Society: ASGE

Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO₂ tubing, O₂ connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.

Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.

<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1^st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.

Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.

Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Background and Aim
Recently, advances have been made in image-enhanced endoscopy (IEE) technology and several methods that can be used in a clinical setting are available. Linked color imaging (LCI) is useful for surveillance endoscopy in high-risk patients; however, standard endoscopy is based on white light imaging (WLI) and IEE is not yet standard. Also, the superiority of narrow-band imaging (NBI), which was first developed, to WLI for detection of neoplastic lesions has not been clarified. The aim in this study was to verify the superiority of LCI to NBI for surveillance endoscopy using IEE.
Method
This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial and registered in the Japan Registry of Clinical Trials (jRCT1012200006). Patients aged 20–85 years with a treatment history or with follow-up of epithelial tumors of the upper gastrointestinal tract who received surveillance endoscopy were recruited. Patients were assigned in a 1:1 ratio to an NBI group and an LCI group using a computerized minimization procedure. The endoscopy systems used were the LASEREO system (FUJIFILM Co., Tokyo, Japan) for LCI and the EVIS LUCERA ELITE system (Olympus Co., Tokyo, Japan) for NBI. According to randomization, endoscopic observation was performed with primary IEE followed by WLI (primary LCI and secondary WLI or primary NBI and secondary WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the pharynx, esophagus and stomach, which was defined as the proportion of patients with tumors detected in the primary examination. The secondary endpoints included overlooked neoplastic lesions and procedure time.
Results
During the study period, a total of 372 patients in the NBI group and 378 patients in the LCI group in whom EGD was performed were analyzed. Neoplastic lesions were detected by NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). In secondary WLI, neoplastic lesions were detected in 11 patients in the NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003). There was no significant difference between the two groups in the total number of neoplasms detected. Overlooked ratios were 36.7 % in primary NBI and 4.2% in primary LCI (P = 0.007). The mean observation times for primary IEE were 209.9 s in NBI and 215.3 s in LCI (P = 0.27).
Conclusions
LCI did not show superiority to NBI for detection of neoplastic lesions in high-risk patients. However, the percentage of overlooked lesions during primary NBI was significantly higher than that during primary LCI.

Background and study aim
Endoscopic ultrasound guided through-the-needle biopsy (EUS-TTNB) has improved the diagnostic algorithm of pancreatic cystic neoplasms (PCN). However, the fragments obtained are very small and sometimes not eye-visible with the risk of loss during the preparation process.
Fluorescence Confocal Laser Microscopy (FCM) allows imaging of tissues in the fresh state, requiring minimal preparation without damage or loss of tissue.
The primary aim of this study was to assess the feasibility of the FCM with MAVIG VivaScope^® 2500M-G4 microscope on the fragment obtained from EUS TTNB. The secondary aim was to assess the concordance between the diagnosis with VivaScope^® and the standard technique.
Methods
Single centre prospective study conducted on consecutive patients with PCN who underwent EUS-TTNB at the Endoscopy Unit of Campus Bio-Medico University hospital. A 19 G needle with pre-loaded micro-forcep was used in all cases. Obtained samples were placed directly in a dedicated scaffold (Cytomatrix, UCS Diagnostics) and evaluated at FCM and classified as “Inadequate” or “Adequate”. Adequate samples were classified as serous, mucinous or other on the sole basis of the morphological characteristics of the epithelial lining.
Results
From June 2021 to September 2022, 15 patients were enrolled.
Seven (47%) PCNs were located in the body of the pancreas, while 5 (33.3%) in the head and 3 (22%) in the tail. The mean size of PCNs was 39.2±8.8 mm.
At VivaScope® evaluation, the sample was defined adequate in 14/15 (93.3%).
Among the adequate samples, 10/14 (71.4%) was defined mucinous, 2/14 (14.3%) serous cystoadenoma, 1/14 (7.1%) pseudocyst and 1 (7.1%) neuroendocrine cystic tumour.
There was a good agreement between the VivaScope^® diagnosis and the final histological diagnosis (kappa Cohen’s coefficient 1, p = 0.001).
When evaluating VivaScope^®’s diagnostic performances the Sensitivity was 100%, 95% CI 76.8%-100%, the Specificity 100%, 95% CI 2.5%-100%, PPV 100%, NPV 100% and Accuracy 100% 95% CI 78.2-100%.
Conclusion
FCM represents a new technique successfully applicable to micro-histological specimens. It provides fast information about sample adequacy and diagnosis in small specimens with good agreement with the final histology. However, a larger sample is necessary to confirm these data.

Serena Stigliano

Appearances