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Background: Published decision analyses show that screening for colorectal cancer is cost-effective. However, because of the number of tests available, the optimal screening strategy in Canada is unknown. We estimated the incremental cost-effectiveness of 10 strategies for colorectal cancer screening, as well as no screening, incorporating quality of life, noncompliance and data on the costs and benefits of chemotherapy.Methods: We used a probabilistic Markov model to estimate the costs and quality-adjusted life expectancy of 50-year-old average-risk Canadians without screening and with screening by each test. We populated the model with data from the published literature. We calculated costs from the perspective of a third-party payer, with inflation to 2007 Canadian dollars.Results: Of the 10 strategies considered, we focused on three tests currently being used for population screening in some Canadian provinces: low-sensitivity guaiac fecal occult blood test, performed annually; fecal immunochemical test, performed annually; and colonoscopy, performed every 10 years. These strategies reduced the incidence of colorectal cancer by 44%, 65% and 81%, and mortality by 55%, 74% and 83%, respectively, compared with no screening. These strategies generated incremental cost-effectiveness ratios of $9159, $611 and $6133 per quality-adjusted life year, respectively. The findings were robust to probabilistic sensitivity analysis. Colonoscopy every 10 years yielded the greatest net health benefit.Interpretation: Screening for colorectal cancer is cost-effective over conventional levels of willingness to pay. Annual high-sensitivity fecal occult blood testing, such as a fecal immunochemical test, or colonoscopy every 10 years offer the best value for the money in Canada. [ABSTRACT FROM AUTHOR]

Introduction/Objective  Colonoscopy with polypectomy is an integral component of colorectal cancer screening. There are limited data and consensus on periprocedural anticoagulation management, especially regarding bleeding risk with uninterrupted anticoagulation and thromboembolic risk with interruption. Our aim was to determine the incidence of bleeding and thromboembolic complications among colon screening participants undergoing colonoscopy following implementation of a novel patient care pathway for standardized periprocedural anticoagulation management. Methods  We conducted a retrospective study including all participants (age 50-74) on an oral anticoagulant (e.g., vitamin K antagonists, direct oral anticoagulants) referred to the British Columbia Colon Screening Program for colonoscopy following abnormal fecal immunochemical test in a 6-month period (March-August 2022). Data relating to their specific periprocedural anticoagulant management and colonoscopy results including method of polypectomy were obtained. Primary outcomes were major bleeding and arterial or venous thromboembolic events from time of oral anticoagulant interruption until 14 days of postcolonoscopy. Secondary outcomes included nonmajor and minor bleeding, acute coronary syndrome, emergency room visit, hospital admission, and death due to any cause. Results  Over the 6-month period, 162 participants completed standardized periprocedural anticoagulation management, colonoscopy ± polypectomy, and 14-day follow-up. One (0.6%) had a major bleeding event and one (0.6%) had an arterial thromboembolic event. Conclusions  A novel patient care pathway for standardized periprocedural anticoagulation management with a multidisciplinary team is associated with low rates of major bleeding and thrombotic complications after colonoscopy with polypectomy., Competing Interests: Conflict of Interest T.W. received honoraria from AstraZeneca for the development of the regional direct oral anticoagulant reversal order set. M.C., J.Y., J.T., and T.D. have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

Importance: Recent US guideline updates have advocated for colorectal cancer (CRC) screening to begin at age 45 years in average-risk adults, whereas Canadian screening programs continue to begin screening at age 50 years. Similarities in early-onset CRC rates in Canada and the US warrant discussion of earlier screening in Canada, but there is a lack of Canadian-specific modeling data to inform this., Objective: To estimate the association of a lowered initiation age for CRC screening by biennial fecal immunochemical test (FIT) with CRC incidence, mortality, and health care system costs in Canada., Design, Setting, and Participants/exposures: This economic evaluation computational study used microsimulation modeling via the OncoSim platform., Main Outcomes and Measures: Modeled rates of CRC incidence, mortality, and health care costs in Canadian dollars., Results: This analysis included 4 birth cohorts (1973-1977, 1978-1982, 1983-1987, and 1988-1992) representative of the Canadian population accounting for previously documented effects of increasing CRC incidence in younger birth cohorts. Screening initiation at age 45 years resulted in a net 12 188 fewer CRC cases, 5261 fewer CRC deaths, and an added 92 112 quality-adjusted life-years (QALYs) to the cohort population over a 40-year period relative to screening from age 50 years. Screening initiation at age 40 years yielded 18 135 fewer CRC cases, 7988 fewer CRC deaths, and 150 373 QALYs. The cost per QALY decreased with younger birth cohorts to a cost of $762 per QALY when Canadians born in 1988 to 1992 began screening at age 45 years or $2622 per QALY with screening initiation at age 40 years. Although costs associated with screening and resulting therapeutic interventions increased with earlier screening, the overall health care system cost of managing CRC decreased., Conclusions and Relevance: This economic evaluation study using microsimulation modeling found that earlier screening may reduce CRC disease burden and add life-years to the Canadian population at a modest cost. Guideline changes suggesting earlier CRC screening in Canada may be justified, but evaluation of the resulting effects on colonoscopy capacity is necessary.

Background: Development of bowel preparation products has been based upon colon cleansing rating by a local endoscopist. It is unclear how bowel preparation scales perform when centrally evaluated., Aims: To evaluate the reliability of bowel preparation quality scales when assessed by central readers., Methods: Four central readers evaluated 52 videos in triplicate, 2 weeks apart, during the entire endoscopic procedure (insertion/withdrawal of the colonoscope) and exclusively on colonoscope withdrawal using the Boston Bowel Preparation Scale (BBPS), Chicago Bowel Preparation scale, Harefield Cleansing Scale, Ottawa Bowel Preparation Quality Scale (OBPQS), Aronchick score, a visual analogue scale, and additional items proposed in a modified Research and Development/University of California Los Angeles appropriateness process. Reliability was assessed with intraclass correlation coefficients., Results: Intraclass correlation coefficients (95% confidence interval) for inter-rater reliability of the quality scales ranged from 0.51 to 0.65 (consistent with moderate to substantial inter-rater reliability) during the entire procedure. Corresponding intraclass correlation coefficients for intra-rater reliability ranged from 0.69 to 0.77 (consistent with substantial intra-rater reliability). Reliability was highest in the right colon and lowest in the left colon. No differences were observed in reliability when assessed for the procedure overall (insertion/withdrawal) relative to assessment on withdrawal alone., Conclusion: All five bowel preparation quality scales had moderate to substantial inter-rater reliability. Panelists considered the Aronchick score too simplistic for clinical trials and recognized that assessment of residual fluid in the Ottawa Bowel Preparation Quality Scale was not amenable to central assessment., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Competing Interests: Competing interests: NF is a consultant for and has received speaker’s fees from Pentax Medical and Boston Scientific, is a consultant for Pendopharm and has received research funding from Pentax Medical. MA has received speaker’s fees from Olympus, Medtronic and Fujifilm and is a consultant for Ambu. Y-IC is a consultant for Boston Scientific and has received research funding from Boston Scientific. KM is a consultant for Sebela Pharmaceuticals, Pentax, Boston Scientific and Fujifilm and owns shares in Kate Farms and Virgo SVS. PDS has received research funding from Pentax Medical, The E-Nose company, MicroTech, Norgine and Motus GI, and is on the advisory board of Boston Scientific and Motus GI. ZLS is a consultant for STERIS Endoscopy. JJT has received research funding from Penodpharm and was on an advisory board for Pendopharm. SW is a consultant for Exact Sciences and Interpace, is on the Advisory Board for Cernostics and has received research funding from Lucid, Ambu and CDx. All other authors have no conflicts to declare.

Background & Aims: The aim of this study was to compare high-volume polyethylene glycol (PEG) with low-volume PEG with bisacodyl split-dosing regimens., Methods: Adult outpatients in 10 Canadian tertiary hospitals were randomized, stratified by morning or afternoon colonoscopy, to high-volume split-dose PEG (2 L + 2 L) (High-SD) or low volume (1 L + 1 L) + bisacodyl (15 mg) PEG (Low-SD), with a second randomization to liquid or low-residue diets. The primary end point, using noninferiority hypothesis testing, was adequate bowel cleansing (Boston Bowel Preparation Scale total score of ≥6, with each of 3 colonic segments subscores ≥2). Secondary objectives were willingness to repeat the preparation, withdrawal time, cecal intubation, and polyp detection rates., Results: Over 29 months, 2314 subjects were randomized to High-SD (N = 1157) or Low-SD (N = 1157) (mean age, 56.2 ± 13.4 y; 52.1% women). Colonoscopy indications were 38.2% diagnostic, 36.8% screening, and 25.0% surveillance, with no between-group imbalances in patient characteristics. Low-SD satisfied noninferiority criteria vs High-SD for adequate bowel cleanliness with only marginally inferior results (90.1% vs 88.1%; P = .02; difference, 2.0%; 95% CI [0.0%; 4.5%]). High-SD was associated with lower willingness to repeat (66.9% vs 91.9%; P < .01), was less well tolerated (7.3 ± 2.3 vs 8.1 ± 1.9; P < .01), causing more symptoms. No differences in procedural outcomes were noted except for more frequent cecal intubation rates after High-SD (97.4% vs 95.6%; P = .02). Among the High-SD group, adequate bowel preparation was greater after a clear liquid diet (93.6% vs 87.9%; P < .01), a finding not seen in the Low-SD group., Conclusions: Low-SD is noninferior to High-SD in providing adequate bowel preparation. Low-SD results in fewer symptoms, with greater willingness to repeat and tolerability. The overall impact of diet was modest.The study was approved by the research ethic boards from all sites and was registered at ClinicalTrials.gov (NCT02547571)., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Antithrombotic medications, including antiplatelet drugs and anticoagulants, are widely prescribed to prevent thromboembolic disease. There is limited evidence informing gastroenterologists of the management of patients on antithrombotic medications undergoing colonoscopy and polypectomy. A patient's risk of thromboembolism versus postpolypectomy bleeding should be carefully considered, incorporating patient preferences concerning benefits and harms of temporary antithrombotic interruption. We will review the available consensus guidelines, current literature, and strategies to mitigate the risk of bleeding following polypectomy. These will be interpreted in the framework of shared decision-making with the patient to arrive at the safest solution best aligned with the patient's preferences., Competing Interests: Disclosure The authors have no disclosures, (Copyright © 2021 Elsevier Inc. All rights reserved.)

We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1-7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1-7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence., (Copyright © 2022 The American College of Gastroenterology and the Canadian Association of Gastroenterology.)

Background: Serrated lesions give rise to 15% to 30% of all colorectal cancers, driven predominantly by the sessile serrated polyp (SSP). Fecal immunochemical test (FIT), has low sensitivity for SSPs. SSP detection rate (SSPDR) is influenced by performance of both endoscopists and pathologists, as diagnosis can be subtle both on endoscopy and histology., Goals: To evaluate the SSPDR in a population-based screening program, and the influence of subspecialty trained pathologists on provincial reporting practices., Study: The colon screening program database was used to identify all FIT-positive patients that received colonoscopy between January 2014 and June 2017. Patient demographics, colonoscopy quality indicators, pathologic diagnoses, and FIT values were collected. This study received IRB approval., Results: A total of 74,605 colonoscopies were included and 26.6% had at least 1 serrated polyp removed. The SSPDR was 7.0%, with 59% of the SSPs detected having a concurrent conventional adenoma. The mean FIT value for colonoscopies with only serrated lesions was less than that for colonoscopies with a conventional adenoma or colorectal cancer (P<0.0001). Centers with a gastrointestinal subspecialty pathologist diagnosed proportionally more SSPs (P<0.0001), and right-sided SSPs than centers without subspecialists., Conclusions: Serrated lesions often occur in conjunction with conventional adenomas and are associated with lower FIT values. Knowledge of the characteristics of SSPs is essential for pathologists to ensure accurate diagnosis of SSPs., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and second leading cause of cancer death in Canada. Organized screening programs targeting Canadians aged 50 to 74 at average risk of developing the disease have contributed to decreased rates of CRC, improved patient outcomes and reduced healthcare costs. However, data shows that recent incidence reductions are unique to the screening-age population, while rates in people under-50 are on the rise. Similar incidence patterns in the United States prompted the American Cancer Society and U.S. Preventive Services Task Force to recommend screening begin at age 45 rather than 50. We conducted a review of screening practices in Canada, framing them in the context of similar global health systems as well as the evidence supporting the recent U.S. recommendations. Epidemiologic changes in Canada suggest earlier screening initiation in average-risk individuals may be reasonable, but the balance of costs to benefits remains unclear.

Introduction: Bowel cleanliness has been shown to be superior with split-dose vs nonsplit preparations; we aimed to directly assess the poorly characterized comparative efficacies of split-dose vs same-day polyethylene glycol (PEG) regimens., Methods: In this study, one of a series of randomized trials performed across 10 Canadian endoscopy units, patients undergoing colonoscopies between 10:30 and 16:30 were allocated to PEG low-volume same-day (15 mg bisacodyl the day before, 2 L the morning of the procedure), low-volume split-dose (15 mg bisacodyl the day before, 1 L + 1 L), or high-volume split-dose (2 L + 2 L). Coprimary endpoints were adequate bowel cleansing based on the Boston Bowel Preparation Scale using in turn different threshold cutoffs., Results: Overall, 1,750 subjects were randomized equally across the 3 groups, with no differences in adequate bowel cleanliness rates (low-volume same-day, 90.5%; high-volume split-dose, 92.2%; P = 0.34; and low-volume split-dose, 87.9%; P = 0.17) for the Boston Bowel Preparation Scale ≥6 and 2 for each segment. Willingness to repeat the preparation was not significantly different between low-volume same-day (91.0%) and low-volume split-dose (92.5%; P = 0.40) but was greater than the high-volume split-dose (68.9%; P < 0.01). No significant differences were noted for withdrawal time, cecal intubation, or polyp detection rates., Discussion: In this large randomized trial of PEG regimens, low-volume same-day resulted in similar bowel cleanliness compared with high-volume or low-volume split-dosing. Willingness to repeat and tolerability were superior with low-volume same-day compared with high-volume split-dose and similar to low-volume split-dose.

Background: The British Columbia Colon Screening Program (BCCSP) is a population-based colon cancer screening program. In December 2018, physicians in Vancouver, Canada agreed to switch from a low-volume split preparation to a high-volume polyethylene glycol preparation after a meta-analysis of studies suggested superiority of the higher volume preparation in achieving adequate bowel cleansing and improving adenoma detection rates., Aims: To compare the quality of bowel preparation and neoplasia detection rates using a high-volume split preparation (HVSP) versus a low-volume split preparation (LVSP) in patients undergoing colonoscopy in the BCCSP., Methods: A retrospective review of patients undergoing colonoscopy through the BCCSP at St. Paul's Hospital from July 2017 to November 2018 and December 2018 to November 2019 was conducted. Inclusion criteria included age 50 to 74 and patients undergoing colonoscopy through the BCCSP. Variables collected included patient demographics and bowel preparation quality. Rates of bowel preparation and neoplasia detection were analyzed using chi-squared test., Results: A total of 1453 colonoscopies were included, 877 in the LVSP group and 576 in the HVSP group. No statistically significant difference was noted between rates of inadequate bowel preparation (LVSP 3.6% versus HVSP 2.8%; P = 0.364). Greater rates of excellent (48.4% versus 40.1%; P = 0.002) and optimal (90.1% versus 86.5%; P = 0.041) bowel preparation were achieved with HVSP. The overall adenoma detection rate was similar between the two groups (LVSP 53.1% versus HVSP 54.0%; P = 0.074). LVSP demonstrated higher overall sessile serrated lesion detection rate (9.5% versus 5.6%; P = 0.007)., Conclusions: Compared to LVSP, HVSP was associated with an increase in excellent and optimal bowel preparations, but without an improvement in overall neoplasia detection., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

Malignant colorectal polyps have a risk of lymph node metastases between 9 and 24%, but patients who are negative for certain histologic poor prognostic factors have the potential to be treated with polypectomy alone. Retrospective cohort of 216 malignant polyps from 213 patients identified through the British Columbia Colon Screening Program. Complete pathologic reporting (reporting of tumor grade, lymphovascular invasion, margin status, and tumor budding) was present in only 43% of patients. Sixty-one patients had no poor prognostic factors on polypectomy, and 23 (37%) of those underwent surgery. A positive margin cutoff of tumor at cautery showed significantly increased rates of lymph node metastases (p = 0.04) compared to a margin of greater than 0 mm, and polyps with a margin of greater than 0 mm had no risk of residual carcinoma. A submucosal depth of ≥ 2000 μm had an increased rate of lymph node metastases compared to < 2000 μm (p = 0.01). Malignant polyps with either tumor at cautery or a submucosal depth of ≥ 2000 μm, compared to polyps without these risk factors, had a relative risk for lymph node metastases of 16.3. Adoption of submucosal depth and refinement of the cutoffs for positive margin and submucosal depth have the potential to identify high-risk patients and reduce the number of surgeries required in patients with malignant polyps, a group that continues to grow significantly in part due to the introduction of colon screening programs.

Background: Colorectal cancer (CRC) screening is an evidence-based strategy to reduce CRC-related mortality., Objective: This study identifies physician and participant characteristics, as well as previous FIT values associated with premature FIT usage., Design: This is a retrospective review of all FITs ordered from January 1, 2016, until June 30, 2017. For each ordered FIT, the participant's chart was reviewed to identify if a previous FIT had occurred in the prior 21 months. A premature FIT was defined as an ordered test with a negative FIT in the preceding 21 months., Participants: Screening participants were average risk for CRC, aged 50-74, and had a FIT ordered by their primary care provider in British Columbia, Canada., Main Measures: The BC College of Physicians and Surgeons' database was used to identify the location of referring physician, date of graduation from medical school, and gender. The participant's age, gender, and value of previous FIT were recorded. Physician and participant variables and previous FIT value were examined with logistic regression to identify associations with premature FIT ordering., Key Results: In total, 385,375 FITs were ordered during this period with 116,727 representing participants returning following a previous negative FIT. In total, 35,148 (30.1%) returned early for screening. Men were more likely to return early than women (OR 1.14; 95% CI 1.11-1.17; p < 0.0001). Male physicians were more likely to order premature FITs (OR 1.15; 95% CI 1.06-1.24; p < 0.0001). A higher quantitative FIT value (ng/mL) of the previous FIT was also associated with early screening (OR 1.11; 95% CI 1.09-1.14; < 0.0001)., Conclusions: This study found that approximately 30% of FIT tests, ordered for CRC screening, were ordered before they were due. This may lead to wasted resources, unnecessary participant stress, and unwarranted patient risk.

Objective: To review and summarize the recently developed Canadian Association of Gastroenterology screening recommendations for patients with a family history of colorectal cancer (CRC) or adenoma from a family medicine perspective., Quality of Evidence: A systematic review and meta-analysis was performed to synthesize knowledge regarding family history and CRC. The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched with the following MeSH terms: colorectal cancers or neoplasms, screen or screening or surveillance, and family or family history. Known hereditary syndromes were excluded. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to establish certainty in reviewed evidence. Most recommendations are conditional recommendations with very low-quality evidence., Main Message: Individuals who have 1 first-degree relative (FDR) with CRC or an advanced adenoma diagnosed at any age are recommended to undergo colonoscopy every 5 to 10 years starting at age 40 to 50 years or 10 years younger than the age at diagnosis of the FDR, although fecal immunochemical testing at an interval of every 1 to 2 years can be used. Individuals with FDRs with non-advanced adenomas or a history of CRC in second-degree relatives should be screened according to average-risk guidelines. Lifestyle modification can statistically significantly decrease risk of CRC and should be considered in all patients., Conclusion: These guidelines acknowledge the many factors that can increase an individual's risk of developing CRC and allow for judgment to be employed depending on the clinical scenario. Lifestyle advice already given to patients for weight, blood pressure, and heart disease management will reduce the risk of CRC if implemented, and this combined with more targeted screening for higher-risk individuals will hopefully be successful in decreasing CRC mortality in Canada., (Copyright© the College of Family Physicians of Canada.)

Background: Wait times for gastroenterology care in Canada exceed recommended benchmarks set by the Canadian Association of Gastroenterology wait-time consensus. Patient-centered prioritization tools may help improve efficiency., Methods: We conducted a survey on gastroenterology outpatients assessing their experience with accessing care, global health status and health care service utilization while waiting for a gastroenterology appointment. Thematic analysis of survey results informed the questions for a discrete choice experiment (DCE). Three attributes included were the following: clinical indication, functional status and time already waiting, which the study patients considered when prioritizing hypothetical patients. The DCE was analyzed using a conditional logit model., Results: One hundred seventy-three patients completed all questions and were included in the final analysis. Over 80% reported good or excellent physical and mental health with 11% utilizing health care resources while waiting; 14% had waited more than 25 weeks for their appointment. Seventy-seven per cent of the patients were satisfied or better with their experience. Eighty-one per cent of the patients agreed with a prioritization system. Patients would prioritize a patient with a potentially more severe diagnosis or functional impairment over a patient with a less severe diagnosis clinical or functional impairment who had been waiting longer. The most severe clinical attributes were prioritized over the most severe functional attributes., Conclusion: Patients support a prioritization tool for access to gastroenterology care. DCE indicated that patients are willing to wait longer in order for those with more severe clinical or functional attributes to be seen earlier. The relative times patients are willing to wait could be used to create a prioritization model for outpatients referred to gastroenterology., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

Background: Nonpharmacologic factors, including patient education, affect bowel preparation for colonoscopy. Optimal cleansing increases quality and reduces repeat procedures. This study prospectively analyzes use of an individualized online patient education module in place of traditional patient education., Aims: To determine the effectiveness of online education for patients, measured by the proportion achieving sufficient bowel preparation. Secondary measures include assessment of patient satisfaction., Methods: Prospective, single-center, observational study. Adults aged 19 years and over, with an e-mail account, scheduled for nonurgent colonoscopy, with English proficiency (or someone who could translate for them) were recruited. Demographics and objective bowel preparation quality were collected. Patient satisfaction was assessed via survey to assess clarity and usefulness of the module., Results: Nine hundred consecutive patients completed the study. 84.6% of patients achieved adequate bowel preparation as measured by Boston bowel preparation score ≥ 6 and 90.1% scored adequately using Ottawa bowel preparation score ≤7. 94.2% and 92.1% of patients rated the web-education module as 'very useful' and 'very clear', respectively (≥8/10 on respective scales)., Conclusions: Our analysis suggests that internet-based patient education prior to colonoscopy is a viable option and achieves adequate bowel preparation. Preparation quality is comparable to previously published trials. Included patients found the process clear and useful. Pragmatic benefits of a web-based protocol such as time and cost savings were not formally assessed but may contribute to greater satisfaction for endoscopists and patients., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

Background & Aims: A family history (FH) of colorectal cancer (CRC) increases the risk of developing CRC. These consensus recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on screening these high-risk individuals., Methods: Multiple parallel systematic review streams, informed by 10 literature searches, assembled evidence on 5 principal questions around the effect of an FH of CRC or adenomas on the risk of CRC, the age to initiate screening, and the optimal tests and testing intervals. The GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach was used to develop the recommendations., Results: Based on the evidence, the Consensus Group was able to strongly recommend CRC screening for all individuals with an FH of CRC or documented adenoma. However, because most of the evidence was very-low quality, the majority of the remaining statements were conditional ("we suggest"). Colonoscopy is suggested (recommended in individuals with ≥2 first-degree relatives [FDRs]), with fecal immunochemical test as an alternative. The elevated risk associated with an FH of ≥1 FDRs with CRC or documented advanced adenoma suggests initiating screening at a younger age (eg, 40-50 years or 10 years younger than age of diagnosis of FDR). In addition, a shorter interval of every 5 years between screening tests was suggested for individuals with ≥2 FDRs, and every 5-10 years for those with FH of 1 FDR with CRC or documented advanced adenoma compared to average-risk individuals. Choosing screening parameters for an individual patient should consider the age of the affected FDR and local resources. It is suggested that individuals with an FH of ≥1 second-degree relatives only, or of nonadvanced adenoma or polyp of unknown histology, be screened according to average-risk guidelines., Conclusions: The increased risk of CRC associated with an FH of CRC or advanced adenoma warrants more intense screening for CRC. Well-designed prospective studies are needed in order to make definitive evidence-based recommendations about the age to commence screening and appropriate interval between screening tests., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is the method of choice for sampling pancreatic lesions. This study compares the diagnostic accuracy and safety of FNB using a novel core needle to FNA in solid pancreatic lesions., Methods: A retrospective review of patients in whom EUS FNA or FNB was performed for solid pancreatic lesions was conducted. Diagnostic performance was calculated based upon a dual classification system: classification 1, only malignant pathology considered a true positive, versus classification 2, atypical, suspicious, and malignant pathology considered a true positive., Results: 43 patients underwent FNB compared with 51 FNA. Using classification 1, sensitivity was 74.0% versus 80.0%, specificity 100% versus 100%, and diagnostic accuracy 77.0% versus 80.0% for FNB versus FNA, respectively (all p > 0.05). Using classification 2, sensitivity was 97% versus 94.0%, specificity 100% versus 100%, and diagnostic accuracy 98.0% versus 94.0% for FNB versus FNA, respectively (all p > 0.05). FNB required significantly fewer needle passes (median = 2) compared to FNA (median = 3; p < 0.001). Adverse events occurred in two (4.5%) FNB patients compared with none in the FNA group ( p > 0.05)., Conclusion: FNA and FNB have comparable sensitivity and diagnostic accuracy. FNB required fewer passes.

Background: Periodically surveying wait times for specialist health services in Canada captures current data and enables comparisons with previous surveys to identify changes over time., Methods: During one week in April 2012, Canadian gastroenterologists were asked to complete a questionnaire (online or by fax) recording demographics, reason for referral, and dates of referral and specialist visits for at least 10 consecutive new patients (five consultations and five procedures) who had not been seen previously for the same indication. Wait times were determined for 18 indications and compared with those from similar surveys conducted in 2008 and 2005., Results: Data regarding adult patients were provided by 173 gastroenterologists for 1374 consultations, 540 procedures and 293 same-day consultations and procedures. Nationally, the median wait times were 92 days (95% CI 85 days to 100 days) from referral to consultation, 55 days (95% CI 50 days to 61 days) from consultation to procedure and 155 days (95% CI 142 days to 175 days) (total) from referral to procedure. Overall, wait times were longer in 2012 than in 2005 (P<0.05); the wait time to same-day consultation and procedure was shorter in 2012 than in 2008 (78 days versus 101 days; P<0.05), but continued to be longer than in 2005 (P<0.05). The total wait time remained longest for screening colonoscopy, increasing from 201 days in 2008 to 279 days in 2012 (P<0.05)., Discussion: Wait times for gastroenterology services continue to exceed recommended targets, remain unchanged since 2008 and exceed wait times reported in 2005.

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management in most situations when a benign biliary stricture is suspected. Although management principles are similar in all subgroups, the anticipated response rates, need for ancillary medical and endoscopic approaches, and use of less proven strategies vary between differing causes. Exclusion of malignancy should always be a focus of management. Newer endoscopic techniques such as endoscopic ultrasound, cholangioscopy, confocal endomicroscopy, and metal biliary stenting are increasingly complementing traditional ERCP techniques in achieving long-term sustained stricture resolution. Surgery remains a definitive management alternative when a prolonged trial of endoscopic therapy does not achieve treatment goals.

Decisions regarding colorectal cancer screening will continue to depend on local resources, which in some jurisdictions includes programmatic screening and individual patient preferences. I encourage gastroenterologists to participate in programmatic screening and assist in developing the colonoscopy quality assurance and improvement programs. Our involvement would ensure that we remain leaders in this area and that our expertise in quality in endoscopy is recognized. Finally, participation in programmatic screening should benefit endoscopic services by increasing resources to support higher colonoscopy volumes, shorter wait lists and continuing quality assurance.

Background: The most common complication of uncovered biliary self-expandable metal stents (SEMSs) is tumor ingrowth. The addition of an impenetrable covering may prolong stent patency., Objective: To compare stent patency between uncovered and partially covered SEMSs in malignant biliary obstruction., Design: Multicenter randomized trial., Setting: Four teaching hospitals., Patients: Adults with inoperable distal malignant biliary obstruction., Interventions: Uncovered or partially covered SEMS insertion., Main Outcome Measures: Time to recurrent biliary obstruction, patient survival, serious adverse events, and mechanism of recurrent biliary obstruction., Results: From October 2002 to May 2008, 129 patients were randomized. Recurrent biliary obstruction was observed in 11 of 61 uncovered SEMSs (18%) and 20 of 68 partially covered SEMSs (29%). The median times to recurrent biliary obstruction were 711 days and 357 days for the uncovered and partially covered SEMS groups, respectively (P = .530). Median patient survival was 239 days for the uncovered SEMS and 227 days for the partially covered SEMS groups (P = .997). Serious adverse events occurred in 27 (44%) and 42 (62%) patients in the uncovered and partially covered SEMS groups, respectively (P = .046). None of the uncovered and 8 (12%) of the partially covered SEMSs migrated (P = .0061)., Limitations: Intended sample size was not reached. Allocation to treatment groups was unequal., Conclusions: There was no significant difference in time to recurrent biliary obstruction or patient survival between the partially covered and uncovered SEMS groups. Partially covered SEMSs were associated with more serious adverse events, particularly migration., (Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Limited data are available regarding the best mechanism and timing for assessing patient satisfaction with endoscopy., Objective: To identify factors related to patient satisfaction with endoscopy and to determine if satisfaction after the procedure correlates with measurements at a later date., Design: A prospective cohort study., Setting: Tertiary academic hospital., Patients: Patients undergoing EGD, colonoscopy, or both., Interventions: Patients received preprocedure and postprocedure questionnaires on the procedure day. A third questionnaire (telephone or mail) was administered at least 1 week later., Main Outcome Measurements: Satisfaction scores., Results: A total of 261 patients were studied (53% men). The mean age was 55 +/- 14 years. A total of 226 patients (86.6%) were very satisfied with their endoscopy. Factors positively associated with satisfaction were as follow: doctor's personal manner (odds ratio [OR] 3.00 [95% CI, 1.80-5.03]), doctor's technical skills (OR 2.65 [95% CI, 1.55-4.51]), nurse's personal manner (OR 2.84 [95% CI, 1.74-4.63]), physical environment (OR 1.75 [95% CI, 1.16-2.64]), and more time with doctor discussing the procedure (OR 1.66 [95% CI, 1.02-2.69]). Higher levels of pain or discomfort were associated with less satisfaction (OR 0.57 [95% CI, 0.36-0.90]). A total of 141 of 261 patients (54%) were reached for follow-up (mean [SD] 39 +/- 26 days). These patients were less satisfied (rating dropped mean 0.35 points, P = .03) than those questioned sooner after the procedure and recalled experiencing more pain (rating increased mean 0.44 points, P = 0.01)., Limitation: Single center., Conclusions: This study identified several factors that impacted patient satisfaction. Most patients initially appeared very satisfied, perhaps because of residual sedation and the distinct setting of the surveys. However, patient satisfaction tended to decrease over time, possibly because of recall bias. Future studies with patient satisfaction may require assessment at a date further removed from their endoscopy.

Objectives: Guidelines have been published as a framework for therapy of patients with inflammatory bowel disease (IBD). The purpose of this study was to determine whether patients referred for a second opinion were receiving therapy in accordance with practice guidelines., Methods: Patients with luminal IBD under the care of a gastroenterologist who sought a a second opinion at Brigham and Women's Hospital between January 2001 and April 2003 were enrolled in this study. Clinical information was obtained by direct patient interview at the time of initial patient visit and by a review of prior records. Data obtained included the diagnosis, clinical symptoms, prior medical therapy, preventive measures for metabolic bone disease, and colon-cancer screening., Results: The study population consisted of 67 consecutive patients: 21 with ulcerative colitis, 44 with Crohn's disease and 2 in whom the diagnosis of IBD could not be confirmed. Of the 65 patients with confirmed IBD, 56 patients had symptoms of active disease and 9 were asymptomatic. All analyses were carried out on the 56 patients with active disease. Of the 33 patients treated with aminosalicylates, 21 (64%) were not receiving maximal doses. Nine of 12 (75%) patients with distal ulcerative colitis were not receiving rectal aminosalicylate therapy. Within 6 months of their clinic visit, 35 patients had received corticosteroid therapy, and 27 (77%) patients had been treated with corticosteroids for greater than 3 months. In 16 of 27 (59%) there was no attempt to start steroid sparing medications such as 6-mercaptopurine (6MP), azathioprine, or infliximab. Of the 11 patients treated with either 6MP or azathioprine, 9 (82%) were suboptimally dosed without an attempt to increase dosage. Of the 27 patients on prolonged corticosteroid therapy 21 (78%) received inadequate treatment to prevent metabolic bone disease. Three of 9 patients (33%) meeting indications for surveillance colonoscopy for dysplasia had not undergone colonoscopy at the appropriate interval., Conclusions: Patients with IBD often do not receive optimal medical therapy. In particular, there is suboptimal dosing of 5-ASA and immunomodulatory medications, prolonged use of corticosteroids, failure to use steroid-sparing agents, inadequate measures to prevent metabolic bone disease, and inadequate screening for colorectal cancer.

Background: Endoscopic placement of self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction is safe and feasible., Methods: Patients with malignant gastric outlet obstruction undergoing enteral stent insertion were identified from endoscopy databases. Duration of oral intake after stent insertion was calculated by using the log-rank test. Factors associated with duration of oral intake were assessed by using Cox multivariable regression analysis., Results: A total of 176 patients (mean age 65 [14] years) treated at 4 centers from 1996 to 2003 were identified. Obstruction was caused by cancer of the pancreas in 84, the stomach in 20, the bile duct in 15, the major duodenal papilla in 8, another primary site in 16, and metastases in 33. The site of obstruction was the duodenum in 125, the distal stomach in 17, the stomach and the duodenum in 18, and surgical anastomosis in 16 patients. Stent deployment was technically successful in 173. Complications occurred in 14 patients. Seventeen patients were lost to follow-up. Of the remaining 159 patients, 133 resumed oral intake for a median time of 146 days: 95% CI [65, 202]. On regression analysis, chemotherapy after stent placement was associated with prolonged duration of oral intake (hazard ratio 0.41: 95% CI [0.23, 0.72])., Conclusions: After enteral stent insertion for malignant gastric outlet obstruction, 84% of patients resumed oral intake for a median time of 146 days. Chemotherapy after enteral stent insertion was independently associated with prolongation of oral intake.

Background: The mechanism by which pancreas divisum may lead to recurrent episodes of acute pancreatitis in a subset of individuals is unknown. Abnormalities of the cystic fibrosis gene product (CFTR) have been implicated in the genesis of idiopathic chronic pancreatitis. The aim of this study was to determine if CFTR function is abnormal in patients with pancreas divisum and recurrent acute pancreatitis (PD/RAP)., Methods: A total of 69 healthy control subjects, 12 patients with PD/RAP, 16 obligate heterozygotes with a single CFTR mutation, and 95 patients with cystic fibrosis were enrolled. CFTR function was analyzed by nasal transepithelial potential difference testing in vivo. The outcomes of the PD/RAP patients following endoscopic and surgical treatments were concomitantly analyzed., Findings: Direct measurement of CFTR function in nasal epithelium in response to isoproterenol demonstrated that the values for PD/RAP were intermediate between those observed for healthy controls and cystic fibrosis patients. The median value was 13 mV for PD/RAP subjects, which was statistically different from healthy controls (22 mV, p= 0.001) and cystic fibrosis pancreatic sufficient (-1 mV, p < 0.0001) and pancreatic insufficient (-3 mV, p < 0.0001) patients., Interpretations: These results suggest a link between CFTR dysfunction and recurrent acute pancreatitis in patients with pancreas divisum and may explain why a subset of patients with pancreas divisum develops recurrent acute pancreatitis., (Copyright 2004 American College of Gastroenterology)

Background: Although radical resection and postoperative chemoradiation have been the standard therapy for patients with rectal cancer, preoperative staging by local imaging and chemoradiation are widely used. We used a decision analysis to compare the two strategies for rectal cancer management., Methods: We developed a decision model to compare survival outcomes after postoperative chemoradiation versus preoperative staging and chemoradiation in patients aged 70 years with resectable rectal cancer. In the postoperative chemoradiation strategy, patients undergo radical resection and receive postoperative chemoradiation. In the preoperative staging and chemoradiation strategy, patients with locally advanced cancer receive preoperative chemoradiation and radical resection, whereas those with amenable localized tumors undergo local excision. The cohorts of patients were entered into a Markov model incorporating age-adjusted and disease-specific mortality. Outcomes were evaluated by modeling 5-year disease-specific survival for preoperative chemoradiation as less than, equal to, or greater than that of postoperative chemoradiation. Base-case probabilities were derived from published data; the Surveillance, Epidemiology, and End Results (SEER) Program database; and U.S. Life Tables. One-way and two-way sensitivity analyses were performed. The outcome measures were life expectancy and quality-adjusted life expectancy., Results: Life expectancy and quality-adjusted life expectancy were 9.72 and 8.72 years, respectively, in the postoperative chemoradiation strategy. In the preoperative staging and chemoradiation strategy, life expectancy was 9.36, 9.72, and 10.09 years and quality-adjusted life expectancy was 8.71, 9.04, and 9.37 years when 5-year disease-specific survival was less than, equal to, or greater than that of postoperative chemoradiation, respectively. The decision model was sensitive to differences in the long-term toxicity of pre- and postoperative chemoradiation. When the 5-year disease-specific survival for patients after pre- or postoperative chemoradiation was equal, the decision model was sensitive to surgical mortality and to the probability of residual lymph node disease after local excision., Conclusion: If efficacy and toxicity after preoperative chemoradiation are equal to or better than that after postoperative chemoradiation in patients with locally advanced rectal cancer, then preoperative staging to select patients appropriate for preoperative chemoradiation is beneficial.

ERCP and pancreatoscopy may establish a diagnosis of IPMT and differentiate it from a pseudocyst or cystic neoplasm of the pancreas. These techniques may also assess risk of malignancy, extent of disease, allow tissue sampling, and provide therapeutic intervention.

Background: The aim of this study was to identify predictors of outcome after pancreatic duct stent placement for duct disruption., Methods: Patients were identified from endoscopy databases. Disruption was defined by extravasation of contrast from the pancreatic duct during endoscopic retrograde pancreatography. Data collected included demographic information, imaging studies, management before and outcome after stent placement. Success was defined as resolution of the disruption clinically, on radiologic imaging, and/or at endoscopic retrograde pancreatography., Results: Forty-three patients (23 women, 20 men; mean age 57 years, [SD] 15.2 years) were studied. The etiology of pancreatic duct disruption was acute pancreatitis in 24, chronic pancreatitis in 9, operative injury in 7, and trauma in 3 patients. In 25 patients there was resolution of the disruption, whereas stent therapy was unsuccessful in 16 and the outcome was indeterminate in 2 patients. On univariate analysis, stent positioned to bridge the disruption (p = 0.04) and longer duration of stent therapy (p = 0.002) were associated with a successful outcome. Female gender (p = 0.05) and acute pancreatitis (p = 0.05) were associated with a lack of success. On multivariate analysis, only the bridging stent position remained correlated to outcome. Complications occurred in 4 patients., Conclusions: A bridging stent is associated with a successful outcome after pancreatic duct stent placement for duct disruption.