Representation by Gender of Recognition Award Recipients from Gastroenterology and Hepatology Professional Societies.

Background: Recognition awards from professional medical societies play an important role in physicians' career advancement. Our aim was to evaluate the gender representation of award recipients from gastroenterology and hepatology societies. Methods: We analyzed the lists of award recipients from the American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy and determined the gender of these award recipients. The primary outcome was the overall representation of women physician award recipients as compared with the representation of women in the specialty. Results: Between 1941 and 2019, there were 921 awards, of which 77 (8.4%) were given to women and 844 (91.6%) to men. There was a significant increase in the proportion of women recipients over time, from 0% in 1970-1984 to 22.0% in 2015-2019 (p for trend <0.0001). Compared with the concurrent representation of women in the specialty, women physician recipients were underrepresented from 1970 to 1981 and 1984 to 2015, equitably represented from 1981 to 1984, and overrepresented from 2015 to 2019. Of the total number of awards in each category, women received 13.8% of teaching/mentorship awards and 3.8% of the highest achievement awards (p = 0.002). The proportion of women recipients varied among the societies, from 6.8% to 14.5%. Conclusions: The representation of women physician recipients of gastroenterology and hepatology society recognition awards has generally been low until most recently, when it has surpassed the proportion of women in the specialty. Because award recognition is important to career development, professional societies should have transparent processes that aim to identify and reduce various forms of bias, including gender-related bias, in all phases of award recognition.

Endoscopic or Conservative Management of Iatrogenic Duodenal Perforations Caused by Long Plastic Biliary Stent Distal Migration.

Plastic biliary stents are associated with rare but potentially life-threatening distal stent migration. We present 4 patient cases with distal migration, whereas the proximal aspect remained in the bile duct. Time to stent migration ranged from 1 week to 2 months. Stent migration caused contralateral duodenal wall perforation; 2 underwent endoscopic over-the-scope clip placement for defect closure. All required previous stent removal and stent exchange. This case series highlights that proximal stricture and longer stents have higher migration risk, also shown in the literature. We also show that duodenal perforation can successfully be managed endoscopically with an over-the-scope clip.

A gender comparison of motivations for seeking leadership positions among gastroenterologists.

BACKGROUND AND AIMS: A gender gap exists in leadership positions in gastroenterology. However, individual motivations for seeking leadership positions within the gastroenterology community among men and women have not been explored. The primary aim of this study was to determine whether motivations for pursuing and attaining leadership positions in gastroenterology differ by gender. METHODS: A 20-question survey was created by the authors and shared with gastroenterologists electronically via a social media group (Facebook) and emails gathered through publicly available society websites and professional and social contacts. Data gathered from the survey included demographics, practice characteristics, presence of spouse or domestic partner, past and present leadership positions, motivations for pursuit of leadership positions, and reasons for lack of desire for a leadership position. RESULTS: The survey was sent to 981 gastroenterologists (679 women, 302 men). The overall response rate was 21.4% (n = 210) (20.9% for women, 22.5% for men). Overall, 41% of respondents (84 of 206) currently hold a leadership position, including more males than females (52% vs 36%, respectively; P = .03). However, among those who completed their training in the past 5 years, more women than men hold a current leadership role (25% vs 6%; P = .11). Other factors associated with currently holding a leadership position included age and years since completion of training, practice type, full-time status, and having a spouse who is not a physician. The positive factors of leadership cited most frequently were (1) ability to effect change, (2) furthering the goals of the organization, and (3) opportunity for career advancement. The negative factors cited most frequently were increased workload and decreased time for personal life. These reported positive and negative factors were similar for male and female respondents. Forty-nine respondents did not desire a leadership position now or in the future. The most common reason cited was lack of interest in the responsibilities, long hours, or stress that accompanies a leadership position (22 of 42, 52%). The second most common reason was that respondents were too busy at home or work to take on the extra responsibilities. CONCLUSIONS: A gender gap in gastroenterology leadership exists but is closing. There is fairly equal representation of men and women in leadership positions among those who completed training in the last 5 years. Many gastroenterologists are motivated for a leadership position and at the same time, many qualified individuals do not desire a leadership position because of factors that affect work-life balance. Ongoing efforts to engage motivated individuals into leadership positions and to revise the nature of leadership positions may allow for a larger talent pool from which to recruit.

Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know.

Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patient's clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ©RSNA, 2018.

ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts.

Pancreatic cysts are very common with the majority incidentally identified. There are several types of pancreatic cysts; some types can contain cancer or have malignant potential, whereas others are benign. However, even the types of cysts with malignant potential rarely progress to cancer. At the present time, the only viable treatment for pancreatic cysts is surgical excision, which is associated with a high morbidity and occasional mortality. The small risk of malignant transformation, the high risks of surgical treatment, and the lack of high-quality prospective studies have led to contradictory recommendations for their immediate management and for their surveillance. This guideline will provide a practical approach to pancreatic cyst management and recommendations for cyst surveillance for the general gastroenterologist.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass.

BACKGROUND AND AIMS: The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS: This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS: A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS: Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Increase in female faculty in American Society for Gastrointestinal Endoscopy-sponsored programming over time.

BACKGROUND AND AIMS: Female representation in medicine is increasing across all levels of medical training, yet women hold fewer senior leadership positions than men. National recognition, including participation as faculty in society-sponsored programs, is one component of academic advancement. The aim of this study was to characterize female representation among faculty in courses sponsored by the American Society for Gastrointestinal Endoscopy (ASGE). METHODS: We performed a retrospective review of demographic data, including faculty gender and role, year, and program type, from the ASGE database of its sponsored programs between 2009 and 2014. Female faculty rates were compared with the rate of female membership in the ASGE and by faculty role and course type over time. RESULTS: Between 2009 and 2014 there were a total of 2020 ASGE course faculty positions of which women comprised 19%. There was a significant increase in the proportion of women that served as course faculty over time (P < .0005). Female faculty participation exceeded the ASGE female domestic membership rate in all years. Women were more likely to serve as course directors than lecturers (25% vs 18%, P = .004) and to participate in smaller courses (P = .0003). CONCLUSIONS: We found an increase in female participation in ASGE programming over time, suggesting that specialty societies are making efforts to improve female representation at the national level. Future work should evaluate whether or not these opportunities translate into leadership roles for women within their own institutions or lead to promotions for women over time.

Does Sex Influence Publication Productivity Among Colorectal Surgeons Participating in Fellowship Training Programs?

BACKGROUND: Underrepresentation of highly ranked women in academic surgery is recognized. OBJECTIVE: Our objective was to examine whether sex differences exist in faculty representation, academic rank, and publication productivity among colorectal faculty in fellowship programs. DESIGN: American Society of Colon and Rectal Surgeons fellowship program faculty were identified. Bibliometric data were obtained for each faculty member, including Hirsch index, the Hirsch index divided by research career duration, and number of publications. Linear mixed-effect regression models were constructed to determine the association between the Hirsch index and the Hirsch index divided by research career duration and sex, when controlling for institutional measures. A subset analysis of academic faculty examined the association between academic rank, sex, and Hirsch index and the Hirsch index divided by research career duration. SETTINGS: Colorectal fellowship programs, defined as academic, satellite-academic, and nonacademic, were evaluated. RESULTS: Three hundred fifty-eight faculty members were examined across 55 training programs; 22% (n = 77) were women and 78% (n = 281) were men. Sixty-one percent (n = 220) practiced in an academic setting, 23% (n = 84) in a satellite-academic setting, and 15% (n = 54) in a nonacademic setting. There was no difference in median number of publications between sexes (15 vs 10, p = 0.33); men, however, had longer careers (18 vs 11 years, p < 0.001). When controlling for confounders, there was no difference in the Hirsch index (p = 0.42) or the Hirsch index divided by research career duration (p = 0.73) between sexes. Academic rank was significantly associated with Hirsch index and the Hirsch index divided by research career duration (p < 0.001) after controlling for sex. LIMITATIONS: Our assessment of association between publication productivity and academic rank was only possible in the subset of academic faculty. In addition, this study is limited by its retrospective nature. CONCLUSIONS: We found no difference in median number of publications between men and women. When controlling for possible confounders, sex was not a significant predictor of a faculty member's publication productivity, as measured by the Hirsch index or the Hirsch index divided by research career duration; academic rank, however, was.

Sponge Sampling with Fluorescent In Situ Hybridization as a Screening Tool for the Early Detection of Esophageal Cancer.

INTRODUCTION: Sponge cytology is a novel screening tool for esophageal cancer but has been unable to be validated for widespread use. Our aim was to apply fluorescent in situ hybridization to sponge cytology samples in order to evaluate the safety and efficacy of this modality in screening for esophageal cancer. MATERIALS AND METHODS: At a single, multidisciplinary, NCI-designated cancer center, patients completed sponge cytology sampling prior to upper endoscopy. Samples were analyzed by p53 fluorescent in situ hybridization, and results were compared to the endoscopic diagnosis. RESULTS: Fifty patients were enrolled (96 % Caucasian, 68 % male, median age of 67). All patients successfully swallowed the capsule. No complications (string breakage, bleeding, mucosal injury) occurred. Endoscopy revealed that 38 % had normal esophageal mucosa and 62 % had an esophageal mucosal abnormality. In total, six samples demonstrated p53 loss (94 % specificity for any abnormality). The sensitivity of the p53 fluorescent in situ hybridization probe was13.3 % for any abnormality, 10 % for intestinal metaplasia, and 0 % for dysplasia or esophageal cancer. DISCUSSION: Esophageal sponge cytology is a promising, safe, and tolerable method for collecting esophageal cell samples. However, our data suggest that p53 fluorescent in situ hybridization does not improve the sensitivity for detecting cancer in these samples.

Gender Differences in Publication Productivity, Academic Rank, and Career Duration Among U.S. Academic Gastroenterology Faculty.

PURPOSE: Female representation in academic medicine is increasing without proportional increases in female representation at senior ranks. The purpose of this study is to describe the gender representation in academic gastroenterology (GI) and compare publication productivity, academic rank, and career duration between male and female gastroenterologists. METHOD: In 2014, the authors collected data including number of publications, career duration, h-index, and m-index for faculty members at 114 U.S. academic GI programs. RESULTS: Of 2,440 academic faculty, 1,859 (76%) were men and 581 (24%) were women. Half (50%) of men held senior faculty position compared with 29% of women (P < .001). Compared with female faculty, male faculty had significantly (P < .001) longer careers (20 vs. 11 years), more publications (median 24 [0-949] vs. 9 [0-438]), and higher h-indices (8 vs. 4). Higher h-index correlated with higher academic rank (P < .001). The authors detected no difference in the h-index between men and women at the same rank for professor, associate professor, and instructor, nor any difference in the m-index between men and women (0.5 vs. 0.46, respectively, P = .214). CONCLUSIONS: A gender gap exists in the number and proportion of women in academic GI; however, after correcting for career duration, productivity measures that consider quantity and impact are similar for male and female faculty. Women holding senior faculty positions are equally productive as their male counterparts. Early and continued career mentorship will likely lead to continued increases in the rise of women in academic rank.

ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for adopting real-time imaging-assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett's esophagus.

BACKGROUND AND AIMS: Endoscopic real-time imaging of Barrett's esophagus (BE) with advanced imaging technologies enables targeted biopsies and may eliminate the need for random biopsies to detect dysplasia during endoscopic surveillance of BE. This systematic review and meta-analysis was performed by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee to specifically assess whether acceptable performance thresholds outlined by the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) document for clinical adoption of these technologies have been met. METHODS: We conducted meta-analyses calculating the pooled sensitivity, negative predictive value (NPV), and specificity for chromoendoscopy by using acetic acid and methylene blue, electronic chromoendoscopy by using narrow-band imaging, and confocal laser endomicroscopy (CLE) for the detection of dysplasia. Random effects meta-analysis models were used. Statistical heterogeneity was evaluated by means of I(2) statistics. RESULTS: The pooled sensitivity, NPV, and specificity for acetic acid chromoendoscopy were 96.6% (95% confidence interval [CI], 95-98), 98.3% (95% CI, 94.8-99.4), and 84.6% (95% CI, 68.5-93.2), respectively. The pooled sensitivity, NPV, and specificity for electronic chromoendoscopy by using narrow-band imaging were 94.2% (95% CI, 82.6-98.2), 97.5% (95% CI, 95.1-98.7), and 94.4% (95% CI, 80.5-98.6), respectively. The pooled sensitivity, NPV, and specificity for endoscope-based CLE were 90.4% (95% CI, 71.9-97.2), 98.3% (95% CI, 94.2-99.5), and 92.7% (95% CI, 87-96), respectively. CONCLUSIONS: Our meta-analysis indicates that targeted biopsies with acetic acid chromoendoscopy, electronic chromoendoscopy by using narrow-band imaging, and endoscope-based CLE meet the thresholds set by the ASGE PIVI, at least when performed by endoscopists with expertise in advanced imaging techniques. The ASGE Technology Committee therefore endorses using these advanced imaging modalities to guide targeted biopsies for the detection of dysplasia during surveillance of patients with previously nondysplastic BE, thereby replacing the currently used random biopsy protocols.

Impact of gender on requests for ASGE leadership assignments.

BACKGROUND AND AIMS: Committee membership in gastroenterology national societies is considered prestigious, opening the door for leadership roles and professional advancement. Some have hypothesized that women ask for leadership opportunities less frequently than men. Our aim was to examine the gender representation of requests for placement on an American Society for Gastrointestinal Endoscopy (ASGE) committee. METHODS: We analyzed deidentified records of all requests for assignment to ASGE committees from 2011 to 2014, including applicant's gender, prior service to ASGE, year of application, and whether the applicant was appointed. The primary outcome was the proportion of requests from women compared with the overall ASGE female membership. RESULTS: There were 513 requests for ASGE committee appointments; 101 (20%) were from women, exceeding the active ASGE female membership (15%; P = .004). Overall, the total number of committee requests increased over time from 89 to 195 (P = .08); the proportion of requests from women remained stable at 16% to 21% (P = .51). Compared with men, women were significantly less likely to have had previous ASGE service (28% vs 42%; P = .01) and more likely to have a statement of endorsement from a mentor (33% vs 24%; P = .06). The rate of appointment to a committee was 47% (95% confidence interval [CI], 41-52) overall, 42% (95% CI, 37-48) for male applicants, and 65% (95% CI, 54-76) for female applicants. Female gender (odds ratio [OR] 2.6; 1.5-4.5), endorsement from a mentor (OR 3.4; 2.1-5.6), and prior ASGE service (OR 2.3; 1.5-3.5) predicted committee appointment. CONCLUSIONS: For ASGE committee appointments, it appears that women who make requests are successful in receiving these appointments. Future work should evaluate requests and appointments by gender among other gastroenterology societies and explore whether service translates into leadership opportunities for women.

Colonoscopy Identifies Increased Prevalence of Large Polyps or Tumors in Patients 40-49 Years Old With Hematochezia vs Other Gastrointestinal Indications.

BACKGROUND & AIMS: There is an unclear role for colonoscopy in the evaluation of symptomatic individuals younger than 50 years old. We aimed to determine the prevalence of large polyps (>9 mm) or tumors in individuals 40 to 49 years old who underwent colonoscopy for various signs and symptoms, and compare the results with those from average-risk individuals ages 50 to 54 years who underwent screening colonoscopy. METHODS: We collected data from a national endoscopy database, from 2000 through 2012, and identified patients 40 to 49 years old who underwent colonoscopy for bleeding and nonbleeding indications. The prevalence of large polyps (>9 mm) or tumors was compared with the prevalence in a reference group (n = 99,713 average-risk individuals ages 50-54 undergoing screening colonoscopy). RESULTS: A total of 65,892 patients ages 40 to 49 years underwent colonoscopy for a variety of indications. Significantly larger proportions of male and female patients with hematochezia without anemia or iron-deficiency anemia (IDA) had large polyps or tumors (7.2%) compared with the reference group (men, 7.2% vs 6.2%; P = .0001; and women, 5.5% vs 4.1%; P < .0001). Patients with weight loss, anemia or IDA, or hematochezia with anemia or IDA did not have a significantly higher prevalence of large polyps or tumors than the reference group. Significantly lower proportions of patients with general gastrointestinal symptoms (pain, bloating, or change in bowel habits) had advanced neoplasia compared with the reference group (men, 3.9% vs 6.2%; P < .0001; and women, 2.7% vs 4.1%; P < .0001). CONCLUSIONS: An analysis of a national endoscopy database supports the role of colonoscopy to evaluate hematochezia in patients 40 to 49 years old. A lower proportion of patients with anemia, weight loss, and general abdominal symptoms had large polyps or tumors compared with average-risk patients 50 to 54 years old. A significantly lower proportion of patients younger than 50 years with general gastrointestinal symptoms had large polyps-these patients are therefore less likely to benefit from colonoscopy.

Management of Suspected Choledocholithiasis: A Decision Analysis for Choosing the Optimal Imaging Modality.

BACKGROUND AND AIMS: Magnetic resonance cholangiography (MRC), endoscopic ultrasound (EUS), and endoscopic retrograde cholangio-pancreatography (ERCP) all represent viable options to establish the diagnosis of choledocholithiasis. The aim of the study was to assess how the three imaging modalities perform in head-to-head comparisons and in what order to apply them when using these procedures sequentially. METHODS: A threshold analysis using a decision tree was modeled to compare the costs associated with different imaging techniques of the biliary system in a patient with suspected cholestasis secondary to choledocholithiasis. The main outcome parameter was the pre-test probability of common bile duct (CBD) stones that would guide the physician towards starting the work-up with MRC or EUS versus going straight to ERCP as the primary procedure. RESULTS: For low pre-test probabilities of CBD stones in the common bile duct, MRC represents the procedure of choice. For pre-test probabilities ranging between 40 and 91 %, EUS should be the preferred imaging modality. If CBD stones are suspected with an even higher pre-test probability, patients could go straight to ERCP as their first procedure. Low costs associated with any of the three procedures increase its range of applicability at the expense of the other competing imaging modalities. CONCLUSIONS: MRC, EUS, and ERCP should be used in sequence and dependent on the pre-test probability of choledocholithiasis.