Faculty Bibliography

The 4-quadrant forceps biopsy (FB) protocol for identifying Barrett's esophagus (BE) and esophageal dysplasia (ED) suffers from poor sensitivity due to significant sampling error. We investigated the benefit of wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS) used adjunctively to the combination of random and targeted FB in the detection of ED, and as a secondary outcome, BE. In this multicenter prospective trial, community endoscopists at 21 sites utilized WATS as an adjunct to both targeted and random FB in patients undergoing BE screening and surveillance. Investigators alternated taking FB and WATS samples first. WATS specimens were analyzed at CDx Diagnostics (Suffern, NY) while FB samples were analyzed by each site's regular pathologists. Data were de-identified and then aggregated for analysis. Of 12,899 patients enrolled, FB identified 88 cases of ED, and WATS detected an additional 213 cases missed by FB. These 213 cases represented an absolute increase of 1.65%, raising the yield from 0.68% to 2.33%. Adding WATS to FB increased the overall detection of ED by 242% (95% CI: 191%-315%). Fewer than 61 patients needed to be tested with WATS to identify an additional case of ED. The combination of random and targeted FB identified 1,684 cases of BE, and WATS detected an additional 2,570 BE cases. The absolute incremental yield of adding WATS to FB is 19.9%, increasing the rate of detection from 13.1% to 33%. Adding WATS to FB increased the overall detection of BE by 153% (95% CI: 144-162%). The number needed to test with WATS in order to detect an additional case of BE was 5. Whether FB or WATS was done first did not impact the results. In this study, comprised of the largest series of patients evaluated with WATS, adjunctive use of the technique with targeted and random FB markedly improved the detection of both ED and BE. These results underscore the shortcomings of FB in detecting BE-associated neoplasia, which can potentially impact the management and clinical outcomes of these patients.

BACKGROUND:Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy (SC) still occur. Increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device comprises a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing ADR. METHODS:In this randomized, controlled, international, multicenter study (11 centers), subjects (age ≥50) referred to colonoscopy for screening, surveillance, or due to changes in bowel habits, were randomized to undergo either balloon-assisted colonoscopy using an insufflated balloon during withdrawal or standard high-definition colonoscopy. Primary endpoint was ADR. RESULTS:One thousand subjects were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (SC: n=396; balloon-assisted colonoscopy: n=407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the SC group (28% increase, p=0.0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (p=0.0033), flat adenomas (p<0.0001), and sessile serrated adenoma/polyp (SSA/Ps) (p=0.0026). CONCLUSIONS:Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat and SSA/Ps when compared with SC. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates, and consequently reducing of interval cancers incidence; clinicaltrials.gov (NCT01917513).

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.

Esophageal adenocarcinoma is increasing in frequency in the United States. Barrett's esophagus is the strongest risk factor for esophageal adenocarcinoma making evaluation for Barrett's esophagus of utmost importance. Currently screening and surveillance are accomplished with regular white light endoscopy; however, new advances in both population screening and surveillance are being developed. This review will cover selecting the appropriate patient population for Barrett's esophagus screening, available and upcoming technologies for screening and surveillance, and lastly treatment of Barrett's esophagus.

Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma, one of the few cancers with increasing incidence in developed countries. The pathogenesis of BE is unclear with regard to either the cellular origin of this metaplastic epithelium or the manner in which malignant transformation occurs, although recent data indicate a possible junctional origin of stem cells for BE. Treatment of BE may be achieved using endoscopic eradication therapy; however, there is a lack of discriminatory tools to identify individuals at sufficient risk for cancer development in whom intervention is warranted. Reduction in gastroesophageal reflux of gastric contents including acid is mandatory to achieve remission from BE after endoscopic ablation, and can be achieved using medical or nonmedical interventions. Research topics of greatest interest include the mechanism of BE development and transformation to cancer, risk stratification methods to identify individuals who may benefit from ablation of BE, optimization of eradication therapy, and surveillance methods to ensure that remission is maintained after eradication is achieved.

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 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.

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.