The synergistic role of virtual coaching with simulation-based mastery learning for upper endoscopy.

Introduction: Our simulation-based mastery learning (SBML) curriculum, delivered in person, has been shown to successfully train novices in structured esophagogastroduodenoscopy (EGD). SBML with virtual coaching (VC) has the potential to improve the effectiveness and efficiency of endoscopy training and expand access to trainees from around the world. We share our observations conducting an EGD training course using SBML with VC. Methods: We conducted a 1-week virtual SBML course for novice trainees across seven academic centers in the USA and Asia. The cognitive component was delivered using an online learning platform. For technical skills, a virtual coach supervised hands-on training and local coaches provided assistance when needed. At the end of training, an independent rater assessed simulation-based performance using a validated assessment tool. We assessed the clinical performance of 30 EGDs using the ASGE Assessment of Competency in Endoscopy tool. We compared the trainees' scores to our cohort trained using in-person SBML training using non-inferiority t-tests. Results: We enrolled 21 novice trainees (mean age: 30.8 ± 3.6 years; female: 52%). For tip deflection, the trainees reached the minimum passing standard after 31 ± 29 runs and mastery after 52 ± 37 runs. For structured EGD, the average score for the overall exam was 4.6 ± 0.6, similar to the in-person cohort (4.7 ± 0.5, p = 0.49). The knowledge-based assessment was also comparable (virtual coaching: 81.9 ± 0.1; direct coaching: 78.3 ± 0.1; p = 0.385). Over time, our novice trainees reached clinical competence at a similar rate to our historical in-person control. Conclusions: VC appears feasible and effective for training novice gastroenterology trainees. VC allowed us to scale our SBML course, expand access to experts, and administer SBML simultaneously across different sites at the highest standards.

Endoscopic sleeve gastroplasty reintervention score using supervised machine learning.

BACKGROUND AND AIMS: Reintervention after endoscopic sleeve gastroplasty (ESG) can be indicated because of postprocedural adverse events from various preinterventional or postprocedural comorbidities. We developed and internally validated an ESG reintervention score (ESG-RS) that determines the individualized risk of reintervention within the first 30 days after ESG. METHODS: We used data from a sample of 3583 patients who underwent ESG in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database (2016-2021). The least absolute shrinkage and selection operator (LASSO)-penalized regression was used to select the most promising predictors of reintervention after ESG within 30 days. The predictive variables extracted by LASSO regression were entered into multivariate analysis to generate an ESG-RS by using the coefficients of the statistically significant variables. The model performance was assessed using receiver-operator curves by 10-fold cross-validation. RESULTS: Eleven variables were selected by LASSO regression and used in the final multivariate analysis. The ESG-RS was inferred using 5 factors (history of previous foregut surgery, preoperative anticoagulation use, female gender, American Society of Anesthesiologists class ≥II, and hypertension) weighted by their regression coefficients in the multivariable logistic regression model. The area under the curve of the ESG-RS was .74 (95% confidence interval, .70-.78). For the ESG-RS, the optimal cutpoint was 67.9 (high risk vs low risk), with a sensitivity of .76 and specificity of .71. CONCLUSIONS: The ESG-RS aids clinicians in preoperative risk stratification of patients undergoing ESG while clarifying factors contributing to a higher risk of reintervention.

Varied Trainee Competence in Cold Snare Polypectomy: Results of the COMPLETE Randomized Controlled Trial.

INTRODUCTION: Cold snare polypectomy (CSP) is strongly recommended as the optimal technique for the complete removal of small polyps. Though significant variability in polypectomy technique and quality has been established, the learning curve and impact of targeted training on CSP are unknown. Video feedback has shown promise as an effective pedagogy to improve performance among surgical trainees. We aimed to compare CSP performance between trainees who received video-based feedback and those who received conventional apprentice-based concurrent feedback. We hypothesized that video-based feedback would accelerate competence. METHODS: We conducted a single-blinded, randomized controlled trial on competence for CSP of polyps <1 cm, comparing video-based feedback with conventional feedback. We randomly assigned deidentified consecutively recorded CSP videos to blinded raters to assess using the CSP Assessment Tool. We shared cumulative sum learning curves every 25 CSP with each trainee. The video feedback trainees also received biweekly individualized terminal feedback. Control trainees received conventional feedback during colonoscopy. The primary outcome was CSP competence. We also assessed competence across domains and change over polypectomy volume. RESULTS: We enrolled and randomized 22 trainees, 12 to video-based feedback and 10 to conventional feedback, and evaluated 2,339 CSP. The learning curve was long; 2 trainees (16.7%) in the video feedback achieved competence, after a mean of 135 polyps, and no one in the control ( P = 0.481) achieved competence. Overall and in all steps of CSP, a higher percentage of the video feedback group met competence, increasing 3% every 20 CSP ( P = 0.0004). DISCUSSION: Video feedback aided trainees to competence in CSP. However, the learning curve was long. Our findings strongly suggest that current training methods are not sufficient to support trainees to competency by the completion of their fellowship programs. The impact of new training methods, such as simulation-based mastery learning, should be assessed to determine whether such methods can result in achievement of competence at a faster rate; ClinicalTrials.gov : NCT03115008.

Current treatment landscape for obesity in Singapore.

The rising prevalence of obesity in Singapore is a harbinger for a corresponding increase in obesity-related complications such as type 2 diabetes mellitus (T2DM) and coronary heart disease. Obesity is a complex disease driven by multiple factors, and hence, treatment cannot follow a 'one-size-fits-all' approach. Lifestyle modifications involving dietary interventions, physical activity and behavioural changes remain the cornerstone of obesity management. However, similar to other chronic diseases such as T2DM and hypertension, lifestyle modifications are often insufficient on their own, hence the importance of other treatment modalities including pharmacotherapy, endoscopic bariatric therapy and metabolic-bariatric surgery. Weight loss medications currently approved in Singapore include phentermine, orlistat, liraglutide and naltrexone-bupropion. In recent years, endoscopic bariatric therapies have evolved as an effective, minimally invasive and durable therapeutic option for obesity. Metabolic-bariatric surgery remains the most effective and durable treatment for patients with severe obesity, with an average weight loss of 25%-30% after one year.

Endoscopic sleeve gastroplasty using the novel single-channel suturing device: A multicenter experience.

Background and aim: Endoscopic sleeve gastroplasty (ESG) is an effective treatment for obesity. Recently, a novel single-channel endoscopic suturing device has been made available to overcome the need for a double-channel endoscope. However, there is limited evidence evaluating its utility for ESG. In this multicenter study, we aim to assess the efficacy and safety of the single-channel suturing device for ESG. Methods: We reviewed the records of 18 patients who underwent ESG using the novel device at the Singapore General Hospital, Singapore, and Siriraj Hospital, Bangkok, between 2020-2021. We adopted a "U" suture pattern. Our primary outcome was to assess technical feasibility and safety. The secondary outcome was to determine the percentage of total body weight loss at 1 year. Results: The mean ± SD age and body mass index were 42 ± 8.5 years and 34.9 ± 4.4 kg/m2, respectively. The majority were female (61%). ESG was technically successful in 94% (n = 17) of patients. Device dislodgement occurred in one patient. We used an average of five sutures (range, 4-8), and the mean ± SD procedure time was 96.5 ± 43.8 min. No complications occurred. The mean ± SD length of stay was 2.3 ± 1.5 days. The mean ± SD percentage of total body weight loss at 6 and 12 months were 16 ± 5.2% and 13.1 ± 5.8%, respectively. We found that >5%, >10%, and >15% total body weight loss was observed in 83.3%, 72.2%, and 56%, respectively. Conclusion: ESG using the single-channel endoscopic suturing system is safe and effective for inducing weight loss at 1 year in patients with obesity.

Motorized spiral enteroscopy versus double-balloon enteroscopy: a case-matched study.

BACKGROUND AND AIMS: Motorized spiral enteroscopy (MSE) has been postulated to ease the complexities of the standard-of-care double-balloon enteroscopy (DBE). However, there are no comparative studies between MSE and DBE. This study aimed to compare the therapeutic outcomes and safety between MSE and DBE. METHODS: In this case-matched study, patients were matched 1:2 (MSE/DBE) by age, sex, body mass index, and American Society of Anesthesiology scores. Thirty-one patients who underwent MSE were compared with 62 patients who underwent DBE from 2014 to 2022. Our primary outcomes were to compare the technical and diagnostic success rates between DBE and MSE. Our secondary outcomes were to compare the therapeutic success and adverse event rates. RESULTS: The main indications for enteroscopy were suspected GI bleeding and positive radiologic findings. Prior abdominal surgery was reported in 35.5% and 22.6% of DBE and MSE patients, respectively. Most were antegrade enteroscopy (71%). We found no significant difference in the technical success (DBE 98.4% vs MSE 96.8%, P = .62), diagnostic success (DBE 66.1% vs MSE 54.8%, P = .25), and therapeutic success rates (DBE 62.8% vs MSE 52.9%, P = .62) between the groups. Adverse events occurred in 1 DBE and 11 MSE patients. Most were minor (n = 10, 25.6%). Two patients (5.1%) in the MSE group sustained deep lacerations in the proximal esophagus requiring hospitalization. One developed ileal perforation after MSE needing surgical repair. CONCLUSIONS: In patients requiring enteroscopy, the diagnostic and therapeutic performance of MSE is similar to DBE. An increased frequency of adverse events was observed with MSE. There are some restrictions in the indication because of the design of MSE.

Prospective Multicenter Study of the Primary Obesity Surgery Endoluminal (POSE 2.0) Procedure for Treatment of Obesity.

BACKGROUND & AIMS: The Primary Obesity Surgery Endoluminal (POSE) 2.0 procedure involves a novel pattern of full-thickness gastric body plications to shorten and narrow the stomach using durable suture anchor pairs. Our prospective, multicenter trial examined the safety, efficacy, durability, and physiologic effects of POSE 2.0 in adults with obesity. METHODS: Adults with obesity underwent POSE 2.0 at 3 centers. Primary outcomes were percent total body weight loss (%TBWL) and proportion of patients achieving >5% TBWL at 12 months. Secondary outcomes included change in obesity comorbidities, satiety, quality of life at 6 months, and durability of plications at 12 and 24 months. Subjects were followed for adverse events throughout the study duration. RESULTS: 44 patients (61% female; mean age, 45 ± 9.7 years; mean body mass index, 37 ± 2.1 kg/m2) were enrolled. This procedure used an average of 19 suture anchor pairs, with a mean duration of 37 ± 11 minutes, and was technically successful in all subjects. Mean %TBWL at 12 months was 15.7% ± 6.8%. At 12 months, %TBWL >5%, >10%, and >15% was achieved in 98%, 86%, and 58% of patients, respectively. Improvements in lipid profile, liver biochemistries, and hepatic steatosis were seen at 6 months. Improvements in hepatic steatosis persisted for 24 months in a subgroup of patients (P < .01). POSE 2.0 reduced maximum tolerated meal volume (P = .03) and was associated with increased fullness (P < .01) and improved eating behavior (P < .01) at 6 months. Impact of weight on quality-of-life questionnaire improved at 6 months (2.23 vs 1.23; P < .01). Repeat assessment at 24 months (n = 26) showed fully intact plications. No serious adverse events occurred. CONCLUSION: POSE 2.0 is an effective and durable endoscopic bariatric therapy which may influence physiologic pathways impacting satiety. Larger comparative studies are needed to further elucidate these initial findings. CLINICALTRIALS: gov Identifier: NCT03721731.

Nutritional Management and Role of Multidisciplinary Follow-Up after Endoscopic Bariatric Treatment for Obesity.

The prevalence of obesity has risen exponentially, and patients living with obesity suffer from its debilitating consequences. The treatment options for obesity have expanded significantly and include lifestyle changes, pharmacotherapy, endoscopic bariatric therapies (EBTs), and bariatric surgery. Endoscopic bariatric therapies comprise volume-reducing procedures such as endoscopic gastroplasty and gastric space-occupying devices such as intragastric balloons. Because of its minimally invasive nature and ease of delivery, EBTs are increasingly being adopted as a treatment option for obesity in several centers. These procedures mainly achieve weight loss by inducing early satiety and reducing meal volume. While the technical aspects of EBTs have been well explained, the nutritional management surrounding EBTs and the effectiveness of multidisciplinary team for maximizing weight loss is less described. There is considerable variation in post-EBT care between studies and centers. In this paper, we review the existing literature and share our experience on nutrition and the role of multidisciplinary management of obesity following EBT.

Pooled rates of adenoma detection by colonoscopy in asymptomatic average-risk individuals with positive fecal immunochemical test: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Current adenoma detection rate (ADR) benchmarks for colonoscopy in individuals positive for a fecal immunochemical test (FIT) are ≥45% in men and ≥35% in women. These are based on weak, low-quality evidence. We performed a meta-analysis to ascertain the pooled ADR in FIT-positive colonoscopy. METHODS: Major databases like PubMed, EMBASE, and Web of Science were searched in October 2021 for studies reporting on ADR of colonoscopy in a FIT-positive population. Meta-analysis was performed by standard methodology using the random-effects model. Heterogeneity was assessed by I2 and 95% prediction interval statistics. RESULTS: Thirty-four high-quality studies that included more than 6 million asymptomatic average-risk individuals were analyzed; 2,655,345 individuals completed a screening FIT test. The pooled FIT screening rate was 69.8% (95% CI, 62.8-76.1), the pooled FIT positivity rate was 5.4% (95% CI, 4.3-6.9), and the colonoscopy completion rate was 85% (95% CI, 82.8-86.9). The pooled ADR was 47.8% (95% CI, 44.1-51.6), pooled advanced ADR was 25.3% (95% CI, 22-29), and the pooled colorectal cancer detection rate was 5.1% (95% CI, 4.4-5.9). The pooled ADR in men was 58.3% (95% CI, 52.8-63.6) and in women was 41.9% (95% CI, 36.4-47.6). The pooled ADR with qualitative FIT assessment was 67.7% (95% CI, 50.7-81), with 1-stool sample FIT was 52.8% (95% CI, 48.8-56.8), and at a cutoff threshold of 100 ng hemoglobin/mL was 52.1% (95% CI, 47-57.1). Based on time-period cumulative analysis, the ADR improved over time from 30.5% (95% CI, 24.6-37.2) to 47.8% (95% CI, 44.1-51.6). CONCLUSIONS: This meta-analysis supports the current ADR benchmarks for colonoscopy in FIT-positive individuals. Excellent pooled ADR parameters were demonstrated with qualitative assessment of 1 stool sample at a test cutoff value of 100 ng hemoglobin/mL, and ADR per endoscopist improved over time.

Colonic angiodysplasia: a culprit of obscure gastrointestinal bleeding in a patient with Heyde syndrome.

A 77-year-old woman presented with obscure gastrointestinal bleeding requiring multiple hospitalisations and blood transfusions. The patient underwent repeated investigations over four hospital admissions across a span of two months. These included upper and lower gastrointestinal endoscopy, video capsule endoscopy as well as CT enterography, without definitive localisation or treatment of the source of bleeding. Finally, a technetium-99m-labelled red blood cell scan demonstrated a 'blush' at the proximal transverse colon on delayed imaging. Targeted colonoscopic evaluation showed a subcentimetre angiodysplastic lesion in the corresponding spot at the proximal transverse colon with slow persistent oozing. Endoscopic clips were applied with successful haemostasis. The patient recovered well without further symptom recurrence 5 months postdischarge. We review the literature on colonic angiodysplasias and discuss the diagnostic challenges in obscure gastrointestinal bleeding.

Endoscopic sleeve gastroplasty (ESG) for morbid obesity: how effective is it?

INTRODUCTION: ESG is an effective treatment for classes I and II obesity. However, the benefit of ESG in patients with morbid obesity (BMI ≥ 40 kg/m2) who decline surgery is not known. The study aims to compare the effectiveness and safety of ESG in all three obesity classes at 1 year. METHODS: We reviewed 484 patient records and identified 435 patients (class I: 105, class II: 169, class III: 161) who underwent ESG at our unit between May 2013 and March 2020. We compared their total body weight loss (%TBWL) and safety over 1 year. We used a linear mixed model (LMM) to analyse repeated measures of weight loss outcomes at 3, 6, 9, and 12 months for comparison between the three BMI groups. RESULTS: Among the 435 patients, 396 patients (class I: 99, class II: 151, class III: 146) completed 6 months, and 211 patients reached 1 year (class I: 50, class II: 77, class III: 84). There was no difference in age between the groups. In LMM analysis, adjusting for age and sex, we found ESG had a significantly higher TBWL, %TBWL, and BMI decline in class III compared to classes I and -II obesity at all time points (p < 0.001). The adjusted mean %TBWL at 1 year with classes I, -II, and -III obesity was 16.5%, 18.2%, and 20.5%, respectively. The overall complication rate and the hospital stay was identical in the three groups. CONCLUSION: ESG induced significant weight loss in all classes of obesity. In class III obesity, the weight loss achieved was significantly higher at 1 year. In patients declining or unsuitable for surgery, ESG could be considered as an alternative treatment option.

Safety and early efficacy of endoscopic sleeve gastroplasty (ESG) for obesity in a multi-ethnic Asian population in Singapore.

BACKGROUND AND AIM: Endoscopic sleeve gastroplasty (ESG) is an alternative nonsurgical treatment option for obesity. However, most studies on the utility and efficacy of ESG are derived from the Western population. It is unknown if ESG elicits similar results in Asians with different fat distribution, sociocultural customs, and dietary practices. Our study aims to assess the safety and efficacy of ESG among a multi-ethnic Asian population. METHODS: We reviewed 35 patient records who underwent primary ESG for obesity at our unit. We followed a U-shaped suture pattern. Our primary outcome was to assess technical feasibility and safety. The secondary outcome was to determine the percentage total body weight loss (TBWL) at the last follow-up. RESULTS: The mean ± SD age and body mass index were 43.6 ± 11.3 years and 34 ± 4.9 kg/m2, respectively. The majority were female (57%) and of Chinese ethnicity (51%). The procedure was technically successful in all patients. We used an average of five sutures (range, 4-7), and the mean ± SD procedure time was 65 ± 10 min. No major complications occurred, and the average length of stay was 1 day. Twenty-one patients completed 3 months of follow-up, and 10 patients 6 months. The mean ± SD TBWL at 3 and 6 months were 14.5 ± 4.8% and 16.2 ± 4.9%, respectively. We observed improvement in diabetes mellitus (87%), fatty liver (86%), and hypertension (58%) during the follow-up. CONCLUSION: ESG is a safe and effective option for promoting weight loss in a multi-ethnic Asian population. ESG-induced weight loss may improve obesity-related comorbidities.