Cold versus hot endoscopic mucosal resection for large sessile colon polyps: a cost-effectiveness analysis.

BACKGROUND : For large sessile colorectal polyps (LSCPs), endoscopic mucosal resection without diathermy ("cold endoscopic mucosal resection [EMR]") is gaining popularity because of its safety advantages over conventional EMR ("hot EMR"). Polyp recurrence rates have been reported to be higher with cold EMR. Considering these differences, we performed a cost-effectiveness analysis of these two techniques. METHODS : A decision analysis model was constructed for EMR of an LSCP. The decision tree incorporated the EMR method, clip use, procedural mortality, adverse events and their management, and polyp recurrence. Outcomes included days of lost productivity and marginal cost difference. Adverse event and recurrence rates were extracted from the existing literature, giving emphasis to recent systematic reviews and randomized controlled trials. RESULTS : Through 30 months of follow-up, the average cost of removing an LSCP by cold EMR was US$5213, as compared to $6168 by hot EMR, yielding a $955 cost difference (95 % confidence interval $903-$1006). Average days of lost productivity were 6.2 days for cold EMR and 6.3 days for hot EMR. This cost advantage remained over several analyses accounting for variations in recurrence rates and clip closure strategies. Clip cost and LSCP recurrence rate had the greatest and the least impacts on the marginal cost difference, respectively. CONCLUSION : Cold EMR is the dominant strategy over hot EMR, with lower cost and fewer days of lost productivity. In theory, a complete transition to cold EMR for LSCPs in the USA could result in an annual cost saving approaching US$7 million to Medicare beneficiaries.

Variation in Aptitude of Trainees in Endoscopic Ultrasonography, Based on Cumulative Sum Analysis.

BACKGROUND & AIMS: Studies have reported substantial variation in the competency of advanced endoscopy trainees, indicating a need for more supervised training in endoscopic ultrasound (EUS). We used a standardized, validated, data collection tool to evaluate learning curves and measure competency in EUS among trainees at multiple centers. METHODS: In a prospective study performed at 15 centers, 17 trainees with no prior EUS experience were evaluated by experienced attending endosonographers at the 25th and then every 10th upper EUS examination, over a 12-month training period. A standardized data collection form was used (using a 5-point scoring system) to grade the EUS examination. Cumulative sum analysis was applied to produce a learning curve for each trainee; it tracked the overall performance based on median scores at different stations and also at each station. Competency was defined by a median score of 1, with acceptable and unacceptable failure rates of 10% and 20%, respectively. RESULTS: Twelve trainees were included in the final analysis. Each of the trainees performed 265 to 540 EUS examinations (total, 4257 examinations). There was a large amount of variation in their learning curves: 2 trainees crossed the threshold for acceptable performance (at cases 225 and 245), 2 trainees had a trend toward acceptable performance (after 289 and 355 cases) but required continued observation, and 8 trainees needed additional training and observation. Similar results were observed at individual stations. CONCLUSIONS: A specific case load does not ensure competency in EUS; 225 cases should be considered the minimum caseload for training because we found that no trainee achieved competency before this point. Ongoing training should be provided for trainees until competency is confirmed using objective measures.

Open-access endoscopy.

OAE is commonly used. The majority of patients referred for OAE are considered appropriate for endoscopy according to ASGE guidelines. Most patients undergoing OAE procedures are knowledgeable about the study and are satisfied with the experience. Several potential problems have been identified, including inappropriate referrals, communication errors, and inadequately prepared or informed patients. OAE can be safely used if preprocedure assessment, informed consent, information transfer, patient safety, and satisfaction are addressed in all cases.

The role of endoscopy in the management of GERD.

We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. 44BB We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. We suggest that endoscopy be considered in patients with multiple risk factors for Barrett's esophagus. We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett's esophagus. We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options.

Development of a program to train physician extenders to perform transnasal esophagoscopy and screen for Barrett's esophagus.

BACKGROUND & AIMS: Screening for Barrett's esophagus (BE) and esophageal adenocarcinoma is not recommended because it was not found to be cost effective. However, physician extenders (PEs) are able to perform unsedated procedures; their involvement might reduce the costs of BE screening. We examined the feasibility of training PEs to independently perform transnasal esophagoscopy (TNE) and screen patients for BE and measured their learning curve. METHODS: Two PEs at a Veterans Affairs (VA) medical center underwent a structured didactic training program and observed nasopharyngoscopies before performing TNE under the supervision of attending endoscopists. Individual technical and cognitive components of TNE were rated on a 9-point structured scale. Learning curves were constructed using cumulative summation. Once the PEs were judged to be technically competent, each PE performed 10 independent videotaped TNEs, which were graded. RESULTS: Both PEs identified anatomic landmarks after 18 consecutive procedures. PE1 and PE2 performed satisfactory nasal intubations after 20 and 25 procedures and esophageal intubations after 29 and 35 procedures, respectively. They acquired overall competence after supervised training on 43 and 47 procedures, respectively. CONCLUSIONS: We developed a program at a VA medical center to train PEs to perform TNE to screen for BE. The PEs were able to perform TNE and recognize esophageal landmarks independently after a modest number of supervised procedures.

Comparative acceptability of transnasal esophagoscopy and esophageal capsule esophagoscopy: a randomized, controlled trial in veterans.

BACKGROUND: EGD screening for Barrett's esophagus (BE) is costly, with insufficient evidence to support its effectiveness. OBJECTIVE: To compare acceptance and tolerability of 2 novel, office-based, endoscopic screening techniques done on nonsedated patients. DESIGN: Randomized block study design with allocation concealment. SETTING: Outpatient clinic setting at a Veterans Affairs medical center. PATIENTS: A total of 184 veterans with or without GERD symptoms. INTERVENTIONS: Transnasal esophagoscopy (TNE) or esophageal capsule esophagoscopy (ECE). MAIN OUTCOME MEASUREMENTS: Acceptance and tolerability of TNE and ECE and effectiveness of BE screening. RESULTS: Esophageal screening was accepted by 184 of 1210 (15.2%) veterans. The majority were men (96%) and African American (58%), with a mean (± standard deviation) age of 58.9 (± 8.1) years. Five TNE participants (5%) and 2 ECE participants (2%) refused the assigned procedure after randomization (P = .25). Eleven patients (12.6%) randomized to TNE crossed the minimal clinically important threshold for overall procedure tolerability, as opposed to no patients randomized to ECE (P = .001). Effectiveness of BE screening was not significantly different in both procedures (TNE vs ECE = 3.2% vs 5.4%; P = .47). Overall, BE was present in 8 of 75 white participants (10.6%) and in 0 of 107 African American participants (P < .001). LIMITATIONS: The general veteran population may not reflect the screening population for BE. CONCLUSION: Despite a small proportion of veterans expressing interest in esophageal screening, both TNE and ECE were feasible in the outpatient clinic setting and were accepted by >95% of participants who did express an interest. Screening was effective only in white participants. Moderate differences in tolerability between TNE and ECE notwithstanding, cost considerations along with availability of equipment and trained personnel should guide the modality to be used for BE screening.

Small-bowel endoscopy core curriculum.

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.

Immediate unprepared hydroflush colonoscopy for severe lower GI bleeding: a feasibility study.

BACKGROUND: Urgent colonoscopy is not always the preferred initial intervention in severe lower GI bleeding because of the need for a large volume of oral bowel preparation, the time required for administering the preparation, and concern regarding adequate visualization. OBJECTIVE: To evaluate the feasibility, safety, and outcomes of immediate unprepared hydroflush colonoscopy for severe lower GI bleeding. DESIGN: Prospective feasibility study of immediate colonoscopy after tap-water enema without oral bowel preparation, aided by water-jet pumps and mechanical suction devices in patients admitted to the intensive care unit with a primary diagnosis of severe lower GI bleeding. SETTING: Tertiary referral center. MAIN OUTCOME MEASUREMENTS: Primary outcome measurement was the percentage of colonoscopies in which the preparation permitted satisfactory evaluation of the entire length of the colon suspected to contain the source of bleeding. Secondary outcome measurements were visualization of a definite source of bleeding, length of hospital and intensive care unit (ICU) stays, rebleeding rates, and transfusion requirements. RESULTS: Thirteen procedures were performed in 12 patients. Complete colonoscopy to the cecum was performed in 9 of 13 patients (69.2%). However, endoscopic visualization was thought to be adequate for definitive or presumptive identification of the source of bleeding in all procedures, with no colonoscopy repeated because of inadequate preparation. A definite source of bleeding was identified in 5 of 13 procedures (38.5%). The median length of ICU stay was 1.5 days; of hospital stay, 4.3 days. Recurrent bleeding during the same hospitalization, requiring repeated endoscopy, surgery, or angiotherapy, was seen in 3 of 12 patients (25%). LIMITATIONS: Uncontrolled feasibility study of selected patients. CONCLUSION: Immediate unprepared hydroflush colonoscopy in patients with severe lower GI bleeding is feasible with the hydroflush technique.

Characterization of the pancreas in vivo using EUS spectrum analysis with electronic array echoendoscopes.

BACKGROUND: Spectral analysis of the radiofrequency (RF) signals that underlie grayscale EUS images has been used to provide quantitative, objective information about tissue histology. OBJECTIVE: Our purpose was to validate RF spectral analysis as a method to distinguish between chronic pancreatitis (CP) and pancreatic cancer (PC). DESIGN AND SETTING: A prospective study of eligible patients was conducted to analyze the RF data obtained by using electronic array echoendoscopes. PATIENTS: Pancreatic images were obtained by using electronic array echoendoscopes from 41 patients in a prospective study, including 15 patients with PC, 15 with CP, and 11 with a normal pancreas. MAIN OUTCOME MEASUREMENTS: Midband fit, slope, intercept, correlation coefficient, and root mean square deviation from a linear regression of the calibrated power spectra were determined and compared among the groups. RESULTS: Statistical analysis showed that significant differences were observable between groups for mean midband fit, intercept, and root mean square deviation (t test, P < .05). Discriminant analysis of these parameters was then performed to classify the data. For CP (n = 15) versus PC (n = 15), the same parameters provided 83% accuracy and an area under the curve of 0.83. LIMITATIONS: Moderate sample size and spatial averaging inherent in the technique. CONCLUSIONS: This study shows that mean spectral parameters of the backscattered signals obtained by using electronic array echoendoscopes can provide a noninvasive method to quantitatively discriminate between CP and PC.

Feasibility, safety, acceptability, and yield of office-based, screening transnasal esophagoscopy (with video).

BACKGROUND: Endoscopic screening for esophageal neoplasia can identify patients eligible for early intervention for precancerous lesions. Unsedated transnasal esophagoscopy may provide an efficient and accurate endoscopic assessment with fewer risks and less cost, compared with conventional upper endoscopy. OBJECTIVE: To assess the feasibility, safety, acceptability, and yield of unsedated transnasal esophagoscopy in a primary care population. DESIGN: Multicenter, prospective, cross-sectional study. SETTING: Two outpatient tertiary-care centers. PATIENTS: This study involved a general medical clinic population aged between 40 and 85 years. INTERVENTION: Unsedated, office-based transnasal esophagoscopy. MAIN OUTCOME MEASUREMENTS: Procedure yield; completeness of examination; procedure length; adverse events and complications; choking, gagging, pain, or anxiety during the examination; and overall tolerability. RESULTS: A total of 426 participants (mean [± standard deviation] age 55.8 ± 9.5 years; 43% male) enrolled in the study, and 422 (99%) completed the examination. Mean (± standard deviation) examination time was 3.7 ± 1.8 minutes. There were no serious adverse events, and 12 participants (2.8%) reported minor complications. Participants reported minimal choking, gagging, pain, or anxiety. The examination was well-tolerated by most participants. Overall, 38% of participants had an esophageal finding that changed management (34% erosive esophagitis, 4% Barrett's esophagus). LIMITATIONS: Nonrandomized study, tertiary-care centers only, self-selected population with a large proportion reporting esophageal symptoms. CONCLUSION: Unsedated transnasal esophagoscopy is a feasible, safe, and well-tolerated method to screen for esophageal disease in a primary care population. Endoscopic findings are common in this patient population.

Variability in measurements of pancreatic cyst size among EUS, CT, and magnetic resonance imaging modalities.

BACKGROUND: Cyst size is an important factor in the management of pancreatic cysts, both in predicting the need for surgery and the frequency of follow-up. OBJECTIVE: To determine agreement and precision of EUS, CT, and magnetic resonance imaging (MRI) modalities in the evaluation of pancreatic cyst diameter. DESIGN: Retrospective chart review. SETTING: Tertiary-care center, January 2000 to June 2009. PATIENTS: This study involved 175 patients presenting for EUS evaluation of pancreatic cysts, with size measured by at least two of the aforementioned imaging studies within a 90-day period. MAIN OUTCOME MEASUREMENTS: Largest cyst diameter from EUS, CT, MRI/MRCP, and surgical pathology. RESULTS: A total of 175 patients underwent EUS. Seventy-three had CT plus EUS, 33 had MRI/MRCP plus EUS, 23 had MRI/MRCP plus CT, and 15 had all imaging studies, occurring within 90 days of each other. Median size differences between studies: EUS and CT (ie, absolute value of size determined by EUS minus size determined by CT) = 4 mm (range 0-25 mm), EUS and MRI = 4 mm (range 0-17 mm), CT and MRI = 3 mm (range 2-20 mm). Median size differences for surgical pathology specimens compared with results of 12 EUS, 13 CT, and 8 MRI/MRCP studies were as follows: EUS and pathology = 9.5 mm (range 0-20 mm), CT and pathology = 5 mm (range 0-21 mm), MRI and pathology = 5.5 mm (range 2-44 mm). LIMITATIONS: Interobserver variability and small sample of surgical pathology cysts. CONCLUSION: There is considerable variation in size estimates of pancreatic cysts by different imaging modalities, which practitioners should take into account when making management decisions. Use of a single imaging modality is recommended during follow-up. The precision of imaging studies for measuring pancreatic cysts must be prospectively defined if change in size is to be reliably used for clinical management.

Initial evaluation of a novel, prototype, forward-viewing echoendoscope in a porcine arterial bleeding model (with video).

BACKGROUND: Real-time visualization of submucosal arterial flow at the base of an ulcer might improve endoscopic hemostasis by permitting more accurate assessment of the artery, precise targeting of therapy, and confirmation of vessel ablation. OBJECTIVE: To evaluate the utility of a novel, forward-viewing echoendoscope in identifying bleeding submucosal arteries, guiding hemostatic therapy, and confirming cessation of flow through treated vessels. DESIGN: In 7 pigs, a previously described porcine model for peptic ulcer hemorrhage was created by isolating the gastroepiploic and/or short gastric artery and tunneling it into the subserosal space at laparotomy. SETTING: Animal research facility. INTERVENTION: The prototype endoscope was used to image submucosal arterial flow. EUS guidance was then used to deliver endoscopic hemostatic therapy and assess treatment adequacy. MAIN OUTCOME MEASUREMENTS: Identification of the target submucosal artery and successful delivery of EUS-guided endoscopic therapy, evidenced by cessation of Doppler flow through the target vessel. RESULTS: Tunneled arteries were visualized endosonographically in all 7 cases. EUS-guided submucosal injection of epinephrine was successful in 2 of 2 cases. EUS-guided delivery of thermal hemostatic therapy was successful in 2 of 4 cases. Absence of flow through treated vessels was confirmed in cases in which EUS-guided therapy was successfully delivered. LIMITATIONS: Acute animal model. CONCLUSION: Proof of principle experiments in a porcine peptic ulcer hemorrhage model suggest that real-time sonographic imaging of submucosal arteries is feasible with a forward-viewing echoendoscope, and guided hemostatic therapy can be delivered.