Brintha K. Enestvedt

Adenoma detection rate increases with each decade of life after 50 years of age

BACKGROUND The adenoma detection rate (ADR) has recently been used as a quality measure for screening colonoscopy. We hypothesize that the ADR will increase with each decade of life after 50 years of age. OBJECTIVE The aim of this study was to define age-based goals for the ADR and advanced neoplasia to improve the quality of colonoscopy. METHODS Using the Clinical Outcomes Research Initiative database, we identified patients who underwent screening colonoscopy between 2005 and 2006. Pathology of polyp findings was reviewed, and the ADR and the prevalence of advanced neoplasia were calculated based on age and sex. RESULTS A total of 7756 polypectomies (44.9%) were performed on 17,275 patients between 2005 and 2006. Of these polyps, 56.3% (4363) were adenomas or more advanced lesions. The ADR was higher in men than women and increased with age. The ADR in men younger than age 50 was 24.7 (95% CI, 18.2-31.2); for those 50 to 59 years of age, it was 27.8 (95% CI, 26.5-29.1); for those 60 to 69 years of age, it was 33.6 (95% CI, 31.7-35.4); for those 70 to 79 years of age, it was 34.3 (95% CI, 31.5-37.1); and for those older than 80 years of age, it was 40.0 (95% CI, 32.9-47.1). The ADR in women younger than 50 years old was 12.6 (95% CI, 6.8-18.4); in those 50 to 59 years of age, it was 17.0 (85% CI, 15.9-18.1); for those 60 to 69 years of age, it was 22.4 (95% CI, 20.8-24.0); for those 70 to 79 years of age, it was 26.1 (95% CI, 23.7-28.5); and for those older than 80 years of age, it was 26.9 (95% CI, 21.4-32.5). LIMITATIONS The Clinical Outcomes Research Initiative database offers access to demographic information as well as endoscopy and pathology data, but there is limited clinical information about patients in the database. CONCLUSION The ADR, and, importantly, the rate of advanced neoplasia increased with each decade of life after the age of 50 and are higher in men than women in each decade of life.

Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures

BACKGROUND The American Society of Anesthesiologists (ASA) physical status classification is a measurement of comorbidity and a predictor of perioperative morbidity and mortality. OBJECTIVE To assess the predictive ability of the ASA class for periendoscopic adverse events. DESIGN Retrospective cohort analysis. SETTING A total of 74 sites in the United States comprising academic, community/health maintenance organization, and Veterans Affairs/military practices affiliated with the Clinical Outcomes Research Initiative (CORI) database. PATIENTS Patients who were 18 years or older who underwent an endoscopic procedure between 2000 and 2008. INTERVENTIONS EGD, colonoscopy, flexible sigmoidoscopy, and ERCP. MAIN OUTCOME MEASUREMENTS Immediate adverse event requiring an unplanned intervention. RESULTS A total of 1,590,648 endoscopic procedures were performed on 1,318,495 individual patients. The majority of patients were designated as ASA class I or II (I: 27%, II: 63%). An immediate adverse event occurred in 0.35% of all endoscopic procedures (n = 5596) and was proportionally highest for ERCPs (1.84%). Increasing ASA class was associated with higher prevalence and a stepwise increase in the odds ratio of serious adverse events for EGD (II: 1.54 [95% confidence interval (CI), 1.31-1.82]; III: 3.90 [95% CI, 3.27-4.64]; IV/V: 12.02 [95% CI, 9.62-15.01]); and colonoscopy (II: 0.92 [95% CI, 0.85-1.01]; III: 1.66 [95% CI, 1.46-1.87]; IV/V: 4.93 [95% CI, 3.66-66.3]). This trend was not significant for flexible sigmoidoscopy and ERCP. LIMITATIONS Retrospective; endpoint was a surrogate for periprocedure morbidity. CONCLUSIONS ASA class is associated with increased risk of adverse events at endoscopy, particularly for EGD and colonoscopy. It is useful in endoscopic risk stratification and an important quality indicator for endoscopy.

ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for adopting real-time imaging–assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett’s esophagus

BACKGROUND AND AIMS Endoscopic real-time imaging of Barretts esophagus (BE) with advanced imaging technologies enables targeted biopsies and may eliminate the need for random biopsies to detect dysplasia during endoscopic surveillance of BE. This systematic review and meta-analysis was performed by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee to specifically assess whether acceptable performance thresholds outlined by the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) document for clinical adoption of these technologies have been met. METHODS We conducted meta-analyses calculating the pooled sensitivity, negative predictive value (NPV), and specificity for chromoendoscopy by using acetic acid and methylene blue, electronic chromoendoscopy by using narrow-band imaging, and confocal laser endomicroscopy (CLE) for the detection of dysplasia. Random effects meta-analysis models were used. Statistical heterogeneity was evaluated by means of I(2) statistics. RESULTS The pooled sensitivity, NPV, and specificity for acetic acid chromoendoscopy were 96.6% (95% confidence interval [CI], 95-98), 98.3% (95% CI, 94.8-99.4), and 84.6% (95% CI, 68.5-93.2), respectively. The pooled sensitivity, NPV, and specificity for electronic chromoendoscopy by using narrow-band imaging were 94.2% (95% CI, 82.6-98.2), 97.5% (95% CI, 95.1-98.7), and 94.4% (95% CI, 80.5-98.6), respectively. The pooled sensitivity, NPV, and specificity for endoscope-based CLE were 90.4% (95% CI, 71.9-97.2), 98.3% (95% CI, 94.2-99.5), and 92.7% (95% CI, 87-96), respectively. CONCLUSIONS Our meta-analysis indicates that targeted biopsies with acetic acid chromoendoscopy, electronic chromoendoscopy by using narrow-band imaging, and endoscope-based CLE meet the thresholds set by the ASGE PIVI, at least when performed by endoscopists with expertise in advanced imaging techniques. The ASGE Technology Committee therefore endorses using these advanced imaging modalities to guide targeted biopsies for the detection of dysplasia during surveillance of patients with previously nondysplastic BE, thereby replacing the currently used random biopsy protocols.

Randomised clinical trial: MiraLAX vs. Golytely – a controlled study of efficacy and patient tolerability in bowel preparation for colonoscopy

Aliment Pharmacol Ther 2011; 33: 33–40

Epidemiology and practice patterns of achalasia in a large multi-centre database.

Aliment Pharmacol Ther 2011; 33: 1209–1214

Small-bowel endoscopy core curriculum.

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.

Endoscopic retrograde cholangiopancreatography in the pediatric population is safe and efficacious

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being used in the evaluation and management of biliary and pancreatic disorders in children. The aim of this study was to review the pediatric ERCP experience of a large academic referral center affiliated with a tertiary care childrens hospital. Methods: This is a retrospective review of medical records, endoscopic and operative reports, and radiography of those patients ages 0 to 21 years who underwent ERCP for any indication between 1993 and 2011 at a tertiary referral center affiliated with a large urban pediatric hospital. ERCP technical success was defined as cannulation of the desired duct. Serious adverse events included bleeding, perforation, pancreatitis, or death. Results: Four hundred twenty-nine ERCPs were performed on 296 patients. The mean age was 14.9 ± 4.8 years (3 months–21 years); 51.1% were boys. Patients with a history of previous liver transplant comprised 13.1% (56) of all ERCPs. Abnormal liver chemistries or suspected choledocholithiasis accounted for half of the indications. A therapeutic intervention was performed in 64.1%. Technical success was achieved in 95.2% of ERCPs. Serious adverse events occurred in 7.7%. Conclusions: Pediatric ERCP is highly efficacious in the pediatric population, with the rates of technical success and use of therapeutic interventions mirroring those in adults. There is a low overall rate of serious adverse events. The overall efficacy and safety support the performance of pediatric ERCP by experienced endoscopists at high-volume centers.

The use of carbon dioxide in gastrointestinal endoscopy

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of gastrointestinal endoscopy. Evidence-based methodology is used by performing a MEDLINE literature search to identify pertinent clinical studies on the topic as well as a MAUDE (U.S. 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. Technology Status Evaluation Reports 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. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through December 2014 for relevant articles by using the key words “carbon dioxide” and “gastrointestinal endoscopy,” combined with other relevant terms such as “esophagogastroduodenoscopy,” “ERCP,” “balloon enteroscopy,” “colonoscopy,” and “complications or adverse events,” among others. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating,

Gender differences in publication productivity, academic rank, and career duration among U.S. academic gastroenterology faculty

Purpose Female representation in academic medicine is increasing without proportional increases in female representation at senior ranks. The purpose of this study is to describe the gender representation in academic gastroenterology (GI) and compare publication productivity, academic rank, and career duration between male and female gastroenterologists. Method In 2014, the authors collected data including number of publications, career duration, h-index, and m-index for faculty members at 114 U.S. academic GI programs. Results Of 2,440 academic faculty, 1,859 (76%) were men and 581 (24%) were women. Half (50%) of men held senior faculty position compared with 29% of women (P < .001). Compared with female faculty, male faculty had significantly (P < .001) longer careers (20 vs. 11 years), more publications (median 24 [0–949] vs. 9 [0–438]), and higher h-indices (8 vs. 4). Higher h-index correlated with higher academic rank (P < .001). The authors detected no difference in the h-index between men and women at the same rank for professor, associate professor, and instructor, nor any difference in the m-index between men and women (0.5 vs. 0.46, respectively, P = .214). Conclusions A gender gap exists in the number and proportion of women in academic GI; however, after correcting for career duration, productivity measures that consider quantity and impact are similar for male and female faculty. Women holding senior faculty positions are equally productive as their male counterparts. Early and continued career mentorship will likely lead to continued increases in the rise of women in academic rank.

MiraLAX vs. Golytely: is there a significant difference in the adenoma detection rate?

Aliment Pharmacol Ther 2011; 34: 775–782