User login
How to Optimize EHR Use in Gastroenterology Practices
, a new practice management article suggests.
Michelle Kang Kim, MD, PhD, AGAF, chair of gastroenterology at Cleveland Clinic, Ohio, and colleagues provide EHR improvement strategies and examples that can be adapted for use in a variety of gastroenterology clinic settings. 
Their article, which was published online in Clinical Gastroenterology and Hepatology , includes the following suggestions, among others:
- Develop optimization teams. An example is SPRINT, a short, intensive team-based intervention at the University of Colorado Health, Aurora, Colorado, that developed specialty-specific tools, provided EHR efficiency training, and helped streamline workflows. The optimization project increased EHR satisfaction scores and reduced documentation time.
- Reroute low-acuity messages. Low-risk medication refills or appointment requests can be handled by nurses and medical assistants. This strategy has helped reduce the inbox burden.
- Create order sets for complex treatment dosing. One example is Cleveland Clinic’s Helicobacter pylori order set, which enables clinicians to quickly place orders with built-in dosages.
- Personalize EHR drop-down menus. Incorporate inflammatory bowel disease (IBD) severity scores, biopsy sampling, resection protocols, specimen container numbering, and other workflow-specific documentation into the EHR.
- Employ medical scribes. These professionals can serve as personal assistants, supporting care teams and reducing clinician documentation time. Alternatively, clinical support staff, such as nurses, can assist with documentation and messages, helping to reduce physician burnout. “These models could be particularly useful in GI specialties that require a multidisciplinary approach, for example, IBD and hepatology,” the authors write.
- Provide real-time training on best practices. There is no widely accepted EHR training curriculum for students, and experienced physicians face time constraints in learning new practices. Real-time training can help clinicians at all levels optimize their time outside the clinic.
In addition, the authors addressed novel tools and strategies that have been recently deployed and/or are in development, which are based largely on artificial intelligence (AI), natural language processing, and speech recognition. For now, these tools are digitizing data to help automate some EHR tasks, supporting communications with patients, and assisting in clinical decision making.
However, the authors note that although current optimization tools are promising, “there is still a lack of knowledge about their usability and effects on provider and patient well-being. More research is needed to evaluate current methodologies and design intelligent tools for the future that will help GI providers overcome the EHR-related obstacles specific to our field and harness the enormous potential of AI in optimizing the busy GI practice.”
This work received no external funding, and the authors disclosed no conflicts.
A version of this article appeared on Medscape.com.
, a new practice management article suggests.
Michelle Kang Kim, MD, PhD, AGAF, chair of gastroenterology at Cleveland Clinic, Ohio, and colleagues provide EHR improvement strategies and examples that can be adapted for use in a variety of gastroenterology clinic settings.
Their article, which was published online in Clinical Gastroenterology and Hepatology , includes the following suggestions, among others:
- Develop optimization teams. An example is SPRINT, a short, intensive team-based intervention at the University of Colorado Health, Aurora, Colorado, that developed specialty-specific tools, provided EHR efficiency training, and helped streamline workflows. The optimization project increased EHR satisfaction scores and reduced documentation time.
- Reroute low-acuity messages. Low-risk medication refills or appointment requests can be handled by nurses and medical assistants. This strategy has helped reduce the inbox burden.
- Create order sets for complex treatment dosing. One example is Cleveland Clinic’s Helicobacter pylori order set, which enables clinicians to quickly place orders with built-in dosages.
- Personalize EHR drop-down menus. Incorporate inflammatory bowel disease (IBD) severity scores, biopsy sampling, resection protocols, specimen container numbering, and other workflow-specific documentation into the EHR.
- Employ medical scribes. These professionals can serve as personal assistants, supporting care teams and reducing clinician documentation time. Alternatively, clinical support staff, such as nurses, can assist with documentation and messages, helping to reduce physician burnout. “These models could be particularly useful in GI specialties that require a multidisciplinary approach, for example, IBD and hepatology,” the authors write.
- Provide real-time training on best practices. There is no widely accepted EHR training curriculum for students, and experienced physicians face time constraints in learning new practices. Real-time training can help clinicians at all levels optimize their time outside the clinic.
In addition, the authors addressed novel tools and strategies that have been recently deployed and/or are in development, which are based largely on artificial intelligence (AI), natural language processing, and speech recognition. For now, these tools are digitizing data to help automate some EHR tasks, supporting communications with patients, and assisting in clinical decision making.
However, the authors note that although current optimization tools are promising, “there is still a lack of knowledge about their usability and effects on provider and patient well-being. More research is needed to evaluate current methodologies and design intelligent tools for the future that will help GI providers overcome the EHR-related obstacles specific to our field and harness the enormous potential of AI in optimizing the busy GI practice.”
This work received no external funding, and the authors disclosed no conflicts.
A version of this article appeared on Medscape.com.
, a new practice management article suggests.
Michelle Kang Kim, MD, PhD, AGAF, chair of gastroenterology at Cleveland Clinic, Ohio, and colleagues provide EHR improvement strategies and examples that can be adapted for use in a variety of gastroenterology clinic settings.
Their article, which was published online in Clinical Gastroenterology and Hepatology , includes the following suggestions, among others:
- Develop optimization teams. An example is SPRINT, a short, intensive team-based intervention at the University of Colorado Health, Aurora, Colorado, that developed specialty-specific tools, provided EHR efficiency training, and helped streamline workflows. The optimization project increased EHR satisfaction scores and reduced documentation time.
- Reroute low-acuity messages. Low-risk medication refills or appointment requests can be handled by nurses and medical assistants. This strategy has helped reduce the inbox burden.
- Create order sets for complex treatment dosing. One example is Cleveland Clinic’s Helicobacter pylori order set, which enables clinicians to quickly place orders with built-in dosages.
- Personalize EHR drop-down menus. Incorporate inflammatory bowel disease (IBD) severity scores, biopsy sampling, resection protocols, specimen container numbering, and other workflow-specific documentation into the EHR.
- Employ medical scribes. These professionals can serve as personal assistants, supporting care teams and reducing clinician documentation time. Alternatively, clinical support staff, such as nurses, can assist with documentation and messages, helping to reduce physician burnout. “These models could be particularly useful in GI specialties that require a multidisciplinary approach, for example, IBD and hepatology,” the authors write.
- Provide real-time training on best practices. There is no widely accepted EHR training curriculum for students, and experienced physicians face time constraints in learning new practices. Real-time training can help clinicians at all levels optimize their time outside the clinic.
In addition, the authors addressed novel tools and strategies that have been recently deployed and/or are in development, which are based largely on artificial intelligence (AI), natural language processing, and speech recognition. For now, these tools are digitizing data to help automate some EHR tasks, supporting communications with patients, and assisting in clinical decision making.
However, the authors note that although current optimization tools are promising, “there is still a lack of knowledge about their usability and effects on provider and patient well-being. More research is needed to evaluate current methodologies and design intelligent tools for the future that will help GI providers overcome the EHR-related obstacles specific to our field and harness the enormous potential of AI in optimizing the busy GI practice.”
This work received no external funding, and the authors disclosed no conflicts.
A version of this article appeared on Medscape.com.
No-Biopsy Approach to Celiac Disease Diagnosis Appears Effective for Select Adult Patients
Select adult patients with immunoglobulin A-tissue transglutaminase antibody levels (IgA-tTG) greater than or equal to 10 times the upper limit of normal (ULN) and a moderate-to-high pretest probability of celiac disease could be diagnosed without undergoing invasive endoscopy and duodenal biopsy, according to a new study.
, the authors wrote.
“Our study confirms the high accuracy of serology-based diagnosis of coeliac disease in select adult patients,” said Mohamed G. Shiha, MBBCh, MRCP, lead author and a clinical research fellow in gastroenterology at Sheffield Teaching Hospitals in the United Kingdom.
“This no-biopsy approach could lead to a shorter time to diagnosis, increased patient satisfaction, and reduced healthcare costs,” he said.
The study was published online in Gastroenterology.
Evaluating the No-Biopsy Approach
Dr. Shiha and colleagues conducted a systematic review and meta-analysis to evaluate to the accuracy of a no-biopsy approach for diagnosing celiac disease in adults. They looked for studies that reported the sensitivity and specificity of IgA-tTG ≥10xULN compared with duodenal biopsies (with a Marsh grade ≥2) in adults with suspected celiac disease.
The research team used a bivariate random-effects model to calculate the summary estimates of sensitivity, specificity, and positive and negative likelihood ratios. Then the positive and negative likelihood ratios were used to calculate the positive predictive value (PPV) of the no-biopsy approach across different pretest probabilities of celiac disease.
Among 18 studies with 12,103 participants from 15 countries, the pooled prevalence of biopsy-proven celiac disease was 62%. The proportion of patients with IgA-tTG ≥10xULN was 32%.
The summary sensitivity of IgA-tTG ≥10xULN was 51%, and the summary specificity was 100% for the diagnosis of celiac disease. The positive and negative likelihood ratios were 183.42 and .49, respectively. The area under the summary receiver operating characteristic curve was .83.
Overall, the PPV of IgA-tTG ≥10xULN to identify patients with celiac disease was 98%, which varied according to pretest probability of celiac disease in the studied population. Specifically, the PPV was 65%, 88%, 95%, and 99% if celiac disease prevalence was 1%, 4%, 10%, and 40%, respectively. The 40% prevalence represents the lower confidence interval of the pooled prevalence from the included studies, the authors noted.
“We provided PPV estimates of IgA-tTG ≥10xULN for common pretest probabilities of coeliac disease to aid clinicians and patients in reaching an informed decision on a no-biopsy diagnosis based on the best available evidence,” the authors wrote.
Considering Additional Factors
Due to the increased accuracy of serological tests, pediatric guidelines have adopted a no-biopsy approach, the authors wrote. Children with IgA-tTG ≥10xULN and positive serum endomysial antibodies (EMA) can be diagnosed with celiac disease without biopsy.
However, the no-biopsy approach remains controversial for diagnosing adult patients and requires additional study, the authors wrote. They noted a limitation that all included studies were conducted in secondary and tertiary care settings and excluded patients with known celiac disease or on a gluten-free diet, so the results may not be generalizable to primary care settings.
In addition, relying on serology testing alone could lead to potential false-positive diagnoses, unnecessary dietary restriction, and negative effects on patients’ quality of life, the authors wrote.
At the same time, duodenal biopsy may not always be accurate due to inadequate sampling and could result in false-negative histology. The no-biopsy approach could mitigate this potential risk, the authors noted.
“This study systematically collates the growing data supporting the accuracy of antibody testing to diagnose celiac disease,” said Benjamin Lebwohl, MD, AGAF, professor of medicine and epidemiology at Columbia University Medical Center and director of clinical research for the Celiac Disease Center at Columbia University, New York. Dr. Lebwohl wasn’t involved with this study.
“We have historically relied on duodenal biopsy to confirm the diagnosis of celiac disease, and the biopsy will still have a central role in most cases in the foreseeable future,” he said. “But as we hone our understanding of antibody testing, one day we may be able to accept or even recommend a biopsy-free approach in select patients.”
Two authors reported grant support from the National Institute for Health and Care Research and National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Shiha reported speaker honorarium from Thermo Fisher. Dr. Lebwohl reported no relevant disclosures.
Select adult patients with immunoglobulin A-tissue transglutaminase antibody levels (IgA-tTG) greater than or equal to 10 times the upper limit of normal (ULN) and a moderate-to-high pretest probability of celiac disease could be diagnosed without undergoing invasive endoscopy and duodenal biopsy, according to a new study.
, the authors wrote.
“Our study confirms the high accuracy of serology-based diagnosis of coeliac disease in select adult patients,” said Mohamed G. Shiha, MBBCh, MRCP, lead author and a clinical research fellow in gastroenterology at Sheffield Teaching Hospitals in the United Kingdom.
“This no-biopsy approach could lead to a shorter time to diagnosis, increased patient satisfaction, and reduced healthcare costs,” he said.
The study was published online in Gastroenterology.
Evaluating the No-Biopsy Approach
Dr. Shiha and colleagues conducted a systematic review and meta-analysis to evaluate to the accuracy of a no-biopsy approach for diagnosing celiac disease in adults. They looked for studies that reported the sensitivity and specificity of IgA-tTG ≥10xULN compared with duodenal biopsies (with a Marsh grade ≥2) in adults with suspected celiac disease.
The research team used a bivariate random-effects model to calculate the summary estimates of sensitivity, specificity, and positive and negative likelihood ratios. Then the positive and negative likelihood ratios were used to calculate the positive predictive value (PPV) of the no-biopsy approach across different pretest probabilities of celiac disease.
Among 18 studies with 12,103 participants from 15 countries, the pooled prevalence of biopsy-proven celiac disease was 62%. The proportion of patients with IgA-tTG ≥10xULN was 32%.
The summary sensitivity of IgA-tTG ≥10xULN was 51%, and the summary specificity was 100% for the diagnosis of celiac disease. The positive and negative likelihood ratios were 183.42 and .49, respectively. The area under the summary receiver operating characteristic curve was .83.
Overall, the PPV of IgA-tTG ≥10xULN to identify patients with celiac disease was 98%, which varied according to pretest probability of celiac disease in the studied population. Specifically, the PPV was 65%, 88%, 95%, and 99% if celiac disease prevalence was 1%, 4%, 10%, and 40%, respectively. The 40% prevalence represents the lower confidence interval of the pooled prevalence from the included studies, the authors noted.
“We provided PPV estimates of IgA-tTG ≥10xULN for common pretest probabilities of coeliac disease to aid clinicians and patients in reaching an informed decision on a no-biopsy diagnosis based on the best available evidence,” the authors wrote.
Considering Additional Factors
Due to the increased accuracy of serological tests, pediatric guidelines have adopted a no-biopsy approach, the authors wrote. Children with IgA-tTG ≥10xULN and positive serum endomysial antibodies (EMA) can be diagnosed with celiac disease without biopsy.
However, the no-biopsy approach remains controversial for diagnosing adult patients and requires additional study, the authors wrote. They noted a limitation that all included studies were conducted in secondary and tertiary care settings and excluded patients with known celiac disease or on a gluten-free diet, so the results may not be generalizable to primary care settings.
In addition, relying on serology testing alone could lead to potential false-positive diagnoses, unnecessary dietary restriction, and negative effects on patients’ quality of life, the authors wrote.
At the same time, duodenal biopsy may not always be accurate due to inadequate sampling and could result in false-negative histology. The no-biopsy approach could mitigate this potential risk, the authors noted.
“This study systematically collates the growing data supporting the accuracy of antibody testing to diagnose celiac disease,” said Benjamin Lebwohl, MD, AGAF, professor of medicine and epidemiology at Columbia University Medical Center and director of clinical research for the Celiac Disease Center at Columbia University, New York. Dr. Lebwohl wasn’t involved with this study.
“We have historically relied on duodenal biopsy to confirm the diagnosis of celiac disease, and the biopsy will still have a central role in most cases in the foreseeable future,” he said. “But as we hone our understanding of antibody testing, one day we may be able to accept or even recommend a biopsy-free approach in select patients.”
Two authors reported grant support from the National Institute for Health and Care Research and National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Shiha reported speaker honorarium from Thermo Fisher. Dr. Lebwohl reported no relevant disclosures.
Select adult patients with immunoglobulin A-tissue transglutaminase antibody levels (IgA-tTG) greater than or equal to 10 times the upper limit of normal (ULN) and a moderate-to-high pretest probability of celiac disease could be diagnosed without undergoing invasive endoscopy and duodenal biopsy, according to a new study.
, the authors wrote.
“Our study confirms the high accuracy of serology-based diagnosis of coeliac disease in select adult patients,” said Mohamed G. Shiha, MBBCh, MRCP, lead author and a clinical research fellow in gastroenterology at Sheffield Teaching Hospitals in the United Kingdom.
“This no-biopsy approach could lead to a shorter time to diagnosis, increased patient satisfaction, and reduced healthcare costs,” he said.
The study was published online in Gastroenterology.
Evaluating the No-Biopsy Approach
Dr. Shiha and colleagues conducted a systematic review and meta-analysis to evaluate to the accuracy of a no-biopsy approach for diagnosing celiac disease in adults. They looked for studies that reported the sensitivity and specificity of IgA-tTG ≥10xULN compared with duodenal biopsies (with a Marsh grade ≥2) in adults with suspected celiac disease.
The research team used a bivariate random-effects model to calculate the summary estimates of sensitivity, specificity, and positive and negative likelihood ratios. Then the positive and negative likelihood ratios were used to calculate the positive predictive value (PPV) of the no-biopsy approach across different pretest probabilities of celiac disease.
Among 18 studies with 12,103 participants from 15 countries, the pooled prevalence of biopsy-proven celiac disease was 62%. The proportion of patients with IgA-tTG ≥10xULN was 32%.
The summary sensitivity of IgA-tTG ≥10xULN was 51%, and the summary specificity was 100% for the diagnosis of celiac disease. The positive and negative likelihood ratios were 183.42 and .49, respectively. The area under the summary receiver operating characteristic curve was .83.
Overall, the PPV of IgA-tTG ≥10xULN to identify patients with celiac disease was 98%, which varied according to pretest probability of celiac disease in the studied population. Specifically, the PPV was 65%, 88%, 95%, and 99% if celiac disease prevalence was 1%, 4%, 10%, and 40%, respectively. The 40% prevalence represents the lower confidence interval of the pooled prevalence from the included studies, the authors noted.
“We provided PPV estimates of IgA-tTG ≥10xULN for common pretest probabilities of coeliac disease to aid clinicians and patients in reaching an informed decision on a no-biopsy diagnosis based on the best available evidence,” the authors wrote.
Considering Additional Factors
Due to the increased accuracy of serological tests, pediatric guidelines have adopted a no-biopsy approach, the authors wrote. Children with IgA-tTG ≥10xULN and positive serum endomysial antibodies (EMA) can be diagnosed with celiac disease without biopsy.
However, the no-biopsy approach remains controversial for diagnosing adult patients and requires additional study, the authors wrote. They noted a limitation that all included studies were conducted in secondary and tertiary care settings and excluded patients with known celiac disease or on a gluten-free diet, so the results may not be generalizable to primary care settings.
In addition, relying on serology testing alone could lead to potential false-positive diagnoses, unnecessary dietary restriction, and negative effects on patients’ quality of life, the authors wrote.
At the same time, duodenal biopsy may not always be accurate due to inadequate sampling and could result in false-negative histology. The no-biopsy approach could mitigate this potential risk, the authors noted.
“This study systematically collates the growing data supporting the accuracy of antibody testing to diagnose celiac disease,” said Benjamin Lebwohl, MD, AGAF, professor of medicine and epidemiology at Columbia University Medical Center and director of clinical research for the Celiac Disease Center at Columbia University, New York. Dr. Lebwohl wasn’t involved with this study.
“We have historically relied on duodenal biopsy to confirm the diagnosis of celiac disease, and the biopsy will still have a central role in most cases in the foreseeable future,” he said. “But as we hone our understanding of antibody testing, one day we may be able to accept or even recommend a biopsy-free approach in select patients.”
Two authors reported grant support from the National Institute for Health and Care Research and National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Shiha reported speaker honorarium from Thermo Fisher. Dr. Lebwohl reported no relevant disclosures.
FROM GASTROENTEROLOGY
Automated ADR Software Shows Promise
, according to investigators.
The new software, which automatically integrates endoscopy and pathology reports across a variety of practice settings, delivered an ADR on par with manual review, supporting its accuracy and feasibility for real-world usage, reported Todd A. Brenner, MD, of Johns Hopkins Hospital, Baltimore, and colleagues.
“ADR calculation is resource-intensive, often requiring manual collation of endoscopy and pathology data across multiple reporting modalities, making it an impractical tool for frequent quality audits at many centers,” the investigators wrote in Techniques and Innovations in Gastrointestinal Endoscopy.
Although others have tried to streamline ADR calculation, most efforts have relied upon manual entry of pathology data, while approaches using artificial intelligence tend to be costly and clumsy to implement across different databases, according to the investigators.
“Thus, there is a substantial demand for a novel tool to extract and analyze colonoscopy indicators from text-based reports that provides accurate data extraction in a package that is easily implemented and modified by clinicians,” they wrote.
Dr. Brenner and colleagues developed a web-based platform to meet these goals.
Following colonoscopy, the system gathers procedural and histopathology results, extracts and classifies relevant data, then outputs ADR, along with cecal intubation rate, Boston Bowel Preparation Score (BBPS), and withdrawal time.
The software was evaluated using endoscopy and pathology reports from 3,809 colonoscopies performed at six centers over 3 months. Six months later, the investigators manually reviewed data from a validation cohort of 1384 colonoscopies conducted over a 1-month period.
Comparing the automated versus manual approach revealed high congruity, with an ADR of 45.1% for the automated system vs 44.3% for manual review. The software also correctly identified most ADR-qualifying screening colonoscopies (sensitivity, 0.918; specificity, 1.0).
“The discrepancy between manual and automated ADR calculations was exclusively attributable to missed (i.e., false negative) identification of ADR-qualifying procedures,” the investigators wrote.
Of these 43 mislabeled cases, about half involved pending pathology results or erroneous pathology sample entries, while the remainder were due to spelling and/or syntax issues that stumped the system.
Still, Dr. Brenner and colleagues suggested that additional programming can overcome these kinds of issues and allow for generalizability across institutions. They noted that search terms can be edited to match local practice patterns, while the web-based reporting platform can be customized to deliver desired quality metrics.
The publication includes a screenshot of one such dashboard, including a readout of ADR, a comparison of ADR across sexes, a pie chart of BBPS score distribution, and gauge charts for cecal intubation rate and mean withdrawal time.
“Further development of this Internet-based colonoscopy quality reporting platform will focus on integrating additional metrics, such as adenomas per colonoscopy, as well as novel metrics, such as a size-stratified ADR, location-stratified ADR, or ADR stratified by polyp histology,” the investigators wrote.
They predicted that automating data collection in this way could help determine which metrics provide clinically meaningful insights, potentially expanding the roster of standard performance benchmarks.
“We further intend to study the integration of this platform into colonoscopy quality improvement and transparency programs to better characterize the impact of frequent, on-demand ADR feedback on colonoscopy performance,” Dr. Brenner and colleagues concluded.The investigators disclosed relationships with Olympus, Medtronic, Apollo Endosurgery, and others.
Adenoma detection rate (ADR) has proven to be a useful metric for the evaluation of quality in screening colonoscopies. Outside of its proven inverse associations with interval colon cancer, ADR also can facilitate quality improvement interventions aimed at improving colonoscopy quality among low performing endoscopists. By focusing on this metric, healthcare providers can identify areas for improvement, ensuring a higher standard of care and ensuring maximum benefit of screening colonoscopies for patients.
Brenner and colleagues describe an automated system importing smart-phrase–based pathology reports into the endoscopy reporting software allowing for the subsequent calculation of an endoscopist-specific ADR. The automated reporting system provided a high level of agreement against manual review and correlated with average withdrawal time. Additional available quality metrics included cecal intubation rate and individual endoscopist procedural volumes.
The added methodology for developing endoscopist and site-specific ADR is an exciting and potentially more generalizable tool that will allow for widespread adoption of this quality metric. Site-specific data limitations and the use of smart-phrase–based reporting systems may limit the utility of this methodology, but it can also encourage more uniform reporting in pathologic and endoscopic reports. Regular service intervals may be required to inspect the quality of the reporting when initially implementing systems at a variety of practice settings.
Vijaya L. Rao, MD, is Assistant Professor of Medicine in the Division of Digestive Diseases & Nutrition at Rush University Medical Center, Chicago. She reports no conflicts of interest.
Adenoma detection rate (ADR) has proven to be a useful metric for the evaluation of quality in screening colonoscopies. Outside of its proven inverse associations with interval colon cancer, ADR also can facilitate quality improvement interventions aimed at improving colonoscopy quality among low performing endoscopists. By focusing on this metric, healthcare providers can identify areas for improvement, ensuring a higher standard of care and ensuring maximum benefit of screening colonoscopies for patients.
Brenner and colleagues describe an automated system importing smart-phrase–based pathology reports into the endoscopy reporting software allowing for the subsequent calculation of an endoscopist-specific ADR. The automated reporting system provided a high level of agreement against manual review and correlated with average withdrawal time. Additional available quality metrics included cecal intubation rate and individual endoscopist procedural volumes.
The added methodology for developing endoscopist and site-specific ADR is an exciting and potentially more generalizable tool that will allow for widespread adoption of this quality metric. Site-specific data limitations and the use of smart-phrase–based reporting systems may limit the utility of this methodology, but it can also encourage more uniform reporting in pathologic and endoscopic reports. Regular service intervals may be required to inspect the quality of the reporting when initially implementing systems at a variety of practice settings.
Vijaya L. Rao, MD, is Assistant Professor of Medicine in the Division of Digestive Diseases & Nutrition at Rush University Medical Center, Chicago. She reports no conflicts of interest.
Adenoma detection rate (ADR) has proven to be a useful metric for the evaluation of quality in screening colonoscopies. Outside of its proven inverse associations with interval colon cancer, ADR also can facilitate quality improvement interventions aimed at improving colonoscopy quality among low performing endoscopists. By focusing on this metric, healthcare providers can identify areas for improvement, ensuring a higher standard of care and ensuring maximum benefit of screening colonoscopies for patients.
Brenner and colleagues describe an automated system importing smart-phrase–based pathology reports into the endoscopy reporting software allowing for the subsequent calculation of an endoscopist-specific ADR. The automated reporting system provided a high level of agreement against manual review and correlated with average withdrawal time. Additional available quality metrics included cecal intubation rate and individual endoscopist procedural volumes.
The added methodology for developing endoscopist and site-specific ADR is an exciting and potentially more generalizable tool that will allow for widespread adoption of this quality metric. Site-specific data limitations and the use of smart-phrase–based reporting systems may limit the utility of this methodology, but it can also encourage more uniform reporting in pathologic and endoscopic reports. Regular service intervals may be required to inspect the quality of the reporting when initially implementing systems at a variety of practice settings.
Vijaya L. Rao, MD, is Assistant Professor of Medicine in the Division of Digestive Diseases & Nutrition at Rush University Medical Center, Chicago. She reports no conflicts of interest.
, according to investigators.
The new software, which automatically integrates endoscopy and pathology reports across a variety of practice settings, delivered an ADR on par with manual review, supporting its accuracy and feasibility for real-world usage, reported Todd A. Brenner, MD, of Johns Hopkins Hospital, Baltimore, and colleagues.
“ADR calculation is resource-intensive, often requiring manual collation of endoscopy and pathology data across multiple reporting modalities, making it an impractical tool for frequent quality audits at many centers,” the investigators wrote in Techniques and Innovations in Gastrointestinal Endoscopy.
Although others have tried to streamline ADR calculation, most efforts have relied upon manual entry of pathology data, while approaches using artificial intelligence tend to be costly and clumsy to implement across different databases, according to the investigators.
“Thus, there is a substantial demand for a novel tool to extract and analyze colonoscopy indicators from text-based reports that provides accurate data extraction in a package that is easily implemented and modified by clinicians,” they wrote.
Dr. Brenner and colleagues developed a web-based platform to meet these goals.
Following colonoscopy, the system gathers procedural and histopathology results, extracts and classifies relevant data, then outputs ADR, along with cecal intubation rate, Boston Bowel Preparation Score (BBPS), and withdrawal time.
The software was evaluated using endoscopy and pathology reports from 3,809 colonoscopies performed at six centers over 3 months. Six months later, the investigators manually reviewed data from a validation cohort of 1384 colonoscopies conducted over a 1-month period.
Comparing the automated versus manual approach revealed high congruity, with an ADR of 45.1% for the automated system vs 44.3% for manual review. The software also correctly identified most ADR-qualifying screening colonoscopies (sensitivity, 0.918; specificity, 1.0).
“The discrepancy between manual and automated ADR calculations was exclusively attributable to missed (i.e., false negative) identification of ADR-qualifying procedures,” the investigators wrote.
Of these 43 mislabeled cases, about half involved pending pathology results or erroneous pathology sample entries, while the remainder were due to spelling and/or syntax issues that stumped the system.
Still, Dr. Brenner and colleagues suggested that additional programming can overcome these kinds of issues and allow for generalizability across institutions. They noted that search terms can be edited to match local practice patterns, while the web-based reporting platform can be customized to deliver desired quality metrics.
The publication includes a screenshot of one such dashboard, including a readout of ADR, a comparison of ADR across sexes, a pie chart of BBPS score distribution, and gauge charts for cecal intubation rate and mean withdrawal time.
“Further development of this Internet-based colonoscopy quality reporting platform will focus on integrating additional metrics, such as adenomas per colonoscopy, as well as novel metrics, such as a size-stratified ADR, location-stratified ADR, or ADR stratified by polyp histology,” the investigators wrote.
They predicted that automating data collection in this way could help determine which metrics provide clinically meaningful insights, potentially expanding the roster of standard performance benchmarks.
“We further intend to study the integration of this platform into colonoscopy quality improvement and transparency programs to better characterize the impact of frequent, on-demand ADR feedback on colonoscopy performance,” Dr. Brenner and colleagues concluded.The investigators disclosed relationships with Olympus, Medtronic, Apollo Endosurgery, and others.
, according to investigators.
The new software, which automatically integrates endoscopy and pathology reports across a variety of practice settings, delivered an ADR on par with manual review, supporting its accuracy and feasibility for real-world usage, reported Todd A. Brenner, MD, of Johns Hopkins Hospital, Baltimore, and colleagues.
“ADR calculation is resource-intensive, often requiring manual collation of endoscopy and pathology data across multiple reporting modalities, making it an impractical tool for frequent quality audits at many centers,” the investigators wrote in Techniques and Innovations in Gastrointestinal Endoscopy.
Although others have tried to streamline ADR calculation, most efforts have relied upon manual entry of pathology data, while approaches using artificial intelligence tend to be costly and clumsy to implement across different databases, according to the investigators.
“Thus, there is a substantial demand for a novel tool to extract and analyze colonoscopy indicators from text-based reports that provides accurate data extraction in a package that is easily implemented and modified by clinicians,” they wrote.
Dr. Brenner and colleagues developed a web-based platform to meet these goals.
Following colonoscopy, the system gathers procedural and histopathology results, extracts and classifies relevant data, then outputs ADR, along with cecal intubation rate, Boston Bowel Preparation Score (BBPS), and withdrawal time.
The software was evaluated using endoscopy and pathology reports from 3,809 colonoscopies performed at six centers over 3 months. Six months later, the investigators manually reviewed data from a validation cohort of 1384 colonoscopies conducted over a 1-month period.
Comparing the automated versus manual approach revealed high congruity, with an ADR of 45.1% for the automated system vs 44.3% for manual review. The software also correctly identified most ADR-qualifying screening colonoscopies (sensitivity, 0.918; specificity, 1.0).
“The discrepancy between manual and automated ADR calculations was exclusively attributable to missed (i.e., false negative) identification of ADR-qualifying procedures,” the investigators wrote.
Of these 43 mislabeled cases, about half involved pending pathology results or erroneous pathology sample entries, while the remainder were due to spelling and/or syntax issues that stumped the system.
Still, Dr. Brenner and colleagues suggested that additional programming can overcome these kinds of issues and allow for generalizability across institutions. They noted that search terms can be edited to match local practice patterns, while the web-based reporting platform can be customized to deliver desired quality metrics.
The publication includes a screenshot of one such dashboard, including a readout of ADR, a comparison of ADR across sexes, a pie chart of BBPS score distribution, and gauge charts for cecal intubation rate and mean withdrawal time.
“Further development of this Internet-based colonoscopy quality reporting platform will focus on integrating additional metrics, such as adenomas per colonoscopy, as well as novel metrics, such as a size-stratified ADR, location-stratified ADR, or ADR stratified by polyp histology,” the investigators wrote.
They predicted that automating data collection in this way could help determine which metrics provide clinically meaningful insights, potentially expanding the roster of standard performance benchmarks.
“We further intend to study the integration of this platform into colonoscopy quality improvement and transparency programs to better characterize the impact of frequent, on-demand ADR feedback on colonoscopy performance,” Dr. Brenner and colleagues concluded.The investigators disclosed relationships with Olympus, Medtronic, Apollo Endosurgery, and others.
FROM TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY
Meta-Analysis Highlights Litany of MASLD-Associated Complications, Encouraging New Treatment Targets
, based on a large-scale meta-analysis of longitudinal data.
These findings emphasize the multisystemic nature of MASLD, suggesting that broader treatment targets are needed to reduce systemic events and end organ complications, reported lead author Kai En Chan, MBBS, of the National University of Singapore, and colleagues.
“[D]espite the substantial impact of MASLD, with direct medical costs estimated to reach $103 billion in the United States alone, a comprehensive umbrella meta-analysis of the longitudinal complications associated with MASLD has yet to be conducted,” the investigators wrote in Clinical Gastroenterology and Hepatology, noting that key outcomes associated with sex and disease severity have yet to be elucidated. “A comprehensive understanding of the spectrum of clinical complications associated with MASLD is thus crucial in developing effective disease management strategies and optimizing the allocation of limited healthcare resources.”
To this end, the investigators analyzed data from 129 studies reporting longitudinal risks of clinical outcomes among adults with MASLD. Assessed complications spanned a broad array of organ systems and pathologies. Cardiovascular and oncologic conditions predominated, while chronic kidney disease, liver-related outcomes, gallstone formation, dementia, and reflux esophagitis were also considered.
The analysis revealed significant associations between MASLD and — in ascending level of risk — chronic kidney disease (hazard ratio [HR], 1.38), cardiovascular diseases (HR, 1.43), cancer (HR, 1.54), prediabetes (HR, 1.69), hypertension (HR, 1.75), diabetes (HR, 2.56), and metabolic syndrome (HR, 2.57).
Across cardiovascular diseases, MASLD raised risk of hypertension the most, by 75%. Among cancer types, MASLD increased risk of hepatocellular carcinoma to the greatest degree, by more than fourfold.
No significant sex-specific differences in MASLD-associated risk were detected for cancer, chronic kidney disease, diabetes, or cardiovascular disease, although the investigators urged a cautious interpretation of these findings, since relevant data were scarce.
“It is imperative to understand that MASLD is a complex and multifaceted condition that requires a comprehensive approach to recognition and treatment beyond that of the hepatologist alone,” the investigators wrote.
They also suggested that the link between MASLD and cancer deserves particular attention.
“Although the mechanism by which MASLD gives rise to cardiovascular disease and diabetes has been thoroughly researched, the pathophysiology of MASLD leading to extrahepatic carcinogenesis is less well understood and has been postulated to be linked to chronic inflammation and dysregulation of the gut microbiome in MASLD,” they wrote.
Lastly, considering the multiprong association between MASLD and so many complications, the investigators recommended broader clinical metrics for measuring outcomes in patients with MASLD.
“With the synergistic increases of metabolic diseases globally, treatment targets should in turn act beyond the resolution of fibrosis but also to reduce systemic end organ complications,” they concluded.The investigators disclosed relationships with AbbVie, Echosens, Gilead Sciences, and others.
In a massive meta-analysis of 129 studies that included over 6 million participants, Chan and colleagues evaluated the associations of MASLD with incident hepatic and extrahepatic outcomes. They report numerous associations for MASLD with metabolic, cardiovascular, and renal events as well as with gastrointestinal, hepatobiliary, and other types of cancers.
The unimpeded pace of the obesity pandemic remains a steady driver of the rise in the burden of metabolic syndrome and its components, including MASLD. Thus, approaches to tackle the rising burden of metabolic diseases including MASLD should start with the root driver, obesity. It is also imperative to consider addressing the cardiometabolic milieu in any approach designed to specifically target MASLD/MASH. Lifestyle modifications that include weight loss, smoking cessation, and avoidance of alcohol use may help reduce risks of cardiovascular disease and cancer, the leading causes of death in patients with MASLD. Anticipated pharmacologic therapies for MASH should not only improve liver endpoints but also have a beneficial or, at minimum, neutral extrahepatic effects on coexisting cardiometabolic conditions.
Samer Gawrieh, MD, is professor of clinical medicine in the Division of Gastroenterology and Hepatology at Indiana University School of Medicine, Indianapolis, where he serves as the Director of Hepatology Research and Clinical Fellowship Program. He receives funding for the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute on Alcohol Abuse and Alcoholism, and research grant support from Zydus and Viking, and serves on safety committees with TransMedics, Pfizer and Spruce.
In a massive meta-analysis of 129 studies that included over 6 million participants, Chan and colleagues evaluated the associations of MASLD with incident hepatic and extrahepatic outcomes. They report numerous associations for MASLD with metabolic, cardiovascular, and renal events as well as with gastrointestinal, hepatobiliary, and other types of cancers.
The unimpeded pace of the obesity pandemic remains a steady driver of the rise in the burden of metabolic syndrome and its components, including MASLD. Thus, approaches to tackle the rising burden of metabolic diseases including MASLD should start with the root driver, obesity. It is also imperative to consider addressing the cardiometabolic milieu in any approach designed to specifically target MASLD/MASH. Lifestyle modifications that include weight loss, smoking cessation, and avoidance of alcohol use may help reduce risks of cardiovascular disease and cancer, the leading causes of death in patients with MASLD. Anticipated pharmacologic therapies for MASH should not only improve liver endpoints but also have a beneficial or, at minimum, neutral extrahepatic effects on coexisting cardiometabolic conditions.
Samer Gawrieh, MD, is professor of clinical medicine in the Division of Gastroenterology and Hepatology at Indiana University School of Medicine, Indianapolis, where he serves as the Director of Hepatology Research and Clinical Fellowship Program. He receives funding for the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute on Alcohol Abuse and Alcoholism, and research grant support from Zydus and Viking, and serves on safety committees with TransMedics, Pfizer and Spruce.
In a massive meta-analysis of 129 studies that included over 6 million participants, Chan and colleagues evaluated the associations of MASLD with incident hepatic and extrahepatic outcomes. They report numerous associations for MASLD with metabolic, cardiovascular, and renal events as well as with gastrointestinal, hepatobiliary, and other types of cancers.
The unimpeded pace of the obesity pandemic remains a steady driver of the rise in the burden of metabolic syndrome and its components, including MASLD. Thus, approaches to tackle the rising burden of metabolic diseases including MASLD should start with the root driver, obesity. It is also imperative to consider addressing the cardiometabolic milieu in any approach designed to specifically target MASLD/MASH. Lifestyle modifications that include weight loss, smoking cessation, and avoidance of alcohol use may help reduce risks of cardiovascular disease and cancer, the leading causes of death in patients with MASLD. Anticipated pharmacologic therapies for MASH should not only improve liver endpoints but also have a beneficial or, at minimum, neutral extrahepatic effects on coexisting cardiometabolic conditions.
Samer Gawrieh, MD, is professor of clinical medicine in the Division of Gastroenterology and Hepatology at Indiana University School of Medicine, Indianapolis, where he serves as the Director of Hepatology Research and Clinical Fellowship Program. He receives funding for the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute on Alcohol Abuse and Alcoholism, and research grant support from Zydus and Viking, and serves on safety committees with TransMedics, Pfizer and Spruce.
, based on a large-scale meta-analysis of longitudinal data.
These findings emphasize the multisystemic nature of MASLD, suggesting that broader treatment targets are needed to reduce systemic events and end organ complications, reported lead author Kai En Chan, MBBS, of the National University of Singapore, and colleagues.
“[D]espite the substantial impact of MASLD, with direct medical costs estimated to reach $103 billion in the United States alone, a comprehensive umbrella meta-analysis of the longitudinal complications associated with MASLD has yet to be conducted,” the investigators wrote in Clinical Gastroenterology and Hepatology, noting that key outcomes associated with sex and disease severity have yet to be elucidated. “A comprehensive understanding of the spectrum of clinical complications associated with MASLD is thus crucial in developing effective disease management strategies and optimizing the allocation of limited healthcare resources.”
To this end, the investigators analyzed data from 129 studies reporting longitudinal risks of clinical outcomes among adults with MASLD. Assessed complications spanned a broad array of organ systems and pathologies. Cardiovascular and oncologic conditions predominated, while chronic kidney disease, liver-related outcomes, gallstone formation, dementia, and reflux esophagitis were also considered.
The analysis revealed significant associations between MASLD and — in ascending level of risk — chronic kidney disease (hazard ratio [HR], 1.38), cardiovascular diseases (HR, 1.43), cancer (HR, 1.54), prediabetes (HR, 1.69), hypertension (HR, 1.75), diabetes (HR, 2.56), and metabolic syndrome (HR, 2.57).
Across cardiovascular diseases, MASLD raised risk of hypertension the most, by 75%. Among cancer types, MASLD increased risk of hepatocellular carcinoma to the greatest degree, by more than fourfold.
No significant sex-specific differences in MASLD-associated risk were detected for cancer, chronic kidney disease, diabetes, or cardiovascular disease, although the investigators urged a cautious interpretation of these findings, since relevant data were scarce.
“It is imperative to understand that MASLD is a complex and multifaceted condition that requires a comprehensive approach to recognition and treatment beyond that of the hepatologist alone,” the investigators wrote.
They also suggested that the link between MASLD and cancer deserves particular attention.
“Although the mechanism by which MASLD gives rise to cardiovascular disease and diabetes has been thoroughly researched, the pathophysiology of MASLD leading to extrahepatic carcinogenesis is less well understood and has been postulated to be linked to chronic inflammation and dysregulation of the gut microbiome in MASLD,” they wrote.
Lastly, considering the multiprong association between MASLD and so many complications, the investigators recommended broader clinical metrics for measuring outcomes in patients with MASLD.
“With the synergistic increases of metabolic diseases globally, treatment targets should in turn act beyond the resolution of fibrosis but also to reduce systemic end organ complications,” they concluded.The investigators disclosed relationships with AbbVie, Echosens, Gilead Sciences, and others.
, based on a large-scale meta-analysis of longitudinal data.
These findings emphasize the multisystemic nature of MASLD, suggesting that broader treatment targets are needed to reduce systemic events and end organ complications, reported lead author Kai En Chan, MBBS, of the National University of Singapore, and colleagues.
“[D]espite the substantial impact of MASLD, with direct medical costs estimated to reach $103 billion in the United States alone, a comprehensive umbrella meta-analysis of the longitudinal complications associated with MASLD has yet to be conducted,” the investigators wrote in Clinical Gastroenterology and Hepatology, noting that key outcomes associated with sex and disease severity have yet to be elucidated. “A comprehensive understanding of the spectrum of clinical complications associated with MASLD is thus crucial in developing effective disease management strategies and optimizing the allocation of limited healthcare resources.”
To this end, the investigators analyzed data from 129 studies reporting longitudinal risks of clinical outcomes among adults with MASLD. Assessed complications spanned a broad array of organ systems and pathologies. Cardiovascular and oncologic conditions predominated, while chronic kidney disease, liver-related outcomes, gallstone formation, dementia, and reflux esophagitis were also considered.
The analysis revealed significant associations between MASLD and — in ascending level of risk — chronic kidney disease (hazard ratio [HR], 1.38), cardiovascular diseases (HR, 1.43), cancer (HR, 1.54), prediabetes (HR, 1.69), hypertension (HR, 1.75), diabetes (HR, 2.56), and metabolic syndrome (HR, 2.57).
Across cardiovascular diseases, MASLD raised risk of hypertension the most, by 75%. Among cancer types, MASLD increased risk of hepatocellular carcinoma to the greatest degree, by more than fourfold.
No significant sex-specific differences in MASLD-associated risk were detected for cancer, chronic kidney disease, diabetes, or cardiovascular disease, although the investigators urged a cautious interpretation of these findings, since relevant data were scarce.
“It is imperative to understand that MASLD is a complex and multifaceted condition that requires a comprehensive approach to recognition and treatment beyond that of the hepatologist alone,” the investigators wrote.
They also suggested that the link between MASLD and cancer deserves particular attention.
“Although the mechanism by which MASLD gives rise to cardiovascular disease and diabetes has been thoroughly researched, the pathophysiology of MASLD leading to extrahepatic carcinogenesis is less well understood and has been postulated to be linked to chronic inflammation and dysregulation of the gut microbiome in MASLD,” they wrote.
Lastly, considering the multiprong association between MASLD and so many complications, the investigators recommended broader clinical metrics for measuring outcomes in patients with MASLD.
“With the synergistic increases of metabolic diseases globally, treatment targets should in turn act beyond the resolution of fibrosis but also to reduce systemic end organ complications,” they concluded.The investigators disclosed relationships with AbbVie, Echosens, Gilead Sciences, and others.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
AGA Gives Guidance on Subepithelial Lesions
The new guidance document, authored by Lionel S. D’Souza, MD, of Stony Brook University Hospital, Stony Brook, New York, and colleagues, offers a framework for deciding between various EFTR techniques based on lesion histology, size, and location.
“EFTR has emerged as a novel treatment option for select SELs,” the update panelists wrote in Gastroenterology. “In this commentary, we reviewed the different techniques and uses of EFTR for the management of SELs.”
They noted that all patients with SELs should first undergo multidisciplinary evaluation in accordance with a separate AGA guidance document on SELs.
The present update focuses specifically on EFTR, first by distinguishing between exposed and nonexposed techniques. While the former involves resection of the mucosa and all other layers of the wall, the latter relies upon a ‘close first, then cut’ method to prevent perforation, or preservation of an overlying flap of mucosa.
The new guidance calls for a nonexposed technique unless the exposed approach is necessary.
“In our opinion, the exposed EFTR technique should be considered for lesions in which other methods (i.e., endoscopic mucosal resection, endoscopic submucosal dissection, and nonexposed EFTR) cannot reliably and completely excise SELs due to larger size or difficult location of the lesion,” the update panelists wrote. “The exposed EFTR technique may be best suited for gastric lesions and as an alternative to other endoscopic approaches for SELs in the rectum. The exposed technique should be avoided in the esophagus and duodenum, as the clinical consequences of a leak can be devastating and endoscopic closure is notoriously challenging.”
Dr. D’Souza and colleagues went on to discuss various nonexposed techniques, including submucosal tunneling and endoscopic resection and peroral endoscopic tunnel resection (STER/POET), device-assisted endoscopic full-thickness resection, and full-thickness resection with an over-the-scope clip with integrated snare (FTRD).
They highlighted how STER/POET encourages traction on the lesion and scope stability while limiting extravasation of luminal contents, and closure tends to be easier than with exposed EFTR. This approach should be reserved for tumors smaller than approximately 3-4 cm, however, with the update noting that lesions larger than 2 cm may present increased risk of incomplete resection. Similarly, device-assisted endoscopic full-thickness resection, which involves pulling or suctioning the lesion into the device, is also limited by lesion size, although fewer data are available to guide size thresholds.
FTRD, which involves “a 23-mm deep cap with a specially designed over-the-scope clip and integrated cautery snare,” also lacks a broad evidence base.
“Although there has been reasonable clinical success reported in most case series, several factors should be considered with the use of the FTRD for SELs,” the update cautions.
Specifically, a recent Dutch and German registry study of FTRD had an adverse event rate of 11.3%, with an approximate 1% perforation rate. More than half of the perforations were due to technical or procedural issues.
“This adverse event rate may improve as individual experience with the device is gained; however, data on this are lacking,” the panelists wrote, also noting that lesions 1.5 cm or larger may carry a higher risk of incomplete resection.
Ultimately, the clinical practice update calls for a personalized approach to EFTR decision-making that considers factors extending beyond the lesion.
“The ‘ideal’ technique will depend on various patient and lesion characteristics, as well as the endoscopist’s preference and available expertise,” Dr. D’Souza and colleagues concluded. “Further research into the efficacy of these resection techniques and the long-term outcomes in patients after endoscopic resection of SELs will be essential in standardizing appropriate resection algorithms.”
This clinical practice update was commissioned and approved by AGA Institute. The investigators disclosed relationships with Olympus, Fujifilm, Apollo Endosurgery, and others.
The new guidance document, authored by Lionel S. D’Souza, MD, of Stony Brook University Hospital, Stony Brook, New York, and colleagues, offers a framework for deciding between various EFTR techniques based on lesion histology, size, and location.
“EFTR has emerged as a novel treatment option for select SELs,” the update panelists wrote in Gastroenterology. “In this commentary, we reviewed the different techniques and uses of EFTR for the management of SELs.”
They noted that all patients with SELs should first undergo multidisciplinary evaluation in accordance with a separate AGA guidance document on SELs.
The present update focuses specifically on EFTR, first by distinguishing between exposed and nonexposed techniques. While the former involves resection of the mucosa and all other layers of the wall, the latter relies upon a ‘close first, then cut’ method to prevent perforation, or preservation of an overlying flap of mucosa.
The new guidance calls for a nonexposed technique unless the exposed approach is necessary.
“In our opinion, the exposed EFTR technique should be considered for lesions in which other methods (i.e., endoscopic mucosal resection, endoscopic submucosal dissection, and nonexposed EFTR) cannot reliably and completely excise SELs due to larger size or difficult location of the lesion,” the update panelists wrote. “The exposed EFTR technique may be best suited for gastric lesions and as an alternative to other endoscopic approaches for SELs in the rectum. The exposed technique should be avoided in the esophagus and duodenum, as the clinical consequences of a leak can be devastating and endoscopic closure is notoriously challenging.”
Dr. D’Souza and colleagues went on to discuss various nonexposed techniques, including submucosal tunneling and endoscopic resection and peroral endoscopic tunnel resection (STER/POET), device-assisted endoscopic full-thickness resection, and full-thickness resection with an over-the-scope clip with integrated snare (FTRD).
They highlighted how STER/POET encourages traction on the lesion and scope stability while limiting extravasation of luminal contents, and closure tends to be easier than with exposed EFTR. This approach should be reserved for tumors smaller than approximately 3-4 cm, however, with the update noting that lesions larger than 2 cm may present increased risk of incomplete resection. Similarly, device-assisted endoscopic full-thickness resection, which involves pulling or suctioning the lesion into the device, is also limited by lesion size, although fewer data are available to guide size thresholds.
FTRD, which involves “a 23-mm deep cap with a specially designed over-the-scope clip and integrated cautery snare,” also lacks a broad evidence base.
“Although there has been reasonable clinical success reported in most case series, several factors should be considered with the use of the FTRD for SELs,” the update cautions.
Specifically, a recent Dutch and German registry study of FTRD had an adverse event rate of 11.3%, with an approximate 1% perforation rate. More than half of the perforations were due to technical or procedural issues.
“This adverse event rate may improve as individual experience with the device is gained; however, data on this are lacking,” the panelists wrote, also noting that lesions 1.5 cm or larger may carry a higher risk of incomplete resection.
Ultimately, the clinical practice update calls for a personalized approach to EFTR decision-making that considers factors extending beyond the lesion.
“The ‘ideal’ technique will depend on various patient and lesion characteristics, as well as the endoscopist’s preference and available expertise,” Dr. D’Souza and colleagues concluded. “Further research into the efficacy of these resection techniques and the long-term outcomes in patients after endoscopic resection of SELs will be essential in standardizing appropriate resection algorithms.”
This clinical practice update was commissioned and approved by AGA Institute. The investigators disclosed relationships with Olympus, Fujifilm, Apollo Endosurgery, and others.
The new guidance document, authored by Lionel S. D’Souza, MD, of Stony Brook University Hospital, Stony Brook, New York, and colleagues, offers a framework for deciding between various EFTR techniques based on lesion histology, size, and location.
“EFTR has emerged as a novel treatment option for select SELs,” the update panelists wrote in Gastroenterology. “In this commentary, we reviewed the different techniques and uses of EFTR for the management of SELs.”
They noted that all patients with SELs should first undergo multidisciplinary evaluation in accordance with a separate AGA guidance document on SELs.
The present update focuses specifically on EFTR, first by distinguishing between exposed and nonexposed techniques. While the former involves resection of the mucosa and all other layers of the wall, the latter relies upon a ‘close first, then cut’ method to prevent perforation, or preservation of an overlying flap of mucosa.
The new guidance calls for a nonexposed technique unless the exposed approach is necessary.
“In our opinion, the exposed EFTR technique should be considered for lesions in which other methods (i.e., endoscopic mucosal resection, endoscopic submucosal dissection, and nonexposed EFTR) cannot reliably and completely excise SELs due to larger size or difficult location of the lesion,” the update panelists wrote. “The exposed EFTR technique may be best suited for gastric lesions and as an alternative to other endoscopic approaches for SELs in the rectum. The exposed technique should be avoided in the esophagus and duodenum, as the clinical consequences of a leak can be devastating and endoscopic closure is notoriously challenging.”
Dr. D’Souza and colleagues went on to discuss various nonexposed techniques, including submucosal tunneling and endoscopic resection and peroral endoscopic tunnel resection (STER/POET), device-assisted endoscopic full-thickness resection, and full-thickness resection with an over-the-scope clip with integrated snare (FTRD).
They highlighted how STER/POET encourages traction on the lesion and scope stability while limiting extravasation of luminal contents, and closure tends to be easier than with exposed EFTR. This approach should be reserved for tumors smaller than approximately 3-4 cm, however, with the update noting that lesions larger than 2 cm may present increased risk of incomplete resection. Similarly, device-assisted endoscopic full-thickness resection, which involves pulling or suctioning the lesion into the device, is also limited by lesion size, although fewer data are available to guide size thresholds.
FTRD, which involves “a 23-mm deep cap with a specially designed over-the-scope clip and integrated cautery snare,” also lacks a broad evidence base.
“Although there has been reasonable clinical success reported in most case series, several factors should be considered with the use of the FTRD for SELs,” the update cautions.
Specifically, a recent Dutch and German registry study of FTRD had an adverse event rate of 11.3%, with an approximate 1% perforation rate. More than half of the perforations were due to technical or procedural issues.
“This adverse event rate may improve as individual experience with the device is gained; however, data on this are lacking,” the panelists wrote, also noting that lesions 1.5 cm or larger may carry a higher risk of incomplete resection.
Ultimately, the clinical practice update calls for a personalized approach to EFTR decision-making that considers factors extending beyond the lesion.
“The ‘ideal’ technique will depend on various patient and lesion characteristics, as well as the endoscopist’s preference and available expertise,” Dr. D’Souza and colleagues concluded. “Further research into the efficacy of these resection techniques and the long-term outcomes in patients after endoscopic resection of SELs will be essential in standardizing appropriate resection algorithms.”
This clinical practice update was commissioned and approved by AGA Institute. The investigators disclosed relationships with Olympus, Fujifilm, Apollo Endosurgery, and others.
FROM GASTROENTEROLOGY
Telephone Best for Switching Patients to New Colonoscopy Intervals
In an article published in Clinical Gastroenterology and Hepatology, a group led by Jeffrey K. Lee, MD, MPH, a gastroenterologist at Kaiser Permanente Medical Center in San Francisco, reported the following 60-day response rates for the three contact methods in potentially transitioning more than 600 post-polypectomy patients to the new interval:
- Telephone: 64.5%
- Secure messaging: 51.7%
- Mailed letter: 31.3%
Compared with letter outreach, overall rate differences were significant for telephone (18.1%) and secure message outreach (13.1%).
Such interventions are widely used, the authors noted , but have not been compared for efficacy terms of communicating updated colonoscopy intervals.
The trial’s aim was to inform low-risk patients of the recommended interval update from 5 years — used since the 1990s — to 7-10 years. Given a choice, more patients opted to transition to the 10-year surveillance interval in the telephone (37%) and secure messaging arms (32.%) compared with mailed-letter arm (18.9%).
In addition to telephone and secure messaging outreach, factors positively associated with adoption of the 10-year interval were a positive fecal immunochemical test–based index colonoscopy and increasing age. Patients with these characteristics may be biased toward avoiding colonoscopy if not medically necessary, the authors conjectured.
Inversely associated factors included Asian or Pacific Islander race (odds ratio .58), Hispanic ethnicity (OR .40), and a higher Charlson comorbidity score of 2 vs 0 (OR .43).
Possible explanations for the race and ethnicity associations include gaps in culturally component care, lack of engagement with the English-based outreach approaches, and medical mistrust, the authors said.
“In this study, we gave all our patients an option to either extend their surveillance interval to current guideline recommendations or continue with their old interval, and some chose to do that,” Dr. Lee said in an interview. “Patients really appreciated having a choice and to be informed about the latest guideline changes.”
“A critical challenge to health systems is how to effectively de-implement outdated surveillance recommendations for low-risk patients who have a 5-year follow-up interval and potentially transition them to the recommended 7- to 10-year interval,” Dr. Lee and colleagues wrote.
More than 5 million surveillance colonoscopies are performed annually in US patients with a history of adenomas, the main precursor lesion for colorectal cancer, the authors noted.
With the recent guidelines issued in 2020 by the US Multi-Society Task Force on Colorectal Cancer lengthening the follow-up interval to 7-10 years , physicians are being advised to reevaluate low-risk patients previously scheduled with 5-year surveillance and provide an updated recommendation for follow-up.
Study Details
The three-arm pragmatic randomized trial was conducted in low-risk patients 54-70 years of age with one or two small (< 10 mm) tubular adenomas at baseline colonoscopy. Participants due for 5-year surveillance in 2022 were randomly assigned to one of three outreach arms: telephone (n = 200], secure messaging (n = 203), and mailed letter (n = 201). Stratified by age, sex, race, and ethnicity, participants could change their assigned interval to 10 years or continue with their previously scheduled 5-year interval.
As to economic considerations, the authors said that telephone may be the costliest form of outreach in terms of staffing resources. “We don’t know because we did not conduct a formal cost-effectiveness analysis,” Dr. Lee said. “However, we do know phone outreach requires a lot of personnel effort, which is why we also explored the less costly option of secure messaging/email.”
But based on the findings, telephone outreach would be a reasonable approach to update patients on post-polypectomy surveillance guideline changes if secure messaging or text messaging isn’t available, he added.
Downsides to Retroactive Changes?
Commenting on the study but not involved in it, Nabil M. Mansour, MD, an assistant professor and director of the McNair General GI Clinic at Baylor College of Medicine in Houston, noted that unlike Kaiser Permanente, his center decided against an overall effort to switch patients colonoscopied before the release of the new guidelines over to the new interval.
“Several of our physicians may have chosen to recommend a 5-year interval specifically for a variety of reasons and we felt going back, and making a blanket change to everyone’s interval retrospectively might create confusion and frustration and might actually delay the colonoscopies of some patients for which their doctors had a very good, legitimate reason to recommend a 5-year interval,” he said in an interview.
Dr. Mansour added that no difficulties were encountered in getting patients to agree to a 10-year interval. In his view telephone communication or in-person clinic visits are likely the most effective ways but both are more labor-intensive than automated patient portal messages. “I do not think traditional snail mail is effective.” His clinic uses automatic EMR reminders.
Offering another perspective on the study, Aditya Sreenivasan, MD, a gastroenterologist at Northwell Health in New York City, said his center has not reached out to correct the old intervals. “When I see a patient who previously had a colonoscopy with another physician, I always follow the previous recommendation for when the next colonoscopy should be, regardless of whether or not it technically meets guideline recommendations,” he told this news organization. “I do this because I was not there during the procedure and am not aware of any circumstances that would require a shorter interval that may not be apparent from the report.”
While he agrees with the new guidelines, Dr. Sreenivasan is “not sure if retroactively changing intervals is beneficial to patients, as the presence of guidelines may subconsciously influence the behavior of the endoscopist at the time of the procedure. For example, if a patient has a technically challenging colonoscopy and the endoscopist is running late, the endoscopist may drop their guard once they find a polyp and miss 1-2 additional small polyps that they would have spent more time looking for if they knew their next one would be in 10 years instead of 5.”
As for notification method, despite the logistical downside of taking dedicated staff time to make telephone calls, Dr. Sreenivasan said, “I think having a conversation with the patient directly is a much better way to communicate this information as it allows the patient to ask and answer questions. Things like tone of voice can provide reassurance that one cannot get via email.” Looking to the future, the study authors acknowledged that combinations of initial and reminder outreach approaches — for example, a mailed letter followed by secure message or telephone call — could potentially yield higher response rates and/or adoption rates than they observed. And a longer follow-up period with additional reminders may have produced higher yields. Additional studies are needed to optimize outreach approaches and to understand patient barriers to adopting the new guideline recommendations in different healthcare settings.
The study was supported by a Delivery Science grant from the Kaiser Permanente Northern California.
The authors disclosed no conflicts of interest. Dr. Mansour and Dr. Sreenivasan disclosed no conflicts of interest relevant to their comments.
In an article published in Clinical Gastroenterology and Hepatology, a group led by Jeffrey K. Lee, MD, MPH, a gastroenterologist at Kaiser Permanente Medical Center in San Francisco, reported the following 60-day response rates for the three contact methods in potentially transitioning more than 600 post-polypectomy patients to the new interval:
- Telephone: 64.5%
- Secure messaging: 51.7%
- Mailed letter: 31.3%
Compared with letter outreach, overall rate differences were significant for telephone (18.1%) and secure message outreach (13.1%).
Such interventions are widely used, the authors noted , but have not been compared for efficacy terms of communicating updated colonoscopy intervals.
The trial’s aim was to inform low-risk patients of the recommended interval update from 5 years — used since the 1990s — to 7-10 years. Given a choice, more patients opted to transition to the 10-year surveillance interval in the telephone (37%) and secure messaging arms (32.%) compared with mailed-letter arm (18.9%).
In addition to telephone and secure messaging outreach, factors positively associated with adoption of the 10-year interval were a positive fecal immunochemical test–based index colonoscopy and increasing age. Patients with these characteristics may be biased toward avoiding colonoscopy if not medically necessary, the authors conjectured.
Inversely associated factors included Asian or Pacific Islander race (odds ratio .58), Hispanic ethnicity (OR .40), and a higher Charlson comorbidity score of 2 vs 0 (OR .43).
Possible explanations for the race and ethnicity associations include gaps in culturally component care, lack of engagement with the English-based outreach approaches, and medical mistrust, the authors said.
“In this study, we gave all our patients an option to either extend their surveillance interval to current guideline recommendations or continue with their old interval, and some chose to do that,” Dr. Lee said in an interview. “Patients really appreciated having a choice and to be informed about the latest guideline changes.”
“A critical challenge to health systems is how to effectively de-implement outdated surveillance recommendations for low-risk patients who have a 5-year follow-up interval and potentially transition them to the recommended 7- to 10-year interval,” Dr. Lee and colleagues wrote.
More than 5 million surveillance colonoscopies are performed annually in US patients with a history of adenomas, the main precursor lesion for colorectal cancer, the authors noted.
With the recent guidelines issued in 2020 by the US Multi-Society Task Force on Colorectal Cancer lengthening the follow-up interval to 7-10 years , physicians are being advised to reevaluate low-risk patients previously scheduled with 5-year surveillance and provide an updated recommendation for follow-up.
Study Details
The three-arm pragmatic randomized trial was conducted in low-risk patients 54-70 years of age with one or two small (< 10 mm) tubular adenomas at baseline colonoscopy. Participants due for 5-year surveillance in 2022 were randomly assigned to one of three outreach arms: telephone (n = 200], secure messaging (n = 203), and mailed letter (n = 201). Stratified by age, sex, race, and ethnicity, participants could change their assigned interval to 10 years or continue with their previously scheduled 5-year interval.
As to economic considerations, the authors said that telephone may be the costliest form of outreach in terms of staffing resources. “We don’t know because we did not conduct a formal cost-effectiveness analysis,” Dr. Lee said. “However, we do know phone outreach requires a lot of personnel effort, which is why we also explored the less costly option of secure messaging/email.”
But based on the findings, telephone outreach would be a reasonable approach to update patients on post-polypectomy surveillance guideline changes if secure messaging or text messaging isn’t available, he added.
Downsides to Retroactive Changes?
Commenting on the study but not involved in it, Nabil M. Mansour, MD, an assistant professor and director of the McNair General GI Clinic at Baylor College of Medicine in Houston, noted that unlike Kaiser Permanente, his center decided against an overall effort to switch patients colonoscopied before the release of the new guidelines over to the new interval.
“Several of our physicians may have chosen to recommend a 5-year interval specifically for a variety of reasons and we felt going back, and making a blanket change to everyone’s interval retrospectively might create confusion and frustration and might actually delay the colonoscopies of some patients for which their doctors had a very good, legitimate reason to recommend a 5-year interval,” he said in an interview.
Dr. Mansour added that no difficulties were encountered in getting patients to agree to a 10-year interval. In his view telephone communication or in-person clinic visits are likely the most effective ways but both are more labor-intensive than automated patient portal messages. “I do not think traditional snail mail is effective.” His clinic uses automatic EMR reminders.
Offering another perspective on the study, Aditya Sreenivasan, MD, a gastroenterologist at Northwell Health in New York City, said his center has not reached out to correct the old intervals. “When I see a patient who previously had a colonoscopy with another physician, I always follow the previous recommendation for when the next colonoscopy should be, regardless of whether or not it technically meets guideline recommendations,” he told this news organization. “I do this because I was not there during the procedure and am not aware of any circumstances that would require a shorter interval that may not be apparent from the report.”
While he agrees with the new guidelines, Dr. Sreenivasan is “not sure if retroactively changing intervals is beneficial to patients, as the presence of guidelines may subconsciously influence the behavior of the endoscopist at the time of the procedure. For example, if a patient has a technically challenging colonoscopy and the endoscopist is running late, the endoscopist may drop their guard once they find a polyp and miss 1-2 additional small polyps that they would have spent more time looking for if they knew their next one would be in 10 years instead of 5.”
As for notification method, despite the logistical downside of taking dedicated staff time to make telephone calls, Dr. Sreenivasan said, “I think having a conversation with the patient directly is a much better way to communicate this information as it allows the patient to ask and answer questions. Things like tone of voice can provide reassurance that one cannot get via email.” Looking to the future, the study authors acknowledged that combinations of initial and reminder outreach approaches — for example, a mailed letter followed by secure message or telephone call — could potentially yield higher response rates and/or adoption rates than they observed. And a longer follow-up period with additional reminders may have produced higher yields. Additional studies are needed to optimize outreach approaches and to understand patient barriers to adopting the new guideline recommendations in different healthcare settings.
The study was supported by a Delivery Science grant from the Kaiser Permanente Northern California.
The authors disclosed no conflicts of interest. Dr. Mansour and Dr. Sreenivasan disclosed no conflicts of interest relevant to their comments.
In an article published in Clinical Gastroenterology and Hepatology, a group led by Jeffrey K. Lee, MD, MPH, a gastroenterologist at Kaiser Permanente Medical Center in San Francisco, reported the following 60-day response rates for the three contact methods in potentially transitioning more than 600 post-polypectomy patients to the new interval:
- Telephone: 64.5%
- Secure messaging: 51.7%
- Mailed letter: 31.3%
Compared with letter outreach, overall rate differences were significant for telephone (18.1%) and secure message outreach (13.1%).
Such interventions are widely used, the authors noted , but have not been compared for efficacy terms of communicating updated colonoscopy intervals.
The trial’s aim was to inform low-risk patients of the recommended interval update from 5 years — used since the 1990s — to 7-10 years. Given a choice, more patients opted to transition to the 10-year surveillance interval in the telephone (37%) and secure messaging arms (32.%) compared with mailed-letter arm (18.9%).
In addition to telephone and secure messaging outreach, factors positively associated with adoption of the 10-year interval were a positive fecal immunochemical test–based index colonoscopy and increasing age. Patients with these characteristics may be biased toward avoiding colonoscopy if not medically necessary, the authors conjectured.
Inversely associated factors included Asian or Pacific Islander race (odds ratio .58), Hispanic ethnicity (OR .40), and a higher Charlson comorbidity score of 2 vs 0 (OR .43).
Possible explanations for the race and ethnicity associations include gaps in culturally component care, lack of engagement with the English-based outreach approaches, and medical mistrust, the authors said.
“In this study, we gave all our patients an option to either extend their surveillance interval to current guideline recommendations or continue with their old interval, and some chose to do that,” Dr. Lee said in an interview. “Patients really appreciated having a choice and to be informed about the latest guideline changes.”
“A critical challenge to health systems is how to effectively de-implement outdated surveillance recommendations for low-risk patients who have a 5-year follow-up interval and potentially transition them to the recommended 7- to 10-year interval,” Dr. Lee and colleagues wrote.
More than 5 million surveillance colonoscopies are performed annually in US patients with a history of adenomas, the main precursor lesion for colorectal cancer, the authors noted.
With the recent guidelines issued in 2020 by the US Multi-Society Task Force on Colorectal Cancer lengthening the follow-up interval to 7-10 years , physicians are being advised to reevaluate low-risk patients previously scheduled with 5-year surveillance and provide an updated recommendation for follow-up.
Study Details
The three-arm pragmatic randomized trial was conducted in low-risk patients 54-70 years of age with one or two small (< 10 mm) tubular adenomas at baseline colonoscopy. Participants due for 5-year surveillance in 2022 were randomly assigned to one of three outreach arms: telephone (n = 200], secure messaging (n = 203), and mailed letter (n = 201). Stratified by age, sex, race, and ethnicity, participants could change their assigned interval to 10 years or continue with their previously scheduled 5-year interval.
As to economic considerations, the authors said that telephone may be the costliest form of outreach in terms of staffing resources. “We don’t know because we did not conduct a formal cost-effectiveness analysis,” Dr. Lee said. “However, we do know phone outreach requires a lot of personnel effort, which is why we also explored the less costly option of secure messaging/email.”
But based on the findings, telephone outreach would be a reasonable approach to update patients on post-polypectomy surveillance guideline changes if secure messaging or text messaging isn’t available, he added.
Downsides to Retroactive Changes?
Commenting on the study but not involved in it, Nabil M. Mansour, MD, an assistant professor and director of the McNair General GI Clinic at Baylor College of Medicine in Houston, noted that unlike Kaiser Permanente, his center decided against an overall effort to switch patients colonoscopied before the release of the new guidelines over to the new interval.
“Several of our physicians may have chosen to recommend a 5-year interval specifically for a variety of reasons and we felt going back, and making a blanket change to everyone’s interval retrospectively might create confusion and frustration and might actually delay the colonoscopies of some patients for which their doctors had a very good, legitimate reason to recommend a 5-year interval,” he said in an interview.
Dr. Mansour added that no difficulties were encountered in getting patients to agree to a 10-year interval. In his view telephone communication or in-person clinic visits are likely the most effective ways but both are more labor-intensive than automated patient portal messages. “I do not think traditional snail mail is effective.” His clinic uses automatic EMR reminders.
Offering another perspective on the study, Aditya Sreenivasan, MD, a gastroenterologist at Northwell Health in New York City, said his center has not reached out to correct the old intervals. “When I see a patient who previously had a colonoscopy with another physician, I always follow the previous recommendation for when the next colonoscopy should be, regardless of whether or not it technically meets guideline recommendations,” he told this news organization. “I do this because I was not there during the procedure and am not aware of any circumstances that would require a shorter interval that may not be apparent from the report.”
While he agrees with the new guidelines, Dr. Sreenivasan is “not sure if retroactively changing intervals is beneficial to patients, as the presence of guidelines may subconsciously influence the behavior of the endoscopist at the time of the procedure. For example, if a patient has a technically challenging colonoscopy and the endoscopist is running late, the endoscopist may drop their guard once they find a polyp and miss 1-2 additional small polyps that they would have spent more time looking for if they knew their next one would be in 10 years instead of 5.”
As for notification method, despite the logistical downside of taking dedicated staff time to make telephone calls, Dr. Sreenivasan said, “I think having a conversation with the patient directly is a much better way to communicate this information as it allows the patient to ask and answer questions. Things like tone of voice can provide reassurance that one cannot get via email.” Looking to the future, the study authors acknowledged that combinations of initial and reminder outreach approaches — for example, a mailed letter followed by secure message or telephone call — could potentially yield higher response rates and/or adoption rates than they observed. And a longer follow-up period with additional reminders may have produced higher yields. Additional studies are needed to optimize outreach approaches and to understand patient barriers to adopting the new guideline recommendations in different healthcare settings.
The study was supported by a Delivery Science grant from the Kaiser Permanente Northern California.
The authors disclosed no conflicts of interest. Dr. Mansour and Dr. Sreenivasan disclosed no conflicts of interest relevant to their comments.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Gastric cancer screening benefits may vary by country
South Korea’s gastric cancer screening (GC) program has reduced disease-related mortality by 41%.
Japan’s? Not at all.
These findings suggest that the benefits of nationwide gastric cancer screening may vary widely between countries while offering insights into program best practices, reported lead author Dianqin Sun, a PhD candidate at the University Medical Center, Rotterdam, the Netherlands, and colleagues.
“Despite the lack of evidence from randomized controlled trials, South Korea and Japan, two countries with a high GC incidence, have been at the forefront of GC secondary prevention and have implemented nationwide organized GC screening programs for decades using endoscopy or upper gastrointestinal series,” the investigators wrote in Gastroenterology.
Although individual-level data from both programs supports their efficacy in reducing GC-related death, the investigators noted that these studies have been limited by volunteer bias, and population-level data remain scarce.
To address this knowledge gap, Mr. Sun and colleagues used the flexible synthetic control method to determine how screening programs affected GC mortality rate, as well as a composite mortality rate for esophageal cancer and peptic ulcer.
“The concept of the synthetic control method is to construct a synthetic control for the treated country by deriving a weighted average of multiple control countries without intervention,” the investigators wrote. “The weight of controls is determined in a data-driven way to minimize the differences in preintervention outcomes (i.e., GC mortality before the introduction of nationwide screening) and other covariates associated with GC mortality between the treated country and the synthetic control.”
This approach revealed starkly different benefits for South Korea and Japan.
Compared with the synthetic control, South Korea’s screening program was associated with a 17% reduction in GC mortality risk on average, with risk dropping as far as 41% after the 15th year of screening. The Korean program was also associated with a 28% reduction in mortality from esophageal cancer and peptic ulcer, with this rate decreasing as much as 53% after 15 years of screening.
In sharp contrast, Japan’s mortality rates for GC and the other GI diseases were not significantly different from the synthetic control after 34 years of screening.
The investigators suggested several possible factors behind the lack of benefit in Japan, including the absence of a recommendation for endoscopic screening until 2014. In 2015, just 19% of municipalities in Japan were using endoscopy for screening, compared with more than 72% in South Korea in 2011. Furthermore, guideline adherence and screening program adherence are lower in Japan, they noted.
“Therefore, the findings in our study may have been expected,” the investigators wrote. “However, it is important to note that certain covariates were unavailable for the analysis in Japan, which may have introduced potential biases, the directions of which are unclear. Further studies are needed to compare the screening impact in South Korea and Japan.”
Meanwhile, the present results could guide screening programs around the world, Mr. Sun and colleagues suggested.
“This [study] highlights the significance of a well-planned organizational structure and evidence-based decision making when organized screening is started,” they wrote. “With a quasi-experimental design, this study will facilitate triangulating current observational evidence and provide valuable insights while the GC screening randomized controlled trials are still underway. The data and experience from South Korea and Japan will inform GC screening policy in other countries.”
The investigators disclosed no conflicts of interest.
Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide. It remains a common cancer in some Asian countries and among Asian immigrants in western countries.
To date, only Japan and South Korea have national GC screening programs. Previous observational data from these screening programs indicated their effectiveness in reducing GC mortality but were susceptible to volunteer bias. The population impact of these national programs remains uncertain.
The disparities in screening programs between South Korea and Japan suggest that factors like screening method, participation rates, and organizational strategies might influence the effectiveness of GC screening. Currently, at least 2 large-scale randomized trials of GC screening are underway. It remains uncertain how the experience from South Korea and Japan will inform GC screening policy in other countries.
Francis K.L. Chan, MD, is professor of medicine at The Chinese University of Hong Kong. He has no conflicts to declare in relation to this commentary.
Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide. It remains a common cancer in some Asian countries and among Asian immigrants in western countries.
To date, only Japan and South Korea have national GC screening programs. Previous observational data from these screening programs indicated their effectiveness in reducing GC mortality but were susceptible to volunteer bias. The population impact of these national programs remains uncertain.
The disparities in screening programs between South Korea and Japan suggest that factors like screening method, participation rates, and organizational strategies might influence the effectiveness of GC screening. Currently, at least 2 large-scale randomized trials of GC screening are underway. It remains uncertain how the experience from South Korea and Japan will inform GC screening policy in other countries.
Francis K.L. Chan, MD, is professor of medicine at The Chinese University of Hong Kong. He has no conflicts to declare in relation to this commentary.
Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide. It remains a common cancer in some Asian countries and among Asian immigrants in western countries.
To date, only Japan and South Korea have national GC screening programs. Previous observational data from these screening programs indicated their effectiveness in reducing GC mortality but were susceptible to volunteer bias. The population impact of these national programs remains uncertain.
The disparities in screening programs between South Korea and Japan suggest that factors like screening method, participation rates, and organizational strategies might influence the effectiveness of GC screening. Currently, at least 2 large-scale randomized trials of GC screening are underway. It remains uncertain how the experience from South Korea and Japan will inform GC screening policy in other countries.
Francis K.L. Chan, MD, is professor of medicine at The Chinese University of Hong Kong. He has no conflicts to declare in relation to this commentary.
South Korea’s gastric cancer screening (GC) program has reduced disease-related mortality by 41%.
Japan’s? Not at all.
These findings suggest that the benefits of nationwide gastric cancer screening may vary widely between countries while offering insights into program best practices, reported lead author Dianqin Sun, a PhD candidate at the University Medical Center, Rotterdam, the Netherlands, and colleagues.
“Despite the lack of evidence from randomized controlled trials, South Korea and Japan, two countries with a high GC incidence, have been at the forefront of GC secondary prevention and have implemented nationwide organized GC screening programs for decades using endoscopy or upper gastrointestinal series,” the investigators wrote in Gastroenterology.
Although individual-level data from both programs supports their efficacy in reducing GC-related death, the investigators noted that these studies have been limited by volunteer bias, and population-level data remain scarce.
To address this knowledge gap, Mr. Sun and colleagues used the flexible synthetic control method to determine how screening programs affected GC mortality rate, as well as a composite mortality rate for esophageal cancer and peptic ulcer.
“The concept of the synthetic control method is to construct a synthetic control for the treated country by deriving a weighted average of multiple control countries without intervention,” the investigators wrote. “The weight of controls is determined in a data-driven way to minimize the differences in preintervention outcomes (i.e., GC mortality before the introduction of nationwide screening) and other covariates associated with GC mortality between the treated country and the synthetic control.”
This approach revealed starkly different benefits for South Korea and Japan.
Compared with the synthetic control, South Korea’s screening program was associated with a 17% reduction in GC mortality risk on average, with risk dropping as far as 41% after the 15th year of screening. The Korean program was also associated with a 28% reduction in mortality from esophageal cancer and peptic ulcer, with this rate decreasing as much as 53% after 15 years of screening.
In sharp contrast, Japan’s mortality rates for GC and the other GI diseases were not significantly different from the synthetic control after 34 years of screening.
The investigators suggested several possible factors behind the lack of benefit in Japan, including the absence of a recommendation for endoscopic screening until 2014. In 2015, just 19% of municipalities in Japan were using endoscopy for screening, compared with more than 72% in South Korea in 2011. Furthermore, guideline adherence and screening program adherence are lower in Japan, they noted.
“Therefore, the findings in our study may have been expected,” the investigators wrote. “However, it is important to note that certain covariates were unavailable for the analysis in Japan, which may have introduced potential biases, the directions of which are unclear. Further studies are needed to compare the screening impact in South Korea and Japan.”
Meanwhile, the present results could guide screening programs around the world, Mr. Sun and colleagues suggested.
“This [study] highlights the significance of a well-planned organizational structure and evidence-based decision making when organized screening is started,” they wrote. “With a quasi-experimental design, this study will facilitate triangulating current observational evidence and provide valuable insights while the GC screening randomized controlled trials are still underway. The data and experience from South Korea and Japan will inform GC screening policy in other countries.”
The investigators disclosed no conflicts of interest.
South Korea’s gastric cancer screening (GC) program has reduced disease-related mortality by 41%.
Japan’s? Not at all.
These findings suggest that the benefits of nationwide gastric cancer screening may vary widely between countries while offering insights into program best practices, reported lead author Dianqin Sun, a PhD candidate at the University Medical Center, Rotterdam, the Netherlands, and colleagues.
“Despite the lack of evidence from randomized controlled trials, South Korea and Japan, two countries with a high GC incidence, have been at the forefront of GC secondary prevention and have implemented nationwide organized GC screening programs for decades using endoscopy or upper gastrointestinal series,” the investigators wrote in Gastroenterology.
Although individual-level data from both programs supports their efficacy in reducing GC-related death, the investigators noted that these studies have been limited by volunteer bias, and population-level data remain scarce.
To address this knowledge gap, Mr. Sun and colleagues used the flexible synthetic control method to determine how screening programs affected GC mortality rate, as well as a composite mortality rate for esophageal cancer and peptic ulcer.
“The concept of the synthetic control method is to construct a synthetic control for the treated country by deriving a weighted average of multiple control countries without intervention,” the investigators wrote. “The weight of controls is determined in a data-driven way to minimize the differences in preintervention outcomes (i.e., GC mortality before the introduction of nationwide screening) and other covariates associated with GC mortality between the treated country and the synthetic control.”
This approach revealed starkly different benefits for South Korea and Japan.
Compared with the synthetic control, South Korea’s screening program was associated with a 17% reduction in GC mortality risk on average, with risk dropping as far as 41% after the 15th year of screening. The Korean program was also associated with a 28% reduction in mortality from esophageal cancer and peptic ulcer, with this rate decreasing as much as 53% after 15 years of screening.
In sharp contrast, Japan’s mortality rates for GC and the other GI diseases were not significantly different from the synthetic control after 34 years of screening.
The investigators suggested several possible factors behind the lack of benefit in Japan, including the absence of a recommendation for endoscopic screening until 2014. In 2015, just 19% of municipalities in Japan were using endoscopy for screening, compared with more than 72% in South Korea in 2011. Furthermore, guideline adherence and screening program adherence are lower in Japan, they noted.
“Therefore, the findings in our study may have been expected,” the investigators wrote. “However, it is important to note that certain covariates were unavailable for the analysis in Japan, which may have introduced potential biases, the directions of which are unclear. Further studies are needed to compare the screening impact in South Korea and Japan.”
Meanwhile, the present results could guide screening programs around the world, Mr. Sun and colleagues suggested.
“This [study] highlights the significance of a well-planned organizational structure and evidence-based decision making when organized screening is started,” they wrote. “With a quasi-experimental design, this study will facilitate triangulating current observational evidence and provide valuable insights while the GC screening randomized controlled trials are still underway. The data and experience from South Korea and Japan will inform GC screening policy in other countries.”
The investigators disclosed no conflicts of interest.
FROM GASTROENTEROLOGY
Dueling Gut Bacteria Impact Chronic HBV Progression
, according to investigators.
While Ruminococcus gnavus promotes immune tolerance and therefore HBV persistence, Akkermansia muciniphila stimulates the immune system, promoting viral clearance, reported lead author Huey-Huey Chua, MD, of the National Taiwan University College of Medicine and Children’s Hospital, Taipei, and colleagues.
These findings could lead to new therapeutic strategies, such as administration of the secretory products of A. muciniphila, or provision of probiotics and prebiotics that tip the balance toward this more beneficial bacterium, the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.
Their study, which included data from both human patients and mouse models of CHB, was grounded in prior research showing a link between gut microbiota and the age-dependence of HBV immunity.
“Sterilization of the gut microbiota using antibiotics prevents adult mice from rapidly clearing HBV and restores the tolerance phenotype, implying that the gut microbiota may transmit signals to break liver tolerance and evoke rapid HBV clearance,” Dr. Chua and colleagues wrote. “We hypothesized that the wax and wane of gut microbiota signatures may determine the progression of CHB. We aimed to delineate what the pivotal bacteria are and how they manipulate the progression of CHB.”
They began by analyzing fecal samples from 102 patients with CHB either in the immune-tolerant (IT) or immune-active (IA) phase of infection.
R. gnavus was the most abundant species among IT patients, whereas A. muciniphila was most abundant among patients in the IA phase. Higher levels of A. muciniphila were also associated with early hepatitis B e-antigen (HBeAG) loss, HBeAG seroconversion, and flares of aminotransferase. A mouse model echoed these findings.
Further experiments with mouse models revealed that R. gnavus modulates bile acids to promote HBV persistence and prolongation of the IT course. In opposition, A. muciniphila removes cholesterol and secretes metabolites that inhibit growth and function of R. gnavus.
“These novel findings will certainly confer a groundbreaking impact on the future therapy of CHB,” Dr. Chua and colleagues wrote.
They went on to describe several therapeutic strategies worth further investigation.
“A key step to promote switching from the IT to IA phase is to lessen the richness of R. gnavus and bile acid bioconversion from cholesterol,” they wrote. The secretory products of A. muciniphila that successfully ameliorate the burden of R. gnavus outgrowth can be provided as useful means to induce anti-HBV efficacy. Also, the development of targeted probiotics or prebiotics that can modulate the gut microbiota composition to favor the beneficial effects of A. muciniphila while inhibiting the detrimental effects of R. gnavus may have translational value for CHB.”
The study was supported by the Ministry of Science and Technology, Executive Yuan, Taiwan and the Center of Precision Medicine from Featured Areas Research Center Program within the Framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan. The investigators disclosed no conflicts of interest.
Clinical observations have long indicated that chronic hepatitis B (CHB) patients with a prolonged immune-tolerant (IT) phase are at a higher risk of liver diseases, while those with an early transition to the immune-active (IA) phase are associated with a better clinical outcome. However, the underlying mechanisms remain unclear.
This study merits attention as it marks an important advancement in our understanding of how gut microbiota affects the immune response and, in turn, the progression of CHB, offering insights for potential A. muciniphila–based therapies. Nonetheless, the research is still in its infancy, and further studies, including longitudinal analysis to determine gut microbiota changes from IT to IA, are required. The prospect of A. muciniphila supplementation could be beneficial for CHB patients, warranting clinical trials. Continued research could lead to improved management and prevention of liver diseases in this patient population with CHB.
Qirong Jiang, MD, and Dawu Zeng, MD, are based in the Hepatology Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China. They report no conflicts of interest.
Clinical observations have long indicated that chronic hepatitis B (CHB) patients with a prolonged immune-tolerant (IT) phase are at a higher risk of liver diseases, while those with an early transition to the immune-active (IA) phase are associated with a better clinical outcome. However, the underlying mechanisms remain unclear.
This study merits attention as it marks an important advancement in our understanding of how gut microbiota affects the immune response and, in turn, the progression of CHB, offering insights for potential A. muciniphila–based therapies. Nonetheless, the research is still in its infancy, and further studies, including longitudinal analysis to determine gut microbiota changes from IT to IA, are required. The prospect of A. muciniphila supplementation could be beneficial for CHB patients, warranting clinical trials. Continued research could lead to improved management and prevention of liver diseases in this patient population with CHB.
Qirong Jiang, MD, and Dawu Zeng, MD, are based in the Hepatology Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China. They report no conflicts of interest.
Clinical observations have long indicated that chronic hepatitis B (CHB) patients with a prolonged immune-tolerant (IT) phase are at a higher risk of liver diseases, while those with an early transition to the immune-active (IA) phase are associated with a better clinical outcome. However, the underlying mechanisms remain unclear.
This study merits attention as it marks an important advancement in our understanding of how gut microbiota affects the immune response and, in turn, the progression of CHB, offering insights for potential A. muciniphila–based therapies. Nonetheless, the research is still in its infancy, and further studies, including longitudinal analysis to determine gut microbiota changes from IT to IA, are required. The prospect of A. muciniphila supplementation could be beneficial for CHB patients, warranting clinical trials. Continued research could lead to improved management and prevention of liver diseases in this patient population with CHB.
Qirong Jiang, MD, and Dawu Zeng, MD, are based in the Hepatology Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China. They report no conflicts of interest.
, according to investigators.
While Ruminococcus gnavus promotes immune tolerance and therefore HBV persistence, Akkermansia muciniphila stimulates the immune system, promoting viral clearance, reported lead author Huey-Huey Chua, MD, of the National Taiwan University College of Medicine and Children’s Hospital, Taipei, and colleagues.
These findings could lead to new therapeutic strategies, such as administration of the secretory products of A. muciniphila, or provision of probiotics and prebiotics that tip the balance toward this more beneficial bacterium, the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.
Their study, which included data from both human patients and mouse models of CHB, was grounded in prior research showing a link between gut microbiota and the age-dependence of HBV immunity.
“Sterilization of the gut microbiota using antibiotics prevents adult mice from rapidly clearing HBV and restores the tolerance phenotype, implying that the gut microbiota may transmit signals to break liver tolerance and evoke rapid HBV clearance,” Dr. Chua and colleagues wrote. “We hypothesized that the wax and wane of gut microbiota signatures may determine the progression of CHB. We aimed to delineate what the pivotal bacteria are and how they manipulate the progression of CHB.”
They began by analyzing fecal samples from 102 patients with CHB either in the immune-tolerant (IT) or immune-active (IA) phase of infection.
R. gnavus was the most abundant species among IT patients, whereas A. muciniphila was most abundant among patients in the IA phase. Higher levels of A. muciniphila were also associated with early hepatitis B e-antigen (HBeAG) loss, HBeAG seroconversion, and flares of aminotransferase. A mouse model echoed these findings.
Further experiments with mouse models revealed that R. gnavus modulates bile acids to promote HBV persistence and prolongation of the IT course. In opposition, A. muciniphila removes cholesterol and secretes metabolites that inhibit growth and function of R. gnavus.
“These novel findings will certainly confer a groundbreaking impact on the future therapy of CHB,” Dr. Chua and colleagues wrote.
They went on to describe several therapeutic strategies worth further investigation.
“A key step to promote switching from the IT to IA phase is to lessen the richness of R. gnavus and bile acid bioconversion from cholesterol,” they wrote. The secretory products of A. muciniphila that successfully ameliorate the burden of R. gnavus outgrowth can be provided as useful means to induce anti-HBV efficacy. Also, the development of targeted probiotics or prebiotics that can modulate the gut microbiota composition to favor the beneficial effects of A. muciniphila while inhibiting the detrimental effects of R. gnavus may have translational value for CHB.”
The study was supported by the Ministry of Science and Technology, Executive Yuan, Taiwan and the Center of Precision Medicine from Featured Areas Research Center Program within the Framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan. The investigators disclosed no conflicts of interest.
, according to investigators.
While Ruminococcus gnavus promotes immune tolerance and therefore HBV persistence, Akkermansia muciniphila stimulates the immune system, promoting viral clearance, reported lead author Huey-Huey Chua, MD, of the National Taiwan University College of Medicine and Children’s Hospital, Taipei, and colleagues.
These findings could lead to new therapeutic strategies, such as administration of the secretory products of A. muciniphila, or provision of probiotics and prebiotics that tip the balance toward this more beneficial bacterium, the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology.
Their study, which included data from both human patients and mouse models of CHB, was grounded in prior research showing a link between gut microbiota and the age-dependence of HBV immunity.
“Sterilization of the gut microbiota using antibiotics prevents adult mice from rapidly clearing HBV and restores the tolerance phenotype, implying that the gut microbiota may transmit signals to break liver tolerance and evoke rapid HBV clearance,” Dr. Chua and colleagues wrote. “We hypothesized that the wax and wane of gut microbiota signatures may determine the progression of CHB. We aimed to delineate what the pivotal bacteria are and how they manipulate the progression of CHB.”
They began by analyzing fecal samples from 102 patients with CHB either in the immune-tolerant (IT) or immune-active (IA) phase of infection.
R. gnavus was the most abundant species among IT patients, whereas A. muciniphila was most abundant among patients in the IA phase. Higher levels of A. muciniphila were also associated with early hepatitis B e-antigen (HBeAG) loss, HBeAG seroconversion, and flares of aminotransferase. A mouse model echoed these findings.
Further experiments with mouse models revealed that R. gnavus modulates bile acids to promote HBV persistence and prolongation of the IT course. In opposition, A. muciniphila removes cholesterol and secretes metabolites that inhibit growth and function of R. gnavus.
“These novel findings will certainly confer a groundbreaking impact on the future therapy of CHB,” Dr. Chua and colleagues wrote.
They went on to describe several therapeutic strategies worth further investigation.
“A key step to promote switching from the IT to IA phase is to lessen the richness of R. gnavus and bile acid bioconversion from cholesterol,” they wrote. The secretory products of A. muciniphila that successfully ameliorate the burden of R. gnavus outgrowth can be provided as useful means to induce anti-HBV efficacy. Also, the development of targeted probiotics or prebiotics that can modulate the gut microbiota composition to favor the beneficial effects of A. muciniphila while inhibiting the detrimental effects of R. gnavus may have translational value for CHB.”
The study was supported by the Ministry of Science and Technology, Executive Yuan, Taiwan and the Center of Precision Medicine from Featured Areas Research Center Program within the Framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan. The investigators disclosed no conflicts of interest.
FROM CELLULAR AND MOLECULAR GASTROENTEROLOGY AND HEPATOLOGY
AGA updates polypectomy guidance
The new guidance document, authored by Andrew P. Copland, MD, of the University of Virginia Health System, Charlottesville, and colleagues, includes 12 pieces of best practice advice pertaining to polyp removal, including the need for evaluation, considerations for selecting a resection strategy, and reasons for referral.
“Polypectomy techniques are continually evolving with improvements in the ability to assess polyps for high-risk features and with development of appropriate procedures for complete and safe polyp resection,” the authors wrote in Clinical Gastroenterology and Hepatology. “This clinical practice update provides guidance in characterizing polyps and choosing appropriate polypectomy techniques for polyps 2 cm or less in size, which comprise most polyps encountered by most endoscopists.”
To begin, they advised a “structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation” for all polyps identified during routine colonoscopy, with close attention to any features suggesting submucosal invasion.
Next, in a series of statements, the guidance document steers appropriate use of various cold and hot polypectomy techniques.
Cold snare polypectomy should be used for polyps less than 10 mm in size, while cold forceps may be considered for polyps 1-3 mm in diameter. Cold resection techniques should also be used for serrated polyps, with use of submucosal injection, if needed, for polyps greater than 10 mm with unclear margins.
For polyps of intermediate size (10-19 mm), both cold and hot snare polypectomy should be considered, alongside endoscopic mucosal resection for polyps, Dr. Copland and colleagues wrote, noting that hot snare polypectomy should be used for removal of pedunculated lesions greater than 10 mm in size.
In contrast, the update advises against use of hot forceps polypectomy in any scenario.
“Hot forceps polypectomy for diminutive and small polyps is associated with higher incomplete polyp removal rates compared with cold snare polypectomy,” the update panelists wrote. “It is also associated with higher risks of postpolypectomy hemorrhage, particularly in the right colon with higher risks of deep thermal injury. Therefore, the use of hot forceps polypectomy is discouraged.”
In another best practice advice statement, the panelists advised against routine use of clips to close resection sites for polyps less than 20 mm. For larger polyps, they advised “selective use” of clips, most suitably in the proximal colon.
Alternatively, patients with polyps at least 20 mm in size should be considered for referral to endoscopic referral centers, along with patients who have polyps in “challenging” locations, and those with a recurrent polyp at a prior polypectomy site.
Patients with nonpedunculated polyps that exhibit “clear evidence of submucosally invasive cancer” should be referred for surgical evaluation, they added. On a similar note, the update advises tattooing lesions that may need to be located at a future surgery or endoscopy.
Finally, Dr. Copland and colleagues advised all endoscopists to understand appropriate selection of electrosurgical generator settings for various polypectomy or postpolypectomy thermal techniques.
“Ongoing research will allow further tailoring of polypectomy techniques to improve patient outcomes,” they concluded.This clinical practice update was commissioned and approved by the AGA Institute. The working group disclosed relationships with Olympus, Boston Scientific, GIE Medical, and others.
The new guidance document, authored by Andrew P. Copland, MD, of the University of Virginia Health System, Charlottesville, and colleagues, includes 12 pieces of best practice advice pertaining to polyp removal, including the need for evaluation, considerations for selecting a resection strategy, and reasons for referral.
“Polypectomy techniques are continually evolving with improvements in the ability to assess polyps for high-risk features and with development of appropriate procedures for complete and safe polyp resection,” the authors wrote in Clinical Gastroenterology and Hepatology. “This clinical practice update provides guidance in characterizing polyps and choosing appropriate polypectomy techniques for polyps 2 cm or less in size, which comprise most polyps encountered by most endoscopists.”
To begin, they advised a “structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation” for all polyps identified during routine colonoscopy, with close attention to any features suggesting submucosal invasion.
Next, in a series of statements, the guidance document steers appropriate use of various cold and hot polypectomy techniques.
Cold snare polypectomy should be used for polyps less than 10 mm in size, while cold forceps may be considered for polyps 1-3 mm in diameter. Cold resection techniques should also be used for serrated polyps, with use of submucosal injection, if needed, for polyps greater than 10 mm with unclear margins.
For polyps of intermediate size (10-19 mm), both cold and hot snare polypectomy should be considered, alongside endoscopic mucosal resection for polyps, Dr. Copland and colleagues wrote, noting that hot snare polypectomy should be used for removal of pedunculated lesions greater than 10 mm in size.
In contrast, the update advises against use of hot forceps polypectomy in any scenario.
“Hot forceps polypectomy for diminutive and small polyps is associated with higher incomplete polyp removal rates compared with cold snare polypectomy,” the update panelists wrote. “It is also associated with higher risks of postpolypectomy hemorrhage, particularly in the right colon with higher risks of deep thermal injury. Therefore, the use of hot forceps polypectomy is discouraged.”
In another best practice advice statement, the panelists advised against routine use of clips to close resection sites for polyps less than 20 mm. For larger polyps, they advised “selective use” of clips, most suitably in the proximal colon.
Alternatively, patients with polyps at least 20 mm in size should be considered for referral to endoscopic referral centers, along with patients who have polyps in “challenging” locations, and those with a recurrent polyp at a prior polypectomy site.
Patients with nonpedunculated polyps that exhibit “clear evidence of submucosally invasive cancer” should be referred for surgical evaluation, they added. On a similar note, the update advises tattooing lesions that may need to be located at a future surgery or endoscopy.
Finally, Dr. Copland and colleagues advised all endoscopists to understand appropriate selection of electrosurgical generator settings for various polypectomy or postpolypectomy thermal techniques.
“Ongoing research will allow further tailoring of polypectomy techniques to improve patient outcomes,” they concluded.This clinical practice update was commissioned and approved by the AGA Institute. The working group disclosed relationships with Olympus, Boston Scientific, GIE Medical, and others.
The new guidance document, authored by Andrew P. Copland, MD, of the University of Virginia Health System, Charlottesville, and colleagues, includes 12 pieces of best practice advice pertaining to polyp removal, including the need for evaluation, considerations for selecting a resection strategy, and reasons for referral.
“Polypectomy techniques are continually evolving with improvements in the ability to assess polyps for high-risk features and with development of appropriate procedures for complete and safe polyp resection,” the authors wrote in Clinical Gastroenterology and Hepatology. “This clinical practice update provides guidance in characterizing polyps and choosing appropriate polypectomy techniques for polyps 2 cm or less in size, which comprise most polyps encountered by most endoscopists.”
To begin, they advised a “structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation” for all polyps identified during routine colonoscopy, with close attention to any features suggesting submucosal invasion.
Next, in a series of statements, the guidance document steers appropriate use of various cold and hot polypectomy techniques.
Cold snare polypectomy should be used for polyps less than 10 mm in size, while cold forceps may be considered for polyps 1-3 mm in diameter. Cold resection techniques should also be used for serrated polyps, with use of submucosal injection, if needed, for polyps greater than 10 mm with unclear margins.
For polyps of intermediate size (10-19 mm), both cold and hot snare polypectomy should be considered, alongside endoscopic mucosal resection for polyps, Dr. Copland and colleagues wrote, noting that hot snare polypectomy should be used for removal of pedunculated lesions greater than 10 mm in size.
In contrast, the update advises against use of hot forceps polypectomy in any scenario.
“Hot forceps polypectomy for diminutive and small polyps is associated with higher incomplete polyp removal rates compared with cold snare polypectomy,” the update panelists wrote. “It is also associated with higher risks of postpolypectomy hemorrhage, particularly in the right colon with higher risks of deep thermal injury. Therefore, the use of hot forceps polypectomy is discouraged.”
In another best practice advice statement, the panelists advised against routine use of clips to close resection sites for polyps less than 20 mm. For larger polyps, they advised “selective use” of clips, most suitably in the proximal colon.
Alternatively, patients with polyps at least 20 mm in size should be considered for referral to endoscopic referral centers, along with patients who have polyps in “challenging” locations, and those with a recurrent polyp at a prior polypectomy site.
Patients with nonpedunculated polyps that exhibit “clear evidence of submucosally invasive cancer” should be referred for surgical evaluation, they added. On a similar note, the update advises tattooing lesions that may need to be located at a future surgery or endoscopy.
Finally, Dr. Copland and colleagues advised all endoscopists to understand appropriate selection of electrosurgical generator settings for various polypectomy or postpolypectomy thermal techniques.
“Ongoing research will allow further tailoring of polypectomy techniques to improve patient outcomes,” they concluded.This clinical practice update was commissioned and approved by the AGA Institute. The working group disclosed relationships with Olympus, Boston Scientific, GIE Medical, and others.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Colorectal Cancer Risk Increasing Across Successive Birth Cohorts
Colorectal cancer (CRC) epidemiology is changing due to a birth cohort effect, also called birth cohort CRC — the observed phenomena of the rising risk for CRC across successive generations of people born in 1960 and later — according to a new narrative review.
Birth cohort CRC is associated with increasing rectal cancer (greater than colon cancer) diagnosis and distant-stage (greater than local-stage) CRC diagnosis, and a rising incidence of early-onset CRC (EOCRC), defined as occurring before age 50.
Recognizing this birth cohort effect could improve the understanding of CRC risk factors, etiology, mechanisms, as well as the public health consequences of rising rates.
“The changing epidemiology means that we need to redouble our efforts at optimizing early detection and prevention of colorectal cancer,” Samir Gupta, MD, the review’s lead author and professor of gastroenterology at the University of California, San Diego, California, told this news organization. Dr. Gupta serves as the co-lead for the cancer control program at Moores Cancer Center at UC San Diego Health.
This requires “being alert for potential red flag signs and symptoms of colorectal cancer, such as iron deficiency anemia and rectal bleeding, that are otherwise unexplained, including for those under age 45,” he said.
We also should make “sure that all people eligible for screening — at age 45 and older — have every opportunity to get screened for colorectal cancer,” Dr. Gupta added.
The review was published online in Clinical Gastroenterology and Hepatology.
Tracking Birth Cohort Trends
CRC rates have increased in the United States among people born since the early 1960s, the authors wrote.
Generation X (individuals born in 1965-1980) experienced an increase in EOCRC, and rates subsequently increased in this generation after age 50. Rates are 1.22-fold higher among people born in 1965-1969 and 1.58-fold higher among those born 1975-1979 than among people born in 1950-1954.
Now rates are also increasing across younger generations, particularly among Millennials (individuals born in 1981-1996) as they enter mid-adulthood. Incidence rates are 1.89-fold higher among people born in 1980-1984 and 2.98-fold higher among those born in 1990-1994 than among individuals born in 1950-1954.
These birth cohort effects are evident globally, despite differences in population age structures, screening programs, and diagnostic strategies around the world. Due to this ongoing trend, physicians anticipate that CRC rates will likely continue to increase as higher-risk birth cohorts become older, the authors wrote.
Notably, four important shifts in CRC incidence are apparent, they noted. First, rates are steadily increasing up to age 50 and plateauing after age 60. Rectal cancers are now predominant through ages 50-59. Rates of distant-stage disease have increased most rapidly among ages 30-49 and more slowly decreased among ages 60-79 compared with those of local-stage disease. In addition, the increasing rates of EOCRC have been observed across all racial and ethnic groups since the early 1990s.
These shifts led to major changes in the types of patients diagnosed with CRC now vs 30 years ago, with a higher proportion being patients younger than 60, as well as Black, Asian or Pacific Islander, American Indian/Alaska Native, and Hispanic patients.
The combination of age-related increases in CRC and birth cohort–related trends will likely lead to substantial increases in the number of people diagnosed with CRC in coming years, especially as Generation X patients move into their 50s and 60s, the authors wrote.
Research and Clinical Implications
Birth cohort CRC, including increasing EOCRC incidence, likely is driven by a range of influences, including demographic, lifestyle, early life, environmental, genetic, and somatic factors, as well as interactions among them, the authors noted. Examples within these broad categories include male sex, food insecurity, income inequality, diabetes, alcohol use, less healthy dietary patterns, in utero exposure to certain medications, and microbiome concerns such as early life antibiotic exposure or dysbiosis.
“From a research perspective, this means that we need to think about risk factors and mechanisms that are associated with birth cohorts, not just age at diagnosis,” Dr. Gupta said. “To date, most studies of changing epidemiology have not taken into account birth cohort, such as whether someone is Generation X or later versus pre-Baby Boomer.”
Although additional research is needed, the epidemiology changes have several immediate clinical implications, Dr. Gupta said. For those younger than 45, it is critical to raise awareness about the signs and symptoms of CRC, such as hematochezia, iron deficiency anemia, and unintentional weight loss, as well as family history.
For ages 45 and older, a major focus should be placed on increasing screening participation and follow-up after abnormal results, addressing disparities in screening participation, and optimizing screening quality.
In addition, as CRC incidence continues to increase, health systems and policymakers should ensure every patient has access to guideline-appropriate care and innovative clinical trials, the authors wrote. This access may be particularly important to address the increasing burden of rectal cancer, as treatment approaches rapidly evolve toward more effective therapies, such as neoadjuvant chemotherapy and radiation prior to surgery, and with less-morbid treatments on the horizon, they added.
‘An Interesting Concept’
“Birth cohort CRC is an interesting concept that allows people to think of their CRC risk according to their birth cohort in addition to age,” Shuji Ogino, MD, PhD, chief of the Molecular Pathological Epidemiology program at Brigham & Women’s Hospital, Boston, Massachusetts, told this news organization.
Dr. Ogino, who wasn’t involved with this study, serves as a member of the cancer immunology and cancer epidemiology programs at the Dana-Farber Harvard Cancer Center. In studies of EOCRC, he and colleagues have found various biogeographical and pathogenic trends across age groups.
“More research is needed to disentangle the complex etiologies of birth cohort CRC and early-onset CRC,” Dr. Ogino said. “Tumor cells and tissues have certain past and ongoing pathological marks, which we can detect to better understand birth cohort CRC and early-onset CRC.”
The study was funded by several National Institutes of Health/National Cancer Institute grants. Dr. Gupta disclosed consulting for Geneoscopy, Guardant Health, Universal Diagnostics, InterVenn Bio, and CellMax. Another author reported consulting for Freenome, Exact Sciences, Medtronic, and Geneoscopy. Dr. Ogino reported no relevant financial disclosures.
A version of this article appeared on Medscape.com .
Colorectal cancer (CRC) epidemiology is changing due to a birth cohort effect, also called birth cohort CRC — the observed phenomena of the rising risk for CRC across successive generations of people born in 1960 and later — according to a new narrative review.
Birth cohort CRC is associated with increasing rectal cancer (greater than colon cancer) diagnosis and distant-stage (greater than local-stage) CRC diagnosis, and a rising incidence of early-onset CRC (EOCRC), defined as occurring before age 50.
Recognizing this birth cohort effect could improve the understanding of CRC risk factors, etiology, mechanisms, as well as the public health consequences of rising rates.
“The changing epidemiology means that we need to redouble our efforts at optimizing early detection and prevention of colorectal cancer,” Samir Gupta, MD, the review’s lead author and professor of gastroenterology at the University of California, San Diego, California, told this news organization. Dr. Gupta serves as the co-lead for the cancer control program at Moores Cancer Center at UC San Diego Health.
This requires “being alert for potential red flag signs and symptoms of colorectal cancer, such as iron deficiency anemia and rectal bleeding, that are otherwise unexplained, including for those under age 45,” he said.
We also should make “sure that all people eligible for screening — at age 45 and older — have every opportunity to get screened for colorectal cancer,” Dr. Gupta added.
The review was published online in Clinical Gastroenterology and Hepatology.
Tracking Birth Cohort Trends
CRC rates have increased in the United States among people born since the early 1960s, the authors wrote.
Generation X (individuals born in 1965-1980) experienced an increase in EOCRC, and rates subsequently increased in this generation after age 50. Rates are 1.22-fold higher among people born in 1965-1969 and 1.58-fold higher among those born 1975-1979 than among people born in 1950-1954.
Now rates are also increasing across younger generations, particularly among Millennials (individuals born in 1981-1996) as they enter mid-adulthood. Incidence rates are 1.89-fold higher among people born in 1980-1984 and 2.98-fold higher among those born in 1990-1994 than among individuals born in 1950-1954.
These birth cohort effects are evident globally, despite differences in population age structures, screening programs, and diagnostic strategies around the world. Due to this ongoing trend, physicians anticipate that CRC rates will likely continue to increase as higher-risk birth cohorts become older, the authors wrote.
Notably, four important shifts in CRC incidence are apparent, they noted. First, rates are steadily increasing up to age 50 and plateauing after age 60. Rectal cancers are now predominant through ages 50-59. Rates of distant-stage disease have increased most rapidly among ages 30-49 and more slowly decreased among ages 60-79 compared with those of local-stage disease. In addition, the increasing rates of EOCRC have been observed across all racial and ethnic groups since the early 1990s.
These shifts led to major changes in the types of patients diagnosed with CRC now vs 30 years ago, with a higher proportion being patients younger than 60, as well as Black, Asian or Pacific Islander, American Indian/Alaska Native, and Hispanic patients.
The combination of age-related increases in CRC and birth cohort–related trends will likely lead to substantial increases in the number of people diagnosed with CRC in coming years, especially as Generation X patients move into their 50s and 60s, the authors wrote.
Research and Clinical Implications
Birth cohort CRC, including increasing EOCRC incidence, likely is driven by a range of influences, including demographic, lifestyle, early life, environmental, genetic, and somatic factors, as well as interactions among them, the authors noted. Examples within these broad categories include male sex, food insecurity, income inequality, diabetes, alcohol use, less healthy dietary patterns, in utero exposure to certain medications, and microbiome concerns such as early life antibiotic exposure or dysbiosis.
“From a research perspective, this means that we need to think about risk factors and mechanisms that are associated with birth cohorts, not just age at diagnosis,” Dr. Gupta said. “To date, most studies of changing epidemiology have not taken into account birth cohort, such as whether someone is Generation X or later versus pre-Baby Boomer.”
Although additional research is needed, the epidemiology changes have several immediate clinical implications, Dr. Gupta said. For those younger than 45, it is critical to raise awareness about the signs and symptoms of CRC, such as hematochezia, iron deficiency anemia, and unintentional weight loss, as well as family history.
For ages 45 and older, a major focus should be placed on increasing screening participation and follow-up after abnormal results, addressing disparities in screening participation, and optimizing screening quality.
In addition, as CRC incidence continues to increase, health systems and policymakers should ensure every patient has access to guideline-appropriate care and innovative clinical trials, the authors wrote. This access may be particularly important to address the increasing burden of rectal cancer, as treatment approaches rapidly evolve toward more effective therapies, such as neoadjuvant chemotherapy and radiation prior to surgery, and with less-morbid treatments on the horizon, they added.
‘An Interesting Concept’
“Birth cohort CRC is an interesting concept that allows people to think of their CRC risk according to their birth cohort in addition to age,” Shuji Ogino, MD, PhD, chief of the Molecular Pathological Epidemiology program at Brigham & Women’s Hospital, Boston, Massachusetts, told this news organization.
Dr. Ogino, who wasn’t involved with this study, serves as a member of the cancer immunology and cancer epidemiology programs at the Dana-Farber Harvard Cancer Center. In studies of EOCRC, he and colleagues have found various biogeographical and pathogenic trends across age groups.
“More research is needed to disentangle the complex etiologies of birth cohort CRC and early-onset CRC,” Dr. Ogino said. “Tumor cells and tissues have certain past and ongoing pathological marks, which we can detect to better understand birth cohort CRC and early-onset CRC.”
The study was funded by several National Institutes of Health/National Cancer Institute grants. Dr. Gupta disclosed consulting for Geneoscopy, Guardant Health, Universal Diagnostics, InterVenn Bio, and CellMax. Another author reported consulting for Freenome, Exact Sciences, Medtronic, and Geneoscopy. Dr. Ogino reported no relevant financial disclosures.
A version of this article appeared on Medscape.com .
Colorectal cancer (CRC) epidemiology is changing due to a birth cohort effect, also called birth cohort CRC — the observed phenomena of the rising risk for CRC across successive generations of people born in 1960 and later — according to a new narrative review.
Birth cohort CRC is associated with increasing rectal cancer (greater than colon cancer) diagnosis and distant-stage (greater than local-stage) CRC diagnosis, and a rising incidence of early-onset CRC (EOCRC), defined as occurring before age 50.
Recognizing this birth cohort effect could improve the understanding of CRC risk factors, etiology, mechanisms, as well as the public health consequences of rising rates.
“The changing epidemiology means that we need to redouble our efforts at optimizing early detection and prevention of colorectal cancer,” Samir Gupta, MD, the review’s lead author and professor of gastroenterology at the University of California, San Diego, California, told this news organization. Dr. Gupta serves as the co-lead for the cancer control program at Moores Cancer Center at UC San Diego Health.
This requires “being alert for potential red flag signs and symptoms of colorectal cancer, such as iron deficiency anemia and rectal bleeding, that are otherwise unexplained, including for those under age 45,” he said.
We also should make “sure that all people eligible for screening — at age 45 and older — have every opportunity to get screened for colorectal cancer,” Dr. Gupta added.
The review was published online in Clinical Gastroenterology and Hepatology.
Tracking Birth Cohort Trends
CRC rates have increased in the United States among people born since the early 1960s, the authors wrote.
Generation X (individuals born in 1965-1980) experienced an increase in EOCRC, and rates subsequently increased in this generation after age 50. Rates are 1.22-fold higher among people born in 1965-1969 and 1.58-fold higher among those born 1975-1979 than among people born in 1950-1954.
Now rates are also increasing across younger generations, particularly among Millennials (individuals born in 1981-1996) as they enter mid-adulthood. Incidence rates are 1.89-fold higher among people born in 1980-1984 and 2.98-fold higher among those born in 1990-1994 than among individuals born in 1950-1954.
These birth cohort effects are evident globally, despite differences in population age structures, screening programs, and diagnostic strategies around the world. Due to this ongoing trend, physicians anticipate that CRC rates will likely continue to increase as higher-risk birth cohorts become older, the authors wrote.
Notably, four important shifts in CRC incidence are apparent, they noted. First, rates are steadily increasing up to age 50 and plateauing after age 60. Rectal cancers are now predominant through ages 50-59. Rates of distant-stage disease have increased most rapidly among ages 30-49 and more slowly decreased among ages 60-79 compared with those of local-stage disease. In addition, the increasing rates of EOCRC have been observed across all racial and ethnic groups since the early 1990s.
These shifts led to major changes in the types of patients diagnosed with CRC now vs 30 years ago, with a higher proportion being patients younger than 60, as well as Black, Asian or Pacific Islander, American Indian/Alaska Native, and Hispanic patients.
The combination of age-related increases in CRC and birth cohort–related trends will likely lead to substantial increases in the number of people diagnosed with CRC in coming years, especially as Generation X patients move into their 50s and 60s, the authors wrote.
Research and Clinical Implications
Birth cohort CRC, including increasing EOCRC incidence, likely is driven by a range of influences, including demographic, lifestyle, early life, environmental, genetic, and somatic factors, as well as interactions among them, the authors noted. Examples within these broad categories include male sex, food insecurity, income inequality, diabetes, alcohol use, less healthy dietary patterns, in utero exposure to certain medications, and microbiome concerns such as early life antibiotic exposure or dysbiosis.
“From a research perspective, this means that we need to think about risk factors and mechanisms that are associated with birth cohorts, not just age at diagnosis,” Dr. Gupta said. “To date, most studies of changing epidemiology have not taken into account birth cohort, such as whether someone is Generation X or later versus pre-Baby Boomer.”
Although additional research is needed, the epidemiology changes have several immediate clinical implications, Dr. Gupta said. For those younger than 45, it is critical to raise awareness about the signs and symptoms of CRC, such as hematochezia, iron deficiency anemia, and unintentional weight loss, as well as family history.
For ages 45 and older, a major focus should be placed on increasing screening participation and follow-up after abnormal results, addressing disparities in screening participation, and optimizing screening quality.
In addition, as CRC incidence continues to increase, health systems and policymakers should ensure every patient has access to guideline-appropriate care and innovative clinical trials, the authors wrote. This access may be particularly important to address the increasing burden of rectal cancer, as treatment approaches rapidly evolve toward more effective therapies, such as neoadjuvant chemotherapy and radiation prior to surgery, and with less-morbid treatments on the horizon, they added.
‘An Interesting Concept’
“Birth cohort CRC is an interesting concept that allows people to think of their CRC risk according to their birth cohort in addition to age,” Shuji Ogino, MD, PhD, chief of the Molecular Pathological Epidemiology program at Brigham & Women’s Hospital, Boston, Massachusetts, told this news organization.
Dr. Ogino, who wasn’t involved with this study, serves as a member of the cancer immunology and cancer epidemiology programs at the Dana-Farber Harvard Cancer Center. In studies of EOCRC, he and colleagues have found various biogeographical and pathogenic trends across age groups.
“More research is needed to disentangle the complex etiologies of birth cohort CRC and early-onset CRC,” Dr. Ogino said. “Tumor cells and tissues have certain past and ongoing pathological marks, which we can detect to better understand birth cohort CRC and early-onset CRC.”
The study was funded by several National Institutes of Health/National Cancer Institute grants. Dr. Gupta disclosed consulting for Geneoscopy, Guardant Health, Universal Diagnostics, InterVenn Bio, and CellMax. Another author reported consulting for Freenome, Exact Sciences, Medtronic, and Geneoscopy. Dr. Ogino reported no relevant financial disclosures.
A version of this article appeared on Medscape.com .
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY