Journal of the Canadian Association of Gastroenterology最新文献

Introduction: Patients with surgically altered gastrointestinal anatomy undergoing endoscopic retrograde cholangiopancreatography (ERCP) pose challenges due to anatomical distortions. Various patient and endoscopic factors, such as sex and positioning, may impact procedural success. It is unclear how these factors may impact the technical success of ERCP among patients with altered anatomy.

Objective: We aimed to determine the patient and endoscopic factors that were associated with technical success of ERCP.

Methods: We conducted a retrospective single-centre study using data from 2010 to 2020 that included patients with hepaticojejunostomy, Roux-en-Y anastomosis, Billroth-1, or Billroth-2 anatomy at a single tertiary care centre in Toronto, Canada. We extracted data from a database. The primary outcome was technical success of the ERCP, defined as successful navigation to the papilla or surgical anastomosis, selective cannulation and cholangiography or pancreatography. Penalized logistic regression with elastic net regularization was used to identify significant predictors of technical success. Effect size was odds ratio with 95% confidence interval. The model was evaluated using the area under the curve (AUC) metric.

Results: Overall, there were 205 patients included in the analysis. In the multivariate analysis, the most significant contributors to predicting technical success of ERCP were expert endoscopic experience and non-Roux-en Y anatomy. The elastic net model demonstrated moderate predictive performance, with an AUC of 0.656.

Conclusions: The findings emphasize the importance of tailored procedural planning to optimize ERCP success in patients with altered anatomy.

Background and aims: Endoscopic mucosal resection (EMR) is not systematically taught during most training programs. The aim of this study was to evaluate the effectiveness and clinical utility of a 1-day didactic and simulation-based EMR curriculum for practicing endoscopists without prior formal training in advanced endoscopic tissue resection.

Methods: We designed a 1-day lecture and simulation-based EMR course. Twelve participants completed the course. Effectiveness and clinical utility were evaluated using sequential explanatory mixed methods. All participants completed a pre-course multiple choice question (MCQ) examination followed by a separate, post-course MCQ examination with a similar blueprint. A survey was also conducted to assess cognitive fatigue, perceived benefit, and potential for change in EMR practice. Finally, a delayed MCQ examination was administered 10-14 weeks later to assess knowledge retention and qualitative data were sequentially collected from 3 candidates via semi-structured interviews.

Results: The mean pre-course score was 47.8% (SD 12.4%). The mean post-course score was 75% (9.9%) and the mean delayed score was 70.8% (13.6%), both significantly higher than the mean pre-course score (P < .001; Cohen's d = 1.86 and P < .001; Cohen's d = 1.47, respectively). There was no significant difference between the mean post- and delayed-course test scores (P = .2). Three themes emerged from the interviews: (1) a need for EMR training, (2) improved knowledge evaluating polyps, and (3) changed or refined EMR technique after the course.

Conclusions: This study demonstrates significant knowledge acquisition and retention of cognitive skills and suggests a change in practice following a 1-day focused didactic and simulation-based EMR course.

Aims: Electrosurgical units (ESUs) are essential for tissue dissection hemostasis during ESD. The ERBE VIO 3, enables rapid setting changes, facilitating the swift application of vessel sealing current. Additionally, features such as PreciseSect mode allow dynamic modulation frequency adjustment, making it suitable for submucosal dissection and vessel management. Our comparison of the ERBE VIO3 and 300d aims to assess whether these functionalities enhance the ESD experience.

Methods: From 2021 to 2024, 88 patients undergoing ESD for colorectal lesions were identified from a prospectively maintained database. Lesions were categorized based on the ESU utilized.

Results: Eighty-eight procedures were identified. Forty-four (50.0%) procedures were performed using VIO 3 and 44 (50.0%) using VIO 300d. 40 (45.5%) lesions were colonic and 48 (54.5%) rectal. Median lesion diameter was 4.5 cm. Lesions in the VIO3 group were significantly larger (P = 0.027). All ESDs were completed en bloc. Use of the VIO3 resulted in a significantly fewer uses of coagulation graspers overall (28 vs 23, P < 0.001), fewer uses of coagulation graspers for arterial bleeding (1 vs 2, P < 0.001), fewer uses of coagulation graspers per cm² (0.17 vs 0.58, P < 0.001), and fewer uses of coagulation graspers per minute (0.011 vs 0.066, P < 0.001). This led to a non-significant trend in increased efficiency with use of the VIO3 (4.6 vs 5.1 min/cm², P = 0.667).

Conclusions: The VIO 3 significantly decreased reliance on coagulation graspers, particularly in addressing arterial bleeding. This holds the potential to enhance procedural efficiency, reduce bleeding, and lower costs associated with coagulation graspers usage.

Background: Acute severe ulcerative colitis (ASUC) is associated with significant morbidity. In patients with ulcerative colitis (UC), the estimated lifetime risk of developing severe colitis is 25%. Several gastrointestinal societies have provided recommendations on pathways of care for managing ASUC. The degree to which they are adhered to in different care settings remains unclear.

Methods: We conducted a retrospective review using data from 7 acute-care hospitals collected through the general medicine inpatient initiative (GEMINI), a hospital research collaborative that collects administrative and clinical data from hospital information systems. We identified all patients with the most responsible inpatient discharge diagnosis of ulcerative colitis between April 2015 and December 2019. The primary outcome was the difference in hospital length of stay of patients admitted with ASUC based on hospital-type; community, academic, or inflammatory bowel disease (IBD)-focussed sites.

Results: 765 eligible patients were identified between April 2015 and December 2019. The mean hospital length of stay was 9.21 days for the academic sites, 6.94 days for the community sites, and 8.03 for the IBD specialty centre (P = .094). Adverse events were uncommon overall. In our multiple logistic regression analysis, we identified that admission to an IBD-focussed centre compared to an academic centre, carried an odds ratio of 2.07 (95% CI, 1.16-3.78) for the outcome of inpatient-colectomy.

Conclusions: The processes of care for patients with ASUC varied on the basis of the type of hospital they were admitted to, with the IBD specialty centre providing the most guideline adherent care. Low-cost interventions should be utilized to promote adherence to clinical practice recommendations.

Objectives: Despite rapidly rising rates of pediatric inflammatory bowel disease (IBD), literature exploring the financial burden on families of children with IBD remains limited. This study sought to better understand the socioeconomic burden of pediatric IBD on families at our institution and compare IBD provider practices and perceptions across the country.

Methods: Two separate electronic surveys exploring demographics, financial impacts of an IBD diagnosis, and perceptions around IBD care were developed for patient families and IBD providers respectively. Descriptive statistics and regression analysis took place to assess survey responses. Thematic analysis was also undertaken to qualitatively assess family survey comments.

Results: Patient survey results (N = 69) indicated missed time off work and school and dietary therapy costs as considerable burdens on families. Nearly 60% of respondents also reported significant mental health impacts on the family. Provider data (N = 18) suggests some variability in clinical practice, allied health support, and financial support for families. However, providers almost universally recognize the financial, mental health, and employment impacts on families as significant socioeconomic burdens on families.

Conclusions: This is the first study in Canada to directly explore national provider practices and the socioeconomic burden on families of children with IBD. Results indicate a good correlation between provider awareness and the increased financial burden on families but suggest ongoing care gaps to address impacts on employment, mental health, and out-of-pocket costs. This data suggests that various quality improvement opportunities for research and advocacy exist to better support families, both locally and beyond.

Background/aims: Among Crohn's disease patients with loss of response or non-response to ustekinumab (UST), there remains no clear strategy for dose escalation. Moreover, clinical associations and the role of therapeutic drug monitoring (TDM) are poorly understood. This study assessed response to escalation of UST therapy via increased dosing frequency or re-induction, as well as assessed associations of response.

Methods: A single-centre retrospective cohort study was performed. Adults who underwent dose escalation to every 4 weeks or reinduction of UST were included. The primary outcome was clinical and biochemical remission which was defined as a Harvey Bradshaw Index (HBI) of <5 and a C-reactive protein (CRP) level within the normal limit or a Fecal Calprotectin (FCP) level <250 ug/g. Partial response to treatment was defined as a 50% decrease from baseline HBI, CRP, or FCP.

Results: Thirty-nine patients were included. Clinical outcomes were assessed at a median of 17 weeks (IQR 12-21). Clinical and biochemical remission was achieved in 30.8% of patients (n = 12). Remission was found to be more likely among patients with lower baseline HBI (5.2 vs 9.0 P = .044) and younger patients (29.8 years vs 37.7 P = .046). No association was observed between baseline TDM values in the remission vs the non-remission group (3.32 ug/mL vs 2.91 ug/mL p=0.77). No severe adverse events were recorded.

Conclusion: UST dose escalation, in the form of reinduction or increased frequency to every 4 weeks may be effective among patients with loss of response or partial response, though predictors of response and strategy of escalation remain unclear.

Background: First Nations (FN) people in Canada are commonly diagnosed with colorectal cancers. Although Canada has treaty responsibilities to ensure FNs people have equitable access to quality health services, access to colorectal cancer screening in Canada by FNs people has not been fully assessed.

Methods: The objectives of our retrospective population-level study that linked multiple administrative databases were to investigate differences in colorectal cancer screening rates: participation, retention, positivity, follow-up colonoscopy, and invasive colorectal cancer detection, as well as wait times to follow-up colonoscopy, and stages at diagnosis between FNs and non-FNs people in Alberta. All Alberta residents eligible for colorectal cancer screening (aged 50-74) between 2012 and 2018 were included. The study and descriptive methods adhered to FNs principles of ownership, control, access, and possession.

Results: FNs people were less likely to participate in colorectal cancer screening (lower by 15.9% among women, P < 0.00001, and 17.0% among men; P = 0.0007), and less likely to be retained in the screening program (lower by 11.6%, P = 0.0013, among women and 9.9% %, P = 0.034, among men). They were more likely to screen positive (average difference of 7.0% among women and 7.3%, among men, both P < 0.0002). Invasive colorectal cancer detection rates were higher (3.2/1000) versus (2.3/1000) as were late-stage diagnoses (61% versus 43%, P = P = 0.004) among FNs people than non-FNs people, respectively.

Conclusions: Higher invasive colorectal cancer detection rates and more late-stage diagnoses in FNs people can be due to lower participation and retention in colorectal cancer screening programs. Understanding and addressing the reasons for these inequities are needed to improve these outcomes for FNs people.

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder which can respond to proton-pump inhibitors (PPIs). Genetic variation in the CYP2C19 metabolism gene influences PPI efficacy and adverse effects. Pharmacogenetic testing (PGx) can predict PPI response by analyzing genetic variation, particularly identifying patients categorized as CYP2C19 rapid or ultra-rapid metabolizers who might benefit from PPI dosage increases or changes to pharmacotherapy. Although PGx clinical practice guidelines have been established for PPI use, routine clinical implementation has been slow.

Methods: We conducted a non-interventional prospective cohort study of patients followed by a paediatric EoE clinic between 2020 and 2023. Eligible patients underwent CYP2C19 PGx testing, with results correlated to PPI use and histological outcomes assessed via endoscopic biopsies.

Results: Sixty-nine patients underwent PGx testing; 20 (29%) and 5 (7%) were determined to be rapid and ultra-rapid metabolizers, respectively. PGx-based management changes were made in 44 (64%) patients. Forty-three (62%) patients completed reassessment endoscopy, of which 21 (49%) demonstrated histological remission; 17 (40%) of these patients achieved remission after PGx-guided drug changes.

Conclusions: This study demonstrates that PPI non-response in patients with EoE may partly be due to inadequate PPI dosing in those with rapid or ultra-rapid CYP2C19 metabolizer status. Identifying CYP2C19 metabolizer status in pediatric patients with EoE for first-generation PPIs leads to therapeutic management changes and can improve histological remission rates. Clinicians treating EoE patients should consider routine PGx testing in combination with monitoring clinical factors to guide individualized PPI therapy and optimize dosing.