Early detection of duodenal cancer by upper gastrointestinal-endoscopy in Lynch syndrome.

Small bowel cancer (SBC) is the malignancy with the highest standardized incidence ratio in Lynch syndrome (LS) patients. Of all SBCs, about 50% are duodenal cancers (DCs), therefore being accessible by esophago-gastro-duodenoscopy (EGD) for surveillance. We asked whether early detection of DC is possible for LS patients undergoing surveillance by EGD and if surveillance should be limited to specific subgroups. Data for LS patients with DC were retrieved from the registry of the German Consortium for Familial Intestinal Cancer. Patients undergoing active surveillance by EGDs (surveillance group) were compared to those who did not (nonsurveillance group) regarding tumor stage at diagnosis. Union for International Cancer Control stages I-IIA were defined as early stage disease and IIB-IV as advanced stage disease. Statistical analysis was performed using Fisher's exact test. Among 2015 patients with pathogenic variants in any mismatch-repair-gene, 47 patients with 49 DCs were identified. In 10% of cases, patients were under 35 years at diagnosis; family and personal tumor history did not correlate with DC diagnosis. Pathogenic germline variants in MSH6, PMS2 or EPCAM were present in 10% of patients. Statistical analysis could be performed on 13 DC patients in the surveillance group and 14 in the nonsurveillance group. Early detection was possible for 71% of patients in the surveillance group and 29% of patients in the nonsurveillance group (P = .021). Early detection of DC by EGD in LS patients is feasible regardless of family history, mutational status and should start no later than 25 years of age.

Society Guidelines-Where Is the Consensus?

With reports of ongoing duodenoscope contamination and pathogen transmission despite strict adherence to manufacturer reprocessing instructions, professional societies continue to release updated recommendations. Despite general guideline similarities, there are differences. Although adherence to guidelines does not entirely eliminate pathogen contamination or transmission, it is critical to strictly adhere to updated guidelines for maximum risk reduction. In the United States, the Food and Drug Administration and Centers for Disease Control and Prevention continue to offer updates regarding improved duodenoscope reprocessing techniques and endoscope design. This article critically analyzes currently available national and international duodenoscope reprocessing guidelines.

Evaluation of long-term adherence to oesophagogastroduodenoscopy quality indicators. / Evaluación del cumplimiento a largo plazo de los indicadores de calidad en la esofagogastroduodenoscopia.

INTRODUCTION: In a previous study we demonstrated that a simple training programme improved quality indicators of Oesophagogastroduodenoscopy (OGD) achieving the recommended benchmarks. However, the long-term effect of this intervention is unknown. The aim of this study was to assess the quality of OGDs performed 3 years after of having completed a training programme. MATERIAL AND METHODS: A comparative study of 2 cohorts was designed as follows: Group A included OGDs performed in 2016 promptly after a training programme and Group B with OGDs performed from January to March 2019, this group was also divided into 2 subgroups: subgroup B1 of Endoscopists who had participated in the previous training programme and subgroup B2 of Endoscopists who had not. The intra-procedure quality indicators proposed by ASGE-ACG were used. RESULTS: A total of 1236 OGDs were analysed, 600 from Group A and 636 from Group B (439 subgroup B1 and 197 subgroup B2). The number of complete examinations was lower in Group B (566 [94.3%] vs. 551 [86.6%]; p<0.001). A significant decrease was observed in nearly all quality indicators and they did not reach the recommended benchmarks: retroflexion in the stomach (96% vs. 81%; p<0.001); Seattle biopsy protocol (86% vs. 50%; p=0.03), description of the upper GI bleeding lesion (100% vs. 62%; p<0.01), sufficient intestinal biopsy specimens (at least 4) in suspected coeliac disease (92.5% vs. 18%; p<0.001), photo documentation of the lesion (94% vs. 90%; p<0.05). Regarding the overall assessment of the procedure (including correct performance and adequate photo documentation), a significant decrease was also observed (90.5% vs. 62%; p<0.001). There were no differences between subgroups B1 and B2. CONCLUSIONS: The improvement observed in 2016 after a training programme did not prevail after 3 years. In order to keep the quality of OGDs above the recommended benchmarks, it is necessary to implement continuous training programmes.

Quality indicators in gastroscopy. Gastroscopy procedure.

Within the project "Quality indicators in digestive endoscopy", pioneered by the Spanish Society for Digestive Diseases (SEPD), the objective of this research is to suggest the structure, process, and results procedures and indicators necessary to implement and assess quality in the gastroscopy setting. First, a chart was designed with the steps to be followed during a gastroscopy procedure. Secondly, a team of experts in care quality and/or endoscopy performed a qualitative review of the literature searching for quality indicators for endoscopic procedures, including gastroscopies. Finally, using a paired analysis approach, a selection of the literature obtained was undertaken. For gastroscopy, a total of nine process indicators were identified (one preprocedure, eight intraprocedure). Evidence quality was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification scale.

The importance of disease prevalence in assessing the diagnostic value of a test: endoscopic markers in celiac disease.

BACKGROUND/AIMS: We evaluated the diagnostic variability and reproducibility of endoscopic signs in two populations with a different pretest likelihood of celiac disease (CD). METHODS: We recruited 289 CD patients (both adults and children) in a multicenter prospective study. Group 1 (high risk) included 111 patients referred for positive serology. Group 2 (low risk) included 178 unselected patients. Mosaic pattern, reduction/loss of Kerckring's folds, scalloping of the valvulae conniventes and a nodular pattern were the endoscopic findings looked for in the duodenum. RESULTS: In group 1, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of endoscopic findings were 100, 84.6, 94.2 and 100% in adults, and 86.8, 9.1, 82.1 and 12.5% in children. In group 2, the sensitivity, specificity, PPV and NPV of endoscopic findings were 33.3, 91.4, 7.7 and 98.5% in adults, and noncalculable, 78.3, 0.0 and 100% in children. Comparing group 1 and group 2, there was a statistically significant difference in sensitivity and PPV in adults, and in specificity, PPV and NPV in children. Concerning the reproducibility of endoscopic findings, a wide variability of κ values was found. CONCLUSION: Endoscopic signs have low reproducibility for CD, and their diagnostic value in selecting patients for multiple intestinal biopsies is unacceptable, especially in populations with low disease prevalence.

Lack of a discriminatory function for endoscopy skills on a computer-based simulator.

BACKGROUND: Computer-based endoscopy simulators have been developed to enable trainees to learn and gain technical endoscopic skills before operating on patients. However, these simulators have not been validated as models of patient-based endoscopy. This study aimed to determine whether a computer-based simulator can accurately represent an actual esophagogastroduodenoscopy (EGD) and colonoscopy and to evaluate its ability to discriminate between varying levels of expertise in performing endoscopic procedures based on objective parameters. METHODS: In a prospective, observational trial, five first-year gastroenterology fellows and six gastroenterology attendings from a single academic center completed six endoscopy cases on the Simbionix GI Mentor II endoscopy simulator. The cases were selected to represent common clinical scenarios. The performance parameters were collected by the simulator. The 13 performance parameters measured by the endoscopy simulator were compared between the two study groups. After the simulator cases, the participants completed a survey evaluating the realism of the simulator. RESULTS: Novices and experts were able to complete the tasks in the simulated cases with no significant overall differences between the two groups. The computer-based simulator was able to discriminate levels of expertise only for parameters related to the time spent on the procedure (total time, time to reach the second duodenum, time to reach the cecum, and efficiency of screening). No statistically significant differences were found for the other nine performance parameters measured by the simulator. Based on the survey data, expert opinion concluded that the simulator does not offer a realistic simulation of human endoscopy. CONCLUSIONS: The computer-based endoscopy simulator displays a lack of ability to discriminate between novices and experts in terms of endoscopic skills based on measured objective performance parameters. The findings of this study suggest that the computer-based simulator lacks fidelity and that upgrades are necessary to increase the simulator's ability to reproduce human endoscopy more accurately.

Endoscopic evaluation of significant gastrointestinal lesions in patients with iron deficiency with and without anaemia: a Korean Association for the Study of Intestinal Disease study.

BACKGROUND: Although endoscopy is recommended for patients with iron deficiency anaemia, there is, currently, no consensus on the role of endoscopy for iron-deficient patients without anaemia. The goal of this study was to determine the prevalence of serious gastrointestinal (GI) lesions, identified by endoscopy in patients with iron deficiency and anaemia compared with patients with iron deficiency without anaemia. METHODS: One thousand five hundred and eighteen patients with a ferritin value of or=300 mg/dL were retrospectively investigated using oesophagogastroduodenoscopy and colonoscopy between January 2005 and September 2006. The lesions identified were classified as clinically important according to standard predetermined criteria. RESULTS: Among the 1518 cases, 749 patients had anaemia and 769 had normal haemoglobin levels. Clinically important lesions were identified in 24.6% of the patients with anaemia and in 22.8% of the patients without anaemia (P > 0.05). The frequency of lower GI tract lesions (13.6 vs 11.4%, P > 0.05) and upper GI tract lesions (11.9 vs 12.5%, P > 0.05) was similar in the comparisons between the two groups. However, the frequency of malignant GI lesions was higher in the patients with anaemia (5.1 vs 0.7%, P < 0.01). In addition, the patients without anaemia were significantly more likely to have early-stage neoplasia (adenoma, early gastric cancer and Dukes' A and B colon cancer) than were the patients with anaemia (98.4 vs 52.5%, P < 0.01). CONCLUSION: The results of this study suggest that patients with iron deficiency should undergo endoscopic evaluation of the GI tract, irrespective of whether they have anaemia. The endoscopic evaluation of the GI tract in patients with iron deficiency without anaemia could provide an opportunity for the detection of early-stage neoplasia at a curable stage.

The water immersion technique is easy to learn for routine use during EGD for duodenal villous evaluation: a single-center 2-year experience.

GOALS: We investigated the learning parameters of the immersion technique for the assessment of marked villous atrophy (MVA), during routine esophagogastroduodenoscopy (EGD). BACKGROUND: The immersion technique offers a proven possibility of enhancing the sensitivity of endoscopy in detecting duodenal villous atrophy patterns. STUDY: Nine endoscopists with at least 2 years of experience, who had previously been trained to perform the immersion technique, searched for duodenal villi during routine EGD. In a 2-year study, duodenal villi were evaluated underwater duodenoscopy in 432 patients from whom duodenal biopsies had been, for various reasons, obtained. The endoscopic findings were compared with the histology. The learning parameters of the water immersion technique and the accuracy in detecting subjects with MVA were observed. RESULTS: A total of 28 (6.5%) patients with MVA were identified during endoscopy by the trained endoscopists. All these patients were diagnosed as being celiac patients. The sensitivity, specificity, and accuracy (positive and negative predictive values) of the immersion technique in detecting MVA patterns, irrespective of the endoscopist who performed the examination, were always 100%. CONCLUSIONS: The underwater evaluation of the duodenum can be efficiently and regularly performed during routine EGD by endoscopists with 2 years of experience, after a specific, brief training period. This procedure is simple, feasible, and can accurately detect MVA patterns.

Role of esophagogastroduodenoscopy in the initial assessment of children with inflammatory bowel disease.

INTRODUCTION: Diagnosis of inflammatory bowel disease (IBD) and differentiation between Crohn's disease (CD) and ulcerative colitis (UC) can be difficult in children. Several previous studies suggest that esophagogastroduodenoscopy (EGD) and biopsies are important in the initial investigation of children with suspected IBD. The aim of the present paper was to assess the importance of EGD in the initial diagnostic appraisal of children with suspected IBD. METHODS: Children diagnosed with IBD over a 4-year period were identified from a dedicated IBD database. Retrospective chart review documented presenting signs and symptoms, endoscopic features in the upper and lower gastrointestinal tract and histological findings on mucosal biopsies. RESULTS: Eighty-six children were diagnosed with IBD of whom 61 (70.9%) had CD, 13 (21.3%) UC, and the remainder, indeterminate colitis. Esophagogastroduodenoscopy was performed in 76 (88.4%). Nine children were diagnosed with IBD solely on the basis of information obtained following EGD. None of these children had colitis and all had abnormal histological findings on review of mucosal biopsies from the upper gastrointestinal tract. Thirteen (23.6%) of 55 children with CD had granulomas noted within biopsies obtained during EGD and another 20 had significant inflammatory changes on histological examination of upper gastrointestinal tract biopsies. Crohn's disease was diagnosed in 25 of 38 children with pan-colitis. Thirteen children were correctly classified as having CD only following assessment of their upper gastrointestinal tract. This included the presence of upper gut granulomata in eight children. CONCLUSION: The performance of EGD in these children with IBD provided additional diagnostic yield and guided the differentiation of disease type in many patients. Esophagogastroduodenoscopy is an essential component in the initial diagnostic assessment of children with possible CD or UC.

The role of ERCP and pancreatoscopy in cystic and intraductal tumors.

ERCP and pancreatoscopy may establish a diagnosis of IPMT and differentiate it from a pseudocyst or cystic neoplasm of the pancreas. These techniques may also assess risk of malignancy, extent of disease, allow tissue sampling, and provide therapeutic intervention.

Diagnosis and fine needle aspiration of pancreatic pseudocysts: the role of endoscopic ultrasound.

Pseudocysts are localized collections of pancreatic fluid surrounded by nonepithelialized granulation tissue that occur following an insult to the pancreas. High image resolution and the ability sample in real-time by fine needle aspiration permit accurate distinction between various cystic lesions in the pancreas by endoscopic ultrasound (EUS). Other cyst characteristics and background pancreatic changes detectable at EUS assist in the diagnostic process. The use of Doppler flow ultrasound allows diagnosis of important pseudocyst complications such as pseudoaneurysms and varices. Endoscopic approaches to the drainage of symptomatic lesions previously relied on the use of cross-sectional imaging studies such as computed tomography scanning in combination with stent placement using a duodenoscope in the presence of an endoscopically visible cyst bulge. EUS facilitates this process allowing accurate imaging of the lesion prior to stent placement via the echoendoscope and overcomes many of the drawbacks and pitfalls of other endoscopic techniques.

[Esophago-gastro-duodenoscopy of pediatric patients]. / Osofago-gastro-duodenoskopi af paediatriske patienter.

In total 199 oesophago-gastro-duodenoscopies (OGD) were performed in 71 female and 71 male paediatric patients (three months-15 years, median 8 years 2 months). The endoscopy was performed in general anaesthesia in children less than five years old, and in an intravenous sedation in older patients. The indications for OGD were: recurrent abdominal pain and concomitant positive antibodies against Helicobacter pylori as a part of a scientific project, upper dyspepsia, upper gastrointestinal bleeding, failure to thrive, coeliac disease, suspicion of chronic inflammatory bowel disease and a percutaneous gastrostomy. Seventy-two OGD were carried out in general anaesthesia, 86 in intravenous sedation with midazolam and pethidine and 41 in intravenous midazolam sedation. Complications related to the sedation or to the endoscopy were not observed. Amnesia was reported in 94/95 children who were sedated intravenously with midazolam and pethidine or midazolam alone. Six endoscopies could not be carried out in intravenous sedation because of agitation. In the primary OGD endoscopy revealed a normal mucosa in 121/142 (85%), oesophagitis in four (3%), nodular mucosa in six (4%), gastritis in four (3%) and a duodenal ulcer in one (0.7%). Histology disclosed active or inactive chronic gastritis at the primary endoscopy in 35/69 (51%) of the children with recurrent abdominal pain and antibodies against H. pylori. In children with failure to thrive an avillous duodenal mucosa was seen in 3/32 (9%). A comparison between histological and stereomicroscopical evaluation of the duodenal biopsies revealed agreement in 41/47 (87%). We conclude that OGD is a safe and tolerable procedure in paediatric patients, in whom possible morphological changes are suspected. The indications for an OGD need further evaluation.