A national evaluation of geographic accessibility and provider availability of obesity medicine diplomates in the United States between 2011 and 2019.

BACKGROUND/OBJECTIVES: Obesity is a pressing health concern within the United States (US). Obesity medicine "diplomates" receive specialized training, yet it is unclear if their accessibility and availability adequately serves the need. The purpose of this research was to understand how accessibility has evolved over time and assess the practicality of serving an estimated patient population with the current distribution and quantity of diplomates. METHODS: Population-weighted Census tracts in US counties were mapped to the nearest facility on a road network with at least one diplomate who specialized in adult (including geriatric) care between 2011 and 2019. The median travel time for all Census tracts within a county represented the primary geographic access measure. Availability was assessed by estimating the number of diplomates per 100 000 patients with obesity and the number of facilities able to serve assigned patients under three clinical guidelines. RESULTS: Of the 3371 diplomates certified since 2019, 3036 were included. The median travel time (weighted for county population) fell from 28.5 min [IQR: 13.7, 68.1] in 2011 to 9.95 min [IQR: 7.49, 18.1] in 2019. There were distinct intra- and inter-year travel time variations by race, ethnicity, education, median household income, rurality, and Census region (all P < 0.001). The median number of diplomates per 100 000 with obesity grew from 1 [IQR: 0.39, 1.59] in 2011 to 5 [IQR: 2.74, 11.4] in 2019. In 2019, an estimated 1.7% of facilities could meet the recommended number of visits for all mapped patients with obesity, up from 0% in 2011. CONCLUSIONS: Diplomate geographic access and availability have improved over time, yet there is still not a high enough supply to serve the potential patient demand. Future studies should quantify patient-level associations between travel time and health outcomes, including whether the number of available diplomates impacts utilization.

Radiofrequency ablation for the treatment of weight regain after Roux-en-Y gastric bypass surgery.

BACKGROUND AND AIMS: Roux-en-Y gastric bypass (RYGB) surgery is an established modality for the treatment of morbid obesity. However, approximately one-quarter of patients experience weight regain after initially successful weight loss. Endoscopic therapy targeting the gastric remnant pouch represents a novel potential strategy to re-induce weight loss in this population. We performed a pilot trial of radiofrequency ablation (RFA) of the gastric remnant pouch after RYGB to determine feasibility, safety, and efficacy for weight loss. METHODS: We identified patients who had undergone RYGB, achieved >40% excess body weight loss (EBWL), and then regained >25% of lost weight. RFA was applied to the gastrojejunal anastomosis and the entire surface area of the gastric remnant pouch. Treatment was repeated at 4 and 8 months if patients did not meet specified weight loss targets. Weekly weights were obtained for 12 months. The primary efficacy outcome was percent EBWL at 12 months, compared with baseline. RESULTS: Twenty-five patients were enrolled at 4 centers. Mean (± standard deviation [SD]) age was 45.4 ± 9.1 years, and 84% (21/25) were female. Mean (± SD) baseline body mass index was 40.2 ± 7.8. Twenty-two of 25 patients completed 12 months of follow-up. At 12 months, median (± SD) EBWL was 18.4% (interquartile ratio 10.8, 33.7; P < .0001). Significant weight loss was seen at 3.5 months (P < .0001) and at 7.5 months (P < .0001), with a significant trend for continued weight loss over the 12-month period (P = .013). Two patients had serious adverse events requiring hospitalization. CONCLUSIONS: RFA of the gastric remnant pouch in patients with weight regain after RYGB resulted in significant reductions in excess body weight with an acceptable safety profile. Continued weight loss was observed after each RFA treatment. Further clinical trials in well-selected populations are warranted to determine the optimal number and frequency of RFA treatments and to assess durability of weight loss. (Clinical trial registration number: NCT01910688.).

Subsquamous intestinal metaplasia is common in treatment-naïve Barrett's esophagus.

BACKGROUND AND AIMS: Barrett's intestinal metaplasia may extend beneath normal squamous epithelium at the squamocolumnar junction (SCJ) and therefore escape surveillance biopsy sampling. The prevalence of subsquamous intestinal metaplasia (SSIM) in patients undergoing Barrett's esophagus (BE) surveillance is unknown. Our aim was to examine the prevalence and distribution of SSIM proximal to the SCJ in patients undergoing BE surveillance. METHODS: We enrolled consecutive patients with biopsy specimen-proven BE. Biopsy specimens were obtained from the squamous epithelium at 5 mm and 10 mm above the SCJ. The primary outcomes were the proportion of patients with SSIM at each level. We further assessed factors associated with SSIM. RESULTS: We examined 515 squamous epithelial biopsy specimens from 106 BE patients (95% men; mean age, 66 years) with a mean Barrett's length of 3.0 cm. SSIM was present in 39% at 5 mm (95% CI, 29.4-48.6) and 21% (95% CI, 11.7-32.1) at 10 mm proximal to the SCJ. Among all biopsy specimens, 13% (95% CI, 10.6-16.6) contained SSIM: 17% (95% CI, 13-21.6) of biopsy samples at 5 mm and 8% (95% CI, 4.3-12.2) at 10 mm proximal to the SCJ. SSIM was more common in the anterior/right lateral position compared with the posterior/left lateral position (21% vs 11%, P = .001). None of the biopsy specimens showed dysplasia. Length of BE or duration of reflux symptoms were not associated with the presence of SSIM. CONCLUSIONS: This cross-sectional study found a surprisingly high proportion of SSIM in treatment-naïve patients proximal to the SCJ. These findings raise questions regarding BE management and the prevalence of SSIM in normal-appearing esophagus.

Incidence of Esophageal Adenocarcinoma and Causes of Mortality After Radiofrequency Ablation of Barrett's Esophagus.

BACKGROUND & AIMS: Radiofrequency ablation (RFA) is commonly used to treat Barrett's esophagus (BE). We assessed the incidence of esophageal adenocarcinoma (EAC) after RFA, factors associated with the development of EAC, and EAC-specific and all-cause mortality. METHODS: We collected data for outcomes of patients who underwent RFA for BE from July 2007 through July 2011 from US multicenter RFA Patient Registry. Patients were followed until July 2014. Kaplan-Meier curves of EAC incidence were stratified by baseline histology. Crude EAC incidence and mortality (all-cause and EAC-specific) were calculated, and adjusted all-cause mortality was assessed. Logistic regression models were constructed to assess predictors of EAC and all-cause mortality. RESULTS: Among 4982 patients, 100 (2%) developed EAC (7.8/1000 person-years [PY]) and 9 patients (0.2%) died of EAC (0.7/1000 PY) in a mean 2.7 ± 1.6 years. The incidence of EAC in nondysplastic BE was 0.5/1000 PY. Overall, 157 patients (3%) died during follow-up (all-cause mortality, 11.2/1000 PY). On multivariate logistic regression, baseline BE length (odds ratio, 1.1/ cm) and baseline histology (odds ratios, 5.8 and 50.3 for low-grade dysplasia and high-grade dysplasia [HGD] respectively) predicted EAC incidence. Among 9 EAC deaths, 6 (67%) had baseline HGD, and 3 (33%) had baseline intramucosal EAC. The most common causes of death were cardiovascular (15%) and extraesophageal cancers (15%). No deaths were associated with RFA. CONCLUSIONS: Based on analysis of a multicenter registry of patients who underwent RFA of BE, less than 1% died from EAC. The incidence of EAC was markedly lower in this study than in other studies of disease progression, with the greatest absolute benefit observed in patients with HGD.

Quality of optical diagnosis of diminutive polyps and associated factors.

BACKGROUND AND AIMS: The aim of the study was to identify endoscopist-related and procedural factors that may be associated with the quality of optical diagnosis of diminutive polyps using narrow-band imaging (NBI). METHODS: All subjects who participated in a randomized trial on cap-assisted colonoscopy were eligible for the current study. Optical polyp diagnosis was an a priori outcome of the initial trial. Ten participating endoscopists used NBI to assess all of the diagnosed polyps as adenomatous or non-adenomatous in real-time and provided a degree of diagnostic certainty. The main outcome measures were quality benchmarks of optical diagnosis (negative predictive value [NPV] for diminutive rectosigmoid adenomas, agreement with pathology-based surveillance interval) and assessment of endoscopist-related and procedural factors potentially associated with the quality of optical diagnosis. RESULTS: A total of 1650 polyps were found in 607 patients, with 1311 polyps (79 %) being diminutive, of which 672 (53 %) were adenomatous. The NPV of optical diagnosis for rectosigmoid adenomas was 95 %. The optical diagnosis-based surveillance interval agreed with the pathology-based recommendation in 93 % of patients. Prior experience with image-enhanced endoscopy had no effect on optical diagnosis. Low and high adenoma detectors were not different in achieving the quality benchmarks. Cap-assisted colonoscopy was not associated with quality of optical diagnosis. Quality metrics of optical diagnosis remained similar during the first and second half of the study period. CONCLUSION: High quality optical diagnosis of diminutive polyps can be achieved and sustained by endoscopists previously inexperienced in this practice with minimal training. None of the examined factors appear to affect the quality of optical diagnosis; particularly, endoscopists' adenoma detection was not associated with optical diagnosis.

Sex and race and/or ethnicity differences in patients undergoing radiofrequency ablation for Barrett's esophagus: results from the U.S. RFA Registry.

BACKGROUND: Little is known about differences in Barrett's esophagus (BE) characteristics by sex and race and/or ethnicity or these differences in response to radiofrequency ablation (RFA). OBJECTIVE: We compared disease-specific characteristics, treatment efficacy, and safety outcomes by sex and race and/or ethnicity in patients treated with RFA for BE. DESIGN: The U.S. RFA patient registry is a multicenter collaboration reporting processes and outcomes of care for patients treated with RFA for BE. PATIENTS: Patients enrolled with BE. INTERVENTIONS: RFA. MAIN OUTCOME MEASUREMENTS: We assessed safety (stricture, bleeding, perforation, hospitalization), efficacy (complete eradication of intestinal metaplasia [CEIM]), complete eradication of dysplasia, and number of treatments to CEIM by sex and race and/or ethnicity. RESULTS: Among 5521 patients (4052 men; 5126 white, 137 Hispanic, 82 African American, 40 Asian, 136 heritage not identified), women were younger (60.0 vs 62.1 years) and had shorter BE segments (3.2 vs 4.4 cm) and less dysplasia (37% vs 57%) than did men. Women were almost twice as likely to stricture (odds ratio 1.7; 95% confidence interval, 1.2-2.3). Although white patients were predominantly male, about half of African Americans and Asians with BE were female. African Americans and Asians had less dysplasia than white patients. Asians and African Americans had more strictures than did white patients. There were no sex or race differences in efficacy. LIMITATIONS: Observational study with non-mandated paradigms, no central laboratory for reinterpretation of pathology. CONCLUSION: In the U.S. RFA patient registry, women had shorter BE segments and less-aggressive histology. The usual tendency toward BE in men was absent in African Americans and Asians. Posttreatment stricture was more common among women and Asians. RFA efficacy did not differ by sex or race.

Cap-assisted colonoscopy and detection of Adenomatous Polyps (CAP) study: a randomized trial.

BACKGROUND AND STUDY AIM: Cap-assisted colonoscopy has improved adenoma detection in some but not other studies. Most previous studies have been limited by small sample sizes and few participating endoscopists. The aim of the current study was to evaluate whether cap-assisted colonoscopy improves adenoma detection in a two-center, multi-endoscopist, randomized trial. PATIENTS AND METHODS: Consecutive patients who presented for an elective colonoscopy were randomized to cap-assisted colonoscopy (4-mm cap) or standard colonoscopy performed by one of 10 experienced endoscopists. Primary outcome measures were mean number of adenomas per patient and adenoma detection rate (ADR). Secondary outcomes included procedural measures and endoscopist variation; a logistic regression model was employed to examine predictors of increased detection with cap use. RESULTS: A total of 1113 patients (64 % male, mean age 62 years) were randomized to cap-assisted (n = 561) or standard (n = 552) colonoscopy. The mean number of adenomas detected per patient in the cap-assisted and standard groups was similar (0.89 vs. 0.82; P = 0.432), as was the ADR (42 % vs. 40 %; P = 0.452). Cap-assisted colonoscopy achieved a faster cecal intubation time (4.9 vs. 5.8 minutes; P < 0.001), a similar cecal intubation rate (99 % vs. 98 %; P = 0.326), and a higher terminal ileum intubation rate (93 % vs. 89 %; P < 0.028). Cap-assisted colonoscopy resulted in a 20 % increase in ADR for some endoscopists and in a 15 % decrease for others. Individual preference for the cap was an independent predictor of increased adenoma detection in adjusted analysis (P < 0.001), whereas baseline low adenoma detection was not. CONCLUSION: Although the efficiency of cecal and terminal ileum intubation was slightly improved by cap-assisted colonoscopy, adenoma detection was not. Cap-assisted colonoscopy may be beneficial for selected endoscopists. TRIAL REGISTRATION: clinicalTrials.gov (NCT01935180).

Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study.

BACKGROUND & AIMS: Although the adenoma detection rate is used as a measure of colonoscopy quality, there are limited data on the quality of endoscopic resection of detected adenomas. We determined the rate of incompletely resected neoplastic polyps in clinical practice. METHODS: We performed a prospective study on 1427 patients who underwent colonoscopy at 2 medical centers and had at least 1 nonpedunculated polyp (5-20 mm). After polyp removal was considered complete macroscopically, biopsies were obtained from the resection margin. The main outcome was the percentage of incompletely resected neoplastic polyps (incomplete resection rate [IRR]) determined by the presence of neoplastic tissue in post-polypectomy biopsies. Associations between IRR and polyp size, morphology, histology, and endoscopist were assessed by regression analysis. RESULTS: Of 346 neoplastic polyps (269 patients; 84.0% men; mean age, 63.4 years) removed by 11 gastroenterologists, 10.1% were incompletely resected. IRR increased with polyp size and was significantly higher for large (10-20 mm) than small (5-9 mm) neoplastic polyps (17.3% vs 6.8%; relative risk = 2.1), and for sessile serrated adenomas/polyps than for conventional adenomas (31.0% vs 7.2%; relative risk = 3.7). The IRR for endoscopists with at least 20 polypectomies ranged from 6.5% to 22.7%; there was a 3.4-fold difference between the highest and lowest IRR after adjusting for size and sessile serrated histology. CONCLUSIONS: Neoplastic polyps are often incompletely resected, and the rate of incomplete resection varies broadly among endoscopists. Incomplete resection might contribute to the development of colon cancers after colonoscopy (interval cancers). Efforts are needed to ensure complete resection, especially of larger lesions. ClinicalTrials.gov Number: NCT01224444.

Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery.

BACKGROUND & AIMS: Weight regain or insufficient loss after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of RYGB. Endoluminal interventions for GJ reduction are being explored as alternatives to revision surgery. We performed a randomized, blinded, sham-controlled trial to evaluate weight loss after sutured transoral outlet reduction (TORe). METHODS: Patients with weight regain or inadequate loss after RYGB and GJ diameter greater than 2 cm were assigned randomly to groups that underwent TORe (n = 50) or a sham procedure (controls, n = 27). Intraoperative performance, safety, weight loss, and clinical outcomes were assessed. RESULTS: Subjects who received TORe had a significantly greater mean percentage weight loss from baseline (3.5%; 95% confidence interval, 1.8%-5.3%) than controls (0.4%; 95% confidence interval, 2.3% weight gain to 3.0% weight loss) (P = .021), using a last observation carried forward intent-to-treat analysis. As-treated analysis also showed greater mean percentage weight loss in the TORe group than controls (3.9% and 0.2%, respectively; P = .014). Weight loss or stabilization was achieved in 96% subjects receiving TORe and 78% of controls (P = .019). The TORe group had reduced systolic and diastolic blood pressure (P < .001) and a trend toward improved metabolic indices. In addition, 85% of the TORe group reported compliance with the healthy lifestyle eating program, compared with 53.8% of controls; 83% of TORe subjects said they would undergo the procedure again, and 78% said they would recommend the procedure to a friend. The groups had similar frequencies of adverse events. CONCLUSIONS: A multicenter randomized trial provides Level I evidence that TORe reduces weight regain after RYGB. These results were achieved using a superficial suction-based device; greater levels of weight loss could be achieved with newer, full-thickness suturing devices. TORe is one approach to avoid weight regain; a longitudinal multidisciplinary approach with dietary counseling and behavioral changes are required for long-term results. ClinicalTrials.gov identifier: NCT00394212.

Durability and predictors of successful radiofrequency ablation for Barrett's esophagus.

BACKGROUND & AIMS: After radiofrequency ablation (RFA), patients may experience recurrence of Barrett's esophagus (BE) after complete eradication of intestinal metaplasia (CEIM). Rates and predictors of recurrence after successful eradication have been poorly described. METHODS: We used the US RFA Registry, a nationwide registry of BE patients receiving RFA, to determine rates and factors that predicted recurrence of intestinal metaplasia (IM). We assessed recurrence by Kaplan-Meier analysis for the overall cohort and by worst pretreatment histology. Characteristics associated with recurrence were included in a logistic regression model to identify independent predictors. RESULTS: Among 5521 patients, 3728 had biopsies 12 months or more after initiation of RFA. Of these, 3169 (85%) achieved CEIM, and 1634 (30%) met inclusion criteria. The average follow-up period was 2.4 years after CEIM. IM recurred in 334 (20%) and was nondysplastic or indefinite for dysplasia in 86% (287 of 334); the average length of recurrent BE was 0.6 cm. In Kaplan-Meier analysis, more advanced pretreatment histology was associated with an increased yearly recurrence rate. Compared with patients without recurrence, patients with recurrence were more likely, based on bivariate analysis, to be older, have longer BE segments, be non-Caucasian, have dysplastic BE before treatment, and require more treatment sessions. In multivariate analysis, the likelihood for recurrence was associated with increasing age and BE length, and non-Caucasian race. CONCLUSIONS: BE recurred in 20% of patients followed up for an average of 2.4 years after CEIM. Most recurrences were short segments and were nondysplastic or indefinite for dysplasia. Older age, non-Caucasian race, and increasing length of BE length were all risk factors. These risk factors should be considered when planning post-RFA surveillance intervals.

Radiofrequency ablation for Barrett's-associated intramucosal carcinoma: a multi-center follow-up study.

BACKGROUND: Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett's esophagus. Its durability in eradicating Barrett's-associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC. METHODS: Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy-proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and for IMC and associated dysplasia. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC/dysplasia. Our secondary outcome of interest was treatment-related complications. RESULTS: 36 patients (26 male; mean age 64 ± 12 years), with a mean Barrett's length of 3.5 ± 2.5 cm, underwent RFA for biopsy-proven IMC. EMR was performed in 31 (86%) prior to or during RFA. Complete eradication of IMC/dysplasia was achieved in 32/36 (89%) and patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC/dysplasia was achieved in 29/36 (81%) patients. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC/dysplasia (p = 0.03). Treatment-related complications included: bleeding (3%) and stricture formation (19%). CONCLUSION: RFA is an effective and durable treatment option for Barrett's-associated IMC. Greater than 80% of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up.

Gastric Tube Volvulus Occurring Years After Esophagectomy and Its Successful Treatment Via Endoscopic Stenting.

Esophageal cancer is frequently treated with esophagectomy, which is associated with distinct complications. Delayed gastric conduit emptying is a well-recognized complication that usually occurs within the postoperative period. By contrast, gastric tube volvulus is a rarer complication with a more variable time course of onset after esophagectomy and can be mistaken for delayed gastric conduit emptying. We describe the fifth reported case of gastric tube volvulus occurring years after esophagectomy and its successful treatment via endoscopic stenting.

Radiofrequency ablation for long- and ultralong-segment Barrett's esophagus: a comparative long-term follow-up study.

BACKGROUND: The safety, efficacy, and durability of radiofrequency ablation (RFA), with or without EMR, have been established for long-segment Barrett's esophagus (LSBE). Ablating ultralong-segment Barrett's esophagus (ULSBE) may be associated with increased stricture formation, eradication failure, and treatment session requirements. OBJECTIVES: Our primary objective was to compare eradication and stricture rates between LSBE (≥3 to <8 cm) and ULSBE (≥8 cm). Our secondary objective was to evaluate treatment durability and session requirements. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care facility. PATIENTS: A total of 72 patients (34 ULSBE, 38 LSBE; mean Barrett's segment length of 10.8 and 4.7 cm) underwent RFA between August 2005 and September 2010. Mean follow-up was 45 and 34 months, respectively. MAIN OUTCOME MEASUREMENTS: Eradication and complication rates for ULSBE and LSBE. RESULTS: Eradication rates for dysplasia (90% vs 88%, P = 1.0) and intestinal metaplasia (IM) (77% vs 82%, P = .77) were similar. ULSBE patients required more overall (P < .01) and circumferential (P < .01) RFA; however, stricture rates were identical (14%). There was no dysplasia recurrence, and IM recurrence was similar (ULSBE, 23%; LSBE, 16%; P = .52). At 3 years, IM remained eradicated in 65% of ULSBE and 82% of LSBE, without maintenance RFA. On multivariate regression analysis, increasing Barrett's length was associated with a reduced likelihood for eradicating IM (odds ratio 0.87; 95% CI, 0.75-1.00), but not dysplasia (odds ratio 1.13; 95% CI, 0.95-1.35). LIMITATIONS: Single center. CONCLUSION: ULSBE can be treated in its entirety at each session with efficacy and safety comparable to LSBE. ULSBE requires more effort to achieve IM eradication, and RFA is less durable in maintaining this eradication at 3-year follow-up.

Pancreatic acinar metaplasia at the gastroesophageal junction is associated with protective effect against intestinal metaplasia in patients with gastroesophageal reflux disease.

Anecdotal evidence suggests that pancreatic acinar metaplasia (PAM) and intestinal metaplasia (IM) overlap infrequently at the gastroesophageal junction/distal esophagus (GEJ/DE). The goal of this study was to evaluate the significance of PAM at GEJ/DE in relation to IM in patients with gastroesophageal reflux disease (GERD). Group 1 comprised 230 consecutive patients with GEJ/DE biopsies (80.6% with GERD symptoms). Group 2 comprised 151 patients with established GERD and GEJ/DE biopsies taken before Nissen fundoplication. Group 3 comprised 540 consecutive patients used for a follow-up study of PAM. PAM was present in 15.7%-15.9% and IM in 24.8%-31.1% of patients in groups 1 and 2, respectively. PAM-IM overlap was present in 2.2%-3.3%, respectively. Patients with PAM were, on average, 6-12 years younger than patients with IM, and were predominantly female (72.2%-75%), in contrast to patients with IM (47.3%-32%). In the unadjusted logistic regression model, patients with PAM were 69%-65% less likely to also have IM, as compared to patients without PAM. In the fully adjusted model, patients with PAM were 35%-61% less likely to also have IM, although the P-value was not significant. Follow-up analysis of patients with PAM from group 3 (n = 28) demonstrated the prevalence of IM and PAM in subsequent biopsies at 7.1% and 60.7%, respectively. No cases showed PAM-IM overlap on follow-up. The data suggests that PAM at the GEJ/DE is associated with protective effect against IM and thus could be useful as a marker of decreased susceptibility to IM.

Radiofrequency ablation in Barrett's esophagus with dysplasia.

BACKGROUND: Barrett's esophagus, a condition of intestinal metaplasia of the esophagus, is associated with an increased risk of esophageal adenocarcinoma. We assessed whether endoscopic radiofrequency ablation could eradicate dysplastic Barrett's esophagus and decrease the rate of neoplastic progression. METHODS: In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic Barrett's esophagus in a 2:1 ratio to receive either radiofrequency ablation (ablation group) or a sham procedure (control group). Randomization was stratified according to the grade of dysplasia and the length of Barrett's esophagus. Primary outcomes at 12 months included the complete eradication of dysplasia and intestinal metaplasia. RESULTS: In the intention-to-treat analyses, among patients with low-grade dysplasia, complete eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared with 22.7% of those in the control group (P<0.001). Among patients with high-grade dysplasia, complete eradication occurred in 81.0% of those in the ablation group, as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of patients in the ablation group had complete eradication of intestinal metaplasia, as compared with 2.3% of those in the control group (P<0.001). Patients in the ablation group had less disease progression (3.6% vs. 16.3%, P=0.03) and fewer cancers (1.2% vs. 9.3%, P=0.045). Patients reported having more chest pain after the ablation procedure than after the sham procedure. In the ablation group, one patient had upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture. CONCLUSIONS: In patients with dysplastic Barrett's esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)

Durability of radiofrequency ablation in Barrett's esophagus with dysplasia.

BACKGROUND & AIMS: Radiofrequency ablation (RFA) can eradicate dysplasia and intestinal metaplasia in patients with dysplastic Barrett's esophagus (BE), and reduce rates of esophageal adenocarcinoma. We assessed long-term rates of eradication, durability of neosquamous epithelium, disease progression, and safety of RFA in patients with dysplastic BE. METHODS: We performed a randomized trial of 127 subjects with dysplastic BE; after cross-over subjects were included, 119 received RFA. Subjects were followed for a mean time of 3.05 years; the study was extended to 5 years for patients with eradication of intestinal metaplasia at 2 years. Outcomes included eradication of dysplasia or intestinal metaplasia after 2 and 3 years, durability of response, disease progression, and adverse events. RESULTS: After 2 years, 101 of 106 patients had complete eradication of all dysplasia (95%) and 99 of 106 had eradication of intestinal metaplasia (93%). After 2 years, among subjects with initial low-grade dysplasia, all dysplasia was eradicated in 51 of 52 (98%) and intestinal metaplasia was eradicated in 51 of 52 (98%); among subjects with initial high-grade dysplasia, all dysplasia was eradicated in 50 of 54 (93%) and intestinal metaplasia was eradicated in 48 of 54 (89%). After 3 years, dysplasia was eradicated in 55 of 56 of subjects (98%) and intestinal metaplasia was eradicated in 51 of 56 (91%). Kaplan-Meier analysis showed that dysplasia remained eradicated in >85% of patients and intestinal metaplasia in >75%, without maintenance RFA. Serious adverse events occurred in 4 of 119 subjects (3.4%); the rate of stricture was 7.6%. The rate of esophageal adenocarcinoma was 1 per 181 patient-years (0.55%/patient-years); there was no cancer-related morbidity or mortality. The annual rate of any neoplastic progression was 1 per 73 patient-years (1.37%/patient-years). CONCLUSIONS: In subjects with dysplastic BE, RFA therapy has an acceptable safety profile, is durable, and is associated with a low rate of disease progression, for up to 3 years.

Robotics in endoscopy.

PURPOSE OF REVIEW: The increasing complexity of intralumenal and emerging translumenal endoscopic procedures has created an opportunity to apply robotics in endoscopy. Computer-assisted or direct-drive robotic technology allows the triangulation of flexible tools through telemanipulation. The creation of new flexible operative platforms, along with other emerging technology such as nanobots and steerable capsules, can be transformational for endoscopic procedures. In this review, we cover some background information on the use of robotics in surgery and endoscopy, and review the emerging literature on platforms, capsules, and mini-robotic units. RECENT FINDINGS: The development of techniques in advanced intralumenal endoscopy (endoscopic mucosal resection and endoscopic submucosal dissection) and translumenal endoscopic procedures (NOTES) has generated a number of novel platforms, flexible tools, and devices that can apply robotic principles to endoscopy. The development of a fully flexible endoscopic surgical toolkit will enable increasingly advanced procedures to be performed through natural orifices. SUMMARY: The application of platforms and new flexible tools to the areas of advanced endoscopy and NOTES heralds the opportunity to employ useful robotic technology. Following the examples of the utility of robotics from the field of laparoscopic surgery, we can anticipate the emerging role of robotic technology in endoscopy.

Disseminated sarcoidosis presenting as granulomatous gastritis: a clinical review of the gastrointestinal and hepatic manifestations of sarcoidosis.

Commonly considered a pulmonary disease, sarcoidosis is actually a multisystemic granulomatous disorder of unclear etiology. There is a wide range of organ system involvement, with gastrointestinal being among the rarest. We describe the diagnostic challenge of a patient presenting with gastritis without pulmonary complaints who was later found to have extrathoracic disseminated sarcoidosis. This case highlighted both the variability in the presentation of the disease and difficulties in its diagnosis. We performed a literature review to identify studies published on gastrointestinal and hepatic sarcoidosis to better understand the characteristics of this disease and help in the differentiation between other commonly encountered disorders that may be mimicked in presentation. We have also created a diagnostic approach that can be applied when endoscopic or hepatic biopsies reveal granulomas. We anticipate that this review may be useful for clinicians who face these diagnostic dilemmas and management decisions for this complex and variable condition.