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INTRODUCTION:Adenoma per colonoscopy (APC) has recently been proposed as a quality measure for colonoscopy. We evaluated the impact of a novel artificial intelligence (AI) system, compared with standard high-definition colonoscopy, for APC measurement.METHODS:This was a US-based, multicenter, prospective randomized trial examining a novel AI detection system (EW10-EC02) that enables a real-time colorectal polyp detection enabled with the colonoscope (CAD-EYE). Eligible average-risk subjects (45 years or older) undergoing screening or surveillance colonoscopy were randomized to undergo either CAD-EYE-assisted colonoscopy (CAC) or conventional colonoscopy (CC). Modified intention-to-treat analysis was performed for all patients who completed colonoscopy with the primary outcome of APC. Secondary outcomes included positive predictive value (total number of adenomas divided by total polyps removed) and adenoma detection rate.RESULTS:In modified intention-to-treat analysis, of 1,031 subjects (age: 59.1 ± 9.8 years; 49.9% male), 510 underwent CAC vs 523 underwent CC with no significant differences in age, gender, ethnicity, or colonoscopy indication between the 2 groups. CAC led to a significantly higher APC compared with CC: 0.99 ± 1.6 vs 0.85 ± 1.5, P = 0.02, incidence rate ratio 1.17 (1.03-1.33, P = 0.02) with no significant difference in the withdrawal time: 11.28 ± 4.59 minutes vs 10.8 ± 4.81 minutes; P = 0.11 between the 2 groups. Difference in positive predictive value of a polyp being an adenoma among CAC and CC was less than 10% threshold established: 48.6% vs 54%, 95% CI −9.56% to −1.48%. There were no significant differences in adenoma detection rate (46.9% vs 42.8%), advanced adenoma (6.5% vs 6.3%), sessile serrated lesion detection rate (12.9% vs 10.1%), and polyp detection rate (63.9% vs 59.3%) between the 2 groups. There was a higher polyp per colonoscopy with CAC compared with CC: 1.68 ± 2.1 vs 1.33 ± 1.8 (incidence rate ratio 1.27; 1.15-1.4; P < 0.01).DISCUSSION:Use of a novel AI detection system showed to a significantly higher number of adenomas per colonoscopy compared with conventional high-definition colonoscopy without any increase in colonoscopy withdrawal time, thus supporting the use of AI-assisted colonoscopy to improve colonoscopy quality (ClinicalTrials.gov NCT04979962).

Background Periampullary duodenal diverticulum (PAD) is a common finding in ERCP. Duodenal diverticulitis is rare and can result in pancreatico-biliary complications. Lemmel's syndrome is a rare complication of periampullary diverticulum that results in obstructive jaundice in absence of stones or malignancy. In our case, duodenal diverticulitis lead to biliary obstruction, and was diagnosed at the time of ERCP. Case report The patient is a 66-year-old woman with a history of migraine, osteoarthritis, rheumatoid arthritis and prior cholecystectomy 17 years ago who presented with epigastric and right upper quadrant abdominal pain radiating to the back with associated nausea, vomiting and diarrhea after she had an undercooked meal. Initial work up revealed leukocytosis of 16,000 with no fever. Transaminases and bilirubin were normal initially. CT abdomen showed non-obstructive bowel gas pattern, post operative cholecystectomy with secondary CBD dilation and a 3.6x4.5 cm periampullary diverticulum without signs of inflammation. Two days later she developed fever, acute rise in transaminases and bilirubin (AST 524 IU/L, ALT 767 IU/L, T. bilirubin 6 mg/dl). She was started on IV Zosyn with fluid resuscitation. MRI/MRCP showed mild to moderate intra and extrahepatic dilation with tapering of distal CBD (13 mm) without stones or signs of diverticulitis. She subsequently underwent ERCP that showed duodenal diverticulitis causing obstruction of the adjacent ampulla and distal bile duct. Pancreatic and CBD stents were inserted. Repeat review of the prior MRI/MRCP confirmed duodenal diverticular inflammation that was not initially appreciated. The patient's fever and symptoms resolved after the ERCP and with antibiotics. Follow up ERCP after 6 weeks showed scarring down of the PAD opening and resolution of bile duct stricture. Discussion Periampullary duodenal diverticulum are located within 3 cm from the ampulla of Vater and found in 10-20% of patients undergoing ERCP. PAD may be associated with CBD stones, acute pancreatitis and can lead to difficult cannulation during ERCP. Lemmel's syndrome is a rare complication from PAD in which obstructive jaundice occurs secondary to compression from the PAD. Duodenal diverticulitis is very rare and usually diagnosed with CT scan in most of cases. In our case, it was diagnosed at the time of ERCP.

Precision therapies for patients with driver mutations can offer deep and durable responses that correlate with diagnosis, metastasis prognosis, and improvement in survival. The use of such targeted therapies will continue to increase, pushing us to change our traditional approaches. We needed to search for new tools to effectively integrate technological advancements into our practices because of their capability to improve the efficiency and accuracy of our diagnostic and treatment approaches. Perhaps nothing is as relevant as identifying and implementing new workflows for processing pathologic specimens and for improving communication of critical laboratory information to and from clinicians for appropriate care of patients in an efficient and timely manner. To define the gold standard in delivering the best care for patients, to identify gaps in the process, and to identify potential solutions that would improve our process, including gaps related to knowledge, skills, attitudes, and practices. We assembled a multidisciplinary team to systematically perform a gap analysis study to clarify the discrepancy between the current reality in pathology specimen processing and the desired optimal situation to deliver the results intended for patient care. A practical collaborative workflow for specimen management that seeks the cooperation of stakeholders in each medical discipline to provide guidelines in specimen collection, delivery, processing, and reporting of results with the ultimate goal of improving patient outcomes is provided. New tools are required to effectively integrate data-driven approaches in specimen processing to meet the new demands.

Background and Aims: There is limited literature on sample adequacy for molecular testing in pancreatic ductal adenocarcinoma obtained via endoscopic ultrasound (EUS) fine-needle aspiration (FNA) versus EUS fine-needle biopsy (FNB). We aimed to compare these two modalities regarding sample adequacy for molecular and genomic sequencing. Methods: We reviewed all patients with pancreatic ductal adenocarcinoma who underwent EUS at Saint Luke’s Hospital from 2018 to 2021. The patients were categorized based on the method of EUS tissue acquisition, specifically FNA or FNB. A comprehensive evaluation was conducted for all cases by cytotechnologists. Results: Out of 132 patients who underwent EUS-guided biopsies, 76 opted for FNA, 48 opted for FNB, and 8 opted for a combination of both. The average number of passes required for FNB and FNA was 2.58 ± 1.06 and 2.49 ± 1.07, respectively (p = 0.704), indicating no significant difference. Interestingly, 71.4% (35) of FNB-obtained samples were deemed adequate for molecular testing, surpassing the 32.1% (26) adequacy observed with FNA (p < 0.001). Additionally, 46.4% (26) of FNB-obtained samples were considered adequate for genomic testing, a notable improvement over the 23.8% (20) adequacy observed with FNA (p = 0.005). Conclusion: Although the number of passes required for cytologic diagnosis did not differ significantly between EUS-FNB and EUS-FNA, the former demonstrated superiority in obtaining samples adequate for molecular testing. Tumor surface area and cellularity were crucial parameters in determining sample adequacy for molecular testing, irrespective of the chosen tissue acquisition modality.