Introduction

Fecal Microbiota Transplantation (FMT) stands as a promising therapeutic approach for gastrointestinal disorders, notably recurrent Clostridioides difficile infection. Despite its potential, the awareness and perceptions surrounding FMT among stakeholders in low and middle-income countries, such as Armenia, remain relatively unexplored.

Aims & Methods

This study aimed to assess awareness and attitudes towards FMT among 4th to 6th-year medical students of Yerevan State Medical University (YSMU), healthcare professionals at Mikayelyan University Hospital, and patients of the same hospital in Armenia. The primary aim is to evaluate awareness and attitudes towards FMT among these groups and, as a conclusion, to increase awareness among the Armenian population, both patients and physicians, and to promote the integration of microbiota-based researches and therapeutic methods in Armenia. Methods: A questionnaire-based study was conducted among 143 medical students from YSMU (Yerevan State Medical University), 56 healthcare professionals (including gastroenterologists, infectious disease specialists, internists, and endoscopists) at Mikayelyan University Hospital, and 82 patients undergoing outpatient and inpatient treatment at the same hospital. Participants were surveyed to gauge their awareness level, perceptions, and willingness regarding FMT.

Results

This study explores the intricate landscape of awareness and attitudes towards Fecal Microbiota Transplantation (FMT) among medical students, healthcare professionals, and hospital patients in Armenia. Delving into their perspectives, this research offers nuanced insights into the reception and readiness for FMT adoption. Among surveyed medical students, university education emerged as the predominant source of knowledge (47.5%), while 43.4% recognized FMT's efficacy in treating Clostridium difficile infection, with notable percentages acknowledging its potential for inflammatory bowel disease (37.3%) and irritable bowel syndrome (12.0%). Among healthcare professionals, insights revealed that conferences/seminars (41.4%) and scientific journals/publications (37.5%) played pivotal roles in information dissemination, with a striking 72.1% recognizing FMT's effectiveness against Clostridium difficile infection. However, challenges such as the lack of clear guidelines (40.3%) and limited donor material availability (25.8%) underscored existing barriers to FMT application. Patient perspectives offered invaluable insights, with 12.5% exhibiting prior awareness of FMT, prompting further exploration into their readiness and reservations. Post-information dissemination, 33.8% expressed a newfound readiness for FMT application, highlighting the pivotal role of education in shaping patient attitudes. Noteworthy concerns among patients included apprehensions regarding the procedure's unpleasantness (52.2%) and the perceived lack of evidence (13.0%). Furthermore, preferred delivery methods, such as oral capsules (70.6%) and colonoscopy (23.5%), shed light on patient preferences and comfort levels.

Conclusion

The study highlights a significant knowledge gap regarding Fecal Microbiota Transplantation (FMT) among medical students, doctors, and patients in Armenia. Specifically, 44.1% of students, 21.4% of doctors, and 83.3% of patients had never heard of FMT. Despite this initial lack of awareness, 33.8% of patients expressed willingness to undergo FMT after receiving explanations. This underscores the potential for education and awareness-raising initiatives to positively impact attitudes towards FMT adoption in Armenia.

Introduction

STRIDE-II has underscored the importance of achieving timely, pre-defined therapeutic targets predictive of favorable long-term outcomes in patients with Inflammatory Bowel Disease. Early targets include post-induction clinical response (Clin-Resp), and clinical remission (Clin-Rem), whereas endoscopic healing is, currently proposed as the optimal long-term endpoint.

Aims & Methods

This study aims to record rates of Clin-Resp, Clin-Rem and endoscopical healing and evaluate their predictive value for long-term outcomes in patients with Ulcerative Colitis (UC), in a real-world setting. It is a retrospective cohort study of patients who have been followed up in the GI unit of “Sotiria” hospital, and commenced treatment with either infliximab, vedolizumab, or ustekinumab. We compared patients who achieved Clin-Resp (drop of UC-PRO2≥50%) without Clin-Rem at the end of induction to those with Clin-Rem (UC-PRO2=0) regarding rates of drug continuation, clinical remission, steroid-free clinical remission, and mucosal healing at one year on treatment. Additionally, we compared patients with endoscopic MAYO score (endo-MAYO) of 0 or 1 on treatment, regarding drug continuation rates 1, 2, 3 and 4 years post-endoscopy. SPSS 23 (IBM, Armonk, NY, USA) was used for the statistical analysis.

Results

In total, 145 patients were included [mean age=41.6 years (SD=16.6), men: 50.3% (n=73)]. Sixty-eight (46.9%) received infliximab, 41 (28.3%) vedolizumab and 36 (24.8%) ustekinumab. At the end of induction, 90 patients (62.1%) had Clin-Resp and 72 (49.7%) Clin-Rem. After one year of treatment, higher rates of drug continuation (94.4% vs 55.6%, P<0.001), clinical remission (87.5% vs 44.4%, P<0.001), steroid-free clinical remission (85.9% vs 33.3%, P<0.001) and mucosal healing (57.6% vs 23.5%, P=0.001) were reported for patients in Clin-Rem at the end of induction compared to those with sole Clin-Resp. Patients with endo-MAYO=0, at their first endoscopic evaluation after drug commencement, demonstrated higher rates of 1- (100% vs 70.6%, log-rank P=0.007) and 2-year (81.6% vs 41.7%, log-rank P=0.033) drug continuation, compared to those with endo-MAYO=1. No statistically significant difference was recorded regarding their 3- (61.5% vs 22.2%, log-rank P=0.088) and 4-year (33.3% vs 22.2%, log-rank P=0.254) drug continuation rates.

Conclusion

In ulcerative colitis, the achievement of clinical remission at the end of induction is a major predictive factor of long-term effectiveness of treatment. Simultaneously, our analysis shows the importance of optimal control of inflammation as a therapeutic target, since patients with complete endoscopic healing have a higher probability of prolonged drug continuation.

Disclosure

GB: Advisor/lecturer for Janssen, Pfizer, Takeda, Abbvie, MSD, Mylan, Genesis Pharma, Adacyte Therapeutics, Amgen, Ferring, Cooper; Funding (Grants/Honoraria): Pfizer, Takeda, Abbvie, Aenorasis; Research/Clinical Trials: Abbvie, Takeda.

Introduction

Superior Mesenteric Artery Syndrome (SMAS), also known as Wilkie’s syndrome, is a rare gastrointestinal condition characterized by compression of the distal duodenum between the abdominal aorta (AA) and the superior mesenteric artery (SMA). Evidence on Wilkie’s syndrome is limited, reviews are based on small cohorts and case studies^1-3. Patients with SMAS typically present with postprandial epigastric discomfort, nausea, vomiting, stomach distention, and reflux, leading to malnutrition and weight loss. As mesenteric fat decreases due to the weight loss, the duodenal obstruction worsens, increasing SMAS symptoms. SMAS mostly affects young females aged 20-30 years and is challenging to diagnose due its overlap with dyspepsia, anorexia nervosa and median arcuate ligament syndrome^1-3. SMAS can present acutely, after weight loss from bariatric surgery, malnutrition or (hyper)metabolic disorders. It also presents chronically, due to an anatomically high duodenal position or a low aortic SMA origin^1-3. Diagnostic imaging, including computed tomography (CT) typically reveals a reduced SMA-AA angle <25° and a characteristic vertical, abrupt duodenal obstruction on barium X-ray series^1,2. Conservative treatment focuses on improving gastrointestinal motility and increasing the SMA-AA angle by weight gain to regain mesenteric fat¹. If conservative treatment fails, surgical intervention is considered, with duodenojejunostomy being most commonly performed. Yet, this carries potential severe complications such as anastomotic leakage and non-physiological gastro-duodenal changes. Recent evidence suggests laparoscopic Treitz ligament release may offer a viable and low-risk alternative^3,4.

Aims & Methods

This study aims to introduce a standardized, low risk treatment protocol for SMAS. The protocol includes: 1) Jejunal tube feeding for six-eight weeks, 2) Laparoscopic release of the Treitz ligament, and 3) SMA reimplantation⁵. The protocol was implemented at three hospitals in the Netherlands, Medisch Spectrum Twente, Franciscus, and Erasmus MC.

Results

A total of 12 patients were treated according to this protocol from 2020 until 2024. The cohort consisted of 7 (58.3%) female patients, with a mean age of 29.2 years (SD 11.8). The average weight and body mass index were 60.33 kg (SD 6.5) and 20.01 (SD 3.4). The mean SMA-AA angle measured on CT scans was 22.55° (SD 13.1). All patients started treatment with jejunal feeding. Nine patients underwent laparoscopic Treitz ligament release, with 7 experiencing complete resolution of symptoms. One patient with co-existing Nutcracker syndrome received primary SMA infra-renal reimplantation, with complete symptom release after the surgery. In two patients, symptoms persisted following Treitz ligament release, resembling gastroparesis and irritable bowel syndrome. The 2 remaining patients are planned for laparoscopic Treitz ligament release.

Conclusion

The combination of jejunal feeding followed by laparoscopic Treitz ligament release, represents a safe and effective treatment approach for SMAS; 7/9 patients who underwent the Treitz ligament release experienced resolution of all symptoms, demonstrating the efficacy of protocol. This approach offers an alternative to traditional surgical procedures, such as duodenojejunostomy, and reduces the risks of substantial short- and long-term complications. Further research with larger sample sizes is required to confirm the long-term outcomes and advantages of this protocol compared to other treatment strategies for SMAS.

References

1. Oka A, Awoniyi M, Hasegawa N, Yoshida Y, Tobita H, Ishimura N, Ishihara S. Superior mesenteric artery syndrome: Diagnosis and management. World J Clin Cases. 2023 May 26;11(15):3369-3384. doi: 10.12998/wjcc.v11.i15.3369. PMID: 37383896;
2. Navandhar PS, Shinde RK, Gharde P, Nagtode T, Badwaik N. Understanding Superior Mesenteric Artery Syndrome: Etiology, Symptoms, Diagnosis, and Management. Cureus. 2024 Jun 2;16(6):e61532. doi: 10.7759/cureus.61532. PMID: 38957238; PMCID: PMC11218894
3. Beita AKV, Whayne TF. The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old. Cardiovasc Hematol Agents Med Chem. 2019;17(2):74-81. doi: 10.2174/1871525717666190920100518. PMID: 31538906.
4. Fang JF, Wei B, Zheng ZH, Lei PR, Chen TF, Wei HB. Laparoscopic lysis of the ligament of treitz for superior mesenteric artery syndrome. Dig Surg. 2014;31(4-5):291-6. doi: 10.1159/000367670. Epub 2014 Oct 17. PMID: 25342434.
5. Ali T, Tomka J, Bakirli I, Bakirov I. Surgical Treatment of Wilkie's Syndrome by Vascular Transposition. Cureus. 2022 Apr 18;14(4):e24251. doi: 10.7759/cureus.24251. PMID: 35475250; PMCID: PMC9018456.
6. Pourhassan S, Grotemeyer D, Fürst G, Rudolph J, Sandmann W. Infrarenal transposition of the superior mesenteric artery: a new approach in the surgical therapy for Wilkie syndrome. J Vasc Surg. 2008 Jan;47(1):201-4. doi: 10.1016/j.jvs.2007.07.037. Epub 2007 Oct 18. PMID: 17949939

Introduction

There has been a rise in the uptake of endoscopic submucosal dissection (ESD) for superficial pharyngeal cancers, including in patients with previous history of radiotherapy, whether as salvage treatment of residual lesions or for metachronous lesions inside the irradiated field. Previous studies have demonstrated the safety and effectiveness of ESD for pharyngeal cancers¹. However, the safety and the effectiveness of pharyngeal ESD in cases with previous history of radiotherapy is not clear^2,3.

Aims & Methods

Our aim was to investigate whether radiotherapy affects outcomes after pharyngeal ESD. We conducted a retrospective cohort study of consecutive patients who underwent pharyngeal ESD between December 2016 and February 2025 at our institution. All the cases were managed together with otolaryngologists, including the daily assessment of the wound and swallowing function with the transnasal flexible laryngoscope in order to decide the timing of the re-initiation of food after ESD. The ESD itself, as well as the short and long-term outcomes were compared between the patients with or without history of radiotherapy.

Results

There were 22 cases (25 lesions) of ESD performed with previous history of radiotherapy and 32 cases (33 lesions) without prior radiotherapy. The median age was 71 (range 55-85) and 98.3% were men. Radiotherapy dose ranged from 54 to 70 Gy. There were no significant differences in the baseline characteristics between the groups of patients with or without prior radiotherapy including the age, sex, or the proportion of patients with previous history of pharyngeal ESD. En-bloc resection was achieved in all cases. ESD in the pharynx post-radiotherapy was associated with an increased percentage of cases with severe fibrosis (41% vs. 14% p<0.05), and the speed of dissection was slower (33.4mm²/min vs. 45.8mm²/min p=0.03), but there were no significant differences in the short-term outcomes between the groups of patients with or without prior radiotherapy in terms of of bleeding (0% vs. 3%), aspiration pneumonia (8% vs. 9%), the duration to the resumption of food (median 4 vs. 5 days) or hospital stay (median 9 vs. 9 days). During a median follow-up period of 906.5 days (range 22-3021 days), the 3-year overall survival rate was lower in patients with previous history of radiotherapy compared to patients without prior radiotherapy (55.1% vs. 100%, p=0.000177). Of the patients with previous history of radiotherapy, one patient died from metastatic recurrence of pharyngeal cancer, but the other five deaths were not directly associated with pharyngeal cancer (1=acute cardiac death, 1=unknown cause but unrelated to pharyngeal cancer, 1=lung cancer, 1=mantle cell lymphoma, 1=sinonasal neuroendocrine cancer) . There were no significant differences in the 3-year recurrence-free survival and the 3-year disease-related survival rates between the patients with and without prior history of radiotherapy (92.9% vs. 91.7% and 92.3% vs. 100%, respectively).

Conclusion

Previous history of radiotherapy increases the risk of severe fibrosis during ESD and is associated with slower speed of dissection, but does not compromise the safety or the swallowing function. In the long-term, ESD is an effective method for the treatment of superficial pharyngeal cancers, including in patients with previous history of radiotherapy. Furthermore, ESD is a minimally-invasive and surgery-sparing treatment option, which may be all the more important in patients with prior history of radiotherapy, given the worse prognosis from illnesses other than pharyngeal cancers in this group of patients.

References

1. Watanabe A, Taniguchi M, Kimura Y, Hosokawa M, Ito S, Tsukamoto S, Sasaki S. Synopsis of transoral endoscopic laryngopharyngeal surgery for superficial pharyngeal cancers. Head Neck. 2017 Sep;39(9):1779-1787.
2. Yoshida T, Shimizu Y, Ono S, Oridate N, Kato M, Asaka M. Successful salvage endoscopic mucosal resection for residual superficial hypopharyngeal carcinoma after chemoradiotherapy, with long-term survival. Endoscopy. 2009 Jun;41(6):568-9.
3. Satake H, Yano T, Yoda Y, Fujii S, Zenda S, Tomioka T, Shinozaki T, Miyazaki M, Kaneko K, Hayashi R. Feasibility of salvage endoscopic resection for patients with locoregional failure after definitive radiotherapy for pharyngeal cancer. Endosc Int Open. 2015 Aug;3(4):E274-80.

Introduction

The STRIDE-2 consensus emphasizes achieving specific endoscopic targets in ulcerative colitis (UC), but robust evidence on the effectiveness of the Treat-to-Target (T2T) approach in UC is limited in the real-world setting.

Aims & Methods

TACTIC-UC is a monocentric, retrospective, observational study evaluating UC patients managed according to a T2T algorithm. Eligible patients: 1) were receiving anti-TNF (aTNF), vedolizumab (VDZ) or ustekinumab (UST) at standard doses, 2) had quiescent/mild clinical activity (stool frequency and rectal bleeding <1), 3) had moderate/severe endoscopic activity (endoscopic Mayo score, eMS≥2). All patients received dose optimization and had at least 1 follow-up endoscopy. Observation period lasted from optimization until 1 year /drug discontinuation/last available follow-up. The primary outcome was the probability of mucosal healing (MH, eMS≤1) within 1 year. Secondary outcomes included: 1) probability of endoscopic remission (ER, eMS=0) within 1 year, 2) adverse events (AEs) incidence. Inverse probability of treatment weighting was used to adjust cohorts’ imbalances. False discovery rate correction was applied for multiple comparisons.

Results

The cohort included 178 patients (main characteristics in Table 1); after IPTW, no significant differences were observed. The cumulative probabilities of achieving MH within the first year were 41%, 11% and 23% for aTNF, VDZ and UST, respectively. At pair-wise comparison, aTNF was superior to both VDZ and UST(p<.05), with UST trending towards superiority (p=.05) over VDZ. Cox-regression (bootstrapping, 1000 iterations) identified factors associated with a significantly reduced (p<.05) probability of achieving MH: difficult-to-treat UC (aHR 0.6, 95%CI 0.5-0.7), E3 (aHR 0.7, 95%CI 0.5-0.9), elevated CRP (aHR0.96, 95%CI 0.94-0.9), and elevated FCP (aHR 0.98, 95%CI 0.97-0.99); aTNF was associated with increased probability of MH compared to VDZ (aHR 1.4, 95%CI 1.1-1.7, p<.05) and UST (aHR 1.4, 95%CI 1.2-2.0, p<.05). For ER, the cumulative probabilities at 1 year were 13%, 3% and 9% for aTNF, VDZ and UST, respectively. Pairwise comparisons showed that aTNF was superior to VDZ (p<.05), and UST trended towards superiority over VDZ (p=.05). Cox regression (bootstrapping, 1000 iterations) found that difficult-to-treat UC (aHR 0.6, 95%CI 0.5-0-8), E3 (aHR 0.7, 95%CI 0.6-0.), higher CRP (aHR 0.97, 95% CI 0.95-0.99), higher FCP (aHR 0.99, 95%CI 0.98-1.0) were significantly (p<.05) associated with reduced probability of achieving ER; aTNF was associated with increased probability of achieving ER compared to VDZ (aHR 1.3, 95%CI 1.1-1.7, p<.05) and UST (aHR 1.4, 95%CI 1.1-2.0, p<.05), with no significant difference for VDZ vs UST. AEs were infrequent and mild across all groups (mostly infections and infusion reactions), with no significant differences in safety profiles. No serious AE was reported.
Table 1.

Conclusion

In this cohort of UC patients treated according to an endoscopy-driven T2T approach, aTNF outperformed VDZ and UST in inducing MH and ER. Disease severity markers were associated with reduced probabilities of achieving endoscopic targets. Safety profiles were comparable across therapies.