Faculty Bibliography

BACKGROUND:Devices used to improve polyp detection during colonoscopy have seldom been compared with each other. METHODS:We performed a 3-center prospective randomized trial comparing high-definition (HD) forward-viewing colonoscopy alone to HD with Endocuff to HD with EndoRings to the Full Spectrum Endoscopy (FUSE) system. Patients were age ≥50 years and had routine indications and intact colons. The study colonoscopists were all proven high-level detectors. The primary endpoint was adenomas per colonoscopy (APC) RESULTS: Among 1,188 patients who completed the study, APC with Endocuff (APC Mean ± SD 1.82 ± 2.58), EndoRings (1.55 ± 2.42), and standard HD colonoscopy (1.53 ± 2.33) were all higher than FUSE (1.30 ± 1.96,) (p<0.001 for APC). Endocuff was higher than standard HD colonoscopy for APC (p=0.014) . Mean cecal insertion times with FUSE (468 ± 311 seconds) and EndoRings (403 ± 263 seconds) were both longer than with Endocuff (354 ± 216 seconds) (p=0.006 and 0.018, respectively). CONCLUSIONS:For high-level detectors at colonoscopy, forward-viewing HD instruments dominate the FUSE system, indicating that for these examiners image resolution trumps angle of view. Further, Endocuff is a dominant strategy over EndoRings and no mucosal exposure device on a forward-viewing HD colonoscope.

BACKGROUND AND AIMS/OBJECTIVE:The need to increase the adenoma detection rate (ADR) for colorectal cancer screening has ushered in devices that mechanically or optically improve conventional colonoscopy. Recently, new technology devices (NTDs) have become available. We aimed to compare the ADR, polyp detection rate (PDR), and adenoma miss rate (AMR) between NTDs and conventional colonoscopy and between mechanical and optical NTDs. METHODS:MEDLINE and Embase databases were searched from inception through September 2017 for articles or abstracts reporting ADR, PDR, and AMR with NTDs. Randomized controlled trials and case-control studies with >10 subjects were included. Primary outcomes included ADR, PDR, and AMR odds ratio (OR) between conventional colonoscopy and NTDs. Secondary outcomes included cecal intubation rates, adverse events, cecal intubation time, and total colonoscopy time. RESULTS:From 141 citations, 45 studies with 20,887 subjects were eligible for ≥1 analyses. Overall, the ORs for ADR (1.35; 95% confidence interval [CI] 1.24-1.47; P < .01) and PDR (1.51; 95% CI, 1.37-1.67; P < .01) were higher with NTDs. Higher ADR (OR, 1.52 vs 1.25; P = .035) and PDR (OR, 1.63 vs 1.10; P ≤ .01) were observed with mechanical NTDs. The overall AMR with NTDs was lower compared with conventional colonoscopy (OR, .19; 95% CI, .14-.26; P < .01). Mechanical NTDs had lower AMRs compared with optical NTDs (OR, .10 vs .33; P < .01). No differences in cecal intubation rates, cecal intubation time, or total colonoscopy time were found. CONCLUSIONS:Newer endoscopic technologies are an effective option to improve ADR and PDR and decrease AMR, particularly with mechanical NTDs. No differences in operability and safety were found.

BACKGROUND:Prediction of histology of small polyps facilitates colonoscopic treatment. The aims of this study were: 1) to develop a simplified polyp classification, 2) to evaluate its performance in predicting polyp histology, and 3) to evaluate the reproducibility of the classification by trainees using multiplatform endoscopic systems. METHODS:In phase 1, a new simplified endoscopic classification for polyps - Simplified Identification Method for Polyp Labeling during Endoscopy (SIMPLE) - was created, using the new I-SCAN OE system (Pentax, Tokyo, Japan), by eight international experts. In phase 2, the accuracy, level of confidence, and interobserver agreement to predict polyp histology before and after training, and univariable/multivariable analysis of the endoscopic features, were performed. In phase 3, the reproducibility of SIMPLE by trainees using different endoscopy platforms was evaluated. RESULTS: = 0.002). The sensitivity, specificity, positive predictive value, and negative predictive value after training were 97 %, 88 %, 95 %, and 91 %. The interobserver agreement of polyp diagnosis improved from 0.46 (95 %CI 0.30 - 0.64) before to 0.66 (95 %CI 0.48 - 0.82) after training. The trainees demonstrated that the SIMPLE classification is applicable across endoscopy platforms, with similar post-training accuracies for narrow-band imaging NBI classification (0.69; 95 %CI 0.64 - 0.73) and SIMPLE (0.71; 95 %CI 0.67 - 0.75). CONCLUSIONS:Using the I-SCAN OE system, the new SIMPLE classification demonstrated a high degree of accuracy for adenoma diagnosis, meeting the ASGE PIVI recommendations. We demonstrated that SIMPLE may be used with either I-SCAN OE or NBI.

Background and study aims /UNASSIGNED:The anatomical meaning of the terms "proximal" and "distal" in relation to the pancreaticobiliary anatomy can be confusing. We aimed to investigate practice patterns of use of the terms "proximal" and "distal" for pancreaticobiliary anatomy amongst various medical specialties. Materials and methods /UNASSIGNED:An online survey link to a normal pancreaticobiliary diagram was emailed to a multispecialty physician pool. Respondents were asked to label various parts of the common bile duct (CBD) and pancreatic duct (PD) using the terms "proximal," "distal," "not sure," or "other." Variability in use of these terms between specialties was assessed. Results /UNASSIGNED: = 0.1821). Conclusions /UNASSIGNED:Although use of the terms "proximal" and "distal" is still very common to describe pancreaticobiliary anatomy, there is a discordance about its meaning, particularly for the PD. Use of descriptive terminology may be a more accurate alternative to prior ambiguous terminologies such as "proximal" or "distal" and can serve to improve communication and decrease the possibility of medical errors.

Background: New technology devices (NTDs) - including Endocuff, Endoring, and Full Spectrum Endoscopy (FUSE) have recently been described as having increased performance in adenoma detection rate as compared to conventional colonoscopy by means of improving colonic mucosal visualization. An increasing awareness of the significant risk of sessile-serrated adenoma progression to malignancy has ushered a need for increased detection of these characteristically flat lesions. Two prior studies evaluating the Endocuff technology and sessile-serrated adenoma detection rate have been published. This is the first meta-analysis comparing the sessile-serrated adenoma detection rate of NTDs and conventional colonoscopy. Methods: Embase and PubMed/MEDLINE databases were searched from inception through November 2017 for published manuscripts or major conference abstracts reporting sessile-serrated adenoma detection rate (SSADR) with Endocuff, EndoRing, G-Eye, FUSE, Third-Eye and conventional colonoscopy. Randomized controlled trials and high-quality case-control studies in adults with >10 subjects were included. Studies excluded were those with overlap in data collection site or time frame. The primary outcome was pooled sessile-serrated adenoma detection rate odds ratio (OR) with 95% confidence interval (95% CI) between conventional colonoscopy and new technology devices. A sub-analysis between Endocuff technology and conventional colonoscopy was performed. Results: Of 163 citations identified, 15 studies with 14,546 subjects were eligible. Four studies were excluded for overlapping collection site or time frame, and two additional studies were excluded for incomplete data reporting within the abstract. A total of nine studies with 5,667 subjects were included in our analysis (2,658 subjects with NTDs and 3,009 with conventional colonoscopy). Seven studies included Endocuff, one with EndoRing, and one with FUSE technology. Mean age was 61.5 (range 59-65), and 60.5% were males. Calculated SSADR with NTDs was 12.6 as compared to 6.5 with conventional colonoscopy, with an increased OR 2.57 (95% CI: 2.09-3.16, p<0.01; I2: 69%)(Figure 1). On Endocuff sub-analysis, seven studies with 4,655 patients were included (2,153 with Endocuff and 2,502 in conventional colonoscopy). Mean age in the sub-analysis was 62.1 (59.8-65), and 62.8% were males. Endocuff sub-analysis of SSADR was 14.0 as compared with 7.3 in conventional colonoscopy, with an increased OR 2.64 (95% CI: 2.12-3.28, p<0.01; I2: 76%). Conclusion: New technology devices, including Endocuff, are an effective option to increase sessileserrated adenoma detection rate. Further studies are needed to evaluate other new technology devices, as well as the long-term impact of increased sessile-serrated adenoma detection rate in colon malignancy. (Table Presented)

Background and Aim: Colonic mucosal exposure devices such as Endocuff, EndoRings, and Full Spectrum Endoscopy (FUSE) have been investigated in two-arm studies in comparison with standard colonoscopy, but not to each other. We aimed to compare these devices in the hands of colonoscopists with known high adenoma detection rates. Methods: We performed a three center prospective randomized trial. Eligible subjects were 50 years or with indication of screening, surveillance and/or diagnostic and had intact colons. The primary outcome was the rate of conventional adenomas per colonoscopy (APC). Secondary outcomes included the adenoma detection rate (ADR), sessile serrated polyps per colonoscopy (SSPC), the sessile serrated polyp detection rate (SPDR), and colonoscopy insertion times. Results: A total of 1,262 individuals were randomized, of which 1,177 (48.8% female: mean age +/- standard deviation (SD) 62.6 +/- 8.3 years) completed the study. Two hundred and ninety five individuals were randomized to Endocuff; 289 to EndoRings; 298 to FUSE; and 295 to standard HD colonoscopy (control). The overall APC with Endocuff (1.84), EndoRings (1.57), and control (1.53) were all higher than FUSE (1.30) (p=0.001); APC with Endocuff was higher than EndoRings (p=0.048) and control (p=0.004).Right colon APC was higher for Endocuff (p<0.001), EndoRings (p=0.028) and control (p=0.013) compared to FUSE; Endocuff was higher than control (p=0.023). The adenoma detection rate (ADR) was higher with Endocuff, EndoRings and control compared to FUSE; Endocuff was superior to EndoRings (p< 0.001) and control (p<0.004). There was no difference between modalities in detection of conventional adenomas that are 10 mm in size (p=0.537). There were some statistically significant differences between devices in serrated detection but they were small and did not appear clinically significant (Table). The mean cecal insertion times with FUSE (468 sec) and EndoRings (404 sec) were both longer than with Endocuff (354 sec) (p=0.006 and 0.018, respectively). Conclusions: For colonoscopists who are high detectors, forward viewing HD instruments dominate the FUSE system, indicating that for these examiners image resolution trumps angle of view. Further, Endocuff is a dominant strategy over EndoRings and no mucosal exposure device on a forward viewing HD colonoscope

Background/UNASSIGNED:Barrett's esophagus (BE) and esophageal dysplasia (ED) are frequently missed during screening and surveillance esophagoscopy because of sampling error associated with four-quadrant random forceps biopsy (FB). Aim/UNASSIGNED:The aim of this article is to determine if wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS) used adjunctively with FB can increase the detection of BE and ED. Methods/UNASSIGNED:In this multicenter prospective trial, patients screened for suspected BE and those with known BE undergoing surveillance were enrolled. Patients at 25 community-based practices underwent WATS adjunctively to targeted FB and random four-quadrant FB. Results/UNASSIGNED:Of 4203 patients, 594 were diagnosed with BE by FB alone, and 493 additional cases were detected by adding WATS, increasing the overall detection of BE by 83% (493/594, 95% CI 74%-93%). Low-grade dysplasia (LGD) was diagnosed in 26 patients by FB alone, and 23 additional cases were detected by adding WATS, increasing the detection of LGD by 88.5% (23/26, 95% CI 48%-160%). Conclusions/UNASSIGNED:Adjunctive use of WATS to FB significantly improves the detection of both BE and ED. Sampling error, an inherent limitation associated with screening and surveillance, can be improved with WATS allowing better informed decisions to be made about the management and subsequent treatment of these patients.

Barrett esophagus (BE) is the precursor lesion to adenocarcinoma of the esophagus. The current surveillance strategy of 4-quadrant Seattle protocol biopsies has been associated with sampling error and missing higher-risk lesions, and there is often less adherence to endoscopic surveillance with long segments. Advancements in endoscopic imaging and sampling techniques allow for better surveillance of BE, particularly when assessing for dysplasia. This article highlights the key endoscopic imaging and sampling advancements in the evaluation of dysplasia in BE.

BACKGROUND AND AIMS: Adequate bowel preparation is essential for a quality colonoscopy. Poor bowel preparation can result in longer procedural times, missed adenomas, earlier repeat procedures, increase costs, and decreased patient satisfaction [1-5]. Pure-Vu (MOTUS GI, Tirat Carmel, Israel) is a system that facilitates intra-procedural cleaning of a poorly prepared colon during a colonoscopy by irrigating the colon and evacuating the fluid and feces. The study aims were to evaluate Pure-Vu's cleansing capabilities and its usability and safety, in a live animal colon METHODS: The Pure-Vu system was used by four experienced gastroenterologists in 35 Yorkshire cross swine (66% female) that received a reduced bowel preparation to ensure an inadequate bowel preparation at baseline. Before the colonoscopy the Pure-Vu was attached to the colonoscope and the baseline prep was assessed during insertion. The Pure-Vu system was then used to cleanse the colon and the prep was then assessed post-Pure-Vu use. RESULTS: No adverse effects and no failed or prematurely terminated cases were noted. Fourteen percent of the swine colons were adequately prepped at baseline (median BBPS score = 0 [25 percentile=0, 75 percentile =1 ;IQR=1]) and improved to 100% after use of Pure-Vu (Wilcoxon signed rank test p <0.001) (median BBPS score = 3 [25 percentile=3, 75 percentile =3 ;IQR=0]). The physicians found Pure-Vu easy and intuitive to operate. DISCUSSION: The Pure-Vu system effectively cleaned inadequately prepped swine colons and proved to be easy to use. The Pure-Vu device, applied in clinical practice, may result in improved overall prep quality and a reduction in repeat examinations due to inadequately prepped colons.