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Despite regular need for colonoscopy in patients with Crohn's disease (CD), the efficacy and tolerability of bowel preparation (BP) agents is rarely assessed in this population. Assessing BP quality with existing scales may be challenging in CD due to presence of inflammation, bowel resection, and strictures.To provide recommendations for assessing BP quality in clinical trials for CD using a modified Research and Development/University of California, Los Angeles appropriateness process.Based on systematic reviews and a literature search, 110 statements relating to BP quality assessment in CD were developed. A panel of 15 gastroenterologists rated the statements as appropriate, uncertain, or inappropriate using a 9-point Likert scale.Panelists considered it appropriate that central readers, either alone or with local assessment, score BP quality in clinical trials. Central readers should be trained on scoring BP quality and local endoscopists on performing high-quality video recording. Both endoscope insertion and withdrawal phases should be reviewed to score BP quality in each colonic segment and segments should align with endoscopic disease activity indices. The Harefield Cleansing Scale and the Boston Bowel Preparation Scale were considered appropriate. The final score should be calculated as the average of all visualized segments. Both total and worst segment scores should also be assessed.We developed a framework for assessing BP quality in patients with CD based on expert feedback. This framework could support the development or refinement of BP quality scales and the integration of BP quality assessment in future CD studies.

Background Little is known about patient or provider experience and perceptions of stopping surveillance among older adults with a history of colon polyps. While guidelines recommend ceasing routine colorectal cancer screening in adults > 75 years and those with limited life expectancy, guidance for ceasing surveillance colonoscopy in those with prior colon polyps suggests individualizing recommendations. Objective Identify processes, experiences, and gaps around individualizing decisions to stop or continue surveillance colonoscopy for older adults and areas for improvement. Design Phenomenological qualitative study design using recorded semi-structured interviews from May 2020 through March 2021. Participants 15 patients aged ≥ 65 in polyp surveillance, 12 primary care providers (PCPs), and 13 gastroenterologists (GIs). Approach Data were analyzed using a mixed deductive (directed content analysis) and inductive (grounded theory) approach to identify themes related to stopping or continuing surveillance colonoscopies. Key Results Analysis resulted in 24 themes and were clustered into three main categories: health and clinical considerations; communication and roles; and system-level processes or structures. Overall, the study found support for discussions around age 75–80 on stopping surveillance colonoscopy with considerations for health and life expectancy and that PCPs should take a primary role. However, systems and processes for scheduling surveillance colonoscopies largely bypass PCPs which reduces opportunities to both individualize recommendations and facilitate patients’ decision-making. Conclusions This study identified gaps in processes to implement current guidelines for individualizing surveillance colonoscopy as adults grow older, including opportunities to discuss stopping. Increasing the role of PCPs in polyp surveillance as patients grow older provides more opportunities for individualized recommendations, so patients can consider their own preferences, ask questions, and make a more informed choice for themselves. Changing existing systems and processes and creating supportive tools for shared decision-making specific to older adults with polyps would improve how surveillance colonoscopy is individualized in this population.

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Vitamin D and calcium supplementation are postulated to have chemopreventive effects against colorectal neoplasia, yet in our previously reported randomized trial, there was no overall efficacy of calcium and/or vitamin D3 against colorectal adenoma recurrence. It is possible vitamin D3 and calcium chemopreventive effects are not detectable until beyond the 3- to 5-year follow-up captured in that trial. Accordingly, we explored possible vitamin D and calcium effects on posttreatment (observational) adenoma occurrence. In this secondary analysis of the observational follow-up phase of the Vitamin D/Calcium Polyp Prevention Study, participants who completed the treatment phase were invited to be followed for one additional surveillance colonoscopy cycle. We evaluated adenoma occurrence risk at surveillance colonoscopy, with a mean of 55 ± 15 months after treatment follow-up, according to randomized treatment with vitamin D versus no vitamin D, calcium versus no calcium, and calcium plus vitamin D versus calcium alone. Secondary outcomes included advanced and multiple adenomas. Among the 1,121 participants with observational follow-up, the relative risk (95% confidence interval, CI) of any adenoma was 1.04 (0.93–1.17) for vitamin D versus no vitamin D; 0.95 (0.84–1.08) for calcium versus no calcium; 1.07 (0.91–1.25) for calcium plus vitamin D versus calcium; and 0.96 (0.81–1.15) for calcium plus vitamin D versus neither. Risks of advanced or multiple adenomas also did not differ by treatment. Our results do not support an association between supplemental calcium and/or vitamin D3 for 3 to 5 years and risk of recurrent colorectal adenoma at an average of 4.6 years after treatment.

Background & Aims Older adults with colorectal polyps undergo frequent surveillance colonoscopy. There is no specific guidance regarding when to stop surveillance. We aimed to characterize endoscopist recommendations regarding surveillance colonoscopy in older adults and identify patient, procedure, and endoscopist characteristics associated with recommendations to stop. Methods This was a retrospective cohort study at a single academic medical center of adults aged ≥75 years who underwent colonoscopy for polyp surveillance or screening during which polyps were found. The primary outcome was a recommendation to stop surveillance. Predictors examined included patient age, sex, family history of colorectal cancer, polyp findings, and endoscopist sex and years in practice. Associations were evaluated using multilevel logistic regression. Results Among 1426 colonoscopies performed by 17 endoscopists, 34.6% contained a recommendation to stop and 52.3% to continue. Older patients were more likely to receive a recommendation to stop, including those 80–84 years (odds ratio [OR], 7.7; 95% confidence interval [CI], 4.8–12.3) and ≥85 years (OR, 9.0; 95% CI, 3.3–24.6), compared with those 75–79 years. Family history of colorectal cancer (OR, 0.42; 95% CI, 0.24–0.74) and a history of low-risk (OR, 0.17; 95% CI, 0.11–0.24) or high-risk (OR, 0.02; 95% CI, 0.01–0.04) polyps were inversely associated with recommendations to stop. The likelihood of a recommendation to stop varied significantly across endoscopists. Conclusions Only 35% of adults ≥75 years of age are recommended to stop surveillance colonoscopy. The presence of polyps was strongly associated with fewer recommendations to stop. The variation in endoscopist recommendations highlights an opportunity to better standardize recommendations following colonoscopy in older adults.

Background Endoscopic screening with polypectomy reduces the incidence of colorectal cancer (CRC). Incomplete polyp removal may attenuate the effect of screening. This randomized trial compared cold snare polypectomy (CSP) with hot snare polypectomy (HSP) in terms of complete polyp resection. Methods We included patients ≥ 40 years of age at eight hospitals in four countries who had at least one non-pedunculated polyp of 4–9 mm detected at colonoscopy. Patients were randomized 1:1 to CSP or HSP. Biopsies from the resection margins were obtained systematically after polypectomy in both groups. We hypothesized that CSP would be non-inferior to HSP, with a non-inferiority margin of 5 %. Logistic regression models were fitted to identify the factors explaining incomplete resection. Results 425 patients, with 601 polyps, randomized to either CSP or HSP were included in the analysis. Of 318 polyps removed by CSP and 283 polyps removed by HSP, 34 (10.7 %) and 21 (7.4 %) were incompletely resected, respectively, with an adjusted risk difference of 3.2 % (95 %CI −1.4 % to 7.8 %). There was no difference between the groups in terms of post-polypectomy bleeding, perforation, or abdominal pain. Independent risk factors for incomplete removal were serrated histology (odds ratio [OR] 3.96; 95 %CI 1.63 to 9.66) and hyperplastic histology (OR 2.52; 95 %CI 1.30 to 4.86) in adjusted analyses. Conclusion In this randomized trial, non-inferiority for CSP could not be demonstrated. Polyps with serrated histology are more prone to incomplete resection compared with adenomas. CSP can be used safely for small polyps in routine colonoscopy practice.

BACKGROUND: Colonoscopy is frequently performed in older adults, yet data on current use, and clinical outcomes of and follow-up recommendations after colonoscopy in older adults are lacking. METHODS: This was an observational study using the New Hampshire Colonoscopy Registry of adults age ≥65 years undergoing colonoscopy for screening, surveillance of prior polyps, or evaluation of symptoms. The main outcomes were clinical findings of polyps and colorectal cancer and recommendations for future colonoscopy by age. RESULTS: Between 2009 and 2019, there were 42,611 colonoscopies, of which 17,527 (41%) were screening, 19,025 (45%) surveillance, and 6059 (14%) for the evaluation of symptoms. Mean age was 71.1 years (SD 5.0), and 49.3% were male. The finding of colorectal cancer was rare (0.71%), with the highest incidence among diagnostic examinations (2.4%). The incidence of advanced polyps increased with patient age from 65–69 to ≥85 years for screening (7.1% to 13.6%; p = 0.05) and surveillance (9.4% to 12.0%; p < 0.001). Recommendations for future colonoscopy decreased with age and varied by findings at current colonoscopy. In patients without any significant findings, 85% aged 70–74 years, 61.9% aged 75–79 years, 39.1% aged 80–84 years, and 27.4% aged ≥85 years (p < 0.001) were told to continue colonoscopy. Among patients with advanced polyps, 97.2% aged 70–74 years, 89.6% aged 75–79 years, 78.4% aged 80–84 years, and 66.7% aged ≥85 years were told to continue colonoscopy (p < 0.001). CONCLUSIONS: Within this comprehensive statewide registry, clinical findings during colonoscopy varied by indication and increased with age. Overall rates of finding advanced polyps and colorectal cancer are low. Older adults are frequently recommended to continue colonoscopy despite advanced age and insignificant clinical findings on current examination. These data inform the potential benefits of ongoing colonoscopy, which must be weighed with the low but known potential immediate and long-term harms of colonoscopy, including cost, psychological distress, and long lag time to benefit exceeding life expectancy.

The benefit of surveillance colonoscopy in older adults is not well described. To quantify the detection of colorectal cancer (CRC) and advanced polyps during surveillance colonoscopy in older adults with a history of colon polyps. We conducted a systematic review (MEDLINE, Cochrane Library, Web of Science, and Embase) for all published studies through May 2020 in adults age > 70 undergoing surveillance colonoscopy. The main outcome was CRC and advanced polyps detection. We performed meta-analysis to pool results by age (>70 vs. 50–70). The search identified 6239 studies, of which 569 underwent full-text review and 64 data abstraction, of which 19 were included. The risk of detecting CRC (N = 11) was higher in those >70 compared to 50–70 (risk ratio 1.5 (95% CI 1.1–2.2); risk difference 0.8% (95% CI −0.2%–1.8%)). Similarly, the risk of detecting advanced polyps (N = 8) was higher in those >70 compared to 50–70 (risk ratio 1.3 (95% CI 1.2–1.3), risk difference 2.7% (95% CI 1.3%–4.0%)). Most studies did not stratify results by baseline polyp risk. The detection of CRC and advanced polyps during surveillance colonoscopy in older individuals was higher than in younger controls; however, the absolute risk increase for both was small. These differences must be weighed against competing medical problems and limited life expectancy in older adults when making decisions about surveillance colonoscopy. More primary data on the risks of CRC and advanced polyps accounting for number of past colonoscopies, prior polyp risk, and duration of time since last polyp are needed.

The purpose of this American Gastroenterological Association Institute Clinical Practice Update was to review the available evidence and provide best practice advice regarding strategies to improve the quality of screening and surveillance colonoscopy. This review is framed around 15 best practice advice statements regarding colonoscopy quality that were agreed upon by the authors, based on a review of the available evidence and published guidelines. This is not a formal systematic review and thus no formal rating of the quality of evidence or strength of recommendation has been carried out.

ImportanceSurveillance after prior colon polyps is the most frequent indication for colonoscopy in older adults. However, to our knowledge, the current use of surveillance colonoscopy, clinical outcomes, and follow-up recommendations in association with life expectancy, factoring in both age and comorbidities, have not been studied.ObjectiveTo evaluate the association of estimated life expectancy with surveillance colonoscopy findings and follow-up recommendations among older adults.Design, Setting, and ParticipantsThis registry-based cohort study used data from the New Hampshire Colonoscopy Registry (NHCR) linked with Medicare claims data and included adults in the NHCR who were older than 65 years, underwent colonoscopy for surveillance after prior polyps between April 1, 2009, and December 31, 2018, and had full Medicare Parts A and B coverage and no Medicare managed care plan enrollment in the year prior to colonoscopy. Data were analyzed from December 2019 to March 2021.ExposuresLife expectancy (Main Outcomes and MeasuresThe main outcomes were clinical findings of colon polyps or colorectal cancer (CRC) and recommendations for future colonoscopy.ResultsAmong 9831 adults included in the study, the mean (SD) age was 73.2 (5.0) years and 5285 (53.8%) were male. A total of 5649 patients (57.5%) had an estimated life expectancy of 10 or more years, 3443 (35.0%) of 5 to less than 10 years, and 739 (7.5%) of less than 5 years. Overall, 791 patients (8.0%) had advanced polyps (768 [7.8%]) or CRC (23 [0.2%]). Among the 5281 patients with available recommendations (53.7%), 4588 (86.9%) were recommended to return for future colonoscopy. Those with longer life expectancy or more advanced clinical findings were more likely to be told to return. For example, among patients with no polyps or only small hyperplastic polyps, 132 of 227 (58.1%) with life expectancy of less than 5 years were told to return for future surveillance colonoscopy vs 940 of 1257 (74.8%) with life expectancy of 5 to less than 10 years and 2163 of 2272 (95.2%) with life expectancy of 10 years or more (P Conclusions and RelevanceIn this cohort study, the likelihood of finding advanced polyps and CRC on surveillance colonoscopy was low regardless of life expectancy. Despite this observation, 58.1% of older adults with less than 5 years’ life expectancy were recommended to return for future surveillance colonoscopy. These data may help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.

Goals The authors aimed to characterize older adults' intentions for future surveillance colonoscopy, knowledge of polyps, and predictors of colonoscopy plans. Background Guidelines recommend that the decision to continue or stop surveillance colonoscopy in older adults with colon polyps be "individualized." Although older adults want to be included in decision making, how knowledge regarding polyps influences decisions is unknown. Study In collaboration with a rural family medicine practice, the authors invited adults aged 65 years and older with a history of colon adenomas to complete a 14-item survey regarding intention for colonoscopy and knowledge of colon polyps. Results Sixty-seven of 105 (63%) patients completed the survey. The mean age was 72 years. Regarding future surveillance, 53% planned to return, 25% were unsure, and 22% did not plan to return. There were no significant differences in baseline characteristics on the basis of the intention for future colonoscopy. Regarding polyp knowledge, 73% had correct knowledge around how common polyps are; 50% thought that more than half of untreated polyps would become cancerous-an inaccurately elevated perception by 10 folds. Respondents who perceived polyps to have a high malignant potential were more likely to report plans for surveillance colonoscopy (68% vs. 39%; P=0.03). Conclusions In this survey of older adults with a history of polyps, many had a falsely elevated perception of polyps' potential for cancer that was associated with a higher intention for future colonoscopy. Ensuring older adults have an understanding of the risks of polyps is an essential step toward improving decision making around surveillance colonoscopy.

Background: Medical training occurs during peak childbearing years for most medical students. Many factors influence specialty selection. The aim of this study was to determine whether being a parent affects specialty choice among United States medical students in 2020.Methods: The authors performed a multicenter web-based survey study of medical students enrolled in Oregon Health and Science University, Dartmouth’s Geisel School of Medicine, and University of Michigan Medical School. The 22-item instrument assessed parenthood status, specialty preference, specialty perceptions, and factors influencing specialty choice.Results: 537 out of 2236 (24.0%) students responded. Among respondents, 59 (10.9%) were current or expecting parents. The majority (359, 66.8%) were female and 24-35 years old (430, 80.1%). Of the students who were parents or expecting, 30 (50.9%) were female, and the majority (55, 93.2%) were partnered. Top specialties preferred by both groups were family medicine, emergency medicine, obstetrics and gynecology (OB/GYN), internal medicine, psychiatry, and pediatrics. Specialties rated most family-friendly included family medicine, dermatology, pediatrics, psychiatry, radiology, emergency medicine and pathology. The specialties rated least family-friendly were surgery, neurosurgery, orthopedic surgery, plastic surgery, and OB/GYN. These rankings were the same between groups. Passion for the field, culture of the specialty, and quality of life were the top three factors students considered when choosing a specialty. Being a parent or future parent ranked more highly for parents than non-parents, but was not in the top three factors for either group.Conclusions: Parental status did not affect specialty choices of medical students. While being a parent was considered more heavily by current student parents than non-parents, this was not weighed as heavily as passion for the field, culture of the specialty and quality of life. Medical school training and simultaneous parenting is daunting, yet student parents are putting their passion first when making a career choice.

A reliable assessment of bowel preparation is important to ensure high-quality colonoscopy. Current bowel preparation scoring systems are limited by interobserver variability. This study aimed to demonstrate objective assessment of bowel preparation adequacy using an artificial intelligence (AI)/convolutional neural network (CNN) algorithm developed from colonoscopy videos.Two CNNs were developed using a training set of 73,304 images from 200 colonoscopies. First, a binary CNN was developed and trained to distinguish video frames that were appropriate versus inappropriate for scoring with the Boston Bowel Preparation Scale (BBPS). A second multiclass CNN was developed and trained on 26,950 appropriate frames that were expertly annotated with BBPS segment scores (0-3). We validated the algorithm using 252 10-second video clips that were assigned BBPS segment scores by 2 experts. The algorithm provided mean BBPS scores based on the algorithm (AI-BBPS) by calculating mean BBPS based on each frame's scoring. We maximized the algorithm's performance by choosing a dichotomized AI-BBPS score that closely matched dichotomized BBPS scores (ie, adequate vs inadequate). We tested the mean BBPS score based on the algorithm AI-BBPS against human rating using 30 independent 10-second video clips (test set 1) and 10 full withdrawal colonoscopy videos (test set 2).In the validation set, the algorithm demonstrated an area under the curve of .918 and accuracy of 85.3% for detection of inadequate bowel cleanliness. In test set 1, sensitivity for inadequate bowel preparation was 100% and agreement between raters and AI was 76.7% to 83.3%. In test set 2, sensitivity for inadequate bowel preparation for each segment was 100% and agreement between raters and AI was 68.9% to 89.7%. Agreement between raters alone versus raters and AI were similar (κ = .694 and .649, respectively).The algorithm assessment of bowel cleanliness as measured with the BBPS showed good performance and agreement with experts including full withdrawal colonoscopies.

BACKGROUND AND AIMS: Routine screening for colorectal cancer is typically recommended until age 74 years. Although it has been proposed that screening stop age could be determined based on sex and comorbidity, less is known about the impact of screening history. We investigated the effects of screening history on selection of optimal age to stop screening. METHODS: We used the microsimulation model MISCAN-Colon to estimate harms and benefits of screening with biennial faecal immunochemical tests by sex, comorbidity status, and screening history. The optimal screening stop age was determined based on incremental number needed for 1 additional life-year per 1000 screened individuals compared to threshold provided by stopping screening at 76 years in the average-health population with perfect screening history (attended all required screening, diagnostic and follow-up tests) to biennial faecal immunochemical testing from age 50 years. RESULTS: For persons of age 76 years, 157 women and 108 men with perfect screening history would need to be screened to gain 1 life-year per 1000 screened individuals. Previously unscreened women with no comorbid conditions and no history of screening could undergo an initial screening through 90 years, whereas unscreened males could undergo initial screening through 88 years, before this balance is reached. As screening adherence improved or as comorbidities increased, the optimal age to stop screening decreased to a point that, regardless of sex, individuals with severe comorbidities and perfect screening history should stop screening at age 66 years or younger. CONCLUSIONS: Based on the harm-benefit balance, optimal stop age for colorectal cancer screening ranges from 66 years for unhealthy individuals with perfect screening history to 90 years for healthy individuals without prior screening. These findings can be used to assist patients and clinicians in making decisions about screening participation.

Background Incomplete resection of neoplastic polyps is considered an important reason for the development of colorectal cancer. However, there are no data on the natural history of polyps that were incompletely removed. Objective To examine the risk for metachronous neoplasia during surveillance colonoscopy after documented incomplete polyp resection. Design Observational cohort study of patients who participated in the CARE (Complete Adenoma REsection) study (2009 to 2012). Setting 2 academic medical centers. Patients Patients who had resection of a 5- to 20-mm neoplastic polyp, had a documented complete or incomplete resection, and had a surveillance examination. Measurements Segment metachronous neoplasia, defined as the proportion of colon segments with at least 1 neoplastic polyp at first surveillance examination, was measured. Segment metachronous neoplasia was compared between segments with a prior incomplete polyp resection (incomplete segments) and those with a prior complete resection (complete segments), accounting for clustering of segments within patients. Results Of 233 participants in the original study, 166 (71%) had at least 1 surveillance examination. Median time to surveillance was shorter after incomplete versus complete resection (median, 17 vs. 45 months). The risk for any metachronous neoplasia was greater in segments with incomplete versus complete resection (52% vs. 23%; risk difference [RD], 28% [95% CI, 9% to 47%]; P = 0.004). Incomplete segments also had a greater number of neoplastic polyps (mean, 0.8 vs. 0.3; RD, 0.50 [CI, 0.1 to 0.9]; P = 0.008) and greater risk for advanced neoplasia (18% vs. 3%; RD, 15% [CI, 1% to 29%]; P = 0.034). Incomplete resection was the strongest independent factor associated with metachronous neoplasia (odds ratio, 3.0 [CI, 1.12 to 8.17]). Limitation Potential patient selection bias due to incomplete follow-up. Conclusion This natural history study found a statistically significantly greater risk for future neoplasia and advanced neoplasia in colon segments after incomplete resection compared with segments with complete resection. Primary funding source None.

Background and Aims The coronavirus disease 2019 (COVID-19) pandemic has limited the ability to perform endoscopy. The aim of this study was to quantify the impact of the pandemic on endoscopy volumes and indications in the United States. Methods We performed a retrospective analysis of data from the GI Quality Improvement Consortium (GIQuIC) registry. We compared volumes of colonoscopy and esophagogastroduodenoscopy (EGD) during the pandemic (March-September 2020) to before the pandemic (January 2019-February 2020). The primary outcome was change in monthly volumes. Secondary outcomes included changes in the distribution of procedure indications and in procedure volume by region of United States, patient characteristics, trainee involvement, and practice setting, as well as colorectal cancer diagnoses. Results Among 451 sites with 3514 endoscopists, the average monthly volume of colonoscopies and EGDs dropped by 38.5% and 33.4%, respectively. There was regional variation, with the greatest and least decline in procedures in the Northeast and South, respectively. There was a modest shift in procedure indications from prevention to diagnostic, an initial increase in performance in the hospital setting, and a decrease in procedures with trainees. The decline in volume of colonoscopy and EGD during the first 7 months of the pandemic was equivalent to approximately 2.7 and 2.4 months of prepandemic productivity, respectively. Thirty percent fewer colorectal cancers were diagnosed compared to expected. Conclusion These data on actual endoscopy utilization nationally during the pandemic can help in anticipating impact of delays in care on outcomes and planning for the recovery phase.

PURPOSE OF REVIEW: The purpose of this chapter is to highlight current recommendations regarding colorectal cancer (CRC) screening and post-polypectomy surveillance colonoscopy in older adults and to review the available literature in order to help inform decision-making in this age group. RECENT FINDINGS: Age is a risk factor for CRC, however, older adults with a history of prior screening are at lower risk for CRC compared to those who have never been screened. Decision-making for CRC screening and post-polypectomy surveillance colonoscopy in older adults is complex and several factors including age, screening history, comorbidities, functional status, bowel preparation, prior experiences, preferences, and barriers need to be considered when weighing risks and benefits. Recent guidelines have started to incorporate life expectancy and prior screening history into their recommendations; however, how to incorporate these factors into actual clinical practice is less clear. SUMMARY: There are limited data on the relative benefits of screening and surveillance in older adults and therefore, at this time, decision-making should be individualized and incorporate patient preferences in addition to medical factors.

The benefit of surveillance colonoscopy in older adults is not well described.To quantify the detection of colorectal cancer (CRC) and advanced polyps during surveillance colonoscopy in older adults with a history of colon polyps.We conducted a systematic review (MEDLINE, Cochrane Library, Web of Science, and Embase) for all published studies through May 2020 in adults age 70 undergoing surveillance colonoscopy. The main outcome was CRC and advanced polyps detection. We performed meta-analysis to pool results by age (70 vs. 50-70).The search identified 6239 studies, of which 569 underwent full-text review and 64 data abstraction, of which 19 were included. The risk of detecting CRC (N = 11) was higher in those70 compared to 50-70 (risk ratio 1.5 (95% CI 1.1-2.2); risk difference 0.8% (95% CI -0.2%-1.8%)). Similarly, the risk of detecting advanced polyps (N = 8) was higher in those70 compared to 50-70 (risk ratio 1.3 (95% CI 1.2-1.3), risk difference 2.7% (95% CI 1.3%-4.0%)). Most studies did not stratify results by baseline polyp risk.The detection of CRC and advanced polyps during surveillance colonoscopy in older individuals was higher than in younger controls; however, the absolute risk increase for both was small. These differences must be weighed against competing medical problems and limited life expectancy in older adults when making decisions about surveillance colonoscopy. More primary data on the risks of CRC and advanced polyps accounting for number of past colonoscopies, prior polyp risk, and duration of time since last polyp are needed.

Background and Aims Endoscopist recommendations around repeating colonoscopy after inadequate bowel cleanliness have not been fully described. Our aim was to evaluate the timing of recommendations for repeat colonoscopy after inadequate bowel preparation using a large, national colonoscopy registry. Methods We performed a cross-sectional analysis of all outpatient screening and surveillance colonoscopies among adults age 50 to 75 reported in the GI Quality Improvement Consortium (GIQuIC) from 2011 to 2018. The primary outcome was a recommendation to repeat colonoscopy within 1 year. Secondary outcomes included recommendations based on indication of colonoscopy and colonoscopy findings, and predictors of a recommendation to follow-up within 1 year. Results There were 260,314 colonoscopies with inadequate bowel preparation performed at 672 different sites by 4,001 endoscopists. Of these, 31.9% contained a recommendation for follow-up within 1 year. This did not differ meaningfully by examination indication. The severity of colonoscopy findings influenced the recommendations for follow-up (within 1 year in 84.0% of cases with adenocarcinoma, 51.8% with any advanced lesion, and 23.2% with 1-2 small adenomas). Younger age, more severe pathology, location in the Northeast, and performance by an endoscopist with an adenoma detection rate ≥25% were associated with recommendations for follow-up within 1 year. Conclusions A minority of colonoscopies with inadequate bowel preparation are recommended to be repeated within 1 year, which may have implications for potential missed lesions. Further understanding of reasons driving recommendations is an important next step to improving guideline-concordant colonoscopy practice.

Background: Recognition awards from professional medical societies play an important role in physicians' career advancement. Our aim was to evaluate the gender representation of award recipients from gastroenterology and hepatology societies. Methods: We analyzed the lists of award recipients from the American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy and determined the gender of these award recipients. The primary outcome was the overall representation of women physician award recipients as compared with the representation of women in the specialty. Results: Between 1941 and 2019, there were 921 awards, of which 77 (8.4%) were given to women and 844 (91.6%) to men. There was a significant increase in the proportion of women recipients over time, from 0% in 1970–1984 to 22.0% in 2015–2019 (p for trend

Background and Aims As the COVID-19 pandemic moves into the postpeak period, the focus has now shifted to resuming endoscopy services to meet the needs of patients who were deferred. By using a modified Delphi process, we sought to develop a structured framework to provide guidance regarding procedure indications and procedure time intervals. Methods A national panel of 14 expert gastroenterologists from throughout the US used a modified Delphi process, to achieve consensus regarding: (1) common indications for general endoscopy, (2) critical patient-important outcomes for endoscopy, (3) defining time-sensitive intervals, (4) assigning time-sensitive intervals to procedure indications. Two anonymous rounds of voting were allowed before attempts at consensus were abandoned. Results Expert panel reached consensus that procedures should be allocated to one of three timing categories: (1) time-sensitive emergent = scheduled within 1 week, (2) time-sensitive urgent = scheduled within 1-8 weeks, (3) nontime sensitive = defer to > 8 weeks and reassess timing then. The panel identified 62 common general endoscopy indications (33 for EGD, 21 for colonoscopy, 5 for sigmoidoscopy). Consensus was reached on patient-important outcomes for each procedure indication, and consensus regarding timing of the procedure indication was achieved for 74% of indications. Panelists also identified adequate personal-protective-equipment, rapid point-of-care testing, and staff training as critical preconditions before endoscopy services could be resumed. Conclusion We used the validated Delphi methodology, while prioritized patient-important outcomes, to provide consensus recommendations regarding triaging a comprehensive list of general endoscopic procedures.

BACKGROUND AND AIMS: Serrated polyps (SPs) and conventional high‐risk adenomas (HRAs) derive from two distinct biological pathways but can also occur synchronously. Adults with synchronous SPs and adenomas have been shown to be a high‐risk group and may have a unique risk factor profile that differs from adults with conventional HRAs alone. We used the population‐based New Hampshire Colonoscopy Registry (NHCR) to examine the risk profile of individuals with synchronous conventional HRAs and SPs. METHODS: Our study population included 20,281 first time screening colonoscopies from asymptomatic NHCR participants 40 years or older between 2004‐15. Exams were categorized by findings: (1) normal, (2) HRA only (adenomas ≥ 1 cm, villous, high grade dysplasia, multiple adenomas (> 2) and adenocarcinoma), (3) clinically significant SP (CSSP) only (any hyperplastic polyp ≥ 1 cm, sessile serrated adenomas/polyps or traditional serrated adenomas), and (4) synchronous HRA + CSSP. Risk factors examined included exposure of interest, smoking (never, past, and current/pack years), as well as age, sex, alcohol, education, and family history of colorectal cancer (CRC). Multivariable unconditional logistic regression tested the relation of risk factors with having synchronous HRA + CSSP versus having a normal exam or HRA alone. RESULTS: Among NHCR participants with 18,354 screening colonoscopies (with complete smoking, sex, bowel preparation data, and adequate preparation) there were 16,495 normal; 1309 HRA alone; 461 CSSP alone, and 89 synchronous HRA + CSSP. Current smoking was associated with an almost threefold increased risk for HRA or CSSP, and an eightfold risk for synchronous HRA + CSSP (aOR = 8.66; 95% CI: 4.73‐15.86) compared to normal exams. Adults with synchronous HRA + CSSP were threefold more likely to be current smokers than those with HRA alone (aOR = 3.27; 95% CI:1.74‐6.16). CONCLUSIONS: Our data suggest that current smokers may be at a higher risk for synchronous CSSP + HRA even when compared to having HRA alone.

Female representation in medicine is increasing across all levels of medical training, yet women hold fewer senior leadership positions than men. National recognition, including participation as faculty in society-sponsored programs, is one component of academic advancement. The aim of this study was to characterize female representation among faculty in courses sponsored by the American Society for Gastrointestinal Endoscopy (ASGE).We performed a retrospective review of demographic data, including faculty gender and role, year, and program type, from the ASGE database of its sponsored programs between 2009 and 2014. Female faculty rates were compared with the rate of female membership in the ASGE and by faculty role and course type over time.Between 2009 and 2014 there were a total of 2020 ASGE course faculty positions of which women comprised 19%. There was a significant increase in the proportion of women that served as course faculty over time (P .0005). Female faculty participation exceeded the ASGE female domestic membership rate in all years. Women were more likely to serve as course directors than lecturers (25% vs 18%, P = .004) and to participate in smaller courses (P = .0003).We found an increase in female participation in ASGE programming over time, suggesting that specialty societies are making efforts to improve female representation at the national level. Future work should evaluate whether or not these opportunities translate into leadership roles for women within their own institutions or lead to promotions for women over time.

This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses primary drainage modality (percutaneous transhepatic biliary drainage [PTBD] vs endoscopic biliary drainage [EBD]), drainage strategy (unilateral vs bilateral), and stent selection (plastic stent [PS] vs self-expandable metal stent [SEMS]). Regarding drainage modality, in patients with MHO undergoing drainage before potential resection or transplantation, the panel suggests against routine use of PTBD as first-line therapy compared with EBD. In patients with unresectable MHO undergoing palliative drainage, the panel suggests PTBD or EBD. The final decision should be based on patient preferences, disease characteristics, and local expertise. Regarding drainage strategy, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placement of bilateral stents compared with a unilateral stent in the absence of liver atrophy. Finally, regarding type of stent, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placing SEMSs or PSs. However, in patients who have a short life expectancy and who place high value on avoiding repeated interventions, the panel suggests using SEMSs compared with PSs. If optimal drainage strategy has not been established, the panel suggests placing PSs. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention ( 48 hours), and extent of initial intervention (comprehensive therapy vs decompression alone). Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to formulate recommendations on these topics. The ASGE suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours. Additionally, the panel suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment.

Significant efforts have been dedicated to defining what constitutes high-quality endoscopy. These efforts, centered on developing, refining, and implementing procedure-associated quality indicators1, 2, 3, 4, 5 have been helpful in promoting best practices among endoscopists and providing evidence-based care for our patients. At the same time, the American Society for Gastrointestinal Endoscopy (ASGE) has generated programming to assist physicians and allied healthcare professionals in understanding how to translate quality concepts into practice. With this work, we now have a stronger sense of how to measure quality at the patient and procedural level. A critical component of high-quality endoscopy services relates to the site of the procedure: the endoscopy unit. Unlike many procedure-associated quality indicators, evidenced-based indicators used to measure the quality of endoscopy units are lacking. Outside of the United States, the United Kingdom’s National Health Services developed the Global Rating Scale (GRS) in 20046 with the dual aims of enhancing quality while developing uniformity in endoscopy unit processes and operations. This scoring system was the first to assess service at the level of the endoscopy unit and has been instrumental in reducing wait times, identifying service gaps, increasing patient satisfaction, and reducing adverse events within endoscopy units in the United Kingdom.7 Additionally, the GRS has demonstrated that measuring an endoscopy unit parameter repeatedly and incorporating it into a quality improvement program leads to improvement for many indicators.6, 7, 8 Use of the GRS has spread with modification and adoption for use in other countries across Europe8, 9 and Canada.10, 11 However, there are limitations with the GRS. Whether improvements in 1 particular indicator are correlated with other areas of endoscopy unit performance and outcomes cannot be ascertained from the GRS data. Also, the process for developing and reaching consensus on the GRS indicators has varied extensively in their rigor and breadth of stakeholder participation. To date, no such effort to identify and promote endoscopy unit–level quality indicators has been performed in the United States. A compendium of quality indicators for endoscopy units in the United States is needed to strengthen programming around the promotion of quality and to give endoscopy units an organizational framework within which they can direct their efforts. As healthcare reimbursement in the United States becomes more dependent upon demonstration of performance and quality, endoscopists, governing organizations, payers, and patients will be looking for guidance on endoscopy unit–wide performance. Consequently, the ASGE convened a taskforce whose primary objectives were to (1) develop a comprehensive document that identifies key quality indicators for endoscopy units as defined by the literature and expert opinion and (2) achieve consensus on these quality indicators from important stakeholders involved in endoscopy unit operations and quality improvement (Video 1, available online at www.VideoGIE.org).

In “Contrasting Effectiveness and Cost-Effectiveness of Colorectal Cancer (CRC) Screening under Commercial Insurance vs. Medicare”, Ladabaum et al. model different CRC screening scenarios that vary the combination of payer, perspective, screening ages, and time horizons. Fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), colonoscopy and flexible sigmoidoscopy were all cost effective compared to no screening, even if initiating or stopping at age 65 years. Assuming perfect adherence, FIT and FOBT were cost saving and dominated colonoscopy. Screening between ages 50 and 64 years appeared relatively costly if only a limited time horizon was considered since the benefits accrue after age 65 years under Medicare.

OBJECTIVES There is little guidance regarding when to stop surveillance colonoscopy in individuals with a history of adenomas or colorectal cancer (CRC). We evaluated both yield and recommendations for follow-up colonoscopy in a large cohort of older individuals undergoing colonoscopy, using the GI Quality Improvement Consortium registry. METHODS We analyzed the yield of colonoscopy in adults aged ≥75 years, comparing those who had an indication of surveillance as opposed to an indication of diagnostic or screening, stratified by 5-year age groups. Our primary outcome was CRC and advanced lesions. We also evaluated recommended follow-up intervals by age and findings. RESULTS Between 2010 and 2017, 376,686 colonoscopies were performed by 3,976 endoscopists at 628 sites, of which 43.2% were for surveillance. Detection of CRC among surveillance patients increased with age from 0.51% (age 75-79 years) to 1.8% (age ≥ 90 years); however, these risks were lower when compared with both the diagnostic and screening for the same age band (P < 0.0001). Yield of advanced lesions also increased by every 5-year interval of age across all groups by indication. Even at the most advanced ages and in those with nonadvanced findings, only a minority of patients were recommended for no further colonoscopy. For example, in patients aged 90 years and older with only low risk findings, 62.9% were recommended to repeat colonoscopy. DISCUSSION Surveillance colonoscopy is frequently recommended at advanced ages even when recent findings may be clinically insignificant. Further work is needed to develop guidelines to inform best practice around when to stop surveillance in older adults.

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.