Techniques and Innovations in Gastrointestinal Endoscopy最新文献

BACKGROUND AND AIMS

With the rising incidence of colorectal cancer in younger individuals, guidelines now recommend initiating average-risk screening at age 45 years. We sought to assess the impact of this younger screening population on established and emerging colonoscopy quality metrics.

METHODS

We compared all well-described lesion detection rates by colonic segment removed during initial, average-risk screening colonoscopies in the San Antonio Market military healthcare network from July 2019 to September 2022.

RESULTS

A total of 2165 colonoscopies met the inclusion criteria, with 755 (34.9%) colonoscopies performed on patients aged 45-49 years old. The detection rates for adenomas, proximal adenomas, advanced adenomas, and adenomas per colonoscopy were lower in the 45-49 years old group (33.4%, 18.7%, 3.8%, and 0.58, respectively) compared with the 50-75 years old group (42.7%, 24.2%, 7.7%, and 1.11, respectively; all P < 0.05). There was no difference in serrated polyp detection in the 45-49 years old group (11.5%) compared with the 50-75 years old group (12.5%; P = 0.287). There were no differences in withdrawal times, cecal intubation rates, or bowel preparation adequacy across age groups.

CONCLUSION

In our screening population, we found that adenoma-based colonoscopy quality metrics were significantly lower in the 45-49 years old population compared to the traditional screening age cohort, while there was no difference in serrated polyp detection. Endoscopists should anticipate a small decline in colonoscopy quality benchmarks as the screening population becomes younger, although these results require validation through multicenter, prospective monitoring.

Endoscopy service provision in low-income countries is sparse and inadequate to meet patient demands. Although novel endoscopic therapeutics have dramatically changed the way diseases are treated in the developed world, in low-resource countries, even basic services such as upper gastrointestinal (GI) endoscopy and colonoscopy are lacking. The need for endoscopy is apparent with high rates of upper GI bleeding from varices and peptic ulcers, and the rapidly growing rates of inflammatory bowel disease and GI cancers in these regions. There are limited alternatives to endoscopy available and are in general more risky and less efficacious. In Africa, the barriers to endoscopy service provision vary across the continent and serve as a model for challenges to overcome in providing health services in limited-resource environments. Although the clinical need for endoscopy grows, there has not been a parallel growth in the number of trained endoscopists with most regions having only one endoscopist for every 400,000 people. Many countries do not have a formal GI training program. Infrastructure investment remains insufficient, not fit-for-purpose, and endoscopy equipment is not consistently available in many regions. Nevertheless, some units continue to provide endoscopy services in challenging environments, modifying workflow to suit the limited structure, and adapting to local constraints while still trying to maintain endoscopy standards for their patients. The challenges are further amplified in bringing services to remote areas where, in some countries, more than 75% of the population resides, requiring innovative approaches such as mobile endoscopy units. Endoscopy is an essential life-saving medical service that is scarcely available in low-income countries. By examining the challenges to the development of endoscopy services throughout Africa, we hope to understand better the mechanisms by which GI medical services can be optimally delivered in low-and-middle–income countries.

Background and Aims

High-quality colonoscopy reduces the risk of death from colorectal cancer. The adenoma detection rate (ADR) is the principal measure of colonoscopy quality but is onerous to calculate. We report the development of a fully automated platform for calculation of the ADR and other key colonoscopy quality indicators without the need for manual data entry.

Methods

Endoscopy and pathology reports from 6 centers were collected over a 3-month period and collated using a novel data transfer interface. Text-based classification parameters were developed to identify average-risk screening colonoscopies, adenomatous pathology, cecal intubation, and withdrawal time. Automated quality metrics calculators based on these classifications were built into a web-based reporting platform, and the resulting quality metrics were benchmarked against those produced through a manual record review. Confirmation of the calculator's performance was performed in a validation cohort with data collected over a 1-month period, 6 months after the initial study.

Results

The study included 3809 colonoscopies (mean age 56.1 ± 6.40 years, 53.7% female, 38 endoscopists). The automated calculator yielded an ADR of 45.1% compared with 44.3% on manual review. Correct classification of ADR-qualifying screening colonoscopies was achieved with high predictive value, with a sensitivity of 0.918 and specificity of 1.0. The cecal intubation rate was 95.8%, and the average withdrawal time was 10:05 minutes.

Conclusion

We demonstrate the feasibility and performance of a colonoscopy quality reporting platform capable of calculating the ADR and other key metrics using novel, fully automated pathology report integration and a text query-based classification accessible in a wide range of practice settings.

Gastroparesis is a chronic debilitation condition characterized by delayed gastric emptying. Medically refractory gastroparesis poses a significant burden on patients and the health care system. Managing these patients can be challenging, partly due to the overlap of symptoms with other functional disorders and the lack of a consistent association between symptoms and the degree of gastric dysmotility. Gastric peroral endoscopic myotomy (G-POEM) has recently emerged as a novel therapeutic option for managing gastroparesis. This review provides an overview of G-POEM for medically refractory gastroparesis, discussing patient selection, technical aspects of the procedure, clinical outcomes, and future directions.

This comprehensive review addresses the critical role of colonoscopy in colorectal cancer (CRC) prevention. With CRC as one of the most common cancer types in men and women, high-quality colonoscopy is vital to reduce CRC incidence and mortality. Persistent gaps in quality, evidenced by interval CRCs and large variations in both provider adenoma detection rate (ADR) and resection methods, highlight the need to prioritize colonoscopy quality improvement through feedback and training.

This review delves into key factors influencing colonoscopy quality with lesion detection and removal. Excellent bowel preparation is necessary for effective colonoscopy, impacting lesion detection, ADR, procedure time, and complication risk. Optimal inspection techniques, encompassing provider maneuvers and utilization of technological devices such as distal attachment devices and artificial intelligence, hold promise in enhancing inspection quality. For optimal lesion resection, we explore cold snare polypectomy as a safe, cost-effective, and efficacious technique, particularly for diminutive and small polyps, and endoscopic mucosal resection for large (≥20 mm) polyps.

We outline the importance and critical need for quality assurance programs and to implement education science principles into endoscopy training. Innovative simulation-based mastery learning training, which includes various educational strategies to engage endoscopists in deliberate practice with assessment and feedback, holds great potential to efficiently scale the practice of high-quality colonoscopy to improve ADR and resection methods.

The need for endoscopic service has been well established within gastroenterology globally, and it is equally critical in areas with limited resources. We highlight the educational situation in underserved areas, pertinent goals to aim for, current initiatives and programs, as well as limitations and potential for improvement. Gastroenterology training for medical and surgical endoscopists includes variable components of basic and advanced endoscopies. Various models for training have been used, including traditional 1- to 3-year fellowships, short courses for upskilling, exchange programs, bolus or apprenticeship training, and training camps. There is a steadily increasing demand for endoscopic procedures in the region. We highlight the successes and challenges of current models, which are at various levels, including trainee, institutional, and even geopolitical. In addition, we explore the role that national and international societies as well as industry partners and other stakeholders play in influencing and implementing training. Given the diversity in access to resources as well as endoscopic capacity, we also highlight some of the innovative ways that have been used to provide and continue endoscopy training. Successful training also involves curriculum development, adoption of guidelines, and discussions on assessment of competency as well as having a glimpse into the future of endoscopy training in resource-limited settings. Ultimately, the goal is to ensure harmonized and quality training efforts across the various settings.