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Barsuk JH, Cohen ER, Patel RV, Keswani RN, Aadam AA, Wayne DB, Cameron KA, Komanduri S. Effect of Polypectomy Simulation-Based Mastery Learning on Skill Retention Among Practicing Endoscopists. Acad Med 2024; 99:317-324. [PMID: 37934830 PMCID: PMC10922268 DOI: 10.1097/acm.0000000000005538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
PURPOSE Practicing endoscopists frequently perform and teach screening colonoscopies and polypectomies, but there is no standardized method to train and assess physicians who perform polypectomy procedures. The authors created a polypectomy simulation-based mastery learning (SBML) curriculum and hypothesized that completion of the curriculum would lead to immediate improvement in polypectomy skills and skill retention at 6 and 12 months after training. METHOD The authors performed a pretest-posttest cohort study with endoscopists who completed SBML and were randomized to follow-up at 6 or 12 months from May 2021 to August 2022. Participants underwent SBML training, including a pretest, a video lecture, deliberate practice, and a posttest. All learners were required to meet or exceed a minimum passing standard on a 17-item skills checklist before completing training and were randomized to follow-up at 6 or 12 months. The authors compared simulated polypectomy skills performance on the checklist from pretest to posttest and posttest to 6- or 12-month follow-up test. RESULTS Twenty-four of 30 eligible participants (80.0%) completed the SBML intervention, and 20 of 24 (83.3%) completed follow-up testing. The minimum passing standard was set at 93% of checklist items correct. The pretest passing rate was 4 of 24 participants (16.7%) compared with 24 of 24 participants (100%) at posttest ( P < .001). There were no significant differences in passing rates from posttest to combined 6- and 12-month posttest in which 18 of 20 participants (90.0%) passed. CONCLUSIONS Before training and despite years of clinical experience, practicing endoscopists demonstrated poor performance of polypectomy skills. SBML was an effective method for practicing endoscopists to acquire and maintain polypectomy skills during a 6- to 12-month period.
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Enke T, Keswani R, Triggs J, Gannavarapu B, Mittal C, Sinha J, Kwasny MJ, Komanduri S. Adherence to quality indicators and best practices in surveillance endoscopy of Barrett's esophagus: A video-based assessment. Endosc Int Open 2024; 12:E90-E96. [PMID: 38250164 PMCID: PMC10798847 DOI: 10.1055/a-2226-3689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/30/2023] [Indexed: 01/23/2024] Open
Abstract
Background and study aims Adherence to quality indicators (QIs) and best practices (BPs) for endoscopic surveillance of Barrett's esophagus (BE) is low based on clinical documentation which is an inaccurate representation of events occurring during procedures. This study aimed to assess adherence to measurable QI and BP using video evaluation. Methods We performed a single center video-based retrospective review of surveillance endoscopies performed for BE ≥1 cm between March 1, 2018 and October 1, 2020. Adherence to QIs and BPs was assessed through video review and documentation. Videos were evaluated by five gastroenterologists. Interrater variability was determined using 10 videos before reviewing the remaining 128 videos. A generalized linear regression model was used to determine predictors of adherence to QIs and BPs. Results There were 138 endoscopies reviewed. Inspection with virtual chromoendoscopy (VC) occurred in 75 cases (54%) on video review with documentation in 50 of these cases (67%). Adherence to the Seattle protocol (SP) occurred in 74 cases (54%) on video review with documentation in 28 of these cases (38%). Use of VC or the SP was documented but not observed on video review in 16 (12%) and 30 (22%) cases, respectively. Length of BE was associated with increased use of the Prague classification (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.07-1.37) while years in practice was associated with a decreased likelihood of VC use (OR 0.93, 95% CI 0.88-0.99). Conclusions This study validates prior data demonstrating poor adherence to QIs and BPs and highlights discrepancies between clinical documentation and events occurring during procedures.
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Affiliation(s)
- Thomas Enke
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, United States
| | - Rajesh Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, United States
| | - Joseph Triggs
- Division of Gastroenterology, Fox Chase Cancer Center, Philadelphia, United States
| | - Bhargava Gannavarapu
- Division of Gastroenterology, inSite Digestive Health Care, San Jose, United States
| | - Chetan Mittal
- Division of Gastroenterology, Aurora St Luke's Medical Center, Milwaukee, United States
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, United States
| | - Mary J Kwasny
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, United States
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, United States
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Komanduri S, Sethi A, Muthusamy VR. Future Implications of Innovation in Gastroenterology for Clinical Practice: A Call to Action. Am J Gastroenterol 2023; 118:1307-1310. [PMID: 36705491 DOI: 10.14309/ajg.0000000000002194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Srinadh Komanduri
- Northewestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amrita Sethi
- Columbia University Irving Medical Center, New York, New York, USA
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Reiter AJ, Farina DA, Fronza JS, Komanduri S. Magnetic sphincter augmentation: considerations for use in Barrett's esophagus. Dis Esophagus 2023; 36:doac096. [PMID: 36575922 PMCID: PMC10267686 DOI: 10.1093/dote/doac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 12/29/2022]
Abstract
Barrett's esophagus (BE) occurs in 5-15% of patients with gastroesophageal reflux disease (GERD). While acid suppressive therapy is a critical component of BE management to minimize the risk of progression to esophageal adenocarcinoma, surgical control of mechanical reflux is sometimes necessary. Magnetic sphincter augmentation (MSA) is an increasingly utilized anti-reflux surgical therapy for GERD. While the use of MSA is listed as a precaution by the United States Food and Drug Administration, there are limited data showing effective BE regression with MSA. MSA offers several advantages in BE including effective reflux control, anti-reflux barrier restoration and reduced hiatal hernia recurrence. However, careful patient selection for MSA is necessary.
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Affiliation(s)
- Audra J Reiter
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Domenico A Farina
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeffrey S Fronza
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Srinadh Komanduri
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Triggs JR, Krogh K, Simon V, Krause A, Kaplan JB, Yang GY, Wani S, Kahrilas PJ, Pandolfino J, Komanduri S. Novel histologic score predicts recurrent intestinal metaplasia after successful endoscopic eradication therapy. Dis Esophagus 2023; 36:doac078. [PMID: 36446594 PMCID: PMC10150172 DOI: 10.1093/dote/doac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/17/2022] [Accepted: 10/08/2022] [Indexed: 12/02/2022]
Abstract
Endoscopic eradication therapy (EET) is an effective treatment for Barrett's esophagus (BE); however, disease recurrence remains problematic requiring surveillance post-treatment. While data regarding predictors of recurrence are limited, uncontrolled reflux may play a significant role. Our aim was to develop a scoring system based on histopathologic reflux in surveillance biopsies following EET to identify patients at high risk for recurrence of BE. Patients were identified from two centers in the treatment with resection and endoscopic ablation techniques for BE consortium. Hematoxylin and eosin-stained slides of surveillance biopsies post-EET were assessed for histologic changes associated with reflux from a cohort of patients who also underwent pH-metry (derivation cohort). We developed a novel scoring system (Recurrent Epithelial Changes from Uncontrolled Reflux [RECUR]) composed of dilated intercellular spaces, epithelial ballooning, basal cell hyperplasia, and parakeratosis, to identify patients with abnormal esophageal acid exposure. This scoring system was then used to grade surveillance biopsies from patients with or without recurrence of BE following EET (validation cohort). Of 41 patients in the derivation cohort, 19.5% had abnormal acid exposure times (AET) while on proton pump inhibitor therapy. The mean (SD) RECUR score for patients with AET <4% was 4.0 (1.6), compared with 5.5 (0.9) for AET ≥4% (P = 0.015). In the validation cohort consisting of 72 patients without recurrence and 64 patients with recurrence following EET, the RECUR score was the only significant predictor of recurrence (odds ratio: 1.36, 95% confidence interval: 1.10-1.69, P = 0.005). Histologic grading of surveillance biopsies using the RECUR scoring system correlates with BE recurrence following EET.
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Affiliation(s)
- Joseph R Triggs
- Division of Gastroenterology, Department of Medicine, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Katrina Krogh
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Violette Simon
- Division of Gastroenterology, Department of Medicine, University of Colorado, Denver, CO, USA
| | - Amanda Krause
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeffrey B Kaplan
- Department of Pathology, University of Colorado, Denver, CO, USA
| | - Guang-Yu Yang
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sachin Wani
- Division of Gastroenterology, Department of Medicine, University of Colorado, Denver, CO, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Khashab MA, Muthusamy VR, Akshintala VS, Kothari S, Sethi A, Rastogi A, Palmisano DJ, Zhang LY, Hess MRR, Rashba K, Gupta N, Wani S, Komanduri S. Best live endoscopy practices: an ASGE white paper. Gastrointest Endosc 2023; 97:383-393.e3. [PMID: 36639318 DOI: 10.1016/j.gie.2022.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/27/2022] [Indexed: 01/15/2023]
Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland.
| | - V Raman Muthusamy
- Division of Digestive Diseases, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Venkata S Akshintala
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Shivangi Kothari
- Division of Gastroenterology/Hepatology, University of Rochester Medical Center & Strong Memorial Hospital, Rochester, New York
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York
| | - Amit Rastogi
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City VA, Kansas City, Kansas
| | | | - Linda Yun Zhang
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Mary-Rose R Hess
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kira Rashba
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Neil Gupta
- Department of Gastroenterology, Loyola Medicine, Maywood, Illinois
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Beveridge CA, Mittal C, Muthusamy VR, Rastogi A, Kushnir V, Wood M, Wani S, Komanduri S. Identification of visible lesions during surveillance endoscopy for Barrett's esophagus: a video-based survey study. Gastrointest Endosc 2023; 97:241-247.e2. [PMID: 36007583 DOI: 10.1016/j.gie.2022.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/17/2022] [Accepted: 08/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Visible lesion (VL) detection is essential in patients with Barrett's esophagus (BE). We sought to assess the rate of VL detection by academic and community endoscopists using high-definition white-light endoscopy (HD-WLE) and narrow-band imaging (NBI) during surveillance endoscopy. METHODS Fifty endoscopists were invited to participate in a prospective video survey study. Participants viewed 25 standardized clips of patients referred for endoscopic therapy. Participants noted identification of anatomic landmarks and VLs using HD-WLE and NBI and reported practice-level data. The criterion standard of VL identification was established by consensus of 5 BE experts. Our primary outcome was the rate of VL identification using HD-WLE and NBI. RESULTS Forty-four of 50 participants completed the study (22 academic and 22 community). Compared with the criterion standard, participants did not identify 28% (HD-WLE) and 31% (NBI) of VLs. Community endoscopists had more experience (>5 years in practice: community 85% vs academic 54.5%, P = .041; >5 surveillance endoscopies a month: community 85% vs academic 31.8%, P = .046). Across all participants, VL detection using NBI improved significantly with a minimum of 5 surveillance endoscopies per month (area under the curve = .72; 95% confidence interval, .56-.85; P = .006). CONCLUSIONS Despite improved endoscope resolution and availability of virtual chromoendoscopy, the overall rate of VL detection remains low. Identification of VLs using NBI may be volume dependent. Further education and training efforts focused on VL detection during BE surveillance endoscopy are needed.
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Affiliation(s)
- Claire A Beveridge
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Chetan Mittal
- Interventional Oncology and Surgical Endoscopy, Parkview Cancer Institute, Parkview Health System, Fort Wayne, Indiana, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Amit Rastogi
- Department of Medicine, Division of Gastroenterology, University of Kansas Medical Center, Kansas University School of Medicine, Kansas City, Kansas, USA
| | - Vladimir Kushnir
- Department of Medicine, Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Mariah Wood
- Department of Medicine, Division of Gastroenterology, Northwestern Medical Center, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sachin Wani
- Department of Medicine, Division of Gastroenterology, University of Colorado Anschutz Medical Campus, University of Colorado School of Medicine, Boulder, Colorado, USA
| | - Srinadh Komanduri
- Department of Medicine, Division of Gastroenterology, Northwestern Medical Center, Feinberg School of Medicine, Chicago, Illinois, USA
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Muthusamy VR, Wani S, Gyawali CP, Komanduri S. AGA Clinical Practice Update on New Technology and Innovation for Surveillance and Screening in Barrett's Esophagus: Expert Review. Clin Gastroenterol Hepatol 2022; 20:2696-2706.e1. [PMID: 35788412 PMCID: PMC10203866 DOI: 10.1016/j.cgh.2022.06.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/14/2022] [Accepted: 06/10/2022] [Indexed: 01/27/2023]
Abstract
DESCRIPTION The purpose of this best practice advice (BPA) article from the Clinical Practice Update Committee of the American Gastroenterological Association is to provide an update on advances and innovation regarding the screening and surveillance of Barrett's esophagus. METHODS The BPA statements presented here were developed from expert review of existing literature combined with discussion and expert opinion to provide practical advice. Formal rating of the quality of evidence or strength of BPAs was not the intent of this clinical practice update. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. BEST PRACTICE ADVICE 1: Screening with standard upper endoscopy may be considered in individuals with at least 3 established risk factors for Barrett's esophagus (BE) and esophageal adenocarcinoma, including individuals who are male, non-Hispanic white, age >50 years, have a history of smoking, chronic gastroesophageal reflux disease, obesity, or a family history of BE or esophageal adenocarcinoma. BEST PRACTICE ADVICE 2: Nonendoscopic cell-collection devices may be considered as an option to screen for BE. BEST PRACTICE ADVICE 3: Screening and surveillance endoscopic examination should be performed using high-definition white light endoscopy and virtual chromoendoscopy, with endoscopists spending adequate time inspecting the Barrett's segment. BEST PRACTICE ADVICE 4: Screening and surveillance exams should define the extent of BE using a standardized grading system documenting the circumferential and maximal extent of the columnar lined esophagus (Prague classification) with a clear description of landmarks and the location and characteristics of visible lesions (nodularity, ulceration), when present. BEST PRACTICE ADVICE 5: Advanced imaging technologies such as endomicroscopy may be used as adjunctive techniques to identify dysplasia. BEST PRACTICE ADVICE 6: Sampling during screening and surveillance exams should be performed using the Seattle biopsy protocol (4-quadrant biopsies every 1-2 cm and target biopsies from any visible lesion). BEST PRACTICE ADVICE 7: Wide-area transepithelial sampling may be used as an adjunctive technique to sample the suspected or established Barrett's segment (in addition to the Seattle biopsy protocol). BEST PRACTICE ADVICE 8: Patients with erosive esophagitis should be biopsied when concern of dysplasia or malignancy exists. A repeat endoscopy should be performed after 8 weeks of twice a day proton pump inhibitor therapy. BEST PRACTICE ADVICE 9: Tissue systems pathology-based prediction assay may be utilized for risk stratification of patients with nondysplastic BE. BEST PRACTICE ADVICE 10: Risk stratification models may be utilized to selectively identify individuals at risk for Barrett's associated neoplasia. BEST PRACTICE ADVICE 11: Given the significant interobserver variability among pathologists, the diagnosis of BE-related neoplasia should be confirmed by an expert pathology review. BEST PRACTICE ADVICE 12: Patients with BE-related neoplasia should be referred to endoscopists with expertise in advanced imaging, resection, and ablation. BEST PRACTICE ADVICE 13: All patients with BE should be placed on at least daily proton pump inhibitor therapy. BEST PRACTICE ADVICE 14: Patients with nondysplastic BE should undergo surveillance endoscopy in 3 to 5 years. BEST PRACTICE ADVICE 15: In patients undergoing surveillance after endoscopic eradication therapy, random biopsies should be taken of the esophagogastric junction, gastric cardia, and the distal 2 cm of the neosquamous epithelium as well as from all visible lesions, independent of the length of the original BE segment.
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Affiliation(s)
- V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Denver, Colorado
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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Komanduri S, Wani S, Muthusamy VR. Reply. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00963-6. [PMID: 36257511 DOI: 10.1016/j.cgh.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - V Raman Muthusamy
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Komanduri S, Dominitz JA, Rabeneck L, Kahi C, Ladabaum U, Imperiale TF, Byrne MF, Lee JK, Lieberman D, Wang AY, Sultan S, Shaukat A, Pohl H, Muthusamy VR. AGA White Paper: Challenges and Gaps in Innovation for the Performance of Colonoscopy for Screening and Surveillance of Colorectal Cancer. Clin Gastroenterol Hepatol 2022; 20:2198-2209.e3. [PMID: 35688352 DOI: 10.1016/j.cgh.2022.03.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 02/23/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
In 2018, the American Gastroenterological Association's Center for GI Innovation and Technology convened a consensus conference, entitled "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The conference participants, which included more than 60 experts in colorectal cancer, considered recent improvements in colorectal cancer screening rates and polyp detection, persistent barriers to colonoscopy uptake, and opportunities for performance improvement and innovation. This white paper originates from that conference. It aims to summarize current patient- and physician-centered gaps and challenges in colonoscopy, diagnostic and therapeutic challenges affecting colonoscopy uptake, and the potential use of emerging technologies and quality metrics to improve patient outcomes.
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Affiliation(s)
- Srinadh Komanduri
- Department of Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System and the Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Linda Rabeneck
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Charles Kahi
- Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Thomas F Imperiale
- Department of Medicine, Indiana University School of Medicine, the Regenstrief Institute, the Simon Cancer Center, and the Center for Innovation at Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Michael F Byrne
- Division of Gastroenterology, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey K Lee
- Collaborative Health Outcomes Research in Digestive Diseases (CHORD) Group, Kaiser Permanente Division of Research, Kaiser Permanente San Francisco, San Francisco, California
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aasma Shaukat
- Division of Gastroenterology, Minneapolis Veterans Affairs Health Care System and Department of Medicine, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heiko Pohl
- Veterans Affairs Medical Center White River Junction, Vermont; Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California.
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Mittal C, Muthusamy VR, Simon VC, Brauer BC, Mullady DK, Hollander T, Sloan I, Kushnir V, Early D, Rastogi A, Hammad HT, Edmundowicz SA, Han S, Thaker AM, Ezekwe E, Wani S, Kwasny MJ, Komanduri S. Threshold evaluation for optimal number of endoscopic treatment sessions to achieve complete eradication of Barrett's metaplasia. Endoscopy 2022; 54:927-933. [PMID: 35135015 DOI: 10.1055/a-1765-7197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Endoscopic eradication therapy (EET) is the standard of care for Barrett's esophagus (BE)-associated neoplasia. Previous data suggest the mean number of EET sessions required to achieve complete eradication of intestinal metaplasia (CE-IM) is 3. This study aimed to define the threshold of EET sessions required to achieve CE-IM. METHODS The TREAT-BE Consortium is a multicenter outcomes cohort including prospectively enrolled patients with BE undergoing EET. All patients achieving CE-IM were included. Demographic, endoscopic, and histologic data were recorded at treatment onset along with treatment details and surveillance data. Kaplan-Meier analysis was performed to define a threshold of EET sessions, with 95 %CI, required to achieve CE-IM. A secondary analysis examined predictors of incomplete response to EET using multiple logistic regression and recurrence rates. RESULTS 623 patients (mean age 65.2 [SD 11.6], 79.6 % male, 86.5 % Caucasian) achieved CE-IM in a mean of 2.9 (SD 1.7) EET sessions (median 2) and a median total observation period of 2.7 years (interquartile range 1.4-5.0). After three sessions, 73 % of patients achieved CE-IM (95 %CI 70 %-77 %). Age (odds ratio [OR] 1.25, 95 %CI 1.05-1.50) and length of BE (OR 1.24, 95 %CI 1.17-1.31) were significant predictors of incomplete response. CONCLUSION The current study found that a threshold of three EET sessions would achieve CE-IM in the majority of patients. Alternative therapies and further diagnostic testing should be considered for patients who do not have significant response to EET after three sessions.
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Affiliation(s)
- Chetan Mittal
- Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, United States
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, United States
| | - Violette C Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Brian C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Ian Sloan
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Dayna Early
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Amit Rastogi
- Division of Gastroenterology, Kansas University, Kansas City, Kansas, United States
| | - Hazem T Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Adarsh M Thaker
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, United States
| | - Ezenwanyi Ezekwe
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Mary J Kwasny
- Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, United States
| | - Srinadh Komanduri
- Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, United States
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Hall M, Bergman J, Canto MI, Chak A, Corley DA, Falk GW, Fitzgerald RC, Haidry R, Inadomi JM, Iyer PG, Kolb J, Komanduri S, Konda V, Montgomery EA, Muthusamy VR, Rubenstein JH, Schnoll-Sussman F, Shaheen NJ, Smith M, Spechler S, Vajravelu R. Post-endoscopy Esophageal Neoplasia in Barrett's Esophagus: Consensus Statements From an International Expert Panel. Gastroenterology 2022; 162:366-372. [PMID: 34655571 PMCID: PMC8792371 DOI: 10.1053/j.gastro.2021.09.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Matthew Hall
- Children’s Hospital Association, Leawood, Kansas
| | - Jacques Bergman
- Division of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Marcia I. Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Amitabh Chak
- Division of Gastroenterology and Hepatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Douglas A. Corley
- The Permanente Medical Group; Kaiser Permanente, Northern California
| | - Gary W. Falk
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca C. Fitzgerald
- MRC Cancer Unit, Hutchison-MRC Research Center, University of Cambridge, Cambridge, United Kingdom
| | - Rehan Haidry
- Division of Gastroenterology and Hepatology, University College Hospital, London, United Kingdom
| | - John M. Inadomi
- Division of Gastroenterology and Hepatology, University of Utah, Salt Lake City, Utah
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jennifer Kolb
- Division of Gastroenterology, University of California Irvine, Irvine, California
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Vani Konda
- Division of Gastroenterology and Hepatology, Baylor University Medical Center and Baylor Scott and White Health, Dallas, Texas
| | | | - V. Raman Muthusamy
- Division of Gastroenterology and Hepatology, University of California, Los Angeles, Los Angeles, CA
| | - Joel H. Rubenstein
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor,Michigan Barrett’s Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Felice Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Weill Cornell University, New York, New York
| | - Nicholas J. Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Michael Smith
- Division of Gastroenterology and Hepatology, Mount Sinai West and Mount Sinai Morningside Hospitals, New York, New York
| | - Stuart Spechler
- Division of Gastroenterology and Hepatology, Baylor University Medical Center and Baylor Scott and White Health, Dallas, Texas
| | - Ravy Vajravelu
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Patel RV, Barsuk JH, Cohen ER, Wani SB, Rastogi A, McGaghie WC, Wayne DB, Keswani RN, Komanduri S. Simulation-based training improves polypectomy skills among practicing endoscopists. Endosc Int Open 2021; 9:E1633-E1639. [PMID: 34790525 PMCID: PMC8589541 DOI: 10.1055/a-1525-5620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/04/2021] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Practicing endoscopists have variable polypectomy skills during colonoscopy and limited training opportunities for improvement. Simulation-based training enhances procedural skill, but its impact on polypectomy is unclear. We developed a simulation-based polypectomy intervention to improve polypectomy competency. Methods All faculty endoscopists at our tertiary care center who perform colonoscopy with polypectomy were recruited for a simulation-based intervention assessing sessile and stalked polypectomy. Endoscopists removed five polyps in a simulation environment at pretest followed by a training intervention including a video, practice, and one-on-one feedback. Within 1-4 weeks, endoscopists removed five new simulated polyps at post-test. We used the Direct Observation of Polypectomy Skills (DOPyS) checklist for assessment, evaluating individual polypectomy skills, and global competency (scale: 1-4). Competency was defined as an average global competency score of ≥ 3. Results 83 % (29/35) of eligible endoscopists participated and 95 % (276/290) of planned polypectomies were completed. Only 17 % (5/29) of endoscopists had average global competency scores that were competent at pretest compared with 52 % (15/29) at post-test ( P = 0.01). Of all completed polypectomies, the competent polypectomy rate significantly improved from pretest to post-test (55 % vs. 71 %; P < 0.01). This improvement was significant for sessile polypectomy (37 % vs. 65 %; P < 0.01) but not for stalked polypectomy (82 % vs. 80 %; P = 0.70). Conclusions Simulation-based training improved polypectomy skills among practicing endoscopists. Further studies are needed to assess the translation of simulation-based education to clinical practice.
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Affiliation(s)
- Ronak V. Patel
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Jeffrey H. Barsuk
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States,Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Elaine R. Cohen
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Sachin B. Wani
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, United States
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas, Kansas City, Kansas, United States
| | - William C. McGaghie
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Diane B. Wayne
- Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Rajesh N. Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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14
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Campbell CH, Triggs JR, Miller FH, Komanduri S. Endoscopic Ultrasound for Evaluation of Pancreatic Duct "Cutoff" Identified on Magnetic Resonance Imaging Improves the Diagnostic Yield of Occult Malignancy. Pancreas 2021; 50:e43-e45. [PMID: 33939682 DOI: 10.1097/mpa.0000000000001789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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15
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Xiao AH, Chang SY, Stevoff CG, Komanduri S, Pandolfino JE, Keswani RN. Adoption of Multi-society Guidelines Facilitates Value-Based Reduction in Screening and Surveillance Colonoscopy Volume During COVID-19 Pandemic. Dig Dis Sci 2021; 66:2578-2584. [PMID: 32803460 PMCID: PMC7429116 DOI: 10.1007/s10620-020-06539-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/05/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND COVID-19 has caused a backlog of endoscopic procedures; colonoscopy must now be prioritized to those who would benefit most. We determined the proportion of screening and surveillance colonoscopies appropriate for rescheduling to a future year through strict adoption of US Multi-Society Task Force (USMSTF) guidelines. METHODS We conducted a single-center observational study of patients scheduled for "open-access colonoscopy"-ordered by a primary care provider without being seen in gastroenterology clinic-over a 6-week period during the COVID-19 pandemic. Each chart was reviewed to appropriately assign a surveillance year per USMSTF guidelines including demographics, colonoscopy history and family history. When guidelines recommended a range of colonoscopy intervals, both a "conservative" and "liberal" guideline adherence were assessed. RESULTS We delayed 769 "open-access" screening or surveillance colonoscopies due to COVID-19. Between 14.8% (conservative) and 20.7% (liberal), colonoscopies were appropriate for rescheduling to a future year. Conversely, 415 (54.0%) patients were overdue for colonoscopy. Family history of CRC was associated with being scheduled too early for both screening (OR 3.9; CI 1.9-8.2) and surveillance colonoscopy (OR 2.6, CI 1.0-6.5). The most common reasons a colonoscopy was inappropriately scheduled this year were failure to use new surveillance colonoscopy intervals (28.9%), incorrectly applied family history guidelines (27.2%) and recommending early surveillance colonoscopy after recent normal colonoscopy (19.3%). CONCLUSION Up to one-fifth of patients scheduled for "open-access" colonoscopy can be rescheduled into a future year based on USMSTF guidelines. Rigorously applying guidelines could judiciously allocate colonoscopy resources as we recover from the COVID-19 pandemic.
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Affiliation(s)
| | - Stephen Y Chang
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Digestive Health Center, Northwestern Medicine, 676 N. St. Clair, Suite 1400, Chicago, IL, 60611, USA
| | - Christian G Stevoff
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Digestive Health Center, Northwestern Medicine, 676 N. St. Clair, Suite 1400, Chicago, IL, 60611, USA
| | - Srinadh Komanduri
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Digestive Health Center, Northwestern Medicine, 676 N. St. Clair, Suite 1400, Chicago, IL, 60611, USA
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Digestive Health Center, Northwestern Medicine, 676 N. St. Clair, Suite 1400, Chicago, IL, 60611, USA
| | - Rajesh N Keswani
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Digestive Health Center, Northwestern Medicine, 676 N. St. Clair, Suite 1400, Chicago, IL, 60611, USA.
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16
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Abstract
Endoscopic eradication therapy (EET) is recommended for patients with Barrett's esophagus (BE)-associated neoplasia and is effective in achieving complete eradication of intestinal metaplasia (CE-IM). However, BE that is refractory to EET, defined as partial or no improvement in dysplasia after less than or equal to 3 ablative sessions, and the development of recurrence post-EET is not uncommon. Identification of refractory BE or recurrent intestinal metaplasia should prompt esophageal physiologic testing and modification of antireflux strategy, as appropriate. In patients who ultimately fail standard EET despite optimization of reflux control, salvage EET with alternate modalities may need to be considered.
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Affiliation(s)
- Domenico A Farina
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - Ashwinee Condon
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
| | - Srinadh Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA.
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17
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Wani S, Williams JL, Falk GW, Komanduri S, Muthusamy VR, Shaheen NJ. An Analysis of the GIQuIC Nationwide Quality Registry Reveals Unnecessary Surveillance Endoscopies in Patients With Normal and Irregular Z-Lines. Am J Gastroenterol 2020; 115:1869-1878. [PMID: 33156106 DOI: 10.14309/ajg.0000000000000960] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Population-based estimates of adherence to Barrett's esophagus (BE) guidelines are not available. Using a national registry, we assessed surveillance intervals for patients with normal and irregular Z-lines based on the presence or absence of intestinal metaplasia (IM) and among patients with suspected or confirmed BE. METHODS We analyzed data from the GI Quality Improvement Consortium Registry. Endoscopy data, including procedure indication, demographics, endoscopy and histology findings, and recommendations for further endoscopy, were assessed from January 2013 through December 2019. Patients with an indication of BE screening or surveillance or an endoscopic finding of BE were included. Biopsy and surveillance practices were assessed based on the length of columnar epithelium (0 cm, <1 cm, 1-3 cm, and >3 cm) and diagnosis based on histology findings. RESULTS A total of 1,907,801 endoscopies were assessed; 135,704 endoscopies (7.1%) performed in 114,894 patients met the inclusion criteria (men 61.4%, Whites 91%, and mean age of 61.7 years [SD 12.5]). Among patients with normal Z-lines, surveillance endoscopy was recommended for 81% of patients with IM and 20% of individuals without IM. Among patients with irregular Z-lines, surveillance endoscopy was recommended for 81% with IM and 24% without IM. Approximately 30% of patients with confirmed nondysplastic BE (lengths 1-3 and >3 cm) had recommended surveillance intervals of <3 years. DISCUSSION An analysis of data from a nationwide quality registry demonstrated that patients without BE are receiving recommendations for surveillance endoscopies and many patients with nondysplastic BE are reexamined too soon.
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Affiliation(s)
- Sachin Wani
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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18
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Wani S, Han S, Kushnir V, Early D, Mullady D, Hammad H, Brauer B, Thaker A, Simon V, Ezekwe E, Hollander T, Wood M, Rastogi A, Edmundowicz S, Muthusamy VR, Komanduri S. Recurrence Is Rare Following Complete Eradication of Intestinal Metaplasia in Patients With Barrett's Esophagus and Peaks at 18 Months. Clin Gastroenterol Hepatol 2020; 18:2609-2617.e2. [PMID: 31982610 DOI: 10.1016/j.cgh.2020.01.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/12/2019] [Accepted: 01/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There have been few studies describing the long-term durability of complete eradication of intestinal metaplasia (CE-IM) in patients with Barrett's esophagus (BE)-related neoplasia who received endoscopic eradication therapy (EET). Data are needed to guide surveillance interval protocols and identify patients at risk for recurrence. We assessed the rate of recurrence of intestinal metaplasia and dysplasia, histologic features, and outcomes after recurrence of CE-IM, and identified factors associated with recurrence. METHODS We performed a prospective study of 807 patients with BE who underwent EET, which produced CE-IM, at 4 tertiary-care referral centers, from January 2013 to October 2018. Kaplan-Meier estimates of cumulative incidence rates (IR) of recurrence were calculated for up to 5 years following CE-IM and were stratified by baseline level of histology. Density estimates of recurrence were used to determine the change in the rate of recurrence over time. We conducted logistic regression analysis to identify factors associated with recurrence. RESULTS Intestinal metaplasia recurred in 121 patients (15%; IR, 5.2/100 person-years), and dysplasia recurred in 41 patients (5.1%; IR, 1.8/100 person-years), after a median follow-up time of 2317 person-years. The rate of recurrence was not constant and the time to any recurrence converged to a normal distribution; recurrences peaked at 1.6 y after patients had CE-IM. Baseline high-grade dysplasia or intramucosal cancer (adjusted odds ratio [aOR], 4.19), presence of reflux symptoms (aOR, 12.1) or hiatal hernia (aOR, 13.8), and number of sessions required to achieve CE-IM (aOR, 1.8) were associated with recurrence. CONCLUSIONS In a prospective study of a large cohort of patients with BE undergoing EET, we found a low rate of recurrence after CE-IM. The rate of recurrence peaked at 1-2 y after CE-IM. These findings indicate that aggressive surveillance might not be necessary more than 1 y after CE-IM and should be considered in surveillance guidelines. Clinicaltrials.gov no: NCT02634645.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Vladimir Kushnir
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St Louis, Missouri
| | - Dayna Early
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Mullady
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St Louis, Missouri
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brian Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Adarsh Thaker
- Vatche and Tamar Maoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Eze Ezekwe
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Thomas Hollander
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St Louis, Missouri
| | - Mariah Wood
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - V Raman Muthusamy
- Vatche and Tamar Maoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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19
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Farina DA, Komanduri S, Aadam AA, Keswani RN. Endoscopic retrograde cholangiopancreatography (ERCP) in critically ill patients is safe and effective when performed in the endoscopy suite. Endosc Int Open 2020; 8:E1165-E1172. [PMID: 32904818 PMCID: PMC7458757 DOI: 10.1055/a-1194-4049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/12/2020] [Indexed: 01/30/2023] Open
Abstract
Background and study aims Critically ill patients may require endoscopic retrograde cholangiopancreatography (ERCP) but performing ERCP in the intensive care unit (ICU) poses logistic and technical challenges. There are no data on ICU patients undergoing ERCP in the endoscopy suite. The primary aim of this study was to report outcomes, including safety, when ERCP in critically ill patients is performed in the endoscopy suite. Patients and methods We queried our institutional endoscopy database to identify all ICU patients who underwent ERCP at a single academic medical center from 04/01/2010 to 11/30/2017. Only patients admitted to an ICU prior to ERCP were included. Results Of 7,218 ERCPs performed during the study period, 260 ERCPs (3.6 %) were performed in 231 ICU patients (mean age 61y; 53 % male); nearly all ICU patient ERCPs (n = 258; 99 %) occurred in the endoscopy suite. ERCP indications included cholangitis (50 %), post-liver transplant cholestasis (15 %), and bile leak (10 %). All ERCPs were performed with anesthesiology, most with general anesthesia (60 %) and in the prone position (60 %). Most patients (73 %) had sepsis. Prior to ERCP, 17 % of patients required vasopressors; vasopressors were begun during ERCP in 4 %. The cannulation success rate was 95 % (94 % in native papillae). Adverse events occurred in 9 % (n = 23) of cases with post-ERCP pancreatitis most common. No patients died during or within 24 hours of ERCP. Mortality at 30 days was 16 %, all attributed to underlying disease. Conclusions When advanced ventilatory and hemodynamic support is available, critically ill patients can safely and effectively undergo ERCP in the endoscopy suite.
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Affiliation(s)
- Domenico A. Farina
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
| | - Srinadh Komanduri
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
| | - A. Aziz Aadam
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
| | - Rajesh N. Keswani
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
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20
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Johnston A, Serhal A, Lopes Vendrami C, McCarthy RJ, Komanduri S, Horowitz JM, Nikolaidis P, Miller FH. The abrupt pancreatic duct cutoff sign on MDCT and MRI. Abdom Radiol (NY) 2020; 45:2476-2484. [PMID: 32444890 DOI: 10.1007/s00261-020-02582-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the pancreatic duct cutoff sign in detecting pancreatic adenocarcinoma using CT and MRI. METHODS A retrospective analysis of patients with a pancreatic duct (PD) cutoff sign on CT or MRI from 2000 to 2019 was performed. The primary outcome measured was the presence or absence of a malignant pancreatic tumor. Variables evaluated included imaging characteristics of patients with a malignant versus non-malignant cause of duct cutoff and included PD size and PD-to-parenchyma ratio, contour abnormality, abnormal enhancement, diffusion abnormality, and upstream parenchymal atrophy. RESULTS Seventy-two patients (44:28 M:F, mean age 64 years) were identified with a PD cutoff sign. Fifty-eight percent (42/72) of these patients were diagnosed with malignancy, 62% (26/42) of whom were diagnosed with pancreatic ductal adenocarcinoma. In patients diagnosed with a non-malignant cause of duct cutoff, 37% (11/30) were diagnosed with chronic pancreatitis. Eighty-eight percent (37/42) of patients with malignant causes and 33% (10/30) of patients with non-malignant causes were noted to have an associated mass on imaging. The presence of contour abnormality, diffusion abnormality, or abnormal enhancement at the level of the pancreatic cutoff was significantly higher in patients with malignancy (p < 0.05). There was no difference between groups in location of the pancreatic duct cutoff, degree of pancreatic duct dilatation, PD-to-parenchyma ratio, or presence of upstream atrophy. CONCLUSION Abrupt cutoff of the pancreatic duct was associated with an increased likelihood of detecting malignancy. All patients who demonstrate this sign should undergo expedited workup with dedicated MRI and EUS with biopsy.
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Affiliation(s)
- Andrew Johnston
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Ali Serhal
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Camila Lopes Vendrami
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University, Chicago, IL, 60612, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeanne M Horowitz
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Paul Nikolaidis
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Frank H Miller
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St., Suite 800, Chicago, IL, 60611, USA.
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21
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Dey N, Kochman ML, Komanduri S, Melson JE, Muthusamy VR. Report from the AGA Center for GI Innovation and Technology's Consensus Conference: Envisioning Next-Generation Paradigms in Colorectal Cancer Screening and Surveillance. Gastroenterology 2020; 158:455-460. [PMID: 31525354 DOI: 10.1053/j.gastro.2019.05.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Neelendu Dey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington.
| | - Michael L Kochman
- Gastroenterology Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Srinadh Komanduri
- Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joshua E Melson
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, Rush Medical College, Chicago, Illinois
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Wani S, Williams JL, Komanduri S, Muthusamy VR, Shaheen NJ. Time Trends in Adherence to Surveillance Intervals and Biopsy Protocol Among Patients With Barrett's Esophagus. Gastroenterology 2020; 158:770-772.e2. [PMID: 31622626 DOI: 10.1053/j.gastro.2019.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/25/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Sachin Wani
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
| | | | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Wani S, Williams JL, Komanduri S, Muthusamy VR, Shaheen NJ. Endoscopists systematically undersample patients with long-segment Barrett's esophagus: an analysis of biopsy sampling practices from a quality improvement registry. Gastrointest Endosc 2019; 90:732-741.e3. [PMID: 31085185 DOI: 10.1016/j.gie.2019.04.250] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/28/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Guidelines recommend systematic biopsy sampling in Barrett's esophagus (BE) to reduce sampling error. Adherence to this biopsy sampling protocol has been suggested as a quality indicator; however, estimates of adherence are not available. Using a national registry, we assessed adherence and identified predictors of adherence to biopsy sampling protocols. METHODS We analyzed data from the GI Quality Improvement Consortium Registry that included procedure indication, demographics, endoscopy, and pathology results. Patients with an indication of BE screening/surveillance or an endoscopic finding of BE were included. Adherence to the Seattle protocol was assessed by dividing BE length by number of pathology jars, with a ratio ≤2.0 with rounding down (lenient definition) or rounding up (stringent definition) for odd BE lengths considered adherent. Variables associated with adherence were assessed using generalized estimating equations to control for clustering within individual physicians. RESULTS Of 786,712 EGDs assessed, 58,709 (7.5%) EGDs in 53,541 patients met inclusion criteria (mean age, 61.3 years; 60.4% men; 90.2% white; mean BE length, 2.3 cm). When the lenient and stringent definitions for adherence were used, 87.8% and 82.7% of EGDs were adherent, respectively. Increasing BE length was the most significant predictor of nonadherence (odds ratio, .69; 95% confidence interval, .67-.71). Other predictors were increasing age, male gender, increasing American Society of Anesthesiologists class, and practice location. Performance of EGD by nongastroenterologist physicians was associated with nonadherence (odds ratio, .07; 95% confidence interval, .06-.10). CONCLUSIONS Nearly 20% of endoscopies performed in BE patients were not adherent to the Seattle protocol. As BE length increases, endoscopists become less compliant with odds of nonadherence increasing by 31% with every 1-cm increase in length.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - V Raman Muthusamy
- Division of Gastroenterology and Hepatology, University of California, Los Angeles, Los Angeles, California, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Omar M, Thaker AM, Wani S, Simon V, Ezekwe E, Boniface M, Edmundowicz S, Obuch J, Cinnor B, Brauer BC, Wood M, Early DS, Lang GD, Mullady D, Hollander T, Kushnir V, Komanduri S, Muthusamy VR. Anatomic location of Barrett's esophagus recurrence after endoscopic eradication therapy: development of a simplified surveillance biopsy strategy. Gastrointest Endosc 2019; 90:395-403. [PMID: 31004598 DOI: 10.1016/j.gie.2019.04.216] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/02/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Surveillance endoscopy is recommended after endoscopic eradication therapy (EET) for Barrett's esophagus (BE) because of the risk of recurrence. Currently recommended biopsy protocols are based on expert opinion and consist of sampling visible lesions followed by random 4-quadrant biopsy sampling throughout the length of the original BE segment. Despite this protocol, some recurrences are not visibly identified. We aimed to identify the anatomic location and histology of recurrences after successful EET with the goal of developing a more efficient and evidence-based surveillance biopsy protocol. METHODS We performed an analysis of a large multicenter database of 443 patients who underwent EET and achieved complete eradication of intestinal metaplasia (CE-IM) from 2005 to 2015. The endoscopic location of recurrence relative to the squamocolumnar junction (SCJ), visible recurrence identified during surveillance endoscopy, and time to recurrence after CE-IM were assessed. RESULTS Fifty patients with BE recurrence were studied in the final analysis. Seventeen patients (34%) had nonvisible recurrences. In this group, biopsy specimens demonstrating recurrence were taken from within 2 cm of the SCJ in 16 of these 17 patients (94%). Overall, 49 of 50 recurrences (98%) occurred either within 2 cm of the SCJ or at the site of a visible lesion. Late recurrences (>1 year) were more likely to be visible than early (<1 year) recurrences (P = .006). CONCLUSIONS Recurrence after EET detected by random biopsy sampling is identified predominately in the distal esophagus and occurs earlier than visible recurrences. As such, we suggest a modified biopsy protocol with targeted sampling of visible lesions followed by random biopsy sampling within 2 cm of the SCJ to optimize detection of recurrence after EET. (Clinical trial registration number: NCT02634645.).
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Affiliation(s)
- Mahmoud Omar
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
| | - Adarsh M Thaker
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Eze Ezekwe
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Megan Boniface
- Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Steven Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Joshua Obuch
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Birtukan Cinnor
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Brian C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Mariah Wood
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Srinadh Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - V Raman Muthusamy
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
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25
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Affiliation(s)
- V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.
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26
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Wani S, Keswani RN, Han S, Aagaard EM, Hall M, Simon V, Abidi WM, Banerjee S, Baron TH, Bartel M, Bowman E, Brauer BC, Buscaglia JM, Carlin L, Chak A, Chatrath H, Choudhary A, Confer B, Coté GA, Das KK, DiMaio CJ, Dries AM, Edmundowicz SA, Chafic AHE, Hajj IE, Ellert S, Ferreira J, Gamboa A, Gan IS, Gangarosa LM, Gannavarapu B, Gordon SR, Guda NM, Hammad HT, Harris C, Jalaj S, Jowell PS, Kenshil S, Klapman J, Kochman ML, Komanduri S, Lang G, Lee LS, Loren DE, Lukens FJ, Mullady D, Muthusamy VR, Nett AS, Olyaee MS, Pakseresht K, Perera P, Pfau P, Piraka C, Poneros JM, Rastogi A, Razzak A, Riff B, Saligram S, Scheiman JM, Schuster I, Shah RJ, Sharma R, Spaete JP, Singh A, Sohail M, Sreenarasimhaiah J, Stevens T, Tabibian JH, Tzimas D, Uppal DS, Urayama S, Vitterbo D, Wang AY, Wassef W, Yachimski P, Zepeda-Gomez S, Zuchelli T, Early D. Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice. Gastroenterology 2018; 155:1483-1494.e7. [PMID: 30056094 PMCID: PMC6504935 DOI: 10.1053/j.gastro.2018.07.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/18/2018] [Accepted: 07/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.
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Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado.
| | - Rajesh N. Keswani
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Samuel Han
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | | | - Violette Simon
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | | | - Todd H. Baron
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael Bartel
- Mayo Clinic School of Graduate Medical Education, Jacksonville, Florida
| | | | - Brian C. Brauer
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | | | - Linda Carlin
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Hemant Chatrath
- University of California-Los Angeles, Los Angeles, California
| | | | | | - Gregory A. Coté
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | | | | | | | | | - Swan Ellert
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Jason Ferreira
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Ian S. Gan
- Virginia Mason Medical Center, Seattle, Washington
| | - Lisa M. Gangarosa
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Hazem T. Hammad
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Cynthia Harris
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | - Sujai Jalaj
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Sana Kenshil
- University of Alberta, Edmonton, Alberta, Canada
| | - Jason Klapman
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gabriel Lang
- Washington University in St Louis, St Louis, Missouri
| | - Linda S. Lee
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Frank J. Lukens
- Mayo Clinic School of Graduate Medical Education, Jacksonville, Florida
| | | | | | | | | | | | | | | | | | | | | | | | - Brian Riff
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Shreyas Saligram
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | | | - Raj J. Shah
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Rishi Sharma
- University of California-Davis, Davis, California
| | | | - Ajaypal Singh
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Muhammad Sohail
- University of Massachusetts Medical Center, Worcester, Massachusetts
| | | | | | | | | | - Dushant S. Uppal
- University of Virginia School of Medicine, Charlottesville, Virginia
| | | | | | - Andrew Y. Wang
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wahid Wassef
- University of Massachusetts Medical Center, Worcester, Massachusetts
| | | | | | | | - Dayna Early
- Washington University in St Louis, St Louis, Missouri
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Han S, Yadlapati R, Simon V, Ezekwe E, Early DS, Kushnir V, Hollander T, Brauer BC, Hammad H, Edmundowicz SA, Wood M, Shaheen NJ, Muthusamy RV, Komanduri S, Wani S. Dysplasia severity is associated with poor quality of life in patients with Barrett's esophagus referred for endoscopic eradication therapy. Dis Esophagus 2018; 32:5085984. [PMID: 30169612 PMCID: PMC6303730 DOI: 10.1093/dote/doy086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Limited data exist regarding patient-reported outcomes and quality of life (QOL) experienced by patients with Barrett's esophagus (BE) referred for endoscopic eradication therapy (EET). Specifically, the impact of grade of dysplasia has not been explored. The purpose of this study is to measure patient-reported symptoms and QOL and identify factors associated with poor QOL in BE patients referred for EET. This was a prospective multicenter study conducted from January 2015 to October 2017, which included patients with BE referred for EET. Participants completed a set of validated questionnaires to measure QOL, symptom severity, and psychosocial factors. The primary outcome was poor QOL defined by a PROMIS score >12. Multivariable logistic regression analysis was performed to identify factors associated with poor QOL. In total, 193 patients participated (mean age 64.6 years, BE length 5.5 cm, 82% males, 92% Caucasians) with poor QOL reported in 104 (53.9%) participants. On univariate analysis, patients with poor QOL had lower use of twice daily proton pump inhibitor use (61.5% vs. 86.5%, P = 0.03), shorter disease duration (4.9 vs. 5.9 years, P = 0.04) and progressive increase in grade of dysplasia (high-grade dysplasia: 68.8% vs. 31.3%, esophageal adenocarcinoma: 75.5% vs. 24.5%, P < 0.001). Multivariate analysis demonstrated that high-grade dysplasia was independently associated with poor QOL (OR: 5.57, 95% CI: 1.05, 29.5, P = 0.04). In summary, poor QOL is experienced by the majority of patients with BE referred for EET and the degree of dysplasia was independently associated with poor QOL, which emphasizes the need to incorporate patient-centered outcomes when studying treatment of BE-related dysplasia.
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Affiliation(s)
- S Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - R Yadlapati
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - V Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - E Ezekwe
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - D S Early
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, Missouri
| | - V Kushnir
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, Missouri
| | - T Hollander
- Division of Gastroenterology, Washington University in St. Louis, St. Louis, Missouri
| | - B C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - H Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - S A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - M Wood
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - N J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - R V Muthusamy
- Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
| | - S Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - S Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado,Address correspondence to: Sachin Wani, Associate Professor of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, 1635 Aurora Court, Rm 2.031, Aurora, CO 80045, USA.
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28
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Marshall C, Mounzer R, Hall M, Simon V, Centeno B, Dennis K, Dhillon J, Fan F, Khazai L, Klapman J, Komanduri S, Lin X, Lu D, Mehrotra S, Muthusamy VR, Nayar R, Paintal A, Rao J, Sams S, Shah J, Watson R, Rastogi A, Wani S. Suboptimal Agreement Among Cytopathologists in Diagnosis of Malignancy Based on Endoscopic Ultrasound Needle Aspirates of Solid Pancreatic Lesions: A Validation Study. Clin Gastroenterol Hepatol 2018; 16:1114-1122.e2. [PMID: 28911946 DOI: 10.1016/j.cgh.2017.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/17/2017] [Accepted: 09/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Despite the widespread use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to sample pancreatic lesions and the standardization of pancreaticobiliary cytopathologic nomenclature, there are few data on inter-observer agreement among cytopathologists evaluating pancreatic cytologic specimens obtained by EUS-FNA. We developed a scoring system to assess agreement among cytopathologists in overall diagnosis and quantitative and qualitative parameters, and evaluated factors associated with agreement. METHODS We performed a prospective study to validate results from our pilot study that demonstrated moderate to substantial inter-observer agreement among cytopathologists for the final cytologic diagnosis. In the first phase, 3 cytopathologists refined criteria for assessment of quantity and quality measures. During phase 2, EUS-FNA specimens of solid pancreatic lesions from 46 patients were evaluated by 11 cytopathologists at 5 tertiary care centers using a standardized scoring tool. Individual quantitative and qualitative measures were scored and an overall cytologic diagnosis was determined. Clinical and EUS parameters were assessed as predictors of unanimous agreement. Inter-observer agreement (IOA) was calculated using multi-rater kappa (κ) statistics and a logistic regression model was created to identify factors associated with unanimous agreement. RESULTS The IOA for final diagnoses, based on cytologic analysis, was moderate (κ = 0.56; 95% CI, 0.43-0.70). Kappa values did not increase when categories of suspicious for malignancy, malignant, and neoplasm were combined. IOA was slight to moderate for individual quantitative (κ = 0.007; 95% CI, -0.03 to -0.04) and qualitative parameters (κ = 0.5; 95% CI, 0.47-0.53). Jaundice was the only factor associated with agreement among all cytopathologists on multivariate analysis (odds ratio for unanimous agreement, 5.3; 95% CI, 1.1-26.89). CONCLUSIONS There is a suboptimal level of agreement among cytopathologists in the diagnosis of malignancy based on analysis of EUS-FNA specimens obtained from solid pancreatic masses. Strategies are needed to refine the cytologic criteria for diagnosis of malignancy and enhance tissue acquisition techniques to improve diagnostic reproducibility among cytopathologists.
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Affiliation(s)
- Carrie Marshall
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rawad Mounzer
- Digestive Institute, Banner - University Medical Center, Phoenix, Arizona
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Barbara Centeno
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Katie Dennis
- Department of Pathology, University of Kansas School of Medicine, Kansas City, Kansas
| | | | - Fang Fan
- Department of Pathology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Laila Khazai
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Jason Klapman
- Gastrointestinal Tumor Program, Moffitt Cancer Center, Tampa, Florida
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Xiaoqi Lin
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - David Lu
- Department of Pathology, University of California Los Angeles, Los Angeles, California
| | - Sanjana Mehrotra
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California
| | - Ritu Nayar
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - Ajit Paintal
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - Jianyu Rao
- Department of Pathology, University of California Los Angeles, Los Angeles, California
| | - Sharon Sams
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Janak Shah
- Division of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, Louisiana
| | - Rabindra Watson
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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29
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Rosenberg AJ, Wainwright DA, Rademaker A, Galvez C, Genet M, Zhai L, Lauing KL, Mulcahy MF, Hayes JP, Odell DD, Horbinski C, Komanduri S, Tetreault MP, Kim KYA, Villaflor VM. Indoleamine 2,3-dioxygenase 1 and overall survival of patients diagnosed with esophageal cancer. Oncotarget 2018; 9:23482-23493. [PMID: 29805749 PMCID: PMC5955099 DOI: 10.18632/oncotarget.25235] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 04/04/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Indoleamine 2,3-dioxygenase 1 (IDO1) is an enzyme with immunomodulatory properties that has emerged as a potential immunotherapeutic target in human cancer. However, the role, expression pattern, and relevance of IDO1 in esophageal cancer (EC) are poorly understood. Here, we utilize gene expression analysis of the cancer genome atlas (TCGA) and immunohistochemistry (IHC) to better understand the role and prognostic significance of IDO1 in EC. RESULTS High IDO1 mRNA levels were associated with worse overall survival (OS) in both esophageal squamous cell carcinoma (SCC) (P = 0.02) and adenocarcinoma (AC) (P = 0.036). High co-expression of IDO1 and programmed death ligand 1 (PD-L1) was associated with worse OS in SCC (P = 0.0031) and AC (P = 0.0186). IHC for IDO1 in SCC showed a significant correlation with PD-L1 (P < 0.0001) and CD3ε (P < 0.0001). CONCLUSIONS EC with high IDO1 and PD-L1 expression is significantly correlated with decreased patient survival, and may correlate with increased T-cells. These data suggest that simultaneous inhibition of IDO1 and PD-(L)1 may overcome important barriers to T-cell mediated immune rejection of EC. MATERIALS AND METHODS mRNA expression data from TCGA (SCC N = 87; AC N = 97). IHC in a second cohort of EC (N = 93) were stained for IDO1, PD-L1, and CD3ε, followed by light microscopic analysis.
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Affiliation(s)
- Ari J. Rosenberg
- Department of Medicine, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
- Division of Hematology and Oncology, Northwestern University, Chicago, 60611 IL, USA
| | - Derek A. Wainwright
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, 60611 IL, USA
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
| | - Alfred Rademaker
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, 60611 IL, USA
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
| | - Carlos Galvez
- Department of Medicine, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
| | - Matthew Genet
- Department of Medicine, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
| | - Lijie Zhai
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
| | - Kristen L. Lauing
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
| | - Mary F. Mulcahy
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, 60611 IL, USA
- Department of Medicine, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
- Division of Hematology and Oncology, Northwestern University, Chicago, 60611 IL, USA
- Northwestern Medicine Developmental Therapeutics Institute, Chicago, 60611 IL, USA
| | - John P. Hayes
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, 60611 IL, USA
- Department of Radiation Oncology, Northwestern University, Chicago, 60611 IL, USA
| | - David D. Odell
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, 60611 IL, USA
- Department of Thoracic Surgery, Northwestern University, Chicago, 60611 IL, USA
| | - Craig Horbinski
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, 60611 IL, USA
- Department of Pathology, Northwestern University, Chicago, 60611 IL, USA
| | - Srinadh Komanduri
- Department of Gastroenterology, Northwestern University, Chicago, 60611 IL, USA
| | | | - Kwang-Youn A. Kim
- Department of Preventive Medicine, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
| | - Victoria M. Villaflor
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, 60611 IL, USA
- Department of Medicine, Feinberg School of Medicine of Northwestern University, Chicago, 60611 IL, USA
- Division of Hematology and Oncology, Northwestern University, Chicago, 60611 IL, USA
- Northwestern Medicine Developmental Therapeutics Institute, Chicago, 60611 IL, USA
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Komanduri S, Muthusamy VR, Wani S. Controversies in Endoscopic Eradication Therapy for Barrett's Esophagus. Gastroenterology 2018; 154:1861-1875.e1. [PMID: 29458152 DOI: 10.1053/j.gastro.2017.12.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/05/2017] [Accepted: 12/20/2017] [Indexed: 02/07/2023]
Abstract
Advances in endoscopic eradication therapy for Barrett's Esophagus-associated neoplasia have resulted in a significant paradigm shift in the diagnosis and management of this complex disease. A robust body of literature critically evaluating outcomes of resection and ablative strategies has allowed gastroenterologists to make quality, evidence-based decisions for their patients. Despite this progress, there are still many unanswered questions and challenges that remain. Ultimately, identification of a cost-effective screening modality, biomarkers for risk stratification, and strides to eliminate post surveillance endoscopy after endoscopic eradication therapy are essential to reach our long-term goal for eradication of esophageal adenocarcinoma.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois.
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Tempero MA, Malafa MP, Al-Hawary M, Asbun H, Bain A, Behrman SW, Benson AB, Binder E, Cardin DB, Cha C, Chiorean EG, Chung V, Czito B, Dillhoff M, Dotan E, Ferrone CR, Hardacre J, Hawkins WG, Herman J, Ko AH, Komanduri S, Koong A, LoConte N, Lowy AM, Moravek C, Nakakura EK, O'Reilly EM, Obando J, Reddy S, Scaife C, Thayer S, Weekes CD, Wolff RA, Wolpin BM, Burns J, Darlow S. Pancreatic Adenocarcinoma, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2018; 15:1028-1061. [PMID: 28784865 DOI: 10.6004/jnccn.2017.0131] [Citation(s) in RCA: 662] [Impact Index Per Article: 110.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection.
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Gluskin AB, Komanduri S. Gastrointestinal: Mirizzi syndrome masquerading as primary cholangiocarcinoma. J Gastroenterol Hepatol 2018; 33:335. [PMID: 28768367 DOI: 10.1111/jgh.13915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- A B Gluskin
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - S Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Wani S, Keswani R, Hall M, Han S, Ali MA, Brauer B, Carlin L, Chak A, Collins D, Cote GA, Diehl DL, DiMaio CJ, Dries A, El-Hajj I, Ellert S, Fairley K, Faulx A, Fujii-Lau L, Gaddam S, Gan SI, Gaspar JP, Gautamy C, Gordon S, Harris C, Hyder S, Jones R, Kim S, Komanduri S, Law R, Lee L, Mounzer R, Mullady D, Muthusamy VR, Olyaee M, Pfau P, Saligram S, Piraka C, Rastogi A, Rosenkranz L, Rzouq F, Saxena A, Shah RJ, Simon VC, Small A, Sreenarasimhaiah J, Walker A, Wang AY, Watson RR, Wilson RH, Yachimski P, Yang D, Edmundowicz S, Early DS. A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills Study. Clin Gastroenterol Hepatol 2017; 15. [PMID: 28625816 PMCID: PMC7042954 DOI: 10.1016/j.cgh.2017.06.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS On the basis of the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) by using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. METHODS ASGE recognized training programs were invited to participate, and AETs were graded on ERCP and EUS exams by using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done by using a 4-point scoring system, and a comprehensive data collection and reporting system was built to create learning curves by using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. RESULTS Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range, 155-650) and 350 (125-500), respectively. Overall, 3786 exams were graded (EUS, 1137; ERCP-biliary, 2280; ERCP-pancreatic, 369). Learning curves for individual end points and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS, 82%; ERCP, 60%) and cognitive (EUS, 76%; ERCP, 100%) competence at conclusion of training. CONCLUSIONS These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP. ClinicalTrials.gov: NCT02509416.
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Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | | | - Matt Hall
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samuel Han
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Meer Akbar Ali
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Brian Brauer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Linda Carlin
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Dan Collins
- Carolinas Medical Center, Charlotte, North Carolina
| | - Gregory A. Cote
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | - Andrew Dries
- Carolinas Medical Center, Charlotte, North Carolina
| | | | - Swan Ellert
- Colorado Clinical and Translational Sciences Institute, Aurora, Colorado
| | | | - Ashley Faulx
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St Louis, Missouri
| | - Seng-Ian Gan
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Stuart Gordon
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Sarah Hyder
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ross Jones
- Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen Kim
- University of California, Los Angeles, Los Angeles, California
| | | | - Ryan Law
- Northwestern University, Chicago, Illinois
| | - Linda Lee
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rawad Mounzer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Mullady
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | | | | | | | | | - Fadi Rzouq
- University of Kansas, Kansas City, Kansas
| | | | - Raj J. Shah
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Aaron Small
- Virginia Mason Medical Center, Seattle, Washington
| | | | | | - Andrew Y. Wang
- University of Virginia Health System, Charlottesville, Virginia
| | | | - Robert H. Wilson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Dennis Yang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Dayna S. Early
- Washington University School of Medicine, St Louis, Missouri
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Wani S, Muthusamy VR, Shaheen NJ, Yadlapati R, Wilson R, Abrams JA, Bergman J, Chak A, Chang K, Das A, Dumot J, Edmundowicz SA, Eisen G, Falk GW, Fennerty MB, Gerson L, Ginsberg GG, Grande D, Hall M, Harnke B, Inadomi J, Jankowski J, Lightdale CJ, Makker J, Odze RD, Pech O, Sampliner RE, Spechler S, Triadafilopoulos G, Wallace MB, Wang K, Waxman I, Komanduri S. 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. Am J Gastroenterol 2017; 112:1032-1048. [PMID: 28570552 DOI: 10.1038/ajg.2017.166] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - V Raman Muthusamy
- University of California in Los Angeles, Los Angeles, California, USA
| | | | | | - Robert Wilson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | | | | | | | - Kenneth Chang
- University of California in Irvine, Irvine, California, USA
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona, USA
| | - John Dumot
- University Hospitals, Cleveland, Ohio, USA
| | | | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Lauren Gerson
- California Pacific Medical Center, San Francisco, California, USA
| | - Gregory G Ginsberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Matt Hall
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Ben Harnke
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John Inadomi
- University of Washington, Seattle, Washington, USA
| | | | | | - Jitin Makker
- University of California in Los Angeles, Los Angeles, California, USA
| | - Robert D Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Oliver Pech
- St. John of God Hospital, Regensburg, Germany
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Mohamadnejad M, Mullady D, Early DS, Collins B, Marshall C, Sams S, Yen R, Rizeq M, Romanas M, Nawaz S, Ulusarac O, Hollander T, Wilson RH, Simon VC, Kushnir V, Amateau SK, Brauer BC, Gaddam S, Azar RR, Komanduri S, Shah R, Das A, Edmundowicz S, Muthusamy VR, Rastogi A, Wani S. Increasing Number of Passes Beyond 4 Does Not Increase Sensitivity of Detection of Pancreatic Malignancy by Endoscopic Ultrasound-Guided Fine-Needle Aspiration. Clin Gastroenterol Hepatol 2017; 15:1071-1078.e2. [PMID: 28025154 DOI: 10.1016/j.cgh.2016.12.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/10/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear exactly how many passes are required to determine whether pancreatic masses are malignant using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We aimed to define the per-pass diagnostic yield of EUS-FNA for establishing the malignancy of a pancreatic mass, and identify factors associated with detection of malignancies. METHODS In a prospective study, 239 patients with solid pancreatic masses were randomly assigned to groups that underwent EUS-FNA, with the number of passes determined by an on-site cytopathology evaluation or set at 7 passes, at 3 tertiary referral centers. A final diagnosis of pancreatic malignancy was made based on findings from cytology, surgery, or a follow-up evaluation at least 1 year after EUS-FNA. The cumulative sensitivity of detection of malignancy by EUS-FNA was calculated after each pass; in the primary analysis, lesions categorized as malignant or suspicious were considered as positive findings. RESULTS Pancreatic malignancies were found in 202 patients (84.5% of the study population). EUS-FNA detected malignancies with 96% sensitivity (95% confidence interval [CI], 92%-98%); 4 passes of EUS-FNA detected malignancies with 92% sensitivity (95% CI, 87%-95%). Tumor size greater than 2 cm was the only variable associated with positive results from cytology analysis (odds ratio, 7.8; 95% CI, 1.9-31.6). In masses larger than 2 cm, 4 passes of EUS-FNA detected malignancies with 93% sensitivity (95% CI, 89%-96%) and in masses ≤2 cm, 6 passes was associated with 82% sensitivity (95% CI, 61%-93%). Sensitivity of detection did not increase with increasing number of passes. CONCLUSIONS In a prospective study, we found 4 passes of EUS-FNA to be sufficient to detect malignant pancreatic masses; increasing the number of passes did not increase the sensitivity of detection. Tumor size greater than 2 cm was associated with malignancy, and a greater number of passes may be required to evaluate masses 2 cm or less. ClinicalTrials.gov number, NCT01386931.
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Affiliation(s)
- Mehdi Mohamadnejad
- University of California, Los Angeles, Los Angeles, California; Liver and Pancreatobiliary Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Daniel Mullady
- Washington University School of Medicine, St. Louis, Missouri
| | - Dayna S Early
- Washington University School of Medicine, St. Louis, Missouri
| | - Brian Collins
- Washington University School of Medicine, St. Louis, Missouri
| | - Carrie Marshall
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sharon Sams
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Roy Yen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mona Rizeq
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Maria Romanas
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | - Samia Nawaz
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ozlem Ulusarac
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | | | - Robert H Wilson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Violette C Simon
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Stuart K Amateau
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brian C Brauer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, Missouri
| | - Riad R Azar
- Washington University School of Medicine, St. Louis, Missouri
| | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Raj Shah
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona
| | | | | | - Amit Rastogi
- Kansas City VA Medical Center and University of Kansas, Kansas City, Missouri
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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Fujii-Lau LL, Cinnor B, Shaheen N, Gaddam S, Komanduri S, Muthusamy VR, Das A, Wilson R, Simon VC, Kushnir V, Mullady D, Edmundowicz SA, Early DS, Wani S. Recurrence of intestinal metaplasia and early neoplasia after endoscopic eradication therapy for Barrett's esophagus: a systematic review and meta-analysis. Endosc Int Open 2017; 5:E430-E449. [PMID: 28573176 PMCID: PMC5451278 DOI: 10.1055/s-0043-106578] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Conflicting data exist with regard to recurrence rates of intestinal metaplasia (IM) and dysplasia after achieving complete eradication of intestinal metaplasia (CE-IM) in Barrett's esophagus (BE) patients. AIM (i) To determine the incidence of recurrent IM and dysplasia achieving CE-IM and (ii) to compare recurrence rates between treatment modalities [radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) vs stepwise complete EMR (SRER)]. METHODS A systematic search was performed for studies reporting on outcomes and estimates of recurrence rates after achieving CE-IM. Pooled incidence [per 100-patient-years (PY)] and risk ratios with 95 %CI were obtained. Heterogeneity was measured using the I2 statistic. Subgroup analyses, decided a priori, were performed to explore heterogeneity in results. RESULTS A total of 39 studies were identified (25-RFA, 13-SRER, and 2 combined). The pooled incidence of any recurrence was 7.5 (95 %CI 6.1 - 9.0)/100 PY with a pooled incidence of IM recurrence rate of 4.8 (95 %CI 3.8 - 5.9)/100 PY, and dysplasia recurrence rate of 2.0 (95 %CI 1.5 - 2.5)/100 PY. Compared to the SRER group, the RFA group had significantly higher overall [8.6 (6.7 - 10.5)/100 PY vs. 5.1 (3.1 - 7)/100 PY, P = 0.01] and IM recurrence rates [5.8 (4.3 - 7.3)/100 PY vs. 3.1 (1.7 - 4)/100 PY, P < 0.01] with no difference in recurrence rates of dysplasia. Significant heterogeneity between studies was identified. The majority of recurrences were amenable to repeat endoscopic eradication therapy (EET). CONCLUSION The results of this study demonstrate that the incidence rates of overall, IM, and dysplasia recurrence rates post-EET are not inconsiderable and reinforce the importance of close surveillance after achieving CE-IM.
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Affiliation(s)
| | - Birtukan Cinnor
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, MO, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine Northwestern University, Chicago, IL, USA
| | | | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, AZ, USA
| | - Robert Wilson
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Daniel Mullady
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Dayna S. Early
- Washington University School of Medicine, St. Louis, MO, USA
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA,Corresponding author Sachin Wani, MD Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CenterMail Stop F7351635 Aurora CourtRm 2.031AuroraCO 80045USA+1-720-848-2749
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Komanduri S, Kahrilas PJ, Krishnan K, McGorisk T, Bidari K, Grande D, Keefer L, Pandolfino J. Recurrence of Barrett's Esophagus is Rare Following Endoscopic Eradication Therapy Coupled With Effective Reflux Control. Am J Gastroenterol 2017; 112:556-566. [PMID: 28195178 DOI: 10.1038/ajg.2017.13] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 01/06/2017] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kumar Krishnan
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tim McGorisk
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kiran Bidari
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David Grande
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Laurie Keefer
- Ichan School of Medicine at Mount Sinai, New York, New York, USA
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Yang D, Amin S, Gonzalez S, Mullady D, Edmundowicz SA, DeWitt JM, Khashab MA, Wang AY, Nagula S, Buscaglia JM, Bucobo JC, Wagh MS, Draganov PV, Stevens T, Vargo JJ, Khara HS, Diehl DL, Keswani RN, Komanduri S, Yachimski PS, Prabhu A, Kwon RS, Watson RR, Goodman AJ, Benias P, Carr-Locke DL, DiMaio CJ. Clinical outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts: a large multicenter study. Endosc Int Open 2017; 5:E130-E136. [PMID: 28210709 PMCID: PMC5305425 DOI: 10.1055/s-0042-121666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, University of Florida College of Medicine, Gainesville, Florida, United Sates
| | - Sunil Amin
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Susana Gonzalez
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, United States
| | - Steven A. Edmundowicz
- Division of Gastroenterology, University of Colorado, Aurora, Colorado, United States
| | - John M. DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Andrew Y. Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Satish Nagula
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Jonathan M. Buscaglia
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, United States
| | - Juan Carlos Bucobo
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, United States
| | - Mihir S. Wagh
- Division of Gastroenterology, University of Colorado, Aurora, Colorado, United States
| | - Peter V. Draganov
- Division of Gastroenterology, University of Florida College of Medicine, Gainesville, Florida, United Sates
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - John J. Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Harshit S. Khara
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, United States
| | - David L. Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, United States
| | - Rajesh N. Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Patrick S. Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anoop Prabhu
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Richard S. Kwon
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Rabindra R. Watson
- Division of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, California, United States
| | - Adam J. Goodman
- Division of Gastroenterology, New York University School of Medicine, New York, New York, United States
| | - Petros Benias
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, United States
| | - David L. Carr-Locke
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, United States
| | - Christopher J. DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, United States,Corresponding author Christopher J. DiMaio, MD Dr. Henry D. Janowitz Division of GastroenterologyIcahn School of Medicine at Mount SinaiOne Gustave L. Levy Place, Box 1069New York, NY 10029+1-212-241-7535
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Watson RR, Klapman J, Komanduri S, Shah JN, Wani S, Muthusamy R. Wide disparities in attitudes and practices regarding Type II sphincter of Oddi dysfunction: a survey of expert U.S. endoscopists. Endosc Int Open 2016; 4:E941-6. [PMID: 27652298 PMCID: PMC5025319 DOI: 10.1055/s-0042-110789] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/13/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Sphincter of Oddi manometry (SOM) is recommended in the evaluation of suspected Type II sphincter of Oddi dysfunction (SOD2), though its utility is uncertain. Little is known about the practice of expert endoscopists in the United States regarding SOD2. METHODS An anonymous electronic survey was distributed to 128 expert biliary endoscopists identified from U.S. advanced endoscopy training programs. RESULTS The response rate was 46.1 % (59/128). Only 55.6 % received training in SOM, and 49.2 % currently perform SOM. For biliary SOD2, 33.3 % routinely obtain SOM, 33.3 % perform empiric sphincterotomy, and 26.3 % perform single session endoscopic ultrasound/endoscopic retrograde cholangiopancreatography (EUS/ERCP). In contrast, an equal number (35.1 %) favor SOM or single session EUS/ERCP for suspected acute idiopathic recurrent pancreatitis, while 19.3 % would perform empiric sphincterotomy. Those who perform SOM believe it to be important in predicting response to treatment compared with those who do not (71.8 % vs 23.1 %, P = 0.01). Yet only 51.7 % of this group performs SOM for suspected SOD2. Most (78.6 %) believe that < 50 % of patients report improvement in symptoms after sphincterotomy. Common reasons for not obtaining SOM included unreliable results (50 %), and procedure-related risks (39.3 %). Most (59.3 %) believe SOD2 is at least in part a functional disorder; only 3.7 % felt SOD is a legitimate disorder of the sphincter of Oddi. CONCLUSIONS Our survey of U.S. expert endoscopists suggests that SOM is not routinely performed for SOD2 and concerns regarding its associated risks and validity persist. Most endoscopists believe SOD2 is at least in part a functional disorder that will not respond to sphincterotomy in the majority of cases.
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Affiliation(s)
- Rabindra R. Watson
- UCLA Medical Center – Digestive Diseases, Los Angeles, California, USA,Corresponding author Rabindra R. Watson, MD UCLA Medical Center – Digestive Diseases200 Medical Plaza 330-33Los AngelesCalifornia 90095USA
| | - Jason Klapman
- Moffitt Cancer Center – Gastrointestinal Oncology, Tampa, Florida, USA
| | | | - Janak N. Shah
- California Pacific Medical Center – Interventional Endoscopy, IES Lab, San Francisco, California, USA
| | - Sachin Wani
- University of Colorado and Veterans Affairs Medical Center – Gastroenterology, Aurora, Colorado, USA
| | - Raman Muthusamy
- UCLA Medical Center – Digestive Diseases, Los Angeles, California, USA
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Nelson M, Ganger D, Keswani R, Grande D, Komanduri S. Endoscopic resection is effective for the treatment of bleeding gastric hyperplastic polyps in patients with and without cirrhosis. Endosc Int Open 2016; 4:E874-7. [PMID: 27540576 PMCID: PMC4988837 DOI: 10.1055/s-0042-109773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 05/30/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Matthew Nelson
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States,Corresponding author Matthew Nelson, MD Department of Gastroenterology and HepatologyNorthwestern University676 N. Saint Clair Suite 1400Chicago, IL 60611
| | - Daniel Ganger
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
| | - Rajesh Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
| | - David Grande
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
| | - Srinadh Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
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Li N, Pasricha S, Bulsiewicz WJ, Pruitt RE, Komanduri S, Wolfsen HC, Chmielewski GW, Corbett FS, Chang KJ, Shaheen NJ. Effects of preceding endoscopic mucosal resection on the efficacy and safety of radiofrequency ablation for treatment of Barrett's esophagus: results from the United States Radiofrequency Ablation Registry. Dis Esophagus 2016; 29:537-43. [PMID: 26121935 PMCID: PMC4977202 DOI: 10.1111/dote.12386] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The effects of preceding endoscopic mucosal resection (EMR) on the efficacy and safety of radiofrequency ablation (RFA) for treatment of nodular Barrett's esophagus (BE) is poorly understood. Prior studies have been limited to case series from individual tertiary care centers. We report the results of a large, multicenter registry. We assessed the effects of preceding EMR on the efficacy and safety of RFA for nodular BE with advanced neoplasia (high-grade dysplasia or intramucosal carcinoma) using the US RFA Registry, a nationwide study of BE patients treated with RFA at 148 institutions. Safety outcomes included stricture, gastrointestinal bleeding, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia (CEIM), complete eradication of dysplasia (CED), and number of RFA treatments needed to achieve CEIM. Analyses comparing patients with EMR before RFA to patients undergoing RFA alone were performed with Student's t-test, Chi-square test, logistic regression, and Kaplan-Meier analysis. Four hundred six patients were treated with EMR before RFA for nodular BE, and 857 patients were treated with RFA only for non-nodular BE. The total complication rates were 8.4% in the EMR-before-RFA group and 7.2% in the RFA-only group (P = 0.48). Rates of stricture, bleeding, and hospitalization were not significantly different between patients treated with EMR before RFA and patients treated with RFA alone. CEIM was achieved in 84% of patients treated with EMR before RFA, and 84% of patients treated with RFA only (P = 0.96). CED was achieved in 94% and 92% of patients in EMR-before-RFA and RFA-only group, respectively (P = 0.17). Durability of eradication did not differ between the groups. EMR-before-RFA for nodular BE with advanced neoplasia is effective and safe. The preceding EMR neither diminished the efficacy nor increased complication rate of RFA treatment compared to patients with advanced neoplasia who had RFA with no preceding EMR. Preceding EMR is not associated with poorer outcomes in RFA.
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Affiliation(s)
- N. Li
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - S. Pasricha
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - W. J. Bulsiewicz
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - R. E. Pruitt
- Nashville Gastrointestinal Specialists, Nashville, Tennessee
| | - S. Komanduri
- Northwestern University School of Medicine, Chicago, Illinois
| | | | | | - F. S. Corbett
- Gastroenterology Associates of Sarasota, Sarasota, Florida
| | - K. J. Chang
- University of California at Irvine, Orange, California, USA
| | - N. J. Shaheen
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Law R, Das A, Gregory D, Komanduri S, Muthusamy R, Rastogi A, Vargo J, Wallace MB, Raju GS, Mounzer R, Klapman J, Shah J, Watson R, Wilson R, Edmundowicz SA, Wani S. Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis. Gastrointest Endosc 2016; 83:1248-57. [PMID: 26608129 DOI: 10.1016/j.gie.2015.11.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/07/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP. METHODS A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges. RESULTS LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000. CONCLUSIONS Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ananya Das
- Arizona Digestive Health, Gilbert, Arizona, USA
| | - Dyanna Gregory
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Raman Muthusamy
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Amit Rastogi
- Division of Gastroenterology, The University of Kansas Hospital, Kansas City, Kansas, USA
| | - John Vargo
- Digestive Diseases Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic-Jacksonville, Jacksonville, Florida, USA
| | - G S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rawad Mounzer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jason Klapman
- Gastrointestinal Oncology Department, Moffitt Cancer Center, Tampa, Florida, USA
| | - Janak Shah
- Department of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra Watson
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Robert Wilson
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Aadam AA, Wani S, Amick A, Shah JN, Bhat YM, Hamerski CM, Klapman JB, Muthusamy VR, Watson RR, Rademaker AW, Keswani RN, Keefer L, Das A, Komanduri S. A randomized controlled cross-over trial and cost analysis comparing endoscopic ultrasound fine needle aspiration and fine needle biopsy. Endosc Int Open 2016; 4:E497-505. [PMID: 27227104 PMCID: PMC4874800 DOI: 10.1055/s-0042-106958] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Techniques to optimize endoscopic ultrasound-guided tissue acquisition (EUS-TA) in a variety of lesion types have not yet been established. The primary aim of this study was to compare the diagnostic yield (DY) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for pancreatic and non-pancreatic masses. PATIENTS AND METHODS Consecutive patients referred for EUS-TA underwent randomization to EUS-FNA or EUS-FNB at four tertiary-care medical centers. A maximum of three passes were allowed for the initial method of EUS-TA and patients were crossed over to the other arm based on on-site specimen adequacy. RESULTS A total of 140 patients were enrolled. The overall DY was significantly higher with specimens obtained by EUS-FNB compared to EUS-FNA (90.0 % vs. 67.1 %, P = 0.002). While there was no difference in the DY between the two groups for pancreatic masses (FNB: 91.7 % vs. FNA: 78.4 %, P = 0.19), the DY of EUS-FNB was higher than the EUS-FNA for non-pancreatic lesions (88.2 % vs. 54.5 %, P = 0.006). Specimen adequacy was higher for EUS-FNB compared to EUS-FNA for all lesions (P = 0.006). There was a significant rescue effect of crossover from failed FNA to FNB in 27 out of 28 cases (96.5 %, P = 0.0003). Decision analysis showed that the strategy of EUS-FNB was cost saving compared to EUS-FNA over a wide range of cost and outcome probabilities. CONCLUSIONS RESULTS of this RCT and decision analysis demonstrate superior DY and specimen adequacy for solid mass lesions sampled by EUS-FNB.
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Affiliation(s)
- A. Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
| | - Ashley Amick
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
| | - Janak N. Shah
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, United States
| | - Yasser M. Bhat
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, United States
| | - Christopher M. Hamerski
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, United States
| | - Jason B. Klapman
- Division of Gastroenterology, Moffitt Cancer Center, Tampa, Florida, United States
| | - V. Raman Muthusamy
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, United States
| | - Rabindra R. Watson
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, United States
| | - Alfred W. Rademaker
- Department of Preventative Medicine, Northwestern University, Chicago, Illinois, United States
| | - Rajesh N. Keswani
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
| | - Laurie Keefer
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States
| | - Ananya Das
- Arizona Digestive Health, Gilbert, Arizona, United States
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States,Corresponding author Srinadh Komanduri, MD MS Division of Gastroenterology and HepatologyFeinberg School of MedicineNorthwestern University675 N. St. Clair StreetGalter Pavilion 17-250Chicago, IL 60611
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Yang D, Amin S, Gonzalez S, Mullady D, Hasak S, Gaddam S, Edmundowicz SA, Gromski MA, DeWitt JM, El Zein M, Khashab MA, Wang AY, Gaspar JP, Uppal DS, Nagula S, Kapadia S, Buscaglia JM, Bucobo JC, Schlachterman A, Wagh MS, Draganov PV, Jung MK, Stevens T, Vargo JJ, Khara HS, Huseini M, Diehl DL, Keswani RN, Law R, Komanduri S, Yachimski PS, DaVee T, Prabhu A, Lapp RT, Kwon RS, Watson RR, Goodman AJ, Chhabra N, Wang WJ, Benias P, Carr-Locke DL, DiMaio CJ. Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 2016; 83:720-9. [PMID: 26548849 DOI: 10.1016/j.gie.2015.10.040] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/29/2015] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sunil Amin
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Susana Gonzalez
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Mullady
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephen Hasak
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Srinivas Gaddam
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mark A Gromski
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John M DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohamad El Zein
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jonathan P Gaspar
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dushant S Uppal
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Satish Nagula
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Samir Kapadia
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Jonathan M Buscaglia
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Juan Carlos Bucobo
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Alex Schlachterman
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Min Kyu Jung
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Harshit S Khara
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Mustafa Huseini
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tomas DaVee
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anoop Prabhu
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert T Lapp
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Richard S Kwon
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Rabindra R Watson
- Division of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, California, USA
| | - Adam J Goodman
- Division of Gastroenterology, New York University School of Medicine, New York, New York, USA
| | - Natasha Chhabra
- Division of Gastroenterology, New York University School of Medicine, New York, New York, USA
| | - Wallace J Wang
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, USA
| | - Petros Benias
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, USA
| | - David L Carr-Locke
- Division of Digestive Diseases, Beth Israel Medical Center, New York, New York, USA
| | - Christopher J DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Korrapati P, Ciolino J, Wani S, Shah J, Watson R, Muthusamy VR, Klapman J, Komanduri S. The efficacy of peroral cholangioscopy for difficult bile duct stones and indeterminate strictures: a systematic review and meta-analysis. Endosc Int Open 2016; 4:E263-75. [PMID: 27004242 PMCID: PMC4798839 DOI: 10.1055/s-0042-100194] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 12/15/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Current evidence supporting the efficacy of peroral cholangioscopy (POC) in the evaluation and management of difficult bile duct stones and indeterminate strictures is limited. The aims of this systematic review and meta-analysis were to assess the following: the efficacy of POC for the therapy of difficult bile duct stones, the diagnostic accuracy of POC for the evaluation of indeterminate biliary strictures, and the overall adverse event rates for POC. PATIENTS AND METHODS Patients referred for the removal of difficult bile duct stones or the evaluation of indeterminate strictures via POC were included. Search terms pertaining to cholangioscopy were used, and articles were selected based on preset inclusion and exclusion criteria. Quality assessment of the studies was completed with a modified Newcastle-Ottawa Scale. After critical literature review, relevant outcomes of interest were analyzed. Meta-regression was performed to examine potential sources of between-study variation. Publication bias was assessed via funnel plots and Egger's test. RESULTS A total of 49 studies were included. The overall estimated stone clearance rate was 88 % (95 % confidence interval [95 %CI] 85 % - 91 %). The accuracy of POC was 89 % (95 %CI 84 % - 93 %) for making a visual diagnosis and and 79 % (95 %CI 74 % - 84 %) for making a histological diagnosis. The estimated overall adverse event rate was 7 % (95 %CI 6 % - 9 %). CONCLUSIONS POC is a safe and effective adjunctive tool with endoscopic retrograde cholangiopancreatography (ERCP) for the evaluation of bile duct strictures and the treatment of bile duct stones when conventional methods have failed. Prospective, controlled clinical trials are needed to further elucidate the precise role of POC during ERCP.
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Affiliation(s)
- Praneet Korrapati
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago Illinois, USA
| | - Jody Ciolino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago Illinois, USA
| | - Sachin Wani
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Janak Shah
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra Watson
- UCLA Division of Digestive Diseases, Los Angeles, California, USA
| | | | - Jason Klapman
- Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago Illinois, USA,Corresponding author Srinadh Komanduri, MD MS Division of Gastroenterology and HepatologyNorthwestern UniversityFeinberg School of Medicine676 St. Clair St., Suite 14-003Chicago, IL 60611USA+1-312-926-0239
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Komanduri S, Quinton S, Srivastava A, Keefer L. Endosonographers' approach to delivering a diagnosis of pancreatic cancer: obligated but undertrained. Endosc Int Open 2016; 4:E242-8. [PMID: 27004238 PMCID: PMC4798836 DOI: 10.1055/s-0041-109085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/12/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND STUDY AIMS No data are available on the practice patterns of endosonographers as they pertain to the disclosure of a pancreatic cancer diagnosis. We sought to understand the current practice and coping strategies of physicians who perform endoscopic ultrasound (EUS) procedures in patients with suspected pancreatic cancer. METHODS This study used a nonexperimental, cross-sectional survey design. A total of 707 endosonographers were contacted and asked to complete an online survey encompassing both demographic and practice data. In addition, participants had the option to complete a second survey assessing common coping strategies. RESULTS A total of 152 physicians (22 %) participated in the study. The sample was split between community (47 %) and academic centers (53 %). A total of 92 % of the respondents felt an obligation to share a cancer diagnosis when it was available to them; however, only 45 % felt they were adequately trained to do so. Comfort levels were higher in those who performed more than 200 EUS procedures annually and in those practicing for longer than 5 years (P = 0.044). A total of 98 physicians (64.5 %) also completed the Brief COPE questionnaire, and the results indicated that the more experienced endosonographers were less likely to experience emotional distress when disclosing a cancer diagnosis. CONCLUSION The comfort level for disclosing a pancreatic cancer diagnosis after EUS appears to be higher in experienced endosonographers (> 5 years in practice) and in those who conduct a higher volume of procedures. Although the majority of endosonographers feel obligated to disclose a cancer diagnosis, the lack of time and proper training is limiting. Formal communication skills training within a gastrointestinal fellowship should be considered.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA,Corresponding author Srinadh Komanduri, MD, MS Division of Gastroenterology and HepatologyNorthwestern UniversityFeinberg School of Medicine676 St. Clair Street, 14-003Chicago, Illinois 60611USA+1-630-908-7499
| | - Sarah Quinton
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Arth Srivastava
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laurie Keefer
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Wani S, Komanduri S, Muthusamy VR. Endoscopic Eradication Therapy in Barrett's Esophagus-Related Neoplasia: Setting the Bar Right to Optimize Patient Outcomes. Gastroenterology 2016; 150:772-4. [PMID: 26820917 DOI: 10.1053/j.gastro.2016.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Kushnir VM, Keswani RN, Hollander TG, Kohlmeier C, Mullady DK, Azar RR, Murad FM, Komanduri S, Edmundowicz SA, Early DS. Compliance with surveillance recommendations for foregut subepithelial tumors is poor: results of a prospective multicenter study. Gastrointest Endosc 2016; 81:1378-84. [PMID: 25660977 DOI: 10.1016/j.gie.2014.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 11/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND American Gastroenterological Association guidelines recommend performing EUS to characterize subepithelial lesions (SELs) discovered on upper endoscopy (EGD), followed by surveillance if no high-risk features are identified. However, limited data are available on the impact of and compliance with surveillance recommendations. OBJECTIVE To determine the natural history of SELs<30 mm in size evaluated by EUS and to determine the degree of patient compliance with surveillance recommendations. DESIGN Prospective registry. SETTING Two tertiary centers. PATIENTS We studied 187 consecutive adult patients referred for EUS evaluation of foregut SELs. MAIN OUTCOME MEASUREMENTS Proportion of patients in whom SELs change in size or echo-features and compliance with follow-up recommendations. RESULTS Surveillance was recommended in 65 patients with hypoechoic SELs (44.6% women, age 59.5±13.2 years); of these, 29 (44.6%) underwent surveillance EUS as recommended and were followed for a median of 30 months (range, 12-105). During follow-up, 16 SELs (25%) increased in size, with a mean increase of 3.4±3.9 mm (range, 1-15). No changes in echo-texture of the SELs were observed. One patient was referred to surgery during follow-up (because of SEL growth>30 mm). LIMITATIONS Short follow-up duration; compliance was a secondary aim. CONCLUSIONS During a median follow-up of 30 months, growth in size was observed in 25% of small foregut SELs. However, change in size was minimal, and only 1 patient was referred for surgery based on surveillance EUS findings. Compliance with surveillance recommendations is poor, with fewer than 50% of patients undergoing surveillance EUS as recommended.
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Affiliation(s)
- Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rajesh N Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Thomas G Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Cara Kohlmeier
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Riad R Azar
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Faris M Murad
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Srinadh Komanduri
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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Donnan E, Bentrem DJ, Komanduri S, Mahvi DM, Keswani RN. ERCP in potentially resectable malignant biliary obstruction is frequently unsuccessful when performed outside of a comprehensive pancreaticobiliary center. J Surg Oncol 2016; 113:647-51. [PMID: 26830790 DOI: 10.1002/jso.24191] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 01/20/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES ERCP prior to pancreaticoduodenectomy is unnecessary in select patients. When performed, it should be in conjunction with endoscopic ultrasound (EUS) to increase diagnostic sensitivity and allow for metal stent placement. The aim of this study was to determine differences in endoscopic practice patterns at community medical centers (CMC) and a comprehensive pancreaticobiliary referral center (PBRC). METHODS Retrospective cohort study of all patients seen at a PBRC for endoscopic and/or surgical management of potentially resectable malignant distal biliary obstruction from 1/2011 to 6/2014. RESULTS Of 75 patients, 30 underwent endoscopic management at a CMC and 45 were initially managed at our PBRC. ERCP was attempted in 92% of patients. EUS was performed more frequently (100% vs. 13.3 %, P < 0.0001), ERCP was more successful (93% vs. 69%, P = 0.02), and metal stent placement more likely (41% vs. 5%, P = 0.005) at our PBRC compared to a CMC. The majority (81%) of patients undergoing initial endoscopy at a CMC required repeat endoscopy at our PBRC. CONCLUSIONS Patients who are candidates for pancreaticoduodenectomy frequently undergo ERCP. At a CMC, ERCP is often unsuccessful, is rarely accompanied by EUS, and often requires repeat endoscopy. Our findings support regionalizing the management of suspected pancreatic malignancy into dedicated specialty centers. J. Surg. Oncol. 2016;113:647-651. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Erica Donnan
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Srinadh Komanduri
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David M Mahvi
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rajesh N Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Wolf WA, Pasricha S, Cotton C, Li N, Triadafilopoulos G, Muthusamy VR, Chmielewski GW, Corbett FS, Camara DS, Lightdale CJ, Wolfsen H, Chang KJ, Overholt BF, Pruitt RE, Ertan A, Komanduri S, Infantolino A, Rothstein RI, Shaheen NJ. Incidence of Esophageal Adenocarcinoma and Causes of Mortality After Radiofrequency Ablation of Barrett's Esophagus. Gastroenterology 2015; 149:1752-1761.e1. [PMID: 26327132 PMCID: PMC4785890 DOI: 10.1053/j.gastro.2015.08.048] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 08/01/2015] [Accepted: 08/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA) is commonly used to treat Barrett's esophagus (BE). We assessed the incidence of esophageal adenocarcinoma (EAC) after RFA, factors associated with the development of EAC, and EAC-specific and all-cause mortality. METHODS We collected data for outcomes of patients who underwent RFA for BE from July 2007 through July 2011 from US multicenter RFA Patient Registry. Patients were followed until July 2014. Kaplan-Meier curves of EAC incidence were stratified by baseline histology. Crude EAC incidence and mortality (all-cause and EAC-specific) were calculated, and adjusted all-cause mortality was assessed. Logistic regression models were constructed to assess predictors of EAC and all-cause mortality. RESULTS Among 4982 patients, 100 (2%) developed EAC (7.8/1000 person-years [PY]) and 9 patients (0.2%) died of EAC (0.7/1000 PY) in a mean 2.7 ± 1.6 years. The incidence of EAC in nondysplastic BE was 0.5/1000 PY. Overall, 157 patients (3%) died during follow-up (all-cause mortality, 11.2/1000 PY). On multivariate logistic regression, baseline BE length (odds ratio, 1.1/ cm) and baseline histology (odds ratios, 5.8 and 50.3 for low-grade dysplasia and high-grade dysplasia [HGD] respectively) predicted EAC incidence. Among 9 EAC deaths, 6 (67%) had baseline HGD, and 3 (33%) had baseline intramucosal EAC. The most common causes of death were cardiovascular (15%) and extraesophageal cancers (15%). No deaths were associated with RFA. CONCLUSIONS Based on analysis of a multicenter registry of patients who underwent RFA of BE, less than 1% died from EAC. The incidence of EAC was markedly lower in this study than in other studies of disease progression, with the greatest absolute benefit observed in patients with HGD.
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Affiliation(s)
- W. Asher Wolf
- From the University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Sarina Pasricha
- From the University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Cary Cotton
- From the University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Nan Li
- From the University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | | | | | | | - F. Scott Corbett
- Gastroenterology Associates of Sarasota, Sarasota, FL, Florida Digestive Health Specialists
| | | | | | | | | | | | - Ron E. Pruitt
- Nashville Gastrointestinal Associates, Nashville, TN
| | - Atilla Ertan
- Department of Medicine, University of Texas Health Medical School
| | - Srinadh Komanduri
- Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine
| | | | | | - Nicholas J. Shaheen
- From the University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
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