Faculty Bibliography

Obesity is a major risk factor for nonalcoholic steatohepatitis (NASH). Although weight loss has been shown to reverse histologic features of NASH, lifestyle intervention alone is often challenging and unfeasible. In this case report, we discuss the effects of intragastric balloon (IGB) therapy on steatosis, fibrosis, and portal pressures. We also demonstrate that improvement in histologic features persist at least 6 months after IGB removal. Although there are little data thus far to support IGB therapy in the treatment of NASH, our case provides evidence of the potential benefit of IGB on improving metabolic parameters and markers of liver fibrosis.

INTRODUCTION: Colonoscopy is the best tool for to screen for colorectal cancer. Adenoma detection rate (ADR) is the main quality control indicator for colonoscopy. An improvement in ADR translates into a reduction in the number of index and interval colorectal cancers. Computer-aided polyp detection (CADe) can improve ADR but the impact of real-time CADe on colonoscopy metrics has not been rigorously studied. We aim to conduct a systematic review with meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of CADe to detect colorectal neoplasia.
METHOD(S): Electronic databases (Pubmed Central, OVID Medline, Embase, EBM Reviews Cochrane Central Register of Controlled Trials) were interrogated from inception until May 2020 for RCTs that compared real-time CADe with standard colonoscopy (E). Data was reviewed separately by two authors. Adult patients undergoing diagnostic and screening colonoscopies were included. Primary outcomes were polyp detection rate (PDR) and ADR. Secondary outcomes were total number of polyps detected, pooled ADR and withdrawal time. A random effects model was used to estimate mean differences (MD), odds ratios (OR) and rate ratios (RR) with 95% confidence intervals (95% CI). Heterogeneity was assessed with I² statistic, with >50% considered substantial.
RESULT(S): The search yielded 923 results. 6 studies met inclusion criteria. Controls included a sham system and colonoscopies without AI. The total number of subjects included in all studies were 5214. The mean age of patients was 49.49 years, and 47.55 % of the subjects were female. The mean BPPS in the CADe group was 6.7 (95% CI 6.61,6.8), similar to that in the E group. The pooled ADR for colonoscopy with CAD was 33%, and the pooled ADR for colonoscopy alone was 22.8%. Both, ADR and PDR were higher with CADe, OR 1.54 (95% CI 1.23-1.94) and OR 1.49 (95% CI 1.24-1.80), I² 5 0 for both. Number of polyps detected was also higher with CADe, OR 2.42 (95% CI 2.12-2.76), I² = 0. Withdrawal time was significantly longer (by less than a minute) in the CADe group, MD of 0.74 (95% CI).
CONCLUSION(S): Automatic polyp detection systems resulted in improved polyp and adenoma detection rates, but with increased withdrawal times, compared to standard colonoscopy. CADe use was associated with a significantly higher adenoma detection rate (ADR; 34% vs. 23%). CADe and standard colonoscopies had comparable detection rates of polyps 5-10 mm in size, but CADe had higher ADRs for diminutive polyps, and for polyps greater than 10 mm

INTRODUCTION: Endoscopic bariatric therapies (EBTs) have become available for the treatment of obesity, but their role in the treatment of diabetes is not well defined. EBTs can loosely be grouped into gastric or small bowel EBTs, with some data suggesting that small bowel EBTs have greater effect on diabetes. Our aim is to assess the impact of EBTs on diabetes and compare the effect of small bowel EBTs to gastric EBTs on diabetes outcomes, gut hormones, and weight loss parameters.
METHOD(S): MEDLINE, Embase, and Cochrane were searched through 2018. Randomized clinical trials and observational studies of EBTs that reported diabetic outcomes with >5 adult patients with obesity and at least 3 months of follow up were included. Primary outcomes included the pooled mean difference (MD) in baseline and final values in weight loss (% total weight loss, % excess weight loss, BMI change from baseline) and glycemic control (fasting glucose, HbA1c) parameters. Secondary analyses included changes in gut hormones by Hedges' g: ghrelin, glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and glucose-dependent insulinotropic peptide (GIP). Gastric EBTs included intragastric balloons, gastric restrictive procedures such as endoscopic sleeve gastroplasty (ESG), primary obesity surgery endoluminal procedure (POSE), transoral endoscopic vertical gastroplasty (TOGA), aspiration therapy. Small bowel EBTs included duodenal-jejunal bypass liner (DJBL), duodenal mucosal resurfacing (DMR), incisionless intestinal anastomosis system (IAS).
RESULT(S): From 1053 citations, 79 studies with 7,692 subjects were included. EBT use for 3-12 months was associated with significant improvements in diabetes outcomes and weight loss indices compared to baseline or control groups (Table 1). Weight loss outcomes with small bowel EBTs were similar to gastric EBTs. Small bowel EBTs led to a statistically significant greater improvement than gastric EBTs in diabetic parameters. Improvements in diabetes were associated with weight loss for gastric EBTs and an increase in postprandial GLP-1 and PYY for small bowel EBTs (Table 2).
CONCLUSION(S): Discussion: Diabetes and weight loss parameters improved significantly after 3-12 months of EBT. Small bowel EBTs were more effective than gastric EBTs, likely due to different mechanisms of action. EBT should be considered as an option to treat obesity in patients with diabetes in conjunction with diet and lifestyle interventions

INTRODUCTION: Early-onset colorectal cancer (CRC diagnosed <50 years) is on the rise, making prevention a public health priority. However, debate still exists on whether to initiate CRC screening at age 45 vs. 50. Further, fifty percent of early-onset CRC is diagnosed <45 years of age. We hypothesize a gradual increase in the rate of advanced colorectal neoplasia (i.e., CRC or high-risk polyps) with advancing years of age as opposed to a spike at age 50. We also propose that lack of CRC screening in ages 40-49 underestimates the true burden of advanced neoplasia in that age group.
METHOD(S): We performed a cross-sectional analysis of adults aged 20-60 years who underwent colonoscopies in 2017-2020. All subjects were average-risk for CRC with a complete colonoscopy and adequate bowel preparation. Our primary outcome was the rate and number of detected colorectal neoplasia in 1-year age increments, focusing on the transition between ages 40-44, 45-49, and 50-54 years. We compared advanced neoplasia, high-risk polyps (size $10, villous morphology or highgrade dysplasia), and non-high-risk polyps.
RESULT(S): The cohort included 8,593 adults aged 20-60 (55.9% female and 21.3% racial/ethnic minorities). The majority of adults (n = 5,927 or 68.9%) had a colonoscopy $50, mainly for CRC screening (Figure 1a). Advanced neoplasia rates increased gradually per age-year between 20 and 60 (Figure 1b). Specifically, the mean rate of advanced neoplasia was not statistically different from 40-44 (5.4%) to 45-49 (8.0%) to 50-54 (8.4%), although it was higher in 50-54 vs. 40-44 (Table 1). In contrast, there was a steep increase in detection of advanced neoplasia at age 50. Specifically, the number of adults with newly diagnosed advanced neoplasia increased by 103% from 40-44 to 45-49 and by 340% from 45-49 to 50-54 (Figure 2a). This rise was mainly due to uptake of CRC screening that increased the detection of advanced neoplasia by 67% in ages 45-49 and 467% in 50-54, as opposed to undergoing diagnostic colonoscopies alone (Figure 2b).
CONCLUSION(S): We report slow rise in rates of advanced neoplasia as adults approach age 50. Our data also solidify the impact of CRC screening uptake with a spike in advanced neoplasia burden $50. Combined, these findings supports an opportunity to detect neoplasia earlier, and prevent early-onset CRC, by starting screening at age 45 or 40. Future studies assessing novel, cost-effective, strategies to achieve earlier screening are urgently needed

Introduction: Women remain underrepresented in gastroenterology (GI), especially interventional endoscopy. Women represented 32% of first year GI fellows in 2017/2018, yet in 2019, only 12.8% of fellows who matched into interventional endoscopy were women.
Aim(s): To assess perceived barriers toward women pursuing interventional endoscopy training, Methods: We administered a 21-question web-based survey to program directors of interventional endoscopy fellowships participating in the 2018-2019 ASGE match. We assessed program director and program characteristics and asked program directors to rank barriers and facilitators (Scale 1-5, 5= most important) that may influence women pursuing interventional endoscopy training. Program characteristics affecting female interventional fellow graduation rates were assessed.
Result(s): We received 38 (59%) responses from 64 program directors. Program director and program characteristics are summarized in Table1. Only 16% (6/38) of programs had a woman as interventional endoscopy program director and 13.2% (5/38) had a woman as endoscopy chief. The mean (+/-SD) percentage of interventional faculty who were women was 15% (+/-17%). 47.4% (18/38) programs reported no women interventional faculty. Only 12% of interventional fellowship graduates from each program over the past 10 years were women, and 32% (12/38) of programs have never had a woman graduate. The percentage of female interventional fellowship graduates was strongly associated with percentage of female interventional faculty (s= 0.43, p< 0.001). Percentage of female interventional endoscopy graduates was higher in programs with female leadership, with highest association with programs with female endoscopy chiefs (20% vs 11%, p=0.09). There was no significant association between percentage of female interventional fellowship graduates and call structure or parental leave policy. Difficult or inflexible hours and call (mean rank 3.3+/- SD 1.1), exposure to fluoroscopy during childbearing age (2.9+/-1.1), lack of women endoscopists at national conferences and courses (2.9+/-1.1), and lack of mentorship to female trainees (2.9+/-1.0) were cited as the most important barriers regarding recruitment. Figure 1 summarizes potential facilitators for women pursuing a career in interventional endoscopy.
Discussion(s): We utilized a survey of program directors from interventional endoscopy fellowships participating in the ASGE match to determine program characteristics and identify contributors to gender disparity. We found women represent a minority of interventional endoscopy program directors, endoscopy chiefs, interventional endoscopy faculty and interventional fellowship graduates. Our study highlights barriers and facilitators to recruitment, and emphasizes the importance of having female representation in faculty and leadership positions in endoscopy. [Formula presented] [Formula presented]
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Introduction: Endoscopic bariatric therapies have emerged as a potential treatment option for metabolic disease. Duodenal mucosal resurfacing (DMR) is an endoscopic procedure that aims to ablate the hypertrophic duodenal mucosa noted to be associated with diabetes mellitus type 2 (DM2).
Aim(s): To assess the effect of DMR on metabolic outcomes associated with DM2.
Method(s): MEDLINE, Embase, and Cochrane Database were searched from inception through November 2019. Data extraction was performed independently by two authors. Inclusion criteria were metabolic parameters data before and after DMR treatment in studies with greater than 5 adult patients. Primary outcomes included the mean difference (MD) in hemoglobin A1C (HbA1c), fasting blood glucose (FBG), fasting insulin, HOMA-IR, liver transaminases (ALT), weight (kg) between the baseline and final values in patients undergoing DMR in RCT and observational studies; secondary outcomes were adverse events and co-variate predictors. Random effects model was used for all primary outcomes. Heterogeneity was assessed by the I² statistic, with I²> 50% considered substantial.
Result(s): Eighty-one citations were identified; 9 observational studies including 179 subjects were analyzed (4 primary studies, with 5 overlapping studies providing additional missing data). The majority of studies included only subjects with DM2 (HbA1c 7.5-10% on stable oral medications), average age was 56 years. DMR lead to a decrease in HbA1c by 1.1% (95% CI -1.2, -0.9) in subjects followed up to 6 months after DMR (Figure 1). By meta-regression, baseline HbA1c and ALT predicted changes in HbA1c, with respective R² values of 0.95 and 0.98, with slightly worse outcomes in patients with higher ALT. Additionally, in subjects followed up to 6 months, DMR was associated with decrease in FBG by 30.8 mg/dL (95% CI -35.3, -26.3); fasting insulin by 2.8 mIU/L (95% CI -6.1, 0.5); weight by 3.7 kg (95% CI -5.4, -2.0); ALT by -8 U/L (95% CI -10.5, -5.5); HOMA-IR by -2.6 (95% CI -3.7, -1.5), as shown in Table 1. The rate of serious adverse was 4.13%. Two studies reported limited follow-up data after 6 months, reporting a decrease in HbA1c of 1.5% (SD 0.7, N=22) and 1.4% (SD 0.8, N=21) at 12 months and 24 months follow-up respectively. One study reported decrease in liver fat by 30% from baseline to three months after DMR. There was insufficient data to investigate heterogeneity, with the exception of HbA1c.
Conclusion(s): DMR therapy led to significant improvements in several metabolic parameters including HbA1c, fasting insulin, FBG and ALT. These improvements were independent of weight loss, suggesting a direct metabolic effect that could offer a new treatment option for patients with DM2 and steatosis. More long-term data are needed to confirm durability of results. [Formula presented] [Formula presented]
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BACKGROUND AND AIMS/OBJECTIVE:Gastric stenosis is a rare but potentially serious adverse event after sleeve gastrectomy. Despite current suboptimal treatments, endoscopic balloon dilatation (EBD) has emerged as a safe and efficacious approach. The purpose of this study is to assess the overall success of EBD for sleeve gastrectomy stenosis (SGS) as first-line therapy. METHODS:MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane Database were searched from inception to July 2018, whereas OPUS, LILACS, BVS, CINAHL were not searched. The primary outcome was defined as overall success rate of clinical resolution of SGS obstructive symptoms with EBD, expressed as pooled event rate and 95% confidence interval (95% CI). The secondary predefined outcomes include EBD success rates for SGS in proximal (cardia) location or mid-distal location (antrum/incisura), in early SGS (up to 3 months after LSG) and late SGS (3 months or longer after LSG), and success rate of cases requiring stents or salvage surgery. RESULTS:Eighteen studies encompassing 426 patients were analyzed. The average age and BMI were 41.7 and 40.1, respectively, and average number of dilations for all cases was 1.8 per person. Overall EBD success rate was 76% (95% CI, 0.67-0.86). EBD success rates were as follows: proximal SGS was 90% (95% CI, 63%-98%); distal SGS was 70% (95% CI, 47%-86%); early SGS within 3 months was 59% (95% CI, 34%-79%); and late SGS after 3 months was 61% (95% CI, 41%-78%). Seventeen percent of patients underwent secondary salvage surgery, with a success rate of 91% (95% CI, 80%-96%). CONCLUSION/CONCLUSIONS:EBS appears to be a safe and effective minimally invasive alternative to surgical revision and should be used as first-line therapy for SGS.

INTRODUCTION: Anastomotic gastric adenocarcinoma (GAC) following distal gastrectomy Billroth II for peptic ulcer disease (PUD) has long been recognized but remains poorly studied. CASE DESCRIPTION/METHODS: A 65-year-old male with history of PUD status post Billroth II in 1991 presented with multiple episodes of melena and abdominal pain. EGD revealed friable gastric mucosa with oozing ulcers on the gastric side of the gastrojejunal anastomosis (GJA) (Figure 1a-c) and severe bile reflux. Stomach biopsies were negative for H. pylori or other pathology. Patient was subsequently admitted four more times that year for similar symptoms, each time presenting with symptomatic anemia that resolves with therapy, and EGD showing superficial erosions near the GJA. It was suspected however, that the initial biopsies were likely taken from areas far from the actively bleeding sites. Therefore, the GI team insisted on an outpatient EGD when the patient was asymptomatic to accurately investigate the GJA. After multiple missed appointments, he had an outpatient EGD (Figure 1d) with biopsies of the friable mucosa positive for GAC, and eventually underwent Roux-en-Y gastrectomy with esophagojejunostomy. Biopsy of the mesenteric nodules confirmed the diagnosis of moderately differentiated Stage IIIA GAC. Chemoradiation therapy was initiated, but patient left against medical advice and ended up in hospice care eight months later. DISCUSSION: We present a patient with persistent bleeding ulcers and symptomatic anemia 25 years after a Billroth II procedure, who despite multiple endoscopic evaluations with stomach biopsies, was not diagnosed on time. Eventually, the correct diagnosis of Stage III primary GAC was made after an outpatient EGD with targeted biopsies of the area associated with recurrent bleeding. Given the negative biopsies, the persistent gastric ulcers were thought to be complications of Billroth II with a short limb leading to bile reflux, or due to patient's poor compliance and follow up. However, it was recognized that the patient had a higher risk of GAC as he was 15-20 years after Billroth II, and more importantly, that the inpatient EGD biopsies were not of the actively bleeding area of interest. Our patient presented after a long asymptomatic interval with symptoms initially misinterpreted as benign. It is therefore imperative to maintain a high suspicion of gastric malignancy for these patients to encourage earlier diagnosis. (Figure Presented)

INTRODUCTION: Bariatric surgery has become a common therapeutic approach to obesity. However, bariatric procedures may affect bowel habits due to changes in dietary intake as well as altered anatomy. To date, few studies have evaluated the impact of bariatric surgery on post-operative constipation. The aim of this study is to determine if patients experience a greater rate of constipation after bariatric surgery compared to non-bariatric controls.
METHOD(S): A retrospective chart review at New York Langone Hospital (NYU) was performed on 160 bariatric surgery patients who had surgery in the year 2012 and 160 control patients with BMI < 30 kg/m2 seen in primary care in 2012. Reports of constipation were recorded up until November 2018. Exclusion criteria included those with inflammatory bowel disease or hereditary colorectal cancer syndromes prior to age 50. The primary outcome was diagnosis of post-operative constipation. Secondary outcomes included rates of constipation according to surgical procedure. Presence of constipation was recorded if listed on the problem list or if medications for constipation were prescribed. Logistic regression and chi-squared testing was used to assess differences in groups.
RESULT(S): Table 1 shows patient characteristics of the study population. The average age of bariatric surgery patients was 64.1 years compared to 69.8 in the control group. Overall, 20% of bariatric patients were diagnosed with constipation compared to 15% of controls (P = 0.239). Constipation rates post-bariatric surgery were 17.9% in lap band, 20.6% in sleeve gastrectomy, and 7.1% in gastric bypass patients (P = 0.256). A logistic regression controlling for age, sex, and Charlson co-morbidity index was performed between controls and post-surgery subjects. This revealed no significant difference in rates of constipation between the two groups (OR 1.158, 95% CI 0.790 - 1.696 P-value = 0.45). There was, however, a significant difference in constipation rates between the bariatric group pre-surgery (13.8%) and post-surgery (17.5%) (P = < 0.001) (Table 2).
CONCLUSION(S): Bariatric surgery patients experience significantly higher rates of constipation after surgery compared to prior to surgery, but similar rates to controls without obesity. Constipation impairs quality of life and is associated with significant health care costs. Further studies investigating the mechanisms underlying this increase in constipation after bariatric surgery and effective measures to treat it are warranted. (Figure Presented)