COMMENTARY

Gastroenterology Game Changers: Top 10 Articles of 2019

David A. Johnson, MD

Disclosures

December 31, 2019

This year was a particularly exciting time to work in gastroenterology, as our ever-advancing specialty saw the development of new technologies, enhanced diagnostic techniques, and a greater understanding of some of the most common diseases we treat. What follows is a list of the top 10 gastroenterology articles published in 2019. Summaries of the articles, and my thoughts on them, are presented in no particular order. In a year with so many potentially game-changing articles, how could one pick favorites?

Outcomes of Surgical Resections for Benign Colon Polyps: A Systematic Review

The surgical resection of benign colon polyps has become a major topic of concern in gastroenterology, given the high prevalence of referral (> 50%) and general lack of understanding of the implications of or alternatives to this surgery.

To determine the postoperative outcomes associated with resecting such polyps, investigators conducted a systematic literature review of 26 relevant studies (139,897 patients). The most common indications for surgical resection were polyp location in the right-sided colon, nonpedunculated morphology, and large polyp size. The pooled 1-month complication and mortality rates were 24% (95% confidence interval [CI]: 15%-36%) and 0.7% (95% CI: 0.6%-0.8%), respectively. Anastomotic leak ranged from 0.3% to 87%. Mean length of stay was 5.1 days.

These results show just how significant the perioperative complications related to this surgery can be. Addressing this requires a new standard of care, especially given the growing recognition that most benign polyps can be completely removed by a nonsurgical endoscopic technique. If this cannot be done by the initial colonoscopist, then we should at least consider referring to a therapeutic endoscopist capable of primary complete resection.

It is also essential to not biopsy these polyps or attempt partial resection. Tattooing should be done at least 3-4 cm away from the distal margin of the polyp and clearly described in the endoscopy report. Failure to discuss endoscopic resection options before surgical referral may have extended implications for the referring physicians or surgeons.

Vedolizumab Versus Adalimumab for Moderate-to-Severe Ulcerative Colitis

Despite the availability of various approved biologic agents for treating inflammatory bowel disease, there has been a lack of head-to-head studies comparing their use.

This study conducted in 34 countries is the first double-blind randomized phase 3 comparison of the GI-specific integrin antagonist vedolizumab and the anti-tumor necrosis factor alpha agent adalimumab. Standard dosing of both agents was used in patients with moderately to severely active ulcerative colitis. At week 52, patients receiving vedolizumab had a 9% higher rate of clinical remission, the study's primary endpoint. It was brave of these drugs' manufacturers to agree to such a head-to-head active drug comparison study, and the result was an impressive display of superiority for vedolizumab.

In a separate 2019 study, researchers also showed that maintenance therapy with a subcutaneous formulation of vedolizumab was as effective as intravenous administration, which will offer patients with ulcerative colitis an effective, at-home option in the very near future.

Management of Hepatitis C in 2019

The availability of direct-acting antivirals has rewritten the rules for how we manage hepatitis C virus (HCV) infections.

This review gives clinicians a timely assist in meeting the considerable challenge of keeping up to date. Its authors compare treatment efficacy and address the role of patient characteristics (eg, naive, cirrhotic, renal insufficiency, genotype) in order to guide the selection of the best therapeutic options for HCV.

Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients with Achalasia: A Randomized Clinical Trial

Peroral endoscopic myotomy (POEM) has become a viable therapeutic option for patients with achalasia. Although the standards of care and guideline recommendations have suggested surgical myotomy or endoscopic pneumatic dilation as the traditional therapeutic approaches, appropriate comparisons with POEM have been lacking.

This rigorous, well-conducted, multicenter randomized controlled study supports the use of POEM as an effective and relatively safe treatment option for achalasia. Despite methodologic limitations (such as sufficient power to compare the achalasia Chicago classification subtypes), POEM seems to perform better than pneumatic dilation at improving symptoms.

POEM should be considered as a definitive treatment option for achalasia, if adequate expertise and surgical support are available. However, as a relatively new therapy, learning curves for procedural technique and long-term outcomes need to be further studied, as does the mechanism by which POEM potentially achieves superior outcomes to pneumatic dilation.

POEM has been my preferred initial treatment for type III achalasia because, in my opinion, longer myotomy has a better response to chest pain. Yet given these results, I now plan on considering POEM as a viable initial option for all treatment-naive patients with achalasia.

Risk of Postpolypectomy Bleeding with Uninterrupted Clopidogrel Therapy in an Industry-Independent, Double-Blind, Randomized Trial

The prevalence of antiplatelet and anticoagulant use in the general population is increasing. Disruption of these agents for endoscopic procedures may reduce bleeding risk, albeit with an associated risk for thromboembolic complications (approximately 1%). Given the often delayed nature of these postoperative complications, gastroenterologists may not notice when they occur.

The 90% of polyps we remove by colonoscopic polypectomy are < 10mm, with an extremely low risk for acute or delayed bleeding. The "cold snare" technique has been proffered by experts as a safe and effective way to perform polypectomy in these polyps without cautery.

This study highlights the safety of performing cold snare polypectomy without interruption of clopidogrel. It showed no difference in bleeding rates between those randomized to continue clopidogrel until the morning of surgery or to receive placebo.

It is reassuring that the direct oral anticoagulants, such as warfarin, and the antiplatelet therapy clopidogrel have been well studied in this setting and appear to show no increased bleeding risk if continued in appropriate patients. The use of cold snare polypectomy should be the standard approach for these patients. And gastroenterologists should be more sanguine about the limited bleeding risks for even temporary discontinuation of antiplatelet and anticoagulant therapy when using this technique.

Prucalopride in Gastroparesis: A Randomized Placebo-Controlled Crossover Study

There is wide agreement that the pharmacologic treatment for gastroparesis has been a plague to patients and a conundrum for their treating physicians.

Metoclopramide has medicolegal implications surrounding its neurologic complications. Domperidone is not available in the United States and has drug-drug interactions (ie, prolongation of the QT interval). Erythromycin is associated with tachyphylaxis and selective resistance to it among certain organisms.

Prucalopride is a highly selective 5-hydroxytryptamine receptor 4 agonist, which has been well studied for its prokinetic effect, particularly in the lower gastrointestinal tract. This randomized, placebo-controlled, crossover study evaluated 34 patients with gastroparesis (28 idiopathic, 6 diabetic), all with abnormal gastric emptying and associated symptoms. Prucalopride led to significant improvements in the primary measure of gastroparetic symptoms, as well in the secondary endpoint of gastric emptying.

Although prucalopride is currently approved only for idiopathic constipation, this is the first glimmer of hope that the void of treatment options for gastroparesis may soon be filled. It is only a proof-of-concept study from a tertiary referral center, but I am intrigued by these results that suggest it may be safe and effective.

Risk of Bacterial Exposure to the Endoscopist's Face During Endoscopy

As endoscopists, we may know there is a theoretical risk for errant facial exposure to patient secretions or blood during procedures. This is why face and eye protection is routinely recommended. However, in my experience, the physicians and endoscopic team only variably comply with these recommendations.

This study evaluated the bacterial colonization of facial shields, both worn by the endoscopist and hanging on a wall within 6 feet of the patient. Alarmingly, definite facial contamination was seen in 5.6 per 100 half-days of endoscopy, despite physicians recognizing it only in rare cases. More distressing for the staff was the observation that significant contamination was evident on the facial shield on the wall, which had no direct contact with any splash contamination.

These data clearly and immediately changed my practice. I now insist on facial shield protection for all involved staff in proximity to the patient.

Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management

Acute pancreatitis is one of the leading causes of hospitalizations in the United States, with mortality ranging from 3%-15% (and up to 35% if accompanied by persistent organ failure). There is a clear need for high-level evidence to guide a quality approach to treating this condition.

This American College of Gastroenterology Task Force consisted of an expert multidisciplinary panel of gastroenterologists, surgeons, and hospitalists, who used a Delphi consensus approach to develop and formalize 40 quality indicators for the management of patients with known or suspected acute pancreatitis. They proposed quality indicators for several relevant domains, including initial assessment, risk stratification, and management of early complications.

I highly recommend you consult this brilliantly structured, must-read document before caring for your patients with acute pancreatitis.

Magnetic Sphincter Augmentation Superior to Proton Pump Inhibitors for Regurgitation in a 1-Year Randomized Trial

Proton pump inhibitors (PPIs) are remarkably effective for treating heartburn related to gastroesophageal reflux disease (GERD). They are decidedly less useful, however, for treating the primary symptoms of regurgitation in this condition.

The use of a magnetic sphincter augmentation (MSA) device, consisting of interlocked titanium beads placed laparoscopically at the lower esophagus, has been shown to be an effective alternative to surgical fundoplication.

This randomized trial compared the effects of MSA with those of PPIs. Patients had moderate to severe regurgitation despite once-daily PPI therapy. They had similar outcomes regardless of whether they received MSA from the outset or crossed over to the MSA group after PPI therapy (n = 75). Control of regurgitation was noted in 72 of 75 patients (96%) receiving MSA, compared with 8 of 43 patients (19%) receiving PPIs. Improved GERD health-related quality of life and reduced dysphagia were also significantly better with MSA. There was no reported association between MSA and any perioperative events, device explants, erosions, or migrations

This device appears to be extremely safe and effective for GERD patients with primary regurgitation not responding to PPI treatment. However, before incorporating these data, we must make sure these symptoms are truly related to "refractory" GERD and not rumination. Impedance pH testing is a helpful tool for discriminating postprandial regurgitation from rumination.

Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians

This guidance statement from the American College of Physicians offers several notable updates regarding the various modalities of colorectal cancer (CRC) screening. Fecal occult blood test (FOBT) or fecal immunohistochemical test (FIT) are now recommended as options every 2 years. This is discordant from the US Multi-Society Task Force on Colorectal Cancer, which stated that FIT should replace FOBT and be performed annually, given its improved specificity. CT colonography is also not recommended in this guidance statement from the American College of Physicians—and very notably, it does not recommend multitarget stool DNA.

I suspect that gastroenterologists in the United States would agree there has been a strikingly increased use of multitarget stool DNA tests by primary care physicians, fueled in part by the media. Although this technology is clearly designed for CRC screening, I know from observation in our community that this test is being used for symptom- or sign-directed testing, as well as colon polyp follow-up. Unfortunately, many patients are having the test done for indications not intended by the manufacturer. A recent analysis comparing multitarget DNA testing with all other CRC screening modalities reported that this approach was never cost-effective. The only exception was when it was compared against a no-screening approach. Hopefully these new data will dissuade the seemingly inappropriate enthusiasm for and overuse of this testing approach.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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