Introduction

The benefit of computer-assisted detection systems (CADe) has been evaluated in several randomized controlled trials (RCTs) showing improved adenoma detection rate (ADR) and polyp detection rates (PDR) (1-3). However, the generalizability of these studies is questioned as these studies are performed in highly controlled setting and thus not representing a real-world clinical setting (4). It is also believed that the increase in ADR by CADe-assisted colonoscopy is mainly observed in lower detector endoscopists (5, 6).
We aimed to evaluate the effect of CADe-assisted colonoscopy on ADR in an actual clinical setting in a high-volume, non-tertiary endoscopy centre with high detector endoscopists.

Aims & Methods

A single-centre, observational study was conducted on all patients undergoing colonoscopy due to symptoms of colorectal cancer (CRC), screening colonoscopies for CRC, post-polypectomy surveillance, or colonoscopy due to positive results from a fecal immunochemical test in an Australian hospital between March 2023 to October 2023. Colonoscopies were performed by 19 experienced endoscopists using the validated CADe system that allows for real-time image analysis (GI Genius, Cosmo IMD Ireland). Historical procedural data regarding colonoscopies were obtained up to 10 months before the start of the study and were compared to the CADe-assisted colonoscopies in a 2:1 fashion. The primary outcome of the study was the ADR. Data were analyzed using logistic mixed effects models with random intercepts for patient and endoscopist, expressed as Odds ratio (OR) with a 95% confidence interval (CI).

Results

A total of 7798 colonoscopies were performed for 7460 patients during the timeframe, including 2813 colonoscopies using CADe and 4985 standard colonoscopies. The ADR in the CADe-assisted colonoscopy group was 52% compared to 46% in the standard colonoscopy group. There was a significant difference in ADR (OR 1.22, 95% CI 1.09 - 1.36, p<0.001) and PDR (OR 1.22, 95% CI 1.09 - 1.37, p<0.001) between CADe-assisted colonoscopy and standard colonoscopy respectively, adjusted for age, bowel preparation quality, withdrawal time and sex.

Table 1 Adenoma detection and polyp detection rate of the CADe-assisted colonoscopy group compared to the standard colonoscopy group.

Conclusion

In this real-time, observational study, CADe-assisted colonoscopy significantly improves the adenoma detection rate and polyp detection rate. Our study shows that the implementation of CADe-assisted colonoscopies in daily practice is useful, even in high-detector endoscopists.

References

1. Wang P, Liu X, Berzin TM, Glissen Brown JR, Liu P, et al. Effect of a deep-learning computer-aided detection system on adenoma detection during colonoscopy (CADe-DB trial): a double-blind randomised study. Lancet Gastroenterol Hepatol. 2020;5(4):343-51.
2. Repici A, Spadaccini M, Antonelli G, Correale L, Maselli R, et al. Artificial intelligence and colonoscopy experience: lessons from two randomised trials. Gut. 2022;71(4):757-65.
3. Hassan C, Spadaccini M, Mori Y, Foroutan F, Facciorusso A, et al. Real-Time Computer-Aided Detection of Colorectal Neoplasia During Colonoscopy : A Systematic Review and Meta-analysis. Ann Intern Med. 2023;176(9):1209-20.
4. Patel HK, Mori Y, Hassan C, Rizkala T, Radadiya DK, et al. Lack of Effectiveness of Computer Aided Detection for Colorectal Neoplasia: A Systematic Review and Meta-Analysis of Nonrandomized Studies. Clin Gastroenterol Hepatol. 2023.
5. Karsenti D, Tharsis G, Perrot B, Cattan P, Percie du Sert A, Venezia F, et al. Effect of real-time computer-aided detection of colorectal adenoma in routine colonoscopy (COLO-GENIUS): a single-centre randomised controlled trial. Lancet Gastroenterol Hepatol. 2023;8(8):726-34.
6. Mangas-Sanjuan C, de-Castro L, Cubiella J, Diez-Redondo P, Suarez A, Pellise M, et al. Role of Artificial Intelligence in Colonoscopy Detection of Advanced Neoplasias : A Randomized Trial. Ann Intern Med. 2023;176(9):1145-52.

Introduction

Anastomotic leakage after foregut surgeries are often difficult to manage. The conventional way of endoscopic treatment is endoscopic stenting (ES). However, it carries a risk of stent migration and erosion. Endoscopic vacuum therapy (EVT) has recently been proposed as an alternative way of treating these leaks. EVT has the benefit of providing negative suction and promotion of granulation tissue¹. However, an exchange every 3-7 days has been suggested.

Aims & Methods

The aim of this study was to compare the treatment outcomes between ES, EVT and the combination of both. This was a retrospective multi-centre cohort study from 3 major centres in Hong Kong that performs esophagectomy and gastrectomy. All patients with anastomotic leak after total gastrectomy and esophagectomy and who were treated with ES or EVT between Jul 2008 and Apr 2023 from the Prince of Wales Hospital, Queen Mary Hospital and United Chistian Hospital were included. Patients’ demographics, type of surgery, size of anastomotic defect, treatment success rate, complications, number of procedures, duration to healing were recorded and compared. Continuous data are compared with Mann-Whitney test and categorical data are compared with Chi-square/ Fisher's exact test.

Results

A total of 63 patients were recruited (ES: 49; EVT 14. The outcomes of the study are listed in Table 1. The mean (S.D.) of defect was 15.4 (16.0)mm in the ES group and 17.8 (14.1)mm in the EVT group (p=0.39). in the EVT group, there are 3/14 patients who had failed EVT therapy and converted to ES. The success rate of each arm as a single arm therapy were similar (29/49(59.2%) in the ES group vs 6/14(42.9%) in the EVT group; p=0.28). However, there were less complications in the EVT group (2/14 (14.3%) in ES group vs. 23/49(46.9%) in EVT group; p=0.03). On the other hand, the EVT group required more endoscopic procedures (median (range) 3 1-137) procedures in the ES group vs 6(2-16) in the EVT group ; p 0.002). The days required for the anastomosis to heal were also similar (ES (61.7 (38.4) vs EVT 45.3 (25.8); p=0.37). When comparing patients treated as a single-arm therapy (ES or ET) to combination therapy (ES + EVT), the success rates has a trend towards favouring combination treatment (p=0.07).

Conclusion

Both EVT and ES are feasible and safe in treating anastomotic leaks after foregut surgeries. Although more procedures are required, EVT achieved similar success rate while having less complications when compared to ES a single arm. The use of combination therapy as compared to single-arm endoscopic therapy may achieve a higher treatment success rate.

References

1. Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc. 2022 Jan;34(1):43-62. doi: 10.1111/den.14061. Epub 2021 Jul 19. PMID: 34115407.

Disclosure

There is no COI.

Clinical Case Summary

A 43-year-old woman with a rectal 90mm granular laterally spreading tumor involving 50% of the circumference (distal limit at 12cm from the anal verge) underwent endoscopic submucosal dissection (ESD). Due to submucosal fibrosis, deep laceration of the muscularis propria occurred at the end of the procedure and two through-the-scope (TTS) clips were applied and broad-spectrum antibiotics were administered. In the following day, the patient developed sepsis and an emergency CT scan revealed free air in mesorectum and densification of the perirectal/presacral adipose tissues with contrast extravasation. Proctosigmoidoscopy showed an orifice of approximately 12mm, near the previous TTS clips, that communicated with a 15mm abscessed cavity, compatible with delayed perforation (Figure 1). Endoluminal vacuum therapy (EVT) was initiated with a 2cm Endo-SPONGE^® (B.Braun Medical B.V., Melsungen, Germany), partially intraluminal, without immediate complications (Figure 2). The patient was kept under parenteral nutritional, antibiotics and twice weekly EVT sponge replacement, with a total of four substitutions. The evolution was favorable with sepsis resolution, decrease of the cavity length and complete tissue granulation (Figure 3). The patient was discharged after 16 days and remained asymptomatic with complete closure at the 1.5 months follow up (Figure 4).

References

(Figure 1). (Figure 2). (Figure 3) (Figure 4).

Introduction

Treatment targets of ulcerative colitis (UC) have evolved to include not only endoscopic but also histologic remission. However, the concept of histological activity is still in its early days. We aimed to capture the attitudes towards UC histology and the uptake of standardized reporting of endoscopy and histology of UC in daily practice.

Aims & Methods

We conducted a cross-sectional survey of physicians involved in the care of IBD worldwide. The survey included 21 questions divided into 3 sections. The first recorded demographics, specialty, and level of experience of participants; the second covered clinical practices and attitudes towards the use and reporting of endoscopy, and the third of histology.

Results

Participants: In total 359 physicians, from 60 countries (54.4% Europe, 24.4% Asia, 12.9% South America, 3.7% North America, 3.2% Africa, and 1.4% Oceania) responded; 87% were gastroenterologists, the remainder other specialists involved in the care of IBD. The majority practiced in academic hospitals (54.5%) or tertiary centers (22.1%), and only around one-fifth worked in secondary hospitals (12.8%) or local practices (8.1%).
Endoscopy: When performing endoscopy in quiescent UC, 72.1% of respondents reported taking biopsies also to assess microscopic activity, while 16.8% only for dysplasia detection, and 10.4% just in case of suspicious lesions; the average number of biopsies was 10.8 (SD 7.34, range 0 to 36). In the case of active UC, the percentage of operators collecting biopsies increased to 93.6%.
Endoscopy reports included a validated score in 91.9% of cases. Mayo was nearly always used (90%), with a large difference from the second most common score UCEIS (26.5%); other indices accounted for 1.7%. Of note, except for 1 respondent, all scores different from Mayo were used in addition to, and not instead of, Mayo. When restricting the analysis to participants working in high-volume centers (>500 UC patients cared for per year) all but one (117/118) reported using the Mayo score to grade endoscopic activity, and 32% (38/117) used also other scores in addition to Mayo, mainly UCEIS.
Histology: Centers represented in the survey were roughly equally split between those with a pathologist dedicated to IBD (46.2%) and those without (51%). UC histology was used by nearly all respondents (90.5%) for initial diagnosis, 72% to monitor disease course, 62.4% to determine microscopic extension, 59.9% to confirm deep remission when considering stopping treatment, and 42.3% to increase/optimize treatment. Nevertheless, 77.2% of participants reported that standard histological indices were not routinely available, although 21.7% of these used scores in selected cases, such as clinical trials or research. Among those who used (or worked in a center that used) standard scores (160/357) the choice of which index was mixed: 64.4% (103/160) used the Nancy index, followed by Geboes 31.9% (51/160), and Robarts 20.6% (33/160), a minority applied other scores.
The majority of respondents welcomed as useful or very useful an artificial intelligence system to automate scoring of endoscopy (69%) or histology (73%).

Conclusion

UC histology reports are less standard than endoscopy ones. Most physicians consider histological activity useful when managing UC and would welcome artificial intelligence systems to automate endoscopic and histological scoring.

Disclosure

OMN has served as a speaker for Janssen, Ferring, Takeda, Pfizer, Fresenius Kabi
MI has received research grants and equipment loans from Pentax USA, Olympus, and Fujifilm; is partially funded by NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham.
LPB reports personal fees from Galapagos, AbbVie, Janssen, Genentech, Ferring, Tillots, Celltrion, Takeda, Pfizer, Index Pharmaceuticals, Sandoz, Celgene, Biogen, Samsung Bioepis, Inotrem, Al-lergan, MSD, Roche, Arena, Gilead, Amgen, BMS, Vifor, Norgine, Mylan, Lilly, Fresenius Kabi, OSE Immunotherapeutics, Enthera, Theravance, Pandion Therapeutics, Gossamer Bio, Viatris, Thermo Fisher; grants from Abbvie, MSD, Takeda, Fresenius Kabi; stock options: CTMA.
SG has served as consultant, Steering committee member, Advisory Board Member and Drug Monitoring committee member for Janssen, Pfizer, Takeda, Abbvie, BMS, Gilead, Galapagos, Celltrion, Eli Lilly, Ferring.
SD has served as a speaker, consultant and advisory board member for Schering Plough, Abbott (AbbVie) Laboratories, Merck and Co, UCB Pharma, Ferring, Cellerix, Millenium Takeda, Nycomed, Pharmacosmos, Actelion, Alfa Wasserman, Genentech, Grunenthal, Pfizer, AstraZeneca, Novo Nordisk, Vifor and Johnson and Johnson.

Remaining authors declare no relevant conflict of interest.

Introduction

Since the report of Shaker in 1994, transnasal esophagogastroduodenoscopy (T-EGDS) has been reported worldwide as one technique to facilitate comfortable procedures avoiding sedation. From 1996 in our Centre, we routinely use this technique in all the patients for diagnostic and selected operative EGDS. This approach is also suitable for the placement of percutaneous endoscopy gastrostomy (PEG) but in the published papers it has been performed only when conventional upper gastrointestinal endoscopy was unusable (dysphagic patients with neurological disease or with stenosis and/or occlusion of the mouth or pharynx). On the contrary, since 2000 we have routinely used the transnasal approach for all patients requiring PEG, reserving the oral technique when the transnasal access route is impossible.

Aims & Methods

We performed a retrospective analysis of all patients who underwent PEG placement between January 2000 and March 2023 in the Unit of Gastroenterology of San Camillo De Lellis Hospital, Rieti, Italy, in order to demonstrate the feasibility and safety of T-PEG placement in routine practice. We used ultrathin gastroscope through a nostril after assessment and lubrification, and the pull technique was used for tube placement.

Results

PEG placement was required for 256 consecutive patients (male 49.4%; female 51.6%), the average age was 79 years, within a range from 26 to 104 years. Transnasal approach was used in 162 patients (nasal group: 63.3%) while oral approach was used in 94 (oral group: 36.7%). The failure of transnasal approach was related to impossibility of nasal intubation due to narrow nasal passages or to inability to transilluminate the stomach. In these cases we needed transoral route. 14 patients underwent transoral PEG placement due to unavailability of transnasal gastroscope. The duration of the procedures was similar in both approaches (12 ±3 minutes oral vs 13±4 minutes nasal).
The most common indications for PEG insertion were neurologic disorders (n=132, 51.6 %), cerebrovascular accident (n=73, 28.5 %), esophageal cancer or head and neck cancer (n=18, 7 %), other pathologies (n=33, 12.9 %). 167 procedures were performed without sedation: 77.8 % ( n= 130) in the nasal group and only 22.1% (n=37) in the oral group. Outpatient regimen PEG placement was also significantly higher in trans nasal group (79 % vs 58 % oral group). We registered 3 major complications, 1 in oral group and 2 in nasal group (one necessitated surgery). No procedure-related death was registered. There were no unplanned re-admissions of outpatients discharged from the gastroenterology unit for procedure-related complications.

Conclusion

The more than twenty years’ experience of our center demonstrates that the transnasal approach is safety, feasible and could be routinely used in daily endoscopic practice for PEG placement. The minimally invasive technique therefore reserves sedation to a few selected cases to reduce costs, improve logistic organization and avoid anesthesia related complications.

References

1. Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety, and tolerance. Endoscopy. 1998 Jun;30(5):448-52.
2. Schuldt AL, Kirsten H, Tuennemann J, Heindl M, van Bommel F, Feisthammel J, Hollenbach M, Hoffmeister A. Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis. BMJ Open Gastroenterol. 2019 Apr 14;6(1):e000264.
3. Dumortier J, Lapalus MG, Pereira A, Lagarrigue JP, Chavaillon A, Ponchon T. Unsedated transnasal PEG placement. Gastrointest Endosc. 2004 Jan;59(1):54-7.
4. Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, Ponchon T. Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients. Gastrointest Endosc. 2003 Feb;57(2):198-204
5. Preiss C, Charton JP, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy. 2003 Aug;35(8):641-6.

Introduction

Inflammatory bowel disease (IBD), consisting of Crohn’s disease (CD) and Ulcerative colitis (UC), is a group of chronic, relapsing disorders in the gastrointestinal tract. The disease mechanisms are largely unknown. We hypothesized that the interaction of genetic variants and tobacco smoking can influence the disease risk of IBD and impact the disease progression in CD and UC differently.

Aims & Methods

3530 IBD patients were included in the present study via Parelsnoer IBD Biobank (PSI), a Dutch prospective, nationwide biobank of IBD patients. Phenotypic data on smoking status at the time of diagnosis was obtained through the PSI questionnaire. Genome-wide genotyping was conducted on all PSI participants using the Global Screening Array and divided into two independent datasets, the discovery (N=990) and replication cohort (N=2540). Case-only study design was applied to estimate the interaction effects for IBD, CD, and UC separately with subsequent meta-analysis between discovery and replication cohorts.

Results

572 lead single nucleotide polymorphisms (SNPs) were demonstrated with interaction effect of smoking (meta-analysis P < 5e-5, heterogeneity Cochrane Q test P > 0.05). 30 interacting SNPs showed distinct opposite effects between CD and UC (the ratio of interaction effect sizes between CD and UC > 5 or < 0.1). Our analysis also confirmed 9 previously reported interacting SNPs in the regions of NOTCH4, TSBP1-AS1, HLA-DRA, HLA-DRA-HLA-DRB5, HLA-DRB9, DNMT3A, MUC22, and CCR3.

Conclusion

Our present study identified a large number of new interaction loci for IBD on a genome wide scale and shed new light on the disease mechanisms.

Disclosure

No conflict of interest