Continuing Medical Education Exam: September 2020

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:

Sawhney MS, Bilal M, Pohl H, et al. Triaging advanced GI endoscopy procedures during the COVID-19 pandemic: consensus recommendations using the Delphi method. Gastrointest Endosc 2020;92:535-42.

Lipman G, Markar S, Gupta A, et al. Learning curves and the influence of procedural volume for the treatment of dysplastic Barrett’s esophagus. Gastrointest Endosc 2020;92:543-50.

Horibe M, Iwasaki E, Bazerbachi F, et al. Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding. Gastrointest Endosc 2020;92:578-88.

Nakai Y, Sato T, Hakuta R, et al. Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction (with video). Gastrointest Endosc 2020;92:623-31.

• 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.Demonstrate triaging advanced GI endoscopy procedures during the COVID-19 pandemic.
• 2.Describe the learning curve for ablative therapy for dysplastic Barrett’s esophagus and the effect of center volumes on outcomes.
• 3.Explain the utility of a new GI bleeding prediction score for patients with upper GI bleeding
• 4.Report the long-term efficacy and safety of EUS-guided hepaticogastrostomy for treatment of malignant biliary obstruction.

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 Credit ^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Activity Start Date: September 1, 2020

Activity Expiration Date: September 30, 2022

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:

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

Karthik Ravi, MD (CME Editor):

Disclosed no relevant financial relationships.

William Ross, MD (CME Editor):

Consulting/Advisory/Speaking: Boston Scientific, Olympus

Ara Sahakian, MD (CME Editor):

Disclosed no relevant financial relationships.

Brian Weston, MD (CME Editor):

Disclosed no relevant financial relationships.

All CME activities, including their associated articles are copyrighted by the ASGE.

Continuing Medical Education Questions: September 2020

Question 1 objective:

Demonstrate triaging advanced GI endoscopy procedures during the COVID-19 pandemic.

Triaging advanced GI endoscopy procedures during the COVID-19 pandemic

Question 1:

Due to the resurgence of COVID-19 in your area, health officials issue a mandate to cease elective procedures. Based on the findings of the current study, a consensus was reached that all of the following advanced GI procedures can be safely deferred for >8 weeks except:

Possible answers: (A-E)

• A.ERCP for asymptomatic choledocholithiasis
• B.Radiofrequency ablation for Barrett’s esophagus with high-grade dysplasia
• C.Endoscopic mucosal resection for Barrett’s esophagus with nodular high-grade dysplasia
• D.Endoscopic mucosal resection for a >2 cm adenomatous colon polyp with high-grade dysplasia
• E.EUS for incident pancreatic and common bile duct dilation on CT or MRI (normal liver function tests)

Look-up: Sawhney MS, Bilal M, Pohl H, et al. Triaging advanced GI endoscopy procedures during the COVID-19 pandemic: consensus recommendations using the Delphi method. Gastrointest Endosc 2020;92:535-42.

Question 2 objective:

Describe the learning curve for ablative therapy for dysplastic Barrett’s esophagus and the effect of center volumes on outcomes.

Learning curves and the influence of procedural volume for the treatment of dysplastic Barrett’s esophagus

Question 2:

A 53-year-old man returns for surveillance endoscopy of C3M5 nondysplastic Barrett’s esophagus initially diagnosed 3 years prior. The patient has been compliant with twice-daily proton pump inhibitor therapy and denies any heartburn, acid regurgitation, or dysphagia. He has no other significant medical history. You perform an EGD, which again reveals a C3M5 Barrett’s segment without any nodularity. Biopsy specimens are obtained and subsequently reveal multifocal low-grade dysplasia, which is subsequently confirmed by an expert GI pathologist. After a subsequent discussion regarding ablative therapy with radiofrequency ablation (RFA) versus continued surveillance, the patient wishes to pursue ablation. You discuss referral to a new colleague who joined your practice several months earlier. The colleague is the first endoscopist to perform RFA at your institution and has treated a total of 14 patients. The patient inquires whether he would be more likely to have a successful outcome if he is referred to a more-experienced endoscopist at a high-volume center. Which of the following is true?

Possible answers: (A-D)

• A.The patient is more likely to achieve complete remission of intestinal metaplasia (CR-IM) if he undergoes ablation at a center that has treated more than 100 patients.
• B.The patient is more likely to achieve complete remission of dysplasia (CR-D) if he undergoes ablation at a center that has treated more than 100 patients.
• C.The patient is more likely to achieve CR-IM if he undergoes ablation by an endoscopist who has treated more than 20 patients.
• D.The patient is more likely to achieve CR-D if he undergoes ablation by an endoscopist who has treated more than 20 patients.

Look-up: Lipman G, Markar S, Gupta A, et al. Learning curves and the influence of procedural volume for the treatment of dysplastic Barrett’s esophagus. Gastrointest Endosc 2020;92:543-50.

Question 3 objective:

Explain the utility of a new GI bleeding prediction score for patients with upper GI bleeding

The Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding

Question 3:

You are called to the emergency department to see a patient who has just arrived with the complaint of black tarry stools. The emergency department physician has not yet seen the patient, but the nurse relays vital signs, lab results, and history sufficient to calculate a HARBINGER score. According to the study by Horibe et al in this month’s issue, this score is used to assess risk of which of the following?

Possible answers: (A-D)

• A.Death
• B.Need for blood transfusion
• C.Need for endoscopic intervention
• D.Presence of high-risk stigmata

Look-up: Horibe M, Iwasaki E, Bazerbachi F, et al. Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding. Gastrointest Endosc 2020;92:578-88.

Question 4 objective:

Report the long-term efficacy and safety of EUS-guided hepaticogastrostomy for treatment of malignant biliary obstruction.

Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction

Question 4:

A 58-year-old man is transferred to your hospital for management of a pancreatic head mass causing obstructive jaundice and gastric outlet obstruction. An endoscopic ultrasound with fine-needle aspiration of the mass confirmed pancreatic adenocarcinoma, and a contrast-enhanced computed tomography scan demonstrated numerous liver lesions compatible with metastatic disease. A duodenal stent was placed, which precluded an ERCP procedure for biliary drainage. Biliary drainage is necessary before chemotherapy can be initiated. Various options are discussed with the patient, including EUS-guided hepaticogastrostomy (EUS-HGS). According to the current study by Nakai et al, which of the following is accurate?

Possible answers: (A-D)

• A.Success rate of EUS-HGS is less than 80%.
• B.Adverse events occur in less than 10% of cases.
• C.Recurrent biliary obstruction occurs in about one-third of patients.
• D.Prior biliary drainage has no impact on the likelihood of recurrent biliary obstruction.

Look-up: Nakai Y, Sato T, Hakuta R, et al. Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction (with video). Gastrointest Endosc 2020;92:623-31.

Continuing Medical Education Answers: September 2020

Question 1

Correct Response: E

Rationale for correct response:

The COVID-19 pandemic has necessitated many elective procedures to be rescheduled in order to mitigate the spread of infection and conserve vital resources. Choosing which advanced endoscopic procedures should be performed or safely deferred during the COVID-19 pandemic may be a complex decision.^1-4 The aim of the current study was to provide guidance for triaging advanced endoscopic procedures using a modified Delphi method. The Delphi method is a validated and structured technique to obtain expert consensus, which is useful in the present situation in which outcome data are limited.^1,5,6 The following important patient outcomes were used: (1) avoidance of death/prolongation of life, (2) avoidance of cancer/cancer progression, (3) avoidance of major surgery and/or hospitalization, and (4) improvement or palliation of symptoms. The following procedural timing categories were used: (1) time-sensitive emergent (schedule within 1 week), (2) time-sensitive urgent (schedule within 1 to 8 weeks), or (3) non-time sensitive (defer for >8 weeks and then reassess the timing).

A prespecified consensus threshold of 66.7% was achieved in 40 of 41 advanced endoscopy indications reviewed by 14 expert gastroenterologists. One hundred percent consensus was achieved in 12 of 41 indications. In 20 of 41 indications, 75% to 99% consensus was achieved. The only indication for which consensus could not be achieved was “incidentally found pancreatic duct dilation >6 mm and common bile duct dilation >10 mm on CT scan or MRI (with normal liver function tests).”

This study provides a decision-making framework for endoscopists to determine the timing for endoscopic procedures during and after the pandemic. The decision to perform endoscopy during the COVID-19 pandemic needs to balance the risks associated with delaying the procedure in the individual patient with the risk of viral exposure to patients and health care providers.

Take-home message: Triaging advanced GI procedures during the COVID-19 pandemic may be facilitated by the current consensus recommendations using the Delphi method. Individual practice and patient factors must also be considered.

References:

• 1.Sawhney MS, Bilal M, Pohl H, et al. Triaging advanced GI endoscopy procedures during the COVID-19 pandemic: consensus recommendations using the Delphi method. Gastrointest Endosc 2020;92:535-42.
• 2.Sultan S, Lim JK, Altayer O, et al. AGA institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. Epub 2020 Mar 31.
• 3.Joint GI Society Message on COVID-19. Available at: https://gi.org/2020/03/15/joint-gi-society-message-on-covid-19/. Accessed March 24, 2020.
• 4.Gastroenterology professional society guidance on endoscopic procedures during the COVID-19 pandemic. Available at: https://webfiles.gi.org/links/media/Joint_GI_Society_Guidance_on_Endoscopic_Procedure_During_COVID19_FINAL_impending_3312020.pdf. Accessed April 17, 2020.
• 5.Hsu C-C, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res Eval 2007;12:1–8.
• 6.Donohoe H, Stellefson M, Tennant B. Advantages and limitations of the e-Delphi technique: implications for health education researchers. Am J Health Educ 2012;43:38-46.

Question 2

Correct Response: C

Rationale for correct response:

Endoscopic eradication therapy for dysplastic Barrett’s typically uses endoscopic mucosal resection of visible lesions with subsequent ablation of the flat Barrett’s segment with RFA. This approach has demonstrated high clinical success, with estimates that CR-D is achieved in over 90% and CR-IM in over 80% of treated patients.¹ However, studies assessing the learning curve associated with attaining proficiency with endoscopic therapy of dysplastic Barrett’s and the effect of case volumes at centers on outcomes have yielded unclear results.^2,3 Consequently, current guidelines suggesting minimum numbers of cases to achieve competence for individual endoscopists or reflecting quality for centers are based on limited evidence.⁴

In this month’s issue of GIE, Lipman and colleagues⁵ report results from a retrospective study examining patients treated in the U.K. RFA Registry to assess CR-D, CR-IM, and dysplasia recurrence based on endoscopist experience and center case volumes.⁵ A total of 678 consecutive patients were identified from 24 centers, which were further divided into 115 patients treated at 15 low-volume centers (<50 patients treated), 145 patients treated at 4 medium-volume centers (50-100 patients treated), and 418 patients treated at 5 high-volume centers (>100 patients treated). Rates of CR-D (86.4%-89.5%) and CR-IM (73.7%-81.1%) at 12 months did not differ based on center volumes. However, dysplasia recurrence was higher in patients treated at low-volume centers. Further analysis using a risk-adjustment cumulative risk sum curve was done to assess the effect of the learning curve on individual endoscopists. A significant reduction of CR-D was seen at 12 cases (89.6%-75.5%), whereas a similar reduction of CR-IM was seen at 18 cases (81.4%-69.3%).

Take-home message: In conclusion, this study suggests that the learning curve for RFA may be relatively short, with fewer than 20 cases required to achieve competency. Further, center volume may have a very limited effect on outcomes. Future prospective studies are still required to assess the optimal number of training cases required to achieve endoscopic ablative competency.

References:

• 1.Haidry RJ, Dunn JM, Butt MA, et al. Radiofrequency ablation and endoscopic mucosal resection for dysplastic Barrett’s esophagus and early esophageal adenocarcinoma: outcomes of the UK National RFA Registry. Gastroenterology 2013;145:87-95.
• 2.Pasricha S, Cotton C, Hathorn KE, et al. Effects of the learning curve on efficacy of radiofrequency ablation for Barrett’s esophagus. Gastroenterology 2015;149:890-6.
• 3.Fudman DI, Lightdale CJ, Poneros JM, et al. Positive correlation between endoscopist radiofrequency ablation volume and response rates in Barrett’s esophagus. Gastrointest Endosc 2014;80:71-7.
• 4.Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014;63:7-42.
• 5.Lipman G, Markar S, Gupta A, et al. Learning curves and the influence of procedural volume for the treatement of dysplastic Barrett’s esophagus. Gastrointest Endosc 2020;92:543-50.

Question 3

Correct Response: D

Rationale for correct response:

For decades, gastroenterologists have been searching for a straightforward method to determine whether a patient presenting with an upper gastrointestinal bleed is at high risk of needing hospital admission, therapeutic interventions, or death. Multiple scoring systems have been proposed, but systematic reviews have found them all flawed to various degrees.^1,2 However, one of the better-known scores proposed by Blatchford et al has been recommended in recent guidelines to assess risk of requiring an intervention.^3,4 Yet the quest for a more predictive model continues, with some groups turning to machine learning methods for an answer.⁵

In this month’s issue of GIE, Horibe et al⁶ report on a simple 3-factor assessment to predict the likelihood of finding high-risk stigmata (HRS) on endoscopy, which they call HARBINGER. Because their median time to endoscopy was only 4 hours, the prevalence of HRS was quite high, up to 35% even in patients deemed to be low risk for stigmata. Predictably the intervention rate was more than double that in a large international trial (42% vs 19%).⁷ Comparing HARBINGER to other scoring systems, including Blatchford’s, the authors found their model to be superior. This outperformance could have been predicted because the other models were designed to detect risk of other endpoints, such as mortality or need for intervention, not HRS.

In addition, the performance of the model was not consistently strong across the study institutions because AUC values for HARBINGER ranged from 0.84 to 0.75 between institutions with no overlap in confidence intervals between the top and low scores.⁶ Concerns about how HARBINGER would perform in other settings are reasonable as factors like access to PPIs varies across markets.

In a resource-constrained world, the ability to predict need for interventions would seem more helpful than predicting endoscopic appearance. Although HRS are linked to the need for interventions, the rapid time to endoscopy skews the linkage by ballooning the prevalence of HRS. Many of these patients are likely to have far less ominous endoscopic appearances if the endoscopy was done 24 hours after presentation.

References:

• 1.Ramaekers R, Mukarram M, Smith CAM, et al. The predictive value of preendoscopic risk scores to predict outcomes in emergency department patients with upper gastrointestinal bleeding: a systematic review. Acad Emerg Med 2016;23:1218-27.
• 2.de Groot NL, Bosman JH, Siersema PD, et al. Prediction scores in gastrointestinal bleeding: a systematic review and quantitative analysis. Endoscopy 2012;44:731-9.
• 3.Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal hemorrhage. Lancet 2000;356:1318-21.
• 4.Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Ann Int Med 2019;171:805-22.
• 5.Shung DL, Au B, Taylor RA, et al. Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Gastroenterology 2020;158:160-7.
• 6.Horibe M, Iwasaki E, Bazerbachi F, et al. Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding. Gastrointest Endosc 2020;92:578-88.
• 7.Stanley AJ, Laine L, Dalton HR, et al. Comparison or risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicenter prospective study. BMJ 2017;356:i6432.

Question 4:

Correct Response: C

Rationale for correct response:

Biliary drainage options may be limited by gastric outlet obstruction or surgically altered anatomy. EUS-guided hepaticogastrostomy (EUS-HGS) provides an effective alternative to ERCP and percutaneous drainage in these complex cases.¹ Additionally, EUS-HGS has been compared to ERCP for primary biliary drainage and outcomes were found to be comparable.² However, potential adverse events of EUS-HGS such as stent migration and peritonitis can be severe, and long-term data thus far have been lacking.³

In the current issue of GIE, Nakai and colleagues⁴ present a retrospective study of 110 patients who underwent EUS-HGS for drainage of malignant biliary obstruction. Partially covered metallic stents ranging in length from 8 to 15 cm were used to create the hepaticogastrostomy. Technical and functional success rates were 100% and 94%, respectively. Adverse events occurred in 25% of patients, with the most common being fever and abdominal pain. Peritonitis occurred in 4% and cholangitis in 3% of patients. No cases of stent dislodgement were reported. Recurrent biliary obstruction (RBO) occurred in 33% of patients, in a median time of 6.3 months. Short length of the intragastric portion of the stent and prior biliary drainage were both associated with recurrent biliary obstruction. Of the patients who had RBO, 92% underwent successful reintervention with EUS-HGS.

Take-home message: EUS-guided hepaticogastrostomy is an effective alternative for long-term biliary drainage. Recurrences can be successfully managed with repeat hepaticogastrostomy.

References:

• 1.Nakai Y, Isayama H, Yamamoto N, et al. Safety and effectiveness of a long, partially covered metal stent for endoscopic ultrasound-guided hepaticogastrostomy in patients with malignant biliary obstruction. Endoscopy 2016;48:1125-8.
• 2.Paik WH, Lee TH, Park DH, et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial. Am J Gastroenterol 2018;113:987-97.
• 3.Giovannini M. EUS-guided hepaticogastrostomy. Endosc Ultrasound 2019;8:S35-s9.
• 4.Nakai Y, Sato T, Hakuta R, et al. Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction (with video). Gastrointest Endosc 2020;92:623-31.