Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Colonoscopy serves a vital role in screening and surveillance for colorectal cancer and has seen incredible innovations in the past several decades. Amidst a growing landscape of emerging technologies, it has become increasingly critical to develop a process for the evaluation and adoption of new technology into the endoscopy suite. In this paper, we propose a framework for assessing a new colonoscopy technology utilizing quality improvement principles applied in procedural and integration assessments. After defining key quality indicators in colonoscopy, we follow the arc of innovation across preprocedural, intraprocedural, and postprocedural advancements in colonoscopy to highlight the process and outcome measures that constitute the procedural assessment. This discussion is followed by case studies in key structure and balance measures that serve to assess the feasibility of integrating novel technology into the endoscopy suite. At both assessment levels, we explore the advent of artificial intelligence in colonoscopy, citing relevant examples in computer-aided detection and computer-aided diagnosis. We highlight innovations that have been successfully adopted into clinical practice alongside technologies that had limited uptake or were otherwise retired from standard of care. In doing so, we illustrate the iterative nature of this process of innovation and technological development.

BACKGROUND AND AIMS

Obesity is prevalent in the United States. Endoscopic sleeve gastroplasty (ESG) has been shown to produce effective weight loss and improvement in obesity-related disease. The cost effectiveness of ESG is currently unclear in patients with obesity with and without type 2 diabetes (T2DM).

METHODS

A decision analytic model with time horizon of 5 years and lifetime, from a health system's perspective was constructed to compare ESG to no weight loss intervention (no ESG) in patients with obesity aged 35-45 years with a body mass index of ≥30 kg/m² with or without T2DM. Parameters were obtained based on peer-reviewed data. One-way and 2-way sensitivity analyses were performed for variations in T2DM resolution and ESG costs.

RESULTS

For the 5-year time horizon in patients with T2DM, ESG produced 4.28 quality-adjusted life years (QALYs) and cost $77,874, compared with 3.99 QALYs and a cost of $73,738 for no ESG, resulting in an incremental cost-effectiveness ratio (ICER) of $13,922 per QALY. For the lifetime horizon, ESG produced 29.57 QALYs and a lifetime cost of $451,261, compared with 26.69 QALYs and a lifetime cost of $493,806 for no ESG, resulting in a negative ICER (ie, cost saving). The 5-year time horizon in patients without T2DM demonstrated that ESG produced 4.42 QALYs, compared with 4.08 QALYs with no ESG, resulting in an ICER of $39,116 per QALY gained. For the lifetime horizon ESG produced 34.21 QALYs, compared with 31.60 QALYs for no ESG, resulting ICER of $4752.

CONCLUSION

This cost-effectiveness analysis suggests that ESG is cost effective in 5 years and cost saving over a lifetime for patients with obesity and type 2 diabetes. ESG remains cost effective at 5 years and over a lifetime in patients without T2DM.

BACKGROUND AND AIMS

METHODS

RESULTS

CONCLUSION

Peroral endoscopic myotomy (POEM) is increasingly employed as therapy for sphincteric abnormalities of the gastrointestinal tract, including achalasia, gastroparesis, Zenker's diverticulum, and other esophageal dysmotility syndromes. The capabilities of functional lumen imaging probe (FLIP) testing include measurement of sphincteric distensibility, diameter, cross-sectional area (CSA), and pressure in these disorders before and after POEM. FLIP can also characterize phasic contractility in non-sphincteric regions, including the esophageal body and pre-pyloric gastric antrum. Increases in distensibility and CSA after POEM are associated with reductions in symptoms and improvements in gut transit, including esophageal barium clearance in achalasia and gastric emptying in gastroparesis. Several studies have identified FLIP metrics that are associated with successful POEM outcomes in these 2 conditions. Intraprocedural FLIP can determine the adequacy of the initial myotomy and suggest the need for additional incision before mucosotomy closure. However, the definition of pre-myotomy FLIP parameters that can be used for reliable patient selection for subsequent POEM remains incomplete. Future investigations to establish normal sphincter parameters in healthy controls, standardize FLIP methods across sites, and adopt the technology in multicenter trials are warranted.

In this narrative review, we provide an overview of the current reach of colorectal cancer (CRC) screening in the US population; how persistent inequities in CRC across age and sociodemographic groups and changes in epidemiology, as well as population structure, have increased the urgency of achieving optimal reach; and current and future strategies for optimizing the reach and impact of screening across the population. CRC screening saves lives, but reach across the population, including across age and sociodemographic groups, is highly variable. CRC screening participation in the United States remains at under 60% and has been stagnant over time. Lower screening participation is observed for individuals of younger age; of American Indian/Alaska Native, Asian, and Hispanic backgrounds; with Medicaid insurance; and with recent immigration. Addressing suboptimal reach is increasingly important due to changing CRC epidemiology and US population structure. Recent trends demonstrate increases in early (<50 years) and middle age (50-60 years) onset of CRC and nonlocalized-stage CRC, as well as persistent inequities in CRC outcomes among multiple racial/ethnic groups. These trends exist in a context where the US population is increasingly composed of individuals from diverse backgrounds associated with lower screening rates and higher rates of adverse CRC outcomes. Screening reach can be optimized by building on successes of previous impactful policies, implementing evidence-based interventions for screening, and developing novel strategies that address challenges at patient, clinician, healthcare system, and policy levels. Gastroenterologists, other clinicians, and public health advocates have a major role in leading positive change at each of these levels. Overall, the need to optimize the reach of CRC screening represents a pressing opportunity for improving health equity across all populations in the United States.

The aim of this review is to provide an overview of peroral endoscopic myotomy (POEM) and its utilization in major motor disorders of the esophagus. POEM, a relatively novel endoscopic technique, involves a mucosal incision followed by submucosal tunneling to access esophageal muscle layers, enabling selective myotomy and mitigating the consequences of motor disorders of the esophagus. A number of recent studies have demonstrated noninferiority in shorter myotomy lengths in nonspastic (type I and II) achalasia as compared with standard-length myotomy, which has ramifications for procedural length, reflux disease, and more. Long-term data on POEM as a treatment modality for achalasia have demonstrated its robustness in providing a durable and sustainable treatment response. Challenges of POEM include the learning curve associated with mastering this technique, as well as the management of possible procedural complications including ineffective myotomy, blown-out myotomy, and/or gastroesophageal reflux disease. In conclusion, POEM has been demonstrated to be an effective and durable treatment option for achalasia and has an increasing role in other motility disorders of the esophagus.