Introduction

Delayed perforation (DP) is a serious complication after colorectal endoscopic submucosal dissection (CESD), often requiring emergent surgery. Traditionally, DP has been managed conservatively or surgically. Recently, successful endoscopic closures have been reported. Since 2021, we have attempted endoscopic closure in patients meeting the following: (1) localized symptoms with stable condition, (2) no or minimal oral intake, and (3) endoscopic accessibility and feasibility of closure.

Aims & Methods

To compare clinical outcomes before and after the introduction of endoscopic closure for DP and to examine closure techniques. Among Among 4,848 CESD procedures (April 2008–December 2024), 16 cases (0.3%) of DP were identified. In Analysis 1, patients were divided into Group A (before closure: 2008–2020) and Group B (after closure: 2021–). In Analysis 2, closure techniques were reviewed. DP was defined as a perforation undetected during ESD but confirmed postoperatively by imaging or endoscopy.

Results

Analysis 1: Group A: 9 patients; Group B: 7. Median age: 72 vs. 70 years; male/female: 5/4 vs. 4/3. Lesion locations (cecum/ascending/transverse/sigmoid/rectum): Group A, 3/2/1/1/2; Group B, 1/3/2/1/0. Median specimen size: 48 mm vs. 46 mm.
Ulcer base closure (complete/partial/none): Group A, 2/2/5; Group B, 2/4/1. Histology (adenoma/serrated lesion/carcinoma in situ/adenocarcinoma/others): Group A, 3/4/1/1; Group B, 4/1/1/1. Median time to DP diagnosis: 63 vs. 55 hours.
Treatment in Group A was determined case-by-case; Group B applied defined criteria. Initial treatments (conservative/surgical/endoscopic): Group A, 5/4/0; Group B, 1/0/6. One case in each group initially managed conservatively required surgery later. Of 7 surgical cases, all underwent partial colectomy or drainage without stoma creation. All 6 endoscopic closure cases avoided surgery. Surgical avoidance rate: 33% vs. 86% (p=0.06).
Median time to oral intake: 8 vs. 7 days (p=0.67). Median hospitalization: 16 vs. 11 days (p<0.05).
Analysis2: All 6 closures were performed without bowel preparation. Two patients had resumed oral intake, but endoscopy was performed early.
Perforation diameter: median 10 mm (5–15). Closure methods: over-the-scope clip (OTSC; n=1), hemostatic clips (n=4), clips with polyglycolic acid (PGA) sheet (n=1).

Conclusion

Endoscopic closure for DP was associated with higher surgical avoidance and shorter hospitalization, without worsening outcomes. It may offer an effective treatment option for selected patients.​

Introduction

Delayed bleeding after gastric endoscopic submucosal dissection (ESD) is a serious complication in older adults. The BEST-J score, developed by Hatta et al. (Gut, 2021), is widely used for bleeding risk stratification but does not reflect systemic factors. The Prognostic Nutritional Index (PNI), calculated as [10 × serum albumin (g/dL)] + [0.005 × total lymphocyte count (/μL)], may complement this score. This study evaluated whether combining PNI with the BEST-J score improves risk stratification.

Aims & Methods

We retrospectively analyzed 252 patients who underwent gastric ESD between April 2016 and February 2025, including 127 older (≥75 years) and 125 younger (<75 years) individuals. Patients were classified into low (<40) and high (≥40) PNI groups. The association between delayed bleeding, PNI, and BEST-J score was analyzed using receiver operating characteristic (ROC) analysis. To evaluate internal validity, we conducted 5-fold cross-validation of a logistic regression model that added 1 point for PNI < 40 to the BEST-J score. A cutoff value of PNI < 40 was used, based on previously reported clinical thresholds reflecting impaired nutritional and immune status, including its predictive value for bleeding in various clinical settings (Zhao et al., 2024; Lin et al., 2021).

Results

The delayed bleeding rate was 4.7% in the older group and 0.8% in the younger group. Mean PNI was lower in bleeding cases (44.7) than in non-bleeding cases (48.5). Among older adults, the AUCs for PNI and BEST-J alone were 0.65 and 0.72, respectively. Adding 1 point for PNI < 40 improved the AUC to 0.82. Cross-validation confirmed good model reproducibility, with a mean AUC of 0.861 and standard deviation of 0.147, indicating stable predictive performance without overfitting. The inclusion of PNI < 40 enhanced model sensitivity for identifying bleeding cases without substantially compromising specificity, improving clinical applicability. These associations were most prominent in older patients, supporting age-specific application of the combined model.

Conclusion

The combination of BEST-J and PNI provides an improved and practical approach to risk stratification for delayed bleeding after gastric ESD in older adults. Cross-validation supports the model's internal validity and suggests applicability to broader clinical populations. Given the disproportionately higher bleeding risk in the older cohort, our findings underscore the importance of incorporating host-related factors such as nutrition into stratification strategies specifically in this age group.

References

1. Hatta W, Tsuji Y, Yoshio T, et al. Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut. 2021;70(3):476–484. doi:10.1136/gutjnl-2019-319926.
2. Zhao Y, Chen X, Zhang M, et al. Association of Prognostic Nutritional Index with Post-Discharge Bleeding in Acute Coronary Syndrome Patients on Dual Antiplatelet Therapy. Front Cardiovasc Med. 2024;11:11995920.
3. Lin Y, Wang J, Chen Z, et al. Preoperative Prognostic Nutritional Index Predicts Intraoperative Transfusion and Surgical Outcomes in Hepatocellular Carcinoma Patients Undergoing Hepatectomy. Cancers (Basel). 2021;13(11):2508.

Introduction

International guidelines recommend endoscopic submucosal dissection (ESD) for en-bloc resection of rectal lesions suspected of submucosal invasive cancer (SMI). ESD achieves favorable outcomes for benign lesions and early rectal cancers (ERC) with superficial (<1000μm) SMI. However, for ERCs with deep (≥1000μm) SMI, the rate of histologically radical (R0) resection remains suboptimal, at maximum 64% for SM2-3 lesions, even in expert centres. The muscle-retracting sign (MRS) has emerged as a potential endoscopic marker of deep SMI detected during endoscopic resection. Predicting deep SMI is particularly relevant in rectal lesions, as incorrect selection of resection modality may lead to non-radical endoscopic resections and the need for surgical salvage, which carries significant morbidity. To address some of these limitations, we applied the novel pocket-detection method (PDM) for MRS detection. This approach enhances visualization of the submucosal space and facilitates early identification of the MRS.

Aims & Methods

The aim of this study was to evaluate the diagnostic accuracy of the MRS detected using the PDM as an innovative approach for identifying deeply invasive ERC during endoscopic resection of rectal lesions.
In this prospective, observational, single-centre study consecutive rectal lesions that underwent endoscopic resection using the PDM between August 2023 and March 2025 were included. Directionality of initial submucosal dissection targeted any morphological or surface vascular pattern at risk of deep SMI to attempt MRS identification. Histopathology was the reference standard for MRS diagnostic accuracy in detecting deep SMI. Deep SMI was defined as ≥1000μm invasion from the muscularis mucosa at histopathology.

Results

38 rectal lesions, median size 30 mm (IQR 20-40), were included. PDM for MRS detection was successful in all cases, with MRS-positive in 15/38 (39.5%). Deep SMI was confirmed in 15/38 (39.5%). Accuracy of MRS-positive for deep SMI detection was 84.2%, (95% CI 69.6-92.6%), sensitivity 80% (95% CI 54.8-92.9%), specificity 87% (95% CI 67.9-95.5%), positive predictive value 80% (95% CI 54.8-92.9%), negative predictive value 87% (95% CI 67.9-95.5%), positive likelihood ratio 6.13, negative likelihood ratio 0.23, area under the curve 0.83 (95% CI: 0.71–0.96). The rate of R0 resection was 92.1% (35/38).

Conclusion

MRS detected using the PDM demonstrated moderate-to-high accuracy in predicting deep SMI in early rectal cancer. This finding may allow selection of endoscopic resection strategy based on invasion depth.

Introduction

Post endoscopy upper gastrointestinal cancers (PEUGIC) are often missed opportunities to diagnose earlier or even prevent cancer. Up to 71% of PEUGIC are potentially avoidable, but identifying and investigating them can be challenging. A national process for identifying all PEUGIC in the English National Health Service and performing root cause analysis was developed.

Aims & Methods

Potential PEUGIC between 2017 and 2023 occurring 3-36 months after an index endoscopy which did not result in a cancer diagnosis were identified from National Cancer Registration Dataset and Hospital Episode Statistics held by the National Cancer Registration and Analysis Service. Data from local root cause analysis were uploaded onto a secure portal for national analysis. PEUGIC following surveillance endoscopies were excluded from this analysis. Logistic regression analysis was used to identify associations with outcomes of interest.

Results

3151 potential PEUGIC were examined by local reviewers in 144 English hospitals. 635 (20%) were excluded on local review and data were available for 2516 PEUGIC. 1897 (75.4%) PEUGIC followed diagnostic, follow-up or screening endoscopies. PEUGIC sites were oesophagus 61%, stomach 34% and duodenum 5%.
Table 1 shows the summary PEUGIC root cause results analysis based on the World Endoscopy Organisation categorisation. Categories C and D were associated with poor outcomes with 29% and 23% of cases receiving curative treatment, respectively. Compared to categories A and B receiving curative treatment in 53% and 37% of cases, respectively. Squamous cell cancers accounted for 37.5% of oesophageal PEUGIC and were associated with no lesion being detected (category C or D) in the PEUGIC segment OR 1.71 (95% CI 1.21-2.43).
Findings on index endoscopy (category A or B) at later oesophageal PEUGIC: pre-malignant lesion 23% (e.g. Barrett’s), cancer associated lesion 20% (e.g. ulcer) and other oesophageal focal lesions 15%. Findings on index endoscopy in gastric PEUGIC: cancer associated lesion 26%, pre-malignant lesion 7% and other gastric focal lesions 18%. 45% of the index endoscopies were classified as inadequate. Patient harm and adverse treatment outcomes were associated with an inadequate index endoscopy OR 1.56 (95% CI 1.28-1.91). The most common reason for inadequate endoscopy was inadequate management of lesions identified, which were most likely to be cancer associated lesions OR 1.43 (95% CI 1.11-1.69), specifically oesophageal strictures (24%) and gastric ulcers (23%).
Gastric diagnostic PEUGIC were diagnosed with more advanced cancer (40% stage 4 at diagnosis vs 30% oesophageal PEUGIC). Treatment following cancer diagnosis was adversely affected in 42% of PEUGIC. Reviewers considered that 57% of PEUGIC were at least possibly avoidable and 9% led to premature death.

Table 1 Root causes of all diagnostic PEUGIC

Conclusion

Abnormalities in the area of the later cancer were detected at index endoscopy in 59% of PEUGIC. Inadequate lesion assessment, endoscopy and/or decision making was noted in 45% of PEUGIC, which adversely affected treatment outcome. Oesophageal squamous cell cancer was a common cause of PEUGIC, suggesting issues with lesion recognition in this cancer. Many patients had incurable disease when diagnosed and treatment was adversely affected in 42%.

Introduction

Helicobacter pylori (HP) has been designated as a Grade I Carcinogen by the WHO and remains an important factor in the pathogenesis of intestinal-type gastric cancer. Gastric cancer was the fifth most common malignant disease in the world in 2022 (Globocan) with 968,784 new cases(1), after lung, breast, colorectal and prostate cancers. The incidence of gastric cancer has changed significantly since the first estimates in 1975, when stomach cancer was the leading cancer, and one of the most important factors has been the eradication of HP.(2)

Aims & Methods

The purpose of this study was to determinate the trends in the incidence of HP in our region, and also of the precancerous lesions.
There have been included in the study a group of 12541 patients from the years 2014-2018 and a group of 7138 patients from more recently years 2020-2024.
All the patients had dyspeptic syndrome and in all the patients upper digestive endoscopy has been performed in the Gastroenterology Clinic from Târgu Mureș, Emergency Clinical Hospital. Patients with haemorrhage were excluded from the study. In all the patients gastric biopsies and histopathological exam were made, OLGA classification was used.

Results

From the first group, in 2131 patients (52,9% males and 47,1% females) were found gastric changes. Histopathological, 32,7% of the patients had atrophic gastritis, 43,1% intestinal metaplasia (23,7% complete metaplasia and 19,4% incomplete metaplasia) and 0,7% dysplasia. Active gastritis/pangastritis with HP was identified in 59,3% of the patients. In 4,8% of cases there were revealed polyps (hyperplastic, adenomatous) and were removed.
In the second group from 2560 patients (54,4% males and 45,6 females) that underwent upper gastrointestinal with biopsy sampling, HP was present in 442 patients (17,26%.) Histopathological, 14,50% of the patients had atrophic gastritis, 23,8% intestinal metaplasia and 2,58% dysplasia.

Conclusion

HP incidence is decreasing, as it has been treated by the gastroenterologist and also by the general practitioner. The decreasing in incidence of HP is corelating with the decreasing of the precancerous lesions and gastric cancer, so ​it is worth to treat it.

References

1. Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer incidence and mortality worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: Inter- national Agency for Research on Cancer Available from: http://globocan.iarc.fr. Accessed 27.03.2025
2. Malfertheiner P, Megraud F, Rokkas T, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report, Gut 2022;71:1724–1762.

Disclosure

no conflict of interest

Introduction

It remains uncertain if the addition of Saccharomyces boulardii (S. boulardii) to Vonoprazan-amoxicillin dual therapy as a first-line treatment can enhance the Helicobacter pylori (H. pylori) eradication rate and decrease the incidence of adverse events. Therefore, we conducted the randomized controlled trials (RCTs) to address this issue.

Aims & Methods

This is a single-center, prospective randomized controlled study. A total of 150 eligible patients, recruited from December 2023 to November 2024, were randomly assigned to the VA (vonoprazan 20 mg twice daily, amoxicillin 750 mg 3 times daily for 10 days) and VAS groups (vonoprazan 20 mg twice daily, amoxicillin 750 mg 3 times daily, and S. boulardii 250 mg twice daily for 10 days). The eradication rates, adverse events, safety, and compliance were compared between the two groups. Factors associated with eradication rate were explored.

Results

The eradication rates of VA and VAS were 89.3% and 93.3%, respectively, by intention-to-treat analysis (P = 0.384); 93.1%, and 94.6%, respectively, by per-protocol analysis (P=0.966). The incidence of adverse events significantly lower in the VAS group (5.4%) than in the VA group (22.2%; P=0.003). There was no significant difference in compliance between the VA (96%) and VAS groups (98.7%, P = 0.612). Body surface area (BSA) was found to be a influencing factor for eradication rate in both VA and VAS groups. Serum chemistry tests revealed no significant differences in liver and kidney function before and after treatment in both groups.

Conclusion

Although the addition of S. boulardii to VA dual therapy could not increase the eradication rate, it could decrease the incidence of adverse events. Low-BSA patients are more suitable candidates for this regimen.

Introduction

Minocycline is considered the most potent semi-synthetic tetracycline, demonstrates promising pharmacokinetic and antimicrobial properties against Helicobacter pylori (H. pylori). While previous studies suggested the efficacy of minocycline-containing bismuth quadruple therapy for H. pylori eradication, real-world evidence remains limited.

Aims & Methods

his study aimed to evaluate the clinical efficacy, safety, and cost-effectiveness of minocycline-containing bismuth quadruple therapy in routine clinical practice.This multicenter, real-world observational study was conducted at 25 hospitals in Fujian China between January and March 2025. Patients diagnosed with H. pylori infection received one of three 14-day bismuth-containing quadruple regimens with b.i.d. esomeprazole 20 mg and bismuth 220 mg, plus amoxicillin 1000 mg b.i.d. and clarithromycin 250 mg b.i.d. (PBAC), or minocycline 100 mg b.i.d. and clarithromycin 250 mg b.i.d. (PBMC), or minocycline 100 mg twice b.i.d. and levofloxacin 500mg q.d. (PBML). The primary outcome was the H. pylori eradication rate, secondary outcomes included the frequency of adverse events, patient compliance, and cost-effectiveness.

Results

A total of 347 patients were enrolled, with 110 patients completing treatment in each group. In the intention-to-treat (ITT) analysis, eradication rates were 77.4% (PBAC), 85.5% (PBMC), and 84.3% (PBML). In the per-protocol (PP) analysis, eradication rates were 80.9%, 90.9%, and 88.2%, respectively. Although the differences among the three regimens were not statistically significant, minocycline-based regimens achieved numerically higher eradication rates. Adverse event incidence was 32.73%, 20.91%, and 23.64% in the three groups, respectively. Compliance rates exceeded 94% across all groups. Cost-effectiveness analysis showed PBML had the lowest cost-effectiveness ratio (5.38 CNY per 1% eradication), followed by PBAC (5.41 CNY) and PBMC (6.06 CNY).

Conclusion

H. pylori eradication, with favorable patient compliance and pharmacoeconomic profiles. These regimens present a viable alternative to traditional amoxicillin-or tetracycline-based therapies. Further large-scale randomized controlled trials are warranted to confirm these findings.