Background Breast cancer incidence is higher among black women than white women before age 40 years, but higher among white women than black women after age 40 years (black–white crossover). We used newly available population-based data to examine whether the age-specific incidences of breast cancer subtypes vary by race and ethnicity.
Introduction: Obesity is associated with an increased risk of colorectal cancer. A study by Grewal, et al showed that adenoma detection rate (ADR) is higher among overweight and obese males compared to their normal weight counterparts, suggesting a higher prevalence of precancerous adenomas in this population. ADR, however, is not a direct measure of adenoma prevalence because of its dependence on colonoscopy quality, including the quality of the bowel prep. Obesity is an independent risk factor for suboptimal bowel prep, suggesting that ADR may significantly underestimate adenoma prevalence in this group. Because split-dose bowel prep is associated with improved bowel prep scores, our aim was to determine if split-dose bowel prep is also associated with higher ADR among obese patients. Methods: This study utilized prospectively collected data at point-of-care using Qualoscopy (Docbot, Inc). Inclusion criteria was all obese patients, defined as a BMI ≥30, who had colonoscopies performed for any indication at our outpatient facilities from June, 2012 to April, 2017. Statistical analysis was performed using chi-square and two-sample t-test. For reference, the same measures were analyzed in normal/underweight (< 25) and overweight BMIs (25-29.9). Results: Of 1419 colonoscopies performed among obese patients, 856 (60.3%) received split-dose bowel prep and 563 (39.7%) received single-dose prep. The split-dose group was weighted towards female patients, but there were no significant differences in BMI, gender, or primary indication (table 1). ADR was significantly higher among those who received split-dose (50.7% vs 38.4%, p < 0.001). Similarly, adequate bowel prep (defined as a Boston Bowel Prep Score ≥8) was significantly more frequent in the splitdose compared to single-dose groups (72% vs 60%, p < 0.001). The degree of benefit of split-dose prep, as measured by % improvement in ADR and % improvement in fraction of adequate preps, was highest in obese patients compared to those who were normal/underweight or overweight (table 2).Table: Table. Patient DemographicsTable: Table. Outcomes Based on BMI and Bowel Preparation UsedConclusion: Our data shows that split-dose bowel prep in obese patients is associated with significantly higher ADR and percentage of patients with adequate prep. Furthermore, these benefits of split-dose prep were most pronounced among the obese population. Based on compelling evidence that higher ADRs are associated with lower interval cancer rates, our data supports widespread use of split-dose prep in this high-risk population.
Introduction: Bowel preparation is a key determinant of colonoscopy quality, particularly when performed for colorectal cancer screening. Underwater colonoscopy (UW), performed using water exchange or water immersion techniques, has been suggested to improve bowel prep scores compared to air insufflation colonoscopy (AI). Objective: Determine if UW, compared to AI, are associated with higher rates of adequate bowel prep scores Methods: Colonoscopy quality data was collected prospectively at our single tertiary referral center beginning in June 2012. For this study, the dataset included all colonoscopies performed for screening or surveillance indications for which UW and AI were recorded (September 2014 to May 2017). 5037 colonoscopies, including 2841 underwater (UW) and 2196 air insufflation colonoscopies (AI), were included. These two groups were compared with respect to mean Boston Bowel Prep Scores (BBPS) overall and by location within colon, as well for number of procedures with “adequate” bowel prep, defined as an average BBPS score ≥8.0. Subgroup analysis was conducted on basis of gender, race and BMI. Statistical analysis was performed using unpaired T-test and Fischer's exact test. Results: Compared to AI, UW was associated with higher BBPS overall (7.8 vs. 8.0, p = 0.007), as well as in the transverse (2.6 vs. 2.7, p = 0.003), and left colon (2.6 vs. 2.7, p = 0.002). UW was also associated with significantly higher percentage of procedures with adequate bowel prep (73.2% vs. 76.5%, p = 0.009). On subgroup analysis, UW was associated with higher rates of adequate bowel preparation in women (75.2% vs 78.6%, p = 0.03), normal BMI individuals (73.1% vs. 78.3%, p = 0.006), and Caucasians (71.7% vs. 75.2%, p = 0.02). Liters of bowel preparation utilized was similar between the two groups (3.46L vs. 3.53L, p = 0.22). Conclusion: Adequate bowel preparation is necessary to allow for thorough inspection of the colon during screening and surveillance colonoscopy. Inadequate prep may obscure smaller or more subtle lesions, such as sessile adenomas, allowing them to progress towards malignancy. UW technique has many benefits, including improved patient tolerance, lower sedation requirements and higher adenoma detection rates. Our results indicate that UW is also associated with improved bowel preparation, providing further support for use of UW.Table: Table. Mean Boston Bowel Prep Scores (BBPS) in AI vs. UWTable: Table. Comparison of Rates of Adequate Bowel Prep in AI vs. UW
This is a 44-year-old male with a reported history of GERD symptoms who underwant Nissen Fundoplication in 2013 in South America. Some intermittent heartburn symptoms appeared to improve but post surgical dysphagia became a problem for him. In 2015, dysphagia symptoms progressed and started to lose weight. Bravo pH monitoring revealed acid reflux was well controlled. An EGD with Endoflip balloon manometry was performed, which was remarkable for a a narrow esophageal diameter and and poor GEJ compliance. Conservative management was pursued at first, given there was a possibility a tight fundoplication could relax. However, the symptoms persisted, and underlying Achalasia was suspected. Thus decision was made to use intraoperative EndoFLIP to help make the diagnosis. The previously performed Nissen Fundoplication was taken down and with no mechanical constriction on the GEJ, intraoperative EGD with repeat Endoflip balloon manometry was performed with measurements consistent with Achalasia (Diameter 6mm, Compliance 2.1mm/Hg2). As a result, a heller Myotomy with Dor Fundoplication was then completed. The patient had a drastic improvement in symptoms and continues to do well 1 year after this procedure. This study highlights the importance of a thorough pre-operative work up prior to Nissen Fundoplication. This patient had a minimal pre-fundoplication workup performed and the patients original symptoms in retrospect may not have been all GERD related. Evaluating a patient who presents with dysphagia after fundoplication is a difficult task. It is difficult to discern if the dysphagia is due to a tight fundoplication or an underlying condition such as Achalasia. This is the first case to our knowledge that used EndoFLIP balloon manometry intraoperatively after a fundoplication was taken down to make a diagnosis of Achalasia such that the appropriate therapy could be carried out on the same day.
Introduction: Adenoma detection rate (ADR) is an important marker for colonoscopy quality. Various techniques, including underwater insertion and use of caps and other assistive devices, such as Endocuff, are associated with increased ADR. However, it is unknown if there is a cumulative effect of these techniques on polyp detection. Thus, the objective of our study was to determine if Endocuff (EC) further improves polyp detection rates in underwater colonoscopy. Methods: Colonoscopy quality data was collected prospectively at our single tertiary referral center beginning in June 2012. EC was first implemented in Aug 2014 and utilized at the discretion of the endoscopist. Data included all colonoscopies performed between Aug 2014 and May 2017. Colonoscopies were categorized as conventional (CC), Endocuff-assisted (EC) with air insufflation (AI) or underwater (UW). Three groups AI/CC, UW/CC, and EC/UW were compared by procedure times, cecal intubation rate, and detection rates of polyps (PDR), adenomas (ADR) and SSAs (SSADR). Significance was determined using ANOVA for continuous variables and chi-square test for categorical variables.Figure: Green bars represent % change in detection rate with UW/CC, relative to AI/CC. Blue bars represent % change in detection rate with UW/EC, relative to UW/CC.Results: Compared to baseline detection rates in the AI/CC group, UW/CC, and UW/EC was associated with significant incremental increases in PDR, ADR and SSADR. In particular, there was a robust response to the addition of Endocuff, as demonstrated by significant improvements in PDR (59.9 vs. 79.1%, p < 0.0001), ADR (37.3% vs. 53.2%, p < 0.0001) and SSADR (8.4% vs. 14.1%, p < 0.0001) between UW/CC and UW/EC groups, respectively. These significant trends persisted on subgroup analysis in left and right colon (see table 2). Insertion time (IT) were similar between the three groups, though withdrawal (WT) and total times (TT) were progressively longer with added techniques and interventions. CIR rates were higher with UW/CC and UW/EC compared to AI/CC. Conclusion: Our results confirm previous reports of improved polyp detection rates with UW compared to AI. Concomitant use of Endocuff (UW/EC) is associated with an additive effect on polyp detection rates. These techniques were associated with marginally increased procedure times, which is likely accounted for by additional polyps requiring polypectomy. Overall, our results support use of UW + EC to maximize polyp detection and thereby reduce rates of interval colorectal cancers.Figure: Green bars represent % change in detection rate with UW/CC, relative to AI/CC. Blue bars represent % change in detection rate with UW/EC, relative to UW/CC.Table: Table. Comparison of Procedure Times between AI/CC vs. UW/CC vs. UW/ECTable: Table. Comparison of Procedure Times between AI/CC vs. UW/CC vs. UW/EC
Percutaneous endoscopic gastrostomy (PEG) tube placement remains a core competency of gastroenterology fellowship, although this procedure is performed infrequently. Some training programs lack sufficient procedural volume for trainees to develop confidence and competence in this procedure. We aimed to determine the impact of a simulation-based educational intervention on trainee technical skill and procedural attitudes in simulated PEG tube placement.Gastroenterology fellows were invited to participate in the study. Baseline procedural attitudes toward PEG tube placement (self-confidence, perceived skill level, perceived level of required supervision) were assessed before simulation training using a Likert scale. Baseline technical skills were assessed by video recording-simulated PEG tube placement on a PEG tube simulator with scoring using a procedural checklist. Fellows next underwent individualized simulation training and repeated simulated PEG tube placement until greater than 90% of checklist items were achieved. Procedural attitudes were reassessed directly after the simulation. Technical skill and procedural attitudes were then reassessed 6 to 12 weeks later (delayed posttraining).Twelve fellows completed the study. Simulation training led to significant improvement in technical skill at delayed reassessment (52.9 ± 14.3% vs. 78.0 ± 8.9% correct, P = 0.0002). Simulation training also led to significant immediate improvements in self-confidence (2.1 ± 0.7 vs. 3.1 ± 0.3, P = 0.001), perceived skill level (2.2 ± 1.0 vs. 4 ± 1.1, P < 0.001), and perceived level of required supervision (2.2 ± 0.9 vs. 3.2 ± 0.6, P = 0.003).Simulation training led to sustained improvements in gastroenterology fellows' technical skill and procedural attitudes in PEG tube placement. Incorporation of simulation curricula in gastroenterology fellowships for this infrequently performed procedure should be considered.
Introduction: The American Cancer Society recently released updated “qualified recommendations” on Colorectal screening, recommending to start screening at age 45 for average risk population. These recommendations came out as a response to the increasing rates of CRC among adults less an age 50. The goal of our study was to analyze the adenoma detection rates (ADR) among people less than age 50 based on indication, particularly in compared to those who underwent “early” colonoscopy for average risk. Methods: Colonoscopy quality data was collected prospectively at our single tertiary referral center from June 2012 to June 2018. Inclusion criteria for the current study included all colonoscopies in patients aged 20 - 49, excluding those with inflammatory bowel disease and indications that had less than 30 total procedures. Within this cohort, ADR was analyzed by indication for colonoscopy. Significance was determined via a two-tailed Fisher’s exact test. Results: 1393 colonoscopies met our inclusion criteria. Average age (SD) of patients was 38.8 years (8.4). A breakdown of indications for this group are shown in Table 1. Subgroup analysis showed that ADR of patients 45-50 years old getting colonoscopy for “average risk” was 0.39 (OR 0.87 95% CI 0.59 to 1.3), 0.28 for females and 0.46 for males. The ADR for our average risk population > age 50 in our database is also 0.46. Conclusion: We are in the early days of the new ACS recommendation. The USPSTF and GI societies will soon decide if new guidelines will lower the screening age for colonoscopy. In the setting of what can be a pivotal moment in CRC screening guidelines, we present data showing that the risk of having a precancerous adenoma in the average risk population is near that of the population we are currently screening, and in the case of males aged 45-50 the risk of a precancerous adenoma is equal to that of the established screening population, further warranting CRC screening for all people aged 45-50 years.228_A Figure 1. Indications and ADR for Colonoscopy in Patients < 50 years228_B Figure 2. ADR for Average Risk Patients aged 45-50 Compared to Average Risk age > 50
Introduction: Crohn's disease (CD) is a chronic, relapsing-remitting disorder of the gastrointestinal tract. CD patients often undergo surgical resection for treatment of their disease, though are still at risk of postoperative recurrence. Enteral nutrition (EN) is frequently used in CD as adjunct to medical therapy to manage protein-calorie malnutrition. It has also been suggested that EN may help both induce and maintain remission and promote mucosal healing. While several studies have shown decreased rates of postoperative CD recurrence following EN treatment, this association has not been well established. Objective: Assess effect of EN on postoperative clinical and endoscopic recurrence in Crohn's disease patients. Methods: A thorough search of multiple databases, including Scopus, Cochrane, MEDLINE/PubMed, and CINAHL were performed (May 2018). Studies assessing the role of pre- or postoperative enteral nutrition in preventing postoperative clinical and endoscopic recurrence of CD were included. A metaanalysis was completed using the Mantel-Haenszel model. Results: In a complete analysis of five studies, there was a 5-fold decrease risk in developing clinical recurrence at one year (OR 5.04 95% CI 2.66, 9.952, p2=80%). Sensitivity analysis excluded one study with lowest rate of recurrence in non-EN group to minimize heterogeneity there remains a dramatic decrease in clinical recurrence among patients on EN relative to no EN (OR 16.68 95% CI 6.37,43.66 p2=0%). Similar results were noted for clinical recurrence with EN at 5 year postoperatively with decreased risk for recurrence more than 24-fold in the group receiving EN compared to no EN (OR 24.61 95% CI 11.52,52.57 p2=78%). Two studies, by Wang, et al, and Yamamoto, et al, also assessed for endoscopic recurrence. Risk of endoscopic recurrence at 1 year was decreased by nearly 3-fold in the EN group relative to no EN (OR 2.69 95% CI 1.22,5.92 p=0.01, I2=48%) with EN. Conclusion: Postoperative enteral nutrition is associated with decreased rates of clinical and endoscopic recurrence after surgical resection. Further studies are needed to assess optimal duration of EN and longer-term effects.
Introduction: Underwater colonoscopy has been associated with increased patient tolerance and decreased need for sedation compared to traditional air-insufflation colonoscopy. The effect of underwater colonoscopy on polyp detection has not been as thoroughly assessed, especially among those in gastroenterology fellowship. Our objective was to determine if GI fellows performing underwater colonoscopies have higher detection rates of polyps, adenoma and sessile serrated adenomas compared to fellows performing air-insufflation colonoscopies.Figure: Percent Improvement in Detection Rates with Underwater vs. Air-Insufflation Colonoscopy.Table: Table. Baseline CharacteristicsTable: Table. Average Polyp Detection Rates in Underwater vs. Air-Insufflated ColonoscopyMethods: Colonoscopy quality data was collected prospectively at our single tertiary referral center from June 2012 to May 2017 using Qualoscopy (Docbot, Inc.). 29 GI fellows performed 2270 colonoscopies (1237 underwater (UW) and 1033 air-insufflation (AI)). UW and AI cases were compared for detection rates of polyps (PDR), adenomas (ADR), and sessile serrated adenoma (SSADR), as well as procedure times and cecal intubation rates. Subgroup analysis included polyp location. Significance was determined by a two-tailed Fischer's exact test and T-test. Results: UW compared to AI was associated with a higher PDR (77.0% vs. 69.3%, P=0.0001), ADR (53.1% vs. 48.2%, P=0.02) and SSDAR (15.6% vs. 10.2%, P=0.0001) among fellow-performed colonoscopies. Significant differences were retained in the left colon for ADR (29.2% vs. 23.6%, P=0.003) and SSADR (7.10% vs. 3.20%, P=0.0001). In the right colon, significant differences were retained for PDR (60.9% vs. 50.5%, P=0.0001) and SSADR (13.0% vs. 9.60%, P=0.01). Insertion time (14.1 vs. 13.9min, P=0.96), withdrawal time (24.5 vs. 21.9min, P=0.29), total time (38.6 vs. 35.8min, P=0.46) and cecal intubation rates (98.9% vs. 98.8%, P=0.44) were similar within UW and AI colonoscopy, respectively. Conclusion: GI fellow-performed UW colonoscopy compared to air-insufflation colonoscopy is associated with higher PDR, ADR and SSDAR. This data supports future prospective randomized studies to verify improved polyp detection with underwater colonoscopy and suggest that underwater techniques should be included in the training curriculum of GI fellows to further improve colonoscopy quality and reduce interval colorectal cancers.
Introduction: Rates of colorectal cancer (CRC) in adults under age 50 is increasing, leading the American Cancer Society (ACS) to recommend lowering the initial screening age to 45. Little is known about best screening practices in this population. Underwater insertion (UW) has been shown to improve polyp detection rates among older adults. However, its effect on polyp detection in the young is less well understood. Objective: Assess the effect of underwater insertion on polyp detection among young adults undergoing colonoscopy. Methods: Colonoscopy quality data was prospectively collected at our single, tertiary referral center beginning in June 2012. We analyzed all colonoscopies performed between Aug 2014 and June 2018 in patients age 19-49, inclusive of all indications. Procedures were categorized based on insertion type: air/CO2-insufflated (AI) or underwater (UW). The two groups were compared with respect to polyp detection rates, procedural times, and cecal intubation rates. Significance was determined using chi-square test and unpaired T-test. Results: 583 colonoscopies were included in final analysis, including 168 AI and 415 UW procedures. The most common indications for colonoscopy were personal history, abdominal pain, and bleeding. Bowel prep scores were higher in UW group (7.7 vs. 8.1, p=0.02). UW was associated with a significant increase in ADR over AI (5.2% vs. 16.4%, p<0.0001). Overall PDR also improved with UW, though these results did not reach significance (24.4% vs. 31.0%, p=0.08). Similar significant increases in ADR were seen on subgroup analysis by gender in both females (2.1% vs. 14.6%, p<0.0001) and males (7.5% vs. 18.3%, p=0.01). UW also improved detection of both polyps in the left colon (2.1% vs. 10.5, p=0.0002) and right colon (4.3% vs. 9.8%, p=0.03). Procedural times were marginally longer with UW, though this was not significant (see table 3). Conclusion: The ACS has recommended expanding the target CRC screening population to include younger patients. UW has been shown to significantly improve polyp detection and bowel prep scores, and reduce sedation need in the age 50 and older screening cohort. Our results suggest these benefits extend to younger patients. Our results are limited by the retrospective analysis and non-screening indications for procedures. Further prospective studies are needed to assess the role of UW, as well as other techniques and devices, on polyp detection in younger patients.165_A Figure 1. Baseline characteristics of patient population165_B Figure 2. Polyp detection rates with air-insufflation vs. underwater insertion165_C Figure 3. Procedure times and Boston Bowel Prep Scores with air insufflation vs. underwater insertion
