Faculty Bibliography

Background and study aim Cold snare endoscopic mucosal resection (CS-EMR) can reduce some of the risks associated with electrocautery use during colon polyp resection. Data regarding efficacy have yielded variable results. We conducted a systematic review and meta-analysis to estimate the pooled efficacy and safety rates of CS-EMR. Patients and methods We conducted a literature search of multiple databases for studies addressing outcomes of CS-EMR for colon polyps from inception through March 2023. The weighted pooled estimates with the 95% confidence interval (95% CI) were calculated using the random effects model. I2 statistics was used to evaluate heterogeneity. Results 4137 articles were reviewed, and 16 studies met the inclusion criteria. 2584 polyps were removed from 1930 patients and48.9% were females. 54.4% were adenomas, 45% were sessile serrated lesions (SSLs), and 0.6% were invasive carcinoma. Polyp recurrence after CS-EMR was 6.7% (95% CI: [2.4-17.4%], I2=94%). The recurrence rate for polyps ≥ 20 mm was 12.3% (95% CI: [3.4-35.7%], I2= 94.%), 17.1% (95% CI: [4.6-46.7%], I2= 93%) for adenomas, and 5.7% (95% CI: [3.2-9.9%], I2= 50%) for SSLs. The pooled intraprocedural bleeding rate was 2.6% (95% CI: [1.5-4.4%], I2=51%), the delayed bleeding rate was 1.5% (95% CI: [0.9-2.8%], I2=20%) and no perforations or post-polypectomy syndromes were reported with estimated rates of 0.6% (95% CI: [0.3-1.2%], I2=0%) and 0.6% (95% CI: [0.2-1.3%], I2=0%), respectively. Conclusion CS-EMR demonstrated an excellent safety profile for colon polyps with variable recurrence rates based on polyp size and histology. Large prospective studies are needed to validate these findings.

BACKGROUND:Colorectal cancer among adults aged <50 years [early-onset colorectal cancer (EOCRC)] is projected to be the leading cause of cancer-related death by 2030. Although evidence-based guidelines for colorectal cancer screening now recommend beginning screening at age 45, the needs of many at-risk young adults are potentially being overlooked. Unanswered questions also remain regarding the effects of EOCRC on quality-of-life and psychosocial outcomes. This qualitative study explored the lived experiences and perceptions of a sample of adult EOCRC survivors in the United States through one-on-one interviews. METHODS:An EOCRC advocate survivor team member led 27 structured virtual interviews using a 10-question interview guide. Data were analyzed using a 9-step inductive approach. RESULTS:Participants were geographically diverse. Most were women (66.6%) who self-identified as non-Hispanic White (85.2%). The mean age at interview was 40.19 ± 5.99; at diagnosis, 33.93 ± 5.90. Six overarching themes emerged: signs and symptoms, risk factors, system-level factors, quality of life, social support, and reflection. CONCLUSIONS:The specific needs of individuals in this younger population of patients with colorectal cancer should be considered during treatment and future interventions and throughout survivorship. IMPACT:While the reasons for the increasing incidence of EOCRC are currently unknown, the lived experiences and perceptions of EOCRC survivors noted in this study highlight specific needs of this population that can inform educational materials, comprehensive care, future research, and policy change.

INTRODUCTION/BACKGROUND:Adenoma detection rate (ADR) is a quality metric that has been emphasized by multiple societies as improved ADR leads to reduced interval colorectal cancer (CRC). It is postulated that increased withdrawal time (WT) can lead to higher ADR. Multiple randomized controlled trials (RCTs) were undertaken to evaluate this. We performed a systematic review and meta-analysis of RCTs to analyze the impact of higher WT on ADR during colonoscopy. METHODS:The following databases were comprehensively searched through November 8, 2022: Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar. Only RCTs were eligible for inclusion. We applied the random effects model using the DerSimonian Laird approach and calculated risk ratio (RR) for binary outcomes and mean difference (MD) for continuous outcomes. 95% CI and P values were generated. RESULTS:A total of 3 RCTs with 2159 patients were included of which 1136 patients were included in the 9-minute withdrawal group (9WT) and 1023 patients in the 6-minute withdrawal group (6WT). The mean age range was 53.6 to 56.8 years and the male gender was 50.7%. The overall ADR was significantly higher for 9WT (RR=1.23; 95% CI, 1.09-1.40; P<0.001). The overall adenoma per colonoscopy (APC) was also higher for the 9WT group (MD: 0.14; 95% CI, 0.04-0.25; P=0.008). CONCLUSION/CONCLUSIONS:The 9-minute withdrawal time improved ADR and APC compared with the 6-minute withdrawal. Given the high-quality evidence, we recommend that clinicians at least perform a 9-minute withdrawal to achieve higher quality metrics including ADR to reduce interval CRC.

INTRODUCTION:To investigate the impact of procedure-related and endoscopist-related factors on the effectiveness of a computer-aided detection (CADe) device in adenomas per colonoscopy (APC) detection. METHODS:The SKOUT clinical trial was conducted at 5 US sites. We present prespecified analyses of procedure-related and endoscopist-related factors, and association with APC across treatment and control cohorts. RESULTS:There were numeric increases in APC between SKOUT vs standard colonoscopy in community-based endoscopists, withdrawal time of ≥8 minutes, for endoscopists with >20 years of experience, and endoscopists with baseline adenoma detection rate <45%. DISCUSSION:The application of CADe devices in clinical practice should be carefully evaluated. Larger studies should explore differences in endoscopist-related factors for CADe.

DESCRIPTION/METHODS:Belching, bloating, and abdominal distention are all highly prevalent gastrointestinal symptoms and account for some of the most common reasons for patient visits to outpatient gastroenterology practices. These symptoms are often debilitating, affecting patients' quality of life, and contributing to work absenteeism. Belching and bloating differ in their pathophysiology, diagnosis, and management, and there is limited evidence available for their various treatments. Therefore, the purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to provide best practice advice based on both controlled trials and observational data for clinicians covering clinical features, diagnostics, and management considerations that include dietary, gut-directed behavioral, and drug therapies. METHODS:This Expert Review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature based on clinical trials, the more robust observational studies, and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Clinical history and physical examination findings and impedance pH monitoring can help to differentiate between gastric and supragastric belching. BEST PRACTICE ADVICE 2: Treatment options for supragastric belching may include brain-gut behavioral therapies, either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators. BEST PRACTICE ADVICE 3: Rome IV criteria should be used to diagnose primary abdominal bloating and distention. BEST PRACTICE ADVICE 4: Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing. In a small subset of at-risk patients, small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth. BEST PRACTICE ADVICE 5: Serologic testing may rule out celiac disease in patients with bloating and, if serologies are positive, a small bowel biopsy should be done to confirm the diagnosis. A gastroenterology dietitian should be part of the multidisciplinary approach to care for patients with celiac disease and nonceliac gluten sensitivity. BEST PRACTICE ADVICE 6: Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only. BEST PRACTICE ADVICE 7: Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders. BEST PRACTICE ADVICE 8: In patients with abdominal bloating and distention thought to be related to constipation or difficult evacuation, anorectal physiology testing is suggested to rule out a pelvic floor disorder. BEST PRACTICE ADVICE 9: When dietary modifications are needed (eg, low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet), a gastroenterology dietitian should preferably monitor treatment. BEST PRACTICE ADVICE 10: Probiotics should not be used to treat abdominal bloating and distention. BEST PRACTICE ADVICE 11: Biofeedback therapy may be effective for bloating and distention when a pelvic floor disorder is identified. BEST PRACTICE ADVICE 12: Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities. BEST PRACTICE ADVICE 13: Medications used to treat constipation should be considered for treating bloating if constipation symptoms are present. BEST PRACTICE ADVICE 14: Psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain-gut behavior therapies may be used to treat patients with bloating and distention. BEST PRACTICE 15: Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia.

IMPORTANCE:The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy. OBJECTIVE:To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors. DESIGN, SETTING, AND PARTICIPANTS:This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022. EXPOSURE:Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals. MAIN OUTCOMES AND MEASURES:Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year. RESULTS:A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25). CONCLUSIONS AND RELEVANCE:In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

BACKGROUND & AIMS/OBJECTIVE:Colorectal cancer (CRC) screening guidelines include screening colonoscopy and sequential high-sensitivity fecal occult blood testing (HSgFOBT), with expectation of similar effectiveness based on the assumption of similar high adherence. However, adherence to screening colonoscopy compared with sequential HSgFOBT has not been reported. In this randomized clinical trial, we assessed adherence and pathology findings for a single screening colonoscopy vs sequential and nonsequential HSgFOBTs. METHODS:Participants aged 40-69 years were enrolled at 3 centers representing different clinical settings. Participants were randomized into a single screening colonoscopy arm vs sequential HSgFOBT arm composed of 4-7 rounds. Initial adherence to screening colonoscopy and sequential adherence to HSgFOBT, follow-up colonoscopy for positive HSgFOBT tests, crossover to colonoscopy, and detection of advanced neoplasia or large serrated lesions (ADN-SERs) were measured. RESULTS:There were 3523 participants included in the trial; 1761 and 1762 participants were randomized to the screening colonoscopy and HSgFOBT arms, respectively. Adherence was 1473 (83.6%) for the screening colonoscopy arm vs 1288 (73.1%) for the HSgFOBT arm after 1 round (relative risk [RR], 1.14; 95% CI, 1.10-1.19; P ≤ .001), but only 674 (38.3%) over 4 sequential HSgFOBT rounds (RR, 2.19; 95% CI, 2.05-2.33). Overall adherence to any screening increased to 1558 (88.5%) in the screening colonoscopy arm during the entire study period and 1493 (84.7%) in the HSgFOBT arm (RR, 1.04; 95% CI, 1.02-1.07). Four hundred thirty-six participants (24.7%) crossed over to screening colonoscopy during the first 4 rounds. ADN-SERs were detected in 121 of the 1473 participants (8.2%) in the colonoscopy arm who were adherent to protocol in the first 12 months of the study, whereas detection of ADN-SERs among those who were not sequentially adherent (n = 709) to HSgFOBT was subpar (0.6%) (RR, 14.72; 95% CI, 5.46-39.67) compared with those who were sequentially adherent (3.3%) (n = 647) (RR, 2.52; 95% CI, 1.61-3.98) to HSgFOBT in the first 4 rounds. When including colonoscopies from HSgFOBT patients who were never positive yet crossed over (n = 1483), 5.5% of ADN-SERs were detected (RR, 1.50; 95% CI, 1.15-1.96) in the first 4 rounds. CONCLUSIONS:Observed adherence to sequential rounds of HSgFOBT was suboptimal compared with a single screening colonoscopy. Detection of ADN-SERs was inferior when nonsequential HSgFOBT adherence was compared with sequential adherence. However, the greatest number of ADN-SERs was detected among those who crossed over to colonoscopy and opted to receive a colonoscopy. The effectiveness of an HSgFOBT screening program may be enhanced if crossover to screening colonoscopy is permitted. CLINICALTRIALS/RESULTS:gov, Number: NCT00102011.