Representation by Gender of Recognition Award Recipients from Gastroenterology and Hepatology Professional Societies

Background: Recognition awards from professional medical societies play an important role in physicians' career advancement. Our aim was to evaluate the gender representation of award recipients from gastroenterology and hepatology societies. Methods: We analyzed the lists of award recipients from the American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy and determined the gender of these award recipients. The primary outcome was the overall representation of women physician award recipients as compared with the representation of women in the specialty. Results: Between 1941 and 2019, there were 921 awards, of which 77 (8.4%) were given to women and 844 (91.6%) to men. There was a significant increase in the proportion of women recipients over time, from 0% in 1970-1984 to 22.0% in 2015-2019 (p for trend <0.0001). Compared with the concurrent representation of women in the specialty, women physician recipients were underrepresented from 1970 to 1981 and 1984 to 2015, equitably represented from 1981 to 1984, and overrepresented from 2015 to 2019. Of the total number of awards in each category, women received 13.8% of teaching/mentorship awards and 3.8% of the highest achievement awards (p = 0.002). The proportion of women recipients varied among the societies, from 6.8% to 14.5%. Conclusions: The representation of women physician recipients of gastroenterology and hepatology society recognition awards has generally been low until most recently, when it has surpassed the proportion of women in the specialty. Because award recognition is important to career development, professional societies should have transparent processes that aim to identify and reduce various forms of bias, including gender-related bias, in all phases of award recognition.

A gender comparison of motivations for seeking leadership positions among gastroenterologists

BACKGROUND AND AIMS

A gender gap exists in leadership positions in gastroenterology. However, individual motivations for seeking leadership positions within the gastroenterology community among men and women have not been explored. The primary aim of this study was to determine whether motivations for pursuing and attaining leadership positions in gastroenterology differ by gender.

METHODS

A 20-question survey was created by the authors and shared with gastroenterologists electronically via a social media group (Facebook) and emails gathered through publicly available society websites and professional and social contacts. Data gathered from the survey included demographics, practice characteristics, presence of spouse or domestic partner, past and present leadership positions, motivations for pursuit of leadership positions, and reasons for lack of desire for a leadership position.

RESULTS

The survey was sent to 981 gastroenterologists (679 women, 302 men). The overall response rate was 21.4% (n = 210) (20.9% for women, 22.5% for men). Overall, 41% of respondents (84 of 206) currently hold a leadership position, including more males than females (52% vs 36%, respectively; P = .03). However, among those who completed their training in the past 5 years, more women than men hold a current leadership role (25% vs 6%; P = .11). Other factors associated with currently holding a leadership position included age and years since completion of training, practice type, full-time status, and having a spouse who is not a physician. The positive factors of leadership cited most frequently were (1) ability to effect change, (2) furthering the goals of the organization, and (3) opportunity for career advancement. The negative factors cited most frequently were increased workload and decreased time for personal life. These reported positive and negative factors were similar for male and female respondents. Forty-nine respondents did not desire a leadership position now or in the future. The most common reason cited was lack of interest in the responsibilities, long hours, or stress that accompanies a leadership position (22 of 42, 52%). The second most common reason was that respondents were too busy at home or work to take on the extra responsibilities.

CONCLUSIONS

A gender gap in gastroenterology leadership exists but is closing. There is fairly equal representation of men and women in leadership positions among those who completed training in the last 5 years. Many gastroenterologists are motivated for a leadership position and at the same time, many qualified individuals do not desire a leadership position because of factors that affect work-life balance. Ongoing efforts to engage motivated individuals into leadership positions and to revise the nature of leadership positions may allow for a larger talent pool from which to recruit.

Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know

Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patient's clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ^©RSNA, 2018.

ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts

Pancreatic cysts are very common with the majority incidentally identified. There are several types of pancreatic cysts; some types can contain cancer or have malignant potential, whereas others are benign. However, even the types of cysts with malignant potential rarely progress to cancer. At the present time, the only viable treatment for pancreatic cysts is surgical excision, which is associated with a high morbidity and occasional mortality. The small risk of malignant transformation, the high risks of surgical treatment, and the lack of high-quality prospective studies have led to contradictory recommendations for their immediate management and for their surveillance. This guideline will provide a practical approach to pancreatic cyst management and recommendations for cyst surveillance for the general gastroenterologist.

Increase in female faculty in American Society for Gastrointestinal Endoscopy-sponsored programming over time

BACKGROUND AND AIMS

Female representation in medicine is increasing across all levels of medical training, yet women hold fewer senior leadership positions than men. National recognition, including participation as faculty in society-sponsored programs, is one component of academic advancement. The aim of this study was to characterize female representation among faculty in courses sponsored by the American Society for Gastrointestinal Endoscopy (ASGE).

METHODS

We performed a retrospective review of demographic data, including faculty gender and role, year, and program type, from the ASGE database of its sponsored programs between 2009 and 2014. Female faculty rates were compared with the rate of female membership in the ASGE and by faculty role and course type over time.

RESULTS

Between 2009 and 2014 there were a total of 2020 ASGE course faculty positions of which women comprised 19%. There was a significant increase in the proportion of women that served as course faculty over time (P < .0005). Female faculty participation exceeded the ASGE female domestic membership rate in all years. Women were more likely to serve as course directors than lecturers (25% vs 18%, P = .004) and to participate in smaller courses (P = .0003).

CONCLUSIONS

We found an increase in female participation in ASGE programming over time, suggesting that specialty societies are making efforts to improve female representation at the national level. Future work should evaluate whether or not these opportunities translate into leadership roles for women within their own institutions or lead to promotions for women over time.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMS

The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP.

METHODS

This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated.

RESULTS

A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred.

CONCLUSIONS

Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Sponge Sampling with Fluorescent In Situ Hybridization as a Screening Tool for the Early Detection of Esophageal Cancer

INTRODUCTION

Sponge cytology is a novel screening tool for esophageal cancer but has been unable to be validated for widespread use. Our aim was to apply fluorescent in situ hybridization to sponge cytology samples in order to evaluate the safety and efficacy of this modality in screening for esophageal cancer.

MATERIALS AND METHODS

At a single, multidisciplinary, NCI-designated cancer center, patients completed sponge cytology sampling prior to upper endoscopy. Samples were analyzed by p53 fluorescent in situ hybridization, and results were compared to the endoscopic diagnosis.

RESULTS

Fifty patients were enrolled (96 % Caucasian, 68 % male, median age of 67). All patients successfully swallowed the capsule. No complications (string breakage, bleeding, mucosal injury) occurred. Endoscopy revealed that 38 % had normal esophageal mucosa and 62 % had an esophageal mucosal abnormality. In total, six samples demonstrated p53 loss (94 % specificity for any abnormality). The sensitivity of the p53 fluorescent in situ hybridization probe was13.3 % for any abnormality, 10 % for intestinal metaplasia, and 0 % for dysplasia or esophageal cancer.

DISCUSSION

Esophageal sponge cytology is a promising, safe, and tolerable method for collecting esophageal cell samples. However, our data suggest that p53 fluorescent in situ hybridization does not improve the sensitivity for detecting cancer in these samples.

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.

Colonoscopy Identifies Increased Prevalence of Large Polyps or Tumors in Patients 40-49 Years Old With Hematochezia vs Other Gastrointestinal Indications

BACKGROUND & AIMS

There is an unclear role for colonoscopy in the evaluation of symptomatic individuals younger than 50 years old. We aimed to determine the prevalence of large polyps (>9 mm) or tumors in individuals 40 to 49 years old who underwent colonoscopy for various signs and symptoms, and compare the results with those from average-risk individuals ages 50 to 54 years who underwent screening colonoscopy.

METHODS

We collected data from a national endoscopy database, from 2000 through 2012, and identified patients 40 to 49 years old who underwent colonoscopy for bleeding and nonbleeding indications. The prevalence of large polyps (>9 mm) or tumors was compared with the prevalence in a reference group (n = 99,713 average-risk individuals ages 50-54 undergoing screening colonoscopy).

RESULTS

A total of 65,892 patients ages 40 to 49 years underwent colonoscopy for a variety of indications. Significantly larger proportions of male and female patients with hematochezia without anemia or iron-deficiency anemia (IDA) had large polyps or tumors (7.2%) compared with the reference group (men, 7.2% vs 6.2%; P = .0001; and women, 5.5% vs 4.1%; P < .0001). Patients with weight loss, anemia or IDA, or hematochezia with anemia or IDA did not have a significantly higher prevalence of large polyps or tumors than the reference group. Significantly lower proportions of patients with general gastrointestinal symptoms (pain, bloating, or change in bowel habits) had advanced neoplasia compared with the reference group (men, 3.9% vs 6.2%; P < .0001; and women, 2.7% vs 4.1%; P < .0001).

CONCLUSIONS

An analysis of a national endoscopy database supports the role of colonoscopy to evaluate hematochezia in patients 40 to 49 years old. A lower proportion of patients with anemia, weight loss, and general abdominal symptoms had large polyps or tumors compared with average-risk patients 50 to 54 years old. A significantly lower proportion of patients younger than 50 years with general gastrointestinal symptoms had large polyps-these patients are therefore less likely to benefit from colonoscopy.

Impact of gender on requests for ASGE leadership assignments

BACKGROUND AND AIMS

Committee membership in gastroenterology national societies is considered prestigious, opening the door for leadership roles and professional advancement. Some have hypothesized that women ask for leadership opportunities less frequently than men. Our aim was to examine the gender representation of requests for placement on an American Society for Gastrointestinal Endoscopy (ASGE) committee.

METHODS

We analyzed deidentified records of all requests for assignment to ASGE committees from 2011 to 2014, including applicant's gender, prior service to ASGE, year of application, and whether the applicant was appointed. The primary outcome was the proportion of requests from women compared with the overall ASGE female membership.

RESULTS

There were 513 requests for ASGE committee appointments; 101 (20%) were from women, exceeding the active ASGE female membership (15%; P = .004). Overall, the total number of committee requests increased over time from 89 to 195 (P = .08); the proportion of requests from women remained stable at 16% to 21% (P = .51). Compared with men, women were significantly less likely to have had previous ASGE service (28% vs 42%; P = .01) and more likely to have a statement of endorsement from a mentor (33% vs 24%; P = .06). The rate of appointment to a committee was 47% (95% confidence interval [CI], 41-52) overall, 42% (95% CI, 37-48) for male applicants, and 65% (95% CI, 54-76) for female applicants. Female gender (odds ratio [OR] 2.6; 1.5-4.5), endorsement from a mentor (OR 3.4; 2.1-5.6), and prior ASGE service (OR 2.3; 1.5-3.5) predicted committee appointment.

CONCLUSIONS

For ASGE committee appointments, it appears that women who make requests are successful in receiving these appointments. Future work should evaluate requests and appointments by gender among other gastroenterology societies and explore whether service translates into leadership opportunities for women.

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 Barrett's 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.

Enteroscopy

Noninvasive imaging with CT and magnetic resonance enterography or direct visualization with wireless capsule endoscopy can provide valuable diagnostic information and direct therapy. Enteroscopy technology and techniques have evolved significantly and allow diagnosis and therapy deep within the small bowel, previously attainable only with intraoperative enteroscopy. Push enteroscopy, readily available in most endoscopy units, plays an important role in the evaluation and management of lesions located up to the proximal jejunum. Currently available device-assisted enteroscopy systems, DBE, SBE, and spiral enteroscopy each have their technical nuances, clinical advantages, and limitations. Newer, on-demand enteroscopy systems appear promising, but further studies are needed. Despite slight differences in parameters such as procedural times, depths of insertion, and rates of complete enteroscopy, the overall clinical outcomes with all overtube-assisted systems appear to be similar. Endoscopists should therefore master the enteroscopy technology based on institutional availability and their level of technical expertise.

Echoendoscopes

Advances in echoendoscopes and their processors have significantly expanded the role of EUS and its clinical applications.The diagnostic and therapeutic capabilities of EUS continue to evolve and improve. EUS has made a large impact on patient care but comes with significant startup and maintenance costs. As improved technology continues to enhance image resolution while decreasing the size of EUS processors, use of endosonography will become more widespread. EUS will continue to be a vital part of patient care and complement currently available cross-sectional imaging.

Endoscopic mucosal resection

EMR has become an established therapeutic option for premalignant and early-stage GI malignancies, particularly in the esophagus and colon. EMR can also aid in the diagnosis and therapy of subepithelial lesions localized to the muscularis mucosa or submucosa. Several dedicated EMR devices are available to facilitate these procedures. Adverse event rates, particularly bleeding and perforation, are higher after EMR relative to other basic endoscopic interventions but lower than adverse event rates for ESD. Endoscopists performing EMR should be knowledgeable and skilled in managing potential adverse events resulting from EMR.

Double balloon enteroscopy: effective and minimally invasive method for removal of retained video capsules

BACKGROUND AND AIM

Prior case series document removal of retained video capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules are limited. Our aim was to describe an endoscopic method of retrieval using double balloon enteroscopy (DBE).

METHODS

A retrospective case series examination found 10 patients who underwent DBE for retrieval of a retained video capsule at two large tertiary referral academic centers from May 2007 to June 2013.

RESULTS

Mean age of patients was 64.9 ± 18.1 years (four females, six males). Five patients failed to pass the capsule as a result of an ileal or jejunal stricture (one patient with ulcerative colitis; four patients with Crohn's disease); two patients had a small bowel stricture as a result of non-steroidal anti-inflammatory drug enteropathy; one patient had intermittent partial small bowel obstruction without evidence of a stricture; one patient had an obstructing malignant jejunal mass and one patient had a small bowel stricture as a result of radiation enteritis. Endoscopic removal via DBE was successful in eight of 10 patients (80%). The remaining two patients underwent surgical removal of the retained capsule. The two failed cases of capsule retrieval were both patients with suspected ileal disease.

CONCLUSIONS

The most common cause of capsule retention was underlying Crohn's disease. DBE is an effective and minimally invasive method of capsule retrieval, including those patients with ileal disease, which has not been previously described. DBE can prevent unnecessary surgery while providing endoscopic therapy of inflammatory strictures by dilation.

To cease or 'de-cyst'? The evaluation and management of pancreatic cystic lesions

Due to the widespread use of cross-sectional imaging and advances in imaging technology, pancreatic cystic lesions are increasingly being detected. The diagnosis and management of such cysts remains challenging and continues to evolve. Different pancreatic cyst types have varying malignant potential. Thus, accurate cyst characterization is essential to appropriate management; the most clinically important distinction is differentiating mucinous lesions, which have malignant potential and may benefit from surgical resection, from non-mucinous cystic lesions. Endoscopic ultrasound with fine needle aspiration with cytologic, chemical,, and tumor marker analysis appears to be the best currently available method for accurately characterizing a cyst's malignant potential, and therefore impacts the most important management decision for a pancreatic cyst-continued surveillance or surgical resection.

Location, location, location: does early cancer in Barrett's esophagus have a preference?

BACKGROUND

Early cancer (high-grade dysplasia [HGD] and intramucosal carcinoma [ImCa]) associated with Barrett's esophagus (BE) may have a circumferential spatial predilection.

OBJECTIVE

To describe the esophageal circumferential location of early cancer in BE.

DESIGN AND SETTING

Retrospective study, single tertiary referral center.

PATIENTS AND INTERVENTION

One hundred nineteen patients were referred for endoscopic eradication therapy for early cancer associated with BE. Endoscopic images and reports and pathology were reviewed.

MAIN OUTCOME MEASUREMENTS

Circumferential location designation of early cancer in BE by using a clock-face orientation.

RESULTS

One hundred nineteen of 131 patients referred for endoscopic eradication therapy had a location designation for their advanced histology (91.9%). There were a total of 57 patients (47.9%) with HGD and 62 patients (52.1%) with ImCa. There was a significantly higher rate of early cancer (HGD or ImCa) in the right hemisphere (12 to 6 o'clock location) compared with the left hemisphere (84.9% vs 15.1%, P < .0001). The highest percentage of early cancer was found in the 12 to 3 o'clock quadrant (64.7%); 71.9% of HGD and 58.1% of ImCa lesions were located in the 12 to 3 o'clock quadrant.

LIMITATIONS

Retrospective design, single center.

CONCLUSIONS

Early cancer associated with BE is far more commonly found in the right hemisphere of the esophagus (12 to 6 o'clock) with the highest rate in the 12 to 3 o'clock quadrant. These findings support enhanced scrutiny of the right hemisphere of the esophagus during surveillance and endoscopic treatment of patients with BE.

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.

Advances in endoluminal therapy for esophageal cancer

Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer is managed as well as in the palliation of dysphagia related to advanced esophageal cancer. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective therapies for accurate histopathologic staging and provide a potential for complete cure. Mucosal ablative techniques (radiofrequency ablation and cryotherapy) are effective adjuncts to EMR and ESD and reduce the occurrence of synchronous and metachronous lesions within the Barrett esophagus. The successes of these techniques have made endoscopic therapy the primary means of management of early esophageal cancer.

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.

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

BACKGROUND

In recent clinical trials (RCT) of bowel preparation, Golytely was more efficacious than MiraLAX. We hypothesised that there is a difference in adenoma detection between Golytely and MiraLAX.

AIMS

To compare the adenoma detection rate (ADR) between these bowel preparations, and to identify independent predictors of bowel preparation quality and adenoma detection.

METHODS

This was a post hoc analysis of an RCT that assessed efficacy and patient tolerability of Golytely vs. MiraLAX/Gatorade in average risk screening colonoscopy patients. Bowel preparation quality was measured with the Boston Bowel Preparation Scale (BBPS). An excellent/good equivalent BBPS score was defined as ≥ 7. Polyp pathology review was performed. ADR was defined as the proportion of colonoscopies with an adenoma. Univariate and multivariate analyses were conducted.

RESULTS

One hundred and ninety patients were prospectively enrolled (87 MiraLAX, 103 Golytely). Golytely had a higher rate of a BBPS score ≥ 7 (82.5% vs. MiraLAX 67.8%, P=0.02). The ADR in the Golytely cohort was 26.2% (27/103), and was 16.1% (14/87) for MiraLAX (P = 0.091). On multivariate analyses, Golytely was 2.13 × more likely to be associated with a BBPS ≥ 7 (95% CI 1.05-4.32, P = 0.04) and 2.28 × more likely to be associated with adenoma detection (95% CI 1.05-4.98, P = 0.04) than MiraLAX.

CONCLUSIONS

Golytely was more efficacious than MiraLAX in bowel cleansing, and was independently associated with both bowel prep quality (BBPS ≥ 7) and higher adenoma detection. Golytely should be used as first line for bowel prep for colonoscopy. Studies with larger populations are needed to confirm these results.

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.

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

BACKGROUND

Due to its rarity, achalasia remains a difficult disease to study.

AIMS

To describe the epidemiology of achalasia and practice patterns in its endoscopic management, utilising patient records from a large national database of endoscopic procedures.

METHODS

The Clinical Outcomes Research Initiative maintains a database of endoscopic procedures in diverse clinical practices. The data from 89 endoscopy practices distributed throughout the US during 2000-2008 were used to analyse the characteristics and therapy of patients with achalasia.

RESULTS

Among 521,497 upper endoscopies during the study period, we identified 896 patients with achalasia. Compared with the entirety of all other endoscopic diagnoses, achalasia was more common in men than in women (OR=1.39, CI 1.22-1.59), but similar among nonwhites and whites (OR=0.87, CI 0.74-1.03). Relatively, more achalasia patients were treated at university than at community practices (OR=1.52, CI 1.30-1.78). Botox injection was most frequently used as first choice of endoscopic therapy in 41%, followed by balloon dilation in 21%, Savary dilation in 20%, Maloney dilation in 10%, Rigiflex in 4% and other modalities in 4% of patients. One quarter of achalasia patients treated endoscopically underwent a repeat therapy about every 14 months.

CONCLUSIONS

Botox has become the primary choice of initial endoscopic therapy in achalasia. Despite their partial deviation from guidelines and recommendations, these endoscopic patterns reflect the current clinical practice in the United States.

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

BACKGROUND

MiraLAX is gaining acceptance as a bowel cleanser for colonoscopy. We hypothesize that MiraLAX/Gatorade is as efficacious for bowel cleansing as Golytely and is more tolerable for patients undergoing screening colonoscopy.

AIM

To compare bowel preparation scores of MiraLAX/Gatorade vs. Golytely and examine differences in patient tolerability.

METHODS

  Patients undergoing screening colonoscopy were randomized to 4 L Golytely or 238 g MiraLAX in 64 ounces Golytely and four bisacodyl tablets. Efficacy in bowel cleansing was assessed using the Boston Bowel Preparation Scale (BPPS). Subjects completed a brief survey assessing patient tolerability.

RESULTS

A total of 190 patients were enrolled (85 male, 105 female; mean age 56.9 years, s.d. 6.3); 87 were randomized to MiraLAX, 103 to Golytely. There was no difference in age, gender or timing of colonoscopy between the bowel preparation groups. Golytely's median total BBPS score was significantly higher than that of MiraLAX [9 (IQR 7-9) vs. 8 (IQR 6-9), P = 0.034]. Golytely had a higher rate of an excellent equivalent BBPS score of 8 or 9 than MiraLAX (70% vs. 55%, P = 0.036). There was no difference in patient tolerability (P = 0.857).

CONCLUSIONS

Golytely was more efficacious than MiraLAX/Gatorade in bowel cleansing; both preparations were equally tolerated by patients.

Endoscopic therapy for peptic ulcer hemorrhage: practice variations in a multi-center U.S. consortium

BACKGROUND

Peptic ulcer disease is a common cause of acute upper gastrointestinal hemorrhage. The aim of this study was to describe the endoscopic management of bleeding peptic ulcers in a large, U.S. multi-center endoscopic consortium with diverse practice settings.

METHODS

Adult patients who underwent upper endoscopy (EGD) for hematemesis, melena or "suspected upper GI bleed" between January 2000 and December 2004 in the Clinical Outcomes Research Initiative (CORI) endoscopic database were screened for the finding of peptic ulcer. The ulcer stigmata, endoscopic therapy and the need for repeat EGD were compared across practice sites.

RESULTS

Of 12,392 patients who underwent EGD for an upper gastrointestinal bleeding indication, 3,692 (30%) had at least one peptic ulcer (clean base 59.9%; flat pigmented spot 13.4%; active bleeding 10.7%; clot 7.2%; non-bleeding visible vessel (NBVV) 6.3%). Endoscopic therapy was applied to 93% of actively bleeding ulcers and 95% of NBVV. Repeat endoscopy was required in 7.3% of patients. Ulcers treated with injection monotherapy had the highest repeat EGD rates (12.2%) compared with contact thermal monotherapy (6.1%) and combination thermal/injection therapy (7.1%) (P=0.02). Immediate hemostasis rates were 88-97% across all therapeutic modalities. There was no statistical difference in hemostasis rates across therapy nor practice types.

CONCLUSION

In this multi-center consortium, initial hemostasis rates were high across therapy types and sites studied. Injection monotherapy was associated with the highest rates of repeat EGD, supporting guidelines that advise against its use in bleeding peptic ulcers.

An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium

BACKGROUND

The majority of studies on upper-GI hemorrhage (UGIH) to date have been based on clinical experience at academic centers. There is limited information about patients with UGIH who are evaluated by endoscopy at nonacademic settings, which comprise the majority of endoscopic practices in the United States.

OBJECTIVE

The aims of this retrospective study were to use a large national endoscopy database to describe the population of patients who received an EGD for nonvariceal upper-GI hemorrhage at diverse clinical practice sites and to characterize their endoscopic diagnoses.

METHODS

Between 2000 and 2004, the Clinical Outcomes Research Initiative (CORI) database received endoscopic reports from 72 diverse practice sites in the United States. All adult patients who underwent an EGD during this period at a CORI site for the indications of hematemesis, melena, or "suspected upper-GI bleed" were identified. Variceal bleeding was excluded. The nonvariceal UGIH cohort was described, and this group's endoscopic findings were characterized by the prevalence, indication, and location of an EGD (inpatient vs outpatient). A repeat EGD within a 2-week period was also evaluated.

RESULTS

A total of 243,427 EGDs were performed during the study period; 12,392 (4.9% of all EGDs) were performed for evaluation of hematemesis, melena, or "suspected" upper-GI bleed. Patients in this cohort were more likely to be older, men, and nonwhite compared with their nonbleeding counterparts. Melena was the most common indication for an EGD. The most common endoscopic finding was an ulcer (32.7%), followed by erosion (18.8%). A "normal" EGD was reported on 17.2% of EGDs. Among patients with ulcers, gastric ulcers were more common that duodenal ulcers (54.4% vs 37.1%), whereas clean-based ulcers comprised 52% of all ulcers. Ulcers and Mallory-Weiss tears were significantly more common on inpatient procedures. Ulcers identified on outpatient EGDs were more likely to be clean based. A repeat endoscopy was performed on 4% of the cohort within a 2-week follow-up period, hematemesis was the most common indication for a repeat EGD, and 24.3% of the cohort had a documented therapeutic intervention on their initial EGD. Among inpatients, 6.0% had a repeat EGD within two weeks for an UGIH indication compared with only 1.4% of outpatients (P < .0001).

CONCLUSIONS

These results allow association of EGD findings with patient presentation. Furthermore, it allows us to characterize endoscopic findings in a particular patient population (those patients with UGIH) in clinical practice, outside of traditional academic medical centers. The CORI database is a valuable resource for characterizing the epidemiology of endoscopic findings and, in particular, patient populations and across diverse practice settings, thus, enabling the development of hypotheses for future studies.