An Approach to the Primary and Secondary Prevention of Gastric Cancer in the United States.

BACKGROUND & AIMS: Gastric cancer (GC) remains a leading cause of mortality among certain racial, ethnic, and immigrant groups in the United States (US). The majority of GCs are diagnosed at advanced stages, and overall survival remains poor. There exist no structured national strategies for GC prevention in the US. METHODS: On March 5-6, 2020 a summit of researchers, policy makers, public funders, and advocacy leaders was convened at Stanford University to address this critical healthcare disparity. After this summit, a writing group was formed to critically evaluate the effectiveness, potential benefits, and potential harms of methods of primary and secondary prevention through structured literature review. This article represents a consensus statement prepared by the writing group. RESULTS: The burden of GC is highly inequitably distributed in the US and disproportionately falls on Asian, African American, Hispanic, and American Indian/Alaskan Native populations. In randomized controlled trials, strategies of Helicobacter pylori testing and treatment have been demonstrated to reduce GC-specific mortality. In well-conducted observational and ecologic studies, strategies of endoscopic screening have been associated with reduced GC-specific mortality. Notably however, all randomized controlled trial data (for primary prevention) and the majority of observational data (for secondary prevention) are derived from non-US sources. CONCLUSIONS: There exist substantial, high-quality data supporting GC prevention derived from international studies. There is an urgent need for cancer prevention trials focused on high-risk immigrant and minority populations in the US. The authors offer recommendations on how strategies of primary and secondary prevention can be applied to the heterogeneous US population.

Recommendations for follow-up interval after colonoscopy with inadequate bowel preparation in a national colonoscopy quality registry.

BACKGROUND AND AIMS: Endoscopist recommendations regarding a repeat colonoscopy after inadequate bowel cleanliness have not been fully described. Our aim was to evaluate the timing of recommendations for repeat colonoscopy after inadequate bowel preparation using a large, national colonoscopy registry. METHODS: We performed a cross-sectional analysis of all outpatient screening and surveillance colonoscopies among adults ages 50 to 75 reported in the GI Quality Improvement Consortium from 2011 to 2018. The primary outcome was a recommendation to repeat colonoscopy within 1 year. Secondary outcomes were recommendations based on indication of colonoscopy and colonoscopy findings and predictors of a recommendation to follow-up within 1 year. RESULTS: There were 260,314 colonoscopies with inadequate bowel preparation performed at 672 different sites by 4001 endoscopists. Of these, 31.9% contained a recommendation for follow-up within 1 year. This did not differ meaningfully by examination indication. The severity of colonoscopy findings influenced the recommendations for follow-up (within 1 year in 84.0% of cases with adenocarcinoma, 51.8% with any advanced lesion, and 23.2% with 1-2 small adenomas). Younger age, more severe pathology, location in the Northeast, and performance by an endoscopist with an adenoma detection rate ≥25% were associated with recommendations for follow-up within 1 year. CONCLUSIONS: Only some colonoscopies with inadequate bowel preparation are recommended to be repeated within 1 year, which may have implications for potential missed lesions. Further understanding of reasons driving recommendations is an important next step to improving guideline-concordant colonoscopy practice.

Gender-Specific Factors Influencing Gastroenterologists to Pursue Careers in Advanced Endoscopy: Perceptions vs Reality.

INTRODUCTION: In 2020, only 19% of 63 matched advanced endoscopy (AE) fellows were women. This study evaluates the gender-specific factors that influence gastroenterologists to pursue careers in AE. METHODS: An anonymous survey was distributed to gastroenterology fellows and attendings through various gastroenterology society online forums. Data were collected on demographics, training, mentorship, current practice, family planning, and career satisfaction. RESULTS: Women comprised 71.1% of the 332 respondents. 24.7% of female fellows plan to pursue an AE career compared with 37.5% of male fellows (P = 0.195). The main motivating factor for both genders was interest in the subject area. Interest in another subspecialty was the main deterring factor for both genders. Women were more deterred by absence of same-sex mentors (P < 0.001), perception of gender-based bias in the workplace (P = 0.009), family planning (P = 0.018), fertility/pregnancy risks from radiation (P < 0.001), and lack of ergonomic equipment (P = 0.003). AE gastroenterologists of both genders were satisfied with their career decision and would recommend the field to any fellow. Most respondents (64%) believed that more female role models/mentors would improve representation of women in AE. DISCUSSION: There are multiple gender-specific factors that deter women from pursuing AE. Increasing the number of female role models is strongly perceived to improve representation of women in AE. Most AE attendings are satisfied with their career and would recommend it to fellows of any gender. Thus, early targeted mentorship of female trainees has potential to improve recruitment of women to the field.

Survey Finds Gender Disparities Impact Both Women Mentors and Mentees in Gastroenterology.

INTRODUCTION: Gastroenterologists at all levels of practice benefit from formal mentoring. Much of the current literature on mentoring in gastroenterology is based on expert opinion rather than data. In this study, we aimed to identify gender-related barriers to successful mentoring relationships from the mentor and mentee perspectives. METHODS: A voluntary, web-based survey was distributed to physicians at 20 academic institutions across the United States. Overall, 796 gastroenterology fellows and faculty received the survey link, with 334 physicians responding to the survey (42% response rate), of whom 299 (90%; 129 women and 170 men) completed mentorship questions and were included in analysis. RESULTS: Responses of women and men were compared. Compared with men, more women preferred a mentor of the same gender (38.6% women vs 4.2% men, P < 0.0001) but less often had one (45.5% vs 70.2%, P < 0.0001). Women also reported having more difficulty finding a mentor (44.4% vs 16.0%, P < 0.0001) and more often cited inability to identify a mentor of the same gender as a contributing factor (12.8% vs 0.9%, P = 0.0004). More women mentors felt comfortable advising women mentees about work-life balance (88.3% vs 63.8%, P = 0.0005). Nonetheless, fewer women considered themselves effective mentors (33.3% vs 52.6%, P = 0.03). More women reported feeling pressured to mentor because of their gender (39.5% vs 0.9% of men, P < 0.0001). Despite no gender differences, one-third of respondents reported negative impact of the COVID-19 pandemic on their ability to mentor and be mentored. DISCUSSION: Inequities exist in the experiences of women mentees and mentors in gastroenterology, which may affect career advancement and job satisfaction.

Gender dynamics in education and practice of gastroenterology.

BACKGROUND AND AIMS: With an increasing number of women joining procedural fields, including gastroenterology, optimizing the work environment for learning, teaching, and clinical practice is essential to the well-being of both physicians and their patients. We queried female and male gastroenterologists on their beliefs toward the endoscopy suite environment, as well as their experiences in learning and teaching endoscopic skills. METHODS: We distributed a web-based survey to 403 gastroenterology fellows and practicing gastroenterologists at 12 academic institutions and 3 large private practices. We used univariate and multivariate analysis to compare the responses of female and male gastroenterologists. RESULTS: The overall response rate was 32% (n = 130); 54 women and 61 men completed the survey in its entirety and were included in the analysis (15 respondents did not meet the inclusion criteria). Baseline demographics were comparable between the groups. Overall, fewer women than men were trained using tactile instruction (41% vs 67%; P = .004). Of those trained using tactile instruction, 60.3%, with no gender differences, felt it was also important for endoscopic learning. More women reported experiencing gender bias toward themselves during training (57.4% vs 13.1%; P = .001) as well as in their current careers (50.0% vs 9.8%; P = .001). When queried on treatment of gastroenterologists by endoscopy staff, 75.9% of women reported that men were treated more favorably, whereas 70.5% of men felt that both male and female gastroenterologists were treated equally. CONCLUSIONS: Inequities exist with regard to the experience of men and women in gastroenterology, and specific challenges for women may have an impact on their career choices and ability to safely and effectively learn, teach, and practice endoscopy.

Pancreatic Fungal Infection in Patients With Necrotizing Pancreatitis: A Systematic Review and Meta-analysis.

GOAL: The goal of this study was to study the incidence of fungal infection in necrotizing pancreatitis (NP) and its impact on mortality. BACKGROUND: Infected pancreatic necrosis is a major contributor to morbidity and mortality in patients with NP. While pancreatic fungal infection (PFI) has frequently been identified in patients with NP, its effect on the clinical outcomes is unclear. MATERIALS AND METHODS: A literature search was performed in Medline (Ovid), Embase (Ovid), and the Cochrane library. All prospective and retrospective studies that examined the incidence of fungal infection in NP with subgroup mortality data were included. For fungal infection of NP, studies with fungal isolation from pancreatic necrotic tissue were included. Newcastle Ottawa Scale and Joanna Briggs Institute's critical appraisal tool were used for bias assessment. RESULTS: Twenty-two studies comprising 2151 subjects with NP were included for the quantitative analysis. The mean incidence of fungal infection was 26.6% (572/2151). In-hospital mortality in the pooled sample of NP patients with PFI (N=572) was significantly higher [odds ratio (OR)=3.95, 95% confidence interval (CI): 2.6-5.8] than those without PFI. In a separate analysis of 7 studies, the mean difference in the length of stay between those with and without fungal infection was 22.99 days (95% CI: 14.67-31.3). The rate of intensive care unit admission (OR=3.95; 95% CI: 2.6-5.8), use of prophylactic antibacterials (OR=2.76; 95% CI: 1.31-5.81) and duration of antibacterial therapy (mean difference=8.71 d; 95% CI: 1.33-16.09) were all significantly higher in patients with PFI. Moderate heterogeneity was identified among the studies on estimating OR for mortality (I2=43%) between the 2 groups. CONCLUSIONS: PFI is common in patients with NP and is associated with increased mortality, intensive care unit admission rate, and length of stay. Further prospective studies are needed to better understand the pathophysiology of PFIs and to determine the role for preemptive therapeutic strategies, such as prophylactic antifungal therapy.

Yield and Practice Patterns of Surveillance Colonoscopy Among Older Adults: An Analysis of the GI Quality Improvement Consortium.

OBJECTIVES: There is little guidance regarding when to stop surveillance colonoscopy in individuals with a history of adenomas or colorectal cancer (CRC). We evaluated both yield and recommendations for follow-up colonoscopy in a large cohort of older individuals undergoing colonoscopy, using the GI Quality Improvement Consortium registry. METHODS: We analyzed the yield of colonoscopy in adults aged ≥75 years, comparing those who had an indication of surveillance as opposed to an indication of diagnostic or screening, stratified by 5-year age groups. Our primary outcome was CRC and advanced lesions. We also evaluated recommended follow-up intervals by age and findings. RESULTS: Between 2010 and 2017, 376,686 colonoscopies were performed by 3,976 endoscopists at 628 sites, of which 43.2% were for surveillance. Detection of CRC among surveillance patients increased with age from 0.51% (age 75-79 years) to 1.8% (age ≥ 90 years); however, these risks were lower when compared with both the diagnostic and screening for the same age band (P < 0.0001). Yield of advanced lesions also increased by every 5-year interval of age across all groups by indication. Even at the most advanced ages and in those with nonadvanced findings, only a minority of patients were recommended for no further colonoscopy. For example, in patients aged 90 years and older with only low risk findings, 62.9% were recommended to repeat colonoscopy. DISCUSSION: Surveillance colonoscopy is frequently recommended at advanced ages even when recent findings may be clinically insignificant. Further work is needed to develop guidelines to inform best practice around when to stop surveillance in older adults.

Segmental increases in force application during colonoscope insertion: quantitative analysis using force monitoring technology.

BACKGROUND: Colonoscopy is a frequently performed procedure that requires extensive training and a high skill level. OBJECTIVE: Quantification of forces applied to the external portion of the colonoscope insertion tube during the insertion phase of colonoscopy. DESIGN: Observational cohort study of 7 expert and 9 trainee endoscopists for analysis of colonic segment force application in 49 patients. Forces were measured by using the colonoscopy force monitor, which is a wireless, handheld device that attaches to the insertion tube of the colonoscope. SETTING: Academic gastroenterology training programs. PATIENTS: Patients undergoing routine screening or diagnostic colonoscopy with complete segment force recordings. MAIN OUTCOME MEASUREMENTS: Axial and radial force and examination time. RESULTS: Both axial and radial force increased significantly as the colonoscope was advanced from the rectum to the cecum. Analysis of variance demonstrated highly significant operator-independent differences between segments of the colon (zones) in all axial and radial forces except average torque. Expert and trainee endoscopists differed only in the magnitude of counterclockwise force, average push/pull force rate used, and examination time. LIMITATIONS: Small study, observational design, effect of prototype device on insertion tube manipulation. CONCLUSION: Axial and radial forces used to advance the colonoscope increase through the segments of the colon and are operator independent.

Upper Gastrointestinal Bleeding.

Upper gastrointestinal (GI) bleeding is a common reason for hospital admission in older adult patients and carries a high morbidity and mortality if not properly managed. Risk factors include advanced age, Helicobacter pylori infection, medication use, smoking, and history of liver disease. Patients with known or suspected liver disease and suspected variceal bleeding should also receive antibiotics and somatostatin analogues. Risk stratification scores should be used to determine patients at highest risk for further decompensation. Upper endoscopy is both a diagnostic and therapeutic tool used in the management of upper GI bleeding. Endoscopy should be performed within 24 hours of presentation after appropriate resuscitation. Management of anticoagulation in upper GI bleeding largely depends on the indication for anticoagulation, the risk of continued bleeding with continuing the medication, and the risk of thrombosis with discontinuing the medication. A multidisciplinary approach to the decision of anticoagulation continuation is preferred when possible.

Prevention of Recurrent Lower Gastrointestinal Hemorrhage.

This article summarizes current knowledge regarding the incidence of and risk factors associated with recurrent lower gastrointestinal hemorrhage. The literature regarding medical, endoscopic, and surgical methods to prevent rebleeding from diverticulosis, angioectasia, and chronic hemorrhagic radiation proctopathy is reviewed. In addition, the evidence for endoscopic clipping as primary prophylaxis against postpolypectomy bleeding is explored.

Peri-procedure pharmacotherapy, preparation, and infection control.

Minimizing endoscopic complications includes attention to the details about each patient's current medical condition before they undergo an invasive procedure. This article focuses on critical issues about proper preparation for endoscopic procedures and examines potential modifications to a patient's medical regimen near the time of an endoscopic procedure, highlighting recently published standards and guidelines. This article also reviews important issues related to infection control in endoscopy.

Current Management of Benign Epithelial Gastric Polyps.

OPINION STATEMENT: Purpose of review Benign epithelial gastric polyps, although typically asymptomatic, are identified incidentally on upper endoscopy in up to 23% of patients. These include fundic gland, hyperplastic, and adenomatous polyps. Their appropriate characterization is critical as some have malignant potential, may be indicative of a gastric mucosal field defect, or may be related to an underlying polyposis syndrome. This review will discuss the current management of benign epithelial gastric polyps. Recent findings Association of gastric polyps with proton pump inhibitor use, Helicobacter pylori infection, risk of malignant transformation, and association with polyposis syndromes have been the focus of recent literature. Summary All symptomatic polyps, polyps larger than 1 cm in size, and polyps later found to contain dysplasia or cancer should be completely removed. Additionally, random biopsies from the intervening non-polypoid mucosa should be obtained. Finally, identification of multiple polyps of fundic gland type and/or concomitant dysplasia should raise suspicion for an underlying polyposis syndrome and prompt appropriate workup. Surveillance is generally only indicated if there is confirmed dysplasia and/or carcinoma within the polyp itself or if preneoplastic changes are identified in the non-polypoid gastric mucosa.