Introduction

Currently, we can reliably and non-invasively determine steatosis and liver fibrosis by CAP/ATI/PDFF and ET/2D-SWE/MRE, respectively. However, it is not possible to accurately determine the inflammatory component without biopsy. In addition to 2D-SWE and Attenuation Imaging, some new multiparametric US devices incorporate the tissue viscosity-dependent 2D-SWD dispersion slope parameter. The liver is not a purely elastic but a viscoelastic organ, so that 2D-SWD measurement could be useful in the determination of necroinflammation. Our aim was to evaluate the correlation of SWD with the inflammatory component of MAFLD.

Aims & Methods

Prospective study. Immediately prior to liver biopsy (Tru-Cut 16G) in patients with suspected MAFLD, SWD (Canon Aplio i800) was performed. Exclusion criteria were: liver biopsy length <1.5 cm/<11 portal tracts, absence of MAFLD on final biopsy result (steatosis <5%). MAFLD was classified according to NASH-CRN. Normally distributed quantitative variables were described using the mean; otherwise, the median was calculated.

Results

112 patients were included: age 53 years, women 55%, BMI 30.9 kg/m², diabetes 39%, GPT 62 U/L. Biopsy: 2.5 cm, 14 portal spaces. Fibrosis distribution was: F0 53 (46%), F1/F2 37 (32%), F3/F4 25 (22%). Steatosis distribution was: S1 35 (34%), S2 30 (29%), S3 39 (37%). Steatohepatitis: definite 52 (45%), absent 47 (41%), indeterminate 16 (14%). SWD values showed statistically significant differences between patients without steatohepatitis/indeterminate vs. steatohepatitis (13 (m/s)/KHz vs. 13.750 (m/s)/KHz; p=0.015). A positive linear correlation was also observed between SWD and NAS score (rho = 0.216; p=0.028). For the lobular inflammation component, a value of 14.5 (m/s)/KHz had Esp 89.5%, PPV 93.1%, while 10.5 (m/s)/KHz had Sens 90.5%, NPV 80.9%.

Conclusion

The SWD dispersion parameter determined by mulparametric ultrasound could be useful in the non-invasive assessment of liver inflammation and the diagnosis of steatohepatitis in MAFLD patients.

Introduction

Although Gastric Peroral Endoscopic Myotomy (G-POEM) has shown substantial efficacy in patients with medically refractory gastroparesis (GP), comprehensive long-term data on its effectiveness are lacking.

Aims & Methods

We conducted a systematic review and meta-analysis including observational studies assessing long-term outcomes after G-POEM in patients with refractory GP. Our primary outcome was the pooled rate of clinical success1-year after G-POEM. Secondary outcomes included clinical success rates beyond 1 year, and the rate of adverse events (AEs).

Results

Fifteen studies, comprising 986 patients with refractory GP undergoing G-POEM, were eligible. The pooled 1 year-success rate was 0.722 (95% CI: 0.56, 0.86, I²=94.92%). In the subgroup analysis, which included only studies enrolling patients with 4-hour Postprandial Gastric Residual (PGR) ≥ 10%, the clinical success rate was 0.610 (95% CI: 0.526, 0.709, I²=46.66%). The pooled success rates at 2 and 3 years calculated on followed-up patients were 0.861 (95% CI: 0.72, 0.96, I²=85.11%) and 0.838 (95% CI: 0.56, 0.99, I²=91.90%), respectively. In the subgroup analysis including studies that did not exclude non-responding patients from follow-up, the 2-year pooled success rate was 0.838 (95% CI: 0.60, 0.98, I²=89.49%). The pooled rate of AEs was 0.092 (95% CI: 0.06, 0.13, I²=81.35%), specifically 0.078 mild and 0.014 moderate AEs, according to the American Society for Gastrointestinal Endoscopy classification.

Conclusion

G-POEM is a safe procedure with 1-year success in more than 2/3 of treated cases and substantial benefit also at 2 and 3-years follow-ups. Future studies with strict patient selection and uniform outcome definitions are warranted.

Introduction

Propofol administration managed directly by the gastroenterologist is a sedation regimen, which is broadly spreading, in clinical practice in Endoscopy Units (EU) all over the world [1]. This is primarily due to a very high patient and endoscopist satisfaction. Moreover, fears associated with propofol use by non-anesthesia providers are based on sound theoretical principles. Non-anesthesiologist-administered-propofol (NAAPS) managed by the gastroenterologist is an issue still controversial for many anesthesiologist societies.

Aims & Methods

This study aims to analyze safety outcomes between NAAPS sedation and anesthesiologist-assisted deep sedation during endoscopic procedures for low-risk patients. We retrospectively assessed data from low anesthesiologist risk-patients (American Society of Anesthesiologists I-II), undergone esophagogastroduodenoscopies (EGDs) and colonoscopies under NAAPS sedation, and assisted anesthesiologist-deep sedation, between May 2019 and October 2021, in a tertiary center. Primary outcome was to compare sedation related-adverse events rates between NAAPS and deep sedation. Propensity score matching analysis was performed using sex, age, Body Mass Index (BMI), smoking, comorbidities and time examination in order to standardize baseline variables.

Results

Overall, in colonoscopies subset, 2491 patients were managed under NAAPS and 257 patients under deep sedation, whereas in EGDs subset, 2439 patients were managed under NAAPS and 282 patients under deep sedation. In unmatched analysis, no difference was shown in terms of adverse events rates between NAAPS and deep sedation, both in EGDs and colonoscopies subsets (1.8% vs 3.5%; p=0.202 and 1 vs 0,4%, p=0.815, respectively). After matching, EGDs subset analysis comprised 282 procedures in NAAPS group versus 188 in deep sedation group, whereas colonoscopies subset included 256 patients in NAAPS group and 174 in deep sedation group. Matched analysis revealed non-different adverse events rate between moderate and deep sedation groups (colonoscopies 3.5% vs 0.6%, p=0.249 and EGD 0.4% vs 1%, p=0.452, respectively).

Conclusion

NAAPS during endoscopy represents a safe sedation modality, comparable with safety outcomes of anesthesiologist-assisted deep sedation. Cost-efficacy analyses are needed, in order to highlight economic advantages of non-anesthesiologist management of propofol during endoscopy.

References

[1] Gouda B, Gouda G, Borle A, Singh A, Sinha A, Singh PM. Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis. Saudi J Gastroenterol. 2017;23(3):133-143. doi:10.4103/sjg.SJG_501_16

Disclosure

Prof.Silvio Danese has served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millenium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor. The other authors declare no conflict of interests.

Introduction

Scarred colo-rectal lesions still represent an endoscopic challenge due to technical feasibility and histologic radicality. The optimal endoscopic technique of choice remains controversial.
Endoscopic submucosal dissection (ESD) has been proposed as an option since it allows “en-bloc” resection and low rates of recurrence [1],[2]. Nevertheless, it represents a time-consuming procedure, burdened by complications in non-experts’ hands. Hybrid ESD (H-ESD), has been suggested as rescue therapy in cases where complete ESD is not feasible [3].

Aims & Methods

We retrospectively analyzed a prospectively collected cohort of 180 patients who underwent ESD for scarred colorectal lesions at San Raffaele Scientific Institute in Milan and Arcispedale Santa Maria Nuova, Reggio Emilia, Italy, between January 2009 and October 2022. Procedures were performed by expert endoscopists, who had completed more than 60 colo-rectal ESD. Primary outcome was to assess technical success, defined as the completion of an “en-bloc” ESD. Technical failure was defined as the need of conversion to H-ESD to complete the procedure. Secondary outcomes included: curative resection (cR), defined as submucosal invasion < 1,000-micron, complete resection (CR), defined as en-bloc resection with free histologic margins and recurrence rate at follow-up. Lesions characteristics, technical data of procedures, adverse events rate were also collected. Predictive factors of technical success were assessed through univariate analysis and multivariate logistic regression.

Results

Mean age was 68.42±11.4 years (range 38-89), with a 56/44 female to male ratio. Most of the lesions were in the rectum (50.6%), followed by left colon (13.9%), transversum (9.4%) and right colon (26.1%). Grade of fibrosis was mostly severe (F3 56.7%; F2 24.4%; F1 18.9%), due to previous treatment attempts (70.6%) or biopsy sampling (29.4%). Mean diameter of lesions was 35.06±20.04 cm² with a mean procedural time 99.9±60.4 min and a mean dissection speed of 9.13±8.13 mm²/min. Technical success with completion of the ESD was 62.2% (112/180) with an overall en-bloc resection rate of 96.4%, while conversion to H-ESD was needed in 37.8% (68/112) of cases with en-bloc resection rate of 32.3%, due to severe fibrosis (38/68), difficult access (17/68), perforation (4/68), hemodynamic instability (2/68). Overall, CR rate was 60.6%, while cR was obtained in 92.3% of cases. No difference between ESD and H-ESD were found in term of neither CR and cR (p=0.725 and p=0.787 respectively). Nine patients (4.8%) were referred for additional surgery due to non-curative histology after endoscopic treatment (adenocarcinomas 11.7% and neuroendocrine carcinomas 1.7%). In total, 24 adverse events (13.3%) occurred, the majority in completed ESD group (20/24 cases), mostly perforations (7%) which were all managed endoscopically. Recurrence occurred in 13 patients (7%) during a mean follow-up period of 374 days (range 55-1808). At the multivariate analysis fibrosis due to previous treatment (OR 3.08 [95 % CI 1.25-7.58], p=0.0243), high grade of fibrosis (OR 2.30 [95 % CI 1.35-3.93], p=0.0021) and right colon location (OR 1.96 [95 % CI 1.48-2.62], p=0.000003) resulted as predictive factors of technical failure.

Conclusion

ESD is a feasible, safe and effective treatment for colorectal-scarred lesion, when performed by expert endoscopists, showing high rates of “en-bloc” resection and assuring high histologic radicality and low rate of recurrence. H-ESD is a viable rescue treatment when the completion of ESD is not feasible.

References

1. Azzolini F, Camellini L, Sassatelli R, et al. Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (Esd in scar-embedded rectal polyps). Clin Res Hepatol Gastroenterol. 2011;35(8-9):572-579. doi:10.1016/j.clinre.2011.04.013
2. Hurlstone DP, Shorthouse AJ, Brown SR, Tiffin N, Cross SS. Salvage endoscopic submucosal dissection for residual or local recurrent intraepithelial neoplasia in the colorectum: a prospective analysis. Colorectal Dis. 2008;10(9):891-897. doi:10.1111/j.1463-1318.2008.01510.x
3. Chedgy FJ, Bhattacharyya R, Kandiah K, Longcroft-Wheaton G, Bhandari P. Knife-assisted snare resection: a novel technique for resection of scarred polyps in the colon. Endoscopy. 2016;48(3):277-280. doi:10.1055/s-0035-1569647

Disclosure

Prof.Silvio Danese has served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millenium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor. The other authors declare no conflict of interests.

Introduction

In recent years, propofol has become the sedative of choice for gastrointestinal endoscopy. Despite large cohort studies demonstrating its safety and effectiveness, the adoption of Non-Anesthesiologist Administration of Propofol (NAAP) in clinical practice still faces numerous challenges, both in Europe and globally. Consequently, propofol-based sedation remains largely in the hands of anesthesia professionals.

Aims & Methods

This study was conducted in two phases. Initially, a preliminary analysis was carried out to compare adverse event (AE) rates between NAAP and Anesthesiologist Administration of Propofol (AAP) at a tertiary academic center (San Raffaele Hospital, Milan, Italy). In the second phase, potential cost savings from implementing NAAP over AAP at the hospital, local, and national levels were examined.
Propensity score matching (PSM), based on age, sex, body mass index (BMI), and ASA Physical Status Classification System score, was used to compare the two cohorts. A 3-year budget impact model (BIM) was implemented based on the annual volume of outpatient endoscopy procedures performed at San Raffaele Hospital and estimates of the Italian adult population by Italian National Institute of Statistics (ISTAT).

Results

From May 2019 to October 2021, 2,721 patients who underwent esophagogastroduodenoscopy (EGD) (2,439 NAAP and 282 AAP) and 2,748 who underwent colonoscopy (2,491 NAAP and 257 AAP) in outpatient setting were enrolled. Only diagnostic procedures were included. After PSM, the EGD cohort included 282 patients under NAAP and 188 under AAP, while the colonoscopy cohort consisted of 256 patients under NAAP and 174 under AAP. No significant differences in AE rates were observed between the groups in both the EGD (overall: NAAP 1.1% vs AAP 0.8%, p=0.815; after PSM: NAAP 0.4% vs. AAP 1.0%, p=0.452) and colonoscopy cohorts (overall: NAAP 1.7% vs AAP 3.5%, p=0.202; after PSM: NAAP 3.5% vs. AAP 0.6%, p=0.249). All AEs were managed without leading to major or long-term sequelae.
According to the BIM, a complete implementation of NAAP instead of AAP for patients classified as ASA 1 and 2 would lead to financial savings of €851,649 at our hospital, €8.3 million for the Local Health Authority of Milan, €19.8 million for the Lombardy region, and €124.7 million for the Italian National Health System over the triennium 2023-2025.

Conclusion

NAAP is a safe sedation modality for outpatient gastrointestinal endoscopy, with AE rates comparable to those of AAP. Its widespread implementation, at the expense of AAP, could result in savings exceeding €120 million for the Italian National Health System over the triennium 2023-2025.

References

NAAP is a safe sedation modality with AE rates comparable to AAP. The widespread implementation of NAAP, rather than reliance on anesthesiologist-led propofol sedation, could result in savings exceeding €120 million for the Italian National Health System over the triennium 2023-2025.

Introduction

Bowel cleansing completion time is one of the important factors for optimal bowel preparation. The recommended completion time is within 3-8 hours of colonoscopy.

Aims & Methods

In this randomized study, we investigated the optimal bowel preparation completion time between short interval and long interval. Study participants were randomized into two groups: short interval, bowel preparation completion time (2-4 hours of colonoscopy); long interval (4-8 hours of colonoscopy). The primary endpoint was successful bowel cleansing assessed by Boston bowel preparation (BBPS) scale. Secondary endpoint included Aronchick scale and patient’s tolerability investigated by sleep disturbance and patients’ satisfaction. Bowel preparation was performed using 4 L polyethylene glycol.

Results

​A total of 504 individuals were included (short interval, 255; long interval, 249). Mean time for bowel preparation finish time was 2.99 and 5.12 hours respectively. The rate for successful preparation was comparable between the two groups (short interval, 97.6% and long interval, 95.2%, p=0.136). Total BBPS score was 8.22 in the short interval group, which was higher than that of long interval group (7.82, p<0.001). Regional score for Rt. colon (2.65 vs 2.44, p < 0.001) and Lt. colon (2.65 vs 2.56, p=0.057) of short interval group was higher than that of long interval group. Regional score for T-colon (2.92 vs 2.82, p = 0.002) and was comparable between the two groups. Sleep disturbance was higher in the long interval group. Safety did not differ between the two groups.

Conclusion

The rate for successful preparation were similar for the two groups. Total BBPS score and regional scores for Rt. colon and T-colon were higher in the short interval group. For better bowel cleansing, bowel preparation finish time is recommended 2-4 hours of colonoscopy.

References

Gastrointest Endosc 2015;81:31-53
Gastroenterology 2016;150:396–405
WJGE 2013 February 16; 5(2): 39-46
Endoscopy. 2019;51(8):775-794