Introduction

The Kimura-Takemoto's (KT) classification, the endoscopic assessment for the extent of gastric atrophy, has been recommended to useful risk marker of gastric cancer (GC) in Japan. In Western countries, recent studies suggest the endoscopic findings with narrow band imaging (NBI) according to the classification of endoscopic grading of gastric intestinal metaplasia (EGGIM) are useful markers for GC risk. However we reported that both KT and EGGIM are useful stratification method for the GC in Japanese, the association between KT and EGGIM is unknown.

Aims & Methods

This study is a post-hoc analysis of a multicenter prospective study for a histological and endoscopic risk for GC in 10 Japanese facilities (UMIN00027023). We assessed the KT classification with white-light endoscopy and EGGIM score with NBI endoscopy in all subjects. We also evaluated the histological findings using biopsy specimens according to the operative link for gastritis assessment (OLGA) and the operative link for gastric intestinal metaplasia (OLGIM). The biopsy specimens were taken randomly according to the updated Sydney system, not guided target biopsy with NBI. We evaluated the association between KT and EGGIM. We also analyzed the diagnostic ability for histological findings (OLGA/OLGIM) using receiver operating characteristic (ROC) analysis. In OLGA, OLGIM and EGGIM analysis, We assessed four points (lesser and greater curvatures of antrum and corpus), not included angularis because of a questionable diagnostic benefit.

Results

The 380 subjects (115 GC and 265 non-GC) were analyzed. The white-light endoscopy revealed that 99 patients were non to mild atrophy (C-0, C-1; low risk for GC), 104 were moderate atrophy (C-2,C-3; moderate risk) and 177 were extent atrophy (O-1, O-2, O-3; high risk) in KT classification. The NBI findings showed that 109 were low risk (score 0), 158 were moderate risk (score 1 to 4), 113 were high risk (score 5-8) in EGGIM score. The high risk group in KT classification had significant association with that of EGGIM score (odds ratio (OR) 4.3 [95% confidence interval (CI) 2.6-6.8]). The high risk group in KT classification showed significant relationship not only high risk group of histological atrophy (OLGA stage III/IV) with OR 5.5 [3.4-8.8], and also that of histological IM (OGIM stage III/IV) with OR 8.5 [4.5-16.0]. The area under the ROC curve of diagnostic ability for OLGA III/IV were 0.786 in KT and 0.769 in EGGIM. Also those of OLGIM IIII/IV were 0.761in KT and 0.734 in EGGIM.

Conclusion

Endoscopic assessments according to the Japanese traditional method (KT) and Western method (EGGIM) showed significant association. The KT classification associated with not only extent of histological atrophy but also extent of histological IM.

References

1. Kawamura M, Uedo N, Koike T,et al : Kyoto classification risk scoring system and endoscopic grading of gastric intestinal metaplasia for gastric cancer: Multicenter observation study in Japan. Dig Endosc 2022; 34: 508-516.
2. Kimura K, Takemoto T. An endoscopic recognition of the atrophic border and its significance in chronic gastritis. Endoscopy 1969; 1: 87–97.
3. Pimentel-Nunes P, Libânio D, Lage J et al. A multicenter prospective study of the real-time use of narrow-band imaging in the diagnosis of premalignant gastric conditions and lesions. Endoscopy 2016; 48 :723-730.
4. Esposito G, Pimentel-Nunes P, Angeletti S et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): a multicenter validation study. Endoscopy 2019; 51: 515-521.
5. Marcos, P.; Brito-Gonçalves, G.; Libânio, D.; Pita, I.; Castro, R.; Sá, I.; Dinis-Ribeiro, M.; Pimentel-Nunes, P. Endoscopic grading of gastric intestinal metaplasia on risk assessment for early gastric neoplasia: Can we replace histology assessment also in the West? Gut 2020; 69: 1762–1768.

Disclosure

All authors disclose no financial relationships relevant to this study

Clinical Case Summary

We report the case of a 54-year-old male with harmful alcohol consumption who presented to the emergency department for hematemesis with acute anaemisation. After stabilising the patient, an urgent gastroscopy was performed and large esophageal varices with red points were found, over which elastic bands (EVBL) were placed.
Hours after the endoscopic procedure, the patient presented a new episode of hematemesis and hemodynamic instability. After resucitation, he was transferred to the care unit for a new gastroscopy. In it, four small varicose cords with constant drooling of blood and clots were observed. Given the impossibility of EVBL, the patient was fitted with a fully covered self-expanding metal stent (SEMSs), achieving clinical stability for him.
Following this procedure, an etiological study was carried out, concluding that portal cavernomatosis secondary to chronic pancreatitis was the cause of the current clinical case. Given the etiology and what happened, five days after the endoscopic procedure, endovascular treatment was performed by Interventional Radiology with complete embolisation of oesophageal varices and subsequent recanalisation of the splenoportal axis by angioplasty and placement of a vascular stent. After that, the oesophageal stent was removed without complications. Six months later, the patient underwent clinical and endoscopic follow-ups, showing a lack of esophageal varices and other data of portal hypertension.
According to the latest consensus of Baveno VII and ESGE for the management of variceal hemorrhage, SEMSs implantation is considered the safest option as a bridge therapy to a more definitive treatment of refractory variceal bleeding; allowing time for etiological investigation and appropriate patient management^1-2.

References

1. ​de Franchis R, Bosch J, Garcia-Tsao G et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol 2022; 76: 959-74 https://doi.org/10.1016/j.jhep.2021.12.022
2. ​Gralnek IM, Camus-Duboc M, García-Pagán JC et al. Endoscopic diagnosis and managemet of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54 (11): 1094-1120 https://doi.org/10.1055/a-1939-4887

Introduction

Chronic pancreatitis is one of the well-known risk factors of pancreatic adenocarcinoma, the 4th leading cause of cancer mortality. Excessive chronic alcohol consumption is the first cause leading to chronic pancreatic and hepatic inflammation. The intestinal microbiota plays a role in the pathogenesis of these two diseases and patients with chronic alcoholic pancreatitis (CAP) or alcoholic hepatitis (AH) display altered and specific gut dysbiosis, with a higher relative abundance of Enterococcus in patients with CAP compared to AH(1). A recent study identified strains of E. faecalis able to produce a toxin, called cytolysin, responsible for liver lesions in chronic liver diseases. Its presence was associated with the worst clinical outcomes(2). It is yet unknown whether patients with CAP also exhibit an elevated relative abundance of cytolysin-producing E. faecalis strains.

Aims & Methods

The objectives of this study were 1/ to assess the presence of E. faecalis strains expressing or not cytolysin, in the intestinal microbiota of patients with CAP (n = 24) compared to patients with AH (n = 27) and to healthy controls (HC, n = 28), 2/ to evaluate the role of E. faecalis strains (isolated from the patients), in the genesis and potentiation of pancreatitis lesions and early precancerous lesions (acinar-to-ductal metaplasia), in a murine model of pancreatitis induced by cerulein, and 3/ to assess the presence of Enterococcus in surgical specimens of patients who went under pancreatic resection for CAP, (n = 6) compared to controls (normal pancreatic parenchyma apart of benign tumors n = 4).

Results

Our data showed that the relative abundance of cytolysin-positive E. faecalis in the intestinal microbiota is elevated in patients with AH and even more in patients with CAP. Genomic DNA of E. faecalis was detected in 96% of CAP patients, and 85% of AH patients. CAP patients were more frequently cytolysin-positive (96%) than HC (39%, p < 0.001) or AH patients (48%, p < 0.001). The relative abundance of cytolysin-positive E. faecalis was elevated in CAP and AH patients (p = 0.0006 and p= 0.0067) but not HC. In our murine model of cerulein-induced chronic pancreatitis, E. faecalis tend to increase the rate of pancreatitis lesions, as well as the number of acinar-to-ductal metaplasia lesions, specifically when pancreatitis is triggered. We used two different anti-Enterococcus antibodies with concordant results, showing that Enterococcus is present in the pancreatic parenchyma of patients with CAP, but not in the healthy pancreas of controls.

Conclusion

These results support a potentially detrimental role of Enterococcus, and especially E. faecalis, in the evolution of pancreatic inflammation. This study opens new research perspectives to investigate the pathophysiological mechanisms of intestinal microbiota species in the pancreatic exocrine tissue. Microbiota and metabolites produced by these microorganisms (like cytolysin) are probably key actors in the pancreatic inflammation process, involved in the cross-talk between the ​gut and pancreas. It could lead to consider potential new therapeutic targets in patients with chronic pancreatitis at risk of developing aggressive pancreatic cancers.

References

1. Ciocan D, Rebours V, Voican CS, Wrzosek L, Puchois V, Cassard AM, et al. Characterization of intestinal microbiota in alcoholic patients with and without alcoholic hepatitis or chronic alcoholic pancreatitis. Sci Rep. 19 mars 2018;8(1):4822.
2. Duan Y, Llorente C, Lang S, Brandl K, Chu H, Jiang L, et al. Bacteriophage targeting of gut bacterium attenuates alcoholic liver disease. Nature. nov 2019;575(7783):505‑11.

Introduction

Plastic stent placement during endoscopic retrograde cholangiopancreatography (ERCP) is a well-established therapy for a wide variety of obstructive biliary and pancreatic disorders. While proximal or distal stent migration is uncommon, with migration rates ranging from 4.1% to 13.5%, it can result in serious complications. Endoscopic retrieval of proximally migrated stents is intricate and may present a technical challenge to the endoscopist.

Aims & Methods

Aims: This study aims to ascertain the proximal stent migration rate, complications associated, risk factors, success rate, and the endoscopic techniques applied for retrieval.
Materials and Methods: We conducted a retrospective cohort study including 546 consecutive ERPC procedures performed at a tertiary center between January 2022 and March 2023. Data regarding indications for stenting, presentation of migration, stent length and diameter, endoscopic retrieval techniques, and success rate were collected.

Results

Overall, a total of 429 plastic stents were inserted (372 biliary and 57 pancreatic) in 245 patients. Proximal migration occurred in 2.8% of cases (9 biliary and 3 pancreatic), all of which were asymptomatic. Stent length <10cm (p=0.08) was identified as a risk factor for proximal migration. The success rate of endoscopic retrieval was 100%. Stent extraction was accomplished on the first attempt in 9 cases (75%), with three cases (25%) requiring re-attempt. Retrieval techniques employed included the Soehendra stent retriever (n=5, 41.7%), forceps (n=3, 25%), snare (n=3, 25%), and balloon catheter (n=1, 8.3%). Cholangiopancreatoscopy-assisted retrieval was necessary in two cases as a rescue therapy. Notably, there were no complications or procedure-related mortality.

Conclusion

ERCP is an effective and safe approach for the retrieval of proximally migrated plastic stents, however, it requires experience with different techniques and endoscopic accessories. In challenging scenarios, cholangiopancreatoscopy-assisted stent retrieval may offer a viable solution when conventional methods are unsuccessful. Our cohort analysis revealed that stent length <10cm was potentially associated with an increased risk of proximal migration.

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

Upper gastrointestinal tract leaks and fistulae following surgery present significant challenges, associated with high morbidity and mortality. Self-expanding metal stents (SEMS) have conventionally been utilized as the primary endoscopic treatment. However, endoscopic vacuum therapy (EVT) has emerged as a promising alternative.

Aims & Methods

This study aims to compare the efficacy and safety of EVT against SEMS in managing postoperative upper gastrointestinal tract surgical leaks/fistulae. We included 61 patients, 18 of whom underwent EVT from 2022-2024, and 43 who received SEMS treatment from 2014-2024. Demographic data, clinical characteristics, and treatment outcomes were retrospectively analyzed. Success rate, defined as complete closure of the leak/fistulae, as well as rates of complications, readmission, and mortality were compared between the two endoscopic modalities.

Results

There were no statistically significant differences regarding distribution by gender, age, benign vs malignant disease, time from surgery to endoscopic treatment and leak size (p>0.05). Larger leak size was associated with significantly lower likelihood of closure (p=0.025). EVT demonstrated a remarkable success rate, achieving complete closure of the leaks/fistulae in 94.4%, compared to 55.8% success with SEMS (p<0.001). EVT was associated with less endoscopic adjuvant therapy (22.2% vs. 46.5%, p=0.009), despite a higher number of treatment sessions (4 vs. 2, p<0.001). SEMS patients experienced higher rates of technique-related complications (76.7% vs. 5.5%, p<0.001), readmission (55.8% vs. 0%, p=0.016) and mortality (34.9% vs. 11.1%, p=0.059), although deaths were not related to endoscopic treatment.

Conclusion

This study results indicate that endoscopic vacuum therapy (EVT) significantly outperforms self-expanding metal stents (SEMS) in treating postoperative upper gastrointestinal leaks and fistulae. EVT achieved a notably higher success rate in terms of complete leak/fistula closure compared to SEMS, while also showing fewer technique-related complications, readmissions, and lower mortality rates. These findings suggest that EVT may represent a safer and more effective approach to managing these complex postoperative complications, potentially redefining the standard of care. Given its benefits, EVT could become the new gold standard for these entities, leading to improved patient outcomes and reduced healthcare burdens. Further research with larger patient cohorts is recommended to solidify the evidence supporting EVT's superiority in this clinical context.