Faculty Bibliography

BACKGROUND AND AIMS: Wide-area transepithelial sampling (WATS) with computer-assisted 3-dimensional analysis is a sampling technique that combines abrasive brushing of the Barrett's esophagus (BE) mucosa followed by neural network analysis to highlight abnormal-appearing cells. METHODS: We performed a randomized trial of referral BE patients undergoing surveillance at 16 medical centers. Subjects received either biopsy followed by WATS, or vice versa. The primary outcome was rate of detection of HGD/EAC using WATS in conjunction with biopsy compared with biopsy alone using standard histopathologic criteria. Secondary aims included evaluating neoplasia detection rates (1) based on the procedure order (WATS vs biopsy first) (2) of each procedure separately, and (3) the additional time required for WATS. RESULTS: One hundred sixty patients (mean age 63.4 years, 76% male; 95% white) completed the trial. The median circumferential and maximal BE extents were 1.0 (IQR: 0.0-5.0) cm and 4.0 (IQR, 2.0-8.0) cm, respectively. The diagnostic yield for biopsy alone was as follows: HGD/EAC, 7 (4.4%); low-grade dysplasia (LGD), 28 (17.5%); non-dysplastic BE (NDBE), 106 (66.25%); and no BE, 19 (11.9%). The addition of WATS to biopsy yielded an additional 23 cases of HGD/EAC (absolute increase, 14.4%; 95% CI, 7.5%-21.2%). Among these 23 patients, 11 were classified by biopsy as NDBE, and 12 as LGD/IND; 14 received biopsy and 9 WATS first (p=NS) and the majority (n=21; 91.7%) had a prior dysplasia history. WATS added average of 4.5 minutes to the procedure. CONCLUSION: Results of this multicenter, prospective, randomized trial demonstrate that the use of WATS in a referral BE population increases the detection of HGD/EAC.

Introduction: Colorectal Cancer (CRC) prevention has resulted in the implementation of screening programs worldwide in hopes to reduce the number of CRC incidences. Despite these programs' best efforts, interval cancers continue to arise from lesions missed during standard procedures. Interval cancers have been found to occur more frequently in the right colon, often developing from flat and sessile lesions. These lesions have had reported miss rates of up to 60% compared to reported miss rates of 20%-30% for polyps and adenomas. The innovative G-EYE endoscope (SMART Medical Systems Ltd, Ra'anana, Israel) includes an integral, reusable balloon that is permanently installed on the distal end of a standard endoscope. Upon withdrawal, inflation of the GEYE balloon to a partial pressure results in the centralization of endoscope optics, reduction in bowel slippage, and flattening of colon topography. The enhanced visualization provided by the G-EYE balloon can result in an increase detection of lesions. Aims & Methods: In this prospective, randomized, multicentre study, patients (age >50) referred to colonoscopy as a result of screening, surveillance, positive FOBT or change in bowel habits were randomized to either standard colonoscopy (SC) or G-EYE colonoscopy. Detected lesions were removed and sent for pathology. We compared the detection rates of G-EYE colonoscopy with that of SC in the right colon. Results: 1000 patients were enrolled in the study, of which 498 underwent SC and 502 underwent G-EYE colonoscopy. Baseline parameters were similar in both groups. The right colon was defined as the cecum, ascending colon, and hepatic flexure. Results are presented in Table 1. In addition, the G-EYEincreased the detection of both advanced and large-size adenomas by 40% in the right colon Conclusion: Our study shows that G-EYE colonoscopy has the potential to significantly improve the quality of CRC screening through improved adenoma detection rates. Special attention should be given to the significant increase in right-sided flat lesions and sessile serrated adenomas by the G-EYE, as these lesions are strongly attributed to CRC. Through increased detection of these right-sided lesions, G-EYE colonoscopy can impact the quality of CRC screening by reducing miss rates and consequently reduce the incidents of interval cancers. (Table Presented)

Introduction: The need to increase adenoma detection rate (ADR) for colorectal cancer screening has ushered in enhanced visualization devices, designed to mechanically (Endocuff, Endorings and G-Eye) or optically (G-Eye, FUSE and EWAVE) improve conventional colonoscopy (CC). Cap-assisted colonoscopy (CAC) was the first device in the market but studies have not shown benefit over CC. In recent years, newer enhanced technology devices (NTD) have become available. Our aims were: 1) to compare the ADR, adenoma miss rate (AMR) and polyp detection rate (PDR) between CC and NTD 2) to compare the ADR, AMR and PDR between mechanical and optical NTD. Methods: MEDLINE and Embase databases were searched from inception through May 2017 for manuscripts or conference abstracts reporting ADR, AMR and PDR with the available NTD. Data on CAC was collected and analyzed separately. Randomized controlled trials and high-quality casecontrol studies in adults with >10 subjects were included, with dual extraction of data. Primary outcomes included pooled ADR, AMR and PDR odds ratio (OR) with 95% confidence interval (95% CI) between CC and NTD. AMR was assessed in RCTs with tandem colonoscopies. Secondary outcomes included cecal intubation rates (CIR), complications, cecal intubation time (CIT), and total colonoscopy time (TCT). Results: Of 247 citations identified without CAC, 47 studies with 17,543 subject were eligible for >=1 analyses. Mean age was 61.3 years (range 37.1-76.0) and 50.3% were males. The overall OR for ADR/ PDR was higher with NTD than CE (Fig 1). Sub-analysis between NTD showed a higher ADR (OR1.44 vs 1.18, P=0.03) and PDR (OR1.63 vs 1.16, P=0.01) for mechanical compared to optical NTD. Comparison of each NTD to CC showed an improved ADR/PDR with Endocuff and higher ADR with G-Eye, but not with FUSE (Table 1). No significant ADR difference was found between CAC and CC. The overall AMR with NTD was lower than CC (Fig 2). Mechanical NTD had lower AMR compared to optical NTD (OR0.11 vs 0.33, P<0.01). There was no difference in CIR (OR1.03, 0.81-1.30). The CIT was 7.33 min (+/-2.5) in NTD vs 7.39 min (+/-2.88) in CC. The TCT was 18.54 (+/-5.92) in NTD and 19.01 (+/-6.31) in CC. Major complications were uncommon (9 in NTD and 10 CC). Conclusion: Newer endoscopic technologies are an effective option to increase ADR/PDR, and decrease AMR, particularly mechanical NTD. Overall, the risk of major complications is similar to CC. Further comparisons between devices are warranted

Despite the small bowel comprising 90% of the mucosal surface area of the gastrointestinal tract, it is a rare site for neoplasia and only accounts for a little over 3% of the tumors that arise in the digestive tract. Benign small bowel lesions include lipomas, lymphangiomas, leiomyomas, neurofibromas, nodular lymphoid hyperplasia and adenomas, many of which are precursors to malignant lesions. Several polyposis syndromes are associated with small bowel polyps as well, including familial adenomatous polyposis syndrome, lynch syndrome, Peutz-Jeghers syndrome, Cowden syndrome and juvenile polyposis syndrome. Our aim was to review non-malignant small bowel polyps and discuss the prevalence, typical location, clinical presentation, diagnosis, endoscopic and histologic description and lastly management of each of these lesions.

Worldwide, colorectal cancer is the third commonest cancer. Over 90% follow an adenoma-to-cancer sequence over many years. Colonoscopy is the gold standard method for cancer screening and early adenoma detection. However, considerable variation exists between endoscopists' detection rates. This review considers the effects of different endoscopic techniques on adenoma detection. Two areas of technological interest were considered: (1) optical technologies and (2) mechanical technologies. Optical solutions, including FICE, NBI, i-SCAN and high definition colonoscopy showed mixed results. In contrast, mechanical advances, such as cap-assisted colonoscopy, FUSE, EndoCuff and G-EYE, showed promise, with reported detections rates of up to 69%. However, before definitive recommendations can be made for their incorporation into daily practice, further studies and comparison trials are required.

BACKGROUND & AIMS: The incidence and predictors of non-gastrointestinal (GI) adverse events (AEs) following colonoscopy are not well understood. We studied the effects of anti-thrombotic agents, cardiopulmonary comorbidities, and age on risk of non-GI AEs after colonoscopy. METHODS: We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010 - March 2012). Data from patients at increased risk (n=82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring anti-thrombotic medications) were compared with data from 398,663 average-risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (based on age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1-30 days after colonoscopy. RESULTS: Thirty days after outpatient colonoscopy, non-GI AEs were significantly higher in patients taking anti-thrombotic medications (7.3%; odds ratio [OR], 10.75; 95% CI, 10.13-11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% CI, 2.27-2.62) vs average-risk patients (0.7%), and in patients 60-69 yrs old (OR, 2.21; 95% CI, 2.01-2.42) or 70 yrs or older (OR, 6.45; 95% CI, 5.89-7.06), compared to patients younger than 50 yrs. The 30-day incidence of non-GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy, in the anticoagulant group (OR, 2.31; 95% CI, 2.01-2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% CI, 1.13-1.56). CONCLUSIONS: Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non-GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating anti-thrombotic management prior to colonoscopy.