Endoscopic submucosal dissection for colorectal lesions: outcomes from a United States experience.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is commonly used in Asia for resection of large non-pedunculated colorectal polyps (LNPCPs) and early (T1) colorectal cancers. It allows for en bloc removal and is often curative. We describe outcomes of colorectal ESD from a United States (US) academic medical center and compare this to international experiences. METHODS: Retrospective review was performed of colonic lesions referred to the University of Chicago Medical Center for ESD from 2012 to 2020. Clinical and procedural data were collected. RESULTS: The study included 78 lesions with mean size of 29.7 mm (range 10-100 mm). The overall en bloc resection rate was 73.1% (n = 57). Between the first and second half of the study, it improved from 61.5 to 84.6% (p = 0.02). Histology showed adenocarcinoma in fifteen lesions (19.2%). Of all neoplastic lesions (n = 68), resection with negative margins (R0) was achieved in 54 cases (79.4%). Adverse events occurred in 9 cases (11.5%), but most (n = 6, 66.7%) were successfully treated endoscopically. Follow-up endoscopy was performed in 46 patients (59.0%) at a mean interval of 6.8 months (SD ± 5.0 months) with two case of recurrent lesion (4.3%). CONCLUSIONS: This study shows successful colorectal ESD outcomes at a US tertiary center. The en bloc resection rate was lower than other cohorts, but a learning curve was demonstrated. The R0 resection, lesion recurrence, and adverse event rates were similar to other non-Asian experiences, but not as favorable as in Asia [Fuccio et al. in Gastrointest Endosc 86:74-86.e17, 2017]. Increased ESD training in the US can help optimize utilization and outcomes.

How many is too many? Polyposis syndromes and what to do next.

PURPOSE OF REVIEW: The goal of this review is to help providers recognize, diagnose and manage gastrointestinal (GI) polyposis syndromes. RECENT FINDINGS: Intestinal polyps include a number of histological sub-types such as adenomas, serrated, hamartomas among others. Over a quarter of individuals undergoing screening colonoscopy are expected to have colonic adenomas. Although it is not uncommon for adults to have a few GI polyps in their lifetime, some individuals are found to have multiple polyps of varying histology throughout the GI tract. In these individuals, depending on polyp histology, number, location and size as well as extra-intestinal features and/or family history, a polyposis syndrome should be considered with appropriate testing and management. SUMMARY: Diagnosis and management of polyposis syndromes has evolved with advent of multigene panel testing and new data on optimal surveillance strategies. Evidence-based recommendations and current practice guidelines for polyposis syndromes are reviewed here. Areas of uncertainty and future research are also highlighted.

Predictors of mortality and endoscopic intervention in patients with upper gastrointestinal bleeding in the intensive care unit.

BACKGROUND: The outcomes of patients undergoing esophagogastroduodenoscopy (EGD) in the intensive care unit (ICU) for upper gastrointestinal bleeding (UGIB) are not well described. Our aims were to determine predictors of 30-day mortality and endoscopic intervention, and assess the utility of existing clinical-prediction tools for UGIB in this population. METHODS: Patients hospitalized in an ICU between 2008 and 2015 who underwent EGD were identified using a validated, machine-learning algorithm. Logistic regression was used to determine factors associated with 30-day mortality and endoscopic intervention. Area under receiver-operating characteristics (AUROC) analysis was used to evaluate established UGIB scoring systems in predicting mortality and endoscopic intervention in patients who presented to the hospital with UGIB. RESULTS: A total of 606 patients underwent EGD for UGIB while admitted to an ICU. The median age of the cohort was 62 years and 55.9% were male. Multivariate analysis revealed that predictors associated with 30-day mortality included American Society of Anesthesiologists (ASA) class (odds ratio [OR] 4.1, 95% confidence interval [CI] 2.2-7.9), Charlson score (OR 1.2, 95% CI 1.0-1.3), and duration from hospital admission to EGD (OR 1.04, 95% CI 1.01-1.07). Rockall, Glasgow-Blatchford, and AIMS65 scores were poorly predictive of endoscopic intervention (AUROC: 0.521, 0.514, and 0.540, respectively) and in-hospital mortality (AUROC: 0.510, 0.568, and 0.506, respectively). CONCLUSIONS: Predictors associated with 30-day mortality include ASA classification, Charlson score, and duration in the hospital prior to EGD. Existing risk tools are poorly predictive of clinical outcomes, which highlights the need for a more accurate risk-stratification tool to predict the benefit of intervention within the ICU population.

Rapid Onset of Inflammatory Bowel Disease after Receiving Secukinumab Infusion.

Secukinumab, an interleukin (IL)-17A antagonist, was associated with disease exacerbations in Crohn's disease, and de novo cases of inflammatory bowel disease (IBD) have been reported in studies of rheumatoid diseases. However, there has been no detailed report demonstrating the linkage between secukinumab therapy and new-onset IBD. We present a unique case of rapid-onset fulminant colitis after receiving 1 dose of secukinumab infusion followed by improvement with combination antibiotics, corticosteroids, and calcineurin inhibition. Health care providers should be aware of the possible association between IL-17 antagonist therapy and the risk of developing new-onset fulminant IBD.

Use of volumetric laser endomicroscopy for dysplasia detection at the gastroesophageal junction and gastric cardia.

AIM: To determine specific volumetric laser endomicroscopy (VLE) imaging features associated with neoplasia at the gastroesophageal junction (GEJ) and gastric cardia. METHODS: During esophagogastroduodenoscopy for patients with known or suspected Barrett's esophagus, VLE was performed before biopsies were taken at endoscopists' discretion. The gastric cardia was examined on VLE scan from the GEJ (marked by top of gastric folds) to 1 cm distal from the GEJ. The NinePoints VLE console was used to analyze scan segments for characteristics previously found to correlate with normal or abnormal mucosa. Glands were counted individually. Imaging features identified on VLE scan were correlated with biopsy results from the GEJ and cardia region. RESULTS: This study included 34 cases. Features characteristic of the gastric cardia (gastric rugae, gastric pit architecture, poor penetration) were observed in all (100%) scans. Loss of classic gastric pit architecture was common and there was no difference between those with neoplasia and without (100% vs 74%, P = NS). The abnormal VLE feature of irregular surface was more often seen in patients with neoplasia than those without (100% vs 18%, P < 0.0001), as was heterogeneous scattering (86% vs 41%, P < 0.005) and presence of anomalous glands (100% vs 59%, P < 0.05). The number of anomalous glands did not differ between individual histologic subgroups (ANOVA, P = NS). CONCLUSION: The transition from esophagus to gastric cardia is reliably identified on VLE. Histologically abnormal cardia mucosa produces abnormal VLE features. Optical coherence tomography algorithms can be expanded for use at the GEJ/cardia.

Assessing the validity of sales self-efficacy: a cautionary tale.

We developed a focused, context-specific measure of sales self-efficacy and assessed its incremental validity against the broad Big 5 personality traits with department store salespersons, using (a) both a concurrent and a predictive design and (b) both objective sales measures and supervisory ratings of performance. We found that in the concurrent study, sales self-efficacy predicted objective and subjective measures of job performance more than did the Big 5 measures. Significant differences between the predictability of subjective and objective measures of performance were not observed. Predictive validity coefficients were generally lower than concurrent validity coefficients. The results suggest that there are different dynamics operating in concurrent and predictive designs and between broad and contextualized measures; they highlight the importance of distinguishing between these designs and measures in meta-analyses. The results also point to the value of focused, context-specific personality predictors in selection research.