Great strides have been made in perfecting CT colonography (CTC), noted Don C. Rockey, MD, AGAF, during his presentation “Controversy: CT Colonography — Ready for Screening Patients?” at Sunday’s AGA Institute Spring Postgraduate Course.

“Technically, we are there, but practically, we are nowhere near implementing CTC for colon cancer screening. It won’t be until 2009 when CTC will be ready for prime time,” said Dr. Rockey, the Dr. Carey G. King, Jr. and Dr. Henry M. Winans, Sr. Chair in Internal Medicine at UT Southwestern Medical Center, Dallas.

CTC sensitivity and specificity have evolved over the years from low-detection sensitivity to extremely high sensitivity. In three recently published multicenter trials, one showed 94 percent sensitivity, while another two showed 55 percent and 59 percent sensitivity, respectively. Two unpublished trials show better results, with one trial demonstrating 78 percent sensitivity in lesions 6 mm or greater and 90 percent in lesions of 10 mm or greater and another trial showing 84 percent sensitivity in 6 mm lesions and 91 percent in 10 mm lesions.

“The take-home points in terms of accuracy are that the sensitivity has improved over some of the previous trials and it’s probably going to be pretty close to colonoscopy,” Dr. Rockey said.

CTC appears relatively safe, with a small risk for perforation of the bowel — one in 1,000 to 2,000, Dr. Rockey said. The current estimate of CTC radiation exposure risk appears to be a one in 700 changes for a healthy 50-year-old patient.

CT colonography reading requires special training. An AGA Institute task force white paper recommends that gastroenterologists should be proficient after 75 training cases, Dr. Rockey said.

What impact will CTC have on screening colonoscopy? Dr. Rockey said the current projections are a 33 percent decline.

More choices sum up the cancer screening modalities, which was addressed in the “Colon Cancer Screening and Surveillance” presentation by Douglas K. Rex, MD, FACP, FACG, director of endoscopy, Indiana University Hospital, Indianapolis.

In screening modalities, Dr. Rex categorized them as either the “menu of options” or “colonoscopy preferred,” with separate clinical guidelines for both. The menu of options for low-risk patients are colonoscopy every 10 years, fecal occult blood testing annually, double contrast barium enema every five years, or flexible sigmoidoscopy every five to 10 years. The colonoscopy-preferred approach for low-risk patients is screening colonoscopy every 10 years.

Postpolypectomy surveillance guidelines recommend five to 10-year follow-up in patients with one or two tubular adenomas under 1 cm in size with only low-grade dysplasia, Dr. Rex said. Patients with three to 10 adenomas, villous adenomas with villous elements, high-grade dysplasia and any adenoma 1 cm or larger should undergo repeat colonoscopy every three years. Those with 10 or more adenomas should undergo colonoscopy at shorter intervals and should be considered for possible inherited polyp syndrome.

Among cancer detection tests, fecal immuno-chemical testing appears to receive the most use and is more effective than the guaiac-based fecal occult blood test and comparable in effectiveness to fecal DNA testing, Dr. Rex reported. One fecal DNA test demonstrated 89 percent sensitivity for cancer.

“Screening examinations are more important in general and have greater impact on cancer prevention than surveillance examinations,” Dr. Rex said. “Colonoscopy or imaging tests should be recommended to patients first, and if they decline those, then the fecal immuno-chemical tests and hemocult test should now replace the old guaiac-based fecal occult blood test.”

NOTES™ holds promise for weight loss procedures
Bariatric procedures are highly effective and the preferred surgical treatment for long-term weight reduction in the morbidly obese. These conclusions were presented by Anthony N. Kalloo, MD, in his talk, “Endoscopic and Surgical Approaches to Weight Loss (including NOTES™),” during Sunday’s AGA Institute Spring Postgraduate Course.

“Bariatric surgery is effective for morbid obesity, but has significant risks, cost and complications,” said Dr. Kalloo, chief of Johns Hopkins Division of Gastroenterology and Hepatology, Baltimore. “Endoscopic approaches are rapidly evolving. I believe that NOTES (Natural Orifice Translumenal Endoscopy Surgery) will be the future platform of endoscopic surgeries for obesity.”

Dr. Kalloo listed the most effective bariatric procedures to be intragastric balloon, bioenteric intragastric balloon, endoscopic restriction procedures and botulinum toxin. Surgery benefits include a weight loss range from 40 percent to 70 percent of excess body weight within two years.

NOTES is a particularly promising approach, which provides access to explore the peritoneal cavity and perform diagnostic and therapeutic interventions with making wall incisions, according to Dr. Kalloo. Avoiding abdominal wall incisions in the morbidly obese is a significant advantage.

“The technical feasibility of creating a small gastric pouch as well as performing a bypass procedure has already been demonstrated by the use of NOTES,” Dr. Kalloo stated.

The prognosis for hepatitis B virus (HBV) is dependent on its genotype, and treatment options for the 1.1 million Americans who carry it are expanding to include combination therapy according to Sunday’s AASLD State-of-the-Art lecturer.

HBV is classified into eight genotypes — labeled “A” through “H” — and the most common types in the U.S. are A, B and H, said Emmet B. Keeffe, MD, Stanford University Medical Center. Type B is the most common, affecting up to 44 percent of hepatitis patients in the U.S., and it is a slower progressing disease with less incidence of hepatocellular carcinoma (HCC) compared with type C.

“The driver for us is to be more proactive in treating these individuals,” he said. “There are significant advances in therapeutic options.”

Knowing the genotype is important because type B is the “good genotype.”

“Genotype to some extent predicts the response to interferon-based therapy,” Dr. Keeffe said. “A and B respond better than C and D, and particularly A is better than D. On the other hand, genotype does not predict the response to oral therapy, which is most commonly used in the U.S.”

In addition, the incidence of HBV can depend on geographic location. It is most common in Alaska, South America, Africa and Asia, and so immigration patterns to the continental U.S. affect its growth. The prevalence of HBV is greatest in larger cities where immigrants are more likely to reside, reaching 14 percent in San Francisco and 15 percent in New York. The overall incidence in the U.S. is 10.4 percent.

“There has been progress in the incidence of acute HBV largely due to vaccinations and a major program by the CDC,” Dr. Keeffe said.

The successful treatment of the HBV can also depend on timing. There are four phases of infection: immune tolerance, immune clearance, inactive carrier and reactivation. Candidates for treatment are in phases of immune clearance or reactivation.

The timing can also apply to age. For example, most Caucasian Americans get the disease in adulthood, whereas the majority of Asians and Africans get chronic HBV infection in early childhood and have a less favorable response to interferon therapy, Dr. Keeffe said.

HBV can also progress to HCC, driven by factors that include increasing age, male gender, presence of cirrhosis, family history of HCC and race — particularly for Asians and Africans. Other factors include alcohol consumption, smoking and diabetes.

Treatment of HBV has come under study by a panel of U.S. physician experts who began meeting in 2003 to develop an HBV treatment algorithm. The goal is to provide clear direction to treating physicians regarding diagnosis, treatment and monitoring, Dr. Keeffe said. The recommendations are expected to be published this year.

In addition, HBV DNA has also been found to be a predictor of progression to cancer cirrhosis, he said. Serum HBV DNA greater than 104 copies/mL may be an independent predictor of the development of cirrhosis and HCC in dose-response fashion, but it is not known if results can be generalized to all HBV carriers.

“These data support the possibility of preventing long-term risk of cirrhosis and HCC by sustained suppression of HBV replication,” Dr. Keeffe said. “The hypothesis needs to be proven prospectively.”

The treatment algorithm calls for a baseline evaluation that should include HBV genotype, particularly if peginterferon therapy is considered, he said. The preferred treatment options are: entecavir, tenofovir (pending FDA approval) and peginterferon alfa-2a.

Once resistance to therapy begins, it is best to have an add-on therapy, which has led to the development of combination therapy, Dr. Keeffe said. He added that the data on such therapy is “attractive, but data is limited.”

“We need trials,” he said. “My hope is that it will become a priority in coming years,” Dr. Keeffe said.

Dr. Keeffe is vice president and chief medical officer for Romark Laboratories, LC.

Two presentations during the first of three days of AASLD Presidential Plenaries highlighted acetaminophen (APAP) toxicity as an explanation for acute liver failure (ALF) of unknown etiology and the role of toll-like receptor 9 (TLR9) in the evolution of APAP toxicity.

Niraj Khandelwal, MD, of the University of Texas Southwestern Medical Center, presented data that showed a subset of patients with ALF of unknown causes show exactly the same profile as patients with documented APAP toxicity.

Using an assay that has been newly developed for determining APAP levels, serum samples from 113 patients with indeterminate ALF were used to determine APAP levels. The assay identified APAP adducts — APAP that has formed a complex with proteins from hepatocytes — and can be detected up to 12 days after APAP ingestion.

Based on information already published on APAP overdoses, toxic levels of APAP were defined when sera showed APAP adducts of at least 1 nanomole per milliliter. Of 113 patients, sera from 20 patients were identified to have toxic levels of APAP. In additional analyses, compared with patients with normal levels of APAP, higher percent of these patients were women (80 percent) and high APAP levels were also associated with higher levels of liver enzymes (ALT: 5156 versus 842 IU/L), lower bilirubin levels (5 versus 24 mg/dL), and better survival rate (55 percent versus 20 percent).

An important observation was made regarding the use of N-acetylcysteine (NAC) in managing ALF. In a subset of patients with APAP toxicity, it was observed that the use of NAC increased survival. Dr. Khandelwal concluded, “One of five patients with indeterminate ALF have evidence of APAP toxicity. However, until an assay can be ordered for APAP, high ALT and low bilirubin levels may be indicative of APAP toxicity and should dictate the use of NAC in clinical practice.”

In another presentation, Wajahat Mehal, MD, of Yale University, tested the hypothesis that activation of TLR9 by apoptotic DNA plays a critical role in APAP-induced liver injury. Dr. Mehal indicated that in APAP toxicity there are danger-associated molecules that are sensed by certain cells that release inflammatory cytokines such as IL-1 beta and IL-18. In liver injury, DNA from dying hepatocytes (apoptotic DNA) is the danger-associated molecule that can trigger TLR9. In fact, when mice are given a toxic dose of APAP, levels of IL-I beta and IL-18 are seen to significantly increase compared with animals not given APAP (healthy controls).

IL-1 and IL-18 are known to increase levels of TLR9 on cells. Hence it was decided to test whether mice that lack TLR9 (also called TLR9 -/- or TLR knock out) are protected from APAP toxicity. TLR9 -/- mice are in fact protected from APAP toxicity and do not show elevated levels of IL-1 and IL-18 as seen in normal animals. In addition, when normal animals are given TLR antagonists, protection from APAP toxicity was also seen. When looking at survival over 72 hours, TLR-/- showed better survival outcomes compared with normal animals.

Dr. Mehal showed that after DNA from healthy and apoptotic hepatocytes were introduced into the portal vein, IL-1 levels were significantly high in normal animals given apoptotic DNA, but not in TLR9 -/- animals. Liver histology showed that the cells that sensed this insult were sinusoidal endothelial cells, but not endothelial cells.

According to Dr. Mehal, “Activation of TLR9 by DNA from apoptotic hepatocytes is an important mechanism in APAP hepatoxicity and antagonists of IL-1 beta, IL-18 and TLR9 may all have therapeutic applications not only in APAP toxicity, but also in a wide range of liver diseases.”

With typical sources for clinical and basic science research funding winnowing away, researchers have had to become more savvy in their efforts to identify other opportunities for funding.

DDW® attendees gained tips for how to collaborate with industry for alternate funding sources during a Sunday AGA Institute Committee-Sponsored Symposium.

Phillip P. Toskes, MD, recommended that researchers first look to their own areas of interest for inspiration and then partner with an industry collaborator via small business grants.

Dr. Toskes, who has 12 such grants, said his “niche” was pancreatic research.

“I have a very successful partnership with Dr. David Wagner of Metabolic Solutions on a 13c xylose breath test for bacterial overgrown, a 13c propionate breath test for cobalamin (B12) deficiency and a 13c urea blood test of H. pylori,” said Dr. Toskes, a professor of medicine at the University of Florida College of Medicine, Gainesville.

While Dr. Toskes has brought basic science skills to the partnership, he said the work has created a two-way education.

“I made him a damn good GI, and I learned a little about carbon 13 labeling,” he said.

“You become known to people in industry, and I’ve found them to be very receptive,” Dr. Toskes added. “They may not always accept your ideas, but I found them to always be open to new ideas.”

Duane J. Roth, CEO of Connect, a public benefits organization fostering entrepreneurship in the San Diego region, described how researchers have and might connect with biotechnology companies and venture capitalists. Roth’s company works to catalyze, accelerate and support the growth of the most promising technology and life sciences businesses. Founded in 1985, his group now supports 1,500 companies with $10 billion in funding.

“We need a new model to fund innovation. We’re in a ‘bet-the-ranch’ model, and I think that this existing model is broken,” said Roth, pointing to California’s voter approved Institutes for Science in Innovation and co-partnering models as such alternatives.

“I submit that in the future almost all ideas will come from academic research centers,” Roth said. “They are the only place left in the world where one can get a grant free to pursue the science you believe in.”

Advanced imaging techniques changing endoscopic practice

A select group of endoscopists peered into the future of clinical practice on Sunday morning. The ASGE session introduced four endoscopic imaging technologies, providing hands-on time for two of them.

“There are lots of new techniques for diagnosing and treating early stage cancers and premalignant lesions,” Christopher J. Gostout, MD, FASGE, director of endoscopy research and development at the Mayo Clinic College of Medicine, Rochester, MN told attendees at ASGE’s Hands-on Course on Advanced Imaging. “It is the responsibility of ASGE to introduce you to these new techniques.”

All four technologies are commercially available, but have not yet been widely adopted, Dr. Gostout said. They include narrow band imaging (NBI), endocytoscopy using ultra high magnification, confocal microscopy and autofluorescence imaging (AFI).

The newest development is multimodal units that allow endoscopists to switch between familiar high-resolution white light endoscopy and AFI or NBI during the procedure. Each technology offers a different view to help clinicians isolate, identify and treat suspicious tissues more quickly and more accurately.

“I’m seeing microscopic detail,” said Michael Biederman, DO, a group GI practice physician from Farmington Hills, MI after trying endocytoscopy for the first time. “These techniques will let me pick up disease earlier and maybe do treatment on the initial endoscopy rather than just diagnose.”

NBI is the most familiar alternative imaging technology, said Prateek Sharma, MD, professor of Medicine and director of GI Fellowship Training at the University of Kansas School of Medicine, Kansas City, KS, and Veterans Affairs Medical Center, Kansas City, MO. NBI uses filters to illuminate targets with red, blue or green light.

Each wavelength highlights different tissues and structures, Dr. Sharma explained. Blue light, for example, shows more surface detail, while red illuminates deeper structures. The visual effect is similar to WLE using dyes, but without the concerns associated with contrast agents.

In clinical practice, NBI helps identify areas with abnormal mucosal or capillary structure that may indicate dysplasic or malignant tissue.

“Any irregularity you see in NBI has great potential for dysplasia,” Dr. Sharma said. “You get false positives, but you are focusing biopsies in the areas of highest risk. NBI helps you take targeted biopsies instead of random biopsies.”

Endocytoscopy offers real-time cytoscopy of living tissue with magnification of 500X and higher. That compares to 100X magnification with conventional magnifying endoscopy, said Haruhiro Inoue, MD, Showa University Northern Yokohama, Yokohama, Japan.

“If we can observe the cellular structure in vivo, we can better evaluate tissue atypia,” Dr. Inoue said. “This is an actual image of actual tissue.”

Staining is key to successful endocytoscopy as it is in traditional cytoscopy. Esophageal tissue can be imaged in fine detail at the cellular level using methylene blue, Dr. Inoue reported. Glandular epithelium such as stomach tissue needs double staining with crystal violet and methylene blue to provide adequate contrast for clear visualization.

Tissue motion has also emerged as a key factor in image quality for highly magnified images. The same magnification that shows microscopic details also magnifies movement from heart beat, swallowing or any other physical shift. Dr. Inoue recommended contacting the target tissue with the scope to stabilize the image.

Tissue movement is also an issue with confocal imaging, a technique that allows the operator to magnify and visualize tissue surfaces as well as structures up to 250 microns beneath the surface. The endoscopist can track the movement of fluorescent dye in living tissue, identify Helicobacter pylori and other pathogens and view images utilizing dyes that target dysplasic cells.

“This technique is going to change the way we identify and deal with dysplasia,” said Louis-Michael Wong Kee Song, MD, FASGE, Mayo Clinic, College of Medicine, Rochester, MN.

Confocal imaging uses a fluorescent contrast agent, typically Fluorescein 10 percent. Nuclear structures cannot be resolved, Dr. Song said, because typical nuclear stains such as acriflavin and cresyl violet have mutagenic potential and cannot be used in living tissues.

AFI uses no dyes or contrast agents, he continued. The technique uses blue light to excite tissue chromophores, which fluoresce longer wavelengths. Normal tissue fluoresces green, he said, dysplasic tissue appears purple and malignant tissue shows in shades of red.

“The color differentiation makes it easy to distinguish lesion margins,” Dr. Song said.

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Endoscopists address management of bariatric surgery complications

Weight loss surgery is one of the most common surgical procedures in the U.S. with more than 240,000 surgeries annually.

That is good news for GI surgeons, said Lawrence S. Friedman, MD, FASGE, professor of medicine and Harvard University and Tufts University School of Medicine, Boston, reminding the ASGE Clinical Symposium on the role of the endoscopist in managing the complications of bariatric surgery.

The growing popularity of weight loss surgery isn’t all good news. Bariatric surgery patients are morbidly obese, which makes them a high-risk population. While the 30-day mortality rates hover at 0.5 percent for gastric bypass and 0.1 percent for adjustable gastric band procedures, complications are more common in the highest risk populations.

Older age, male gender and lower surgical volume are the primary risk factors, Dr. Friedman said. For patients over the age of 60, the 30-day mortality rate jumps to 4.85 percent. Surgeons who perform fewer than 15 procedures annually have a 30-day mortality rate of 9 percent.

“As in everything GI, you have to choose your surgeon very carefully,” Dr. Friedman said.

Morbidity is another significant concern following weight loss surgery.

During the first six weeks after weight loss surgery, bleeding, bowel perforation, myocardial infarct, pneumonia and other acute conditions are likely to be seen.

Between seven and 12 weeks post op, expect vomiting, marginal ulcers and similar problems.

From 13 weeks to 12 months post op, patients often display positive changes such as altered eating and continuing weight loss as well as hernia, gallstones and similar problems.

“The GI endoscopist plays an increasing role in post op care,” Dr. Friedman said.

Endoscopic management
Laparoscopic gastric bypass will become the most commonly performed surgical procedure in the U.S. during this decade, predicted Adam Slivka, MD, PhD, FASGE, professor of medicine and associate chief of gastroenterology, hepatology and nutrition at the University of Pittsburgh Medical Center. Four types of bariatric surgery are generally performed in the U.S: laparoscopic banding, adjustable banding, gastric sleeve and Roux-en-Y gastric bypass.

Laparoscopic banding and adjustable banding are the most common procedures, he added.

Regardless of the procedure used, patients with cardiovascular conditions as well as diseases of the digestive tract, endocrine system, musculoskeletal system, reproductive system, respiratory system, genitourinary system and immune system can expect to benefit from weight loss surgery. Skin conditions such as cellulitis, fungal infections and panniculitis are the most common category showing little or no improvement from bariatric surgery.

But, despite the expected benefits of weight loss surgery, post surgical morbidity is common. Most complications can be handled endoscopically or even less invasively, Dr. Slivka said.

Anastomotic ulcers occur in up to 14 percent of patients and typically present with pain and bleeding. Ulcers can be ischemic or caused by factors such as acid production, Helicobacter pylori or foreign bodies in the pouch, he said.

Ulcers usually resolve with PPIs or carafate suspension. Ulcers linked to foreign bodies such as stapes or sutures typically resolve once the foreign body is removed. Re-operation may be necessary for refractory disease including esophagojejunostomy.

Anastomic leaks occur in 2.3 percent of patients and usually present with intraabdominal sepsis.

“The main treatment is drainage,” Dr. Slivka said, “but re-operation or revision may be necessary.”

Anastomotic strictures occur in about 6 percent of cases and usually present with vomiting about two months post op. Management usually involves balloon dilation to 12 mm.

Gastrogastric fistulae occur in 6 percent of patients and presents with pain and failure to lose weight. Endoscopic management typically involves APC and thrombin glue to close the fistula.

Surgical management
Larger fistulae and other complex complications may need surgical management, said Matthew Hutter, MD, MPH, director of the center for clinical effectiveness in surgery, Massachusetts General Hospital, Boston.

Laparoscopic adjustable gastric bands have a relatively high re-operation rate, Dr. Hutter said. Depending on the study, re-operation is needed in less than 5 percent to 25 percent of patients. FDA trials found a reoperation rate of 23 percent.

If the problem is mechanical failure of the band, the band itself can be replaced. Other problems such as infection, obstruction, esophageal dysmotility, intolerance of the band or pouch dilation, call for conversion to gastric bypass.

“If the band is removed and nothing else is done,” he cautioned, “people will regain their weight.”

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Course examines success in treating metastatic liver cancers

The latest approaches to the treatment of colorectal liver metastases were presented Sunday in the first session of the SSAT Postgraduate Course.

Speakers discussed the promise of PET scans, chemotherapy to improve resectability, when and how to use ablation, and the promise of molecular markers in predicting long-term outcomes.

Preoperative and intraoperative mapping of metastases
All the speakers stressed complete tumor removal from the liver, but determining the resectability of tumors has grown more complicated in the last five years, said Reid B. Adams, MD, who discussed the success of PET scans compared with other scanning techniques.

“A PET scan is the most sensitive method for detecting intrahepatic disease,” said Dr. Adams, of the University of Virginia Health System. “It is also the most sensitive test for extrahepatic disease.

Research shows that PET scans detected additional disease in up to 30 percent of patients, resulting in a management change in 25 percent of patients, he said.

In discussing chest imaging, Dr. Adams called the procedure “overkill” that often leads to unnecessary biopsies. He also said that his institution uses MRIs rather than CT scans because they are better at lesion characterization, detecting small lesions, distinguishing lesions in steatotic livers, and allow preoperative mapping and planning.

Methods to improve resectability
The improved use of neoadjuvant chemotherapy before and after resection has improved outcomes in the treatment of metatstatic colorectal cancer, according to J. Nicolas Vauthey, MD, of M.D. Anderson Cancer Center, Houston.

The obvious question is how successful the use of chemotherapy before resection can be in the potential downsizing of tumors, the identification of responders and an improvement in disease-free survival, Dr. Vauthey said.

An M.D. Anderson study of 248 patients who received oxaliplatin for neoadjuvant chemotherapy showed an association with sinusoidal dilation that did not affect the post-operative complication rate.

However, the use of irinotecan was associated with steatohepatitis that grew more pronounced in patients with a higher body mass index. Patients with steatohepatitis had a post-operative mortality of 14.7 percent compared with a mortality of 1.6 percent in patients without steatohepatitis.

The use of chemotherapy in a two-stage hepatectomy has also been successful in an M.D. Anderson study. The chemotherapy is generally administered before the first stage and after the second-stage resection, and between the two stages as needed. The result was an 86 percent survival rate at three years, Dr. Vauthey said.

“You should wait between the chemotherapy and the surgery, and the interval should be five weeks at least,” he said.

Ablative techniques: when and how
Resection is generally accepted as the best treatment of liver metastases, but radio frequency ablation (RFA) can be a successful treatment when used properly, according to Michael A. Choti, MD, Johns Hopkins University.

Dr. Choti, though, questioned whether research on the success of resection versus ablation treatments compared similar or different cohorts of patients.

“Patients who undergo ablation are different patients. It is difficult to know whether outcomes are comparable,” he said as he discussed the results of controversial ablation studies conducted in China and the Netherlands.

He concluded that: RFA is an effective local therapy for hepatic tumors; improved local control is seen in tumors smaller than 3 cm and in non-central locations; improvements in devices, targeting and imaging are leading to better results; and in HCC, RFA may be superior to resection in eligible patients.

Predicting long-term outcomes and a way forward
The final speaker, John S. Boston, MD, Ochsner Clinic, discussed tests to establish prognostic variables for patients with resectable colorectal liver metastases and the potential of molecular markers.

“But as I hear all these speakers, I am struck by how important clinical judgment is in these treatments,” Dr. Bolton said.

Two prognostic scoring systems — Nordlinger and MSKCC — address several variables, such as age, tumor size, serosa and N status in developing a score, but most patients are “lumped into the middle, and it is still not very satisfying,” he said.

Molecular markers may hold promise, but there are still problems because validation is scarce, results vary and the study populations are small, Dr. Bolton said.

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Presidential Profile

As his term as AGA Institute president winds down, Nicholas F. LaRusso, MD, AGAF, reflects on a year of successful initiatives and accomplishments, and he is bullish about the future of the organization and the profession.

“It has been one of the most exciting and satisfying years of my professional career,” Dr. LaRusso said. “I have enjoyed the challenges and the brilliant people that I worked with. I remain even more optimistic about the future of medicine and gastroenterology in particular.”

That optimism is well deserved. As he prepared for his term as president a little more than a year ago, Dr. LaRusso outlined an aggressive agenda for the association, setting several lofty goals that would help to define and measure the quality of care for GI patients. Chief among them is improving educational resources for continuing medical education. It’s part of a concept of lifelong learning, which Dr. LaRusso said he believes can transform the field of gastroenterology and, ultimately, benefit patients.

To that end, he said, the AGA Institute has created GI LEARN, an online educational platform for AGA members. It features a Personal Learning Portfolio, dynamic search engine and online self-assessment modules. Members can manage their educational activities in one online location.

“It’s an online education hub for AGA members. The Personal Learning Portfolio tracks members’ CME points, state licensing requirements and board certifications,” he said. “Members can also define their personal interests, record links to articles and any pertinent Web sources to this one, all-inclusive Web-based personal learning portfolio.”

A new search engine makes it easy to locate AGA Institute content, and new GI online self-assessment modules will offer CME credit and points toward ABIM Maintenance of Certification. The self-assessment modules will launch later in 2008, but demonstrations of modules on IBD and GI Bleeding, as well as the full GI LEARN system, are available at the AGA Booth (#2529).

As chair of the department of medicine at the Mayo Clinic College of Medicine, Rochester, MN, Dr. LaRusso knows firsthand about the funding pressures facing scientists, so at the beginning of his term as president he committed to supporting the AGA Institute’s advocacy for increased federal funding for biomedical research.

Funding issues will continue to put pressure on scientists and their ability to treat and serve patients, he said, while noting several positive advancements the AGA has made the past year.

The National Commission on Digestive Diseases at NIDDK, which AGA proposed, has issued a draft report that defines a long-term strategic approach for digestive disease research. This landmark report represents the enormous intellectual firepower of many AGA members and is a major milestone in our long-standing campaign for increased funding for biomedical research.

The results from the Commission’s findings will be aggressively communicated to the appropriate places in government where there is the strongest chance of affecting funding decisions.

One of the newest initiatives launched by the AGA Institute could prove to be Dr. LaRusso’s most enduring legacy.

“The title of the Plenary Address from my presidency will be ‘The AGA in the 21st Century: A Professional Society with a Social Conscience,’” Dr. LaRusso said. “This is a new and aggressive initiative to document and categorize all of the pro bono work that is being done already by members of the organization and to develop initiatives to facilitate and expand the pro bono work that is an important societal responsibility.”

Dr. LaRusso asserts that the Social Conscience Initiative could help drive and define much of the critical work to be done by the AGA Institute and its members for years to come.

“The most critical issue facing us in the years ahead will fall under the Social Conscience Initiative,” he said, “and that’s to help expand screening for colorectal cancer. We will do that in a number of ways, including possibly forging partnerships with other organizations that share our interests to help scientifically evaluate the appropriate place for the current screening techniques and to expand the number of people being screened.”

It is also important, he said, to explore new pathways of training gastroenterologists that ultimately result in well-trained physicians and medical scientists to deal creatively with digestive diseases.

“We need to ask, ‘What is the optimal curriculum for the next generation of gastroenterologists with regard to advances in imaging and personalized medicine?’” Dr. LaRusso said.

The personal and professional rewards of years of involvement with the AGA Institute lead Dr. LaRusso to share this advice with anyone else who is thinking about becoming more involved with the society: “Stop thinking and start doing.”

AGA Institute President Nicholas F. LaRusso, MD
Nicholas F. LaRusso, MD, is the Charles H. Weinman endowed professor of medicine and chair of the department of medicine at the Mayo Clinic College of Medicine, Rochester, MN, and a distinguished investigator of the Mayo Foundation. Prior to becoming chair in 1999, he was vice chair for research and then chair of the division of gastroenterology and hepatology at Mayo.

He received his undergraduate degree magna cum laude from Boston College in 1960, his medical degree from New York Medical College in 1969 and his training in internal medicine and gastroenterology at Mayo, the latter as an NIH fellow in the laboratory of Alan Hofmann, MD, PhD, from 1972 to 1974. Before assuming a faculty position at Mayo in 1977, he was a guest investigator at the Rockefeller University in the laboratory of the Noble laureate, Christian de Duve, MD, MSc, PhD.

A member of the American Association of Clinical Investigation and the Association of American Physicians, he is the former editor of Gastroenterology and past president of AASLD. Among other honors, he is a recipient of a MERIT Award and the principle investigator on two R01s from NIH. He also has received Distinguished Achievement Awards from both the AGA Institute and AASLD and the Distinguished Mentor Award from the AGA Institute.

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