The Endoscopy News Podcast (Bjorn Rembacken)

In this podcast we discuss Serrated Polyps with Professor Neil Shepherd. There is much more to these lesions than Size and Number!  Did you know that there may be two distinct syndromes and it's the Site of the lesions which distinguishes the two?  That is just the start.  It gets weirder! 

We cover a huge amount of ground and headings include (in chronological order):

• Serrated polyps - one or two distinct syndromes?
• Can you tell histologically?
• How does the Serrated Polyposis Syndrome fit ?
• What matters the most when deciding on the significance of a serrated polyp?
• Dysplasia inside a serrated polyp? - Well it's complicated ! 
• The heterogeneity of serrated lesions is also problematic
• Could AI help the Pathologist in the future?
• How can we identify patients with serrated polyposis syndrome ?
• Can we explain finding both serrated and adenomatous polyps in serrate polyposis syndrome?
• Why should I refer patient with serrated polyposis syndrome to geneticists?
• Can we tell which cancer has developed from a serrated precursor?
• What is the link between serrated polyps and colitis?
• The weird issue of stromal changes below serrated polyps
• 'Mixed polyp' or 'collision polyp'?
• How can we as endoscopist help the pathologist?
• Do you believe in DISCARD?
• What remains the remit of the pathologist to diagnose?

Today I am talking to Dr Nick Burr, one of our Rising Stars in Gastroenterology, working in Leeds.  You may recognise his name from some of the most influential papers written on the topic of ADR and PCCRC in the recent past.  I’ve decided to ambush him with some difficult questions about our unhealthy obsession with ADR and see if I can convince him that the PCRCR rate is irrelevant to individual colonoscopists.   I am armed with the references below to support my argument ! 

1. Karminski MF. Quality Indicators for Colonoscopy and the Risk of Interval Cancer. NEJM 2010;362:1795-803
2. Eide T. Risk of CRC in adenoma bearing individuals. Intern J Cancer 1986;38;173–6
3. Stryker S. Natural history of untreated colonic polyps. Gastroenterology 1987;93:1009–13
4. Pickhart PJ. Assessment of volumetric growth rates of small colorectal polyps with CT colonography: a longitudinal study of natural history.  Lancet Oncol. 2013;14(8):711–20
5. Kuntz KM.  A Systematic Comparison of Microsimulation Models of Colorectal Cancer: The Role of Assumptions about Adenoma Progression.  Medical Decision making 2011;31(4):530-9 https://doi.org/10.1177/0272989X11408730
6. Djinbachian R. Rates of Incomplete Resection of 1- to 20-mm Colorectal Polyps: A Systematic Review and Meta-Analysis.  Gastroenterology 2020;159(3):904-14   https://doi.org/10.1053/j.gastro.2020.05.018

The UK 'National Endoscopy Database' (NED)  is set to be the largest Endoscopy Dataset in the World.  In theory, it should capture information on every single endoscopy carried out in the UK, providing detailed, up-to-the minute information.  Matt Rutter has been there from the start and tells us about it's origins, current challenges and future hopes. 

Srisha Hebbar and Peter Siersema challenge my prejudices and suggest that endoscopy can help patients with colonic lipomas and local recurrence after chemo-radiotherapy, two relatively uncommon conditions.  They both make convincing arguments!  Srisha has also uploaded a video to explain how to safely deal with colonic lipomas.  Of course, the video and references are available on the website  

Bjorn has reviewed the upcoming 'in-press' endoscopy related manuscripts and provides his usual opinionated and patronising feedback to the brave authors of 14 manuscripts. Of course, you may agree or disagree with his comments and could even find yourself fired up to read some of the articles yourself!  But then again you don't need to, as everything is covered in his Podcast !   References are listed on the website: www.friendsofendoscopy.org  Don't forget to say Thank You, next time you see someone from Pentax Medical because this wouldn't be possible without them !!!  

Jamal Al-Asiry (Wakefield), Mo Thoufeeq (Sheffield), Pradeep Mundre (Bradford) and Nick Burr, (Endoscopy Fellow at Leeds) Battle it out at this Years Leeds Endoscopy Christmas Quiz !  Ten Questions, 3 answer options and 1 correct answer. 

Dr Andreia Albuguerque from Lisbon discusses her paper on the neglected topic of anal cancer recently published in Lancet Gastroenterology and Hepatology 2021;6:327-34. As larger endoscopy units should find 4-5 early anal cancers every year, I have a terrible suspicion that many of these lesions go undetected. 

The BSG Campus 2021 was a great success with nine half days of Gastroenterology news, 700 abstracts and 1400 delegates taking part.  The podcasts gives you a 30 minute update on Endoscopy related news and research from the Campus meeting.  A transcript and full list of references will be published on the www.friendsofendoscopy.org website 

Post colonoscopy colorectal cancer is arguable one of the 'hardest' quality measures in colonoscopy. Until now, it has been difficult to identify cases often presenting several years after their colonoscopy and sometimes to a different institution. From September, NHS endoscopy units will have access to a bespoke online resource identifying cases of PCCRC. From September, this online tool will be used to audit the 1400 PCCRC cases which we see in the NHS every year. Roland Valori explains the idea behind the audit. 

This time our Podcast is full of both important and interesting studies.  We present new evidence on how to treat pancreatic pseudocysts with hydrogen peroxide, the benefit of PPI's on EoE, an large study of endoscopic treatment of appendicitis, and find that our trusty indigo carmine dye spray is still going strong!  Then we have an interesting paper on the appalling effect of mountain sickness on the stomach, transplantation on the risk of polyps and when to stop Barrett's surveillance.  Thanks to our Partners at Pentax medical for your Support !

References reviewed includes; 

1. Laserna MEJ et.al. Efficacy of Therapy for Eosinophilic Esophagitis in Real-World Practice.
2. Clinical Gastroenterology & Hepatology. 18(13):2903-2911.e4, 2020 12.
3. Greuter T et.al. Effectiveness and Safety of High- vs Low-Dose Swallowed Topical Steroids for Maintenance Treatment of Eosinophilic Esophagitis: A Multicenter Observational Study.
4. Clinical Gastroenterology & Hepatology. 2020 Aug 13.
5. Ding W et.al. Endoscopic retrograde appendicitis therapy (ERAT) for management of acute appendicitis. Surgical Endoscopy. 2021 May 13.
6. Becq A et.al. ERCP within 6 or 12 h for acute cholangitis: a propensity score-matched analysis. Surgical Endoscopy. 2021 May 11.
7. Ashkar MH et.al. Increased Risk of Advanced Colonic Adenomas and Timing of Surveillance Colonoscopy Following Solid Organ Transplantation. Digestive Diseases & Sciences. 2021 May 10.
8. Chandrasekhara V et.al. Predicting the need for step-up therapy after EUS-guided drainage of pancreatic fluid collections with lumen-apposing metal stents. Clinical Gastroenterology & Hepatology. 2021 May 06.
9. Messallam AA et.al. Endoscopic Necrosectomy With and Without Hydrogen Peroxide for Walled-off Pancreatic Necrosis: A Multicenter Comparative Study. American Journal of Gastroenterology. 116(4):700-709, 2021 Apr.
10. Shiroma S et.al. Timing of bleeding and thromboembolism associated with endoscopic submucosal dissection for gastric cancer in Japan. Journal of Gastroenterology & Hepatology. 2021 May 07
11. Yasuda T et.al. Benefits of linked color imaging for recognition of early differentiated-type gastric cancer: in comparison with indigo carmine contrast method and blue laser imaging. Surgical Endoscopy. 35(6):2750-2758, 2021 Jun.
12. Kim JW et.al. Narrowband imaging with near-focus magnification for discriminating the gastric tumor margin before endoscopic resection: A prospective randomized multicenter trial. Journal of Gastroenterology & Hepatology. 35(11):1930-1937, 2020 Nov.
13. Surek A et.al. Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience. International Journal of Colorectal Disease. 36(6):1221-1229, 2021 Jun.
14. Clark G et.al. Transition to quantitative faecal immunochemical testing from guaiac faecal occult blood testing in a fully rolled-out population-based national bowel screening programme. Gut. 70(1):106-113, 2021 Jan.
15. Gachabayov M et.al. Performance evaluation of stool DNA methylation tests in colorectal cancer screening: a systematic review and meta-analysis. Colorectal Disease. 23(5):1030-1042, 2021 05.
16. Forbes N et.al. Association Between Endoscopist Annual Procedure Volume and Colonoscopy Quality: Systematic Review and Meta-analysis. Clinical Gastroenterology & Hepatology. 18(10):2192-2208.e12, 2020 09.
17. Fruehauf H et.al. Evaluation of Acute Mountain Sickness by Unsedated Transnasal Esophagogastroduodenoscopy at High Altitude. Clinical Gastroenterology & Hepatology. 18(10):2218-2225.e2, 2020 09.
18. Goverde A et.al. Yield of Lynch Syndrome Surveillance for Patients With Pathogenic Variants in DNA Mismatch Repair Genes. Clinical Gastroenterology & Hepatology. 18(5):1112-1120.e1, 2020 05.
19. Lamba M et.al. Associations Between Mutations in MSH6 and PMS2 and Risk of Surveillance-detected Colorectal Cancer. Clinical Gastroenterology & Hepatology. 18(12):2768-2774, 2020 11.
20. Omidvar AH et.al. The optimal age to stop endoscopic surveillance of Barrett's esophagus patients based on sex and comorbidity: a comparative cost-effectiveness analysis. Gastroenterology. 2021 May 08.

This week, Prof Marco Bruno, Department of Gastroenterology and Hepatology at the Erasmus University Medical Centre in Rotterdam is explaining about the problem we have with scope contamination.  Last year his department published a Nationwide Study of bacterial colonization of endoscopes. The study included 74 Dutch Centres and reported that 17% of duodenoscopes and 13% of EUS scopes were contaminated!  What can we do about this? With Marco, I discuss the current situation and possible solutions, like new endoscope designs, continuous monitoring and culturing of scopes and the training for reprocessing colleagues.

Arguably, the most exciting thing which has happen in ERCP, in the last 50 years, is EUS and the development of easy to place, 'lumen apposing metal stents' (LAMS).  It's transforming ERCP for the benefits of patients who no longer need to put up with painful PTC's.  Ideally, every region should offer this service but who should be referred for EUS-guided biliary drainage (EUS-BD) and what risks should you quote to your patients?  Monz Ahmed poses some probing questions to Bharat Paranandi and Aaron On in Leeds. 

We can now offer patients procedures which, 20 yrs ago were unthinkable.  Procedures which improves health, reduces morbidity and saves lives. But, these procedures are longer and more uncomfortable and therefore patients require deeper sedation than before.  Unfortunately, at the same time, patients are older and with more comorbidities.  This dual problem of frail patients requiring deeper sedation for longer procedures, has narrowed our ‘sedation window’.

The old way of monitoring patients, with a nurse and an oxygen saturation monitor, is no longer enough.  It's for this reason that the Academy of Medical Royal Colleges in February 2021, updated their guidelines on Safe Sedation practises.  Now they recommend that patients requiring 'moderate sedation' should be monitored more closely, not only by a dedicated nurse and oxygen saturation monitor but also with ECG, BP and Capnography.

Of course, this is a huge change for endoscopy units.  Our staff are now asked to do three things at the same time; maintain the airway, listen to the pitch of the oxygen saturation monitor and interpret that ECG and Capnography traces. 

Dr Martin Lees , Clinical Director of Cardiac Anaesthesia and Perioperative Medicine at St Barts Heart Centre in London and Nurse Specialist Andreia Trigo with SedateUK, discuss the new guidelines and the implications it has for endoscopy units around the World.

Professor Mark Pritchard, has a simple plea; when you are dealing with gastric NET's, make sure that you know what you are doing!  In this Podcast he highlights the pitfalls and provides us with Endoscopy Gold !!! 

COVID never posed an existential threat but nevertheless had a devastating impact, including on our Endoscopy services. Now we do have an existential threat which Endoscopy is actively driving us towards.  Endoscopy is the third greatest hospital contributor to Global Warming !!! 

You may be tempted to 'cop out', deciding that you can do nothing, but you would be wrong. There are 3 things which you can do; Reduce Reuse and Recycle.  Listen to the suggestions, read the NHS Net Zero document and join By Hayee at Kings College as a 'Green Endoscopists'.  By the way, we have had statements from all the main Endoscopy organisations on COVID but apart from BSG and the World Gastroenterology Organisation, very little on 'future sustainability'.   Isn't it about time that we all 'Look UP'? 

There have been some recent developments shedding welcome light on the issue of cancer in colitis.  We take a closer look at the papers and have a chat with Lauranne Derikx about her recent GIE publication.  To my surprise, I find that my long lamented 'cancer field theory' is very much alive !  

References  ■ Derikx LAAP, Kievit W, Drenth JPH et.al. Prior Colorectal Neoplasia Is Associated With Increased Risk of Ileoanal Pouch Neoplasia in IBD. Gastroenterology 2014;146:119-28.

■ de Jong ME, van Tilburg SB, Nissen LHC et.al. Long-term Risk of advanced Neoplasia after finding LGD in pts with IBD - A Nationwide Cohort Study. Journal of Crohn's and Colitis 2019;1485-91.

■ de Jong ME, Kanne H, Nissen LHC et.al. Increased risk of HGD and CRC in IBD patients with recurrent LGD. GIE 2020;91:1334-42. ■ Wijnands AM, de Jong ME, Lutgens MWMD. Prognostic factors for advanced colorectal neoplasia in inflammatory bowel disease: systematic review and meta-analysis. Gastroenterology 2020; 22 December

Artificial Intelligence (AI) will soon be touching all areas of medicine. The first is already affecting lesion detection and characterisation.  Hot on the heels of radiology and histopathology comes endoscopy ... 

The annual UEG Week has gone virtual

Bjorn's trawl of newsworthy Endoscopy papers currently in press includes; Which patients don't heal well after RFA, Chances of successfully removing a 45mm polyp is only 75% in the Netherlands,  What is 'tip-In EMR?, Tumour biology is important in UC-related PCCRC,  We should be doing more TIPS (and presumably therefore, less emergency band ligation)  and finally musculoskeletal injury is rife amongst endoscopists! 

This week Nick Burr and Bjorn Rembacken are discussing the bright new world of molecular screening for occult cancers as the NHS starts screening for more than 50 cancers.  This summer the “Galleri blood test”, developed by an American company called ‘GRAIL’ will be piloted on 140.000 healthy people in the UK.  

Naturally, Bjorn remains sceptical, and after an unsuccessful search for the ‘study aims’, asks if getting a positive result always mean that the cancer is treatable?  Furthermore, how do you tell the difference between a true positive and a false positive? 

Surprisingly, we are also standing up for the effectiveness of CTC and wonder why an American study reports such shockingly poor results. 

Today we are reporting on the 'FLIP device' and give you an update on the likely aetiology of achalasia. 

There have been studies on 'motorised spiral enteroscopy'. Is a motor really a good thing inside the small bowel? 

We are surprised to see a complete turnaround in the recommendations from Sheffield on how to diagnose Coeliac disease ! 

Sadly, surveillance in patients with MUTyH related polyposis doesn't seem to save lives. 

Should we all start doing 'full thickness' colonic resections?  I urge caution!  

Finally, there have been some good news and some bad news on the topic of emergency GI bleeding ...

References:

1. Savarino E. T Use of the Functional Lumen Imaging Probe.  American Journal of Gastroenterology 2020;115(11):1786-96
2. Campagna RAJ. Intraoperative assessment of oesophageal motility using FLIP during myotomy for achalasia.  Surgical Endoscopy 2020;34(6):2593-2600
3. Ikebuchi Y. microRNAs in biopsy samples of lower oesophageal sphincter muscle during peroral endoscopic myotomy for oesophageal achalasia.  Digestive Endoscopy. 2020;32(1):136-42
4. Ramchandani M. Diagnostic yield and therapeutic impact of novel motorized spiral enteroscopy in small-bowel disorders: a single-center, real-world experience from a tertiary care hospital.  Gastrointestinal Endoscopy.  2020 Jul 12.
5. Beyna T. Total motorized spiral enteroscopy: first prospective clinical feasibility trial.  Gastrointestinal Endoscopy.  2020 Oct 31.
6. Penny HA. Accuracy of a no-biopsy approach for the diagnosis of coeliac disease across different adult cohorts. Gut 2020 Nov 02.
7. Guz-Mark A. High rates of serology testing for coeliac disease, and low rates of endoscopy in serologically positive children and adults in Israel: lessons from a large real-world database.  European Journal of Gastroenterology & Hepatology. 2020;32(3):329-34
8. Thomas LE.  Duodenal adenomas and cancer in MUTYH-associated polyposis: an international cohort study.  Gastroenterology.  2020 Oct 29.
9. Patel R.  MUTYH-associated polyposis - colorectal phenotype and management.  Colorectal Disease 2020;22(10):1271-78
10. Yeh JH.  Long-term Outcomes of Primary Endoscopic Resection vs Surgery for T1 Colorectal Cancer: A Systematic Review and Meta-analysis.  Clinical Gastroenterology & Hepatology. 2020;18(12):2813-23
11. Boger P.  Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry. European Journal of Gastroenterology & Hepatology.  2020 Oct 29.
12. Zwager LW.  Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry.  Endoscopy. 2020;52(11):1014-23
13. Lee HS.  Comparison of conventional and modified endoscopic mucosal resection methods for the treatment of rectal neuroendocrine tumors.  Surgical Endoscopy.  2020 Oct 22.
14. Kherad O. Systematic review with meta-analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding. [Review] Alimentary Pharmacology & Therapeutics. 52(5):774-88, 2020 09.
15. Alzoubadi D. Outcomes from an international multicenter registry of patients with acute gastrointestinal bleeding undergoing endoscopic treatment with Hemospray.  Digestive Endoscopy. 2020;32(1):96-110

Topics included artificial intelligence, an overview of bariatric endoscopy, the less than straightforward management of early rectal cancer, how safe is spiral enteroscopy?, should we place a duodenal or a hot Axios stent in gastric outlet obstruction and why would you take papillary biopsies in FAP?  What would you say to a patient, with a germline E-cadherin mutation, who decline a prophylactic gastrectomy?  

As usual, the most interesting findings are hidden in the details. For example, did you know that the introduction of colonic cancer screening doesn't appear to have had any impact on mortality rates ... 

Today we are reviewing 15 recent endoscopy publications ranging from the effect of Covid on our endoscopy service and training, a Delphi review of water immersion vs exchange, AI and scoring colitis, adrenaline and pancreatitis.  We are asking if gastric GIST’s are not better removed laparoscopically after all. Finally, a reminder about the new WHO criteria for the diagnosis of SSPS.

1. Rutter M. Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis. GUT 2020, July 20 (http://dx.doi.org/10.1136/gutjnl-2020-322179 )
2. Lantinga MA. Impact of the COVID-19 pandemic on gastrointestinal endoscopy in the Netherlands: analysis of a prospective endoscopy database. Endoscopy 2020, Oct 20
3. Clarke K. Impact of COVID-19 Pandemic on Training: Global Perceptions of Gastroenterology and Hepatology Fellows in the USA. Digestive Diseases & Sciences.  2020 Oct 19
4. Sonnenberg A. Digestive Diseases & Sciences. 2020 Oct 21 (https://doi.org/10.1007/s10620-020-06661-0)
5. Maclean W. Adoption of Faecal Immunochemical Testing for two-week wait colorectal patients during the COVID-19 pandemic: An observational cohort study reporting a new service at a regional centre. Colorectal Disease. 2020 Oct 17
6. McSorley ST. Yield of colorectal cancer at colonoscopy according to faecal haemoglobin concentration in symptomatic patients referred from primary care. Colorectal Disease.  2020 Oct 16
7. Pin-Vieito N. Risk of gastrointestinal cancer in a symptomatic cohort after a complete colonoscopy: Role of faecal immunochemical test. World Journal of Gastroenterology 2020 26(1):70-85, 2020
8. Ebigbo A. Cost-effectiveness analysis of SARS-CoV-2 infection-prevention strategies including pre-endoscopic virus testing and use of high-risk personal protective equipment.. Endoscopy.  2020 Oct 20
9. Cadoni S. Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations. Gastrointestinal Endoscopy. 2020 Oct 15.
10. Bhambhvani HP. Deep learning enabled classification of Mayo endoscopic subscore in patients with ulcerative colitis. European Journal of Gastroenterology & Hepatology.  2020 Oct 16
11. Luo H. Rectal Indomethacin and Spraying of Duodenal Papilla with Epinephrine Increases Risk of Pancreatitis Following Endoscopic Retrograde Cholangiopancreatography. Clinical Gastroenterology & Hepatology. 17(8):1597-1606.e5, 2019 07
12. Dong X. Laparoscopic resection is better than endoscopic dissection for gastric gastrointestinal stromal tumor between 2 and 5 cm in size: a case-matched study in a gastrointestinal center. Surgical Endoscopy. 34(11):5098-5106, 2020 Nov
13. Ezaz G. Association Between Endoscopist Personality and Rate of Adenoma Detection. Clinical Gastroenterology & Hepatology. 17(8):1571-1579.e7, 2019 07
14. Lee JY. Association Between Cigarette Smoking and Alcohol Consumption and Sessile Serrated Polyps in Subjects 30 to 49 Years Old. Clinical Gastroenterology & Hepatology. 17(8):1551-1560.e1, 2019 07
15. Dekker E. Update on the World Health Organization Criteria for Diagnosis of Serrated Polyposis Syndrome. Gastroenterology 2020, January 23 (https://doi.org/10.1053/j.gastro.2019.11.310)