Introduction

Endoscopic resection of colonic tumors by endoscopic submucosal dissection (ESD) is now gaining worldwide acceptance. However, it is a technically challenging procedure with a delayed bleeding and perforation rate of 0.1-3.1% and 0.3-0.7% respectively.^{1, 2} Prophylactic closure of post endoscopic mucosal resection (EMR) defects in the right colon has been recommended to reduce adverse events.³But there is no consensus on post ESD closure. There have been many reports regarding prophylactic clip closure being beneficial to prevent delayed adverse events post colorectal ESD.^{4, 5} Though there is no data that exclusively evaluates colonic defects which may be more high risk than rectal defects due to thinner wall and intra- peritoneal location. Several endoscopic techniques are now available for closure of large mucosal defects.

Aims & Methods

This study aims to determine the impact of prophylactic closure on outcomes of colonic ESD and evaluate various closure methods. This is a retrospective, multicenter study which included consecutive patients undergoing ESD for resection of superficial colonic neoplasm from April-October, 2024. Rectal, ileo cecal valve, and appendiceal orifice lesions were excluded. Recurrent lesions, multiple lesions simultaneously treated, and lesions associated with inflammatory bowel disease were also excluded. Patients were allocated to closure and non closure groups which were compared using univariate analysis. Primary outcomes were delayed adverse events (bleeding and perforation), and duration of hospitalization. Sub group analysis was done to compare the closure methods used in this study.

Results

Total 271 patients were involved in this study where 190 patients (mean + SD age 63.5 ± 10.36 years, 92(48.4%) men) underwent post ESD closure and 81 patients (mean + SD age 65.4 ± 11.92 years, 32(40%) men) were in the non closure group. There were no significant differences in age, sex, location (Table), patients using anticoagulants (32(16.8%) vs 11(13.6%), P= 0.501), and patients having intraprocedural perforation/deep muscle injury in both groups (Table). The en bloc resection rate was 263/271 (97%) and R0 resection rate was 204/271 (75.3%). The mean specimen size of the closure group was significantly higher (Table). There was no significant difference in delayed adverse events (Table). The procedure time was higher in the closure group (median(IQR) 62(31.5-106.5) vs 37(25-57.75) minutes, P<0.001), but the duration of hospitalization was lesser (median(IQR) 1(0-5) vs 4(1-6) minutes, P<0.001). The closure methods used were endoclips only (n=125), clip with line pulley securing (CLiPS) technique ⁶ (n=54), X-tack (n=10), and overstitch (n=1). CLiPS technique was associated with shortest procedure time (median(IQR) 72(39.5-109) vs 38(24-57) vs 124.5(110.5-164.5) minutes, P<0.001). X-tack could close significantly larger defects (mean + SD 34.24 + 12.89 vs 40.47 + 14.78 vs 59.6 + 25.61 mm, P<0.001).

Conclusion

Prophylactic closure of post colonic ESD defects has no significant impact on delayed adverse events, but it reduces hospitalization time.

References

1. Fujishiro M, Yahagi N, Kakushima N, et al. Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol. 2007;5(6):678 83.
2. Isomoto H, Nishiyama H, Yamaguchi N, et al. Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy. 2009;41(8):679–83.
3. Ferlitsch M, Hassan C, Bisschops R, et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline–Update 2024. Endoscopy. 2024 Apr 26.
4. Omori J, Goto O, Habu T, et al. Prophylactic clip closure for mucosal defects is associated with reduced adverse events after colorectal endoscopic submucosal dissection: a propensity-score matching analysis. BMC gastroenterology. 2022 Mar 26;22(1):139.
5. Liu M, Zhang Y, Wang Y, et al. Effect of prophylactic closure on adverse events after colorectal endoscopic submucosal dissection: A meta‐analysis. Journal of Gastroenterology and Hepatology. 2020 Nov;35(11):1869-77.
6. Minato Y, Ohata K, Kimoto Y, et al. A modified approach for closing endoscopic submucosal dissection defects using clip with line pulley securing technique and endoloop. VideoGIE. 2024 Jul 1;9(7):320-3.
   

Introduction

Red blood cell distribution width (RDW), is a routinely available parameter from complete blood counts, reflecting variability in erythrocyte size. Beyond its traditional hematological use, RDW has emerged as a potential prognostic marker in various systemic diseases, including chronic liver disease.

Aims & Methods

In this cross-sectional study, 200 cirrhotic patients with varying degrees of severity and etiologies were enrolled from a tertiary care hepatogastroenterology department. RDW was assessed in all patients, with a normal range set between 11% and 15%. Our aim is to assess the relationship between RDW values and cirrhosis severity, as evaluated by Child-Pugh scores and the Model for End-Stage Liver Disease (MELD). Statistical analyses included ANOVA, post-hoc Tukey tests, and Spearman correlation to determine the association between RDW and cirrhosis severity.

Results

Our study comprised 200 cirrhotic patients, 111 females and 89 males, with an average age of 58,06 ± 15.21 years (range: 19–95).The patients were distributed across different disease stages: 99 had Child-Pugh score A, 80 had Child-Pugh score B, and 21 had Child-Pugh score C.
ANOVA test was conducted to compare the mean RDW across the different Child-Pugh stages (A, B, and C). The analysis revealed a statistically significant difference between the 3 groups: A (15,83), B (17,02), C (18,04)(p < 0.001). Tukey's post-hoc test showed that: Stage C had a significantly higher RDW compared to stages A (p = 0.020) and B (p = 0.020). These results suggest a progressive increase in RDW with worsening severity of liver disease.
Among patients classified as Child A, only 36.4% exhibited a high RDW, while in groups Child B and Child C, higher rates of RDW were observed, reaching 68.7% and 87.5% respectively. A significant positive correlation was found between the Child-Pugh stage and the RDW (p < 0.001), as assessed by Spearman’s correlation test. Similarly, a significant positive correlation was found between the MELD score and the RDW (p < 0.001). This finding suggests that patients with more advanced liver disease, tend to exhibit greater anisocytosis, possibly reflecting underlying inflammation, nutritional deficiencies, or bone marrow stress.

Conclusion

In conclusion, our findings suggest that RDW tends to rise with the progression of hepatic dysfunction, underscoring its potential as a simple and accessible biomarker for assessing disease severity in patients with cirrhosis. Nonetheless, further studies are needed to comprehensively evaluate the utility of RDW as a reliable predictor of cirrhosis severity.

Introduction

Physical activity (PA) is associated with improved quality of life in patients with Crohn’s disease (CD). However, there is limited evidence of its impact on the clinical course of the disease and the separate effects of aerobic and anaerobic-resistance PA.

Aims & Methods

We aimed to evaluate the association between PA and the incidence of relapse in patients with CD in clinical remission and to assess the role of PA in patients with CD using patient-reported outcome measures (PROMs), with separate analyses for PA type. A prospective cohort study of adult patients with CD in clinical remission followed for one year or until relapse according to the Harvey Bradshaw Index. At baseline, participants completed a detailed PA questionnaire, nutritional questionnaires, and a patient-reported outcomes measurement information system (PROMIS). Multivariable Cox proportional hazards models were used to assess the association between PA and relapse risk, adjusted for confounders, including dietary factors and fecal calprotectin levels.

Results

A total of 106 patients (mean age 37.9 ± 13.9 years) were included and followed for 9.9±3.2 months, during which 23 (21.7%) experienced clinical relapse. PA at least twice a week was associated with a reduced risk of relapse (HR = 0.26, 95% CI 0.09–0.79). Specifically, only aerobic activity was significantly associated with a reduced risk of relapse (HR = 0.31, 95% CI 0.10-0.95). High-resistance PA was significantly associated with better quality of life parameters, including pain interference (P=0.013), sleep disturbance (P=0.040), better physical function (P=0.029), and enhanced social roles (P=0.020). While aerobic PA showed benefit in physical function (P=0.016).

Conclusion

PA in general and specifically aerobic PA, is associated with a reduced risk of relapse in patients with CD in remission. Additionally, resistance PA is associated with a better quality of life. These findings highlight the importance of incorporating PA into the management of CD in remission state.

Disclosure

None

Introduction

Hepatocellular Carcinoma is One of the highest incidence among all hepatic malignancies. Most HCC cases occur in patients with underlying liver disease. HCC is the second most frequent cancer in men and the sixth most frequent cancer in women in Egypt where post HCV-related cirrhosis is the most common cause.

Aims & Methods

This is a retrospective record-based analysis of prospectively collected data done in the Tropical Medicine Department, Mansoura University Hospital, Egypt covering the 10 years period. It included all HCC patients who received treatment during the period from 2011 to2020. Patients with hepatic tumor other than HCC , or missed follow up were excluded. A total of 202 out of 715 HCC patients (28.3%) were included in the studywas elgible for Loco regional treatment according to Barcelona clinic of liver cancer in the form of Radiofrequency (RF),tranansarterialchemoembolization(TACE)and Microwaveablation (MWA). Modified Response Evaluation Criteria In Solid Tumors(mRIST) and Hepatoma Arterial-embolisation Prognostic (HAP) Score were applied in this study

Results

This study included 202 patients with age ranging from 42 to 81 years with a mean of 58.8 ± 7.1 years. The duration of follow-up ranged from 11 to 132 months with a mean 37.9 ± 15.6 months and a median of 36 months. All cases was post HCV related cirrhosis. At the start of the study 33.7% received no locoregional treatment, while 41.5%, 41.6%, 0.03,%, 0.05% and 15.34% undergo TACE,MWA,RF,and multiple interventions respectively while at the end of the study 70.3%,19.3% and 10.4% undergo TACE, MWA and RF respectively
According to mRIST the complete response, partial response, stationary and progressive course accounted for 48.5%, 46.0%, 0.99% and 4.45%; respectively.
The overall complete response was 48.5%. The complete response is significantly higher in females (CRR=2.0), CHILD A5 (CRR=2.4), BCBC (CRR=4.2), single nodule (CRR=5.1), nodule size of <2 and 2 to <3 (CRR=6.1 and 8.1; respectively), AFP <400 (CRR=6.3), HAP score 1and treated HCV (CRR=3.2 and 4.4; respectively)and treatment with MWA and RF (CRR=6.1 and 11.0; respectively).
The independent predictors of complete response are BCLC of 0 & A (ARR=2.6), Single nodule (ARR=3.8), nodule size of <2 and 2-<3 (ARR=4.7 and 8.0; respectively), AFP<400 (ARR=7.7) and cured past hepatitis (ARR=4.4).( NB:CRR= crude relative risk ,ARR= adjusted relative risk)
the overall mean survival is 49.9 months. The mean overall survival is significantly longer in age ≤60 years, males, BCLC of 0 & A, single node affection, AFP <400, Previous treatment with MWA and HAPscore (0 & 1) P< 0.001).
The overall mean progression free survival (PFS) is 19.4 months. The mean PFS is significantly longer in BCLC of B & C ,HAP (0&1) and single node affection P<0.005).
The cox regression analysis revealed that the independent predictors of overall survival are age >60 years (HR=0.6), BCLC B&C (HR=2.3) and multiple nodes affection (HR=0.1) while the independent predictor of PFS is multiple nodes affection (HR=0.4).

Conclusion

The complete response and the over all survival (mean49.4 months) were significantly higher in younger age .early child score, early staging, HAP score (0&1) AFP<400 and treatment with MWA. The overall mean progression free survival (PFS) is 19.4 months. The mean PFS is significantly longer in BCLC of B & C, HAP (0&1) and single node affection.

Disclosure

No conflict of interest to be diclosed

Clinical Case Summary

A 58-year-old male attended with epigastric pain, acid reflux and dyspepsia. An upper endoscopy was performed showing a longitudinal ulcer in gastric incisura of which biopsies were taken (Figure 1). Histopathology revealed lymphoid proliferation of large cells with discrete cytoplasm and irregular, vesicular nuclei, with nucleoli and frequent mitotic figures. Helicobacter pylori (HP) was positive in the samples and immunohistochemistry analysis revealed positive CD20 and CD79a and negative CD3 and CD5. CD10 was also negative and Ki67 proliferation index was of 80-90%. Immunofluorescence analysis with FISH technique revealed EBER, c-MYC, BCL2 and BCL6 all negative (Figure 2). A diagnosis of diffuse large B-cell lymphoma (DLBCL) was made, and the patient was referred to hematology department. Positron emission tomography and Computed tomography (PET-CT) showed gastric involvement (SUVmax 10,35) and hilar, paratracheal, interlobar, subcarinal and mediastinal areas of increased metabolism demonstrating active lymphoproliferative supra and infra-diaphragmatic disease (Figure 3). He started treatment with R-CHOP according to guidelines. After 3 months a reduction in size and hypermetabolism was observed in control PET-CT revealing adequate response to treatment.
Lymphoproliferative diseases can present with gastrointestinal involvement and first symptoms in a low percentage of cases, being gastric location the most prevalent. Symptoms are most times nonspecific as reflux and dyspepsia so endoscopic studies are crucial to establish a differential diagnosis with other entities, with a remarkable importance of adequate biopsy samples in order to stablish a correct diagnosis. HP infection has a role in pathogenesis of gastric lymphomas, and it must be eradicated. Molecular and extension studies nowadays guide best treatment and prognosis in DLBCL.

References

1. Fox CP, Chaganti S, McIlroy G, Barrington SF, Burton C, Cwynarski K, Eyre TA, Illidge T, Kalakonda N, Kuhnl A, McKay P, Davies AJ. The management of newly diagnosed large B-cell lymphoma: A British Society for Haematology Guideline. Br J Haematol. 2024 Apr;204(4):1178-1192.
2. Graham DY. History of Helicobacter pylori, duodenal ulcer, gastric ulcer and gastric cancer. World J Gastroenterol. 2014 May 14;20(18):5191-204.
3. Doglioni C, Ponzoni M, Ferreri AJ, Savio A; Gruppo Italiano Patologi Apparato Digerente (GIPAD); Società Italiana di Anatomia Patologica e Citopatologia Diagnostica/International Academy of Pathology, Italian division (SIAPEC/IAP). Gastric lymphoma: the histology report. Dig Liver Dis. 2011 Mar;43 Suppl 4:S310-8.

Introduction

Adherence to colorectal cancer (CRC) screening is crucial for the effectiveness of any screening program.

Aims & Methods

Our goal is to identify individuals who are likely to show low adherence over the next two years, defined as having less than 50% proportional time coverage (PTC) during that period.
We included individuals aged 50 to 74 from Clalit Health between January 2008 and January 2020. Participants with less than four years of follow-up, a history of CRC, a family history of CRC, or a positive fecal occult blood test were excluded. We used individual-level data to calculate the PTC up to December 2017 and developed an XGBoost model to predict low adherence to screening over the next two years. According to Clalit Health policy, a colonoscopy is valid for ten years, while a fecal occult blood test is valid for one year.

Results

The final cohort included 553,180 individuals, with 53.9% female. The screening rate at the end of follow-up was 55%. The model had an AUC of 0.917 (95% CI: 0.909-0.913) and an accuracy of 83.58% (95% CI: 83.47%-83.68%). Key factors influencing the model were low prior PTC, no prior colonoscopy, and older age at the first test.

Conclusion

We developed a machine-learning model using individual-level data to predict low adherence to CRC screening within two years. This tool can help organizations identify individuals at high risk of low adherence.

Introduction

Duodenal covered self-expandable metal stent (SEMS) placement is used to treat gastric and duodenal stenosis. The main adverse event after duodenal SEMS placement is stent migration. We evaluated the stent fixation with a novel over-the-scope clip device (stentfix OTSC^® System; Ovesco Endoscopy AG, Tübingen, Germany) to prevent migration.

Aims & Methods

This is a single-center retrospective observational cohort study performed to analyze stent migration rates before and after availability of the stentfix OTSC^® System. A cohort of patients who underwent SEMS fixation with the stentfix OTSC^® system (SC cohort) was compared with an historical cohort of patients (NC) who did not receive any other stent fixation method before the stentfix OTSC system became available. Outcome variables including technical success, adverse events and clinical success were analyzed.

Results

45 patients (SC cohort, 15; NC cohort, 30) underwent covered duodenal SEMS implantation for benign conditions. The technical success rate of stent fixation was 100%. No procedure-related adverse events occured. The stent migration rate was significantly lower in the SC cohort compared with the NC cohort (6.66% vs 36.66%). 20% of adverse events were observed during the withdrawal of the OTSC (3 AGREE grade IIIa :one delayed bleeding, one buried-in stentfix treated with APC and one mucosal tear fixed with classic clips).

Conclusion

In patients with benign pyloro-duodenal stenosis, there was a significantly lower stent migration rate with the stentfix OTSC system compared with those without stent fixation. The application was technically successful in all cases, no adverse events related to OTSC fixation and 20% moderate adverse events following the removal were observed.

References

Duodenal stent migration. Tringali A, Mutignani M, Spera G, Costamagna G.Gastrointest Endosc. 2003 Nov;58(5):759. doi: 10.1016/s0016-5107(03)01878-9.
Patient-related adverse events and device failures associated with commercially available enteral or duodenal self-expanding metal stents: an analysis of the MAUDE database.Kennington D, Ramai D, Adler DG.Gastrointest Endosc. 2023 Feb;97(2):309-313. doi: 10.1016/j.gie.2022.10.008. Epub 2022 Oct 8.PMID: 36220381