Introduction

The technique of colorectal ESD has become increasingly standerdised, but challenges still remain for difficult cases. These include lesions occurring on the gravity side that become submerged in fluids, lesions at the colonic flexures that are difficult to approach, and lesions that face the endoscope perpendicularly. The advantages of “gel-immersion endoscopy”, include not only the easier identification of the bleeding point, but also enhancement of the visual field by clearing away the intestinal fluids and residues, aid traction of the lesion using buoyancy, and allowing to secure the visual field between the intestinal folds without needing to insufflate of the intestinal tract with gas. These advantages are favorable for colorectal ESD, and there are case reports of colorectal gel-immersion ESD (Gi-ESD), but there have been no studies of consecutive case series.

Aims & Methods

The present study aimed to clarify the indications and outcomes of Gi-ESD. This was a retrospective cohort study of consecutive patients with colorectal neoplasms who underwent ESD between July 2022 and May 2024. The inclusion criteria consisted of all colorectal ESD performed in our hospital. The exclusion criteria include (i) non-neoplastic lesion; (ii) carcinoma invading muscularis propria; (iii) underwater ESD method; and (iv) use of traction devices, (v)significant loss of clinical data. Gi-ESD was defined as mucosal incision and submucosal dissection performed partially or totally under clear gel (VISCOCLEAR, Otsuka pharmaceutical factory, Japan). Conventional ESD (c-ESD) was defined as all incisions and dissection performed without gel. The primary outcomes were en bloc resection rate and histologic R0 resection rate. Secondary outcomes were procedure time, dissection speed, intraoperative or postoperative perforation, postoperative hemorrhage, and gel-related adverse events.

Results

Among the 260 ESD, 29 were Gi-ESD group and 231 were c-ESD group. Gi-ESD group had significantly larger tumor diameters (25mm vs 18mm, p = 0.001), had a higher rate of lesions located in the cecum or ascending colon (55.2% vs 31.2%, P = 0.01), and had a higher rate of factors associated with difficult ESD (24.1% vs 9.5%, P< 0.05).
Gel was used to improve the visual field and aid traction during ESD, by lifting the lesion using buoyancy in 14 cases(48.3%) where the lesions occurred on the gravity side, to secure the visual field in cases where the lesion could not be approached without degassing such as behind the folds or colonic flexure in 9 cases(31%), and to allow ESD to be performed in a parallel direction with the muscularis propria in lesions that would otherwise have faced the endoscope perpendicularly under CO₂ insufflation in 6 cases(20.7%). Procedure time was significantly longer in the Gi-ESD group (50min vs 32min; P<0.001), but there was no significant difference in the dissection speed (14mm2/min vs 16.1mm2/min, p=0.45). There were no significant differences in the incidences of intraoperative perforation (0% vs 0.4%), delayed perforation (0% vs 0%), or post operative hemorrhage (3.4% vs 0.4%, p=0.21). There were no significant differences in both the en bloc resection rate (100% vs 99.1%) and the pathologic complete resection rate (96.6% vs 88.7%, p=0.33).

Conclusion

Using gel, en bloc resection was obtained without reducing the dissection speed, even for larger lesions associated with factors that make ESD difficult. Gi-ESD for colorectal lesions may be an alternative approach for lesions occurring on the gravity side and for lesions that are difficult to approach under CO₂ insufflation.

References

Yano T et al. Gel immersion endoscopy: A novel method to secure the visual field during endoscopy in bleeding patients. Gastrointestinal endoscopy 2016; 83: 809-11.
Nakano Y et al. Colorectal gel immersion endoscopic submucosal dissection using the tunneling method. Endoscopy 2023; 55: E864-e5.

Introduction

The prevalence of adenoma in patients with positive fecal immunochemical tests (FIT) is shown to be higher. Increased adenoma detection and removal during colonoscopy have been shown to prevent CRC and interval cancers. However, there is considerable variation in the adenoma detection rate (ADR) among colonoscopies performed for FIT. We hypothesize that the ability of dye-based chromoendoscopy to stain the colorectal lesion and their borders and increase their contrast against the normal colorectal mucosa would enhance the detection of adenoma and non-polypoid colorectal neoplasms (NPCRN) in patients undergoing FIT positive colonoscopy. In this randomized control trial, we aim to compare the effectiveness of pan-colonic indigo carmine chromoendoscopy (PCC) to high-definition white light colonoscopy (WLC) in individuals undergoing colonoscopy for positive FIT test.

Aims & Methods

Patients undergoing colonoscopy after a FIT positive test were randomized 1:1 to undergo PCC or WLC. The study was conducted between January 2021 to May 2023 at the Singapore General Hospital, Singapore. Colonoscopy was performed by general and advanced endoscopists, and all received training on PCC before the study. The primary outcome was ADR between the two groups. The secondary outcomes were advanced adenoma detection rate (AADR), NPCRN detection rate, sessile serrated lesion detection rate (SSLDR), and withdrawal time between the groups. We used the two-tailed Mann–Whitney U test and Chi-squared statistics for comparison. The ethics committee approved the study, and it was registered with clinicaltrials.gov (NCT04512612)

Results

We recruited 256 patients (PCC-128; WLC-128). The mean age of the entire cohort was 66 + 8.4 years. The mean ADR was comparable between PCC and WLC (70.3% vs. 64.8%, p-0.350). Likewise, the AADR (19.5% vs. 14.8%, p-0.320], and SSLDR (6.25% vs. 1.56%, p-0.102] were similar between the two groups. We found PCC detected more diminutive adenomas (0.97% vs. 0.58%, p-0.025] and NPCRN per colonoscopy (0.35% vs. 0.17%, p-0.028). The mean withdrawal time was longer with PCC compared to WLC (13.3 min vs. 10.2 min, p-0.001). General and advanced endoscopists had no difference in performance measures for APC and NPCRN per colonoscopy.

Conclusion

The ADR in FIT-positive colonoscopy is higher, and both PCC and WLC yielded comparable results. PCC merits consideration because of its increased ability to detect NPCRNs, which are precursors for interval cancer.

Introduction

Thyroidectomy is one of the most common surgical procedures worldwide, yet its potential effects on esophageal function remain inadequately characterized. While post-thyroidectomy issues such as voice changes have been well-documented, alterations in esophageal motility following this procedure have received limited attention in scientific literature.

Aims & Methods

This study aims to evaluate the impact of thyroidectomy on esophageal motility parameters using High-resolution manometry (HRM), with particular attention to upper esophageal sphincter (UES) function. Seventeen patients (11 females), who were to undergo total thyroidectomy or hemithyroidectomy, were prospectively recruited between the months of February and May 2023. Ten of them had goiters, while seven had thyroid nodules. Exclusion criteria were having an age under 30 or over 70 years old, having to also undergo a parathyroid surgery and taking medications that could alter the esophageal sphincter. All of them underwent a pre-operative HRM and a second one thirty days after surgery. HRM were performed according to the Chicago Classification 4.0 and the data were analyzed using the online analysis platform “Swallow Gateway”. Gastrointestinal (GI) symptoms were assessed using a standardized questionnaire, before the first and the second HRM. No after procedural complication was reported.

Results

UES function significatively changed after thyroidectomy, as it is shown by HRM metrics such as Pharyngeal Contractile Integral (CI), Velopharyngeal CI, Hypopharyngeal CI, UES-CI, UES Integrated Relaxation Pressure (UES-IRP), Post-Deglutitive UES CI, Proximal Contractile Integral (PCI), which all significatively decreased (p < 0.05) at the HRM performed after surgery. Compared to Swallow Gateway normal values, there was an important increase of pathological HRM metrics after thyroidectomy. No significant HRM difference was found between the two categories of patients (goiter and thyroid nodules) and no significant correlation was registered between GI symptoms pre- and post-surgery and between GI symptoms and HRM metrics.

Conclusion

Thyroidectomy may significantly affect esophageal motility, especially the function of the upper esophageal sphincter. This finding could be useful in the diagnostic and therapeutic pathway of these patients, although further and larger studies are required to confirm this result.

Introduction

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (SESCC) involving the entire circumference carries the extremely high risk of stricture and also raises concerns about curative resection. Therefore, the current Japanese guidelines weakly recommend ESD only for circumferential SESCCs diagnosed as cEP/LPM and sized ≤ 50 mm, while surgery or chemoradiotherapy (CRT) is recommended for circumferential SESCCs other than the above. ¹ However, in clinical practice, ESD is implemented on a case-by-case basis through the discussion in a multi-disciplinary cancer board at each institution because the outcomes of each treatment for circumferential SESCCs remain unclear.²

Aims & Methods

This multicenter prospective observational study aimed to reveal the outcomes of each treatment for circumferential SESCCs. Patients with cT1a-EP/LPM or cT1a-MM/T1b-SM1 N0M0 SESCCs involving the entire circumference were enrolled in this study. At this stage, short-term outcomes, such as the proportion of curative resection after ESD, complete response (CR) after CRT/radiotherapy (RT), and adverse events including esophageal stricture, were evaluated. Curative resection in ESD was defined as pT1a without lymphovascular invasion (LVI). Esophageal stricture was defined as inability to pass the ordinary-sized endoscope thorough the treated site, and refractory stricture was defined as stricture requiring ≥ 6 endoscopic balloon dilation procedures.

Results

A total of 126 patients with circumferential SESCCs were enrolled from 16 Japanese tertiary institutions between May 2021 and November 2024. ESD was performed for 90 (71.4%) patients including 6 undergoing stepwise ESD, surgery for 18 (14.3%), CRT for 16 (12.7%), and RT alone for 2 (1.6%). Median longitudinal length of tumor was 55 (range: 30–140) mm in the ESD group, 80 (50–150) mm in the surgery group, and 70 (30–100) mm in the CRT/RT group. Tumor depth was diagnosed as cEP/LPM in 65.4% (55/84) of the ESD group, 38.9% (7/18) of the surgery group, and 50.0% (9/18) of the CRT/RT group, and the others were diagnosed as cMM/SM1. As stricture prevention method after ESD, local injection or filling of triamcinolone (TA) alone was used in 9 patients (10.7%), and both local injection of TA and oral steroid of prednisolone were used in 75 (89.3%). Among the 63 patients who did not receive additional treatment after ESD, the proportion of stricture and refractory stricture were 46.0% (29/63) and 27.0% (17/63), respectively. Curative resection after ESD was achieved in 58 patients (69.0%), including 46 (83.6%) with cEP/LPM and 12 (41.4%) with cMM/SM1. Of 26 patients with non-curative resection after ESD, 20 (76.9%) received additional treatment of either surgery, CRT, or RT, while the remaining 6 opted for follow-up. Of 18 patients in the surgery group, 7 with cEP/LPM and 4 with cMM/SM1 were diagnosed as pT1aN0 without LVI, while the remaining 7 with cMM/SM1 were diagnosed as pT1b, 3 of whom had lymph node metastasis. Anastomotic stricture was observed in 11.1% (2/18) of patients treated with surgery. Of 18 patients in the CRT/RT group, CR was confirmed in all patients without forming stricture.

Conclusion

Considering the high curative resection rate, ESD could be indicated for circumferential SESCCs diagnosed as cEP/LPM. In contrast, the careful consideration may be required in indicating ESD for circumferential SESCCs diagnosed as cMM/SM1 due to its low curative resection rate. Long-term outcome needs to be confirmed for further treatment comparisons.

References

1. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020; 32: 452–93.
2. Kadota T, Ishihara R, Hatta W, et al. Multi-institutional questionnaire on treatment strategies for superficial entire circumferential esophageal squamous cell carcinoma. DEN Open. 2023; 3: e206.

Introduction

Primary biliary cholangitis (PBC) is often associated with extrahepatic autoimmune diseases (EAIDs) such as Sjögren’s syndrome, autoimmune thyroiditis, and connective tissue disorders. While this association suggests a shared immunological predisposition, its effect on disease prognosis remains unclear.

Aims & Methods

This retrospective study included 69 patients diagnosed with PBC, excluding those with overlap syndromes involving autoimmune hepatitis. Patients were divided into two groups: isolated PBC (n = 35) and PBC associated with EAIDs (n = 34). The two groups were compared based on clinical, immunological, elastometric characteristics, disease progression, and prognostic scores (Paris I, Paris II, Rotterdam, Barcelona, Rochester, GLOBE, UK-PBC). Statistical analysis was conducted using appropriate tests, with a significance threshold set at p < 0.05.

Results

The average age at diagnosis was 55.6 years. The disease was initially suspected based on functional symptoms in 39% of cases (fatigue, pruritus, arthralgia), biological cholestasis in 33.3%, and decompensated cirrhosis in 20.3%. The most common associated autoimmune diseases were Sjögren’s syndrome (17.4%), thyroid disorders (13%), and systemic lupus erythematosus (10.1%). All patients received treatment with ursodeoxycholic acid at 13-15 mg/kg/day. No significant differences were found between the two groups regarding functional symptoms, biological markers (bilirubin, albumin, prothrombin time), autoantibodies (AMA, Anti-GP210, anti-SP100, anti-PML), non-invasive fibrosis scores (Fib4, Fibroindex, Fibroscan, S-index), or hepatic complications (HDH, cirrhosis, hepatic encephalopathy, liver-related death). Prognostic scores were also comparable between both groups: Paris I (p = 0.468), Paris II (p = 0.519), GLOBE score (p = 0.6), UK-PBC (p = 0.49), Rotterdam (p = 0.897), Barcelona (p = 0.181), Rochester (p = 0.727).

Conclusion

The presence of extrahepatic autoimmune diseases in PBC does not appear to affect the clinical, biological, or prognostic profiles of patients. Despite their frequency, these comorbidities do not seem to influence the progression of PBC.

Disclosure

None.

Clinical Case Summary

A 58 year-old woman was admitted for an elective rectosigmoidectomy after two previous uncomplicated diverticulitis episodes. On the third postoperative day, her clinical status deteriorated, and an abdominal CT scan revealed an anastomotic leak, leading to a new surgery and confection of a protective ileostomy. Her condition improved progressively, and she was discharged 10 days after. However, the patient came back to the emergency one week later with abdominal pain, fatigue, and refractory nausea and vomiting, in addition to acute renal failure with severe hyponatremia and hyperkalemia. Because her daily ileostomy’s output reached about 2 liters/day, she was started on high dose opioids and loperamide to decrease the stoma’s output, as well as replacement fluid therapy, improving quickly within 24 to 48 hours. She was discharged in 5 days.
Despite the adequate control of the ileostomy’s output, her second readmission occurred 12 days later, showing the same clinical and laboratorial patterns. Considering she had a typical profile for adrenal insufficiency, fludrocortisone was associated with the antimotility agents, showing a significant improvement within hours. Nonetheless, she discontinued fludrocortisone on her own, and a third readmission occurred in 10. One more time, clinical and laboratorial characteristics were the same, with rapid improvement in the short term. An extensive investigation was conducted, revealing an aldosterone level more than 10 times higher than upper limit of normal, with normal renin levels and an adrenocorticotropic hormone in the lower limit of normal. These paradoxical findings were reinforced with a low urine and high ileostomy sodium dosages, and a diagnosis of a type 3 pseudohypoaldosteronism was made. Definitive treatment with intestinal transit’s reconstruction was performed, with complete resolution.

References

1. Carl C, Dinkelbach L, Mohr J, Perez R, Vera Lopez T, Fricke-Otto S, Niehues T. Case report: Life threatening hyponatremia in infants with urinary tract infections: two cases of type III pseudohypoaldosteronism and review of the literature. Front Pediatr. 2024 Jan 5;11:1233205. doi: 10.3389/fped.2023.1233205. PMID: 38250595; PMCID: PMC10797885.
2. Amir Babiker, Haya Aldabas, Shahad Alanazi, Bashayer Alahmadi, Waleed Tamimi, Mohsen Al Atawi, Fahad Aljuraibah, Angham Almutair. Pseudohypoaldosteronism: A challenging diagnosis with management pitfalls - Case series. Journal of Clinical and Translational Endocrinology: Case Reports, Volume 32, 2024, 100172. ISSN 2214-6245
3. Stojanović, V., Spasojević, S., Radovanović, T., & Doronjski, A. (2017). Pseudohypoaldosteronism: report of three cases. Journal of Endocrinology, Metabolism and Diabetes of South Africa, 22(2), 17–20. https://doi.org/10.1080/16089677.2017.1335532
4. Nakasone, Ruka et al. Three cases of pseudohypoaldosteronism following ileostomy in preterm infants. Pediatrics & Neonatology, Volume 62, Issue 1, 119 - 121

Introduction

Eosinophilic oesophagitis [EoE] is a chronic, antigen-driven, immune-mediated oesophageal disease characterised by eosinophil-predominant inflammation. It typically presents with dysphagia, food bolus impaction, and, in children, feeding difficulties and failure to thrive [1]. Histologically, it is defined by ≥15 eosinophils per high-power field on oesophageal biopsy in the absence of other causes of eosinophilia [2]. The incidence and prevalence of EoE have increased markedly over recent decades, particularly in Western countries, likely due to increased recognition, changing environmental exposures, and altered microbiota [3,4]. Though EoE is increasingly reported worldwide, data specific to Aotearoa New Zealand, and especially regional patterns by ethnicity, remain limited.

Aims & Methods

This study aimed to describe the incidence, demographic distribution, and clinical characteristics of EoE in the Canterbury region over an 11-year period.
We conducted a retrospective analysis of electronic medical records from 2013 to 2023, identifying EoE cases using diagnostic codes and histological confirmation. Demographic data, clinical presentations, and laboratory findings were collected. Crude incidence rates were calculated using average population data for the Canterbury region, stratified by ethnicity (European vs. non-European). Clinical features including food bolus obstruction, oesophageal strictures, and peripheral eosinophilia were assessed. Incidence rates are reported per 100,000 population with 95% confidence intervals (CI).

Results

A total of 219 cases of EoE were identified between 2013 and 2023. The average annual incidence was 3.23 per 100,000 population (95% CI: 1.82–4.65), based on a regional population of 618,409. The mean number of cases per year was 20 (IQR 16–22). Among European individuals (average population 395,690), the mean annual incidence was 4.42 per 100,000 (95% CI: 2.35–6.49), with 17.5 average cases per year (IQR 14–21). Among non-European individuals (average population 222,627), the mean incidence was 1.08 per 100,000 (95% CI: -0.29–2.44), with 2.4 average cases per year (IQR 1–4).
Of the 219 cases, 70 patients (31.9%) presented with oesophageal food bolus impaction. The annual number of such presentations ranged from 3 to 12 per year (median 6, IQR 4–9). Twenty patients (9.1%) had documented stricturing disease on endoscopy, and 60 patients (27.4%) exhibited peripheral eosinophilia at diagnosis.

Conclusion

In our cohort, eosinophilic oesophagitis presents commonly with oesophageal food bolus impaction. There was a higher incidence of EoE observed in individuals of European descent. Just under one-third of patients in our cohort presented with oesophageal food bolus impaction and about 9% had stricturing disease. The frequent presentation with food bolus obstruction and the presence of complications such as strictures highlight the importance of timely recognition and management. Peripheral eosinophilia was found commonly in our cohort but the prevalence of this finding is not adequate to be used as a diagnostic test in EoE, although more studies are needed.

References

1. Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology. 2018;155(4):1022-1033.e10.
2. Lucendo AJ, Molina-Infante J, Arias Á, et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J. 2017;5(3):335-358.
3. Hruz P, Straumann A, Bussmann C, et al. Escalating incidence of eosinophilic esophagitis: A 20-year prospective, population-based study in Olten County, Switzerland. J Allergy Clin Immunol. 2011;128(6):1349-1350.e5.
4. Arias Á, Lucendo AJ. Epidemiology and risk factors for eosinophilic esophagitis: Lessons for clinicians. Expert Rev Gastroenterol Hepatol. 2020;14(2):103–115.

Disclosure

None