Introduction

Screening by fecal immunochemical test (FIT) reduces colon cancer (CC) mortality and incidence, yet its efficiency may vary depending upon tumor location and recipient demographics. We addressed the modifications of left and right CC epidemiology following screening adoption.

Aims & Methods

To address the differences between left and right CC, we analyzed by Joinpoint, robust and logistic regression models the data of Parma County tumor registry, comprising 6697 incident cases above 50 years of age in the period 1994-2018 and recording screening adherence since the start in 2005.

Results

Adjusted standardized rates of left-CC declined significantly within screening age (50-69 years) (male annual percent changes [APC] -8.38; p<.001; female APC -13.1; p=.007), as well above it (male APC-4.97; p=.001; female APC -3.96; p=.003). The incidence of right-CC did not decline in screening age and increased above (male APC, 1.91%; p=0.001; female APC, 2.23%; p<0.001). Robust regression confirmed that left-CC decreased irrespectively of sex and age (all p<.001, but for elder males, p=.03), pointing to significant increase of right-CC across sexes and ages (all p£.006).
In multivariable regression models, as compared left-CC the risk of right-CC almost doubled in the 7^thdecade (Odds Ratio 1.89, 95%CI 1.43-2.44; p=.001), was higher for females (OR 1.40; 95%CI 1.27-1.54; p<.001) and after screening adoption (OR 1.44, 95%CI 1.27-1.54; p<.001).
In sex specific models, the probability of right-CC in females increased from 65 years of age (OR 1.80, 95%CI 1.18-2.75; p=.007) and in males from 75 years (OR 1.58, 95% CI 1.09-2.27; p=.015).
Due to the unequal distribution of right-CC, the rate of interval cancers over screen detected ones was significantly different between males (78/315; 25%) and females (93/200; 46.5%; p=.0004).
Independently from screening participation, right-CC in females brought an increased risk only of stage II (OR 1.43, 95%CI 1.06-1.92; p=.017) while in males it also enhanced the risks of stage III (OR 1.54, 95%CI 1.17-2.02; p=0.002), and IV (OR 1.47, 95%CI 1.06-2.03; p=.02) cancers.
At Cox modeling, right-CC carried a lower risk of death in females than in males (HR 0.77, 95%CI 0.67-0.89; p<.001), independently from tumor stage and screening status.

Conclusion

The screening reduced only the incidence of left-CC, while that of right-CC raised with aging, primarily and earlier in females. Right-CC progression in males carried a higher risk of death. Unimodal administration of FIT was followed by increasing burden of right-CC, advocating awareness on its specific development and progression by sex and age.

Introduction

Uncontrolled sepsis following leak from major oesophago-gastric surgery is a devastating condition with increased morbidity and mortality and intensive care stay. We hypothesised that endoluminal vacuum therapy (EVT) could be used in the prophylactic setting to provide source-control, prevent mediastinitis and minimise sepsis related morbidity from leaks.

Aims & Methods

An ad-hoc EVT device was created using VAC granufoam (KCI) and a nasogastric-tube (16/18Fr), and placed intraluminally across the high risk anastomosis/area of repair. Continuous negative pressure (75–125mmHg) was applied. Assessment of the repair site/anastomosis was performed by radiology, endoscopy, clinical assessment or a combination following cessation of EVT and removal of the prophylactic EVT device.

Results

Twenty-seven patients had prophylactic EVT; M:F ratio was 3:1 and the median age was 68 years (range: 41-82 years). Twenty-six patients had cancer resections while 1 had benign surgery. The rationale for prophylactic EVT included preoperative factors (10), intra-operative factors (16) or both (1). The median duration of prophylactic EVT was 7 days (range: 4-14 days). The median length of stay was 19.7 days (range: 6-96 days), the two longest admissions were unrelated to the anastomosis (prolonged chyle leak, and long-term-sequelae of life-threatening bleed). One patient developed full-thickness microleak at endoscopic evaluation, remained clinically well with no systemic signs of sepsis, and was successfully managed with luminal EVT for a further 6 days in a ward-based environment. Though prophylactic EVT did not prevent the leak, it significantly minimised the systemic hit that traditionally results from leak and associated mediastinal sepsis.

Conclusion

Prophylactic EVT is a useful adjunct for management of patients with a high-risk for leak and can serve as a risk reducing strategy in select cases. There are no short-term complications, yet the additional morbidity, mortality, and length of stay associated with a fully-fledged leak is avoided. Our results lay the foundation for the use of prophylactic EVT in randomised controlled trials to further standardise selection criteria, assess longer term potential patient benefit and impact on survivorship.

References

1. Pournaras DJ, Hardwick RH, Safranek PM, Sujendran V, Bennett J, Macaulay GD, Hindmarsh A. Endoluminal vacuum therapy (E-Vac): a treatment option in oesophagogastric surgery. World journal of surgery. 2018 Aug;42:2507-11.
2. Afzal Z, Gourgiotis S, Hardwick R, Safranek P, Sujendran V, Bennett J, O'Neill R, Noorani A, Hindmarsh A. O-EGS08 Endoluminal Vacuum Therapy (EVT) for leaks in the upper gastrointestinal (UGI) tract; 10-years’ experience in a specialist Oesphagogastric centre. British Journal of Surgery. 2021 Dec 1;108(Supplement_9):znab429-022.
3. Müller PC, Morell B, Vetter D, Raptis DA, Kapp JR, Gubler C, Gutschow CA. Preemptive endoluminal vacuum therapy to reduce morbidity after minimally invasive Ivor Lewis esophagectomy: including a novel grading system for postoperative endoscopic assessment of GI-anastomoses. Annals of Surgery. 2021 Nov 1;274(5):751-7.

Introduction

There is an increasing incidence of young-onset colorectal cancer (YOCRC), which is defined as patients with colorectal cancer at age 50 years and younger. They present with a distinct clinical phenotype compared to classical-onset CRC (COCRC), with a more aggressive disease at presentation, as well as different tumour location and mutational signatures. There is an unmet clinical need to elucidate the unexplained epidemiologic rise in incidence as well as disease pathogenesis of YOCRC.

Aims & Methods

Aim: To compare the clinical presentation, tumour characteristics and survival of young-onset versus classical-onset CRC.

A retrospective evaluation of patients diagnosed with colorectal cancer from 2019 to 2022 at a district general hospital was performed. We extracted data from electronic patient records for clinical, biochemical, radiological as well as histopathological reports. Comparisons were made between patients diagnosed at </=50 years (YOCRC) and >50 years of age (COCRC) respectively, and statistical analyses were performed. A p-value of <0.05 was considered statistically significant.

Results

34 (11.1%) and 273 (88.9%) patients were diagnosed as YOCRC and COCRC respectively. There was a difference in clinical presentation between the two groups, with haematochezia (n=12, 35.3%) (p=0.03) and change in bowel habit (n=7, 20.6%) predominating in the YOCRC group, versus positive faecal immunochemical test (FIT) (n=102, 37.4%) and anaemia (n=78, 28.6%) in the COCRC group respectively. There were no differences in the tumour location between groups, with >50% of cases arising from the left colon (22 YOCRC versus 149 COCRC). Thrombocytosis (platelet count>450x10⁹/L) (24% vs 11%, p=0.038) and tumour budding (12% vs 3%, p=0.006) were significantly increased in the YOCRC group. There were no significant differences in the histological subtype, TNM staging, mutational profiling and survival between groups. 6 (17.6%) YOCRC patients had died compared to 116 (37.8%) in the COCRC cohort over a median follow-up of 16 months.

Conclusion

Young-onset colorectal cancer represents a challenging subset of CRC, which has a different clinical and tumour phenotype to classical-onset CRC. Our study reflects the reported incidence rates of YOCRC of 11%, although the true epidemiology and frequency of YOCRC remains to be clarified. Haematochezia was the commonest presentation, while thrombocytosis and tumour budding were higher in the YOCRC group, suggesting a more advanced disease at diagnosis. Although the overall survival rates were similar between groups, further research would benefit from larger prospective studies with subdivision of YOCRC cases by age as poorer survival have been suggested in patients aged <30 years. There is a need to elucidate the respective aetiologies, environmental risk factors and pathogenesis of YOCRC, to allow early targeted treatment of such cases.

Table 1: Clinical presentation of YOCRC and COCRC

References

Mauri G, Sartore-Bianchi A, Russo AG, Marsoni S, Bardelli A, Siena S. Early-onset colorectal cancer in young individuals. Mol Oncol. 2019;13(2):109-131.

Introduction

The need for endoscopic necrosectomy (EN) has increased dramatically, as endoscopic EUS-guided drainage has become gold standard for treatment of pancreatic walled-off-necrosis (WON)[1,2]. Although snares and baskets are commonly used in EN procedures, they can be ineffective and dedicated instruments specifically designed for EN are scarce. Recently, an innovative powered endoscopic debridement system (EndoRotor, Interscope Inc., Northbridge, MA, USA) designed to excise and remove necrotic tissue within the WON was introduced specifically for EN with promising results[3,4]. While the first generation EndoRotor catheter was limited to 3.2 mm diameter, a larger catheter that fits into a large-channel gastroscope with a working channel of 6.0 mm has now been introduced. This study evaluates the clinical outcomes, safety, and feasibility of the novel 6.0 catheter for EN of WON.

Aims & Methods

This retrospective study was performed using prospectively collected data from all patients who underwent EN with the 6.0 catheter between December 2021 and March 2023 at Gastro Unit, Copenhagen University Hospital Hvidovre, a tertiary referral center in Denmark. All patients with symptomatic WON and need for necrosectomy were considered eligible for this study. Technical feasibility, safety, and clinical outcomes were evaluated.

Results

Sixteen patients underwent a total of 25 EN procedures with the 6.0 catheter. The mean age of the patients was 51.8 years (SD 17.7 years) and 11 (68.8%) were male. The etiology of the acute necrotizing pancreatitis was alcohol in 4 patients (25.0%), gall stones in 7 patients (43.8%), post-endoscopic retrograde cholangiopancreatography (ERCP) in 3 patients (18.8%), and idiopathic in 2 patients (12.5%). The mean size of the WON was 27.5 cm (SD 10.5 cm). The median computed tomography severity index (CTSI) was 8.5 (P25-P75: 6.0-9.0) and median modified CTSI (mCTSI) was 9.0 (P25-P75: 8.0-10). Two patients did not achieve clinical resolution (12.5%), as they died from multisystem organ failure before resolution of the WON was achieved. The median length of stay in hospital for the patients who achieved clinical resolution was 56.0 days (P25-P75: 36.5-96.0 days) and the median number of necrosectomy procedures performed to achieve clinical resolution was 5.0 (P25-P75: 2.0-8.5). All patients had EN procedures performed with snares in addition to the procedures with the powered debridement system. Five patients had necrosectomy performed with the 3.2 catheter (31.0%) as well as the 6.0 catheter. The median duration of EN with the 6.0 catheter was 60.0 minutes (P25-P75: 45.0-100 minutes) per procedure.
A device-related adverse event was noted in one instance (4.0%). The patient exhibited symptoms of peritoneal reaction in the hours following the procedure, which may have been caused by perforation of the WON into the peritoneal cavity. The patient was treated with laparoscopic peritoneal lavage and drainage and recovered without further interventions. No other procedure-related adverse events were identified. Malfunction of the catheter was observed in 7 procedures (28.0%).

Conclusion

To perform necrosectomy procedures optimally, dedicated endoscopic instruments designed for debridement of pancreatic WON are required. This study suggests that EN with the novel EndoRotor 6.0 catheter is safe and feasible with promising clinical results for EN of pancreatic WON. To assess the efficacy relative to standard techniques, comparative studies are warranted.

References

[1] Karstensen JG, Novovic S, Hansen EF, et al. EUS-guided drainage of large walled-off pancreatic necroses using plastic versus lumen-apposing metal stents: A single-centre randomised controlled trial. Gut 2022; 0: 1–7. doi:10.1136/gutjnl-2022-328225
[2] Ebrahim M, Werge MP, Hadi A, et al. Clinical outcomes following endoscopic or video-assisted retroperitoneal management of acute pancreatitis with large (>15 cm) walled-off pancreatic necrosis: Retrospective, single tertiary center cohort study. Dig Endosc 2022; 34: 1245–1252. doi:10.1111/den.14295
[3] Stassen PMC, de Jonge PJF, Bruno MJ, et al. Safety and efficacy of a novel resection system for direct endoscopic necrosectomy of walled-off pancreas necrosis: a prospective, international, multicenter trial. Gastrointest Endosc 2022; 95: 471–479. doi:10.1016/J.GIE.2021.09.025
[4] Wiel SE van der, May A, Poley JW, et al. Preliminary report on the safety and utility of a novel automated mechanical endoscopic tissue resection tool for endoscopic necrosectomy: a case series. Endosc Int Open 2020; 08: E274–E280. doi:10.1055/A-1079-5015

Introduction

In recent years, evidence shows that long non-coding RNAs (lncRNAs) are key regulators of gene transcription and play important roles in the pathogenesis of inflammatory bowel diseases. LncRNAs are involved in the regulation of intestinal epithelial cell apoptosis, cell-cell interactions, and enhancing inflammation, among others. Biological therapies, which are considered the most potent for disease control, only benefit one-third of patients. For this reason, a deeper understanding of the mechanisms by which biological drugs elicit their effect on intestinal mucosal is needed. Hence, we aimed to unravel the ex vivo modulator effect of infliximab on the lncRNAs expression in intestinal biopsies from patients with Crohn´s Disease (CD).

Aims & Methods

We performed an unbiased transcriptomic analysis of intestinal biopsies from the ileum and colon from 30 patients [active CD = 10, quiescent CD = 10, healthy controls (HC) = 10] to identify lncRNA differentially expressed in the setting of infliximab modulation. Endoscopic biopsies were cultured with or without infliximab and the transcriptome was determined by Illumina gene expression array. We used different databases (Ensembl Biomart, RNAcentral and ToppGene) to search for non-annotated lncRNA information and data on the location (cellular component), biological process and molecular function of differentially expressed lncRNAs.

Results

Transcriptomic results revealed a widespread dysregulation of lncRNAs in ileum biopsies from patients with active CD, quiescent CD and HC compared to the colon at baseline and after infliximab culture. These differentially expressed lncRNAs were enriched in such pathways as proliferation, apoptosis, migration, inflammatory response of fibroblasts, response to wounding, posttranscriptional regulation of inflammatory genes and activation of the mitogen-activated protein kinase signaling pathways. Regarding the effect of infliximab according to intestinal location, presence of disease and activity, no significant lncRNAs were identified in the different study comparatives.

Conclusion

We have characterized the basal transcriptomic landscape of lncRNAs in patients with CD (active and quiescent) and HC both in ileum and left colon. However, we have not found differential lncRNA expression due to the effect of infliximab, suggesting that the location (ileum or colon) is more relevant when analyzing differences in lncRNA expression in the intestinal tissue.

Introduction

Endoscopic colonic stenting is a treatment method in which a colonoscope is used to insert a self-expandable metal stent (SEMS) into a stenotic site and allow its expansion to alleviate colonic obstruction and permit urgent colonic decompression. It is an effective and extensively practiced minimally invasive procedure compared with emergency surgery. However, perforation, stent migration, and reocclusion may occur. Perforation is particularly a serious adverse event with a mortality rate of 50%. There are three possible causes of perforation:
(1) Local perforation due to stimulation of the stent itself directly into the intestinal tract;
(2) Perforation due to guidewire or catheter manipulation during stent insertion; and
(3) Perforation due to increased pressure in the intestinal tract at the oral side of the obstruction (especially in the cecum) caused by air supply during colonoscopy insertion.
For the first possible cause, an improved colonic stent was developed to reduce irritation to the intestinal tract, and for the second possible cause, a strategy for safe stent insertion was established.
However, perforation due to the third possible cause remains a concern, and appropriate countermeasures should be urgently developed.
In endoscopic colonic stenting, we hypothesized that colonoscope insertion using the gel immersion method, which uses a recently developed endoscopic view-securing gel, would allow safe and rapid access to the lesion without increasing intestinal pressure, thereby decreasing the incidence of perforation.

Aims & Methods

This study aimed to clarify the usefulness of the gel immersion method during colonoscope insertion with endoscopic view-securing gel for colonic stenting. Eight patients in whom colorectal stenting was performed using the gel immersion method between May 2022 and January 2023 were included.
The primary endpoint was the endoscopic lesion reach rate, and the secondary endpoints were the technical and clinical success rates of SEMS deployment, colonoscope insertion time, total procedure time, and adverse event rate.

Results

Of the included patients, four were males (50%), and the mean age of patients was 67.6 ± 15.6 years. Seven patients (87.5%) had colorectal cancer and one patient (12.5%) had gastric cancer. The cancer was localized at the following sites: sigmoid colon in three patients, descending colon in three patients, transverse colon in one patient, and ascending colon in one patient. The purpose of SEMS deployment was bridge to surgery in four (50%) and palliation in four (50%) patients. In all cases, the endoscope was inserted without the preparation and insertion of the endoscope into the lesion at the origin of the obstruction without insufflation, and the endoscopic lesion reach rate was 100% (8/8). No worsening of intestinal dilatation was observed. The technical and clinical success rates each were 100% (8/8). The scope insertion time was 9.8 ± 5.2 min, total procedure time was 27.3 ± 6.5 min, and the adverse event rate was 0% (0/8).

Conclusion

For endoscopic colonic stenting, endoscope insertion using the gel immersion method could be performed safely and effectively and has the potential to become the standard method.

Introduction

Gastroenterology (GE) is a medical discipline that studies all diseases of the digestive system. It comprises several areas of study and offers a large variety of sub-specializations: proctology, interventional endoscopy or even digestive oncology. The decisive elements in the choice of this specialty vary among interns. The aim of our study is to determine the various factors influencing the choice of gastroenterology as a specialty among medical interns.

Aims & Methods

This is a cross-sectional, multicentric, survey-type study, conducted from September 1 to 30, 2023, involving 7 national medical faculties. All medical interns, regardless of sex or age, participated in our study.
An electronic survey with 29 items was created using Google Forms®. It was divided into two parts: the first part contained 13 questions on socio-demographic characteristics and exposure to GE during the academic curriculum, while the second part concerned the factors motivating the choice or not of GE as a specialty.
A statistical analysis using the Fisher’s exact test was performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

A total of 329 responses were collected: the majority were women 208 (63.2) with a F/M sex ratio of 1.7 and a median age of 27 [25; 28] years. The majority had already completed a GE rotation during their training course n=205 (62.3), of which 90 (44.1) had found it "satisfactory". More than half of the participants n= 178 (54.1) had already considered GE as a future specialty, and this choice was mostly made during GE lectures given in medical school n= 66 (36.9). Among those who had never considered GE, the main reasons were lack of interest in the specialty, the fact that it is a medical specialty, lack of information about GE, potential remuneration, and dissatisfaction with GE rotation during the training course (59.2%, 28.9%, 13.9%, 10.4% and 10% respectively).
Among those who finally opted for GE, the majority were women (70.2% vs. 29.8%, p=0.004). Satisfaction with the GE rotation during the training course had an impact on the final choice: "satisfactory" vs. "mediocre" (43.8% vs. 6.3% p=0.009).
Multivariate analysis showed that early interest in fields such as endoscopy (OR= 4.46, CI95%: 1.44-13.78, p=0.009) or proctology (OR= 4.26, CI95%: 1.01-18.01, p=0.05) increased the chance of choosing GE.

Conclusion

This study showed that there is a gender disparity in the choice of GE as a specialty. The fact that it is a medical discipline may lead men to choose another path. Our study also highlighted the importance of GE training courses during the medical curriculum to motivate interns to join our specialty, as well as the need to spotlight certain areas such as endoscopy or proctology.