Faculty Bibliography

BACKGROUND & AIMS: Colon capsule endoscopy (CCE) is a non-invasive technique used to explore the colon without sedation or air insufflation. A second-generation capsule was recently developed to improve accuracy of detection, and clinical use has expanded globally. We performed a systematic review and meta-analysis to assess the accuracy of CCE in detecting colorectal polyps. METHODS: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and other databases, from 1966 through 2015, for studies that compared accuracy of colonoscopy with histologic evaluation with CCE. The risk of bias within each study was ascertained according to QUADAS recommendations. Per-patient accuracy values were calculated for polyps, overall and for first- (CCE1) and second-generation (CCE2) capsules. We analyzed data using forest plots, the I2 statistic to calculate heterogeneity, and meta-regression analyses. RESULTS: Fourteen studies provided data from 2420 patients (1128 for CCE1 and 1292 for CCE2). CCE2 and CCE1 detected polyps >6 mm with 86% sensitivity (95% confidence interval [CI], 82%-89%) and 58% sensitivity (95% CI, 44%-70%), respectively and 88.1% specificity (95% CI, 74.2%-95.0%) and 85.7% specificity (95% CI, 80.2%-90.0%), respectively. CCE2 and CCE1 detected polyps >10 mm with 87% sensitivity (95% CI, 81%-91%) and 54% sensitivity (95% CI, 29%-77%), respectively and 95.3% specificity (95% CI, 91.5%-97.5%) and 97.4% specificity (95% CI, 96.0%-98.3%), respectively. CCE2 identified all 11 invasive cancers detected by colonoscopy. CONCLUSIONS: The sensitivity in detection of polyps >6 mm and >10 mm increased substantially between development of first- and second-generation colon capsules. High specificity values for detection of polyps by CCE2 seems to be achievable with a 10 mm cut-off and in a screening setting.

GOAL: The purpose of this study was to assess the effect of decreased colonoscopy reimbursement on gastroenterologist practice behavior, including time to retirement and procedure volume. BACKGROUND: In 2015, the Centers for Medicare and Medicaid Services proposed reductions in colonoscopy reimbursements. With new initiatives for increased colorectal cancer screening, it is crucial to understand how reimbursement changes could affect these efforts. STUDY: Randomly selected respondents from the American College of Gastroenterology membership database were surveyed on incremental changes in practice behavior if colonoscopy reimbursement were to decrease by 10, 20, 30, or 40 %. Data were analyzed using both Pearson's Chi-square and analysis of variance. RESULTS: Two thousand and nine gastroenterologists received the survey with a 16.3 % response rate. Procedure volume significantly decreased with degree of reimbursement reductions (p < 0.001). With a 10 % decrease, 72 % of respondents reported no change in the number of colonoscopies performed. With a 20 % decrease, 39 % would decrease their procedure volume, while 21 % of respondents would increase their procedure volume. With a 30 and 40 % decrease, procedure volume decreased by 48 and 50 %, respectively. In terms of retirement, current plans predict a cumulative retirement rate of 29.4 % at 10 years. More than 42 % of respondents plan to retire after 2030. In the 2014-2023 retirement subgroup (N = 74 responses), there was a significant hastening of retirement year at 20 % (p = 0.016), 30 % (p < 0.001), and 40 % (p < 0.001) reimbursement reductions as compared to baseline responses. CONCLUSION: Decreasing colonoscopy reimbursements may have a significant effect on the effective gastroenterology work force.

Introduction: The prevention of colorectal cancer (CRC) by colonoscopy is attributed to the identification and removal of adenomas. A significant number of adenomas are missed during Standard Colonoscopy (SC), e.g., due to polyps hidden behind colon folds and flexures. The newly developed G-EYETM Endoscope (SMART Medical Systems Ltd, Ra'anana, Israel) combines a forward viewing endoscope with an integral, reusable balloon at its bending section. During withdrawal of the G-EYETM Endoscope, the balloon is partially inflated, allowing for the flattening of colon folds, centralization of the optical image, and reduction in bowel slippage, thus providing enhanced visualization of the colon and increased detection of polyps and adenomas. Aims & Methods: The aim of this study is to compare the adenoma detection rate (ADR) of G-EYETM high definition (HD) colonoscopy with that of standard HD colonoscopy. From May 2014 to April 2015, patients (age450) referred to colonoscopy for screening, surveillance, following positive fecal occult blood test (FOBT), or due to change of bowel habits, were randomized to either SC group or G-EYETM group. The G-EYETM Endoscope was based on the same instrument as the conventional HD-colonoscope. Results: 360 subjects were enrolled to the study, of which 177 subjects were randomized to the SC group and 183 subjects were randomized to the GEYE TM group. The ADR, adenoma per patient, number of advanced adenomas and large-size adenomas for each group are presented in Table 1. Compared with conventional colonoscopy, G-EYETM colonoscopy increased ADR by 58%. Special attention should be given to 55% and 56% increase in number of advanced adenomas and large-size adenomas, respectively. Procedural times were similar between the two groups. Conclusion: Our study has shown that the G-EYETM endoscope has a substantially higher ADR, compared to SC, which is considered to be one of the indicators for quality in colonoscopy. Moreover, the G-EYETM endoscope is able to detect not only small and diminutive adenomas but also a larger number of advanced and large size adenomas. It is therefore concluded that the GEYETM has the potential to reduce colonoscopic miss rates and reduce interval cancer incidents. (Table Presented)

Introduction: Barrett's esophagus (BE) is a known precursor to esophageal adenocarcinoma. Endoscopic guidelines for BE and esophageal dysplasia (ED), rely on random four-quadrant forceps biopsies (FB) obtained every 1-2 cm in the BE segment, and are subject to sampling error. Wide area transepithelial brush biopsy combined with 3 dimensional computer image analysis of the sample (WATS^3D) previously has been shown to provide incremental value as an adjunct to FB in the detection of both BE and ED. Aims & Methods: A prospective multi-center, community-based trial utilizing WATS^3D testing was conducted during the period 2012-2014. Patents with symptoms of reflux, suspected BE, and known BE undergoing surveillance for ED were enrolled. A specially designed transepithelial WATS^3D biopsy brushes for tissue sampling in addition to forceps biopsies (FB) during the same endoscopy. WATS^3D and FB samples were sent to a central laboratory for analysis. In contrast to the standard 2 micron cut tissue slice, WATS^3D biopsy specimens also include an uncut direct smear of up to 150 microns in thickness to better capture the natural three dimensional appearance of the glandular tissue. Laboratory analysis of this uniquely thick tissue sample is aided by a computer based image processing system that integrates into a single three dimensional image information taken from up to 150 separate one micron focal planes. This information is then automatically reviewed by the systems image processing algorithms and neural networks which select and display to the pathologist the most suspicious cells that are found in every focal plane of the entire WATS^3D specimen. Results: There were 4203 patients enrolled in the study with adequate FB and WATS^3D specimens. The medianage was 59 yr with 43% being males. BE was diagnosed in 594 patients by FB and in 799 patients byWATS^3D. Of these 799 patients, 493 had no BE seen on FB. Thus, the addition WATS^3D tothe standard forceps biopsy protocol increased the detection of BE by 83.0% (493/594; 95%confidence interval 74%493%), This added detection of BE in 12% (493/ 4203) of all patients testedwith WATS^3D results in a number of patients needed to test (NNT) to obtain one additional BEpatient of 8.53. Esophageal dysplasia was diagnosed in 26 patients by FB and in 33 patients byWATS^3D. Of these 33 patients, 23 had no ED on FB. Thus, the addition of WATS^3D to the standardforceps biopsy protocol increased ED detection by 88.5% (23/26; 95% confidenceinterval 48%4160%). This augmented ED detection in 0.5% (23/4203) of all screening patients testedwith WATS^3D, results in an NNT to obtain one additional ED case of 182.7. There were no adverse events which resulted from use of WATS^3D. Conclusion: This multi-center trial demonstrates the benefit of WATS^3D use in daily community-based endoscopic practice. These results underscore previous data demonstrating the adjunctive benefit of adding WATS^3D to FB for augmented detection of both Barrett's metaplasia and dysplasia. (Table Presented)