from Nepal, five were blacks born in the USA, and two did not have their birthplace documented. The main presenting complaints were diarrhea (9/22), abdominal pain (6/22), vomiting (7/22), and weight loss (8/22). Seventeen patients demonstrated eosinophilia. Four patients were positive for human T-lymphotropic virus-1 antibodies, and three patients were infected with HIV. Diagnosis was made with stool examination (19/22), bronchoalveolar lavage (1/22), gastric biopsy (1/22), and duodenal biopsy (3/22). Among six patients who had upper endoscopy performed, the findings commonly included gastritis and gastric and duodenal ulcers. After treatment, 12/22 showed resolution of symptoms. Although a diagnostic approach tends to start with stool collections, consideration of upper endoscopy with biopsy in symptomatic patients is advisable. The absence of eosinophilia should not deter the clinician from seeking a diagnosis. Although often not done, ascertaining HIV and human T-lymphotropic virus-1 status should be part of the work-up.

Practice patterns in FNA technique: A survey analysis.

AIM To ascertain fine needle aspiration (FNA) techniques by endosonographers with varying levels of experience and environments. METHODS A survey study was performed on United States based endosonographers. The subjects completed an anonymous online electronic survey. The main outcome measurements were differences in needle choice, FNA technique, and clinical decision making among endosonographers and how this relates to years in practice, volume of EUS-FNA procedures, and practice environment. RESULTS A total of 210 (30.8%) endosonographers completed the survey. Just over half (51.4%) identified themselves as academic/university-based practitioners. The vast majority of respondents (77.1%) identified themselves as high-volume endoscopic ultrasound (EUS) (> 150 EUS/year) and high-volume FNA (> 75 FNA/year) performers (73.3). If final cytology is non-diagnostic, high-volume EUS physicians were more likely than low volume physicians to repeat FNA with a core needle (60.5% vs 31.2%; P = 0.0004), and low volume physicians were more likely to refer patients for either surgical or percutaneous biopsy, (33.4% vs 4.9%, P < 0.0001). Academic physicians were more likely to repeat FNA with a core needle (66.7%) compared to community physicians (40.2%, P < 0.001). CONCLUSION There is significant variation in EUS-FNA practices among United States endosonographers. Differences appear to be related to EUS volume and practice environment.

Endoscopic anti-reflux devices (with videos)

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have the potential to affect the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic and a MAUDE (Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched through December 2015 by using the keywords “gastroesophageal reflux disease,” “GERD,” “endoscopic surgery,” “minimally invasive treatment,” “endoscopic treatment,” “radiofrequency,” “radiofrequency energy,” “Stretta,” “endoscopic fundoplication,” “endoscopic incisionless fundoplication,” and “fundoplication.” Reports on Emerging Technologies are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the governing board of the ASGE. These reports are scientific reviews provided solely for educational and informational purposes. These reports on emerging technologies are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

A Nationwide Survey of Gastroenterologists and Their Acquisition of Knowledge

OBJECTIVES:The Gastroenterology (GI) Core Curriculum is a culmination of efforts from the American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy to develop a review of knowledge and skills for those training in a gastrointestinal subspecialty. Fellows are expected to conduct scholarly activity, attend seminars, and read textbooks and syllabus materials. While efforts to standardize education across the nation are welcomed, we sought to ascertain the learning preferences of GI fellows and attending physicians.METHODS:A national online survey was e-mailed to directors of US adult GI programs, who were also asked to invite their colleagues and fellows to participate.RESULTS:While majorities of both fellows and attendings affirmed regular attendance at national conferences, more attendings affirmed that their knowledge was improved by their participation. Asked how they acquire knowledge best, 45 fellows and 67 attendings responded; 42% of attendings favored journal articles, and 40% of fellows favored conferences. More attendings than fellows felt that writing a manuscript and belonging to a GI society improved knowledge.CONCLUSIONS:We believe the Gastroenterology Core Curriculum provides trainees with essential tools for becoming an autonomous gastroenterologist who can appreciate various learning modalities.

The study of bone demineralization and its risk factors in an Afro-Caribbean subset of patients with inflammatory bowel disease.

Introduction Bone demineralization has been increasingly recognized as a disease process concurrent with inflammatory bowel disease (IBD). Racial variation in osteoporosis in IBD patients has been poorly described. We sought to identify the risk factors for demineralization in Afro-Caribbeans (AC) with IBD. Methods A retrospective chart review was performed from a 10-year prospectively collected database of IBD patients seen at an urban medical center. Data on dual-energy X-ray absorptiometry (DXA) scanning, use of steroids, bisphosphonates, calcium, and vitamin D, as well as blood chemistries were collected. Results One hundred and fifteen charts of AC IBD patients were reviewed, of which 24 patients had undergone DXA scanning. Fourteen patients with a T-score of less than −1 were compared with 10 patients with DXA scores of more than −1. Two patients with T-scores of less than −1 had fractures, whereas none were observed in the comparison group (P=0.5). The mean BMI for those with T-scores of less than −1 was 23.9 kg/m2 compared with 31.5 kg/m2 in those with T-scores of more than −1 (P=0.0034). Conclusion Screening for bone demineralization in ethnic populations with IBD is lacking as only 21% of AC IBD patients seen in our institution had undergone a DXA scan. Of those who were scanned, more than half of the patients had T-scores suggestive of bone demineralization. Although those who were obese did not have demineralization, our sample sizes were small and the results from this study should prompt further investigation to determine the prevalence and significance of bone demineralization in minority populations with IBD.

Metastatic signet ring colon cancer in a Caribbean young adult and review of the literature.

Colorectal cancer is the third most common neoplasm diagnosed in the USA, with less than 3% of patients younger than 40 years. Although most of the literature indicates that younger patients present with a higher stage and grade of cancer, mortality is not clearly correlated. Furthermore, the literature pertaining to colorectal cancer in the nonwhite youth is limited. In this case report, we report a case of aggressive colorectal cancer metastasizing in a young Afro-Caribbean woman with no known risk factors. The aim of this report is to raise awareness of this entity in the younger population, particularly in Afro-Caribbeans, which remains a highly understudied group compared with the rest of the US population.

Biliary and pancreatic lithotripsy devices

Background and Aims Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). Methods In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. Results Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. Conclusions Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Clinical outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts: A large multicenter study

Background and study aims Data on clinical outcomes of endoscopic drainage of debris-free pseudocysts (PDF) versus pseudocysts containing solid debris (PSD) are very limited. The aims of this study were to compare treatment outcomes between patients with PDF vs. PSD undergoing endoscopic ultrasound (EUS)-guided drainage via transmural stents. Patients and methods Retrospective review of 142 consecutive patients with pseudocysts who underwent EUS-guided transmural drainage (TM) from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TM technical success, treatment outcomes (symptomatic and radiologic resolution), need for endoscopic re-intervention at follow-up, and adverse events (AEs). Results TM was performed in 90 patients with PDF and 52 with PSD. Technical success: PDF 87 (96.7 %) vs. PSD 51 (98.1 %). There was no difference in the rates for endoscopic re-intervention (5.5 % in PDF vs. 11.5 % in PSD; P = 0.33) or AEs (12.2 % in PDF vs. 19.2 % in PSD; P = 0.33). Median long-term follow-up after stent removal was 297 days (interquartile range [IQR]: 59 – 424 days) for PDF and 326 days (IQR: 180 – 448 days) for PSD (P = 0.88). There was a higher rate of short-term radiologic resolution of PDF (45; 66.2 %) vs. PSD (21; 51.2 %) (OR = 0.30; 95 % CI: 0.13 – 0.72; P = 0.009). There was no difference in long-term symptomatic resolution (PDF: 70.4 % vs. PSD: 66.7 %; P = 0.72) or radiologic resolution (PDF: 68.9 % vs. PSD: 78.6 %; P = 0.72) Conclusions There was no difference in need for endoscopic re-intervention, AEs or long-term treatment outcomes in patients with PDF vs. PSD undergoing EUS-guided drainage with transmural stents. Based on these results, the presence of solid debris in pancreatic fluid collections does not appear to be associated with a poorer outcome.

How We Cleaned It Up: A Simple Method That Improved Our Practice’s Bowel Prep

Colonoscopy is the only screening test that allows for direct visualization of the entire colon and removal of polyps. Poor bowel preparation limits the diagnostic accuracy of colonoscopy, lowering rates of cecal intubation and adenoma detection ( 1–3 ). Th us, adequate bowel cleansing serves to avoid the risk associated with repeat colonoscopies. Split-dose bowel preparation with polyethylene glycol (PEG) has emerged as the preferred regimen for purgative dosing ( 4 ). Medical and socioeconomic factors contribute to the risk of poor preparation, including history of diabetes, cirrhosis, dementia, colonic resection, and spinal cord injury ( 5 ). Medicaid status, interpreter requirement, and being unmarried are some of the social factors linked with poor bowel preparation ( 6,7 ). Furthermore, a complex relationship between these socioeconomic factors, poor health literacy, and low patient participation in health care may decrease the likelihood of adequate preparation ( 6–8 ). Previous studies that examine the eff ect of educational material on the quality of bowel preparation have not focused on populations with high-risk socioeconomic barriers to health care. Bellevue Hospital Center is a New York City public hospital that serves a high proportion of uninsured, underinsured, Medicaid patients and non-English speakers. Data collected on patients presenting to our suite show that ~46% have limited English profi ciency, 29% are uninsured, and 32% have Medicaid. Th e primary languages spoken in our hospital other than English include Spanish and Chinese Mandarin. Review of our data showed that nearly 35% of our patients who undergo colonoscopy have an inadequate bowel preparation requiring repeat procedures. Improving bowel preparation in this setting is a challenge; however, we utilized elements of the Plan Do Study Act (PDSA) cycle to characterize the eff ect of split-dose preparation and the use of a multi-language educational booklet on bowel cleanliness in our high-risk patient population. Th e PDSA cycle is a structure for testing changes to improve quality. Th e steps involve planning a test or observation (Plan), testing it out (Do), analyzing the data (Study), and making changes based on lessons learned (Act). We used a modifi ed version of an educational booklet that was originally developed by Spiegel et al. ( 9 ) at UCLA. Th is quality improvement project tested the implementation of a split-dose preparation and multi-language educational booklet on outpatients from January to December 2014. Th e study population included all outpatients undergoing colonoscopy, including procedures aborted because of inadequate preparation. Inpatients, unknown prep quality, and procedures aborted for reasons not related to the preparation were excluded from the analysis. Data were retrospectively and prospectively collected in monthly “snapshots” and included indication, extent reached, and preparation quality. An adequate preparation was defi ned as a Boston Bowel Preparation Score (BBPS) score of ≥6 with minimum of 2 in each segment or an Aronchick score of “good” or “excellent.” χ 2 testing was performed to evaluate for diff erences in preparation quality before and aft er cycles 1 and 2. Logistic regression analysis was performed with the stats package in R (v3.2.0, Bell Laboratories, Murray Hill, NJ), using prep dosing (single vs. split) and booklet use as independent categorical variables on the outcome variable of prep adequacy. Cycle 1: In January 2014, split-dose bowel preparation with 4 l of PEG and bisacodyl (20 mg) was initiated. Th e standard multilingual nurse teaching instructions were revised to include descriptions of the split-dose preparation. Within the endoscopy suite, the BBPS was implemented to quantify bowel preparation across all procedures to minimize bias. Prior to implementation of the BBPS score, our endoscopy staff quantifi ed bowel preparations using the Aronchick scale. Faculty and trainees were given a brief lecture on the BBPS scoring system prior to initiation of the intervention. Cycle 2: Aft er reviewing results from cycle 1, in August 2014, a multi-language educational booklet utilizing a visual aid was implemented ( Figure 1 ). Th e booklets were professionally translated to Spanish and Chinese, as these languages are the two most commonly spoken languages in our hospital other than English. Booklets were then distributed to the clinics, and the nursing staff was instructed to distribute the booklets during the standard teaching provided to the patients. Th e nurses reviewed the booklet with the use of a certifi ed medical translator for patients who did not speak English, Spanish, or Chinese. Feedback from the nursing staff demonstrated a positive impact of the visual aids for this subset of patients. How We Cleaned It Up: A Simple Method That Improved Our Practice’s Bowel Prep