Faculty Bibliography

PURPOSE OF REVIEW/UNASSIGNED:Dysphagia is a common medical condition among the geriatric population that can significantly impact a patient's quality of life. The manifestations, diagnosis, and treatment of esophageal dysphagia differ greatly based on the underlying etiology, especially in older individuals who may have accompanying complex medical comorbidities. This review explores the intricacies of esophageal dysphagia in the older population and how they are managed. RECENT FINDINGS/UNASSIGNED:Novel modalities, like the functional luminal imaging probe (FLIP) and timed barium esophagram (TBE), are now woven into our diagnostic schemas for esophageal dysphagia. Studies have also looked at the safety profile of available therapeutic interventions for older individuals. There are newer, less invasive treatment options, including radiofrequency application (RFA) and transoral incisionless fundoplication (TIF) for GERD management, that may benefit the geriatric population. SUMMARY/UNASSIGNED:In this review, we discuss the most likely etiologies of esophageal dysphagia in the elderly population. We then explore a diagnostic schema and highlight treatment choices based on diagnosis. Our review specifically explores the risks and benefits of management options in more medically complex geriatric patients.

With nearly 60 million Americans aged 65 and older, gastrointestinal (GI) conditions are a leading cause of healthcare utilization in this population. Despite this, older adults remain underrepresented in GI clinical trials and research, limiting evidence-based care. This review highlights three pivotal studies addressing this gap: (1) proton pump inhibitors, which are commonly used to treat gastroesophageal reflux disease, are not associated with the later development of dementia; (2) undertreatment of chronic inflammation among older adults with inflammatory bowel disease is associated with a higher rate of adverse events compared to treatment with anti-TNF therapy, a biologic agent; (3) the majority (85%) of surveillance colonoscopies among older adults with a life expectancy of ≥ 10 years did not yield colorectal cancer, advanced dysplasia, or ≥ 3 polyps.

Early detection of pancreatic cancer (PC) remains challenging largely due to the low population incidence and few known risk factors. However, screening in at-risk populations and detection of early cancer has the potential to significantly alter survival. In this study, we aim to develop a predictive model to identify patients at risk for developing new-onset PC at two and a half to three year time frame. We used the Electronic Health Records (EHR) of a large medical system from 2000 to 2021 (N = 537,410). The EHR data analyzed in this work consists of patients' demographic information, diagnosis records, and lab values, which are used to identify patients who were diagnosed with pancreatic cancer and the risk factors used in the machine learning algorithm for prediction. We identified 73 risk factors of pancreatic cancer with the Phenome-wide Association Study (PheWAS) on a matched case-control cohort. Based on them, we built a large-scale machine learning algorithm based on EHR. A temporally stratified validation based on patients not included in any stage of the training of the model was performed. This model showed an AUROC at 0.742 [0.727, 0.757] which was similar in both the general population and in a subset of the population who has had prior cross-sectional imaging. The rate of diagnosis of pancreatic cancer in those in the top 1 percentile of the risk score was 6 folds higher than the general population. Our model leverages data extracted from a 6-month window of time in the electronic health record to identify patients at nearly sixfold higher than baseline risk of developing pancreatic cancer 2.5-3 years from evaluation. This approach offers an opportunity to define an enriched population entirely based on static data, where current screening may be recommended.

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

BACKGROUND:Limited literature exists on labor and delivery outcomes after bariatric surgery. This study assesses the impact of prior bariatric surgery on peripartum outcomes. METHODS:We queried the National Inpatient Sample (2016-2020) for labor and delivery admissions, categorizing them into three cohorts: prior bariatric surgery (BaS), obesity without prior bariatric surgery, and controls without obesity. We used a multivariate regression model, adjusting for confounders, to compare peripartum outcomes. RESULTS:We identified 22,685 BaS cases, 2.1 million pregnant controls with obesity, and 16.37 million pregnant controls without obesity. Compared to controls with obesity, the BaS cohort had lower rates of cesarean delivery [43% vs 46.8%, adjusted odds ratio (aOR) 0.72, p < 0.001], fetal distress [aOR 0.79, p < 0.001), post-partum hemorrhage (aOR 0.67, p < 0.001), fetal disproportion (aOR 0.36, p < 0.001), and premature rupture of membranes (aOR 0.88, p = 0.04). Compared to controls without obesity, the BaS group had higher rates of cesarean delivery (43% vs 29.57%, aOR 1.43, p < 0.001), breech presentation (aOR 1.4, p < 0.001), thromboembolic events (aOR 2.47, p = 0.01), and pregnancy termination (aOR 1.59, p = 0.048), but lower rates of assisted delivery (aOR 0.54, p < 0.001), fetal disproportion (aOR 0.56, p = 0.025), PROM (aOR 0.87, p = 0.024), and placenta previa (aOR 0.63, p = 0.019). The BaS group had longer hospitalizations (3.11 vs 2.56 days, p < 0.001) and higher hospitalization charges ($25,941 vs $20,760, p < 0.001) compared to controls without obesity. CONCLUSION/CONCLUSIONS:Pregnancy after bariatric surgery is associated with lower odds of cesarean delivery and postpartum complications, relative to the general population with obesity. This underscores the positive impact of bariatric surgery on peripartum outcomes.

BACKGROUND AND AIMS/OBJECTIVE:The COVID-19 pandemic significantly decreased procedural volume in 2020, thus limiting training opportunities. First-year fellows (1YF) are particularly susceptible to reduction in endoscopic volume as they build foundational endoscopic skills. We used an objective validated tool, the Assessment of Competency in Endoscopy (ACE), to determine the effect of the pandemic on endoscopy competency in gastroenterology fellows. METHODS:This was a prospective cohort study conducted across two fellowship programs in New York City. Our primary outcome was the comparison of ACE scores of fellows starting gastroenterology fellowships in 2020 to the scores of those starting in 2016-2018. Our secondary outcome was to compare colonoscopy quality metrics and endoscopy volume between these cohorts. RESULTS:ACE scores were available from 11 pandemic and 10 pre-pandemic 1YFs, and five pandemic and 19 pre-pandemic second (2YF) and third-year fellows (3YF). ACE scores for 1YFs showed significantly higher rating in the pre-pandemic cohort for 4 domains including knowledge of indications and medical issues (p = 0.03), effective and efficient use of air, water, and suction (p = 0.04), pathology identification (p = 0.001), and overall hands-on skills (p = 0.004). 2YFs showed no significant differences. 3YFs showed significantly lower scores in the pandemic cohort in the effective and efficient use of air, water, and suction (p = 0.03), fellows' knowledge of therapeutic tools (p = 0.05), and fellows overall cognitive skills (p = 0.05). There were no significant differences in quality metrics between the cohorts, except longer procedure time for the pandemic cohort (p < 0.01). CONCLUSION/CONCLUSIONS:Following the COVID-19 pandemic, there was a decline in multiple aspects of endoscopic competency both at the beginning and the end of fellowship training. These trends are likely the result of a decrease in overall procedure volume early in training and highlight the need for supplementing trainee education with other modalities.

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

BACKGROUND & AIMS/OBJECTIVE:This American Gastroenterological Association (AGA) guideline is intended to provide an overview of the evidence and support endoscopists and patients on the use of computer-aided detection (CADe) systems for the detection of colorectal polyps during colonoscopy. METHODS:A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework and relied on the following sources of evidence: (1) a systematic review examining the desirable and undesirable effects (ie, benefits and harms) of CADe-assisted colonoscopy, (2) a microsimulation study estimating the effects of CADe on longer-term patient-important outcomes, (3) a systematic search of evidence evaluating the values and preferences of patients undergoing colonoscopy, and (4) a systematic review of studies evaluating health care providers' trust in artificial intelligence technology in gastroenterology. RESULTS:The panel reached the conclusion that no recommendation could be made for or against the use of CADe-assisted colonoscopy in light of very low certainty of evidence for the critical outcomes, desirable and undesirable (11 fewer colorectal cancers per 10,000 individuals and 2 fewer colorectal cancer deaths per 10,000 individuals), increased burden of more intensive surveillance colonoscopies (635 more per 10,000 individuals), and cost and resource implications. The panel acknowledged the 8% (95% CI, 6%-10%) increase in adenoma detection rate and 2% (95% CI, 0%-4%) increase in advanced adenoma and/or sessile serrated lesion detection rate. CONCLUSIONS:This guideline highlights the close tradeoff between desirable and undesirable effects and the limitations in the current evidence to support a recommendation. The panel acknowledged the potential for CADe to continually improve as an iterative artificial intelligence application. Ongoing publications providing evidence for critical outcomes will help inform a future recommendation.

BACKGROUND AND AIMS/OBJECTIVE:In patients with inflammatory bowel disease (IBD) and a history of cancer, retrospective studies suggest that exposure to immunosuppressive agents does not increase the risk of incident (recurrent or new) cancer compared to unexposed patients. SAPPHIRE is a prospective registry aimed at addressing this issue. METHODS:Since 2016, patients with IBD and confirmed index cancer prior to enrollment were followed annually. Patients receiving chemotherapy or radiation at enrollment, or recurrent cancer within five years were excluded. Primary outcome was development of incident cancer related to exposure to immunosuppressive medications. RESULTS:Among 305 patients (47% male, 88% white), median age at IBD diagnosis and cancer were 32 and 52 years, respectively. Index cancers were solid organ (46%), dermatologic (32%), gastrointestinal (13%), and hematologic (9%). During median follow-up of 4.8 years, 210 (69%) were exposed to immunosuppressive therapy and 46 (15%) developed incident cancers (25 new, 21 recurrent). In unadjusted analysis, the crude rate of incident cancer in unexposed patients was 2.58/100 person-years versus 4.78/100 PY (relative risk 1.85, 95% CI 0.92-3.73) for immunosuppression exposed patients. In a proportional hazards model adjusting for sex, smoking history, age and stage at index malignancy, and non-melanoma skin cancer, no significant association was found between receipt of immunosuppression and incident cancer (adjusted hazard ratio, aHR, 1.41, 95% CI: 0.69-2.90), or with any major drug class. CONCLUSION/CONCLUSIONS:In this interim analysis of patients with IBD and a history of cancer, despite numerically elevated aHRs, we did not find a statistically significant association between subsequent exposure to immunosuppressive therapies and development of incident cancers.