Introduction

There is a paucity of information on the efficacy and safety of endoscopic resection (ER) of gastric submucosal tumors (SMT) in Japan where ER for early gastric cancer is extremely popular.

Aims & Methods

A multicenter retrospective study was conducted to elucidate the current situation of ER for gastric SMT in Japanese endoscopic practice. Clinicopathological data of consecutive patients with gastric SMT who underwent ER in 12 Japanese hospitals were collected from the first case until August 2020.

Results

A total of 117 patients with 118 lesions were enrolled. The number of patients with gastric SMT who underwent ER increased over the years. The mean (SD) endoscopic tumor size was 20 (7.2) mm. The growth type was primarily intraluminal (90%). 87 (74%) of the procedures were performed in an operating room under general anesthesia. The tunneling method was used in 5 (4%) cases. The mean (SD) resection and wound closure times were 58 (38) min and 31 (41) min, respectively. Complete ER was achieved for 117 (99%) lesions. Full-thickness resection rate was 44%; however, only 12 (10%) patients required abdominal paracentesis for pneumoperitoneum. Endoscopic treatments were completed in 115 (97%) lesions, while three lesions required conversions to laparoscopic surgery due to luminal collapse, uncontrolled bleeding, and difficulty in defect closure. Two cases of delayed bleeding were managed by endoscopic hemostasis, one of which required a blood transfusion. Gastrointestinal stromal tumors were the most common pathology (74%). The R0 resection rate was 76%. Survival and recurrence on August 31, 2021, were confirmed in 112 patients (96%) with a mean (SD) follow-up period of 4.3 (2.9) years. 109 (94%) were confirmed alive, the vital status of five patients was unknown, and three patients had died of other diseases. No recurrence was observed. The 5-year overall survival rate was 98.9% (95% confidence interval, 97.8−100%).

Conclusion

The performance of ER for gastric SMT is increasing in Japan. The technique seems feasible in Japanese endoscopic practice, warranting further validation in a prospective study.

Introduction

Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) is the most prevalent hepatic disorder worldwide. While histology remains the gold standard, a shift is evident in emerging studies favoring Magnetic Resonance Imaging Proton Density Fat Fraction (MRI-PDFF) over biopsy as a reliable alternative for steatosis assessment. Similarly, Controlled Attenuation Parameter (CAP) enables the noninvasive assessment of liver steatosis.

Aims & Methods

To assess the accuracy of CAP for MASLD diagnosis as defined by MRI-PDFF. We performed a cross-sectional, diagnostic accuracy study with prospectively collected data. We included consecutive adult participants with type 2 diabetes (T2D) and increased body mass index (BMI ≥25 kg/m²). We used receiver operating characteristic (ROC) curve analyses to assess the accuracy of CAP for diagnosing MASLD (MRI-PDFF ≥5%), and hepatic fat content (HFC) ≥10%. For each ROC analysis, we calculated the area under the ROC (AUROC) alongside 95% Confidence Intervals (CIs), and cutoffs for ruling out (sensitivity >90%) and ruling in (specificity >90%) the target condition. For each cutoff, we calculated the negative (NPV) and positive predictive values (PPV), as well as negative (LRn) and positive (LRp) likelihood ratios with their 95% CIs.

Results

We included 113 participants (58.4% males, mean age 59.6 years). Most participants (95.6%) had a BMI ≥30 kg/m². CAP measurements were performed with the M probe in 36.3% of the participants, and the remaining (63.7%) were scanned with the XL probe. MRI-PDFF values ranged from 1.9% to 37.8% covering the whole spectrum of steatosis. The prevalence of MASLD was 72.6%. The AUROC of CAP for MASLD diagnosis was 0.82 (0.74 to 0.89). The threshold for ruling out MASLD was 249 dB/m yielding a sensitivity (Sens) of 90.2% (81.7 to 95.7), specificity (Sp) 35.5% (19.2 to 54.6), LRp 1.40 (1.07 to 1.83), LRn 0.27 (0.12 to 0.62), PPV 78.7% (73.8 to 82.9) and NPV 57.9% (37.9 to 75.6). Similarly, the threshold for ruling in MASLD was 328 dB/m yielding a Sens, Sp, LRp, LRn, PPV and NPV of 47.6% (36.4 to 58.9), 90.3% (74.2 to 98.0), 4.91 (1.64 to 14.75) and 0.58 (0.46 to 0.74), 92.9% (81.2 to 97.5) and 39.4% (34.0 to 45.2), respectively. The AUROC of CAP for detecting HFC ≥10% was 0.81 (0.73 to 0.88). CAP thresholds for ruling out/in HFC ≥10% were 271 dB/m and 345 dB/m respectively. CAP measurements with IQR < 30 dB/ did not improve the accuracy of CAP for MASLD diagnosis

Conclusion

CAP has acceptable diagnostic accuracy in identifying patients with MRI-PDFF defined MASLD. Thresholds below 249 and 271 dB/m can be used to exclude MALSD and HFC ≥10% with adequate sensitivity. Similarly, CAP values over 328 and 345 dB/m can rule in MASLD and HFC ≥10% respectively.

Disclosure

This study was supported by the Hellenic Association for the Study and Education of Diabetes Mellitus

Introduction

Endoscopic submucosal dissection (ESD) is a common treatment for early-stage gastrointestinal cancers, but managing delayed bleeding from post-ESD ulcers can be challenging. With more patients taking antithrombotic drugs, reliable bleeding prevention methods are crucial. This study presents the Dumpling technique, a new solution for preventing delayed bleeding from these ulcers.

Aims & Methods

Dumpling technique: The technique involves using a double-lumen catheter to inject fibrin glue into the pocket created after suturing an artificial ulcer post-ESD. This technique not only covers the ulcer but also provides a tamponade effect through compression. The fibrin glue is encased by the sutured mucosa, giving it the appearance of a dumpling. An important point of this technique is the use of a double-lumen catheter for fibrin glue injection. Fibrin glue consists of a fibrinogen solution and thrombin solution. Single-lumen catheters cannot be used because the two solutions begin to form a gel in just a few seconds when mixed. One advantage of this technique is that it combines existing products, so no new product development time is required.
An artificial ulcer was created in the resected bovine rectum by ESD flow, fixed to a jig, and a defect of 2.7 mm in diameter was created using an Aorta/Vein Punch. Pig blood that had lost coagulability was then injected to create a hemorrhage model. First, pressure resistance was measured after clip sutures only. Next, the same ulcer was used as is, the blood was washed out, fibrin glue was injected, and pressure resistance was measured again and compared between the two groups (Clip suture group vs Dumpling technique group). In addition, to confirm the feasibility of the technique, the Dumpling technique was performed endoscopically on porcine explanted stomach and bovine explanted rectum, and the excised specimens were evaluated.

Results

The mean ± SD pressure resistance in the bleeding model was 40.2 ± 14.0 mmHg in the clip suture group and 134.5 ± 36.8 mmHg in the Dumpling technique group (N = 5). Feasibility checks confirmed that suture spacing could be performed endoscopically without problems by setting the suture spacing to allow catheter tip insertion. The resection specimen was confirmed to be sufficiently filled with fibrin glue in the pocket.

Conclusion

This study suggests that the Dumpling technique improves the bleeding prevention effect of ulcer closure. Although various methods of ulcer suturing are still being developed, the injection of fibrin glue itself is expected to be adoptable by many clinicians because it does not require high skill if the tip of the catheter can be inserted through the gap between the sutures. We plan to confirm the feasibility of the Dumpling method in an in vivo study using pigs, followed by a clinical trial to confirm the effectiveness of the Dumpling technique.

Disclosure

Mr. Takegawa is employees of KM Biologics Co., Ltd. and the fibrin glue (BOLHEAL®) used in this article is manufactured by KM Biologics Co., Ltd.

Introduction

Control of intraoperative bleeding is vital in endoscopic submucosal dissection (ESD) for gastric neoplasms. We developed an ESD method specialized for hemostasis (Spray-ESD) focusing on the Spray coagulation mode (VIO3; ERBE) with high voltage, easy spark control, and improved incision performance.

Aims & Methods

This study aimed to determine the efficacy of Spray-ESD for gastric neoplasms compared to conventional ESD (C-ESD).
An open-label, randomized, controlled trial was conducted from June 2021 to February 2022 at five centers in Japan, and patients with gastric neoplasms meeting the absolute indication for ESD were included in the study. (The clinical registration number is UMIN000034353) Patients were randomized 1:1 to Spray-ESD or C-ESD, and the outcomes of both groups were compared. ESD was performed with an electrosurgical knife: ProKnife. Hemostatic forceps: Hemostat-Y was used for soft coagulation when bleeding was difficult to control. The primary endpoint was the completion rate of ESD using the knife alone without hemostatic forceps. Secondary endpoints were the number and duration of hemostatic forceps use, ESD procedure time, radical cure, and safety.

Results

We analyzed 130 registered cases (Spray-ESD: 65 cases, C-ESD: 65 cases). The completion rate of ESD using the knife alone was significantly higher in Spray-ESD (83.1% vs. 13.8%, P<0.001). The number and duration of hemostatic forceps use were significantly lower in Spray-ESD (median: 1 vs. 3.5 times, P<0.001; 2.0 min vs. 5.5 min, P<0.001). ESD procedure time was not significantly different between the two groups (48.0 min vs. 56.0 min, P=0.11). Both groups had equally high resection rates (complete en bloc resection rate: 100% vs. 95.4%, P=0.24; curative resection rate: 90.8% vs. 87.7%, P=0.78), with a low adverse events rate. (3.1% [posterior bleeding in 2 cases] vs. 6.2% [intraoperative perforation in 1 case, posterior bleeding in 3 cases], P=0.68).

Conclusion

Spray-ESD has been shown to significantly reduce major bleeding requiring hemostats while maintaining a high en bloc resection rate; mastery of the Spray coagulation mode allows for safe ESD with reduced bleeding risk.

Introduction

Steatotic liver disease (SLD) encompasses a spectrum of conditions, including metabolic dysfunction-associated SLD (MASLD), alcohol-related liver disease (ALD), and the overlapping category of MetALD. SLD affects more than a third of adults globally, but the majority remain undiagnosed, partially due to its lack of symptoms and limited awareness among patients and physicians. Adults undergoing screening colonoscopy, typically aged ≥50 years, represent a key population for targeted SLD detection, as they have a higher prevalence of cardiometabolic risk factors and is already engaged with preventive healthcare.

Aims & Methods

We examined 610 consecutive individuals aged ≥50 years with no known history of chronic liver disease who were referred for a colonoscopy for colorectal cancer screening. The protocol included sonographic assessment of liver steatosis and point shear wave elastography (pSWE) for liver fibrosis quantification, anthropometric measurements, biochemistry, medical history and alcohol intake evaluation. From the collected data, non-invasive fibrosis scores were calculated and used for aetiological and risk stratification.

Results

A total of 543 patients were included in the final analysis, after excluding patients with an invalid pSWE measurement (5.3%, n=29) and then excluding patients with incomplete results (n=38). The median age was 64 years (IQR 57-70) and 54.0% were male. The median BMI was 28.7 kg/m² (IQR 25.8–31.4) in males and 28.3 kg/m² (IQR 24.2-31.5) in females. SLD was identified in 63.4 % (n=344) of participants. Elevated liver stiffness (pSWE ≥ 1.30 m/s) was found in 26.9 % (n=146), and 4.8% (n=26) had values ≥1.70 m/s, suggestive of compensated advanced chronic liver disease. Among patients with pSWE ≥ 1.30 m/s, MASLD was the predominant aetiology (69.9%, n=102), followed by MetALD (15.8%, n=23), ALD (1.4%, n=2), cryptogenic (11.6%, n=17) and other etiologies (1.4%, n=2). Preselection using EASL-EASD-EASO criteria (i.e. presence of type 2 diabetes or central obesity plus ≥1 cardiometabolic risk factor and elevated liver enzymes) would have detected 365 at-risk individuals (67.2% of the cohort) of whom 55.9% (n=204) had a FIB-4 index ≥1.30. This approach would have identified only 30.4% (n=38) of all the patients with MASLD/MetALD with elevated liver stiffness (n=125).

Conclusion

Opportunistic screening for SLD in patients undergoing screening colonoscopy could be a useful strategy for detecting asymptomatic and potentially progressive liver disease. This approach identified a high prevalence of SLD (63.4%) and elevated liver stiffness (26.9%) in this population, primarily due to MASLD and MetALD. The integration of ultrasound and elastography added minimal burden to the existing workflow while enabling early risk stratification without the need for additional patient visits or referrals.

References

1 Tacke F, Horn P, Wong VWS, Ratziu V, Bugianesi E, Francque S, et al. EASL–EASD–EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). Journal of Hepatology [Internet]. 2024 Jun 7;81(3):492–542.
2 Lazarus JV, Miralles-Sanchez JE, Agirre-Garrido L, Brachowicz N, Nicolàs A, Armenta A, et al. A call to action to address the steatotic liver disease public health threat in Barcelona. The Lancet Regional Health - Europe [Internet]. 2025 Mar 22;52:101272.
3 Barr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the Society of Radiologists in Ultrasound Liver Elastography Consensus Statement. Radiology [Internet]. 2020 Jun 9;296(2):263–74.

Introduction

Increased intestinal permeability, or leaky gut, is a condition where the gut's epithelial barrier is compromised, allowing bacteria and toxins to enter the blood stream. In liver cirrhosis, this can exacerbate liver damage and accelerate disease progression by perpetuating inflammation and immune system activation. Accurate assessment of this dysfunction is critical to the management of cirrhotic patients, but traditional methods such as serum markers and indirect assays often lack specificity and sensitivity.
Confocal laser endomicroscopy (CLE) is an advanced imaging technique that provides real-time, high-resolution visualisation of the gastrointestinal tract at the cellular and subcellular levels. CLE is used to diagnose leaky gut by directly observing disruptions in the intestinal mucosa. It integrates a confocal microscope within an endoscope, enabling in vivo histology-like imaging during routine endoscopic examinations.

Aims & Methods

We aimed to use confocal laser microendoscopy (CLE) in the diagnosis of intestinal barrier dysfunction by direct observation of the intestinal mucosa, in patients with liver cirrhosis. CLE (Cellvizio, Mauna Kea Technologies) was performed in the second part of the duodenum following intravenous administration of 2.5 – 5 mg of fluorescein in 58 patients with liver cirrhosis of various aetiologies. These patients were undergoing routine endoscopic surveillance or therapeutic intervention for oesophageal varices. The study cohort consisted of 39 men (61.9%) and 19 women (30.2%), with a mean age of 53.9 ± 14.0 years. We collected and analysed the most recent results of hepatic venous pressure gradient (HVPG), liver stiffness measurement (LSM), and fibrosis index for liver fibrosis (Fib-4). A Watson score of 1 indicates normal barrier function, while a Watson score of 2 indicates impaired barrier function. Data are given as mean± standard deviation, statistical analysis included Chi-square tests and Student’s t-tests, with a significance level set at p<0.05. NS=not significant.

Results

We observed a gradation of intestinal barrier dysfunction that correlated with the severity of liver cirrhosis. Specifically, of the 35 patients with Child-Pugh A cirrhosis, 18 (51.4%) had a Watson score of 2. In the group of 14 patients with Child-Pugh B cirrhosis, 9 (64.3%) had a Watson score of 2 and of the 9 patients with Child-Pugh C cirrhosis, 8 (88.9%) had a Watson score of 2, further underscoring the trend of increasing intestinal barrier dysfunction with increasing liver disease severity (p<0.05). In contrast, no significant differences in hepatic venous pressure gradient (HVPG) were observed between patients with Watson score 1 (16.8 ± 6.2 mmHg) and Watson score 2 (17.2 ± 6.2 mmHg, p NS). Similarly, liver stiffness measurements (LSM) showed no statistical difference between patients with Watson score 1 (39.0+/-23.7 kPa) and those with score 2 (40.2 ± 22.9 kPa) (p NS)=. Similarly, Fib-4 was 4.5 +/-3.1 in patients with Watson score 1 and 5.7+/-3.6 in patients with Watson 2 (p NS).

Conclusion

The findings suggest an association between the severity of liver cirrhosis and impaired intestinal barrier function as assessed by CLE. This impairment does not correlate with changes in haemodynamic parameters or liver fibrosis. The CLE promises to provide accurate and immediate diagnostic data and to improve our understanding of the pathophysiological changes in the gut associated with liver cirrhosis. Further research is needed to explore the mechanisms linking the severity of cirrhosis to intestinal barrier dysfunction and its clinical implications.

Disclosure

No conflict of interest to declare

Introduction

Endoscopic submucosal dissection (ESD) is a common treatment for low-risk gastric cancers, but postoperative bleeding, affecting 0%-15.6% of patients, remains a concern. With aging populations and increased antithrombotic agent use, post-ESD bleeding may soon become even more frequent. Fibrin glue with polyglycolic acid (PGA) sheets has shown promise in preventing post-ESD bleeding, but challenges exist, especially when applying sheets against gravity in gastrointestinal ulcers. Moreover, the PGA sheets themselves can be difficult to manipulate and place onto the ulcer bed. The envelope method, developed in 2017, involves storing PGA sheets in a protective envelope that is carried alongside the endoscope, preventing exposure to saliva or mucus which commonly occurs when PGA sheets are individually passed down the endoscope channel. The envelope then adheres to the gastric wall, and clean PGA sheets can be drawn easily using forceps. This method has demonstrated efficient PGA sheet delivery and fixation but was only found to be effective for gravitational ulcers.

Aims & Methods

The study aims to evaluate the envelope method's efficacy in treating both gravitational and anti-gravitational post-ESD ulcers in living porcine stomachs.Gravitational and anti-gravitational artificial ulcers were created via ESD in living porcine stomachs, using a standardized template as a sizing guide. PGA sheets were then applied to each ulcer, employing the conventional and envelope methods six times each. To standardize the ulcer location and characteristics, the sheets were removed after application, and reapplied over the same ulcer bed. To account for minute changes in ulcer environment over time, the method of re-application was alternated between the conventional and envelope methods. The delivery time of PGA sheets and the endoscopic and histological observations of the treated ulcer surfaces were comparatively analyzed. The ulcers were measured with an endoscopic scale, and the delivery time was presented in min/cm² to allow for subtle differences in ulcer size.

Results

The envelope method showed significantly shorter application times compared to the conventional method for both gravitational (1.0 min/cm² vs 0.32 min/cm², p=0.002) and anti-gravitational ulcers (1.2 min/cm² vs 0.50 min/ cm² p=0.002). In endoscopic examinations, the envelope group demonstrated appropriately applied PGA sheets in anti-gravitational ulcers, with flat sheets and minimal overlapping, while the conventional group showed uneven sheets and clumping. Histologically, the envelope method provided uniform coverage of the ulcer floor with a mixture of PGA sheets and fibrin glue, while the conventional method left gaps between sheets.

Conclusion

The envelope method enables swift transportation and accurate fixation of PGA sheets within living porcine stomachs. This approach is applicable for addressing both gravitational and anti-gravitational ulcers, and may have utility in the prevention of post gastric ESD bleeding.