The new normal: a review of the impact of COVID-19 on gastroenterology fellowship training.

The COVID-19 pandemic had a significant impact on medical education and gastroenterology fellowship training. As a result of the pandemic, a trainee's physical safety, mental health and wellness, clinical and procedural training, and educational opportunities were all potentially altered. Changes necessitated at the start of the pandemic were different than those needed further along in the pandemic course. Fellowship programs were required to modify policies and adapt to changes rapidly to advocate for their trainees and ensure quality education. Much of COVID-19's initial impact on education - decreased endoscopic procedures and the loss of educational conferences - has largely returned to pre-pandemic form. However, other changes made during the pandemic have persisted and likely will continue in the future. This includes a virtual interview format for fellowship matches, a virtual option for many national conferences, and an expansion of simulation training. This article reviews the impact that COVID-19 had on medical education with a specific focus on gastroenterology fellowship. The paper highlights the initial impact of COVID-19, the lingering effects, and discusses the areas needed for further research to best understand the total impact COVID-19 had on our trainees' education.

Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation.

BACKGROUND: Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons. METHODS: Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated. RESULTS: There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf's alpha <0.30), indicating low to no agreement between providers. CONCLUSION: In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.

Thromboelastography versus standard coagulation testing in the assessment and reversal of coagulopathy among cirrhotics: a systematic review and meta-analysis.

The utility of thromboelastography/thromboelastometry currently has unvalidated clinical benefit in the assessment and reversal of coagulopathy among cirrhotic patients as compared to standard coagulation testing. A novel systematic review and meta-analysis was conducted in order to assess pooled outcome data among patients receiving thromboelastography/thromboelastometry as compared to standard coagulation testing. As compared to standard coagulation testing, there was a significant reduction in the number of patients requiring pRBC, platelet, and fresh frozen plasma transfusions among thromboelastography/thromboelastometry group with pooled OR 0.53 (95% CI 0.32-0.85; P = 0.009), 0.29 (95% CI 0.12-0.74; P = 0.009), and 0.19 (95% CI 0.12-0.31; P < 0.00001), respectively. Similarly, there was a significant reduction in number of pRBC, platelet, and fresh frozen plasma units transfused in the thromboelastography/thromboelastometry group with pooled MD -1.53 (95% CI -2.86 to -0.21; P = 0.02), -0.57 (95% CI -1.06 to -0.09; P = 0.02), and -2.71 (95% CI -4.34 to -1.07; P = 0.001), respectively. There were significantly decreased total bleeding events with pooled OR 0.54 (95% CI 0.31-0.94; P = 0.03) and amount of intraoperative bleeding during liver transplantation with pooled MD -1.46 (95% CI -2.49 to -0.44; P = 0.005) in the thromboelastography/thromboelastometry group. Overall, there was no significant difference in mortality between groups with pooled OR 0.91 (95% CI 0.63-1.30; P = 0.60). As compared to standard coagulation testing, a thromboelastography/thromboelastometry-guided approach to the assessment and reversal of cirrhotic coagulopathy improves overall number of patients exposed to blood product transfusions, quantity of transfusions, and bleeding events.

Adjunctive Yield of Wide-Area Transepithelial Sampling for Dysplasia Detection After Advanced Imaging and Random Biopsies in Barrett's Esophagus.

INTRODUCTION: Little is known about the additive yield of wide-area transepithelial sampling with computer-assisted three-dimensional analysis (WATS-3D) after a thorough examination with advanced imaging. The aim was to evaluate the adjunctive yield of WATS-3D after advanced imaging. METHODS: This is an observational cohort study from January 2017 to December 2018 for consecutive patients who underwent an examination that consists of high-definition white light endoscopy (HDWLE), narrow-band imaging (NBI), volumetric laser endomicroscopy (VLE), and Seattle protocol (SP) biopsies (collectively termed HDWLE-NBI-VLE-SP examination). Raised lesions were removed by endoscopic resection. Areas suspicious for dysplasia on NBI and VLE were biopsied. This was followed by random biopsies and WATS-3D brush biopsies. RESULTS: One hundred thirty-eight cases were included in this study. Thirty-five cases (25% of the total) were identified as some degree of dysplasia on the HDWLE-NBI-VLE-SP examination. Adjunctive use of WATS-3D yielded an additional 12 new cases of dysplasia (9 with crypt dysplasia and 3 with low-grade dysplasia [LGD]), for added yield of 34.3% (=12/35, 95% confidence interval 14.6%-62.2%). When restricting the analysis to LGD and higher, 21 dysplastic cases (15% of the total cases) were identified by HDWLE-NBI-VLE-SP, while WATS-3D found 4 additional new cases (3 with LGD and 1 with high-grade dysplasia) for an added yield of 19% (=4/21, 95% confidence interval 0.6%-45.7%). DISCUSSION: The addition of WATS-3D to an already thorough examination with HDWLE-NBI-VLE-SP may increase the yield of dysplasia detection.

Esophageal Lichen Planus: Clinical and Radiographic Findings in Eight Patients.

OBJECTIVE: The purpose of this study is to present the clinical and radiographic findings of esophageal lichen planus. MATERIALS AND METHODS: A search of computerized medical records identified 15 patients with pathologic findings of esophageal lichen planus on endoscopic biopsy specimens. Three other patients had presumed esophageal lichen planus, although no biopsy specimens were obtained. Twelve of these 18 patients (67%) had double-contrast esophagography performed at our institution; for eight of the 12 patients (67%), the studies revealed abnormalities in the esophagus. These eight patients constituted our study group. The barium esophagrams and medical records of these eight patients were reviewed to determine the clinical, radiographic, and endoscopic findings of esophageal lichen planus as well as the treatment and patient outcome. RESULTS: All eight patients were women (median age, 66.5 years), and all eight presented with dysphagia (mean duration, 3.2 years). Four patients had previous lichen planus that involved the skin (n = 1), the oral cavity (n = 2), or both (n = 1), and one patient later had lichen planus that involved the vagina. Five patients had a small-caliber esophagus with diffuse esophageal narrowing. The remaining three patients had segmental strictures in the cervical (n = 1), upper thoracic (n = 1), and distal thoracic (n = 1) esophagus. CONCLUSION: Esophageal lichen planus typically occurs in older women with longstanding dysphagia and often develops in the absence of extraesophageal disease. Barium esophagrams may reveal a small-caliber esophagus or, less commonly, segmental esophageal strictures. Greater awareness of the radiographic findings of esophageal lichen planus hopefully will lead to earlier diagnosis and better management of this condition.

Predictors of Progression to High-Grade Dysplasia or Adenocarcinoma in Barrett's Esophagus.

The prevalence of esophageal adenocarcinoma is increasing dramatically. Barrett's esophagus remains the most well-established risk factor for the development of esophageal adenocarcinoma. There are multiple clinical, endoscopic, and pathologic factors that increase the risk of neoplastic progression to high-grade dysplasia or esophageal adenocarcinoma in Barrett's esophagus. This article reviews both risk and protective factors for neoplastic progression in patients with Barrett's esophagus.

Is production pressure jeopardizing the quality of colonoscopy? A survey of U.S. endoscopists' practices and perceptions.

BACKGROUND: Fatigue is an underestimated cause of underperformance among physicians. There is evidence that fatigue or other byproducts of production pressure may negatively influence the quality of colonoscopy. OBJECTIVE: To investigate the practices and perceptions of U.S. endoscopists regarding the effect of production pressure on the performance of colonoscopy. DESIGN: We conducted a 40-question online survey to assess endoscopists' practices and perceptions concerning production pressure. SETTING: A total of 5030 U.S. American Society for Gastrointestinal Endoscopy members. MAIN OUTCOME MEASUREMENTS: The proportion of endoscopists responding positively to questions pertaining to the impact of production pressure on colonoscopy practice. RESULTS: Ninety-two percent of respondents indicated that production pressure influenced one or more aspects of their endoscopic practices. Examples of production pressure included (1) postponing polypectomy for a subsequent session (2.8%), (2) reducing the length of time spent inspecting the colon (7.2%), and (3) proceeding with colonoscopy in a patient with an unfavorable risk/benefit ratio (69.2%). Forty-eight percent of respondents reported witnessing the effects of production pressure on a colleague. Respondents working fee-for-service and those with >10 years since completion of fellowship were more likely to describe their weekly workloads as excessive compared with those who were salaried (81.3% vs 71.3%; P = .01) and <10 years out of training (81% vs 72.7%; P = .01). LIMITATIONS: Nonresponse bias due to low response rate (22.3%). CONCLUSION: Production pressure influences the conduct of colonoscopy for many endoscopists and could have an adverse effect on the outcome of colorectal cancer screening. ( CLINICAL TRIAL REGISTRATION NUMBER: RE:GIE D 11-01288R1.) The study was an Internet study and did not involve human subjects.

Is gastroduodenal biopsy safe in patients receiving aspirin and clopidogrel?: a prospective, randomized study involving 630 biopsies.

GOALS: To assess prospectively the bleeding risk attributable to gastroduodenal biopsy in subjects taking antiplatelet medications. BACKGROUND: No prospective data exist regarding the bleeding risk attributable to endoscopic biopsy in patients taking antiplatelet agents. A majority of Western endoscopists withdraw antiplatelet agents before upper endoscopy, despite expert guidelines to the contrary. STUDY: We performed a prospective, single-blind, randomized study in healthy volunteers participating in a larger study regarding the effect of antiplatelet agents on gastroduodenal mucosal healing. Multiple gastroduodenal biopsies were performed during 2 esophagogastroduodenoscopy in subjects dosed with aspirin enteric-coated 81 mg once daily or clopidogrel 75 mg once daily. Data for endoscopic bleeding, clinical bleeding, blood vessel size, and depth of biopsy in histology specimens were collected. RESULTS: Four hundred and five antral biopsies and 225 duodenal biopsies were performed during 90 esophagogastroduodenoscopy in 45 subjects receiving aspirin or clopidogrel. Median maximum blood vessel diameter per biopsy was 31.9 µ (range: 9.2 to 133.8). About 50.8% of biopsy specimens breached the muscularis mucosa. In the clopidogrel group, no bleeding events were noted after 350 biopsies [upper confidence limit (UCL) for probability of bleeding=0.0085]. In the aspirin group, there were no clinical events (UCL=0.0106) and one minor endoscopic bleeding event (UCL=0.0169). CONCLUSIONS: Consistent with expert guidelines, the absolute risk attributable to gastroduodenal biopsy in adults taking antiplatelet agents seems to be low. Half of routine biopsies enter submucosa. The largest blood vessels avulsed during biopsy correspond to midsized and large arterioles and venules.