August 11, 2022

Gastroenterology

By: Outpatient Surgery Editors

Published: 8/10/2022

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THIS WEEK'S ARTICLES

Mechanical Enhancement Improves Colonoscopy Screenings

NYU Study Shows Promising AI Colonoscopy Results

Proper Care, Handling and Reprocessing of Rigid Endoscopes - Sponsored Content

Smartphone App Shown to Improve Stool Assessments

New Reprocessing Standards Address Endoscope Drying and Storage

 

Mechanical Enhancement Improves Colonoscopy Screenings

Research shows flattening folds in the mucosa improves adenoma detection rates.

CuffBETTER VIEW Skilled endoscopists could better diagnose adenomas with the help of mechanical manipulation devices that expose difficult-to-visualize folds and blind spots.

Colonoscopy is the gold standard for colorectal cancer screening and surveillance, but folds and blind spots within the colon can harbor precancerous polyps that may be easily missed by skilled endoscopists, says Seth Gross, MD, a gastroenterologist at NYU Langone Health in New York City. He says caps and cuffs attached to the distal tips of colonoscopes provide mechanical manipulation of colonic folds to increase visualization of adenomas.

Those attachments connect to the tip of the colonoscope before insertion and expand as the endoscopist withdraws the scope to flatten folds in the colon and hold the scope steady, providing a more centralized view for the physician.

This mechanical manipulation of the colon is a more effective screening technique than optical surveillance alone, according to Dr. Gross. His study, the first to compare the performance of colonoscope attachments, shows the balloon was more effective than the cuff in assisting endoscopists in detecting large and advanced cancerous growths.

The research, which included 727 patients, indicates the balloon attachment resulted in an adenoma detection rate that was nearly 10% higher than the cuff's results. Additionally, the number of adenomas detected per patient was significantly higher when the balloon attachment was used.

Dr. Gross, who presented his findings at the American College of Gastroenterology's annual meeting last October, says the balloon attachment has a short learning curve and provides physicians with improved visualization and control during colonoscopy screenings. "Increasing the detection of adenomas during colonoscopy will prevent the development of colon cancer and improve patient outcomes," he says.

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NYU Study Shows Promising AI Colonoscopy Results

Research shows that computer-assisted procedures detect more precancerous polyps than traditional colonoscopies.

ColonoscopySMARTER EXAMS Artificial intelligence could help make routine colonoscopies more effective.

New data from an NYU Grossman School of Medicine study presented at this year's Digestive Disease Week Annual Meeting shows that colonoscopies performed with artificial intelligence (AI) increased the detection rate of adenoma by 27% in average-risk patients.

The study, published in May in the journal Gastroenterology, also shows the discovery rate of cancerous or precancerous polyps increased from 0.82% to 1.05% with computer-aided detection technology, which is considered a significant improvement, according to Aasma Shaukat, MD, MPH, Grossman's clinician-scientist who led the prospective, randomized, multicenter study.

The study's findings suggest that AI can be an efficient tool for gastroenterologists and endoscopists to incorporate into their colonoscopy screenings to reduce the number of polyps missed and left behind in the colon, many of which can be precancerous.

"Our findings add to the growing amount of literature that shows using computer-aided technology during an endoscopy procedure can improve the quality of exams performed and improve outcomes for our patients," says Dr. Shaukat, who notes that several such software technologies are currently available for clinicians.

While traditional colonoscopy techniques are effective, AI platforms act as a second set of eyes for the endoscopist. The detection device used in the study was deployed in high-definition white-light colonoscopy screenings, allowing the video feed from the colonoscope to be analyzed by AI in real time. Areas of concern for potential polyps are identified and immediately pop up on the surgeon's monitor, leading to the higher detection rates during the procedure.

The study tracked 1,440 colonoscopies performed by 22 gastroenterologists from January to September 2021, all on patients older than 40 who hadn't had a colonoscopy in at least three years. The researchers say long-term follow-up studies are needed to further evaluate the benefit of computer-assisted devices on clinical outcomes.

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Proper Care, Handling and Reprocessing of Rigid Endoscopes
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Important steps are required for the safe handling of endoscopes in their utilization journey.

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The endoscope is the most vulnerable and important component of the "video chain" as OR teams work to keep surgical procedures safe for their patients. In fact, the rigid endoscope goes through a robust cycle to ensure that all steps for safe surgery and proper sterilization of the instrument are followed.

These important steps include the transport to the procedure, which requires the selection of an appropriate transport device, protective containers or trays and proper handling. The use of the instrument in the procedure itself involves inspection, and after use, includes the flushing of lumens and surface cleaning.

Endoscope manufacturer's reprocessing instructions should always be followed. Additionally, reprocessing instructions for specific guidance regarding cleaning brushes should also be followed. The reduction of bio burden minimizes the potential for pyrogenic reactions.

Another important aspect of the care and handling of the rigid endoscope is regular physical inspections. This should include inspection of the eyepiece where the rasping mechanism of the camera connects to the endoscope to check for excessive wear. Additional inspection of the light post/light concentration case for any pitting is necessary as well. Also requiring close physical inspection are the shaft assembly and distal tip assembly. Finally, optical inspection should be performed for review of the entire field of view.

Sterilization and proper storage are both key to the safe handling of endoscopes in their utilization journey. The most damage to these instruments occurs during improper cleaning techniques or the use of improper containers and protection. It is up to the OR team and the facility leaders to ensure that the care and handling of rigid endoscopes is a priority in their workflow as cases and procedures in the outpatient environment continue to evolve and grow.

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Smartphone App Shown to Improve Stool Assessments

Using artificial intelligence instead of the patient's subjective score leads to more accurate treatment plans.

A new study calls into question the efficacy of patients' subjective stool form assessments using the Bristol Stool Scale (BSS) that subsequently inform treatment responses to luminal GI disorders. The research team deployed a novel HIPPA-compliant smartphone app that trains artificial intelligence (AI) to capture and characterize digital images of users' stool, and then evaluated the AI for accuracy.

The study, published last month in The American Journal of Gastroenterology, says patient-reported outcomes (PROs) used to measure the effects and adverse events of interventional trials display significant intraindividual and interindividual variability. The subjectivity of current PROs, such as abdominal pain, bloating and nausea, influence treatment/placebo response rates. The commonly used BSS ranks stool on a seven-step scale from hard lumps (1) to liquid (7). The researchers note that even daily reporting based on BSS can be inaccurate because bowel movements may vary in form throughout the day, as do subjects' interpretation of the BSS scale itself.

The novel app in the study uses AI to measure five visual stool characteristics: BSS, consistency, edge fuzziness, fragmentation and volume. Subjects were participants in a randomized clinical trial for IBS with diarrhea. Over the course of two weeks, some subjects image-captured every stool using the app, while others took images but only reported subjectively using BSS. Two expert gastroenterologists evaluated and compared the results of both groups' sensitivity, specificity, accuracy and diagnostic odds ratios. Agreements between AI-graded and subject-reported daily average BSS scores were determined, and subject BSS and AI stool characteristics scores were correlated with diarrhea-predominant irritable bowel syndrome symptom severity scores.

They found good agreement between the two experts and the AI characterizations for BSS, which outperformed subjects' self-reports in categorizing daily average BSS scores as constipation, normal or diarrhea. AI stool characterization also correlated better than subject reports with diarrhea severity scores.

The researchers conclude that the AI smartphone app that captured real-time stool images was both accurate and objective while demonstrating that subject-reported BSS scores do not accurately describe the features of stool. "Additional stool features such as consistency, edge fuzziness, fragmentation and volume may provide added objective benefits in the study of GI disorders," they say, calling the app a potentially valuable new tool for use in trials of luminal GI diseases involving changes in stool form.

"AI assessments could provide more objective outcome measures for stool characterization in gastroenterology," the study concludes, while encouraging additional research into the matter.

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New Reprocessing Standards Address Endoscope Drying and Storage

AAMI update acknowledges that automated endoscope reprocessors alone do not reliably dry internal channels.

In March, the Association for the Advancement of Medical Instrumentation (AAMI) released the updated ANSI/AAMI ST91:2021/ standard for reprocessing flexible and semi-rigid endoscopes. Included is an increased focus on drying and revised storage requirements.

"Drying and storage has become one of the elements being looked at more closely, due to the fact that wet endoscopes are a hazard for bacterial growth," says James Collins, BS, RN, CNOR, endoscopy accreditation nurse for the Digestive Disease & Surgical Institute at the Cleveland Clinic. "We know more about biofilms and how they work, and the effects they have on wet scopes that aren't dried properly."

Randall Rentschler, RN, BA, CNOR, CSSM, TNS, perioperative service director at Artesia (N.M.) General Hospital, says the latest revisions could prove disruptive both financially and operationally at some facilities. "The expectation is to have drying cabinets with integrated adapters that connect to flexible scopes and force HEPA-filtered air through their channels," he says. "Also, the scope cabinet can no longer be kept in rooms where procedures are performed. There needs to be a separated area for scope storage, and facilities must maintain separation between clean and dirty workflows."

Frank Edward Myers III, MA, CIC, FAPIC, director of infection prevention and clinical epidemiology at UC San Diego Health, supports the updated standard. "I'm excited about beginning to assess drying cabinets," he says. "We know there are many AERs [automated endoscope reprocessors] on the market that haven't been adequately drying internal channels of scopes. Overall, everyone understands the importance of these process improvements."

AAMI's full ST91 update, its first in seven years, is available here.

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