Environmental and health outcomes of single-use versus reusable duodenoscopes.

BACKGROUND AND AIMS: The large-scale effects of duodenoscopes on the environment and public health have not been quantified. Our aim was to perform an exploratory life cycle assessment comparing environmental and human health effects of single-use duodenoscopes (SDs) and reusable duodenoscopes (RDs). METHODS: We evaluated 3 duodenoscopes: conventional RDs, RDs with disposable endcaps, and SDs. The primary outcomes were impacts on climate change and human health, complemented by multiple environmental impacts. RESULTS: Performing ERCP with SDs releases between 36.3 and 71.5 kg of CO2 equivalent, which is 24 to 47 times greater than using an RD (1.53 kg CO2) or an RD with disposable endcaps (1.54 kg CO2). Most of the impact of SDs comes from its manufacturing, which accounts for 91% to 96% of its greenhouse gas emission. The human health impact of RDs becomes comparable with the SD lower bound if disposable endcaps or other design modifications can reduce serious infection rates below a target rate of 23 cases per year (.0046%). CONCLUSIONS: Although SDs may provide incremental public health benefit compared with RDs, it comes at a substantially higher cost to the environment. As infection rates continue to decrease from more regimented cleaning protocols and enhanced designs such as disposable endcaps to facilitate cleaning, the negative impact to human health from contaminated RDs could be comparable with SDs.

An international study of interobserver variability of "string sign" of pancreatic cysts among experienced endosonographers.

BACKGROUND AND OBJECTIVES: No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the "string sign" test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied. METHODS: An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: "Is the string sign positive?" and "If the string sign is positive, what is the length of the formed string?" Also asked "What is the cutoff length for string sign to be considered positive?" Interobserver variability was assessed using the kappa statistic (κ). RESULTS: A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive. CONCLUSION: String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.

Do Nontechnical Skills Affect Legal Outcomes After Endoscopic Perforations?

INTRODUCTION: Health systems often emphasize technical skills to reduce iatrogenic injuries. Nontechnical skills such as clinical and communication skills are mostly overlooked or not readily retrievable from medical records. Our aim was to estimate the association of technical and nontechnical skills of endoscopists with indemnity payments to patients after endoscopic perforations. METHODS: This is an observational registry-based study of closed claims against gastroenterologists involved in endoscopic perforations. RESULTS: We analyzed 175 closed claims related to perforations, all of which involved allegations of improper performance of the endoscopic procedure. Inadequate communication (n = 71, 41%) and clinical judgment (n = 60, 34%) on the part of the endoscopists were observed. Inadequate communication and clinical judgment were associated with over 3-fold odds of indemnity payment (odds ratio [OR] 3.31; 95% confidence interval [CI], 1.46-7.48, and OR 3.18; 95% CI, 1.44-7.01, respectively). However, if there were no communication breakdown or clinical judgment issues and the only allegation was poor technical skill, the odds of indemnity payments were less than half of those cases (OR 0.43; 95% CI 0.15-0.80). There was no evidence of a statistically significant interaction among age, procedure type, trainee involvement, clinical severity, need for surgery, and procedure-related death. DISCUSSION: We observed that inadequate communication and clinical judgment were associated with indemnity payment, independent of the severity of clinical outcomes. On the other hand, cases wherein there was an allegation of poor technical skills alone, without communication breakdown or clinical judgment issues, were associated with favorable legal outcomes for the defendant. (See the Visual Abstract at http://links.lww.com/AJG/B568.).

Longitudinal assessment of colonoscopy quality indicators: a report from the Gastroenterology Practice Management Group.

BACKGROUND: There is increasing demand for colonoscopy quality measures for procedures performed in ambulatory surgery centers. Benchmarks such as adenoma detection rate (ADR) are traditionally reported as static, one-dimensional point estimates at a provider or practice level. OBJECTIVE: To evaluate 6-year variability of ADRs for 370 gastroenterologists from across the nation. DESIGN: Observational cross-sectional analysis. SETTING: Collaborative quality metrics database from 2007 to 2012. PATIENTS: Patients who underwent colonoscopies in ambulatory surgery centers. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: The number of colonoscopies with an adenomatous polyp divided by the total number of colonoscopies (ADR-T), inclusive of indication and patient's sex. RESULTS: Data from 368,157 colonoscopies were included for analysis from 11 practices. Three practice sites (5, 8, and 10) were significantly above and 2 sites (3, 7) were significantly below mean ADR-T, with a 95% confidence interval (CI). High-performing sites had 9.0% higher ADR-T than sites belonging to the lowest quartile (P < .001). The mean ADR-T remained stable for 9 of 11 sites. Regression analysis showed that the 2 practice sites where ADR-T varied had significant improvements in ADR-T during the 6-year period. For each, mean ADR-T improved an average of 0.5% per quarter for site 2 (P = .001) and site 3 (P = .021), which were average and low performers, respectively. LIMITATIONS: Summary-level data, which does not allow cross-reference of variables at an individual level. CONCLUSION: We found performance disparities among practice sites remaining relatively consistent over a 6-year period. The ability of certain sites to sustain their high-performance over 6 years suggests that further research is needed to identify key organizational processes and physician incentives that improve the quality of colonoscopy.

A pilot study of endoluminal US for stool liquefaction.

BACKGROUND: There is a need to cleanse patients who are poorly prepared for colonoscopy safely and efficiently during the procedure to minimize rescheduling. US is already being used in catheter-based intravascular thrombolysis, and time-reversal acoustic (TRA) has been explored in assisting drug delivery to the brain. OBJECTIVE: To explore the efficacy and safety of a miniaturized endoluminal US device in stool dissolution as a means to salvage poor bowel preparation. DESIGN: Proof of concept experimental study. SETTINGS: Animal laboratory. INTERVENTIONS: Low-frequency US and TRAs. MAIN OUTCOME MEASUREMENTS: Feasibility, efficacy, and safety of US to liquefy stools ex vivo. RESULTS: Depending on parameters, such as pulse rate, acoustic intensity, and duration, increases in liquefaction speeds by a factor of 50 and 100 times were obtained. There was a significant difference in weight change between the 20-kHz-treated sample compared with controls (P ≤ .0001). There was no difference in sloughing of mucosa and mechanical injury among the US, water spray, and control groups. LIMITATIONS: Animal model. CONCLUSION: Endoluminal US can liquefy stools at acoustic exposure levels that do not damage ex vivo colonic mucosa. Endoluminal US should be able to dissolve stools more rapidly than water spray alone, thereby optimizing colonoscopic evaluation in vivo.

Clinical decision making in the management of pancreatic cystic neoplasms.

Pancreatic cystic lesions continue to pose diagnostic and management dilemmas for physicians. This may be related, in part, to the fact that these lesions represent a range of diagnostic possibilities, from inflammatory cysts and nonmucinous cysts to mucinous cysts, which may or may not have foci of invasive malignancy. Adequate characterization of cystic lesions is necessary to help devise a management plan. Moreover, patient-related factors such as comorbid conditions are often essential in deciding whether patients should be managed by a conservative approach of watchful waiting versus surgical resection, if so indicated. This review summarizes the recent advances in the management of pancreatic cystic neoplasms.

Malpractice claims for endoscopy.

AIM: To summarize the magnitude and time trends of endoscopy-related claims and to compare total malpractice indemnity according to specialty and procedure. METHODS: We obtained data from a comprehensive database of closed claims from a trade association of professional liability insurance carriers, representing over 60% of practicing United States physicians. Total payments by procedure and year were calculated, and were adjusted for inflation (using the Consumer Price Index) to 2008 dollars. Time series analysis was performed to assess changes in the total value of claims for each type of procedure over time. RESULTS: There were 1901 endoscopy-related closed claims against all providers from 1985 to 2008. The specialties include: internal medicine (n = 766), gastroenterology (n = 562), general surgery (n = 231), general and family practice (n = 101), colorectal surgery (n = 87), other specialties (n = 132), and unknown (n = 22). Colonoscopy represented the highest frequencies of closed claims (n = 788) and the highest total indemnities ($54 093 000). In terms of mean claims payment, endoscopic retrograde cholangiopancreatography (ERCP) ranked the highest ($374  794) per claim. Internists had the highest number of total claims (n = 766) and total claim payment ($70  730  101). Only total claim payments for colonoscopy and ERCP seem to have increased over time. Indeed, there was an average increase of 15.5% per year for colonoscopy and 21.9% per year for ERCP after adjusting for inflation. CONCLUSION: There appear to be differences in malpractice coverage costs among specialties and the type of endoscopic procedure. There is also evidence for secular trend in total claim payments, with colonoscopy and ERCP costs rising yearly even after adjusting for inflation.

EUS in the diagnosis of early-stage chronic pancreatitis.

Chronic pancreatitis (CP) is a progressive inflammatory disease that is difficult to diagnose due to the paucity of a diagnostic gold standard. For almost two decades, early-stage CP has been recognised in the context of endoscopic ultrasound (EUS) when a patient presents with typical pancreatic-type pain, normal conventional imaging examinations, and subtle findings of CP by EUS. Whether these EUS findings represent true early-stage CP that will progress or whether they are false positive findings remain unclear. The key to enhancing the diagnostic precision of EUS in CP is to use objective, widely-accepted criteria that are reproducible. The Rosemont Criteria is a significant step towards achieving this goal and needs to be validated in conjunction with long-term studies of early-stage CP.

Anatomic-manometric correlation of the upper esophageal sphincter: a concurrent US and manometry study.

BACKGROUND: The pharyngoesophageal segment commonly referred to as the upper esophageal sphincter (UES) generates a high-pressure zone (HPZ) between the pharynx and the esophagus. However, the exact anatomical components of the UES-HPZ remain incompletely determined. OBJECTIVE: To systematically define the US signature of various components of the pharyngoesophageal junction and to determine how these structures contribute to the development of the UES-HPZ. DESIGN: Prospective, experimental study. SETTING: Tertiary Academic Medical Center. PATIENTS: This study involved 18 healthy volunteers. INTERVENTION: We studied 5 participants by using a high-frequency US miniprobe (US-MP) and concurrent fluoroscopy and another 13 participants by using the US-MP and concurrent manometry. MAIN OUTCOME MEASUREMENTS: Relative contribution of various muscles in the UES-HPZ. RESULTS: Manometrically, the UES-HPZ had a median length of 4.0 cm (range 3.0-4.5 cm). A C-shaped muscle, believed to represent the cricopharyngeus muscle, was observed for a median length of 3.5 cm (range 2.0-4.0 cm). The oval configuration representing the esophageal contribution to the UES was seen in 10 of 13 participants (77%) at the distal HPZ (esophagus to UES transition zone). The flat configuration of the inferior constrictor muscle was noted in 7 of 13 participants (54%) at the proximal HPZ (UES to pharynx transition zone). There were 4 to 5 wall layers versus 3 layers in the distal and proximal HPZ, respectively. The mean (+/- SD) muscle thickness was relatively constant along the length of the UES-HPZ. LIMITATIONS: Air artifacts in the UES-HPZ. CONCLUSION: The configuration and layers of the UES-HPZ vary along its length. The upper esophagus is a significant contributor to the distal UES-HPZ.

Quality-adjusted life expectancy benefits of laparoscopic bariatric surgery: a United States perspective.

OBJECTIVES: The method of choice for bariatric surgery remains controversial. The aim of this study was to compare the outcome of laparoscopic Roux-en-Y gastric bypass (L-RYGB) versus laparoscopic adjustable gastric banding (LAGB) using quality-adjusted life-years (QALYs). METHODS: We developed a Markov model of the quality of life and survival of L-RYGB and LAGB in obese patients. Using census data, we estimated the probability of dying and quality of life for each year of each cohort. RESULTS: For all cohorts, L-RYGB offers the highest advantage in QALYs compared with gastric banding. The youngest cohort showed the greatest discrepancy between the two surgical methods, with 7.8, 6.4, and 4.7 QALYs gained with L-RYGB over LAGB for the age groups 35, 45, and 55, respectively. Those with the highest presurgical body mass index (BMI) acquired the most advantage with L-RYGB, with 2.8, 6.4, and 9.6 QALYs gained with L-RYGB over LAGB for the BMI groups 40, 50, and 60. Males had a slightly higher advantage with L-RYGB, with 6.5 QALYs gained with L-RYGB over LAGB compared with 6.0 QALYs for females. CONCLUSIONS: For the cohorts studied, L-RYGB is the preferred surgical treatment for obesity if the sole metric is QALYs. The young and extremely obese are core groups who will gain the most QALYs following L-RYGB.