The timing of recurrence after endoscopic papillectomy.

BACKGROUND: Endoscopic papillectomy (EP) offers a safe and effective method for resection of ampullary adenomas. Data regarding the long-term resolution of adenoma following EP are limited. The aim of this study therefore was to examine the timing of recurrence after EP of ampullary adenomas. METHODS: This was a single-center retrospective study including patients who received EP for ampullary adenomas from 8/2000 to 1/2018. Patients with confirmed complete eradication of adenoma were included in the recurrence analysis with recurrence defined as finding adenomatous histology after 1 negative surveillance endoscopy. Kaplan-Meier estimates were calculated to determine recurrence rates. RESULTS: Of the 165 patients who underwent EP, 136 patients (mean age 61.9, 51.5% female) had adenomatous histology with a mean lesion size of 21.2 mm. A total of 124 (91.2%) achieved complete eradication with a follow-up of 345.8 person-years. Recurrence occurred in 20 (16.1%) patients at a mean of 3.2 (± 3) years (range 0.5-9.75 years) for a recurrence rate of 5.8 (95% CI 3.6-8.8) per 100 person-years. Nine (45%) recurrences occurred after the 1st 2 years of surveillance. Recurrence rate did not differ by baseline pathology [low-grade dysplasia: 5.2 (95% CI 3.0-9.0), high-grade dysplasia: 6.9 (95% CI 2.3-15.5), adenocarcinoma: 7.7 (95% CI 0.9-25.1)]. CONCLUSION: Recurrence remains a significant concern after EP. Given the timing of recurrence, long surveillance periods may be necessary. Larger multicenter studies are needed, however, to determine appropriate surveillance intervals.

Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them.

Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.

A Prospective Multicenter Study Evaluating Endoscopy Competence Among Gastroenterology Trainees in the Era of the Next Accreditation System.

PURPOSE: The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy. METHOD: During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis. RESULTS: Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills. CONCLUSIONS: This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.

Effect of individualized feedback on learning curves in EGD and colonoscopy: a cluster randomized controlled trial.

BACKGROUND AND AIMS: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy. METHODS: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills. RESULTS: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77). CONCLUSIONS: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.).

Assessing the Quality of Polypectomy and Teaching Polypectomy.

Ineffective polypectomy technique may lead to incomplete polyp resection, high complication rates, interval colorectal cancer, and costly referral to surgery. Despite its central importance to endoscopy, training in polypectomy is not standardized nor has the most effective training approach been defined. Polypectomy competence is rarely reported and quality metrics for this skill are lacking. Use of tools and measurements to assess polypectomy outcomes is low. There is a need for standardization of training and remediation in polypectomy; defining standards of competent polypectomy and how it is feasibly measured; and integration of polypectomy quality metrics into training programs and the accreditation process.

Colon polypectomy report card improves polypectomy competency: results of a prospective quality improvement study (with video).

BACKGROUND AND AIMS: Polypectomy competency varies significantly among providers. Poor polypectomy technique may lead to interval cancer and/or adverse events. Our aim was to determine the effect of a polypectomy skills report card on subsequent polypectomy performance. METHODS: We conducted a 3-phase, prospective, single-blinded study. In phase 1 ("baseline"), we graded 10 polypectomies per endoscopist using the Direct Observation of Polypectomy Skills (DOPyS) tool (scores 1-4); mean overall scores ≥3 are competent. In phase 2 ("pre-report card"), we selected 10 additional polypectomies per endoscopist. We subsequently gave endoscopists a report card with baseline scores and instructional videos demonstrating optimal polypectomy technique. In phase 3 ("post-report card"), 10 additional polypectomies per endoscopist were selected. Raters, blinded to study phase, graded 10 pre- and 10 post-report card polypectomies per endoscopist. We compared mean DOPyS scores and rate of competent polypectomy in the pre- and post-report card phases. RESULTS: We graded 110 pre- and 110 post-report card polypectomies performed by 11 endoscopists. The mean DOPyS score increased between the pre- and post-report card phases (2.7 ± .9 vs 3.0 ± .8, P = .01); this improvement was seen for diminutive (P < .0001) but not for small-to-large polyps. Rate of competent polypectomy significantly improved from the pre- to post-report card phase (56% vs 69%, P = .04); this improvement was seen for diminutive (57% vs 81%, P = .001) but not for small-to-large polyps (55% vs 36%, P = .2). CONCLUSIONS: Report cards with educational videos effectively improved polypectomy technique, primarily because of improvements in resecting diminutive polyps. The improved competency and decreased piecemeal resection may reduce the risk of polyp recurrence. Further education is needed to improve larger polyp resection.

Assessing colon polypectomy competency and its association with established quality metrics.

BACKGROUND AND AIMS: Inadequate polypectomy leads to incomplete resection, interval colorectal cancer, and adverse events. However, polypectomy competency is rarely reported, and quality metrics are lacking. The primary aims of this study were to assess polypectomy competency among a cohort of gastroenterologists and to measure the correlation between polypectomy competency and established colonoscopy quality metrics (adenoma detection rate and withdrawal time). METHODS: We conducted a prospective observational study to assess polypectomy competency among 13 high-volume screening colonoscopists at an academic medical center. Over 6 weeks, we made video recordings of ≥28 colonoscopies per colonoscopist and randomly selected 10 polypectomies per colonoscopist for evaluation. Two raters graded the polypectomies by using the Direct Observation of Polypectomy Skills, a polypectomy competency assessment tool, which assesses individual polypectomy skills and overall competency. RESULTS: We evaluated 130 polypectomies. A total of 83 polypectomies (64%) were rated as competent, which was more likely for diminutive (70%) than small and/or large polyps (50%, P = .03). Overall Direct Observation of Polypectomy Skills competency scores varied significantly among colonoscopists (P = .001), with overall polypectomy competency rates ranging between 30% and 90%. Individual skills scores, such as accurately directing the snare over the lesion (P = .02) and trapping an appropriate amount of tissue within the snare (P = .001) varied significantly between colonoscopists. Polypectomy competency rates did not significantly correlate with the adenoma detection rate (r = 0.4; P = .2) or withdrawal time (r = 0.2; P = .5). CONCLUSIONS: Polypectomy competency varies significantly among colonoscopists and does not sufficiently correlate with established quality metrics. Given the clinical implications of suboptimal polypectomy, efforts to educate colonoscopists in polypectomy techniques and develop a metric of polypectomy quality are needed.

HIV infection and obesity: a review of the evidence.

This article provides a review of recent evidence pertinent to the prevalence, morbidities, and predictive value of overweight and obesity in PLWH. Implications for clinical outcomes are discussed, and recommendations for patient management and future research are advanced.

Economic impact of chronic prostatitis.

There are four types of prostatitis, including type I (acute bacterial prostatitis), type II (chronic bacterial prostatitis), type III (chronic prostatitis/chronic pelvic pain syndrome, or CP/CPPS), and type IV (asymptomatic inflammatory prostatitis). These prostatitis conditions account for approximately 2 million office visits each year to primary care physicians and urologists. The annual cost to treat prostatitis is approximately $84 million. Compared with control subjects, men with prostatitis incur significantly greater costs, predominantly due to increased outpatient visits and pharmacy expenses. CP/CPPS is the most common type of prostatitis. The condition is characterized by chronic, idiopathic pelviperineal pain. Due to the lack of effective treatments for CP/CPPS, the per-person costs associated with the condition are substantial and are similar to those reported for peripheral neuropathy, low back pain, fibromyalgia, and rheumatoid arthritis. Costs appear to be higher in men with more severe symptoms. Indirect costs (eg, work and productivity loss) are incurred by many patients with CP/CPPS. Identification of effective treatments for CP/CPPS would be expected to substantially reduce the costs associated with the condition.