Digestive Disease Week (DDW 2012)

SAN DIEGO – Patients with Helicobacter pylori infection face a significantly increased risk for developing colonic neoplasms, according to what is believed to be the largest investigation of the association.

Several studies have suggested that H. pylori infection is a risk factor for colonic neoplasms, but all of them involved relatively small case populations, Dr. Amnon Sonnenberg explained at the annual Digestive Disease Week.

Photo courtesy nddic.nih.gov

Dr. Sonnenberg, a gastroenterologist with the Portland (Ore.) VA Medical Center, investigated the relationship between H. pylori infection and the presence of colonic neoplasms in 156,269 patients who had undergone both a colonoscopy and an esophagogastroduodenoscopy. Surgical pathology samples from all the patients were stored in an electronic database at the Miraca Research Institute, a specialized gastrointestinal lab that serves private outpatient endoscopy centers throughout the United States. More than 1,500 gastroenterologists contributed to the database between January 2008 and December 2011.

Patients were an average age of 58 years, and 59% were female. Among the total, 16,759 (11%) had H. pylori gastritis on immunochemistry. The prevalence of H. pylori gastritis was 9% in patients without polyps, 11% in patients with hyperplastic polyps, 12% in patients with adenoma, 14% in patients with advanced adenoma, 15% in patients with villous adenoma or polyps with high-grade dysplasia, and 18% in patients with colonic adenocarcinoma.

There was a slight trend for the prevalence of H. pylori to rise with the increasing number, as well as the size, of adenomatous polyps. The prevalence of H. pylori was similar for all colon sites.

Significant associations also were noted between the development of colonic adenoma and the following other types of gastric histopathology: intestinal metaplasia, gastric adenoma, gastric cancer, and gastric lymphoma. Similar but even more significant associations were seen between advanced adenoma and these types of gastric histopathology.

Multivariate logistic regression confirmed that the development of H. pylori gastritis was associated with advanced age, male gender, hyperplastic polyps, adenoma, villous adenoma or high-grade dysplasia, and adenocarcinoma.

"H. pylori gastritis confers an increased risk for colonic neoplasm," concluded Dr. Sonnenberg, who is also professor of medicine in the division of gastroenterology and hepatology at Oregon Health and Science University.

"The risk applies to all types of colonic neoplasms and appears to increase with advancing stage of the neoplasm from hyperplastic and adenomatous polyps to tubulovillous adenoma, adenoma with high-grade dysplasia, and adenocarcinoma. Such risk is not limited to chronic active gastritis but is found in other types of gastric histopathology related to H. pylori, such as gastric intestinal metaplasia, gastric adenoma, gastric lymphoma, and gastric cancer," he said.

Long-term infection with H. pylori "may be related to elevated gastrin levels that may act as a growth factor," he speculated.

Dr. Sonnenberg disclosed having received a research grant from Takeda Pharmaceutical Company. No support was received for this study.

SAN DIEGO – Patients with Helicobacter pylori infection face a significantly increased risk for developing colonic neoplasms, according to what is believed to be the largest investigation of the association.

Several studies have suggested that H. pylori infection is a risk factor for colonic neoplasms, but all of them involved relatively small case populations, Dr. Amnon Sonnenberg explained at the annual Digestive Disease Week.

Photo courtesy nddic.nih.gov

Dr. Sonnenberg, a gastroenterologist with the Portland (Ore.) VA Medical Center, investigated the relationship between H. pylori infection and the presence of colonic neoplasms in 156,269 patients who had undergone both a colonoscopy and an esophagogastroduodenoscopy. Surgical pathology samples from all the patients were stored in an electronic database at the Miraca Research Institute, a specialized gastrointestinal lab that serves private outpatient endoscopy centers throughout the United States. More than 1,500 gastroenterologists contributed to the database between January 2008 and December 2011.

Patients were an average age of 58 years, and 59% were female. Among the total, 16,759 (11%) had H. pylori gastritis on immunochemistry. The prevalence of H. pylori gastritis was 9% in patients without polyps, 11% in patients with hyperplastic polyps, 12% in patients with adenoma, 14% in patients with advanced adenoma, 15% in patients with villous adenoma or polyps with high-grade dysplasia, and 18% in patients with colonic adenocarcinoma.

There was a slight trend for the prevalence of H. pylori to rise with the increasing number, as well as the size, of adenomatous polyps. The prevalence of H. pylori was similar for all colon sites.

Significant associations also were noted between the development of colonic adenoma and the following other types of gastric histopathology: intestinal metaplasia, gastric adenoma, gastric cancer, and gastric lymphoma. Similar but even more significant associations were seen between advanced adenoma and these types of gastric histopathology.

Multivariate logistic regression confirmed that the development of H. pylori gastritis was associated with advanced age, male gender, hyperplastic polyps, adenoma, villous adenoma or high-grade dysplasia, and adenocarcinoma.

"H. pylori gastritis confers an increased risk for colonic neoplasm," concluded Dr. Sonnenberg, who is also professor of medicine in the division of gastroenterology and hepatology at Oregon Health and Science University.

"The risk applies to all types of colonic neoplasms and appears to increase with advancing stage of the neoplasm from hyperplastic and adenomatous polyps to tubulovillous adenoma, adenoma with high-grade dysplasia, and adenocarcinoma. Such risk is not limited to chronic active gastritis but is found in other types of gastric histopathology related to H. pylori, such as gastric intestinal metaplasia, gastric adenoma, gastric lymphoma, and gastric cancer," he said.

Long-term infection with H. pylori "may be related to elevated gastrin levels that may act as a growth factor," he speculated.

Dr. Sonnenberg disclosed having received a research grant from Takeda Pharmaceutical Company. No support was received for this study.

SAN DIEGO – Patients with Helicobacter pylori infection face a significantly increased risk for developing colonic neoplasms, according to what is believed to be the largest investigation of the association.

Several studies have suggested that H. pylori infection is a risk factor for colonic neoplasms, but all of them involved relatively small case populations, Dr. Amnon Sonnenberg explained at the annual Digestive Disease Week.

Photo courtesy nddic.nih.gov

Dr. Sonnenberg, a gastroenterologist with the Portland (Ore.) VA Medical Center, investigated the relationship between H. pylori infection and the presence of colonic neoplasms in 156,269 patients who had undergone both a colonoscopy and an esophagogastroduodenoscopy. Surgical pathology samples from all the patients were stored in an electronic database at the Miraca Research Institute, a specialized gastrointestinal lab that serves private outpatient endoscopy centers throughout the United States. More than 1,500 gastroenterologists contributed to the database between January 2008 and December 2011.

Patients were an average age of 58 years, and 59% were female. Among the total, 16,759 (11%) had H. pylori gastritis on immunochemistry. The prevalence of H. pylori gastritis was 9% in patients without polyps, 11% in patients with hyperplastic polyps, 12% in patients with adenoma, 14% in patients with advanced adenoma, 15% in patients with villous adenoma or polyps with high-grade dysplasia, and 18% in patients with colonic adenocarcinoma.

There was a slight trend for the prevalence of H. pylori to rise with the increasing number, as well as the size, of adenomatous polyps. The prevalence of H. pylori was similar for all colon sites.

Significant associations also were noted between the development of colonic adenoma and the following other types of gastric histopathology: intestinal metaplasia, gastric adenoma, gastric cancer, and gastric lymphoma. Similar but even more significant associations were seen between advanced adenoma and these types of gastric histopathology.

Multivariate logistic regression confirmed that the development of H. pylori gastritis was associated with advanced age, male gender, hyperplastic polyps, adenoma, villous adenoma or high-grade dysplasia, and adenocarcinoma.

"H. pylori gastritis confers an increased risk for colonic neoplasm," concluded Dr. Sonnenberg, who is also professor of medicine in the division of gastroenterology and hepatology at Oregon Health and Science University.

"The risk applies to all types of colonic neoplasms and appears to increase with advancing stage of the neoplasm from hyperplastic and adenomatous polyps to tubulovillous adenoma, adenoma with high-grade dysplasia, and adenocarcinoma. Such risk is not limited to chronic active gastritis but is found in other types of gastric histopathology related to H. pylori, such as gastric intestinal metaplasia, gastric adenoma, gastric lymphoma, and gastric cancer," he said.

Long-term infection with H. pylori "may be related to elevated gastrin levels that may act as a growth factor," he speculated.

Dr. Sonnenberg disclosed having received a research grant from Takeda Pharmaceutical Company. No support was received for this study.

SAN DIEGO – Radiofrequency ablation was found to be safe and effective in treating Barrett’s esophagus patients, whether or not they had undergone a prior fundoplication, based on results from a multicenter registry study.

"Gastroesophageal reflux causes esophageal mucosal injury and inflammation that may impair healing and squamous re-epithelialization after treatment of Barrett’s esophagus [BE] with radiofrequency ablation [RFA]," Dr. Nicholas J. Shaheen said at the annual Digestive Disease Week.

Photo courtesy Dr. Nicholas J. Shaheen

"It is unclear if fundoplication surgery, as a mechanical barrier to all reflux, improves treatment outcomes of RFA for BE. Similarly, some have postulated that change in the conformation of the hiatus with surgery might make ablation problematic."

Dr. Shaheen, director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina, Chapel Hill, and his associates conducted the largest study of its kind, he said. They evaluated records from the RFA Patient Registry to assess the relationship between prior fundoplication and both efficacy and safety outcomes in patients with BE who were treated with RFA.

The registry comprises 113 community-based and 35 academic-affiliated medical institutions in the United States. "About 75% of these institutions are private practices, so this is an interesting snapshot of RFA as it’s practiced outside of tertiary care centers," Dr. Shaheen said.

All study patients had BE confirmed by endoscopy and histology, and had undergone treatment with RFA. Enrollment commenced in July 2007 and ended in July 2011. Data were gleaned from standard case report forms and included demographics; relevant medical history; histologic grade prior to treatment; endoscopic findings; dates and total number of RFA treatment sessions; and ablation outcomes and complications.

"The vast amount of data is prospective, but less than 15% is retrospective," Dr. Shaheen said. "This is a registry study, so we could not mandate treatment, but a treatment protocol was suggested." Twice-daily use of proton pump inhibitors (PPIs) was recommended to everyone in the study, including those post fundoplication.

The mean age of patients was 61 years, and the majority were white. The mean pretreatment length of BE was about 4 cm, and patients received an average of 2.5 treatments with RFA. "Importantly, in this registry, about half of the patients had nondysplastic disease," Dr. Shaheen said. "Also, roughly 20% in each group had low- and high-grade dysplasia."

Dr. Shaheen reported results from the safety cohort, which included 5,537 patients who received RFA, and results from the efficacy cohort, which included 2,466 patients with biopsies performed 12 months after enrollment. Safety outcomes included perforation, stricture that required dilation, bleeding that required hospitalization or transfusion, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia and dysplasia.

Among patients in the safety cohort, 301 had a prior fundoplication, whereas 5,236 had received medical therapy only. Patients in the fundoplication group had a somewhat lower mean age than those in the medical therapy group (59 vs. 62 years, P = .0002), and were slightly less likely to be African American (0.3% vs. 1.6%, P = .03) or Hispanic (0.7% vs. 2.6%, P = .03). In the fundoplication group, the length of BE was greater (5.0 cm vs. 4.1 cm, P less than .0001), and the prevalence of nondysplastic BE was higher (53% vs. 49%, P = .05).

In addition, fewer patients in the fundoplication group were taking twice-daily PPIs compared with those in the medical therapy group (82% vs. 95%, P less than .001). There were no significant between-group differences in the rates of bleeding, hospitalization, or stricture.

Among patients in the efficacy cohort, 136 had a prior fundoplication and 2,330 had received medical therapy only. The fundoplication patients were slightly younger than the medical therapy patients (59 vs. 62 years, P = .004), had a somewhat greater length of BE (5.0 cm vs. 4.3 cm, P = .009), and were less likely to be taking twice-daily PPIs (75% vs. 93%, P less than .001).

Rates of complete eradication of intestinal metaplasia were 71% in the fundoplication group vs. 73% in the medical therapy group, a nonsignificant difference, while the rate of complete eradication of dysplasia was identical in both groups at 87%.

Among patients who had nondysplastic BE, 75% in the fundoplication group achieved complete eradication of intestinal metaplasia, compared with 81% in the medical therapy group, a nonsignificant difference.

Regarding combined efficacy for dysplastic BE and intramucosal carcinoma, 67% of patients in the fundoplication group achieved complete eradication of intestinal metaplasia, compared with 66% in the medical therapy group, and both groups had a rate of 87% for complete eradication of dysplasia; none of these differences were significant.

Dr. Shaheen acknowledged certain limitations of the study, including the fact that the functional status of the fundoplications was not known. "All we know is that some patients had them," he said. "These are observational data and subject to selection bias. Also note that this is hardly a pure comparison, because the people who got fundoplication were also getting PPIs. However, one might expect that to bias the study in favor of fundoplication, to the degree that the addition of PPIs helps."

The study was funded by Covidien, which provided the RFA equipment used in the study, and by grants from the National Institutes of Health. Dr. Shaheen disclosed that he has consulting relationships with numerous pharmaceutical and medical device companies, but none with Covidien.

SAN DIEGO – Radiofrequency ablation was found to be safe and effective in treating Barrett’s esophagus patients, whether or not they had undergone a prior fundoplication, based on results from a multicenter registry study.

"Gastroesophageal reflux causes esophageal mucosal injury and inflammation that may impair healing and squamous re-epithelialization after treatment of Barrett’s esophagus [BE] with radiofrequency ablation [RFA]," Dr. Nicholas J. Shaheen said at the annual Digestive Disease Week.

Photo courtesy Dr. Nicholas J. Shaheen

"It is unclear if fundoplication surgery, as a mechanical barrier to all reflux, improves treatment outcomes of RFA for BE. Similarly, some have postulated that change in the conformation of the hiatus with surgery might make ablation problematic."

Dr. Shaheen, director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina, Chapel Hill, and his associates conducted the largest study of its kind, he said. They evaluated records from the RFA Patient Registry to assess the relationship between prior fundoplication and both efficacy and safety outcomes in patients with BE who were treated with RFA.

The registry comprises 113 community-based and 35 academic-affiliated medical institutions in the United States. "About 75% of these institutions are private practices, so this is an interesting snapshot of RFA as it’s practiced outside of tertiary care centers," Dr. Shaheen said.

All study patients had BE confirmed by endoscopy and histology, and had undergone treatment with RFA. Enrollment commenced in July 2007 and ended in July 2011. Data were gleaned from standard case report forms and included demographics; relevant medical history; histologic grade prior to treatment; endoscopic findings; dates and total number of RFA treatment sessions; and ablation outcomes and complications.

"The vast amount of data is prospective, but less than 15% is retrospective," Dr. Shaheen said. "This is a registry study, so we could not mandate treatment, but a treatment protocol was suggested." Twice-daily use of proton pump inhibitors (PPIs) was recommended to everyone in the study, including those post fundoplication.

The mean age of patients was 61 years, and the majority were white. The mean pretreatment length of BE was about 4 cm, and patients received an average of 2.5 treatments with RFA. "Importantly, in this registry, about half of the patients had nondysplastic disease," Dr. Shaheen said. "Also, roughly 20% in each group had low- and high-grade dysplasia."

Dr. Shaheen reported results from the safety cohort, which included 5,537 patients who received RFA, and results from the efficacy cohort, which included 2,466 patients with biopsies performed 12 months after enrollment. Safety outcomes included perforation, stricture that required dilation, bleeding that required hospitalization or transfusion, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia and dysplasia.

Among patients in the safety cohort, 301 had a prior fundoplication, whereas 5,236 had received medical therapy only. Patients in the fundoplication group had a somewhat lower mean age than those in the medical therapy group (59 vs. 62 years, P = .0002), and were slightly less likely to be African American (0.3% vs. 1.6%, P = .03) or Hispanic (0.7% vs. 2.6%, P = .03). In the fundoplication group, the length of BE was greater (5.0 cm vs. 4.1 cm, P less than .0001), and the prevalence of nondysplastic BE was higher (53% vs. 49%, P = .05).

In addition, fewer patients in the fundoplication group were taking twice-daily PPIs compared with those in the medical therapy group (82% vs. 95%, P less than .001). There were no significant between-group differences in the rates of bleeding, hospitalization, or stricture.

Among patients in the efficacy cohort, 136 had a prior fundoplication and 2,330 had received medical therapy only. The fundoplication patients were slightly younger than the medical therapy patients (59 vs. 62 years, P = .004), had a somewhat greater length of BE (5.0 cm vs. 4.3 cm, P = .009), and were less likely to be taking twice-daily PPIs (75% vs. 93%, P less than .001).

Rates of complete eradication of intestinal metaplasia were 71% in the fundoplication group vs. 73% in the medical therapy group, a nonsignificant difference, while the rate of complete eradication of dysplasia was identical in both groups at 87%.

Among patients who had nondysplastic BE, 75% in the fundoplication group achieved complete eradication of intestinal metaplasia, compared with 81% in the medical therapy group, a nonsignificant difference.

Regarding combined efficacy for dysplastic BE and intramucosal carcinoma, 67% of patients in the fundoplication group achieved complete eradication of intestinal metaplasia, compared with 66% in the medical therapy group, and both groups had a rate of 87% for complete eradication of dysplasia; none of these differences were significant.

Dr. Shaheen acknowledged certain limitations of the study, including the fact that the functional status of the fundoplications was not known. "All we know is that some patients had them," he said. "These are observational data and subject to selection bias. Also note that this is hardly a pure comparison, because the people who got fundoplication were also getting PPIs. However, one might expect that to bias the study in favor of fundoplication, to the degree that the addition of PPIs helps."

The study was funded by Covidien, which provided the RFA equipment used in the study, and by grants from the National Institutes of Health. Dr. Shaheen disclosed that he has consulting relationships with numerous pharmaceutical and medical device companies, but none with Covidien.

SAN DIEGO – Radiofrequency ablation was found to be safe and effective in treating Barrett’s esophagus patients, whether or not they had undergone a prior fundoplication, based on results from a multicenter registry study.

"Gastroesophageal reflux causes esophageal mucosal injury and inflammation that may impair healing and squamous re-epithelialization after treatment of Barrett’s esophagus [BE] with radiofrequency ablation [RFA]," Dr. Nicholas J. Shaheen said at the annual Digestive Disease Week.

Photo courtesy Dr. Nicholas J. Shaheen

"It is unclear if fundoplication surgery, as a mechanical barrier to all reflux, improves treatment outcomes of RFA for BE. Similarly, some have postulated that change in the conformation of the hiatus with surgery might make ablation problematic."

Dr. Shaheen, director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina, Chapel Hill, and his associates conducted the largest study of its kind, he said. They evaluated records from the RFA Patient Registry to assess the relationship between prior fundoplication and both efficacy and safety outcomes in patients with BE who were treated with RFA.

The registry comprises 113 community-based and 35 academic-affiliated medical institutions in the United States. "About 75% of these institutions are private practices, so this is an interesting snapshot of RFA as it’s practiced outside of tertiary care centers," Dr. Shaheen said.

All study patients had BE confirmed by endoscopy and histology, and had undergone treatment with RFA. Enrollment commenced in July 2007 and ended in July 2011. Data were gleaned from standard case report forms and included demographics; relevant medical history; histologic grade prior to treatment; endoscopic findings; dates and total number of RFA treatment sessions; and ablation outcomes and complications.

"The vast amount of data is prospective, but less than 15% is retrospective," Dr. Shaheen said. "This is a registry study, so we could not mandate treatment, but a treatment protocol was suggested." Twice-daily use of proton pump inhibitors (PPIs) was recommended to everyone in the study, including those post fundoplication.

The mean age of patients was 61 years, and the majority were white. The mean pretreatment length of BE was about 4 cm, and patients received an average of 2.5 treatments with RFA. "Importantly, in this registry, about half of the patients had nondysplastic disease," Dr. Shaheen said. "Also, roughly 20% in each group had low- and high-grade dysplasia."

Dr. Shaheen reported results from the safety cohort, which included 5,537 patients who received RFA, and results from the efficacy cohort, which included 2,466 patients with biopsies performed 12 months after enrollment. Safety outcomes included perforation, stricture that required dilation, bleeding that required hospitalization or transfusion, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia and dysplasia.

Among patients in the safety cohort, 301 had a prior fundoplication, whereas 5,236 had received medical therapy only. Patients in the fundoplication group had a somewhat lower mean age than those in the medical therapy group (59 vs. 62 years, P = .0002), and were slightly less likely to be African American (0.3% vs. 1.6%, P = .03) or Hispanic (0.7% vs. 2.6%, P = .03). In the fundoplication group, the length of BE was greater (5.0 cm vs. 4.1 cm, P less than .0001), and the prevalence of nondysplastic BE was higher (53% vs. 49%, P = .05).

In addition, fewer patients in the fundoplication group were taking twice-daily PPIs compared with those in the medical therapy group (82% vs. 95%, P less than .001). There were no significant between-group differences in the rates of bleeding, hospitalization, or stricture.

Among patients in the efficacy cohort, 136 had a prior fundoplication and 2,330 had received medical therapy only. The fundoplication patients were slightly younger than the medical therapy patients (59 vs. 62 years, P = .004), had a somewhat greater length of BE (5.0 cm vs. 4.3 cm, P = .009), and were less likely to be taking twice-daily PPIs (75% vs. 93%, P less than .001).

Rates of complete eradication of intestinal metaplasia were 71% in the fundoplication group vs. 73% in the medical therapy group, a nonsignificant difference, while the rate of complete eradication of dysplasia was identical in both groups at 87%.

Among patients who had nondysplastic BE, 75% in the fundoplication group achieved complete eradication of intestinal metaplasia, compared with 81% in the medical therapy group, a nonsignificant difference.

Regarding combined efficacy for dysplastic BE and intramucosal carcinoma, 67% of patients in the fundoplication group achieved complete eradication of intestinal metaplasia, compared with 66% in the medical therapy group, and both groups had a rate of 87% for complete eradication of dysplasia; none of these differences were significant.

Dr. Shaheen acknowledged certain limitations of the study, including the fact that the functional status of the fundoplications was not known. "All we know is that some patients had them," he said. "These are observational data and subject to selection bias. Also note that this is hardly a pure comparison, because the people who got fundoplication were also getting PPIs. However, one might expect that to bias the study in favor of fundoplication, to the degree that the addition of PPIs helps."

The study was funded by Covidien, which provided the RFA equipment used in the study, and by grants from the National Institutes of Health. Dr. Shaheen disclosed that he has consulting relationships with numerous pharmaceutical and medical device companies, but none with Covidien.

SAN DIEGO – Changing the acid content of the gastrointestinal tract may reduce the risk of developing pouchitis following ileal pouch anal anastomosis, based on a review of 85 patients at one U.S. center.

After patients underwent ileal pouch anal anastomosis (IPAA) for ulcerative colitis, those who did not develop pouchitis used a proton pump inhibitor (PPI) or histamine₂ (H₂) blocker on a daily basis significantly more often than did patients who developed pouchitis during follow-up, Dr. Lisa S. Poritz said at the annual Digestive Disease Week.

Patients who did not develop pouchitis also regularly used an antacid significantly more often than did those with pouchitis during follow-up, but "occasional" use of a PPI or H₂ blocker showed no statistically significant association with reduced pouchitis incidence, said Dr. Poritz, a colon and rectal surgeon at Pennsylvania State University, Hershey.

Pouchitis is the most common complication of IPAA, occurring in about half of these patients, and chronic pouchitis develops in 5%-19% of them, Dr. Poritz said. Pouchitis produces urgency, bloody bowel movements, and abdominal pain.

IPAA patients who require chronic antibiotic treatment for pouchitis are the subgroup with the best chance to benefit from daily treatment to stop or neutralize acid secretion, a strategy that would "hopefully get them off chronic antibiotics," she said.

The study reviewed ulcerative colitis patients from the Penn State Familial IBD Registry who had undergone IPAA and had at least 2 subsequent years of follow-up. In all, 45 patients developed no pouchitis, and 40 had pouchitis. The registry data showed no demographic or clinical differences between the two subgroups.

The researchers limited their analysis of acid treatment associations to the subgroup of patients for whom data were available. In all, 15 of 30 patients who had no pouchitis following IPAA and 5 of 35 who developed pouchitis received daily treatment with a PPI or H₂ blocker, a statistically significant difference. And 12 of 21 patients with no pouchitis took an antacid more than once a week, compared with 3 of 25 patients who developed pouchitis, also a statistically significant difference.

The analysis showed very similar usage rates among the pouchitis and no-pouchitis subgroups for a variety of other agents that could potentially influence this complication, including probiotics, NSAIDs, fiber supplements, antidiarrheal drugs, and immunosuppressive drugs.

The treatment effects of a PPI or H₂ blocker on the incidence of pouchitis may be mediated by changes in fecal flora, but clear evidence for the mechanism of action will require further study, she said.

Dr. Poritz said that she had no disclosures.

SAN DIEGO – Changing the acid content of the gastrointestinal tract may reduce the risk of developing pouchitis following ileal pouch anal anastomosis, based on a review of 85 patients at one U.S. center.

After patients underwent ileal pouch anal anastomosis (IPAA) for ulcerative colitis, those who did not develop pouchitis used a proton pump inhibitor (PPI) or histamine₂ (H₂) blocker on a daily basis significantly more often than did patients who developed pouchitis during follow-up, Dr. Lisa S. Poritz said at the annual Digestive Disease Week.

Patients who did not develop pouchitis also regularly used an antacid significantly more often than did those with pouchitis during follow-up, but "occasional" use of a PPI or H₂ blocker showed no statistically significant association with reduced pouchitis incidence, said Dr. Poritz, a colon and rectal surgeon at Pennsylvania State University, Hershey.

Pouchitis is the most common complication of IPAA, occurring in about half of these patients, and chronic pouchitis develops in 5%-19% of them, Dr. Poritz said. Pouchitis produces urgency, bloody bowel movements, and abdominal pain.

IPAA patients who require chronic antibiotic treatment for pouchitis are the subgroup with the best chance to benefit from daily treatment to stop or neutralize acid secretion, a strategy that would "hopefully get them off chronic antibiotics," she said.

The study reviewed ulcerative colitis patients from the Penn State Familial IBD Registry who had undergone IPAA and had at least 2 subsequent years of follow-up. In all, 45 patients developed no pouchitis, and 40 had pouchitis. The registry data showed no demographic or clinical differences between the two subgroups.

The researchers limited their analysis of acid treatment associations to the subgroup of patients for whom data were available. In all, 15 of 30 patients who had no pouchitis following IPAA and 5 of 35 who developed pouchitis received daily treatment with a PPI or H₂ blocker, a statistically significant difference. And 12 of 21 patients with no pouchitis took an antacid more than once a week, compared with 3 of 25 patients who developed pouchitis, also a statistically significant difference.

The analysis showed very similar usage rates among the pouchitis and no-pouchitis subgroups for a variety of other agents that could potentially influence this complication, including probiotics, NSAIDs, fiber supplements, antidiarrheal drugs, and immunosuppressive drugs.

The treatment effects of a PPI or H₂ blocker on the incidence of pouchitis may be mediated by changes in fecal flora, but clear evidence for the mechanism of action will require further study, she said.

Dr. Poritz said that she had no disclosures.

SAN DIEGO – Changing the acid content of the gastrointestinal tract may reduce the risk of developing pouchitis following ileal pouch anal anastomosis, based on a review of 85 patients at one U.S. center.

After patients underwent ileal pouch anal anastomosis (IPAA) for ulcerative colitis, those who did not develop pouchitis used a proton pump inhibitor (PPI) or histamine₂ (H₂) blocker on a daily basis significantly more often than did patients who developed pouchitis during follow-up, Dr. Lisa S. Poritz said at the annual Digestive Disease Week.

Patients who did not develop pouchitis also regularly used an antacid significantly more often than did those with pouchitis during follow-up, but "occasional" use of a PPI or H₂ blocker showed no statistically significant association with reduced pouchitis incidence, said Dr. Poritz, a colon and rectal surgeon at Pennsylvania State University, Hershey.

Pouchitis is the most common complication of IPAA, occurring in about half of these patients, and chronic pouchitis develops in 5%-19% of them, Dr. Poritz said. Pouchitis produces urgency, bloody bowel movements, and abdominal pain.

IPAA patients who require chronic antibiotic treatment for pouchitis are the subgroup with the best chance to benefit from daily treatment to stop or neutralize acid secretion, a strategy that would "hopefully get them off chronic antibiotics," she said.

The study reviewed ulcerative colitis patients from the Penn State Familial IBD Registry who had undergone IPAA and had at least 2 subsequent years of follow-up. In all, 45 patients developed no pouchitis, and 40 had pouchitis. The registry data showed no demographic or clinical differences between the two subgroups.

The researchers limited their analysis of acid treatment associations to the subgroup of patients for whom data were available. In all, 15 of 30 patients who had no pouchitis following IPAA and 5 of 35 who developed pouchitis received daily treatment with a PPI or H₂ blocker, a statistically significant difference. And 12 of 21 patients with no pouchitis took an antacid more than once a week, compared with 3 of 25 patients who developed pouchitis, also a statistically significant difference.

The analysis showed very similar usage rates among the pouchitis and no-pouchitis subgroups for a variety of other agents that could potentially influence this complication, including probiotics, NSAIDs, fiber supplements, antidiarrheal drugs, and immunosuppressive drugs.

The treatment effects of a PPI or H₂ blocker on the incidence of pouchitis may be mediated by changes in fecal flora, but clear evidence for the mechanism of action will require further study, she said.

Dr. Poritz said that she had no disclosures.

SAN DIEGO  – Since the late 1990s, when the annual number of antireflux procedures performed in the United States peaked, the overall rate of complications has increased, operations have shifted to more complex procedures in sicker patients, and the largest gains in caseload have occurred at urban nonteaching hospitals.

Those are three key findings from a large analysis of National Inpatient Sample (NIS) data reported by Dr. Paul D. Colavita at the annual Digestive Disease Week.

"Around the same time that antireflux surgery surged in the late 1990s, the Leapfrog Group – a large consortium of public and private health care purchasers – emerged as leaders in the national call for regionalization of complex surgical procedures in 2000," said Dr. Colavita, of the general surgery department at Carolinas Medical Center, Charlotte, N.C. "The objective of our study was to measure the extent of regionalization from its peak in 1998-1999 with data from 2008-2009."

He and his associates examined NIS data from 1998-1999 and 2008-2009 for antireflux procedures performed on patients with a diagnosis of gastroesophageal reflux, esophagitis, esophageal ulcer, and hiatal hernia. They excluded cases of achalasia, gangrenous/incarcerated diaphragmatic hernia, and patients younger than 18 years.

To measure the effect of regionalization, the researchers used 1998-1999 annual hospital volume of antireflux operations stratified into one of three baseline terciles: low-volume centers, defined as 1-14 annual procedures; medium-volume centers (15-37 annual procedures); and high-volume centers (38 or more annual procedures). The researchers also compared complications and outcomes that occurred in 1998-99 (time period 1) with those that occurred in 2008-09 (time period 2).

Dr. Colavita reported that 11,803 procedures were performed in time period 1, compared with 8,855 in time period 2. The proportion of procedures performed at low-volume centers increased between time periods 1 and 2 (from 33.3% to 40.4%) and declined at high-volume centers (from 33.4% to 25.3%).

As has been found with other surgical procedures, outcomes improved in high-volume centers, he said. The researchers attribute the lack of regionalization, in part, to the increased number of surgeons trained to perform these procedures. "In the past decade, surgical residents have been trained to perform antireflux procedures," Dr. Colavita said. "These former residents are now general surgeons who are performing these procedures in a variety of hospitals in different locations, both urban and rural."

Certain baseline characteristics differed significantly between time periods 1 and 2, including age (a mean of 50 vs. 57 years, respectively), percentage of women (57% vs. 69%), percentage of white patients (91% vs. 85%), and those with a Charlson comorbidity index score of more than 1 (5% vs. 10%). All differences had a P value of less than .0001.

There was no difference in inpatient mortality between time periods 1 and 2 (0.41% vs. 0.34%, respectively; P = .433), but there were significant increases in the rate of complications (4% vs. 6%) and total charges ($16,000 vs. $40,000), while the frequency of routine discharge decreased (95% vs. 92%). All differences had a P value of less than .0001. The average length of stay increased by 0.15 days (P = .001).

Multivariate regression analysis revealed that between time periods 1 and 2, low-volume centers remained independently associated with increased complications (odds ratio 1.8 vs. 1.9, respectively), nonroutine discharge (OR 2.0 vs. 1.8), length of stay (0.82 vs. 0.94 days), and higher total charges ($2,700 vs. $3,200).

"Taking these findings into consideration, we as health care providers must decide whether or not to call for increased referrals to high-volume centers," Dr. Colavita said.

Multivariate regression revealed two significant predictors of antireflux procedures performed at low-volume centers during time periods 1 and 2: emergent admission (OR 3.7 vs. 3.0, respectively) and lack of private insurance (OR 1.3 in both). Nonwhite race was a significant predictor in time period 1 only (OR 1.8), while significant predictors in time period 2 only included residing in the poorest vs. wealthiest zip code (OR 1.2), decreasing age (OR 1.1), and female gender (OR 1.2).

Dr. Colavita also reported that rural hospitals had decreased surgical volume between time periods 1 and 2 (19% to 10%), while the volume increased at urban nonteaching hospitals (from 33% to 39%) and at urban teaching hospitals (from 48% to 51%).

"Urban teaching hospitals had the highest proportion of high-volume cases in both eras, while urban nonteaching hospitals had the highest proportion of low-volume cases in both eras," he said.

Dr. Colavita acknowledged certain limitations of the study, including the lack of opportunity for follow-up in the NIS database and the fact that there are no codes for redo fundoplications. Also, "higher volumes have a shorter length of stay," he said. "This is a smaller window to detect death, complications, and overall cost. We also lack operative details such as operative time."

Dr. Colavita said he had no relevant financial conflicts to disclose.

SAN DIEGO  – Since the late 1990s, when the annual number of antireflux procedures performed in the United States peaked, the overall rate of complications has increased, operations have shifted to more complex procedures in sicker patients, and the largest gains in caseload have occurred at urban nonteaching hospitals.

Those are three key findings from a large analysis of National Inpatient Sample (NIS) data reported by Dr. Paul D. Colavita at the annual Digestive Disease Week.

"Around the same time that antireflux surgery surged in the late 1990s, the Leapfrog Group – a large consortium of public and private health care purchasers – emerged as leaders in the national call for regionalization of complex surgical procedures in 2000," said Dr. Colavita, of the general surgery department at Carolinas Medical Center, Charlotte, N.C. "The objective of our study was to measure the extent of regionalization from its peak in 1998-1999 with data from 2008-2009."

He and his associates examined NIS data from 1998-1999 and 2008-2009 for antireflux procedures performed on patients with a diagnosis of gastroesophageal reflux, esophagitis, esophageal ulcer, and hiatal hernia. They excluded cases of achalasia, gangrenous/incarcerated diaphragmatic hernia, and patients younger than 18 years.

To measure the effect of regionalization, the researchers used 1998-1999 annual hospital volume of antireflux operations stratified into one of three baseline terciles: low-volume centers, defined as 1-14 annual procedures; medium-volume centers (15-37 annual procedures); and high-volume centers (38 or more annual procedures). The researchers also compared complications and outcomes that occurred in 1998-99 (time period 1) with those that occurred in 2008-09 (time period 2).

Dr. Colavita reported that 11,803 procedures were performed in time period 1, compared with 8,855 in time period 2. The proportion of procedures performed at low-volume centers increased between time periods 1 and 2 (from 33.3% to 40.4%) and declined at high-volume centers (from 33.4% to 25.3%).

As has been found with other surgical procedures, outcomes improved in high-volume centers, he said. The researchers attribute the lack of regionalization, in part, to the increased number of surgeons trained to perform these procedures. "In the past decade, surgical residents have been trained to perform antireflux procedures," Dr. Colavita said. "These former residents are now general surgeons who are performing these procedures in a variety of hospitals in different locations, both urban and rural."

Certain baseline characteristics differed significantly between time periods 1 and 2, including age (a mean of 50 vs. 57 years, respectively), percentage of women (57% vs. 69%), percentage of white patients (91% vs. 85%), and those with a Charlson comorbidity index score of more than 1 (5% vs. 10%). All differences had a P value of less than .0001.

There was no difference in inpatient mortality between time periods 1 and 2 (0.41% vs. 0.34%, respectively; P = .433), but there were significant increases in the rate of complications (4% vs. 6%) and total charges ($16,000 vs. $40,000), while the frequency of routine discharge decreased (95% vs. 92%). All differences had a P value of less than .0001. The average length of stay increased by 0.15 days (P = .001).

Multivariate regression analysis revealed that between time periods 1 and 2, low-volume centers remained independently associated with increased complications (odds ratio 1.8 vs. 1.9, respectively), nonroutine discharge (OR 2.0 vs. 1.8), length of stay (0.82 vs. 0.94 days), and higher total charges ($2,700 vs. $3,200).

"Taking these findings into consideration, we as health care providers must decide whether or not to call for increased referrals to high-volume centers," Dr. Colavita said.

Multivariate regression revealed two significant predictors of antireflux procedures performed at low-volume centers during time periods 1 and 2: emergent admission (OR 3.7 vs. 3.0, respectively) and lack of private insurance (OR 1.3 in both). Nonwhite race was a significant predictor in time period 1 only (OR 1.8), while significant predictors in time period 2 only included residing in the poorest vs. wealthiest zip code (OR 1.2), decreasing age (OR 1.1), and female gender (OR 1.2).

Dr. Colavita also reported that rural hospitals had decreased surgical volume between time periods 1 and 2 (19% to 10%), while the volume increased at urban nonteaching hospitals (from 33% to 39%) and at urban teaching hospitals (from 48% to 51%).

"Urban teaching hospitals had the highest proportion of high-volume cases in both eras, while urban nonteaching hospitals had the highest proportion of low-volume cases in both eras," he said.

Dr. Colavita acknowledged certain limitations of the study, including the lack of opportunity for follow-up in the NIS database and the fact that there are no codes for redo fundoplications. Also, "higher volumes have a shorter length of stay," he said. "This is a smaller window to detect death, complications, and overall cost. We also lack operative details such as operative time."

Dr. Colavita said he had no relevant financial conflicts to disclose.

SAN DIEGO  – Since the late 1990s, when the annual number of antireflux procedures performed in the United States peaked, the overall rate of complications has increased, operations have shifted to more complex procedures in sicker patients, and the largest gains in caseload have occurred at urban nonteaching hospitals.

Those are three key findings from a large analysis of National Inpatient Sample (NIS) data reported by Dr. Paul D. Colavita at the annual Digestive Disease Week.

"Around the same time that antireflux surgery surged in the late 1990s, the Leapfrog Group – a large consortium of public and private health care purchasers – emerged as leaders in the national call for regionalization of complex surgical procedures in 2000," said Dr. Colavita, of the general surgery department at Carolinas Medical Center, Charlotte, N.C. "The objective of our study was to measure the extent of regionalization from its peak in 1998-1999 with data from 2008-2009."

He and his associates examined NIS data from 1998-1999 and 2008-2009 for antireflux procedures performed on patients with a diagnosis of gastroesophageal reflux, esophagitis, esophageal ulcer, and hiatal hernia. They excluded cases of achalasia, gangrenous/incarcerated diaphragmatic hernia, and patients younger than 18 years.

To measure the effect of regionalization, the researchers used 1998-1999 annual hospital volume of antireflux operations stratified into one of three baseline terciles: low-volume centers, defined as 1-14 annual procedures; medium-volume centers (15-37 annual procedures); and high-volume centers (38 or more annual procedures). The researchers also compared complications and outcomes that occurred in 1998-99 (time period 1) with those that occurred in 2008-09 (time period 2).

Dr. Colavita reported that 11,803 procedures were performed in time period 1, compared with 8,855 in time period 2. The proportion of procedures performed at low-volume centers increased between time periods 1 and 2 (from 33.3% to 40.4%) and declined at high-volume centers (from 33.4% to 25.3%).

As has been found with other surgical procedures, outcomes improved in high-volume centers, he said. The researchers attribute the lack of regionalization, in part, to the increased number of surgeons trained to perform these procedures. "In the past decade, surgical residents have been trained to perform antireflux procedures," Dr. Colavita said. "These former residents are now general surgeons who are performing these procedures in a variety of hospitals in different locations, both urban and rural."

Certain baseline characteristics differed significantly between time periods 1 and 2, including age (a mean of 50 vs. 57 years, respectively), percentage of women (57% vs. 69%), percentage of white patients (91% vs. 85%), and those with a Charlson comorbidity index score of more than 1 (5% vs. 10%). All differences had a P value of less than .0001.

There was no difference in inpatient mortality between time periods 1 and 2 (0.41% vs. 0.34%, respectively; P = .433), but there were significant increases in the rate of complications (4% vs. 6%) and total charges ($16,000 vs. $40,000), while the frequency of routine discharge decreased (95% vs. 92%). All differences had a P value of less than .0001. The average length of stay increased by 0.15 days (P = .001).

Multivariate regression analysis revealed that between time periods 1 and 2, low-volume centers remained independently associated with increased complications (odds ratio 1.8 vs. 1.9, respectively), nonroutine discharge (OR 2.0 vs. 1.8), length of stay (0.82 vs. 0.94 days), and higher total charges ($2,700 vs. $3,200).

"Taking these findings into consideration, we as health care providers must decide whether or not to call for increased referrals to high-volume centers," Dr. Colavita said.

Multivariate regression revealed two significant predictors of antireflux procedures performed at low-volume centers during time periods 1 and 2: emergent admission (OR 3.7 vs. 3.0, respectively) and lack of private insurance (OR 1.3 in both). Nonwhite race was a significant predictor in time period 1 only (OR 1.8), while significant predictors in time period 2 only included residing in the poorest vs. wealthiest zip code (OR 1.2), decreasing age (OR 1.1), and female gender (OR 1.2).

Dr. Colavita also reported that rural hospitals had decreased surgical volume between time periods 1 and 2 (19% to 10%), while the volume increased at urban nonteaching hospitals (from 33% to 39%) and at urban teaching hospitals (from 48% to 51%).

"Urban teaching hospitals had the highest proportion of high-volume cases in both eras, while urban nonteaching hospitals had the highest proportion of low-volume cases in both eras," he said.

Dr. Colavita acknowledged certain limitations of the study, including the lack of opportunity for follow-up in the NIS database and the fact that there are no codes for redo fundoplications. Also, "higher volumes have a shorter length of stay," he said. "This is a smaller window to detect death, complications, and overall cost. We also lack operative details such as operative time."

Dr. Colavita said he had no relevant financial conflicts to disclose.

SAN DIEGO – Elderly patients who never previously underwent screening colonoscopy have a high prevalence of colorectal cancer and could benefit from screening if they are healthy and functional and have a life expectancy of at least about 7 years, based on a review of colonoscopies done on people aged 76-85 at one U.S. center.

The results also showed a reasonable detection rate for colorectal cancers in the same age group when their prior colonoscopy had last been done 10 or more years before, Dr. Therese G. Kerwel said at the annual Digestive Disease Week meeting.

"The U.S. Preventive Services Task Force says that you don’t see benefit [from screening colonoscopy] until about 7 years so that’s the benchmark. If you think the person will live for another 7 or more years, then screen. If not, then it’s not worth the resources," said Dr. Kerwel, a surgeon at Spectrum Health in Grand Rapids, Mich.

"The headline from the U.S. Preventive Services Task Force is to stop screening at age 75; that’s what everyone knows. A lot of people don’t read the fine print, the loophole that you can screen elderly people if they are healthy and functional," Dr. Kerwel said in an interview.

Another reason to strongly consider screening elderly patients who are healthy enough to potentially benefit is that if they develop colorectal cancer, they have an increased risk for an emergency presentation compared with younger adults, with the potential to develop bleeding, obstruction, or perforation, she said.

"It’s always a balance of risk and benefit, but there is definitely a subset of the elderly who need to be focused on a little more."

The review also showed a sizeable percent of elderly people underwent colonoscopy at Spectrum Health roughly 5 years following a prior procedure, with no cases of colorectal cancer detected, indicating that a significant number of elderly people had been subjected to overly aggressive colonoscopy, Dr. Kerwel said.

She and her associates reviewed 903 people, aged 76-85 years, who underwent colonoscopy at Spectrum Health during January 2009 to December 2010. The colonoscopy occurred purely for screening in 19%, for surveillance in 42%, for symptoms in 35%, and for other reasons in 4%.

Fifty-three of the people had never previously undergone colonoscopy (in this subgroup roughly half the procedures were for screening and half were for symptoms). Colonoscopy identified colorectal carcinoma in 9%. An additional 56 people from the study group had not had a prior colonoscopy for at least 10 years; in this group the new procedure detected carcinoma in 5%.

The remaining 88% of the procedures reviewed occurred within 9 years or less of prior colonoscopy. The largest subgroup was 247 people (27% of the study group) examined 4-5 years after a prior colonoscopy. In this subgroup the procedure identified no carcinomas, and in everyone else examined 9 or fewer years after their prior examination, about 3% had cancers identified.

These results suggest that repeat colonoscopies at intervals shorter than 10 years may have questionable utility in the elderly, Dr. Kerwel said.

She said that she had no relevant financial disclosures.

SAN DIEGO – Elderly patients who never previously underwent screening colonoscopy have a high prevalence of colorectal cancer and could benefit from screening if they are healthy and functional and have a life expectancy of at least about 7 years, based on a review of colonoscopies done on people aged 76-85 at one U.S. center.

The results also showed a reasonable detection rate for colorectal cancers in the same age group when their prior colonoscopy had last been done 10 or more years before, Dr. Therese G. Kerwel said at the annual Digestive Disease Week meeting.

"The U.S. Preventive Services Task Force says that you don’t see benefit [from screening colonoscopy] until about 7 years so that’s the benchmark. If you think the person will live for another 7 or more years, then screen. If not, then it’s not worth the resources," said Dr. Kerwel, a surgeon at Spectrum Health in Grand Rapids, Mich.

"The headline from the U.S. Preventive Services Task Force is to stop screening at age 75; that’s what everyone knows. A lot of people don’t read the fine print, the loophole that you can screen elderly people if they are healthy and functional," Dr. Kerwel said in an interview.

Another reason to strongly consider screening elderly patients who are healthy enough to potentially benefit is that if they develop colorectal cancer, they have an increased risk for an emergency presentation compared with younger adults, with the potential to develop bleeding, obstruction, or perforation, she said.

"It’s always a balance of risk and benefit, but there is definitely a subset of the elderly who need to be focused on a little more."

The review also showed a sizeable percent of elderly people underwent colonoscopy at Spectrum Health roughly 5 years following a prior procedure, with no cases of colorectal cancer detected, indicating that a significant number of elderly people had been subjected to overly aggressive colonoscopy, Dr. Kerwel said.

She and her associates reviewed 903 people, aged 76-85 years, who underwent colonoscopy at Spectrum Health during January 2009 to December 2010. The colonoscopy occurred purely for screening in 19%, for surveillance in 42%, for symptoms in 35%, and for other reasons in 4%.

Fifty-three of the people had never previously undergone colonoscopy (in this subgroup roughly half the procedures were for screening and half were for symptoms). Colonoscopy identified colorectal carcinoma in 9%. An additional 56 people from the study group had not had a prior colonoscopy for at least 10 years; in this group the new procedure detected carcinoma in 5%.

The remaining 88% of the procedures reviewed occurred within 9 years or less of prior colonoscopy. The largest subgroup was 247 people (27% of the study group) examined 4-5 years after a prior colonoscopy. In this subgroup the procedure identified no carcinomas, and in everyone else examined 9 or fewer years after their prior examination, about 3% had cancers identified.

These results suggest that repeat colonoscopies at intervals shorter than 10 years may have questionable utility in the elderly, Dr. Kerwel said.

She said that she had no relevant financial disclosures.

SAN DIEGO – Elderly patients who never previously underwent screening colonoscopy have a high prevalence of colorectal cancer and could benefit from screening if they are healthy and functional and have a life expectancy of at least about 7 years, based on a review of colonoscopies done on people aged 76-85 at one U.S. center.

The results also showed a reasonable detection rate for colorectal cancers in the same age group when their prior colonoscopy had last been done 10 or more years before, Dr. Therese G. Kerwel said at the annual Digestive Disease Week meeting.

"The U.S. Preventive Services Task Force says that you don’t see benefit [from screening colonoscopy] until about 7 years so that’s the benchmark. If you think the person will live for another 7 or more years, then screen. If not, then it’s not worth the resources," said Dr. Kerwel, a surgeon at Spectrum Health in Grand Rapids, Mich.

"The headline from the U.S. Preventive Services Task Force is to stop screening at age 75; that’s what everyone knows. A lot of people don’t read the fine print, the loophole that you can screen elderly people if they are healthy and functional," Dr. Kerwel said in an interview.

Another reason to strongly consider screening elderly patients who are healthy enough to potentially benefit is that if they develop colorectal cancer, they have an increased risk for an emergency presentation compared with younger adults, with the potential to develop bleeding, obstruction, or perforation, she said.

"It’s always a balance of risk and benefit, but there is definitely a subset of the elderly who need to be focused on a little more."

The review also showed a sizeable percent of elderly people underwent colonoscopy at Spectrum Health roughly 5 years following a prior procedure, with no cases of colorectal cancer detected, indicating that a significant number of elderly people had been subjected to overly aggressive colonoscopy, Dr. Kerwel said.

She and her associates reviewed 903 people, aged 76-85 years, who underwent colonoscopy at Spectrum Health during January 2009 to December 2010. The colonoscopy occurred purely for screening in 19%, for surveillance in 42%, for symptoms in 35%, and for other reasons in 4%.

Fifty-three of the people had never previously undergone colonoscopy (in this subgroup roughly half the procedures were for screening and half were for symptoms). Colonoscopy identified colorectal carcinoma in 9%. An additional 56 people from the study group had not had a prior colonoscopy for at least 10 years; in this group the new procedure detected carcinoma in 5%.

The remaining 88% of the procedures reviewed occurred within 9 years or less of prior colonoscopy. The largest subgroup was 247 people (27% of the study group) examined 4-5 years after a prior colonoscopy. In this subgroup the procedure identified no carcinomas, and in everyone else examined 9 or fewer years after their prior examination, about 3% had cancers identified.

These results suggest that repeat colonoscopies at intervals shorter than 10 years may have questionable utility in the elderly, Dr. Kerwel said.

She said that she had no relevant financial disclosures.

SAN DIEGO – Patients who underwent laparoscopic resection of gastric submucosal neoplasms had shorter operative times, less blood loss, lower postoperative morbidity, and shorter hospital lengths of stay compared with those who underwent open resection, according to results from a single-center study.

"Numerous reports not only have assessed the feasibility, but confirmed the long-term oncologic efficacy of laparoscopic resection for gastrointestinal stromal tumors [GISTs]," Dr. Sabha Ganai said at the annual Digestive Disease Week.

"However, in 2004, the European Society of Medical Oncology published a consensus report suggesting that laparoscopic surgery may result in a higher risk of tumor rupture and peritoneal seeding, and suggested that laparoscopic resection may be acceptable in cases of small intramural tumors – those 2 cm or smaller," she added (Ann. Oncol. 2005;16:566-78).

Dr. Ganai, a fellow in surgical oncology and clinical medical ethics at the University of Chicago, noted that concerns exist "regarding the ability to generalize laparoscopic techniques to the spectra of gastric submucosal neoplasms, specifically related to tumor size and location, particularly the GE junction/cardia, the antrum/pylorus, and posteriorly based lesions."

To evaluate patient selection for a minimally invasive approach to resection, Dr. Ganai and her associates compared laparoscopic and open techniques used in the resection of gastric submucosal neoplasms. "We hypothesized that there are predictors of unsuccessful laparoscopic resection, with failures defined by conversions, complications, and recurrences," she said.

The retrospective study involved 106 patients with gastric submucosal neoplasms who underwent operative management at the university from October 2002 to March 2012. There were 79 patients in the laparoscopic group and 27 in the open group. The mean age was 63 years, the mean body mass index was 29 kg/m², and 57% were male.

There was less preoperative use of ultrasound in the open group vs. the laparoscopic group (67% vs. 87%, respectively), and greater pretreatment lesion size (9.5 cm vs. 3.9 cm). In addition, the open group had a 6-month greater interval from diagnosis to surgery (10.1 months vs. 4.4 months), and more neoadjuvant imatinib was used in the open group (26% vs. 5%).

Most tumors (76%) were GISTs; the rest were leiomyomas (9%), schwannomas (6%), carcinoids (3%), and other types (6%).

There were no significant differences between the groups in terms of tumor location; most were found in the greater curvature (41% open vs. 32% laparoscopic). "There were slightly more posterior lesions in the open group, but this was not statistically significant," she said. "On presentation, patients in the open group had a significantly greater presentation with abdominal pain, while those in the laparoscopic group were more likely to present with GI bleed."

Most patients underwent sleeve or wedge resection, with 11% of patients undergoing transgastric wedge resections. A higher proportion of the open group required a gastroenteric anastomosis (37% vs. 6%) and a multivisceral resection (41% vs. 1%). Overall, operative time was significantly greater in the open group (a mean of 230 minutes vs. 132 minutes), as was the amount of estimated blood loss (a mean of 364 mL vs. 35 mL).

Most GISTs in the laparoscopic group (64%) ranged in size from 2 cm to 5 cm, while the majority in the open group (58%) were greater than 5 cm. In addition, the open group had a higher mitotic index (44% vs. 20%).

Postoperatively, hospital length of stay was significantly shorter in the laparoscopic group (a mean of 3.3 days) than in the open group (a mean of 8.4 days). The laparoscopic group also had significantly fewer surgical site infections (1% vs. 22%), anastomotic leaks (0% vs. 7%), and postoperative arrhythmias (0% vs. 15%).

Overall complications, evaluated on the basis of the Accordion Severity Grading System of surgical complications, were less severe in the laparoscopic group. "However, there was one perioperative death in the laparoscopic group related to a massive myocardial infarction, as well as two reoperations, one related to a port site hernia and one related to a gastric outlet obstruction in an antral lesion," Dr. Ganai said.

On multivariate analysis, conversion was predicted by tumor size greater than 8 cm (odds ratio, 18.48), while recurrence was predicted by having a mitotic rate of greater than 5 mitoses per 50 high-power fields (OR, 4.68). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, shorter operative times, less blood loss, and shorter lengths of stay (P less than .05). No significant difference was seen in survival; 90% and 81% of patients were alive 3 years after laparoscopic and open resection, respectively (hazard ratio, 0.4; P = .13). "Tumor biology and imatinib may play a greater role in oncologic outcome than technical considerations," Dr. Ganai suggested.

She acknowledged certain limitations of the study, including its retrospective design, the potential for selection bias, and limited follow-up, "especially in the lower-risk tumors."

Dr. Ganai said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Patients who underwent laparoscopic resection of gastric submucosal neoplasms had shorter operative times, less blood loss, lower postoperative morbidity, and shorter hospital lengths of stay compared with those who underwent open resection, according to results from a single-center study.

"Numerous reports not only have assessed the feasibility, but confirmed the long-term oncologic efficacy of laparoscopic resection for gastrointestinal stromal tumors [GISTs]," Dr. Sabha Ganai said at the annual Digestive Disease Week.

"However, in 2004, the European Society of Medical Oncology published a consensus report suggesting that laparoscopic surgery may result in a higher risk of tumor rupture and peritoneal seeding, and suggested that laparoscopic resection may be acceptable in cases of small intramural tumors – those 2 cm or smaller," she added (Ann. Oncol. 2005;16:566-78).

Dr. Ganai, a fellow in surgical oncology and clinical medical ethics at the University of Chicago, noted that concerns exist "regarding the ability to generalize laparoscopic techniques to the spectra of gastric submucosal neoplasms, specifically related to tumor size and location, particularly the GE junction/cardia, the antrum/pylorus, and posteriorly based lesions."

To evaluate patient selection for a minimally invasive approach to resection, Dr. Ganai and her associates compared laparoscopic and open techniques used in the resection of gastric submucosal neoplasms. "We hypothesized that there are predictors of unsuccessful laparoscopic resection, with failures defined by conversions, complications, and recurrences," she said.

The retrospective study involved 106 patients with gastric submucosal neoplasms who underwent operative management at the university from October 2002 to March 2012. There were 79 patients in the laparoscopic group and 27 in the open group. The mean age was 63 years, the mean body mass index was 29 kg/m², and 57% were male.

There was less preoperative use of ultrasound in the open group vs. the laparoscopic group (67% vs. 87%, respectively), and greater pretreatment lesion size (9.5 cm vs. 3.9 cm). In addition, the open group had a 6-month greater interval from diagnosis to surgery (10.1 months vs. 4.4 months), and more neoadjuvant imatinib was used in the open group (26% vs. 5%).

Most tumors (76%) were GISTs; the rest were leiomyomas (9%), schwannomas (6%), carcinoids (3%), and other types (6%).

There were no significant differences between the groups in terms of tumor location; most were found in the greater curvature (41% open vs. 32% laparoscopic). "There were slightly more posterior lesions in the open group, but this was not statistically significant," she said. "On presentation, patients in the open group had a significantly greater presentation with abdominal pain, while those in the laparoscopic group were more likely to present with GI bleed."

Most patients underwent sleeve or wedge resection, with 11% of patients undergoing transgastric wedge resections. A higher proportion of the open group required a gastroenteric anastomosis (37% vs. 6%) and a multivisceral resection (41% vs. 1%). Overall, operative time was significantly greater in the open group (a mean of 230 minutes vs. 132 minutes), as was the amount of estimated blood loss (a mean of 364 mL vs. 35 mL).

Most GISTs in the laparoscopic group (64%) ranged in size from 2 cm to 5 cm, while the majority in the open group (58%) were greater than 5 cm. In addition, the open group had a higher mitotic index (44% vs. 20%).

Postoperatively, hospital length of stay was significantly shorter in the laparoscopic group (a mean of 3.3 days) than in the open group (a mean of 8.4 days). The laparoscopic group also had significantly fewer surgical site infections (1% vs. 22%), anastomotic leaks (0% vs. 7%), and postoperative arrhythmias (0% vs. 15%).

Overall complications, evaluated on the basis of the Accordion Severity Grading System of surgical complications, were less severe in the laparoscopic group. "However, there was one perioperative death in the laparoscopic group related to a massive myocardial infarction, as well as two reoperations, one related to a port site hernia and one related to a gastric outlet obstruction in an antral lesion," Dr. Ganai said.

On multivariate analysis, conversion was predicted by tumor size greater than 8 cm (odds ratio, 18.48), while recurrence was predicted by having a mitotic rate of greater than 5 mitoses per 50 high-power fields (OR, 4.68). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, shorter operative times, less blood loss, and shorter lengths of stay (P less than .05). No significant difference was seen in survival; 90% and 81% of patients were alive 3 years after laparoscopic and open resection, respectively (hazard ratio, 0.4; P = .13). "Tumor biology and imatinib may play a greater role in oncologic outcome than technical considerations," Dr. Ganai suggested.

She acknowledged certain limitations of the study, including its retrospective design, the potential for selection bias, and limited follow-up, "especially in the lower-risk tumors."

Dr. Ganai said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Patients who underwent laparoscopic resection of gastric submucosal neoplasms had shorter operative times, less blood loss, lower postoperative morbidity, and shorter hospital lengths of stay compared with those who underwent open resection, according to results from a single-center study.

"Numerous reports not only have assessed the feasibility, but confirmed the long-term oncologic efficacy of laparoscopic resection for gastrointestinal stromal tumors [GISTs]," Dr. Sabha Ganai said at the annual Digestive Disease Week.

"However, in 2004, the European Society of Medical Oncology published a consensus report suggesting that laparoscopic surgery may result in a higher risk of tumor rupture and peritoneal seeding, and suggested that laparoscopic resection may be acceptable in cases of small intramural tumors – those 2 cm or smaller," she added (Ann. Oncol. 2005;16:566-78).

Dr. Ganai, a fellow in surgical oncology and clinical medical ethics at the University of Chicago, noted that concerns exist "regarding the ability to generalize laparoscopic techniques to the spectra of gastric submucosal neoplasms, specifically related to tumor size and location, particularly the GE junction/cardia, the antrum/pylorus, and posteriorly based lesions."

To evaluate patient selection for a minimally invasive approach to resection, Dr. Ganai and her associates compared laparoscopic and open techniques used in the resection of gastric submucosal neoplasms. "We hypothesized that there are predictors of unsuccessful laparoscopic resection, with failures defined by conversions, complications, and recurrences," she said.

The retrospective study involved 106 patients with gastric submucosal neoplasms who underwent operative management at the university from October 2002 to March 2012. There were 79 patients in the laparoscopic group and 27 in the open group. The mean age was 63 years, the mean body mass index was 29 kg/m², and 57% were male.

There was less preoperative use of ultrasound in the open group vs. the laparoscopic group (67% vs. 87%, respectively), and greater pretreatment lesion size (9.5 cm vs. 3.9 cm). In addition, the open group had a 6-month greater interval from diagnosis to surgery (10.1 months vs. 4.4 months), and more neoadjuvant imatinib was used in the open group (26% vs. 5%).

Most tumors (76%) were GISTs; the rest were leiomyomas (9%), schwannomas (6%), carcinoids (3%), and other types (6%).

There were no significant differences between the groups in terms of tumor location; most were found in the greater curvature (41% open vs. 32% laparoscopic). "There were slightly more posterior lesions in the open group, but this was not statistically significant," she said. "On presentation, patients in the open group had a significantly greater presentation with abdominal pain, while those in the laparoscopic group were more likely to present with GI bleed."

Most patients underwent sleeve or wedge resection, with 11% of patients undergoing transgastric wedge resections. A higher proportion of the open group required a gastroenteric anastomosis (37% vs. 6%) and a multivisceral resection (41% vs. 1%). Overall, operative time was significantly greater in the open group (a mean of 230 minutes vs. 132 minutes), as was the amount of estimated blood loss (a mean of 364 mL vs. 35 mL).

Most GISTs in the laparoscopic group (64%) ranged in size from 2 cm to 5 cm, while the majority in the open group (58%) were greater than 5 cm. In addition, the open group had a higher mitotic index (44% vs. 20%).

Postoperatively, hospital length of stay was significantly shorter in the laparoscopic group (a mean of 3.3 days) than in the open group (a mean of 8.4 days). The laparoscopic group also had significantly fewer surgical site infections (1% vs. 22%), anastomotic leaks (0% vs. 7%), and postoperative arrhythmias (0% vs. 15%).

Overall complications, evaluated on the basis of the Accordion Severity Grading System of surgical complications, were less severe in the laparoscopic group. "However, there was one perioperative death in the laparoscopic group related to a massive myocardial infarction, as well as two reoperations, one related to a port site hernia and one related to a gastric outlet obstruction in an antral lesion," Dr. Ganai said.

On multivariate analysis, conversion was predicted by tumor size greater than 8 cm (odds ratio, 18.48), while recurrence was predicted by having a mitotic rate of greater than 5 mitoses per 50 high-power fields (OR, 4.68). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, shorter operative times, less blood loss, and shorter lengths of stay (P less than .05). No significant difference was seen in survival; 90% and 81% of patients were alive 3 years after laparoscopic and open resection, respectively (hazard ratio, 0.4; P = .13). "Tumor biology and imatinib may play a greater role in oncologic outcome than technical considerations," Dr. Ganai suggested.

She acknowledged certain limitations of the study, including its retrospective design, the potential for selection bias, and limited follow-up, "especially in the lower-risk tumors."

Dr. Ganai said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Researchers have taken a major step toward eliminating the need for routine pathology on every polyp removed during colonoscopy.

Use of a high-definition, dual-focus colonoscope allowed endoscopists to perform "significantly more accurate, high-confidence endoscopic diagnosis of diminutive polyps," Dr. Tonya Kaltenbach said at the annual Digestive Disease Week.

"In many hospitals, about 20%-25% of all pathology samples are small colon polyps, almost all of which are benign. This is a lot of money that can be saved," said Dr. Kaltenbach in a written statement. About 80% of all polyps found during screening colonoscopy are diminutive, 5 mm in diameter or less, and the current standard of care is to do a pathology analysis on each of these polyps.

As used by five gastroenterologists who participated in the study at three U.S. centers to assess 530 polyps in 277 people, the high-definition scope produced a 95.9% agreement in polyp assignment for follow-up surveillance, compared with pathology-laboratory analysis of the same polyps, and a 96.4% negative predictive value for adenomas, said Dr. Kaltenbach, a gastroenterologist at the VA Medical Center in Palo Alto, Calif.

These performance levels surpassed the greater than 90% targets for colonoscopic assessment of diminutive polyps set last year by a committee organized by the American Society of Gastrointestinal Endoscopy (Gastrointest. Endosc. 2011;73:419-22). Notably, the 90% threshold for assignment of postpolypectomy surveillance accuracy and negative predictive value was set by the ASGE committee before dual-focus colonoscopies like the one used in the current study were in widespread use, said Dr. Roy Soetikno, chief of endoscopy at the Palo Alto VA and senior investigator on the study.

Today, some of the scopes used in routine U.S. practice have the high-definition, dual focus features of the one used in the study, and within the next 5 years essentially all U.S. colonoscopies will have these performance characteristics, he said in an interview.

Although the new study results showed that endoscopists can surpass the thresholds set by the ASGE for visual assessment, widespread use of the method will require further validation, Dr. Soetikno said. "We need to develop programs to teach gastroenterologists and incorporate them into fellowship programs. We also need a way to store the images so that people can document their diagnoses. But [our study] is the beginning," he said.

Dr. Soetikno also noted that the idea of visual assessment of potentially cancerous or precancerous lesions is not new, as the same approach is routinely used in dermatology. With new technologies, gastroenterologists "may be able to do the same thing. We can save our resources, and not spend money on evaluating polyps of no consequence."

Dr. Soetikno, Dr. Kaltenbach, and their associates designed the Veterans Affairs Colorectal Lesion Interpretation and Diagnosis (VALID) study to test the hypothesis that colonoscopy using a high-definition, narrow-band imaging, dual focus colonoscope could increase the rate of accurate, high-confidence histology predictions of diminutive polyps. Five endoscopists working at three VA Medical Centers randomized 558 patients scheduled to undergo routine colonoscopy. The patients averaged 63 years old, 95% were men, and about 80% were white. Roughly 38% underwent colonoscopy for screening, 44% for surveillance following a history of polyps, and for 19% the examination was symptom driven (total is 101% due to rounding).

The protocol randomized 277 people to high-definition colonoscopy with an Olympus model CF-HQ190, and 281 people to examination with an older model without dual-focus capability, the Olympus CF-H180. Examination of the people in the dual-focus group found 710 polyps, including 530 diminutive lesions; the control group had 599 polyps, including 445 that were 5 mm or less.

The endoscopists made accurate, high-confidence endoscopic predictions on 75% of the diminutive polyps that they saw using the dual-focus device, compared with a 63% when they used the less advanced endoscope, a statistically significant difference. When compared with the pathologic assessments, 95.9% of the high-confidence, dual-focus diagnoses produced correct surveillance-interval recommendations, compared with a 95.2% rate using the standard-focus device. Negative predictive value was 96.4% using the dual-focus scope and 92.0% for the more conventional scope. In addition, the dual-focus scope produced no misdiagnoses of advanced histology as non-neoplasia, and use of this scope did not result in any meaningful increase in examination time, nor did it produce any bleeding or perforation.

The VALID study received partial funding from Olympus America, the company that markets the dual-focus, high-definition colonoscope tested. Dr. Soetikno said that he has been a consultant to Olympus. Dr. Kaltenbach and Dr. Kochman said they had no disclosures.

SAN DIEGO – Researchers have taken a major step toward eliminating the need for routine pathology on every polyp removed during colonoscopy.

Use of a high-definition, dual-focus colonoscope allowed endoscopists to perform "significantly more accurate, high-confidence endoscopic diagnosis of diminutive polyps," Dr. Tonya Kaltenbach said at the annual Digestive Disease Week.

"In many hospitals, about 20%-25% of all pathology samples are small colon polyps, almost all of which are benign. This is a lot of money that can be saved," said Dr. Kaltenbach in a written statement. About 80% of all polyps found during screening colonoscopy are diminutive, 5 mm in diameter or less, and the current standard of care is to do a pathology analysis on each of these polyps.

As used by five gastroenterologists who participated in the study at three U.S. centers to assess 530 polyps in 277 people, the high-definition scope produced a 95.9% agreement in polyp assignment for follow-up surveillance, compared with pathology-laboratory analysis of the same polyps, and a 96.4% negative predictive value for adenomas, said Dr. Kaltenbach, a gastroenterologist at the VA Medical Center in Palo Alto, Calif.

These performance levels surpassed the greater than 90% targets for colonoscopic assessment of diminutive polyps set last year by a committee organized by the American Society of Gastrointestinal Endoscopy (Gastrointest. Endosc. 2011;73:419-22). Notably, the 90% threshold for assignment of postpolypectomy surveillance accuracy and negative predictive value was set by the ASGE committee before dual-focus colonoscopies like the one used in the current study were in widespread use, said Dr. Roy Soetikno, chief of endoscopy at the Palo Alto VA and senior investigator on the study.

Today, some of the scopes used in routine U.S. practice have the high-definition, dual focus features of the one used in the study, and within the next 5 years essentially all U.S. colonoscopies will have these performance characteristics, he said in an interview.

Although the new study results showed that endoscopists can surpass the thresholds set by the ASGE for visual assessment, widespread use of the method will require further validation, Dr. Soetikno said. "We need to develop programs to teach gastroenterologists and incorporate them into fellowship programs. We also need a way to store the images so that people can document their diagnoses. But [our study] is the beginning," he said.

Dr. Soetikno also noted that the idea of visual assessment of potentially cancerous or precancerous lesions is not new, as the same approach is routinely used in dermatology. With new technologies, gastroenterologists "may be able to do the same thing. We can save our resources, and not spend money on evaluating polyps of no consequence."

Dr. Soetikno, Dr. Kaltenbach, and their associates designed the Veterans Affairs Colorectal Lesion Interpretation and Diagnosis (VALID) study to test the hypothesis that colonoscopy using a high-definition, narrow-band imaging, dual focus colonoscope could increase the rate of accurate, high-confidence histology predictions of diminutive polyps. Five endoscopists working at three VA Medical Centers randomized 558 patients scheduled to undergo routine colonoscopy. The patients averaged 63 years old, 95% were men, and about 80% were white. Roughly 38% underwent colonoscopy for screening, 44% for surveillance following a history of polyps, and for 19% the examination was symptom driven (total is 101% due to rounding).

The protocol randomized 277 people to high-definition colonoscopy with an Olympus model CF-HQ190, and 281 people to examination with an older model without dual-focus capability, the Olympus CF-H180. Examination of the people in the dual-focus group found 710 polyps, including 530 diminutive lesions; the control group had 599 polyps, including 445 that were 5 mm or less.

The endoscopists made accurate, high-confidence endoscopic predictions on 75% of the diminutive polyps that they saw using the dual-focus device, compared with a 63% when they used the less advanced endoscope, a statistically significant difference. When compared with the pathologic assessments, 95.9% of the high-confidence, dual-focus diagnoses produced correct surveillance-interval recommendations, compared with a 95.2% rate using the standard-focus device. Negative predictive value was 96.4% using the dual-focus scope and 92.0% for the more conventional scope. In addition, the dual-focus scope produced no misdiagnoses of advanced histology as non-neoplasia, and use of this scope did not result in any meaningful increase in examination time, nor did it produce any bleeding or perforation.

The VALID study received partial funding from Olympus America, the company that markets the dual-focus, high-definition colonoscope tested. Dr. Soetikno said that he has been a consultant to Olympus. Dr. Kaltenbach and Dr. Kochman said they had no disclosures.

SAN DIEGO – Researchers have taken a major step toward eliminating the need for routine pathology on every polyp removed during colonoscopy.

Use of a high-definition, dual-focus colonoscope allowed endoscopists to perform "significantly more accurate, high-confidence endoscopic diagnosis of diminutive polyps," Dr. Tonya Kaltenbach said at the annual Digestive Disease Week.

"In many hospitals, about 20%-25% of all pathology samples are small colon polyps, almost all of which are benign. This is a lot of money that can be saved," said Dr. Kaltenbach in a written statement. About 80% of all polyps found during screening colonoscopy are diminutive, 5 mm in diameter or less, and the current standard of care is to do a pathology analysis on each of these polyps.

As used by five gastroenterologists who participated in the study at three U.S. centers to assess 530 polyps in 277 people, the high-definition scope produced a 95.9% agreement in polyp assignment for follow-up surveillance, compared with pathology-laboratory analysis of the same polyps, and a 96.4% negative predictive value for adenomas, said Dr. Kaltenbach, a gastroenterologist at the VA Medical Center in Palo Alto, Calif.

These performance levels surpassed the greater than 90% targets for colonoscopic assessment of diminutive polyps set last year by a committee organized by the American Society of Gastrointestinal Endoscopy (Gastrointest. Endosc. 2011;73:419-22). Notably, the 90% threshold for assignment of postpolypectomy surveillance accuracy and negative predictive value was set by the ASGE committee before dual-focus colonoscopies like the one used in the current study were in widespread use, said Dr. Roy Soetikno, chief of endoscopy at the Palo Alto VA and senior investigator on the study.

Today, some of the scopes used in routine U.S. practice have the high-definition, dual focus features of the one used in the study, and within the next 5 years essentially all U.S. colonoscopies will have these performance characteristics, he said in an interview.

Although the new study results showed that endoscopists can surpass the thresholds set by the ASGE for visual assessment, widespread use of the method will require further validation, Dr. Soetikno said. "We need to develop programs to teach gastroenterologists and incorporate them into fellowship programs. We also need a way to store the images so that people can document their diagnoses. But [our study] is the beginning," he said.

Dr. Soetikno also noted that the idea of visual assessment of potentially cancerous or precancerous lesions is not new, as the same approach is routinely used in dermatology. With new technologies, gastroenterologists "may be able to do the same thing. We can save our resources, and not spend money on evaluating polyps of no consequence."

Dr. Soetikno, Dr. Kaltenbach, and their associates designed the Veterans Affairs Colorectal Lesion Interpretation and Diagnosis (VALID) study to test the hypothesis that colonoscopy using a high-definition, narrow-band imaging, dual focus colonoscope could increase the rate of accurate, high-confidence histology predictions of diminutive polyps. Five endoscopists working at three VA Medical Centers randomized 558 patients scheduled to undergo routine colonoscopy. The patients averaged 63 years old, 95% were men, and about 80% were white. Roughly 38% underwent colonoscopy for screening, 44% for surveillance following a history of polyps, and for 19% the examination was symptom driven (total is 101% due to rounding).

The protocol randomized 277 people to high-definition colonoscopy with an Olympus model CF-HQ190, and 281 people to examination with an older model without dual-focus capability, the Olympus CF-H180. Examination of the people in the dual-focus group found 710 polyps, including 530 diminutive lesions; the control group had 599 polyps, including 445 that were 5 mm or less.

The endoscopists made accurate, high-confidence endoscopic predictions on 75% of the diminutive polyps that they saw using the dual-focus device, compared with a 63% when they used the less advanced endoscope, a statistically significant difference. When compared with the pathologic assessments, 95.9% of the high-confidence, dual-focus diagnoses produced correct surveillance-interval recommendations, compared with a 95.2% rate using the standard-focus device. Negative predictive value was 96.4% using the dual-focus scope and 92.0% for the more conventional scope. In addition, the dual-focus scope produced no misdiagnoses of advanced histology as non-neoplasia, and use of this scope did not result in any meaningful increase in examination time, nor did it produce any bleeding or perforation.

The VALID study received partial funding from Olympus America, the company that markets the dual-focus, high-definition colonoscope tested. Dr. Soetikno said that he has been a consultant to Olympus. Dr. Kaltenbach and Dr. Kochman said they had no disclosures.