Community gastroenterologists can learn diminutive colon polyp histology characterization with narrow band imaging by a computer-based teaching module.

BACKGROUND AND AIM: The aim of the present study was to evaluate the impact of a computer-based teaching module on the performance of community gastroenterologists for characterization of diminutive polyps (≤5 mm) using narrow band imaging video clips. METHODS: Eighty videos were distributed in pre- and post-test DVD along with a 20-min audiovisual teaching presentation detailing endoscopic features differentiating adenomas from hyperplastic polyps using narrow band imaging. Each participant first reviewed pretest video clips and entered their responses for polyp histology and their confidence in diagnosis: high: ≥90% or low: <90%. Following this, they reviewed the teaching module and assessed the post-test videos. Performance characteristics were calculated for pre- and post-test videos by comparing predicted histology with actual histology. Fisher's exact test was used for analysis and the kappa statistic was calculated for interobserver agreement. RESULTS: Fifteen gastroenterologists in community practice completed the study. Sensitivity, specificity, accuracy and negative predictive value in characterization of polyp histology improved significantly post-test compared to pretest. In post-test, accuracy was 92% for high-confidence diagnoses and the proportion of these increased with training from 46% (pretest) to 64% (post-test); P < 0.001. Interobserver agreement for diagnosis improved from fair (kappa = 0.23) in pretest to moderate (kappa = 0.56) in post-test. CONCLUSIONS: A teaching module using video clips can be used to teach community gastroenterologists polyp histology characterization by narrow band imaging. Whether this translates into real-time high accuracy in polyp detection needs to be further evaluated.

Longitudinal assessment of colonoscopy quality indicators: a report from the Gastroenterology Practice Management Group.

BACKGROUND: There is increasing demand for colonoscopy quality measures for procedures performed in ambulatory surgery centers. Benchmarks such as adenoma detection rate (ADR) are traditionally reported as static, one-dimensional point estimates at a provider or practice level. OBJECTIVE: To evaluate 6-year variability of ADRs for 370 gastroenterologists from across the nation. DESIGN: Observational cross-sectional analysis. SETTING: Collaborative quality metrics database from 2007 to 2012. PATIENTS: Patients who underwent colonoscopies in ambulatory surgery centers. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: The number of colonoscopies with an adenomatous polyp divided by the total number of colonoscopies (ADR-T), inclusive of indication and patient's sex. RESULTS: Data from 368,157 colonoscopies were included for analysis from 11 practices. Three practice sites (5, 8, and 10) were significantly above and 2 sites (3, 7) were significantly below mean ADR-T, with a 95% confidence interval (CI). High-performing sites had 9.0% higher ADR-T than sites belonging to the lowest quartile (P < .001). The mean ADR-T remained stable for 9 of 11 sites. Regression analysis showed that the 2 practice sites where ADR-T varied had significant improvements in ADR-T during the 6-year period. For each, mean ADR-T improved an average of 0.5% per quarter for site 2 (P = .001) and site 3 (P = .021), which were average and low performers, respectively. LIMITATIONS: Summary-level data, which does not allow cross-reference of variables at an individual level. CONCLUSION: We found performance disparities among practice sites remaining relatively consistent over a 6-year period. The ability of certain sites to sustain their high-performance over 6 years suggests that further research is needed to identify key organizational processes and physician incentives that improve the quality of colonoscopy.

Capsule endoscopy is superior to small-bowel follow-through and equivalent to ileocolonoscopy in suspected Crohn's disease.

BACKGROUND & AIMS: Evaluation of the small intestine for inflammation has traditionally relied on small-bowel follow-through (SBFT), but multiple studies have demonstrated its low diagnostic accuracy. Capsule endoscopy (CE) transmits high-quality images of the small intestinal mucosa; it can be used to visualize the entire length of the small bowel and much of the mucosa. We compared the diagnostic yields of CE vs SBFT in a prospective study of patients with suspected small-bowel Crohn's disease. METHODS: Eighty patients with signs and/or symptoms of small-bowel Crohn's disease (age, 10-65 years) underwent CE, followed by SBFT and ileocolonoscopy. Readers were blinded to other test results. The primary outcome was the diagnostic yield for inflammatory lesions found with CE before ileocolonoscopy compared with SBFT and ileocolonoscopy. A secondary outcome was the incremental diagnostic yield of CE compared with ileocolonoscopy and CE compared with SBFT. RESULTS: The combination of CE and ileocolonoscopy detected 107 of 110 inflammatory lesions (97.3%), whereas the combination of SBFT and ileocolonoscopy detected only 63 lesions (57.3%) (P < .001). The diagnostic yield of CE compared with ileocolonoscopy was not different (P = .09). The diagnostic yield was higher for CE than for SBFT (P < .001). Of the 80 patients with suspected Crohn's disease, 25 (31.3%) had the diagnosis confirmed. Eleven were diagnosed by CE findings alone and 5 by ileocolonoscopy findings alone. In the remaining 9 patients, diagnostic findings were identified by at least 2 of the 3 modalities. No diagnoses were made on the basis of SBFT findings alone. CONCLUSIONS: CE was better than SBFT and equivalent to ileocolonoscopy in detecting small-bowel inflammation. Although ileocolonoscopy remains the initial diagnostic test of choice, CE is safe and can establish the diagnosis of Crohn's disease in patients when ileocolonoscopy results are negative or the terminal ileum cannot be evaluated. ClinicalTrials.gov Number: NCT00487396.

Appropriate use of special stains for identifying Helicobacter pylori: Recommendations from the Rodger C. Haggitt Gastrointestinal Pathology Society.

Helicobacter pylori is a major cause of gastroduodenal injury, gastric cancer, and lymphoma, and, thus, there is great interest in its detection and eradication. Several detection methods are available, including histochemical and immunohistochemical stains. Application of these stains in clinical practice is heterogenous, to say the least. Although they were developed to enhance H. pylori detection, changing practice models, financial considerations, and a perceived need for rapid case turnaround have led to their widespread use in routine staining studies ordered reflexively on all gastric biopsies. Emerging data suggest that most of these stains are not needed to establish a diagnosis of H. pylori infection, and their added value when biopsies show minimal, or no, inflammation is not clear. In this manuscript, the Rodger C. Haggitt Gastrointestinal Pathology Society puts forth recommendations regarding ancillary stain usage for H. pylori detection based upon critical literature review and collective experience. Pathologists rarely, if ever, detect H. pylori in "normal" biopsies, but readily observe them in optimally stained hematoxylin and eosin sections from infected patients. Therefore, we suggest that use of ancillary stains is appropriate when biopsies show chronic, or chronic active, gastritis without detectable H. pylori in hematoxylin and eosin-stained sections, but performing them "up front" on all gastric biopsies is generally unnecessary. Application of these stains to nongastric biopsies and polyps is appropriate in an extremely limited set of circumstances. It is our hope that recommendations provided herein will provide helpful information to gastroenterologists, pathologists, and others involved in the evaluation of patients for possible H. pylori infection.

Stenosis of the gastroenterostomy after laparoscopic gastric bypass.

BACKGROUND: Stenosis of the gastroenterostomy after laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a serious problem that occurs after stapled (linear or circular) and hand-sewn anastomoses. METHODS: Data was prospectively entered into a database to track complications of bariatric surgery. Between Feb 27, 1999 and June 13, 2000, 1000 patients underwent LRYGBP. All patients met NIH criteria for bariatric surgery.The gastroenterostomy was constructed with a linear stapler inserted to 20 mm (15 mm cut). The stapler defect was closed with a polyester running suture to construct a 12-mm diameter anastomosis. The anastomosis was banded with fascia lata to prevent late enlargement. All patients with suspected stenosis were endoscoped. RESULTS: 32 patients (3.2%) developed stenosis (<10 mm diameter orifice) at the gastroenterostomy. There were 27 females. Average age was 44.8. Average BMI was 45.0. Average stenotic orifice was 5.7 mm in diameter. Stenoses occurred in 18 of 32 patients (56.3%) by 3 months, 26 (81.3%) by 6 months, and 31 (96.9%) by 1 year. 30 of the 32 patients underwent endoscopic dilation as initial therapy. 17 of the 32 underwent multiple dilations. Dilation caused 4 perforations, resulting in 2 emergency operations. Perforation occurred at the first attempt at dilation in 3 of 4 patients. Stenoses could not be successfully dilated in 8 patients, and all 8 underwent surgical revision. There were no deaths in these 32 patients, but there were 68 dilations and 10 re-operations. CONCLUSION: Stenosis of the gastroenterostomy after LRYGBP is an infrequent but serious problem, which results in considerable morbidity.