From the AGA Journals

Fifteen years after treatment for localized prostate cancer, men who underwent radical prostatectomy reported no differences in urinary, bowel, or sexual function compared with men who underwent external-beam radiation, according to a report published online Jan. 30 in the New England Journal of Medicine.

Using data from the Prostate Cancer Outcomes Study (PCOS), a population-based cohort of men across the United States diagnosed as having prostate cancer in the mid-1990s, researchers tracked the long-term disease-specific outcomes of 1,655 men who underwent radical prostatectomy (70.3% of patients) or radiotherapy (29.7%), with or without androgen-deprivation therapy.

Source: American Gastroenterological Association (www.youtube.com/AmerGastroAssn)

"Since the median life expectancy after treatment for prostate cancer is 13.8 years, a careful evaluation of long-term functional outcomes is critical to an understanding of the comprehensive experience of men living with a diagnosis of prostate cancer," said Dr. Matthew J. Resnick of the department of urologic surgery and the Center for Surgical Quality and Outcomes Research, Vanderbilt University, Nashville, Tenn., and his associates.

Even though men who had radical prostatectomy were more likely to be bothered by such difficulties as urinary incontinence, bowel urgency, and erectile dysfunction at 2 years and 5 years after treatment, those differences disappeared by the 15-year mark. At that time, the prevalence of ED was "nearly universal," affecting 87% of men in the prostatectomy group and 94% of those in the radiotherapy group; yet only 43% and 38%, respectively, reported that this bothered them.

"Long-term follow-up reveals consistent functional declines after 5 years. It remains unknown whether this continued decline is due to prostate cancer and its treatment, the normal aging process, or a combination of factors," the investigators said (N. Engl. J. Med. 2013 [doi10.1056/NEJMoa1209978]).

This study was funded by the National Cancer Institute. Dr. Resnick was supported by the VA National Quality Scholars Program and the T. J. Martell Foundation. Dr. Resnick reported ties to Dendreon and Bayer Healthcare, and his associates reported ties to Ferring and Johnson & Johnson.

Fifteen years after treatment for localized prostate cancer, men who underwent radical prostatectomy reported no differences in urinary, bowel, or sexual function compared with men who underwent external-beam radiation, according to a report published online Jan. 30 in the New England Journal of Medicine.

Using data from the Prostate Cancer Outcomes Study (PCOS), a population-based cohort of men across the United States diagnosed as having prostate cancer in the mid-1990s, researchers tracked the long-term disease-specific outcomes of 1,655 men who underwent radical prostatectomy (70.3% of patients) or radiotherapy (29.7%), with or without androgen-deprivation therapy.

Source: American Gastroenterological Association (www.youtube.com/AmerGastroAssn)

"Since the median life expectancy after treatment for prostate cancer is 13.8 years, a careful evaluation of long-term functional outcomes is critical to an understanding of the comprehensive experience of men living with a diagnosis of prostate cancer," said Dr. Matthew J. Resnick of the department of urologic surgery and the Center for Surgical Quality and Outcomes Research, Vanderbilt University, Nashville, Tenn., and his associates.

Even though men who had radical prostatectomy were more likely to be bothered by such difficulties as urinary incontinence, bowel urgency, and erectile dysfunction at 2 years and 5 years after treatment, those differences disappeared by the 15-year mark. At that time, the prevalence of ED was "nearly universal," affecting 87% of men in the prostatectomy group and 94% of those in the radiotherapy group; yet only 43% and 38%, respectively, reported that this bothered them.

"Long-term follow-up reveals consistent functional declines after 5 years. It remains unknown whether this continued decline is due to prostate cancer and its treatment, the normal aging process, or a combination of factors," the investigators said (N. Engl. J. Med. 2013 [doi10.1056/NEJMoa1209978]).

This study was funded by the National Cancer Institute. Dr. Resnick was supported by the VA National Quality Scholars Program and the T. J. Martell Foundation. Dr. Resnick reported ties to Dendreon and Bayer Healthcare, and his associates reported ties to Ferring and Johnson & Johnson.

Fifteen years after treatment for localized prostate cancer, men who underwent radical prostatectomy reported no differences in urinary, bowel, or sexual function compared with men who underwent external-beam radiation, according to a report published online Jan. 30 in the New England Journal of Medicine.

Using data from the Prostate Cancer Outcomes Study (PCOS), a population-based cohort of men across the United States diagnosed as having prostate cancer in the mid-1990s, researchers tracked the long-term disease-specific outcomes of 1,655 men who underwent radical prostatectomy (70.3% of patients) or radiotherapy (29.7%), with or without androgen-deprivation therapy.

Source: American Gastroenterological Association (www.youtube.com/AmerGastroAssn)

"Since the median life expectancy after treatment for prostate cancer is 13.8 years, a careful evaluation of long-term functional outcomes is critical to an understanding of the comprehensive experience of men living with a diagnosis of prostate cancer," said Dr. Matthew J. Resnick of the department of urologic surgery and the Center for Surgical Quality and Outcomes Research, Vanderbilt University, Nashville, Tenn., and his associates.

Even though men who had radical prostatectomy were more likely to be bothered by such difficulties as urinary incontinence, bowel urgency, and erectile dysfunction at 2 years and 5 years after treatment, those differences disappeared by the 15-year mark. At that time, the prevalence of ED was "nearly universal," affecting 87% of men in the prostatectomy group and 94% of those in the radiotherapy group; yet only 43% and 38%, respectively, reported that this bothered them.

"Long-term follow-up reveals consistent functional declines after 5 years. It remains unknown whether this continued decline is due to prostate cancer and its treatment, the normal aging process, or a combination of factors," the investigators said (N. Engl. J. Med. 2013 [doi10.1056/NEJMoa1209978]).

This study was funded by the National Cancer Institute. Dr. Resnick was supported by the VA National Quality Scholars Program and the T. J. Martell Foundation. Dr. Resnick reported ties to Dendreon and Bayer Healthcare, and his associates reported ties to Ferring and Johnson & Johnson.

Nearly 9% of all routine outpatient colonoscopies that were performed in 1 year in a nationally representative sample of Medicare beneficiaries used anesthesia assistance – an anesthesiologist or nurse-anesthetist – to administer deep sedation using propofol.

The American Society for Gastrointestinal Endoscopy recommends against anesthesia assistance for such average-risk patients because it isn’t warranted and is cost-prohibitive. Nevertheless, in this retrospective cohort study using a nationally representative sample of 328,177 Medicare patients who underwent routine outpatient colonoscopy during 2003, anesthesia assistance was used in 8.7% of the procedures. This included 8.2% of procedures done in patients who had no comorbidities (Gastroenterology 2012 Oct. 29 [doi: 10.1053/j.gastro.2012.10.038]).

The researchers, led by Dr. Jason A. Dominitz of the VA Puget Sound Health Care System in Seattle, found that the use of anesthesia assistance varied dramatically by geographic location and by the endoscopist’s specialty. A very small proportion of the endoscopists in this study, 4.5%, accounted for more than 40% of the procedures performed using anesthesia assistance.

"Those endoscopists with very high rates of anesthesia assistance overwhelmingly practiced in an urban setting (95%) and were disproportionately represented by gastroenterologists (76%) and colorectal surgeons (10%)," as compared with general surgeons, internists, family physicians, or others.

"This practice has enormous economic implications for society, as the use of an anesthesia provider adds a considerable cost to each procedure and is at variance with recommendations from professional societies. In 2003, charges to Medicare for sedation by anesthesia professionals during colonoscopy were nearly $80 million," said Dr. Dominitz, who is also with the division of gastroenterology at the University of Washington, Seattle, and his associates.

"If the projected growth in the use of anesthesia assistance does reach 53% by 2015, the total national expenditure for this service could range from approximately $800 million to $3.8 billion annually," they noted.

The investigators studied this issue because the use of propofol for deep sedation during routine colonoscopies has increased markedly.

The study sample included only colonoscopies performed in hospital outpatient clinics, ambulatory surgery centers, private offices, and other outpatient settings by 18,578 physicians.

Among the study’s findings:

• Use of anesthesia assistance didn’t alter the rate of detection of colonic polyps or the rate of complications such as GI bleeding, perforation, and hospital/ED visits within 30 days.

• Use of anesthesia assistance varied widely among the states, and even between states that bordered each other. The lowest rates of use were in Montana (0.1%) and South Dakota (0.2%); the highest were in New Jersey (48.1%), New York (27.9%), and Nevada (26.0%). "This variation is most likely attributable to variation in reimbursement practices by different carriers," Dr. Dominitz and his associates said.

• Younger endoscopists and those with fewer years in practice were more likely than older endoscopists and those with more years in practice to use anesthesia assistance.

• The volume of patients seen by the endoscopist did not correlate with use of anesthesia assistance.

• More than 80% of general surgeons, internists, and family physicians performed no colonoscopies with anesthesia assistance.

• Anesthesia assistance was more frequently used in black than in white patients, perhaps because of the very high rates of use in urban settings, where there is more racial diversity. Urban patients were more than twice as likely to receive anesthesia assistance as rural patients.

In a sensitivity analysis excluding patients with comorbidities, the findings confirmed those of the main analysis.

This study was not designed to determine the reasons for these variations in the use of anesthesia assistance. However, the researchers speculated that because propofol has a faster onset and more rapid recovery time than opiates and benzodiazepines, it improves practice efficiency, allowing more procedures to be performed per day.

In addition, employing anesthesia providers can generate an extra income stream for endoscopy practices. And if endoscopists who practice outside of hospitals already employ anesthesia providers for higher-risk or hard-to-sedate patients, "it may be prudent business practice to utilize these providers for more routine cases as well," Dr. Dominitz and his colleagues said.

This study was supported by the American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the VA Puget Sound Health Care System. No financial conflicts of interest were reported.

Nearly 9% of all routine outpatient colonoscopies that were performed in 1 year in a nationally representative sample of Medicare beneficiaries used anesthesia assistance – an anesthesiologist or nurse-anesthetist – to administer deep sedation using propofol.

The American Society for Gastrointestinal Endoscopy recommends against anesthesia assistance for such average-risk patients because it isn’t warranted and is cost-prohibitive. Nevertheless, in this retrospective cohort study using a nationally representative sample of 328,177 Medicare patients who underwent routine outpatient colonoscopy during 2003, anesthesia assistance was used in 8.7% of the procedures. This included 8.2% of procedures done in patients who had no comorbidities (Gastroenterology 2012 Oct. 29 [doi: 10.1053/j.gastro.2012.10.038]).

The researchers, led by Dr. Jason A. Dominitz of the VA Puget Sound Health Care System in Seattle, found that the use of anesthesia assistance varied dramatically by geographic location and by the endoscopist’s specialty. A very small proportion of the endoscopists in this study, 4.5%, accounted for more than 40% of the procedures performed using anesthesia assistance.

"Those endoscopists with very high rates of anesthesia assistance overwhelmingly practiced in an urban setting (95%) and were disproportionately represented by gastroenterologists (76%) and colorectal surgeons (10%)," as compared with general surgeons, internists, family physicians, or others.

"This practice has enormous economic implications for society, as the use of an anesthesia provider adds a considerable cost to each procedure and is at variance with recommendations from professional societies. In 2003, charges to Medicare for sedation by anesthesia professionals during colonoscopy were nearly $80 million," said Dr. Dominitz, who is also with the division of gastroenterology at the University of Washington, Seattle, and his associates.

"If the projected growth in the use of anesthesia assistance does reach 53% by 2015, the total national expenditure for this service could range from approximately $800 million to $3.8 billion annually," they noted.

The investigators studied this issue because the use of propofol for deep sedation during routine colonoscopies has increased markedly.

The study sample included only colonoscopies performed in hospital outpatient clinics, ambulatory surgery centers, private offices, and other outpatient settings by 18,578 physicians.

Among the study’s findings:

• Use of anesthesia assistance didn’t alter the rate of detection of colonic polyps or the rate of complications such as GI bleeding, perforation, and hospital/ED visits within 30 days.

• Use of anesthesia assistance varied widely among the states, and even between states that bordered each other. The lowest rates of use were in Montana (0.1%) and South Dakota (0.2%); the highest were in New Jersey (48.1%), New York (27.9%), and Nevada (26.0%). "This variation is most likely attributable to variation in reimbursement practices by different carriers," Dr. Dominitz and his associates said.

• Younger endoscopists and those with fewer years in practice were more likely than older endoscopists and those with more years in practice to use anesthesia assistance.

• The volume of patients seen by the endoscopist did not correlate with use of anesthesia assistance.

• More than 80% of general surgeons, internists, and family physicians performed no colonoscopies with anesthesia assistance.

• Anesthesia assistance was more frequently used in black than in white patients, perhaps because of the very high rates of use in urban settings, where there is more racial diversity. Urban patients were more than twice as likely to receive anesthesia assistance as rural patients.

In a sensitivity analysis excluding patients with comorbidities, the findings confirmed those of the main analysis.

This study was not designed to determine the reasons for these variations in the use of anesthesia assistance. However, the researchers speculated that because propofol has a faster onset and more rapid recovery time than opiates and benzodiazepines, it improves practice efficiency, allowing more procedures to be performed per day.

In addition, employing anesthesia providers can generate an extra income stream for endoscopy practices. And if endoscopists who practice outside of hospitals already employ anesthesia providers for higher-risk or hard-to-sedate patients, "it may be prudent business practice to utilize these providers for more routine cases as well," Dr. Dominitz and his colleagues said.

This study was supported by the American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the VA Puget Sound Health Care System. No financial conflicts of interest were reported.

Nearly 9% of all routine outpatient colonoscopies that were performed in 1 year in a nationally representative sample of Medicare beneficiaries used anesthesia assistance – an anesthesiologist or nurse-anesthetist – to administer deep sedation using propofol.

The American Society for Gastrointestinal Endoscopy recommends against anesthesia assistance for such average-risk patients because it isn’t warranted and is cost-prohibitive. Nevertheless, in this retrospective cohort study using a nationally representative sample of 328,177 Medicare patients who underwent routine outpatient colonoscopy during 2003, anesthesia assistance was used in 8.7% of the procedures. This included 8.2% of procedures done in patients who had no comorbidities (Gastroenterology 2012 Oct. 29 [doi: 10.1053/j.gastro.2012.10.038]).

The researchers, led by Dr. Jason A. Dominitz of the VA Puget Sound Health Care System in Seattle, found that the use of anesthesia assistance varied dramatically by geographic location and by the endoscopist’s specialty. A very small proportion of the endoscopists in this study, 4.5%, accounted for more than 40% of the procedures performed using anesthesia assistance.

"Those endoscopists with very high rates of anesthesia assistance overwhelmingly practiced in an urban setting (95%) and were disproportionately represented by gastroenterologists (76%) and colorectal surgeons (10%)," as compared with general surgeons, internists, family physicians, or others.

"This practice has enormous economic implications for society, as the use of an anesthesia provider adds a considerable cost to each procedure and is at variance with recommendations from professional societies. In 2003, charges to Medicare for sedation by anesthesia professionals during colonoscopy were nearly $80 million," said Dr. Dominitz, who is also with the division of gastroenterology at the University of Washington, Seattle, and his associates.

"If the projected growth in the use of anesthesia assistance does reach 53% by 2015, the total national expenditure for this service could range from approximately $800 million to $3.8 billion annually," they noted.

The investigators studied this issue because the use of propofol for deep sedation during routine colonoscopies has increased markedly.

The study sample included only colonoscopies performed in hospital outpatient clinics, ambulatory surgery centers, private offices, and other outpatient settings by 18,578 physicians.

Among the study’s findings:

• Use of anesthesia assistance didn’t alter the rate of detection of colonic polyps or the rate of complications such as GI bleeding, perforation, and hospital/ED visits within 30 days.

• Use of anesthesia assistance varied widely among the states, and even between states that bordered each other. The lowest rates of use were in Montana (0.1%) and South Dakota (0.2%); the highest were in New Jersey (48.1%), New York (27.9%), and Nevada (26.0%). "This variation is most likely attributable to variation in reimbursement practices by different carriers," Dr. Dominitz and his associates said.

• Younger endoscopists and those with fewer years in practice were more likely than older endoscopists and those with more years in practice to use anesthesia assistance.

• The volume of patients seen by the endoscopist did not correlate with use of anesthesia assistance.

• More than 80% of general surgeons, internists, and family physicians performed no colonoscopies with anesthesia assistance.

• Anesthesia assistance was more frequently used in black than in white patients, perhaps because of the very high rates of use in urban settings, where there is more racial diversity. Urban patients were more than twice as likely to receive anesthesia assistance as rural patients.

In a sensitivity analysis excluding patients with comorbidities, the findings confirmed those of the main analysis.

This study was not designed to determine the reasons for these variations in the use of anesthesia assistance. However, the researchers speculated that because propofol has a faster onset and more rapid recovery time than opiates and benzodiazepines, it improves practice efficiency, allowing more procedures to be performed per day.

In addition, employing anesthesia providers can generate an extra income stream for endoscopy practices. And if endoscopists who practice outside of hospitals already employ anesthesia providers for higher-risk or hard-to-sedate patients, "it may be prudent business practice to utilize these providers for more routine cases as well," Dr. Dominitz and his colleagues said.

This study was supported by the American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the VA Puget Sound Health Care System. No financial conflicts of interest were reported.

High-resolution manometry with esophageal pressure topography is known to improve the accuracy of manometry for detecting achalasia and defined clinically relevant subtypes prior to treatment, but new data demonstrate that the procedure also is useful for evaluating treatment efficacy.

In a study of 31 men and 19 women aged 20-79 years, resolution of the achalasia pattern on high-resolution manometry with esophageal pressure topography (HRM-EPT) after treatment was associated with symptom improvement and reduced bolus retention, reported Dr. Frédéric Nicodème of Northwestern University, Chicago, and his colleagues.

Video source: American Gastroenterological Association's YouTube Channel

Study participants included one cohort of 25 patients who underwent endoscopy, HRM, timed barium esophagram (TBE) following a 200-mL barium swallow, and symptom assessment before treatment, and a second cohort of 25 treated patients who had pretreatment type 1 or 2 achalasia and who were undergoing a posttreatment study protocol including HRM, TBE, endoscopy, and symptom assessment. The investigators assessed dysphagia, regurgitation, retrosternal pain, and weight loss and used them to calculate an Eckardt score (ES) for both cohorts.

In the untreated cohort, which included 10 patients with type 1 achalasia and 15 with type 2 achalasia, the key EPT metric of integrated relaxation pressure (IRP) was significantly greater in the type 2 patients, as was the nadir-relaxation pressure. No differences were seen based on disease type with respect to resting esophagogastric junction (EGJ) pressure, barium column height, barium column width, or ES (Clin. Gastroenterol. Hepatol. 2012 Oct. 12 [doi: 10.1016/j.cgh.2012.10.015]).

No correlation was found between TBE column height at 5 minutes and IRP, resting EGJ pressure, nadir-EGJ relaxation pressure, or ES, and no correlation was seen between ES and IRP, resting EGJ pressure, or nadir-EGJ relaxation pressure.

In the posttreatment cohort, 10 patients, including 6 with type 1 disease and 4 with type 2 disease, had EPT findings of persistent achalasia pattern, and 15 had resolution of the achalasia pattern. Of these 15 patients, 8 converted to absent peristalsis and 7 to weak peristalsis.

"The IRP, resting EGJ pressure, and nadir-EGJ were all significantly correlated with posttreatment ES," the investigators noted.

Furthermore, TBE column height at 5 minutes, IRP, and ES were significantly lower in patients with resolved achalasia patterns on HRM than in those with a persistent achalasia pattern; the subgroup of 7 patients with weak peristalsis appeared to have the best outcome.

"The median TBE column height at 5 minutes was significantly lower [in those with weak peristalsis] than the three other groups, and ES showed a trend toward a lower value compared to the other 3 groups," they explained.

No significant correlations between TBE column height at 5 minutes and resting EGJ pressure or nadir-EGJ relaxation pressure were noted in the posttreatment patients. Only the IRP showed a weak correlation.

"The correlation between TBE column height at 5 minutes and ES after treatment was also not significant. However, the median TBE column height at 5 minutes for patients with an ES of 3 or greater was significantly greater than that for patients with an ES less than 3," they wrote.

"Our findings suggest that resolution of the achalasia pattern on EPT after treatment was associated with an improvement in symptoms and reduced bolus retention. Although the IRP was not strongly linearly correlated with symptom severity, when analyzed dichotomously patients with an IRP greater than or equal to 15 mm Hg had worse symptom scores and greater bolus retention on TBE compared to those with normal IRP values," the investigators wrote.

In contrast, no EPT pattern or metric, and no TBE variable predicted symptom severity in the untreated cohort, and barium height on TBE did not distinguish achalasia EPT subtypes, they noted.

"These findings suggest that in addition to its proven utility in detecting pretreatment achalasia, EPT also has utility in the management of posttreatment achalasia that can complement TBE," they said.

Although TBE did not distinguish disease subtypes, it does complement EPT, especially when the disease has progressed to an anatomic-dominant disorder, they said. Additional studies in larger series of patients are needed before and after therapy to confidently establish the relative merits of each evaluation with respect to the prediction of long-term outcomes and cost-effectiveness, they said.

This study was supported by the Public Health Service. The authors reported having no disclosures.

High-resolution manometry with esophageal pressure topography is known to improve the accuracy of manometry for detecting achalasia and defined clinically relevant subtypes prior to treatment, but new data demonstrate that the procedure also is useful for evaluating treatment efficacy.

In a study of 31 men and 19 women aged 20-79 years, resolution of the achalasia pattern on high-resolution manometry with esophageal pressure topography (HRM-EPT) after treatment was associated with symptom improvement and reduced bolus retention, reported Dr. Frédéric Nicodème of Northwestern University, Chicago, and his colleagues.

Video source: American Gastroenterological Association's YouTube Channel

Study participants included one cohort of 25 patients who underwent endoscopy, HRM, timed barium esophagram (TBE) following a 200-mL barium swallow, and symptom assessment before treatment, and a second cohort of 25 treated patients who had pretreatment type 1 or 2 achalasia and who were undergoing a posttreatment study protocol including HRM, TBE, endoscopy, and symptom assessment. The investigators assessed dysphagia, regurgitation, retrosternal pain, and weight loss and used them to calculate an Eckardt score (ES) for both cohorts.

In the untreated cohort, which included 10 patients with type 1 achalasia and 15 with type 2 achalasia, the key EPT metric of integrated relaxation pressure (IRP) was significantly greater in the type 2 patients, as was the nadir-relaxation pressure. No differences were seen based on disease type with respect to resting esophagogastric junction (EGJ) pressure, barium column height, barium column width, or ES (Clin. Gastroenterol. Hepatol. 2012 Oct. 12 [doi: 10.1016/j.cgh.2012.10.015]).

No correlation was found between TBE column height at 5 minutes and IRP, resting EGJ pressure, nadir-EGJ relaxation pressure, or ES, and no correlation was seen between ES and IRP, resting EGJ pressure, or nadir-EGJ relaxation pressure.

In the posttreatment cohort, 10 patients, including 6 with type 1 disease and 4 with type 2 disease, had EPT findings of persistent achalasia pattern, and 15 had resolution of the achalasia pattern. Of these 15 patients, 8 converted to absent peristalsis and 7 to weak peristalsis.

"The IRP, resting EGJ pressure, and nadir-EGJ were all significantly correlated with posttreatment ES," the investigators noted.

Furthermore, TBE column height at 5 minutes, IRP, and ES were significantly lower in patients with resolved achalasia patterns on HRM than in those with a persistent achalasia pattern; the subgroup of 7 patients with weak peristalsis appeared to have the best outcome.

"The median TBE column height at 5 minutes was significantly lower [in those with weak peristalsis] than the three other groups, and ES showed a trend toward a lower value compared to the other 3 groups," they explained.

No significant correlations between TBE column height at 5 minutes and resting EGJ pressure or nadir-EGJ relaxation pressure were noted in the posttreatment patients. Only the IRP showed a weak correlation.

"The correlation between TBE column height at 5 minutes and ES after treatment was also not significant. However, the median TBE column height at 5 minutes for patients with an ES of 3 or greater was significantly greater than that for patients with an ES less than 3," they wrote.

"Our findings suggest that resolution of the achalasia pattern on EPT after treatment was associated with an improvement in symptoms and reduced bolus retention. Although the IRP was not strongly linearly correlated with symptom severity, when analyzed dichotomously patients with an IRP greater than or equal to 15 mm Hg had worse symptom scores and greater bolus retention on TBE compared to those with normal IRP values," the investigators wrote.

In contrast, no EPT pattern or metric, and no TBE variable predicted symptom severity in the untreated cohort, and barium height on TBE did not distinguish achalasia EPT subtypes, they noted.

"These findings suggest that in addition to its proven utility in detecting pretreatment achalasia, EPT also has utility in the management of posttreatment achalasia that can complement TBE," they said.

Although TBE did not distinguish disease subtypes, it does complement EPT, especially when the disease has progressed to an anatomic-dominant disorder, they said. Additional studies in larger series of patients are needed before and after therapy to confidently establish the relative merits of each evaluation with respect to the prediction of long-term outcomes and cost-effectiveness, they said.

This study was supported by the Public Health Service. The authors reported having no disclosures.

High-resolution manometry with esophageal pressure topography is known to improve the accuracy of manometry for detecting achalasia and defined clinically relevant subtypes prior to treatment, but new data demonstrate that the procedure also is useful for evaluating treatment efficacy.

In a study of 31 men and 19 women aged 20-79 years, resolution of the achalasia pattern on high-resolution manometry with esophageal pressure topography (HRM-EPT) after treatment was associated with symptom improvement and reduced bolus retention, reported Dr. Frédéric Nicodème of Northwestern University, Chicago, and his colleagues.

Video source: American Gastroenterological Association's YouTube Channel

Study participants included one cohort of 25 patients who underwent endoscopy, HRM, timed barium esophagram (TBE) following a 200-mL barium swallow, and symptom assessment before treatment, and a second cohort of 25 treated patients who had pretreatment type 1 or 2 achalasia and who were undergoing a posttreatment study protocol including HRM, TBE, endoscopy, and symptom assessment. The investigators assessed dysphagia, regurgitation, retrosternal pain, and weight loss and used them to calculate an Eckardt score (ES) for both cohorts.

In the untreated cohort, which included 10 patients with type 1 achalasia and 15 with type 2 achalasia, the key EPT metric of integrated relaxation pressure (IRP) was significantly greater in the type 2 patients, as was the nadir-relaxation pressure. No differences were seen based on disease type with respect to resting esophagogastric junction (EGJ) pressure, barium column height, barium column width, or ES (Clin. Gastroenterol. Hepatol. 2012 Oct. 12 [doi: 10.1016/j.cgh.2012.10.015]).

No correlation was found between TBE column height at 5 minutes and IRP, resting EGJ pressure, nadir-EGJ relaxation pressure, or ES, and no correlation was seen between ES and IRP, resting EGJ pressure, or nadir-EGJ relaxation pressure.

In the posttreatment cohort, 10 patients, including 6 with type 1 disease and 4 with type 2 disease, had EPT findings of persistent achalasia pattern, and 15 had resolution of the achalasia pattern. Of these 15 patients, 8 converted to absent peristalsis and 7 to weak peristalsis.

"The IRP, resting EGJ pressure, and nadir-EGJ were all significantly correlated with posttreatment ES," the investigators noted.

Furthermore, TBE column height at 5 minutes, IRP, and ES were significantly lower in patients with resolved achalasia patterns on HRM than in those with a persistent achalasia pattern; the subgroup of 7 patients with weak peristalsis appeared to have the best outcome.

"The median TBE column height at 5 minutes was significantly lower [in those with weak peristalsis] than the three other groups, and ES showed a trend toward a lower value compared to the other 3 groups," they explained.

No significant correlations between TBE column height at 5 minutes and resting EGJ pressure or nadir-EGJ relaxation pressure were noted in the posttreatment patients. Only the IRP showed a weak correlation.

"The correlation between TBE column height at 5 minutes and ES after treatment was also not significant. However, the median TBE column height at 5 minutes for patients with an ES of 3 or greater was significantly greater than that for patients with an ES less than 3," they wrote.

"Our findings suggest that resolution of the achalasia pattern on EPT after treatment was associated with an improvement in symptoms and reduced bolus retention. Although the IRP was not strongly linearly correlated with symptom severity, when analyzed dichotomously patients with an IRP greater than or equal to 15 mm Hg had worse symptom scores and greater bolus retention on TBE compared to those with normal IRP values," the investigators wrote.

In contrast, no EPT pattern or metric, and no TBE variable predicted symptom severity in the untreated cohort, and barium height on TBE did not distinguish achalasia EPT subtypes, they noted.

"These findings suggest that in addition to its proven utility in detecting pretreatment achalasia, EPT also has utility in the management of posttreatment achalasia that can complement TBE," they said.

Although TBE did not distinguish disease subtypes, it does complement EPT, especially when the disease has progressed to an anatomic-dominant disorder, they said. Additional studies in larger series of patients are needed before and after therapy to confidently establish the relative merits of each evaluation with respect to the prediction of long-term outcomes and cost-effectiveness, they said.

This study was supported by the Public Health Service. The authors reported having no disclosures.

Approximately 10% of neoplastic polyps that were 5-20 mm in size were not completely resected in a series of 1,427 patients undergoing colonoscopy, Dr. Heiko Pohl and his colleagues reported in the January issue of Gastroenterology.

Biopsies from the resection margins of 346 neoplastic polyps showed that some neoplastic tissue had been left behind in 35 cases in the Complete Adenoma Resection (CARE) study, which involved 11 experienced gastroenterologists practicing at two large academic medical centers.

Video source: American Gastroenterological Association YouTube channel

The rate of incomplete resections varied widely across the different endoscopists, from 6.5% to 22.7%. Moreover, these physicians were aware that they were participating in the study and may have been more careful than usual to accomplish complete resection.

"Our study provides plausible data that incomplete polyp resection in daily clinical practice is relatively common and may contribute to future interval cancers," said Dr. Pohl of White River Junction (Vt.) VA Medical Center and Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and his associates.

The findings also suggest that quality measures for colonoscopy, which to date have focused primarily on detection rates, should now include the completeness of the resection. "The performance of high-quality and effective colonoscopy not only requires expertise in finding neoplastic polyps, but also removing them," the investigators noted (Gastroenterology 2013;144:74-80).

Until now, there has been "surprisingly little direct information on the adequacy of polyp resection. It is generally assumed that resection is complete if no apparent polyp tissue is visible after resection. Using a snare with electrocautery should further destroy any remaining polyp tissue," but whether it actually does so has never been tested, they said.

Dr. Pohl and his colleagues reviewed the cases of all adults aged 40-85 years who presented for outpatient colonoscopy at the two study centers, had no history of inflammatory bowel disease, had no coagulopathies, and were found to have at least one polyp that was 5-20 mm in size.

The board-certified gastroenterologists participating in the study used standard colonoscopes and polypectomy snares to remove the lesions, along with standard electrocautery equipment. The polyps were measured and resected, then the gastroenterologists inspected the resection margins macroscopically, obtained forceps biopsies of the resection margins, and attested that the removal was complete.

They also recorded whether the resection had been easy, moderately difficult, or difficult.

The use of narrow band imaging, chromoendoscopy, or argon plasma coagulation was not required by the study protocol but was allowed at the discretion of each gastroenterologist.

An expert gastrointestinal pathologist independently examined all the biopsies for residual adenomatous tissue, as well as to classify the polyps.

A total of 346 polyps (83%) were neoplastic.

Sixty-eight percent of these polyps were classified as tubular, tubulovillous, or villous adenomas. Twelve percent had a serrated histology, including 42 (10%) that were sessile serrated adenomas/polyps.

The expert reviewer found that overall, 10% of the neoplastic polyps were incompletely resected.

Large (10- to 20-mm) growths were more than twice as likely to be incompletely resected (17.3%) than were small (5- to 9-mm) growths (6.8%). Sessile serrated adenomas/polyps were four times more likely than other types to be incompletely resected (31% vs. 7%).

As a result, almost half (48%) of all large sessile serrated adenomas/polyps were incompletely resected.

"Because adenoma size is associated with both a higher prevalence of advanced histology and greater near-term risk of transition to cancer, incomplete resection of large neoplastic polyps is concerning," Dr. Pohl and his colleagues wrote.

No other factors were found to correspond with incomplete removal, including whether the resection was rated as difficult rather than easy, whether the polyps had to be removed piecemeal rather than all at once, whether the polyps were located in the right or left colon, and whether they had flat or other morphology.

"Our results raise questions regarding the quality of polyp resection and call for efforts to improve resection of neoplastic polyps, especially large polyps and sessile serrated adenomas/polyps," the researchers wrote.

In particular, increased attention to the polyp margin using special imaging may be warranted. Outlining and marking the margin before resection also might improve the completeness of the removal. And in some cases, adjunctive ablation of the margins after resection may be useful, they added.

The authors reported no relevant financial conflicts.

Approximately 10% of neoplastic polyps that were 5-20 mm in size were not completely resected in a series of 1,427 patients undergoing colonoscopy, Dr. Heiko Pohl and his colleagues reported in the January issue of Gastroenterology.

Biopsies from the resection margins of 346 neoplastic polyps showed that some neoplastic tissue had been left behind in 35 cases in the Complete Adenoma Resection (CARE) study, which involved 11 experienced gastroenterologists practicing at two large academic medical centers.

Video source: American Gastroenterological Association YouTube channel

The rate of incomplete resections varied widely across the different endoscopists, from 6.5% to 22.7%. Moreover, these physicians were aware that they were participating in the study and may have been more careful than usual to accomplish complete resection.

"Our study provides plausible data that incomplete polyp resection in daily clinical practice is relatively common and may contribute to future interval cancers," said Dr. Pohl of White River Junction (Vt.) VA Medical Center and Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and his associates.

The findings also suggest that quality measures for colonoscopy, which to date have focused primarily on detection rates, should now include the completeness of the resection. "The performance of high-quality and effective colonoscopy not only requires expertise in finding neoplastic polyps, but also removing them," the investigators noted (Gastroenterology 2013;144:74-80).

Until now, there has been "surprisingly little direct information on the adequacy of polyp resection. It is generally assumed that resection is complete if no apparent polyp tissue is visible after resection. Using a snare with electrocautery should further destroy any remaining polyp tissue," but whether it actually does so has never been tested, they said.

Dr. Pohl and his colleagues reviewed the cases of all adults aged 40-85 years who presented for outpatient colonoscopy at the two study centers, had no history of inflammatory bowel disease, had no coagulopathies, and were found to have at least one polyp that was 5-20 mm in size.

The board-certified gastroenterologists participating in the study used standard colonoscopes and polypectomy snares to remove the lesions, along with standard electrocautery equipment. The polyps were measured and resected, then the gastroenterologists inspected the resection margins macroscopically, obtained forceps biopsies of the resection margins, and attested that the removal was complete.

They also recorded whether the resection had been easy, moderately difficult, or difficult.

The use of narrow band imaging, chromoendoscopy, or argon plasma coagulation was not required by the study protocol but was allowed at the discretion of each gastroenterologist.

An expert gastrointestinal pathologist independently examined all the biopsies for residual adenomatous tissue, as well as to classify the polyps.

A total of 346 polyps (83%) were neoplastic.

Sixty-eight percent of these polyps were classified as tubular, tubulovillous, or villous adenomas. Twelve percent had a serrated histology, including 42 (10%) that were sessile serrated adenomas/polyps.

The expert reviewer found that overall, 10% of the neoplastic polyps were incompletely resected.

Large (10- to 20-mm) growths were more than twice as likely to be incompletely resected (17.3%) than were small (5- to 9-mm) growths (6.8%). Sessile serrated adenomas/polyps were four times more likely than other types to be incompletely resected (31% vs. 7%).

As a result, almost half (48%) of all large sessile serrated adenomas/polyps were incompletely resected.

"Because adenoma size is associated with both a higher prevalence of advanced histology and greater near-term risk of transition to cancer, incomplete resection of large neoplastic polyps is concerning," Dr. Pohl and his colleagues wrote.

No other factors were found to correspond with incomplete removal, including whether the resection was rated as difficult rather than easy, whether the polyps had to be removed piecemeal rather than all at once, whether the polyps were located in the right or left colon, and whether they had flat or other morphology.

"Our results raise questions regarding the quality of polyp resection and call for efforts to improve resection of neoplastic polyps, especially large polyps and sessile serrated adenomas/polyps," the researchers wrote.

In particular, increased attention to the polyp margin using special imaging may be warranted. Outlining and marking the margin before resection also might improve the completeness of the removal. And in some cases, adjunctive ablation of the margins after resection may be useful, they added.

The authors reported no relevant financial conflicts.

Approximately 10% of neoplastic polyps that were 5-20 mm in size were not completely resected in a series of 1,427 patients undergoing colonoscopy, Dr. Heiko Pohl and his colleagues reported in the January issue of Gastroenterology.

Biopsies from the resection margins of 346 neoplastic polyps showed that some neoplastic tissue had been left behind in 35 cases in the Complete Adenoma Resection (CARE) study, which involved 11 experienced gastroenterologists practicing at two large academic medical centers.

Video source: American Gastroenterological Association YouTube channel

The rate of incomplete resections varied widely across the different endoscopists, from 6.5% to 22.7%. Moreover, these physicians were aware that they were participating in the study and may have been more careful than usual to accomplish complete resection.

"Our study provides plausible data that incomplete polyp resection in daily clinical practice is relatively common and may contribute to future interval cancers," said Dr. Pohl of White River Junction (Vt.) VA Medical Center and Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and his associates.

The findings also suggest that quality measures for colonoscopy, which to date have focused primarily on detection rates, should now include the completeness of the resection. "The performance of high-quality and effective colonoscopy not only requires expertise in finding neoplastic polyps, but also removing them," the investigators noted (Gastroenterology 2013;144:74-80).

Until now, there has been "surprisingly little direct information on the adequacy of polyp resection. It is generally assumed that resection is complete if no apparent polyp tissue is visible after resection. Using a snare with electrocautery should further destroy any remaining polyp tissue," but whether it actually does so has never been tested, they said.

Dr. Pohl and his colleagues reviewed the cases of all adults aged 40-85 years who presented for outpatient colonoscopy at the two study centers, had no history of inflammatory bowel disease, had no coagulopathies, and were found to have at least one polyp that was 5-20 mm in size.

The board-certified gastroenterologists participating in the study used standard colonoscopes and polypectomy snares to remove the lesions, along with standard electrocautery equipment. The polyps were measured and resected, then the gastroenterologists inspected the resection margins macroscopically, obtained forceps biopsies of the resection margins, and attested that the removal was complete.

They also recorded whether the resection had been easy, moderately difficult, or difficult.

The use of narrow band imaging, chromoendoscopy, or argon plasma coagulation was not required by the study protocol but was allowed at the discretion of each gastroenterologist.

An expert gastrointestinal pathologist independently examined all the biopsies for residual adenomatous tissue, as well as to classify the polyps.

A total of 346 polyps (83%) were neoplastic.

Sixty-eight percent of these polyps were classified as tubular, tubulovillous, or villous adenomas. Twelve percent had a serrated histology, including 42 (10%) that were sessile serrated adenomas/polyps.

The expert reviewer found that overall, 10% of the neoplastic polyps were incompletely resected.

Large (10- to 20-mm) growths were more than twice as likely to be incompletely resected (17.3%) than were small (5- to 9-mm) growths (6.8%). Sessile serrated adenomas/polyps were four times more likely than other types to be incompletely resected (31% vs. 7%).

As a result, almost half (48%) of all large sessile serrated adenomas/polyps were incompletely resected.

"Because adenoma size is associated with both a higher prevalence of advanced histology and greater near-term risk of transition to cancer, incomplete resection of large neoplastic polyps is concerning," Dr. Pohl and his colleagues wrote.

No other factors were found to correspond with incomplete removal, including whether the resection was rated as difficult rather than easy, whether the polyps had to be removed piecemeal rather than all at once, whether the polyps were located in the right or left colon, and whether they had flat or other morphology.

"Our results raise questions regarding the quality of polyp resection and call for efforts to improve resection of neoplastic polyps, especially large polyps and sessile serrated adenomas/polyps," the researchers wrote.

In particular, increased attention to the polyp margin using special imaging may be warranted. Outlining and marking the margin before resection also might improve the completeness of the removal. And in some cases, adjunctive ablation of the margins after resection may be useful, they added.

The authors reported no relevant financial conflicts.

Only 3 of 12 gastroenterologists in a community practice were able to assess colon polyps 5 mm or less in size with 90% accuracy after completing a computer-based self-training program for "optical biopsy" using narrow band imaging, Dr. Uri Ladabaum and his colleagues reported in the January issue of Gastroenterology.

This performance was not as good as that reported for experts evaluated in clinical studies, but it was similar to that reported for students at academic medical centers.

Video Source: American Gastroenterological Association YouTube channel

Although it is "promising" that three gastroenterologists learned how to perform optical biopsy using this method, "better results in community practice must be achieved before NBI [narrow band imaging]-based optical biopsy methods can be used routinely to evaluate polyps," wrote Dr. Ladabaum of Stanford (Calif.) University and his associates (Gastroenterology 2013;144:81-91).

The American Society of Gastrointestinal Endoscopy recommends a negative predictive value threshold of 90% or greater for adenomatous histology of diminutive colorectal polyps using optical biopsy.

The investigators evaluated a self-training program that was designed to be practical to implement in a busy community gastroenterology practice. None of the study subjects had significant experience or formal training with NBI, which uses narrow band light filters to highlight colonic mucosal architecture and vasculature.

Participants first completed three self-administered units at their own pace during the first week of the program: a pretest, a learning module instructing them on using narrow band imaging to help distinguish adenomas from hyperplastic polyps, and a posttest. The two tests featured different sets of 25 endoscopic images of polyps and asked the study subjects to judge whether they were adenomas or hyperplastic, or to indicate that they couldn’t decide.

Next, the participants put their learning into practice, using optical biopsy with NBI on all colonoscopies they performed in which at least one polyp was removed. They noted the location, size, and morphology of each lesion; took photographs under white light and under NBI; classified the features they observed; predicted whether the lesions would prove to be adenomas or hyperplastic on pathologic examination; and recorded their level of confidence (high or low) in their predictions.

After the specimens were examined and classified by fellowship-trained GI pathologists, the study gastroenterologists were required to record the actual diagnosis for each lesion and encouraged to compare that with their own optical diagnoses. They received ongoing confidential feedback as to the accuracy of their work every 1-2 weeks.

Polyps were classified by size as diminutive (5 mm or smaller), small (6-9 mm), or large (10 mm or larger). The primary analysis focused on the study subjects’ success in optical diagnosis of diminutive polyps only, and each subject’s final evaluation was performed after he or she assessed at least 90 such lesions.

The 12 gastroenterologists who participated in both the ex vivo and in vivo study phases of the training program performed a total of 1,673 colonoscopies and removed 2,596 polyps. This included 1,858 diminutive, 547 small, and 177 large polyps; the size was not recorded for the remaining 14 polyps.

All 12 study subjects scored 90% or greater accuracy on the posttests they took after training.

However, only three of them performed that well in their real world practice. The other nine gastroenterologists did not achieve 90% or greater accuracy in assessing the histology of diminutive polyps using NBI.

The participants did not show typical learning curves with the technique over time. "There was no clear pattern of early learning with later stabilization of performance at a higher level," Dr. Ladabaum and his colleagues wrote.

Many factors that might have influenced subjects’ accuracy in distinguishing adenomas from hyperplasia actually proved to have no such effect. The location of the polyp within the colon, the endoscopists’ years in practice and colonoscopy volume, and the changes in subjects’ scores from pretest to posttest all showed no association with their final accuracy in optical biopsy.

One factor that predicted such accuracy was the participant’s confidence in each of his or her predictions.

Finally, there was some attrition over the course of the study, as some subjects who took part in the initial computer-based training did not proceed to the in vivo phase, "and not all participants remained engaged in the in vivo phase. Incentives may need to be developed for busy clinicians to learn and use optical biopsy techniques," the investigators wrote.

Overall, the study findings show that "high accuracy can be achieved ex vivo by community gastroenterologists after self-paced training with a computerized module." However, it remains to be seen whether a gastroenterologist’s ultimate proficiency in optical diagnosis "is determined by technical issues, dedication, motivation, or innate skill," they added.

This study was supported by Stanford University. One author reported receiving research support from and serving on the speakers bureau for Olympus Corp.

Only 3 of 12 gastroenterologists in a community practice were able to assess colon polyps 5 mm or less in size with 90% accuracy after completing a computer-based self-training program for "optical biopsy" using narrow band imaging, Dr. Uri Ladabaum and his colleagues reported in the January issue of Gastroenterology.

This performance was not as good as that reported for experts evaluated in clinical studies, but it was similar to that reported for students at academic medical centers.

Video Source: American Gastroenterological Association YouTube channel

Although it is "promising" that three gastroenterologists learned how to perform optical biopsy using this method, "better results in community practice must be achieved before NBI [narrow band imaging]-based optical biopsy methods can be used routinely to evaluate polyps," wrote Dr. Ladabaum of Stanford (Calif.) University and his associates (Gastroenterology 2013;144:81-91).

The American Society of Gastrointestinal Endoscopy recommends a negative predictive value threshold of 90% or greater for adenomatous histology of diminutive colorectal polyps using optical biopsy.

The investigators evaluated a self-training program that was designed to be practical to implement in a busy community gastroenterology practice. None of the study subjects had significant experience or formal training with NBI, which uses narrow band light filters to highlight colonic mucosal architecture and vasculature.

Participants first completed three self-administered units at their own pace during the first week of the program: a pretest, a learning module instructing them on using narrow band imaging to help distinguish adenomas from hyperplastic polyps, and a posttest. The two tests featured different sets of 25 endoscopic images of polyps and asked the study subjects to judge whether they were adenomas or hyperplastic, or to indicate that they couldn’t decide.

Next, the participants put their learning into practice, using optical biopsy with NBI on all colonoscopies they performed in which at least one polyp was removed. They noted the location, size, and morphology of each lesion; took photographs under white light and under NBI; classified the features they observed; predicted whether the lesions would prove to be adenomas or hyperplastic on pathologic examination; and recorded their level of confidence (high or low) in their predictions.

After the specimens were examined and classified by fellowship-trained GI pathologists, the study gastroenterologists were required to record the actual diagnosis for each lesion and encouraged to compare that with their own optical diagnoses. They received ongoing confidential feedback as to the accuracy of their work every 1-2 weeks.

Polyps were classified by size as diminutive (5 mm or smaller), small (6-9 mm), or large (10 mm or larger). The primary analysis focused on the study subjects’ success in optical diagnosis of diminutive polyps only, and each subject’s final evaluation was performed after he or she assessed at least 90 such lesions.

The 12 gastroenterologists who participated in both the ex vivo and in vivo study phases of the training program performed a total of 1,673 colonoscopies and removed 2,596 polyps. This included 1,858 diminutive, 547 small, and 177 large polyps; the size was not recorded for the remaining 14 polyps.

All 12 study subjects scored 90% or greater accuracy on the posttests they took after training.

However, only three of them performed that well in their real world practice. The other nine gastroenterologists did not achieve 90% or greater accuracy in assessing the histology of diminutive polyps using NBI.

The participants did not show typical learning curves with the technique over time. "There was no clear pattern of early learning with later stabilization of performance at a higher level," Dr. Ladabaum and his colleagues wrote.

Many factors that might have influenced subjects’ accuracy in distinguishing adenomas from hyperplasia actually proved to have no such effect. The location of the polyp within the colon, the endoscopists’ years in practice and colonoscopy volume, and the changes in subjects’ scores from pretest to posttest all showed no association with their final accuracy in optical biopsy.

One factor that predicted such accuracy was the participant’s confidence in each of his or her predictions.

Finally, there was some attrition over the course of the study, as some subjects who took part in the initial computer-based training did not proceed to the in vivo phase, "and not all participants remained engaged in the in vivo phase. Incentives may need to be developed for busy clinicians to learn and use optical biopsy techniques," the investigators wrote.

Overall, the study findings show that "high accuracy can be achieved ex vivo by community gastroenterologists after self-paced training with a computerized module." However, it remains to be seen whether a gastroenterologist’s ultimate proficiency in optical diagnosis "is determined by technical issues, dedication, motivation, or innate skill," they added.

This study was supported by Stanford University. One author reported receiving research support from and serving on the speakers bureau for Olympus Corp.

Only 3 of 12 gastroenterologists in a community practice were able to assess colon polyps 5 mm or less in size with 90% accuracy after completing a computer-based self-training program for "optical biopsy" using narrow band imaging, Dr. Uri Ladabaum and his colleagues reported in the January issue of Gastroenterology.

This performance was not as good as that reported for experts evaluated in clinical studies, but it was similar to that reported for students at academic medical centers.

Video Source: American Gastroenterological Association YouTube channel

Although it is "promising" that three gastroenterologists learned how to perform optical biopsy using this method, "better results in community practice must be achieved before NBI [narrow band imaging]-based optical biopsy methods can be used routinely to evaluate polyps," wrote Dr. Ladabaum of Stanford (Calif.) University and his associates (Gastroenterology 2013;144:81-91).

The American Society of Gastrointestinal Endoscopy recommends a negative predictive value threshold of 90% or greater for adenomatous histology of diminutive colorectal polyps using optical biopsy.

The investigators evaluated a self-training program that was designed to be practical to implement in a busy community gastroenterology practice. None of the study subjects had significant experience or formal training with NBI, which uses narrow band light filters to highlight colonic mucosal architecture and vasculature.

Participants first completed three self-administered units at their own pace during the first week of the program: a pretest, a learning module instructing them on using narrow band imaging to help distinguish adenomas from hyperplastic polyps, and a posttest. The two tests featured different sets of 25 endoscopic images of polyps and asked the study subjects to judge whether they were adenomas or hyperplastic, or to indicate that they couldn’t decide.

Next, the participants put their learning into practice, using optical biopsy with NBI on all colonoscopies they performed in which at least one polyp was removed. They noted the location, size, and morphology of each lesion; took photographs under white light and under NBI; classified the features they observed; predicted whether the lesions would prove to be adenomas or hyperplastic on pathologic examination; and recorded their level of confidence (high or low) in their predictions.

After the specimens were examined and classified by fellowship-trained GI pathologists, the study gastroenterologists were required to record the actual diagnosis for each lesion and encouraged to compare that with their own optical diagnoses. They received ongoing confidential feedback as to the accuracy of their work every 1-2 weeks.

Polyps were classified by size as diminutive (5 mm or smaller), small (6-9 mm), or large (10 mm or larger). The primary analysis focused on the study subjects’ success in optical diagnosis of diminutive polyps only, and each subject’s final evaluation was performed after he or she assessed at least 90 such lesions.

The 12 gastroenterologists who participated in both the ex vivo and in vivo study phases of the training program performed a total of 1,673 colonoscopies and removed 2,596 polyps. This included 1,858 diminutive, 547 small, and 177 large polyps; the size was not recorded for the remaining 14 polyps.

All 12 study subjects scored 90% or greater accuracy on the posttests they took after training.

However, only three of them performed that well in their real world practice. The other nine gastroenterologists did not achieve 90% or greater accuracy in assessing the histology of diminutive polyps using NBI.

The participants did not show typical learning curves with the technique over time. "There was no clear pattern of early learning with later stabilization of performance at a higher level," Dr. Ladabaum and his colleagues wrote.

Many factors that might have influenced subjects’ accuracy in distinguishing adenomas from hyperplasia actually proved to have no such effect. The location of the polyp within the colon, the endoscopists’ years in practice and colonoscopy volume, and the changes in subjects’ scores from pretest to posttest all showed no association with their final accuracy in optical biopsy.

One factor that predicted such accuracy was the participant’s confidence in each of his or her predictions.

Finally, there was some attrition over the course of the study, as some subjects who took part in the initial computer-based training did not proceed to the in vivo phase, "and not all participants remained engaged in the in vivo phase. Incentives may need to be developed for busy clinicians to learn and use optical biopsy techniques," the investigators wrote.

Overall, the study findings show that "high accuracy can be achieved ex vivo by community gastroenterologists after self-paced training with a computerized module." However, it remains to be seen whether a gastroenterologist’s ultimate proficiency in optical diagnosis "is determined by technical issues, dedication, motivation, or innate skill," they added.

This study was supported by Stanford University. One author reported receiving research support from and serving on the speakers bureau for Olympus Corp.

Aspirin therapy should be continued at the time of hospital discharge in patients with cardiovascular comorbidities treated for peptic ulcer bleeding, researchers say.

Among patients taking low-dose aspirin therapy who were hospitalized for bleeding of peptic ulcers, those who stopped aspirin altogether were more than six times as likely to die or have a cardiovascular event in the near future as were patients who resumed aspirin therapy after discharge, according to a database analysis. Researcher Maryam Derogar of the Karolinska Institute, Stockholm, and her associates reported their findings in the January issue of Clinical Gastroenterology and Hepatology.

Video Source: American Gastroenterological Association YouTube channel

"Balancing between the cardioprotective effect of aspirin and the increased risk of rebleeding associated with aspirin use requires a careful clinical tradeoff," the investigators wrote (Clin. Gastroenterol. Hepatol. 2013;11:38-42).

They noted that all deaths or acute CV events in the study were among patients at least 64 years old. The study findings indicate that aspirin therapy should not be permanently discontinued in older patients at cardiovascular risk who develop bleeding peptic ulcer, but should resume after the bleeding episode is treated, they wrote.

Given the ulcerogenic properties of aspirin, "concomitant prescription of acid suppressants in the form of proton pump inhibitors is highly recommended," the researchers added.

Only one randomized clinical trial has examined the consequences of discontinuing aspirin therapy in this patient population, and it found a substantially higher risk of short-term mortality in patients who didn’t resume taking aspirin after treatment of the bleeding ulcer (Ann. Intern. Med. 2010;152:1-9). However, that trial had methodological flaws and a short follow-up of only 8 weeks, the investigators said.

They used an administrative database at their hospital to examine this issue, reviewing the medical records of 118 adults treated in 2007-2010 for upper GI bleeding. All the study subjects had endoscopically verified peptic ulcer and were taking low-dose aspirin therapy (75 mg or 160 mg daily) at the time of hospitalization.

Patients who had bleeding from sources other than peptic ulcer, such as esophageal varices or angiodysplasia, were excluded from the study.

Aspirin therapy was permanently discontinued in 40% (47) of the study subjects. Forty percent of patients (48) restarted aspirin therapy immediately after hospital discharge, and the remaining 20% (23) restarted aspirin therapy a median of 1 week later (range, 2 days to 2 months).

During a median follow-up of 2 years, 37% (44) of study subjects either died or had acute cardiovascular events.

The rate of death or acute CV events during the first 6 months of follow-up was more than sixfold higher in patients who discontinued aspirin therapy than in those who resumed aspirin therapy, with a hazard ratio of 6.8, the investigators said. The investigators adjusted the comparison to account for numerous potential confounders, such as alcohol abuse, chronic ischemic heart disease (angina), chronic heart failure, previous MI, atrial fibrillation, previous stroke or TIA, chronic renal failure, diabetes, COPD, and cancer.

Further analysis showed that the rate of mortality and acute CV events during the first 6 months of follow-up rose only in study subjects who had existing cardiovascular comorbidities at hospitalization, and did not rise in those who had no CV comorbidities. This rate was 31% in the 26 such patients who stopped aspirin therapy, compared with only 8% in the 50 who resumed aspirin therapy.

After 6 months of follow-up, the rate of mortality and acute CV events was not significantly different between patients who stopped and patients who resumed aspirin therapy.

Six percent of patients required rehospitalization for recurrent peptic ulcer bleeding during follow-up. No patients died from such rebleeding.

These findings confirm and extend those of the previous randomized clinical trial, which reported an eightfold increase in mortality during 2 months of follow-up for patients who permanently discontinued aspirin therapy, Ms. Derogar and her colleagues said.

No patients in their study who were under age 64 died or developed an acute CV event. "The results are therefore not fully applicable to younger patients and might imply that the elderly are more susceptible to discontinuation of aspirin therapy," they wrote.

Ms. Derogar reported no potential financial conflicts of interest. One of her associates reported receiving a scholarship from the Olle Engkvist Byggmastare Foundation.

Aspirin therapy should be continued at the time of hospital discharge in patients with cardiovascular comorbidities treated for peptic ulcer bleeding, researchers say.

Among patients taking low-dose aspirin therapy who were hospitalized for bleeding of peptic ulcers, those who stopped aspirin altogether were more than six times as likely to die or have a cardiovascular event in the near future as were patients who resumed aspirin therapy after discharge, according to a database analysis. Researcher Maryam Derogar of the Karolinska Institute, Stockholm, and her associates reported their findings in the January issue of Clinical Gastroenterology and Hepatology.

Video Source: American Gastroenterological Association YouTube channel

"Balancing between the cardioprotective effect of aspirin and the increased risk of rebleeding associated with aspirin use requires a careful clinical tradeoff," the investigators wrote (Clin. Gastroenterol. Hepatol. 2013;11:38-42).

They noted that all deaths or acute CV events in the study were among patients at least 64 years old. The study findings indicate that aspirin therapy should not be permanently discontinued in older patients at cardiovascular risk who develop bleeding peptic ulcer, but should resume after the bleeding episode is treated, they wrote.

Given the ulcerogenic properties of aspirin, "concomitant prescription of acid suppressants in the form of proton pump inhibitors is highly recommended," the researchers added.

Only one randomized clinical trial has examined the consequences of discontinuing aspirin therapy in this patient population, and it found a substantially higher risk of short-term mortality in patients who didn’t resume taking aspirin after treatment of the bleeding ulcer (Ann. Intern. Med. 2010;152:1-9). However, that trial had methodological flaws and a short follow-up of only 8 weeks, the investigators said.

They used an administrative database at their hospital to examine this issue, reviewing the medical records of 118 adults treated in 2007-2010 for upper GI bleeding. All the study subjects had endoscopically verified peptic ulcer and were taking low-dose aspirin therapy (75 mg or 160 mg daily) at the time of hospitalization.

Patients who had bleeding from sources other than peptic ulcer, such as esophageal varices or angiodysplasia, were excluded from the study.

Aspirin therapy was permanently discontinued in 40% (47) of the study subjects. Forty percent of patients (48) restarted aspirin therapy immediately after hospital discharge, and the remaining 20% (23) restarted aspirin therapy a median of 1 week later (range, 2 days to 2 months).

During a median follow-up of 2 years, 37% (44) of study subjects either died or had acute cardiovascular events.

The rate of death or acute CV events during the first 6 months of follow-up was more than sixfold higher in patients who discontinued aspirin therapy than in those who resumed aspirin therapy, with a hazard ratio of 6.8, the investigators said. The investigators adjusted the comparison to account for numerous potential confounders, such as alcohol abuse, chronic ischemic heart disease (angina), chronic heart failure, previous MI, atrial fibrillation, previous stroke or TIA, chronic renal failure, diabetes, COPD, and cancer.

Further analysis showed that the rate of mortality and acute CV events during the first 6 months of follow-up rose only in study subjects who had existing cardiovascular comorbidities at hospitalization, and did not rise in those who had no CV comorbidities. This rate was 31% in the 26 such patients who stopped aspirin therapy, compared with only 8% in the 50 who resumed aspirin therapy.

After 6 months of follow-up, the rate of mortality and acute CV events was not significantly different between patients who stopped and patients who resumed aspirin therapy.

Six percent of patients required rehospitalization for recurrent peptic ulcer bleeding during follow-up. No patients died from such rebleeding.

These findings confirm and extend those of the previous randomized clinical trial, which reported an eightfold increase in mortality during 2 months of follow-up for patients who permanently discontinued aspirin therapy, Ms. Derogar and her colleagues said.

No patients in their study who were under age 64 died or developed an acute CV event. "The results are therefore not fully applicable to younger patients and might imply that the elderly are more susceptible to discontinuation of aspirin therapy," they wrote.

Ms. Derogar reported no potential financial conflicts of interest. One of her associates reported receiving a scholarship from the Olle Engkvist Byggmastare Foundation.

Aspirin therapy should be continued at the time of hospital discharge in patients with cardiovascular comorbidities treated for peptic ulcer bleeding, researchers say.

Among patients taking low-dose aspirin therapy who were hospitalized for bleeding of peptic ulcers, those who stopped aspirin altogether were more than six times as likely to die or have a cardiovascular event in the near future as were patients who resumed aspirin therapy after discharge, according to a database analysis. Researcher Maryam Derogar of the Karolinska Institute, Stockholm, and her associates reported their findings in the January issue of Clinical Gastroenterology and Hepatology.

Video Source: American Gastroenterological Association YouTube channel

"Balancing between the cardioprotective effect of aspirin and the increased risk of rebleeding associated with aspirin use requires a careful clinical tradeoff," the investigators wrote (Clin. Gastroenterol. Hepatol. 2013;11:38-42).

They noted that all deaths or acute CV events in the study were among patients at least 64 years old. The study findings indicate that aspirin therapy should not be permanently discontinued in older patients at cardiovascular risk who develop bleeding peptic ulcer, but should resume after the bleeding episode is treated, they wrote.

Given the ulcerogenic properties of aspirin, "concomitant prescription of acid suppressants in the form of proton pump inhibitors is highly recommended," the researchers added.

Only one randomized clinical trial has examined the consequences of discontinuing aspirin therapy in this patient population, and it found a substantially higher risk of short-term mortality in patients who didn’t resume taking aspirin after treatment of the bleeding ulcer (Ann. Intern. Med. 2010;152:1-9). However, that trial had methodological flaws and a short follow-up of only 8 weeks, the investigators said.

They used an administrative database at their hospital to examine this issue, reviewing the medical records of 118 adults treated in 2007-2010 for upper GI bleeding. All the study subjects had endoscopically verified peptic ulcer and were taking low-dose aspirin therapy (75 mg or 160 mg daily) at the time of hospitalization.

Patients who had bleeding from sources other than peptic ulcer, such as esophageal varices or angiodysplasia, were excluded from the study.

Aspirin therapy was permanently discontinued in 40% (47) of the study subjects. Forty percent of patients (48) restarted aspirin therapy immediately after hospital discharge, and the remaining 20% (23) restarted aspirin therapy a median of 1 week later (range, 2 days to 2 months).

During a median follow-up of 2 years, 37% (44) of study subjects either died or had acute cardiovascular events.

The rate of death or acute CV events during the first 6 months of follow-up was more than sixfold higher in patients who discontinued aspirin therapy than in those who resumed aspirin therapy, with a hazard ratio of 6.8, the investigators said. The investigators adjusted the comparison to account for numerous potential confounders, such as alcohol abuse, chronic ischemic heart disease (angina), chronic heart failure, previous MI, atrial fibrillation, previous stroke or TIA, chronic renal failure, diabetes, COPD, and cancer.

Further analysis showed that the rate of mortality and acute CV events during the first 6 months of follow-up rose only in study subjects who had existing cardiovascular comorbidities at hospitalization, and did not rise in those who had no CV comorbidities. This rate was 31% in the 26 such patients who stopped aspirin therapy, compared with only 8% in the 50 who resumed aspirin therapy.

After 6 months of follow-up, the rate of mortality and acute CV events was not significantly different between patients who stopped and patients who resumed aspirin therapy.

Six percent of patients required rehospitalization for recurrent peptic ulcer bleeding during follow-up. No patients died from such rebleeding.

These findings confirm and extend those of the previous randomized clinical trial, which reported an eightfold increase in mortality during 2 months of follow-up for patients who permanently discontinued aspirin therapy, Ms. Derogar and her colleagues said.

No patients in their study who were under age 64 died or developed an acute CV event. "The results are therefore not fully applicable to younger patients and might imply that the elderly are more susceptible to discontinuation of aspirin therapy," they wrote.

Ms. Derogar reported no potential financial conflicts of interest. One of her associates reported receiving a scholarship from the Olle Engkvist Byggmastare Foundation.