Introduction

Lactose malabsorption (LM) is a common digestive disorder. The hydrogen breath test (HBT) is currently the non-invasive gold standard in diagnosing LM and lactose intolerance (LI), which is defined only in case of developing symptoms directly related to lactose ingestion in subjects with LM. (Misselwitz et al. 2019) The analysis of methane values in air samples may increase the accuracy of the test by including subjects “non hydrogen producers”. (De Geyter et al. 2021)

Aims & Methods

The aim of this study is to describe the relationship between pre-test clinical features, symptoms reported during lactose challenge and the result of the HBT in adults. In this prospective study we included a consecutive series of adult patients who underwent a HBT during a 5-month period. Air samples were taken every 30 minutes for 4 hours after the ingestion of a charge of 25 g of lactose. Symptoms reported in the previous 15 days (abdominal pain, bloating, diarrhoea, flatulence) and those experienced after lactose ingestion were assessed using a standard questionnaire establishing their presence or absence, and relative severity using 0-10 scale. The results were considered positive when a H₂ peak exceeded 20 parts per million (ppm) above the baseline or in case CH₄ excretion reached 10 ppm above the baseline, for experimental purpose. LI was defined by at least one symptom experienced during the test in subjects with LM.

Results

68 patients were included in the study and 40 of them (59%) were positive at the HBT. 52 (76%) developed at least one symptom while LI was diagnosed in 34 patients of them (65%). Only 40% of patients who referred pre-test symptoms had LM and none of the four symptoms was associated with LM or LI. A positive trend was found between abdominal bloating after lactose ingestion and a positive HBT (p 0.08). This association was statistically significant (73% vs 43%, p 0.02), with a positive trend also for flatulence (p 0.08) (Table), implementing diagnostic test with values of exhaled methane, finding 10 more intolerant patients. Considering the variation of symptoms (new or worsening of symptoms after lactose ingestion), the worsening of bloating was significantly more frequent in subjects with positive HBT compared to those with a negative test (40% vs 14%, p 0.03) and predictive of LI (PPV= 80%). Diarrhoea was the most predictive symptom of LI (PPV up to 88%). An association between the number of symptoms experienced during the test and LM was confirmed, while we didn’t find the same relationship with pre-test symptoms. (Beyerlein et al. 2008)

Symptoms during the test	Total number of patients. N=68	positive H2 /CH4 BT , N=45	negative H2 /CH4 BT-, N=23	p value
Abdominal pain	38 (56%)	28 (62%)	10 (43%)	non statistically significant
Abdominal bloating	43 (63%)	33 (73%)	10 (43%)	0,02
Flatulence	40 (59%)	30 (67%)	10 (43%)	0,08
Diarrhoea	12 (18%)	10 (22%)	2 (9%)	non statistically significant

Conclusion

Symptoms reported before HBT seems to be non-related to LI. This may lead to arbitrary dietary exclusion of dairy products with consequences on bone health (Infante and Tormo 2000) and suggest that the causal role of lactose should be confirmed by HBT. In adult, the development ex-novo or the exacerbation of abdominal bloating and diarrhoea during the test, in subjects with LM, seems to be the most predictive of LI. Furthermore, the increase of the number of symptoms complained makes the diagnosis of LI more likely. On these basis, a domestic screening with 25 g of lactose (500 ml of milk) to establish whether the patient really needs the execution of breath test should be explored.

References

Beyerlein et al. 2008
De Geyter et al. 2021
Infante and Tormo 2000
Misselwitz et al. 2019

Introduction

EUS guided cysto- gastrostomy/duodenostomy is well established now as a standard treatment option for symptomatic pancreatic pseudocyst in adult. Pancreatic pseudocyst in children is rare and tend to resolve spontaneously. Pancreatic pseudocyst that persists more than 6 weeks and cause symptoms considered a troublesome and need drainage either surgical, radiological or endoscopic. There are limited data regarding EUS guided cysto-gastrostomy in the childhood age group (2- 12 years). This is due to limited number of cases in this age group, the lack of experienced pediatric gastroenterologist with this technique and relatively large diameter of therapeutic EUS with a rigid tip that may restricts its use in young children.
We assessed the feasibility of EUS guided drainage of symptomatic pancreatic pseudocyst in children as an effective and safe procedure.

Aims & Methods

This is a multi-center retrospective study. We reviewed our data base for all children between the ages of 3 and 12 years underwent EUS guided pancreatic pseudocyst drainage between Oct 2018 and Dec 2022. We assessed preprocedural patient indication (including cause of previous pancreatitis, present complaint, and imaging), procedure technical success, early and delayed procedure related complication and clinical success.

Results

EUS guided cysto-gastrostomy was performed in nine children (six were males and 3 were females). The median age of the included children was 8 years (ranging from 3: 12 years) and the median Weight was 26.4 kg (ranging from 14.5: 37 kg). The cause of previous pancreatitis was blunt trauma in 4 cases, post chemotherapy for ALL in 3 cases and two were biliary cause. We had 100% clinical success with deployment of short double pigtail plastic stent (10Fr x 5 or 7 cm) through created fistula between the gastric lumen and cyst (the fistula was done by using 6 fr cystotome over guidewire and was dilated using mechanical dilator in 5 cases and 6:8 mm balloon in 4 cases). All patients resolved completely from pre- procedure symptoms and eight patients had complete cyst resolution after one month. One case has marked regression from 9.5 cm to less than 2 cm, this case also did trans-papillary drainage for pancreatic duct disruption. No post procedure complications were observed, only mild pancreatitis managed conservatively for 3 days in the child underwent concomitant trans-papillary drainage.

Conclusion

EUS guided cysto- gastrostomy for childhood population with symptomatic pseudocyst appeared to be feasible, effective, and safe procedure using therapeutic endoscopic ultrasound. Larger number of cases needed to support this procedure as a standard treatment option for these cases.

Introduction

Superficial esophageal squamous cell carcinoma (SESCC) was enabled detection by the innovation of Narrow Band Imaging (NBI). However, NBI has insufficient sensitivity for detecting SESCC when used by inexperienced endoscopists.¹⁾ To solve these problems, the construction and usefulness of endoscopic detection models for SESCC using artificial intelligence (AI) have been reported.²⁾ On the other hand, the assistant effect of the AI model for endoscopists has not been fully examined.

Aims & Methods

The aim of this study is to create an AI model to assist in detecting SESCC and to assess the effect of the AI assistance on the endoscopist's diagnostic performance using endoscopic video. We collected endoscopic videos of cases with lesions and without lesions from May 2020 to September 2021 for training data to create an AI model for detecting SESCC and from October 2021 to January 2022 for test data. All videos were taken 3 to 5 seconds at National Cancer Center Hospital East by using NBI. Eligibility criteria for cases with lesions were as follows: i) histopathologically diagnosed ESCC or high-grade intraepithelial neoplasia (HGIN); ii) the depth of lesion shallower than cMM/SM1. Residual lesions after endoscopic resection for ESCC were excluded. The eligibility criteria for cases without lesions were the absence of ESCC or HGIN by endoscopic diagnosis. Patients with a history of chemotherapy, radiotherapy, chemoradiotherapy, or surgery for ESCC were excluded. The performances of the AI model and 18 endoscopists (8 experts and 10 non-experts) for detecting SESCC were evaluated using the test data. Furthermore, to explore the assistance ability of the AI model, the endoscopists were required to diagnose again on the same test data after 4 weeks, referring to the results predicted by the AI model. The diagnostic performance of the endoscopists with and without the AI assistance was compared to assess the sensitivity, specificity, accuracy, and interobserver agreement. The recognition to the lesions by the AI model was defined to detect with Intersection over the Union > 0.3 for 5 consecutive frames for each video. The results of the endoscopists were presented as averages.

Results

We collected 280 cases (140 with lesions and 140 without lesions) videos as training data and 115 cases (52 with lesions and 63 without lesions) videos as test data. The clinicopathological characteristics of the lesions were as follow: median lesion size was 15mm (range:1-100mm), and the pathological depth of tumor were EP/LPM/MM/SM1/SM2=10/17/0/4/4/4. The sensitivity, specificity, and accuracy of the AI model were 76.0%, 79.4% and 77.2% respectively. With the AI assistance, the sensitivity and accuracy of the endoscopists were significantly improved (without vs with the AI assistance: 57.4% vs 66.5%, P<0.05, 68.6% vs 75.9%, p<0.05), while the specificity were slightly improved (87.0% vs 91.6%, P=0.059). For experts, the sensitivity and accuracy were significantly improved (59.1% vs 70.0%, P<0.05, 72.1% vs 79.3%, p<0.05). For non-experts, the accuracy was significantly improved (65.8% vs 73.3%, P<0.05), while the sensitivity and specificity were slightly improved (56.1% vs 63.7%, P=0.07, 81.9% vs 89.2%, p=0.07). The interobserver agreement for diagnosis among the endoscopists was improved with the AI assistance (κ=0.429 vs κ=0.547).

Conclusion

The assistance of the AI model improved the endoscopist's sensitivity of detection of SESCC without reducing the specificity, regardless of their experience. The AI model would be effective in improving the endoscopist's ability to detect SESCC in practice.

References

1) Ishihara R, Takeuchi Y, Chatani R et al. Prospective evaluation of narrow-band imaging endoscopy for screening of esophageal squamous mucosal high-grade neoplasia in experienced and less experienced endoscopists. Dis Esophagus 2010; 23: 480–6.
2) Waki K, Ishihara R, Kato Y et al. Usefulness of an artificial intelligence system for the detection of esophageal squamous cell carcinoma evaluated with videos simulating overlooking situation. Digestive Endoscopy 2021; 33: 1101–1109.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) is an established endoscopic treatment for common bile duct stones and acute cholangitis. Due to its less invasiveness compared to surgery, it has been accepted as a first choice even for the elderly receiving anticoagulants. However, there is only a limited number of reports of the safety of EST after minimal cessation of anticoagulant based upon the Japan Gastroenterological Endoscopy Society (JGES)guideline.

Aims & Methods

To evaluate the safety, we aimed to clarify the bleeding risk in patients taking anticoagulants in our institute. Patients who underwent ERCP at double institutes from January 2018 to December 2021. Among them, we compared the rate of bleeding after EST and bleeding requiring blood transfusion in anticoagulant patients and non-administrators. Patients taking anticoagulants were allowed to discontinue the direct oral anticoagulant (DOAC) on the day before or the day of ERCP, and those who followed the JGES guideline for warfarin were included.

Results

ERCP was performed in 1616 patients and an analysis of a total of 882 patients of EST including 69 patients taking anticoagulants revealed that there were no significant differences in the bleeding rate although the blood transfusion rate was significantly higher in the DOAC group (2/52 3.9%) and antiplatelet drug combination cases (1/15 6.7%) compared to other cases (5/805 0.6%). Univariate and multivariate analyzes were performed according to background age, sex, hypertension, diabetes mellitus, heart disease, cerebrovascular disease, hemodialysis, platelet count decreased (less than 10x10⁴/μL), and urgency (within 24 hours after consultation). In the univariate analysis for EST bleeding, cerebrovascular disease, hemodialysis, and thrombocytopenia were significant risk factors(p<0.05). As a result of the multivariate analysis of these, only cerebrovascular disease was a significant risk factor (OR=2.11, 95%CI: 1.21-3.68, p=0.0086). In the univariate analysis for blood transfusion, DOAC users, cerebrovascular disease, and hemodialysis patients were significant risk factors(p<0.05). A multivariate analysis that added EST bleeding to these results also found significant risk factors for similar items. DOAC(OR=6.89, 95%CI: 1.06-44.65, p=0.043) and cerebrovascular disease(OR=18.85, 95%CI: 3.01-117.93, p=0.0017), hemodialysis(OR=55.68, 95%CI: 6.51-475.99, p=0.00024) were significant risk factors for severe bleeding requiring blood transfusion.

Conclusion

Although there were no significant differences between the bleeding rates of EST for those taking anticoagulants and those not taking anticoagulants, it was suggested that there is a possibility of serious bleeding requiring blood transfusion in patients receiving anticoagulants, especially DOAC.

Disclosure

none

Introduction

The ulcers after duodenal endoscopic resection (ER) are exposed to bile and pancreatic juice, therefore delayed perforation and bleeding are common. As a preventive measure, the suture of the ulcer after ER has been reported to be effective. Our data are shown as follows. From January 2007 to January 2018, ER was performed for 219 duodenal tumors. We compared 211 lesions in the suture group with 8 lesions in the non-suture group. Delayed perforation was 0% in the suture group and 13% (1/8) in the non-suture group, showing a significant difference (p=0.0365). Delayed bleeding was 1% (3/211) in the suture group and 25% (2/8) in the non-suture group, showing a significant difference (p=0.01). Therefore, the suture of the ulcer after ER is essential. If the ulcer is small after ER, it can be sutured endoscopically, but if it exceeds 3 cm, it is difficult to suture with the endoscope alone.

Aims & Methods

The aim of this study is to investigate the outcome of duodenal laparoscopic and endoscopic co-operative surgery (D-LECS) for superficial non-ampullary duodenal epithelial tumors (SNADETs).
First, tissue around duodenum is dissected laparoscopically. Second, endoscopic submucosal dissection (ESD) is performed using saline injection, Hook knife, and VIO 300D or VIO3. Sites with poor maneuverability endoscopically were resected with laparoscopic assistance. Third, ulcer after ER is sutured laparoscopically. If inadequate, endo clip is added.
Thirty-five patients with SNADETs who underwent D-LECS from January 2014 to March 2023 were investigated outcome of procedure. The patient’s characteristics were as follows. male/female: 23/12, median age 65 (37-83) years old, location of the tumor (bulbs/2^nd/3rd portion): 3/27/5, major macroscopic type (0-I/0-IIa/0-IIc): 1/29/5. pancreatic side/ non-pancreatic side of duodenum: 26/9.
SM1 was defined as submucosal invasion of less than 500 μm, and SM2 was defined as deeper. R0 was defined as lateral and vertical margin negative, and lymph-vascular involvement negative. Median follow-up period was 13 (0-42) months.

Results

1. Median procedure time was 351 (195-673) minutes. In it, median endoscopic procedure time and laparoscopic procedure time were 205(132-429) and 131(67-420) minutes, respectively. Median diameter of resected specimen and tumor were 40 (26-70) and 27 (14-53) mm, respectively. Intramucosal tumor (Vienna classification category 3 to 5.1) /T1bSM2 (category 5.2): 31/4. The median length of hospital stay was 9 (8-15) days.
2. The en bloc resection and R0 resection rate were 94% (33/35), 83% (29/35), respectively.
3. Complications: intraoperative perforation was 8% (3/35). The intraoperative perforation site was sutured laparoscopically after ESD was completed. Intraoperative bleeding requiring blood transfusion, delayed perforation, and delayed bleeding were 0%.
4. The rate of complete closure by laparoscopy was 0% (0/26) for pancreatic side, and all of them were sutured with endo-clips and polyglycolic acid sheets. And that for non-pancreatic side was 100% (9/9).
5. Prognosis
Two cases of T1bSM2 were underwent pancreaticoduodenectomy, and there were no residual tumor and no lymph node metastasis. There has been no recurrence during twenty-eight and forty-two months after DLECS,
T1aM and T1bSM1 were followed up, and no local or metastatic recurrence was observed.

Conclusion

DLECS enabled complete closure of ulcers after ER regardless of size or location. Therefore, it is a safe and effective treatment for large SNADETs.

Introduction

Crohn's disease (CD) is a chronic inflammatory bowel disease, characterized by a progressive course that leads to structural bowel damage (SBD). There is no clear definition of SBD. The Lémann index has been proposed, but it's too complicated to calculate. However, the presence of detectable complications through imaging techniques, such as strictures, fistulas or abscesses is widely accepted to describe SBD. Their presence is strongly associated with the severity of the disease and predicts the risk of hospitalization and surgery. Therefore, reversing structural bowel damage is an emerging medical goal in the time of biological treatments.

Aims & Methods

The main objective of this study was to assess the ability of biological treatments to reverse structural bowel damage monitored by intestinal ultrasound (IUS) and compare the disease course of patients with CD with inflammatory behaviour vs complicated behaviour (stricturing or penetrating -abscesses and fistulas-).
This was a longitudinal observational study, which included patients with CD who started a biological treatment in our center and that were monitored with IUS. Clinical, laboratory and ultrasound variables were collected at the beginning of biological treatment, after 12 weeks and after one year of treatment in order to study the evolution of the disease.
To achieve our objective, we compared the transmural healing (TH) at 12 weeks and one year after starting biological treatment. TH is defined as intestinal parietal thickness ≤3 mm, with no detectable Doppler signals and absence of complications.
As a secondary objective, we compared the need for medical treatment, hospital admission and surgery during the first year of biological treatment

Results

A total of 137 patients with CD were included in this study. Their characteristics and treatments are shown in Table 1.

Variables		Absolute frequency (%)
M​ale		67 (48.9%)
Initial bowel damage	Stricturing	31 (22.6%)
	Abscesses	11 (8%)
	Fistula	21 (15.3%)
Montreal Classification	Age	≤16 years: 12 (8.8%) 17-40 years: 79 (57.7%) ≥ 41 years: 46 (33.6%)
	Location	Ileal: 75 (54.7%) Colonic: 19 (13.9%) Ileocolonic: 43 (31.4%) Upper disease: 1 (0.7%)
	Behaviour	Inflammatory: 53 (38.7%) Stricturing: 30 (21.9%) Penetrating: 54 (39.4%)
Indication for initiating biologic treatment​​	Stenotic complication	25 (18.2%)
​	Penetrating complication	22 (16.1%)

At the beginning of biological treatment, 50 patients (36.5%) exhibited a complicated behaviour (strictures, abscesses, and fistulas).

After 12 weeks of treatment, TH was achieved in 22.9% of all evaluated patients. By groups, 8.2% of patients with complicated CD and 31.3% with an inflammatory behavior achieved TH, being the last difference statistically significant (p 0.02). After one year of treatment, TH on IUS was achieved in 46% of all evaluated patients. 31.8% of these patients had a complicated EC and 45.1% presented an inflammatory behavior, without reaching statistical significance (p 0.159).
Furthermore, the group with complicated behavior exhibited a significantly higher need for corticosteroid therapy, hospital admission, and surgery.

Conclusion

Patients with SBD showed a significantly lower rate of TH compared to patients with an inflammatory behaviour after 12 weeks of biological treatment. Additionally, the need for corticosteroid therapy, hospital admission, and surgery was significantly higher in patients with a complicated CD. However, after one year, the TH rate showed no differences between groups. This suggests that reversing structural bowel damage is possible but that the treatment of these patients is more complex.

References

1. Wilkens, Rune et al. Relevance of monitoring transmural disease activity in patients with Crohn's disease: current status and future perspectives. TherapAdvGastroenterol. 2021 Apr 16;14:17562848211006672.
2. Paredes, José María et al. Clinical Impact of Sonographic Transmural Healing After Anti-TNF Antibody Treatment in Patients with Crohn's Disease. Dig Dis Sci. 2019 Sep;64(9):2600-2606
3. Muñoz, Fernando et al. Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of abdominal ultrasound in inflammatory bowel disease. GastroenterolHepatol. 2021 Feb;44(2):158-174.
4. Calabrese, Emma et al. Ultrasonography Tight Control and Monitoring in Crohn's Disease During Different Biological Therapies: A Multicenter Study. ClinGastroenterolHepatol. 2022 Apr;20(4):e711-e722
5. Fraquelli, Mirella et al. Impact of intestinal ultrasound on the management of patients with inflammatory bowel disease: how to apply scientific evidence to clinical practice. Dig Liver Dis. 2020 Jan;52(1):9-18.
6. Wilkens, Rune et al. Relevance of monitoring transmural disease activity in patients with Crohn's disease: current status and future perspectives. TherapAdvGastroenterol. 2021 Apr 16;14:17562848211006672
7. Roda, Giulia et al. Crohn's disease. Nat Rev Dis Primers. 2020 Apr 2;6(1):22
8. Fiorino, Gionata et al. Impact of therapies on bowel damage in Crohn's disease. United European Gastroenterol J. 2020 May;8(4):410-417