Adherence to quality indicators and best practices in surveillance endoscopy of Barrett's esophagus: A video-based assessment.

Background and study aims Adherence to quality indicators (QIs) and best practices (BPs) for endoscopic surveillance of Barrett's esophagus (BE) is low based on clinical documentation which is an inaccurate representation of events occurring during procedures. This study aimed to assess adherence to measurable QI and BP using video evaluation. Methods We performed a single center video-based retrospective review of surveillance endoscopies performed for BE ≥1 cm between March 1, 2018 and October 1, 2020. Adherence to QIs and BPs was assessed through video review and documentation. Videos were evaluated by five gastroenterologists. Interrater variability was determined using 10 videos before reviewing the remaining 128 videos. A generalized linear regression model was used to determine predictors of adherence to QIs and BPs. Results There were 138 endoscopies reviewed. Inspection with virtual chromoendoscopy (VC) occurred in 75 cases (54%) on video review with documentation in 50 of these cases (67%). Adherence to the Seattle protocol (SP) occurred in 74 cases (54%) on video review with documentation in 28 of these cases (38%). Use of VC or the SP was documented but not observed on video review in 16 (12%) and 30 (22%) cases, respectively. Length of BE was associated with increased use of the Prague classification (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.07-1.37) while years in practice was associated with a decreased likelihood of VC use (OR 0.93, 95% CI 0.88-0.99). Conclusions This study validates prior data demonstrating poor adherence to QIs and BPs and highlights discrepancies between clinical documentation and events occurring during procedures.

Racial Disparities in Adherence to Quality Indicators in Barrett's Esophagus: An Analysis Using the GIQuIC National Benchmarking Registry.

INTRODUCTION: Racial disparities in outcomes in esophageal adenocarcinoma are well established. Using a nationwide registry, we aimed to compare clinical and endoscopic characteristics of blacks and whites with Barrett's esophagus (BE) and adherence to defined quality indicators. METHODS: We analyzed data from the Gastrointestinal Quality Improvement Consortium Registry between January 2012 and December 2019. Patients who underwent esophagogastroduodenoscopy with an indication of BE screening or surveillance, or an endoscopic finding of BE, were included. Adherence to recommended endoscopic surveillance intervals of 3-5 years for nondysplastic BE and adherence to Seattle biopsy protocol were assessed. Multivariate logistic regression was conducted to assess variables associated with adherence. RESULTS: A total of 100,848 esophagogastroduodenoscopies in 84,789 patients met inclusion criteria (blacks-3,957 and whites-96,891). Blacks were less likely to have histologically confirmed BE (34.3% vs 51.7%, P < 0.01), had shorter BE lengths (1.61 vs 2.35 cm, P < 0.01), and were less likely to have any dysplasia (4.3% vs 7.1%, P < 0.01). Although whites were predominantly male (62.2%), about half of blacks with BE were female (53.0%). Blacks with nondysplastic BE were less likely to be recommended appropriate surveillance intervals (OR 0.78; 95% CI 0.68-0.89). Adherence rates to the Seattle protocol were modestly higher among blacks overall (OR 1.12, 95% CI 1.04-1.20), although significantly lower among blacks with BE segments >6 cm. DISCUSSION: The use of sex as a risk factor for BE screening may be inappropriate among blacks. Fewer blacks were recommended appropriate surveillance intervals, and blacks with longer segment BE were less likely to undergo Seattle biopsy protocol.

A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills Study.

BACKGROUND & AIMS: On the basis of the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) by using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. METHODS: ASGE recognized training programs were invited to participate, and AETs were graded on ERCP and EUS exams by using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done by using a 4-point scoring system, and a comprehensive data collection and reporting system was built to create learning curves by using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. RESULTS: Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range, 155-650) and 350 (125-500), respectively. Overall, 3786 exams were graded (EUS, 1137; ERCP-biliary, 2280; ERCP-pancreatic, 369). Learning curves for individual end points and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS, 82%; ERCP, 60%) and cognitive (EUS, 76%; ERCP, 100%) competence at conclusion of training. CONCLUSIONS: These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP. ClinicalTrials.gov: NCT02509416.

Wide disparities in attitudes and practices regarding Type II sphincter of Oddi dysfunction: a survey of expert U.S. endoscopists.

BACKGROUND: Sphincter of Oddi manometry (SOM) is recommended in the evaluation of suspected Type II sphincter of Oddi dysfunction (SOD2), though its utility is uncertain. Little is known about the practice of expert endoscopists in the United States regarding SOD2. METHODS: An anonymous electronic survey was distributed to 128 expert biliary endoscopists identified from U.S. advanced endoscopy training programs. RESULTS: The response rate was 46.1 % (59/128). Only 55.6 % received training in SOM, and 49.2 % currently perform SOM. For biliary SOD2, 33.3 % routinely obtain SOM, 33.3 % perform empiric sphincterotomy, and 26.3 % perform single session endoscopic ultrasound/endoscopic retrograde cholangiopancreatography (EUS/ERCP). In contrast, an equal number (35.1 %) favor SOM or single session EUS/ERCP for suspected acute idiopathic recurrent pancreatitis, while 19.3 % would perform empiric sphincterotomy. Those who perform SOM believe it to be important in predicting response to treatment compared with those who do not (71.8 % vs 23.1 %, P = 0.01). Yet only 51.7 % of this group performs SOM for suspected SOD2. Most (78.6 %) believe that < 50 % of patients report improvement in symptoms after sphincterotomy. Common reasons for not obtaining SOM included unreliable results (50 %), and procedure-related risks (39.3 %). Most (59.3 %) believe SOD2 is at least in part a functional disorder; only 3.7 % felt SOD is a legitimate disorder of the sphincter of Oddi. CONCLUSIONS: Our survey of U.S. expert endoscopists suggests that SOM is not routinely performed for SOD2 and concerns regarding its associated risks and validity persist. Most endoscopists believe SOD2 is at least in part a functional disorder that will not respond to sphincterotomy in the majority of cases.

A randomized controlled cross-over trial and cost analysis comparing endoscopic ultrasound fine needle aspiration and fine needle biopsy.

BACKGROUND AND STUDY AIMS: Techniques to optimize endoscopic ultrasound-guided tissue acquisition (EUS-TA) in a variety of lesion types have not yet been established. The primary aim of this study was to compare the diagnostic yield (DY) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for pancreatic and non-pancreatic masses. PATIENTS AND METHODS: Consecutive patients referred for EUS-TA underwent randomization to EUS-FNA or EUS-FNB at four tertiary-care medical centers. A maximum of three passes were allowed for the initial method of EUS-TA and patients were crossed over to the other arm based on on-site specimen adequacy. RESULTS: A total of 140 patients were enrolled. The overall DY was significantly higher with specimens obtained by EUS-FNB compared to EUS-FNA (90.0 % vs. 67.1 %, P = 0.002). While there was no difference in the DY between the two groups for pancreatic masses (FNB: 91.7 % vs. FNA: 78.4 %, P = 0.19), the DY of EUS-FNB was higher than the EUS-FNA for non-pancreatic lesions (88.2 % vs. 54.5 %, P = 0.006). Specimen adequacy was higher for EUS-FNB compared to EUS-FNA for all lesions (P = 0.006). There was a significant rescue effect of crossover from failed FNA to FNB in 27 out of 28 cases (96.5 %, P = 0.0003). Decision analysis showed that the strategy of EUS-FNB was cost saving compared to EUS-FNA over a wide range of cost and outcome probabilities. CONCLUSIONS: RESULTS of this RCT and decision analysis demonstrate superior DY and specimen adequacy for solid mass lesions sampled by EUS-FNB.

Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis.

BACKGROUND AND AIMS: Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP. METHODS: A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges. RESULTS: LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000. CONCLUSIONS: Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.

Endoscopy for diagnosis and treatment in esophageal cancers: high-technology assessment.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the endoscopic tools to recognize squamous cell dysplasia; confocal laser endomicroscopy for Barrett's esophagus; confocal microscopy in the cancer patient; optical coherence tomography in the assessment of subsquamous Barrett's metaplasia; endoscopic mucosal resection for high-grade dysplasia in Barrett's esophagus; HALO in the treatment of squamous dysplasia; and the use of fluorescence in situ hybridization to detect dysplasia and adenocarcinoma in patients with Barrett's esophagus.

Inpatient weekend ERCP is associated with a reduction in patient length of stay.

OBJECTIVES: Endoscopic retrograde cholangiopancreatography (ERCP) performed on the weekend requires significant effort from the endoscopist, nursing staff, and anesthesia services. These factors often result in delaying the procedure until the following Monday. No data exist on whether performing weekend ERCP reduces length of stay (LOS) and total cost to justify the additional physician and nursing burden. METHODS: In this single tertiary academic center, institutional review board-approved study, we retrospectively reviewed all hospitalized patients in whom an ERCP had been completed from May 2010 to September 2011. Demographic and clinical information, procedure details as well as total hospitalization charges (USD) were compared between patients who had an ERCP either on the weekend or weekday holiday (WE ERCP) or Monday (MON ERCP). Statistical comparisons were made using χ(2) and Fischer's exact test. A logistic regression model adjusted for propensity scores (PSs) was used to estimate the risk in prolonged LOS and high total charges associated with WE ERCPs vs. MON ERCPs. RESULTS: A total of 1,114 ERCP's were performed during the time period, 123 of which met inclusion criteria (52 WE, 71 MON). Mean patient age was 56.3±16.7 years (54.5% female, 60.2% Caucasian). There were no significant demographic differences between the two groups. The most common procedure indications were choledocholithiasis (34.9%) and elevated liver enzymes after liver transplantation (25.2%). The analysis showed a significantly decreased LOS (P=0.010) and a trend towards decreased cost (P=0.050) associated with WE ERCP. In the multivariate analysis adjusted for PS, WE ERCP had a significantly decreased odds ratio of LOS>3 days (odds ratio: 0.37 (0.16-0.85); P=0.019). CONCLUSIONS: We demonstrated a significant decrease in LOS and a trend towards decrease in charges in patients who underwent weekend ERCP compared with delaying ERCP until Monday. Thus, health-care organizations should consider removing barriers to weekend inpatient ERCPs.