Introduction

Individuals with Lynch syndrome (LS) are predisposed to different tumors, including gastric (GC) and duodenal (DC) cancer, especially those with specific mutations or familial aggregation. However, the role of esophagogastroduodenoscopy (EGD) in these patients is still uncertain, with heterogeneous recommendations among different guidelines.

Aims & Methods

To estimate the overall incidence of GC and DC in individuals with LS, to determine the incidence of GC and DC in higher-risk subgroups within these patients, as well as to clarify the usefulness of screening or surveillance by EGD.

Systematic search of Pubmed and Embase for cohort studies and clinical trials from inception to April 2024. Incidences of GC and DC were calculated, as well as the relative risk (RR) and their respective 95% confidence intervals in those studies comparing patients under surveillance with EGD vs without. A meta-analysis was performed using a random-effects model. Heterogeneity was assessed with the I² statistic.

Results

A total of 584 studies were obtained, of which 30 were finally included, with a total of 31264 patients with LS. The overall incidence of GC was 2.04% (95%CI 1.63-2.45). The incidence of GC was 2.60% (95%CI 1.61-3.60) in MLH1 carriers and 2.91% (95%CI 1.63-2.45) in MSH2 carriers. In those with LS and family history, the incidence of GC was 25.94% (95%CI 15.01-36.87). The incidence of DC was 1.61% (95%CI 1.21-2.00).
Only 3 studies compared patients with LS in follow-up with EGD vs those without follow-up, evidencing a protective effect of EGD for GC [RR 0.31 (95%CI 0.14-0.69)], but not for DC [RR 0.65 (95%CI 0.22-1.32)].

Conclusion

The incidence of GC and DC in patients with LS is higher than that of the general population, especially in those patients with MLH1, MSH2 mutations or family aggregation. Surveillance with EGD could help to reduce this incidence through the diagnosis of premalignant lesions.

Introduction

Colorectal cancer surveillance recommendations for individuals with Lynch Syndrome (LS) differ between professional associations and the data on interval colorectal cancer (I-CRC) and interval advanced polyps (I-AP) are limited. We aimed to measure the rate of I-CRC and I-AP within a surveillance program.

Aims & Methods

Retrospective study involved individuals with LS who participated in CRC surveillance program at Clalit Health hospitals, Israel. The main outcomes were the rates of I-CRC and I-AP ≤36 months, categorized by 12-month intervals. Included only colonoscopies with adequate preparation. I-CRC and I-AP (≥10 mm or containing high-grade dysplasia or villous histology) were defined as interval advanced neoplasia (I-AN).

Results

The cohort included 342 individuals, 52.3% females, with a median age at data analysis of 49.0 (IQR 37.7-64). At interval ≤ 12 months, there were 7 cases of I-CRC [6/142 (4.2%) of MSH2; 1/46 (2.2%) of MLH1] and 13 cases of I-AP (10/142 (7.0%) of MSH2, 2/46 (4.3%) of MLH1, 1/136 (0.7%) of MSH6]. At 12-24 months, there were 3 cases of I-CRC [2/142 (1.4%) of MSH2, 1/136 (0.7%) of MSH6] and 10 cases of I-AP [8 /142 (5.6%) of MSH2, 1/46 (2.2%) of MLH1, 1/136 (0.7%) of MSH6]. At 24-36 months, there were 3 cases of I-CRC [2/142 (1.4%) of MSH2, 1/18 (5.6%) of PMS2] and 4 cases of I-AP [1 /142 (0.7%) of MSH2, 3/136 (2.2%) of MSH6]. Of all I-CRC, four were diagnosed at stage 3 [4/342 (1.2%)], all at interval ≤24months [3-MSH2, 1-MSH6]. Increasing age and path_MSH2 were significantly associated with I-AN.

Conclusion

Extending surveillance colonoscopy intervals could result in significant rates of I-CRC and I-AP. Diagnosis of I-CRC at advance stage can occur at interval less than 24 months.

Clinical Case Summary

A 19-year-old man with a long-standing history of recurrent abdominal pain and a recent episode of melena of unknown origin. He presented to the emergency department (ED) with hematochezia and asthenia, with a drop in hemoglobin to 8.9 g/dL. Upper and lower endoscopy were inconclusive. Capsule enteroscopy revealed a double-lumen sign and mildly erythematous mucosa, raising suspicion of Meckel’s diverticulum. A technetium-99m pertechnetate (Tc-99m) scan confirmed the presence of ectopic gastric mucosa. The patient subsequently underwent enterectomy, and histological analysis confirmed gastric mucosal heterotopia.
A 13-year-old man with a history of iron-deficiency anaemia requiring transfusion at 7 years old, and previous episodes of abdominal pain due to ileo-ileal intussusception. He had
undergone an inconclusive exploratory laparoscopy. He was admitted to the ED with melena and hypogastric pain. Blood tests revealed hemoglobin of 12.9 g/dL. Abdominal ultrasound showed thickening of the distal ileum over 11 cm, without signs of intussusception. Capsule enteroscopy revealed a segment of circumferential edema and erythema in the ileum, with absence of a clear villous pattern and an appearance suggestive of gastric mucosa. A Tc-99m scan confirmed the presence of ectopic gastric mucosa. Exploratory laparoscopy identified a 10–15 cm segment with gastric fold-like appearance within otherwise normal small intestinal mucosa, in the absence of a diverticulum. Histological analysis confirmed gastric mucosal heterotopia.
Gastric heterotopia is an important differential diagnosis in patients with gastrointestinal bleeding and can occur independently of the presence of Meckel’s diverticulum. The authors highlight the role of capsule enteroscopy in the diagnostic algorithm.

Introduction

Several Randomized Controlled Trials (RCTs) have evaluated the role of artificial intelligence (AI) Computer-Aided Detection (CADe) systems to enhance polyp detection. However, these studies have focused exclusively on locally deployed hardware-based AI systems, whereas cloud-based systems may improve the accessibility and upgrading of CADe technology. ‘CADDIE’ (Odin Vision, an Olympus company) is a cloud-based CADe system that receives the live endoscopy image stream via the hospital’s internet network, where the AI algorithm processes the images, and overlays real-time bounding boxes on the endoscopy screen to highlight suspected polyps.

Aims & Methods

This prospective RCT aimed to evaluate the efficacy and safety of the novel cloud-based CADe-system in improving polyp detection.

This international, multi-centre, parallel-group RCT was conducted across eight centres in four European countries. Participating endoscopists had a baseline of >1000 colonoscopy procedures and an adenoma detection rate (ADR) of ≥25%. Patients aged ≥40 years and at average risk for colorectal cancer undergoing screening or surveillance indications for colonoscopy were recruited. Patients were randomised in a 1:1 ratio to standard colonoscopy (SoC) or CADDIE-assisted (CADe-arm) colonoscopy. The co-primary endpoints were superiority in adenomas per colonoscopy (APC) as the efficacy endpoint, and non-inferiority for the Positive Percent Agreement (PPA), defined as the percentage of resections that are histologically confirmed adenomas, SSLs and large (>10mm) hyperplastic polyps of the proximal colon, as the safety endpoint.

Results

Overall, 22 endoscopists and 841 participants were included in the analysis. The CADe-arm significantly increased APC by 33% (0.62 vs 0.82, Ratio 1.33 [95%CI 1.06-1.67], p=0.01) and ADR (35.9% vs 43.2%, difference of 7.3% [95%CI 0.7%-13.9%], p=0.03) compared to the SoC-arm. The mean detection of sessile serrated lesions (SSLs) (0.03 vs 0.08, Ratio 3.30 [95%CI 1.41-7.57], p<0.01), large adenomas (0.04 vs 0.09; Ratio 1.93 [95%CI 1.03-3.62], p=0.04), and large polyps (0.05 vs 0.12; Ratio 2.36 [95%CI 1.33-4.17], p<0.01) also significantly improved. A higher proportion of large polyps (27.3% vs. 37.0%) and large adenomas (15.8% vs 24.2%) were non-polypoid ‘flat’ morphology in the CADe-arm compared to the SoC-arm. Other detection metrics, including neoplastic polyps per colonoscopy (0.66 vs 0.91; Ratio 1.39 [95%CI 1.12-1.73], p<0.01) and polyps per colonoscopy (1.06 vs 1.41 (Ratio 1.35 [95%CI 1.13-1.61], p<0.01), also significantly increased.

Non-inferiority in PPA was achieved (53.4% vs 53.9%; 0.5% (-5.0%,∞)), with no increase in unnecessary resections.

Conclusion

This trial demonstrates the safety and efficacy of a cloud-based CADe-system to increase endoscopists' polyp detection across multiple metrics, notably for large adenomas, large polyps, and SSLs.

Disclosure

AR, CS, LBL, RK have received medical consultancy fees from Odin Medical Ltd

Introduction

High-resolution colonic manometry (HRCM) is the gold standard for measuring colonic contractility and guiding decisions for subtotal colectomy in refractory slow-transit constipation (STC). However, it is only available in a handful of centers worldwide. Body surface colonic mapping (BSCM) is a recently validated technology that allows for easy-to-apply and non-invasive transcutaneous evaluation of pre- and post-prandial colonic motility, and has shown strong correlation with HRCM.

Aims & Methods

We sought to evaluate pre- and post-prandial colonic activity using BSCM in patients with refractory STC and correlate with real-time symptoms.
We applied BSCM to refractory chronic constipation patients while undergoing standard diagnostic HRCM. After bowel prep and an overnight fast a HRCM catheter (36 sensors, 3 cm spacing) was advanced and clipped to the caecum. Two BSCM electrode arrays (each 8x8 sensors, 2 cm spacing, Alimetry) were placed on the abdomen after skin prep. Simultaneous HRCM and BSCM recordings were obtained during a 1-hour fasting period, 1 hour after a standardized low-fat meal, and 1 hour after luminally applied 10 mg of bisacodyl. BSCM electrical recordings were band-pass filtered to isolate colonic cyclic motor patterns (CMPs) of 4-10 cycles per minute. The BSCM motility index (MI) was computed from the global continuous wavelet transform spectrum and compared to a real-time symptom score (1-10 scale). Meal response was quantified based on the fasted-fed ratio (FFR) and response time (RT), a marked rise in MI relative to mealtime. Symptoms were recorded for 15 min. during 3,5h.

Results

A total of 9 patients with refractory STC (mean age 45, range 27-60, 22% male) were enrolled. BSCM MI correlated with bloating in 6 subjects, whereof strongly in 2 subjects (R= 0.53 and 0.74). Abdominal discomfort was even correlated to the BSCM MI in 8 subjects, whereof strongly in 2 (R0.74 and 0.79). Flatulence was only reported by 6 subjects and correlated to the BCSM MI in 4 of them, of which 2 strongly (Rs=0.67). While the desire to defecate was correlated with BSCM MI in 6 subjects, the urge to defecate was in 5. However, in both symptoms, there was a strong correlation in 3 subjects (R between 0.69-0.85). These symptoms were mainly provoked by the administration of bisacodyl, followed by strong colonic contractions. Lastly, BSCM MI correlated well with stomach ache symptoms in 6 subjects, of which 2 strongly (R=0.74 and 0.84). Overall symptom burden was strongly correlated with BSCM MI in 3 subjects (R between 0.61-0.8). One subject had clear increases in symptoms, while the colonic activity was low, whereas another subject had an almost perfect correlation between the two. The other subjects had an overall average correlation between symptoms and colonic motility.

Conclusion

BSCM is an easy-to-apply, painless, non-invasive tool that has the potential to elucidate underlying mechanisms driving symptoms in patients with refractory STC. Relating colonic motility to symptoms could aid in developing a more personalized approach to manage these patients' clinical treatment pathway

Introduction

The treatment of esophageal motor disorders (EMD) has historically been focused on decreasing pressure at the gastro-esophageal junction (GEJ) by disrupting muscular fibers at this level. The classic management through dilatation, botulinum toxin injection, and Heller's myotomy (HM) underwent a revolution with the advent of third-space endoscopy, offering safe access to the submucosal space and enabling peroral endoscopic myotomy (POEM).
In this prospective national multicenter study, the results of the implementation period of this technique in Spain from 2016 to the present are analyzed, examining its short, medium, and long-term outcomes. Furthermore, outcomes based on EMD, previous treatments, and other multiple variables are also investigated.

Aims & Methods

The primary aim of this study was to ascertain the clinical efficacy of POEM.
Secondary objectives included the identification of predictors of clinical success and the measurement of the incidence of post-POEM GERD and significant complications, as well as the determination of the risk factors for complications
This is a prospective multicenter study conducted across 13 hospitals in Spain. Symptomatic patients undergoing POEM for any EMD were recruited between June 2016 and February 2023. Baseline characteristics, procedural details and outcomes related to efficacy and safety during short and long-term follow-up were analyzed.

Results

A total of 441 patients were enrolled, with type II achalasia representing the most common diagnosis (62.1%). POEM was the primary treatment in 277 patients (62.8%). Clinical success data were available for 396 patients, with a success rate of 94.4% at the last available follow-up (2 years in 117 patients, 1 year in 140, <1 year in 139). A higher baseline Eckardt score was an independent risk factor for clinical failure in the long-term follow-up (p = 0.024). Symptomatic reflux occurred in 4.7% of the patients, with a significant esophagitis rate of 10.1%. Complication incidence was 9.3% (41/441), including 14 (3.2%) severe events. Older age (p = 0.025) and total procedure duration (p=0.036) were independent risk factors for complications, while mucosal injury was found to be a predictor of severe complications (p = 0.027).

Conclusion

These findings confirm the clinical efficacy and safety during the implementation phase of POEM for all EMD in Spain.