Brian Lacy, MD, on Major Advances in Gastroenterology 2010-2019


In this podcast, Brian Lacy, MD, coeditor of the American Journal of Gastroenterology, discusses the journal's recent publication of a review of major advancements in gastroenterology over the previous decade.

Brian Lacy, MD, is professor of medicine and gastroenterology at the Mayo Clinic in Jacksonville, Florida.


Rebecca Mashaw:  Hello everyone and welcome to another installment of Podcasts 360, your go-to resource for medical news and clinical updates. I'm your moderator, Rebecca Mashaw, with Gastroenterology Consultant.

With us today is Dr. Brian Lacy, a gastroenterologist and professor of medicine at the Mayo Clinic in Jacksonville, Florida, and co‑editor in chief of The American Journal of Gastroenterology.

In that position, he's led a team of gastroenterologists, hepatologists, nutritionists, and others from around the world in putting together an editorial review titled Major Trends in Gastroenterology and Hepatology Between 2010 and 2019. Thanks for joining us today to talk about this review, Dr. Lacy.

Dr. Brian Lacy:  Absolutely. Thank you.

RM:  This article represents a first for "The American Journal of Gastroenterology," I understand. Would you tell us about how the article came about, and the process that you went through to assemble the information?

Dr. Lacy:  Yeah, the idea came together at our editorial board retreat. This is when the entire editorial board got together, thought about where we've been in terms of the Journal, and where we want to go. We reviewed successes and some things that maybe didn't work out as well as they should have. We also brainstormed a lot about new ideas, new columns, and new review articles.

As we are all sitting around in this room, really surrounded by really smart people, it came to our attention that as the decade was ending ‑‑ because our retreat was in early December 2019 ‑‑ we thought it was just natural to take all this great talent in the room and really look at the decade in review and focus on these large topics, whether esophageal disorders or liver disorders, as an example, and really kind of try to summarize major advances in the field for our readership.

Rebecca:  What were these major trends that you identified over the past decade?

Dr. Lacy:  Wow, hopefully we have about 1 hours for this phone interview. Lots of great trends, so let me try to highlight maybe 5 or 6 of them very quickly. I think there's been a lot of   excitement about endoscopic ultrasound and the use of lumen‑apposing stents (LAMS). That's been very exciting in the field of draining the gallbladder and attacking problems with the bile duct.

I think there's been a lot of excitement in the field of submucosal endoscopy, attacking what's called the third space. We talk about the GI lumen as the first space or primary space. We discuss and talk about the peritoneal cavity as the second space, but the third space is that submucosal space and a great example would be the use of POEM, or peroral endoscopic myotomy, for achalasia.

Of course, there's a lot of excitement now about G‑POEM or gastric peroral endoscopic myotomy for achalasia. It would be hard to not talk about advances in the field of esophageal manometry using the revised Chicago 3.0 classification, and that was so important during the last decade.

Of course, we should think too about eosinophilic esophagitis and all the great changes that have occurred in both recognizing and diagnosing the disorder, but also treating the disorder with topical steroids and with biologic agents.

We should mention celiac disease, and there's been a lot of interest in this field and clearly distinguishing celiac disease from a gluten sensitivity. We now know that there's really interesting data that life exposure early in life may increase your risk and will tempt our listeners on the phone today.

There'll be some neat research published later this year in the red journal, the American Journal of Gastroenterology, showing that a prior viral infection may increase your risk for celiac disease, too.

We recognize functional bowel disorders are present in 40% of the US population. We have now changed that term from functional gastrointestinal disorders to disorders of the brain‑gut interaction DGBI.

We've got lots of neat information about how behavioral therapy and hypnotherapy can alter the progress and of that...there are these disorders, whether IBS or dyspepsia. Lastly, we should just mention hepatitis C and how there've been just dramatic advances in that field.

RM:  The review focused on eight key areas. You mentioned disorders of the gut‑brain interaction. In addition to that, endoscopy, gastroesophageal disorders, colorectal disease, small intestinal disorders, hepatology, pancreatology, and IBD were all mentioned.

Of all these subject areas, is there one that stands out as showing the most progress or the most significant advances that you saw?

Dr. Lacy:  I'd like to highlight 2 but focus on 1. That has to be hepatitis C. This was really first identified in 1989. Less than 30 years later, we now have essentially cured hepatitis C. If you come in now with a new diagnosis, we have cure rates of well in the 90s and actually 100%. Hepatitis C, something we dreaded, and basically didn't understand very well, 30 years ago, we're now curing.

A second note would be in the field of inflammatory bowel disorders. For listeners who are a little bit older, thinking about 20 years ago when basically we focused on 5-ASA drugs or steroids, there are now a host of biologic agents that we can use to really individualize therapy for patients with Crohn's disease or ulcerative colitis. That's just been really a landmark progress in the field of inflammatory bowel disease.

RM:  What surprised you when your colleagues the most, do you think, as you've reviewed these advancements over the past decade?

Dr. Lacy:  I think one thing that surprised me— and maybe it shouldn't have was —we are just awash in data. As we were writing this article from all these experts in the field, going back through the literature, just looking at the amazing amount of progress that we've made.

There's been so much research, both at the basic science level, really understanding why disorders or brain gut interaction occur, or why inflammatory bowel develops in some patients but not others, but also in terms of clinical research, too. Really, this is across all the fields.

I think that was so what was so neat about having all these associate editors of the journal really take a deep dive into their field and just explore the literature once again, although they're experts.

We're all impressed with how much research is going on not just in the United States, but worldwide and that's really very exciting for us as clinician scientists, but also for our patients as well.

RM:  Did you find anything during this review that was troubling, such as the increased incidence of certain diseases or disorders?

Dr. Lacy:  I don't know if I would use the word troubling. I understand exactly what you're asking. I guess what I think and I think what many of our associate editors found, too, is as they really dug into their field, what's troubling is how these disorders greatly affect our patients.

This impact is felt just not on a personal level, and how these disorders, whether chronic hepatitis, whether inflammatory bowel disease, whether irritable bowel syndrome, affect the patient's quality of life, but also how it affects the healthcare economic system.

As we move forward over the next decade, in terms of research in terms of patient care, in terms of outcomes, we really need to focus on quality of life, we need to focus on reduction in healthcare costs.

We can't keep spending huge amounts of money but not improving patient care. I think that was troubling, a little bit discouraging to me. That aside, I'm an optimistic person, I hope the next decade, we'll just see some great advances.

RM:  That leads to my next question. If the American College of Gastroenterology does the same sort of review a decade from now, what advancements do you hope to see featured?

Dr. Lacy:  I certainly hope we do this again a decade because I think there'll be another wealth of data to kind of tack into and report. I would love to see the success of hepatitis C mirrored as an example. I would love to see acute pancreatitis really being cured.

I bet there's somebody out there smart enough to figure out how we can stop that inflammatory cascade that begins with acute pancreatitis and stop that pathway. I would love to see a cure for NASH, non‑alcoholic steatohepatitis, which is now really one of the biggest healthcare crisis we face as people become heavier and they have chronic liver disease.

We'll be able to report in a decade that will see really individualized treatment for both inflammatory bowel disease and for these disorders or brain gut interaction, such as dyspepsia and IBS. I'm very hopeful that in a decade, we're going to see this great article once again, highlighting all kinds of wonderful achievements.

RM:  Thank you so much for joining us today, Dr. Lacy. We really appreciate your time.

Dr. Lacy:  Absolutely. Thank you so much for having me.

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