# Quiz Archive

Correct Answer: B. Compared with the standard preparation, antegrade small-bowel preparation with a solution of macrogol 3350 does not increase the diagnostic yield of relevant lesions and has a negative impact on patient tolerability.

For small-bowel capsule endoscopy, patients usually take a clear fluid diet the day before and fast 6 hours before the procedure. Concerning the use of antegrade bowel preparation for patients with suspected small-bowel bleeding submitted to capsule endoscopy, what would you say?

A. Compared with the standard preparation, antegrade small-bowel preparation with a solution of macrogol 3350 increases the diagnostic yield of relevant lesions without impact on patient tolerability. (2 votes, 22%)
B. Compared with the standard preparation, antegrade small-bowel preparation with a solution of macrogol 3350 does not increase the diagnostic yield of relevant lesions and has a negative impact on patient tolerability. (1 vote, 11%)
C. Compared with the standard preparation, antegrade small-bowel preparation with a solution of macrogol 3350 increases the diagnostic yield of relevant lesions but has a negative impact on patient tolerability. (1 vote, 11%)
D. Compared with the standard preparation, antegrade small-bowel preparation with a solution of macrogol 3350 improves the small-bowel visualization quality but does not increase the diagnostic yield of relevant lesions. (5 votes, 56%)

In the November issue of GIE, Lamba et al conducted a multicenter, randomized clinical trial (RCT) to compare 3 bowel preparation regimens for patients with suspected small intestinal bleeding submitted to capsule endoscopy (CE). CE was performed using Pillcam SB3 system (Medtronic, Minneapolis, Minn, USA) in all cases. All patients were asked to exclusively take a clear fluid diet for 18 hours before CE. Patients in the control group (arm A) were asked to fast 6 hours before CE. Patients in arm B were asked to take 2 L of standard polyethylene glycol (PEG; 2 sachets of Glycoprep-C [Fresenius Kabi Mt Kuring-gai, NSW, Australia] containing macrogol 3350 158.7 g, sodium chloride 7.8 g, potassium chloride 2.2 g, and sodium sulfate anhydrous 16.9 g as active ingredients) 15 hours before CE. After that, they could take a clear fluid diet until 6 hours before CE. Patients assigned to arm C were asked to take 1 L PEG-based solution (Moviprep [Norgine, Frenchs Forest, NSW, Australia) containing macrogol 3350 100 g, sodium sulfate 7.5 g, sodium chloride 2.7 g, potassium chloride 1.0 g, ascorbic acid 4.7 g, and sodium ascorbate 5.9 g as active ingredients 4 hours prior to the procedure. Following this, they were asked to fast until CE. Patients were instructed to swallow the capsule with simethicone 200 mg mixed in 150 mL of water. The authors classified the diagnosed lesions as highly relevant (P2) or less relevant (P0 or P1). Overall small-bowel visualization quality (SBVQ) and distal SBVQ were assessed using the Brotz score. Patient tolerability was assessed using a self-reported visual analog scale (score of 0-10, with lower scores indicating better tolerability). From April 2014 to December 2019, 524 patients were screened across 5 centers for inclusion in the study. From them, 237 patients were randomized in the 3 arms in 1:1:1 fashion. Eight patients were excluded following randomization (consent withdrawn in 4, procedure canceled in 3, and incorrect preparation in 1), and per-protocol analysis was possible on 78, 76, and 75 patients in arms A, B, and C, respectively. Overall, P2 lesions were found in 47.6% of patients (95% CI, 41-54.1), and P0 and P1 lesions were detected in 28.2% of patients (95% CI, 22.3-34.1). There was no difference in frequency of detected P2 lesions (48.7%, 48.0%, and 45.9% in arms A, B, and C, respectively; P = .94) or P0 and P1 lesions (28.2%, 32%, and 24.3% in arms A, B, and C, respectively; P = .58). There was no difference for overall SBVQ (P = .96) and distal SBVQ (P = .72) across the 3 study arms. Patient tolerability was lower in arms B and C than the control group. In arms A, B, and C, patients reported some discomfort in 26%, 85.5%, and 75% (P < .001), respectively. Quoting the authors: "In this blinded RCT, the use of a PEG preparation before CE did not result in improved diagnostic yield or SBVQ. Patients receiving PEG reported more adverse events and lower tolerance compared with patients on a clear fluid–only diet. Our results do not support the routine use of purgative preparation in patients undergoing CE."

Lamba M, Ryan K, Hwang J, et al. Clinical utility of purgative bowel preparation before capsule endoscopy: a multicenter, blinded, randomized controlled trial. Gastrointest Endosc 2022;96:822-8.

Correct Answer: B. The 30-day rebleeding rate is lower in the OTSC group. Hospital length of stay and mortality rate are similar between the groups.

Concerning the comparison of the over-the-scope clip (OTSC) and endoscopic standard therapy (STD) for the hemostasis of high-risk nonvariceal upper GI bleeding, what would you say?

A. The 30-day rebleeding rate, hospital length of stay, and mortality rate are similar between the groups. (0 votes, 0%)
B. The 30-day rebleeding rate is lower in the OTSC group. Hospital length of stay and mortality rate are similar between the groups. (1 vote, 11%)
C. The 30-day rebleeding rate, hospital length of stay, and mortality rate are lower in the OTSC group. (6 votes, 67%)
D. The use of OTSC is reserved for rescue treatment of nonvariceal upper GI bleeding. (2 votes, 22%)

In the November issue of GIE, Bapaye et al conducted a systematic review and meta-analysis to compare the over-the-scope clip (OTSC) and endoscopic standard therapy (STD) for the hemostasis of high-risk nonvariceal upper GI bleeding (NVUGIB). They included 10 primary studies (4 randomized controlled trials [RCTs], 4 observational studies, and 2 prospective cohort studies) with a total of 914 patients. All patients were classified as Forrest Ia, Ib, IIa, or IIb and, for that reason, were identified as a high-risk group for rebleeding. In only 1 primary study, 1 patient with Forrest IIc lesion was included. The etiology of bleeding included peptic ulcer, anastomotic ulcer, Mallory-Weiss tear, and post-EMR bleeding. In the STD treatment group, conventional clipping or thermal hemostasis with or without epinephrine injection were used. Monotherapy with epinephrine injection was not used. In 8 studies, OTSC was used at index endoscopy. In 1 study, it was used as a rescue treatment. In another study, it was used in both situations. The rate of 30-day rebleeding was 9.51% (95% confidence interval [CI], 6.91-12.68) in the OTSC group and 21.95% (95% CI, 18.33-25.91) in the STD group. Pooled risk ratio (RR) of having rebleeding with OTSC versus STD at 30 days was .46 (95% CI, .33-.65; I2 = 0%; P < .0001). In RCTs, the pooled RR was .57 (95% CI, .33-.98; I2 = 0%; P = .04), whereas in cohort studies, the RR was .40 (95% CI, .25-.62; I2 = 0%; P < .0001). The rate of 30-day rebleeding when OTSC was compared with STD when used as index therapy for NVUGIB was 9.79% (95% CI, 6.79-13.53) in the OTSC group and 20.78% (95% CI, 16.71-25.33) with STD. Pooled RR for 30-day rebleeding when OTSC was used as first-line therapy at the index NVUGIB episode was .50 (95% CI, .34-.75; I2 = 0%; P = .0007). There was no impact on hospital length of stay or mortality. Overall, the pooled mortality rate was 3.05% in the OTSC group and 5.16% in the STD group. Among RCTs, the pooled RR was .79 (95% CI, .29-2.15; I2 = 22%; P = .64), whereas in cohort studies, this was .38 (95% CI, .11-1.24; I2 = 0%; P = .11). Quoting the authors: "Our analysis conclusively demonstrates that OTSCs when used for high-risk NVUGIB significantly reduced rebleeding rates as compared with STD, with higher clinical success rates and comparatively shorter procedure times. Despite an improvement in clinical success and rebleeding rates, mortality rates and length of stay were comparable in the 2 groups, highlighting the multifactorial dimensions of this complex clinical problem. Further RCTs comparing OTSC use with STD are required to further validate our findings."

Bapaye J, Chandan S, Naing LY, et al. Safety and efficacy of over-the-scope clips versus standard therapy for high-risk nonvariceal upper GI bleeding: systematic review and meta-analysis. Gastrointest Endosc 2022;96:712-20.

Correct Answer: D. All the above.

Stage T2 colorectal cancer (CRC) invades the muscularis propria of the bowel wall but has not advanced into subserosa or pericolic tissue. Approximately 25% of patients with T2 CRC have lymph node metastases (LNMs) at histopathological assessment. In theory, endoscopic full-thickness resection (EFTR) could be curative for CRC without LNM. In this sense, prediction models of LNM could be useful to select patients for minimally invasive therapy. Concerning the prediction models of LNM of CRC, what would you say?

A. Lymphatic invasion, histological differentiation, tumor size, and tumor budding are variables relevant for LNM risk and should be included in the prediction model. (3 votes, 33%)
B. Tumor size also is relevant because the use of EFTR is limited to lesions measuring up to 20 mm. (1 vote, 11%)
C. A possible strategy to use the prediction model is to compare the false-negative rate for LNM of the model and the expected mortality surgical rate. (0 votes, 0%)
D. All the above. (5 votes, 56%)

In the October issue of GIE, Ichimasa et al developed an artificial intelligence (AI) system to predict lymph node metastasis (LNM) of colorectal cancer (CRC) invading muscularis propria (pT2). The authors hypothesized that patients with T2 CRC without LNM could benefit from endoscopic full-thickness resection (EFTR). The authors included data from all patients with pT2 CRC who underwent surgical resection with lymph node dissection from April 8, 2001, to October 13, 2016, at Showa University Northern Yokohama Hospital. They excluded patients with familial adenomatous polyposis and Lynch syndrome. The prediction model employed 8 variables: patient age, patient sex, tumor size, tumor location, lymphatic invasion, vascular invasion, histological differentiation, and serum carcinoembryonic antigen level. Data from 411 patients (2001-2014) were used for training the AI system, and the remaining 100 patients (2014-2016) were used to validate the system. Rates of LNM in the training and validation datasets were 26% (106 out of 411) and 28% (28 out of 100), respectively. The mean number of removed lymph nodes per patient was 20 (standard deviation, 12), and the median number was 18. The area under the curve of the AI system in the validation data was .93. Lymphatic invasion was the most influential factor for LNM among 8 examined factors. With a 1.18 threshold, sensitivity and specificity were 96% (95% confidence interval, 90%-99%) and 88% (80%-94%), respectively. In this case, 64% (54%-73%) of patients with T2 CRC could avoid surgery, and 1.6% (0%-8.4%) patients with T2 CRC with LNM would lose a chance to receive surgery. Quoting the authors: "In conclusion, this study proposed the resect and analysis approach for T2 CRC after EFTR as a new innovative treatment option. Considering the high prediction capability of the AI system for LNM and the substantial risk of postoperative mortality of CRC, the proposed minimally invasive approach could be an attractive option especially for vulnerable patients for surgical resection."

Ichimasa K, Nakahara K, Kudo S, et al. Novel "resect and analysis" approach for T2 colorectal cancer with use of artificial intelligence. Gastrointest Endosc 2022;96:665-72.

Correct Answer: B. The delayed adverse event rate is higher in the HSP group.

Regarding the comparison of hot snare polypectomy (HSP) and cold snare polypectomy (CSP) for the resection of sporadic nonampullary duodenal adenomas, what would you say?

A. The immediate bleeding rate is higher in the CSP group. (4 votes, 18%)
B. The delayed adverse event rate is higher in the HSP group. (10 votes, 45%)
C. The adenoma recurrence rate is higher in the CSP group. (0 votes, 0%)
D. The duodenal perforation rate is higher in the HSP group. (8 votes, 36%)

Trivedi M, Klapheke R, Youssef F, et al. Comparison of cold snare and hot snare polypectomy for the resection of sporadic nonampullary duodenal adenomas. Gastrointest Endosc 2022;96:657-664.

Correct Answer: A. Clinical screening has low sensitivity, high specificity, and a high negative predictive value for COVID-19 infection.

The COVID-19 pandemic has had a profound impact on elective GI endoscopy procedures. Concerning the diagnostic performance of clinical screening for COVID-19 in patients with appointments for outpatient upper GI endoscopy and colonoscopy, using the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) nucleic acid amplification testing (NAAT) as the gold standard, what would you say?

A. Clinical screening has low sensitivity, high specificity, and a high negative predictive value for COVID-19 infection. (1 vote; 100%)
B. Clinical screening has high sensitivity, low specificity, and a low negative predictive value for COVID-19 infection. (0 votes; 0%)
C. Clinical screening has high sensitivity and specificity for COVID-19 infection, making NAAT optional. (0 votes; 0%)
D. Clinical screening has low sensitivity and specificity for COVID-19 infection. (0 votes; 0%)

In the September issue of GIE, Gawron et al described the results from a testing strategy of pre-endoscopy (outpatient upper GI endoscopy and colonoscopy) screening for COVID-19 infection across the 170 medical facilities and 1074 outpatient sites of the Veterans Affairs (VA) healthcare system. From March 18, 2020, to April 30, 2021, the authors identified 220,891 completed outpatient endoscopies at 118 VA facilities. From those procedures, 115,890 (52.5%) had documented pre-procedure COVID-19 symptom and exposure screening, and 154,127 (69.8%) had pre-procedure SARS-CoV-2 nucleic acid amplification testing (NAAT) results within 7 days prior to the procedure. During the same period, the authors found 26,475 canceled appointments with screening data and 28,505 canceled appointments with SARS-CoV-2 NAAT data out of 131,894 total canceled appointments (20.1% and 21.6%, respectively). There were 14,536 canceled appointments with screening and SARS-CoV-2 NAAT data (11.0%). NAAT positive results were reported in 1.8% of all individuals tested and in 1.3% of those who screened negative. The clinical screening for COVID-19 had sensitivity of 34.6% (95% CI, 32.4%-36.8%), specificity of 96.4% (95% CI, 96.2-96.5%), a positive predictive value of 15.0% (95% CI, 14.0%-16.1%), and a negative predictive value of 98.7% (95% CI, 98.7%-98.8%). Quoting the authors: “This report illustrates 1 of many adaptations made within the VA as a learning healthcare system that seeks to continually generate and apply evidence and innovation to provide high-quality care during an unprecedented time as we continue into the second, and hopefully final, year of the COVID-19 pandemic.”

Gawron AJ, Sultan S, Glorioso TJ, et al. Pre-endoscopy coronavirus disease 2019 screening and severe acute respiratory syndrome coronavirus-2 nucleic acid amplification testing in the Veterans Affairs healthcare system: clinical practice patterns, outcomes, and relationship to procedure volume. Gastrointest Endosc 2022;96:423-432.

Correct Answer: D. All the above.

Nonerosive reflux disease (NERD) is the most common subtype of GERD with low sensitivity of diagnosis on endoscopy. Considering the diagnostic performance of narrow-banding imaging (NBI) for the diagnosis of NERD, what would you say?

A. Intrapapillary capillary loop pattern, microerosions, and ridge/villous pattern (RVP) below the squamous columnar junction are some of the possible NBI findings. (0 votes, 0%)
B. RVP has a high specificity for NERD diagnosis. (0 votes, 0%)
C. Typically, RVP is no longer observed after proton pump inhibitor therapy. (2 votes, 29%)
D. All the above. (5 votes, 71%)

In the September issue of GIE, Desai et al conducted a multicenter cross-sectional study to evaluate the diagnostic performance of narrow-banding imaging (NBI) for nonerosive reflux disease (NERD). From 122 screened patients, the authors included 21 patients with NERD and 21 control subjects. The patients included in the NERD group had heartburn and/or regurgitation on the GERD questionnaire (GERDQ) with symptoms occurring at least twice a week for the preceding 6 months and with a GERDQ score of >3, abnormal acid exposure (>4.2%) on 48-hour acid reflux testing, and EGD without erosive esophagitis. The patients included in the control group selected "no" on the GERDQ and had a GERDQ score <3, an EGD without erosive esophagitis, and normal acid reflux testing results. In the NERD group, patients were randomized to proton pump inhibitor (PPI) treatment: esomeprazole 40 mg/day (group A) or placebo (group B) for 8 weeks. A follow-up endoscopy was completed at the end of the 8-week treatment period by an endoscopist who was blinded to initial study results. At endoscopy under NBI and near focus, the investigators described the intrapapillary capillary loops (IPCLs; number, dilation, and tortuosity), microerosions and columnar islands in the distal esophagus, increased vascularity at the squamous columnar junction (SCJ), and ridge/villous pattern (RVP) below SCJ. Biopsies were taken from predetermined locations, and a final histological "reflux score" was calculated and ranged from 0 to 12. The diagnostic performance of the findings on NBI endoscopy individually and in various combinations for the diagnosis of NERD was calculated as well as the correlation of resolution of changes observed on NBI endoscopy in NERD patients under PPI therapy. The presence of any one of the NBI findings had a sensitivity of 90% for NERD but a specificity of only 38%. Of the NBI findings, RVP had the highest sensitivity and specificity of 62% and 81%, respectively. Microerosions had the highest specificity of 95% but a low sensitivity of 29%. A combination of 3 NBI features (IPCL tortuosity, RVP, and microerosions) achieved the highest specificity of 86% and moderate sensitivity of 60% with an area under the curve of .74 for the diagnosis of NERD. Only microerosions changed after PPI therapy. Microerosions resolved in 66% patients in the PPI group and in no patients in the placebo group. When NBI features were compared before and after PPI therapy, RVP was found to have a significant resolution. Quoting the authors: "In conclusion, NERD, the most common GERD phenotype, lacks an accurate diagnostic test. NERD patients therefore frequently undergo multiple diagnostic investigations that include frequent upper endoscopies, esophageal biopsy sampling, and ambulatory acid reflux monitoring, which all have limitations. NBI at initial endoscopy can identify NERD subjects with high specificity that can obviate the need for additional investigations and reduce unnecessary drug costs. In particular, the RVP feature can be used as a surrogate marker for acid reflux testing for the diagnosis of NERD. NBI has a positive role in diagnosing NERD and identifying subjects who would benefit from acid suppression therapy."

Desai M, Srinivasan S, Sundaram S, et al. Narrow-band imaging for the diagnosis of nonerosive reflux disease: an international, multicenter, randomized controlled trial. Gastrointest Endosc 2022;96:457-466.

Correct Answer: C. Compared with GI fellows, there was no difference in the number of procedures needed to reach the competency benchmark.

Concerning the learning curves of colonoscopy skills of colorectal surgery (CRS) fellows for screening and surveillance colonoscopy using the Assessment of Competency in Endoscopy (ACE) colonoscopy skills assessment tool, what would you say?

A. Compared with GI fellows, CRS fellows need a greater number of procedures to reach the competency benchmark. (5 votes, 42%)
B. Compared with GI fellows, CRS fellows need a lower number of procedures to reach the competency benchmark. (0 votes, 0%)
C. Compared with GI fellows, there was no difference in the number of procedures needed to reach the competency benchmark. (4 votes, 33%)
D. CRS fellows need from 75 to 150 colonoscopies to meet the ACE metrics defining minimal competence. (3 votes, 25%)

In the August issue of GIE, Sedlak et al describe the learning curves of colonoscopy skills of colorectal surgery (CRS) fellows. The authors employed the Assessment of Competency in Endoscopy (ACE) colonoscopy skills assessment tool to evaluate the learning curves for each cognitive and motor colonoscopy skill at every 25 colonoscopies of experience. The authors included all CRS fellows who trained at a single institution from July 2017 to June 2021. The indications for colonoscopy were limited to screening or surveillance purposes, and the exams were performed under conscious sedation. During the study period, 12 CRS fellows performed 1631 screening colonoscopies (an average of 136 colonoscopies per fellow; range, 116-173) that formed this analysis. They had an average prior experience of 123 colonoscopies (range, 50-266) during general surgical residency. The polyp detection rate above the 50% threshold and the polyp miss rate ≤25% were achieved at 125 and 175 procedures, respectively. An average cecal intubation time of ≤15 minutes was consistently achieved at 200 procedures. At 250 procedures, cecal intubation rates achieved the threshold of ≥90%. The individual cognitive ACE skill averages reached the minimum competency threshold scores (≥3.5) around 275 procedures, and the motor skill goals were generally reached around 300 procedures. On average, CRS fellows reached the competency benchmark with 125 procedures, and GI fellows needed 275 procedures to reach it. Although notable, the statistical difference in average scores was not significant for most of the assessment intervals. Quoting the authors: "The colonoscopy learning curves of surgical trainees appear to be identical to those of gastroenterology fellows and suggest that surgical trainees also require on average 275 to 300 colonoscopies to meet the ACE metrics defining minimal competence. Additionally, it appears that performance expectations by CRS staff may differ slightly but not significantly from their gastroenterology counterparts when using the ACE tool. Further research is needed to determine if these findings are supported."

Sedlack RE, Sedlack AR, Kelley SR, League JB. Defining the learning curves of colorectal surgical trainees in colonoscopy using the Assessment of Competency in Endoscopy tool. Gastrointest Endosc 2022;96:301-307.

Correct Answer: C. The crude incidence of invasive cancer is <1 per 100 patient-years.

Considering the results of endoscopic eradication therapy with radiofrequency ablation and EMR for Barrett’s esophagus, what would you say?

A. The risk of progression to invasive (submucosal invasion) cancer is higher in the group with intramucosal cancer and high-grade dysplasia than the group with low-grade dysplasia. (0 votes, 0%)
B. The relapse rate of dysplastic tissue is >10%, and endoscopic retreatment usually fails.(0 votes, 0%)
C. The crude incidence of invasive cancer is <1 per 100 patient-years. (2 votes, 100%)
D. The relapse rate of intestinal metaplasia is >40%, and endoscopic retreatment usually fails. (0 votes, 0%)

In the August issue of GIE, Wolfson et al report the results of endoscopic eradication therapy (EET) for Barrett’s esophagus (BE) based on data collected from the UK National HALO RFA registry encompassing a 10-year period. They evaluated 2535 patients with BE (mean length, 5.2 cm; range, 1-20) and neoplasia (20% low-grade dysplasia [LGD], 54% high-grade dysplasia [HGD], 26% intramucosal carcinoma [IMC]) who underwent radiofrequency ablation (RFA) therapy across 28 UK hospitals. They included patients with BE in whom LGD, HGD, or IMC were confirmed histologically by 2 expert gastrointestinal pathologists. The primary aim was to determine the 10-year cancer progression in patients undergoing EET for BE. The authors also evaluated the relapse rates of clearance of dysplasia (CR-D) and clearance of intestinal metaplasia (CR-IM) together with the success rates of further therapy when CR-D or CR-IM recurred. They also calculated the time to achieve CR-D and CR-IM after relapse. These were defined as CR-D2 and CR-IM2, respectively. During follow-up, 41 (1.6%) patients developed invasive cancer (cancer with submucosal invasion). The initial diagnosis was LGD in 4 (.7% of the LGD cohort), HGD in 24 (1.8%), and IMC in 13 (2.0%) (χ2 P = not significant). Of these 41 patients, 22 progressed to invasive cancer within 18 months of initiating EET. The Kaplan-Meier (KM) cancer rate was 4.1% with a crude incidence rate of .52 per 100 patient-years. After 2 years of EET, CR-D and CR-IM were 88% and 62.6%, respectively. KM relapse rates for CR-D and CR-IM were 5.9% and 18.7%, respectively. Most cases of relapse occurred in the first 2 years. Two years after retreatment, there was a CR-D2 of 63.4% and CR-IM2 of 70%. Primary EMR (EMR prior to any RFA therapy) was performed in 646/1175 (55.0%) of patients. Rescue therapy (EMR, argon plasma coagulation, or yttrium-aluminum garnet laser) during or after reaching CR-D was required by 360 patients (30.6%) and primarily consisted of EMR (n = 351). The CR-D rate was lower in the rescue therapy group. The proportion of patients who developed cancer was significantly higher in those having rescue therapy (5.0%) versus those not having rescue therapy (.9%) (P < .00001). Quoting the authors: "We have shown long-term benefit of EET in reducing rates of invasive cancer in a large cohort of patients, with RFA alone achieving excellent results in selected patients. Durability was high, with most relapses occurring shortly after completion of therapy and being treatable with the same modality. EET with RFA is now firmly established as the primary therapy for dysplastic BE."

Wolfson P, Ho KMA, Wilson A. Endoscopic eradication therapy for Barrett's esophagus–related neoplasia: a final 10-year report from the UK National HALO Radiofrequency Ablation Registry. Gastrointest Endosc 2022;96:223-233.

Correct Answer: D. All of the above.

Concerning the impact of the implementation of an online expert panel on the management of complex colorectal polyps, what would you say?

A. It has the potential to reduce the number of colorectal surgeries of lesions that could be managed endoscopically. (0 votes, 0%)
B. It has the potential to increase the number of colorectal surgeries of lesions that could not be managed endoscopically. (0 votes, 0%)
C. It has the potential to change the treatment strategy, even in the more complex colorectal polyps (size, morphology, site, and access score of 4). (3 votes, 38%)
D. All of the above. (5 votes, 63%)

Zwager LW, Bastiaansen BAJ, Dekker E, Fockens P. Setting up a regional expert panel for complex colorectal polyps. Gastrointest Endosc 2022;96:84-91.

Correct Answer: A. The mean percentage of total weight loss (%TWL) of patients submitted to ESG is not inferior to those submitted to LSG until 3 years after the procedure.

Comparing the results of endoscopic sleeve gastroplasty (ESG) and laparoscopic sleeve gastrectomy (LSG), what would you say?

A. The mean percentage of total weight loss (%TWL) of patients submitted to ESG is not inferior to those submitted to LSG until 3 years after the procedure. (4 votes; 80%)
B. The mean %TWL of patients submitted to ESG is inferior to those submitted to LSG 3 years after the procedure. (0 votes, 0%)
C. The resolution of comorbidities such as hypertension and diabetes are more frequent in the LSG group. (1 vote, 20%)
D. The need for resuture or LSG referral for insufficient weight loss in patients primarily submitted to ESG occurs in 15-20% of the patients. (0 votes, 0%)

In the July issue of GIE, Alqahtani et al conducted a retrospective comparison between endoscopic sleeve gastroplasty (ESG) and laparoscopic sleeve gastrectomy (LSG) for the treatment of obese patients. The authors employed propensity score matching for the control of the confounding variables age, sex, and body mass index. The primary outcome was total weight loss (TWL) at 6,12, 24, and 36 months after the procedures. A noninferiority margin of 10% of TWL was defined a priori. The noninferiority null hypothesis was defined as ESG is inferior to LSG by more than 10% TWL. From the initial cohort of 3018 and 11,787 patients submitted to ESG and LSG, respectively, the authors compared the results of 3018 pairs of patients. Mean percentage of excess weight loss at 12, 24, and 36 months after ESG was 77.1% ± 24.6%, 75.2% ± 47.9%, and 59.7% ± 57.1%, respectively, compared with 95.1% ± 20.5%, 93.6% ± 31.3%, and 74.3% ± 35.2% after LSG, respectively. Mean %TWL at 12, 24, and 36 months after ESG was 28.9% ± 8.2%, 16.2% ± 9.7%, and 14.0% ± 12.1%, respectively. Mean %TWL at 12, 24, and 36 months after LSG was 19.2% ± 7.7%, 22.2% ± 8.2%, and 18.8% ± 7.5%, respectively. Mean %TWL difference (95% confidence interval) at 12, 24, and 36 months was 9.7% (6.9-11.8), 6.0% (–2.0 to 9.4), and 4.8% (–1.5 to 8.7). ESG was noninferior compared with LSG by the 10% noninferiority margin at each follow-up visit. TWL did not differ between the <35 kg/m2 and the 35-40 kg/m2 groups 12, 24, and 36 months after ESG. Comorbidity remission rates after ESG versus LSG were 64% versus 82% for diabetes, 66% versus 64% for dyslipidemia, and 51% versus 46% for hypertension, respectively. Eighty ESG patients (2.7%) underwent LSG for insufficient weight loss or regain, and 28 needed resuturing after primary ESG (0.9%). Quoting the authors: "In conclusion, ESG and LSG were found to have equivalent safety and comorbidity resolution profiles. Additionally, ESG was found to be noninferior to LSG in terms of weight loss beyond the first year. ESG fills a critical gap in treatment of patients who do not qualify for bariatric surgery. The procedure also provides an alternative option for those who do not wish to undergo surgery. However, long-term weight loss durability remains to be investigated."

Alqahtani AR, Elahmedi M, Aldarwish A, Abdurabu HY, Alqahtani S. Endoscopic gastroplasty versus laparoscopic sleeve gastrectomy: a noninferiority propensity score–matched comparative study. Gastrointest Endosc 2022;96:44-50.

Correct Answer: E. All the above.

Concerning the reporting and monitoring of adverse events (AEs) in gastrointestinal endoscopy, what would you say?

A. It is essential for the identification of possible targets for the improvement of endoscopic interventions. (0 votes, 0%)
B. It makes possible comparison between endoscopists and endoscopy unit performances. (0 votes, 0%)
C. It has the potential to make informed consent for patients more accurate. (0 votes, 0%)
D. It is essential for the quantification of the safety of complex endoscopic procedures. (0 votes, 0%)
E. All the above. (2 votes, 100%)

Nass KJ, Zwager LW, van der Vlugt M, et al. Novel classification for adverse events in GI endoscopy: the AGREE classification. Gastrointest Endosc 2022;95:1078-1085.

Correct Answer: D. In patients with firstly diagnosed CLE, WATS detects IM more frequently than FB.

In wide-area transepithelial sampling (WATS), the columnar-lined esophagus (CLE) is brushed, and the sample is sent for a 3-dimensional, computer-assisted diagnosis. Concerning the diagnostic yield of WATS versus the conventional Seattle protocol with forceps biopsy (FB) for the detection of esophageal/cardia intestinal metaplasia (IM), what would you say?

A. Compliance with the FB/Seattle protocol is greater than compliance with the WATS procedure. (0 votes, 0%)
B. With WATS, there is a higher likelihood of high- and low-grade dysplasia detection in CLE than FB. (4 votes, 8%)
C. Adverse events are more common with FB than WATS. (0 votes, 0%)
D. In patients with firstly diagnosed CLE, WATS detects IM more frequently than FB. (1 vote, 20%)

In the June issue of GIE, DeMeester et al conducted a multicenter randomized clinical trial to compare forceps biopsy (FB) with wide-area transepithelial sampling (WATS) for the detection of intestinal metaplasia (IM) in patients with columnar-lined esophagus (CLE). Patients presenting for endoscopic evaluation of foregut symptoms for surveillance of known Barrett’s esophagus (BE) or assessment after endoscopic ablation of BE or dysplasia were eligible for inclusion. Patients with a history of esophageal or gastric malignancy were excluded. The primary endpoint was the frequency of detection of IM or dysplasia by FB versus WATS. Compliance with FB versus WATS for long-segment (≥3 cm) CLE and the number of samples containing only squamous epithelium were the secondary outcomes. FB was performed as per the Seattle protocol. Two WATS brushes were to be used in each patient for every 5 cm of CLE per routine manufacturer recommendations. Central pathology review was not used for the FB samples. The WATS samples were packaged and sent to the CDx Diagnostics central laboratory (Suffern, NY, USA), where 3-dimensional images were created with the aid of artificial intelligence and presented to a dedicated pathologist. From October 2017 to December 2018, 9 centers in the United States enrolled 1002 patients with 505 randomized to FB and 497 to WATS. Patients’ mean age was 57, and 66% were women. In 296 patients (30% of the entire cohort), a CLE (median length, 2 cm; range, .5-15) was found. A short-segment CLE was detected in 219 (74%) and a long-segment CLE in 77 patients (26%). Overall, IM was found in 212 patients (21%), and the frequency of IM detection was similar with FB and WATS (19.6% vs 22.7%, respectively; P = .2). In patients with no known history of esophageal IM but with CLE, the frequency of detection of IM was significantly greater with WATS than FB (32.4% vs 15.2%, respectively; P = .004). The median number of levels biopsied in patients randomized to FB was 1 (range, 1-3). There was no significant difference in the frequency of finding IM by FB or WATS in patients with a known history of IM or prior ablation. The authors found 1 case of adenocarcinoma and 8 patients with low-grade dysplasia. Noncompliance with the Seattle protocol occurred in 27% of the patients in the FB group. Noncompliance with the use of a minimum of 2 WATS brushes for every 5 cm of CLE occurred in 7% of the patients in the WATS group (27.5% vs 7%; P = .01). Quoting the authors: "Overall, FB and WATS detected a similar frequency of IM and dysplasia. WATS was twice as likely as FB to find IM in patients without a history of BE who had CLE on endoscopy. In patients with known BE, WATS and FB showed IM and dysplasia with similar frequency. These findings suggest that WATS can be used instead of FB with similar or improved efficacy at detecting IM and dysplasia."

DeMeester S, Smith C, Severson P, et al. Multicenter randomized controlled trial comparing forceps biopsy sampling with wide-area transepithelial sampling brush for detecting intestinal metaplasia and dysplasia during routine upper endoscopy. Gastrointest Endosc 2022;95:1101-1110.

Correct Answer: A. If the colonoscopist’s ADR is stable and above the recommended minimum threshold of 25% in consecutive years, diversion of resources toward improvement of other quality measures is justified.

The adenoma detection rate (ADR) is considered one of the most relevant quality measures in colonoscopy. Concerning the need for continuous measurement of ADR, what would you say?

A. If the colonoscopist’s ADR is stable and above the recommended minimum threshold of 25% in consecutive years, diversion of resources toward improvement of other quality measures is justified. (2 votes, 11%)
B. ADR should be continuously monitored, irrespective of the stability of the measurement in consecutive years. (13 votes, 72%)
C. The measurement of ADR can be interrupted when the colonoscopist has more than 10 years of practice. (0 votes, 0%)
D. The measurement of ADR can be interrupted for artificial intelligence-aided colonoscopies. (3 votes, 17%)

In the May issue of GIE, El Rahyel et al evaluated the stability of adenoma detection rate (ADR) over time. The authors reviewed a single-center database between January 1999 and November 2019 that contained data for colonoscopists with at least 50 screening colonoscopies for 5 consecutive years. ADR was calculated for 11 gastroenterologists. For the detection of a trend in a change of a gastroenterologist’s ADR, the authors used the National Cancer Institute’s Joinpoint regression model. The Joinpoint can analyze trends in order to describe their apparent change and assess whether any trend is statistically significant. A total of 14,047 patients undergoing screening colonoscopies performed at Indiana University by 11 gastroenterologists were included. The mean patient age was 58.4 ± 7.5 years, and 7584 (54%) of them were women. The mean polyp size was 4.7 mm (range 1-200 mm). In 5912 colonoscopies (42%), there was at least 1 conventional adenoma removed. ADR of 6 gastroenterologists remained stable during the study period, and it increased in 5. Only 1 gastroenterologist did not meet the recommended minimum threshold ADR of 25% continuously over the study period. Quoting the authors: "In conclusion, we demonstrated in a single-center study of 11 endoscopists that the ADR remains stable or increased over time, with no significant trend to decrease. We recommend this issue be studied at other centers to evaluate the appropriateness of cessation of ADR measurement or using intermittent measurement for some colonoscopists."

El Rahyel A, Vemulapalli KC, Lahr RE, Rex DK. Implications of stable or increasing adenoma detection rate on the need for continuous measurement. Gastrointest Endosc 2022;95:948-953.

Correct Answer: C. The PPB rate of CSP is lower than the PPB rate of HSP.

Concerning the postpolypectomy bleeding (PPB) rate of cold snare polypectomy (CSP) and hot snare polypectomy (HSP) of colorectal lesions measuring <10 mm, what would you say?

A. PPB rates are similar in CSP and HSP for colorectal lesions measuring <10 mm, varying from 2% to 5%. (2 votes, 12%)
B. PPB rates are similar in CSP and HSP for colorectal lesions measuring <10 mm, varying from .1% to .6%. (3 votes, 18%)
C. The PPB rate of CSP is lower than the PPB rate of HSP. (9 votes, 53%)
D. The PPB rate of HSP is lower than the PPB rate of CSP. (3 votes, 18%)

In the May issue of GIE, Takamaru et al conducted an observational, single-center study comparing postpolypectomy bleeding (PPB) rate after cold snare (CSP) polypectomy versus hot snare polypectomy for colorectal lesions measuring less than 10 mm. HSP was defined as a snare resection involving electrocautery using "endo cut" (effect 2, interval .8 seconds, and fixed power of 120 W) and "forced coagulation" (fixed power of 50 W) for monopolar snare devices or "forced coagulation" (fixed power of 15 W) for bipolar snare devices, with or without submucosal injection. In CSP, submucosal injection was not performed. Clipping was performed at the endoscopist’s discretion. PPB was defined as the presence of marked bloody stool or the need for post-treatment hemostasis within 14 days of the procedure. Patients in whom bleeding stopped spontaneously and who did not undergo endoscopic examination were not considered to have PPB. Propensity score model was used to make the groups of comparison homogeneous. Markov chain Monte Carlo method was used to compensate for missing values regarding the usage of antithrombotic agents (n = 6178 [40.3%]), location of the lesion (n = 119 [.78%]), and macroscopic features (n = 92 [.60%]). From January 2015 to December 2019, 15,336 lesions (5371 patients), with diameters of <10 mm, were resected using CSP or HSP. After propensity score matching for age, lesion size, macroscopic features, location of the lesions, clipping after resection, and antithrombotic agent use, 2135 lesions (1531 patients for CSP group and 1343 patients for HSP) were analyzed. The PPB rate in the CSP group was .10% and .56% in the HSP group (P = .0075). The OR after matching was 6.0 (95% CI, 1.34-26.80). In the sensitivity analyses using the lesions without submucosal injections, and the lesions with no missing data, there was a trend of a higher PPB rate in the HSP group. Quoting the authors: "In conclusion, our study demonstrated that the PPB rate after CSP was significantly lower than that after HSP for lesions <10 mm in diameter. Therefore, CSP for lesions <10 mm could be safely performed compared with HSP. It may be possible to expand the indications for CSP based on the results of studies."

Takamaru H, Saito Y, Hammoud GM, et al. Comparison of postpolypectomy bleeding events between cold snare polypectomy and hot snare polypectomy for small colorectal lesions: a large-scale propensity score–matched analysis. Gastrointest Endosc 2022;95:982-989.

Correct Answer: A. Patients with a "AI-Active" disease have a higher clinical relapse rate in 1 year than patients with "AI-Healing" disease.

Among the several applications of artificial intelligence (AI), the AI-assisted diagnosis of ultramagnified images of the GI tract is getting special attention. Concerning the performance of AI for the prediction of ulcerative colitis (UC) relapse at 1 year based on the analysis of ultramagnified images of the colorectal mucosa, what would you say?

A. Patients with a "AI-Active" disease have a higher clinical relapse rate in 1 year than patients with "AI-Healing" disease. (4 votes, 100%)
B. The performance of AI in predicting UC relapse is not influenced by the extent of the disease. (0 votes, 0%)
C. AI-assisted diagnosis does not predict UC relapse in 1 year confidently. (0 votes, 0%)
D. The performance of AI in predicting UC relapse is not influenced by the endoscopic appearance of the colorectal mucosa. (0 votes, 0%)

In the April issue of GIE, Maeda et al conducted an open-label, single-center, prospective, cohort study to evaluate the performance of artificial intelligence (AI) for the prediction of relapse of ulcerative colitis (UC). From May to December 2019, they included 145 consecutive patients with UC in remission (corticosteroid-free for 6 months or longer and clinical remission, defined as a partial Mayo score ≤1). During colonoscopy, the authors employed an endocytoscope that has a contact light microscopy system with ultramagnification capability (×520) integrated into the distal tip, in addition to standard colonoscopy function. This system allows the visualization of microvessels on the colorectal mucosa, which were analyzed by the AI system that was directly connected to an endoscopy system. After the endoscopist pressed the capture button on the endoscope to acquire an image, the endoscopy monitor displayed a 2-category ("Active" or "Healing") prediction output with the probability of the prediction. Patients were followed every 8 or 12 weeks for 12 months or until the occurrence of clinical relapse, defined as a partial Mayo score >2. The main outcome was the clinical relapse rate within 12 months after colonoscopy. Secondary outcomes were relapse rates for patients with endoscopic remission (defined as Mayo endoscopic subscore ≤1). The authors also investigated the difference in relapse rates between groups based on the extent of disease: extensive colitis, left-sided colitis, or proctitis. From the 145 patients, 135 patients completed the 12-month follow-up after AI-assisted colonoscopy. Based on AI-assisted colonoscopy, 61 patients were categorized as the AI-Healing group and 74 as the AI-Active group. As per-protocol analysis, the 1-year relapse rate was 28.4% (21 of 74) in the AI-Active group and 4.9% (3 of 61) in the AI-Healing group (P < .001). In the subgroup of the patients who achieved endoscopic remission (MES ≤1), the AI-Active group had a significantly higher clinical relapse rate than the AI-Healing group: 24.5% (13 of 53) versus 4.9% (3 of 61) (P = .003). In addition, among the patients with an MES of 0, there was no significant difference in the clinical relapse rate between the AI-Healing and AI-Active groups: 6.2% (2 of 32) versus 0% (0 of 10) (P = 1.000). Among the patients with extensive colitis and those with left-sided colitis, the AI-Active group had a significantly higher clinical relapse rate than the AI-Healing group: 27.7% (13 of 47) versus 3.2% (1 of 31) (P = .006) and 33.3% (7 of 21) versus 5.3% (1 of 19) (P = .046), respectively. In addition, among the patients with proctitis, there was no significant difference in the clinical relapse rate between the AI-Healing and AI-Active groups: 16.7% (1 of 6) versus 9.1% (1 of 11) (P = 1.000). Quoting the authors: "In conclusion, real-time use of the fully automated AI system can stratify the clinical relapse risk in patients with UC in clinical remission, which may decrease invasiveness, pathologists’ effort, and additional cost. This system can also allow clinicians to make real-time decisions regarding treatment interventions for patients with UC."

Maeda Y, Kudo S, Ogata N, et al. Evaluation in real-time use of artificial intelligence during colonoscopy to predict relapse of ulcerative colitis: a prospective study. Gastrointest Endosc 2022;95:747-756.

Correct Answer: C. "Early" SBCE and DAE have a higher diagnostic yield, a higher therapeutic intervention rate, and a lower rebleeding rate than "non-early" SBCE and DAE.

Concerning "early" versus "non-early" small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) for the diagnosis and treatment of obscure gastrointestinal bleeding, what would you say?

A. "Early" SBCE and DAE have a higher diagnostic yield but no impact on the rebleeding rate compared with "non-early" SBCE and DAE. (3 votes, 23%)
B. "Early" and "non-early" SBCE and DAE have similar diagnostic and therapeutic yields. (0 votes, 0%)
C. "Early" SBCE and DAE have a higher diagnostic yield, a higher therapeutic intervention rate, and a lower rebleeding rate than "non-early" SBCE and DAE. (7 votes, 54%)
D. "Early" SBCE and DAE have a higher diagnostic yield and a higher therapeutic intervention rate without impact on the rebleeding rate than "non-early" SBCE and DAE. (3 votes, 23%)

In the April issue of GIE, Manuela Estevinho et al conducted a systematic review and meta-analysis (SRMA) to compare "early" and "non-early" small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) for the diagnosis and treatment of obscure gastrointestinal bleeding (OGIB). OGIB was defined as bleeding of unknown origin that persists or recurs after a negative colonoscopy and upper endoscopy. The definition of DAE encompassed single-balloon (SBE), double-balloon (DBE), and spiral enteroscopy techniques. "Early" SBCE was defined when the procedure was performed within 14 days of the overt bleeding episode and "early" DAE within 72 hours of the overt bleeding episode. The authors excluded case reports and single-arm studies where the patients underwent only "non-early" SBCE or "non-early" DAE. The primary endpoints evaluated in this SRMA were diagnostic yield corresponding to the proportion of patients with findings that could likely explain gastrointestinal bleeding and therapeutic yield defined as the ability to perform therapeutic procedures after capsule endoscopy or during enteroscopy. The secondary endpoints were active bleeding detection rate, vascular lesion detection rate, and recurrent bleeding rate (defined as a drop in hemoglobin > 2 g/dL), need for blood transfusions or presence of overt bleeding, and mortality. The authors included 39 studies with 4825 patients (30 double-arm studies comparing "early" and "non-early" procedures with 16 on SBCE, 12 on DAE, and 2 on both SBCE and DAE). The pooled diagnostic yields in "early" SBCE and DAE groups were 33.33 (95% CI, 25.09-41.57) and 27.80 (95% CI, 21.74-33.85) points superior when compared with "non-early" SBCE and DAE, respectively. The odds of detecting positive findings in the patients submitted to "early" small-bowel studies were 3.99 times the odds of the "non-early" approach (P < .01, I2 = 45%). The odds of receiving therapeutics were significantly superior for "early" SBCE and DAE: 4.01 (95% CI, 2.18-7.35; P < .01; I2 = 44%) and 3.93 (95% CI, 1.40-10.99; P < .01; I2 = 77%) compared with the "non-early" SBCE and DAE, respectively. The odds of detecting active bleeding were 3.22 (P < .01) and 19.78 (P = .02) times higher in "early" versus "non-early" SBCE and DAE, respectively. The authors observed a lower recurrent bleeding rate in "early" SBCE and DAE (OR, .40; P < .01; I2 = 0%). Quoting the authors: "The role of small-bowel studies in the early evaluation of OGIB is unquestionable, impacting diagnosis, therapeutic intervention, and prognosis. Comparative studies are still needed to identify optimal timing."

Manuela Estevinho M, Pinho R, Fernandes C, et al. Diagnostic and therapeutic yields of early capsule endoscopy and device-assisted enteroscopy in the setting of overt GI bleeding: a systematic review with meta-analysis. Gastrointest Endosc 2022;95:610-625.

Correct Answer: C. CRC patients are willing advocates of screening to their siblings, and siblings’ response rate to this intervention is usually limited.

Siblings of patients with colorectal cancer (CRC) have a 2-fold higher lifetime risk of developing the disease compared to the general population without CRC family history. Concerning the interventions employed to increase this group’s awareness of risk for CRC screening, what would you say?

A. CRC patients are willing advocates of screening to their siblings, and siblings’ response rate to this intervention is usually sound. (3 votes, 75%
B. CRC patients are not good advocates of screening to their siblings, and siblings’ response rate to this intervention is usually limited. (1 vote, 25%)
C. CRC patients are willing advocates of screening to their siblings, and siblings’ response rate to this intervention is usually limited. (0 votes, 0%)
D. CRC patients are not good advocates of screening to their siblings, and siblings’ response to this intervention is usually sound. (0 votes, 0%)

In the March issue of GIE, Choe et al conducted a randomized behavioral intervention with survivors of colorectal cancer (CRC) and their siblings in 2 tertiary hospitals. In the intervention group, survivors of CRC delivered tailored material to their siblings to increase their awareness of CRC screening. In the control group, patients with previous treatment for CRC delivered standard materials to their siblings. The main outcomes were the number of patients who had successfully contacted at least 1 eligible sibling (advocacy rate) and the proportion of eligible siblings who responded to the research team about the CRC screening program. From May 2017 to March 2021, 219 CRC patients were randomized to the intervention (n = 110) and control groups (n = 109). The overall patient advocacy rate was 93.2% (n = 204). No difference was observed in the groups of comparison (96.4% in the intervention group and 89.9% in the control group). The overall proportion of eligible siblings who responded was 14.3% (16.9% in the intervention group and 11.1% in the control group [adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.0, P < .05]). Finally, siblings aged 60 and above were significantly less likely to respond to the research team on CRC screening (adjusted odds ratio, 0.3; 95% confidence interval, 0.1-0.7; P < .01). Quoting the authors: "This study demonstrated that CRC patients are willing advocates of CRC screening to their siblings. Healthcare agencies might consider tapping CRC patients as an avenue to promote screening to eligible individuals. However, because actual sibling response rates left much to be desired, it is likely that patient-led advocacy should at best be used as an adjunct modality in addition to a holistic suite of other CRC screening promotion modalities. Consequently, perhaps our findings also serve to demonstrate the challenges of CRC screening promotion even in a country with a well-developed public healthcare system and universal health coverage."

Choe L, Lau J, Fong S, et al. Colorectal cancer patients advocating screening to their siblings: a randomized behavioral intervention. Gastrointest Endosc 2022;95:519-526.

Correct Answer: D. It is possible to decrease the number of colonoscopies and increase both the sensitivity and specificity of the screening program.

Most national colorectal screening programs that adopted fecal immunochemical testing (FIT) use the same cut-off value of hemoglobin/g for all participants. Concerning the strategy to adopt different cut-off values of hemoglobin/g according to age and sex groups, what would you say?

A. It is possible to decrease the number of colonoscopies, but at the expense of decreasing sensitivity of the screening program in some age and sex groups. (3 votes, 38%)
B. It is possible to decrease the number of colonoscopies, but at the expense of decreasing specificity of the screening program in some age and sex groups. (2 votes, 25%)
C. It is possible to decrease the number of colonoscopies with no impact on sensitivity or specificity of the screening program. (1 vote, 13%)
D. It is possible to decrease the number of colonoscopies and increase both the sensitivity and specificity of the screening program. (2 votes, 25%)

In the March issue of GIE, Njor et al tested the hypothesis that the efficiency of a national colorectal cancer (CRC) screening program could be improved by modifying the cut-off levels of the positive fecal immunochemical testing according to age and sex. They evaluated the data of the first round of the National Danish CRC screening program targeting residents aged 50 to 74 years from March 2014 to December 2015. Patients with a FIT test that contained more than 100 ng hemoglobin (Hb)/mL were referred to a colonoscopy within 14 days of the test result. Sensitivity, specificity, number of positive test results, number of screen-detected CRCs and adenomas, as well as number of interval cancers were estimated for all selected cut-off values (40-1000 ng Hb/mL and age groups for men and women). The authors used 2 perspectives to identify the optimal individual cut-off values for each gender and age group. In the “public health perspective,” they aimed at finding cut-off values that would improve sensitivity and specificity without increasing the number of needed colonoscopies in the entire population. In the “equity perspective,” they aimed at minimizing the variation in sensitivity across age and sex groups while maintaining the overall sensitivity. The National Danish CRC screening program database included 531,828 residents, of which 35,582 (6.7%) returned a stool sample containing ≥100 ng Hb/mL and were referred to colonoscopy. In the public health perspective, the authors suggested decreasing the cut-off value to 75 ng Hb/mL for men aged 70 to 74 years and women aged 65 to 74 years and increase the cut-off value to 300 ng Hb/mL for men aged 50 to 59 years and women aged 50 to 54 years. Using these cut-off values instead of 100 ng Hb/mL, the authors noticed increased overall sensitivity (81.9%-82.3% [Table 2]) and specificity (93.7%-94.1%), decreased number of positive test results and number of needed colonoscopies by 7%, increased number of screen-detected cancer by 1.1%, increased number of screen-detected adenomas by 5%, and decreased number of interval cancers by 1.5%. Using “the equity perspective,” the authors suggested the following cut-off values: 45 ng Hb/mL for women younger than 65, 50 ng Hb/mL for women older than 65, 300 ng Hb/mL for men aged 50 to 54 years, 250 ng Hb/mL for men aged 55 to 64 years, and 150 ng Hb/mL for men aged 65 to 74 years. Using these cut-off values instead of 100 ng Hb/mL increased the overall sensitivity slightly from 81.9% to 82.4%, decreased specificity from 93.6% to 93.0%, increased number of positive test results by 10%, increased number of screen-detected cancer by 1.4%, decreased number of screen-detected adenomas by 7%, and decreased number of interval cancers by 2.2%. Quoting the authors: "This study shows that it is possible to decrease the number of needed colonoscopies while at the same time increase the overall sensitivity and specificity, by using different cut-off values for men and women and for different age groups."

Njor SH, Rasmussen M, Friis-Hansen L, Andersen B. Varying fecal immunochemical test screening cutoffs by age and gender: a way to increase detection rates and reduce the number of colonoscopies. Gastrointest Endosc 2022;95:540-549.

Correct Answer: A. Laparoscopic cholecystectomy with intraoperative cholangiogram (LC-IOC) is the most cost-effective strategy compared with MRCP, EUS and ERCP in separate sessions, and EUS and ERCP in the same session.

Considering the management of patients with symptomatic cholelithiasis and intermediate (50%, range 10%-70%) probability of lithiasis of the common bile duct, what would you say?

A. Laparoscopic cholecystectomy with intraoperative cholangiogram (LC-IOC) is the most cost-effective strategy compared with MRCP, EUS and ERCP in separate sessions, and EUS and ERCP in the same session. (2 votes, 13%)
B. MRCP is the most cost-effective strategy compared with LC-IOC, EUS and ERCP in separate sessions, and EUS and ERCP in the same session. (2 votes, 13%)
C. EUS and ERCP in separate sessions is the most cost-effective strategy compared with MRCP, LC-IOC, and EUS and ERCP in the same session. (0 votes, 0%)
D. EUS and ERCP in the same session is the most cost-effective strategy compared with MRCP, EUS and ERCP in separate sessions, and LC-IOC. (8 votes, 53%)
E. The most cost-effective strategy varies with the range of the probability of choledocholithiasis. (3 votes, 20%)

In the February issue of GIE, Ali et al conducted a cost-effectiveness analysis of the management of patients with cholelithiasis and intermediate probability of choledocholithiasis (IPC). They included four strategies in the development of the decision tree analysis:

• Strategy I: laparoscopic cholecystectomy with intraoperative cholangiogram (LC-IOC).
• Strategy II: EUS; ERCP in the same session if choledocholithiasis is diagnosed.
• Strategy III: EUS; with ERCP in a separate session if choledocholithiasis is diagnosed.
• Strategy IV: MRCP.

They defined the intermediate probability of the model at 50%, in keeping with the current ASGE outlined definition of IPC. They also conducted a sensitivity analysis, setting the lower and upper limits of IPC at 10% and 70%, respectively, to assess the impact of varying the probabilities of choledocholithiasis on the model. As the study focused on the diagnosis of choledocholithiasis, the therapeutic option of choledocholithiasis was limited to ERCP performed by expert operators. The cost data in U.S. dollars were based on multiple sources, including the national samples (NIS) and Medicare claims and reimbursements dataset. The authors employed the Monte Carlo simulation, which ran 10,000 iterations of the model to generate a cost-effectiveness scatter plot and a cost-acceptability curve, with a willingness to pay (WTP) threshold of U.S. $50,000. The outcomes were net-monetary benefit (NMB), average proportion and average cost per true positive diagnosis, and length of stay (LOS). LC-IOC was the most cost-effective strategy to diagnose IPC, with an NMB of$34,612, average cost of $13,260 per true positive diagnosis, and mean LOS of 4.13, compared with strategies II, III, and IV. NMB for strategies II, III, and IV was$26,397, $26,642 and$31,335, respectively. At the sensitivity analysis with IPC probabilities ranging from 10% to 70%, LC-IOC remained the strategy with the most NMB. Quoting the authors: "In light of the strengths and weaknesses of our model and currently available data, we conclude that for patients with cholelithiasis with IPC, performing LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten length of hospital stay. Based on these findings, we have modified our institutional protocol, and LC-IOC now remains the diagnostic test of choice while managing patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis."

Ali FS, DaVee T, Bernstam EV, et al. Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis. Gastrointest Endosc 2022;95:327-338.

Correct Answer: C. A mural nodule >10 mm and a positive cytology of the pancreatic juice are both associated with a higher risk of malignancy.

Main pancreatic duct IPMN (MD-IPMN) is considered to harbor a high potential for invasive pancreatic adenocarcinoma. Most guidelines recommend pancreatic resection for MD-IPMN. However, not all MD-IPMNs are malignant. Concerning the predictive factors of malignancy in MD-IPMN, what would you say?

A. The diameter of the main pancreatic duct >10 mm is associated with a higher risk of malignancy. (4 votes, 17%)
B. The "fish-mouth" sign is associated with a higher risk of malignancy. (0 votes, 0 %)
C. A mural nodule >10 mm and a positive cytology of the pancreatic juice are both associated with a higher risk of malignancy. (17 votes, 74%)
D. Segmental MD-IPMN harbors a higher risk of malignancy compared with diffuse MD-IPMN. (2 votes, 9%)

Uehara H, Abe Y, Kai Y, et al. Predictors of malignancy in main duct intraductal papillary mucinous neoplasm of the pancreas. Gastrointest Endosc 2022;95:291-296.

Correct Answer: E. All the above are correct.

Concerning the surveillance for colorectal endoscopic neoplasia detection and management in inflammatory bowel disease patients, what would you say?

A. The Kudo pit pattern is helpful in the differential diagnosis of neoplastic versus non-neoplastic lesions. (1 vote, 5%)
B. Extensive pseudopolyposis does not consist in a risk factor for adenocarcinoma in patients with longstanding IBD. (0 votes, 0%)
C. Random biopsies have a low diagnostic yield for dysplasia. (0 votes, 0%)
D. High-definition endoscopy, virtual chromoendoscopy, and dye-spray chromoendoscopy are valid alternatives for the detection of dysplasia in patients with IBD. (2 votes, 10%)
E. All the above are correct. (17 votes, 85%)

The SCENIC international consensus statement (Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations) was published both in Gastroenterology and Gastrointestinal Endoscopy in 2015. Since then, new evidence on this arena has been published. In the January issue of GIE, Rabinowitz et al reviewed this post-SCENIC literature in dysplasia surveillance and management in patients with longstanding Crohn’s and ulcerative colitis. Concerning the visual aspect of dysplasia, the authors presented evidence on the use of the Paris classification and the Kudo’s pit pattern for the differentiation of neoplastic from non-neoplastic polyps. In addition, the presence of extensive pseudopolyposis did not consist in a risk factor for adenocarcinoma in patients with longstanding IBD. The real impact of random biopsies remains a matter of controversy. The authors discussed new studies showing the low diagnostic yield of this strategy for the detection of dysplasia. In patients with concomitant primary sclerosing cholangitis, a previous history of neoplasia or a tubular colon, random biopsies have a modest higher diagnostic yield for dysplasia. Based on the current evidence, the authors suggested that high-definition white light endoscopy, virtual chromoendoscopy (NBI, i-SCAN), and dye-spray chromoendoscopy may be successfully used to detect dysplasia in the patient with longstanding colitis, if the endoscopist has enough skill in the surveillance technique of choice. Concerning management of dysplastic lesions, the authors noticed the current evidence confirmed the impact of endoscopic mucosal resection (EMR) and, more recently, endoscopic submucosal dissection (ESD) on the management of both polypoid and flat lesions. However, they reminded that patients with either HGD or carcinoma should not be routinely managed with ESD, but the array of surgical resection options should be offered to them. The authors reason that, with the advent of ESD for the management of dysplastic lesions in patients with IBD, there is a new cohort of patients for whom endoscopic vigilance is not outlined in current guidelines. Quoting the authors: "Advances in colonoscopic technology and endoscopic resection techniques in the years since the publication of the SCENIC guidelines have allowed for improved detection and management of dysplasia. These developments have also created new patient populations that require further study in order to identify optimal methods of and intervals for surveillance. Until more data are available, a personalized approach, with careful consideration of the patient’s inflammatory disease course, comorbidities, and prior history of dysplastic lesions, is needed."

Rabinowitz LG, Kumta NA, Marion JF, et al. Beyond the SCENIC route: updates in chromoendoscopy and dysplasia screening in patients with inflammatory bowel disease. Gastrointest Endosc 2022;95:30-37.

Correct Answer: A. The use of transpancreatic sphincterotomy is related to a higher rate of successful cannulation compared to the other techniques.

Considering the results of needle-knife techniques, pancreatic guidewire-assisted technique, pancreatic stent-assisted technique, transpancreatic sphincterotomy, and persistence with standard cannulation techniques for patients with difficult biliary cannulation, what would you say?

A. The use of transpancreatic sphincterotomy is related to a higher rate of successful cannulation compared to the other techniques. (4 votes, 22%)
B. The use of transpancreatic sphincterotomy is related to a higher incidence of post-ERCP pancreatitis compared to the other techniques. (7 votes, 39%)
C. Pancreatic-guidewire technique is related to a higher rate of successful cannulation and lower incidence of post-ERCP pancreatitis compared to the other techniques. (4 votes, 22%)
D. The use of needle-knife techniques (conventional precut sphincterotomy or fistulotomy) is related to a higher rate of successful cannulation compared to the other techniques. (3 votes, 17%)

In the January issue of GIE, Facciorusso et al conducted a systematic review and network meta-analysis (SRMA) comparing early and late needle-knife techniques (conventional precut sphincterotomy or fistulotomy), pancreatic guidewire-assisted technique, pancreatic stent-assisted technique, transpancreatic sphincterotomy, and persistence with standard cannulation techniques) for patients with difficult biliary cannulation. The 2 main outcomes evaluated were rate of biliary cannulation and incidence of post-ERCP pancreatitis (PEP). The quality of evidence derived from the pairwise and network meta-analysis was judged using the GRADE framework. The authors included 17 RCTs and 2105 patients. The definition of difficult biliary cannulation varied among included studies. Both rate of biliary cannulation and incidence of PEP were reported in all included studies. The patients’ mean age was between 49 and 70.4 years, and the most common indication for ERCP was choledocholitiasis. Only transpancreatic sphincterotomy resulted in statistically significant higher rate of successful biliary cannulation compared to standard cannulation techniques (RR, 1.29; 95% CI, 1.05-1.59), pancreatic guidewire-assisted technique (RR, 1.21; 95% CI, 1.01-1.44), early needle-knife techniques (RR, 1.19; 95% CI, 1.01-1.43), and pancreatic stent-assisted technique (RR, 1.47; 95% CI, 1.03-2.10). Concerning the incidence of PEP, the use of early needle-knife techniques outperformed persistence with standard cannulation techniques in terms of decreased PEP rates (RR, 0.61; 95% CI, 0.37-1.00). In addition, early needle-knife techniques and transpancreatic sphincterotomy reduced the incidence of PEP compared to pancreatic guidewire-assisted technique (RR, 0.49; 95% CI, 0.23-0.99 and RR, 0.53; 95% CI, 0.30-0.92, respectively). The quality of evidence was considered low for all the above-mentioned comparisons due to indirectness and risk of bias in the literature. Quoting the authors: "This is the first network meta-analysis to assess methods applied in the management of difficult biliary cannulation. Although robust GRADE methodology demonstrated only a weak level of evidence, we observed that transpancreatic sphincterotomy was more effective than other methods. As a result, transpancreatic sphincterotomy should be considered when attempting difficult biliary cannulation."

Facciorusso A, Ramai D, Gkolfakis P, et al. Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis. Gastrointest Endosc 2022;95:60-71.

Correct Answer: C. The larger the LNPCP the lower the technical and the clinical success rates of the endoscopic treatment.

Concerning the prevalence and the quality of endoscopic treatment of large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) detected at a colorectal cancer screening program, you would say that:

A. The expected prevalence of LNPCPs is below 5%. (1 vote, 9%)
B. The size of the LNPCP does not relate with technical or clinical success rates of the endoscopic treatment. (1 vote, 9%)
C. The larger the LNPCP the lower the technical and the clinical success rates of the endoscopic treatment. (5 votes, 45%)
D. The larger the LNPCP the lower the technical success rate of the endoscopic treatment, but without association with clinical success rate. (4 votes, 36%)

In the December issue of GIE, Meulen et al1 described the prevalence, the characteristics, and the quality of endoscopic treatment of large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) detected at the national Dutch screening program. Technical success was defined as a macroscopically complete resection during the first attempt, as judged by the endoscopist. Clinical success was defined as the absence of neoplasia 12 months after primary treatment. Clinical success also included cases that showed recurrence after 6 months, were treated successfully, and showed no signs of neoplasia at the 12-month follow-up colonoscopy. From February 2014 to January 2017, 124,155 patients underwent a colonoscopy after a positive fecal immunochemical test (FIT), and LNPCPs were detected in 8% of them. Most LNPCPs were in the proximal colon (52%). Median size of LNPCPs was 25.0 mm (20-35), and 2053 (18%) were ≥40 mm in size. Around 30% of the lesions were not resected at the first colonoscopy. The description of the quality of endoscopic treatment was based on the screening data from 5 endoscopy units in the Southern part of the Netherlands from February 2014 until August 2015. This subgroup of patients was representative of the national cohort. Endoscopic therapy was performed in 266 out of 332 (80%) of the LNPCPs. The majority of LNPCPs (91%) was resected by endoscopic mucosal resection (EMR), whereas only 1% of the lesions were resected by endoscopic submucosal dissection (ESD). Technical success was observed in 231 from 266 cases (87%; 95% CI, 82–91). Technical success rates were similar across the different 5 centers. Technical success decreased with increasing LNPCP size, with 126 out of 135 (93%) in 20 to 29 mm, 56 out of 65 (86%) in 30 to 39 mm, and 49 out of 66 (74%) in ≥40 mm LNPCPs (P = .001). Nonlifting of the lesion and difficult access to the lesion were the main causes of technical failure. Follow-up colonoscopy was performed in 152 patients. After 12 months, the recurrence rate was 22% (21/94; 95% CI, 15-32) for piecemeal and 8% (3/38; 95% CI, 2-22) for en-bloc resection. The overall recurrence rate after 12 months increased with LNPCP size; 5 out of 53 (9%) in 20 to 29 mm LNPCPs, 8 out of 36 (22%) in 30 to 39 mm LNPCPs, and 11 out of 43 (26%) in ≥40 mm LNPCPs (P = .095). Most recurrences at 12 months were smaller than 5 mm and could be treated endoscopically. From 266 lesions, 148 LNPCPs were included for clinical success rate analysis. Clinical success was achieved in 129 out of 148 (87%; 95% CI, 80-92) of cases. Clinical success decreased with increasing LNPCP size, with 61 out of 65 (94%) in 20 to 29 mm, 33 out of 39 (85%) in 30 to 39 mm, and 35 out of 44 (80%) in ≥40 mm LNPCPs (P = .078). Adverse events were observed in 5% of the patients. Quoting the authors: "In conclusion, in this Dutch screening program cohort it was shown that quality parameters for endoscopic resection of LNPCPs are not reached, especially in ≥30 mm polyps. Endoscopic resection of large polyps could benefit from additional training, quality monitoring, and centralization, either within or between centers."

1. Meulen LWT, van der Zander QEW, Bogie RMM, et al. Evaluation of polypectomy quality indicators of large nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort. Gastrointest Endosc. 2021;94:1085-96.

Correct Answer: B. Treatment response rate with EBL is around 80%.

Concerning the use of endoscopic band ligation (EBL) for the treatment of gastric antral vascular ectasia (GAVE), you would say that:

A. EBL-related adverse events rate can be as high as 25%, including severe bleeding from gastric ulcers. (3 votes, 14%)
B. Treatment response rate with EBL is around 80%. (10 votes, 48%)
C. Treatment with EBL has no impact on hemoglobin levels and transfusion needs in patients with GAVE. (2 votes, 10%)
D. Mean number of EBL session for the treatment of GAVE is around 5. (6 votes, 29%)

In the December issue of GIE, Mohan et al1 conducted a systematic review and meta-analysis (SRMA) on the results of endoscopic band ligation (EBL) for the treatment of gastric antral vascular ectasia (GAVE). The authors excluded studies presented only as conference abstracts and those done in the pediatric population (age <18 years). The outcomes evaluated in this SRMA were treatment response, GAVE recurrence, number of treatment sessions, number of bands used, variation of pre- and post-treatment Hb levels, pre- and post-treatment requirement of transfusion, and adverse events related with the endoscopic treatment. Treatment response was defined as complete or near-complete eradication of endoscopically visible GAVE along with stabilization of hemoglobin (Hb) levels and/or decrease in blood transfusion requirements. The authors included 10 studies and 194 patients. Four studies were clinical trials comparing EBL with argon plasma coagulation (APC). Three studies were considered of high quality and the rest were felt to be of medium quality. From the 194 patients treated with EBL, 39 (22%) had received prior treatment with APC, 118 (61%) were diagnosed with cirrhosis, and 66 (34%) presented with signs of overt GI bleeding. The average time of study follow-up was 14.5 months. Treatment response was observed in 81% (95% CI, 62.2-91.7) and GAVE recurrence in 15.4% (95% CI, 4.5-41.3) of the patients. The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI,10.7-19.4). The mean difference of pre- to post-treatment Hb was 1.5 (95% CI, 0.9-2.2; P = .001) and pre- to post-treatment units of PRBCs transfused was 1.1 (95% CI, 0.4-1.9; P = .002). The pooled adverse events rate was 15.9% (95% CI, 10.4-23.7). None of these adverse events required hospitalization. Quoting the authors: "In conclusion, this meta-analysis demonstrates excellent treatment outcomes of EBL in patients with GAVE in terms of response to treatment, increase in post-treatment Hb, reduction of post-treatment PRBC transfusion and hospitalization, with a low rate of adverse events. Multicenter RCTs comparing initial EBL with initial thermal therapies allowing crossover might further define the clinical roles of each method to treat GAVE."

1. Mohan BP, Toy G, Kassab LL, et al. Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis. Gastrointest Endosc 2021;94:1021-9.

Correct Answer: D. Snare-tip soft coagulation of the resection margins and cold avulsion for nonlifting areas increase the clinical success rate without increasing the adverse event rate.

Concerning the outcomes of endoscopic mucosal resection (EMR) of nonpedunculated polyps of the ileocecal valve region (ICV) measuring ≥20 mm, you would say that:

A. It should not be considered a complex polyp; standard EMR achieves a clinical success rate above 90%. (8 votes, 13%)
B. It should be considered a complex polyp, and surgical consultation is recommended. (7 votes, 11%)
C. Snare-tip soft coagulation of the resection margins does not reduce recurrence rate and may increase the risk of late adverse events. (6 votes, 10%)
D. Snare-tip soft coagulation of the resection margins and cold avulsion for nonlifting areas increase the clinical success rate without increasing the adverse event rate. (41 votes, 66%)

In the November issue of GIE, Vosko et al1 conducted a single-center, retrospective comparison of the outcomes of two historical cohorts submitted to endoscopic mucosal resection (EMR) of nonpedunculated polyps (NPPs) of the ileocecal valve region (ICV) measuring ≥20 mm. The first group (N = 76 patients, 76 NPPs) was treated from September 2008 to April 2016, and the second group (N = 66 patients, 66 NPPs), from May 2016 to October 2020. The primary outcome was complete clinical success (successful resection of the NPP and avoidance of surgery) at the index endoscopy. Secondary outcomes included adverse event rate and the recurrence rate at the first control colonoscopy. In the first group, standard EMR was adopted, whereas in the second group, the authors used standard EMR combined with snare-tip soft coagulation (STSC) of the resection margins, and cold avulsion with adjuvant snare-tip soft coagulation (CAST) for nonlifting areas, whenever necessary. The lesions in the first group were larger: 40 m (25-50) vs 30 (25-45), P = .029. In the first group, the extent of the terminal ileum or ICV involvement reduced the clinical success rate. In the second group, this effect was not observed. In the second group, clinical success was higher (93.9 vs 77.6%, P = .007), the procedure was longer (60 vs 40 min; P = .004), and recurrence rate was lower (8.8 vs 25.4%, P = .011). In this group, STSC was applied in most of the patients (96.9% vs 5.9%, P < .001). There were no significant differences in intra- or periprocedural adverse events between the groups of comparison. Quoting the authors: "EMR is an effective and safe treatment modality for ICV-LNPCPs. Moreover, by integrating new technical innovations together with an expanding theoretical knowledgebase in the management of complex LNPCPs, clinical success and procedural outcomes now parallel non-ICV-LNPCPs. Therefore, any ICV-LNPCP without proven cancer should be referred to a specialized tertiary endoscopy unit for review and possible EMR, before consideration of surgery with its attendant morbidity and cost implications."

1. Vosko S, Gupta S, Shahidi N, et al. Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021;94:959-68.

Correct Answer: A. A repeat endoscopy at a referral center for BE is advisable because it increases the detection of visible lesions, high-grade dysplasia, and esophageal adenocarcinoma.

Concerning the impact of the diagnosis of low-grade dysplasia (LGD) in Barrett’s esophagus (BE) at a community endoscopy center, you would say that:

A. A repeat endoscopy at a referral center for BE is advisable because it increases the detection of visible lesions, high-grade dysplasia, and esophageal adenocarcinoma. (9 votes, 64%)
B. A repeat endoscopy with confocal endomicroscopy and volumetric laser endomicroscopy is advisable because it increases the detection of visible lesions, high-grade dysplasia, and esophageal adenocarcinoma. (0 votes, 0%)
C. A repeat endoscopy at the same community center within 2 months is advisable because it increases the detection of visible lesions, high-grade dysplasia, and esophageal adenocarcinoma. (1 vote, 7%)
D. A repeat endoscopy at a referral center for BE for radiofrequency ablation is advisable. (4 votes, 29%)

In the November issue of GIE, Tsoi et al1 conducted a retrospective study reporting the results of 6 Australian Barrrett’s esophagus reference units (BERUs). The authors identified patients who were referred for the identification of low-grade dysplasia (LGD) in Barrett’s esophagus (BE) confirmed by an expert GI pathologist within the last 6 months. The authors aimed to compare the diagnosis of visible lesions and histology outcomes between the community referral endoscopy and the endoscopy performed at a BERU. From 2009 to 2017, 188 patients were referred to a BERU with a diagnosis of LGD in BE. From them, 42 were excluded because the time period between the community center and the BERU center evaluations was longer than 6 months. Another 40 patients were excluded because their slides were not reviewed by an expert GI pathologist. From the remaining 106 patients, 12 (11%) were upgraded to high-grade dysplasia (n=11) and intramucosal adenocarcinoma (n=1). On the other hand, nondysplastic BE and indefinite for dysplasia were observed in 17 and 2 patients, respectively. Finally, 75 patients (59 male, mean age of 72 years) with a confirmed diagnosis of LGD in BE were included in the analysis. At the endoscopic assessment at BERU, the diagnosis of HGD, intramucosal, or submucosal adenocarcinoma was confirmed in 12 (16%), 7 (9.3%), and 1 (1.3%), respectively. On the other hand, LGD, nondysplastic BE, and indefinite for dysplasia were diagnosed in 34 (45.3%), 20 (26.7%), and 1 (1.3%) patients, respectively. The median circumferential and maximal lengths of BE were 2 cm (IQR 0-5) and 4 cm, (IQR 1-7), respectively. In the community referral centers, visible lesions were detected in 9 (12%) out of 75 patients, whereas at BERU, visible lesions were seen in 39 (52%) out of 75 patients (P = .029). Quoting the authors: "Endoscopic assessment at BERU resulted in a higher detection of visible lesions, HGD, and EAC compared with community centers. We believe that some of the reported LGD progression rates in the literature may be overestimated because many studies have included prevalent HGD or EAC during their analysis of the LGD progression rate. However, a community diagnosis of LGD is not benign because in our cohort, 1 in 4 patients with a community diagnosis of BE with LGD was a "missed" HGD or EAC."

1. Tsoi EH,. Mahindra P, Cameron G, et al. Barrett’s esophagus with low-grade dysplasia: high rate of upstaging at Barrett’s esophagus referral units suggests progression rates may be overestimated. Gastrointest Endosc 2021;94:902-8.

Correct Answer: A. Clipping before polypectomy and stalk injection before polypectomy are strategies that increase the risk of delayed bleeding.

Concerning the risk of bleeding after polypectomy of pedunculated colonic polyps and the endoscopic strategies used to avoid this adverse event, you would say that:

A. Clipping before polypectomy and stalk injection before polypectomy are strategies that increase the risk of delayed bleeding. (15 votes, 25%)
B. Endoloop reduces the risk of immediate bleeding for polyps ≥25 mm in size. (17 votes, 28%)
C. Clipping before polypectomy reduces the risk of immediate bleeding (26 votes, 43%)
D. The stalk width does not correlate with the risk of immediate or delayed bleeding. (3 votes. 5%)

In the October issue of GIE, Tagawa et al1 analyzed endoscopic predictive factors of immediate and delayed bleeding after polypectomy of pedunculated colonic polyps. In this retrospective multicenter study performed at 5 institutions in Japan, 932 patients with 1147 pedunculated colonic polyps removed by polypectomy were included from April 2013 to September 2016. Colonic polyps with a stalk length ≥5 mm were considered pedunculated. Immediate bleeding was defined as bleeding seen after endoscopic resection and requiring hemostasis. Delayed bleeding was defined as significant delayed bleeding requiring a second colonoscopy for hemostasis. The independent variables were age, sex, polyp location, polyp size, stalk length, stalk width, endoscopist experience (>5000 or >5000 colonoscopies), use of antithrombotic agents, clipping, endoloop or stalk injection before polypectomy, and polypectomy site closing. Procedure time, blood transfusion, and other adverse events (postpolypectomy syndrome, perforation, emergency operation) were also registered. Immediate and delayed bleeding occurred in 97 (8.5%), and 23 lesions (2%), respectively. In multivariate analysis, stalk width ≥6 mm (odds ratio [OR], 1.9; 95% confidence interval [CI]: 1.1–3.4) was a risk factor for immediate bleeding. In addition, prophylactic endoloop use (OR, 0.17; 95% CI, 0.04–0.72) reduced immediate bleeding for polyps ≥15 mm in size. Prophylactic clipping before polypectomy (OR, 4.2; 95% CI, 1.3–13), and stalk injection before polypectomy (OR, 4.0; 95% CI, 1.4–12) were risk factors for delayed bleeding. Quoting the authors: “The current study showed that injecting the stalk and prophylactic clipping before polypectomy were associated with an increased risk of delayed bleeding, suggesting that simple resection with coagulation mode is a suitable strategy in endoscopic resection of pedunculated polyps. Moreover, prophylactic endoloop use was highly likely to inhibit immediate bleeding with polyp size ≥15 mm. We recommend avoiding prophylactic clipping before polypectomy or injecting the stalk, and using an endoloop prophylactically, instead, with polyp size ≥15 mm, when endoscopically resecting pedunculated polyps.”

1. Tagawa T, Yamada M, Minagawa T, et al. Endoscopic characteristics influencing postpolypectomy bleeding in 1147 consecutive pedunculated colonic polyps: a multicenter retrospective study. Gastrointest Endosc 2021;94:803-11..

Correct Answer: B. Younger patients present more frequently with metastatic disease, but they have a higher survival probability.

Recent guidelines from the American Cancer Society recommended that screening for colorectal cancer (CRC) should start at age 45. Concerning the incidence trends of CRC in the last 30 years and the profile of CRC in younger patients (<50 years old), you would say that:

A. CRC incidence has increased among younger cohorts (less than 50 years old) as well as in individuals 50 or older. (9 votes, 75%)
B. Younger patients present more frequently with metastatic disease, but they have a higher survival probability. (0 votes, 0%)
C. Right-sided colon cancer is more frequent in the younger patients, whereas rectal cancer is more frequent in the standard screening cohort (50 or older). (1 vote, 8%)
D. In younger patients with CRC, there is a lower proportion of African American and Hispanic patients. (2 votes, 17%)

In the September issue of GIE, Vakil et al1 analyzed confirmed cases of colorectal cancer (CRC) in a cancer database from a large integrated health care system composed of 15 hospitals, 150 outpatient clinics, and 20 outpatient oncology clinics (Aurora Health Care). The study spanned more than 30 years (1985 – 2017). The authors compared 3 cohorts based on the patients’ ages at the time of the diagnosis: 18-44 years (young cohort), 45-49 years (new screening cohort), and >50 years (standard screening cohort). The study aimed to evaluate CRC detection rates, to assess the outcomes of treatment in younger individuals, and investigate whether symptoms and family history of CRC could aid in the identification of these patients. From the 11,050 cases of CRC, 397, 409, and 10,244 occurred in the young, new 45-49, and standard screening cohorts, respectively. The younger cohorts had a higher proportion of African American and Hispanic patients, and a higher prevalence of family history of CRC. The proportion of colorectal cancers in the 18- to 44-year cohort (3.87%) and the 45- to 49-year cohort (3.99%) was similar. Rectal cancers and metastatic disease were more prevalent in the younger cohort who received multimodality treatment (surgery with chemoradiation) more frequently. The authors did not find any significant differences in the degree of differentiation of the tumor, microsatellite instability, and positive resection margins between the cohorts. Survival was better in the younger cohorts. Survival probability was similar in different ethnic groups. The analysis of incidence trends of CRC showed a significant increase in the 18 to 44 age group with an annual percentage change of 2.70% from 1988 to 2009 (P < .05). The same observation was noted in the cohort aged 45 to 49, with an annual percentage change of 4.15% in the interval from 1988 to 2013 (P < .05). No significant changes of CRC incidence were observed from 1985 to 2017 in the cohort aged 50 years or older (Fig. 3). Quoting the authors: "In conclusion, colorectal cancer detection rates have increased in young people age 18 to 44 and 45 to 49 at similar rates. Young patients present with more advanced disease but have better survival and received more aggressive therapy. Racial and ethnic disparities in survival may be reduced in Integrated Health Systems and geographic areas with high degrees of access to health care. Changes in bowel habit, rectal bleeding, unexplained weight loss, and anemia should prompt colonoscopy. Because rectal cancers are a major problem in younger subjects, rectal or anal symptoms should also prompt careful physical and endoscopic evaluation."

1. Vakil N, Ciezki K, Singh M. Colorectal cancer in 18- to 49-year-olds: rising rates, presentation, and outcome in a large integrated health system. Gastrointest Endosc 2021;94:618-26.

Correct Answer: C. U-EMR has similar en bloc and R0 resections rates but a lower polyp recurrence rate at the site of resection.

Underwater endoscopic mucosal resection (U-EMR) was recently added to the arsenal of endoscopic therapy of colorectal polyps. Compared with conventional endoscopic mucosal resection (C-EMR) for colorectal polyps larger than 20 mm, you would say that:

A. U-EMR has superior en bloc and R0 resections rates but higher adverse events rates. (1 vote, 7%)
B. U-EMR has superior en bloc and R0 resections rates and lower adverse events rates. (10 votes, 67%)
C. U-EMR has similar en bloc and R0 resections rates but a lower polyp recurrence rate at the site of resection. (2 votes, 13%)
D. U-EMR has lower en bloc and R0 resections rates and lower adverse events rate (2 votes, 13%)

In the September issue of GIE, Chandan et al1 conducted a systematic review and meta-analysis (SRMA) comparing underwater (U-EMR) versus conventional mucosectomy (C-EMR) for the resection of colorectal polyps >20 mm. The authors included 11 studies (4 randomized clinical trials, 6 cohort studies, and 1 propensity-score matched cohort study) with a total of 1851 patients and 2120 polyps. U-EMR was the resection technique used for 1071 polyps and C-EMR, for 1049 polyps. The primary outcomes were en bloc resection rate for all polyps, en bloc resection rate for polyps >20 mm, and the recurrence rate at the resection site. The secondary outcomes were accuracy for colorectal cancer diagnosis on histology, resection time, and adverse events (perforation and immediate and delayed bleeding) rate. The meta-analysis of data from RCTs with those from observational studies is one of the limitations of this SMRA, and the inclusion of studies published only in the abstract format. The overall en-bloc resection rate was marginally superior in the U-EMR group (OR, 1.9, 95% CI, 1-3.5; P = .04), whereas it did not differ when only the results for polyps larger than 20 mm were analyzed (OR, 0.8; 95% CI, 0.3-2.1; P = .75). R0 resection (OR, 3.1; 95% CI, 0.74-12.6; P = .14), piecemeal resection (OR, 3.1; 95% CI, 0.74-12.6; P = .13), and diagnostic accuracy for CRC (OR, 1.1; 95% CI, 0.6-1.8; P = .82) were similar in comparison groups. However, polyp recurrence (OR, 0.3; 95% CI, 0.1-0.8; P = .01) and incomplete resection rates (OR, 0.4; 95% CI, 0.2-0.5; P = .001) were lower in the U-EMR group. Pooled rates of immediate bleeding, delayed bleeding, and perforation were 6.7%, 2.2%, and 0.6% in the U-EMR group and 8.7%, 1.7%, and 0.8% in the C-EMR group, without any significant difference among them. Quoting the authors: "Our results support the use of U-EMR over C-EMR for successful resection of colorectal lesions. Further randomized controlled trials are needed to evaluate the efficacy of U-EMR for resecting polyps >20 mm in size."

1. Chandan S, Khan SR, Kumar A, et al. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta-analysis. Gastrointest Endosc 2021;94:471-82.

Correct Answer: A. Patient adherence to the screening program is crucial for the effectiveness of the program.

Randomized controlled trials comparing the effectiveness of various colorectal cancer (CRC) screening strategies are challenging, due to ethical, financial, and logistical limitations. In this sense, simulation studies adopting computational tools may be useful to test hypothesis in large populations. Considering a simulation study comparing colonoscopy, fecal immunochemical test (FIT), EpiproColon, ColoGuard, and PolypDx for CRC screening, you would say that:

A. Patient adherence to the screening program is crucial for the effectiveness of the program. (10 votes, 50%)
B. Due to their low sensitivity, the nonendoscopic tests need 100% adherence to reduce CRC incidence, mortality, and to be cost-effective. (0 votes, 0%)
C. In all simulations, colonoscopy proves to be superior to the nonendoscopic tests regarding reduction of CRC incidence, mortality, and cost-effectiveness. (6 votes, 30%)
D. In an expected real-world patient adherence scenario, FIT proves to be most efficient and cost-effective CRC screening strategy. (4 votes, 20%)

1. Deibel A, Deng L, Cheng C-Y, et al. Evaluating key characteristics of ideal colorectal cancer screening modalities: the microsimulation approach. Gastrointest Endosc 2021;94:379-90.

Correct Answer: C. Neck and back are the most common sites of pain.

Musculoskeletal injuries are increasingly recognized in the practice of endoscopy, being previously reported in 30% to 90% of gastroenterologists. Concerning the effect of an individualized wellness assessment and an intervention oriented by a physical therapist, you would say that:

A. The configuration of the workplace has no impact on ergonomic performance. (0 votes, 0%)
B. The adherence of gastroenterologists to physical therapy intervention is low. (1 vote, 25%)
C. Neck and back are the most common sites of pain. (3 votes, 75%)
D. Physical therapy intervention has no effect on endoscopy-related pain. (0 votes, 0%)

In the August issue of GIE, Markwell et al1 conducted a clinical trial to develop a comprehensive individualized wellness assessment tool administered to endoscopists by physical therapists and to evaluate the effect of the intervention by a physical therapist. Eight volunteers completed the Nordic Musculoskeletal Questionnaire. Their static and dynamic postures were evaluated during colonoscopy. In addition, several other factors that could influence posture and habitual movement patterns during procedures (eg, footwear, patient positioning on bed, bed location, and configuration of documentation workspaces) were screened. Based on the collected information, the physical therapist developed an individualized wellness plan including postural recommendations, exercises, and pain education. The participants were followed at 1 month and between 6 and 12 months by the physical therapist. Five of the 8 participants complained of 22 pain sites, with back and neck pain being the most common ones. Various ergonomic inefficiencies and suboptimal movement patterns were observed resulting in different wellness plans. By the end of the study, 63% of pain sites were reduced in intensity or resolved, whereas 32% of pain sites were unchanged and 4% increased in intensity. All participants found the wellness plans to be impactful to their ergonomic performance. Quoting the authors: "Our study provides a detailed, pragmatic, and reproducible framework for performing an individualized physical therapist-directed comprehensive assessment and personalized wellness plan in the workplace to help meet the challenges of ergonomics in endoscopy, and although all of the participants found this helpful and the majority of pain sites were improved, this was a small study."

1. Markwell SA, Garman KS, Vance IL, et al. Individualized ergonomic wellness approach for the practicing gastroenterologist (with video). Gastrointest Endosc 2021;94:248-59.

Correct Answer: B. Most gastroenterologists are unaware of institutional or national policies related to code status reversal.

In the United States, code status refers to the patient’s wishes regarding resuscitation attempts. Full resuscitation attempts, limited resuscitation attempts as predefined by the patient, and DNR refer respectively to "full code," "partial code," and "do not resuscitate" code. "Code status reversal" refers to changing a previously indicated DNR. Concerning the current practices and perspectives of gastroenterologists on approaches to code status before inpatient endoscopy, you would say that:

A. Most gastroenterologists discuss the code status with the patient before the endoscopic procedure. (1 vote, 14%)
B. Most gastroenterologists are unaware of institutional or national policies related to code status reversal. (6 votes, 86%)
C. Trainees and senior gastroenterologists have similar approaches to code status before inpatient endoscopy. (0 votes, 0%)
D. Most patients who need an endoscopic inpatient procedure has a DNR order at the time of the procedure. (0 votes, 0%)

In the July issue of GIE, Feld et al1 conducted a survey to evaluate current practices and perspectives of gastroenterologists on approaches to code status before inpatient endoscopy. The survey was distributed via e-mail to 11,116 U.S.-based practicing gastroenterologists. The survey consisted in 24 multiple-choice questions including basic demographic questions, procedural volume, years in practice, and current practice and person opinions related to the reversal of periprocedural "Do not resuscitate (DNR)" orders. Four hundred thirty-six gastroenterologists and 83 (16%) trainees completed the survey, corresponding to a response rate of 4.9% (519/10,555). Most respondents were male (73.4%, n = 381), and geographic distribution was evenly divided. Many respondents had been practicing for over 20 years since completing training (39.5%, n = 205). In addition, 46.1% of the respondents practiced in tertiary care centers, whereas 48.4% practiced in community hospitals. Most respondents (59%) reported that an anesthesia provider (anesthesiologist or nurse anesthetist) administered sedation. Most respondents (71.5%) discussed code status with the patients in fewer than 25% of the cases. In addition, 75.1% of the responders believed that the anesthesia provider was responsible for the code status discussion. Only 15.6% of the respondents were routinely aware of a patient’s code status before performing inpatient endoscopy. Only fewer than 25% of the patients who needed an endoscopic inpatient procedure had a DNR order at the time of the procedure (84.2%, n=437). If a patient had a DNR order, 40.8% of respondents routinely reversed the code status before endoscopy, 18.3% reversed the code status in 75% to 99% of the time, and 17.1% never reversed the code status. Most respondents were unaware of institutional or national policies related to code status reversal (40.7% and 80.7% of them, respectively). When compared with nontrainees, trainees were more likely to discuss code status before a procedure (P = .025) and to automatically reverse code status (P = .027). Quoting the authors: "In conclusion, this study identified significant variation in beliefs and practices among U.S. gastroenterologists in their approach to code status in the periendoscopic period. Trainees and young gastroenterologists are more likely to reverse DNR status to full code, which is not reflective of current national guidelines. This highlights the need for dedicated training in fellowship programs on how to approach code status before endoscopy. In addition, the majority of gastroenterologists were unaware of these guidelines and reported that creation of a gastroenterology-specific guideline would be useful. Integration of broader ethical principles into fellowship programs as well as a guideline addressing code reversal before endoscopy for gastroenterologists would clarify the approach to this important clinical scenario."

1. Feld LD, Mergener K, Rubin DT, et al. Management of code status tin the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists. Gastrointest Endosc 2021;94:172-7.

Correct Answer: A. Prophylactic clipping reduces immediate PPB (IPPB) rate but has no effect on delayed postpolypectomy bleeding (DPPB) rate.

Concerning the use of prophylactic clipping to prevent postpolypectomy bleeding (PPB) in large pedunculated colonic polyps, you would say that:

A. Prophylactic clipping reduces immediate PPB (IPPB) rate but has no effect on delayed postpolypectomy bleeding (DPPB) rate. (36 votes, 44%)
B. Prophylactic clipping reduces both IPPB and DPPB rates. (32 votes, 40%)
C. Prophylactic clipping reduces DPPB rate but has no effect on IPPB. (10 votes, 12%)
D. Prophylactic clipping has no effect in IPPB or DPPB rates. (3 votes, 4%)

In the July issue of GIE, Ji et al1 conducted a multicenter, randomized clinical trial comparing prophylactic clipping to prevent postpolypectomy bleeding (PPB) in large pedunculated colonic polyps (>10 mm in head diameter, >5 mm in stalk diameter, and >10 mm in stalk length). The clips were applied to the polyp stalk before polypectomy. The primary outcome was PPB, which was classified in immediate PPB and delayed PPB. Delayed PPB was further classified in early (first 24 hours) and late (>24 hours, ≤30 days) bleeding. The authors randomized 238 polyps among 204 patients into the clip arm (119 polyps) or the control arm (119 polyps). Polypectomy was successful in all cases. The mean polyp head size was around 17 mm in both groups. The polyp head size was larger than 20 mm in 37% and 27% of the resected polyps in the clip group and control group, respectively. A combination of coagulation and pulsed cut currents was delivered for polypectomy. The mean number of clips was 1.7 in the clip group. PPB was reported in 20 cases (IPPB, n=16; DPPB, n=4). The rates of PPB, IPPB, and DPPB were 8.4%, 6.7%, and 1.7%, respectively. The PPB rate was 4.2% and 12.6% in the clip versus control groups, respectively (P = .033). The number needed to treat (NNT) was 12 (prophylactic clipping was applied in 12 polyps to prevent PPB in one). The IPPB rate was 2.5% and 10.9%, in the clip versus control groups (P = .017; NNT=12). DPPB was reported in 2 (1.6%) polyps in each group of comparison. No perforation occurred. Quoting the authors: "In conclusion, prophylactic hemoclipping before resecting large pedunculated polyps can reduce overall PPB, especially IPPB. Hemoclipping is an effective prophylaxis for the treatment of large pedunculated polyps."

1. Gweon T-G, Lee K-M, Lee S-W, et al. Effect of prophylactic clip appli8cation for the prevention of postpolypectomy bleeding of large pedunculated colonic polyps: a randomized controlled trial. Gastrointest Endosc 2021;94:148-54.

Correct Answer: B. Routine second-look endoscopy does not affect recurrent bleeding, need for surgery, blood transfusion, or mortality.

Concerning the impact of routine second-look endoscopy on the outcomes of patients with upper GI bleeding due to peptic ulcer disease, you would say that:

A. Routine second-look endoscopy does not affect mortality but reduces recurrent bleeding and blood transfusion. (4 votes, 10%)
B. Routine second-look endoscopy does not affect recurrent bleeding, need for surgery, blood transfusion, or mortality. (21 votes, 53%)
C. Routine second-look endoscopy reduces recurrent bleeding when endoscopic hemostatic monotherapy was used at the index endoscopy. (6 votes, 15%)
D. Routine second-look endoscopy reduces recurrent bleeding, need for surgery, or blood transfusion, but has no impact on mortality. (9 votes, 23%)

In the June issue of GIE, Kamal et al1 conducted a systematic review and meta-analysis (SRMA) of randomized clinical trials to evaluate the impact of routine second-look endoscopy on the outcomes of patients with upper gastrointestinal bleeding (UGIB) caused by peptic ulcer disease (PUD). The evaluated outcomes were recurrent bleeding, mortality, need for surgery, and blood transfusion. The literature search included the Pubmed and Medline, Embase, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials databases from inception to September 15, 2020. The authors included 9 randomized clinical trials describing the outcomes of 1452 patients. From them, 726 patients were randomized to the routine second-look endoscopy group and 726 to the control group. Recurrent bleeding rate did not differ between the groups (respectively, 9.6% and 12%; RR, 0,79; 95% CI, 0.51-1.23). Even when only full publications were considered, the results were similar. Sensitivity analysis segregating studies with different PPI regimens, endoscopic combined therapy, and endoscopic monotherapy showed similar results. Based on the GRADE framework, the certainty of this evidence was considered low. Six full publications were used for mortality rate analysis. Mortality rates in the routine second-look endoscopy group versus the control group were 2.3% and 3.4%, respectively (RR, 0.69; 95% CI, 0.33-1.45). Once again, subgroup and sensitivity analyses showed similar results. Based on the GRADE framework, the certainty of this evidence was considered moderate. The need for surgery and blood transfusion did not differ between the groups. Quoting the authors: "In conclusion, we found that a single endoscopy with complete endoscopic hemostasis is not inferior to scheduled second-look endoscopy in reducing the risk of recurrent bleeding, mortality, or need for surgery. Our findings lend further support to current guidelines from ACG, ESGE, and an international consensus group and would support a change in NICE guidelines. Based on our analysis, we recommend reserving second-look endoscopy for patients with evidence of recurrent bleeding or those in whom there was concern about the adequacy of hemostasis at the initial endoscopy."

1. Kamal F, Khan MA, Lee-Smith W, et al. Role of routine second-look endoscopy in patients with acute peptic ulcer bleeding: meta-analysis of randomized controlled trials. Gastrointest Endosc 2021;93:1229-37.

Correct Answer: D. GEJIM may be associated with a low risk of dysplasia.

Concerning the clinical meaning of the finding of intestinal metaplasia in the gastroesophageal junction (GEJIM) of patients who underwent endoscopic eradication of Barrett’s esophagus (BE), you would say that:

A. GEJIM is not a common finding in patients who underwent endoscopic eradication of BE. (1 vote, 5%)
B. The treatment of GEJIM has a protective effect on the dysplasia recurrence. (2 votes, 10%)
C. GEJIM is a risk factor for dysplasia and adenocarcinoma recurrence. (11 votes, 52%)
D. GEJIM may be associated with a low risk of dysplasia. (7 votes, 33%)

In the June issue of GIE, Solfisburg et al1 conducted an observational, retrospective cohort, multicenter study to evaluate the clinical meaning of the finding of intestinal metaplasia in the gastroesophageal junction (GEJIM) of patients who underwent endoscopic eradication of Barrett’s esophagus (BE). A total of 633 patients (mean 64 years, 85% male) from 4 centers were analyzed. The median BE length was 3 cm (IQR 1-6). High-grade dysplasia or intramucosal adenocarcinoma were present in 63% and 18% of them, respectively. The most commonly used treatments were radiofrequency ablation (93%) and endoscopic mucosal resection (67%). Patients were divided in 3 groups: “never-GEJIM” (n=429, 68%), "GEJIM-observed" (n=76, 13%), and “GEJIM-treated” (n=85, 14%). Of notice, treatment of GEJIM was left at the discretion of the endoscopist. The authors observed dysplasia recurrence at a 2.2%/year rate. In the never-GEJIM, GEJIM-observed, and GEJIM-treated groups, the authors found dysplasia recurrence rates of 2.6% per year, 0.6% per year, and 2.2% per year, respectively (log-rank test, P = .07). In multivariate analyses, the risk of dysplasia recurrence was significantly lower in GEJIM-observed patients compared with never-GEJIM (aHR=0.19; 95% CI, 0.05-0.81) and not different in GEJIM-treated patients (aHR=0.81; 95% CI, 0.39-1.67). Older age and longer initial BE length were risk factors for dysplasia recurrence. Quoting the authors: "In conclusion, after successful endoscopic therapy of BE, recurrent GEJIM is a not uncommon finding and may be associated with a low risk of subsequent dysplasia. Because this was a retrospective study, additional prospective randomized studies will be important in determining whether observation may be appropriate for these patients."

1. Solfisburg QS, Sami SS, Gabre J, et al. Clinical significance of recurrent gastroesophageal junction intestinal metaplasia after endoscopic eradication of Barrett’s esophagus. Gastrointest Endosc 2021;93:1250-7.

Correct Answer: B. The observed reductions of TBWL, HOMA-IR, HSI, and NFS scores persist after 2 years of follow-up.

Concerning the long-term effects of endoscopic sleeve gastrectomy (ESG) on total body weight loss (TBWL), insulin resistance (HOMA-IR), and estimated hepatic steatosis (HSI score) and fibrosis (NFS score), you would say that:

A. The observed reductions of TBWL, HOMA-IR, HSI, and NFS scores do not persist after 2 years of follow-up. (1 vote, 10%)
B. The observed reductions of TBWL, HOMA-IR, HSI, and NFS scores persist after 2 years of follow-up. (2 votes, 20%)
C. The observed reductions of TBWL, HOMA-IR, HSI, and NFS scores persist after 2 years of follow-up but only in patients with BMI <40 kg/m2. (3 votes, 30%)
D. After 2 years of follow-up, most patients regain weight, but the improvement of HOMA-IR, HSI, and NFS scores is lasting. (4 votes, 40%)

In the May issue of GIE, Hajifathalian et al1 evaluated the effect of endoscopic sleeve gastrectomy (ESG) on insulin resistance and estimated hepatic steatosis and fibrosis in a group of 118 patients (68% female; mean age of 46±13 years) with nonalcoholic fatty liver disease (NAFLD). The indications of ESG included body mass index (BMI) of more than 30 kg/m2 and failure to sustain a total weight loss (TBWL) >5% with diet, lifestyle change, and pharmacotherapy. The authors included patients with a BMI >40 kg/m2 upon refusal or contraindication to bariatric surgery. They evaluated insulin resistance using the homeostasis model assessment of insulin resistance (HOMA-IR). They estimated hepatic steatosis and fibrosis using the hepatic steatosis index (HSI) model and NAFLD fibrosis score (NFS), respectively. The authors found a decrease of 15.5% (95% CI, 13.3%-17.8%, P < .001) in the mean TBWL at 2 years after ESG. Of notice, 78% and 74% of patients had a TBWL of 10% or more, at 1 and 2 years after ESG, respectively. After 2 years of follow-up, the mean HOMA-IR decreased from 6.7±11 to 2.9±2.0 (P = .03). The authors also observed the improvement of patients’ mean HSI and NFS scores, indicating improvement in hepatic steatosis and fibrosis risk, respectively. The authors provided a subgroup analysis showing that the benefits of TBWL, ie, decrease in HOMA-IR, HSI, and NFS scores, extended to morbidly obese patients. Quoting the authors: "In this study, we show that ESG causes not only a significant and durable weight loss but also provides long-term improvement in hepatic steatosis and risk of liver fibrosis, as well as insulin resistance. Furthermore, improvement in insulin resistance after the procedure appears to be partially independent of weight loss. These results suggest ESG may prove to be a viable alternative treatment in the management of NAFLD and metabolic syndrome/insulin resistance."

1. Hajifathalian K, Mehta A, Ang B, et al. Improvement in insulin resistance and estimated hepatic steatosis and fibrosis after endoscopic sleeve gastroplasty. Gastrointest Endosc 2021;93:1110-9.

Correct Answer: A. From the trainee perspective, fewer women than men were trained using tactile instruction.

Concerning female and male gastroenterologists’ beliefs toward the endoscopy suite environment, as well as their experiences in learning and teaching endoscopic skills, you would say that:

A. From the trainee perspective, fewer women than men were trained using tactile instruction. (3 votes, 30%)
B. Women reported endoscopy-related injuries more frequently than men. (5 votes, 50%)
C. Women and men reported gender bias equally. (0 votes, 0%)
D. Men reported that the endoscopy staff treated female gastroenterologists favorably. (2 votes, 20%)

In the May issue of GIE, Rabinowitz et al1 conducted a survey to assess female and male gastroenterologists’ beliefs toward the endoscopy suite environment, as well as their experiences in learning and teaching endoscopic skills. The authors distributed a web-based survey to fellows and faculty from 12 academic and 3 sizeable private practice centers across the United States (2 to 3 centers selected per region). The survey included demographic data and questions about endoscopic learning, teaching, and perceptions of the environment within the endoscopy unit. The definitions of “tactile instruction” (close, physical contact between attending and trainee during a case) and “gender bias” (unfair differences in the way women and men are treated) were provided in each related question. The questionnaire was sent to 403 doctors, and 115 (54 women - 47.0%) completed it, with a similar distribution of age, marital status, geographic location, and proportion of fellows and attendings. The authors observed a predominance of Asian women and white men among the respondents. Female gastroenterologists had significantly fewer children than men (1.11 vs 1.71, P = .007). There were more women in hepatology and inflammatory bowel diseases (IBD) and more men in general gastroenterology and advanced endoscopy (P = .017). Men occupied most leadership roles in gastroenterology departments, including endoscopy director (85.6% male) and division chief (95.1% male). From the trainee perspective, fewer women than men were trained using tactile instruction (40.7% women vs 67.2% men, P = .004). There was no difference in the reported endoscopy-related injury between men and women. From the trainee perspective, more women reported experiencing gender bias. Around 75% of women reported that the endoscopy staff treated male gastroenterologists favorably. Around 30% of men shared the same opinion, whereas 70% of men felt that the endoscopy staff treated equally male and female gastroenterologists. Quoting the authors: "Our findings suggest that educational approaches, particularly with regard to procedural teaching, should be informed by an understanding of gender dynamics, and that teaching practices should be modified in order to maximize learning for all trainees. Unconscious bias toward female gastroenterologists in the endoscopy suite may lead to or reinforce beliefs that result in detriment to physicians themselves, as well as patient safety. Efforts are warranted to develop a more supportive and equitable environment in procedural and nonprocedural fields, with regard to representation in leadership, equipment design and utility, and treatment of physicians by their colleagues and ancillary staff members."

1. Rabinowitz LF, Grinspan LT, Williams KE, et al. Gender dynamics in education and practice of gastroenterology. Gastrointest Endosc 2021;93:1047-57.

Correct Answer: B. DHLD and LCS are equivalent concerning the total number of positive cultures and the number of cultures positive for high-concern pathogens.

Since the description of outbreaks of multidrug-resistant pathogenic organism infections transmitted via duodenoscopes, there has been a growing concern on the reprocessing of the equipment, including alternative strategies such as the use of disposable duodenoscopes. Concerning the results of the comparison of double high-level disinfection (DHLD) with ortho-Phthalaldehyde versus liquid chemical sterilization (LCS) with a 36.6% solution of peracetic acid for the reprocessing of duodenoscopes, you would say that:

A. LCS is superior to DHLD concerning the total number of positive cultures and the number of cultures positive for high-concern pathogens. (0 votes; 0%)
B. DHLD and LCS are equivalent concerning the total number of positive cultures and the number of cultures positive for high-concern pathogens. (0 votes; 0%)
C. DHLD is superior to LCS concerning the total number of positive cultures and the number of cultures positive for high-concern pathogens. (0 votes; 0%)
D. Compared with DHLD, LCS is related with a reduced total number of positive cultures, but with no difference in the cultures positive for high-concern pathogens. (0 votes; 0%)

In the April issue of GIE, Gromski et al2 conducted a randomized clinical trial, comparing double high-level disinfection (DHLD) with ortho-Phthalaldehyde versus liquid chemical sterilization (LCS) with a 36.6% solution of peracetic acid for the reprocessing of Olympus (Olympus America, Center Valley, Penn, USA) duodenoscopes in a high-volume center (2700 to 2900 ERCP procedures per year). From October 2017 to September 2018, 878 postreprocessing surveillance cultures were obtained, 453 cultures from the DHLD group and 425 cultures from the LCS group. The authors found 8 positive cultures in the DHLD group and 9 positive cultures in the LCS group (1.8% vs 2.1%, respectively, P = .8). A high concern or potentially pathogenic organism (organisms that are more often associated with disease, including gram-negative rods, gram-positive organisms, Enterococcus species, and yeasts) was detected in 2 cultures for each group (0.4% vs 0.5%, P = 1.0). No multidrug-resistant organisms or carbapenem-resistant enterobacteriaceae (CRE) were detected. No infection transmitted via duodenoscope was observed during the study period. Only one duodenoscope had more than one positive culture throughout the study. It was sent for EtO sterilization, and control cultures showed negative results. Quoting the authors: "Based on our study, we do not endorse any comparative advantage of either (DHLD or LCS) enhanced reprocessing strategy over the other."

1. Gromski MA, Sieber MS, Sherman S, et al. Double high-level disinfection versus liquid chemical sterilization for reprocessing of duodenoscopes used for ERCP: a prospective randomized study. Gastrointest Endosc 2021;93:927-32.

Correct Answer: C. There is a protective effect of prophylactic clipping against delayed polypectomy bleeding of colorectal polyps ≥10 mm.

Considering the efficacy of prophylactic clipping for the prevention of delayed polypectomy bleeding of colorectal polyps ≥10 mm, you would say that:

A. There is a protective effect of prophylactic clipping against delayed polypectomy bleeding only of colorectal polyps ≥10 mm located in the left colon segment. (2 votes, 3%)
B. There is a protective effect of prophylactic clipping against delayed polypectomy bleeding only of colorectal polyps larger than 20 mm. (33 votes, 52%)
C. There is a protective effect of prophylactic clipping against delayed polypectomy bleeding of colorectal polyps ≥10 mm. (13 votes, 20%)
D. There is protective effect of prophylactic clipping against delayed polypectomy bleeding in patients under antiplatelet therapy. (16 votes, 25%)

In the April issue of GIE, Chen et al1 conducted a systematic review and meta-analysis (SRMA) of randomized trials to evaluate the efficacy of prophylactic clipping for preventing delayed polypectomy bleeding (DPB). They included studies that compared the DPB rate in patients who received prophylactic clipping versus those who did not for colorectal polyps ≥10 mm. Secondarily, the authors aimed to evaluate the incidences of postpolypectomy syndrome and perforation, as well as the procedure time. Eight studies describing the outcomes of 3415 patients were included. Pedunculated and nonpedunculated polyps were resected by conventional snare polypectomy, EMR, and ESD (a small fraction of the lesions). In 8 studies (N=3415), the pooled incidence of DPB was 3.9% (95% CI, 2.4%-5.4%). The use of prophylactic clipping decreased the DPB rate (RR, 0.61; 95% CI, 0.43-0.85; I2=37.8%) compared with those who did not receive prophylactic clips. From 52 patients who underwent prophylactic clipping, an episode of DBP was prevented in 1 patient (NNT=52, 95% CI, 31-163). The protective effect of prophylactic clipping tended to be greater in polyps larger than 20 mm (NNT=30, 95% CI, 17-106), located proximal to the hepatic flexure (NNT of 25; 95% CI, 15-40), and nonpedunculated morphology (NNT of 39; 95% CI, 24-114). Prophylactic clipping had no effect on the postpolypectomy perforation rate. Quoting the authors: "In conclusion, our meta-analysis was the first to demonstrate a modest reduction of DPB with placement of prophylactic clips after endoscopic resection of colorectal polyp >10 mm based on randomized trials. A larger protective effect of prophylactic clips was observed in patients with polyp size >20 mm, nonpedunculated polyps, or polyps located proximal to the hepatic flexure."

1. Chen B, Du L, Luo L, et al. Prophylactic clips to prevent delayed polypectomy bleeding after resection of large colorectal polyps: a systematic review and meta-analysis of randomized trials. Gastrointest Endosc 2021;92:807-15.

Correct Answer: E. All of the above.

The National Polyp Study (NPS) was a randomized clinical trial sponsored by the American Society for Gastrointestinal Endoscopy (ASGE), American Gastroenterology Association (AGA), and American College of Gastroenterology (ACG), funded by the National Cancer Institute (NCI), that resulted in several impactful publications. Some of the main conclusions of the NPS were:

A. The first surveillance colonoscopy after adenoma removal could be deferred from 1 to 3 years. (1 vote, 4%)
B. The size and the histology of the resected adenoma could segregate patients in low- and high-risk groups for colorectal cancer. (3 votes, 13%)
C. Colonoscopic adenoma resection decreased colorectal cancer incidence and related mortality. (0 votes, 0%)
D. First-degree relatives of patients with adenomas are at higher risk for colorectal cancer. (0 votes, 0%)
E. All of the above. (20 votes, 83%)

1. Winawer SJ, Zauber AG, O’Brien JM, et al. The National Polyp Study at 40: challenges then and now. Gastrointest Endosc 2021;93:720-7.

EUS-guided portal pressure gradient (EUS-PPG) measurement is a novel and emerging approach to the evaluation of the portal venous system pressure in patients with liver disease. Concerning the results of EUS-PPG in patients with acute or subacute portal hypertension, you would say that:

D. Some of the technical principles of EUS-PPG include the puncture of the extrahepatic segments of the portal vein and the inferior vena cava with exclusive use of a 25-gauge EUS-FNA needle. (4 votes, 33%)

In the March 2021 issue of GIE, Zhang et al1 conducted a prospective, single-center study to correlate EUS-guided portal pressure gradient (EUS-PPG) measurement with hepatic venous pressure gradient (HVPG) in patients with acute or subacute portal hypertension caused by pyrrolizidine alkaloid-induced hepatic sinusoidal obstruction syndrome (PA-HSOS) or Budd-Chiari syndrome. For EUS-PPG measurement, the intrahepatic segment of the inferior vena cava and the portal vein and were sequentially punctured using a 22-gauge FNA needle through the gastric wall and the hepatic parenchyma. HVPG measurement was obtained in the standard fashion. All patients received prophylactic antibiotics. The authors included 12 patients, and EUS-PPG measurement was successful in 11 (91.7%). HVPG measurement was possible in 9 patients who were included in the statistical analysis. Portal hypertension was found in all of them. The mean EUS-PPG and HVPG were 18.07±4.32 mm Hg and 18.82±3.43 mm Hg, respectively. Remarkable correlation was observed between the EUS-PPG and HVPG, as reflected by a Pearson correlation coefficient (R) of 0.923 and 95% CI of (0.636 - 0.9821). No adverse events were observed. Quoting the authors: "EUS-guided PPG measurement using a 22-gauge FNA needle is a direct, safe, and accurate method to evaluate portal hypertension. EUS-guided PPG has the potential to supplement HVPG measurement in various liver diseases."

1. Zhang W, Peng C, Zhang S, et al. EUS-guided portal pressure gradient measurement in patients with acute or subacute portal hypertension. Gastrointest Endosc 2021;93:565-73.

Correct Answer: A. UEMR has higher en bloc resection rates and lower adenoma recurrence rates for colorectal polyps ≥20 mm.

Underwater endoscopic mucosal resection (UEMR) has recently emerged as an alternative technique for removing colorectal polyps. Compared with conventional endoscopic mucosal resection (CEMR), you would say that:

A. UEMR has higher en bloc resection rates and lower adenoma recurrence rates for colorectal polyps ≥20 mm. (27 votes, 66%)
B. UEMR has higher en bloc resection rates and lower adenoma recurrence rates irrespective of polyp size and location. (12 votes, 28%)
C. UEMR has higher postprocedure bleeding and perforation rates for colorectal polyps ≥20 mm, and those located in the proximal colon. (2 votes, 5%)
D. UEMR has higher postprocedure bleeding and perforation rates irrespective of polyp size and location. (0 votes, 0%)

In the February issue of GIE, Choi et al1 conducted a systematic review and meta-analysis (SRMA) to compare underwater endoscopic mucosal resection (UEMR) versus conventional endoscopic mucosal resection (CEMR) for the treatment of colorectal polyps. They included studies comparing UEMR versus CEMR for the resection of colorectal polyps ≥10 mm. The primary outcomes were rates of en bloc resection, recurrence, postprocedure bleeding, perforation, and procedure time. They included 7 studies (3 randomized clinical trials) and 1237 polyps (614 of them resected by UEMR). UEMR had a higher en bloc resection rate (OR, 1.84; 95% CI, 1.42-2.39; P < .001; I2=38%). On subgroup analysis, the higher en bloc resection rate remained in the UEMR group only for polyps ≥20 mm. The recurrence rate was greater in the CEMR group (19% vs 7%), with a number needed to treat of 8. Once again, this advantage of UEMR was confirmed only for polyps ≥20 mm. There was no difference between the groups concerning postprocedure bleeding and perforation, irrespective of the location of the resected polyp. Procedure time was shorter in the UEMR group; however, the heterogeneity among the studies was very high (I2=96%). Quoting the authors: "The results of this systematic review and meta-analysis demonstrate that underwater EMR technique is a safe and effective alternative to conventional EMR technique. With appropriate training, underwater EMR may be strongly considered as a first choice for resecting colorectal polyps."

Choi AY, Moosvi ZM, Shah S, et al. Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis. Gastrointest Endosc 2021;93:378-89.

Correct Answer: B. The frequency of BE after SG is around 10% and does not correlate with follow-up time or GERD symptoms.

Sleeve gastrectomy (SG) is one of the most commonly performed bariatric surgeries in the world. Concerning the risk of GERD, reflux esophagitis, and Barrett’s esophagus (BE) after SG, you would say that:

A. The frequency of BE after SG is around 10% and increases with longer (>3 years) follow-up time and the presence of GERD symptoms. (20 votes, 69%)
B. The frequency of BE after SG is around 10% and does not correlate with follow-up time or GERD symptoms. (4 votes, 14%)
C. The frequency of BE after SG is around 10%. The risk of reflux esophagitis does not increase after SG. (3 votes, 10%)
D. The frequency of BE after SG is around 10%. The risk of reflux esophagitis after SG does not correlate with follow-up time. (2 votes, 7%)

In the February issue of GIE, Qumseya et al1 conducted a systematic review and meta-analysis (SRMA) to assess the risk of Barrett’s esophagus (BE) in patients who underwent sleeve gastrectomy (SG) for obesity. They included studies with patients who had an EGD at least 6 months after SG and had histologically proven BE. The primary outcome was the proportion of patients who developed BE after SG. The secondary outcomes included the proportion of patients with esophagitis and GERD symptoms. They included 10 studies and 680 patients. Seven studies assessed patients 3 years after SG. From the 680 patients, 54 developed nondysplastic BE. The pooled frequency of BE was 11.4% (95% CI, 7.7%-16.6%). This figure remained unchanged when only studies with more than 3 years of follow-up were considered. The risk of BE did not increase with follow-up duration, presence of GERD symptoms, or frequency of reflux esophagitis. GERD's rate in the postoperative period was 45% (95% CI, 35%-55%). SG increased the risk of reflux esophagitis, which increased with follow-up time. Quoting the authors: "Patients who undergo SG are at increased risk of developing BE."

1. Qumseya BJ, Qumsiyeh Y, Ponnada S, et al. High pooled performance of convolutional neural networks in computer-aided diagnosis of GI ulcers and/or hemorrhage on wireless capsule endoscopy images: a systematic review and meta-analysis. Gastrointest Endosc 2021;93:356-64.

Correct Answer: D. AI increases the adenoma detection rate and the total number of adenomas detected per colonoscopy.

Missed colorectal neoplasia at screening colonoscopy is one of the main reasons for interval colorectal cancer. Artificial intelligence (AI) has recently been incorporated in endoscopy processors. Concerning the performance of AI during screening colonoscopy, you would say that:

A. AI improves the adenoma detection rate but does not increase the number of adenomas detected per colonoscopy. (3 votes, 16%)
B. AI increases the adenoma detection rate and the withdrawal time. (1 vote, 5%)
C. AI has no impact on the adenoma detection rate. (0 votes, 0%)
D. AI increases the adenoma detection rate and the total number of adenomas detected per colonoscopy. (15 votes, 79%)

In the January issue of GIE, Hassan et al1 conducted a systematic review and meta-analysis (SRMA) to evaluate artificial intelligence's performance in the detection of polyps and adenomas in screening colonoscopy. The primary outcome was adenoma detection rate (ADR). Secondary outcomes were adenoma per colonoscopy (APC), polyp detection rate, polyps per colonoscopy, advanced adenoma detection rate (AADR), sessile serrated lesions per colonoscopy (SPC), and withdrawal time. They included 5 randomized clinical trials (RCTs) and 4354 patients (2163 patients in the AI group and 2191 in the control group). Four studies came from China and one from Italy. Only one study was a multicenter RCT. The ADR was higher in the AI group (36.6% vs 25.5%; RR, 1.44; 95% CI, 1.27-1.62; P < .01; I2=42%). APC was higher in the AI group as well, irrespective of adenoma size (<5 mm, 6-9 mm or ≥10 mm). In the AI group, the SPC was also higher (RR, 1.52; 95% CI, 1.14-2.02). The use of AI did not influence the withdrawal time. Quoting the authors: "In conclusion, lesion detection by AI is not influenced by factors such as size and morphology that are known to affect detection by human observers. According to the current evidence, there is substantial and convergent evidence for the incorporation of AI to increase the detection of colorectal neoplasia during colonoscopy."

1. Hassan C, Spadaccini M, Iannone A, et al. Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis. Gastrointest Endosc 2021;93:77-85.

Correct Answer: E. All the above.

Endoscopic GI anastomosis has recently become a new option for bypassing an obstructed bowel segment or accessing a surgically excluded bowel segment. Concerning the techniques of endoscopic GI anastomosis, you would say that:

A. Access to the peritoneal cavity, closure of the gastric defect, and infection are some of the potential barriers of the techniques that involve the use of NOTES. (3 votes, 10%)
B. In the technique using magnets, the risk of inadvertent entrapment of viscera between the 2 magnets can be reduced with an external view (eg, laparoscopic view). (2 votes, 7%)
C. A minimum diameter of 20 mm is desirable for endoscopic GI anastomosis. (0 votes, 0%)
D. The advent of forward-viewing echoendoscopes with larger working channels will probably make the creation of EUS-guided anastomosis easier and safer. (0 votes, 0%)
E. All the above. (25 votes, 83%)

In the January issue of GIE, Marrache et al1 reviewed the experimental and the clinical results of the techniques of endoscopic creation of GI anastomosis. From 2638 articles published between 1990 and 2019, they found 14 relevant studies describing 4 main methods of endoscopic GI anastomosis: EUS-guided, NOTES, magnets, and buttons. There are some technical variations of the EUS-guided gastroenterostomy (EUS-GE). In the assisted EUS-GE techniques, a retrieval balloon catheter or a dedicated catheter with 2 balloons are used for better visualization of the small bowel. In the direct EUS-guided GE techniques, the bowel is distended with contrast or dye and directly punctured under EUS view. The advent of the luminal apposing metallic stent (LAMS) assembled in a delivery system with electrocautery at the tip made direct EUS-GE possible without previous puncture of the bowel or tract dilation. The authors believe that the advent of forward-viewing echoendoscopes with larger working channels will probably make the creation of EUS-guided anastomosis easier and safer. In the NOTES techniques, the operator creates gastric access to the peritoneal cavity, the bowel loop is pulled into the gastric lumen, incised, and the anastomosed to the gastric wall. Once again, LAMSs can be used in this scenario. Magnets and buttons have successfully been used to create endoscopic GI anastomosis in experimental and small clinical trials. They share the same principle to compress 2 GI walls, producing pressure necrosis and a small communication that can be either dilated or stented. Magnets and buttons also share the same technical limitations of delivery and navigation of the devices. Quoting the authors: "Considering all the methods reviewed, the average size of the anastomosis reported was approximately 16 mm with a trend toward larger anastomosis being created in publications within the last decade. Moreover, using a combination of the various methods may address the shortcomings of each, and lead to improved technique and patient outcomes."

1. Marrache MK, Itani MI, Farha J, et al. Endoscopic gastrointestinal anastomosis: a review of established techniques. Gastrointest Endosc 2021;93:34-46.

Correct Answer: B. The en bloc resection rate of CS-EMR is around 80%.

Cold-snare endoscopic mucosal resection (CS-EMR) for the treatment of colonic sessile adenomas is a technique that is becoming increasingly popular among colonoscopists. Concerning the results of CS-EMR for sessile adenomas measuring 10 to 14 mm, you would say that:

A. A 15 mm, oval, thin-wired snare should be the preferred tool for CS-EMR. (23 votes, 52%)
B. The en bloc resection rate of CS-EMR is around 80%. (12 votes, 27%)
C. It should be expected a bleeding rate of 10% to 15% within the first week after CS-EMR. (2 votes, 5%)
D. A high-frequency electric current is needed to finish the polypectomy in 30% of the cases of CS-EMR of polyps measuring 10 to 14 mm. (7 votes, 16%)

In the December issue of GIE, Yabuuchi et al1 conducted a single-arm clinical trial to evaluate cold snare endoscopic mucosal resection (CS-EMR) for the treatment of sessile colonic adenomas measuring 10 to 14 mm. When magnification and narrow-band imaging (NBI) were used, patients with sessile polyps classified as 2a of the JNET classification were enrolled in the study. The primary outcome was a complete resection rate defined as en bloc resection, negative vertical margin, and no adenomatous tissue in the biopsy specimens obtained from the 4 quadrants of the defect margin. CS-EMR technique involved submucosal injection with a glycerol and indigo carmine solution followed by cold snaring with a 10- or 15-mm oval snare with a 0.3 mm wire diameter. If the polyp could not be guillotined, high-frequency electric current was used to finish the procedure. In this single-center study, 72 patients with 80 polyps met inclusion criteria and were included between March and December 2018. The median age was 68.5 years (IQR, 63–75); 47 (65.3%) were men, and 12 (16.7%) took antithrombotic drugs. High-frequency electric current was necessary in 11 lesions (13.8%). The en bloc resection rate by CS-EMR and the histological complete resection rate were 82.5% (66/80) and 63.8% (51/80), respectively. The reasons for unsuccessful histological complete resection were the need for electrocautery in 11 cases, piecemeal resection in 3 cases, neoplastic tissue in the marginal biopsies in 3 cases, and indeterminable vertical margin in 13 cases. No delayed bleeding or perforation occurred from the CS-EMR site. In the univariate analysis, the use of a 15 mm snare was related to failure of CS-EMR. Quoting the authors: "In conclusion, this study revealed that the rate of complete histological resection by CS-EMR for 10 to 14 mm colorectal adenomas was 63.8%, and there were no severe adverse events. Thus, CS-EMR can be safely performed in en bloc fashion for some 10 to 14 mm colorectal adenomas."

1. Yabuuchi Y, Imai K, Horta K, et al. Efficacy and safety of cold-snare endoscopic mucosal resection for colorectal adenomas 10 to 14 mm in size: a prospective observational study. Gastrointest Endosc 2020;92:1239-46.

Correct Answer: C. The pre- and post-APMC-TORe sizes of the gastrojejunal anastomosis correlate with the % of total body weight loss.

Transoral outlet reduction (TORe) has been increasingly used for the management of weight regain after Roux-en-Y gastric bypass (RYGB). Argon plasma coagulation (APMC-TORe) and argon plasma coagulation combined with full-thickness suturing (ft-TORe) are the most-used techniques. Concerning the comparison of the outcomes of the techniques mentioned above, you would say that:

A. APMC-TORe is safer than ft-TORE but requires more treatment sessions. (2 votes, 18%)
B. With ft-TORe the % of total body weight loss at 12 months is greater compared with APMC-TORe. (5 votes, 45%)
C. The pre- and post-APMC-TORe sizes of the gastrojejunal anastomosis correlate with the % of total body weight loss. (2 votes, 18%)
D. The pre- and post-ft-TORe sizes of the gastrojejunal anastomosis correlate with the % of total body weight loss. (2 votes, 18%)

In the December issue of GIE, Jaruvongvanich et al1 conducted a systematic review and meta-analysis (SRMA) comparing argon plasma coagulation (APMC-TORe) versus argon plasma coagulation combined with full-thickness suturing (ft-TORe) for the management of weight regain after Roux-en-Y gastric bypass (RYGB). Both techniques are in the spectrum of the endoscopic transoral outlet reduction (TORe) procedures. The primary outcome was % of total body weight loss (%TBWL). They included 16 studies (13 of them were single-arm retrospective studies and 3 of them were randomized clinical trials) and 737 patients who underwent ft-TORe, and 888 patients who underwent APMC-TORe. APMC-TORe was performed as a series of sessions (a mean number of sessions ranging from 1.2 to 3), whereas ft-TORe was mostly performed as a single session. Concerning the primary outcome, the %TBWL at 3, 6, and 12 months was, respectively, 8.0% (95% CI, 6.3%-9.7%), 9.5% (95% CI, 8.1%-11.0%), and 5.8% (95% CI, 4.3%-7.1%) after ft-TORe. After APMC-TORe, the %TBWL at 3, 6, and 12 months was 9.0% (95% CI, 4.1%-13.9%), 10.2% (95% CI, 8.4%-12.1%), and 9.5% (95% CI, 5.7%-13.2%), respectively. Of note, only one patient in the APMC-TORe group had a severe adverse event. A larger pre-TORe gastrojejunal anastomosis (GJA) diameter and smaller post-TORe GJA diameter were associated with a higher %TBWL at 6 months (P < .001 and .04) only in the APMC-TORe group. Quoting the authors: “Both ft-TORe and APMC-TORe could offer substantial and sustained weight loss up to 12 months with an excellent safety profile. Further standardized studies with follow-up endoscopy should focus on examining their performance in different GJA diameters for a personalized treatment approach, and the cost-effectiveness between the 2 techniques.”

1. Jaruvongvanich V, Vantanasiri K, Laoveeravat P, et al. Endoscopic full-thickness suturing plus argon plasma mucosal coagulation versus argon plasma mucosal coagulation alone for weight regain after gastric bypass: a systematic review and meta-analysis. Gastrointest Endosc 2020;92:1164-75.

Correct Answer: D. The impact of endoscopist feedback on performance is dependent on the previous adenoma detection rate.

Adenoma detection rate and other colonoscopy quality measures are surrogate markers of the effectiveness of screening colonoscopy. Would the endoscopist feedback on these quality indicators have impact on further performance? You would say that:

A. Endoscopist feedback on colonoscopy quality indicators improves cecal intubation rate.
B. Endoscopist feedback on colonoscopy quality indicators improves withdrawal time.
C. Endoscopist feedback on colonoscopy quality indicators does not impact adenoma detection rate.
D. The impact of endoscopist feedback on performance is dependent on the previous adenoma detection rate.

In the November issue of GIE, Bishay et al1 conducted a systematic review and meta-analysis (SRMA) evaluating whether endoscopist feedback on colonoscopy quality indicators impacts further colonoscopy performance. The authors included 12 studies (4 in abstract form), published between 2010 and 2018, representing a total of 33,184 colonoscopies. All studies evaluated adenoma detection rate (ADR), 5 studies evaluated polyp detection rate, 5 studies evaluated advanced neoplasia detection rate, 4 studies evaluated cecal intubation rate, 4 studies evaluated withdrawal time, and 2 studies evaluated proximal adenoma detection rate. A sensitivity analysis was carried out based on the colonoscopist’s individual ADR. Low and high performers were respectively defined as those from the lowest and highest quintiles compared with their peers. Those in the middle 3 quintiles were considered moderate performers. Knowing one’s own ADR was associated with an improvement in ADR (RR, 1.21; 95% CI, 1.09 – 1.34). In the sensitivity analysis, this positive effect was observed for low and moderate performers, but not for high performers (RR, 1.06; 95% CI, 0.99-1.13). Neither cecal intubation nor withdrawal time were impacted by endoscopist feedback. The authors did not observe publication bias. Quoting the authors: "In conclusion, our findings suggest that the delivery of endoscopist feedback after an audit process is associated with modest improvements in ADR. Low performers appear to benefit the most, followed by moderate performers."

1. Bishay K. Causada-Calo N, Scaffidi MA, et al. Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis. Gastrointest Endosc 2020;92:1030-41.

Correct Answer: E. All the above are correct.

The expansion of novel, complex interventions in the advanced endoscopy arena has recently been observed. Concerning the training in new technologies in advanced endoscopy and the definition of competence in those technologies, it is correct to say that:

A. The "see one, do one, teach one" training strategy is outdated with the increasing complexity of new endoscopic interventions; (0 votes, 0%)
B. The "time-based training" should be gradually replaced by the "competency-based medical education"; (0 votes, 0%)
C. More-complex endoscopic interventions such as POEM and ESD are usually considered major skills, as opposed to radiofrequency ablation and intragastric balloon placement, which could be classified as minor skills; (0 votes, 0%)
D. The implementation of a structured training core curriculum may facilitate the training in new technologies in advanced endoscopy, such as ESD and POEM; (2 votes, 40%)
E. All the above are correct. (3 votes, 60%)

In the November issue of GIE, Yang, Wagh, and Draganov discuss the challenges of training in new technologies in advanced endoscopy. In the time-based training model, the number of interventions usually defines competence in a complex procedure (eg, ERCP). The authors underlined that the definition of this number is mostly based on expert opinion, resulting in variable figures. The time-based training model should be gradually replaced by the competency-based medical education (CBME). In CBME, the competence is evaluated based on predefined core skills, quality metrics, and benchmarks for a given technique (eg, selective biliary cannulation in >90% for ERCP, or en bloc resection rate >90% for ESD). ASGE classifies the more-complex endoscopic interventions such as ESD and peroral endoscopic myotomy (POEM) as major skills, whereas radiofrequency ablation (RFA), intragastric balloon placement, and over-the-scope clipping are minor skills. For the former, dedicated training is desirable. In this sense, a structured training core curriculum could facilitate the training in those complex interventions. For the minor skills, training could be achieved through limited education and practical exposure. However, the authors reasoned that for a novice endoscopist with low exposure to Barrett’s esophagus, a procedure like RFA could be considered a major skill. Quoting the authors: "Training in novel emergent endoscopic techniques can be obtained through various pathways, and the integration of standard advanced fellowships and other resources, including simulation-based learning and video-based teaching, may further broaden and tailor the educational opportunities to a widely diverse trainee population. It cannot be overemphasized that short weekend courses and training in animal models does not necessarily qualify as a permit to start performing these newer endoscopic procedures in humans independently. National consensus standards for endoscopic privileging are needed in order to reduce variation in endoscopy practice and ensure that all patients are optimally managed."

1. Yang D, Wagh MS, Draganov PV. The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging. Gastrointest Endosc 2020;91:1016-25.

Correct Answer: C. AI offers high sensitivity and specificity for the detection of both the bleeding source and small-bowel ulcers.

Concerning the diagnostic performance of artificial intelligence (AI) (deep learning–convolutional neural network) for wireless capsule endoscopy (WCE), you would say that:

A. AI offers high sensitivity and specificity for the detection of the bleeding source but limited performance for the detection of small-bowel ulcers. (0 votes, 0%)
B. AI offers high sensitivity and specificity for the detection of small-bowel ulcers but limited performance for the detection of the bleeding source. (2 votes, 29%)
C. AI offers high sensitivity and specificity for the detection of both the bleeding source and small-bowel ulcers. (5 votes, 71%)
D. The literature on AI for WCE is limited and inconclusive. (0 votes, 0%)

In the October issue of GIE, Soffer et al1 conducted a systematic review and meta-analysis (SRMA) evaluating the diagnostic performance of deep learning (convolutional neural network - CNN) for wireless capsule endoscopy (WCE). The authors found 19 studies that applied CNN for WCE. They included 10 retrospective studies that presented enough data for a quantitative meta-analysis. The pooled sensitivity of CNN for ulcer detection was 0.95 (95% CI, 0.89-0.98). The corresponding pooled specificity was 0.94 (95% CI, 0.90-0.96). The pooled sensitivity for the bleeding or bleeding source was 0.98 (95% CI, 0.96-0.99). The corresponding pooled specificity was 0.99 (95% CI, 0.97-0.99). The authors found high heterogeneity, possibly explained by the retrospective design of the included studies and their high risk of selection bias. Quoting the authors: "CNN research in WCE has been applied to a range of diseases in different parts of the intestinal tract. The research results point to a promising trend with the potential for increased efficiency in WCE. Notwithstanding, current research is based on retrospective studies with a high risk of bias. Thus, future prospective multicenter studies are necessary in order for this technology to be implemented in the routine clinical use of WCE."

1. Soffer A, Klang E, Shimon O, et al. Deep learning for wireless capsule endoscopy: a systematic review and meta-analysis. Gastrointest Endosc 2020;92:831-9.

Correct Answer: E. All of the above are correct.

Considering artificial intelligence (AI), it is correct to say that:

A. "AI systems," "AI algorithms," "AI clinical decision support systems," or "AI platforms" are all synonyms that refer to AI. AI refers to complex algorithms that can perform tasks without explicit instructions. (0 votes, 0%)
B. When data used to train the algorithm are labeled, this is termed "supervised" learning. Unsupervised learning has not yet been used for medical applications. (1 vote, 20%)
C. The data used for the development of AI algorithms are usually separated into a training set, validation set, and test set. (0 votes, 0%)
D. For the FDA, AI tools for clinical support are considered as medical devices. (0 votes, 0%)
E. All of the above are correct. (4 votes, 80%)

In the October issue of GIE, Chahal and Byrne1 explored the concept of artificial intelligence (AI) and its clinical applications in GI endoscopy. AI refers to complex algorithms that can perform tasks without explicit instructions. Data that are used to train the algorithm should be labeled. For example, the algorithm is fed with images of colonic polyps, and the images (data) are labeled as "benign" or "malignant." This is called supervised learning. Unsupervised learning has not yet been used for medical applications. The data used for the development of AI algorithms are usually separated into a training set, validation set, and test set. As with any other biomedical data collected retrospectively, there is a risk of selection bias while creating those algorithms. The endoscopic images used to train the algorithm should preferably be in video form rather than static images. The data sets of those images should be large and mimic the real clinical situation. Data sets collected from expert centers may not reflect the daily practice. This kind of selection bias can result in "overfitting," when the algorithm works nicely in the training set but performs poorly with other data sets. There is extensive literature on the clinical application of AI for detection and characterization of GI lesions: colorectal polyps, early esophageal and early gastric cancers, dysplastic Barrett’s esophagus, inflammatory bowel disease, and capsule endoscopy. Particularly for colonic polyps, AI augmented adenoma detection rate (29% vs 20%) and the number of adenomas detected per patient (0.53 vs 0.31). Quoting the authors: "AI is a truly exciting technology, which will no doubt have profound impact on all areas of healthcare. Gastroenterology and endoscopy have already begun to feel the change. We expect that endoscopy will be one of the first areas in all of medicine in which AI is used on a widescale basis, given its inherent reliance on imaging. GI endoscopists should be proud that our field is helping set the tone of AI development in medicine."

1. Chahal D, Byrne MF. A primer on artificial intelligence and its application to endoscopy. Gastrointest Endosc 2020;92:813-20.

Correct Answer: C. In high-volume centers, the dysplasia recurrence rate at 12 months is lower compared with low-volume centers;

Considering the learning curve of the treatment (endoscopic mucosal resection/radiofrequency ablation) of Barrett’s esophagus (BE) dysplasia and the influence of center volume on the complete resolution of dysplasia (CR-D) and complete resolution of intestinal metaplasia (CR-IM) at 12 months after the beginning of the treatment, you would say that:

A. In high-volume centers, the CR-D and CR-IM at 12 months are higher compared with low-volume centers; (3 votes, 20%)
B. The endoscopic treatment of BE should be centralized to high-volume centers; (2 votes, 13%)
C. In high-volume centers, the dysplasia recurrence rate at 12 months is lower compared with low-volume centers; (5 votes, 33%)
D. A minimum of 50 cases is necessary to achieve competency in endoscopic treatment of dysplastic BE. (5 votes, 33%)

In the September issue of GIE, Lipman et al1 compared the outcomes of radiofrequency ablation (RFA) of Barrett’s esophagus (BE) in high (>100 patients) versus medium (51-100 patients), versus low (<50 patients) volume centers. They examined the outcomes of 678 patients enrolled in the United Kingdom RFA Registry. The U.K. RFA Registry collects data from 24 centers in the U.K. and Ireland treating BE patients. Five centers were classified as high-volume centers (n=418), 4 were medium-volume centers (n=145), and 15 were low-volume centers (n=115). The main outcomes were complete resolution of dysplasia (CR-D) and complete resolution of intestinal metaplasia (CR-IM) at 12 months after the beginning of the treatment. The authors have also performed a combination of a risk-adjusted cumulative sum (RA_CUSUM) and change-point analysis to identify whether a proficiency-gain curve exists for the treatment of BE dysplasia. At 12 months, CR-D and CR-IM did not differ between the high-, medium-, and low-volume groups (CR-D 86.4%-89.5%, CR-IM 73.7%-81.1%). However, in the high-volume centers, the number of treatment sessions was higher and dysplasia recurrence was significantly lower. The number of treatment sessions performed was higher in the high-volume centers, and dysplasia recurrence was significantly lower in high-volume compared with low-volume centers (14.0 vs 19.1%, Log Rank P = .001). Concerning the proficiency-gain curve, the authors found a significant change-point for outcomes at 12 cases for CR-D (reduction from 24.5% to 10.4%; P < .001) and at 18 cases for CR-IM (30.7% to 18.6%; P < .001). Quoting the authors: "This study suggests that fewer than 20 cases of endoscopic ablation may be required before competency in treating Barrett’s dysplasia can be achieved, and that the difference in outcomes between a high-volume and low-volume center does not support further centralization of services to only high-volume centers."

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.

Correct Answer: A. There are no differences in the main outcomes in the quality of bowel preparation and adenoma detection rate;

Comparing the low-residue diet (LRD) versus clear liquid diet (CLD) for bowel preparation before colonoscopy, you would say that:

A. There are no differences in the main outcomes in the quality of bowel preparation and adenoma detection rate; (10 votes, 48%)
B. CLD is associated with a better quality of bowel preparation but similar adenoma detection rate when compared with LRD; (4 votes, 19%)
C. LRD does not mitigate complaints such as hunger, headache, nausea, and vomiting when compared with CLD; (0 votes, 0%)
D. CLD is associated with both better quality of bowel preparation and higher adenoma detection rate when compared with LRD. (7 votes, 33%)

In the September issue of GIE, Zhang et al1 (1.1% vs 1.2%, P = .89) conducted a systematic review and meta-analysis (SRMA) comparing a low-residue diet (LRD) versus clear liquid diet (CLD) for bowel preparation before colonoscopy. The authors included 4323 patients and 20 randomized controlled trials published between 2005 and 2019. The authors found no difference between the 2 diets concerning adequate bowel preparation (P = .31; OR,1.21; 95% CI, 0.84 - 1.74) and adenoma detection rate (P = .78; OR, 1.03; 95% CI, 0.86 - 1.23). Additionally, patients in the LRD group complained significantly less of nausea (P = .02; OR, 0.72; 95% CI, 0.56 - 0.94), vomiting (P = .04; OR, 0.61; 95% CI, 0.38 - 0.98), hunger (P < .001; OR, 0.36; 95% CI, 0.24 - 0.53), and headache (P = .02; OR, 0.64; 95% CI, 0.44 - 0.93). Quoting the authors: "In conclusion, the present study demonstrated that LRD is a promising approach for bowel preparation before colonoscopy with comparable quality of bowel preparation to CLD."

1. Zhang X, Wu Q, Wei M, et al. Low-residual diet versus clear-liquid diet for bowel preparation before colonoscopy: meta-analysis and trial sequential analysis of randomized controlled trials. Gastrointest Endosc 2020;92:508-18.

The multitarget stool DNA test (MT-sDNA) incorporates multitarget DNA testing and fecal immunochemical testing for blood. A dedicated, patented algorithm is used to determine whether the test is positive. Concerning the performance and cost-efficiency of MT-sDNA for colorectal cancer (CRC) screening in patients ≥45 years of age, you would say that:

A. The frequency of adenoma detection is around 25% in male patients and 20% in female patients. (6 votes, 27%)
B. The frequency of adenoma detection is below 10%. (4 votes, 18%)
C. The frequency of CRC detention is around 5% with a favorable cost-efficiency ratio. (4 votes, 18%)
D. Advanced adenomas are detected in 30% of the patients with a positive test. (8 votes, 36%)

In the August issue of GIE, Vakil et al1 reported on the results of multitarget stool DNA test (MT-sDNA) for colorectal cancer (CRC) screening in an integrated healthcare system. The study was not externally funded. They tested 6835 patients (45 years or older) during a 1-year period. In case of a positive test, the patient was referred to colonoscopy. The main outcomes were to determine (1) the cancer and adenoma detection rates, (2) the frequency of positive MT-sDNA without a significant adenoma (adenoma >10 mm) or cancer, and (3) the frequency of positive MT-sDNA tests without any adenoma or cancer. The secondary outcomes were to determine (1) the frequency with which adenomas were detected using the multitarget DNA test, (2) the compliance rate with colonoscopy after a positive test, and (3) the cost and return on investment for a health care system using a MT-sDNA screening strategy for cancer detection or prevention. There were 1242 (18%) positive tests and 5593 (82%) negative tests. From the 1242 patients with a positive test, 1109 (89%) had a colonoscopy ordered, and 905 (73%) completed a colonoscopy within 1 year of the positive MT-sDNA test result. Cecal intubation was achieved in 888 (98%) of the patients submitted to colonoscopy. From the patients with a positive test, 11 (0.9%) had a colorectal cancer, 215 (17%) had advanced adenomas, 110 (9%) had serrated adenomas, and 546 (60%) patients had an adenoma. Adenoma or cancer was found in 557 patients (44.8% of the patients tested positive, 8.1% of the entire cohort). An advanced adenoma or cancer was detected in 226 of the 1242 patients with a positive test (18%). The frequency of positive MT-sDNA without a significant adenoma (adenoma >10 mm) or cancer was 77.7%. The frequency of positive MT-sDNA tests without any adenoma or cancer was 38.5%. Nonadherence with colonoscopy after a positive test was (21%). The cost to detect at least one adenoma was $16,080. The cost to detect one cancer was$798,174, and the cost to detect 1 advanced adenoma or cancer was \$38,849. Quoting the authors: "The frequency of adenoma detection by a MT-sDNA screening strategy is low, and many positive tests are not associated with significant findings at colonoscopy."

1. Vakil N, Ciezki K, Huq N, et al. Multitarget stool DNA testing for the prevention of colon cancer: outcomes in a large integrated healthcare system. Gastrointest Endosc 2020;92:334-41.

Correct Answer: C. The risks of GIB and TE are not different when patients taking warfarin are compared with patients under DOACs.

Concerning the risk of gastrointestinal bleeding (GIB) and thromboembolic events (TE) in patients under direct oral anticoagulants (DOACs) or warfarin submitted to endoscopic procedures, you would say that:

A. Compared with patients taking warfarin, patients under DOACs have a higher risk of GIB and lower risk of TE. (6 votes, 30%)
B. The risk of GIB is higher in patients taking warfarin compared with DOACs. (3 votes, 15%)
C. The risks of GIB and TE are not different when patients taking warfarin are compared with patients under DOACs. (4 votes, 20%)
D. Diagnostic and therapeutic EGD have a similar risk of GIB regardless of anticoagulation used (DOAC or warfarin). (7 votes, 35%)

In the August issue of GIE, Tien et al1 compared the risk of gastrointestinal bleeding (GIB) in patients submitted to endoscopic procedures taking direct oral anticoagulants (DOACs) versus vitamin K antagonist, warfarin. In a large integrated healthcare system database, the authors identified 4303 patients submitted to 6765 outpatient GI endoscopic procedures under either a DOAC (1578 procedures) or warfarin (5178 procedures). Endoscopic procedures included diagnostic and therapeutic EGD, colonoscopy, ERCP, EUS, and gastrostomy (PEG). Patients on heparin, clopidogrel, and low-molecular weight heparin were not included in this study. The mains outcomes were GIB and thrombotic events (myocardial infarction [MI] or thromboembolic events [TE]) 30 days after the procedure. Hypertension and diabetes were more common in the warfarin group, whereas patients in the DOAC group were slightly younger and were seen with atrial fibrillation more frequently. Postprocedure GIB was reported in 4.3% and 3.8% of the patients in the DOAC and warfarin groups, respectively (P = .41). In the subgroup analysis, GIB was more frequent in patients submitted to EGD (both diagnostic and therapeutic) in the DOAC group compared with the warfarin group (OR, 1.80; 95% CI, 1.15 - 2.83; P = .011). Both therapeutic EGDs and therapeutic colonoscopies had a 2-fold increased risk of GIB compared with diagnostic EGDs and colonoscopies. A postprocedure TE was reported in 2.3% of the patients of the DOAC group and 2.6% in the warfarin group (P = .48). When the thromboembolic events were discriminated, there was no difference in the frequency of ischemic stroke (0.5% vs 0.6%, P = .73), hemorrhagic stroke (0% vs 0.6%, P = .13), venous thromboembolism (0.9% vs 0.9%, P = .98), acute myocardial infarction (0.3% vs 0.4%, P = .61), or other thromboembolism (1.1% vs 1.2%, P = .89) between the DOACs and warfarin groups. Quoting the authors: "In conclusion, our data suggest a possible higher postendoscopic GI bleeding risk in the DOAC-managed population relative to the warfarin-managed population specifically after EGD. However, in the aggregate DOAC and warfarin populations undergoing an elective endoscopic procedure, we found no significant difference in postendoscopic bleeding and thrombotic risks."

1. Tien A, Kwok K, Dong E, et al. Impact of direct-acting oral anticoagulants and warfarin on postendoscopic GI bleeding and thromboembolic events in patients undergoing elective endoscopy. Gastrointest Endosc 2020;92:284-92.

Correct Answer: E. All of the above.

Concerning the COVID-19 infection prevention measures during endoscopic examinations, you would say that:

A. COVID-19 infection prevention measures should be taken during all endoscopic procedures, including flexible sigmoidoscopy and colonoscopy. (0 votes, 0%)
B. Respiratory (N95, FFP2, FFP3) masks should be used by all personnel directly involved with the endoscopic examination. (2 votes, 13%)
C. Correct donning and doffing of the personnel protective equipment is paramount to prevent the COVID-19 infection during the endoscopic examination. (1 vote, 6%)
D. Protocols of reprocessing of flexible endoscopes and endoscopic accessories should not be changed. (0 votes, 0%)
E. All of the above. (13 votes, 81%)

In the July issue of GIE, Repici et al1 made recommendations on the safe reopening of endoscopic units during the COVID-19 pandemics. The production of aerosols during endoscopy and the presence of Sars-Cov-2 in the urine and feces of infected patients for 1 to 2 days justify all measures to prevent COVID-19 spread during endoscopic examinations. It is also concerning that asymptomatic carriers may be infecting. Patients undergoing endoscopic examination should be stratified according to their risk to present with COVID-19 infection. Patients are stratified as high risk for Sars-Cov-2 infection if they have been in contact with confirmed infection or have returned from a high-risk country (the updated global situation of COVID19 pandemics can be found at https://www.who.int/health-topics/coronavirus), before the onset of fever (<37.5° C or 99.5° F), cough, acute respiratory infection, or sore throat. Patients scheduled for endoscopic examinations should be surveyed about symptoms the day before. The day of the procedure the patient should be submitted to the same triage protocol at her/his arrival at the endoscopy unit, including body temperature check. Personnel with direct contact with the patient should wear hairnet, waterproof gown, respiratory (N95, FFP2, FFP3) mask, goggles/face shield, and 2 pairs of gloves in this order for donning. After the procedure, the personnel protection equipment should be removed in the following order: gloves, gown, goggles/face shield, mask, hairnet. Hand hygiene with alcohol-base disinfectant is advised throughout this sequence. The endoscopic examinations of high-risk patients should be performed in a negative-pressure room. Quoting the authors: "It is a challenging time for the whole world, and we as endoscopists and physicians have additional responsibility of protecting our patients and ourselves. It is really of paramount importance in the next months to enforce and strictly maintain these infection control measures using written protocols and dedicated meetings."

Repici A, Maselli R, Colombo M. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc 2020;92:192-7.

Correct Answer: C. Laparoscopic fundoplication is considered an appropriate therapy for both complete and partial PPI responders.

Concerning experts’ opinion on the management of a patient with GERD with typical symptoms, you would say that:

A. Radiofrequency energy delivery is considered an appropriate therapy. (2 votes, 11%)
B. Transoral incisionless fundoplication (TIF) is considered an appropriate therapy for partial PPI responders with hiatal hernia. (8 votes, 44%)
C. Laparoscopic fundoplication is considered an appropriate therapy for both complete and partial PPI responders. (6 votes, 33%)
D. Impedance-pH testing is considered useless in PPI nonresponders. (0 votes, 0%)
E. All of the above. (2 votes, 11%)

In the July issue of GIE, Gawron et al1 evaluated expert opinion on the surgical or endoscopic management of distinct GERD profiles (heartburn and regurgitation), using a validated prospective method. The expert panel was composed of 8 foregut surgeons and 8 interventional gastroenterologists. All of them were experts in GERD management. The RAND appropriateness method was adopted. In the first phase, the experts answered 2 surveys. In the second phase, the panelists received a comprehensive literature review and convened for an in-person meeting. Twenty-four clinical scenarios of GERD and 6 possible interventions (laparoscopic fundoplication with crural repair—LF, laparoscopic magnetic sphincter augmentation with crural repair—MSA, transoral incisionless fundoplication (TIF), TIF with laparoscopic crural repair, radiofrequency energy delivery, and optimization of medical therapy) were presented to panelists. According to the RAND method of a 9-point scale, the panelist had to choose whether the intervention was appropriate (7-9 points), equivocal (4-6 points), or "not appropriate" (1-3 points) for the selected clinical scenario. Agreement was considered when at least 80% of the panelists voted the same way. Panelists considered LF and MAS appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication (TIF) was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. There was no agreement on the appropriateness of LF and MSA for PPI nonresponders. Radiofrequency energy was not ranked as appropriate for complete or partial PPI responders. Quoting the authors: "In conclusion, these recommendations provide a framework for approaching patients with heartburn or regurgitation-predominant GERD based on symptom response to PPI. Patients with GERD symptoms are heterogenous, and there are evidence gaps comparing therapeutic approaches, especially for PPI nonresponders."

1. Gawron AJ, Bell R, Abu Dayyah BK, et al. Surgical and endoscopic management options for patients with GERD based on proton pump inhibitor symptom response? Recommendations from an expert U.S. panel. Gastrointest Endosc 2020;92:78-87.

Correct Answer: A. Residual polyp is found in 5% of colonoscopies performed 6 months after the CSP-EMR.

Concerning cold snare piecemeal mucosectomy (CSP-EMR) for the treatment of colorectal polyps measuring 20 mm or larger, you would say that:

A. Residual polyp is found in 5% of colonoscopies performed 6 months after the CSP-EMR. (47 votes, 44%)
B. Intraprocedural bleeding is common (>10%) but can be easily controlled. (28 votes, 26%)
C. Postprocedural bleeding requiring hemostatic intervention occurs in 1%-2% of the cases. (29 votes, 27%)
D. It is a good technique for the resection of a nongranular LST with central depression. (4 votes, 4%)

In the June issue of GIE, Mangira et al1 reported the results of a retrospective multicenter study involving 5 academic hospitals in Australia. They included 186 patients (33.8% men, median age 68y, range 21-91) submitted to cold snare piecemeal mucosectomy (CSP-EMR) for the treatment of 204 colorectal lesions ≥20 mm (median size 20 mm, IQR 20-30 mm). Ninety-two polyps (44%) were ≥25 mm, 61 (29.6%) ≥30 mm, and 19 (9.2%) ≥40 mm. White-light high-definition endoscopy and narrow-band imaging (NBI) were used to evaluate the lesions. The polyps with the following criteria were excluded: Kudo V pit pattern, nongranular LST with depression, and LST with nodule >10 mm. A solution of indigo carmine or methylene blue mixed with succinylated gelatin (Gelofusine; BBraun, Switzerland) was injected using a 23-gauge injector catheter. The most commonly used snares were Exacto 9-mm cold snare (US Endoscopy) or SnareMaster Plus 10 mm hot/cold snare (Olympus, SD-400U-10). Hemostatic clips were applied at the endoscopist’s discretion. Colonoscopy was scheduled 4 to 6 months and 16 to 18 months after the resection. Most resected lesions were sessile serrated adenomas (65.6%), followed by tubular adenomas (21.8%). High-grade and low-grade dysplasia was found in, respectively, 1.9% and 35.3% of the lesions. Residual or recurrent polyp was detected in 5.5% of the cases (95% CI, 3%-11%) at the first colonoscopy and in 3.5% of the cases (95% CI, 0.9%-8.5%) at the second colonoscopy (when the first colonoscopy was normal). Adverse events occurred in 10 pts (5.4%; 95% CI, 2.6% - 9.7%). Persistent intraprocedural bleeding was noted in 4 patients (2.2%) (95% CI, 0.6% - 5.4%). Endoscopic hemostasis was achieved in all cases. Postprocedure bleeding occurred in 7 patients (3.8%; 95% CI, 1.5% - 7.6%). None of them required transfusion or any kind of hemostatic intervention. Quoting the authors: "Even allowing for the limitations of our retrospective study design, our data provide a strong indication that CSP-EMR should be considered a viable technique for excision of large sessile colonic polyps."

1. Mangira D, Cameroin K, Simons K, et al. Cold snare piecemeal EMR of lartge sessile colonic polyps =20 mm (with video). Gastrointest Endosc 2020;91:1343-1352.

Correct Answer: A. There is an increased risk of progression to high-grade dysplasia or colorectal cancer if LGD is persistent in subsequent colonoscopies.

Concerning the finding of low-grade dyplasia (LGD) in a patient with colonic inflammatory bowel disease, you would say that:

A. There is an increased risk of progression to high-grade dysplasia or colorectal cancer if LGD is persistent in subsequent colonoscopies. (6 votes, 55%)
B. The increased risk of colorectal cancer in patients with LGD should prompt surgical consultation. (2 votes, 18%)
C. Surveillance colonoscopy should be scheduled every 2 years. (2 votes, 18%)
D. The polypoid LGD carries a higher risk of subsequent advanced neoplasia compared with flat/invisible LGD. (1 vote, 9%)

1. De Jong ME, Kanne H, Nissen LHC, et al. Increased risk of high-grade dysplasia and colorectal cancer in inflammatory bowel disease patients with recurrent low-grade dysplasia. Gastrointest Endosc 2020;91:1334-1342.

Correct Answer: C. Patient satisfaction and recovery time favor the use of propofol-based sedation regimens versus midazolam-based sedation regimens.

Concerning sedation regimens for patients submitted to colonoscopy, you would say that:

A. Hypoxemia and hypotension are more common with the use of propofol versus midazolam. (5 votes, 20%)
B. The use of short-acting opioids (eg, fentanyl, alfentanil) increases the risk of hypoxemia and hypotension when combined with propofol but not with midazolam. (1 vote, 4%)
C. Patient satisfaction and recovery time favor the use of propofol-based sedation regimens versus midazolam-based sedation regimens. (17 votes, 68%)
D. Propofol-based sedation regimens shorten procedure time. (2 votes, 8%)

In the May issue of GIE, Dossa et al1 conducted a systematic review and meta-analysis (SRMA) comparing 2 sedation regimens, propofol versus midazolam ± short-acting opioids for colonoscopy. The primary outcomes were the frequency of hypotension, bradycardia, and hypoxemia. The secondary outcomes were patient satisfaction, endoscopist satisfaction, procedure difficulty, time to sedation, total procedure time, and time to recovery or discharge. Adenoma detection rate, cecal intubation rate or withdrawal time were not evaluated because they were infrequently reported in primary studies. They included 9 RCTs that evaluated 1427 patients. Most studies were considered as good quality. Hypotension, hypoxemia, and bradycardia were respectively observed in 8%, 8%, and 5% of the procedures, with no difference between the groups. The authors found a greater patient satisfaction and shorter recovery time in the propofol group (median difference of 3 minutes). The authors found high heterogeneity in most meta-analytic results, probably reflecting lack of blinding, and the variation of initial and supplemental doses of propofol and midazolam administered, and of personnel in charge of sedation (ie, anesthesiologist vs nurse anesthetist vs patient-controlled sedation) across the included primary studies. Quoting the authors: "Our study demonstrates improved patient and endoscopist satisfaction and shorter recovery/discharge time with the use of propofol versus midazolam; however, absolute differences in satisfaction and efficiency scores across studies were highly variable and often small. Alternative less costly methods to improve patient experience, such as a focus on optimal technique, CO2 insufflation, and the use of water infusion, may also attenuate the satisfaction and efficiency benefits seen for propofol."

1. Dossa F, Medeiros B, Keng C, et al. Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes. Gastrointest Endosc 2020;91:1015-27.

Correct Answer: B. The revised Vienna classification supports the selective use of endoscopic submucosal dissection (ESD) for the management of colorectal neoplasms.

Concerning endoscopic diagnosis and treatment of superficial colorectal neoplasms, you would say that:

A. The Vienna and the revised Vienna classifications are not useful for the correct management of superficial colorectal neoplasms. (3 votes, 17%)
B. The revised Vienna classification supports the selective use of endoscopic submucosal dissection (ESD) for the management of colorectal neoplasms. (7 votes, 39%)
C. The revised Vienna classification supports the use of endoscopic submucosal dissection (ESD) for the management of most superficial colorectal neoplasms. (3 votes, 17%)
D. The revised Vienna classification was not useful to equalize the discrepancies between East and West classification of colorectal neoplasm. (5 votes, 28%)

In the May issue of GIE, Nishimura et al1 discussed the discrepancies between East and West classification of colorectal neoplasm and their implications on the endoscopic management of superficial colorectal neoplasms, including laterally spreading tumors (LST). The Vienna and the revised Vienna classification represented the efforts to equalize some of those discrepancies. However, it remains a relevant discrepancy between East and West classification of colorectal neoplasm: in the East, the diagnosis of carcinoma relies upon cytologic and structural abnormalities regardless of the presence or absence of invasion, whereas in the West, lamina propria invasion, usually accompanied by desmoplastic stromal reaction, is requested for the diagnosis of carcinoma. This discrepancy, associated with the finding of rare but well-documented cases of fatal distant carcinoma recurrence after piecemeal endoscopic mucosal resection (P-EMR), probably justifies, at least in part, the broad indication of ESD for colorectal neoplasms in Eastern centers. On the other hand, the good results obtained with EMR justify a more-selective use of ESD. In addition, adequate handling of ESD specimens is critical for adequate postoperative staging. The adequate indication of ESD for the treatment of colorectal neoplasms has the potential to reduce the overuse of surgical resection. Quoting the authors: "The Vienna classification/revised Vienna classification facilitates the understanding of Eastern versus Western approaches, and is a milestone toward establishing a unified treatment guideline for early colorectal neoplasms. Future efforts should focus on harmonization of histopathologic diagnoses as well as standardization of endoscopic management between the East and the West."

1. Nishimura M, Saito Y, Nakanishi Y, et al. Pathology definitions and resection strategies for early colorectal neoplasia: Eastern versus Western approaches in the post-Vienna era. Gastrointest Endosc 2020;91:983-8.

Correct Answer: D. Early and delayed endoscopic interventions have similar 30-day mortality rates.

Concerning a patient with esophageal soft food impaction, you would say that:

A. Early (<12 hours from the onset of the symptoms) endoscopic intervention is related with lower risk of esophageal tear and perforation. (8 votes, 33%)
B. Delayed endoscopic intervention is related with higher hospital admission rate. (2 votes, 8%)
C. Early endoscopic intervention has a higher success rate compared with delayed endoscopic intervention. (7 votes, 29%)
D. Early and delayed endoscopic interventions have similar 30-day mortality rates. (7 votes, 29%)

In the April issue of GIE, Krill et al1 presented the results of a case-control study with 110 patients submitted to upper GI endoscopy for esophageal soft food impaction. In 42 patients, endoscopic intervention was performed before 12 hours of the symptom onset (early intervention) and, in 68 patients, more than 12 hours after the symptom onset (delayed intervention). The main outcomes of the study were aspiration, esophageal adverse events such as tear, ulceration, perforation, or surgical intervention, hospital admission (including length of stay), and 30-day mortality rates. The groups of comparison were similar in age, gender, race, comorbidities, alcohol/tobacco use, and esophageal structural findings. Eosinophilic esophagitis was diagnosed in 24% of the entire cohort. The mean time from symptom onset to endoscopy was 6.6 hours in the early intervention group and 30.3 hours in the delayed intervention group (P < .001). Complete esophageal obstruction was detected in 69.1% and 57.4% of the patients in the early and delayed intervention groups, respectively. Endoscopic intervention was successful in 100% and 97% of the patients in the early and delayed intervention groups, respectively. There were no differences between the groups regarding esophageal adverse events (26% vs 25%), perforation (2.4% vs 2.9%), aspiration (2.4% vs 1.5%), 30-day mortality (0% vs 1.5%), and admission rates (19.1% vs 22.1%), respectively. The use of endoscopic accessory was predictive of esophageal adverse events (OR, 6.37; 95% CI, 1.75-32.02), probably reflecting the higher complexity of the cases that required the use of these accessories as opposed to more-conservative measures. Quoting the authors: "Performance of an EGD for an esophageal soft food impaction beyond 12 hours has similar outcomes to those done within 12 hours of symptom onset. Rates of admission, local esophageal adverse events, mortality, and aspiration were similar for both groups. Endoscopic accessory use is independently associated with increased odds of esophageal injury. Instrumentation can be considered when indicated if more conservative measures fail to remove an impaction."

Krill T, Samuel R, Vela A, et al. Outcomes of delayed endoscopic management for esophageal soft food impactions. Gastrointest Endosc 2020;91:806-12.

Correct Answer: C. Emergent (within 48 hours) endoscopic biliary drainage is related with lower in-hospital mortality, organ failure rate, and length of hospitalization.

Concerning patients with acute cholangitis who have indication for endoscopic biliary decompression, you would say that:

A. Emergent (within 48 hours) endoscopic biliary drainage is related with lower in-hospital mortality but has no effect on organ failure rate or length of hospitalization. (6 votes, 16%)
B. Emergent (within 48 hours) endoscopic biliary drainage is related with higher in-hospital mortality but has no effect on organ failure rate or length of hospitalization. (0 votes, 0%)
C. Emergent (within 48 hours) endoscopic biliary drainage is related with lower in-hospital mortality, organ failure rate, and length of hospitalization. (31 votes, 84%)
D. Emergent (within 48 hours) endoscopic biliary drainage is related with higher in-hospital mortality, organ failure rate, and length of hospitalization. (0 votes, 0%)

In the April issue of GIE, Iqbal et al1 conducted a systematic review and meta-analysis (SRMA) comparing the outcomes of patients with acute cholangitis (AC) submitted to emergent (within 48 hours) endoscopic drainage versus those patients submitted to urgent endoscopic drainage. The evaluated outcomes were in-hospital mortality (IHM; primary outcome), 30-day mortality, length of hospitalization (LOS), and organ failure. They included 9 observational studies that evaluated 7534 patients. Seven studies were considered to be of good quality. Choledocholithiasis was the most common etiology of AC in the included studies. In the group of emergent endoscopic biliary decompression, IHM was lower (OR, 0.52; 95% CI, 0.28 - 0.98). In addition, 30-day mortality (OR, 0.39; 95% CI, 0.14 - 1.08), organ failure (OR, 0.69; 95% CI, 0.33 - 1.46) and LOS (mean difference of 5.56 days; 95% CI, 1.59 - 9.53) were reduced in the emergent endoscopic biliary decompression group. The authors pooled the data from 2 population registry studies (81,893 patients) as a sensitivity analysis, and the results of reduced IHM for the emergent endoscopic biliary decompression group were reproduced (OR, 0.58; 95% CI, 0.52 - 0.64). Quoting the authors: "Our study revealed that emergent biliary drainage within 48 hours in patients with acute cholangitis is associated with lower odds of in-hospital mortality, 30 days’ mortality, organ failure, and shorter length of stay. Mortality benefit persist in patients with mild-to-moderate and severe AC who underwent emergent ERCP."

1. Iqbal U, Khara HS, Hu Y, et al. Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis. Gastrointest Endosc 2020;91:753-760.

Correct Answer: D. Diminutive (1-5 mm) adenoma carries a lower risk of advanced neoplasia detected at follow-up colonoscopy compared with small (6-9 mm) adenomas.

Concerning the risk of metachronous advanced colorectal neoplasia (≥10 mm tubular adenoma, villous component, high-grade dysplasia or cancer), in patients with 1 or more resected colorectal adenomas smaller than 10 mm in a previous colonoscopy, you would say that:

A. Compared with conventional adenoma histology, the histology of sessile serrated polyp of the lesion resected at the baseline colonoscopy is related with a reduced risk of advanced colorectal neoplasia detection at follow-up colonoscopy. (3 votes, 16%)
B. Excellent or good bowel preparation at baseline is a risk factor for advanced neoplasia detection at follow-up colonoscopy. (1 vote, 5%)
C. Age and female gender are risk factors for advanced neoplasia detection at follow-up colonoscopy. (0 votes, 0%)
D. Diminutive (1-5 mm) adenoma carries a lower risk of advanced neoplasia detected at follow-up colonoscopy compared with small (6-9 mm) adenomas. (15 votes, 79%)

1. Hartstein JD, Vemulapalli KC, Rex DK. The predictive value of small versus diminutive adenomas for subsequent advanced neoplasia. Gastrointest Endosc 2020;91:614-22.

Correct Answer: B. Younger age is a risk factor for undesired events during CS.

Endoscopist-directed conscious sedation (CS) is still a common and cost-effective strategy adopted for sedation in upper GI endoscopy. However, undesired events can occur during CS such as requirement of high doses of sedatives, need for reversal agent, or even incomplete or aborted procedures. Considering the risk factors for the above-mentioned events, you would say that:

A. The combination of upper endoscopy and colonoscopy in the same session is not a risk factor for undesired events during CS. (0 votes, 0%)
B. Younger age is a risk factor for undesired events during CS. (4 votes, 31%)
C. Clonazepam use is a risk factor for undesired events during CS. (9 votes, 69%)
D. Opiod use is not a risk factor for undesired events during CS. (0 votes, 0%)

In the March issue of GIE, McCain et al1 presented the results of a case-control study to identify risk factors for high conscious sedation requirements (HSCR) in patients submitted to upper endoscopy or colonoscopy. The cases were 488 patients with high conscious sedation requirements (HCSR) and the controls, 976 patients without HCSR. The primary outcome, HCSR, was defined as occurrence of at least one of the following events: (1) dose of midazolam >10 mg, (2) dose of fentanyl >200 µg, (3) dose of meperidine >100 mg, (4) need for a reversal agent (either flumazenil or naloxone), (5) incomplete procedure based on nursing documentation, (6) aborted procedure based on nursing documentation, or (7) “poorly tolerated” procedure based on nursing documentation. Younger patients, female sex (OR, 1.30), nonclonazepam benzodiazepine use (OR, 2.24), opioid use (OR, 1.74), and combination of colonoscopy and esophagogastroduodenoscopy within the same sedation session were risk factors of HSCR in multivariate analysis. Using the 5 risk factors, the authors created an HCSR risk score that was validated in a validation cohort of 250 cases and 250 controls. Compared with the patients with a HCSR risk score of 0, risk of HCSR was significantly higher for patients with a risk score of 1 (OR, 1.84), a risk score of 1.5 (OR, 2.89), a risk score of 2 (OR, 3.78), a risk score of 2.5 (OR, 8.68), a risk score of 3 (OR, 14.26), and a risk score of 3.5 or higher (OR, 17.31). In the validation cohort, the HCSR risk score predicted the risk of HCSR with an AUC equal to 0.68 (95% CI, 0.63-0.72). Quoting the authors: "Our study suggests that variables identified before GI endoscopy can be quantified in terms of their likelihood to portend a sedation failure in specific patients."

1. McCain JD, Stancampiano FF, Bouras EP, et al. Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy. Gastrointest Endosc 2020;91:595-605.

Correct Answer: D. All the above

Artificial intelligence (AI) has been studied to improve diagnostic yield of endoscopic examinations, particularly colonoscopy. Concerning the potential applications of AI in screening colonoscopy, you would say that:

B. It has the potential to prolong colonoscope withdrawal time (3 votes, 6%)
C. It has the potential to improve bowel preparation (2 votes, 4%)
D. All the above (19 votes, 37%)

In the February issue of GIE, Su et al1 presented the results of a randomized clinical trial on the use of an automatic quality control system (AQCS) on the performance of screening colonoscopy. By using deep learning convolutional neuron network (DCNN), they developed an automated system to detect polyps, to monitor the withdrawal time, the quality of the bowel cleansing, and the stability of colonoscope withdrawal. From a total of 623 patients submitted to screening colonoscopy, 308 were allocated to the AQCS group and the remaining 315, to the control group. During the colonoscopy of the patients allocated to the AQCS group, the AQSC system gave (1) an audio prompt that reminded the operator to slow the withdrawal speed and reexamine certain colonic segment when unstable or blurry frames were continuously detected by AQCS; (2) an audio prompt to encourage the endoscopists to clean the mucosa or suctioning liquid pools when an Boston score <2 was given by the system; and (3) a green bounding box on the system monitor for showing the location of detected polyp. In the control group, the colonoscopy was performed without the aid of the AQSC system. The primary outcome of the study was the adenoma detection rate (ADR). In both groups, 169 adenomas were removed, 56 (ADR = 16.5%) from the control group and 113 (ADR = 28.9%) from the AQSC group (OR, 2.055; 95% CI, 1.397 - 3.024; P < .001). The mean number of adenomas detected per patient was 0.367 in AQCS group and 0.178 in the control group (P < .001). There were more adenomas detected in the AQCS group in all colorectal segments, except the cecum and the rectum, regardless of adenoma size. Withdrawal time was significantly longer and adequate bowel prep was superior in the AQCS group. Quoting the authors: "AQCS, an automatic quality control system…greatly improved endoscopists’ performance during the withdrawal phase and significantly increased polyp and adenoma detection in a randomized controlled trial. We believe that this system could increase the efficiency of quality control and improve colonoscopy quality in clinical practice."

1. Su J-R, Li Z, Shao X-J, et al. Impact of a real-time automatic quality control system on colorectal polyp and adenoma detection: a prospective randomi8zed controlled study (with videos). Gastrointest Endosc 2020;91:415-24.

Correct Answer: A. All antiplatelet agents should be resumed once achieving immediate hemostasis after polypectomy, ideally within 24 hours.

Management of antithrombotic agents in patients submitted to removal of colonic polyps is challenging. In this setting, recommendations may vary across guidelines issued by different societies. In this scenario, cold snare polypectomy and prophylactic clipping have been introduced with the promise to reduce the risk of postpolypectomy bleeding. Concerning the impact of antithrombotic agents and the adoption of endoscopic techniques on the risk of postpolypectomy bleeding, you would say that:

A. All antiplatelet agents should be resumed once achieving immediate hemostasis after polypectomy, ideally within 24 hours. (1 vote, 14%)
B. In patients who are not under antithrombotic agents, the risk of peripolypectomy bleeding of cold snare polypectomy of polyps ≤1 cm is below 1%. (4 votes, 57%)
C. Heparine bridge therapy is always necessary when polypectomy is contemplated for patients under the use of direct oral anticoagulant agents or under the use of warfarin. (1 vote, 14%)
D. Prophylactic clipping after polypectomy is not useful for patients under anticoagulant or antiplatelet agents. (1 vote, 14%)

In the February issue of GIE, Neenan S Abraham1 conducted a narrative review on the use of antithrombotic agents and the risk of immediate and delayed postpolypectomy bleeding (PPB). The author also reviewed the impact of polypectomy technique on the risk of postpolypectomy bleeding. The author described the result of a study of 1015 cold polypectomies in patients who were not taking any antithrombotic agents. From them, 18 patients experienced immediate PPB (1.8%) successfully treated with hemostasis. There was no delayed bleeding at 30 days. The calculated per-patient bleeding rate was 2.2% (95% CI, 1.2% - 3.2%) with a per-polyp bleeding rate of 1.8% (95% CI, 1.0% -2.6%). In patients taking warfarin, cold snare polypectomy (CSP) was associated with less immediate (5.7% vs 23%) as well as delayed bleeding rates (14 vs 0%) compared with conventional polypectomy. The authors underlined that immediate bleeding rate was higher than expected for CSP of lesions measuring up to 10 mm. It was also observed that high-quality randomized clinical trials comparing CSP versus conventional polypectomy in patients taking antithrombotic agents are needed. In patients under antiplatelet aggregation, all antiplatelet agents should be resumed once achieving immediate hemostasis after polypectomy, ideally within 24 hours. For patients under direct oral anticoagulant agents (DOAC), interrupt the DOAC 1 day before the day of polypectomy and resume it the day after the procedure without heparin bridge therapy was associated with less than 2% of PPB and less than 1% of arterial thromboembolic event. Heparin bridge therapy is an independent risk factor for PPB and should be reserved for patients at high risk of thromboembolic events. Finally, prophylactic clipping seems reasonable when the PPB risk is ≥3.4% (eg, anticoagulant bleeding risk) or ≥2.5% (eg, antiplatelet bleeding risk). Quoting the author: "The quality of published evidence limits our knowledge of PPB in this unique population. Existing studies under-represent the antithrombotic community, fail to standardize polypectomy technique, clearly define a measurable outcome, or use hemostatic clips without defined criteria. In the future, well-designed randomized trials are essential to quantify PPB risk better and clarify incremental drug-related risk."

1. Abraham NS. Antiplatelets, anticoagulants, and colonoscopic polypectomy. Gastrointest Endosc 2020;91:257-65.

Correct Answer: C. With EUS-FNB, sample adequacy and histological procurement rate are higher, as well as diagnostic accuracy, with a lower number of passes compared with EUS-FNA if rapid-on-site evaluation ROSE is not available with EUS-FNA.

Gastrointestinal subepithelial lesions (SELs) pose a diagnostic challenge to the gastroenterologist. EUS-FNA has suboptimal diagnostic yield in this clinical setting. With the advent of core needles, fine-needle biopsy (EUS-FNB) became available. Concerning the results of EUS-FNA and EUS-FNB for the diagnosis of SELs, you would say that:

A. With EUS-FNB, sample adequacy and histological procurement rates are higher, number of passes is lower, but with no difference on diagnostic accuracy compared with EUS-FNA. (1 vote, 5%)
B. With EUS-FNB, sample adequacy and histological procurement rate are higher, as well as diagnostic accuracy, with a lower number of passes compared with EUS-FNA, regardless of whether rapid-on-site evaluation ROSE is available with EUS-FNA. (9 votes, 47%)
C. With EUS-FNB, sample adequacy and histological procurement rate are higher, as well as diagnostic accuracy, with a lower number of passes compared with EUS-FNA if rapid-on-site evaluation ROSE is not available with EUS-FNA. (8 votes, 42%)
D. With EUS-FNB, histological procurement rate and diagnostic accuracy are similar, with a lower number of passes compared with EUS-FNA. (1 vote, 5%)

In the January issue of GIE, Facciorusso et al1 conducted a systematic review and meta-analysis comparing the performance of EUS-FNB versus EUS-FNA for the diagnosis of SELs. The authors included 10 studies, 669 patients (208 sampled with EUS-FNB, 346 with EUSFNA and 115 with both needles in crossover trials). Out of 10 included studies, 6 were randomized controlled trials and 4 were retrospective studies. Fork-tip and Franseen needles were used in 4 studies, and reverse-bevel needles in 7 studies (one study used both reverse bevel and Franseen needles). Most lesions were located in the stomach and measured from around 2 to 3 cm. Pooled rates of adequate samples were 94.9% (92.3%-97.5%) and 80.6% (71.4%-89.7%) with FNB and FNA, respectively (odds ratio: 2.54, 1.29-5.01; P = .007). When rapid on-site evaluation was available, no significant difference between the 2 techniques was observed. Optimal histologic core procurement rate was 89.7% (84.5%-94.9%) with FNB and 65% (55.5%-74.6%) with FNA (odds ratio: 3.27, 2.03-5.27; P < .0001). Diagnostic accuracy was significantly higher with FNB (odds ratio, 4.10; 2.48- 6.79; P < .0001) with the reduction of the number of passes (mean difference: -0.75, -1.20 to -0.30; P = .001). Quoting the authors: "Our meta-analysis represents the first attempt to systematically compare EUS-guided FNB and FNA in patients with SELs. Our results speak clearly in favor of FNB, which was found to outperform FNA in all of the diagnostic outcomes evaluated."

1. Facciorusso A, Sunny SP, Del Prete V,, et al. Comparison between fine-needle biopsy and fine-needle aspiration for EUS-guided sampling of subepithelial lesions: a meta-analysis. Gastrointest Endosc 2020;91:14-22.

Correct Answer: C. It is as high as the risk of low-grade dysplastic Barrett’s epithelium.

Approximately 4% to 8% of Barrett’s esophagus (BE) biopsy specimens are diagnosed as indefinite for dysplasia (BE-IND). Concerning the risk of progression of BE-IND to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC), you would say that:

A. It is as low as the risk of nondysplastic Barrett’s epithelium. (12 votes, 32%)
B. The pooled incidence of EAC reported in studies from Europe and North America is similar. (3 votes, 8%)
C. It is as high as the risk of low-grade dysplastic Barrett’s epithelium. (21 votes, 55%)
D. It is as high as the risk of high-grade dysplastic Barrett’s epithelium. (2 votes, 5%)

In the January issue of GIE, Krishnamoorthi et al1 presented the results of a systematic review and meta-analysis (SRMA) on the risk of progression of BE-IND to HGD and/or EAC. The authors included 8 studies that reported the risk of progression of BE-IND to HGD and/or EAC and 5 studies reporting on the incidence of EAC in BE-IND. In all of the included studies, esophageal biopsy specimens were reviewed by at least 2 expert GI pathologists, using the revised Vienna classification. In patients with BE-IND, the pooled incidence of HGD and/or EAC (89 cases in 1441 patients over 5306.2 person-years) was 1.5 per 100 person-years (95% CI, 1.0-2.0). The pooled incidence of EAC (40 cases in 1266 patients over 4520.2 person-years) was 0.6 per 100 person-years (95% CI, 0.1 – 1.1). In addition, the pooled incidence of LGD was 11.4 per 100 person-years. The incidence of EAC was higher in studies from Europe compared with North America (0.9% vs 0.1%, P = .01). Quoting the authors: "Based on the current study’s risk estimates of progression, patients with BE-IND should be placed on active endoscopic surveillance after their anti-reflux regimen is optimized. Prospective studies to define the natural history of BE-IND are needed to confirm these data."

1. Krishnamoorthi R, Mohan BP, Jayaraj M, et al. Risk of progression in Barrett’s esophagus indefinite for dysplasia: a systematic review and meta-analysis. Gastrointest Endosc 2020;91:3-10.

Correct Answer: A. It occurs in 40% of ERCP cases in naïve papilla and it is influenced by the endoscopic appearance of the papilla.

One of the possible definitions of difficult bile duct cannulation includes not cannulating the desired duct after 5 minutes, 5 attempts, or 2 pancreatic guidewire cannulations. Concerning difficult biliary cannulation, you would say that:

A. It occurs in 40% of ERCP cases in naïve papilla and it is influenced by the endoscopic appearance of the papilla. (5 votes, 11%)
B. It occurs in 5% of ERCP cases in naïve papilla and it is more common when a trainee initiates the ERCP. (13 votes, 28%)
C. Failed biliary cannulation occurs in 15% of ERCP cases in naïve papilla and it is influenced by the endoscopic appearance of the papilla. (19 votes, 40%)
D. It increases the risk of pancreatitis, and it is not influenced by the endoscopic appearance of the papilla. (10 votes, 21%)

In the December issue of GIE, Haraldsson et al1 presented the results of a prospective multicenter study that correlated the risk of difficult biliary cannulation and the endoscopic appearance of the papilla. The authors have previously validated an endoscopic classification of appearance of the major ampulla2. In 1401 patients from 9 different centers in the Nordic countries, the overall frequency of difficult cannulation was 42% (95% CI, 39%-44%). Type 2, small papilla, (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently associated with difficult cannulation when compared with type 1, regular papilla (36%; 95% CI, 33%-40%, both P < .001). If a trainee started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001) even though the trainee was replaced by a senior endoscopist after 5 minutes. The overall post-ERCP pancreatitis (PEP) frequency regardless of papilla type was 6.7% (95% CI, 5.5%-8.2%). The overall frequency of failed cannulation was 2.8% (95% CI, 2.1%-3.9%), regardless of papilla type. Quoting the authors: "The present study has shown that the endoscopic appearance of the major duodenal papilla affects bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more often difficult to cannulate, especially for inexperienced endoscopists."

1. Haraldsson E, Kylänpää L, Grönroos J, et al. et al., Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc 2019;90:957-63.

2. Haraldsson E, Lundell L, Swahn F, et al. Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study. United Eur Gastroenterol 2016;5:504-10.

Correct Answer: D. Endoscopic testing should be considered in patients with Grade 2 immune-related adverse events and in those refractory to steroid therapy.

Immune checkpoints are the natural mechanism used to prevent autoimmunity. Tumor cells take advantage of this mechanism by expressing these checkpoint receptors, which enable tumor cells to interact with T-cells, rendering them incapable to kill. Several drugs were developed targeting these checkpoint proteins (eg, ipilimumab, pembrolizumab, nivolumab). Concerning the GI adverse events caused by immune-checkpoint inhibitors (IR-AE), you would say that:

A. Onset of GI symptoms usually occurs after 1 to 2 weeks of initiation of immune therapy. (3 votes, 19%)
B. Diarrhea intensity correlates to the degree of colitis as evaluated on endoscopy and histology. (2 votes, 13%)
C. The lowest frequency of GI adverse events is observed with anti-CTLA-4 drugs. (0 votes, 0%)
D. Endoscopic testing should be considered in patients with Grade 2 immune-related adverse events and in those refractory to steroid therapy. (11 votes, 69%)

In the December issue of GIE, Kroner et al1 conducted a narrative review focusing on the GI adverse events caused by immune-checkpoint inhibitors. GI adverse events are the second most common immune-related adverse event, usually occurring 6 to 8 weeks after the beginning of the treatment. However, it can occur even after several months of the beginning of the treatment or even after its cessation. GI adverse events may occur anywhere in the GI lumen as well as in the liver and pancreas. They are more common with anti-CTLA-4 drugs used either as mono or combined therapy. Assessing the degree of diarrhea helps to define management. Diarrhea intensity does not necessarily correlate to the degree of colitis as evaluated on endoscopy and histology Endoscopic testing should be considered in patients with Grade 2 immune-related adverse events and in those refractory to steroid therapy. Although systemic steroids are the mainstay therapy for Grades 2-4 IR-AE, there were anecdotal descriptions of promising results with fecal transplantation. Quoting the authors: "Immunotherapy has demonstrated clinically meaningful efficacy in the treatment of several malignancies. These drugs have been shown to be associated with potentially severe gastrointestinal side effects that need to be quickly recognized. With a growing number of immunotherapy agents and indications, the number of patients exposed to these agents is increasing. For this reason, it is of paramount importance for the gastroenterologist to be aware of the presentation, diagnostic approach and management of patients with gastrointestinal immune-related adverse reactions."

1. Kroner PT, Mody K, Farraye FA. Immune checkpoint inhibitor–related luminal GI adverse events. Gastrointest Endosc 2019;90:881-92.

Correct Answer: B. Neither DA or EC increase the serrated adenoma detection rate compared with high-definition, white-light colonoscopy.

Distal attachments and electronic chromoendoscopy have been used to the improvement of colonic adenoma detection rate. Recently, serrated adenomas of the colon have been implicated in approximately 20% of the cases of colorectal cancers, especially those occurring in the right colon segment. Concerning the results of the endoscopic use of distal attachments (DA) or electronic chromoendoscopy (EC) for the detection of colonic serrated adenomas, you would say that:

A. DA increases the serrated adenoma detection rate compared with high-definition, white-light colonoscopy. (0 votes, 0%)
B. Neither DA or EC increase the serrated adenoma detection rate compared with high-definition, white-light colonoscopy. (3 votes, 43%)
C. EC increases the serrated adenoma detection rate compared with high-definition, white-light colonoscopy. (2 votes, 29%)
D. Both DA an EC increased the mean serrated adenoma per subject (SAPS) rate. (2 votes, 29%)

1. Aziz M, Desai M, Hassan S, et al. Improving serrated adenoma detection rate in the colon by electronic chromoendoscopy and distal attachment: systematic review and meta-analysis. Gastrointest Endosc 2019;90:721–731.e1.

Correct Answer: B. The longer the BE segment, the lower the adherence to the biopsy protocol.

Most guidelines on Barrett’s esophagus (BE) management recommend endoscopic surveillance with random biopsies of patients with nondysplastic BE. In addition, adherence to a biopsy protocol has been suggested as a possible quality measure of management of BE patients. Concerning adherence to the Seattle protocol in the United States, you would say that:

A. The adherence to a biopsy protocol is around 50%. (5 votes, 42%)
B. The longer the BE segment, the lower the adherence to the biopsy protocol. (5 votes, 42%)
C. Gastroenterologists and nongastroenterologists have a similar adherence rate. (0 votes, 0%)
D. ASA class ≥2 is a predictor of nonadherence to the biopsy protocol. (2 votes, 17%)

In the November issue of GIE, Wani et al1 retrospectively analyzed data from the GI Quality Improvement Consortium (GIQuIC) Registry. A total of 58,709 (7.5%) EGDs in 53,541 patients with an indication of BE screening/surveillance, or an endoscopic finding of BE, were included (mean age 61.3 years, 60.4% male, 90.2% white, mean BE length 2.3 cm). The adherence to the Seattle protocol was calculated by dividing the BE length by the number of pathology jars. The authors found no-adherence to the Seattle protocol in around 20% of the EGDs. The most relevant predictive factor of a nonadherent EGD was BE length. Every 1-cm increase in BE length increased by 30% the nonadherence to the biopsy protocol. Male gender, increasing age, and ASA class ≥3 were less-relevant predictors of nonadherence. The odds of a nonadherent EGD were 10x to 15x greater among non-GI endoscopists. Quoting the authors: "nearly 20% of endoscopies performed in BE patients were not adherent to the Seattle biopsy protocol. As BE length increases, endoscopists become less compliant with Seattle protocol, with odds of nonadherence increasing by 31% with every 1-cm increase in BE length. Nonadherence was associated with increasing patient age and endoscopies performed by nongastroenterologist physicians."

1. Wani S, Williams JL, Komanduri S, et al. Endoscopists systematically undersample patients with long-segment Barrett’s esophagus: an analysis of biopsy sampling practices from a quality improvement registry. Gastrointest Endosc 2019;90:732–741.e3.

Correct Answer: D. Spurting bleeding is a predictor of recurrent bleeding in the first 30 days after endoscopic treatment.

Hemostatic powder TC-325 is indicated for the endoscopic control of active gastrointestinal bleeding. Concerning the results of the endoscopic use of this hemostatic agent, you would say that:

A. The severe adverse event rate is not negligible. (2 votes, 4%)
B. Technical success rate (adequate delivery of the powder over the lesion) varies from 65% to 75%. (6 votes, 13%)
C. Intraprocedural hemostasis rate is 80%, and 30-day recurrent bleeding rate is 10%. (10 votes, 22%)
D. Spurting bleeding is a predictor of recurrent bleeding in the first 30 days after endoscopic treatment. (28 votes, 61%)

In the October issue of GIE, Santiago et al1 described the results of a multicenter retrospective single-arm study, involving 21 centers in Spain. The study spanned a long period of time (2011-2018). From the 261 included patients, 84% of them presented with upper GI bleeding. TC-325 powder was used as rescue therapy in 73% of the 261 patients. Rescue therapy was defined as the use of TC-325 after the failure of at least one endoscopic treatment, either during the same or a previous endoscopy. The primary outcome of the study was treatment failure, defined as a composite of failed intraprocedural hemostasis with TC-325 or recurrent bleeding at postprocedural day 30. Technical success was defined as the correct delivery of TC-325 powder over the bleeding lesion. Intraprocedural hemostasis was defined as no evidence of further bleeding after TC-325 documented by endoscopy report. In an intention-to-treat analysis, technical success and intraprocedural hemostasis rates were 97.7% 95% CI, 95.1–99.2) and 93.5% (95% CI, 90-96), respectively. Treatment failure at 30 days was 27.4%. On multivariate analysis, the independent predictive factors of treatment failure were spurting bleeding (hazard ratio=1.97; 95% CI, 1.24-3.13), use of vasoactive drugs (HR=1.10; 95% CI, 1.10-2.95) and hypotension (HR=2.14; 95% CI, 1.22-3.75). Only 3 adverse events were observed: self-limited abdominal distension and pain in a patient with postpolypectomy bleeding; perforation of an esophageal ulcer treated both by sclerotherapy and hemostatic powder; and one case of pulmonary thromboembolism 48 hours after TC-325 in a thrombophilic patient with previous episodes of venous embolism.

Quoting the authors: "In conclusion, TC-325 was very effective for immediate hemostasis regardless of the source of bleeding or its use as first-line or rescue therapy; and intraprocedural hemostasis was independently associated with improved survival. In this high-risk group of patients treated with TC-325, the 30-day failure rate was significant and exceeded 25%. Recurrent bleeding occurred mainly during the first 72 hours and was especially notable in cases of spurting bleeding or hemodynamic instability."

1. Rodriguez de Santiago E, Burgos-Santamaria D, Perez-Carazo L, et al. Hemostatic spray powder TC-325 for GI bleeding in a nationwide study: survival and predictors of failure via competing risks analysis. Gastrointest Endosc 2019;90:581-90.

Correct Answer: A. Low-risk lesions have lower incidence of recurrence and CSM rate compared with high-risk lesions.

Screening colonoscopy has probably increased the diagnosis rate of early (pT1) colorectal adenocarcinoma. Concerning the incidence of recurrence and cancer-specific mortality (CSM) rate of endoscopically resected pT1 colorectal adenocarcinoma, you would say that:

A. Low-risk lesions have lower incidence of recurrence and CSM rate compared with high-risk lesions. (7 votes, 64%)
B. Low- and high-risk lesions have similar behavior after endoscopic resection. (0 votes, 0%)
C. Despite different behavior of low- and high-risk lesions, conservative (nonsurgical) management is the indicated approach. (1 vote, 9%)
D. Patients with endoscopically resected high-risk lesions are best managed by close endoscopic surveillance. (3 votes, 27%)

In the October issue of GIE, Antonelli et al1 conducted a systematic review with meta-analysis on the clinical behavior of patients with pT1 colorectal adenocarcinoma submitted to endoscopic resection. Patients with both polypoid and flat lesions were included. A high-risk lesion was consistent with the finding of at least one of the following histological parameters: poorly differentiated adenocarcinoma, submucosal invasion >1000 microns, vascular invasion, or positive (R1) margins. The absence of all the above-mentioned histological parameters was consistent with a low-risk lesion. Pooled cumulative incidences of recurrence and CSM among high-risk lesions (5 studies/571 patients) were, respectively, 9.5% (95% CI, 6.7%-13.3%; I2=38.4%) and 3.8% (95% CI, 2.4%-5.8%; I2=0%). In low-risk lesions (7 studies/650 patients) they were, respectively, 1.2% (95% CI, 0.6%-2.5%; I2=0%) and 0.6% (95% CI, 0.2%-1.7%; I2=0%). One must consider that that the authors could not evaluate the individual impact of each histological parameter on the clinical behavior of the resected lesion. In addition, this meta-analysis included both piecemeal and en bloc resected lesions. Quoting the authors: "Our meta-analysis suggests a conservative approach for patients with low-risk endoscopically resected pT1 CRCs, provided histopathological accuracy is guaranteed. In patients with high-risk lesions, advanced age or increased surgical risk may also justify a conservative management, whereas in fit-for-surgery patients, recommendation for additional surgical resection seems the most appropriate option."

1. Antonelli G, Vanella G, Orlando D, et al. Recurrence and cancer-specific mortality after endoscopic resection of low- and high-risk pT1 colorectal cancers: a meta-analysis. Gastrointest Endosc 2019;90:559-69.

Correct Answer: C. Successful eradication of Helicobacter pylori infection reduces the risk of gastric cancer by 70%;

Helicobacter pylori infection is involved in the sequence of events that lead to the development of gastric cancer. Concerning the impact of Helicobacter pylori eradication in the risk of development of gastric cancer, you would say that:

A. Successful eradication of Helicobacter pylori infection does not reduce the risk of gastric cancer; ( votes, 14%)
B. Successful eradication of Helicobacter pylori infection reduces the risk of well-differentiated gastric cancer; (13 votes, 45%)
C. Successful eradication of Helicobacter pylori infection reduces the risk of gastric cancer by 70%; (11 votes, 38%)
D. In large cohort studies, the risk of gastric cancer does not differ between those infected with Helicobacter pylori versus those who have never had Helicobacter pylori infection. (1 vote, 3%)

In the September issue of GIE, Nam et al1 described the results of a large retrospective cohort study in which 32,965 people underwent an upper endoscopy and H pylori test from 2003 to 2011. Serum levels of total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), and glucose were measured on the same day of upper endoscopy. The study population was classified into 3 groups by H pylori status: noneradication of H pylori, successful eradication of H pylori, and absence of H pylori. The authors estimated the risk for gastric cancer by regression analysis using hazard ratios (HRs) and 95% confidence intervals (CIs). From the initial cohort of 32,965 persons, 10,328 had a follow-up and could be included in the study. Gastric cancer developed in 31 subjects during follow-up: well/moderate differentiated adenocarcinoma in 68% (n=21) and poor differentiated/signet ring cell in 32% (n=10). H pylori eradication decreased de novo gastric cancer risk (HR, 0.29; 95% CI, 0.10-0.86) compared with the persistent group. The risk of de novo gastric cancer in absence of H pylori was also much lower compared with persistent group (HR, 0.24; 95% CI, 0.09-0.60). In addition, the authors observed that low serum HDL increased the risk of de novo gastric cancer (HR, 2.67; 95% CI, 1.14-6.16) Quoting the authors: "In conclusion, H pylori eradication was associated with a reduced risk of de novo gastric cancer development in this large cohort study. This result provides evidence in support of H pylori eradication for general population in high prevalent areas of gastric cancer."

1. Nam SY, Park BJ, Nam JH, et al. Gastric cancer risk stratification and surveillance after Helicobacter pylori eradication: 2020. Gastrointest Endosc 2019;90:457-60.

Correct Answer: A. Biopsy specimens should be taken from all the visible lesions and from the 2 cm of the esophagus proximal to the squamocolumnar junction;

Surveillance endoscopy is recommended after complete eradication of intestinal metaplasia (CE-IM) in patients with Barrett’s esophagus. Concerning the protocol used for endoscopic surveillance of this group of patients and the risk of intestinal metaplasia/dysplasia recurrence, you would say that:

A. Biopsy specimens should be taken from all the visible lesions and from the 2 cm of the esophagus proximal to the squamocolumnar junction; (4 votes, 21%)
B. Most cases of intestinal metaplasia recurrence present as visible lesions and occur earlier than nonvisible IM recurrence; (2 votes, 11%)
C. Biopsy specimens should be taken from all the visible lesions and from every 1 cm of the 4 quadrants of the previously treated segment of esophagus; (12 votes, 63%)
D. Cases of intestinal recurrence usually have a more-aggressive histology (dysplasia-cancer) compared with the histology of the previously treated segment of esophagus. (1 vote, 5%)

In the September issue of GIE, Omar et al1 presented the results of a multicenter observational study in which 443 patients with CE-IM after endoscopic eradication therapy were studied. Sixty-three patients (13.8%) had recurrence of Barrett’s esophagus with and without neoplasia at a median follow-up of 12 months (1-54 months). Eleven patients were excluded for missing data. From the 50 studied patients, nondysplastic BE (NDBE) was observed in 37 (74%) followed by low-grade dysplasia (10%, N = 5), high-grade dysplasia (10%, N = 5), early adenocarcinoma (4%, N = 2), and indeterminate for dysplasia (2%, N = 1). Most cases of recurrences presented as visible lesions (66%). From the 17 cases of nonvisible recurrence, 16 (98%) were located within 2 cm of the squamocolumnar junction. This trend was also observed for the visible recurrences (21/33, 64%). Quoting the authors: "In conclusion, nonvisible recurrences after EET appear to be concentrated within the distal 2 cm of the esophagus, tend to occur earlier than visible recurrences, and appear to be mucosal in depth. These findings suggest that random biopsies of the entire neosquamous zone may be unnecessary. A simplified surveillance protocol limited to obtaining biopsy specimens of any visible lesions along with random biopsies of the GEJ and in 1 cm intervals within the distal 2 cm of the esophagus would appear to capture all recurrences."

1. Omar M, Thaker AM, Wani S, et al. Anatomic location of Barrett’s esophagus recurrence after endoscopic eradication therapy: development of a simplified surveillance biopsy strategy. Gastrointest Endosc 2019;90:395-403.

Ablative endoscopic therapies were extensively studied for the management of Barrett’s esophagus, but not for esophageal squamous cell neoplasia. Esophageal cancer is prevalent in Central and Eastern Asia and Eastern and Southern Africa, where squamous cell carcinoma corresponds to more than 90% of the cases. Concerning the initial experience on the use of radiofrequency and cryoablation for the management of esophageal squamous cell neoplasia, you would say that:

A. The presence of pink sign in esophageal Lugol-unstained lesions predicts poor outcomes after radiofrequency ablation; (1 vote, 6%)
B. Cryoballoon ablation treatment achieves a 90% complete histologic response rate in squamous cell cancer with superficial (<200 µc) submucosal invasion; (4 votes, 22%)
C. Esophageal stricture is a relevant limitation of cryoballoon ablation treatment; (2 votes, 11%)
D. Cryoballoon ablation treatment achieves a 70% complete histologic response rate in moderate and high-grade dysplasia of the esophageal squamous cell epithelium. (11 votes, 61%)

In the August issue of GIE, Ke et al1 conducted a single-center, prospective, uncontrolled trial on the treatment of moderate- and high-grade dysplasia of the esophageal squamous cell epithelium with balloon cryoablation. They included 80 patients with a single, flat (Paris classification 0-IIb), Lugol-unstained lesion. Based on previous experience, the presence of the "pink sign" in Lugol-unstained lesions was predictive of invasive neoplasia as well as poor outcome after radiofrequency ablation and was considered as an exclusion criterion. Sessions with the cryoballoon focal ablation system (CbFAS) were carried out every 3 months up to a total of 3 sessions, if necessary. The main outcome was complete response (absence of moderate or high-grade dysplasia) 12 months after the first ablation session. In an intention-to-treat analysis, 76 of 80 patients (95%) achieved complete response 12 months after the first treatment. In a per-protocol analysis, 76 of 78 patients (97%) achieved the main outcome. No major adverse events were observed. Thirteen patients (16%) developed fever. A CT scan was performed in the first patients who had fever, and a minimal pleural effusion was observed in all of them. Some patients developed pleural effusion but no fever. Pleural effusion disappeared in all patients without further treatment. Quoting the authors: "In conclusion, in this prospective study in patients with flat-type MGIN or HGIN lesions of limited size and no pink-color sign, cryoballoon ablation using the CbFAS was associated with a high rate of histologic CR (97%), and absence of neoplastic progression or relevant adverse events."

1. Ke Y, van Munster SN, Xue L, et al. Prospective study of endoscopic focal cryoballoon ablation for esophageal squamous cell neoplasia in China. Gastrointest Endosc 2019;90:203-12.

Correct Answer: B. The evidence supports the use of chromoendoscopy when only standard-definition white-light endoscopy is available;

Patients with long-standing inflammatory bowel disease (IBD) are at higher risk of colorectal cancer. Surveillance colonoscopy in patients with long-standing IBD aims to detect and, whenever possible, resect dysplastic tissue. Concerning the impact of chromoendoscopy at the detection of dysplastic tissue in patients with IBD, you would say that:

A. Chromoendoscopy is of no value for the detection of dysplastic tissue in this clinical setting; (0 votes, 0%)
B. The evidence supports the use of chromoendoscopy when only standard-definition white-light endoscopy is available; (9 votes, 50%)
C. The evidence supports the use of chromoendoscopy even when high-definition white-light endoscopy is available; (8 votes, 44%)
D. Random biopsies in the 4 quadrants at every 10 cm is still the strategy with the highest diagnostic yield to detect dysplastic lesions in this clinical setting. (1 vote, 6%)

In the August issue of GIE, Feuerstein et al1 presented the results of a systematic review and meta-analysis (SRMA) where they compared the diagnostic yield of dye-based chromoendoscopy (indigo carmine or methylene blue), standard-definition white-light endoscopy (SDWLE) and high-definition white-light endoscopy (HDWLE) for the detection of dysplastic lesions in patients with IBD. After a comprehensive search of the literature, 10 studies that reported on 1562 patients were included. Six of them were randomized controlled trials (RCTs). When the data of the RCT were meta-analyzed, there was a small benefit of dye-based chromoendoscopy over SDWLE (RR, 2.2; 95% CI, 1.15-3.91), but not over HDWLE. When only the observational studies were evaluated, chromoendoscopy had a higher diagnostic yield for dysplasia compared with both SDWLE and HDWLE. Quoting the authors: "Although overall, chromoendoscopy appears superior to non-chromoendoscopy, these findings are limited to SDWLE and to non-RCT studies. When using HDWLE in RCTs as a comparator, there does not appear to be a difference between chromoendoscopy and HDWLE in detecting dysplasia. Further studies are needed to evaluate chromoendoscopy, HDWLE with biopsies every 10 cm, and HDWLE with targeted biopsies."

1. Feuerstein JD, Rakowsky S, Sattler L, et al. Meta-analysis of dye-based chromoendoscopy compared with standard- and high-definition white-light endoscopy in patients with inflammatory bowel disease at increased risk of colon cancer. Gastrointest Endosc 2019;90:186-95.

Correct Answer: A. Cold snare polypectomy and jumbo forceps polypectomy have similar complete polyp resection rates.

Diminutive colorectal polyps (DCP) are those measuring up to 5 mm. Considering the efficacy of endoscopic techniques of resection of diminutive polyps, you would say that:

A. Cold snare polypectomy and jumbo forceps polypectomy have similar complete polyp resection rates. (18 votes, 35%)
B. Cold snare polypectomy has a higher late bleeding rate compared with jumbo forceps polypectomy. (1 vote, 2%)
C. Cold snare polypectomy is a longer procedure compared with jumbo forceps polypectomy. (4 votes, 8%)
D. Cold snare polypectomy has a lower adenoma recurrence rate compared with jumbo forceps polypectomy. (29 votes, 56%)

In the July issue of GIE, Huh et al1 conducted a noninferiority randomized controlled trial in 2 centers to compare jumbo forceps polypectomy (JFP) and cold snare polypectomy (CSP) for the resection of diminutive (≤5 mm) colorectal polyps (DCP).

After screening a total of 1003 patients,169 patients with 196 diminutive colorectal polyps were included. A total of 98 polyps were resected with a jumbo forceps with a 8.8-mm jaw opening and 98 polyps, with a 10-mm polypectomy snare. After endoscopic polypectomy, the resection site was studied for residual adenomatous tissue under white-light and narrow-band imaging (NBI). When no residual adenomatous tissue was endoscopically detected, 2 biopsy specimens of the resection site were taken.

The main outcome was complete polyp resection rate. It was hypothesized that the JFP complete resection rate would not be inferior to CPS complete resection rate (estimated in 90%) by a noninferiority margin of 10%. Procedure time, adverse event rate, and tissue retrieval rate were also compared. Around 90% of the 196 resected polyps were adenomas. Complete resection rates were, respectively, 92% and 92.2% in the JFP and CSP groups. Even for lesions larger than 3 mm, the complete resection rates did not differ between the groups of comparison (90.3% in JFP group and 89.8% in CSP group).

Polypectomy procedure time was approximately 45 seconds in both groups. Tissue retrieval failure occurred only in one case in the CSP group. No cases of perforation or immediate or delayed bleeding were observed. Quoting the authors: "JFP achieved complete resection rate of 92.0% for adenomatous DCPs and was noninferior to CSP. JFP may be also effective for polyps of >3 mm. If forceps are considered for removal of DCPs, JFP is recommended based on results of this study."

1. Huh CW, Kim JS, Choi HH, et al. Jumbo biopsy forceps versus cold snares for removing diminutive colorectal polyps: a prospective e randomized controlled trial. Gastrointest Endosc 2019;90:105-112.

Correct Answer: C. Surveillance colonoscopy should be scheduled every 2 years after the control of polyp burden.

The World Health Organization has classified the serrated polyposis syndrome (SPS) of the colorectum into 3 types:

Type 1: At least 5 serrated polyps proximal to the sigmoid colon, with at least 2 >10 mm in size; Type 2: An individual with any number of serrated polyps proximal to the sigmoid colon who has a first-degree relative of a patient with SDP; and Type 3: at least 20 serrated polyps of any size distributed throughout the colon.

Concerning the SSP, you would say that:

A. The risk of colorectal adenocarcinoma in type 1 SSP is as high as the risk of cancer in FAP. (10 votes, 40%)
B. Colonoscopic control of the polyp burden in type 1 SSP is difficult. (1 vote, 4%)
C. Surveillance colonoscopy should be scheduled every 2 years after the control of polyp burden. (13 votes, 52%)
D. Lengthy procedures with multiple polypectomies and EMR should be avoided in patients with SSP. (1 vote, 4%)

In the July issue of GIE, MacPhail et al1 present the results of endoscopic management of 115 patients with SSP. Most of them were female patients in the 60s with type 1 SSP (65%). Polyp burden was defined as the number and size of polyps. Endoscopic treatment was divided in 2 phases: clearance phase, where the endoscopist intended to lower the polyp burden with intent of achieving endoscopic control; and maintenance phase: procedures performed to maintain control by keeping the polyp burden low. Endoscopic control was defined as the finding of fewer polyps and if no or only an occasional polyp ≥1 cm was present at subsequent examinations.

In total, 87 patients (75.7%) achieved endoscopic control with a mean of 2.84 colonoscopies and 27.9 polyp resections. Seventy-one patients entered the maintenance phase. Colonoscopy was recommended every 2 years. A mean of 6.7 polyp resections were performed on lesions smaller than 1 cm in this group of patients. No cases of cancer or indication for colorectal surgery were observed during the 25-month period of follow-up. Quoting the authors, "The majority of SPS patients can realize control of their polyp burdens after a few colonoscopies, and subsequently maintain control after expansion of surveillance intervals to 24 months. Expansion of surveillance intervals should increase the acceptance, feasibility, and cost-effectiveness of surveillance colonoscopy in SPS."

1. MacPhail ME, Thygesen SB, Patel N, et al. Endoscopic control of polyp burden and expansion of surveillance intervals in serrated polyposis syndrome. Gastrointest Endosc 2019;90:96-101.

Correct Answer: C. Personalized polypectomy report cards increase the competence of high-volume screening colonoscopists for diminutive polypectomy.

Concerning the impact of the use personalized polypectomy report card on polypectomy competency, you would say that:

A. There is no efficient system to objectively assess polypectomy competence. (1 vote; 14%)
B. Personalized polypectomy report cards have no impact on the competence of high-volume screening colonoscopists for polypectomy. (1 vote; 14%)
C. Personalized polypectomy report cards increase the competence of high-volume screening colonoscopists for diminutive polypectomy. (2 votes; 29%)
D. Personalized polypectomy report cards increase the competence of high-volume screening colonoscopists for polypectomy of small-to-large polyps. (3 votes; 43%)

In the June issue of GIE, Duloy et al1 conducted a single-center prospective study to assess the effect of a polypectomy skills report card with educational videos on 11 high-volume colonoscopists. The Direct Observation of Polypectomy Skills (DOPyS) was adopted to evaluate polypectomy skills. Colonoscopic polypectomies were video-recorded and edited. Two gastroenterologists trained in the DOPyS grading system rated the videos. The colonoscopists had access to their DOPyS reports and to instructional videos with narration, each 2 to 5 minutes in length, that demonstrated optimal and poor technique for skills related with the polypectomy. In a following phase, the colonoscopists had their polypectomy procedures video-recorded, edited, and rated by the same 2 gastroenterologists trained in the DOPyS grading system. Mean DOPyS scores and rate of competent polypectomy in the pre- and post-report card phases were compared. One-hundred ten polypectomies performed by 11 colonoscopists were graded. The authors observed an increase in the mean DOPyS scores between the pre- and post-card phases for diminutive polyps but not for small-to-large polyps. A significant improvement in the rate of competent polypectomy was also observed, once again only for diminutive polyps. Quoting the authors: "In conclusion, this is the first study to show that a personalized polypectomy report card effectively improves polypectomy technique. Our intervention successfully increased the competency of diminutive polypectomy, in part by increasing the use of cold snare technique."

1. Duloy AM, Kaltenbach TR, Wood M, et al. Colon polypectomy report card improves polypectomy competency: results of a prospective quality improvement study (with video). Gastrointest Endosc 2019;89:1212-22.

Correct Answer: B. Complete resection and recurrence rates are respectively 90%-98% and 6%-13%

Underwater mucosal resection (UEMR) was first described for the treatment of large sessile colorectal polyps in 2012. Concerning this new technique, you would say that:

A. Perforation and bleeding rates are respectively 1%-3% and 7%-9% (4 votes, 21%)
B. Complete resection and recurrence rates are respectively 90%-98% and 6%-13% (4 votes, 21%)
C. En bloc resection rate varies between 73%-84% (4 votes, 21%)
D. When compared with conventional EMR, UEMR presents lower recurrence rate. (7 votes, 37%)

In the June issue of GIE, Spadaccini et al1 present the results of systematic review and pooled analysis on the treatment of large sessile colorectal lesions with UEMR. They included 10 uncontrolled, noncomparative studies and 508 colorectal lesions in 433 patients. Complete resection and en bloc resection rates were 96.4% (95% CI, 91.8-98.4) and 57.1% (95% CI, 43.2%-69.9%). The overall adverse event rate was 3.3%. Intraprocedural bleeding was minor and not considered as a real adverse event. The postprocedural bleeding rate was 2.8% (95% CI, 1.6-4.9). No cases of perforation were reported. Eight studies reported 319 patients who were followed up for a mean period of 7.7 months (range 4-15 months). The recurrence rate among these patients was 8.8% (95% CI, 5.8- 13.2). Quoting the authors: "In conclusion, UEMR appears as a very promising snare-based resection technique with convincing data in terms of post-UEMR recurrence and lack of perforation risk."

1. Spadaccini M, Fuccio L, Lamonaca L, et al. Underwater EMR for colorectal lesions: a systematic review with meta-analysis (with video). Gastrointest Endosc 2019;89:1109-17.

Correct Answer: B. The main goal of the endoscopic treatment should be eradication of both dysplastic epithelium and intestinal metaplasia;

Concerning endoscopic eradication therapies of dysplastic Barrett's esophagus, you would say that:

A. The main goal of the endoscopic treatment should be eradication of dysplastic mucosa; (4 votes, 19%)
B. The main goal of the endoscopic treatment should be eradication of both dysplastic epithelium and intestinal metaplasia; (10 votes; 48%)
C. Persistent intestinal metaplasia after endoscopic eradication of dysplastic Barrett's mucosa is associated with a higher risk of dysplasia recurrence but not with adenocarcinoma recurrence; (4 votes, 19%)
D. Complete eradication of intestinal metaplasia after endoscopic eradication of dysplastic Barrett's mucosa is associated with a higher risk of symptomatic esophageal stricture. (3 votes, 14%)

In the May issue of GIE, Sawas et al1 present the results of a meta-analysis evaluating the risk of developing advanced neoplasia in Barrett's patients submitted to complete eradication of intestinal metaplasia (CRIM) versus Barrett's patients submitted to complete eradication of dysplasia (CR-D) only. They included 40 studies and 4410 patients with total follow-up of 12,976 patient-years. A total of 4061 achieved CRIM and 349 CR-D only. Treatment modality was mainly radiofrequency ablation (RFA) ± other endoscopic eradication therapies (EET) (24 studies), endoscopic mucosal resection (EMR) ± other EET (8 studies), cryotherapy (3 studies), photodynamic therapy (2 studies), multiple EET modalities (2 studies), and laser (1 study). The pooled cumulative incidences of any dysplasia recurrence after achieving CRIM and CR-D only were 5% (95% CI, 3% - 7%), and 12% (95% CI, 4% - 23%), respectively. With CR-D only, a higher risk was observed for recurrence of both "any dysplasia" (relative risk, 2.8; 95% CI, 1.7 – 4.6), and "high-grade dysplasia-adenocarcinoma" (relative risk, 3.6; 95% CI, 1.45 - 9). Of the dysplastic recurrences, the pooled cumulative incidence of recurrence of "any dysplasia" in the gastroesophageal junction was 77% (95% CI, 53% - 95%). This study emphasizes that CRIM should remain the goal of EER in dysplastic Barrett's esophagus. Quoting the authors: "In conclusion, persistent intestinal metaplasia after endoscopic eradication of dysplasia is associated with a significantly higher risk of dysplasia recurrence. Endoscopists should diligently aim to achieve CRIM to decrease the risk of recurrence. On the other hand, if there are lesions that are refractory to eradication therapy, they might be more genetically aggressive, and these patients might need closer surveillance than those for whom CRIM is achieved. These data reinforce the need for careful and timely endoscopic surveillance after endoscopic eradicative therapy especially when CR-D only is achieved without CRIM."

1. Sawas T, Alsawas M, Bazerbachi F, et al. Persistent intestinal metaplasia after endoscopic eradication therapy of neoplastic Barrett’s esophagus increases the risk of dysplasia recurrence: meta-analysis. Gastrointest Endosc 2019;89:913-26.

Correct Answer: A. It is an effective and safe technique for resection of sessile colorectal polyps, regardless of the size of the polyp;

Considering the application of cold snare polypectomy for the treatment of colorectal polyps, you would say that:

A. It is an effective and safe technique for resection of sessile colorectal polyps, regardless of the size of the polyp; (4 votes, 29%)
B. It is an effective and safe technique only for resection of sessile colorectal polyps measuring up to 10 mm; (10 votes, 71%)
C. It should be avoided for the resection of serrated sessile adenomas of any size, due to the high residual neoplastic tissue rate; (0 votes, 0%)
D. When compared with hot snare polypectomy, it presents similar perforation and bleeding rates. (0 votes, 0%)

In the May issue of GIE, Thoguluva Chandrasekar et al1 present the results of systematic review and pooled analysis on the treatment of colorectal polyps larger than 10 mm with cold snare polypectomy. They included 8 articles and 522 colorectal polyps measuring 17.5 mm (range 10 mm – 60 mm) treated with that technique. The overall adverse event rate was 1.1% (95% CI, 0.2-2,0%). Intra- and postprocedural bleeding rates were 0.7% (0%-1.4%) and 0.5% (0.1%-1.2%), respectively, with abdominal pain rate being 0.6% (0.1%-1.3%). A polyp ≥20 mm resected with cold snare polypectomy was predictive of intraprocedural bleeding (1.3%, 95% CI, 0.7%-3.3%) and abdominal pain (1.2%, 95% CI, 0.7%-3.0%). No cases of perforation were observed. The authors reported a complete resection rate of 99.3% (98.6%-100%). During a follow-up period ranging from 154 to 258 days, the residual of polyps of any histology, adenomas, and SSPs were 4.1% (0.2%- 8.4%), 11.1% (4.1%-18.1%), and 1.0% (95% CI, 0.4%-2.4%), respectively.

Quoting the authors: "Our study suggests that cold snare techniques can be an alternative to both hot snare polypectomy and conventional hot EMR for resection of colon polyps ≥10 mm."

Correct Answer: A. SRAEs are more frequent with propofol-based monitored anesthesia without endotracheal intubation (MAC) compared with general endotracheal anesthesia (GEA), mainly because of the need for airway maneuvers in MAC patients.

In patients submitted for ERCP who are at risk for sedation-related adverse events (SRAEs), you would say that:

A. SRAEs are more frequent with propofol-based monitored anesthesia without endotracheal intubation (MAC) compared with general endotracheal anesthesia (GEA), mainly because of the need for airway maneuvers in MAC patients. (1 vote, 8%)
B. SRAEs are more frequent with propofol-based monitored anesthesia without endotracheal intubation (MAC) compared with general endotracheal anesthesia (GEA), mainly because the occurrence of hypotension and cardiac arrhythmias. (0 votes, 0%)
C. The frequency of SRAEs is similar in patients submitted to propofol-based monitored anesthesia without endotracheal intubation (MAC) or general endotracheal anesthesia (GEA). (6 votes, 46%)
D. When propofol-based monitored anesthesia without endotracheal intubation (MAC) is used, the ERCP success rate is lower when compared with general endotracheal anesthesia (GEA). (6 votes, 46%)

In the April issue of GIE, Smith et al1 conducted a randomized controlled trial comparing general anesthesia with endotracheal intubation (GEA, n=101) versus propofol-based monitored anesthesia without endotracheal intubation (MAC, n=99) for patients submitted to ERCP who were deemed high risk for sedation-related adverse events (SRAEs). Patients were considered a risk for SRAEs when a dedicated score for detecting obstructive sleep-apnea resulted ≥3 (STOP-BANG score, ref no.12 in the study), abdominal ascites on physical examination or imaging within 14 days of ERCP, BMI ≥35, chronic lung disease, ASA class 4, Mallampati class 4 airway, concurrent moderate to heavy alcohol use (≥4 drinks/day for men and ≥3 drinks/day for women). The primary outcome was the frequency of composite SRAE defined as the presence of any of the following: hypoxemia (SpO2 <90%), the need for airway maneuvers (nasal airway, oral airway, chin lift, jaw thrust, or bag max ventilation), conversion to GEA, hypotension requiring vasopressors, sedation-related procedure interruption or termination, cardiac arrhythmia, and respiratory failure. Composite SRAE were significantly higher in the MAC group compared with GEA (51.5% vs 9.9%, P < .001) at the expenses of the frequent (45%) need for airway maneuvers in the MAC group. ERCP had to be interrupted in 10.1% of the patients in the MAC group in order to convert to GEA (n=8) or due to significant gastric stasis (n=2). ERCP success rate did not differ between the groups. No immediate adverse events were observed. Quoting the authors, "The results of this study suggest that GEA is the preferred mode of anesthesia in patients undergoing ERCP who are at high risk for SRAEs, especially in an efficient endoscopy unit with experienced anesthesia providers."

1. Smith ZL, Mullady DK, Lang GD, et al. A randomized controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients. Gastrointest Endosc 2019;89:855-82.

Correct Answer: D. Buried BE glands are more frequently detected after APC treatment.

Comparing the results obtained with radiofrequency (RFA) versus argon plasma coagulation (APC) for the ablation of residual Barrett’s esophagus (BE) after endoscopic resection of high-grade dysplasia or intramucosal adenocarcinoma, you would say that:

A. Dysplasia and BE clearance rates are greater with RFA. (0 votes, 0%)
B. Stricture is more common after RFA, impacting quality of life. (0 votes, 0%)
C. APC treatment is more costly when compared with RFA. (0 votes, 0%)
D. Buried BE glands are more frequently detected after APC treatment. (2 votes, 100%)

In the April issue of GIE, Peerally et al1 conducted the BRIDE study (Barrett’s Randomised Intervention for Dysplasia by Endoscopy), a pilot trial involving 6 centers and including 71 patients who were submitted to endoscopic resection of nodules containing high-grade dysplasia (HGD) or intramucosal adenocarcinoma (maximum invasion: m3). The patients were randomized in 2 groups: APC (n=40) in which patients were submitted to ablation of residual BE by 60W forced or 50W pulsed APC, and RFA (n=36) in which patients were submitted to ablation of residual BE by the Halo ablator (Barrx Medical, Sunnyvale, Calif). The primary outcome was dysplasia/cancer clearance rate at 12 months. Secondary outcomes were intestinal metaplasia (BE) clearance rate, quality of life, and adverse events rate at 12 months. Dysplasia/cancer clearance rates were 83.8% for APC and 79.4% for RFA (OR, 0.7; 95% CI, 0.2-2.6). BE clearance rates were 48.3 and 455.8% for APC and RFA, respectively (OR, 1.4; 95% CI, 0.5-3.6). Buried BE glands were present in 13.3% and 6.1% of the APC and RFA patients, respectively. Although quality-of-life scores did not differ between the groups, RFA cost £21,147 more per case than APC. Stricture occurred in 8.1% of APC patients and 8.3% of RFA patients. Quoting the authors: "The preliminary results in this pilot study show similar ?dysplasia clearance, safety and quality of life for RFA and APC, but there is a substantial difference in cost favoring APC. These findings should be tested in an adequately powered noninferiority trial."

1. Peerally MF, Bhandari P, Ragunath K, et al. Radiofrequency ablation compared with argon plasma coagulation after endoscopic resection of high-grade dysplasia or stage T1 adenocarcinoma in Barrett’s esophagus: a randomized pilot study (BRIDE). Gastrointest Endosc 2019;89:680-9.

Correct Answer: A. They could be considered equivalent regarding the increase in the adenoma detection rate (ADR) and the reduction of adenoma miss rate (AMR);

Right-sided polyps are frequently missed during colonoscopy. Retroflex view and second forward view are some of the endoscopic maneuvers adopted to increase the right-sided polyp detection rate. Concerning those maneuvers, you would say that:

A. They could be considered equivalent regarding the increase in the adenoma detection rate (ADR) and the reduction of adenoma miss rate (AMR); (8 votes, 27%)
B. Both maneuvers increase the adenoma detection rate (ADR) and decrease the adenoma miss rate, but the retroflex view maneuver is superior to the second forward view of the right side of the colon; (4 votes, 13%)
C. Both maneuvers increase the adenoma detection rate (ADR) and decrease the adenoma miss rate, but the second forward view of the right colon segment is superior to the retroflex view maneuver; (5 votes, 17%)
D. The association of both endoscopic maneuvers (retroflex view and second forward view) offers the highest adenoma detection rate and the lowest adenoma miss rate in the right side of the colon. (13 votes, 43%)

In the March issue of GIE, Desai M et al conducted a systematic review comparing the second forward view versus retroflex view in the adenoma miss rate (AMS) in the right side of the colon. After a systematic search of the literature, 4 studies (1882 patients) were included, 2 of them randomized. In terms of AMR, there was no difference when the second forward view was compared with retroflexion (7.3% vs 6.3%; pooled OR, 1.2; 95% CI, 0.9-1.61; P = .21). The second forward view of the right side of the colon increased the right-side adenoma detection rate (ADR) by 10% (n = 4 studies, second forward view vs standard colonoscopy: 33.6% vs 26.7%) with a pooled risk difference of 0.09 (95% CI, 0.03-0.15; P < .01). Retroflexion increased the right-side ADR by 6% (n=3 studies, RF vs SC: 28.4% vs 22.7%) with a pooled risk difference of 0.06 (95% CI, 0.03-0.09; P < .01). Quoting the authors: "After standard colonoscopy withdrawal, a second forward view and retroflexed view of the right side of the colon are both associated with improvement in ADR. One of these techniques should be considered during standard colonoscopy to increase ADR and improving the quality of colonoscopy."

1. Desai M, Bilal M, Hamade H, et al. Increasing adenoma detection rates in the right side of the colon comparing retroflexion with a second forward view: a systematic review. Gastrointest Endosc 2019;89:453-59.

Correct Answer: C. Cold snaring is the preferred approach for polypectomy of lesions measuring up to 9 mm;

Considering the best technique for polypectomy of colonic polyps, you would say that:

A. Use of hot biopsy forceps plays a major role in the resection of polyps measuring from 5 to 9 mm; (3 votes, 4%)
B. Cold biopsy forceps is the method of choice for polyps measuring up to 5 mm; (10 votes, 12%)
C. Cold snaring is the preferred approach for polypectomy of lesions measuring up to 9 mm; (68 votes, 82%)
D. A soft, braided polypectomy snare is the adequate instrument for cold snaring. (2 votes, 2%)

In the March issue of GIE, Rex and Dekker comprehensively described their approach for the resection of colonic polyps. They advocate cold snaring with a stiff, thin snare for most lesions measuring up to 9 mm, although they recognize that cold biopsy forceps may be appropriate for the resection of polyps measuring up to 2 mm. For serrated lesions measuring from 10 to 19 mm, the authors use either cold or hot endoscopic mucosal resection (EMR). For medium-size (10-19 mm) nonpedunculated conventional adenomas, the evaluation of surface and vessel pattern is critical for the detection of invasive cancer. If cancer is present, the patient is referred to surgery, If not, hot EMR is the preferred approach for the resection of these lesions. For pedunculated polyps, hot snare is advocated, placing the snare halfway down the stalk. Prophylactic hemostasis with loop, clips, or adrenalin injection is recommended. Finally, the authors reserve the use of hot biopsy forceps exclusively for hot avulsion of flat or fibrotic residual polyp during EMR. Quoting the authors: "We review our approach to resection of colorectal polyps <20 mm in size. Careful inspection of all lesions is appropriate to assess the type of lesion (adenoma vs serrated) and evaluate the risk of cancer, which is highly associated with lesion size. Polyp resection is in the midst of a 'cold revolution,' particularly for lesions <10 mm in size, but also for some larger lesions."

1. Rex DK, Dekker E. How we resect colorectal polyps <20 mm in size. Gastrointest Endosc 2019;89:449-52.

Correct Answer: B. The 4 components of Spigelman classification are considered to have the same weight for the prediction of duodenal cancer;

Duodenal cancer is the second-leading cause of mortality in patients with familial adenomatous polyposis (FAP). The Spigelman classification of duodenal polyposis includes number, size, histology (tubular, villous, tubulovillous), and dysplasia (low and high grade) of duodenal polyps and is used to stratify the risk of duodenal cancer in patients with FAP. Concerning FAP and duodenal cancer, we can say that:

A. Spigelman classification is useful to predict the occurrence of either ampullary as well as nonampullary duodenal cancer; (5 votes, 42%)
B. The 4 components of Spigelman classification are considered to have the same weight for the prediction of duodenal cancer; (0 votes, 0%)
C. Patients with FAP and Spigelman stage III should be referred to prophylactic duodenopancreatectomy; (3 votes, 25%)
D. Fundic gland gastric polyposis with low-grade dysplasia and desmoid tumors are also predictors of duodenal cancer in patients with FAP. (4 votes, 33%)

In the February issue of GIE, Thiruvengadam et al1 presented a case-control study of 18 patients with FAP and duodenal cancer (cases) matched with 85 patients with FAP and similar ages (controls). Spigelman stage IV was detected in 47% of the cases and in 15% of the controls (P = .003), meaning that 53% of patients with FAP and duodenal cancer never had a Spigelman stage IV duodenal disease. In the multivariate analysis, Spigelman stage IV polyposis (OR, 3.5; 95% CI, 1.1-11.1), polyp with HGD (OR, 3.8; 95% CI, 0.9-16.5; P = .074) and polyp >10 mm (OR, 3.0; 95% CI, 0.9-10.5; P = .086) were associated with duodenal cancer. The other 2 components of Spigelman classification, ie, polyp number and histology, were not predictive of duodenal cancer. Only 2 of 8 (25%) patients with ampullary cancer had prior Spigelman stage IV polyposis compared with 15% of controls (P = .48). No component of Spigelman classification was positively associated with ampullary cancer. Biopsy specimens from the ampulla that were positive for high-grade dysplasia were predictive of ampullary adenocarcinoma. Desmoid tumors and fundic gland gastric polyposis with low-grade dysplasia/adenoma were more commonly seen in the control group. Quoting the authors: "We believe this is the first study to examine SS, individual SS components… We suggest that the presence of high-grade dysplasia, whether in the duodenum or the papilla, be viewed as particularly significant and treated as a potential indication for surgery."

1. Thiruvengadam SS, Lopez R, O’Malley M, et al. Spigelman stage IV duodenal polyposis does not precede most duodenal cancer cases in patients with familial adenomatous polyposis. Gastrointest Endosc 2019;89:345-54.

Correct Answer: B. AT should usually be interrupted 5 or more days before gastric EMR or ESD;

Concerning the risk of delayed bleeding after gastric endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in patients under antithrombotic therapy (AT), you would say that:

A. Heparin bridging therapy (HBT) does not increase the risk of delayed bleeding; (0 votes, 0%)
B. AT should usually be interrupted 5 or more days before gastric EMR or ESD; (3 votes, 21%)
C. The risk of thromboembolic events ranges between 10% and 15% when AT is interrupted for more than 4 days; (2 votes, 14%)
D. The risk of delayed bleeding after gastric EMR or ESD in patients under AT is higher in the first 48 hours. (9 votes, 64%)

In the February issue of GIE, Ahn et al1 presented a single-center, retrospective, observational, score-matched case-control study, including 7752 patients with 8242 gastric neoplasms submitted to either EMR or ESD. The lesions were divided in 2 groups, the antithrombotic group (AT, n=798) and the matched control group (MC, n=399). The groups were matched by age, sex, specimen size, tumor location, diagnosis, chronic kidney disease, and liver cirrhosis. AT therapy included antiplatelet agents, vitamin K antagonist, heparin derivatives, factor Xa inhibitors, and thrombin inhibitors. Patients under AT were further divided into 3 groups regarding the period when the antithrombotic agent was interrupted: continuation, regular cessation, and prolonged cessation groups, respectively, when the AT agent was interrupted from 0 to 4 days, 5 to 7days, and 8 to 14 days before the endoscopic resection. Each subgroup was matched with a control subgroup. Early delayed bleeding was defined when clinically significant bleeding occurred in the first 48 hours after the endoscopic resections. Late delayed bleeding was defined when it occurred from 48 hours to 30 days after the procedure. The delayed bleeding rate was higher in the AT group compared with the MC group (10.1% vs 6.4%; OR, 1.77; 95% CI, 1.25–2.51; P = .001). Although the early DB rates did not differ between the groups, the late delayed bleeding (DB) rate of the AT group was higher than the MC group. The continuation group (interruption of the AT 0-4 days before the procedure) had a higher incidence of DB than their matched controls, (OR, 3.55; 95% CI, 1.24–10.14; P = .018), unlike the regular and prolonged cessation groups. Finally, an increased frequency of DB was also observed in patients receiving heparin bridging therapy (35.7% vs 10.0%; OR, 5.00; 95% CI, 1.11-22.50; P = .036). A thromboembolic event was not observed in any patients taking antithrombotic agents. Quoting the authors: “In conclusion, patients with gastric neoplasm receiving antithrombotic therapy had a higher risk of DB than those not receiving antithrombotic therapy after endoscopic resection.”

1. So S, Ahn JY, Kim N, et al. Comparison of the effects of antithrombotic therapy on delayed bleeding after gastric endoscopic resection: a propensity score-matched case-control study. Gastrointest Endosc 2019;89:277-86.

Correct Answer: A. Upper GI endoscopy is usually the first diagnostic procedure, and it has a low (<50%) sensitivity to localize the bleeding source;

In hemodynamically stable patients admitted with nonhematemesis upper GI bleeding (ie, melena, hematochezia, symptomatic iron deficiency anemia), you would say that:

A. Upper GI endoscopy is usually the first diagnostic procedure, and it has a low (<50%) sensitivity to localize the bleeding source; (32 votes, 47%)
B. Video capsule endoscopy is usually performed after a negative upper and lower GI endoscopy and has a high (>80%) sensitivity to localize the bleeding source; (3 votes; 46%)
C. The timing of video capsule endoscopy probably has no impact on the sensitivity to localize the bleeding source; (1 vote, 1%)
D. The bleeding sources are most commonly located in the mid foregut (from the ampulla of Vater to the ileocecal valve) (4 votes, 6%)

In the January issue of GIE, Marya et al conducted a single-center, non-blinded, randomized controlled trial in 87 patients admitted with nonhematemesis upper gastrointestinal bleeding (ie, melena, hematochezia, symptomatic iron deficiency anemia). Forty-five patients were allocated to the Standard of Care arm where upper GI endoscopy, colonoscopy, videocapsule endoscopy (VCE), and enteroscopy were performed at the discretion of the consulting gastroenterologist. In the experimental arm, 42 patients were submitted to early VCE with real-time viewer (RTV). If blood was found, the gastroenterology consult team was notified. If no blood was seen, the RTV was rechecked 60 minutes later to ensure that the capsule had entered the small bowel. If the capsule remained in the stomach, prokinetic agents were used. The RTV was checked 8 hours later to ensure cecal transit. The recording was downloaded via a computer workstation. In the experimental group, after the results of the VCE, the sequence of further endoscopic procedures was left at the discretion of the consulting gastroenterologist. The main outcome was the rate of localization of the site of bleeding during hospitalization. Localization of bleeding was defined as identification of blood or identification of a lesion with high-risk stigmata of recent hemorrhage. Foregut (esophagus to second portion of the duodenum), midgut (ampulla of Vater to the ileocecal valve), or colon (cecum to rectum) were considered the areas of localization of bleeding. Localization of the bleeding source was possible in 14 patients (31.1%) in the Standard of Care arm and in 27 patients (64.3%) in the Early Capsule arm (P = .003; OR = 5.28 [1.74 – 16.06]). Vascular bleeding lesions were more commonly found in the Early VCE group (19%), compared with 4.4% in the Standard of Care group, probably reflecting the impact of the timing of VCE. In the early VCE group, bleeding vascular lesions in the right colon segment and bleeding colonic diverticular disease were more commonly diagnosed. On the other hand, there was no difference in the recurrent bleeding, length of hospitalization, or mortality rates between the groups. Quoting the authors: "This randomized controlled trial demonstrates that early VCE allows for localization of bleeding sooner and more frequently than the current standard of care, and because VCE does not require preparation or procedural sedation, patients are not at increased risk of adverse procedure-related events."

Marya NB, Jawaid S, Foley A, et al. A randomized controlled trial comparing efficacy of early video capsule endoscopy with standard of care in the approach to nonhematemesis GI bleeding (with videos). Gastrointest Endosc 2019;89:33-43.

Correct Answer: D. All of the above.

One of the main reasons for interval colorectal cancer (CRC) is a low-quality colonoscopy. In this sense, the assurance of quality of a CRC screening program is of paramount importance. In your view, which are the characteristics that might be useful for a structured process of assurance of quality of a CRC screening program?

A. It should involve all stakeholders of the CRC screening program: endoscopy centers, endoscopists, pathology labs, and labs evaluating the results of fecal testing for blood; (1 vote, 6%)
B. It should admit the endoscopist to the screening program upon previous evaluation of the quality of the colonoscopy delivered by the endoscopist; (0 votes, 0%)
C. It should keep a periodic audit of the quality of the colonoscopy delivered by the endoscopy centers and the endoscopists based on the recognized quality indicators for colonoscopy, eg, cecal intubation rate, withdrawal time, adenoma detection rate (ADR). (3 votes, 19%)
D. All of the above. (12 votes, 75%)

In the January issue of GIE, Bronzwaer et al1 described the quality assurance process adopted by the Dutch National CRC screening program. The CRC screening program and the process of assurance of the quality of the program were both initiated in 2014. The Dutch CRC screening program is based on fecal immunochemical testing (FIT). Patients with a positive FIT are referred to a consultation to discuss and schedule a colonoscopy. Endoscopy centers, endoscopists, pathology labs, and labs evaluating the results of fecal testing for blood are all involved in the process of assurance of quality. Endoscopists are accredited to perform screening colonoscopy upon approval in a 3-module evaluation. To be evaluated, the endoscopist should have a life-time experience of least 500 colonoscopies, of which at least 200 colonoscopies and 50 polypectomies have been performed in the year before the start of the accreditation program. The 3-module evaluation involves (1) quality data of their last 100 consecutive colonoscopies uploaded in the website of the regional screening organization, (2) a theoretical e-learning module combined with online assessment of the acquired knowledge, and (3) a practical evaluation of colonoscopy and polypectomy skills. From Sept 2015 to Jan 2018, 93 endoscopists underwent the accreditation process and 83 (89.2%) were accredited. There is a periodic, continuous plan for monitoring the quality of the CRC program, which also involves the endoscopy centers and the endoscopists. The main quality indicators evaluated are quality of bowel preparation, adenoma detection rate, cecal intubation, and withdrawal time. The endoscopists whose performance does not meet the minimum levels of the quality indicators are reassessed in 3 to 6 months for improvement. If the quality levels are not met, the endoscopist is excluded from the screening program. If the endoscopist wishes, he/she may undergo the accreditation program after 1 year of additional training. Quoting the authors: "In this report, the design, the process, and the details of the quality assurance process for colonoscopies in the Dutch CRCSP was described, focusing mainly on the accreditation program and quality assurance monitoring plan for endoscopists…..We believe that our experience might serve as an example for colonoscopy quality assurance programs in other CRC screening programs."

1. Bronzwaer MES, Depla ACTM, van Lelyveld N, et al. Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program. Gastrointest Endosc 2019;89:1-13.

Correct Answer: D. In patients with resected pancreatic adenocarcinoma submitted to preoperative EUS-FNA, there is no impact on the development of peritoneal metastasis, on cancer-free survival, or on overall survival.

EUS-FNA/FNB is considered the criterion standard method for tissue diagnosis of solid pancreatic tumors. However, it is a matter of debate whether it should be used in patients with resectable tumors. One of the raised concerns of preoperative EUS-FNA/FNB is the risk of tumor seeding during the procedure, potentially leading to a higher risk of peritoneal metastasis. Concerning the risk of peritoneal metastasis related to preoperative EUS-FNA/FNB of pancreatic adenocarcinoma, you would say:

A. There is an increased risk of peritoneal metastasis in patients with resected pancreatic adenocarcinoma submitted to preoperative EUS-FNA, but a causation cannot be established; (4 votes, 17%)
B. The higher risk of peritoneal metastasis occurs when transgastric preoperative EUS-FNA is performed; (3 votes, 13%)
C. There is an increased risk of peritoneal metastasis in patients with resected pancreatic adenocarcinoma submitted to preoperative EUS-FNA, but with no impact on survival; (3 votes, 13%)
D. In patients with resected pancreatic adenocarcinoma submitted to preoperative EUS-FNA, there is no impact on the development of peritoneal metastasis, on cancer-free survival, or on overall survival. (14 votes, 58%)

In the December issue of GIE, Kim et al1 described the results of a retrospective, single-center study where the development of peritoneal metastasis, the cancer-free survival, and the overall survival rates were recorded in 411 patients submitted to pancreatectomy for pancreatic adenocarcinoma with curative intention. The patients were divided into 2 groups: N=90, patients submitted to preoperative EUS-FNA for tissue diagnosis, and N=321, patients not submitted to preoperative EUS-FNA. The 2 groups were similar regarding demographics, size, and location of the tumor, histology, the use of chemoradiation, and the EUS-FNA route (transgastric or transduodenal route). The median length of follow-up was 16.2 months (range, 2 to 46 months). Peritoneal recurrence occurred in 131 patients: 30% (27/90) in the EUS-FNA group versus 32% (104/321) in the non-EUS-FNA group (P = .66). There was no difference in the median overall and cancer-related survival rates between the 2 groups. Interestingly, in the patients submitted to preoperative EUS-FNA (Group 1), peritoneal recurrence was more frequent when the transgastric route was used opposed to the transduodenal route, but without statistical significance (42 vs 25%, P = .10). Quoting the authors, "In conclusion, preoperative EUS-guided FNA for pancreatic mass is unlikely to increase the frequency of peritoneal seeding. It does not negatively affect overall survival or cancer-free survival."

1. Kim SH, Woo YS, Lee KH, et al. Preoperative EUS-guided FNA: effects on peritoneal recurrence and survival in patients with pancreatic cancer. Gastrointest Endosc 2018;88:926-35.

Correct Answer: B. The presence of histologic activity is predictive of disease relapse, dysplasia and colorectal cancer

The therapy of patients with ulcerative colitis (UC) usually aims to achieve both clinical and endoscopic remission (mucosal healing). Concerning histologic remission in patients with UC, you would say that:

A. Histologic activity is very rare in patients with endoscopic remission (mucosal healing); (1 vote; 2%)
B. The presence of histologic activity is predictive of disease relapse, dysplasia and colorectal cancer; (40 votes; 91%)
C. Histologic activity should not change clinical management; (2 votes, 5%)
D. Histologic measurements of disease activity mainly rely on the number of eosinophils in the lamina propria. (1 vote, 2%)

In the December issue of GIE, Pai et al conduct a thorough narrative review on the relevance of histologic disease activity on the natural history of patients with ulcerative colitis. The authors acknowledge that the main target of the therapy is mucosal healing, which is determined endoscopically. However, the authors underlined that there is robust evidence showing that histologic activity is present in 14% to 40% of patients with mucosal healing (endoscopic remission). Still according to them, histologic activity is a predictor of dysplasia and colorectal neoplasia, with a mean OR of 2 or 3. Quoting the authors, "Although mucosal healing is the most widely accepted treatment target in UC, histologic activity assessment may be useful for therapeutic monitoring because it predicts rates of clinical relapse, corticosteroid use, hospitalization, and dysplasia... Persistent histologic inflammation in patients with clinical and endoscopic remission does not currently lead to treatment escalation in most practices; however, persistent microscopic disease should make one cautious of any treatment de-escalation."

1. Pai RK, Jairath V, Vande Casteele N, et al. The emerging role of histologic disease activity assessment in ulcerative colitis. Gastrointest Endosc 2018;88:887-98.

Correct Answer: A. The involvement of fellows of any level of training did not increase the AE rate of any grade;

It is a matter of debate whether the fellow training level might have impact on the frequency of adverse events (AE) related to common endoscopic procedures, such as upper GI endoscopy, colonoscopy, esophageal dilation, foreign body removal, and polypectomy. In your opinion, what is the impact of the fellow training level on the frequency of adverse events related to common pediatric endoscopic procedures?

A. The involvement of fellows of any level of training did not increase the AE rate of any grade; (2 votes, 33%)
B. Grade 1 (home managed) AEs were more frequent when fellows in the first half of the first year of training were involved in the endoscopic procedure; (3 votes, 50%)
C. Endoscopic-related death (grade 5 AE) was more frequent when fellows (from any level of training) were involved in the endoscopic procedure; (0 votes, 0%)
D. The involvement of fellows of any level did not impact on the operative time (time of endoscope insertion until final instrument withdrawal). (1 vote, 17%)

In the November issue of GIE, Mark and Kramer1 evaluated the impact of fellow training level on the frequency of adverse events (AE) related to common endoscopic procedures, such as upper GI endoscopy, colonoscopy, esophageal dilation, foreign body removal, and polypectomy, in pediatric patients. There were 15,886 procedures (6,257 with trainee) including 1,627 therapeutic ones (733 with trainee). AE severity was classified in 4 grades: Grade 1 – home managed, Grade 2—outpatient evaluation, Grade 3—hospitalization and/or repeat endoscopy, Grade 4—surgery and/or intensive care unit admission, Grade 5—death. The authors compared the frequency of AE rates of attending physician versus fellows in the first half of the first year, AP versus fellows in the second half of the first year, attending physician versus second- and third-year fellows for 4 grades of AE severity. A total of 413 AEs (2.6%) and 213 (1.3%) AEs grades 2 to 4 were identified. Fellow presence at any training level did not increase AE rates for any procedures. Attending physicians alone were faster than fellows at any training level for upper GI endoscopy and colonoscopy. Quoting the authors: "We found that the rates of AEs were not significantly affected by fellow presence at any level of training for both minor and severe AEs using a prospective AE monitoring system. This was true for common diagnostic as well as therapeutic pediatric endoscopic procedures. It is not surprising that training fellows increases operative time for procedures, and that this difference is most pronounced early in training."

1. Mark JA, Kramer RE. Impact of fellow training level on adverse events and operative time for common pediatric GI endoscopic procedures. Gastrointest Endosc 2018;88:787-794.

Correct Answer: D. With CbFAS treatment, patients usually refer mild pain and need analgesics for the first 2 days after the treatment.

Focal cryoballoon endoscopic ablation (CbFAS) is a novel modality for the eradication of neoplastic Barrett’s esophagus. When used for patients with non-circumferential, <3cm in length Barrett’s esophagus, you would say that:

A. For this particular group of patients, CbFAS has no advantage over radiofrequency ablation (RFA) concerning post procedure pain; (1 vote, 6%)
B. After Barrett’s eradication with CbFAS, the buried columnar epithelium is found in up to 30% of the biopsies; (0 votes, 0%)
C. Barrett’s esophagus surface regression is higher for patients treated with CbFAS versus RFA; (7 votes, 44%)
D. With CbFAS treatment, patients usually refer mild pain and need analgesics for the first 2 days after the treatment. (8 votes, 50%)

In the November issue of GIE, van Munster et al1 described the results of a retrospective multicenter study comparing 20 patients with Barrett’s esophagus (low-grade dysplasia in 9%-45%, high-grade dysplasia or intramucosal adenocarcinoma in 11%-55%) treated by cryoballoon focal ablation system (CbFAS) versus 26 patients with BE (lo- grade dysplasia in 14%-54%, intramucosal adenocarcinoma in 12%-46%) treated by radiofrequency ablation (RFA). Of note, none of the 46 patients had circumferential BE and, in most of them, BE did not extend for more than 3 cm (mean BE length was C0M2 for both groups). The main outcomes were BE surface regression and pain score. BE surface regression did not differ between the groups. Pain was more common, more intense and required analgesics for a longer period of time in the RFA group compared with the CbFAS group. Quoting the authors, "a single treatment with CRYO might be comparable effective to focal RFA for treatment of short-segment BE. We also show that CRYO is better tolerated in terms of pain and dysphagia as compared with RFA in patients with short segment BE. We encourage validation of our findings in a randomized trial."

Note of the associate editor: the readers are invited to read a similar article published by Canto et al. in the August GIE issue.

1. van Munster SN, Overwater A, Haidry R, et al. Focal cryoballoon versus radiofrequency ablation of dysplastic Barrett’s esophagus: impact on treatment response and postprocedural pain. Gastrointest Endosc 2018;88:795-803.

Correct Answer: B. Chromoendoscopy with indigo carmine increases the number of duodenal adenomas detected both in MAP and FAP patients.

Patients with familial adenomatous polyposis (FAP, an autosomal dominant genetic disorder) and patients with MUTYH-associated polyposis (MAP, an autosomal recessive genetic disorder), commonly present duodenal adenomas, increasing their risk of duodenal adenocarcinoma, in addition to their elevated risk of colorectal adenocarcinoma. Considering endoscopic screening of duodenal adenomas in the above-mentioned populations, you would say that:

A. Examination of the duodenum should be performed under white light with a side-viewing endoscope. (30 votes, 36%)
B. Chromoendoscopy with indigo carmine increases the number of duodenal adenomas detected both in MAP and FAP patients. (30 votes, 36%)
C. Electronic chromoendoscopy increases the duodenal adenoma detection rate with impact on the Spigelman classification. (18 votes, 21%)
D. MAP patients usually have a higher number of duodenal adenomas compared with FAP patients. (6 votes, 7%)

1. Hurley JJ, Thomas LE, Walton S-J, et al. The impact of chromoendeoscopy for surveillance of the duodenum in patients with MUTYH-associated polyposis and familial adenomatous polyposis. 2018;88:665-73.

Currently, colonoscopy can be performed under air insufflation (AI), CO2 insufflation, or water-aided techniques, such as water immersion (WI) and water exchange (WE). When these techniques are compared, you would say that:

A. WE technique usually is associated with a longer withdrawal time. (11 votes, 15%)
B. The 4 techniques have similar results concerning the quality of bowel preparation. (7 votes, 9%)
D. WE technique is usually associated with a shorter cecal intubation time. (12 votes, 16%)

In the October issue of GIE, Fuccio et al1 described the results of a systematic review with network meta-analysis of randomized controlled trials comparing 4 colonoscopy techniques: air insufflation (AI), CO2 insufflation, water immersion (WI), and water exchange (WE). The main outcome was adenoma detection rate (overall, at the right colon segment and by colonoscopy indication). Secondary outcomes were cecal intubation time, withdrawal time, pain, and quality of bowel preparation (Boston Bowel Preparation Scale). Seventeen studies (10,350 patients) were included. Because a head-to-head comparison between 2 or more techniques was not available, the authors used the network meta-analysis tool. Basically, if the technique A was never compared with technique B, but both (A and B) have already been compared with technique C in good-quality randomized trials (AxC, BxC), technique A can be indirectly compared with technique B by using sophisticated statistics. The results showed that WE technique was associated with a higher adenoma detection rate (overall, right colon segment and in colorectal cancer screening cases), less pain, and longer cecal intubation time (extra 3-5 minutes). Quoting the authors, "Current network meta-analysis shows that water exchange significantly increases the adenoma detection rate in the entire colon as well as in the right side of the colon, but with a significant increase in insertion time of about 3 to 5 minutes. Until additional data will be available, water exchange should be considered superior to water immersion."

1. Fuccio L, Frazzoni L, Hassan C, et al. Water exchange colonoscopy increases adenoma detection rate: a systematic review with network meta-analysis of randomized controlled studies. Gastrointest Endosc 2018;88:589-97.

Correct Answer: A. Approximately 15% of patients submitted to cholecystectomy for stone disease are also submitted to ERCP at the same hospitalization;

In patients submitted to cholecystectomy for stone disease and ERCP at the same hospitalization, you would say that:

A. Approximately 15% of patients submitted to cholecystectomy for stone disease are also submitted to ERCP at the same hospitalization; (8 votes, 57%)
B. In this setting, the rate of purely diagnostic ERCP or ERCP without therapeutic maneuvers is low (<5%); (1 vote, 7%)
C. Younger age and no comorbidities are factors associated with having ERCP ≥2 days before cholecystectomy; (2 votes, 14%)
D. When ERCP is performed within 1 day of cholecystectomy, there is a higher adverse event rate and prolonged hospital stay. (3 votes, 21%)

In the August issue of GIE, Suarez et al1 evaluated the National Inpatient Sample database from 1998 to 2013, for patients admitted for gallstone-related diseases who underwent inpatient cholecystectomy and ERCP. There were 1,209,783 hospitalizations for gallbladder-related diseases and, from them, 181,776 (15%) underwent ERCP during the same hospitalization. Despite the reduction in the indication of diagnostic ERCP over the years, purely diagnostic ERCP (ERCP performed without therapeutic maneuvers) was observed in 21% of the patients. Older age, comorbidity and concomitant history of acute pancreatitis, or cholangitis were factors associated with having ERCP ≥2 days before cholecystectomy. Patients who underwent CCY within 1 day of ERCP had significantly shorter length of stay compared with those who had ERCP ≥2 days before or ≥2 days after cholecystectomy. Quoting the authors: "These results demonstrate that ERCP and cholecystectomy performed within 1 day of each other are not associated with different clinical outcomes comparing with those having the procedures 2 or more days apart, other than a decrease in overall length of stay, suggesting delays between inpatient procedures should be minimized unless comorbidities preclude."

1. Suarez AL, Xu H, Cotton PB, et al. Trends in the timing of inpatient ERCP relative to cholecystectomy: a nationwide database studied longitudinally. Gstrointest Endosc 2018;88:502-10.

Correct Answer: B. The complete eradication rates of dysplasia and intestinal metaplasia eradication are comparable with those obtained with radiofrequency ablation (RFA) 1 year after treatment;

Endoscopic cryotherapy is a novel modality for the eradication of neoplastic Barrett’s esophagus. A new type of endoscopic nitrous oxide cryotherapy using a portable cryoballoon focal ablation system (CbFAS) has recently become available. Concerning this novel technique, you would say that:

A. It should not be used in patients with failed dyplasia eradication by other ablative methods, especially those with associated strictures; (6 votes, 17%)
B. The complete eradication rates of dysplasia and intestinal metaplasia eradication are comparable with those obtained with radiofrequency ablation (RFA) 1 year after treatment; (22 votes, 63%)
C. The length of the Barrett’s esophagus segment has no influence on the complete dysplasia eradication rate; (4 votes, 11%)
D. Pain is a common complaint with this technique; around 30% of treated patients are managed with opioids. (3 votes, 9%)

In the September issue of GIE, Canto et al1 described the results of a prospective, single-arm, multicenter study on 41 patients (22 treatment naïve and 19 submitted to previous ablative therapies) with neoplastic Barrett’s esophagus (low-grade dysplasia = 13, high-grade dysplasia = 23, and intramucosal adenocarcinoma = 5) treated by a new type of endoscopic nitrous oxide cryotherapy using a portable cryoballoon focal ablation system (CbFAS). Nine patients (22%) had asymptomatic esophageal strictures caused by previous ablative treatments, endoscopic mucosal resection or GERD. The main outcomes were complete eradication rates of dysplasia (CE-D) and intestinal metaplasia (CE-IM) 1 year after treatment. The mean number of treatment sessions was 3 (IQ range: 2-6). CE-D and CE-IM rates were 95% and 88% 1 year after treatment, with no difference between naïve and previous ablated patients. The CE-D and CE-IM rates in this study are comparable with those obtained with RFA. In patients with long-segment of Barrett’ esophagus (>8 cm), the CE-D rate was lower (67 vs 100%, P = .02). Pain occurred in 11 of 41 patients (37%) but only 2 of them (4.9%) required opioids for pain control. Quoting the authors, “This study suggests that a new type of nitrous oxide cryotherapy using a portable CbFAS applied in a multifocal fashion, with or without prior EMR, is a safe, effective, and well-tolerated modality for the endoscopic treatment of neoplastic BE.”

1. Canto MI, Shaheen NJ, Almario JA, et al. Multifocal nitrous oxide cryoballoon ablation with or without EMR for treatment of neoplastic Barrett’s esophagus (with video). Gastrointest Endosc 2018;88:438-46.

Correct Answer: C. Endocuff improves the adenoma per colonoscopy (APC) rate compared with standard colonoscopy

Novel technologies have recently become available with the intent to improve the adenoma detection rate during screening colonoscopy. Endocuff, EndoRing, and full-spectrum endoscopy (FUSE) are some of them. Concerning those technologies, you would say that:

A. Those technologies do not improve the adenoma detection rate when the operator has a high baseline adenoma detection rate; (4 votes, 15%)
B. Those technologies have no influence on the cecal intubation time; (3 votes, 11%)
C. Endocuff improves the adenoma per colonoscopy (APC) rate compared with standard colonoscopy; (18 votes, 67%)
D. FUSE was related with the highest adenoma per colonoscopy (APC) rate when compared with Endocuff, EndoRing, and standard colonoscopy. (2 votes, 7%)

In the August issue of GIE, Rex et al1 conducted a multicenter, randomized controlled trial, comparing standard white light, high definition colonoscopy, versus Endocuff, EndoRing and full-spectrum endoscopy (FUSE) system in patients submitted mostly to screening or surveillance colonoscopy. The primary endpoint was adenoma per colonoscopy (APC) rate. Secondary endpoints were adenoma detection rate (ADR), sessile serrated polyps per colonoscopy, sessile serrated polyp detection rate, colonoscope insertion time, the failure rate of insertion, and the detection targets noted above for the right side of the colon. Of note, only 3 operators with high baseline adenoma detection rate performed the colonoscope withdrawal. A total of 1188 patients were randomized. APC with standard high-definition colonoscopy with Endocuff and EndoRings were all superior to FUSE. Endocuff was the only technology that had a higher APC rate compared with standard high-definition colonoscopy. Mean cecal intubation times were longer with FUSE and EndoRings when compared with Endocuff. The detection gain with Endocuff was mostly in diminutive, low-grade adenomas located in the right side of the colon. Quoting the authors: "We showed that use of an adjunct (Endocuff) on the end of a high-definition forward-viewing colonoscope produced gains in adenoma detection, even in the hands of examiners who are very skilled with standard instruments lacking adjunctive devices."

1. Rex DK, Repici A, Gross SA, et al. High-definition colonoscopy versus Endocuff versus EndoRings versus full-spectrum endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial. Gastrointest Endosc 2018;88:335-44.

Correct Answer: D. Not all patients with HCC present underlying LC, especially those with hepatitis B virus infection, differently from those with hepatitis C virus infection

Hepatocellular carcinoma (HCC) is a recognized adverse event of liver cirrhosis (LC), being associated with liver-related mortality in patients with compensated liver cirrhosis. Concerning the association of HCC and LC, you would say that:

A. Variceal bleeding is a major cause of mortality in patients with the association of HCC and LC; (3 votes, 8%)
B. Esophagogastroduodenoscopy should be performed in all patients with HCC for the screening of esophageal and gastric varices; (4 votes, 11%)
C. The albumin-bilirubin (ALBI) score proved to be of low utility to assess liver function and prognosis in HCC patients; (1 vite, 3%)
D. Not all patients with HCC present underlying LC, especially those with hepatitis B virus infection, differently from those with hepatitis C virus infection. (29 votes, 78%)

In the August issue of GIE, Chen et al combined the albumin-bilirubin (ALBI) score with the platelet count (ALBI-PLT) for the prediction of the presence of high-risk esophageal varices (HRV) in patients with newly diagnosed, treatment-naïve HCC patients. Considering that not all patients with HCC present LC or portal hypertension and that the ALBI score has proved to be useful for the evaluation of liver function and prognosis in patients with HCC, the authors hypothesized that the combination of the ALBI score with the platelet count could identify correctly HCC patients who do not have HRV. F2, F3 varices, and F1 with red color signs were considered HRV. The study cohort was composed by 887 newly diagnosed HCC patients that fulfilled the diagnostic criteria by the American Association for the Study of Liver disease. The validation cohort was composed by 215 patients with the same condition. In the study cohort, 750 patients died after a media follow-up of 11 months. Progression of HCC was the main cause of death (47.6%). Variceal bleeding accounted for only 6.0% of the mortality. The negative predictive values of the ALBI-PLT score for the prediction of HRV were 97.1 and 98.1% in study and validation cohorts, respectively. Quoting the authors: "In treatment-naïve HCC patients with compensated liver function, an ALBI-PLT score of 2 predicted a very low risk of presence of HRV and variceal hemorrhage; therefore, endoscopic screening for esophageal varices was not recommended in these patients. This strategy may save costs and avoid unnecessary invasive endoscopy for these selected patients."

Chen P-H, Hsieh W-Y, Su C-W, et al. Combination of albumin-bilirubin grade and platelets to predict a compensated patient with hepatocellular carcinoma who does not require endoscopic screening for esophageal varices. Gastrointest Endosc 2018;88:230-39.

Correct Answer: C. Associated coagulopathy is a predictor of mortality

Concerning patients with thrombocytopenia (platelet count <50,000 cells/mL) and clinically overt gastrointestinal bleeding, you would say that:

A. In this clinical scenario, diffuse gastrointestinal bleeding opposed to a defined single bleeding source is the most common situation; (4 votes, 37%)
B. Endoscopy should be deferred until correction of thrombocytopenia, especially in liver cirrhotic patients; (3 votes, 27%)
C. Associated coagulopathy is a predictor of mortality; (3 votes, 27%)
D. One-month mortality is usually low (<10%) in this group of patients. (1 vote, 9%)

In the July issue of GIE, Ramos et al1 described the results of a retrospective analysis of a prospectively maintained database of 144 patients (liver cirrhosis 61%, n=88 and non-liver cirrhosis 39%, n=56) who presented with clinically overt GI bleeding, severe thrombocytopenia (>20,000 cells/mm, <50,000 cells/mL) and were submitted to urgent endoscopy or colonoscopy. Diffuse GI bleeding was found in 25% of the patients. A defined single bleeding source was detected in 68% of them (79% in the non-liver cirrhotic patients versus 61% in the liver cirrhotic patients, P = .04). Endoscopic hemostasis was used in 60% of the patients with no difference between the liver cirrhosis group (60%) versus the non-liver cirrhosis group (59%). The initial endoscopic hemostasis rate was 94%. Overall mortality was 19% at 1 month and 37% at one year. A INR >2 was predictive of mortality (odds ratio, 6.23; 2.26 - 17.2) as well as intensive care unit admission, pulmonary disease, hypotension, and aPTT >38. Quoting the authors: "Based on this study cohort from a single tertiary center, we observed that pursuing endoscopic hemostasis in liver cirrhosis and non-liver cirrhosis patients with overt GIB in the setting of severe thrombocytopenia appears to be a reasonable management strategy."

1. Ramos GP, Binder M, Hampel P, et al. Outcomes of endoscopic intervention for overt GI bleeding in severe thrombocytopenia. Gastrointest Endosc 2018;88:55-61.

Correct Answer: B. Nasogastric tube for enteral feeding is associated with a higher narcotic use rate

Enteral nutrition is usually indicated for patients with dysphagia caused by squamous cell esophageal carcinoma (SCEC) who are sent to either definitive or neoadjuvant chemoradiation. Concerning the possible routes for enteral nutrition in this clinical setting, you would say that:

A. Self-expandable metallic stent insertion palliates dysphagia being also effective as a route for enteral nutrition (29 votes; 64%)
B. Nasogastric tube for enteral feeding is associated with a higher narcotic use rate (4 votes, 9%)
C. Adverse events are rare with gastrostomy or jejunostomy in this group of patients (11 votes, 24%)
D. Pain is an uncommon complain in the patients who received a self-expandable metallic stent (1 vote, 2%)

In the July issue of GIE, Yu et al1 prospectively evaluated 81 patients with SCEC who were sent to chemoradiation (definitive treatment in 57.1% and neoadjuvant treatment in 42.9%). From them, 29 remained with exclusive oral intake, 26 were submitted to surgical ostomy, 19 received a nasogastric tube, and 7 received an 18-mm diameter, self-expandable metallic stent. Body weight, quality of life, narcotic requirement, and albumin serum levels were monitored and compared among the groups. Patients had a similar decrease in mean body weight. Narcotic requirements were higher in the stent group as well as in the nasogastric tube. The patients who underwent stent placement had a more marked decrease in serum albumin levels and worsening of quality of life (QoL) scores. More than 10% of the patients submitted to surgical ostomy needed surgical revision for small-bowel obstruction or tube dislodgement. Quoting the authors, "Our preliminary results suggest that ESCC patients using SEMSs during CRT commonly had intense and prolonged chest pain, poorer QoL, and decreased albumin level compared with the other groups. We suggest a careful endoscopic evaluation, recording the cancer location, length, and severity of stenosis to select the population that could choose NG feeding on an as-needed basis during CRT."

1. Yu F-J, shih H-Y, Wu C-Y, et al. Enteral nutrition and quality of life in patients undergoing chemoradiotherapy for esophageal carcinoma: a comparison of nasogastric tube, esophageal stent, and ostomy tube feeding. Gastrointest Endosc 2018;88:21-31.

Correct Answer: D. There is some evidence that these lesions are associated with a higher risk of synchronous advanced neoplasia.

Hyperplastic polyp (HP), sessile serrated adenoma (SSA), and traditional serrated adenoma (TSA) are the subtypes of colorectal serrated lesions. Although the presence of an HP at the sigmoid colon and rectum does not harbor a risk for cancer, HP =10 mm and located proximally to the sigmoid colon may be associated with synchronous colorectal cancer or advanced adenoma. For HPs measuring less than 1 cm and located proximally to the sigmoid colon, you would say:

A. High-quality evidence supports that their presence puts patients at the average-risk screening category. (7 votes, 21%)
B. The available evidence supports the “resect and discard” policy for these lesions. (2 votes, 6%)
C. These lesions are probably not associated with interval colorectal cancer. (6 votes, 18%)
D. There is some evidence that these lesions are associated with a higher risk of synchronous advanced neoplasia (19 votes, 56%)

In the June issue of GIE, Hamoudah et al1 compared the risk of synchronous advanced neoplasia (AN) in 3 groups of patients submitted to colonoscopy: Group 1 – 482 patients with at least one HP located proximally to the sigmoid colon, Group 2 – 1878 patients without proximal HP or sessile serrated polyp, and Group 3 – 691 patients with 1 to 2 sessile serrated polyps smaller than 1 cm, with at least one of them located proximally to the sigmoid colon. The synchronous AN detection rates were 12.7%, 7.1%, and 14.6% in Groups 1, 2, and 3, respectively. There was a significant difference between Groups 1 and 2 (12.7 vs 7.1, P < .001). Another key finding was that, even for diminutive HP located proximally to the sigmoid colon, the synchronous AN detection rate did not change (12.6% in 5 mm vs =12.8% in 6-9 mm; P = 1.00). If replicated by other studies, these findings might have implications on the United States Multi-Society Task Force (USMSTF) recommendations and on the “resect-discard” policy. Quoting the authors: “In summary, our results suggest that even diminutive proximal hyperplastic polyps are associated with greater rates of synchronous advanced neoplasia than in patients with no serrated lesions, and these rates are actually similar to those with small sessile serrated polyps.”

1. Hamoudah T, Ma K, Esteban M, et al. Patients with small and diminutive proximal hyperplastic polyps have higher rates of synchronous advanced neoplasia compared with patients without serrated lesions. Gastrointest Endosc 2018;87:1518-26.

Correct Answer: A. Mutations at BRCA 1, BRAC2, p53, STK11, MSH2, ATM, and APC genes are related to a higher risk of PC.

Pancreatic cancer (PC) is usually detected at a late stage, leading to a dismal prognosis. Most lesions are considered sporadic tumors, and just a few are related to family history or recognized genetic abnormalities. Regarding the screening of PC in high-risk individuals (HRI), you would say that:

A. Mutations at BRCA 1, BRAC2, p53, STK11, MSH2, ATM, and APC genes are related to a higher risk of PC. (16 votes, 47%)
B. In patients with germline mutations, surveillance should begin after 40 years of age, due to the high diagnostic yield for premalignant pancreatic abnormalities. (5 votes, 15%)
C. In patients with germline mutations, CT-scan, MRI/MRCP, and EUS share a similar diagnostic yield for pancreatic abnormalities, eg, cystic or solid mass, hyperechoic strands, or foci. (9 votes, 26%)
D. CA19-9 serum level is a valuable tool for the screening of PC in the general population. (4 votes, 12%)

In the June issue of GIE, Lee et al1 described the results of a screening program in individuals with germline mutations that put them at a higher risk for PC compared with the general population. The authors reviewed a database of EUS procedures performed from 2005 to 2015 in 86 individuals with mutations at BRCA 1, BRAC2, p53, STK11, MSH2, ATM, and APC genes. Only linear EUS was performed. EUS was compared with the findings of CT scan and MRCP performed up to 5 months before or after EUS. Almost 80% of the individuals were women, with a median age of 49 years. A family history of PC was observed in 43% of them. The median follow-up period was 30 months. The authors detected cysts, hyperechoic strands and foci, and mild pancreatic duct dilation in 48%, 44%, and 9% of the individuals, respectively. In total, 27% of them had some pancreatic abnormality (PA). They found no cases of PC. EUS detected more PA than CT or MRI. PA was more commonly detected in patients older than 60 years. Quoting the authors, "Unless otherwise indicated, screening patients less than 50 years of age is low yield. We suggest EUS as the preferred modality for index screening and MRI for surveillance in cases of an unremarkable initial EUS-guided evaluation."

1. DaVee T, Coronel E. Papafragkakis C, et al. Pancreatic cancer screening in high-risk individuals with germline genetic mutations. Gastrointest Endosc 2018;87:1443-50.

Correct Answer: D. In a population with low to moderate risk for dysplasia, narrow-band imaging and acetic acid chromoendoscopy may not increase the diagnostic yield of dysplasia and cancer compared to the Seattle protocol.

What is the role of narrow-band imaging and acetic acid chromoendoscopy in Barrett’s esophagus?

A. There is unequivocal evidence that high-definition white-light endoscopy associated with narrow-band imaging and acetic acid chromoendoscopy can replace 4-quadrant biopsy Seattle protocol for dysplasia surveillance. (20 votes, 24%)
B. The role of narrow-band imaging and acetic acid chromoendoscopy is limited in Barrett’s esophagus, especially due to related adverse event rate, eg, thoracic pain. (6 votes, 7%)
C. The aceto-whitening reaction is limited to 2 to 3 minutes. The areas with longer duration of the reaction should be biopsy-targeted for dysplasia. (20 votes, 24%)
D. In a population with low to moderate risk for dysplasia, narrow-band imaging and acetic acid chromoendoscopy may not increase the diagnostic yield of dysplasia and cancer compared to the Seattle protocol. (37 votes, 45%)

In the May issue of GIE, Beg et al1 evaluated the diagnostic yield of narrow-band imaging and acetic acid chromoendoscopy for dysplasia and cancer in Barrett’s esophagus (BE) of patients from a community-based hospital. The authors compared the diagnostic yield for dysplasia and cancer using 2 different strategies. From 2007 to 2010 (first period), the strategy to detect dysplasia and cancer in BE was based on white-light high-definition endoscopy associated with the Seattle protocol. From May 2010 to March 2011, a Barrett’s team was trained in narrow-banding imaging plus acetic acid chromoendoscopy. From April 2011 to April 2014 (second period), the Barrett’s team used this more refined strategy (NBI + acetic acid) for the detection of dysplasia and early cancer in BE of 3 cm or more. The total number of procedures was 560 in the first period (2007-2010) and 856 in the second period (2001-2014). The mean length of BE segment was 4.4 and 3.8cm for the first and second periods, respectively. Low-grade dysplasia was detected in 9.7% and 14.7% in the first and second periods, respectively (P = .2). High-grade dysplasia/cancer was detected in 2.9% and 1.8% in the first and second periods, respectively (P = .5). No difference in dysplasia /cancer detection was observed between the 2 periods of the investigation. Quoting the authors: "Advanced imaging techniques are a useful adjunct in selected high-risk cases but do not necessarily confer increased dysplasia detection with routine use in low to moderate risk cases of Barrett’s esophagus. These findings concur with the recommendations of existing guidelines, which advocate the continued use of quadratic biopsies in general surveillance programs."

1. Beg S, Mensa M, Fullard M, et al. Impact of advanced endoscopic imaging on Barrett’s esophagus in daily clinical practice. Gastrointest Endosc 2018;87:1189-94.

A 49-year-old female patient is referred for the evaluation of the second attack of acute pancreatitis (AP) within a 3-month interval. During the hospitalization, she was submitted to abdominal ultrasound and CT-scan. Both imaging studies demonstrated the presence of edema of the pancreas and peripancreatic fat. Calcium and triglycerides serum levels were within the normal range. She denied alcohol abuse, chronic use of medications, or previous surgery. She was discharged from the hospital 2 weeks before the consultation. Which test would you select to complement the diagnostic workup of AP?

B. MRCP with secretin stimulation (13 votes, 30%)
D. EUS with secretin stimulation (5 votes, 11%)

In the May issue of GIE, Wan et al1 conducted a systematic review with meta-analysis (SRMA) comparing MRCP and EUS for the diagnosis of the etiology of AP. From 13,411 related studies, they found 7 studies that used both MRCP and EUS for the diagnostic workup of patients with AP. The overall diagnostic yield was 64% (153/239 patients) for EUS and 34% (82/238) for MRCP (P < .001). The heterogeneity among studies was low (I2 = 10%). The authors have also pooled the results of studies, which individually described the diagnostic yield of EUS, MRCP, and MRCP with secretin stimulation (S-MRCP) for specific conditions, such biliary lithiasis, chronic pancreatitis, and pancreas divisum. Compared with MRCP and S-MRCP, EUS had a higher diagnostic yield for biliary lithiasis and chronic pancreatitis. On the other hand, S-MRCP performed better than MRCP and EUS for the diagnosis of pancreas divisum. For the hypothetical case above (49-year-old female patient with recurrent acute pancreatitis, without previous surgery), the most probable etiologies of AP are gallbladder lithiasis and periampullary neoplasms. For both conditions, EUS seems to have a higher diagnostic yield when compared to MRCP or S-MRCP and should be performed 4 to 6 weeks after the end of the acute attack. Quoting the authors: “In conclusion, EUS and MRCP should both be used in the diagnostic work-up of idiopathic acute pancreatitis (IAP) as complementary techniques. EUS had a higher diagnostic accuracy than MRCP (64% vs 34%) in the etiological diagnosis of IAP and should be preferred for establishing a possible biliary disease and chronic pancreatitis diagnosis, whereas S-MRCP was superior to EUS and MRCP in diagnosing a possible anatomical alteration in the biliopancreatic ductal system, such as pancreatic divisum.”

1. Wan J, Ouyang Y, Yu C, et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc 2018;87:1180-8.

Correct Answer: A. Anticoagulant bridging therapy with heparin, polyp size ≥20 mm, and polyp location in the right side of the colon

A 57-year-old male patient is referred for his first screening colonoscopy. His medical history includes hypertension, diabetes, and the use of warfarin for chronic atrial fibrillation. Which are the risk factors for postpolypectomy bleeding?

A. Anticoagulant bridging therapy with heparin, polyp size ≥20 mm, and polyp location in the right side of the colon (17 votes, 47%)
B. Restart warfarin within 10 days of the procedure, polyp size ≥10 mm, and polyp location in the right side of the colon (2 votes, 6%)
C. No prophylactic clip placement, endoscopic mucosal resection, polyp location in the right side of the colon (10 votes, 28%)
D. Cautery use in the sigmoid colon, polyp size ≥15 mm, polyp location in the right side of the colon (7 votes, 19%)

In the April issue of GIE, Lin et al1 evaluated the postpolypectomy bleeding risk in a large retrospective cohort of 4,923 male patients who were on warfarin, low molecular weight heparin, clopidogrel, or aspirin. This cohort represents roughly 25% of the total number of patients submitted to colonoscopy with polypectomy during the same period (n = 20,372 patients, Jan 2004 – June 2012, 2 VA centers). The overall postpolypectomy bleeding rate was 1.2% (95% CI, 0.9-1.5). The authors matched the 59 patients who bled with 174 patients who did not present postpolypectomy bleeding. Patients were matched for antithrombotic agent, VA site, polypectomy technique, and timing of the procedure. Patients on warfarin with bridging therapy were matched with patients on warfarin without bridging therapy. The risk factors for postpolypectomy bleeding were polyp size ≥20 mm (OR, 5.1; 95% CI, 2-14), restart antithrombotic therapy within 1 week (OR, 4.5; 95% CI, 2.2-9.4), multiple large polyps (OR, 2.92; 95% CI, 1.14-7.29), cautery use in the right side of the colon (OR, 2.61; 95% CI, 1.29-5.52) and heparin bridge therapy (OR, 14.4; 95% CI, 3.28-71.8). In 68% of the cases, postpolypectomy bleeding occurred within 3 days of procedure. It was typically a severe adverse event. Most patients required hospitalization (76%), blood transfusion (76%), urgent colonoscopy (83%), and received endoscopic hemostatic interventions (88%). There were no radiologic or surgical interventions, thromboembolic events, or death. Quoting the authors, "A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk."

1. Lin D, Soetikno RM, McQuaid K, et al. Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications. Gastrointest Endosc 2018;87:1106-13.

Correct Answer: B. An esophageal stricture that was not appreciated on EGD

A 29-year-old male patient with a previous diagnosis of eosinophilic esophagitis (EoE) is referred for evaluation of dysphagia for some solid foods. He was diagnosed with EoE 5 months before and he has been complaining of dysphagia in the previous 3 weeks. He was submitted to an EGD, which revealed mild mucosal edema in the distal 2/3 of the esophagus. No fibrostenotic changes were detected. Eosinophils count was 11 cells per high-power field on histology. A barium upper GI study was indicated. Which are the most probable expected findings?

A. Esophageal furrowing and exudate, both non-appreciated on EGD (20 votes, 20%)
B. An esophageal stricture that was not appreciated on EGD (26 votes, 25%)
C. Esophageal rings, difficult to be detected on EGD (26 votes, 25%)

In the April issue of GIE, Nelson et al1 retrospectively evaluated 70 patients with EoE who were submitted to EGD and a barium upper GI (UGI) study within 6 months of each other. A senior radiologist who was aware of the diagnosis but was masked to previous UGI and endoscopic findings reviewed the UGI studies. They used the EoE endoscopic reference score (EREFS2) to review EGD reports and considered a score ≥1 consistent with the diagnosis of EoE. The authors compared the endoscopic and the radiologic findings. They found that the radiologist’s awareness of the diagnosis improved the UGI sensitivity for the diagnosis of EoE. In addition, EGD had a greater sensitivity for the diagnosis of inflammatory changes (furrowing, mucosal edema) and rings than UGI. On the other hand, UGI had a greater sensitivity to detect strictures than EGD (59 vs 40% respectively, P = .01). This is probably due to long, subtle strictures that may prove difficult to detect on EGD. Quoting the authors, "GI and EGD may provide complementary information in the comprehensive evaluation of EoE disease activity."

1. Nelson MJ, Miller FH, Moy N, et al. Comparison of endoscopy and radiographic imaging for detection of esophageal inflammation and remodeling in adults with eosinophilic esophagitis. Gastrointest Endosc 2018;87:962-8.

2. Hirano I, Moy N, Heckman MG et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 2013;62:489-95.

Correct Answer: D. DOPys scores vary among trained colonoscopists. The best scores do not correlate with other metrics such as adenoma detection rate and colonoscope withdrawal time.

The quality of performed colon polypectomy can be assessed by using the Direct Observation of Polypectomy Skills (DOPys) scoring system. Concerning the colon polypectomy quality assessment, you believe that:

A. It is relevant for the reduction of polypectomy-related adverse events rate but it is unimportant for the referral to surgery and interval colorectal cancer rates. (0 votes, 0%)
B. DOPys scores present low variation among experienced, well-trained colonoscopists. (0 votes, 0%)
C. DOPys scores vary among trained colonoscopists. The best scores correlates with other metrics such as adenoma detection rate and colonoscope withdrawal time. (3 votes, 50%)
D. DOPys scores vary among trained colonoscopists. The best scores do not correlate with other metrics such as adenoma detection rate and colonoscope withdrawal time. (3 votes, 50%)

In the March issue of GIE,1 Duloy et al used the Direct Observation of Polypectomy Skills (DOPys) scoring system to assess the polypectomy skills of 13 high-volume screening colonoscopists. Two previously trained raters evaluated edited videotapes of 130 polypectomies. DOPys scores varied significantly among colonoscopists, ranging from 30% to 90%. The authors found that polyps smaller than 6 mm were more competently removed. They also noticed inadequate use of cold forceps polypectomy and low rates of submucosa-lifting polypectomy. In addition, they did not find a correlation between polypectomy competency rates with adenoma detection rate or withdrawal time. Quoting the authors: "In other words, endoscopists who are high-quality adenoma detectors are not necessarily high-quality adenoma removers."

1. Duloy AM, Kaltenbach TR, Keswani RN. Assessing colon polypectomy competency and its association with established quality metrics. Gastrointest Endosc 2018;87:635-44.

Correct Answer: C. The inadequate bowel preparation in one of the segments of the colon (<2 score) associated with the finding of a polyp increase the risk of both polyp and advance polyp detection at subsequent colonoscopy within a short timeframe.

During a 53-year-old gentleman’s first screening colonoscopy, the Boston Bowel Preparation Scale scored 1-2-3 for the right-sided, transverse, and left-sided colon, respectively. A 4-mm low-grade sessile adenoma was resected from the descending colon. What are the implications of these findings for the colorectal cancer screening program of this particular patient?

A. The fact that an adenoma smaller than 5mm could be identified is reassuring of the good quality of bowel preparation. (3 votes, 3%)
B. The inadequate bowel preparation of the right side of the colon and the finding of a low-grade adenoma in the descending colon increase the risk of a missed serrated lesion in the right colon.(39 votes, 39%)
C. The inadequate bowel preparation in one of the segments of the colon (<2 score) associated with the finding of a polyp increase the risk of both polyp and advance polyp detection at subsequent colonoscopy within a short timeframe. (56 votes, 55%)
D. The inadequate bowel preparation of the right side of the colon should not change the recommendation for the interval of the next colonoscopy. (3 votes, 3%)