Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) poses a risk of patient-to-patient transmission of multidrug-resistant organisms (MDROs) via contaminated duodenoscopes. The prevalence of MDRO carriage in ERCP patients is unknown but crucial for assessing this risk and to determine the impact and choice of targeted infection prevention measures.

Aims & Methods

The aim of this study was to measure MDRO prevalence in ERCP patients across four countries. This observational study included adults undergoing ERCP in the Netherlands, India, Italy, and the United States. Pre-procedural rectal and throat-nose swabs were collected for MDRO detection. Patient- and procedure-related data were systematically collected. Risk factors for MDRO carriage were determined through multivariate logistic regression analysis.

Results

Of 1244 patients, 462 (37.1%) carried an MDRO. Extended-spectrum beta-lactamase-producing Enterobacterales were most common (337/1244, 27.1%), followed by carbapenemase-producing Enterobacterales (94/1244, 7.6%). MDRO prevalence exhibited significant geographical variation, highest in India (83.1%) and lowest in the Netherlands (10.8%), with intermediate rates in Italy (31.6%) and the United States (20.1%). Additionally, MDRO types varied substantially across countries. Pre-procedural MDRO carriage was significantly associated with chronic lung disease (aOR 1.75, 95% CI 1.07–2.86, P = 0.025), congestive heart failure (aOR 2.20, 95% CI 1.33–3.64, P = 0.002), and prior penicillin use (aOR 1.66, 95% CI 1.05–2.63, P = 0.031).

Conclusion

Patients undergoing ERCP have a moderate to high prevalence of MDRO carriage, with significant variation in prevalence, species, and resistance mechanisms across countries. High MDRO prevalence increases the risk of duodenoscope contamination by MDRO and subsequent patient-to-patient transmission via these contaminated endoscopes. Pre-procedural screening could enable targeted infection prevention measures, including enhanced reprocessing or the use of single-use duodenoscopes, to reduce the risk of future duodenoscope-related MDRO outbreaks.

Disclosure

This study was supported by an unrestricted research grant from Boston Scientific and received material support from Copan Italia SpA. The study was investigator-initiated, and neither Boston Scientific nor Copan Italia had any role in the design of the study protocol, data analysis, interpretation of results, or preparation of the abstract.

Introduction

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective treatment for patients in whom transpapillary biliary drainage fails. However, EUS-HGS is associated with a high incidence of early procedure-relatedadverse events (PRAEs) due to bile leakage through a biliogastrointestinal fistula.

Aims & Methods

This multicenter study retrospectively evaluated the clinical outcomes of EUS-HGS. This study included 222 patients (120 men, 102 women; median age, 73 years) who underwent initial EUS-HGS between November 2014 and August 2024. Technical and clinical success rates, PRAEs, and stent dysfunction rates were analyzed. PRAEs were defined as adverse events occurring within 2 weeks according to the assessment of the American Society for Gastrointestinal Endoscopy.

Results

Benign and malignant tumors were observed in 18 (8.1%) and 204 (91.9%) patients, respectively. The median procedure time for EUS-HGS was 41 min (range, 11–173 minutes). Plastic and metal stents were deployed in 51.4% and 48.6% of the patients, respectively. Technical and clinical success rates and PRAEs were 97.8%, 85.1%, and 22.1%, respectively. The PRAEs were classified into mild (16.7%), moderate (4.1%), or severe (1.4%). Recurrent biliary obstruction (RBO) occurred in 51 (23.1%) patients. The median time to RBO in the metal stent group was significantly longer than that in the plastic stent group (313 vs. 162 days, P=0.02). Multivariate analysis identified the use of any dilation device (P=0.01; odds ratio [OR]: 3.55; 95% confidence interval [CI]: 1.35–9.36) and concomitant antegrade stenting (P=0.03; OR: 2.62; 95% CI: 1.12–6.12) as risk factors for PRAEs.

Conclusion

EUS-HGS is feasible; however, careful follow-up is required for patients undergoing fistula dilation and concomitant antegrade stenting.

Introduction

Current colonoscopy quality indicators recommend a minimum withdrawal time (WT) of 6 minutes. However, this standard may reduce colonoscopy efficiency and does not account for endoscopists' experience or bowel preparation quality. This study aims to investigate whether the 6-minute WT remains necessary for experienced endoscopists with excellent bowel preparation (BBPS≥8) by comparing the impact of 5-minute versus 6-minute WT on adenoma detection rate (ADR) and adenoma miss rate (AMR).

Aims & Methods

This study based experienced endoscopists and excellent bowel preparation (Boston Bowel Preparation Scale score, BBPS≥8) is aimed to compare the effect of 5-minute WT versus 6-minute WT on adenoma detection rate (ADR) and adenoma miss rate (AMR).
This multicenter, randomized controlled trial involving 423 patients was conducted from June 2023 to March 2025 in 5 centers, including Wuxi People's Hospital, Jiangsu Province People's hospital, Xuzhou First People's Hospital, The Second Affiliated Hospital of Soochow University, Taizhou People's Hospital. Colonoscope was inserted and withdrew twice on each patient and all procedures for the same patient were done by the same endoscopist. Participants were randomly divided into the 5-minute WT group (the first WT-5-minute and the second WT-6-minute, n =214) and the 6-minute WT group (the first WT-6-minute and the second WT-6-minute, n=209), and a timer was used to adjust the withdrawal speed. The primary outcome was ADR and AMR.

Results

The baseline characteristics of the two groups were similar (Table 1) and colonoscopy characteristics of the patients in the two groups regarding quality of bowel preparation, cecal intubation rate, cecal intubation time, cecal intubation distance, number of abdominal compression, number of position change were comparable (Table 2). Overall ADR (39.7% vs 43.5%, P = 0.425), ADR in the first (36.0% vs 36.4%, P = 0.935) and second withdrawal (10.7% vs 13.9%; P = 0.327) were not significantly increased in the 6-minute WT group compared with the 5-minute WT group. Likewise, the overall advanced adenoma detection (AADR) (4.7% vs 5.3%, P = 0.780), AADR in the first (4.7% vs 5.3%, P = 0.780) and second withdrawal (0.5% vs 0.5%, P = 0.745) did not differ statistically. Further analysis showed that AMR (10.7% vs 13.9%, P = 0.372) was lower in the 5-minute WT group than in the 6-minute WT group, less adenomas were missed in the 5-minute WT group, although not statistically significant (Table 3).
Table 3. Lesion-level detection and miss rate in the two groups
PDR, polyp detection rate; ADR, adenoma detection rate; AADR, advanced adenoma detection rate; AMR, adenoma miss rate; AAMR, advanced adenoma miss rate; PMR, polyp miss rate.
Table 3. Lesion-level detection and miss rate in the two groups

Conclusion

Shortening WT from 6 to 5 minutes didn't reduce ADR based experienced endoscopists and excellent BBPS, a 5-minute WT benchmark was acceptable with experienced endoscopists and excellent bowel preparation quality of colonoscopy.

Introduction

The lymphocyte-to-monocyte ratio (LMR) is widely utilized as a surrogate marker of systemic inflammation and is increasingly recognized as an indicator of immune status within the tumor microenvironment, particularly in the setting of cancer immunotherapy.

Aims & Methods

^​​​​​This study aimed to evaluate the prognostic relevance of LMR in patients undergoing combination therapy with durvalumab (Dur) and tremelimumab (Tre) for unresectable hepatocellular carcinoma (uHCC). A total of 242 patients with uHCC who received Dur/Tre therapy at multiple institutions between February 2023 and March 2025 were retrospectively analyzed. Inclusion criteria encompassed available baseline LMR, Child-Pugh class A liver function, and complete clinical data. Patient characteristics were as follows: median age 74.0 years (IQR: 68.3–77.0); sex distribution, 202 males and 40 females; performance status (PS) 0/1/≥2: 201/32/9; underlying liver disease (HBV/HCV/HBV+HCV/NBNC): 37/72/1/132; BCLC stage (≤A/B/≥C): 19/68/155; Child-Pugh score (5/6): 125/117; alpha-fetoprotein (AFP) level: 57.6 ng/mL (IQR: 4.3–909.8); LMR: 3.14 (2.18–4.15); treatment line (first-/second-line): 94/148; and median observation period: 9.0 months (5.0–14.2).

Results

The median progression-free survival (PFS) and overall survival (OS) were 3.5 months (2.8–4.3) and 19.2 months (15.4–NA), respectively. Time-dependent ROC analysis identified 2.15 as the optimal LMR cutoff at 25% of the observation period (15.4 months). Objective response rates per RECIST version 1.1 were as follows: complete response (CR), 3.2%; partial response (PR), 15.5%; stable disease (SD), 32.4%; and progressive disease (PD), 48.9%. Disease control rate (DCR) was significantly higher in the LMR ≥2.15 group compared to the <2.15 group (55.4% vs. 37.3%, p = 0.026). Patients with LMR ≥2.15 demonstrated significantly longer PFS (3.8 months [95% CI: 3.8–4.6] vs. 2.7 months [95% CI: 2.00–4.00]; p= 0.005) and OS (NA months [95% CI NA: –17.9] vs. 13.2 months [95% CI: 8.5–17.1]; p = 0.005). In multivariate analysis using the Cox proportional hazards model, LMR ≥2.15 emerged as an independent predictor of both PFS (HR = 0.622; 95% CI: 0.438–0.884; p = 0.008) and OS (HR = 0.558; 95% CI: 0.328–0.949; p = 0.031). Hazard ratio approximation curves indicated that the range of LMR associated with significant prognostic impact on both PFS and OS was approximately 1.6 to 2.4. Subgroup analysis further demonstrated that in first-line treatment settings, patients with LMR ≥2.15 had superior PFS and OS outcomes compared to those with LMR <2.15 (PFS: p = 0.028; OS: p = 0.016).

Conclusion

​​​​LMR serves as a valuable prognostic biomarker in patients receiving Dur/Tre combination therapy for uHCC, with potential utility in guiding therapeutic decision-making.

Disclosure

Toshifumi Tada: lecture fees from AbbVie, Eisai, and Chugai
Atsushi Hiraoka: lecture fees from Eisai, Bayer, Eli Lilly, and Otsuka
Hidenori Toyoda: lecture fees from AbbVie, Eisai, Gilead, Terumo, and Bayer

Introduction

Gastric emptying is controlled by phasic gastric contractions which occur at a frequency of ~3 cycles per minute (cpm) in phase with gastric slow waves. Tests to measure slow waves cannot directly detect abnormal contractions. The Atmo Capsule possesses an accelerometer that measures changes in capsule orientation and can thus detect gastric contractions. We analyzed accelerometer data to define its capability to characterize gastric contraction frequency and amplitude in patients with suspected dysmotility, and to assess if frequency or amplitude vary in relation to transit delay.

Aims & Methods

Gut transit was measured by the Atmo Capsule in 209 subjects: 48 with predominant upper GI (UGI) symptoms alone (suspected gastroparesis), 21 with lower GI (LGI) symptoms (suspected slow colon transit) alone, and 140 with combined UGI+LGI symptoms. This analysis utilized data from subjects recording valid gastric emptying time (GET) measures and did not incur protocol deviations affecting gastric transit. Delays in GET were categorized as: normal, <5 h; delayed, 5-10 h; severely delayed, ≥10 h. Fast Fourier Transformation (FFT) of the accelerometer data allows for the identification and analysis of the dominant gastric frequency and amplitude using 10-minute windows and a cutoff frequency of 4.5 cpm. Variability of frequency and amplitude measures were estimated by calculating interquartile range (IQR) and range (max-min) values and were analyzed in relation to presenting symptoms and gastric emptying delays.

Results

Gastric data from 190 subjects were suitable for analysis: gastric contractions with dominant frequencies of 3.30 cpm (IQR 0.47, range 1.47) and amplitudes of 0.10 arbitrary units (au) (IQR 0.04, range 0.14) were detected in 185 (97%) of subjects. Mean contraction frequency tended to be higher in those with delayed GET compared with no delay (p=0.016) and severe delay (p=0.005) (Table 1). Frequency IQR (p=0.002) and range (p=0.002) were higher for GET delay vs. no delay, while range was higher in severe GET delay vs no delay (p<0.001). Mean amplitude was higher in subjects with severe GET delay compared with normal delay (p=0.008) and normal transit (p=0.001). Amplitude IQR and range were both higher in those with severe GET delay compared with normal delay (p=0.002; p=0.001) and no delay (p<0.001 for both). Frequency metrics were similar irrespective of predominant symptoms. Amplitude means (p=0.022), IQR (p=0.030) and range (p=0.0004) were higher for UGI vs. LGI symptoms.

Table 1. Dominant gastric frequencies and amplitudes in relation to gastric emptying delays. Data shown as median (interquartile range) and analyzed via Kruskal-Wallis test.

Conclusion

The Atmo Capsule accelerometer reliably characterizes 3 cpm gastric contraction frequency and amplitude in subjects with proposed delays in gut transit. Increased variabilities in contraction frequency and amplitude were defined in those with severely delayed gastric emptying and increased amplitude variability was found for predominant upper GI symptoms. We propose these higher variations identified by accelerometry may reflect hypomotility or contractile dropout, suggesting additional clinical utility of the Atmo Capsule in suspected gastroparesis.

Disclosure

These authors disclose the following: Braden Kuo, Anthony J. Lembo, Eammon M.M. Quigley, Satish S.C. Rao, and William D. Chey serve on the Medical Advisory Board of Atmo Biosciences. Michael Cline and Baharak Moshiree served on the Medical Advisory Board of Atmo Biosciences. Braden Kuo has received funding from NIH, Vanda, Atmo Biosciences, and Takeda and has consulted for Evoke, Takeda, Ironwood, Novo Nordisk, Cindome, and Neurogastrx. Thomas Abell has received funding from Gastric Dysrhythmias, Neurogastrx, NIH GpCRC, and Vanda and has consulted for Enterra Medical, Novo Nordisk, Nuvaira, and Vanda. Anthony J. Lembo has received funding from Ardelyx, Biomerica, GSK, Ironwood, Takeda, and Vibrant and holds stock with Allurion, Bristol Myer Squibb, and J&J. Abigail Stocker has received funding from Cindome, Enterra Medical, and Vanda. William D. Chey has received funding from Atmo Biosciences, Commonwealth Diagnostics Intl, QOL Medical, and Salix; has consulted for AbbVie, Ardelyx, Biomerica, Comvita, Gemelli, Ironwood, Nestle, QOL Medical, Phathom, Redhill, Salix, Vibrant, and Takeda; has filed patents with My Nutrition Health, Digital Manometry, and Rectal Expulsion Device; and holds stock options with Coprata, Evinature, Food Marble, Kiwi Bioscience, and Modify Health. The remaining authors disclose no conflicts.

Introduction

In pediatric patients, gastrostomy tubes are not always permanent. Sometimes these tubes are removed after the patient can tolerate sufficient oral nutrition and have spontaneous closure. The site becomes a gastrocutaneous fistula (GCF) when persistent leakage occurs for more than one month. Although surgical repair is generally successful for GCF, endoscopic approaches with an over-the-scope clip (OTS clip) are less invasive and have a lot of benefits, such as less postoperative pain and shorter procedure time.

Aims & Methods

Aim: This study aimed to determine the efficacy and safety of therapy with OTS clips combined with fibrin glue for closure GCF in the pediatric population.
Methods: All the procedures were performed under general anesthesia. To cauterize the GCF tract we used argon plasma coagulation, cytology brush or electric scalpel. After scarifying the tract, fibrinogen and thrombin solutions were injected through the skin into the fistulous tract. After that, the GCF was closed with an OTS clip Padlock system. One month and 6 months after postclosure, the patient returned for a follow-up visit and an X-ray.

Results

A total of 10 children were selected for this study. 2 were excluded because the OTS clip didn’t pass through the oropharynx, and one was ruled out for having peptic esophagitis. Therefore, a total of 7 patients were included. Gastrostomy tubes were in place for more than 6 months in all patients.
Patients mean age was 7 years old. The youngest patient was 2 years old and the smallest one weighed 13 kg. The GCF tract was scarified with argon plasma coagulation in 2 patients, cytology brush in 3, and electric scalpel in 3 patients. All the fistulas were closed with fibrin glue and OTS Padlock system. All the patients were sent home 4 hours after the procedure.
In one case the clip spontaneously fell off 2 months after the procedure and the patient underwent a second successful endocliping procedure. A follow-up X-ray performed six months after the procedure confirmed that the clip didn’t fall off in 6 patients (85.7%).
There were no endoscopic or anesthetic complications. There were no reports of disabling pain after the procedure.
A total of five (71.4%) patients had definitive GCF closure in the 6-month follow-up. One patient had a recurrence of closed fistula (14.3%) after a respiratory infection, and another one had the gastric wall closed but the skin was still open.

Conclusion

Our study has shown that the OTS clip combined with fibrin glue are safe and effective in closing GCF in children. The current size of the clip limits its use in small children because it is difficult to navigate through the oropharynx. This combined technique is a potential alternative to standard surgery, with fewer complications, less postoperative pain, and shorter procedure time. Further studies are necessary with more patients.

References

1. Bustamante Bm Bhat s Menoza-Ladd A. Endoscopic closure of chronic trachea-esophageal fistula with an over-the-scope-clip suturing technique. Endoscopy 2018: 50:E155-156.
2. Chandrasekar VT, Desai M, Aziz M et al. Efficacy and safety of over-the-scope-clips for gastrointestinal bleeding: a systematic review and mate-analysis. Endoscopy 2019: 51(10): 941-9.
3. Klinger GM, Cardona AH. Endoscopic closure of tracheoesophageal fistula for tuberculosis with an over-the-scope-clip. Rev Esp Enferm Dig 2018: 110(9): 594-6.
4. Khotay T.H., Haber G., Sonpal N. et al. The over-the-scope clip system – a novel technique for gastrocutaneous fistula closure: The first North American experience. Can J Gastroenterol 2012; 26(4): 193-5.
   

Introduction

Serology plays a key role in the evaluation of celiac disease (CD).

Aims & Methods

We assessed the analytical performance for the detection of CD autoantibodies, compared with routine laboratory methods, of MosaiQ AiPlex^® CD microarray (AiPlex CD. AliveDx, Switzerland) a CE-marked, novel, single-use, multiplexed microarray immunoassay, used with its fully automated proprietary system. The valuated device features the simultaneous, semi-quantitative measurement of both IgA and IgG anti-tissue transglutaminase (tTG) and IgA and IgG anti-deamidated gliadin peptide (DGP) antibodies, as well as a qualitative measurement of total IgA in human serum; however, for this study, the comparison was limited to tTG IgA and tTG IgG as no samples characterized for DGP IgA nor for DGP IgG were available. Banked, de-identified serum samples characterized as reactive or non-reactive for tTG IgA and tTG IgG as per routine methods were tested with the evaluated device. Routine methods included EliA™ Celikey^® IgA (Phadia AB, Sweden), EliA™ Celikey^® IgG (Phadia AB, Sweden), QUANTA^® Flash h-tTG IgA (Inova Diagnostics, USA), QUANTA^® Flash h-tTG IgG (Inova Diagnostics, USA), Anti-Tissue-Transglutaminase IgA (ORGENTEC Diagnostika GmbH, Germany), Anti-Tissue-Transglutaminase IgG (ORGENTEC Diagnostika GmbH, Germany) and QUANTA Lite^® R h-tTG IgA ELISA (Inova Diagnostics, USA). Positive percent agreement (PPA), negative percent agreement (NPA) for individual analytes were calculated as were overall positive and percent agreements.

Results

The evaluated device identified 43 out of 45 samples characterized as reactive for tTG IgA per routine methods and 79 out of 81 samples characterized as non-reactive, for a PPA of 96% (95% CI: 84.8, 99.4) and an NPA of 98% (95% CI: 91.3, 99.7). Likewise, it identified 14 out of 18 samples characterized as reactive for tTG IgG per routine methods and 79 out of 85 samples characterized as non-reactive, for a PPA of 78% (95% CI: 52.3, 93.5) and an NPA of 93% (95% CI: 85.2, 97.3). Overall positive and negative percent agreement were 90% (95% CI: 80.4, 96.4) and 95% (95% CI: 90.7, 97.9), respectively (Table 1).

Conclusion

In the present study, the evaluated multiplexed microarray immunoassay showed high concordance with routine methods for the detection of tTG IgA and tTG IgG. This device may be considered a suitable alternative method for the serological assessment of patients under clinical suspicion of CD and has the potential to help simplifying the laboratory evaluation of this condition by simultaneously and automatically analyzing IgA and IgG isotypes of key CD markers.

Disclosure

This study was funded by AliveDx Suisse SA, Eysins, Switzerland. Gerber Gomez ​and Christian Fischer are AliveDx employees.