Introduction

Fluid therapy (FT) is an essential treatment in the early phase of acute pancreatitis (AP). A complication of FT is fluid overload: signs, symptoms or imaging tests compatible with congestive heart failure due to this treatment. In the WATERFALL clinical trial, aggressive FT was found to be associated with fluid overload.

Aims & Methods

Our main objective is to evaluate which baseline features in our patients are predictors of possible fluid overload. For that purpose,a post hoc analysis of the data obtained from the WATERFALL clinical trial was performed. This was a multicenter randomized clinical trial with a sample size of 249 patients in which 122 patients were included in the aggressive FT group (20 ml/kg lactated ringer solution (LR) bolus over 2 hours and 3 ml/kg/h LR perfusion) and 127 in the moderate FT group (10 ml/kg LR bolus in case of hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml/kg h). Univariate analysis was initially performed to assess the possible association with fluid overload of the different qualitative and quantitative variables collected in the baseline assessment of the patients. Those variables with an association with fluid overload with p<0.1 were included in the multivariate analysis (binary logistic regression). Variables with an independent association for fluid overload were considered to be those with a p<0.05 in the logistic regression.

Results

Of the total number of patients included in the trial (n=249), 33 had fluid overload. Of these, 25 (20.5%) belonged to the aggressive FT group and 8 (6.3%) to the moderate FT group. In univariate analysis, there was a possible association with fluid overload with p<0.1 of the following: treatment arm, age, baseline hypovolemia, ischemic heart disease, diabetes, respiratory rate, systolic pressure, urea, leukocytes at first blood test, pain, abdominal distension, nausea or vomiting, thirst, difficulty eating, or weakness. When exploring these variables in multivariate analysis, only age, baseline hypovolemia and treatment arm showed a statistically significant association (p<0.05). Systolic pressure approached statistical significance with a p=0.057. An age of 70 years is an indicative cutoff point for increased risk of fluid overload (33% vs. 7% in <70 years, p<0.001).

Conclusion

Older patients with baseline hypovolemia who receive aggressive fluid therapy are at risk of fluid overload. Moderate and probably restrictive fluid therapy in elderly patients may avoid this complication.

Introduction

There are doubts about the effectiveness of concomitant use of probiotics (PB) in the treatment of Helicobacter pylori infection. Objective: To determine whether the use of PB improves the effectiveness of eradication treatments used in Europe.

Aims & Methods

Prospective, multicentre, non-interventional, prospective registry (Hp-EuReg) of the clinical practice of European gastroenterologists. Data were collected in an e-CRD in AEG-REDCap from 2013 to 2021. All data from countries with at least 30 cases undergoing eradication therapy and at least 1 with associated PB were included, using patients without PB as controls and grouping by geographical region. Modified intention-to-treat (mITT) analyses were performed, as well as multivariate analysis, assessing factors associated with treatment effectiveness.

Results

36,699 patients were included, 8,233 (22%) with PB. Overall, PB use was associated with greater effectiveness (91% vs 86%; p<0.0001). Adjusting for treatment regimen, this significance held for triple (89% vs 83%; p<0.0001), concomitant quadruple (93% vs 89%; p=0.0009), quadruple with bismuth (92% vs 86%; p<0.0001) and sequential (91% vs 78%; p<0.0001) therapies. In the logistic regression model in first-line eradication (adjusted for age, sex, duration of eradication treatment, PPI dose and adherence), PB use maintained the benefit in the triple, bismuth quadruple and sequential treatments. After adjusting such a model by region, significance was maintained in the Eastern region (low rate of resistance to clarithromycin and metronidazole) for triple therapies, and in the Central region (high rate of resistance) for concomitant quadruple and sequential therapies.

Conclusion

In Europe, the use of formulations with PB adjuvant to eradication therapy is associated with increased effectiveness of eradication therapy, with the benefit being superior in triple and sequential therapies.

Disclosure

Nothing to disclosure

Introduction

Helicobacter pylori (Hp) infection is one of the major causes of gastric cancer and represents a significant global public health challenge. In Japan, where the incidence of gastric cancer is high, reducing the risk through the eradication of Hp is deemed crucial. While enhancing awareness about Hp is thought to encourage testing and contribute to treatment, there is a lack of evaluation regarding the Japanese population's awareness of Hp.

Aims & Methods

In this cross-sectional study, we aim to assess baseline knowledge and attitude tuwards Hp among Japanese population. Participants were recruited through an online survey platform (Macromill, Inc), with ages ranging from 20 to 69, reflecting the age demographic composition of Japan equally across genders. Referencing the existing surveys on Hp^1-3, we assessed knowledge on five key aspects related to Hp: risk of infection (scored out of 7), diseases caused by Hp (scored out of 7), methods of testing (scored out of 5), benefits and side effects of Hp eradication (scored out of 8), and knowledge of gastric cancer prevention (scored out of 10). Attributes of participants, socioeconomic factors, and health literacy (HLS-14)⁴ were also evaluated to study their correlation with knowledge about Hp.

Results

A total of 3,095 individuals participated. Of these, 56.3% reported having some knowledge about Hp. 865 participants (28.0%) had undergone Hp testing, 354 (11.4%) confirmed Hp infection, and 283 (9.1%) had received treatment for Hp. About 55.6% (1,722 participants) consider that the treatment for Hp posed a significant financial burden. The average correct response rate across all knowledge items was 45.6% (SD: 19.0%). The individual correct response rates were 57.3% for risk of Hp infection, 50.9% for diseases caused by Hp, 24.5% for methods of testing, 45.6% for benefits and side effects of Hp eradication, and 44.4% for knowledge of gastric cancer prevention. Higher scores were significantly associated with having an income over 4 million yen, a family history of Hp, personal Hp testing history, Hp treatment history, and higher health literacy. Over 80% of respondents acknowledged that understanding the relationship between Hp and stomach symptoms, recognizing Hp as a gastric cancer risk, and knowing that Hp eradication reduces future gastric cancer risk influenced their decision on the need for eradication. Similarly, the same proportion reported that believing that the harshness of the treatment exceeds the current symptoms and the high costs of testing and treatment influenced their decisions for eradication.

Conclusion

The level of understanding of Hp among the Japanese population is moderate and influenced by income level, health literacy, and personal experience with the Hp infection. Many consider testing and treatment burdensome. Enhancing correct understanding of Hp could potentially increase testing and treatment rates, contributing to the future reduction of gastric cancer in Japan.

References

1. Kimberly S Bailey, et al., Helicobacter pylori treatment knowledge, access and barriers: a cross-sectional study. Helicobacter 2023;28(2):e12954.
2. You Wu, et al., Awareness and attitudes regarding Helicobacter pylori infection in Chinese physicians and public population: A national cross-sectional survey.Helicobacter 2020;25(4):e12705
3. Thomas Zheng Jie Teng, et al., Helicobacter pylori knowledge and perception among multi-ethnic Asians.Helicobacter 2021;26(3):e12794.
4. Machi Suka, et al.,The 14-item health literacy scale for Japanese adults (HLS-14). Environ Health Prev Med. 2013;18(5):407-15.

Introduction

In contrast to mucosal rectal T1 adeno-CA with an R0 rate of up to 92% at centers, the R0 RR in studies drops to 62-64% in case of deep sm infiltration.[1,2] Traditionally total mesorectal excision (TME) follows as completion surgery. Deep sm infiltration as isolated risk factor excluding L+, V+, G3 and Bd2-3 seems associated with a low risk of LN metastases of only 2.6%. [3] MRI and even EUS often lead to a significant T and N overstaging.[4] A min.-invasive diagn.-ther. resection procedure providing a clear histo-pathologic staging without potentially destroying parts of the meso-rectum as it has been reported for full thickness resection techniques would be desirable for potential later surgical resection (TME).[5] Endoscopic Intermuscular Dissection (EID), similar to PAEM uses a new flexible endoscopic dissection technique with separation of the circumferential and longitudinal muscular layer providing a specimen ideally including the entire mucosa, submucosa and the inner circumferential muscle layer.[6,7] The new technique achieved in a first prospective MC study including 67 patients a technical success rate of 96% and a histologic R0 resection rate of 85%.[5] In the following we report on our first experiences using EID as referral center for ESD.

Aims & Methods

To evaluate EID in lesions with biopsy proven ADC of the rectum without endoscopic, EUS or clinical signs of local infiltration. Rectal polyps with biopsy proven HGIEN and/or suspicious for local malignant infiltration. Additionally 2 patients were included who had undergone neo-adjuvant RT/Ch therapy 24 and 26 months before refusing definitive surgery (TME). Both presented with local flat polyps with histopathologically SSA (1) / hyperplastic polyp with focal LGIEN adenoma (2) for diagn.-therapeutic resection. After endoscopic, EUS, MRI, abd/th CT-staging and rectal digital examination without suspicion of local malignant infiltration pts were offered to prospectively undergo EID after extensive informed consent within a prospective protocol. All procedures were carried out under gen. anesthesia by an exp. interv. endoscopist with >1000 ESDs. Post-Op all pts. were hospitalized and closely monitored.

Results

From 11-2023 to 4-2024, 8 EIDs in 8 pts (3 f/ 5 m) were carried out (mean 63 y; 34-83y). 6/8 lesions lower rectum, 1/8 middle, 1/8 upper rectum. 'En bloc' resection was achieved in 100%. Histopathology showed 3x ADC G2, 3 x HGIEN and in both cases with neodajuvant RT/Ch LGIEN adenoma. R0 resection was achieved in 2 of the 3 ADCs, with deep sm T1 infiltration in both but without any other risk factors. Tumor board recommendation was close clinical & imaging FU. In the 3rd ADC tumor infiltration reached the inner muscular layer (T2) and the pat. underwent uneventful TME 10 d after EID. All other cases were follow clinically. Mean length of hosp. stay was 7.1 days. Serious major complications did not occur. All pts. are closely followed with uneventful FU.

Conclusion

EID seems a new perspective for the endosc. resection of T1 ADC and high-risk polyps in the rectum. Two cases after potentially curative neo-adjuvant treatment for rectal cancer and refusal of TME show EID as potential diagnostic tool but have to be regard with caution due to a remaining risk of scattered tumor cells in the mesorectum with TME remaining the gold standard. More experience in multicenter prospective studies with matched pair analysis or a comparison to surgical local procedures (TAMIS etc.) is necessary for the final assessment of EID as new promising endoscopic technique.

References

1. Watanabe D, Toyonaga T, Ooi M et al. Clinical outcomes of deep invasive submucosal colorectal cancer after ESD. Surg Endosc 2018; 32: 2123-30
2. Yamada M, Saito Y, Takamaru H et al. Long-term clinical outcomes of en- doscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017;49: 233-42
3. Zwager LW, Bastiaansen BAJ, Montazeri NSM et al. Deep Submucosal Invasion Is Not an Independent Risk Factor for Lymph Node Metastasis in T1 Colorectal Cancer: A Meta-Analysis. Gastroenterology 2022;163:174-89
4. Detering R, van Oostendorp SE et al. MRI cT1-2 rectal cancer staging accuracy: a population-based study. Br J Surg 2020;107:1372-82
5. Eid Y, Alves A et al. Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature. J Visc Surg 2018; 155: 445–52
6. Moons LMG, Bastiaansen BAJ, Richir MC et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new en- doscopic approach. Endoscopy 2022;54: 993-8
7. Toyonaga T, Ohara Y et al. Peranal endoscopic myectomy (PAEM) for rectal lesions with severe fibrosis and exhibiting the muscle-retracting sign. Endoscopy 2018; 50: 813–7

Introduction

Response rates to the Low FODMAP Diet (LFD) in IBS vary and predictors of benefit remain poorly defined. While several studies from Western populations have identified microbial signatures linked to response, data from Asian cohorts remain limited.

Aims & Methods

This study aims to identify microbial predictors and longitudinal microbiome shifts in Asian IBS-D patients consuming a LFD. We recruited 20 adult Asian patients with IBS-D diagnosed according to the ROME-IV criteria. All subjects received LFD dietary advice from a dietitian at initiation and were followed-up for a total of 28-days. Clinical response was assessed by a ≥50-point improvement in the IBS Symptom Severity Score (IBS-SSS) from Day 0 (baseline) as compared to follow-up at Day 28. Stool samples were collected at baseline, Day 14, and Day 28. Microbial DNA was extracted using bead-beating and Qiagen PowerFecal kits, and the V3–V4 region of the 16S rRNA gene was amplified and sequenced on the Illumina MiSeq platform. Bioinformatic processing included denoising with DADA2, taxonomic assignment using the SILVA 138 database, and rarefaction to even sequencing depth. Microbiome metrics included alpha diversity (Shannon and Simpson), beta diversity (Bray-Curtis PCoA with PERMANOVA), and differential abundance testing with DESeq2.

Results

By Day 28, 11 of 20 patients (55%) achieved clinical response, with a median IBS-SSS reduction of 172 points (IQR: 88–248), compared to 24 points in non-responders (IQR: −11 to 55; p=0.003). Alpha diversity was not significantly different between groups, but responders exhibited a trend toward higher Shannon and Simpson diversity at baseline. Beta diversity analysis using Bray-Curtis dissimilarity revealed partial clustering by responder status (PERMANOVA p=0.06), and PCoA plots showed individual-specific shifts in community structure across time, indicating that the LFD induces personalized microbiome trajectories.
At baseline, responders had significantly higher relative abundances of butyrate-producing and anti-inflammatory genera, including Ruminococcus, Blautia, Eubacterium siraeum, and Bifidobacterium bifidum (adjusted p<0.05). These findings are consistent with prior reports, including Bennet et al. (2018) and Vervier et al. (2022), where such taxa were part of a “health-like” IBS-P (pathogen-enriched) to IBS-H (health-like) axis. The enrichment of Blautia and Ruminococcus is particularly noteworthy as these are established butyrate producers involved in maintaining colonic barrier function and reducing visceral hypersensitivity. By Day 28, differential abundance analysis revealed that responders exhibited increases in Ruminococcus bicirculans, Parabacteroides gordonii, and Weissella cibaria. In contrast, non-responders showed persistence or increases in taxa such as Tyzzerella and Olsenella, which have been associated with inflammation or IBS severity in prior studies (Chuah et al., 2024).

Conclusion

This study provides novel microbiome insights from an underrepresented Asian IBS population consuming a LFD. Despite dietary and baseline microbiota differences from Western populations, we observed remarkably consistent microbiome predictors of response, including higher baseline levels of butyrate-producing taxa and favorable microbial restructuring during the intervention. These results reinforce the reproducibility and functional relevance of microbiome predictors in IBS dietary therapy, and support microbiome profiling as a potential tool for personalized dietary guidance across a diverse global population.

References

Bennet SMP et al. Multivariate modelling of faecal bacterial profiles of patients with IBS predicts responsiveness to a diet low in FODMAPs. Gut. 2018 May;67(5):872-881.
Vervier K et al. Two microbiota subtypes identified in irritable bowel syndrome with distinct responses to the low FODMAP diet. Gut. 2022 Sep;71(9):1821-1830.
Chuah KH, Mahadeva S. Can we predict who will respond to a low-FODMAP diet in irritable bowel syndrome? J Gastroenterol Hepatol. 2024 Feb;39(2):217-218. ​

Introduction

Focal cryoballoon ablation (FCBA) is a relatively new ablation modality for the treatment of Barrett’s esophagus (BE) related neoplasia. This prospective, European multicenter study (Euro-Coldplay, NTR NL7253) aimed to evaluate the efficacy and safety of FCBA for the treatment of limited BE.

Aims & Methods

In eight European Barrett referral centers, patients with C≤2M≤5 BE with an indication for ablation therapy were eligible for inclusion. Before entry, any visible lesion had to be removed by endoscopic resection (max. 2cm in length and 50% of circumference). FCBA was performed by experienced and trained endoscopists at 3 month intervals until complete endoscopic eradication of BE (max. 5 sessions). During every session, the esophagogastric junction was treated circumferentially followed by all visible BE using side-by-side ablations with a dose of 8 seconds per ablation. After at least two FCBA sessions, add-on treatment was allowed with either argon plasma coagulation (APC) for BE lesions of <5mm (max. 2 sessions) or a single endoscopic mucosal resection for lesions of >5mm. Outcomes included complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D), and adverse event rate.

Results

107 patients (91 males; mean age 65) with a median BE length of C0M2 were included, containing low-grade dysplasia (32%), high-grade dysplasia (32%) or early cancer (39%) as worst baseline histology. Currently, 5/107 patients are still under treatment and therefore excluded from further analysis. Of the remaining patients, 97 (97/102; 95%) patients have finished the treatment phase per protocol, while four (4/102; 4%) patients left the study prematurely. Only one (1/102; 1%) patient could not be treated with FCBA due to a device malfunction requiring a switch to radiofrequency ablation. Overall, 65/102 (64%) patients underwent endoscopic resection at entry followed by a median of 2 (IQR 2-2) FCBA treatments with a median of 7 (IQR 5-9) ablations per treatment session. During the treatment phase, 3/102 (3%) patients developed a new visible, neoplastic lesion amenable for endoscopic resection (high-grade dysplasia n = 2, low-risk T1 cancer n = 1). Add-on treatment after at least two FCBA sessions was performed in 38/102 (37%) patients, of whom the most were treated with APC for small remaining Barrett islands (37/38; 97%). CE-D was achieved in 95% (97/102) and CE-IM in 91% (93/102), per intention-to-treat analysis. Per-protocol analysis, CE-D and CE-IM were achieved in 100% (97/97) and 96% (93/97), respectively. Esophageal stricture was the most common adverse event in 13/102 (13%) patients, which resolved after a median of 2 (IQR 1-4) dilations. Only three (3/102; 3%) patients suffered a severe stricture requiring >3 dilations. No perforation or bleeding were observed, while buried BE glands were seen in 1/102 (1%).

Conclusion

In expert hands, endoscopic eradication therapy with FCBA seems to be highly effective with an acceptable safety profile for patients with limited BE. Long-term follow-up is warranted to evaluate the durability of the treatment response.

Disclosure

C.N. Frederiks have received speaker's fee and reimbursement of study-related travel costs from Pentax Medical. A. Overwater has received reimbursement of study-related travel costs from Pentax Medical. J.J.G.H.M. Bergman is a consultant for Medtronic, Cook Medical, and Boston Scientific, and has received research funding from Pentax Medical, C2 Therapeutics, Medtronic, Aqua Medical, Olympus Endoscopy, and Fuji-film. R.E. Pouw is a consultant for MicroTech, and has received speaker’s fee from Medtronic. R. Bisschops is a consultant for Pentax Medical, Medtronic, and Erbe Medical, and has received research funding and speaker’s fees from Pentax Medical, Medtronic, and Erbe Medical. T. Beyna is consultant for Medtronic, Erbe Medical, Microtech Endoscopy, Olympus Endoscopy, and Boston Scientific. B.L.A.M. Weusten has received research funding from Pentax Medical, C2 Therapeutics, and Aqua Medical. The remaining authors declare to have no disclosures relevant to this manuscript.

Introduction

There are several reports about the diagnosis of early gastric cancers (EGCs) using artificial intelligence (AI) systems, but satisfactory data for sensitivity and specificity are not yet available. Linked color imaging (LCI) produces high color contrast between malignant lesions and surrounding mucosa compared to white light imaging (WLI). Therefore, LCI combined with AI (LCI-AI) has the potential to further improve the diagnosis of gastric cancer compared with WLI combined with AI (WLI-AI). We developed three new LCI-AI models to determine their sensitivity and specificity for the diagnosis of EGCs.

Aims & Methods

Three models including a convolutional neural network (CNN) model (high resolution net (HRNet)), a transformer model (Segformer) and a hybrid (combined CNN and transformer) model (Uniformer), were based on MMSegmentation. When each model recognized a gastric cancer lesion from test image data, it was shown with the existing position as a blue area on WLI images and green area on LCI images. Non-neoplastic mucosa was shown as a black area on both images. Endoscopic images using WLI and LCI (LASEREO 7000 system series and scopes of EG-L600ZW and EG-L600ZW7, Fujifilm Corporation, Tokyo, Japan) were collected from patients with EGCs from January 2015 to December 2018 at Jichi Medical University Hospital. A total of 1970 images including 1179 WLI and 791 LCI images of 236 EGCs were used for training the three LCI-AI models. Another set of 414 EGC images was selected for validation from 43 cases. Primary and secondary endpoints were the sensitivity and specificity of each AI model, respectively.
The image-based performance metric was based on Dice loss, calculated by subtracting the mean Dice similarity score. A Dice score >20% was defined as the correct diagnosis of cancer because EGCs sometimes have unclear demarcation lines. The correct diagnosis of a non-malignant lesion was defined as no reactive black areas in surrounding mucosae. Each case had from four to 21 images. Therefore, the median Dice score was used as a representative value in each case to evaluate performance. All three models’ programming and data analysis were supported by AI Medical Service Inc. (Tokyo, Japan).

Results

Analysis of lesions in all EGC images showed both sensitivity (82.8%) and specificity (83.4%) with LCI-AI to be high and similar to those with WLI-AI (83.1% and 84.3%, respectively). Sensitivities of LCI-AI/ WLI-AI among HRNet, SegFormer and UniFormer were 80.9%/81.6% (p=0.625), 83.8%/83.8% (p=0.224) and 83.8%/83.8% (p=0.450), respectively and specificities were 80.0%/86.0% (p=0.120), 86.4%/84.8% (p=0.672) and 86.8%82.0%/ (p=0.214), respectively. Representative Dice values among cases with EGCs showed sensitivities for LCI-AI using HRNet, SegFormer and UniFormer to be extremely high, at 92.7% 90.9% and 93.0%, respectively, although not significantly different when compared to those using WLI-AI, 84.6% (p=0.67), 85.4% (p=0.15) and 80.5% (p=0.19), respectively. Higher sensitivities were found regardless of lesion size, morphology, and Helicobacter pylori status. All sensitivities using LCI-AI were higher than 80% whereas those using WLI-AI varied from 64% to 89%.

Conclusion

LCI-AI showed high sensitivity and specificity for the diagnosis of EGCs using all three models tested, suggesting potential for practical clinical use in the near future.

Disclosure

Hiroyuki Osawa and Hironori Yamamoto have consultant relationships with Fujifilm Corporation and have received honoraria, grants and royalties from the company. Hiroyuki Osawa has a consultant relationship with AI Medical survice inc. and has recieved honoraria.This study received no funding from Fujifilm Corporation and AI Medical survice inc. nor any other funding source.