Faculty Bibliography

Artificial intelligence (AI) was first described in 1950; however, several limitations in early models prevented widespread acceptance and application to medicine. In the early 2000s, many of these limitations were overcome by the advent of deep learning. Now AI systems are capable of analyzing complex algorithms and self-learning, we enter a new age in medicine where AI can be applied to clinical practice through risk assessment models, improving diagnostic accuracy and improving workflow efficiency. This article presents a brief historical perspective on the evolution of AI over the last several decades and the introduction and development of AI in medicine in recent years. A brief summary of the major applications of AI in gastroenterology and endoscopy are also presented, which will be reviewed in further detail by several other articles in this issue of GIE.

INTRODUCTION: Telehealth involves the use of electronic information and telecommunications to promote healthcare. Physician experience is critical in assessing the impact of telehealth on clinical outcomes and utilization. Gastroenterologists' use and attitudes towards telehealth are largely unknown. We aimed to identify gastroenterologists' professional attitudes towards their use of telehealth and its effect on patient care during the COVID-19 pandemic.
METHOD(S): We performed a cross sectional survey of outpatient gastroenterologists and hepatologists at a single tertiary academic medical center in June 2020. Clinicians were invited to participate in an electronic survey. Survey questions involved either single or multiple categorical responses.
RESULT(S): A total of 46 respondents (51 +/- 14 years old) participated, 70% of which were male. 44 (96%) respondents had no telehealth experience prior to the pandemic. Clinicians conducted 19 +/- 13 visits weekly with a mean length of 24 +/- 9 minutes. 88% of providers reported telehealth allowed for increased flexibility, both in patient scheduling and their personal lives. Telehealth was always or usually effective in addressing patients' clinical needs 91% of the time. 29 (63%) respondents estimated that 10% or fewer patients required in-person follow-up. Clinicians estimated 93% of patients desired the continued option of telehealth, and 42 (91%) providers wanted to continue telehealth in some capacity, conditional on reimbursement. Those interested would use telehealth for follow-up visits (28%), on a patient-by-patient basis (23%), or for new visits (20%). While 21 (46%) respondents felt that telehealth and in-person visits required equal effort, 16 (35%) felt telehealth required more effort. Reasons cited for telehealth requiring more effort included coordination of care (30%), technical difficulty for the patient (20%), and more charting (17%).
CONCLUSION(S): While most clinicians had no telehealth experience before the pandemic, a majority were interested in using telehealth in the future, citing increased flexibility for both provider and patient. Physicians felt that telehealth was effective in addressing patients' needs. However, many felt that telehealth required more effort, particularly in regard to coordination of care and technical difficulties. Newer telehealth platforms should address connectivity issues. Future studies should focus on patients' attitudes towards telehealth, and the effect of telehealth on healthcare outcomes, utilization and costs

Introduction: Pancreatic cystic lesions (PCL) are increasingly identified on cross-sectional imaging. Types include intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystadenoma (SCA), solid pseudopapillary tumors (SPT) and pseudocysts. Given the risk of malignancy associated with MCN and IPMN with high risk features, accurate PCL diagnosis is essential. Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) of cyst fluid for cytology remains important for the classification of PCL, but is limited by the ability to obtain a sufficient sample and cellularity of fluid. The specificity for malignant cytology is 94%, but sensitivity remains low at 51%. Recently, introduction of a novel microforceps biopsy (MFB) device (Moray Micro Forceps, US Endoscopy, Mentor, OH) has enabled EUS-guided through-the-needle biopsies of PCL through a 19-gauge needle. The aim of this study is to compare the technical success and diagnostic yield for PCL using MFB versus cyst fluid studies alone, along with identifying adverse events associated with MFB.
Method(s): We conducted a retrospective chart review of adult patients with PCL diagnosed by cross sectional imaging undergoing EUS-guided FNA with MFB at 2 tertiary academic centers from November 2016 to November 2019. FNA of PCL was performed and cyst fluid was sent for cytology, carcinoembryonic antigen (CEA) levels, and mutational analysis. Cyst biopsy was performed using MFB.
Result(s): 14 patients were included. 71% were female. Median age was 60 years. Location of cysts in pancreas were head (4), body (6), and tail (4). MFB was technically successful in 12 of 14 cases (yield 86%) including 1 case where no cyst fluid was able to be obtained. There were no reported adverse outcomes (bleeding, pancreatitis, perforation, infection, abdominal pain). MFB diagnosed IPMN in 2 patients, neither of which were identified by cytology but were identified by fluid mutational analysis; MCN in 2 patients, 1 of which was identified by cytology; and SCA in 1 patient where cytology was concerning for a mucinous lesion. Both MFB and cytology were concerning for pseudocyst in 1 patient who ultimately was found to have MCN.
Discussion(s): The technical success of MFB is high and is associated with increased overall diagnostic yield without significant adverse events. For distinguishing PCL types, MFB provided additive diagnostic information to fluid cytology in 4 of 14 patients in our study. Including mutational analysis which identified IPMN in 2 patients where cytology was negative, MFB still provided further diagnostic information in 2 additional patients. This study suggests that the addition of MFB to EUS-guided sampling for cytology, CEA and mutational analysis further augments PCL diagnosis. Future studies should elucidate the role of MFB in combination with mutational analysis. [Formula presented]
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Introduction: EUS-guided FNA and FNB have been stagnating at accuracy levels which falls short of patient and physician hopes. False negative results for malignancy continue to range from 4% (expert centers) to 30%. Multiple passes of the needles often slide along the same tract as the first pass, limiting diagnostic yield. FNA requires 5 passes, fewer for the FNB needles. Rapid on-site cytology may lower the number of passes, but it is logistically and financially challenging, without proving to improve accuracy. Repeated passes bend needles out of shape leading to use of a second needle, with high cost implications. Tumor composition can be a mosaic of desmoplasia, necrosis, cystic areas, and malignant cells. If a needle is in the wrong plane then wrong diagnosis occurs. Often fanning hardly moves the needle. We introduce a new needle prototype to improve diagnostic yield and lower false negatives, with use of a device which has five needles.
Method(s): A multi-pass needle has been designed which ensures five specimens will be from various sites, because the five needles are all penetrating at the same time along different planes within the lesion. This needle apparatus uses the same sheath as a standard 19 gauge needle, but within the sheath it houses a five-lumen plastic tube, which separates between the central 22g needle and the four peripheral 25g needles. The ergonomically-designed handle has a two-phase mechanism which allows the endoscopist to first place the 22g needle within the target lesion, which is the same as the process done today, and to then deploy the four 25g needles, which are pre-bent so as to spread out to a diameter of about one cm, when needles are about 3cm from the scope. The additional needles will each, without fanning, obtain specimens near to the central needle, thus a greater representation of tumor will be obtained, completing the procedure in one pass, with better accuracy due to decreasing false negatives. The two channels for suction apply to the single central needle and to the four peripheral needles. Each needle has its own stylet.
Result(s): The accompanying figure shows the InstaFan, a disruptive technological advance, made to improve EUS biopsies. Three in vivo porcine studies found that the 5 needles delivered resulted in five distinct adequate specimens for pathology diagnosis by the cell block method. Porcine EUS found good visibility of the needles, ease of deployment and no side effects from multiple deployments of the onepass device, both in EUS-guided gastric and duodenal biopsies of porcine pancreas and liver.
Conclusion(s): Future directions of the Onepass will be additional in vivo animal safety studies by additional endoscopists followed by first trials in humans. The goal of the Onepass will be to reduce false negatives, thus increasing optimization of tumor diagnosis. [Formula presented] [Formula presented]
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PURPOSE OF REVIEW/OBJECTIVE:This review highlights the history, recent advances, and ongoing challenges of artificial intelligence (AI) technology in colonic polyp detection. RECENT FINDINGS/RESULTS:Hand-crafted AI algorithms have recently given way to convolutional neural networks with the ability to detect polyps in real-time. The first randomized controlled trial comparing an AI system to standard colonoscopy found a 9% increase in adenoma detection rate, but the improvement was restricted to polyps smaller than 10 mm and the results need validation. As this field rapidly evolves, important issues to consider include standardization of outcomes, dataset availability, real-world applications, and regulatory approval. AI has shown great potential for improving colonic polyp detection while requiring minimal training for endoscopists. The question of when AI will enter endoscopic practice depends on whether the technology can be integrated into existing hardware and an assessment of its added value for patient care.

PURPOSE OF REVIEW/OBJECTIVE:With the intent of maximizing adenoma detection rate (ADR), different devices and colonoscopic innovations have been introduced over the past few years. There are a variety of attachment devices available for use in colonoscopy, all intended to improve ADR. In this review, we evaluate the evidence surrounding the available attachment devices and their impact on ADR. RECENT FINDINGS/RESULTS:Endocuff, Endoring, Transparent cap, G-EYE balloon, and Third Eye Retroscope were all included in this review. Three of the devices, Endocuff, Endoring, and transparent hood or cap, have been shown to increase ADR without significantly altering the use of the colonoscope. Although balloon-assisted colonoscopy is not currently FDA-approved, it has the potential to increase ADR as well. Mechanical enhancement has been shown to complement the current forward-viewing colonoscope, and Endocuff appears to be the most beneficial attachment to improve ADR.