Society: ASGE

Introduction: Recent data suggested that cold snare EMR (C-EMR) offers equal efficacy, yet superior safety, compared with traditional hot EMR (H-EMR). We performed a systematic review and meta-analysis to assess the safety of C-EMR compared with H-EMR.

Methods: We performed a comprehensive literature search of MEDLINE (Ovid), Web of Science, Embase, Cochrane Library and CENTRAL, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) from inception to September 19, 2022. We included studies of endoscopic mucosal resection of colorectal polyps and/or polypectomy of polyps ≥10 mm and reported rates of adverse events including bleeding, perforation, and post polypectomy syndrome. The primary outcome was the adverse event rate for C-EMR vs. H-EMR for colorectal polyps ≥10mm. For comparative data, we reported odds ratios with 95% confidence intervals (CI’s). For cohort studies, we reported proportions with CI’s. We assessed publication bias by funnel plots with the classic fail-safe test. We used forest plots to report pooled effect estimates and assessed heterogeneity using I² and p-values.

Results: Our systematic review identified 1,215 unique citations, 19 of which met our inclusion criteria. In 4 comparative studies (2 randomized control trials and 2 retrospective studies), 413 patients underwent C-EMR, only two of whom suffered delayed bleeding. 35 of the 658 patients undergoing H-EMR suffered delayed bleeding. On random effect modelling, C-EMR carried a significantly lower risk of delayed bleeding compared to H-EMR (OR 0.2 [CI: 0.05 - 0.88], p=0.033, I² = 0%, Fig. 1). In the 10 cohort studies, the pooled rate of delayed bleeding was only 2% (CI: 1.3 – 3.2%), p<0.001, Fig. 2.

The rate of early bleeding was similar between both groups (OR 1.67, [CI: 0.77 - 3.6], p=0.1916, I² = 26%). On random effect modeling, the pooled rate of early bleeding for C-EMR was 1.9% (CI: 1.1% - 3.2%), p<0.001, I² = 12%.

Only one study by Rex et al. reported residual polyps. Margins were positive in 1 of 82 polyps resected by C-EMR and 4 of 65 resected by H-EMR. In the two comparative studies assessing polyp recurrence, there was a trend towards higher recurrence rates in the C-EMR cohort, but it did not reach statistical significance (OR 0.55 [CI: 0.29 - 1.03], p=0.0631, I² = 0).

There were no cases of perforation from C-EMR vs. 16 perforations from H-EMR. This difference did not reach statistical significance. (OR 0.02 [CI: 0.0 – 2.03], p=0.0995).

Conclusions: C-EMR is associated with equal efficacy compared with H-EMR, with similarly low rates of residual polyp tissue and polyp recurrence. The safety of C-EMR, however, is superior, with significantly lower rates of delayed bleeding than H-EMR. Rates of early bleeding are similar between the two methods.

Figure 1. Delayed bleeding risk for C-EMR vs H-EMR

Figure 1. Delayed bleeding risk for C-EMR vs H-EMR

Figure 2. Pooled rate of delayed bleeding from C-EMR

Figure 2. Pooled rate of delayed bleeding from C-EMR

Background:
Single center studies suggest that adenoma detection rates (ADR) vary between gastroenterologists and surgeons. The generalizability of these findings is unclear. We sought to compare ADR between gastroenterologists and surgeons in the US Veterans Health Administration national healthcare system and to examine the association of patient demographic factors with ADR.

Methods:
We identified colonoscopy procedures of all indications using CPT codes from VA national electronic health records between October 2018-September 2022. We used a previously validated text recognition algorithm to determine histology from the associated pathology reports of patients aged 45-75. We classified providers from administrative codes for surgery and gastroenterology. After excluding providers with fewer than 50 colonoscopy procedures, we calculated each provider ADR as the percentage of colonoscopies with at least one adenoma or adenocarcinoma. We compared average ADR in surgeons and gastroenterologists using a 2-tailed t-test and compared the proportion of providers with ADR <30% using a chi-square test. We also calculated provider ADR in patients with different demographics (gender, race, ethnicity, geographic location and FIT+ testing within one year of colonoscopy) and used a generalized linear model to compare the ADRs before and after adjustment for patient demographics.

Results:
We identified 669,434 colonoscopies by 1,095 unique providers. Gastroenterologists (n=906; 82.7%) conducted 88.8% (n=594,710). The patient demographics are shown in the Table. ADR of surgeons (41.4%; 95% CI [39.5, 43.4]) was significantly lower than that of gastroenterologists (53.33%; 95% CI [52.7, 54.0]), p<0.0001 both before and after adjusting for differences in patient demographics. ADRs <30% were observed in 38 of 189 (20.1%) surgeons compared to 19 of 906 (2.1%) of gastroenterologists; p<0.0001. Surgeon ADRs were distributed across proportionally lower values than gastroenterology ADRs (Figure). Within both provider groups, higher ADRs were observed in men vs. women, in whites vs. non-whites, and in patients with a prior vs. no prior FIT test positive, though surgeon ADR remained consistently lower than gastroenterologist ADR. Among the colonoscopies performed after a positive FIT test, the ADR was significantly lower for surgeons (57.3%; 95% CI [53.7, 60.9]) than gastroenterologists (65.9%; 95% CI [64.8, 67.0]), p<0.0001.

Conclusion:
In this large US national healthcare system colonoscopy cohort, surgeons had a significantly lower ADR for colonoscopy of all indications and a higher proportion of endoscopists with ADRs < 30% than gastroenterologists, irrespective of patient demographics. Our findings highlight potential opportunities for targeted quality improvement and further evaluation of colonoscopy training parameters for surgical specialties.

Table. Adenoma Detection Rates of Gastroenterologists and Surgeons by Patient Demographics

Table. Adenoma Detection Rates of Gastroenterologists and Surgeons by Patient Demographics

Figure: Distribution Histograms of Gastroenterologist and Surgeon Adenoma Detection Rates.<br /> Note: Lines represent the 2-period moving averages of number of providers within each ADR range for GIs and surgeons, respectively.

Figure: Distribution Histograms of Gastroenterologist and Surgeon Adenoma Detection Rates.
Note: Lines represent the 2-period moving averages of number of providers within each ADR range for GIs and surgeons, respectively.

Introduction:
The colorectal Straight-To-Test (STT) pathway is an important service for patients in the UK that works in tandem with the Bowel Cancer Screening Program (BCSP). This allows access to diagnostic colonoscopies within 2 weeks, aiding early detection of colorectal cancer. The indications on the STT pathway are less rigid than the BCSP and accommodate a lower cut-off for FIT at 10μg/g. Since the primary aim is colorectal cancer/polyp detection, the question arises of whether the terminal ileum (TI) needs to be routinely intubated. Incidental findings in the TI often lead to further investigations by way of biopsies, clinic appointments and imaging, increasing the cost of care without significant clinical outcomes. This study aimed to assess the benefits and costs of routine TI intubation in the STT pathway.

Methods:
The study was conducted at a University Hospital in the UK. Patients who had a colonoscopy under the STT pathway between January to November 2021 were included. Incomplete colonoscopies and previous surgical resections were excluded. One-year follow up review was conducted by retrospective data collection from electronic patient records and UniSoft endoscopy reporting tool on MS Excel. Letters by the colorectal team were not considered as resource utilisation. Costs of subsequent appointments, scans (CTs, MRIs) and/or Video Capsule Endoscopy were approximated using NHS Tariff report adjusting for Market Forces Factor.

Results:
After applying the exclusion criteria, 1410 complete colonoscopies were analysed. Of the 709 (50.3%) patients who had their TI intubated, 10 (0.7%) patients had a clinically significant diagnosis affecting the TI in the next 12 months (Figure 1). In the cohort who did not have their TI intubated, 3 (0.2%) patients had a TI pathology diagnosed. Fifty-six patients (mean age 53 years; M:F=34:22) were noted to have macroscopic TI findings, of which 51 had a biopsy. A total of 10 patients had a formal pathological diagnosis (6 Crohn’s Disease, 4 non-specific Ileitis) affecting the TI within the following year. The remaining 49 patients with macroscopic findings without a diagnosis had further follow-up amounting to roughly £11,418 (Figure 2).

Conclusion:
This study shows that the diagnostic yield from TI biopsies in otherwise normal colon is low (0.7%) for any clinically significant TI diagnoses within 12 months. Notwithstanding the high costs associated with evaluating incidental findings that are insignificant, there is an unquantifiable delay in procedure time with multiple attempts at TI intubation. This extra time could be spent on careful inspection to improve polyp and cancer detection. There was a negligible (0.2%) chance of missing a TI pathology if not intubated. We propose that patients on the STT pathway do not require routine TI intubation, thus making this service more efficient and cost effective.

Background:
Epidemiologic data highlight the suboptimal impact of screening and surveillance in Barrett’s esophagus (BE). PEEC and PEEN, similar to post-colonoscopy colorectal cancer, undermines the effectiveness of these practices. Using a population-based cohort study, we aimed to conduct a time trend analysis on PEEC and PEEN rates and neoplasia detection rate (NDR) among newly-diagnosed BE patients.

Methods:
This study was conducted in Denmark, Finland and Sweden from 2006-2020. We included data from the national patient, cancer, causes of death and prescribed drug registries. Patients with newly diagnosed BE were included and excluded patients with prior upper GI cancer, or BE endoscopic therapy. Demographics, country, year of diagnosis, smoking, Charlson comorbidity index score, medications, and hospital volume were collected. PEEC and PEEN were defined as EAC or HGD/EAC, respectively, diagnosed 30-365 days from the index endoscopy that diagnosed BE. NDR was defined as HGD/EAC diagnosed from 0-29 days and incident HGD/EAC was diagnosed >365 days. Patients were followed until diagnosis of HGD/EAC, death or end of study period. Incidence rates (IR)/100,000 person-years (pyrs) for the entire study cohort and for 3 calendar periods: 2006-2010, 2011-2015 and 2016-2020 and incidence rate ratios (IRR) with 95% CI with Poisson regression were calculated. A graphical representation of the predicted probability of EAC by month in the first year after entry is reported and for the 3 calendar periods.

Results:
20,588 newly diagnosed BE patients (mean age 64.6 years, 67% men, Sweden 64.6%, Denmark 14.8% and Finland 20.6%) were included. 279 patients were diagnosed with EAC: NDR (41, 14.6%), PEEC (65, 23.2%) and incident EAC (173, 62%). Overall IRs for NDR, PEEC and incident EAC were 2521 (95% CI 1857-3425), 369 (289-470) and 199 (172-231) /100,000 pyrs. The IRs/100,000 pyrs in the 3 calendar periods for NDR and PEEC were: 2006-2010: 3151 and 194, 2011-2015: 2633 and 271 and 2016-2020: 2080 and 590, respectively (Table 1). Diagnoses of HGD were only available in Swedish database, where 279 patients were diagnosed with HGD/EAC: NDR (41, 14.6%), PEEN (48, 17.2%) and incident HGD/EAC (190, 68,1%). Time-trends in IRs for NDR and PEEN in Sweden were: 2006-2010: 4587 and 260; 2011-2015: 3752 and 333 and 2016-2020: 3501 and 669, respectively (Table). Figure highlights the probability of EAC in the first year after index endoscopy overall and based on age, sex and year of endoscopy. Increasing age and male sex were significant predictors for NDR and PEEC.

Conclusions:
Despite improvements in endoscopic technology, this study showed a decline in NDR with a concurrent 2-3 time increase in PEEC and PEEN rates. Future studies should assess the impact of interventions (education, quality metrics and artificial intelligence) in improving NDR and reducing PEEC/PEEN in practice.

<b>Table: Incidence rates and incidence rate ratios for NDR, PEEC/PEEN and incident HGD/EAC – overall and based on the three calendar periods</b>

Table: Incidence rates and incidence rate ratios for NDR, PEEC/PEEN and incident HGD/EAC – overall and based on the three calendar periods

<b>Figure 1: Probability of PEEC in the overall cohort and based on sex, age and year of diagnosis of Barrett’s esophagus</b>

Figure 1: Probability of PEEC in the overall cohort and based on sex, age and year of diagnosis of Barrett’s esophagus

Introduction
Potentially missed or post endoscopy upper gastrointestinal cancer (PEUGIC) is the cancer diagnosed following endoscopy that did not detect cancer in the previous 3 years. We have examined PEUGIC incidence among providers in England and associated factors.
Methods
Using linked national cancer and endoscopy coding databases, patients diagnosed with UGI cancer between 2009 and 2018 were studied. Endoscopies 6-36 months before UGI cancer diagnosis were defined as false negative endoscopies (FN). Endoscopies within 6 months of UGI cancer diagnosis were true positive endoscopies (TP). The PEUGIC rate was calculated as the proportion of FN out of the sum of TP and FN endoscopies. Multivariable regression analysis examined the factors associated with PEUGIC. Funnel plots with control limits representing two and three standard deviations from mean were produced to assess variations between providers.
Results
106,728 endoscopies in 98,801 patients included. The overall unadjusted PEUGIC rate was 8.5(95% CI 8.3-8.7)%. The PEUGIC rate in patients with Barrett’s oesophagus was 21(20.3-22.0)%. PEUGIC rates were higher in upper third compared to lower third oesophageal cancers (10.6% vs 7.4%, p<0.001) and distal compared to proximal stomach cancers (7.6% vs 6.9%, p=0.04). The PEUGIC rate was higher for UGI cancer diagnosed at earlier clinical stage I compared to stage IV (18.1 vs 5.5% p<0.001).
Factors associated with PEUGIC included: female (Odds Ratio 1.29 , 95% CI 1.23-1.36); younger age (age quintile ≤60, OR 2.04(1.88-2.17), compared to >80); increasing comorbidities (Charlson score >4, OR 5.06(4.45-5.76)); diagnosis route (emergency presentation OR 2.37(2.19-2.56) and routine pathway OR 2.80(2.62-3.00), compared to urgent outpatient); previous diagnosis of oesophageal ulcer (OR 3.13(2.95-3.32)), Barrett’s oesophagus (OR 3.06(2.86-3.26)), oesophageal stricture (OR 1.32(1.23-1.41)), gastric ulcer (OR 1.52(1.42-1.63)) and gastric atrophy (OR 2.27(1.88-2.73)); and histological type (squamous cell cancers OR 1.52(1.41-1.63), compared to adenocarcinomas). National endoscopy accreditation (Joint advisory group on GI endoscopy (JAG)) was also associated with PEUGIC; providers assessed but failed JAG accreditation (OR 1.10 (1.01-1.19)) and providers never assessed (OR 1.24(1.04-1.47)) had higher PEUGIC rates.
The adjusted PEUGIC rates varied from 5.1% to 13.0% among endoscopy providers (Figure 1).
Conclusion:
There is over twofold variation in PEUGIC rates among endoscopy providers in England suggesting important differences in endoscopy quality and decision making during and after endoscopy among providers. PEUGIC rate were higher among younger, females, more comorbid, those with previous high risk endoscopy findings and squamous cell carcinomas. National provider accreditation was associated with lower PEUGIC rates.

Nigel Trudgill

Appearances