This transcript has been edited for clarity.
Hello and welcome. I am Dr Vivek Kaul, from the University of Rochester Medical Center. It gives me great pleasure, once again, to collaborate with WebMD and Medscape to present this video capsule.
This time, we have picked the best GI and GI surgery papers from the recently concluded Digestive Disease Week 2023 international meeting in Chicago. For this edition of the Medscape GI/Primary Care video capsule, I thought it would be nice to present a couple of GI surgical papers that have major impact on common GI conditions seen in primary care.
This first paper in the GI surgery realm is Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study. This comes to us from the Mayo Clinic in Rochester, Minnesota.
This was a retrospective review of 329 patients who had type 2 diabetes, who underwent either Roux-en-Y gastric bypass (two thirds of them) or a surgical sleeve gastrectomy (about one third of them). The mean follow-up was about 6 years. Type 2 diabetes remission was seen in about half of them in this long-term follow-up.
There were significant improvements in hemoglobin A1c, fasting blood glucose, diabetes, and, of course, weight loss — and all were statistically significant. The type of surgery did not seem to make any difference. Both groups really benefited from this.
The take-home point of this study is that patients who have a high BMI and metabolic syndrome, whether they undergo Roux-en-Y gastric bypass or sleeve gastrectomy, should expect to see long-term, durable, positive impact on their diabetes, as well as weight loss, of course, and all the metrics for blood glucose and hemodynamics.
This is an important study and helps us in counseling patients appropriately when they present for selection for these types of surgeries in the appropriate clinical context.
The next paper in the surgical realm is from the University of Padova in Italy, which is Antireflux Surgery's Lifespan: 20 Years After Laparoscopic Fundoplication. This is a prospective study of 137 patients who underwent laparoscopic fundoplication for the management of gastroesophageal reflux disease (n = 107) or a large hiatal hernia (n = 30).
The median follow-up in this study was 22 years, which is among the longest I've seen in recent years for any study. A very small percentage of patients underwent revision surgery, which speaks to the skill set and careful selection of the patient cohort.
Only nine patients of 137 had repeat surgeries. Positive outcomes, on the other hand, were seen in the vast majority of patients with reflux, at 84%, and still, two thirds of patients with hiatal hernia had positive outcomes over the long term.
Failure-free survival was much higher for the gastroesophageal reflux cohort, as expected, compared with the hiatal hernia cohort. Patient satisfaction after two decades was almost 90% both for reflux and for hiatal hernia, which is quite a significant milestone.
The take-home point from this study is that laparoscopic fundoplication is quite durable, with success rates approaching 90%, even two decades after the surgical intervention. This is quite an important data point for us to discuss with patients when they present with a question around surgery for these indications. Although, as we know well in the era of PPI therapy, surgical indications are definitely reduced compared with 20 years ago.
The next paper in this group is related to another very important clinical entity, which is acute pancreatitis and the question of pancreatic cancer in those patients who present with acute pancreatitis.
Our previous work in this realm, published a couple of years ago, suggested that about 3% of patients who come to the hospital with acute pancreatitis may harbor pancreatic malignancy, which can be picked up if we do a diligent follow-up with cross-sectional imaging and endoscopic ultrasound.
This paper talks about acute pancreatitis and the modeling of risk in terms of prediction for early cancer. This study was conducted at the University of Pennsylvania and basically speaks to a clinical prediction model to assess the risk for pancreatic cancer after acute pancreatitis diagnosis.
As we know, the risk for pancreatic cancer is highest within 2 years of the initial presentation of acute pancreatitis, especially if the etiology of that pancreatitis was unclear. In this clinical prediction model, as shown on this slide, a variety of demographic and clinical criteria were used, all of which are easily accessible to us in GI and in primary care to calculate the modeling risk.
A large number of patients were used to apply this model: 51,613 patients. The mean age was 62%, the overwhelming majority were male, and half were Caucasian. Using this clinical prediction model, a 2-year incidence of pancreatic ductal adenocarcinoma was calculated to be 1.6% for an absolute number of 800 cases.
Nearly 50% were discovered after 3 months. There was a positive association with pancreatic cystic disease in these patients, which makes sense in terms of their preneoplastic potential.
The take-home point from this study is that readily available demographic and clinical criteria may be useful in helping us predict diagnosis of early pancreatic cancer in a subset of patients who present with acute pancreatitis, and in my opinion, particularly those who present with pancreatitis for which we cannot explain the etiology.
The next paper we have refers to a very common problem, which is Helicobacter pylori infection. This is almost an endemic problem in the Far East and in the third world, but also an increasing problem in the United States.
This particular study comes to us from Taiwan and is looking at different treatment strategies for H pylori infection. In Taiwan and the Far East, it has been proposed that high acid content in the food might be interfering with efficacy rates. The consideration for antibiotic resistance may be an issue as well. That's in the background of this paper.
This paper is titled Enhanced Efficacy of Combined Bismuth and High-Dose Dual Therapy versus High-Dose Dual Therapy Alone or Quadruple Therapy for First-Line H pylori Eradication. This was an interim report from a large multicenter, randomized controlled trial and included 436 patients with H pylori infection.
Each patient had biopsies with H pylori cultures, and they were randomized to one of three regimens as listed here. They received high-dose dual therapy or bismuth along with high-dose dual therapy — so, triple therapy — or they received the amoxicillin-based bismuth and quadruple-therapy regimen. Breath tests were used to check for eradication at the end of the treatment period.
In terms of the results from this study, it's very clear that the bismuth-based regimen, which is listed here in the middle column, had the highest treatment efficacy rates and moderate adverse event rates when compared with the other two arms.
Reduced eradication in the dual-therapy arm was seen probably due to increased acid food intake. Reduced eradication in the quadruple-therapy arm was likely associated with antibiotic resistance and also with poor compliance, which is understandable when you have more medications to take compared with the group that has fewer medications to take.
The take-home point from this study was that the addition of bismuth might be the silver bullet when you add that to the dual-therapy regimen in difficult cases of H pylori infection. More to come on this, and certainly of relevance to us here as we tackle more and more cases of H pylori infection stateside.
Last but not least, GI and primary care discussions can never be complete without a discussion on colorectal cancer screening. As the NordICC trial has shown us, it's not the issue with the screening modality but more about patients' acceptance of screening, particularly invasive screening.
This paper looked at different strategies and tried to figure out which strategy would be most attractive to bring more people in for screening. This is a large, randomized controlled trial with good distribution of patient populations with approximately half female, half Caucasian, and a mean age around 48 years, with more than 20,000 patients.
One of four screening strategies was used. Patients were invited for a fecal immunochemical test (FIT), a colonoscopy, or they were invited to choose between a FIT test and a colonoscopy. The final group was mailed a FIT test kit as an outreach mechanism.
Invitations were sent via electronic patient portals, which are very common nowadays, and via the United States Postal Service. Text-message reminders were sent a couple of weeks later. The primary outcome of this study was to look at any colorectal cancer completion rate at 26 weeks.
The results of the study were quite interesting. Screening completion rates were relatively low at 18%. It was interesting to note that the highest screening rates were seen with those who had the FIT test mailed to them, whereas each of the other three groups that had only invitations sent to them had relatively lower screening compliance rates.
The lowest participation was in the colonoscopy invitation group, I suspect due to the invasive nature of the procedure and the patients' perception of that. When patients were offered a choice, they were more likely to be compliant with screening. In the end, more patients chose colonoscopy as their screening test of choice compared with FIT testing.
The take-home point from this study is that directly sending test kits as an outreach might be more effective than simply inviting subjects to be screened. From those who do respond to be screened, more patients would choose colonoscopy compared with the FIT test.
With that, I come to the end of this video capsule summary for the Best of GI for Primary Care from DDW 2023. We covered a variety of topics, ranging from pancreatitis to H pylori to colon cancer screening and a couple of GI surgical interventions with long-term outcomes that are very favorable.
I hope you find this information useful in the care of your patients, and I hope to see you next time with yet another edition of the Best of GI for Primary Care in collaboration with WebMD and Medscape. Thank you very much.
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Cite this: DDW 2023: Common GI Conditions in Primary Care - Medscape - Jun 22, 2023.
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