Introduction

Rectal sensitivity is most frequently assessed by elastic balloon distension to a maximum tolerated volume, as determined by the patient. In clinical practice, some of the more commonly used systems to assess rectal sensitivity include the Laborie water-perfused manometry system (LWP, balloon volume 400mL) and the Medtronic solid-state 3D manometry system (MSS, balloon volume 400mL). There are no studies that compare diagnostic yield, as defined by the London Classification^[1], from these two independent systems.

Aims & Methods

This retrospective service evaluation investigates whether the proportion of diagnostic yield for disorders of rectal sensation differed between two commonly utilised rectal sensitivity measurement methods.
Rectal sensitivity data was collected from 200 patients at the same hospital site, with 100 consecutive patients undergoing rectal sensitivity testing with the LWP system and 100 consecutive patients assessed with the MSS system. Standard investigative protocols were followed, and balloon inflation rate was 2mL/s for both systems^[1]. Reference ranges for each system were based on published studies^[2-3]. The elastic balloon volume (mL) at each sensory threshold (first sensation volume, desire to defecate volume, and sustained urgency volume), diagnosis of disorders of rectal sensation according to the London Classification, and patient reported predominant symptom was assessed (urgency +/-incontinence, passive incontinence, obstructive defecation syndrome (ODS)/constipation, or anal pain).

Results

In total, rectal sensitivity data from 200 patients was collected (LWP: 100 patients 90F, MSS: 100 patients 91F), and there were no significant differences between sex per cohort (p=1.00). There were no significant differences in the proportions of patient reported predominant symptom per cohort: urgency +/-incontinence (41 LWP, 42 MSS), passive incontinence (23 LWP, 23 MSS), ODS/constipation (33 LWP, 31 MSS), and anal pain (3 LWP, 4 MSS), (p=0.99).
There were significant differences in the proportions of London Classification diagnoses obtained between the two systems: rectal hypersensitivity (9 LWP, 64 MSS), rectal hyposensitivity (3 LWP, 26 MSS), borderline rectal hyposensitivity (5 LWP, 4 MSS), rectal hypersensitivity and rectal hyposensitivity (0 LWP, 4MSS), no disorder of rectal sensation (83 LWP, 2 MSS) (p<0.001).

Conclusion

Despite there being similar patient cohorts in relation to proportions of sex and predominant bowel symptom, there was a significant difference in diagnoses based on London Classifications obtained by the LWP and MSS systems. A large proportion of patients tested using the LWP system had no disorder of rectal sensation, conversely the MSS system reported a much larger proportion of patients with rectal hypersensitivity. As most patients reported urgency +/- incontinence as their predominant symptom, it is plausible that rectal hypersensitivity is a common finding in this patient cohort.
The diagnostic accuracy of the London Classification is likely dependant on the system used and the available published reference values. Accurate assessment of rectal sensitivity can be valuable in guiding effective management of patients with rectal sensitivity disorder. Thus, this data indicates comparative studies using different systems to reduce discrepancies of diagnoses are required to improve clinical management^[4].

References

[1] Carrington, E.V. et al. Expert consensus document: Advances in the evaluation of anorectal function. Nature Reviews Gastroenterology and Hepatology. 2018. 15(5): p309-323.
[2] Mion, F. et al. 3D High-definition anorectal manometry: Values obtained in asymptomatic volunteers, fecal incontinence and chronic constipation. Results of a prospective multicenter study (NOMAD). Neurogastroenterol Motil. 2017 Aug;29(8).
[3] Townsend, D.C. et al. Pathophysiology of fecal incontinence differs between men and women: a case-matched study in 200 patients. Neurogastroenterol Motil. 2016 Oct;28(10):1580-8.
[4] Chiarioni, G. et al. Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence. American Journal of Gastroenterology. 2002. 97(1): p109-117.

Introduction

Aging is associated with physiological changes in esophageal function, influencing motility and increasing susceptibility to dysphagia.

Aims & Methods

This study investigates esophageal peristaltic reserve across different age groups by employing multiple rapid swallow (MRS) during high-resolution manometry (HRM). A retrospective analysis was conducted on 331 patients presenting with dysphagia who underwent HRM between 2021 and 2023. Participants were stratified into four age groups: early adulthood (≤34 years, 12.1%), early middle-age (35–49 years, 12.7%), late middle-age (50–64 years, 45.3%), and late adulthood (≥65 years, 29.9%). Peristaltic reserve was assessed using MRS to evaluate esophageal contractile function.

Results

Among the 311 patients included, 195 (58.9%) were male, with a median age of 57 years (IQR 45–66). The prevalence of normal esophageal motility was highest in early adulthood (67.5%) and early middle-age (78.6%) but declined significantly in late middle-age (48.7%; p=0.014) and late adulthood (44.4%; p<0.001). Late adulthood was also characterized by lower median upper esophageal sphincter (UES) pressure (101 mmHg) and reduced UES length (3 cm; p<0.05). Additionally, esophagogastric junction (EGJ) type II and III morphology was more frequently observed in late adulthood (52.5%; p<0.05). In patients with normal motility (n=177), MRS motor wave transmission was lower in late adulthood (75%, p<0.05) compared to early adulthood (96.3%), early middle age (88.1%) and late middle age (93.2%), and the prevalence of incomplete MRS inhibition was higher in late adulthood (79.5%, p<0.05) compared to early adulthood (11.1%), early middle age (21.2%) and late middle age (46.6%). The DCI-MRS and DCI wet ratio were significantly lower in late adulthood (0.51, IQR 0.13 – 0.88; p<0.01).

Conclusion

Peristaltic reserve declines with advancing age, which may contribute to dysphagia. MRS proves to be a useful diagnostic tool for detecting subtle motility impairments related to aging.

Introduction

Guidelines recommend independent auditing of diagnostic performance for clinical implementation of computer-aided optical polyp diagnosis (CADx).

Aims & Methods

This study aimed to evaluate diagnostic performance and interobserver agreement of auditors, and to offer guidance on conducting CADx audits. Images and videos of all ≤5-mm polyps from a large prospective study with systematic activation of CADx were audited by three expert endoscopists. Experts performed independent, blinded diagnostic review including documentation of confidence level. The primary outcome was sensitivity of audit by three experts for high-confidence adenomas compared with pathology. Secondary outcomes included the number of reviewers for optimal CADx auditing and interobserver agreement.

Results

487 diminutive polyps were audited (510 patients). Sensitivity was 99.4% (95%CI 96.0–100) using three experts (Strategy A); 88.7% (95%CI 84.1–92.1) using two experts and one referee (Strategy B); 99% (95%CI 96–99.8), 98.8% (95%CI 95.4–99.8), and 99.4% (95%CI 96.3–100) using two-expert combinations (Strategy C); and 98.2% (95% CI 95.1-99.4), 97.3% (95% CI 94.0-98.9), and 88.9% (95% CI 83.6-92.7) for each expert individually (Strategy D). Among 266 pathology-based adenomas, Strategy A evaluated 160 polyps versus 196, 172, and 170 in Strategy C; and 220, 223, and 207 in Strategy D. Strategy B evaluated all 266 adenomas. Overall interobserver agreement was moderate (kappa 0.52), but very high for high-confidence adenomas (kappa 0.89).

Conclusion

Expert audit for evaluating CADx resulted in high sensitivity and interobserver agreement for high-confidence adenomas. Audit by two experts, with a third expert for arbitration, permitted audit of all polyps and could effectively assess CADx within clinical studies.

Disclosure

Daniel von Renteln has received research funding from ERBE Elektromedizin GmbH, Ventage, Pendopharm, Satisfai, Fujifilm, and Pentax, and has received consultant or speaker fees from Boston Scientific Inc., ERBE Elektromedizin GmbH, Medtronic, and Pendopharm. Roupen Djinbachian has received speaker fees from Fujifilm. The remaining authors declare that they have no conflict of interest.

Introduction

The diagnosis of small bowel motility disorders currently relies on identifying abnormal contractile patterns through intestinal manometry, but the technique is restricted to referral centers. Conventional CT scanning, frequently performed in the routine evaluation of these patients, provides images of intestinal content, which might serve as a marker of intestinal dysfunction. We hypothesized that pooling of intestinal content, quantified through computerized analysis of abdominal CT images, could serve as an indirect marker of small intestinal motor dysfunction.

Aims & Methods

Consecutive patients with either a) chronic intestinal pseudo-obstruction (CIPO) or b) suspected small intestinal motor dysfunction, evaluated at our Motility Unit using high-resolution jejunal manometry, were prospectively included. Manometric tracings were categorized as
a) normal,
b) uncoordinated contractile activity with preserved amplitude, or
c) hypomotility (markedly diminished amplitude of contractile activity).
All patients also underwent an abdominal CT scan within three months of the manometric study, as part of the clinical evaluation of the motility disorder. CT images were analyzed using a validated software developed in our laboratory, which applies image processing techniques and deep-learning tools to identify and quantify intestinal content volumes in the small bowel and colon of:
a) gas,
b) chyme-type content (non-gaseous, homogeneous texture), and
c) fecal-type content (non-gaseous, heterogeneous texture).

Results

Of the 66 patients included, 9 had CIPO and 57 suspected dysmotility. Manometry was abnormal in all patients with CIPO and in 22 patients (39%) without CIPO. Total intestinal content was markedly increased in patients with CIPO as compared with patients with normal motility (3034±826 mL vs 398±43 mL, respectively; p<0.001), primarily due to an increase in gas (1086±325 mL vs 22±4; p<0.001) and chyme-type content in the small bowel (1282±544 mL vs 81±11; p<0.001).
Among patients without CIPO, the volume of small bowel content was increased in patients with dysmotility compared to those with normal motility, mainly of chyme-type content (191±39 vs 81±11 mL in normal motility; p=0.006). Colonic volumes of gas and fecal-type content were also higher in patients with dysmotility than in those with normal motility (gas 224±40 vs 115±18 mL, p=0.027; fecal-type 244±59 vs 115±19 mL, p=0.036). Dysmotility patients with hypomotility patterns had overall higher intestinal content volumes than patients with uncoordinated contractile patterns (Table 1).

Table 1. Intestinal content volumes in non-CIPO patients, classified by manometric patterns

Conclusion

Intestinal content, measured on conventional CT scans by a specific analysis program, provides a useful indication of intestinal dysmotility.

Introduction

While anatomical landmark identification and adequate inspection time are recognized as crucial quality indicators in upper endoscopy, they are difficult to document consistently and accurately based solely on endoscopist reports.

Aims & Methods

To address this issue at Assuta Healthcare, a multicenter organization with 20 endoscopy units and over 200 endoscopists, we implemented a video-based AI platform designed to measure total upper endoscopy time (EGD-T), assess photo documentation of landmarks, and streamline the photo labeling process. In the current study, we evaluated the platform and employed it to examine endoscopist-reported quality measures.
For all upper endoscopies performed at Assuta Healthcare in 2024 on patients 45 years and older, the Theator AI-based Surgical Intelligence platform automatically documented total procedure time as well as photo snapshots captured and labeled by endoscopists for seven landmarks: 1. esophagus, 2. gastroesophageal junction, 3. cardia or fundus, 4. body, 5. angulus, 6. antrum or pylorus, and 7. duodenum (second part). In a subset of procedures, the platform facilitated documentation by suggesting labels for captured snapshots. After validating platform accuracy, we examined platform-reported procedure times. We then assessed landmark photo documentation rates in procedures with and without platform labeling suggestions.

Results

The study included 21,989 upper endoscopies (60.7% female, median age of 62.2 years), of which 51.7% were conducted with platform labeling suggestions and the remaining 48.3% were conducted without. Validated platform accuracy was 98%. Median total procedure time measured by the platform was 3.18 minutes (IQR 2.18-4.25). When they did not receive suggestions, endoscopists did not label any landmarks in 25% of procedures. At 12%, this percentage was significantly lower (p < .001) when the platform did provided suggestions. This difference was also reflected in the median number of landmarks labeled, which was 2 (IQR 0-3) in procedures without labeling suggestions and 3 (IQR 1-4) in procedures with labeling suggestions (p < .001).

Conclusion

Implementing an AI tool to automatically assess procedure time in upper endoscopy provided accurate measurements, revealing durations considerably lower than recommended. It further revealed extremely low labeling rates, which increased when automated suggestions were provided. The results highlight critical gaps in the reporting of quality measures for upper endoscopy and indicate that AI-based documentation can be instrumental to quality assurance by identifying and addressing such gaps.

Disclosure

None

Introduction

Intraoperative hypotension (IOH) during endoscopic procedures under general anesthesia is associated with adverse outcomes, including prolonged recovery and increased postoperative complications. However, its clinical impact remains underexplored (Sessler & Saugel, 2019). This study assesses the incidence, risk factors, and consequences of IOH in patients undergoing endoscopic procedures.

Aims & Methods

A prospective observational study was conducted on 1,100 patients undergoing various endoscopic procedures under general anesthesia over 12 months. Continuous hemodynamic monitoring was performed, and IOH was defined as a systolic blood pressure <90 mmHg or a ≥20% reduction from baseline (Bijker et al., 2009). Patient demographics, comorbidities, procedure duration, and clinical outcomes were analyzed. Multivariate regression identified independent risk factors and their association with postoperative complications, unplanned admissions, and recovery time.

Results

IOH occurred in 9.5% of patients and was significantly associated with age ≥40 years (p < 0.05), pre-existing hypertension (p < 0.01), and procedure duration >60 minutes (p < 0.05). Patients with IOH had prolonged recovery times (+45 minutes, p < 0.05), higher postoperative complications (21% vs. 9%, p < 0.01), and increased unplanned hospital admissions (15% vs. 5%, p < 0.01) (Smischney et al., 2015).

Conclusion

Intraoperative hypotension significantly affects patient outcomes, leading to prolonged recovery and increased postoperative morbidity. Early identification and hemodynamic optimization may reduce these risks, improving procedural safety and patient recovery (Brady et al., 2014).

References

1. Sessler DI, Saugel B. Beyond ‘systolic blood pressure’. Anesthesiology. 2019; 131(3):738-740.
2. Bijker JB, Persoon S, Peelen LM, et al. Intraoperative hypotension and 1-year mortality after noncardiac surgery. Anesthesiology. 2009; 111(6):1217-1226.
3. Smischney NJ, Pour-Ghaz I, Kaczmarek HE, et al. Intraoperative hypotension and risk of critical care admission after noncardiac surgery. Anesthesiology. 2015; 123(1):85-95.
4. Brady KM, Rhee CJ, Smielewski P, et al. Poor autoregulation and morbidity in pediatric traumatic brain injury. Pediatr Crit Care Med. 2014; 15(7):636-645.

Introduction

Endoscopic submucosal dissection (ESD) represents a complex endoscopic procedure requiring significant technical expertise. Objective assessment methods for analyzing procedural workflows remain limited despite their potential value for quality assurance and training. This study aimed to develop and validate a novel artificial intelligence (AI) algorithm capable of automated frame-by-frame recognition of procedural phases during ESD procedures, potentially enabling standardized performance evaluation and targeted educational interventions.

Aims & Methods

In this retrospective analysis, complete ESD video recordings from 49 patients were systematically collected from our institutional database. The dataset comprised 6.390.151 individual frames that were annotated. Procedural phases included diagnostics, lesion marking, submucosal injection, dissection, and hemostasis. The dataset was divided into two cohorts: 3.973.712 frames (28 patients) for the training phase, 2.416.439 frames (21 patients) for internal validation. A specialized video swin transformer architecture incorporating temporal sequence analysis through uniform frame sampling was implemented.

Results

When evaluated on the test dataset, the system achieved an F1 score of 0.88 for overall phase identification. It showed F1 scores of 0.99, 0.89, 0.89, 0.91 and 0.52 for diagnostics, marking, injection, dissection and bleeding management, respectively. Sensitivities for the same parameters were 1.00, 0.80, 0.94, 0.89 and 0.67, specificities were 1.00, 1.00, 0.98, 0.88 and 0.93. Positive predictive values were measured at 0.98, 1.00, 0.85, 0.94 and 0.43.

Conclusion

In this preliminary study, an AI algorithm showed high performance for frame-by-frame procedural phase recognition during ESD. The comparatively low performance for the bleeding phase was attributed to bleeding episodes occuring seldom in the training dataset, which at this time comprised only full length videos. Future development of the algorithm will focus on reducing class imbalances by selective annotation protocols.