A survey of colonoscopists with and without in-depth knowledge of water-aided colonoscopy.

BACKGROUND AND AIM: Endoscopy featured water-aided colonoscopy (WAC) as novel in the Innovation Forum in 2011. Gastrointestinal Endoscopy published a modified Delphi consensus review (MDCR) that supports WAC for clinical practice in 2021. We tested the hypothesis that experience was an important predictor of WAC use, either as water immersion (WI), water exchange (WE), or a combination of WI and WE. METHODS: A questionnaire was sent by email to the MDCR authors with an in-depth knowledge of WAC. They responded and also invited colleagues and trainees without in-depth knowledge to respond. Logistic regression analysis was used with the reasons for WAC use treated as the primary outcome. Reports related to WAC post MDCR were identified. RESULTS: Of 100 respondents, > 80% indicated willingness to adopt and modify practice to accommodate WAC. Higher adenoma detection rate (ADR) incentivized WE use. Procedure time slots ≤ 30 and > 30 min significantly predicted WI and WE use, respectively. Co-authors of the MDCR were significantly more likely to perform WAC (odds ratio [OR] = 7.5, P = 0.037). Unfamiliarity with (OR = 0.11, P = 0.02) and absence of good experience (OR = 0.019, P = 0.002) were associated with colonoscopists less likely to perform WAC. Reports related to WAC post MDCR revealed overall and right colon WE outcomes continued to improve. Network meta-analyses showed that WE was superior to Cap and Endocuff. On-demand sedation with WE shortened nursing recovery time. CONCLUSIONS: An important predictor of WAC use was experience. Superior outcomes continued to be reported with WE.

Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations.

BACKGROUND AND AIMS: Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. METHODS: Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. RESULTS: In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). CONCLUSIONS: The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.

Colorectal cancer prevention by a CLEAR principles-based colonoscopy protocol: an observational study.

BACKGROUND AND AIMS: Colorectal cancer (CRC) prevention by colonoscopy has been lower than expected. We studied CRC prevention outcomes of a colonoscopy protocol based on Clean the colon, Look Everywhere, and complete Abnormality Removal (CLEAR) principles. METHODS: This observational follow-up study studied patients provided screening colonoscopy at a free-standing private ambulatory surgery center in South Carolina by 80 endoscopists from October 2001 to December 2014, followed through December 2015. The colonoscopy protocol, optimized for polyp clearance, featured in-person bowel preparation instructions reinforced by phone, polyp search and removal throughout insertion and gradual withdrawal with circumferential tip movements, and a team approach using all personnel present to maximize polyp detection, patient safety, and clear-margin polypectomy including requesting repeat inspection or additional tissue removal. Outcome measures were postscreening lifetime CRC risk relative to Surveillance Epidemiology and End Results (SEER)-18 and interval cancer rate (postcolonoscopy CRCs among cancer-free patients at screening). RESULTS: Of 25,862 patients (mean age, 58.1 years; 52% black; 205,522 person-years of observation), 159 had CRC at screening and 67 patients developed interval CRC. The interval CRC rate was 3.34 per 10,000 person-years of observation, 5.79 and 2.24 among patients with and without adenomas, respectively. The rate was similar among older patients (mean age 68.5 years at screening) and with prolonged follow-up. Postscreening lifetime CRC risk was 1.6% (bootstrap 95% confidence interval, 1.3%-1.8%) versus 4.7% in SEER-18, 67% lower. Subgroups with mean screening ages of 50 and 68.5 years showed risk reductions of 80% and 72%, respectively. The adverse event rate was less than usually reported rates: perforation 2.6 per 10,000, bleeding with hospitalization 2.4 per 10,000, and no deaths. CONCLUSIONS: A colonoscopy protocol optimized for polyp clearance prevented 67% of CRC compared with a SEER-18 population given ongoing population screening.

Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop.

: A workshop on "Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities" was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of "deliberate practice," rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.

Objective Differences in Colonoscopy Technique Between Trainee and Expert Endoscopists Using the Colonoscopy Force Monitor.

BACKGROUND: Learning to perform colonoscopy safely and effectively is central to gastroenterology fellowship programs. The application of force to the colonoscope is an important part of colonoscopy technique. AIMS: We compared force application during colonoscopy between novice and expert endoscopists using a novel device to determine differences in colonoscopy technique. METHODS: This is an observational cohort study designed to compare force application during colonoscopy between novice and experienced trainees, made up of gastroenterology fellows from two training programs, and expert endoscopists from both academic and private practice settings. RESULTS: Force recordings were obtained for 257 colonoscopies by 37 endoscopists, 21 of whom were trainees. Experts used higher average forward forces during insertion compared to all trainees and significantly less clockwise torque compared to novice trainees. CONCLUSIONS: We present significant, objective differences in colonoscopy technique between novice trainees, experienced trainees, and expert endoscopists. These findings suggest that the colonoscopy force monitor is an objective tool for measuring proficiency in colonoscopy. Furthermore, the device may be used as a teaching tool in training and continued medical education programs.

Editorial: Polyps, Pain, and Propofol: Is Water Exchange the Panacea for All?

Water exchange (WE) is a relatively new method of endoscope insertion during colonoscopy. Although its origin is rooted in the insertion phase of colonoscopy, allowing the procedure to proceed with more ease, less discomfort, and less or no sedation, its most important value may reside in the withdrawal phase. In this issue, a randomized, prospective study from China specifically designed to examine the effect of WE on adenoma detection rate (ADR) confirms previous findings: WE improves ADR. Here we discuss the trial results, the benefits of WE, and the challenges that may preclude or delay widespread WE implementation.

Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop.

A workshop on ''Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities'' was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of ''deliberate practice,'' rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.

Colorectal cancer prevention by an optimized colonoscopy protocol in routine practice.

We conducted a retrospective cohort study to investigate the colorectal cancer (CRC) incidence and mortality prevention achievable in clinical practice with an optimized colonoscopy protocol targeting near-complete polyp clearance. The protocol consisted of: (i) telephonic reinforcement of bowel preparation instructions; (ii) active inspection for polyps throughout insertion and circumferential withdrawal; and (iii) timely updating of the protocol and documentation to incorporate the latest guidelines. Of 17,312 patients provided screening colonoscopies by 59 endoscopists in South Carolina, USA from September 2001 through December 2008, 997 were excluded using accepted exclusion criteria. Data on 16,315 patients were merged with the South Carolina Central Cancer Registry and Vital Records Registry data from January 1996 to December 2009 to identify incident CRC cases and deaths, incident lung cancers and brain cancer deaths (comparison control cancers). The standardized incidence ratios (SIR) and standardized mortality ratios (SMR) relative to South Carolina and US SEER-18 population rates were calculated. Over 78,375 person-years of observation, 18 patients developed CRC versus 104.11 expected for an SIR of 0.17, or 83% CRC protection, the rates being 68% and 91%, respectively among the adenoma- and adenoma-free subgroups (all p < 0.001). Restricting the cohort to ensure minimum 5-year follow-up (mean follow-up 6.64 years) did not change the results. The CRC mortality reduction was 89% (p < 0.001; four CRC deaths vs. 35.95 expected). The lung cancer SIR was 0.96 (p = 0.67), and brain cancer SMR was 0.92 (p = 0.35). Over 80% reduction in CRC incidence and mortality is achievable in routine practice by implementing key colonoscopy principles targeting near-complete polyp clearance.

Colonoscopy screening among US adults aged 40 or older with a family history of colorectal cancer.

INTRODUCTION: Colonoscopy screening reduces colorectal cancer (CRC) incidence and mortality. CRC screening is recommended at age 50 for average-risk people. Screening of first-degree relatives of CRC patients is recommended to begin at age 40 or 10 years before the age at diagnosis of the youngest relative diagnosed with CRC. CRC incidence has increased recently among younger Americans while it has declined among older Americans. The objective of this study was to determine whether first-degree relatives of CRC patients are being screened according to recommended guidelines. METHODS: We studied colonoscopy screening rates among the US population reporting a CRC family history using 2005 and 2010 National Health Interview Survey data. RESULTS: Of 26,064 study-eligible respondents, 2,470 reported a CRC family history; of those with a family history, 45.6% had a colonoscopy (25.2% in 2005 and 65.8% 2010). The colonoscopy rate among first-degree relatives aged 40 to 49 in 2010 (38.3%) was about half that of first-degree relatives aged 50 or older (69.7%). First-degree relatives were nearly twice as likely as nonfirst-degree relatives to have a colonoscopy (adjusted odds ratio [AOR], 1.7; 95% confidence interval, 1.5-1.9), but those aged 40 to 49 were less likely to have a colonoscopy than those in older age groups (AOR, 2.6 for age 50-64; AOR, 3.6 for age ≥65). Interactions with age, insurance, and race/ethnicity were not significant. Having health insurance tripled the likelihood of screening. CONCLUSION: Despite a 5-fold increase in colonoscopy screening rates since 2005, rates among first-degree relatives younger than the conventional screening age have lagged. Screening promotion targeted to this group may halt the recent rising trend of CRC among younger Americans.

Abnormal Image Detection in Endoscopy Videos Using a Filter Bank and Local Binary Patterns.

Finding mucosal abnormalities (e.g., erythema, blood, ulcer, erosion, and polyp) is one of the most essential tasks during endoscopy video review. Since these abnormalities typically appear in a small number of frames (around 5% of the total frame number), automated detection of frames with an abnormality can save physician's time significantly. In this paper, we propose a new multi-texture analysis method that effectively discerns images showing mucosal abnormalities from the ones without any abnormality since most abnormalities in endoscopy images have textures that are clearly distinguishable from normal textures using an advanced image texture analysis method. The method uses a "texton histogram" of an image block as features. The histogram captures the distribution of different "textons" representing various textures in an endoscopy image. The textons are representative response vectors of an application of a combination of Leung and Malik (LM) filter bank (i.e., a set of image filters) and a set of Local Binary Patterns on the image. Our experimental results indicate that the proposed method achieves 92% recall and 91.8% specificity on wireless capsule endoscopy (WCE) images and 91% recall and 90.8% specificity on colonoscopy images.

Validation of the ulcerative colitis colonoscopic index of severity and its correlation with disease activity measures.

BACKGROUND & AIMS: Endoscopic healing is likely to become an important goal for treatment of patients with ulcerative colitis (UC). A simple validated endoscopic index is needed. We validated the previously developed UC Colonoscopic Index of Severity (UCCIS). METHODS: In a prospective study, 50 patients with UC were examined by colonoscopy; we analyzed videos of rectum and sigmoid, descending, transverse, and cecum/ascending colon. Eight gastroenterologists blindly rated 4 mucosal lesions (for vascular pattern, granularity, friability, ulceration) and severity of damage to each segment and overall. The global assessment of endoscopic severity (GAES) was based on a 4-point scale and 10-cm visual analogue scale. Correlation of the UCCIS score with clinical indexes (clinical activity index and simple clinical colitis activity index), patient-defined remission, and laboratory measures of disease activity (levels of C-reactive protein, albumin, and hemoglobin and platelet counts) were estimated by using the Pearson (r) or Spearman (r(s)) method. RESULTS: Interobserver agreement was good to excellent for the 4 mucosal lesions evaluated by endoscopy and the GAES. The UCCIS calculated for our data accounted for 74% (R(2) = 0.74) and 80% (R(2) = 0.80) of the variation in the GAES and visual analogue scores, respectively (P < .0001). The UCCIS also correlated with clinical activity index (r = 0.52, P < .001), simple clinical colitis activity index (r = 0.62, P < .0001), and patient-defined remission (r = 0.43, P < .01). The UCCIS also correlated with levels of C-reactive protein (r(s) = 0.56, P < .001), albumin (r = -0.55, P < .001), and hemoglobin (r = -0.39, P < .01). A rederivation of the equation for the UCCIS by using the data from a previous study combined with those of the current study (n = 101) yielded similar results. CONCLUSIONS: The UCCIS is a simple tool that provides reproducible results in endoscopic scoring of patients with UC.

BubR1 insufficiency causes early onset of aging-associated phenotypes and infertility in mice.

Faithful segregation of replicated chromosomes is essential for maintenance of genetic stability and seems to be monitored by several mitotic checkpoints. Various components of these checkpoints have been identified in mammals, but their physiological relevance is largely unknown. Here we show that mutant mice with low levels of the spindle assembly checkpoint protein BubR1 develop progressive aneuploidy along with a variety of progeroid features, including short lifespan, cachectic dwarfism, lordokyphosis, cataracts, loss of subcutaneous fat and impaired wound healing. Graded reduction of BubR1 expression in mouse embryonic fibroblasts causes increased aneuploidy and senescence. Male and female mutant mice have defects in meiotic chromosome segregation and are infertile. Natural aging of wild-type mice is marked by decreased expression of BubR1 in multiple tissues, including testis and ovary. These results suggest a role for BubR1 in regulating aging and infertility.

Muons, mutations, and planetary shielding.

Life on earth is protected from astrophysical cosmic rays by the heliospheric magnetic and slowly varying geomagnetic fields, and by collisions with oxygen and nitrogen molecules in the atmosphere. The collisions generate showers of particles of lesser energy; only muons, a charged particle with a mass between that of an electron and a proton, can reach earth's surface in substantial quantities. Muons are easily detected, used to image interior spaces of pyramids, and known to limit the stability of qubits in quantum computing; yet, despite their charge, average energy of 4 GeV and ionizing properties, muons are not considered to affect chemical reactions or biology. In this Perspective the potential damaging effects of muons on DNA, and hence the repercussions for evolution and disease, are examined. It is argued here that the effect of muons on life through DNA mutations should be considered when investigating the protection provided by the magnetic environment and atmosphere from cosmic rays on earth and exoplanets.

Artificial Intelligence for Colonoscopy: Past, Present, and Future.

During the past decades, many automated image analysis methods have been developed for colonoscopy. Real-time implementation of the most promising methods during colonoscopy has been tested in clinical trials, including several recent multi-center studies. All trials have shown results that may contribute to prevention of colorectal cancer. We summarize the past and present development of colonoscopy video analysis methods, focusing on two categories of artificial intelligence (AI) technologies used in clinical trials. These are (1) analysis and feedback for improving colonoscopy quality and (2) detection of abnormalities. Our survey includes methods that use traditional machine learning algorithms on carefully designed hand-crafted features as well as recent deep-learning methods. Lastly, we present the gap between current state-of-the-art technology and desirable clinical features and conclude with future directions of endoscopic AI technology development that will bridge the current gap.

Use of a fully covered self-expandable metal stent for the treatment of benign esophageal diseases.

BACKGROUND: Fully covered self-expandable metal stents (FCSEMSs) have been proposed for the treatment of benign esophageal diseases. OBJECTIVE: To review our experience with FCSEMSs in patients with benign esophageal diseases. DESIGN: Retrospective case review of patients who underwent FCSEMS placement for benign esophageal diseases, including (1) benign strictures from GERD--caustic and idiopathic causes, (2) radiation-induced strictures, (3) anastomotic strictures, (4) esophageal fistulae/leaks, and (5) esophageal perforations. SETTING: Tertiary-care medical center. PATIENTS: This study involved 37 male and 19 female patients (average age 60 years, range 25-94 years) who underwent FCSEMS placement. INTERVENTION: FCSEMS placement. MAIN OUTCOME MEASUREMENTS: Technical success with stent placement and removal, stent migration, long-term and short-term complications, and treatment success according to clinical symptoms, follow-up endoscopy, or imaging. RESULTS: Stent placement was successful in 100 of 107 (93%) procedures, with a total of 104 stents placed. Migration was noted in 37 of 104 (35.6%) stents and was seen more frequently with proximal stents and stents placed for anastomotic strictures. Initial treatment success was seen in 56% of patients with any stricture and in 38% of patients with a fistula/leak or perforation, although data to document long-term resolution were lacking. LIMITATIONS: This was a retrospective review with patients selected from a tertiary-care medical center. Two endoscopists performed the majority of procedures. CONCLUSION: Temporary placement of FCSEMSs for benign esophageal diseases has moderate clinical efficacy and is limited by stent migration. Removability was easily demonstrated. Newer developments in stent design may improve clinical outcomes for these patients.