- Email: [email protected]
Tu1182 Learning Curves and Competence in Image Interpretation Among Novice Users of Volumetric Laser Endomicroscopy for Barrett's Esophagus Using Cumulative Sum Analysis
Abstracts
and two perforations (4%) (treated with clip and over-the-scope clip, respectively). Conclusions: A structured approach to implementation and use of ESD in a USA center demonstrated that ESD was safe and efficient, reflecting the experience of other large centers in Europe and Japan.
Tu1181 Very Low Rate of Progression to Esophageal Adenocarcinoma in PatientâVäs With Non-Dysplastic and Low-Grade Dysplastic Barrett’s Esophagus at a Tertiary GI Referral Center Harsh Patel*1, Bijun S. Kannadath3, Erik F. Rahimi2, Sushovan Guha2, Atilla Ertan2, Nirav Thosani2 1 Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; 2Gastroenterology, Hepatology & Nutrition, Hermann Hospital, TMC. McGovern Medical School, UTHealth, Houston, TX; 3UTHealth, Houston, TX Introduction: A systematic review and meta-analysis published in March, 2016 highlighted the magnitude of missed cases of esophageal adenocarcinoma (EAC) within 1 year of index endoscopy diagnosing Barrett’s esophagus at a rate of 25%; with other large population based studies supporting these findings. With this high rate of misdiagnosed EAC, we performed a retrospective study with the aim of assessing the rate of progression to EAC within a cohort of patients with Barrett’s esophagus at a tertiary GI referral center. Methods: This was a retrospective single-center cohort study. ICD codes and the electronic medical records were used to collectively create a database of 408 patients with Barrett’s esophagus with demographic data, pertinent history, and endoscopy results. We included a total of 115 patients with nondysplastic BE (NDBE) and low-grade dysplasia (LGBE) on index endoscopy between 2010-2015 (diagnosed by direct visualization and pathology), as well as with endoscopic follow-up within 3 years. The primary outcome being the proportion of missed cases (within 1 year) and incident cases (after 1 year) of EAC following index endoscopy. Results: The study involved adult patients (>18yrs) from the Ertan Digestive Disease Center in Houston, TX. We excluded patients without Barrett’s metaplasia on index, a follow up endoscopy, or pathology on index endoscopy. Subjects with High-grade dysplasia/EAC on index endoscopy and endoscopies before 2010 or after 2015 were also excluded. Of the 115 subjects, there were 97 with NDBE, 11 with LGBE, and 7 indefinite for dysplasia. Based on analysis, there were no missed or incident cases of EAC on follow up endoscopies. However, there were 2 cases of progression from NDBE to LGBE and 1 case from LGBE to HGBE (High-Grade). Conclusion: At our tertiary referral center, we found no cases of missed EAC or progression to EAC in patients with Barrett’s esophagus with follow up ranging from at least 1 year to 5 years.
Barrett’s Esophagus Data Results Total Number of Subjects: Number of Males with Barrett’s Esophagus: Number of Females with Barrett’s Esophagus: Grade of Dysplasia: Number of Non-Dysplastic LesionsNumber of Low-Grade Dysplastic LesionsNumber of Indefinite LesionsSize of Metaplastic Lesions: Number of Short Segment LesionsNumber of Long Segment LesionsNumber of Lesions with undefined SizeNumber of Follow ups within 1 year: Progression of Disease: Progression from NDBE to LGBEProgression from LGBE to HGBEMissed Cases of EAC (within 1 year)Incidental Cases of EAC (after 1 year)-
115 71 44
1
Medicine, Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY; 2Medicine, Gastroenterology, (2) Lewis Katz School of Medicine at Temple University, Philadelphia, PA; 3Biostatistics, Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY; 4H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA; 5Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 6Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY; 7Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA; 8 Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Harvard-MIT Division of Health Sciences Technology, Boston, MA; 9Division of Gastroenterology, Mayo Clinic, Jacksonville, FL Background and Aims: Volumetric laser endomicroscopy (VLE) is a new wide field advanced imaging technology for Barrett’s esophagus (BE). It can distinguish between tissue types. Little is known about the learning curve for image interpretation. The goal of this study was to calculate the learning curve and competence of image interpretation of VLE in BE amongst novice users using cumulative sum analysis. Methods: Thirty-one novice users to VLE were administered 96 slides electronically in a supervised session at three academic institutions. There were 24 slides of each histology type : normal gastric cardia, normal esophagus, BE without neoplasia (nondysplastic BE and BE with low-grade dysplasia), and BE with neoplasia (BE with highgrade dysplasia and intramucosal cancer). Each slide corresponded to a patient from the VLE national registry. Novice users were administered a brief training session followed by the slide set. The user was asked to identify the correct tissue type and level of confidence. Slides were administered randomly, with an explanation of the correct answer after each question. The cumulative summation (Cusum) technique was used to construct a learning curve for each novice enrolled in the study. Our acceptable and unacceptable failure rates, that are required for cusum analysis, were pre-specified as 10% (p0 Z 0.1) and 20% (p1 Z 0.2), respectively based on PIVI criteria and how high-volume users faired in the same slide set. Results: The majority of physicians were fellows (67.7%) and 32.3% were attendings. Twenty-two (71%) of the physicians achieved competency during their 96-slide review. The slide at which half of the physicians achieved competency (i.e., median slide) was 65 (95% CI: 45 to 85). There were no significant differences between attending and fellows (p Z 0.24), EUS experience and no EUS experience (p Z 0.84), institution (p Z 0.28) or prior limited VLE experience and no VLE experience (p Z 0.94) with respect to number of slides until competency. Among the 2,976 slides reviewed (96 slides were reviewed by 31 physicians), physicians were confident in their diagnosis on 50% of slides, fairly certain in their diagnosis on 42.8% of slides and uncertain in their diagnosis on 7.2% of slides. There was a significant association between confidence in diagnosis and histology type (p < 0.0001). BE without neoplasia had significantly greater odds of uncertainty as compared to BE with neoplasia (OR: 3.17, 95% CI: 2.52, 3.99), normal gastric (OR: 3.87, 95% CI: 3.06, 4.90) and normal squamous (OR: 2.61, 95% CI: 2.08, 3.27). Conclusion: The majority of novice users achieve competence in image interpretation of VLE for Barrett’s esophagus at the level of high-volume users with a favorable learning curve.
97 11 7 73 20 22 75 2 1 0 0
Tu1182 Learning Curves and Competence in Image Interpretation Among Novice Users of Volumetric Laser Endomicroscopy for Barrett’s Esophagus Using Cumulative Sum Analysis Arvind J. Trindade*1, Michael S. Smith2, Sumant Inamdar1, Lisa Rosen3, Dennis Han1, Kenneth J. Chang4, Cadman L. Leggett5, Charles J. Lightdale6, Douglas K. Pleskow7, Divyesh V. Sejpal1, Guillermo Tearney8, Michael B. Wallace9
AB572 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Figure 1. Overall CUSUM VLE learning curve; only 12 randomly selected physicians are displayed out of the 31 to reduce clutter
www.giejournal.org
and two perforations (4%) (treated with clip and over-the-scope clip, respectively). Conclusions: A structured approach to implementation and use of ESD in a USA center demonstrated that ESD was safe and efficient, reflecting the experience of other large centers in Europe and Japan.
Tu1181 Very Low Rate of Progression to Esophageal Adenocarcinoma in PatientâVäs With Non-Dysplastic and Low-Grade Dysplastic Barrett’s Esophagus at a Tertiary GI Referral Center Harsh Patel*1, Bijun S. Kannadath3, Erik F. Rahimi2, Sushovan Guha2, Atilla Ertan2, Nirav Thosani2 1 Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; 2Gastroenterology, Hepatology & Nutrition, Hermann Hospital, TMC. McGovern Medical School, UTHealth, Houston, TX; 3UTHealth, Houston, TX Introduction: A systematic review and meta-analysis published in March, 2016 highlighted the magnitude of missed cases of esophageal adenocarcinoma (EAC) within 1 year of index endoscopy diagnosing Barrett’s esophagus at a rate of 25%; with other large population based studies supporting these findings. With this high rate of misdiagnosed EAC, we performed a retrospective study with the aim of assessing the rate of progression to EAC within a cohort of patients with Barrett’s esophagus at a tertiary GI referral center. Methods: This was a retrospective single-center cohort study. ICD codes and the electronic medical records were used to collectively create a database of 408 patients with Barrett’s esophagus with demographic data, pertinent history, and endoscopy results. We included a total of 115 patients with nondysplastic BE (NDBE) and low-grade dysplasia (LGBE) on index endoscopy between 2010-2015 (diagnosed by direct visualization and pathology), as well as with endoscopic follow-up within 3 years. The primary outcome being the proportion of missed cases (within 1 year) and incident cases (after 1 year) of EAC following index endoscopy. Results: The study involved adult patients (>18yrs) from the Ertan Digestive Disease Center in Houston, TX. We excluded patients without Barrett’s metaplasia on index, a follow up endoscopy, or pathology on index endoscopy. Subjects with High-grade dysplasia/EAC on index endoscopy and endoscopies before 2010 or after 2015 were also excluded. Of the 115 subjects, there were 97 with NDBE, 11 with LGBE, and 7 indefinite for dysplasia. Based on analysis, there were no missed or incident cases of EAC on follow up endoscopies. However, there were 2 cases of progression from NDBE to LGBE and 1 case from LGBE to HGBE (High-Grade). Conclusion: At our tertiary referral center, we found no cases of missed EAC or progression to EAC in patients with Barrett’s esophagus with follow up ranging from at least 1 year to 5 years.
Barrett’s Esophagus Data Results Total Number of Subjects: Number of Males with Barrett’s Esophagus: Number of Females with Barrett’s Esophagus: Grade of Dysplasia: Number of Non-Dysplastic LesionsNumber of Low-Grade Dysplastic LesionsNumber of Indefinite LesionsSize of Metaplastic Lesions: Number of Short Segment LesionsNumber of Long Segment LesionsNumber of Lesions with undefined SizeNumber of Follow ups within 1 year: Progression of Disease: Progression from NDBE to LGBEProgression from LGBE to HGBEMissed Cases of EAC (within 1 year)Incidental Cases of EAC (after 1 year)-
115 71 44
1
Medicine, Gastroenterology, Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY; 2Medicine, Gastroenterology, (2) Lewis Katz School of Medicine at Temple University, Philadelphia, PA; 3Biostatistics, Feinstein Institute for Medical Research, Northwell Health System, Manhasset, NY; 4H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA; 5Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; 6Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY; 7Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA; 8 Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Harvard-MIT Division of Health Sciences Technology, Boston, MA; 9Division of Gastroenterology, Mayo Clinic, Jacksonville, FL Background and Aims: Volumetric laser endomicroscopy (VLE) is a new wide field advanced imaging technology for Barrett’s esophagus (BE). It can distinguish between tissue types. Little is known about the learning curve for image interpretation. The goal of this study was to calculate the learning curve and competence of image interpretation of VLE in BE amongst novice users using cumulative sum analysis. Methods: Thirty-one novice users to VLE were administered 96 slides electronically in a supervised session at three academic institutions. There were 24 slides of each histology type : normal gastric cardia, normal esophagus, BE without neoplasia (nondysplastic BE and BE with low-grade dysplasia), and BE with neoplasia (BE with highgrade dysplasia and intramucosal cancer). Each slide corresponded to a patient from the VLE national registry. Novice users were administered a brief training session followed by the slide set. The user was asked to identify the correct tissue type and level of confidence. Slides were administered randomly, with an explanation of the correct answer after each question. The cumulative summation (Cusum) technique was used to construct a learning curve for each novice enrolled in the study. Our acceptable and unacceptable failure rates, that are required for cusum analysis, were pre-specified as 10% (p0 Z 0.1) and 20% (p1 Z 0.2), respectively based on PIVI criteria and how high-volume users faired in the same slide set. Results: The majority of physicians were fellows (67.7%) and 32.3% were attendings. Twenty-two (71%) of the physicians achieved competency during their 96-slide review. The slide at which half of the physicians achieved competency (i.e., median slide) was 65 (95% CI: 45 to 85). There were no significant differences between attending and fellows (p Z 0.24), EUS experience and no EUS experience (p Z 0.84), institution (p Z 0.28) or prior limited VLE experience and no VLE experience (p Z 0.94) with respect to number of slides until competency. Among the 2,976 slides reviewed (96 slides were reviewed by 31 physicians), physicians were confident in their diagnosis on 50% of slides, fairly certain in their diagnosis on 42.8% of slides and uncertain in their diagnosis on 7.2% of slides. There was a significant association between confidence in diagnosis and histology type (p < 0.0001). BE without neoplasia had significantly greater odds of uncertainty as compared to BE with neoplasia (OR: 3.17, 95% CI: 2.52, 3.99), normal gastric (OR: 3.87, 95% CI: 3.06, 4.90) and normal squamous (OR: 2.61, 95% CI: 2.08, 3.27). Conclusion: The majority of novice users achieve competence in image interpretation of VLE for Barrett’s esophagus at the level of high-volume users with a favorable learning curve.
97 11 7 73 20 22 75 2 1 0 0
Tu1182 Learning Curves and Competence in Image Interpretation Among Novice Users of Volumetric Laser Endomicroscopy for Barrett’s Esophagus Using Cumulative Sum Analysis Arvind J. Trindade*1, Michael S. Smith2, Sumant Inamdar1, Lisa Rosen3, Dennis Han1, Kenneth J. Chang4, Cadman L. Leggett5, Charles J. Lightdale6, Douglas K. Pleskow7, Divyesh V. Sejpal1, Guillermo Tearney8, Michael B. Wallace9
AB572 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Figure 1. Overall CUSUM VLE learning curve; only 12 randomly selected physicians are displayed out of the 31 to reduce clutter
www.giejournal.org