Top Tips: Using image-enhanced endoscopy for colonoscopy (with videos)
Gastrointestinal endoscopy during the coronavirus pandemic in the New York area: results from a multi-institutional survey
Mahadev, Srihari; Aroniadis, Olga C; Barraza, Luis H; Agarunov, Emil; Smith, Michael S; Goodman, Adam J; Benias, Petros C; Buscaglia, Jonathan M; Gross, Seth A; Kasmin, Franklin; Cohen, Jonathan; Carr-Locke, David L; Greenwald, David; Mendelsohn, Robin; Sethi, Amrita; Gonda, Tamas A
Background and study aims â€‚The coronavirus disease 2019 (COVID-19), and measures taken to mitigate its impact, have profoundly affected the clinical care of gastroenterology patients and the work of endoscopy units. We aimed to describe the clinical care delivered by gastroenterologists and the type of procedures performed during the early to peak period of the pandemic. Methods â€‚Endoscopy leaders in the New York region were invited to participate in an electronic survey describing operations and clinical service. Surveys were distributed on April 7, 2020 and responses were collected over the following week. A follow-up survey was distributed on April 20, 2020.â€ŠParticipants were asked to report procedure volumes and patient characteristics, as well protocols for staffing and testing for COVID-19. Resultsâ€‚ Eleven large academic endoscopy units in the New York City region responded to the survey, representing every major hospital system. COVID patients occupied an average of 54.5â€Š% (18â€Š-â€Š84â€Š%) of hospital beds at the time of survey completion, with 14.5â€Š% (2â€Š%-23â€Š%) of COVID patients requiring intensive care. Endoscopy procedure volume and the number of physicians performing procedures declined by 90â€Š% (66â€Š%-98â€Š%) and 84.5â€Š% (50â€Š%-97â€Š%) respectively following introduction of restricted practice. During this period the most common procedures were EGDs (7.9/unit/week; 88â€Š% for bleeding; the remainder for foreign body and feeding tube placement); ERCPs (5/unit/week; for cholangitis in 67â€Š% and obstructive jaundice in 20â€Š%); Colonoscopies (4/unit/week for bleeding in 77â€Š% or colitis in 23â€Š%) and least common were EUS (3/unit/week for tumor biopsies). Of the sites, 44â€Š% performed pre-procedure COVID testing and the proportion of COVID-positive patients undergoing procedures was 4.6â€Š% in the first 2 weeks and up to 19.6â€Š% in the subsequent 2 weeks. The majority of COVID-positive patients undergoing procedures underwent EGD (30.6â€Š% COVIDâ€Š+) and ERCP (10.2â€Š% COVIDâ€Š+). Conclusionsâ€‚ COVID-19 has profoundly impacted the operation of endoscopy units in the New York region. Our data show the impact of a restricted emergency practice on endoscopy volumes and the proportion of expected COVID positive cases during the peak time of the pandemic.
Advances in training for advances in endoscopic therapy [Editorial]
Obesity: Core Curriculum
Pannala, Rahul; Sharaiha, Reem Z; Sullivan, Shelby A; Wagh, Mihir S; Cohen, Jonathan; Thompson, Christopher C
This is a document prepared by the Association for Bariatric Endoscopy (ABE), a division of the American Society for Gastrointestinal Endoscopy (ASGE) and the ASGE Training Committee. This curriculum document contains recommendations for training and is intended for use by gastroenterology program directors and faculty, including those involved in teaching endoscopy, and trainees in gastroenterology. Although only a small proportion of gastroenterologists currently treat obesity, given the burden of disease, an urgent need exists for greater involvement of physicians from multiple specialties, including gastroenterology, to be actively involved in the care of patients with obesity. This curriculum was developed to provide an overview of the cognitive and technical content areas that gastroenterology (GI) fellows should learn pertaining to the evaluation and management of patients with obesity and to serve as a guide to published references, videos, and other available resources. Specifically, this document addresses the core concepts that all general gastroenterology fellows should acquire about lifestyle intervention; pharmacologic, endoscopic, and surgical treatments for obesity; evaluation and management of gastrointestinal comorbidities in patients with obesity; challenges associated with sedation in patients with obesity; endoscopic evaluation of postbariatric surgical anatomy; and the management of selected adverse events in patients who have had bariatric surgery. The document also suggests recommendations for those fellows who are interested in acquiring further skills in the treatment of obesity such as incorporating medical treatment of obesity in their practice or those interested in offering endoscopic bariatric therapies (EBTs), treatment of more complex bariatric surgical adverse events, or endoscopic treatment of weight regain after Roux-en-Y gastric bypass (RYGB). By providing this framework to trainers and trainees, the ASGE hopes to facilitate the incorporation of this important material into training programs to ensure that trainees are adequately prepared for future professional responsibilities in this area.
ASGE principles of endoscopic training
Waschke, Kevin A; Anderson, John; Valori, Roland M; MacIntosh, Donald G; Kolars, Joseph C; DiSario, James A; Faigel, Douglas O; Petersen, Bret T; Cohen, Jonathan
This White Paper shares guidance on the important principles of training endoscopy teachers, the focus of an American Society for Gastrointestinal Endoscopy (ASGE)/World Endoscopy Organization Program for Endoscopic Teachers and Leaders of Endoscopic Training held at the ASGE Institute for Training and Technology. Key topics included the need for institutional support and continuous skills development, the importance of consensus and consistency in content and approach to teaching, the role of conscious competence and content breakdown into discreet steps in effective teaching, defining roles of supervisors versus instructors to ensure teaching consistency across instructors, identification of learning environment factors and barriers impacting effective teaching, and individualized training that incorporates effective feedback and adapts with learner proficiency. Incorporating simulators into endoscopy teaching, applying good endoscopy teaching principles outside the endoscopy room, key principles of hands-on training, and effective use of simulators and models in achieving specific learning objectives were demonstrated with rotations through hands-on simulator stations as part of the program. A discussion of competency-based assessment was followed by live sessions in which attendees applied endoscopy teaching principles covered in the program. Conclusions highlighted the need for the following: formal training of endoscopy teachers to a level of conscious competence, incorporation of formal training structures into existing training curricula, intentional teaching preparation, feedback to trainees and instructors alike aimed at improving performance, and competency-based trainee assessment. The article is intended to help motivate individuals who play a role in training other endoscopists to develop their teaching abilities, promote discussions about endoscopy training, and engage both endoscopy trainers and trainees in a highly rewarding learning process that is in the best interest of patients.
ASGE EndoVators Summit: simulators and the future of endoscopic training
Walsh, Catharine M; Cohen, Jonathan; Woods, Karen L; Wang, Kenneth K; Andersen, Dana K; Anderson, Michelle A; Dunkin, Brian J; Edmundowicz, Steven A; Faigel, Douglas O; Law, Joanna K; Marks, Jeffrey M; Sedlack, Robert E; Thompson, Christopher C; Vargo, John J
Interest in the use of simulation for acquiring, maintaining, and assessing skills in GI endoscopy has grown over the past decade, as evidenced by recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines encouraging the use of endoscopy simulation training and its incorporation into training standards by a key accreditation organization. An EndoVators Summit, partially supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, (NIH) was held at the ASGE Institute for Training and Technology from November 19 to 20, 2017. The summit brought together over 70 thought leaders in simulation research and simulator development and key decision makers from industry. Proceedings opened with a historical review of the role of simulation in medicine and an outline of priority areas related to the emerging role of simulation training within medicine broadly. Subsequent sessions addressed the summit's purposes: to review the current state of endoscopy simulation and the role it could play in endoscopic training, to define the role and value of simulators in the future of endoscopic training and to reach consensus regarding priority areas for simulation-related education and research and simulator development. This white paper provides an overview of the central points raised by presenters, synthesizes the discussions on the key issues under consideration, and outlines actionable items and/or areas of consensus reached by summit participants and society leadership pertinent to each session. The goal was to provide a working roadmap for the developers of simulators, the investigators who strive to define the optimal use of endoscopy-related simulation and assess its impact on educational outcomes and health care quality, and the educators who seek to enhance integration of simulation into training and practice.
The path to quality colonoscopy continues after graduation [Editorial]
Poppers, David M; Cohen, Jonathan
The clinical significance of persistent trigeminal nerve contrast enhancement in patients who undergo repeat radiosurgery
Mousavi, Seyed H; Akpinar, Berkcan; Niranjan, Ajay; Agarwal, Vikas; Cohen, Jonathan; Flickinger, John C; Kondziolka, Douglas; Lunsford, L Dade
OBJECTIVE Contrast enhancement of the retrogasserian trigeminal nerve on MRI scans frequently develops after radiosurgical ablation for the management of medically refractory trigeminal neuralgia (TN). The authors sought to evaluate the clinical significance of this imaging finding in patients who underwent a second radiosurgical procedure for recurrent TN. METHODS During a 22-year period, 360 patients underwent Gamma Knife stereotactic radiosurgery (SRS) as their first surgical procedure for TN at the authors' center. The authors retrospectively analyzed the data from 59 patients (mean age 72 years, range 33-89 years) who underwent repeat SRS for recurrent pain at a median of 30 months (range 6-146 months) after the first SRS. The isocenter was 4 mm, and the median maximum doses for the first and second procedures were 80 Gy and 70 Gy, respectively. A neuroradiologist and a neurosurgeon blinded to the treated side evaluated the presence of nerve contrast enhancement on MRI series at the time of the repeat procedure. The authors correlated the presence of this imaging change with clinical outcomes. Pain outcomes and development of trigeminal sensory dysfunction were evaluated with the Barrow Neurological Institute (BNI) Pain Scale and BNI Numbness Scale, respectively. The mean length of follow-up after the second SRS was 58 months (95% CI 49-68 months). RESULTS At the time of the repeat SRS, contrast enhancement of the trigeminal nerve on MRI scans was observed in 31 patients (53%). Five years after the SRS, patients with this enhancement had lower actuarial rates of complete pain relief after the repeat SRS (27% [95% CI 7%-47%]) than patients without the enhancement (76% [95% CI 58%-94%]) (p < 0.001). At the 5-year follow-up, patients with the contrast enhancement also had a higher risk for trigeminal sensory loss after repeat SRS (75% [95% CI 59%-91%]) than patients without contrast enhancement (26% [95% CI 10%-42%]) (p = 0.001). Dysesthetic pain after repeat SRS was observed for 8 patients with and for 2 patients without contrast enhancement. CONCLUSIONS Trigeminal nerve contrast enhancement on MRI scans observed at the time of a repeat SRS for TN was associated with less satisfactory pain control and more frequently detected facial sensory loss. Residual contrast enhancement at the time of a repeat SRS may warrant consideration of dose reduction or further separation of the radiosurgical targets.
The benefit of narrow-band imaging after EMR of laterally spreading lesions [Editorial]
Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity
Trifiletti, Daniel M; Lee, Cheng-Chia; Kano, Hideyuki; Cohen, Jonathan; Janopaul-Naylor, James; Alonso-Basanta, Michelle; Lee, John Y K; Simonova, Gabriela; Liscak, Roman; Wolf, Amparo; Kvint, Svetlana; Grills, Inga S; Johnson, Matthew; Liu, Kang-Du; Lin, Chung-Jung; Mathieu, David; Heroux, France; Silva, Danilo; Sharma, Mayur; Cifarelli, Christopher P; Watson, Christopher N; Hack, Joshua D; Golfinos, John G; Kondziolka, Douglas; Barnett, Gene; Lunsford, L Dade; Sheehan, Jason P
PURPOSE: To pool data across multiple institutions internationally and report on the cumulative experience of brainstem stereotactic radiosurgery (SRS). METHODS AND MATERIALS: Data on patients with brainstem metastases treated with SRS were collected through the International Gamma Knife Research Foundation. Clinical, radiographic, and dosimetric characteristics were compared for factors prognostic for local control (LC) and overall survival (OS) using univariate and multivariate analyses. RESULTS: Of 547 patients with 596 brainstem metastases treated with SRS, treatment of 7.4% of tumors resulted in severe SRS-induced toxicity (grade >/=3, increased odds with increasing tumor volume, margin dose, and whole-brain irradiation). Local control at 12 months after SRS was 81.8% and was improved with increasing margin dose and maximum dose. Overall survival at 12 months after SRS was 32.7% and impacted by age, gender, number of metastases, tumor histology, and performance score. CONCLUSIONS: Our study provides additional evidence that SRS has become an option for patients with brainstem metastases, with an excellent benefit-to-risk ratio in the hands of experienced clinicians. Prior whole-brain irradiation increases the risk of severe toxicity in brainstem metastasis patients undergoing SRS.