Introduction

As the demand for advanced endoscopy procedures grows worldwide, endoscopy units specializing in these procedures face significant challenges in meeting this demand with limited resources. Consequently, there is an urgent need to optimize endoscopy unit efficiency. Previous studies have highlighted non-procedural factors, including room turnover, as a key area to improve efficiency. However, turnover time in advanced endoscopy units varies considerably across the world. To address this issue, our study aims to compare turnover time in different regions globally to identify best practices for enhancing endoscopy unit efficiency.

Aims & Methods

We conducted a retrospective chart review of endoscopic procedures performed between January 2022 and November 2022 in five centers (two in the US, one in Italy, and one in Ecuador) to collect data. Both inpatient and outpatient procedures were included. We categorized the procedures into three groups based on their regions: US, Europe, and Latin America. Turnover time was defined as the time elapsed from one patient leaving the room until the next patient entering the room. Procedure time was defined as the duration from the first scope being inserted to the last scope being removed. We used t-tests to compare the turnover time between the different regions.

Results

Our study analyzed a total of 1,200 cases from three different regions: US (n=910), Italy (n=107), and Ecuador (n=183). Some patients underwent multiple procedures during the same session (Table 1).Among the US group, 34% of procedures were ERCP, 23% were EUS, 23% were EGD, and 14% were colonoscopies. Out of the 910 cases, 655 (73%) were performed on an outpatient basis. The average turnover time for the US group was 39.5 minutes, and the average procedure time was 45 minutes.In the Italy group, 35% of procedures were ERCP, 47% were EUS, and 8% were EGD. Out of the 107 cases, 61 (57%) were performed on an outpatient basis. The average turnover time for the Italy group was 11.6 minutes, and the average procedure time was 42 minutes.Within the Ecuador group, 31% of procedures were ERCP, 32% were EUS, and 4% were EGD. Out of the 183 cases, 141 (77%) were performed on an outpatient basis. The average turnover time for the Ecuador group was 15.7 minutes, and the average procedure time was 131 minutes. In 47 cases (25.7%), more than one endoscopy procedure was performed during the same session.Comparing the results, the US group had a significantly higher turnover time by over 20 minutes compared to the other regions (p < .00001). However, there was no significant difference in the number of EUS and ERCP procedures between the groups.

Conclusion

The results of our study demonstrate a significant difference in turnover time between the US and Italy/Ecuador despite similar numbers of EUS and ERCP procedures and comparable or lower procedure times. With a difference of over 20 minutes, this highlights the urgent need for optimizing the efficiency of endoscopy units in the US. To achieve this, further comparative studies between the US and international centers are necessary. Our findings provide a valuable starting point for developing best practices and strategies to enhance endoscopy unit efficiency and meet the growing demand for these procedures.

Introduction

Low-volume bowel preparation solutions, including 1 L polyethylene glycol plus ascorbate (PEG-A), have been developed to improve tolerability because of the low tolerability of high-volume polyethylene glycol agents. However, 1 L PEG-A still has its typical odor that is not pleasant for most patients. The oral sodium sulfate tablet (OST) is a new agent with simethicone as a preloaded component. OST may have the better tolerability because of little odor due to its tablet formula.

Aims & Methods

We aimed to investigate the efficacy, safety, and tolerability of OST compared to 1 L PEG-A. We randomized patients aged 18 years or older who underwent colonoscopy into the OST (group A) and 1 L PEG-A (group B) groups. Bowel preparation efficacy was assessed on the Boston bowel preparation scale (BBPS) and bubble scale. Bowel preparation success was defined as BBPS score ≥ 6. The bubble scores ranged from 0 to 3 per segment (total from 0 to 9), with a lower score indicating lower bubbles in the colonic lumen. Safety and tolerability were evaluated using a systematized questionnaire.

Results

A total of 171 patients (group A: 87, group B: 84) were included in the final analyses. The average BBPS score of group A was 8.0±1.3, which was similar to that of group B (7.7±1.4) (p=0.215). The proportion of patients showing bowel preparation success was 95.4% in the group A whereas that in the group B was 96.4% (p=0.736). The adenoma detection rate was also similar between groups A (59.6%) and B (41.9%) (p=0.087). The bubble scale in the group A was 0.2±0.9, which was significantly better that that of the group B (1.9±1.7) (p<0.001). All adverse events were mild in both groups. The group A showed lower frequency of nausea compared to the group B (14.9% vs. 38.1%, p=0.001). Overall satisfaction was better in the group A (8.1 ± 2.1 vs. 6.4 ± 2.8, p<0.001).

Conclusion

Although both OST and 1 L PEG-A were efficacious, safe, and tolerable for bowel preparation of colonoscopy, the OST showed fewer bubbles and slightly better tolerability.

Introduction

Bowel preparation is recognized as the most burdensome aspect of the whole colonoscopy procedure, sometimes even worse that the examination itself, and represents a major barrier to screening colonoscopy. Mannitol could significantly improve patient acceptability as it is rapid, requires a single dose, a low volume and has a pleasant taste. The SATISFACTION study compared oral mannitol 100g/750ml with standard split-dose 2L PEG-ASC (MoviPrep®).

Aims & Methods

The SATISFACTION Phase III study was an international, multicentre, randomized (1:1), parallel-group, endoscopist-blinded non inferiority trial. Primary endpoint was the proportion of patients with adequate bowel cleansing. Secondary endpoints concerned efficacy (adenoma detection rate, caecal intubation rate, time of evacuation), safety (intestinal gases concentration, haematobiological parameters, adverse events) and patient satisfaction. The study included 703 patients (352 treated with mannitol and 351 with PEG-ASC) undergoing elective colonoscopy.

Results

Mannitol was not inferior to PEG-ASC for proportion of patients with adequate cleansing (91.1% and 95.5% respectively; p value for the non-inferiority =0.0095). There was no significant difference for secondary efficacy endpoints. The profile of acceptability was significantly better in mannitol group for easy to use, taste, willingness to use (p<0.0001 for all parameters). The concentration of intestinal gases (H₂, CH₄) was similar in the two groups and well below those potentially critical.

Conclusion

Mannitol was not inferior to PEG-ASC for proportion of patients with adequate cleansing (91.1% and 95.5% respectively; p value for the non-inferiority =0.0095). There was no significant difference for secondary efficacy endpoints. The profile of acceptability was significantly better in mannitol group for easy to use, taste, willingness to use (p<0.0001 for all parameters). The concentration of intestinal gases (H₂, CH₄) was similar in the two groups and well below those potentially critical.

Disclosure

Prof. Gian Eugenio Tontini and Prof. Maurizio Vecchi received a consultant fee from NTC Pharma. Anna Orsatti is a current NTC Pharma employee

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

Recent evidence suggests that appendectomy is associated with a reduced risk of developing ulcerative colitis (UC) or even the risk of flare after UC is diagnosed, thus suggesting a potential involvement of the appendix in UC pathogenesis. Interestingly, several studies support the role of the appendix in the maintenance of the intestinal microbiome and gut immunity1. We hypothesize that the appendix in UC may function as a reservoir for dysbiotic microbiota capable of promoting and re-establishing dysbiosis that could fuel inflammation in the colon in patients with UC.

Aims & Methods

The current study aimed to define the tissue-associated microbiota of the UC appendix, and investigate the changes compared to non-UC appendix. Thirty-seven patients operated on for UC or acute appendicitis were recruited. Appendicular wall tissue samples were obtained, inflammatory cells were isolated and analyzed by flow cytometry, and total DNA was extracted from the whole tissue. The V3-V4 region of the 16S rRNA gene was sequenced utilizing a MiSeq Platform (Illumina, USA). Sequences were processed using the QIIME22 pipeline, the taxonomy was assigned using the Greengenes3 database, and statistical analysis was performed in R.

Results

Twenty-seven samples were analyzed from 37 patients, 19 from UC, and 8 from acute appendicitis patients. Analyses revealed Firmicutes was the most proportionally abundant bacterial phylum in the UC appendix (mean=72.6%), followed by Proteobacteria (16%). Analysis of alpha diversity revealed no significant difference in terms of species richness, Shannon, and Pielou indices between UC and non-UC appendix (p=0.9;p=0.087;p=0.26). The PERMANOVA test revealed that UC appendix communities were significantly different from non-UC appendix communities (p=0.015). We identified 5 differentially abundant species in the study's samples, all of these significantly decreased in UC appendix vs. non-UC appendix: Fusobacterium unknown species (p=4.36x10-4), Pseudoramibacter unknown species (p=4.46x10-3), Streptococcus anginosus (p=2.67x10-2), Mogibacterium unknown species (p=2.67x10-2) and Actinomyces hyovaginalis (p=3.64x10-2). Fusobacterium, Pseudoramibacter, and Mogibacterium were also differentially abundant at the genus level (p=3.10x10-4; p=3.17x10-3; p=2.53x10-2). The expression of CD86 on activated dendritic cells (CD1a+HLAdr+CD86+) was significantly higher in UC patients than in appendicitis patients (p=0.049) and in UC patients CD1a+HLAdr+CD86+ cells rate directly correlated with disease activity as expressed by Harvey Bradshaw Index (rho=-0.513, p=0.025). The abundance of Fusobacterium unknown species inversely correlated with CD1a+HLAdr+CD86+ mean fluorescence intensity (rho=-0.466, p=0.047).

Conclusion

These preliminary data showed that specific taxa are significantly less present in the UC appendix compared to the non-UC appendix, suggesting that a distinctive UC appendix microbiota exists. Taxa with altered abundance may contribute to UC pathogenesis. These data may provide microbial signatures useful for guiding both the treatment and diagnosis of UC.

References

1. Arjomand Fard N, Armstrong H, Perry T, Wine E. Appendix and Ulcerative Colitis: a Key to Explaining the Pathogenesis and Directing Novel Therapies? Inflamm Bowel Dis. 2023;29(1):151–160. doi:10.1093/ibd/izac106.
2. Bolyen E, Rideout JR, Dillon MR, Bokulich NA, Abnet CC, Al-Ghalith GA, Alexander H, Alm EJ, Arumugam M, Asnicar F, Bai Y. Reproducible, interactive, scalable and extensible microbiome data science using QIIME 2. Nature biotechnology. 2019 Aug;37(8):852-7.
3. DeSantis TZ, Hugenholtz P, Larsen N, Rojas M, Brodie EL, Keller K, Huber T, Dalevi D, Hu P, Andersen GL. Greengenes, a chimera-checked 16S rRNA gene database and workbench compatible with ARB. Applied and environmental microbiology. 2006 Jul;72(7):5069-72.

Introduction

Motorized spiral enteroscopy (MSE) has shown to be safe and effective for deep small bowel enteroscopy in patients with and without prior abdominal surgery, including patients with Crohn’s disease.
This case series reports our first results regarding the feasibility and safety of the MSE with endoscopic balloon dilatation in patients with small bowel strictures due to Crohn’s disease.

Aims & Methods

Data were collected retrospectively on patients who underwent MSE for endoscopic balloon dilatation of small bowel strictures due to Crohn’s disease. Strictures were either postoperative (P.O.) or post-inflammatory (P.I.).

Results

A total of ten consecutive patients with Crohn’s disease underwent 13 procedures. Propofol sedation without endotracheal intubation was used in all procedures. Demographic and procedure related data are shown in the table. One patient underwent three procedures with 3–4 month intervals. During the third procedure triamcinolone acetonide was injected at four quadrants of the stricture. Fluorescence imaging was used during six procedures. The procedure was technically successful in 12/13 of procedures. In one case, dilatation was not performed because of a longer than anticipated and a sharply angulated stricture.
The number of treated strictures ranged from one to five per procedure. Dilatation of multiple strictures in two patients (4 and 5) was achieved within a relatively short procedure duration of 55 and 70 minutes. Two retained video capsules were retrieved.
Besides the anticipated mild abdominal discomfort and/or sore throat in three patients, no adverse events occurred.

Conclusion

These retrospective data show that MSE with CRE dilatation is feasible and safe in a cohort of patients with strictures due to Crohn’s disease, postoperatively as well as post-inflammatory. The fact that the distal 16 cm of the endoscope are not covered by the spiral overtube makes cautious introduction of the endoscope beyond a recently dilated stricture feasible and safe. Therefore, dilatation of multiple strictures in one session is possible, provided that they are at a short distance from each other. Fluorescence imaging guidance may be helpful in severe stenosis, multiple strictures, or sharp angulations.

Introduction

Bowel urgency is increasingly being recognized as an impactful symptom in patients with ulcerative colitis (UC)¹. However, limited information is available regarding its potential association with other patient reported outcomes. We assessed the association of bowel urgency clinically meaningful improvement (CMI) or bowel urgency remission with Inflammatory Bowel Disease Questionnaire (IBDQ) scores whilst adjusting for the potential confounding effects of stool frequency (SF) and rectal bleeding (RB) remission using data from LUCENT-1 (NCT03518086) and LUCENT-2 (NCT03524092) phase 3 trials.

Aims & Methods

Bowel urgency severity was assessed by the Urgency Numeric Rating Scale (UNRS) (0=no urgency to 10=worst possible urgency). Bowel urgency CMI was defined as ≥3-point decrease in UNRS compared to baseline and bowel urgency remission was defined as UNRS of 0 or 1.² IBDQ scores (range: 32–224) were calculated; higher scores indicate better quality of life. Mediation analyses were performed to examine the relative association between direct effects of bowel urgency CMI and bowel urgency remission (separate predictors) and IBDQ scores while adjusting for the potential confounding effects of SF remission and RB remission (mediators). Analyses were treatment agnostic and combined patients from mirikizumab and placebo groups from LUCENT-1 (N=1162) and LUCENT-2 (N=544) trials at Week (W) 12 and 40 (W52 of continuous treatment).

Results

At W12 and W52, bowel urgency remission directly accounted for 44.8% and 32.5% improvement in IBDQ total score, respectively; 22.7% and 39.1% of improvement was mediated by RB remission and 32.5% and 28.4% by SF remission, respectively. At W12, bowel urgency remission resulted in the largest proportion of improvement in each of the IBDQ domain subscores, whereas at W52, RB remission had a greater confounding effect. At W12 and W52, bowel urgency CMI accounted for 70% and 57.3% improvement in IBDQ total score, respectively; 12.8% and 25.6% of effects were mediated by RB remission and 17.2% and 17.1% by SF remission, respectively. Bowel urgency CMI accounted for the largest proportion of association with improvement in each of the IBDQ domain subscores at both W12 and W52.

Conclusion

​Improvements in IBDQ scores were primarily ascribed to bowel urgency remission and bowel urgency CMI relative to RB remission and SF remission, particularly at W12, in patients with moderately-to-severely active UC. These findings suggest that bowel urgency is a critical and independent symptom that considerably impacts patients’ quality of life.

References

¹Dubinsky MC, et al. J Patient Rep Outcomes. 2022;6(1):31.
²Dubinsky MC, et al., J Patient Rep Outcomes. 2022;6(1):114.

Disclosure

Alessandro Armuzzi: Consulting/advisory board fees: AbbVie, Allergan, Amgen, Arena, Biogen, Boehringer-Ingelheim, BMS, Celgene, Celltrion, Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Mylan, Pfizer, Protagonist Therapeutics, Roche, Samsung Bioepis, Sandoz, Takeda; speaker’s fees: AbbVie, Amgen, Arena, Biogen, BMS, Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Samsung Bioepis, Sandoz, Takeda, Tigenix; research grants: MSD, Takeda, Pfizer, Biogen. Brian Feagan: Consultant: AbbVie, AbolerIS, AgomAB Therapeutics, Allianthera, Amgen, AnaptysBio, Applied Molecular Transport Inc., Arena Pharma, Avir, Azora Therapeutics, BioJamp, Biora Therapeutics, Boehringer-Ingelheim, Boston Pharma, Boxer, Celgene/BMS, Connect BioPharma, Cytoki, Disc Medicine, Duality, EcoR1, Everest Clinical Research Corp., Lilly, Equillium, Ermium, Ferring, First Wave, Galapagos, Galen Atlantica, Genentech/Roche, Gilead, Glenmark, Gossamer Pharma, GSK, Hoffmann-LaRoche, Hot Spot Therapeutics, Index Pharma, Imhotex, ImmunExt, Immunic Therapeutics, Intact Therapeutics, JAKAcademy, Janssen, Japan Tobacco Inc., Kaleido Biosciences, Landos Biopharma, Leadiant, L.E.K. Consulting, LifeSci Capital, Lument AB, Millennium, MiroBio, Morphic Therapeutics, Mylan, OM Pharma, Origo BioPharma, Orphagen, Otsuka, Pandion Therapeutics, Pfizer, Prometheus Therapeutics and Diagnostics, Play to Know AG, Progenity, Protagonist, PTM Therapeutics, Q32 Bio, Rebiotix, RedHill, Biopharma, REDX, Roche, Sandoz, Sanofi, Seres Therapeutics, Silverback Therapeutics, Surrozen Inc., Takeda, Teva, Thelium, Theravance, Tigenix, Tillotts, UCB Pharma, VHSquared Ltd., Viatris, Ysios, Ysopia, Zealand Pharma; speakers bureau: AbbVie, Janssen, Takeda; scientific advisory board member: AbbVie, Amgen, Boehringer-Ingelheim, Celgene/BMS Genentech/Roche, Janssen, Novartis, Origo BioPharma, Pfizer, Prometheus, Takeda, Tillotts Pharma, Teva, Progenity, Index, Ecor1Capital, Morphic, GSK; stock shareholder: Gossamer Pharma; employment: Western University, Alimentiv Inc. Bruce Sands: Consultant: Amgen, Arena Pharmaceuticals, Artugen Therapeutics, AstraZeneca, Bacainn Therapeutics, Boehringer-Ingelheim, Boston Pharmaceuticals, Calibr, Celltrion Healthcare, ClostraBio, Entera, Evommune, Galapagos, Genentech, Gilead Sciences, GlaxoSmithKline, Gossamer Bio, Index Pharmaceuticals, Inotrem, Innovation Therapeutics, Ironwood Pharmaceuticals, Kaleido, Kallyope, Lilly, Miro Bio, Morphic Therapeutics, MRM Health, Progenity, Prometheus Biosciences, Protagonist Therapeutics, Q32 Bio, Surrozen, Teva, TLL Pharmaceutical, USWM Enterprises, VielaBio; consultant, speaker, research funding: Bristol Myers Squibb; consultant, speaker, grant/research support: Janssen; consultant, speaker: Abivax, Pfizer, Takeda. Stefan Schreiber: Consultancy and personal fees: AbbVie, Arena, BMS, Biogen, Celltrion, Celgene, Falk, Ferring, Fresenius, Galapagos/Gilead, IMAB, Janssen, Lilly, MSD, Mylan, Pfizer, Protagonist, Provention Bio, Takeda, and Theravance. Vipul Jairath: Consulting/advisory board fees: AbbVie, Alimentiv Inc., Arena pharmaceuticals, Asahi Kasei Pharma, Asieris, Astra Zeneca, BMS, Celltrion, Lilly, Ferring, Flagship Pioneering, Fresenius Kabi, Galapagos, GlaxoSmithKline, Genentech, Gilead, Janssen, Merck, Metacrine, Mylan, Pandion, Pendopharm, Pfizer, Protagonist, Prometheus, Reistone Biopharma, Roche, Sandoz, Second Genome, Sorriso pharmaceuticals, Takeda, Teva, Topivert, Ventyx, Vividion; speaker’s fees: Abbvie, Ferring, BMS, Galapagos, Janssen Pfizer Shire, Takeda, Fresenius Kabi. Anthony Keohane: Employment: Eli Lilly and Company. Kristina A Traxler: Employment: Eli Lilly and Company. Theresa Hunter Gibble: Employment: Eli Lilly and Company
William J Eastman: Employment: Eli Lilly and Company