I never saw the show, “Office Space.” However, I did see the opening trailer (1 min) recently and it is very funny. YouTube Link: Office Space – Peter’s Original Traffic Scene

MB Wallace et al. Gastroenterol 2022; 162: 295-304. Open access: Impact of Artificial Intelligence on Miss Rate of Colorectal Neoplasia

Design: In a multicenter and multicountry randomized crossover trial, patients (n=230) undergoing CRC screening or surveillance were enrolled in 8 centers (Italy, UK, US), and randomized (1:1) to undergo 2 same-day, back-to-back colonoscopies with or without AI (deep learning computer aided diagnosis endoscopy) in 2 different arms, namely AI followed by colonoscopy without AI or vice-versa.

Key finding: There was an approximately 50% reduction of the miss rate of colorectal neoplasia, mainly due to a decreased miss rate of flat and small lesions.

The editorial (pg 35-38, DK Rex et al. Artificial Intelligence Improves Detection at Colonoscopy: Why Aren’t We All Already Using It?) provides some perspective regarding the study limitations and why AI will not be widely adopted in the near term.

Limitations:

• “Tandem studies are more often positive than parallel design studies.  In a parallel design study, endoscopist bias toward any study arm is mitigated by the clinical and medical-legal demands to protect patients from colorectal cancer in a single withdrawal.”
• “Detection gains for AI are largely for diminutive lesions.³ This is generally true for detection gains from ancillary devices, because powering trials for improved advanced lesion detection is not practical”

Slow Uptake of AI:

• First, other adjunctive detection devices have received approval from the US Food and Drug Administration and then failed to reach widespread use…the limited adoption of this entire category suggests that physicians attach a relatively low price point to the value of detection gains produced by add-on devices…Incorporating detection devices with add-on cost is particularly problematic in US ambulatory surgery centers.”
• The authors indicate that an endoscopy company could add AI to standard equipment as one way to advance use of this technology

My take: AI will likely improve interpretation and usefulness of colonoscopy, whether for cancer surveillance and other reasons. Cost and familiarity are current barriers to early adoption.

Related blog post: #NASPGHAN19 Impact of New Technologies on Patient Health

L Berman et al. Pediatrics 2022; 149 (6): e2021055213. Gastrostomy Tube Use in Pediatrics: A Systematic Review

This lengthy review (27 pages) authored by a multispecialty team makes 17 graded recommendations regarding gastrostomy tubes/gastrostomy tube (GT) placement. The authors state that this review was based on nearly 900 publications with 58 influencing final recommendations.

Here are several of them:

1. Trial of home nasogastric feeding is safe and should be strongly considered before GT placement, especially for patients who are likely to learn to eat by mouth
2. Routine contrast studies are not indicated before gastrostomy placement
3. Laparoscopic placement is associated with the best safety profile
4. For most patients, a low-profile balloon GT is preferred

Elaborating on these recommendations::

• Home NG: The authors note that Lagatta et al found that infants sent home with NG from nursery had shorter length of stay and fewer readmissions/emergency encounters than patient sent home with GT. However, this statement ignores the significant differences in the patient characteristics in the two groups noted in this article (see related blog post: Impact of NG Feeding Program for NICU Graduates). Interestingly, many of the return visits are due to dislodgements of button GTs.

• Preoperative workup: While the authors discourage use of preoperative UGI and except in patients not achieving adequate enteral nutrition due to emesis, they also recommend “GT should only be pursued after appropriate workup has been performed to investigate the underlying medical diagnosis.” I find this vague recommendation to be problematic. Shortly before making this recommendation, the authors state “proper identification and management of the underlying diagnosis (eg. diet modification for eosinophilic esophagitis) may obviate the need for GT placement.” So, do the authors want every child who may need a GT to undergo an EGD? Or perhaps even more, such as an MRI or full exome sequencing? Also, which diet trial do they recommend for potential eosinophilic esophagitis -does this mean an amino acid based formula or is a hydrolysate sufficient?

• GT technique: The review of the techniques of GT placement cite data comparing the techniques and complication rates (though noting critical risk of bias in these studies):

• open gastrostomy (n=1471) vs PEG (n=679): 3.2% vs 4.1% (P=.35)
• laparoscopic gastrostomy (n=787) vs PEG (n=1321) 1.2% vs 5.4% (P<.0001)
• IR placement (n=321) vs PEG (n=417): 3.7% vs 1.9% (P=.04)
• the authors note the decision needs to consider specific patient characteristics and institutional factors
• related post: Is a Laparoscopic Gastrostomy Better Than a Percutaneous Endoscopic Gastrostomy?

My take: This article’s recommendations need to be carefully considered by pediatric gastroenterologists along with pediatric surgeons and interventional radiologists.

Related blog posts:

• Updated ESPGHAN Percutaneous Endoscopic Gastrostomy Position Paper
• Helpful Position Paper: Percutaneous Endoscopic Gastrostomy in Children
• Complications with G-tube Placement (reports 2015 study with same group)
• Which kids who aspirate need a gastrostomy tube?
• Long-term Outcomes with Pediatric PEG Placement
• Helpful Position Paper: …Gastrostomy in Children | gutsandgrowth
• Less stress after gastrostomy tube placement | gutsandgrowth
• PEG Decisions | gutsandgrowth
• 5 Signs Your Child Needs a Feeding Tube

• Is a Laparoscopic Gastrostomy Better Than a Percutaneous Endoscopic Gastrostomy?
• Impact of NG Feeding Program for NICU Graduates

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

J Strauss et al. JPGN 2022; 74: 776-781. Mechanical Complications in Central Lines Using Taurolidine Versus Ethanol Lock Therapy in Children With Intestinal Failure

This retrospective study with 13 patients (10,187 catheter days [CDs]) compared ethanol locks (EL) with taurolidine locks (TL). Taurolidine is a “non-toxic, broad-spectrum antimicrobial” with growing use outside the U.S. Manufacturing issues still need to be addressed to gain FDA approval. Link: CORMEDIX RECEIVES COMPLETE RESPONSE LETTER FROM FDA FOR DEFENCATH™ CATHETER LOCK SOLUTION

Key findings from this study:

• TL (vs EL) had lower rates of CVC breaks (1.11 vs 5.19/1000 CDs, P < 0.001), occlusions (0.83 vs 4.06/1000 CDs, P= 0.01) and repairs (1.94 vs 5.64/1000 CDs, P= 0.01)
• There was no significant difference in CRBSI rates: 0.83/1000 CDs for TL vs 2.03/1000 CDs for EL (P= 0.25)

My take: Taurolidine, when available in U.S., may be a suitable alternative to ethanol, when available in U.S., in preventing CRBSI. In addition, taurolidine locks appear to have fewer mechanical risks.

Related blog posts:

• FDA ‘Safety Initiative’ Now Means an Ounce of Ethanol Costs $30,000
• One More Way to Prevent CVL Infections | gutsandgrowth
• Ethanol locks -jump on the bandwagon | gutsandgrowth
• More on ethanol locks | gutsandgrowth
• Four advances for intestinal failure | gutsandgrowth
• Another option for line locks | gutsandgrowth
• Rehabilitation for Short Bowel Syndrome | gutsandgrowth
• IFfy outcome | gutsandgrowth

In previous posts (see below), the benefits of split-liver transplantation has been discussed, chiefly reducing pediatric waitlist mortality. A recent study (MG Bowring et al. Liver Transplantation 2022; 28: 969-982. Survival Benefit of Split-Liver Transplantation for Pediatric and Adult Candidates) shows split livers improve survival for pediatric and adult recipients.

Methods:  The researchers sought to determine the survival benefit associated with accepting a splittable graft offer for SLT versus declining and waiting for a subsequent offer using 2010 to 2018 Scientific Registry of Transplant Recipients (SRTR) data on 928 pediatric and 1814 adult liver transplantation candidates who were ever offered a splittable graft

Key findings:

• Among adult candidates, split liver offer acceptance was associated with a 43% reduction in mortality (aHR, _0.390.57_0.83 [P = 0.005]; 92.2% versus 84.4% 1-year survival after decision)
• Among pediatric candidates ≤7 kg, split liver offer acceptance versus decline was associated with a 63% reduction in mortality (adjusted hazard ratio [aHR], _0.170.37_0.80 [P = 0.01]; 93.1% versus 84.0% 1-year survival after decision). Among pediatric candidates >7 kg, there was no significant difference associated with acceptance of a split liver offer (aHR, _0.631.07_1.82 [P = 0.81]; 91.7% versus 94.4% 1-year survival after decision)

My take: These findings should spur more efforts at incentivizing the use of split livers.

Unrelated article: ER Perito et al. Liver Transplantation 2022; 28: 1051-1062. Graft Fibrosis Over 10 to 15 Years in Pediatric Liver Transplant Recipients: Multicenter Study of Paired, Longitudinal Surveillance Biopsies

Key findings (n=78):

• The first biopsy, at a median 8.2 years (interquartile range, 5.9-11.6 years) after transplantation, showed moderate (LAFSc 4-6) in 55%, and severe (LAFSc 7 or higher) in 3% of patients.
• The second biopsy, at a median 4.7 years (IQR, 4.3-5.1 years) later, showed moderate (LAFSc 4-6) in 62%, and severe (LAFSc 7 or higher) in 5% of patients.. Thus, there was fibrosis progression (LAFSc increased by ≥3) in 10 (13%) and regression (LAFSc decreased by ≥3) in 4 (5%) patients.

Related blog posts:

• Pediatric Liver Transplantation: Past Time to Split
• More on It’s Past Time to Split
• Pediatric Livers Bypassing Needy Children | gutsandgrowth
• Picking winners and losers with liver transplantation allocation
• Should Younger Transplant Patients Receive Better Organs? | gutsandgrowth
• Projected 20-Year and 30-Year Survival Rates for Pediatric Liver Transplant Recipients (U.S.) | gutsandgrowth