Introduction

Weight regain and dumping syndrome (DS) are two relevant long term adverse events after Roux-en-Y Gastric Bypass (RYGB). Both these conditions are related to the dilation of the gastro-jejunal anastomosis. Transoral outlet reduction (TORe) is minimally invasive endoscopic procedure that was introduced to treat these conditions when medical treatment fails. As every endoscopic procedure, TORe is repeatable per definition. In this case series, we evaluate the technical feasibility and short and medium-term outcomes of the redo TORe in patients with weight regain and/or DS recurrence after primary TORe.

Aims & Methods

A retrospective analysis was done on a prospective database including patients that underwent TORe between January 2015 and October 2021; patients who received a re-TORe because of progressive loss of satiety and weight regain (≥50% of weight loss after primary TORe), or recurrence of DS were included in the analysis. DS recurrence was defined as Sigstad’s dumping score ≥7. Sigstad’s score, early and late Arts Dumping Score (ADS) questionnaires, and percentage of total body weight loss (%TBWL) were assessed at baseline, at 6 and 12 months after re-TORe.

Results

Of 92 patients that underwent TORe, 10 required a re-TORe. Indication to re-TORe was weight regain alone in 3 patients, while the remaining 7 repeated the procedure due to both DS recurrence and weight regain. The median time between the primary TORe and the re-TORe was 28 months (range 14-64 years). The median weight regain was 217% (IQR 400) compared to weight at primary TORe and 31.3 % (IQR 16) compared to weight at RYGB. The median Sigstad’s score for patients with recurrent DS was 14 (IQR 4.5), while median early ADS was 5 (IQR 9.5) and late ADS was 8 (IQR 3.5). The redo TORe was technically feasible in all patients. No periprocedural adverse events occurred. Mean percentage of total body weight loss (%TBWL) was 7.7% (IQR 2) at 1 month, 10.1% (IQR 14.2) at 6 months and 10.1% (IQR 18) at 12 months. 6/7 patients undergoing re-TORe because of recurrent DS reached 6- and 12-months follow-up. 3/6 patients had a complete remission of DS maintained at 1 year. Trends of symptoms-based questionnaire for DS are reported in table 1.

Dumping syndrome outcomes after re-TORe
	Baseline	6 months	12 months	P#
Sigstad’s Score	14 (4.5)	7 (1-14)	4.5 (1-14)	0.04
EADS	5 (1-10.5)	4 (0-4)	4.5 (0-8)	0.01
LADS	8 (5.5-9)	3 (0-4)	2.5 (0-4)	0.06
# Friedman test, Values are median (Q1-Q3) EADS= Early Arts Dumping Score questionnaire; LADQ= Late Arts Dumping Score questionnaire.

Conclusion

According to our experience, redo TORe is technically feasible and has good short and medium-term outcomes in terms of weight loss and DS control. As such, repeating the procedure should be considered before referring patients for revision surgery.

Introduction

Recently, artificial intelligence (AI)-based diagnostic support tools for early gastric cancer have been developed and reported to be superior to endoscopists (accuracy: 70% and sensitivity: 85%).¹ However, These tools could not guarantee reliable diagnostic accuracy in clinical practice. In previous reports, magnifying endoscopy has been recognized as superior to white-light imaging endoscopy for endoscopic diagnosis of early gastric cancers. Therefore, we developed an AI-based diagnostic support system using magnifying endoscopy with narrow band imaging (M-NBI) for early gastric cancers² and improved its application in clinical practice using nondegraded images obtained from selective depth inspection (SDI) output for real-time diagnosis. This study is the first to create an AI-based diagnostic support system using non-degraded M-NBI images obtained from SDI output, as several previous papers have analyzed damaged M-NBI images that were converted from various recording devices.^3,4

Aims & Methods

We built a new AI system (M-NBI AI) which was assembled using four different image recognition models with non-degraded M-NBI images (normal mucosa:1776 images, gastric cancers: 1947 images, and non-neoplastic lesions: 2451 images). We evaluated the performance of this M-NBI AI for diagnosis of early gastric cancer. The diagnostic performances of M-NBI AI and endoscopists (five specialists and five non-specialists) were compared using non-degraded M-NBI images (three images per lesion) of 50 early gastric cancer and 50 non-cancerous lesions. Early gastric cancers included histopathological types of well, moderately, and poorly differentiated adenocarcinomas and signet-ring cell adenocarcinomas. The primary outcome was the superiority of the M-NBI AI (based on accuracy) over the endoscopists. The secondary outcome was the superiority of the M-NBI AI (based on sensitivity) over the endoscopists.

Results

	M-NBI AI	Endoscopists
		Specialists	Non-specialists
Accuracy, % (95% CI)	87.0 (0.80–0.94)	80.0 (0.72–0.88)	71.0 (0.62–0.79)
Sensitivity, % (95% CI)	86.3 (0.77–0.96)	74.2 (0.63–0.85)	70.6 (0.58–0.83)
Specificity, % (95% CI)	88.0 (0.79–0.97)	89.0 (0.80–0.99)	71.0 (0.59–0.84)
PPV, % (95% CI)	88.0 (0.79–0.97)	92.0 (0.84–0.99)	72.0 (0.60–0.84)
NPV, % (95% CI)	86.0 (0.76–0.96)	68.0 (0.55–0.81)	70.0 (0.57–0.83)
PPV, positive predictive value; NPV, negative predictive value

The M-NBI AI was superior to the non-specialists based on accuracy (87.0%, 95%CI: 0.80–0.94 versus 71.0 %, 95%CI: 0.62–0.79; p<0.01), without being superior to the specialists (87.0%, 95%CI: 0.80–0.94 versus 80.0%, 95%CI: 0.72–0.88; p=0.18). The M-NBI AI was superior to the specialists and non-specialists based on sensitivity (86.3%, 95%CI: 0.77–0.96 versus 74.2%, 95%CI: 0.63–0.85 and 70.6%, 95%CI: 0.58–0.83; p<0.05, respectively).

Conclusion

The M-NBI AI was created as a new AI system that could be implemented for current endoscopy systems as a real-time diagnostic support tool for early gastric cancers. It demonstrated a robust performance and may indicate equalization of diagnostic accuracy and superadded effect over the white-light endoscopy for diagnosis of early gastric cancers in clinical practice.

References

1. Ishioka M et al. Dig Endosc. 2022. doi: 10.1111/den.14455.
2. Ueyama H et al. J Gastroenterol Hepatol. 2021;36(2):482-489.
3. Horiuchi Y et al. Dig. Dis. Sci. 2020;65:1355–1363.
4. He X et al. Gastrointest Endosc. 2022;95(4):671-678.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB). In a recent Japanese multicenter retrospective cohort study, 63.6% of patients with ALGIB were ultimately diagnosed with CDB [1]. It has also been reported that CDB in ALGIB is reportedly more severe than in other entities [2, 3]. However, few reports have demonstrated the efficacy and safety of bowel preparation for patients undergoing urgent colonoscopy.

Aims & Methods

We aim to clarify choice a of bowel preparation for urgent colonoscopy in patients with colonic diverticular bleeding. In a multicenter retrospective cohort study at 10 institutions, we analyzed the endoscopic findings and clinical course of patients diagnosed with CDB who underwent urgent colonoscopy within 24 hours after admission. Bowel preparation consisted of oral consumption of 1 to 2 L of polyethylene glycol lavage (PEL); enemas were not used. We compared those CDB patients who underwent PEL (PEL group) with a control group who did not undergo PEL (non-PEL group) before and after propensity score matching. For the matching, we selected variables known at the time of hospital admission (i.e. age, sex, comorbidities, medications, performance status, and laboratory data). The primary endpoint of the study was length of hospital stay, and secondary endpoints included blood transfusion requirements, rebleeding rates, endoscopic findings, and complications.

Results

242 patients were enrolled in this study. The median age was 76 years, and 60.7% of patients were men (n = 147). Approximately half of the patients underwent bowel preparation with PEL prior to urgent colonoscopy (n = 129). We compared with clinical findings between the PEL and non-PEL groups. The length of hospital stay was shorter in the PEL group (8.0 ± 5.1 days vs 10.9 ± 5.8 days; mean ± SD; P < 0.001). Further, the PEL group was significantly younger (72.2 ± 12.1 vs 75.4 ± 13.1; mean ± SD; P = 0.036), had fewer patients with hypertension (62.0% vs 75.2%; P = 0.027) and malignant neoplasm (1.6% vs 10.6%; P = 0.002), and had better performance statuses (86.1% vs 76.1%; P = 0.047). Patients in the PEL group received fewer blood transfusions (25.6% vs 44.3%; P = 0.002), had a higher rate of cecal completion (88.3% vs 49.6%; P < 0.001), and shorter endoscopic observation times (20.8 ± 16.2 min vs 29.9 ± 24.8 min; mean ± SD; P = 0.006). After propensity score matching, there were 91 patients each in PEL group and in non-PEL group. PEL group had a significantly shorter hospital stay (7.9 ± 4.6 days vs 10.7 ± 5.8 days; mean ± SD; P < 0.001), a higher cecum completion rate (87.8% vs 48.3%; P < 0.001), and a shorter endoscopic observation time (20.7 ± 16.8 min vs 28.9 ± 24.1 min; mean ± SD; P = 0.031) than non-PEL group. There were no significant differences in blood transfusion requirements, rebleeding rates, identification of SRH, need for endoscopic hemostatic treatment, or complication rates.

Conclusion

In patients with CDB, urgent colonoscopy under PEL resulted in shorter hospital stays, higher cecal completion rates, and shorter endoscopic observation time in urgent colonoscopy. The safety of urgent colonoscopy with PEL was comparable to colonoscopy without PEL. These results suggest that PEL is preferrable for urgent colonoscopy in patients with CDB.

References

1. Nagata N, Kobayashi K, Yamauchi A, et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J study. Am J Gastroenterol 2021; 116: 2222-2234.
2. Aoki T, Nagata N, Shimbo T, et al. Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol 2016; 14: 1562-1570.e2.
3. Xavier SA, Machado FJ, Magalhães JT, et al. Acute lower gastrointestinal bleeding: are STRATE and BLEED scores valid in clinical practice? Colorectal Dis 2019; 21: 357-364.

Introduction

There are no established treatments for esophageal anastomotic stricture refractory to endoscopic balloon dilation (EBD). Patients experience a reduced quality of life and suffer a financial burden after surgery until the strictures are relieved. New treatments for refractory anastomotic stricture are clearly needed. Local steroid injection is reported to improve the effects of EBD. In addition, EBD with local steroid injection is a current community standard treatment for patients with refractory anastomotic stricture after esophagectomy, although the effect is limited. A new endoscopic treatment for such strictures is radial incision and cutting (RIC), which improves strictures by cutting through scar tissue at the stricture site with an electrocautery knife and removing any fibrous tissue that may cause re-stricture. However, the evidence for its effectiveness is limited to retrospective studies and small case series.

Aims & Methods

The aim of this multicenter, randomized, open-label, phaseⅡ/Ⅲ trial was to investigate the safety and the superiority of RIC with steroid injection compared with EBD with steroid injection for patients with refractory anastomotic stricture after esophagectomy for thoracic esophageal cancer. This is the first randomized controlled trial in the world for patients with refractory esophageal anastomotic strictures. Patients with Dysphagia Score ≥2 (able to swallow only semisolid foods or liquids) who had strictures through which a conventional endoscope (diameter, 9.6–10.4 mm) did not pass despite three or more EBDs or bougienage dilations were eligible for this trial. The primary endpoint in the phase II part was proportion of hemorrhages, post-operative esophageal perforations, esophageal hemorrhages, pneumothorax, lung or mediastinum infections or other unexpected adverse events. Co-primary endpoints in the phase III part were re-stricture-free survival and number of dilations for 24 weeks after treatment. This study was registered with the Japan Registry of Clinical Trials jRCTs031180177.

Results

From May 2014 to March 2022, 130 patients were enrolled from 32 institutions participating Gastrointestinal Endoscopy Study Group of the Japan Clinical Oncology Group and 65 patients each were randomized to EBD arm and RIC arm. The median number of dilations before registration was five in each arm. Dysphagia Score represented grade 2 (able to swallow semisolid foods) in 104 (80.0%) patients, grade 3 (able to swallow liquids only) in 25 (19.2%) patients, and grade 4 (unable to swallow liquids) in 1 (0.8%) patient in whole of study. Grade 3/4 pre-defined adverse events occurred in 1 (1.5%) patient in each arm. Median re-stricture-free survival in EBD arm was 10.6 weeks (95% CI: 6.9-20.1 weeks) and 8.7 weeks (95% CI: 7.1-10.9 weeks) in RIC arm (hazard ratio 1.22, 90% CI 0.85-1.74, one-sided p=0.82). The median number of dilations for 24 weeks after initial treatment was once (IQR: 0-2) in EBD arm and twice (IQR: 0-4) in RIC arm (one-sided p=0.99). The proportion of patients with anastomotic diameter >10 mm at 8 weeks after treatment was 27.7% (95% CI: 17.3-40.2%) in EBD arm and 24.6% (95% CI: 14.8-36.9%) in RIC arm.

Conclusion

RIC with steroid injection was not superior to repeated EBD with steroid injection for refractory anastomotic stricture after esophagectomy. EBD combined with steroid injection remains the standard of care for refractory anastomotic stricture after esophagectomy.

Introduction

The magnifying endoscopy (ME) with narrow-band imaging (NBI), which can visualize the microvascular (MV) architecture and the microsurface (MS) structure showed the acceptable diagnostic ability for early gastric cancer (EGC) even using second-generation NBI. The latest endoscopic system EVIS X1 (Olympus, Tokyo, Japan) includes third-generation (3G) NBI with more brightness and clearness, however, the diagnostic performance of ME with 3G-NBI for EGC was unknown.

Aims & Methods

The aim of this post hoc analysis was to investigate the diagnostic performance of ME with 3G-NBI for EGC using the data from the 3G detection trial, which was the randomized three-arm phase II trial comparing white light imaging (WLI), 3G-NBI, and texture and color enhancement imaging (TXI) for detecting gastric neoplasms (GN). The major inclusion criteria of 3G detection trial were as follows: 1) scheduled surveillance endoscopy after endoscopic resection for GN or endoscopic resection, chemotherapy, or radiotherapy for esophageal cancer (EC), or 2) scheduled preoperative endoscopy for known GN or EC. The EVIS X1 system and a high-definition gastroscope with an optical zoom (GIF-XZ1200) were used. Patients were randomly assigned to the following arms: WLI followed by WLI, 3G-NBI followed by WLI, and TXI followed by WLI. All suspected GN lesions were diagnosed as EGC or non-EGC using ME with 3G-NBI according to ME simple diagnostic algorithm of EGC (MESDA-G), which use the presence of irregular MV and/or MS patterns within the demarcation line, and its confidence level was recorded. Pathological diagnoses were made based on biopsied tissue or final results of resected specimens by expert pathologists at each institution. This post hoc analysis compared the diagnosis of ME with 3G-NBI for EGC with the pathological diagnosis. The primary endpoint was the diagnostic performance of ME with 3G-NBI for EGC, and it also evaluated according to confidence level (high/low), macroscopic type (elevated/flat or depressed), and lesion size (<10 mm/≥10 mm).

Results

Of 901 patients enrolled in the 3G detection trial, a total of 228 suspected GN lesions in 187 patients were analyzed. The median size of the lesions was 5.0 mm (range: 1.0-40.0). In the macroscopic type, 43 (18.9%) lesions were elevated and 185 (81.1%) were flat or depressed. Using ME with 3G-NBI, 62 lesions (27.2%) were diagnosed as EGC, of which 27 were diagnosed with high confidence. And, 166 (72.8%) were diagnosed as non-EGC, of which 91 were diagnosed with high confidence. Finally, 61 were pathologically diagnosed as EGC and other 167 were pathologically diagnosed as non-EGC. The overall diagnostic performance of ME with 3G-NBI for EGC was, sensitivity of 70.5% (43/61), specificity of 88.6% (148/167), accuracy of 83.8% (191/228), positive predictive value (PPV) of 69.6% (43/62) and negative predictive value (NPV) of 89.2% (148/166), respectively. For the lesions diagnosed with high and low confidence, sensitivity was 78.1% (25/32) and 62.1% (18/29), specificity was 97.7% (84/86) and 79.0% (64/81) (p<0.001), accuracy was 92.4% (109/118) and 74.6% (82/110) (p<0.001), respectively. For the elevated and flat or depressed lesions, sensitivity was 84.6% (11/13) and 66.7% (32/48) and specificity was 96.7% (29/30) and 86.9% (119/137), respectively. For the lesions with <10 mm and ≥10 mm in size, sensitivity was 65.7% (23/35) and 76.9% (20/26) and specificity was 88.6% (116/131) and 88.9% (32/36), respectively.

Conclusion

The diagnostic performance of ME with 3G-NBI for EGC was acceptable, especially in the lesions diagnosed with high confidence.