Introduction

In recent years, propofol has become the sedative of choice for gastrointestinal endoscopy. Despite large cohort studies demonstrating its safety and effectiveness, the adoption of Non-Anesthesiologist Administration of Propofol (NAAP) in clinical practice still faces numerous challenges, both in Europe and globally. Consequently, propofol-based sedation remains largely in the hands of anesthesia professionals.

Aims & Methods

This study was conducted in two phases. Initially, a preliminary analysis was carried out to compare adverse event (AE) rates between NAAP and Anesthesiologist Administration of Propofol (AAP) at a tertiary academic center (San Raffaele Hospital, Milan, Italy). In the second phase, potential cost savings from implementing NAAP over AAP at the hospital, local, and national levels were examined.
Propensity score matching (PSM), based on age, sex, body mass index (BMI), and ASA Physical Status Classification System score, was used to compare the two cohorts. A 3-year budget impact model (BIM) was implemented based on the annual volume of outpatient endoscopy procedures performed at San Raffaele Hospital and estimates of the Italian adult population by Italian National Institute of Statistics (ISTAT).

Results

From May 2019 to October 2021, 2,721 patients who underwent esophagogastroduodenoscopy (EGD) (2,439 NAAP and 282 AAP) and 2,748 who underwent colonoscopy (2,491 NAAP and 257 AAP) in outpatient setting were enrolled. Only diagnostic procedures were included. After PSM, the EGD cohort included 282 patients under NAAP and 188 under AAP, while the colonoscopy cohort consisted of 256 patients under NAAP and 174 under AAP. No significant differences in AE rates were observed between the groups in both the EGD (overall: NAAP 1.1% vs AAP 0.8%, p=0.815; after PSM: NAAP 0.4% vs. AAP 1.0%, p=0.452) and colonoscopy cohorts (overall: NAAP 1.7% vs AAP 3.5%, p=0.202; after PSM: NAAP 3.5% vs. AAP 0.6%, p=0.249). All AEs were managed without leading to major or long-term sequelae.
According to the BIM, a complete implementation of NAAP instead of AAP for patients classified as ASA 1 and 2 would lead to financial savings of €851,649 at our hospital, €8.3 million for the Local Health Authority of Milan, €19.8 million for the Lombardy region, and €124.7 million for the Italian National Health System over the triennium 2023-2025.

Conclusion

NAAP is a safe sedation modality for outpatient gastrointestinal endoscopy, with AE rates comparable to those of AAP. Its widespread implementation, at the expense of AAP, could result in savings exceeding €120 million for the Italian National Health System over the triennium 2023-2025.

References

NAAP is a safe sedation modality with AE rates comparable to AAP. The widespread implementation of NAAP, rather than reliance on anesthesiologist-led propofol sedation, could result in savings exceeding €120 million for the Italian National Health System over the triennium 2023-2025.

Introduction

The Updated Sydney System recommends reporting the severity of both glandular atrophy (GA) and intestinal metaplasia (IM) as two independent parameters. However, the OLGA system assesses both GA and IM together as part of the same entity which should be reported as an average severity. The OLGIM system is based on the IM severity recommended by the updated Sydney system. Thus, the final OLGIM score can be estimated by any clinician. Currently, no system addresses the severity of both GA and IM as they are reported following the updated Sydney recommendation.

Aims & Methods

This study aimed to assess the utility of a new system, OLGIMA (Operative Link on Gastric IM and GA assessment), as a tool to identify patients at higher risk for GC in daily practice.
Consecutive diagnostic UGI endoscopies performed for any indications in patients older than 18 years old were recorded prospectively in 21 Spanish hospitals between April 2021 and July 2023. Protocolized gastric biopsies were taken according to the Updated Sydney consensus. We excluded patients with dysplasia, any malignancy, suspicion of autoimmune chronic atrophic gastritis, and lack of histological data. The severity of both GA and IM was assessed in the antrum (including incisura) and corpus following the updated Sydney system. After that, we considered the most advanced severity (none:0; mild:1; moderate:2; marked:3) provided for any of them in each of the two topographical areas. Then, the OLGIMA staging was done according to the same methodology used by the OLGA and OLGIM systems.

Results

A total of 998 patients were included. The median age was 57 (IQR 46 - 67), and 64% were women. Hp infection was identified in 334 (35%) patients (19% active infection and 16% eradicated). GA was identified in 192 (19.2%) patients which was limited to the antrum in 113 (11.3%) cases and extensive in 79 (7.9%). IM was identified in 159 (15.9%) patients which was limited to the antrum in 114 (11.4%) cases and extensive in 45 (4.5%). According to IM severity, 27 (2.7%) patients were OLGIM III/IV. According to GA severity, 22 (2.2%) patients were significantly extensive. The OLGIM system would have missed 12 (1.2%) patients with GA at higher risk. Considering both criteria, we would have detected 39 (3.9%) patients at higher risk in total (17 OLGIM III-IV, 12 extensive significative GA, and 10 both OLGIM III-IV and extensive significative GA). The new OLGIMA system categorized all 39 (3.9%) patients, OLGIM III-IV and significantly extensive GA, in the high-risk group (OLGIMA III/IV).

Conclusion

The new OLGIMA system (based on the severity of IM and GA recommended by the updated Sydney system) was able to detect patients at higher risk including all cases of OLGIM III/IV and also with advanced GA. The OLGIMA staging is much simpler and it can be estimated by any clinician regardless of whether the biopsy from incisura was taken.

References

Rugge M, Meggio A, Pennelli G et al. Gastritis staging in clinical practice: the OLGA staging system. Gut. 2007;56:631-6
Capelle LG, de Vries AC, Haringsma J et al. The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis. Gastrointest Endosc. 2010;71:1150-8
Pimentel-Nunes P, Libânio D, Marcos-Pinto R et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy. 2019;51:365-388.

Introduction

Anastomotic leak remains one of the most critical complication after Ivor-Lewis esophagectomy [1][2]. While intra-cavitary approach for Endoscopic Vacuum Therapy (EVT) has been proved effective for the treatment of large dehiscences [3], no data exist comparing intraluminal EVT and Self-expanding Metal Stent (SEMS) in the management of non-large (<3 cm) anastomotic dehiscences.

Aims & Methods

In this matched-at-enrollment case-control study (1:1), we included patients who received EVT and SEMS for non-large (<3 cm) anastomotic dehiscences after oncologic Ivor-Lewis esophagectomy between May 2014 and July 2022. The primary outcome was successful closure of the leak. Exclusion criteria were: anastomotic dehiscences > 3 cm, early (≤ 2 days) and late (4 weeks) diagnosis after surgery, severe gastric conduit necrosis, sepsis/septic shock at diagnosis.

Results

Overall, 22 patients treated with EVT and 22 treated with SEMS, were matched by age (p=0.070), sex (p=0.262), BMI (0,247), American Society of Anesthesiologists (ASA) score (p=0.386), neoadiuvant radio/chemotherapy (p=0.15), dehiscence diagnosis modality (0.761), defect type (leak or fistula) (p=1.00), PCR values (p=0.103) surgical re-intervention before endoscopic treatment (p=0.472) and leak size (p=0.931). EVT and SEMS revealed no difference in leak resolution (90.9% vs 72.7%, respectively; p=0.21), whereas EVT group was associated with higher number of procedures (4.41 vs 2.18, p= 0.05, respectively). Concerning adverse events (AE’s), both EVT and SEMS showed no statistical difference in AE’s rates (p=0.61). Overall outcomes of endoscopic procedures are shown in Table 1.

Conclusion

EVT and SEMS has shown similar efficacy outcomes in the treatment of non-large (< 3 cm) anastomotic defects after Ivor-Lewis esophagectomy. Prospective comparison data are needed to validated these findings.

References

1. Seesing MFJ, Gisbertz SS, Goense L, van Hillegersberg R, Kroon HM, Lagarde SM, Ruurda JP, Slaman AE, van Berge Henegouwen MI, Wijnhoven BPL (2017) A Propensity Score Matched Analysis of Open Versus Minimally Invasive Transthoracic Esophagectomy in the Netherlands. Ann Surg 266: 839–846
2. Kassis ES, Kosinski AS, Ross P Jr, Koppes KE, Donahue JM, Daniel VC (2013) Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg 96: 1919–1926
3. Zhang CC, Liesenfeld L, Klotz R, Koschny R, Rupp C, Schmidt T, Diener MK, Müller-Stich BP, Hackert T, Sauer P, Büchler MW, Schaible A (2021) Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection. BMC Gastroenterol 21:72

Disclosure

Prof. Silvio Danese has served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millenium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor. The other authors declare no conflict of interests. Dr Francesco Vito Mandarino, Dr Alberto Barchi, Dr Lorenzo Leone, Dr Lorella Fanti, Dr Francesco Azzolini, Dr Edi Viale, Dr Dario Esposito, Dr Noemi Salmeri, Dr Francesco Puccetti, Dr Lavinia Barbieri, Dr Andrea Cossu, Dr Elio Treppiedi, Dr Ugo Elmore and Prof Riccardo Rosati have no conflict of interest to disclose.

Introduction

Per-oral endoscopic myotomy (POEM) has revolutionised achalasia treatment, nevertheless there is still a lack of technical standardization. No clear definition of “long”, “standard” or “short” POEM exists to date. With the exception of type III achalasia, there is evidence that myotomy limited to the lower esophageal sphincter (<6 cm) may be highly effective, time-saving and associated with less post-postoperative gastroesophageal reflux, yet it is common practice to use long myotomy in these patients.

Aims & Methods

We conducted a systematic review with meta-analysis to define current myotomy length standards during POEM. A literature search was performed on MEDLINE-Pubmed, Embase, Scopus, and Cochrane Library (from inception to December 2022). We included prospective, retrospective clinical studies and randomized controlled trials reporting technical details of POEM, in which no definite or comparative myotomy length was intentionally adopted thus representing a “standard” myotomy for the operator. The primary outcome was the pooled mean total myotomy length. Secondary outcomes included clinical success and reflux symptoms. Main exclusion criteria were: patient age < 18 years; studies providing achalasia diagnosis without high-resolution manometry, studies including patients with non-achalasia esophageal motility disorders, studies comparing different myotomy lengths or adopting pre-specified myotomy lengths, studies including type III achalasia patients only. Sub-group analyses were performed to explore heterogeneity across studies and to assess the impact of different subtypes, geography and time trends on the primary outcome.

Results

From initial 7,172 records, after exclusion criteria were applied, a total of 25 articles were included. Of those, 6 provided results on the primary outcome in separate subgroups and were therefore included as separate studies. Overall, 31 studies with a total 3023 patients were evaluated. The pooled mean of total myotomy length was 10.39 cm (95% CI 10.06-10.71; I² 99.3%). The pooled mean of esophageal and gastric myotomy length, provided by 17 studies, was 7.11 cm (95% CI 6.51-7.71; I² 99.8%) and 2.81 cm (95% CI 2.41-3-22; I² 99.8%) respectively. At the subgroup analysis for achalasia subtypes, pooled mean length in non-spastic achalasia (type I and II) was 10.17 cm (95% CI 9.91-10.43; I² 94.2%), while in type III attested at 14.02 cm (95% CI 10.59-17.44; I² 98.9%). Pooled mean myotomy length for studies conducted between 2014-2018 was 10.56 cm (95% CI 9.51-11.61; I² 99.0%) while studies between 2019-2022 showed a mean length of 10.3 cm (95% CI 9.99-10.61; I² 99.6%). No geographical difference was observed: in eastern countries mean length was 10.2 cm (95% CI 9.12-10.92; I² 98.9%), while in western countries was 10.95 cm (95% CI 9.83-12.07; I² 99.5%). At a median follow-up of 29 months, the pooled clinical success rate was 91% (95% CI 88.9%-93.2%; I² 67.2%), while the pooled rate of post-POEM clinical reflux was 26% (95% CI 21.0%-31.3%; I² 89.5%).

Conclusion

Our meta-analysis found that the pooled mean myotomy length during a "standard” POEM is 10.4 cm, remaining over 10 cm in non-spastic (type I and II) achalasia. The high heterogeneity across studies confirms that POEM technique needs further standardization. We found no time trend towards adopting short POEM, despite recent evidence supporting efficacy and safety of this approach.

Introduction

Endoscopic submucosal dissection (ESD) and transanal minimally invasive surgery (TAMIS) are considered standard of care minimally invasive local en bloc resection techniques for larger benign rectal polyps and early-invasive rectal cancer. To optimize post-procedural care for patients, it is important to obtain more insight in the post-procedural physical recovery of both techniques.

Aims & Methods

This is an ancillary study of the multicenter non-inferiority randomized TRIASSIC-trial (Netherlands Trial Register: NL7083) that compares the outcomes of ESD and TAMIS for large (≥20mm) rectal polyps (1). Patients were 1:1 randomized between ESD or TAMIS and monitored with a smartwatch during a 14-day baseline period prior to resection and a 28-day post-procedural recovery period. A mixed-effects model was fitted for physical activity to describe the recovery period. Recovery was defined as reaching ≥90% of the baseline step-count for 2 consecutive days. If patients did not meet this pre-defined definition of recovery within 28 days post-treatment, a recovery time of 30 days was used in the analyses. This study analyzed subjective time to recovery through an end-of-study questionnaire and post-procedural pain through a self-reported pain diary.

Results

A total of 40 patients were included (20 ESD, 20 TAMIS). The mean age was 66.7 years (SD 7.4), 57.5% was male, and median polyp size was 42.5mm (IQR 25). Histological assessment showed a benign polyp in 82.5% and early-stage T1 rectal cancer in 17.5%. Seventeen patients (85%) in the ESD group and 15 patients (75%) in the TAMIS group were physically recovered within the 28-day post-procedural recovery period (p=0.43). The median time to physical recovery was 6.5 days (IQR 18) after ESD and 14.5 days (IQR 21.3) after TAMIS (p=0.022). Subjective time to recovery was 1-2 weeks in 47.5%, 3-4 weeks in 17.5%, and 32.5% did not feel completely recovered within 28 days. There was a significant correlation (Spearman’s rho = 0.66, p<0.001) between the physical (smartwatch) and subjective (end-of-study questionnaire) time to recovery. Post-procedural pain scores in the first week were similar between ESD and TAMIS (p=0.86) and were significantly associated with patients’ level of physical activity (p<0.01); for each point increase in the pain score total step count compared to baseline decreased by 14% after both ESD (95%CI 4-22%) and TAMIS (95%CI 5-22%). Additionally, higher post-procedural pain scores were significantly associated with a prolonged time to recovery (p=0.001). Other factors that were significantly associated with a prolonged time to physical recovery were polyp diameter ≥4cm (only in the ESD group; p=0.003), polyp located ≤1cm from the dentate line, and female sex (only in the TAMIS group, p=0.02 and p=0.03, respectively)

Conclusion

ESD-treated patients have a shorter physical recovery time of ~1 week as compared to ~2 weeks for TAMIS-treated patients. Post-procedural pain is a potentially modifiable factor that significantly influences physical activity and time to physical recovery after ESD and TAMIS.

References

1. Dekkers N, Boonstra JJ, Moons LMG, Hompes R, Bastiaansen BA, Tuynman JB, et al. Transanal minimally invasive surgery (TAMIS) versus endoscopic submucosal dissection (ESD) for resection of non-pedunculated rectal lesions (TRIASSIC study): study protocol of a European multicenter randomised controlled trial. BMC Gastroenterology. 2020;20(1):225.

Disclosure

The TRIASSIC trial is funded by ZonMW (Efficiency program: 852001926) and Applied Medical. Funding bodies had no role in the study design, data collection and analyses, decision to publish, or preparation of this abstract.

Introduction

Little is known on the outcomes of endoscopic submucosal dissection (ESD) in patients with recurrent lesions after surgical local excision (transanal endoscopic surgery TES, transanal endoscopic microsurgery TEM, transanal minimally invasive surgery TAMIS) of superficial rectal neoplasms (1). We aimed to evaluate the feasibility, safety and efficacy of ESD for incomplete or recurrent rectal neoplastic lesions after transanal surgery.

Aims & Methods

This multicenter retrospective study assessed 38 patients who underwent ESD between June 2016 and February 2022 for recurrent or incompletely resected after TES or TEM. Treatment outcomes were evaluated. Primary outcome was the non-recurrence tumoral lesion at first endoscopic follow-up control. Secondary outcome were En bloc resection, R0 resection, curative resection.

Results

Main results are given in Table 1. There were 16 male and 22 female patients. Median age (range) was 68.7 (44–88) years. Seventy-four percent of lesions were located in the lower rectum, and 55% reached the pectineal line. Sixty-one percent of lesions were laterally spreading tumor granular type (LST-G), and 34% were polyps. Forty-four percent of lesions were 0-IIa, and 23% were 0-Is according to the Paris classification. Seventy-one of lesions were Sano II, and 45% of lesions were Kudo IV. The median size of lesions (range) was 44 mm (10-100). Sixty-six percent of ESD were performed starting with full circumferential incision. Median operation time (range) was 79 (10–270) minutes. Thirty-nine percent of lesions has low vascular supply. Severe fibrosis was present in 78%of lesions. Ninety-two percent of lesions were successfully resected en bloc. R0 resection and curative resection rates were both 68%. Rectal fat is visualized in eleven patients, none of them requiring a surgery. Four post-operative bleeding and two stenosis occurred. Median (range) hospital length of stay after ESD was 1.8 days (0-4). Pathological examination revealed 32 adenomas (23 with low-grade dysplasia, 9 with high-grade dysplasia) and 3 adenocarcinomas (3 T2; there was no Tis or T1). All patients were followed up with endoscopic control after ESD, with biopsy samples if residual or recurrent tumor.Median (range) of follow-up period until first endoscopy control was 6.2 (1-13) months. « Only one residual lesion (one of three non-en bloc resections) actually showed low-grade dysplasia adenoma at follow-up.

Conclusion

ESD for incomplete or recurrent superficial rectal neoplastic lesions after transanal surgery (TEM,TES, TAMIS) is highly feasible and safe, and allows curative resection in a vast majority of cases.

References

1) Ikezawa N, et al. Digestion. 2021;102(3):446‑52.