Search

There is a lack of consensus on which GI endoscopic procedures should be performed during the COVID-19 pandemic, and which procedures could be safely deferred without having a significant impact on outcomes. We selected a panel of 14 expert endoscopists. We identified 41 common indications for advanced endoscopic procedures from the ASGE Appropriate Use of GI Endoscopy guidelines. Using a modified Delphi method, we first achieved consensus on the patient-important outcome for each procedural indication. Panelists prioritized consensus patient-important outcome when categorizing each indication into one of the following 3 procedural time periods: (1) time-sensitive emergent (schedule within 1 week), (2) time-sensitive urgent (schedule within 1 to 8 weeks), and (3) non-time sensitive (defer for >8 weeks and then reassess the timing). Three anonymous rounds of voting were allowed before attempts at consensus were abandoned. All 14 invited experts agreed to participate in the study. The prespecified consensus threshold of 51% was achieved for assigning patient-important outcome(s) to each advanced endoscopy indication. The prespecified consensus threshold of 66.7% was achieved for 40 of 41 advanced endoscopy indications in stratifying them into 1 of 3 procedural time periods. For 12 of 41 indications, 100% consensus was achieved; for 20 of 41 indications, 75% to 99% consensus was achieved. By using a Modified Delphi method that prioritized patient-important outcomes, we developed consensus recommendations on procedural timing for common indications for advanced endoscopy. These recommendations and the structured decision framework provided by our study can inform decision making as endoscopy services are reopened. [ABSTRACT FROM AUTHOR]

Clip closure of the mucosal defect after resecting large (≥20 mm) nonpedunculated colorectal polyps reduces postprocedure bleeding and is cost saving for payers. Clip costs are not reimbursed by payers, posing a major barrier to adoption of this technique in the community. We aimed to determine appropriate clip costs to support broader use of this procedure in practice. We performed budget impact analysis using our recent decision analytic model, comparing prophylactic clip closure with no clip closure on national cost and outcomes data, to determine the maximum feasible clip price while maintaining cost savings in practice. Sensitivity analyses were performed on important clinical factors. In the original model, the baseline postprocedure bleeding risk was 6.8%, increasing cost of care by $614.11 averaged among all patients undergoing large polyp resection without clip closure. Prophylactic clip closure of only large right-sided polyps reduced postprocedure bleeding risk by 70.7% but resulted in cost saving only if the price of clips was $100 or less. Comparatively, prophylactic clip closure of large left-sided polyps had no clinical benefit and was not cost saving. Clip closure strategies focused only on extra-large polyps (≥40 mm), or patients taking antithrombotics regardless of polyp characteristics, were only minimally cost saving. Cost savings and maximum tolerated clip prices depended on medical comorbidity, which directly influences the costs of care to manage postprocedure bleeding. Prophylactic clip closure after endoscopic resection of large colon polyps, particularly those in the right colon segment, is cost saving but requires clip costs less than $100. Translating these findings into practice requires gastroenterology practices to obtain reimbursement from payers for improved clinical outcomes and to align commercial clip prices with this clinical indication. [ABSTRACT FROM AUTHOR]

Introduction The environmental impact of endoscopy, including small-bowel capsule endoscopy (SBCE), is a topic of growing attention and concern. This study aimed to evaluate the greenhouse gas (GHG) emissions (kgCO2) generated by an SBCE procedure. Methods Life cycle assessment methodology (ISO 14040) was used to evaluate three brands of SBCE device and included emissions generated by patient travel, bowel preparation, capsule examination, and video recording. A survey of 87 physicians and 120 patients was conducted to obtain data on travel, activities undertaken during the procedure, and awareness of environmental impacts. Results The capsule itself (4 g) accounted for < 6 % of the total product weight. Packaging (43–119 g) accounted for 9 %–97 % of total weight, and included deactivation magnets (5 g [4 %–6 %]) and paper instructions (11–50 g [up to 40 %]). A full SBCE procedure generated approximately 20 kgCO2 , with 0.04 kgCO2 (0.2 %) attributable to the capsule itself and 18 kgCO2 (94.7 %) generated by patient travel. Capsule retrieval using a dedicated device would add 0.98 kgCO2 to the carbon footprint. Capsule deconstruction revealed materials (e. g. neodymium) that are prohibited from environmental disposal; 76 % of patients were not aware of the illegal nature of capsule disposal via wastewater, and 63 % would have been willing to retrieve it. The carbon impact of data storage and capsule reading was negligible. Conclusion The carbon footprint of SBCE is mainly determined by patient travel. The capsule device itself has a relatively low carbon footprint. Given that disposal of capsule components via wastewater is illegal, retrieval of the capsule is necessary but would likely be associated with an increase in device-related emissions. [ABSTRACT FROM AUTHOR]

Endocuff Vision (Olympus Europe, Hamburg, Germany) has been designed to enhance mucosal visualization, thereby improving detection of (pre-)malignant colorectal lesions. This multicenter, international, back-to-back, randomized colonoscopy trial compared the adenoma detection rate (ADR) and adenoma miss rate (AMR) between Endocuff Vision–assisted colonoscopy (EVC) and conventional colonoscopy (CC). Patients aged 40 to 75 years referred for non–immunochemical fecal occult blood test–based screening, surveillance, or diagnostic colonoscopy were included at 10 hospitals and randomized into 4 groups: group 1, 2 × CC; group 2, CC followed by EVC; group 3, EVC followed by CC; and group 4, 2 × EVC. Primary outcomes included ADR and AMR. A total of 717 patients were randomized, of whom 661 patients (92.2%) had 1 and 646 (90.1%) patients had 2 completed back-to-back colonoscopies. EVC did not significantly improve ADR compared to CC (41.1%; [95% confidence interval (CI), 36.1-46.3] vs 35.5% [95% CI, 30.7-40.6], respectively; P =.125), but EVC did reduce AMR by 11.7% (29.6% [95% CI, 23.6-36.5] vs 17.9% [95% CI, 12.5-23.5], respectively; P =.049). AMR of 2 × CC compared to 2 × EVC was also not significantly different (25.9% [95% CI, 19.3-33.9] vs 18.8% [95% CI, 13.9-24.8], respectively; P =.172). Only 3.7% of the polyps missed during the first procedures had advanced pathologic features. Factors affecting risk of missing adenomas were age (P =.002), Boston Bowel Preparation Scale (P =.008), and region where colonoscopy was performed (P <.001). Our trial shows that EVC reduces the risk of missing adenomas but does not lead to a significantly improved ADR. Remarkably, 25% of adenomas are still missed during conventional colonoscopies, which is not different from miss rates reported 25 years ago; reassuringly, advanced features were only found in 3.7% of these missed lesions. (Clinical trial registration number: NCT03418948.) [Display omitted] [ABSTRACT FROM AUTHOR]

Thermal treatment of the defect margin after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions reduces the recurrence rate. Both snare tip soft coagulation (STSC) and argon plasma coagulation (APC) have been used for thermal margin treatment, but there are few data directly comparing STSC with APC for this indication. We performed a randomized 3-arm trial in 9 US centers comparing STSC with APC with no margin treatment (control) of defects after EMR of colorectal nonpedunculated lesions ≥15 mm. The primary end point was the presence of residual lesion at first follow-up. There were 384 patients and 414 lesions randomized, and 308 patients (80.2%) with 328 lesions completed ≥1 follow-up. The proportion of lesions with residual polyp at first follow-up was 4.6% with STSC, 9.3% with APC, and 21.4% with control subjects (no margin treatment). The odds of residual polyp at first follow-up were lower for STSC and APC when compared with control subjects (P =.001 and P =.01, respectively). The difference in odds was not significant between STSC and APC. STSC took less time to apply than APC (median, 3.35 vs 4.08 minutes; P =.019). Adverse event rates were low, with no difference between arms. In a randomized trial STSC and APC were each superior to no thermal margin treatment after EMR. STSC was faster to apply than APC. Because STSC also results in lower cost and plastic waste than APC (APC requires an additional device), our study supports STSC as the preferred thermal margin treatment after colorectal EMR. (Clinicaltrials.gov , Number NCT03654209.) [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose Of Review: The purpose of this review is to summarise the current state of knowledge concerning known types of gain, the reasons why patients might seek it, as well as implications for headache disorders.Recent Findings: Even though the subject has been studied in the past, it received less attention in recent years. There is no doubt that migraine is a highly disabling disorder. However, attacks sometimes may be beneficial for the migraine brain as a time-out from the daily routine. On the other hand, patients are often stigmatised as trying to satisfy other needs through their disease. These "other needs" may be the exaggerated seeking for attention and affection or an undue official sickness certificate and were named secondary gain. Striving for secondary gain denotes a behaviour that aims at benefiting from a disease in a way that is seen as inappropriate by others. The fact that the term has persisted in doctors' vocabulary for decades probably indicates that it designates a concept considered relevant by many. However, its usage is complicated by its usually imprecise definition. We found in a literature search that the strive for secondary gain is not limited to neurosis, might both occur consciously and unconsciously, sometimes may aim at financial gain and sometimes at social gain, and can either be potentially expected or readily obtained. This behaviour mainly seems to aim at shaping one's interactions with the environment. Its causes have not been elucidated completely, though, but "unrequited demands for love, attention and affection" have been postulated. The desire for social gain can be influenced by approaches based upon behavioural psychology. Broaching the issue of secondary gain may be beneficial in the daily clinical routine. [ABSTRACT FROM AUTHOR]

Incomplete resection of polyps could be an important cause of post-colonoscopy colorectal cancer. However, it is difficult to study progression of incompletely removed polyps or their clinical importance. We aimed to estimate incomplete polyp resection using risk of metachronous neoplasia per colon segment. We performed a retrospective study of 1031 patients (6186 colon segments) who initially underwent resection of a large (10–20 mm) neoplastic polyp at 2 academic medical centers (from 2000 through 2012) and then underwent a subsequent colonoscopy within 0.5 to 5 years. We determined the proportions of metachronous neoplasia in colon segments from which a single large neoplastic polyp was removed and in segments without prior neoplasia. We then used the absolute difference in proportions between these groups to estimate the rate of incomplete resection. Our analysis assumed that development of metachronous neoplasia in each colon segment was the consequence of a newly grown polyp, a previously missed polyp, or an incompletely removed polyp. Metachronous neoplasia was detected in 177 of 757 segments (23.4%) with a single large polyp, and in 438 of 4232 segments (10.3%) without any neoplasia at baseline colonoscopy (P <.001). Resections were therefore estimated to be incomplete in 13.0% of segments (95% CI, 9.8–16.2). This proportion was greater for sections with non-pedunculated polyps (18.3%; 95% CI, 14.2–22.5) than pedunculated polyps (3.5%; 95% CI, –0.7 to –11.3; P <.001). A higher proportion of piecemeal resections appeared to be incomplete (28.0%; 95% CI, 20.2–35.7) than of en bloc resections (9.2%; 95% CI, 5.9–12.5) (P <.001). No differences in incomplete resection were associated with polyp histology. Metachronous neoplasia arises in a significantly higher proportion of colon segments from which a polyp was previously removed. Based on these data, we estimate that 13% of all large polyps are incompletely resected and 18% of large non-pedunculated polyps are incompletely resected. These findings indicate that incomplete resection could be a risk factor for later development of neoplasia. Segment metachronous neoplasia might be used as a marker of resection quality. [ABSTRACT FROM AUTHOR]