Techniques and Innovations in Gastrointestinal Endoscopy最新文献

Background and Aims

Current guidelines recommend that the decision to pursue surveillance colonoscopy in older adults with polyps be individualized, yet how these recommendations are communicated has not been characterized. We aimed to evaluate the effectiveness of endoscopist recommendations after colonoscopy in communicating the need for future surveillance in older adults.

Methods

We performed a single-center, retrospective chart review of adults age ≥ 75 years who underwent colonoscopy for polyp surveillance or screening during which polyps were detected. We performed content analysis of the recommendations from both colonoscopy reports and post-pathology follow-up letters. Recommendations were classified as optimal or less optimal based on whether they were clear, contained a rationale, and maintained consistency between the report and follow-up letter.

Results

Between 2012 and 2019, there were 1428 colonoscopies performed by 17 endoscopists, of which 874 (61%) were optimal and 554 (39%) were less optimal. Among the less optimal recommendations, 76 (14%) lacked a recommendation, 233 (42%) were unclear, and 409 (74%) lacked a rationale. Among the 954 post-pathology follow-up letters, 80 (8%) were inconsistent with the original colonoscopy report recommendation, of which 30 (38%) resulted in a change in management. The frequency of less optimal recommendations ranged from 0% to 50% by endoscopist.

Conclusion

Following colonoscopy in older adults, we found that roughly one-third of the reports were less than optimal, and there was sizable variation in individual endoscopist performance. Discrepancies between colonoscopy reports and patient follow-up letters could be minimized by avoiding providing recommendations on future colonoscopy before pathologic interpretation.

Endoscopic submucosal dissection (ESD) is the current standard treatment for early intramucosal gastrointestinal neoplasia, as ESD achieved a higher rate of en bloc resection and lower rate of local recurrence, especially for neoplastic lesions greater than 20 mm, compared with endoscopic mucosal resection. However, colorectal ESD remains technically challenging, with a significant risk of complications, especially perforation during dissection. The higher risk of perforation is related to the intrinsic operational difficulties of using flexible endoscopy and dissection via the coaxial ESD device, as well as the unfavorable anatomical characteristics, including thin colonic wall and haustrations. The lack of bimanual tissue manipulation, mucosal traction, and poor visualization of dissection plane led to the challenges in colorectal ESD. The development of endoluminal flexible robotic systems aims to overcome these challenges with innovative flexible robotics to refine the endoscope and instrumentations, some of which have already been used in clinical trials. Preclinical studies demonstrated promising outcomes with using flexible robotics in improving the learning curve of colorectal ESD. This review will also explore future development of endoluminal flexible robotics and a training system, which are crucial to ensure an effective, efficient, and safe training program for novice endoscopists to perform robotic colorectal ESD.

Background and Aims

The adenoma detection rate (ADR), is a key quality metric for colonoscopy, but it might fail to measure differences in adenoma detection in different parts of the colon. Because many post-colonoscopy cancers arise in the proximal colon, differences in the ADR of proximal vs distal adenomas could be clinically important. Our aim was to determine the feasibility of measuring ADR for both the proximal and distal colon and to understand differences based on age, sex, and race.

Methods

We queried a large claims database (Health Care Service Corporation) to screen colonoscopies from 2016-2018 to determine the location and pathology of detected polyps. We measured the ADR in both the proximal (P-ADR) and distal (D-ADR) colon to determine differences in the ratio of P-ADR vs D-ADR by age, sex, and race.

Results

The cohort included 93,163 women and 89,132 men. A progressive increase in both P-ADR and D-ADR occurs with advancing age, with the P-ADR/D-ADR ratio rising from 1.2 in patients under 40 years of age to 2.65 in patients age 75 and older, in both men and women. This ratio is affected by the experience of the endoscopist. A higher volume of procedures is directly related to higher polyp detection, specifically the P-ADR.

Conclusion

As age advances, there is an increasing predominance of proximal adenomas relative to distal adenomas in both men and women, in all races. With appropriate coding, it is feasible to measure the ADR for the proximal and distal colon. Measurement of P-ADR could be an important new quality metric.

Although stool-based organized colorectal cancer (CRC) screening programs increase screening rates and reduce CRC mortality, there remain barriers to adoption and challenges to successful implementation. Health policies, incentives, and data fragmentation influence the adoption of organized screening programs. Organized outreach programs can uniformly deliver fecal immunochemical tests to nearly all health system members who are due and eligible, but the next level of organized intervention will be to leverage disaggregated data to identify individual members and subgroups that could benefit from additional or tailored services. There is an urgent need for policies to drive more widespread implementation of organized CRC screening programs and for continued innovation in health services delivery so that organized screening programs, when implemented, can achieve their full potential.

Background and Aims

Endoscopic submucosal dissection (ESD) is an important treatment for gastric neoplasia. Some gastric adenomas with low-grade dysplasia (LGD) and high-grade dysplasia (HGD) on endoscopic forceps biopsy (EFB) are diagnosed as gastric adenocarcinoma (GAC) after ESD. We aimed to identify factors associated with histological diagnosis of gastric lesions and predictors for pathological upstaging following ESD.

Methods

This retrospective study analyzed data from 309 patients who underwent gastric ESD at 25 tertiary care centers in North America. Variables assessed included demographic characteristics, endoscopic lesion characteristics, and histopathological diagnoses. We used logistic regression to identify predictors of GAC following ESD, as well as pathologic upstaging from EFB to ESD.

Results

Four point one percent of all cases with LGD and 12.8% with HGD on EFB were upstaged to GAC after ESD. There were no significant predictors of pathologic upstaging. However, logistic regression revealed that age (odds ratio [OR] = 1.05, P < 0.01), the presence of ulceration (OR = 2.76, P < 0.01), and tumors located in the upper third (OR = 2.35, P = 0.01) or lower third of the stomach (OR = 1.92, P = 0.02) significantly predicted GAC.

Conclusion

In this large North American cohort of patients treated with gastric ESD, we found that tumor location in the upper and lower thirds of the stomach, tumor ulceration, and patient age could predict GAC. Endoscopists should be cognizant of these characteristics as up to 16.9% of lesions may be upstaged to GAC.