Introduction

Accepted oncological principles advise enbloc, R0, excision of cancer to provide a cure. In Barrett’s neoplasia, this includes T1a and T1b disease, where histology is favorable. While treatment options include endoscopic mucosal resection (EMR) and submucosal endoscopic dissection (ESD), a mechanism for appropriate technique selection has not been described.

Aims & Methods

We conducted a prospective observational study to evaluate the performance of a selective resection algorithm for Barrett’s neoplasia (SRAB). To achieve an enbloc resection, ESD was selected if there was a suspicion for ≥T1a disease and the lesion was >15 mm (January 2017 to April 2023). This was compared with a conventional EMR predominant approach (CEA), where ESD was only performed in cases suspicious for deep submucosal invasion or T1b disease (February 2013 to December 2016). The primary outcome was curative oncologic resection (R0 resection with favorable histologic features).

Results

A total of 298 resections were performed in 298 patients (68 UEA, 230 SRAB). Median lesion size was 20 mm (IQR 15-30). T1a adenocarcinoma was identified in 83 (27.9%) and T1b in 58 (19.5%), of which 31 (10.4%) were SM1. Comparing T1a and T1b disease, the rate of enbloc resection (CEA 12 [46.2%] vs SRAB 103 [90.4%]; P<0.001), R0 excision (CEA 7 [26.9%] vs SRAB 86 [74.8%]; P<0.001) and curative resection (CEA 6 [23.1%] vs SRAB 58 [50.4%]; P=0.011) was higher in the SRAB group. Among all T1a and T1b-SM1 cases with favorable histology, which underwent ESD, 39/46 (84.8%) were R0 excisions and are likely cured. There were no significant differences in adverse events (P>0.788 for all).

Conclusion

A selective resection algorithm optimizes oncologic outcomes for Barrett’s adenocarcinoma and mitigates the risk of piecemeal resection of cancers.

Disclosure

Michael J. Bourke: Research Support: Olympus, Cook Medical, Boston Scientific.

Clinical Case Summary

Autoimmune gastritis (AIG) is an immune-mediated disease characterized by destruction of gastric parietal cells, which leads to the loss of internal factor Casl and decreased production of hydrochloric acid. When conducting endoscopic examination, it is possible to visualize a specific picture of the gastric body mucosa: diffuse atrophy, revealing changes occurring on the background of long-term hypergastrinemia.
Female patient, 45 years old, complaining of increased gas formation, burning sensation and heaviness in the epigastrium after eating, air burping. Chronic diseases: chronic iron deficiency anemia, B12 deficiency, autoimmune thyroiditis. Notes restriction of eating red meat, which causes heaviness in the abdomen. Heredity for cancer is not aggravated. Esophagogastroduodenoscopy revealed pallor of the mucous membrane of the stomach body, single islets of preserved mucous membrane of the stomach body, presence of multiple point whitish inclusions (WGA - white globe appearance) on all walls, forming the effect of “stardust”.
The diagnosis of autoimmune atrophic gastritis was confirmed by laboratory tests: Gastrin dated 01/20/2024 - 746 pg/mL, Chromogranin A CgA dated 01/2024 - 150.4 ng/mL, antibodies to gastric parietal cells -2560. Gastropanel from 20.01.2024 - gastrin-17 baseline > 30.6 pmol/l; pepsinogen I 21.89 µg/l; pepsinogen II 11.80 µg/l, pepsinogen I/II ratio - 1.9. 13C-urease breath test for HP dated 01.2024 - 1.3. Antibodies to Helicobacter, IgG < 13. Histologic conclusion: Moderate atrophy of the gastric body mucosa with the presence of cystic-expanded glands filled with opaque content.
The “stardust” phenomenon was first described in a case of long-term administration of potassium-competitive hydrochloric acid blockers. Given that elevated gastrin levels always accompany AIG, detection of this phenomenon is also possible in cases of AIG.The present case is the first description of the "stardust" phenomenon in a patient with autoimmune gastritis.

References

"Propensity score matching analysis: incidence and risk factors for "stardust" gastric mucosa, a novel gastric finding potentially induced by vonoprazan" Tetsuya Yoshizaki et al. DOI: 10.1111/apt.16151
https://pubmed.ncbi.nlm.nih.gov/33159407/

Disclosure

Yes

Introduction

Informed consent (IC) serves as the ethical foundation for all medical interventions, empowering patients to make informed, autonomous decisions while safeguarding clinicians. Barriers such as limited health literacy and document complexity may hinder comprehension^1,2. This study evaluated the comprehensibility, readability, and effectiveness of the documents provided for IC and instructions for endoscopic procedures.

Aims & Methods

Outpatients undergoing endoscopic procedures completed a questionnaire assessing their understanding of IC, preparation instructions, and adherence to guidelines. Patient confidence and document comprehensibility were assessed through self-reported scales. Readability was assessed using Flesch Reading Ease score adapted for portuguese (FRE-PT)³.

Results

Among 186 participants (mean age: 58.1 ± 16.1 years), 76.9% reported full-extent reading of the provided instructions and IC document. Patients with primary education (≤4th grade) were less likely to read the documents fully (59.2% vs. 83.2%, p < 0.001) and were independently associated with the need for additional assistance (OR 5.65, 95% CI: 1.92 - 16.68, p = 0.002). Full-extent reading was independently associated with greater risk awareness (OR 5.52, 95% CI: 2.37 - 11.55, p < 0.001), reduced need for additional assistance (OR 0.22, 95% CI: 0.09 - 0.51, p < 0.001), and higher compliance with medication guidelines (75.7% vs. 45.8%, OR 3.42, 95% CI: 1.28 - 9.20, p = 0.015). Patients with primary education rated document’s comprehensibility lower (median:8, IQR 7-10) compared to those with higher education (median: 10, IQR 8 - 10, p < 0.001) and reported lower levels of confidence and preparation for the procedure (median: 8, IQR 7 - 10 vs. median: 9, IQR 8 - 10; p = 0.018). Outcomes did not differ significantly between patients aged 65 years or older compared to younger patients. FRE-PT scores classified readability as ‘’very difficult’’ for both upper endoscopy (20.87) and colonoscopy (26.00).

Conclusion

Full-extent reading IC and instruction documents reduces the need for assistance, improves compliance with pre-procedural measures, risk awareness and patient confidence. However, the document’s complexity and difficult readability disproportionately challenge and discourage patients with limited education. Future research should explore strategies to foster more equitable informed decision-making.

References

1. Protheroe J, Rowlands G. Matching clinical information with levels of patient health literacy. Nurs Manag (Harrow). 2013;20(3):20-21. doi:10.7748/nm2013.06.20.3.20.e1095
2. Ley R, Forio T. The use of readability formulas in health care. Psychol Health Med. 1996;1(1):7-28.
3. Martins TBF, Ghiraldelo CM, Nunes MGV, Oliveira Junior ON. Readability formulas applied to textbooks in Brazilian Portuguese. 1996.

Clinical Case Summary

A 66-year-old female patient with a history of duodenal peptic ulcer disease was referred for evaluation of an 8 mm sessile polyp (Paris 0-ls) located in the terminal ileum. The polyp was excised during a colonoscopy with ileoscopy performed at a private facility in the context of colorectal cancer screening. Histological analysis revealed a well-differentiated NET (Grade 1) in the mucosal and submucosal layers of the terminal ileum, measuring 5.6 mm, with an endoscopic resection achieving R0 status (IVL0, 170 µm from the vertical margin). Following multidisciplinary discussion, staging was performed using CT of the abdomen and pelvis, enterography CT, and 68-Ga PET, which showed an ileocolic lymphadenopathy with high expression of somatostatin receptors and elevated serum Chromogranin A (238.7; N<85). A decision was made to reevaluate with 68-Ga PET in four months to determine the course of action regarding surgery versus chemotherapy. Due to the persistence of findings and after further multidisciplinary discussion, a right hemicolectomy with laparoscopic lymphadenectomy was performed. The procedure revealed no mural lesions; however, 5 out of 20 ileocolic lymph nodes were positive for TNE invasion (ypT1N1M0, Ki-67 <1%, mitotic index <1/10 HPF, stage III). The follow-up at five months showed no recurrence.
This case highlights the importance of ileoscopy during colonoscopy, even in the absence of symptoms, in order to exclude lesions of the small intestine. Given their aggressive nature, increasing incidence, and more frequent ileal location, the performance of ileoscopy during total colonoscopy offers significant clinical benefit without a substantial increase in procedure time, even in asymptomatic individuals.This case also highlights the challenge of histopathological criteria in defining curative disease after endoscopic resection and the discrepancy between pre- and post-operative imaging and functional staging, with prognostic and surveillance implications.

References

Joana Carvão, Mário Dinis-Ribeiro, Pedro Pimentel-Nunes, Diogo Libânio; Neuroendocrine Tumors of the Gastrointestinal Tract: A Focused Review and Practical Approach for Gastroenterologists. GE Port J Gastroenterol 1 September 2021; 28 (5): 336–348.

Introduction

Oesophageal food bolus impaction [OFBI] is a common presentation to emergency room [ER] and often requires endoscopic intervention. We aimed to describe the incidence of OFBI in Canterbury, New Zealand and examine factors predicting the need for endoscopic intervention and complications in the population-based cohort.

Aims & Methods

All ER presentations of OFBI in Canterbury between October 2018 and August 2023 were included. Population data for the Canterbury population was obtained from Statistics NZ. Ethnicity was defined according to hospital records based on patients’ self-identification. Endoscopic intervention was defined as the presence of bolus during the endoscopy requiring any endoscopic manoeuvre for clearance. Complications were defined as unsuccessful attempts requiring a repeat procedure or procedure-related injuries.

	Total (n = 187)
Age (years)	Mean 55 Median 54.9
Gender - Male (%) : Female (%)	113 (60.4) : 74 (39.6)
Ethnicity - European (%) : Non-European (%)	163 (87.2) : 24 (12.8)
Cause of oesophageal impaction (%)	EoE 42 (22.5) Stricture 43 (23)£ Other 15 (8)* Idiopathic/unknown 87 (46.5)¥
Food type (%)	Meat 141 (86.5) Non-meat 46 (24.5)
Spontaneous clearance of food bolus clinically, without endoscopy performed (inpatient or outpatient) (%)	42 (22.5)
Spontaneous clearance of food bolus diagnosed on endoscopy as an inpatient (%)	37 (19.8)
Inpatient endoscopic intervention required (%)	92 (49.2)
Total complications (%)	8 (4.3)

£ cause of impaction from Schatzi ring or benign esophageal stricture
* cause of impaction from severe reflux oesophagitis (Los Angeles Grade C or D), esophageal dysmotility, malignant stricture, or esophageal candidiasis
¥ no cause for impaction found; either no endoscopy performed as an inpatient or outpatient or no pathology found on endoscopy

Results

There were 187 ER presentations of OFBI between October 2018 and August 2023. Clinical characteristics of the population-based cohort are presented in Table 1.
The average annual incidence of ER presentations of OFBI in Canterbury region between 2019 – 2022 was 5.82 per 100,000 population (95% CI 3.96-7.68/100,000). The incidence of ER presentations of OFBI in Europeans and non-Europeans over the same period was 8 per 100,000 European population (95% CI 5.27-10.73/100,000) and 1.94 per 100,000 non-European population (95% CI 0.15-3.73/100,000).
A total of 92 cases (49%) required endoscopic intervention. Factors predicting the need for endoscopic intervention were meat bolus [p= 0.01], stricture [p<0.01], and early endoscopy performed <12hrs [p<0.01]. There were only 8 complications. Predictors with a trend associated with complications were after-hours presentation [p=0.06] and early endoscopy performed <6hrs [p=0.06].

Conclusion

Our population-based cohort showed a significantly higher incidence of ER presentations of OFBI in Europeans than in non-European ethnic groups. Factors predicting the need for endoscopic intervention were meat bolus, stricture and early endoscopy. After-hours presentation and early endoscopy <6hrs showed a trend towards a higher risk of complications. The results suggest that a delayed approach may be associated with a higher chance of spontaneous clearance and a lower risk of complications, although further study is needed.

Disclosure

Not applicable