bluuebunny/crossref_metadata_2025 huggingface dataset:
278 Helicobacter pylori Infection History Is Not a Risk Factor for Metachronous Advanced Adenoma: 8 Years' Follow-Up Study
Authors: Omata Fumio , Matoba Kohei , Ohmuro Akemi , Rai Fumie , Takashima Misako , Kato Akira , Kumakura Yasuhisa , Masuda Katsunori
Published: October 2019

INTRODUCTION:

There have been several studies suggesting the association between Helicobacter pylori. (H. pylori) infection and colorectal adenoma or cancer. However, this causal relationship is still controversial. Most atrophic gastritis (AG) is caused by H. pylori infection and can be used as surrogate marker of H. pylori infection history. On the other hand, advanced adenoma (adenoma more than 10 mm or high-grade dysplasia (HGD) or villous adenoma) has been used as surrogate marker for risk evaluation of colorectal adenocarcinoma. The aim of this study was to determine the association between H. pylori infection and post-colonoscopy advanced adenoma (PCAA).

METHODS:

A retrospective cohort study was conducted in a center of preventive medicine and affiliated tertiary referral center in Tokyo, Japan. Consecutive 3104 individuals had general health check-up including esophagogastroduodenoscopy (EGD) between April 2004 and July 2014 and underwent initial diagnostic or screening colonoscopy within six months after general health check-up. The patients with history of inflammatory bowel disease or colectomy or only index colonoscopy were excluded. Baseline data included age, gender, height, weight, smoking history, index colonoscopy findings (the number of adenoma, maximum size of adenoma, HGD, villous adenoma), and EGD findings (AG). To determine the longitudinal association between baseline AG and PCAA, we calculated Kaplan-Meier estimates within eight years' horizon and performed multivariate Cox proportional hazards regression.

RESULTS:

Mean age [SD] of 3104 patients was 55 [12] years-old and 2169 patients (70%) were male. Mean BMI [SD] was 23 [3.2]. 1188 (39%) patients were diagnosed with AG. At the index colonoscopy, 1310 patients (42%) were diagnosed with colorectal adenoma. The cumulative incidence [95%CI] of PCAA at 3, and 5 years in the patients with AG was 3% [2–5], and 8% [6–10], respectively. Crude hazard ratio (HR) [95% CI] of age, male gender, body mass index, current smoking, and AG was 1.03 [1.02–1.05], 1.35 [0.9–2.03], 1.04 [0.98–1.1], 1.5 [0.98–2.27], and 1.46 [1.02–2.1]. Adjusted HR [95% CI] of age, current smoking, AG was 1.03 [1.02–1.05], 1.6 [1.04–2.5], and 1.2 [0.85–1.8], respectively.

CONCLUSION:

Older age and current smoking were significant risk factors of PCAA, but AG was not. The association between AG (H. pylori infection history) and PCAA was confounded by age and current smoking. The causal relationship between H. pylori infection and PCAA was not supported by our study.
284 Factors That Underpin the Increase in Right Colon Adenoma Detection Rate: A Pooled Analysis of Three Reports Comparing Water Exchange, Water Immersion, and Air Insufflation Colonoscopy
Authors: Leung Felix , Koo Malcolm , Jia Hui , Cadoni Sergio , Hsieh Yu-Hsi , Hu Chi-Tan , Leung Joseph
Published: October 2019

INTRODUCTION:

Interval cancers due to missed adenomas tend to cluster in the right colon. Both water immersion (WI) and water exchange (WE) use water infusion to aid insertion. WI, which is easy to adopt at the discretion of the colonoscopist, removes water mainly during withdrawal. WE, which has evolved from WI, removes water mainly during insertion using new skills. WE, but not WI, provides insertion cleansing and improves bowel cleanliness. Reduced cleaning-related multi-tasking distractions from search for polyps, but not improved bowel cleanliness per se, is linked significantly to the improved adenoma detection rate (ADR) with WE (UEGJ Dec 5, 2018). In a pooled data analysis of three reports, WE significantly increased right colon adenoma detection rate (rADR) compared with WI and air insufflation (AI) (DDW 2019). However, the significant and independent factors that account for the increased rADR have not been described. We aim to assess the factors associated with an increase in rADR by multiple logistic regression analysis of the pooled individual patient data in the three aforementioned reports.

METHODS:

Three reports with data on rADR comparing WE with WI and AI were identified. The demographic and procedural data were extracted, pooled to optimize sample size and analyzed. Multiple logistic regression analysis was conducted using backward likelihood ratio selection procedure.

RESULTS:

Table 1 shows comparable pooled demographic data. Table 2 shows volume infused and suctioned confirm use of WE, WI and AI. WE has highest cleanliness scores, least use of adjunct maneuvers, and highest willingness to repeat. rADR of WE (22.4%) is significantly higher than those of WI (17.4%) (P = 0.009) and AI (15.7%) (P < 0.001); but WI and AI are similar (reported 2019 DDW). Table 3 shows multiple logistic regression analysis (unreported): older age, shorter insertion time, longer withdrawal time, and WE; but not WI (when compared with AI), are significant and independent factors associated with a higher rADR.

CONCLUSION:

WE, compared with AI, was significantly associated with a higher rADR, adjusting for other confounding factors. The improved quality adds value to WE colonoscopy, and justifies the call to incorporate WE into colorectal cancer prevention programs. Since WE = WI + suction of water during insertion, the higher rADR of WE provides incentive for transitioning from WI to WE. The impact of WE on right colon interval cancers warrants further assessment.
288 Multitarget Stool DNA Testing Is for Everyone: Positive Findings in Different Racial Groups
Authors: Huq Nadia , Fahed Gracia , Inaganti Anupama , Affi Aboud , Fahed Julien
Published: October 2019

INTRODUCTION:

Different ethnic/racial groups may have unique incidences of colorectal cancer with some groups being at higher risk than others. Our study aims to look at outcomes of multitarget stool DNA testing in different racial groups.

METHODS:

There were 19400 patients who had multitarget stool DNA tests ordered. Baseline demographic traits were recorded. Of these, 1413 positive stool DNA tests followed by documented subsequent colonoscopy. A total of 12 patients with unknown racial group/ethnicity, unknown indication and findings of other carcinoma other than adenocarcinoma were excluded from analysis. Only the index lesion was recorded. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high risk features. Racial/ethnic groups were divided into white/Caucasian and non-white. Statistical analysis with Chi-square was done to compare the proportions. A P-value < 0.05 was considered statistically significant.

RESULTS:

Of the patients who had multitarget stool DNA tests ordered, 206 (1.06%) were of Hispanic origin, 53 (0.27%) American Indian or Alaskan Native, 242 (1.25%) Asian, 1131 (5.83%) African American/Black, 1 (0.01%) Native Hawaiian, 5 (0.03%) Other Pacific Islander, 17416 (89.77%) Caucasian/White and 346 (1.78%) of unknown/unreported backgrounds. A total of 1401 patients were analyzed. For the white/Caucasian cohort, 1353 (75.54%) had subsequent colonoscopy compared to 97 (75.19%) of the non-white group (P = 0.93). Adenocarcinoma cases were 22 (1.68%) in white patients versus 2 (2.17%) in the nonwhite group (P = 0.67), advanced adenomas were 401 (30.68%) versus 30 (32.61%) (P = 0.70), nonadvanced adenoma was 388 (29.69%) versus 26 (28.26%) (P = 0.77), and no adenoma was 496 (37.95%) versus 34 (36.96%) (P = 0.85), respectively.

CONCLUSION:

From our study, there is no difference in colonoscopy findings from positive multitarget stool DNA tests between racial groups nor is there a difference in adherence to follow-up colonoscopy. Our study is limited by the number of patients within minority groups.
289 What Differences Are There Between Early and Delayed Colonoscopy Following a Positive Stool DNA Test?
Authors: Huq Nadia , Fahed Gracia , Inaganti Anupama , Affi Aboud , Fahed Julien
Published: October 2019

INTRODUCTION:

Previous stool DNA studies excluded patients who had their colonoscopy done more than 3 months after a positive stool DNA test. In this study, we compare patients who had early colonoscopy with patients who had delayed colonoscopy following a positive stool DNA test.

METHODS:

Review of 1413 patients who had a positive stool DNA followed by documented colonoscopy was done. Two patients were excluded because of finding of “other carcinoma” aside from adenocarcinoma. Attention was given to the date of the colonoscopy in regards to the date of the positive stool DNA result. Patients were divided in 2 groups. Group 1 included patients who had their colonoscopy within 3 months of the positive stool DNA test while group 2 included patients who had their colonoscopy at least 3 months after the positive stool DNA test. Only the index lesion was recorded. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high risk features. Statistical analysis with Chi-square and Fisher exact was done to compare the proportions. A P-value < 0.05 was considered to be statistically significant.

RESULTS:

Out of the 1411 patients included in the study, 1144 (81.08%) patients had their colonoscopy done within 3 months of the positive stool DNA results, while 267 (18.92%) had it done at least 3 months after the positive stool DNA test. Between group 1 and group 2, “adenocarcinoma” was found in 1.75% vs. 1.5% respectively (P = 1.00). “Advanced adenoma” was found in 23.25% vs. 25.47% respectively (P = 0.44). “10 mm adenoma” was found in 6.91% vs. 8.24% respectively (P = 0.45). Non advanced adenoma was found in 29.11% vs. 31.09% respectively (P = 0.52). Finally, no adenomas were found in 38.99% vs. 33.71% respectively (P = 0.11).

CONCLUSION:

This study shows similar colonoscopy outcome in patients who have positive stool DNA test whether the colonoscopy was done within 3 months or longer than 3 months after a positive stool DNA test. In future studies, it is not necessary to exclude patients who had their colonoscopy done more than 3 months after a positive DNA test.
300 Predictors of Colonoscopy Use Among Chinese Americans: An Analysis of the New York City Community Health Survey (2003–2016)
Authors: Lin Kevin , Xia Yuhe , Nagpal Neha , Glenn Matthew , Ng Sandy , Liang Peter S.
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is a leading cause of cancer death among Asian Americans, who also have one of lowest rates of CRC screening. Chinese Americans are the largest Asian American subgroup in the United States (US), but there is a paucity of data examining predictors of CRC screening in this population. We used the New York City Community Health Survey (NYCCHS) to study factors associated with up-to-date colonoscopy use among Chinese Americans.

METHODS:

The NYCCHS is an annual population-based telephone survey. For this analysis, we included all Chinese Americans aged ≥50 years who participated in the survey from 2003–2016. We calculated up-to-date CRC screening uptake by colonoscopy, defined as colonoscopy within the last 10 years. To evaluate sociodemographic and medical predictors of colonoscopy use over four consecutive time periods, we entered age, sex, and any additional factors with P < 0.10 on univariate analysis into a multivariable model and reached the final model for each period using stepwise backward selection.

RESULTS:

During the study period, 2,577 Chinese Americans were surveyed and 62.4% had received a colonoscopy within 10 years. On multivariable analysis, receiving a flu shot was the only consistent positive predictor of up-to-date colonoscopy use from 2009–2016 (OR 2.06–2.36, Table 1). Individuals without a primary care provider were less likely to have received a colonoscopy from 2003–2012 (OR 0.25–0.42), and the risk estimate remained consistent but was no longer statistically significant from 2015–2016. Similarly, being born outside of the US was associated with lower colonoscopy uptake from 2009–2014 (OR 0.06–0.22). Compared to never smokers, current but not former smokers were significantly less likely to have received up-to-date colonoscopy (OR 0.37 in 2003–2008; OR 0.16 in 2013–2014). Age, sex, borough of residence, and exercise activity were not consistent predictors of up-to-date colonoscopy uptake.

CONCLUSION:

Among Chinese Americans older than age 50 living in NYC, those who had a primary care provider and received annual flu shots were most likely to be up-to-date with colonoscopy. Foreign-born Chinese Americans and current smokers were less likely to have received colonoscopy. These findings highlight the importance of primary care for CRC prevention and provide insight into the vulnerable populations within the Chinese American community.
301 Improving Colorectal Cancer (CRC) Screening by Offering Less Invasive Testing When Patients Refuse Colonoscopy: A Quality Improvement (QI) Project
Authors: Melki Gabriel , Ghrewati Moutaz , Mohamed Hadir , Kapoor Ashima , Mohamed Abdalla , Ayoub Farhan , Wu Alexander , Barham Shaker , Laham Linda , Karim Gres , Hanna Maggie , Chandran Chandra , Baddoura Walid
Published: October 2019

INTRODUCTION:

CRC is the third leading cause of cancer death, and therefore early detection by screening is beneficial. Residents in primary care clinics offer screening modalities for CRC starting at the age of 50. At a clinic in New Jersey, the primary method offered for screening has always been colonoscopy every 10 years starting at the age of 50. However, when patients refused colonoscopy, other less invasive tests were not being offered. A QI project was undertaken to assess the % of residents not offering less invasive tests, before and 6 months after education about CRC screening modalities.

METHODS:

63 residents were surveyed about their preferred and alternate method of CRC screening. The questionnaire was anonymous. When colonoscopy was refused, results were obtained to assess the % of residents offering less invasive tests before and 6 months after being educated about CRC screening options.

RESULTS:

At this institution, results revealed that 73% of residents offered colonoscopy as a first test, 19% FOBT and 8% other methods. 64% of residents offered less invasive tests when colonoscopy was refused; this increased to 95% at 6 months post education, accounting for a 31% increase.

CONCLUSION:

Most cases of CRC develop from adenomatous polyps. Therefore, early detection and removal by colonoscopy reduces the risk of CRC development. Colonoscopy is the gold standard for CRC screening. However, other modalities are also approved such as yearly FOBT. It is important to offer these modalities when colonoscopy is declined. This QI project demonstrated that an educational intervention about CRC screening modalities given to residents in primary care clinics enhanced the number of patients being screened, especially in the group of patients who refused colonoscopy. In conclusion, offering more CRC screening methods yields to better medical care to our patients.
304 Increasing Incidence of Polyps Greater Than 9 mm in Young Adults Undergoing Colonoscopy: A Prospective Multi-Center Study
Authors: Yip Benjamin , Holub Jennifer , Lieberman David
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the fourth leading newly diagnosed cancer and second most common cause of cancer mortality in the United States. Young adults 40-49 years old have an increasing incidence of CRC. Recent guidelines from the American Cancer Society suggest lowering the age of CRC screening to 45 years of age based on modeling analyses. We hypothesize that rates of polyps > 9 mm would also increase before the age of 50. The aim of this study is to determine the incidence of polyps > 9 mm from 2002 to 2014 in patients under 50 years old.

METHODS:

We reviewed colonoscopy data that was prospectively collected from the Clinical Outcomes Research Initiative (CORI) from 2002 through 2014. CORI uses a computerized endoscopic procedure report generator to collect data in a national endoscopy database from a consortium of 70 adult gastrointestinal practices. We identified all patients who were 40 to 59 years old and reviewed their endoscopic data. We used a robust surrogate marker for advanced adenoma defined as polyps > 9 mm as our end point. Patient outcomes were compared using age groups 40-49, 50-54, 55-59.

RESULTS:

We identified 398672 patients who were 40 to 59 years of age who underwent colonoscopy from 2002 to 2014. Twenty two percent were less than 50 years old. There was a progressive increase in polyps greater than 9 mm for all age groups over the course of this twelve year period (Figure 1). Patients who were under 50 years of age had a rise in advanced adenoma from 4.5% to 6.3% from 2005 to 2014 (Table 1).

CONCLUSION:

From 2002 to 2014 there was an increased rate of polyps > 9 mm in all subjects undergoing colonoscopy aged 40 to 59. By 2014, rates of polyps greater than 9 mm in the 40-49 year old group were similar to the 2005 rates in the 55-59 year old group. Screening before age 50 years should be considered and further studies are needed to validate this recommendation and determine the most optimal form of screening before age 50 years.
308 Impact of Hereditary Cancer Screening in Diverse Practice Settings on Gastroenterolgy Volume
Authors: Crecelius Mary , Raney Deborah , Sharlow Joseph
Published: October 2019

INTRODUCTION:

According to the U.S. Department of Health and Human Services, colorectal cancer is the third most common cancer in the U.S. and the second leading cause of death from cancers in both men and women. Unfortunately, in non-GI settings such as women's imaging centers, OB/GYN or Primary Care Providers, GI-related hereditary cancer risk may go undetected because specialty providers tend to implement risk assessment programs focused on their expertise. Since gastroenterology (GI) is associated with germline mutations that can also have implications in hereditary breast and ovarian cancers (HBOC), a broader risk assessment is critical to the proper management of patients in all settings.

METHODS:

This retrospective study analyzes data from the hereditary cancer risk screening program that has been implemented in the following non-GI settings: Women's Wellness, OB/GYN, Breast Surgery Clinic, and Breast Imaging. By using an automated risk assessment software which flags high-risk patients based on NCCN criteria, we looked at data for the 2018 calendar year and identified the total number of patients screened in these settings. Study metrics include the number of high-risk patients identified with GI-related cancer risk, the number of patients tested, the number of pathogenic mutations found, and the overall impact to GI volume from these risk screenings.

RESULTS:

JOURNAL/ajgast/04.03/00000434-201910001-00308/table1/v/2024-02-04T204205Z/r/image-tiff

CONCLUSION:

By screening patients outside of the GI setting for hereditary cancer risk, we were able to identify that 8% of all patients screened, a significant number, need changes to their GI care management plans. Additionally, for those patients at higher risk that underwent genetic testing, 87% of those who tested positive tested for a mutation that impacts a GI-related cancer and has major impacts to GI management. This data shows that an interdisciplinary approach is needed to fully capture high-risk GI patients, and hereditary screening needs to be done in all settings in order to maximize patient care and outcomes.
315 Can Adenoma Detection Rates Predict a Benchmark for Serrated Polyp and Advanced Adenoma Detection Rates in a Diverse Urban Population?
Authors: Dalal Shaman , Shah Aun , Twohig Patrick , Desai Aakash , Sandhu Dalbir S.
Published: October 2019

INTRODUCTION:

Adenoma detection rate (ADR) benchmark of >25% has been shown to reduce interval colorectal cancer (CRC). Serrated polyp detection rate (SDR) and advanced adenoma detection rate (AADR) can also serve as additional benchmarks to reduce interval CRC, although a standardized benchmark for AADR and SDR doesn’t exist. Recent studies have shown correlation between ADR, SDR and AADR, but in a homogenous patient population. Our study evaluated the correlation between ADR, SDR and AADR and approximated a benchmark for SDR and AADR in a diverse urban population, while attempting to identify any patient variables affecting detection rates.

METHODS:

We reviewed screening colonoscopies performed at our midwest urban, safety-net health care system over a period of one year (2017). We calculated ADR, SDR and AADR for individual providers and established correlation using non-parametric Spearman correlation coefficients between the 3 entities. Logistic regression analysis was used to calculate predictors of adenomas, advanced adenomas and serrated polyps.

RESULTS:

Of the 3000 colonoscopies reviewed, 1488 were screening colonoscopies performed by 9 experienced staff gastroenterologists. The patient population included 48% African-Americans, 42% Caucasians, and 10% others. Median (Interquartile range) ADR of all providers was 42.5 (27-61), SDR 8.4 (3.6-23), and AADR was 2.9 (0.6-4.8). All providers had an overall ADR above 25%. There was a weak positive correlation for ADR and SDR (rho = 0.13), and ADR and AADR (rho = 0.13). Logistic regression analysis identified male gender (P < 0.01) and body mass index (P = 0.02) as predictors of adenomas, while longer withdrawal time was a significant predictor for all types of polyps. We did not find statistical significance for gender or body mass index and SDR.

CONCLUSION:

Based on our study, previously suggested benchmark SDR of 7% seems appropriate. Our AADR of 2.9 was lower than suggested AADR of >6%. Additionally, a weak positive correlation was noted between ADR and SDR, and ADR with AADR although the patient population was heterogeneous and diverse making the results more generalizable for the real world.
316 Colonoscopic Withdrawal Patterns in a Tertiary Academic Medical Center
Authors: Kim David , Stavrakis Dimitris , Cui Haiyan , Roe Denise , Banerjee Bhaskar
Published: October 2019

INTRODUCTION:

Withdrawal time is an important quality measure in colonoscopy as numerous studies have shown its effect on adenoma detection rate. Withdrawal during colonoscopy can be affected by many patient factors, but also individual endoscopist’s preferences and practices. We sought to characterize withdrawal patterns in our academic center for quality improvement purposes.

METHODS:

Inclusion criteria: 1,114 patients at a tertiary academic center who underwent screening and surveillance colonoscopies. Exclusion criteria: patients with missing procedure timestamps, incomplete or aborted procedures, history of gastrointestinal malignancy, prior colon resection, genetic syndromes, or inflammatory bowel disease. For cecal intubation time and withdrawal time, log-transformation was applied to normalize the data. Linear regression was used to assess the association of cecal intubation time with withdrawal time and adjusted for age, gender, and body mass index (BMI). The same analysis was performed by indication (screening and surveillance) and by endoscopist.

RESULTS:

After adjusting for age, gender, and BMI, increased cecal intubation time was associated with longer withdrawal time for all patients (n = 1144, P = 0.049). Subgroup analysis showed that this pattern held true for patients undergoing screening (n = 488, P = 0.033) but not surveillance (n = 656, P = 0.545). Further subgroup analysis excluding procedures that had polyps removed to control for time spent resecting polyps during withdrawal showed similar results (Table 1). When stratified by endoscopist, two of seven faculty members exhibited an association of longer cecal intubation time with increased withdrawal times. Increased withdrawal time was not associated with prior knowledge of positive family history of colon cancer (P = 0.729), nor personal history of cancer (P = 0.464).

CONCLUSION:

Longer cecal intubation times are associated with increased withdrawal times in our center particularly with screening colonoscopies, but variability appears to exist between faculty members. Bias against a patient’s family history of colon cancer or personal history of cancer does not appear to affect withdrawal time. Further studies including other academic centers should be done to validate these findings.
320 Social Determinants of Health on the Choice of Colorectal Cancer Screening Among Louisiana Adults
Authors: Swaminathan Renugadevi , Morris James D.
Published: October 2019

INTRODUCTION:

Colorectal cancer (CRC) is the second leading cause of cancer in the U.S. Louisiana has the third highest mortality rate of CRC. The CRC related morbidity and mortality rates are declining recently with screening by early detection and treatment. The common CRC screening options are FIT, FOBT, sigmoidoscopy, and colonoscopy. Of all the available options colonoscopy allows examination of the entire colon and it offers therapeutic benefit. Studies have shown that various demographic factors can affect the choice of CRC screening. The purpose of the study is to identify the impact of social determinants of health on the choice of CRC screening among Louisiana adults.

METHODS:

We performed a retrospective cohort study using the Behavioral Risk Factor Surveillance System(BRFSS) database from 2016, limiting our evaluation to Louisiana adults of age 50-75 years who had CRC screening (n = 1306). Demographics were categorized and examined among participants who had CRC screening with colonoscopy versus stool-based test. These factors include age (50-64 and 65-75), gender (male and female), ethnicity (Caucasian, African American, Hispanics and Others), education (attended/graduated College and attended/graduated High School), income (≥$50,000 and <$50,000) and health insurance coverage (Medicare and Private). Univariate logistic regression analysis evaluated the association of the demographic factors and the choice of CRC screening. Data analysis was performed using SAS® software.

RESULTS:

The odds of having colonoscopy when compared to a stool-based test was 1.94 times higher (95% CI 1.46 – 2.58) among participants of age 50-64 years compared to age 65-75 years. The participants who have a college education has 1.36 times higher odds (95% CI 1.03 – 1.80) of having colonoscopy compared to participants who did not go to college. The odds of choosing colonoscopy was 2.05 times higher (95% CI 1.55 – 2.71) among participants who have private health insurance compared to Medicare insurance, and 2.04 times higher (95% CI 1.53 – 2.72) among participants with an annual household income of $50,000 or greater compared to participants with income of less than $50,000. Gender and ethnicity have no association with the choice of CRC screening in our cohort.

CONCLUSION:

The social determinants of health that are associated with the greater odds of having colonoscopy compared to the stool-based test include age, income, education, and health insurance in our state-wide cohort.
322 Artificial Intelligence-Aided Colonoscopy: A Retrospective Analysis of Effect on Procedure Time
Authors: Roccato Mary Kathryn , Dao Tyler , Berry Rani , Karnes William , Rael Efren
Published: October 2019

INTRODUCTION:

Artificial intelligence (AI) for colonoscopy promises to assist polyp discovery, in situ diagnosis and automated procedure documentation. Widespread adoption will require ease of use and value, defined as: improved quality at reduced cost. The aim of this study is to determine if use of AI lengthens procedure time.

METHODS:

Data was collected prospectively at a single academic medical center at point-of-care using UCICQD, inclusive of all GIQuIC data and locations, sizes and pathology of all polyps stripped of all PHI and IRB-exempt. AI-assisted colonoscopies (AC) and conventional colonoscopy (CC) were compared for differences in means of total procedure time (TT).

RESULTS:

A total of 8988 CCs and 166 ACs were analyzed without exclusions. Insertion time to cecum averaged 13.0 minutes in CC (95% CI 12.6-13.3 minutes) vs 11.4 minutes (95% CI 10.3-12.4 minutes) in AC, P = 0.007. Withdrawal time averaged 18.2 minutes in CC (95% CI 17.9-18.4 minutes) vs 18.1 minutes (95% CI 16.0-20.1 minutes) in AC, P = 0.03. Total procedure time averaged 31.1 minutes in CC (95% CI 30.7-31.6 minutes) vs 29.4 minutes (95% CI 27.2-31.7 minutes) in AC, P = 0.79.

CONCLUSION:

While excitement is high for AI assistance during colonoscopy, concerns about potential negative effects on efficiency in high volume ASC's remain. This retrospective comparison of AC and CC demonstrates that the use of AI is not associated with increased procedure time.
324 Anesthesia Assistance in Screening Colonoscopy and Adenoma Detection Rate Among Trainees
Authors: Krigel Anna , Patel Anish , Kaplan Jeremy , Kong Xiao-Fei , Garcia-Carasquillo Reuben , Lebwohl Benjamin , Krishnareddy Suneeta
Published: October 2019

INTRODUCTION:

The use of anesthesia assistance (AA) with propofol sedation for screening colonoscopy has been increasing over the past decade, raising concerns about possibly increased complication rates without a proven improvement in colonoscopy quality indicators like adenoma detection rate (ADR). The effect of AA on ADR has not been extensively studied in trainees learning colonoscopy. We aimed to determine if type of sedation used during screening colonoscopy affects trainee ADR.

METHODS:

Using the endoscopy databases of two hospitals in our medical center, we identified all screening colonoscopies performed by 15 trainees from July 2014 through June 2018, including all screening examinations where the cecum was reached. We recorded patient demographics, trainee ADR, year of training, mean withdrawal time, bowel preparation quality, supervising attending ADR (excluding procedures with trainees), and type of sedation used for each procedure. Multivariable analysis was used to determine factors independently associated with trainee ADR.

RESULTS:

We identified 1,420 unique patients who underwent screening colonoscopy by a trainee during the defined time period meeting the inclusion criteria. Of these, 459 (32.3%) were performed with AA. Overall trainee ADR was 39.6%, with ADR increasing from 35.0% in year one of training to 42.8% in year three (P = 0.047). ADR for cases with AA was 37.9% while ADR for conscious sedation (CS) cases was 32.0% (P = 0.374). Despite this absolute difference of 5.9%, the use of AA was not associated with finding an adenoma on colonoscopy on multivariable analysis when controlling for all covariables (OR 0.86; 95% CI 0.67-1.10). Factors independently associated with trainee ADR included male gender (OR 1.66; 95% CI 1.33, 2.08), patient age (OR for patients ages 70-79 compared to ages 50-59: 1.84 [1.33, 2.52]), optimal bowel preparation quality (OR 1.58; 95% CI 1.07, 2.33), and supervising attending ADR (OR for attending ADR 30-39% and ≥40% compared to attending ADR < 20%: 4.22 [1.58, 11.027] and 3.67 [1.37, 9.87], respectively).

CONCLUSION:

Despite providing the ability to more comfortably sedate patients for screening colonoscopy, potentially providing the increased time required to improve trainee ADR, we found that the use of AA for screening colonoscopy did not affect trainee ADR. These results on trainee ADR and sedation type suggest that the overall lack of association between AA use and colonoscopy quality indicators is applicable to the trainee setting.
326 Implementation of Patient Navigators Reveals Barriers to and Increases Uptake of Colonoscopy After Positive Fecal Immunochemical Tests
Authors: Tran Vivy , Corona Edgar , Yang Liu , Boceck Jennifer , Lopez Antonio , Dermenchyan Anna , Roh Lily , Meshkat Sarah , Gomez Daniel , Han Maria , Croymans Daniel , Huang Marcela Zhou , May Folasade
Published: October 2019

INTRODUCTION:

Patients with abnormal fecal immunochemical test (FIT) results require diagnostic colonoscopy to reduce mortality from colorectal cancer (CRC). Barriers to follow-up are multifactorial and include patient-, provider-, and system-level factors. Patient navigators (PN) can be effective in improving follow-up by helping patients overcome these barriers. We aimed to assess the impact of PN on clinical care processes required for colonoscopy completion after positive FIT in a large, academic health care system.

METHODS:

We included all UCLA Health outpatients with an abnormal FIT result between 12/1/2016 and 12/01/2018 without documentation of a colonoscopy. Two PN underwent training with a gastroenterologist and quality officer. For all FIT positive patients, PN 1) conducted a chart review to confirm lack of colonoscopy completion, 2) contacted the primary care provider when there was an inappropriate reason for lack of colonoscopy, and 3) called patients to review FIT results, encourage follow-up, address barriers, and schedule a colonoscopy. Intervention endpoints were 1) colonoscopy completion, 2) patient refusal, 3) provider felt colonoscopy inappropriate, and 4) patient left the health system. We determined the proportion of patients that reached each endpoint at 4 months and reasons providers reported that colonoscopy was not indicated after positive FIT.

RESULTS:

Our cohort included 131 subjects. Mean age was 62.8 (±7.3), 50.3% were female, and 49.6% were White. In all, 87 (66.4%) reached an intervention endpoint at 4 months (Figure 1). Twenty-seven (31.0%) received diagnostic follow-up: 12 (44.5%) had colonoscopy, 3 (11.1%) had CT colonography, 1 (3.7%) had sigmoidoscopy, and 11 (40.7%) reported colonoscopies outside the health system. Primary care providers that were contacted by the PN often did not feel colonoscopy was indicated (25, 19.1%), and many (10, 40.0%) cited recent colonoscopy (Table 1). There were 19 (21.8%) patients that refused follow-up colonoscopy.

CONCLUSION:

PN was effective in increasing diagnostic follow-up after positive FIT and revealed persistent challenges to appropriate resolution of positive FIT. Future efforts will improve provider education about appropriate use of FIT and evaluate if PN can improve timely diagnostic follow-up when tracking positive FIT patients prospectively.
335 Increased Frequency of Colonoscopy Complications in Patients With Positive Multitarget Stool DNA Testing for Colorectal Cancer Screening
Authors: Sadiq Omar , Alimirah Maryam , Naffouj Sandra , Askar Firas , Siddiqui Yousuf , Jinjuvadia Raxitkumar
Published: October 2019

INTRODUCTION:

Large scale studies have demonstrated post-colonoscopy perforation rates to range between 0.005-0.085% with bleeding rates of roughly 0.3%. Standard of care currently requires patients undergo follow up colonoscopies after positive multitarget stool DNA testing to identify any culprit lesions. We hypothesize that endoscopists performing these procedures expose patients to higher risks of complications to locate culprit lesions due to positive multitarget stool DNA testing.

METHODS:

All patients with positive Multitarget Stool DNA Testing for Colorectal-Cancer Screening between January 1st, 2016 and October 30th, 2018 were reviewed. A total of 589 charts were selected for analysis of demographics, post-colonoscopy bleeding, perforation and emergency room visits within 14 days post procedure. Endoscopic findings were also collected. Advanced adenomas were defined as tubular or serrated adenomas with size greater than 1 cm or tubulovillous adenomas of any size.

RESULTS:

A total of 589 patients had positive multitarget stool DNA testing, of which, 427 had undergone subsequent colonoscopies. Sample characteristics showed mean age of 68.6, 60% female, mean BMI 30.2. 58% smoking history and 16% diabetics (mean A1c of 7.4). In addition to 7 diagnosed adenocarcinomas, 221 patients were noted to have an advanced adenoma. Immediate complications were noted primarily in patients with advanced adenomas, with 0.9% of patients demonstrating bleeding compared to 0.5% of patients without any culprit lesions. Overall frequency of bleeding complications was 0.7%. One patient had bowel perforation (0.2%). 10 patients (2.3%) went to the ER within 14 days of colonoscopy. 2.1% of patients with normal colonoscopies presented to the ER within 14 days of their colonoscopies.

CONCLUSION:

Currently, screening colonoscopy is the gold standard for diagnosing malignant and premalignant lesions. Noninvasive forms of screening exist to increase adherence to screening and minimize risk, however we have found that colonoscopies performed to assess positive test results also increase the risk of adverse events in these patients, even in patients with normal endoscopic findings. We found a rate of 2.3% ER visits within 14 days of colonoscopy compared to 0.76% in literature. Our rates of bleeding and perforation were also higher, however our low N limits extensive analysis of these findings.
336 Bowel Preparation for Patients With History of Inadequate Cleansing With 4L PEG-3350 (Golytely) Split-Prep: The 6 Liter PEG-3350 (Golytely®) Split-Prep
Authors: Tama Maher , Kathi Pradeep R. , Ravi Anand K. , Salim Madiha , Lilley Kirthi , Antaki Fadi , Schoenfeld Philip
Published: October 2019

INTRODUCTION:

No prior prospective study has assessed the efficacy of a more intensive bowel preparation (prep) for outpatients who have already failed a 4 liter (4L) PEG-3350 (GoLYTELY®) split-prep. This study assesses efficacy and safety of a 4L-2L PEG-3350 split-prep.

METHODS:

Inclusion Criteria- (a) colonoscopy for average-risk screening, FIT+, family history-CRC, or colon polyp surveillance; (b) history of inadequate prep with 4L GoLYTELY® or >2 risk factors for inadequate prep (daily laxative, BMI > 35, diabetes, daily tricyclic antidepressant, daily opioid). Intervention: 4L-2L PEG-3350 (GoLYTELY®) split-prep consisting of clear liquid diet (all day) and drink 4L GoLYTELY® starting at 6pm on day before procedure PLUS drink 2L of GoLYTELY® starting 5 hours before colonoscopy. Patients completed a questionnaire about demographics, adherence to prep protocol, ease of drinking prep, and adverse events. Primary Outcome: Adequate bowel prep, defined by 2-2-2 or better on Boston Bowel Preparation Scale (BBPS), among patients who failed 4L GoLYTELY® split-prep. Secondary Outcome: (a) Adequate bowel prep among patients who failed 4l GoLYTELY® pm-only prep or any lower volume prep; and, (b) patients with > 2 risk factors for inadequate prep; Tertiary Outcome: Frequency of guideline-adherent recommendations for surveillance colonoscopy among patients with adequate prep and patients with inadequate prep (i.e., repeat colonoscopy in ≤ 1 year). Data Analysis: The intention-to-treat population included all patients who underwent colonoscopy and the per-protocol population only included patients who drank ≥ 75% of prep.

RESULTS:

204 consecutive patients met inclusion criteria and presented for colonoscopy. Demographic data: mean age = 65 (40-79 years); M: F = 189:15. Frequency of adequate prep in each group is presented in Table 1. Frequency of guideline-adherent recommendations was 89.6% in patients with adequate prep and was 96.6% among patients with inadequate prep. Three serious adverse events occurred: vomiting with ED visit, asymptomatic bradycardia (HR = 30-40) and spontaneous paroxysmal atrial fibrillation. Based on questionnaires, 28% stopped to pass stool during trip to endoscopy center and 80% would be willing to repeat the prep in the future.

CONCLUSION:

The 6L GoLYTELY® split-prep achieves adequate prep in > 85% of patients who have already failed a 4l GoLYTELY® split-prep.
337 High Rates of Young-Onset Colorectal Cancer Incidence and Mortality in an Urban Tertiary Referral Center: A Case for Earlier Screening Colonoscopy
Authors: Henry George , Smallfield George B. , Mangray Sasha
Published: October 2019

INTRODUCTION:

The Multi Society Task Force for Prevention of Colorectal Cancer recommends initiating average risk screening for patients at age 45 in African Americans (AA) and at age 50 in all others. In the US, Colorectal Cancer (CRC) incidence and mortality has been increasing at a significant rate each year in patients younger than 50 years. This recent trend has not been insufficiently explored to inform modeling of CRC screening among asymptomatic average-risk patients who are younger than 50 years. Further study of the benefits and harms of screening in persons younger than 50 years is warranted.

METHODS:

We performed a retrospective analysis using TriNetX, a global federated health research network providing access to statistics on electronic medical records (diagnoses, procedures, medications, laboratory values, genomic information). Our analysis included all patients diagnosed with CRC from the period 2010 to 2019. We then excluded patients with a diagnosis of Inflammatory Bowel Disease and Hereditary Cancer Syndromes to identify only spontaneous CRC. We calculated the incidence per 100,000 persons of CRC in 5-year age groups between 20 and 59 years. We also performed Kaplan-Meier survival analysis in these groups.

RESULTS:

Between 2010 and 2019, there were 970 new cases of CRC in persons age 20 -59. The population consisted of 52% males, 48% females, race distribution: 54% Whites, 39% Blacks, 2% Asians, Other 5%. Mean age at diagnosis was 59. The incidence rates per 100 000 population were similar for the 40-45 age group and 45-49 age group (Figure 1). Patients aged less than 50 accounted for 33.7 percent of new CRC cases (Figure 2). Kaplan- Meier 5-year survival analysis showed lower rates of survival for patients aged 40-45 (47.1%) and 45-49 (43.9%), compared with patients aged 50-54 (54.8%) (Figure 3)

CONCLUSION:

Our study demonstrates high rates of CRC in patients less than 50 and this study may give further merit to the consideration of earlier screening in asymptomatic average risk patients. There is a definite need for large scale epidemiological studies to further evaluate this worrisome trend.
341 Association of Fellow Training Year and Sedative Use During Screening Colonoscopy
Authors: Shine Amal , Atassi Hadi , Liu Nanlong , Thomas Chandler , Furmanek Stephen , Liu David , McClain Craig
Published: October 2019

INTRODUCTION:

Colonoscopy has become a key tool for colorectal cancer screening, but like any procedure, it is not without risk. The procedure can be done under conscious sedation. Risks of sedation include hypotension and hypoxia. Therefore, endoscopists aim to minimize the amount of sedation needed to reduce risk but keep the patient comfortable. At centers with gastroenterology fellowships, screening colonoscopies are performed by fellows in training. We sought to examine the relationship between the fellow’s level of training and the amount of sedation used during colonoscopy.

METHODS:

Data were collected on 640 patients undergoing screening colonoscopies at Louisville Veterans Affairs Medical Center, and 509 were excluded based on specific exclusion criteria, including known colonic disorders (e.g., IBD history, pre-existing malignancies) and lack of documented sedative use. Of 131 patients included, median age was 62, 86% patients were male, and 73% were white. Data were gathered by retrospective chart review of the fellow’s level of training (1st, 2nd, 3rdyear) at the time of colonoscopy and dosages of Midazolam, Fentanyl and Diphenhydramine used. Multiple Regression Model was used for analysis with corresponding P-values calculated. Statistical significance was set at P < 0.05. The total number of polyps detected was controlled for as this was thought to affect the duration of colonoscopy.

RESULTS:

Our study indicates that, although a fellow earlier into his/her training was hypothesized to be associated with increased sedative use, the association was not statistically significant for any of the three sedatives in this study. This is most likely due to the fact that there was little variability between the doses of each sedative and the small sample size.

CONCLUSION:

Data in literature is limited regarding the association between a fellow’s level of training and the amount of sedation used. Factors affecting sedation use include the experience of the endoscopist and possibly cecal intubation time. Larger studies are needed to further explore these findings, which may have future clinical implications regarding the introduction of specific guidelines for sedative use based on a fellow’s level of training.
343 Bilateral Metal Stent ERCP Through an Endoscopic Ultrasound-Guided Gastrojejunal Lumen-Apposing Stent
Authors: Hashimoto Rintaro , El Hage Chehade Nabil , Samarasena Jason
Published: October 2019

INTRODUCTION:

ERCP in patients with altered anatomy due to malignant obstruction is consistently a challenge. EUS-guided gastroenterostomy using lumen-apposing metal stents (LAMS) have been shown to be effective and safe for the relief of gastric and intestinal obstruction. We report a successful case of ERCP performed through a recently placed EUS-guided Gastroenterostomy in a patient with both malignant biliary and gastric outlet obstruction.

CASE DESCRIPTION/METHODS:

A 64-year-old male with a history of metastatic gallbladder cancer status-post placement of an internal-external biliary drain and percutaneous cholecystostomy was admitted to our institution with nausea, vomiting, and jaundice with concern for gastric outlet obstruction and worsening biliary obstruction on CT imaging. To relieve the gastric outlet obstruction, the decision was made to perform EUS guided gastroenterostomy with a LAMS using the “double-scope method.” An ultraslim upper endoscope traversed the stricture into the second portion of the duodenum. Water filling of the intestinal lumen was achieved with this scope while a therapeutic linear echoendoscope was simultaneously passed through the mouth into the stomach and visualized the water-distended distal duodenum and proximal jejunum. EUS-guided gastroenterostomy was performed using a 15 mm electrocautery enhanced LAMS. Balloon dilation of the stent lumen up to 15 mm was performed. The patient enjoyed a regular diet that evening. On the next day, ERCP was performed. A double channel therapeutic endoscope was advanced into the duodenum through the LAMS and bilateral metal stenting of the right and left biliary systems was performed. On follow-up, patient was able to tolerate a regular diet and jaundice improved

DISCUSSION:

In this case, we successfully performed bilateral metal stent placement ERCP via EUS-guided gastroenterostomy to relieve gastric outlet obstruction and biliary obstruction. The diameter of the lumen apposing metallic stent was sufficient to insert a double-channel therapeutic scope, which facilitated bilateral metal stenting. Of note, care must be taken when performing endoscopic procedures through a newly created gastrenterostomy.

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