Introduction

Existence of structured colorectal cancer (CRC) screening programs across Europe is inconsistent, moreover, participation rates vary greatly. Similarly, such a program as well as mandatory colonoscopy quality assurance are lacking in Austria. Loco-regional, corporate preventive health initiatives might provide a more direct, effective CRC screening and increase uptake.

Aims & Methods

A state-wide CRC screening of a health care provider with approximately 28´000 employees was planned. We aimed to assess the performance in a real-world setting measured by acceptance rates of a defined target population and quality of colonoscopies performed by unselected endoscopists. All employees ≥50 years were invited (personal invitation letter and promotion at the facilities). Invitees received a stool-based test (FIT and M2PK). Stool tests could be performed at home, dropped at the workplace, and were collected and analyzed at a central facility. All persons with positive tests were called and directly offered a colonoscopy near their work-place/home within 3 weeks. Persons without a colonoscopy registered in records were called up again and received reminders via E-mail. Colonoscopy and histology reports as well as basic demographic data were collected (IRB vote GS1-EK-4/735-2021).

Results

Of 10´239 eligible employees (2706 males, 7533 females), 2´390 (23%) (plus 609 <50 years) age 52.3 (SD 5.4 years) participated in the stool-based screening (18% of males, 25% of females). Of 3063 overall tests, 747 (24%) were positive – more likely in males (29%) than females (23%) (RR 1.25 (95%CI 1.07-1.46). Of 747 positive tests, a minority was FIT- (n=179, 24%), while the majority was M2PK-only (n=568, 76%) positive. A colonoscopy was offered to 747 persons, 117 (16%) refused, 36 (5%) are still undecided, and 593 (79%) initially accepted. The acceptance rate was lower in men (77%) than women (80%). The follow-up rate of 616 persons who accepted or eventually underwent colonoscopy (some after initial refusal) was 84% (n=517 and 1 virtual colonoscopy). Of the 517 colonoscopies, 177 (34%) were performed at a hospital and 340 (66%) by office-based physicians, 304 (59%) were performed by internists/gastroenterologists and 213 (41%) by surgeons. The histological polyp detection rate (PDR) was 32% (n=167). The adenoma detection rate (ADR) was 20.5% (FIT-positive ADR 25.6%) and varied substantially. The ADR was 18.5% among office-based endoscopists and 24.3% in-hospital – however, 15% when excluding endoscopies from the University Hospital of St Pölten (study/reference center, ADR of 36%). No high-grade dysplasias or CRC were detected. The caecum intubation rate was (reportedly) 97%, yet the complete colonoscopy rate (caecum reached, adequate visualization reported) was 84.7%. Bowl preparation was adequate in 88%, a BBPS was reported only in 49%, and merely 10% reported withdrawal times. Polyp sizes were noted in 76% (or 48% if “polyp bud” was not counted), a PARIS or NICE classification was provided in 27%. Of 140 colonoscopies with polyps ≤10 mm, 54% were removed by forceps, 29% by cold snare, and 6% by hot snare. Only 54% of polyps >10 mm were removed during initial colonoscopy. No major complications were reported.

Conclusion

Acceptance rates of CRC screening even among health care(-associated) persons are low and lowest among the highest risk group – men >50a. New strategies to reach high risk populations, possibly adapted to individual groups, must be devised. An ADR of 15-36% among unselected endoscopists in a pre-screened population denotes poor quality, corroborated by low adherence to quality measures. These data support the drive and underscore the urgent need for rigorous quality control in CRC screening colonoscopy.

References

(1) “Colorectal Screening Across Europe” UEG; https://ueg.eu/; August 2023
(2) Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Kaminski MF et al. Endoscopy. 2017 Apr;49(4):378-397. doi: 10.1055/s-0043-103411. Epub 2017 Mar 7.

Disclosure

Tillotts Pharma AG - Travel support UEG Week 2023

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the current standard for drainage of distal malignant biliary obstruction (MBO), but carries a significant risk of post-procedural pancreatitis.[1] EUS-guided choledochoduodenostomy (EUS-CDS) is increasingly used as a promising alternative, but comparative studies are still scarce.[2,3] While previous studies have mainly focused on stent patency, the current study aims to evaluate whether EUS-CDS is superior to ERCP in achieving a textbook outcome for the patients, indicating an optimal post-procedural course.

Aims & Methods

This single-center study included patients with distal MBO who underwent technically successful (1) EUS-CDS with a lumen apposing metal stent (LAMS) plus additional coaxial stent or (2) ERCP with fully covered self-expandable metal stent (FCSEMS) as part of the prospective SCORPION studies and SPHINX trial, respectively.[1,4] The primary endpoint was textbook outcome, defined as the absence of procedure- or stent-related adverse events (AEs), reinterventions, or hospital readmissions within 30 days of the procedure. Secondary endpoints included individual components of the primary outcome, mortality, time to initiation of treatment (e.g., systemic therapy or surgery), and textbook outcome at 90 days.

Results

A total of 144 patients were enrolled for EUS-CDS (n=49) or ERCP (n=95). Primary etiologies included pancreatic cancer (n=117, 81%) and distal cholangiocarcinoma (n=14, 10%). Coaxial stents used in the EUS-CDS group were FCSEMS (n=20) or double pigtail plastic stents (n=29). Textbook outcome was achieved in 44 patients (90%) in the EUS-CDS group and in 67 patients (71%) in the ERCP group at 30 days (RR 1.27, 95% CI 1.08-1.50). EUS-CDS led to fewer procedure- or stent-related AEs (RR 0.35, 95% CI 0.14-0.84) compared with ERCP, particularly post-procedure pancreatitis (0% vs. 23%). Other AEs, including perforation (2% vs. 0%), bleeding (0% vs. 0%), stent dysfunction with or without cholangitis (4% vs. 6%), and cholecystitis (4% vs. 3%) were similar between groups. Hospital readmission rate was lower in the EUS-CDS group (6% vs. 30%, RR 0.21, 95% CI 0.07-0.65), as was the length of hospital stay (mean 0.3 days [SD 1.3] vs. 1.8 days [SD 4.0], P=0.01). In-hospital mortality (8% vs. 5%), need for reinterventions (8% vs. 6%), and time to treatment initiation, either surgery or chemotherapy, did not differ (median 33 days [IQR 23-42] vs. 30 days [IQR 18-41]). At 90 days, textbook outcome was more often present in the EUS-CDS group when compared to ERCP however the difference was no longer significant (78% vs. 69%, RR 1.22, 95% CI 1.02-1.44).

Conclusion

EUS-CDS with LAMS and additional coaxial stent was superior to ERCP with FCSEMS in achieving textbook outcome at 30 days post-procedure. EUS-CDS resulted in less procedure- or stent-related AEs, particularly post-procedure pancreatitis, and consequently in fewer hospital readmissions and shorter hospital stay. Therefore, when expertise is available, EUS-CDS with coaxial stent placement could be considered as primary biliary drainage technique in patients with distal MBO.

References

1. Onnekink, A. M., Gorris, M., Bekkali, N. L., et al (2024). Endoscopic sphincterotomy to prevent post-ERCP pancreatitis after self-expandable metal stent placement for distal malignant biliary obstruction (SPHINX): a multicentre, randomised controlled trial. Gut, gutjnl-332695. https://doi.org/10.1136/gutjnl-2024-332695
2. Teoh, A. Y. B., Napoleon, B., Kunda, R et al (2023). EUS-Guided choledocho-duodenostomy using lumen apposing stent versus ERCP with covered metallic stents in patients with unresectable malignant distal biliary obstruction: a multicenter randomized controlled trial (DRA-MBO trial). Gastroenterology, 165(2), 473-482.e2. https://doi.org/10.1053/j.gastro.2023.04.016
3. Chen, Y., Sahai, A., Donatelli, G. et al (2023). Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial). Gastroenterology, 165(5), 1249-1261.e5. https://doi.org/10.1053/j.gastro.2023.07.024
4. Fritzsche, J. A., Fockens, P., Besselink, M. G. et al (2024). Optimizing EUS-guided choledochoduodenostomy with lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-IIp): a prospective pilot study. Gastrointestinal Endoscopy. https://doi.org/10.1016/j.gie.2024.10.012

Disclosure

Paul Fockens acted as a consultant for Cook Endoscopy and Olympus, outside the submitted work.
Roy L.J. van Wanrooij acted as a consultant for Boston Scientific. Jeanin E. van Hooft has received research support from Cook Medical and acted as lecturer for Cook Medical, Boston Scientific and Falk, and as consultant for Olympus. Rogier P. Voermans received a research grant and acted as consultant for Boston Scientific. All outside the submitted work. All other authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this abstract.

Introduction

Between 50% and 70% of patients with Crohn’s disease (CD) will require an ileocecal resection. Surgery is not curative, and endoscopic recurrence is frequently observed at the anastomosis site and/or in the neo-terminal ileum.
The objective of this study was to analyse the mucosa-associated ileal microbiota at the time of surgery and during the colonoscopy performed 6 months later and to identify predictive factors of post-operative endoscopic recurrence.

Aims & Methods

Patients were recruited from 15 centres within the REMIND group. Since September 2010, the REMIND group has established a homogeneous, prospective, multicenter cohort (POP-REMIND, NCT03458195) of patients undergoing surgery for ileal and/or ileocolonic Crohn’s disease. Samples were collected from the surgical specimen and during endoscopy, centrally stored in a biobank, and analysed to identify factors associated with recurrence.
Inclusion criteria were: age ≥18 years, ileal or ileocecal CD requiring intestinal resection. Data were collected using an electronic case report form (eCRF). Post-operative treatment was prescribed according to a predefined algorithm. Clinical, therapeutic, biological, and endoscopic data (Rutgeerts classification) were collected 6 months after surgery.
The composition of the mucosa-associated ileal microbiota was analysed at the time of surgery in 140 patients (M0) and in 125 samples at the colonoscopy performed 6 months later (M6), using ultra-deep 16S and ITS2 sequencing (MiSeq, Illumina) to characterize bacterial and fungal microbiota.
We specifically selected patients who had not received antibiotics during the perioperative period to avoid biasing the analysed signal. Sequencing data were processed using the DADA2 pipeline. Alpha and beta diversity and microbiota composition were analysed. Bacterial taxa associated with clinical parameters were identified using MaAsLin2 (Multivariate Association with Linear Models), accounting for CD phenotype and treatments.

Results

We observed numerous differences in the ileal bacterial and fungal microbiota between M0 and M6, and between patients who experienced recurrence (>i2a) and those who were in remission at M6. At M6, the Rutgeerts score was the main factor associated with variability in microbiota composition. The abundance of certain species, notably a decrease of Faecalibacterium prausnitzii, or increase of Fusobacterium nucleatum and Akkermansia muciniphila, was differentially associated with a whole range of levels of the Rutgeerts score or with more specific scores characterizing the inflammation of the anastomosis or the ileum. In addition, machine learning approaches displayed better performances when considering the Rutgeerts score as a multilevel prediction instead of a binary classification, further confirming the need to consider its full range. Finally, we investigated the microbial community dynamics, which highlighted a denser network organisation after surgery and in the absence of recurrence, along with changes in keystone species.

Conclusion

The ileal microbiota associated with post-operative recurrence in CD follows a dynamic process characterized by several waves of alterations. The link between ileal microbiota and disease recurrence varies depending on whether the lesions are located at the anastomosis or ileum sites, supporting a different underlying pathogenesis for the inflammatory process at these two locations.