- Email: [email protected]
Continuing Medical Education Exam: September 2013
GIE
TM
CME ACTIVITY
Continuing Medical Education Exam: September 2013 James Buxbaum, MD, William Ross, MD, Shou-Jiang Tang, MD, Brian Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section Glenn M. Eisen, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely on-line. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Hayee B, Inoue H, Sato H, et al. Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist. Gastrointest Endosc 2013;78:452-61. Enestvedt BK, Lugo R, Guarner-Argente C, et al. Location, location, location: does early cancer in Barrett’s esophagus have a preference? Gastrointest Endosc 2013;78:462-7. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013;78:468-75. Menees SB, Kim HM, Elliott EE, et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510-6. 2. Log in on-line 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. Interpret the role of magnification narrow-band imaging in the diagnosis of gastric lesions. 2. Describe the spatial predilection of early cancer associated with Barrett’s esophagus. 3. Discuss the clinical impact of pneumatic dilation and laparoscopic Heller’s myotomy in treating achalasia. 4. Determine the impact of colonoscopy preparation quality on adenoma detection and surveillance 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: September 1, 2013 Activity Expiration Date: September 30, 2015
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: G. S. Raju, MD, FASGE (Associate Editor for Journal CME): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus Shou-Jiang Tang, MD (CME Editor): James Buxbaum, MD (CME Editor): Consulting/Advisory/Speaking: Olympus America Disclosed no relevant financial relationships. Other Financial: Ethicon Endo-Surgery, licensing agreement for magnetic All CME activities, including their associated articles are copyrighted by anchoring and guidance sysytem; Patents pending for magnetic anchoring the ASGE. and guidance system Brian Weston, MD (CME Editor): Minimum Online System Requirements: Disclosed no relevant financial relationships. 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 78, No. 3 : 2013 GASTROINTESTINAL ENDOSCOPY 529
CME ACTIVITY
Continuing Medical Education Questions: September 2013 QUESTION 1 OBJECTIVE: Interpret the role of magnification narrow-band imaging in the diagnosis of gastric lesions.
NBI in the stomach Question 1:
Possible answers: (A-D)
A 68-year-old man with a history of peptic ulcer disease underwent endoscopy 1 year prior at another institution with findings of low-grade dysplasia in the antrum. You perform upper endoscopy for worsening dyspepsia and surveillance. Magnification narrow-band endoscopic imaging (NBI) is available, and you plan to use it for his evaluation. Which of the following findings on NBI is most worrisome?
A. Small round pits B. Uniform polygonal microvascular pattern C. Line of demarcation with altered microsurface and microvascular patterns D. Villiform pattern with blue-white lines seen on the epithelial surface
Look-up: Hayee B, Inoue H, Sato H, et al. Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist. Gastrointest Endosc 2013;78:452-61.
QUESTION 2 OBJECTIVE: Describe the spatial predilection of early cancer associated with Barrett’s esophagus.
Is there a predilection for cancer in Barrett’s esophagus? Question 2:
Possible answers: (A-D)
A 55-year-old man presents for endoscopic surveillance of Barrett’s esophagus. He has a 5-cm segment of Barrett’s esophagus. Which of the following has been shown to be the most common location for detection of early cancer in Barrett’s esophagus?
A. B. C. D.
12 – 3 o’clock position 3 – 6 o’clock position 6 – 9 o’clock position 9 – 12 o’clock position
Look-up: Enestvedt BK, Lugo R, Guarner-Argente C, et al. Location, location, location: does early cancer in Barrett’s esophagus have a preference? Gastrointest Endosc 2013;78:462-7.
529.e1 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 3 : 2013
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CME Exam
QUESTION 3 OBJECTIVE: Discuss the clinical impact of pneumatic dilation and laparoscopic Heller’s myotomy in treating achalasia.
Pneumatic dilation or laparoscopic Heller’s myotomy? Question 3:
Possible answers: (A-D)
A 45-year-old man with a newly diagnosed idiopathic achalasia is referred to you. After reviewing the history and images, you discuss different therapies including their efficacy, complication risk, and outcomes at 1 year after treatment. He prefers laparoscopic Heller’s myotomy to pneumatic dilation. Which of the following parameters responded favorably after Heller myotomy compared to pneumatic dilation?
A. B. C. D.
Symptom resolution Gastroesophageal reflux Quality-of-life score Lower esophageal sphincter pressure
Look-up: Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013;78:468-75.
QUESTION 4 OBJECTIVE: Determine the impact of colonoscopy preparation quality on adenoma detection and surveillance colonoscopy.
When to repeat a colonoscopy in a patient with a fair colonoscopy preparation Question 4: A 52-year-old male presents for average-risk colonoscopy screening examination. The examination shows a single 3-mm adenoma but the preparation is only fair. When will you repeat the colonoscopy?
Possible answers: (A-D) A. B. C. D.
What is the depth of your resection? 1 year 3-5 years 5-10 years 10 years
Look-up: Menees SB, Kim HM, Elliott EE, et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510-6.
www.giejournal.org
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CME ACTIVITY
Continuing Medical Education Answers: September 2013 QUESTION 1 CORRECT RESPONSE: C Rationale for correct response: It is now recognized that intestinal-type gastric cancer is the consequence of a histologic progression from gastritis to atrophy followed by intestinal metaplasia then low-grade and subsequently high-grade dysplasia, carcinoma-in-situ, and eventually malignancy.1-2 Though there are not yet American guidelines, the European Society for Gastrointestinal Endoscopy (ESGE) has proposed surveillance upper endoscopy after discovery of low-grade dysplasia within 1 year of diagnosis.3 Magnification enhances assessment of the microsurface pattern of the gastric mucosa and narrow band imaging allows the microvascular pattern of the stomach to be carefully assessed.4 Magnification narrow band imaging combines these capabilities and represents a powerful tool to evaluate benign and neoplastic gastric lesions. Small round pits and a symmetric polygonal (or honeycombed) microvascular lattice represent the normal gastric pattern. If these findings are seen on the surface of a protruding lesion it suggests the benign fundic polyp. A clear line of demarcation is concerning for gastric cancer. Focal gastritis is part of the differential diagnosis and is differentiated based on the assessment of the microsurface and microvascular features within the demarcation line itself. Aberrant microsurface and microvascular findings in this region are very concerning for malignancy. The light blue crest (LBC) sign along with a villiform pattern are suggestive of intestinal metaplasia.5 Take-home point: Magnification narrow-band imaging enables careful evaluation of the microvascular and microsurface pattern of the gastric mucosa. Accompanied with assessment of color and white light appearance, this enables the endoscopist to differentiate normal mucosa from gastritis, intestinal metaplasia, and early malignancy. Evidence of sharp lines of demarcation in the gastric mucosa accompanied by microvascular and microsurface aberrancies is worrisome for adverse pathology. REFERENCES: 1. Correa P, Fontham ET, Bravo JC, et al. Chemoprevention of gastric dysplasia: randomized trial of antioxidant supplements and anti-helicobacter pylori therapy. J Natl Cancer Inst 2000;92:1881-8. 2. de Vries AC, van Grieken NC, Looman CW, et al. Gastric cancer risk in patients with premalignant gastric lesions: a nationwide cohort study in the Netherlands. Gastroenterology 2008;134:945-52. 3. Dinis-Ribeiro M, Areia M, de Vries AC, et al. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy 2012;44:74-94. 4. Hayee B, Inoue H, Sato H, et al. Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist. Gastrointest Endosc 2013;78:452-61. 5. Uedo N, Ishihara R, Iishi H, et al. A new method of diagnosing gastric intestinal metaplasia: narrow-band imaging with magnifying endoscopy. Endoscopy 2006;38:819-24.
QUESTION 2 CORRECT RESPONSE: A Rationale for correct response: Enestvedt et al1 showed that early cancer associated with Barrett’s esophagus was far more common in the right versus left hemisphere of the esophagus (84.9% versus 15.1%; P ! .0001) in their retrospective analysis of 119 patients referred for endoscopic eradication of Barrett’s with either high-grade dysplasia (47.9%) or intramucosal adenocarcinoma (52.1%). The highest rate of early cancers was found in the 12 to 3 o’clock position (64.7%) including 71.9% of high-grade dysplastic lesions and 58.1% of intramucosal adenocarcinomas. Location designation was determined with the endoscope in the neutral position and the patient in the left lateral position. Similar observations of spatial distribution for high-grade lesions in the setting of Barrett’s have been found. Pech et al noted 48% of all Barrett’s cancers (total 380 lesions) were located in the right upper quadrant between 12 and 3 o’clock.2 Kariyawasam et al3 observed that the 2 to 5 o’clock position accounted for 53.8% (total 80 lesions) of macroscopically visible lesion and associated early neoplasia in Barrett’s segments.
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CME Answers
Reasons for the right hemisphere predilection are not well understood. In the left lateral position with the endoscope in the neutral position, 12 o’clock corresponds to the right lateral wall and 3 o’clock corresponds to the posterior wall of the esophagus. Reflux-associated lesions may be more common in this quadrant suggesting an anatomic relationship or possibly a detection bias as this area is more easily visualized.1,2 Such findings suggest that targeted surveillance in this region may enhance detection of high-risk lesions. Take-home point: Early cancer associated with Barrett’s is most commonly found in the right hemisphere of the esophagus, especially in the 12 to 3 o’clock position suggesting careful attention and targeted surveillance during endoscopy. REFERENCES: 1. Enestvedt BK, Lugo R, Guarner-Argente C, et al. Location, location, location: does early cancer in Barrett’s esophagus have a preference? Gastrointest Endosc 2013;78:462-7. 2. Pech O, Gossner L, Manner H, et al. Prospective valuation of the macroscopic types and location of early Barrett’s neoplasia in 380 lesions. Endoscopy 2007;39:588-93. 3. Kariyawasam VC, Bourke MJ, Hourigan LF, et al. Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in shortsegment Barrett’s esophagus. Gastrointest Endosc 2012;75:938-44.
QUESTION 3 CORRECT RESPONSE: A Rationale for correct response: Achalasia, an uncommon progressive motility disorder of the esophagus, is characterized by esophageal aperistalsis and dysrelaxation of the lower esophageal sphincter. MANAGEMENT OPTIONS:
Endoscopic options: Botulin toxin injection into the lower esophageal sphincter Pneumatic balloon dilation of the lower esophageal sphincter Peroral endoscopic myotomy of the lower esophageal sphincter Surgical option: Laparoscopic Heller myotomy Both pneumatic dilation and laparoscopic Heller myotomy are established treatment options for achalasia, with the following changes on esophageal physiology.1 Decrease lower esophageal sphincter pressure Improve esophageal emptying Increase esophagogastric junction distensibility Although randomized controlled trials have been conducted comparing these 2 interventions, the number of patients among these studies was small. In a recent meta-analysis, a comprehensive literature search was performed and 3 qualified studies involving 346 patients were analyzed.2 All 3 studies used graded pneumatic dilation advancing from 30 mm to 35 mm, and eventually to 40 mm balloons with slightly different criteria. The following are the results of this meta-analysis: At 1 year, the cumulative response rate was significantly higher with Heller myotomy: 86% versus 76%, ORZ1.98 (1.14-3.45); P Z .02 Rates of major mucosal tear requiring subsequent intervention with Heller myotomy were significantly lower than esophageal perforation rates requiring postprocedural medical or surgical therapy: 0.6% and 4.8%, respectively; P Z .04 Other outcomes did not differ with sufficient data: - Gastroesophageal reflux - Esophageal sphincter pressures - Quality-of-life scores Data on longer follow-up were not available Take-home point: At 1 year after therapy, Heller myotomy may provide greater response rates as compared to graded pneumatic dilation in the treatment of treatment-naive achalasia, with lesser rates of adverse events. REFERENCES: 1. Swanstrom LL, Kurian A, Dunst CM, et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012;256:659-67. 2. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a metaanalysis of randomized controlled trials. Gastrointest Endosc 2013;78:468-75.
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CME Answers
QUESTION 4 CORRECT RESPONSE: B Rationale for correct response: In a retrospective study using data from colonoscopies performed 7 to 9 years ago, the authors found 28% adenoma detection rate in patients with a fair preparation.1 Because these lesions were found within 3 years of the initial colonoscopy with fair preparation, the authors referred to the lesions noted on follow up as “missed adenomas.” Their data suggests that initial examinations that were particularly worrisome for missed lesions resulted in earlier follow-up as those seen at 1 year had a 41% missed adenoma rate. So, the initial endoscopist had a sense of which patients were most likely to harbor adenomas. The 2012 guidelines are rather vague on the fair preparation issue arguing that if the preparation was adequate to detection lesions O5 mm, a 5-year follow-up is sufficient even for patients with small adenomas on the initial exam.2 This would argue that for our patient with a single small adenoma, the interval should be 5 years. The authors of the current study may lean more toward 3-year intervals. However, 78% of the patients with 1 to 2 small adenomas were advised to return in the 3 to 5-year period. Although the authors stress the adenoma miss rate, it is not significantly higher than the miss rate for small adenomas (26%) found by van Rijn et al3 in their systematic review of the tandem colonoscopy studies. One could argue that fair preparations may have been more typical during the era of the tandem studies (1991-2004) than currently. Even with miss rates at this level, patients during the 1990s with normal examinations were routinely assigned 10-year intervals, a practice still reflected by a minority of endoscopists in the current study. The lack of consensus guidelines is reflected in the wide range of recommended follow-up intervals noted in the study. Until future studies provide sufficient data for guideline formulation, the best way to address the problem of marginal preparations is to spend effort up front to maximize preparation quality. The colonoscopies studied were performed in 2004 to 2006, before widespread use of split-dose preparation, which has been shown to be superior. The poor compliance with recommendations for early follow-up is another reason to place a greater emphasis on making the preparation for the initial examination as optimal as possible. Finally, the importance of preparation quality and adherence to surveillance intervals will only increase because both are potential quality metrics being considered for widespread use in the near future. It is difficult to put the study into proper context because the adenoma detection rate during the initial examination for patients with good or excellent preparation is not provided. Nor is the ADR for patients seen at 3-year intervals after initial colonoscopy with good or excellent preparation provided, so the impact of fair preparation on the miss rate could not be determined. The adenoma detection rate in the fair group is only 20.5% on initial examinations, but without additional data it is unclear whether this is due to the preparation or the endoscopists. Studies from other centers would argue that the adenoma detection rate for a gender-balanced group should be in the 30% to 40% range. It would be reassuring if the ADR in those with good or excellent preparation was in this range. As pointed out in the accompanying editorial by Deenadayalu,4 the topic deserves more study because too many questions remain to formulate meaningful guidelines. With greater emphasis on preparation quality, the percentage of patients with such marginal preparations will diminish with time. Take-home point: Spend time to counsel patients about the importance of a quality bowel preparation to avoid getting caught in the decisions of when to do a repeat examination. REFERENCES: 1. Menees SB, Kim HM, Elliott EE, et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510-6. 2. Lieberman DA, Rex DK, Winawer SJ, et al. Guideline for colonoscopy surveillance after screening and polypectomy: a consensus update by the US multi-society task force on colorectal cancer. Gastroenterology 2012,143:844-57. 3. van Rijn, JC, Reitsma JB, Stoker J, et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006;101:343-50. 4. Deenadayalu V. When is a fair bowel preparation fair enough? Gastrointest Endosc 2013;78:517-9.
529.e5 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 3 : 2013
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TM
CME ACTIVITY
Continuing Medical Education Exam: September 2013 James Buxbaum, MD, William Ross, MD, Shou-Jiang Tang, MD, Brian Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section Glenn M. Eisen, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely on-line. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Hayee B, Inoue H, Sato H, et al. Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist. Gastrointest Endosc 2013;78:452-61. Enestvedt BK, Lugo R, Guarner-Argente C, et al. Location, location, location: does early cancer in Barrett’s esophagus have a preference? Gastrointest Endosc 2013;78:462-7. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013;78:468-75. Menees SB, Kim HM, Elliott EE, et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510-6. 2. Log in on-line 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. Interpret the role of magnification narrow-band imaging in the diagnosis of gastric lesions. 2. Describe the spatial predilection of early cancer associated with Barrett’s esophagus. 3. Discuss the clinical impact of pneumatic dilation and laparoscopic Heller’s myotomy in treating achalasia. 4. Determine the impact of colonoscopy preparation quality on adenoma detection and surveillance 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: September 1, 2013 Activity Expiration Date: September 30, 2015
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: G. S. Raju, MD, FASGE (Associate Editor for Journal CME): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus Shou-Jiang Tang, MD (CME Editor): James Buxbaum, MD (CME Editor): Consulting/Advisory/Speaking: Olympus America Disclosed no relevant financial relationships. Other Financial: Ethicon Endo-Surgery, licensing agreement for magnetic All CME activities, including their associated articles are copyrighted by anchoring and guidance sysytem; Patents pending for magnetic anchoring the ASGE. and guidance system Brian Weston, MD (CME Editor): Minimum Online System Requirements: Disclosed no relevant financial relationships. 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 78, No. 3 : 2013 GASTROINTESTINAL ENDOSCOPY 529
CME ACTIVITY
Continuing Medical Education Questions: September 2013 QUESTION 1 OBJECTIVE: Interpret the role of magnification narrow-band imaging in the diagnosis of gastric lesions.
NBI in the stomach Question 1:
Possible answers: (A-D)
A 68-year-old man with a history of peptic ulcer disease underwent endoscopy 1 year prior at another institution with findings of low-grade dysplasia in the antrum. You perform upper endoscopy for worsening dyspepsia and surveillance. Magnification narrow-band endoscopic imaging (NBI) is available, and you plan to use it for his evaluation. Which of the following findings on NBI is most worrisome?
A. Small round pits B. Uniform polygonal microvascular pattern C. Line of demarcation with altered microsurface and microvascular patterns D. Villiform pattern with blue-white lines seen on the epithelial surface
Look-up: Hayee B, Inoue H, Sato H, et al. Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist. Gastrointest Endosc 2013;78:452-61.
QUESTION 2 OBJECTIVE: Describe the spatial predilection of early cancer associated with Barrett’s esophagus.
Is there a predilection for cancer in Barrett’s esophagus? Question 2:
Possible answers: (A-D)
A 55-year-old man presents for endoscopic surveillance of Barrett’s esophagus. He has a 5-cm segment of Barrett’s esophagus. Which of the following has been shown to be the most common location for detection of early cancer in Barrett’s esophagus?
A. B. C. D.
12 – 3 o’clock position 3 – 6 o’clock position 6 – 9 o’clock position 9 – 12 o’clock position
Look-up: Enestvedt BK, Lugo R, Guarner-Argente C, et al. Location, location, location: does early cancer in Barrett’s esophagus have a preference? Gastrointest Endosc 2013;78:462-7.
529.e1 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 3 : 2013
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CME Exam
QUESTION 3 OBJECTIVE: Discuss the clinical impact of pneumatic dilation and laparoscopic Heller’s myotomy in treating achalasia.
Pneumatic dilation or laparoscopic Heller’s myotomy? Question 3:
Possible answers: (A-D)
A 45-year-old man with a newly diagnosed idiopathic achalasia is referred to you. After reviewing the history and images, you discuss different therapies including their efficacy, complication risk, and outcomes at 1 year after treatment. He prefers laparoscopic Heller’s myotomy to pneumatic dilation. Which of the following parameters responded favorably after Heller myotomy compared to pneumatic dilation?
A. B. C. D.
Symptom resolution Gastroesophageal reflux Quality-of-life score Lower esophageal sphincter pressure
Look-up: Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013;78:468-75.
QUESTION 4 OBJECTIVE: Determine the impact of colonoscopy preparation quality on adenoma detection and surveillance colonoscopy.
When to repeat a colonoscopy in a patient with a fair colonoscopy preparation Question 4: A 52-year-old male presents for average-risk colonoscopy screening examination. The examination shows a single 3-mm adenoma but the preparation is only fair. When will you repeat the colonoscopy?
Possible answers: (A-D) A. B. C. D.
What is the depth of your resection? 1 year 3-5 years 5-10 years 10 years
Look-up: Menees SB, Kim HM, Elliott EE, et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510-6.
www.giejournal.org
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CME ACTIVITY
Continuing Medical Education Answers: September 2013 QUESTION 1 CORRECT RESPONSE: C Rationale for correct response: It is now recognized that intestinal-type gastric cancer is the consequence of a histologic progression from gastritis to atrophy followed by intestinal metaplasia then low-grade and subsequently high-grade dysplasia, carcinoma-in-situ, and eventually malignancy.1-2 Though there are not yet American guidelines, the European Society for Gastrointestinal Endoscopy (ESGE) has proposed surveillance upper endoscopy after discovery of low-grade dysplasia within 1 year of diagnosis.3 Magnification enhances assessment of the microsurface pattern of the gastric mucosa and narrow band imaging allows the microvascular pattern of the stomach to be carefully assessed.4 Magnification narrow band imaging combines these capabilities and represents a powerful tool to evaluate benign and neoplastic gastric lesions. Small round pits and a symmetric polygonal (or honeycombed) microvascular lattice represent the normal gastric pattern. If these findings are seen on the surface of a protruding lesion it suggests the benign fundic polyp. A clear line of demarcation is concerning for gastric cancer. Focal gastritis is part of the differential diagnosis and is differentiated based on the assessment of the microsurface and microvascular features within the demarcation line itself. Aberrant microsurface and microvascular findings in this region are very concerning for malignancy. The light blue crest (LBC) sign along with a villiform pattern are suggestive of intestinal metaplasia.5 Take-home point: Magnification narrow-band imaging enables careful evaluation of the microvascular and microsurface pattern of the gastric mucosa. Accompanied with assessment of color and white light appearance, this enables the endoscopist to differentiate normal mucosa from gastritis, intestinal metaplasia, and early malignancy. Evidence of sharp lines of demarcation in the gastric mucosa accompanied by microvascular and microsurface aberrancies is worrisome for adverse pathology. REFERENCES: 1. Correa P, Fontham ET, Bravo JC, et al. Chemoprevention of gastric dysplasia: randomized trial of antioxidant supplements and anti-helicobacter pylori therapy. J Natl Cancer Inst 2000;92:1881-8. 2. de Vries AC, van Grieken NC, Looman CW, et al. Gastric cancer risk in patients with premalignant gastric lesions: a nationwide cohort study in the Netherlands. Gastroenterology 2008;134:945-52. 3. Dinis-Ribeiro M, Areia M, de Vries AC, et al. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy 2012;44:74-94. 4. Hayee B, Inoue H, Sato H, et al. Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist. Gastrointest Endosc 2013;78:452-61. 5. Uedo N, Ishihara R, Iishi H, et al. A new method of diagnosing gastric intestinal metaplasia: narrow-band imaging with magnifying endoscopy. Endoscopy 2006;38:819-24.
QUESTION 2 CORRECT RESPONSE: A Rationale for correct response: Enestvedt et al1 showed that early cancer associated with Barrett’s esophagus was far more common in the right versus left hemisphere of the esophagus (84.9% versus 15.1%; P ! .0001) in their retrospective analysis of 119 patients referred for endoscopic eradication of Barrett’s with either high-grade dysplasia (47.9%) or intramucosal adenocarcinoma (52.1%). The highest rate of early cancers was found in the 12 to 3 o’clock position (64.7%) including 71.9% of high-grade dysplastic lesions and 58.1% of intramucosal adenocarcinomas. Location designation was determined with the endoscope in the neutral position and the patient in the left lateral position. Similar observations of spatial distribution for high-grade lesions in the setting of Barrett’s have been found. Pech et al noted 48% of all Barrett’s cancers (total 380 lesions) were located in the right upper quadrant between 12 and 3 o’clock.2 Kariyawasam et al3 observed that the 2 to 5 o’clock position accounted for 53.8% (total 80 lesions) of macroscopically visible lesion and associated early neoplasia in Barrett’s segments.
529.e3 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 3 : 2013
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CME Answers
Reasons for the right hemisphere predilection are not well understood. In the left lateral position with the endoscope in the neutral position, 12 o’clock corresponds to the right lateral wall and 3 o’clock corresponds to the posterior wall of the esophagus. Reflux-associated lesions may be more common in this quadrant suggesting an anatomic relationship or possibly a detection bias as this area is more easily visualized.1,2 Such findings suggest that targeted surveillance in this region may enhance detection of high-risk lesions. Take-home point: Early cancer associated with Barrett’s is most commonly found in the right hemisphere of the esophagus, especially in the 12 to 3 o’clock position suggesting careful attention and targeted surveillance during endoscopy. REFERENCES: 1. Enestvedt BK, Lugo R, Guarner-Argente C, et al. Location, location, location: does early cancer in Barrett’s esophagus have a preference? Gastrointest Endosc 2013;78:462-7. 2. Pech O, Gossner L, Manner H, et al. Prospective valuation of the macroscopic types and location of early Barrett’s neoplasia in 380 lesions. Endoscopy 2007;39:588-93. 3. Kariyawasam VC, Bourke MJ, Hourigan LF, et al. Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in shortsegment Barrett’s esophagus. Gastrointest Endosc 2012;75:938-44.
QUESTION 3 CORRECT RESPONSE: A Rationale for correct response: Achalasia, an uncommon progressive motility disorder of the esophagus, is characterized by esophageal aperistalsis and dysrelaxation of the lower esophageal sphincter. MANAGEMENT OPTIONS:
Endoscopic options: Botulin toxin injection into the lower esophageal sphincter Pneumatic balloon dilation of the lower esophageal sphincter Peroral endoscopic myotomy of the lower esophageal sphincter Surgical option: Laparoscopic Heller myotomy Both pneumatic dilation and laparoscopic Heller myotomy are established treatment options for achalasia, with the following changes on esophageal physiology.1 Decrease lower esophageal sphincter pressure Improve esophageal emptying Increase esophagogastric junction distensibility Although randomized controlled trials have been conducted comparing these 2 interventions, the number of patients among these studies was small. In a recent meta-analysis, a comprehensive literature search was performed and 3 qualified studies involving 346 patients were analyzed.2 All 3 studies used graded pneumatic dilation advancing from 30 mm to 35 mm, and eventually to 40 mm balloons with slightly different criteria. The following are the results of this meta-analysis: At 1 year, the cumulative response rate was significantly higher with Heller myotomy: 86% versus 76%, ORZ1.98 (1.14-3.45); P Z .02 Rates of major mucosal tear requiring subsequent intervention with Heller myotomy were significantly lower than esophageal perforation rates requiring postprocedural medical or surgical therapy: 0.6% and 4.8%, respectively; P Z .04 Other outcomes did not differ with sufficient data: - Gastroesophageal reflux - Esophageal sphincter pressures - Quality-of-life scores Data on longer follow-up were not available Take-home point: At 1 year after therapy, Heller myotomy may provide greater response rates as compared to graded pneumatic dilation in the treatment of treatment-naive achalasia, with lesser rates of adverse events. REFERENCES: 1. Swanstrom LL, Kurian A, Dunst CM, et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012;256:659-67. 2. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a metaanalysis of randomized controlled trials. Gastrointest Endosc 2013;78:468-75.
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Volume 78, No. 3 : 2013 GASTROINTESTINAL ENDOSCOPY 529.e4
CME Answers
QUESTION 4 CORRECT RESPONSE: B Rationale for correct response: In a retrospective study using data from colonoscopies performed 7 to 9 years ago, the authors found 28% adenoma detection rate in patients with a fair preparation.1 Because these lesions were found within 3 years of the initial colonoscopy with fair preparation, the authors referred to the lesions noted on follow up as “missed adenomas.” Their data suggests that initial examinations that were particularly worrisome for missed lesions resulted in earlier follow-up as those seen at 1 year had a 41% missed adenoma rate. So, the initial endoscopist had a sense of which patients were most likely to harbor adenomas. The 2012 guidelines are rather vague on the fair preparation issue arguing that if the preparation was adequate to detection lesions O5 mm, a 5-year follow-up is sufficient even for patients with small adenomas on the initial exam.2 This would argue that for our patient with a single small adenoma, the interval should be 5 years. The authors of the current study may lean more toward 3-year intervals. However, 78% of the patients with 1 to 2 small adenomas were advised to return in the 3 to 5-year period. Although the authors stress the adenoma miss rate, it is not significantly higher than the miss rate for small adenomas (26%) found by van Rijn et al3 in their systematic review of the tandem colonoscopy studies. One could argue that fair preparations may have been more typical during the era of the tandem studies (1991-2004) than currently. Even with miss rates at this level, patients during the 1990s with normal examinations were routinely assigned 10-year intervals, a practice still reflected by a minority of endoscopists in the current study. The lack of consensus guidelines is reflected in the wide range of recommended follow-up intervals noted in the study. Until future studies provide sufficient data for guideline formulation, the best way to address the problem of marginal preparations is to spend effort up front to maximize preparation quality. The colonoscopies studied were performed in 2004 to 2006, before widespread use of split-dose preparation, which has been shown to be superior. The poor compliance with recommendations for early follow-up is another reason to place a greater emphasis on making the preparation for the initial examination as optimal as possible. Finally, the importance of preparation quality and adherence to surveillance intervals will only increase because both are potential quality metrics being considered for widespread use in the near future. It is difficult to put the study into proper context because the adenoma detection rate during the initial examination for patients with good or excellent preparation is not provided. Nor is the ADR for patients seen at 3-year intervals after initial colonoscopy with good or excellent preparation provided, so the impact of fair preparation on the miss rate could not be determined. The adenoma detection rate in the fair group is only 20.5% on initial examinations, but without additional data it is unclear whether this is due to the preparation or the endoscopists. Studies from other centers would argue that the adenoma detection rate for a gender-balanced group should be in the 30% to 40% range. It would be reassuring if the ADR in those with good or excellent preparation was in this range. As pointed out in the accompanying editorial by Deenadayalu,4 the topic deserves more study because too many questions remain to formulate meaningful guidelines. With greater emphasis on preparation quality, the percentage of patients with such marginal preparations will diminish with time. Take-home point: Spend time to counsel patients about the importance of a quality bowel preparation to avoid getting caught in the decisions of when to do a repeat examination. REFERENCES: 1. Menees SB, Kim HM, Elliott EE, et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510-6. 2. Lieberman DA, Rex DK, Winawer SJ, et al. Guideline for colonoscopy surveillance after screening and polypectomy: a consensus update by the US multi-society task force on colorectal cancer. Gastroenterology 2012,143:844-57. 3. van Rijn, JC, Reitsma JB, Stoker J, et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006;101:343-50. 4. Deenadayalu V. When is a fair bowel preparation fair enough? Gastrointest Endosc 2013;78:517-9.
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