Introduction

Endoscopic Sleeve Gastroplasty (ESG) is a safe and effective endoscopic weight-loss procedure. Its outpatient application can reduce hospital stays, improve patient flow, and facilitate faster recovery [1,2]

Aims & Methods

This study aimed to evaluate the feasibility of ESG in an ambulatory setting and to identify factors associated with inpatient management. From November 2016 to March 2025, a total of 430 ESG procedures were performed at our center. Of these, 228 (53%) were completed in an ambulatory setting, while 202 (47%) were performed with in-patient monitoring and hospitalization (HO). Demographic and procedural data were retrospectively analyzed. Statistical analyses included Kruskal-Wallis and chi-squared tests, with logistic regression used to identify predictors associated with inpatient care.

Results

The cohort included 97 males (22.7%) and 333 females (77.4%), with a mean age of 43 years [IQR 33–52], mean weight of 108 kg [IQR 95–123], and a mean BMI of 38.67 [IQR 35.57–42.99].
The mean operative time was 29 minutes [IQR 24–37]. Comparative data between ambulatory and hospitalized patients are summarized in Table 1. Age, BMI, general anaesthesia[sp1] and ASA score were predictors of HO. Of the 228 ambulatory patients, 9 (4%) required unplanned hospitalization post-ESG primarily due to lower post-procedural Chung scores related to nausea and pain. No differences in preoperative characteristics were observed in this subgroup.

Conclusion

Ambulatory ESG is a safe, effective, and efficient option for selected patients, with a low rate of unplanned post-procedural hospitalization. These findings support the growing role of ESG as a valuable ambulatory approach in bariatric endoscopy.

References

1 Reitano E, Riva P, Keller D, Vannucci M, Zappaterra M, Vix M, Mutter D, Marescaux J, Perretta S. Deep sedation versus orotracheal intubation for endoscopic sleeve gastroplasty (ESG): preliminary experience. Surg Endosc. 2023 Aug;37(8):6513-6518. doi: 10.1007/s00464-023-10159-x. Epub 2023 Jun 5. PMID: 37277517.
2 Pizzicannella M, Lapergola A, Fiorillo C, Spota A, Mascagni P, Vix M, Mutter D, Costamagna G, Marescaux J, Swanström L, Perretta S. Does endoscopic sleeve gastroplasty stand the test of time? Objective assessment of endoscopic ESG appearance and its relation to weight loss in a large group of consecutive patients. Surg Endosc. 2020 Aug;34(8):3696-3705. doi: 10.1007/s00464-019-07329-1. Epub 2020 Jan 13. PMID: 31932925.

Disclosure

All the authors declare no conflict of interest

Introduction

Diagnosing the extent of early gastric cancer (EGC) using narrow-band imaging with magnification (NBI-M) can be challenging in cases with large lesions or severe surrounding gastritis. Moreover, if the endoscope tip contacts the lesion and causes bleeding, the quality of the diagnosis of EGC by NBI-M is degraded. The NBI-M method requires the endoscopist's skill because of the delicate manipulation of the endoscopic scope. In contrast, the acetic acid with indigocarmine (AIM) method is a simpler technique that facilitates extent diagnosis regardless of expertise. However, AIM does not yield effective results in all EGC cases.

Aims & Methods

The study aimed to determine the optimal method for delineating EGC extent during endoscopic submucosal dissection (ESD) marking. Informed consent was obtained from 107 patients scheduled for gastric ESD at our institution. The extent of EGC was assessed first with NBI-M, followed by thorough rinsing and spraying with 2% AIM. One minute after spraying AIM, visibility of the lesion extent was graded on a four-point scale: 0= not identifiable, 1= unclear, 2= approximately clear, 3= clear. Resected specimens were immunohistochemically stained for MUC5AC, MUC6, MUC2, and CD10. The immunohistochemical score for each staining was determined as follows: 0= no staining, 1= ≤1/3, 2= 1/3–2/3, 3= ≥2/3 of cancer stained. We examined the relationship between the extent of each staining and the clarity of extent diagnosis of EGC using the AIM method. In addition, a logistic analysis was performed on the factors involved in the cases in which AIM method was superior to NBI-M for extent diagnosis of EGCs.

Results

Of the initial 107 patients, 102 with 102 lesions were analyzed after excluding two cases of signet ring cell carcinomas, one case of gastric carcinoma with fundic gland type, and two cases with consent withdrawal. There were no significant differences in the degree of staining with AIM for gender, infection of Helicobacter pylori, degree of atrophy, lesion size or histological type. Regarding lesion location, EGCs located in the upper third of the stomach showed significantly clearer staining with the AIM method (p=0.0018): 10 lesions (76.9%) were clearly stained, 2 lesions (15.3%) were approximately clear, and 1 lesion (7.6%) was not identifiable. As for the relationship between AIM staining and mucin phenotype expression, only CD10 expression was significantly more frequent in EGCs that showed clear staining with AIM (p=0.019). In the diagnosis of the extent of gastric cancer, AIM was superior in 37 cases, NBI-M was superior in 41 cases, and equivalent in 24 cases. The factors involved in cases with superior AIM method were CD10 (p=0.097, OR 1.14) and upper third of stomach (p=0.042, OR 9.33) in univariate analysis and only upper third of stomach (p=0.027, OR 12.18) in multivariate analysis.

Conclusion

The proposed strategy for determining the extent of EGCs is to prioritize the AIM method for lesions with high CD10 expression and located in the upper third of the stomach.

Introduction

Providing people who have alcohol use disorder (AUD) with feedback about their liver (biofeedback using Fibroscan) may influence their drinking behaviour. It is unclear if and how having a Fibroscan may support behaviour change. There are also questions about how receiving a ‘normal’ result influences an individual’s feelings about their alcohol use.

Aims & Methods

This qualitative study aimed to explore people’s experiences of receiving different Fibroscan results and the impact they felt it had on them. Seventeen qualitative transcripts (11 recovery narratives, 6 post-trial interviews) from the KLIFAD trial (ISRCTN16922410) were analysed. An initial realist programme theory of a complex intervention was produced using the literature and other psychological theories of behaviour change to predict how the Fibroscan may influence behaviour change. A deductive qualitative analysis was conducted to find evidence for an initial programme theory of how the KLIFAD intervention may influence alcohol-related behaviour change. Initial ideas in the programme theory were amended based on qualitative insights.

Results

Of these participants, ten were ≥50 years of age, nine were male, 14 were white and three were of minority ethnicity, most were heavy drinkers. Fibroscan results ranged from normal (≤7 kPa=9), intermediate (8–14 kPa=4) to high (≥15 kPa=4). At follow-up ten reported abstinence and seven reduction in alcohol consumption, none reported increased consumption. Fibroscan was seen by some participants as an opportunity (or a privilege not all get to have) to find out about their health, and a chance to “see inside what is going on”. Those reflecting on receiving high scores described it as a shock, rock bottom, or an instant turning point. Most receiving normal results felt reassured and saw it as an opportunity to change their behaviour. Reducing the score by reducing alcohol use was described as a motivator for three participants. Not all participants (n=2) felt Fibroscan would help reduce alcohol use, often due to acute drinking, co-existing mental health diseases, hopelessness, or memory issues. Other factors influencing its impact included health priorities, loneliness, supportive relationships, age, symptoms such as pain, language barrier, stage of change, recognition of alcohol issues, and service engagement. One participant expressed guilt about self-inflicted harm when preparing for the test.

Conclusion

This study highlights the varied impact of Fibroscan biofeedback on alcohol-related behaviour change, influenced by individual circumstances such as mental health, readiness to change, and social support. High Fibroscan scores often prompted reflection and action, while normal scores reassured and motivated. Addressing barriers and stigma could enhance its effectiveness.

Clinical Case Summary

A 66-year-old female with a history of prior stroke presented with generalized weakness. She was disoriented and unable to provide a reliable history. She was febrile and tachycardic, and labs were notable for elevated direct bilirubin and liver enzymes. Physical exam was notable for right upper quadrant tenderness and well-healed scarring consistent with prior abdominal surgery. CT abdomen showed intrahepatic micro-abscesses and MRI revealed a cystic duct–duodenal fistula. Due to the patient’s clinical improvement with antibiotics, she was able to be discharged with a plan for outpatient ERCP. Due to issues with insurance coverage following discharge, the patient was lost to follow-up.
This is a rare presentation of a cysto-duodenal fistula that was the source of cholangitis and hepatic micro-abscesses resulting in sepsis. The incidence of cysto-duodenal fistulas is unknown, though fewer than 12 case reports of cystic duct-enteric fistulas have been published. The formation of a fistula can occur after cholecystectomy, involving a persistent cystic duct remnant that can become obstructed by calculi, leading to increased pressure and subsequent fistulization. It can present within days to years following cholecystectomy. This patient’s surgical history was unclear due to her altered mental status and a lack of records, though she had abdominal scarring and imaging findings that were consistent with prior cholecystectomy. It was confirmed that the patient did not have any recent abdominal procedure or cholecystectomy, making her presentation even rarer. Patients with a cysto-duodenal fistula typically present with signs of biliary sepsis, like in this case. ERCP is both a key diagnostic and therapeutic tool, as management of the fistula may involve interventions such as sphincterotomy and stenting to relieve obstruction. If endoscopic management is unsuccessful or if symptoms recur, surgical intervention may be necessary.

References

CT abdomen showed multiple small irregular hypodense lesions concerning for intrahepatic micro-abscesses. MRI was performed for further characterization and revealed inflammatory changes of the cystic duct stump with high suspicion for cystic duct–duodenal fistula and hepatic micro-abscesses (most notable in segment VII) with no drainable abscess.

Introduction

The LiverRisk score was recently developed as a tool for predicting liver fibrosis and liver-related outcomes in the general population. We aimed to evaluate the predictive performance of the LiverRisk score for liver fibrosis and overall mortality in HCV patients treated with direct acting antivirals.

Aims & Methods

This was retrospective, descriptive and analytical study conducted in a gastroenterology department over 8 years including patients diagnosed with chronic hepatitis C. Data were collected from patient records and during their follow-up. The data normality test for this study was conducted using the Shapiro-Wilk test. The discrimination ability of the Liver Risk Score was evaluated using the Area Under the Receiver Operating Characteristic (AUROC) curve. Overall mortality was assessed at the conclusion of the follow-up period.

Results

Among 165 patients monitored for hepatitis C and treated with direct-acting antivirals, only 68(41.2%) patients were eligible for this study. Mean age at diagnosis was 61±13.2 year; sex ratio M/W was 0.78 .10(14.7%) of the patients were tobacco users. 22(32.4%) had hypertension, and 14(20.5%) had diabetes.
Regarding hepatic risk factors; 5(7.5%) had alcohol use disorder, and use of cannabinoid substances was reported in 5(3%) of the cases.1(1.4%) had history of drug injection. 7(10.6%) had a history of bloodletting and tattoos, and 4(6%) had high-risk sexual practices.
Regarding the circumstances of diagnosis, 23(39.7%) patients were diagnosed incidentally, 18(26.4%) following an evaluation for asthenia, 4(6.9%) presented with abdominal pain, and 3(4.4%) exhibited signs of portal hypertension.
In terms of laboratory findings, 25(36.7%) had cytolysis, 7(10.2%) showed biochemical cholestasis, 16(23.52%) had thrombocytopenia, and 5(7.3%) presented with sign of hepatocellular insufficiency. Hepatitis B coinfection was identified in 3(4.4%) cases.
The most frequent genotype was 1b, identified in 18(45%) patients, followed by genotype 2 in 17(25%). Genotypes 1a, 3, and 4 were observed in 5(7.3%) patients.
On ultrasound, 15(22%) patients showed signs of chronic liver disease, and 8(11.7%) exhibited signs of portal hypertension. A total of 26(38.2%) patients underwent upper endoscopy, among whom 13(19.11%) had esophageal varices, 2(2.9%) had gastric or gastroesophageal varices (GOV), and 9(13.2%) presented with hypertensive gastropathy.
46(75.4%) were treated with Sofosbuvir and Daclatasvir, followed by Sofosvubir and Velpatasvir for 9(14.8%). Sustained virological response was achieved for 51(91.1%) patients.
For fibrosis, 19(30.2%%) were at stage F4, 9(14.3%) at stage F3, 13(20.6%) at stage F2, and 22(34.9%) at stage F0-F1. Median Liver risk score was 7.58[6.28;8.5].
The LiverRisk Score exhibited high accuracy in predicting liver stiffness and outperformed traditional serum biomarkers of fibrosis. Its discriminatory capacity for detecting liver stiffness ≥10 kPa was reflected by an AUROC of 0.848, compared to 0.779 for the FIB-4 test. After 5 years follow up 8(11.76%) patients died. LiverRisk score was associated with the risk of all cause of mortality (HR= 1.34, 95% IC[0.98;1.83], p = 0.047).

Conclusion

The LiverRisk score is an accurate tool to predict liver fibrosis and mortality in HCV patients treated with direct acting antivirals.

Introduction

The Chicago Classification version 4.0©(CC4) provided an updated classification of oesophageal motility disorders based on high-resolution oesophageal manometry (HRM) findings[1-2]. A key modification included using solid swallows which have been shown to increase the diagnostic yield of oesophageal motility disorders[3]. CC4 fails to offer guidance on the weighting of relevant findings when wet and solid swallows are discordant[3]. Clinical judgement, such as incorporating patient reported symptoms, is therefore required when interpreting HRM findings[2-3].

Aims & Methods

This retrospective service evaluation aimed to determine the frequency of CC4 diagnostic discordance between wet and solid swallows and how this was managed clinically. Data was collected from consecutive patients at a single National Health Service Trust (UK) site over a 6-month period. HRM was performed using a 36-channel HRM solid state catheter with impedance (Medtronic ManoScan™ ESO HRM) following the upright study CC4 protocol[2]. All patients had 5 mL saline swallows and those with dysphagia or abnormal primary swallows underwent solid swallows (rice test meal)[3].

Results

69 patients underwent HRM during the 6-month period. 51 studies included solid swallows, 61% (n=31) showed agreement between wet and solid CC4 findings and 39% (n=20) showed disagreement. Of those with discordance, it was concluded that 9 were inconclusive due to mixed appearances. In 7 studies the solid swallows were deemed more clinically relevant and in 4 studies the liquids swallows best reflected the clinical context.
10 patients had abnormalities detected on wet swallows but normal solids, 50% of which showed ineffective oesophageal motility (IOM) and 50% showed oesophago-gastric junction outflow obstruction (OGJOO). Of the patients with OGJOO on wet swallows and normal solids, 3 were concluded to be normal due to a lack of symptoms, good bolus clearance on HRM and normal endoscopy and barium swallow results. One was deemed inconclusive as the patient was symptomatic to bolus hold-up measured on HRM. One was concluded as OGJOO due to abnormal rapid drink challenge, upright swallows and supine swallows.
Of the 5 studies showing IOM on liquid swallows but normal solids, 2 were overall concluded to be normal due to a lack of symptoms. 2 were concluded as IOM, although only one was symptomatic to ineffective swallows. Both reports did, however, mention evidence of peristaltic reserve. One study was concluded inconclusive as possible IOM.
3 patients who had normal liquid swallows had abnormalities on solids. One showed IOM on solids which was concluded as insignificant due to a lack of symptoms. One had hypercontractile oesophagus which was concluded as significant due to the presence of symptoms[3]. The other showed symptomatic OGJOO with solids. This was classed as inconclusive as the patient had normal bolus clearance on barium swallow.

Conclusion

More patients had abnormalities on liquid swallows which normalised on solids, despite studies indicating increased motility disorder diagnosis with solid swallows[4]. Test analysers placed greater significance on solid swallow findings compared to liquids. However, many tests were reported as inconclusive. Tests with abnormal liquid swallows but normal solids frequently had differing conclusions, in part due to adjunctive test findings and reported symptoms. This emphasizes the importance of symptoms and overall clinical judgement when reporting. Future CC iterations should consider discordant findings and offer guidance on what is clinically relevant during HRM studies.

References

[1] Yadlapati, R. Kahrilas, P.J. Fox, M.R. et al. 2021. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0^©. Neurogastroenterology and Motility. 33(1).
[2] Fox, M.R. Sweis, R. Yadlapati, R. Pandolfino, J. Hani, A. Defilippi, C. Jan, T. and Rommel, N. 2021. Chicago classification version 4.0^© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility. Neurogastroenterology and Motility. 33(4).
[3] Ang, D. Misselwitz, B. Hollenstein, M. Knowles, K. Wright, J. Tucker, E. Sweis, R. and Fox, M. 2017. Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study. The Lancet Gastroenterology & Hepatology. 2(9), 654-661.
[4] Sharma, P. and Yadlapati, R. 2022. Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0. Current Gastroenterology Reports. 24(1):10-17.

Introduction

While the clinical trial (JCOG1009/1010) evaluating the efficacy and safety of endoscopic submucosal dissection (ESD) for intramucosal (T1a(M)) undifferentiated early gastric cancer (UD-EGC) of the predominant type measuring <2 cm not associated with ulceration showed a favorable 5-year survival outcome (99.3% (95% confidence interval: 97.1-99.8 )), the 10-year prognosis is still uncertain. We have followed the patients for 10 years.

Aims & Methods

Main eligibility criteria were endoscopically diagnosed cT1a/N0/M0, single primary lesion, size ≤2 cm, no ulceration, and histological components of undifferentiated adenocarcinoma in biopsy. Based on the histologic findings after ESD, additional gastrectomy was indicated if the histopathologic examination did not meet the criteria for curative resection. The primary endpoint was 5-year overall survival (OS) of the undifferentiated-predominant type group, and 10-years follow-up of patients was planned.

Results

Of a total of 346 patients enrolled between February 2011 and May 2013 from 49 institutions, 337 were eligible and all eligible patients underwent ESD. Histopathologic findings of the resected specimens showed undifferentiated predominant cancer in 275 patients while one patient could not be evaluated due to emergent surgery for a perforation during ESD. Of the 275 patients, 195 whose ESD was judged to result in a curative resection were followed up without additional treatment, and 73 of the remaining 79 patients whose ESD was judged to result in a non-curative resection received additional gastrectomy. Among the 275 patients with UD-EGC, one patient experienced a metastatic recurrence 3,034 days after ESD. The 10-year OS and relapse-free survival (RFS) of patients with undifferentiated-predominant type were 96.2% (95% confidence interval: 93.1-97.9) and 95.7% (95% confidence interval: 92.4-97.6), respectively, while the 10-year OS and RFS for all 346 enrolled patients were 95.1 % and 94.7 %, respectively.

Conclusion

ESD for UD-EGC with tumor size of 2 cm or less is the standard treatment, with excellent 10-year survival results as well as in the 5-year period.