David Grande

Recurrence of Barrett’s Esophagus is Rare Following Endoscopic Eradication Therapy Coupled With Effective Reflux Control

Objectives:Recent data suggest that effective control of gastroesophageal reflux improves outcomes associated with endoscopic eradication therapy (EET) for Barrett’s esophagus (BE). However, the impact of reflux control on preventing recurrent intestinal metaplasia and/or dysplasia is unclear. The aims of the study were: (a) to determine the effectiveness and durability of EET under a structured reflux management protocol and (b) to determine the impact of optimizing anti-reflux therapy on achieving complete eradication of intestinal metaplasia (CE-IM).Methods:Consecutive BE patients referred for EET were enrolled and managed with a standardized reflux management protocol including twice-daily PPI therapy during eradication. Primary outcomes were rates of CE-IM and IM or dysplasia recurrence.Results:Out of 221 patients enrolled (46.0% with high-grade dysplasia/intramucosal carcinoma, 34.0% with low-grade dysplasia, and 20.0% with non-dysplastic BE) an overall CE-IM of 93% was achieved within 11.6±10.2 months. Forty-eight patients did not achieve CE-IM in 3 sessions. After modification of their reflux management, 45 (93.7%) achieved CE-IM in a mean of 1.1 RFA sessions. Recurrence occurred in 13 patients (IM in 10(4.8%), dysplasia in 3 (1.5%)) during a mean follow-up of 44±18.5 months. The only significant predictor of recurrence was the presence of a hiatal hernia. Recurrence of IM was significantly lower than historical controls (10.9 vs. 4.8%, P=0.04).Conclusions:The current study highlights the importance of reflux control in patients with BE undergoing EET. In this setting, EET has long-term durability with low recurrence rates providing early evidence for extending endoscopic surveillance intervals after EET.

Development of Quality Indicators for Endoscopic Eradication Therapies in Barrett’s Esophagus: The TREAT-BE (Treatment With Resection and Endoscopic Ablation Techniques for Barrett’s Esophagus) Consortium

Development of Quality Indicators for Endoscopic Eradication Therapies in Barrett’s Esophagus: The TREAT-BE (Treatment With Resection and Endoscopic Ablation Techniques for Barrett’s Esophagus) Consortium

Evaluation of the 2015 AGA guidelines on pancreatic cystic neoplasms in a large surgically confirmed multicenter cohort

Absract Background and study aims The American Gastroenterological Association (AGA) recently published guidelines for the management of asymptomatic pancreatic cystic neoplasms (PCNs). We aimed to evaluate the diagnostic characteristics of the AGA guidelines in appropriately recommending surgery for malignant PCNs. Patients and methods A retrospective multicenter study was performed of patients who underwent endoscopic ultrasound (EUS) for evaluation of PCNs who ultimately underwent surgical resection from 2004 – 2014. Demographics, EUS characteristics, fine-needle aspiration (FNA) results, type of resection, and final pathologic diagnosis were recorded. Patients were categorized into 2 groups (surgery or surveillance) based on what the AGA guidelines would have recommended. Performance characteristics for the diagnosis of cancer or high-grade dysplasia (HGD) on surgical pathology were calculated. Results Three hundred patients underwent surgical resection for PCNs, of whom the AGA guidelines would have recommended surgery in 121 (40.3 %) and surveillance in 179 (59.7 %) patients. Among patients recommended for surgery, 45 (37.2 %) had cancer, whereas 76 (62.8 %) had no cancer/HGD. Among patients recommended for surveillance, 170 (95.0 %) had no cancer/HGD; however, 9 (5.0 %) patients had cancer that would have been missed. For the finding of cancer/HGD on surgical pathology, the AGA guidelines had 83.3 % sensitivity (95 % CI 70.7 – 92.1), 69.1 % specificity (95 % CI 62.9 – 74.8), 37.2 % positive predictive value (95 % CI 28.6 – 46.4), 95.0 % negative predictive value (95 % CI 90.7 – 97.7), and 71.7 % accuracy (95 % CI 67.4 – 74.6). Conclusions The 2015 AGA guidelines would have resulted in 60 % fewer patients being referred for surgical resection, and accurately recommended surveillance in 95 % of patients with asymptomatic PCNs. Future prospective studies are required to validate these guidelines. Meeting presentations: Presented in part at Digestive Diseases Week 2016

A System to Assess the Competency for Interpretation of Esophageal Manometry Identifies Variation in Learning Curves

BACKGROUND & AIMS: Quality esophageal high‐resolution manometry (HRM) studies require competent interpretation of data. However, there is little understanding of learning curves, training requirements, or measures of competency for HRM. We aimed to develop and use a competency assessment system to examine learning curves for interpretation of HRM data. METHODS: We conducted a prospective multicenter study of 20 gastroenterology trainees with no experience in HRM, from 8 centers, over an 8‐month period (May through December 2015). We designed a web‐based HRM training and competency assessment system. After reviewing the training module, participants interpreted 50 HRM studies and received answer keys at the fifth and then at every second interpretation. A cumulative sum procedure produced individual learning curves with preset acceptable failure rates of 10%; we classified competency status as competency not achieved, competency achieved, or competency likely achieved. RESULTS: Five (25%) participants achieved competence, 4 (20%) likely achieved competence, and 11 (55%) failed to achieve competence. A minimum case volume to achieve competency was not identified. There was no significant agreement between diagnostic accuracy and accuracy for individual HRM skills. CONCLUSIONS: We developed a competency assessment system for HRM interpretation; using this system, we found significant variation in learning curves for HRM diagnosis and individual skills. Our system effectively distinguished trainee competency levels for HRM interpretation and contrary to current recommendations, found that competency for HRM is not case‐volume specific.

An automated inpatient split-dose bowel preparation system improves colonoscopy quality and reduces repeat procedures

Background/Goals: Inpatient colonoscopy preparations are often inadequate, compromising patient safety and procedure quality, while resulting in greater hospital costs. The aims of this study were to: (1) design and implement an electronic inpatient split-dose bowel preparation order set; (2) assess the intervention’s impact upon preparation adequacy, repeated colonoscopies, hospital days, and costs. Study: We conducted a single center prospective pragmatic quasiexperimental study of hospitalized adults undergoing colonoscopy. The experimental intervention was designed using DMAIC (define, measure, analyze, improve, and control) methodology. Prospective data collected over 12 months were compared with data from a historical preintervention cohort. The primary outcome was bowel preparation quality and secondary outcomes included number of repeated procedures, hospital days, and costs. Results: On the basis of a Delphi method and DMAIC process, we created an electronic inpatient bowel preparation order set inclusive of a split-dose bowel preparation algorithm, automated orders for rescue medications, and nursing bowel preparation checks. The analysis data set included 969 patients, 445 (46%) in the postintervention group. The adequacy of bowel preparation significantly increased following intervention (86% vs. 43%; P<0.01) and proportion of repeated procedures decreased (2.0% vs. 4.6%; P=0.03). Mean hospital days from bowel preparation initiation to discharge decreased from 8.0 to 6.9 days (P=0.02). The intervention resulted in an estimated 1-year cost-savings of

Development and validation of an algorithm to complete colonoscopy using standard endoscopes in patients with prior incomplete colonoscopy

46,076 based on a reduction in excess hospital days associated with repeated and delayed procedures. Conclusions: Our interdisciplinary initiative targeting inpatient colonoscopy preparations significantly improved quality and reduced repeat procedures, and hospital days. Other institutions should consider utilizing this framework to improve inpatient colonoscopy value.

Endoscopic resection is effective for the treatment of bleeding gastric hyperplastic polyps in patients with and without cirrhosis

Background and study aims  Incomplete colonoscopy may occur as a result of colon angulation (adhesions or diverticulosis), endoscope looping, or both. Specialty endoscopes/devices have been shown to successfully complete prior incomplete colonoscopies, but may not be widely available. Radiographic or other image-based evaluations have been shown to be effective but may miss small or flat lesions, and colonoscopy is often still indicated if a large lesion is identified. The purpose of this study was to develop and validate an algorithm to determine the optimum endoscope to ensure completion of the examination in patients with prior incomplete colonoscopy. Patients and methods  This was a prospective cohort study of 175 patients with prior incomplete colonoscopy who were referred to a single endoscopist at a single academic medical center over a 3-year period from 2012 through 2015. Colonoscopy outcomes from the initial 50 patients were used to develop an algorithm to determine the optimal standard endoscope and technique to achieve cecal intubation. The algorithm was validated on the subsequent 125 patients. Results  The overall repeat colonoscopy success rate using a standard endoscope was 94 %. The initial standard endoscope specified by the algorithm was used and completed the colonoscopy in 90 % of patients. Conclusions  This study identifies an effective strategy for completing colonoscopy in patients with prior incomplete examination, using widely available standard endoscopes and an algorithm based on patient characteristics and reasons for prior incomplete colonoscopy.

Adverse events after surgery for nonmalignant colon polyps are common and associated with increased length of stay and costs.

Background and study aims: Gastric hyperplastic polyps (GHP) have been identified as a cause of transfusion-dependent iron-deficiency anemia (tIDA) and transfusion-dependent gastrointestinal bleeding and are commonly identified in the setting of cirrhosis. The aim of this study was to assess the effectiveness of endoscopic resection (ER) for the treatment of tIDA or gastrointestinal bleeding due to GHP in patients with and without liver disease. Patients and methods: This was a single-center retrospective review. The primary outcome was clinical success of ER (no transfusion or repeat ER in the following 6 months after first ER). Secondary outcomes included technical success, recurrence of GHP with tIDA or gastrointestinal bleeding, and adverse events (AEs). Results: Sixty-three patients with GHP were included of whom 20 (31 %) had cirrhosis. The majority with cirrhosis presented with gastrointestinal bleeding (n = 13, 65 %, P = 0.52), whereas the majority of non-cirrhotics presented with tIDA (n = 30, 70 %, P = 0.01). Technical success was 100 % with no AEs. The clinical success rate was 94 % (95 % in cirrhotics, 93 % in non-cirrhotics, P = 0.46). The recurrence rate was 32 % (40 % in cirrhotics and 28 % in non-cirrhotics, P = 0.35) with mean time to recurrence of 17.3 ± 13.9 months (P = 0.22). Of those with recurrence, 75 % had no further tIDA or gastrointestinal bleeding after repeat ER (mean follow-up 20 ±11 months). Conclusions: ER is an effective treatment for GHP that causes tIDA or gastrointestinal bleeding. Patients with GHP and cirrhosis tend to present with bleeding rather than anemia and have more frequent recurrence. Symptomatic recurrence of GHP is common and should be recognized early as repeat ER appears to be effective.