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Continuing Medical Education Exam: October 2016
GIE
Ò
CME ACTIVITY
Continuing Medical Education Exam: October 2016 James Buxbaum, MD, Karthik Ravi, MD, William Ross, MD, Brian Weston, MD, Co-Editors, CME Section Prasad G. Iyer, MD, Amit Rastogi, MD, Editors, CME Section Michael B. Wallace, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Mallick R, Rank K, Ronstrom C, et al. Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis. Gastrointest Endosc 2016;84:639-45. Varadarajulu S, Bang JY, Hasan MK, et al. Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video). Gastrointest Endosc 2016;84:681-7. Klein A, Nayyar D, Bahin FF, et al. Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 2016;84:688-96. Pohl H, Robertson DJ, Mott LA, et al. Association between adenoma location and risk of recurrence. Gastrointest Endosc 2016:84:709-16. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives Upon completion of this educational activity, participants will be able to: 1. Assess single-session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis. 2. Determine the usefulness of rapid onsite evaluation for improving the sensitivity of cholangioscopic biopsies 3. Estimate the safety and long-term efficacy of endoscopic mucosal resection for large lateral spreading duodenal adenomas. 4. Define the risk for metachronous polyps based on the site and number of adenomas during baseline colonoscopy.
Continuing Medical Education The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditÔ. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity Start Date: October 1, 2016 Activity Expiration Date: October 31, 2018
Disclosures Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: Brian Weston, MD (CME Editor): Disclosed no relevant financial relationships.
Prasad G. Iyer, MD (Associate Editor for Journal CME) Consulting/Advisory/Speaking: Olympus; Research Support: Takeda Pharma Amit Rastogi, MD (Associate Editor for Journal CME) Consulting/Advisory/Speaking: Olympus James Buxbaum (CME Editor): Disclosed no relevant financial relationships. Karthik Ravi, MD (CME Editor): Disclosed no relevant financial relationships. William Ross, MD (CME Editor): Consulting/Advisory/Speaking: Boston Scientific, Olympus
Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh) Windows 95,98,2000, NT or Mac OS Netscape 4. or Microsoft Internet Explorer 4. and above 16 MB RAM 56.6K modem
www.giejournal.org
Volume 84, No. 4 : 2016 GASTROINTESTINAL ENDOSCOPY 717
All CME activities, including their associated articles are copyrighted by the ASGE.
CME ACTIVITY
Continuing Medical Education Questions: October 2016 QUESTION 1 OBJECTIVE: Assess single-session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis.
Single-session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis Question 1:
Possible answers: (A-E)
A 49-year-old woman is admitted with right upperquadrant abdominal pain. Ultrasound imaging demonstrates multiple gallstones as well as a common bile duct stone. Based on the findings from the current study, which of the following is true regarding performance of ERCP during the same operative session as laparoscopic cholecystectomy?
A. Option included in most major guidelines for the management of choledocholithiasis B. Lower technical success C. Higher adverse event rates D. Shorter total anesthesia and operative times E. Shorter length of hospital stay
Look-up: Mallick R, Rank K, Ronstrom C, et al. Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis. Gastrointest Endosc 2016;84:639-45.
QUESTION 2 OBJECTIVE: Determine the usefulness of rapid onsite evaluation for improving the sensitivity of cholangioscopic biopsies
Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? Question 2:
Possible answers: (A-D)
A 66-year-old woman is referred to you for an indeterminate biliary stricture after ERCP with brushings and EUSFNA. The patient is frustrated and wants to know the yield of direct cholangioscopy. Rapid onsite evaluation (ROSE) is now available at your institution. How much will this improve the sensitivity of cholangioscopic biopsies?
A. B. C. D.
No improvement with ROSE Less than a 10% improvement From 60%-70% to 95% From 60%-70% to 99%
Look-up: Varadarajulu S, Bang JY, Hasan MK, et al. Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video). Gastrointest Endosc 2016;84:681-7.
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CME Exam
QUESTION 3 OBJECTIVE: Estimate the safety and long-term efficacy of endoscopic mucosal resection for large lateral spreading duodenal adenomas.
Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes Question 3:
Possible answers (A-D):
A 55-year-old man with a medical history of atrial fibrillation on Coumadin presents with 6 months of dyspeptic symptoms. He reports no heartburn, no weight loss, and no other worrisome symptoms. An EGD is performed and reveals a normal-appearing esophagus and stomach with negative biopsies for Helicobacter pylori. However, incidentally a 2cm polyp is seen in the second portion of the duodenum. You recommend that the patient hold his Coumadin for 5 days and arrange for endoscopic mucosal resection (EMR) at a tertiary care center. Which of the following is true regarding EMR for this large duodenal polyp?
A. His use of Coumadin increases his risk of intraprocedural bleed. B. Over 90% of patients with similar lesions are free of polyp at 1 year follow-up. C. There is a 10% risk of perforation with EMR. D. Residual polyp or histologic recurrence at initial surveillance endoscopy is present in 40% of patients after EMR.
Look-up: Klein A, Nayyar D, Bahin FF, et al. Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 2016;84:688-96.
QUESTION 4 OBJECTIVE: Define the risk for metachronous polyps based on the site and number of adenomas during baseline colonoscopy.
Association between adenoma location and risk of subsequent polyps Question 4:
Possible answers (A-D):
A 56-year-old man is scheduled for a surveillance colonoscopy. Four years earlier he underwent a screening examination, and 3 tubular adenomas measuring between 6 and 10mm were removed from the ascending colon. He had no left-sided findings. Which of the following is most accurate regarding the potential findings on his upcoming examination?
A. He is less likely to have tubular adenomas than if the polyps on his baseline exam were in the sigmoid colon. B. He is more likely to have tubular adenomas than if the polyps on his baseline exam were in the sigmoid colon. C. He is at no higher risk for metachronous lesions than if a single polyp had been found in the ascending colon. D. He is equally likely to have metachronous polyps in the proximal and distal colon on the upcoming exam.
Look-up: Pohl H, Robertson DJ, Mott LA, et al. Association between adenoma location and risk of recurrence. Gastrointest Endosc 2016:84:709-16.
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CME ACTIVITY
Continuing Medical Education Answers: October 2016 QUESTION 1 CORRECT RESPONSE: E Rationale for correct response: Choledocholithiasis may be present in up to 20% of patients undergoing cholecystectomy for gallstones. Removal of common bile duct (CBD) stones is indicated to prevent adverse events such as ascending cholangitis and pancreatitis, which can be severe.1 Pre- or post-operative ERCP or surgical CBD exploration are recommended options for management. The option to perform ERCP and cholecystectomy in the same session is not currently included in most major guidelines for the management of choledocholithiasis.2,3 A combined approach may offer several potential advantages and be more efficient. In addition, intraoperative cholangiogram or laparoscopic ultrasound may prevent unnecessary ERCP. In the current study, Mallick et al1 evaluated single-session versus separate session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis. Technical success was equivalent. No adverse events (ie, pancreatitis, bleeding, or perforation) were observed in either group. No significant difference was observed for procedure time or duration of anesthesia. The duration of hospital stay was significantly lower in patients undergoing LC in the same session as ERCP (4.8 2.6 vs 6.2 3.3 days; P Z .03). This did not result in a significant reduction in the total cost of care. When both procedures were performed in the same session, it was preferred to complete the cholecystectomy first to avoid limitation in visualization caused by endoscopic insufflation of the bowel. ERCP was performed on the same fluoroscopy table as cholecystectomy without transporting to another suite and generally without repositioning the patient to the prone position. In some instances, endoscopic cannulation of the bile duct may be facilitated via a rendezvous approach with passage of a guidewire via the cystic duct. The combined approach requires careful patient selection. Some patients with altered anatomy, sepsis secondary to cholangitis, or severe biliary pancreatitis may not be candidates. Other limiting factors include logistic difficulties of coordination between providers and non-integrated endoscopic and surgical facilities, which are typically separated.4,5 Although laparoscopic CBD exploration has demonstrated similar rates of morbidity as endoscopic management,6 it is mostly limited to specialized centers and surgeons with advanced laparoscopic training. Take-home message: Single-session laparoscopic cholecystectomy and ERCP may be safe, effective, and feasible for some patients in select centers. It may be associated with a reduced length of stay. REFERENCES: 1. Mallick R, Rank K, Ronstrom C, et al. Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis. Gastrointest Endosc 2016;84:639-45. 2. ASGE Standards of Practice Committee; Maple JT, Ikenberry SO, Anderson MA, et al. The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc 2011;74:731-44. 3. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut 2008;57:1004-21. 4. ElGeidie AA. Single-session minimally invasive management of common bile duct stones. World J Gastroenterol 2014;20:15144-52. 5. Wild JL, Younus MJ, Torres D, et al. Same-day combined endoscopic retrograde cholangiopancreatography and cholecystectomy: Achievable and minimizes costs. J Trauma Acute Care Surg 2015;78:503-7. 6. Dasari BV, Tan CJ, Gurusamy KS, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013;12:CD003327.
QUESTION 2 CORRECT RESPONSE: C Rationale for correct response: The authors demonstrate an improvement in sensitivity with the use of ROSE against the published historical controls for indeterminate stricture biopsy.1 However, the study is flawed in that the additional benefit of ROSE compared with offsite histology alone in their institution is unclear. Given their technical expertise with direct cholangioscopy and the available skill in pathological interpretation, it would be of great interest to see how the reported results compare with their 28 patients who had procedures at a time ROSE was not available. The fact that ROSE was not available to assess half of their direct cholangioscopy biopsies raises the question of cost, extra time, and pathology support that the technique requires. An unanswered question is if ROSE improves the yield of EUS-FNA and intraductal biopsy, would it do the same for cytological brushing? Perhaps the traditionally modest sensitivity of brushings could be significantly improved by ROSE
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CME Answers
without the additional risk and expense of cholangioscopy. Indeterminate stricture assessment is a challenge and ROSE appears to improve the yield of tissue sampling. Yet tissue acquisition carries risks that other techniques under evaluation do not. For example, confocal laser endomicroscopy has been reported to have sensitivity and accuracy comparable to targeted biopsy of indeterminate strictures.2 In the future, perhaps biomarkers in bile collected at time of initial ERCP with stent insertion may prove to be diagnostic.3 REFERENCES: 1. Varadarajulu S, Bang JY, Hasan MK, et al. Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video). Gastrointest Endosc 2016;84:681-7. 2. Yang JF, Sharaiha RZ, Francis G, et al. Diagnostic accuracy of directed cholangioscopic biopsies and confocal laser endomicroscopy in cytology negative indeterminate bile duct stricture: a multicenter comparison trial. Minerva Gastroenterol Dietol 2016;62:227-33. 3. Lourdusamy V, Tharian B, Navaneethan U. Biomarkers in bile-complementing advanced endoscopic imaging in the diagnosis of indeterminate biliary strictures. World J Gastroenterol 2015;7:308-17.
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: Duodenal polyps are incidental findings in up to 5% of patients who undergo EGD. However, duodenal adenomas are relatively rare, accounting for less than 10% of all duodenal polyps.1 Nonetheless, larger adenomas in particular carry similar malignant potential to colonic adenomas, and therefore endoscopic resection is recommended.2 EMR has emerged as an important tool for the resection of large lateral spreading adenomas of the duodenum.3,4 However, while limited data confirm the safety and efficacy of this strategy, little is currently known regarding its long-term outcomes. In this month’s edition of GIE, Klein and colleagues5 provide a retrospective single-center study assessing the safety as well as short-term and long-term efficacy of EMR for these large sporadic duodenal adneomas. A total of 106 cases of large laterally spreading duodenal adenomas, defined as greater than or equal to 10 mm in diameter, are reported. Complete EMR resection was achieved in 96% of these cases. The primary adverse event was intra-procedural bleed, seen in 43% of cases. However, these were able to be managed endoscopically, largely with snare tip soft coagulation. Delayed bleeding was decidedly less common, occurring in only 15% of cases with nearly all either not requiring specific therapy or able to be managed endoscopically. The size of the lesion was associated with an increased risk of both intraprocedural and delayed bleeding while the number of resected specimens and procedural length were associated with intra-procedural bleed alone. Perforation was a rare adverse event, occurring in only 3 of 106 cases. Notably, the presence of major comorbidities and the previous use of antiplatelet or anticoagulants were not associated with adverse events. Although early histologic recurrence or residual polyp was seen in 14.4% of cases at 4 to 6 months after EMR at the initial surveillance endoscopy, nearly 85% were treated endoscopically without evidence of recurrence at subsequent endoscopy. Further, over 90% of patients were free of adenoma at 1-year follow-up. Strikingly, similar outcomes with regards to complete endoscopic resection, histologic recurrence, and adenoma-free rates at 1 year were seen with polyps larger than 30 mm when compared to those between 10 and 30 mm. This highlights the broad applicability of EMR for these lesions at tertiary care centers. Take-home message: EMR is a safe treatment strategy for large duodenal adenomas when performed at tertiary care centers. This is an effective treatment strategy with excellent long-term outcomes. Although procedure-related adverse events may be increased with larger lesions, size alone should not preclude EMR of duodenal adenomas. REFERENCES: 1. Jepsen JM, Persson M, Jakobsen NO, et al. Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy. Scand J Gastroenterol 1994;29:483-7. 2. Witteman BJ, Janssens AR, Griffoen G, et al. Villous tumours of the duodenum. An analysis of the literature with emphasis on malignant transformation. Neth J Med 1993;42:5-11. 3. Abbass R, Rigaux J, Al-Kawas FH. Nonamupullary duodenal polyps: characteristics and endoscopic management. Gastrointest Endosc 2010;71:754-9. 4. Min YW, Min B-H, Kim ER, et al. Efficacy and safety of endoscopic treatment for nonampullary sporadic duodenal adenomas. Dig Dis Sci 2013;58:2926-32. 5. Klein A, Nayyar D, Bahin FF, et al. Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 2016;84:688-96.
QUESTION 4: CORRECT RESPONSE: B Rationale for correct response: In this submission, Pohl et al1 further define the likelihood and features of metachronous adenomas based on the location of lesions on the baseline examination. Using prospectively collected data on 2430 patients, they demonstrated
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CME Answers
that patients with only proximal adenomas were more likely (OR 1.17) than those with only distal adenomas to have metachronous lesions. This effect was more pronounced (OR 1.35) in those with multiple proximal polyps. Their work builds on findings by Martinez and others that large proximal lesions are associated with increased probability of metachronous colon polyps.2,3 Additionally, the authors demonstrated that polyp location predicts the site of subsequent lesions.1 They found that those with only distal adenomas on the baseline examination were equally likely to have metachronous adenomas on the left versus right side of the colon. In contrast, those with only proximal adenomas were more likely to have right-sided adenomas (28.4%) than left-sided adenomas (15.9%) on subsequent colonoscopies. Take-home message: Patients with proximal colon adenomas are more likely to develop metachronous lesion than those with distal polyps. The probability is greater if multiple proximal polyps are found on the baseline examination and subsequent polyps tend to also be on the right side. REFERENCES: 1. Pohl H, Robertson DJ, Mott LA, et al. Association between adenoma location and risk of recurrence. Gastrointest Endosc 2016;84:709-16. 2. Martinez ME, Sampliner R, Marshall JR, et al. Adenoma characteristics as risk factors for recurrence of advanced adenomas. Gastroenterology 2001;120:1077-83. 3. van Heijningen EM, Lansdorp-Vogelaar I, Kuipers EJ, et al. Features of adenoma and colonoscopy associated with recurrent colorectal neoplasia based on a large community-based study. Gastroenterology 2013;144:1410-8.
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CME ACTIVITY
Continuing Medical Education Exam: October 2016 James Buxbaum, MD, Karthik Ravi, MD, William Ross, MD, Brian Weston, MD, Co-Editors, CME Section Prasad G. Iyer, MD, Amit Rastogi, MD, Editors, CME Section Michael B. Wallace, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Mallick R, Rank K, Ronstrom C, et al. Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis. Gastrointest Endosc 2016;84:639-45. Varadarajulu S, Bang JY, Hasan MK, et al. Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video). Gastrointest Endosc 2016;84:681-7. Klein A, Nayyar D, Bahin FF, et al. Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 2016;84:688-96. Pohl H, Robertson DJ, Mott LA, et al. Association between adenoma location and risk of recurrence. Gastrointest Endosc 2016:84:709-16. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives Upon completion of this educational activity, participants will be able to: 1. Assess single-session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis. 2. Determine the usefulness of rapid onsite evaluation for improving the sensitivity of cholangioscopic biopsies 3. Estimate the safety and long-term efficacy of endoscopic mucosal resection for large lateral spreading duodenal adenomas. 4. Define the risk for metachronous polyps based on the site and number of adenomas during baseline colonoscopy.
Continuing Medical Education The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditÔ. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity Start Date: October 1, 2016 Activity Expiration Date: October 31, 2018
Disclosures Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: Brian Weston, MD (CME Editor): Disclosed no relevant financial relationships.
Prasad G. Iyer, MD (Associate Editor for Journal CME) Consulting/Advisory/Speaking: Olympus; Research Support: Takeda Pharma Amit Rastogi, MD (Associate Editor for Journal CME) Consulting/Advisory/Speaking: Olympus James Buxbaum (CME Editor): Disclosed no relevant financial relationships. Karthik Ravi, MD (CME Editor): Disclosed no relevant financial relationships. William Ross, MD (CME Editor): Consulting/Advisory/Speaking: Boston Scientific, Olympus
Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh) Windows 95,98,2000, NT or Mac OS Netscape 4. or Microsoft Internet Explorer 4. and above 16 MB RAM 56.6K modem
www.giejournal.org
Volume 84, No. 4 : 2016 GASTROINTESTINAL ENDOSCOPY 717
All CME activities, including their associated articles are copyrighted by the ASGE.
CME ACTIVITY
Continuing Medical Education Questions: October 2016 QUESTION 1 OBJECTIVE: Assess single-session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis.
Single-session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis Question 1:
Possible answers: (A-E)
A 49-year-old woman is admitted with right upperquadrant abdominal pain. Ultrasound imaging demonstrates multiple gallstones as well as a common bile duct stone. Based on the findings from the current study, which of the following is true regarding performance of ERCP during the same operative session as laparoscopic cholecystectomy?
A. Option included in most major guidelines for the management of choledocholithiasis B. Lower technical success C. Higher adverse event rates D. Shorter total anesthesia and operative times E. Shorter length of hospital stay
Look-up: Mallick R, Rank K, Ronstrom C, et al. Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis. Gastrointest Endosc 2016;84:639-45.
QUESTION 2 OBJECTIVE: Determine the usefulness of rapid onsite evaluation for improving the sensitivity of cholangioscopic biopsies
Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? Question 2:
Possible answers: (A-D)
A 66-year-old woman is referred to you for an indeterminate biliary stricture after ERCP with brushings and EUSFNA. The patient is frustrated and wants to know the yield of direct cholangioscopy. Rapid onsite evaluation (ROSE) is now available at your institution. How much will this improve the sensitivity of cholangioscopic biopsies?
A. B. C. D.
No improvement with ROSE Less than a 10% improvement From 60%-70% to 95% From 60%-70% to 99%
Look-up: Varadarajulu S, Bang JY, Hasan MK, et al. Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video). Gastrointest Endosc 2016;84:681-7.
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CME Exam
QUESTION 3 OBJECTIVE: Estimate the safety and long-term efficacy of endoscopic mucosal resection for large lateral spreading duodenal adenomas.
Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes Question 3:
Possible answers (A-D):
A 55-year-old man with a medical history of atrial fibrillation on Coumadin presents with 6 months of dyspeptic symptoms. He reports no heartburn, no weight loss, and no other worrisome symptoms. An EGD is performed and reveals a normal-appearing esophagus and stomach with negative biopsies for Helicobacter pylori. However, incidentally a 2cm polyp is seen in the second portion of the duodenum. You recommend that the patient hold his Coumadin for 5 days and arrange for endoscopic mucosal resection (EMR) at a tertiary care center. Which of the following is true regarding EMR for this large duodenal polyp?
A. His use of Coumadin increases his risk of intraprocedural bleed. B. Over 90% of patients with similar lesions are free of polyp at 1 year follow-up. C. There is a 10% risk of perforation with EMR. D. Residual polyp or histologic recurrence at initial surveillance endoscopy is present in 40% of patients after EMR.
Look-up: Klein A, Nayyar D, Bahin FF, et al. Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 2016;84:688-96.
QUESTION 4 OBJECTIVE: Define the risk for metachronous polyps based on the site and number of adenomas during baseline colonoscopy.
Association between adenoma location and risk of subsequent polyps Question 4:
Possible answers (A-D):
A 56-year-old man is scheduled for a surveillance colonoscopy. Four years earlier he underwent a screening examination, and 3 tubular adenomas measuring between 6 and 10mm were removed from the ascending colon. He had no left-sided findings. Which of the following is most accurate regarding the potential findings on his upcoming examination?
A. He is less likely to have tubular adenomas than if the polyps on his baseline exam were in the sigmoid colon. B. He is more likely to have tubular adenomas than if the polyps on his baseline exam were in the sigmoid colon. C. He is at no higher risk for metachronous lesions than if a single polyp had been found in the ascending colon. D. He is equally likely to have metachronous polyps in the proximal and distal colon on the upcoming exam.
Look-up: Pohl H, Robertson DJ, Mott LA, et al. Association between adenoma location and risk of recurrence. Gastrointest Endosc 2016:84:709-16.
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CME ACTIVITY
Continuing Medical Education Answers: October 2016 QUESTION 1 CORRECT RESPONSE: E Rationale for correct response: Choledocholithiasis may be present in up to 20% of patients undergoing cholecystectomy for gallstones. Removal of common bile duct (CBD) stones is indicated to prevent adverse events such as ascending cholangitis and pancreatitis, which can be severe.1 Pre- or post-operative ERCP or surgical CBD exploration are recommended options for management. The option to perform ERCP and cholecystectomy in the same session is not currently included in most major guidelines for the management of choledocholithiasis.2,3 A combined approach may offer several potential advantages and be more efficient. In addition, intraoperative cholangiogram or laparoscopic ultrasound may prevent unnecessary ERCP. In the current study, Mallick et al1 evaluated single-session versus separate session laparoscopic cholecystectomy and ERCP for the management of choledocholithiasis. Technical success was equivalent. No adverse events (ie, pancreatitis, bleeding, or perforation) were observed in either group. No significant difference was observed for procedure time or duration of anesthesia. The duration of hospital stay was significantly lower in patients undergoing LC in the same session as ERCP (4.8 2.6 vs 6.2 3.3 days; P Z .03). This did not result in a significant reduction in the total cost of care. When both procedures were performed in the same session, it was preferred to complete the cholecystectomy first to avoid limitation in visualization caused by endoscopic insufflation of the bowel. ERCP was performed on the same fluoroscopy table as cholecystectomy without transporting to another suite and generally without repositioning the patient to the prone position. In some instances, endoscopic cannulation of the bile duct may be facilitated via a rendezvous approach with passage of a guidewire via the cystic duct. The combined approach requires careful patient selection. Some patients with altered anatomy, sepsis secondary to cholangitis, or severe biliary pancreatitis may not be candidates. Other limiting factors include logistic difficulties of coordination between providers and non-integrated endoscopic and surgical facilities, which are typically separated.4,5 Although laparoscopic CBD exploration has demonstrated similar rates of morbidity as endoscopic management,6 it is mostly limited to specialized centers and surgeons with advanced laparoscopic training. Take-home message: Single-session laparoscopic cholecystectomy and ERCP may be safe, effective, and feasible for some patients in select centers. It may be associated with a reduced length of stay. REFERENCES: 1. Mallick R, Rank K, Ronstrom C, et al. Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis. Gastrointest Endosc 2016;84:639-45. 2. ASGE Standards of Practice Committee; Maple JT, Ikenberry SO, Anderson MA, et al. The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc 2011;74:731-44. 3. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut 2008;57:1004-21. 4. ElGeidie AA. Single-session minimally invasive management of common bile duct stones. World J Gastroenterol 2014;20:15144-52. 5. Wild JL, Younus MJ, Torres D, et al. Same-day combined endoscopic retrograde cholangiopancreatography and cholecystectomy: Achievable and minimizes costs. J Trauma Acute Care Surg 2015;78:503-7. 6. Dasari BV, Tan CJ, Gurusamy KS, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013;12:CD003327.
QUESTION 2 CORRECT RESPONSE: C Rationale for correct response: The authors demonstrate an improvement in sensitivity with the use of ROSE against the published historical controls for indeterminate stricture biopsy.1 However, the study is flawed in that the additional benefit of ROSE compared with offsite histology alone in their institution is unclear. Given their technical expertise with direct cholangioscopy and the available skill in pathological interpretation, it would be of great interest to see how the reported results compare with their 28 patients who had procedures at a time ROSE was not available. The fact that ROSE was not available to assess half of their direct cholangioscopy biopsies raises the question of cost, extra time, and pathology support that the technique requires. An unanswered question is if ROSE improves the yield of EUS-FNA and intraductal biopsy, would it do the same for cytological brushing? Perhaps the traditionally modest sensitivity of brushings could be significantly improved by ROSE
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CME Answers
without the additional risk and expense of cholangioscopy. Indeterminate stricture assessment is a challenge and ROSE appears to improve the yield of tissue sampling. Yet tissue acquisition carries risks that other techniques under evaluation do not. For example, confocal laser endomicroscopy has been reported to have sensitivity and accuracy comparable to targeted biopsy of indeterminate strictures.2 In the future, perhaps biomarkers in bile collected at time of initial ERCP with stent insertion may prove to be diagnostic.3 REFERENCES: 1. Varadarajulu S, Bang JY, Hasan MK, et al. Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video). Gastrointest Endosc 2016;84:681-7. 2. Yang JF, Sharaiha RZ, Francis G, et al. Diagnostic accuracy of directed cholangioscopic biopsies and confocal laser endomicroscopy in cytology negative indeterminate bile duct stricture: a multicenter comparison trial. Minerva Gastroenterol Dietol 2016;62:227-33. 3. Lourdusamy V, Tharian B, Navaneethan U. Biomarkers in bile-complementing advanced endoscopic imaging in the diagnosis of indeterminate biliary strictures. World J Gastroenterol 2015;7:308-17.
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: Duodenal polyps are incidental findings in up to 5% of patients who undergo EGD. However, duodenal adenomas are relatively rare, accounting for less than 10% of all duodenal polyps.1 Nonetheless, larger adenomas in particular carry similar malignant potential to colonic adenomas, and therefore endoscopic resection is recommended.2 EMR has emerged as an important tool for the resection of large lateral spreading adenomas of the duodenum.3,4 However, while limited data confirm the safety and efficacy of this strategy, little is currently known regarding its long-term outcomes. In this month’s edition of GIE, Klein and colleagues5 provide a retrospective single-center study assessing the safety as well as short-term and long-term efficacy of EMR for these large sporadic duodenal adneomas. A total of 106 cases of large laterally spreading duodenal adenomas, defined as greater than or equal to 10 mm in diameter, are reported. Complete EMR resection was achieved in 96% of these cases. The primary adverse event was intra-procedural bleed, seen in 43% of cases. However, these were able to be managed endoscopically, largely with snare tip soft coagulation. Delayed bleeding was decidedly less common, occurring in only 15% of cases with nearly all either not requiring specific therapy or able to be managed endoscopically. The size of the lesion was associated with an increased risk of both intraprocedural and delayed bleeding while the number of resected specimens and procedural length were associated with intra-procedural bleed alone. Perforation was a rare adverse event, occurring in only 3 of 106 cases. Notably, the presence of major comorbidities and the previous use of antiplatelet or anticoagulants were not associated with adverse events. Although early histologic recurrence or residual polyp was seen in 14.4% of cases at 4 to 6 months after EMR at the initial surveillance endoscopy, nearly 85% were treated endoscopically without evidence of recurrence at subsequent endoscopy. Further, over 90% of patients were free of adenoma at 1-year follow-up. Strikingly, similar outcomes with regards to complete endoscopic resection, histologic recurrence, and adenoma-free rates at 1 year were seen with polyps larger than 30 mm when compared to those between 10 and 30 mm. This highlights the broad applicability of EMR for these lesions at tertiary care centers. Take-home message: EMR is a safe treatment strategy for large duodenal adenomas when performed at tertiary care centers. This is an effective treatment strategy with excellent long-term outcomes. Although procedure-related adverse events may be increased with larger lesions, size alone should not preclude EMR of duodenal adenomas. REFERENCES: 1. Jepsen JM, Persson M, Jakobsen NO, et al. Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy. Scand J Gastroenterol 1994;29:483-7. 2. Witteman BJ, Janssens AR, Griffoen G, et al. Villous tumours of the duodenum. An analysis of the literature with emphasis on malignant transformation. Neth J Med 1993;42:5-11. 3. Abbass R, Rigaux J, Al-Kawas FH. Nonamupullary duodenal polyps: characteristics and endoscopic management. Gastrointest Endosc 2010;71:754-9. 4. Min YW, Min B-H, Kim ER, et al. Efficacy and safety of endoscopic treatment for nonampullary sporadic duodenal adenomas. Dig Dis Sci 2013;58:2926-32. 5. Klein A, Nayyar D, Bahin FF, et al. Endoscopic mucosal resection of large and giant lateral spreading lesions of the duodenum: success, adverse events, and long-term outcomes. Gastrointest Endosc 2016;84:688-96.
QUESTION 4: CORRECT RESPONSE: B Rationale for correct response: In this submission, Pohl et al1 further define the likelihood and features of metachronous adenomas based on the location of lesions on the baseline examination. Using prospectively collected data on 2430 patients, they demonstrated
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that patients with only proximal adenomas were more likely (OR 1.17) than those with only distal adenomas to have metachronous lesions. This effect was more pronounced (OR 1.35) in those with multiple proximal polyps. Their work builds on findings by Martinez and others that large proximal lesions are associated with increased probability of metachronous colon polyps.2,3 Additionally, the authors demonstrated that polyp location predicts the site of subsequent lesions.1 They found that those with only distal adenomas on the baseline examination were equally likely to have metachronous adenomas on the left versus right side of the colon. In contrast, those with only proximal adenomas were more likely to have right-sided adenomas (28.4%) than left-sided adenomas (15.9%) on subsequent colonoscopies. Take-home message: Patients with proximal colon adenomas are more likely to develop metachronous lesion than those with distal polyps. The probability is greater if multiple proximal polyps are found on the baseline examination and subsequent polyps tend to also be on the right side. REFERENCES: 1. Pohl H, Robertson DJ, Mott LA, et al. Association between adenoma location and risk of recurrence. Gastrointest Endosc 2016;84:709-16. 2. Martinez ME, Sampliner R, Marshall JR, et al. Adenoma characteristics as risk factors for recurrence of advanced adenomas. Gastroenterology 2001;120:1077-83. 3. van Heijningen EM, Lansdorp-Vogelaar I, Kuipers EJ, et al. Features of adenoma and colonoscopy associated with recurrent colorectal neoplasia based on a large community-based study. Gastroenterology 2013;144:1410-8.
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