Introduction

Atrophic gastritis(AG) is mainly caused by Helicobacter pylori(Hp)infection or autoimmunity. Hp-related AG affects both corpus and antral mucosa resulting in multifocal AG(MF-AG), whereas AG driven by autoimmunity is corpus-restricted(CR-AG).
Corpus mucosa gastric atrophy carries an increased risk of gastric dysplasia(GD) and cancer(GC);the neoplastic risk in CR-AG is considered lower, but still debated. GD-GC lesions in AG may arise in the antrum, incisura angularis or, less frequently,the corpus.Data on characteristics and potential differences of GD-GC lesions between MF-AG and CR-AG are lacking.

Aims & Methods

This study aimed to assess clinical,endoscopic,and histological characteristics of GD-GC in MF-AG and CR-AG pts.
A multicenter,cross-sectional study was conducted across 14 Italian GI centers. Data on GD-GC in patients with MF-AG or CR-AG(2001-2023) were retrospectively collected based on clinical,endoscopic, and histological charts: site,dimension,endoscopic,and histologic features of GD-GC, perilesional gastric antral and corpus mucosa(updated Sydney system),and patients’ clinical data (age,sex,outcome after GD-GC diagnosis,Hp infection, parietal cell antibodies(PCA), family history for GC). Inclusion criteria were:patients with MF-AG or CR-AG and GD or GC diagnosis,aged>18 years, availability of endoscopic and histological description of GD-GC and perilesional gastric mucosa, completeness of clinical data.Data were stratified for MF-AG/CR-AG and the GD-GC, perilesional mucosa, and clinical characteristics were compared.

Results

A total of 84 pts[(F46[54.8%];age 70(33-90yrs)] were included. MF-AG and CR-AG were observed in 45(53.6%) and 39(46.4%) pts,respectively. High-grade(HG)-GD,low-grade(LG)-GD,and non-cardia GC were diagnosed in 6(7.1%),31(36.9%), and 47(56.0%)pts.
Age, GC family history,smoking habits, and PCA positivity were similar between MF-AG and CR-AG.Women(69.2% vs 42.2%,p=0.01) and pernicious anemia(29% vs 9.1%,p=0.04) were more frequent in CR-AG than in MF-AG.
The proportion of GD and GC in MF-AG and CR-AG pts was similar:HG-GD was present in 4(8.9%) vs 2(5.1%),LG-GD in 17(37.8%) vs 14(35.9%),GC in 24(53.5%) vs 23(59.0%)pts(p>0.05).
Compared to MF-AG,in CR-AG pts GD-GC were more frequently polypoid lesions (51.6% vs 27.3%,p=0.048) and more frequent in the corpus (55.3% vs 28.6%,p=0.02), but also occurred in the antrum(34.2%) and incisura(10.5%).The intestinal-type GC was the most prevalent and was more frequent in MF-AG than in CR-AG (87%vs60.9%,p>0.046), while diffuse GC was 2 times more frequent in CR-AG than in MF-AG, albeit not reaching statistical significance (26.1% vs 13%, p=0.27).
Concerning GC differentiation grade and staging, no significant differences were observed between MF-AG and CR-AG.Endoscopic treatment of GD-GC was similar in both groups. CR-AG patients underwent surgery more frequently than MF-AG(48.6% vs 23.1%,p=0.0207), but outcome was similar with 90.7% MF-AG and 92.1% CR-AG pts being alive.
Histopathological features of corpus mucosa (acute-chronic inflammation, severity of atrophy,pseudopyloric and intestinal metaplasia) were similar between MF-AG and CR-AG(p>0.05). The histological evidence of Hp in the antrum and corpus was low in both groups (2.3% vs 2.9%,p=0.87).

Conclusion

Non-cardia GC and GD may occur in both,MF-AG and CR-AG, displaying differences in topography and endoscopic presentation, but similarities in perilesional gastric corpus mucosa, differentiation, staging and outcome.
Endo-histological surveillance should be considered in pts with gastric corpus atrophy, irrespective of its etiology and extension.

References

Lahner E, et al. Dig Liver Dis. 2019 Dec;51(12):1621-1632.
Lenti MV, et al. Nat Rev Dis Primers. 2020 Jul 9;6(1):56.
Rugge M, et al. Gut. 2023 Jan;72(1):30-38.

Introduction

Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease in which muscle weakness develops insidiously. In advanced stages of the disease dysphagia, weight loss and malnutrition occur in the majority of patients. Thus, the consideration of Percutaneous Endoscopic Gastrostomy (PEG) tube placement is common. However, the optimal timing and setting for the procedure as well desired spirometry results are either are not stated in most guidelines or debated. Previous studies have suggested greater procedural risk for patients whose forced vital capacity (FVC) was less than 50% than predicted

Aims & Methods

The aim of this study was to assess the safety of our tertiary center simplified approach to PEG tube placement in patients with ALS.
The electronical records of patients who underwent percutaneous endoscopic gastrostomy (PEG) placement between 1.1.2020 to 1.1.2023 were retrospectively reviewed. All adult patients diagnosed with ALS who underwent ambulatory PEG tube placement were included. Patients who underwent PEG tube placement during hospitalization due to acute illness were excluded. The common practice of our center regarding PEG placement in patients with ALS is as follows: initial evaluation at the Gastroenterology clinic of patients referred by the neurology clinic, followed by ambulatory PEG placement under sedation by an anesthesiologist. We collected baseline information from the neurology and gastroenterology clinic visits regarding comorbidities and baseline FVC and the functional rating score [ALS-FRS, 0-48 points, lower score indicating a more severe disease). The data concerning the procedure and possible complications were collected from endoscopy reports, emergency department visits and clinic visits after the procedure.

Results

Six hundred and sixty patients had underwent PEG tube placement in our center during study period. Of them, 67 patients had an established diagnosis of ALS (10.2%). One patient was excluded due to PEG placement in the setting of an acute illness during admission, thus 66 patients were included (mean age at PEG placement 63.5±12.7 years and 37.8% were females). Mean ALS-FRS score was 23.6±8.81 and mean FVC was 49.8±19.45% of predicted. More than half (54.7%) of the patients were using non-invasive ventilation support device at home prior to the procedure and 12.1% of patients had underwent endotracheal tube placement prior to PEG tube placement.
The averaged duration of PEG tube placement was 11.96±5.3 minutes. All PEG procedures were completed successfully. Complications were documented during two PEG placements (3%): one patient suffered from aspiration and was hospitalized and later diagnosed with aspiration pneumonia and the second patient suffered from gastric perforation and peritonitis which was diagnosed a few hours after the procedure. During the 30 days following PEG placement, 3 (4.5%) complications were documented: Two patients (3%) suffered from PEG site infections and were treated with antibiotics and one (1.5%) was diagnosed with aspiration pneumonia. No deaths occurred during the procedure or during the 30 days that followed.

Conclusion

The simple straight forward approach to PEG placement in our institution was successful and safe in the vast majority of cases. The complications rate in our cohort is comparable to other studies, even though the patients in our cohort had significantly reduced lung function and functional scores then accepted in the common practice.

References

1. Miller R G, Jackson C E, Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology, Neurology, 2009 Oct 13;73(15):1218-26
2. EFNS Task Force on Diagnosis and Management of Amyotrophic Lateral Sclerosis: Andersen P M, Abrahams S, EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)--revised report of an EFNS task force, Eur J Neurol 2012 Mar;19(3):360-75.
3. Korner S, Hendricks M, Weight loss, dysphagia and supplement intake in patients with amyotrophic lateral sclerosis (ALS): impact on quality of life and therapeutic options, BMC Neurol 13, 84 (2013).
4. Russ K B, Phillips MC, Percutaneous Endoscopic Gastrostomy in Amyotrophic Lateral Sclerosis, Am J Med Sci . 2015 Aug;350(2):95-7.
5. Gregory S, Siderowf A, Gastrostomy insertion in ALS patients with low vital capacity: respiratory support and survival, Neurology . 2002 Feb 12;58(3):485-7.
6. Thomas K, Schrager J, Percutaneous endoscopic gastrostomy tube placement in amyotrophic lateral sclerosis: a case series with a multidisciplinary, team-based approach, Ann Gastroenterol 2020 Sep-Oct;33(5):480-484

Clinical Case Summary

Introduction: Primary epiploic appendagitis (PEA) is a rare cause of acute abdominal pain. The clinical is non-specific, making the diagnosis difficult; hence the interest of CT scan. The preferred treatment is essentially medical.
Objectives: Focus on the particularities of this entity, which can mimic the picture of an acute surgical abdomen, in order to minimize the risk of an unnecessary surgery.
Materials and methods: We present a retrospective and descriptive study of 4 cases diagnosed with PEA, managed in the hepatogastroenterology department in collaboration with the visceral surgery department 2, during the year 2021.
Results:
- The average age of the patients was 50.75 years, with a male predominance.
- Obesity was a predisposing factor for PEA; three patients were overweight.
- The clinical picture was dominated by abdominal pain, found in all patients.
- Associated signs (nausea, vomiting, transit disorders) were rare or absent, found respectively in 2 patients and one patient.
- The clinical examination revealed abdominal tenderness in 3 patients, defensiveness in only one patient, and a temperature higher than 37.3 °Cin 3 patients.
- Laboratory examinations showed hyperleukocytosis in 2 patients and a moderate increase in C-reactive protein in 3 patients.
- CT scan was the key examination for the diagnosis of PEA, performed in all patients.
- Three patients benefited from conservative management, only one patient was operated on.
- The evolution was favorable; no case of recurrence or complication was noted.
Conclusion: PEA is a condition that should be kept in mind as it is managed medically and to spare patients unnecessary surgery or hospitalization.

Introduction

There is an increasing incidence of young-onset colorectal cancer (YOCRC), which is defined as patients with colorectal cancer at age 50 years and younger. They present with a distinct clinical phenotype compared to classical-onset CRC (COCRC), with a more aggressive disease at presentation, as well as different tumour location and mutational signatures. There is an unmet clinical need to elucidate the unexplained epidemiologic rise in incidence as well as disease pathogenesis of YOCRC.

Aims & Methods

Aim: To compare the clinical presentation, tumour characteristics and survival of young-onset versus classical-onset CRC.

A retrospective evaluation of patients diagnosed with colorectal cancer from 2019 to 2022 at a district general hospital was performed. We extracted data from electronic patient records for clinical, biochemical, radiological as well as histopathological reports. Comparisons were made between patients diagnosed at </=50 years (YOCRC) and >50 years of age (COCRC) respectively, and statistical analyses were performed. A p-value of <0.05 was considered statistically significant.

Results

34 (11.1%) and 273 (88.9%) patients were diagnosed as YOCRC and COCRC respectively. There was a difference in clinical presentation between the two groups, with haematochezia (n=12, 35.3%) (p=0.03) and change in bowel habit (n=7, 20.6%) predominating in the YOCRC group, versus positive faecal immunochemical test (FIT) (n=102, 37.4%) and anaemia (n=78, 28.6%) in the COCRC group respectively. There were no differences in the tumour location between groups, with >50% of cases arising from the left colon (22 YOCRC versus 149 COCRC). Thrombocytosis (platelet count>450x10⁹/L) (24% vs 11%, p=0.038) and tumour budding (12% vs 3%, p=0.006) were significantly increased in the YOCRC group. There were no significant differences in the histological subtype, TNM staging, mutational profiling and survival between groups. 6 (17.6%) YOCRC patients had died compared to 116 (37.8%) in the COCRC cohort over a median follow-up of 16 months.

Conclusion

Young-onset colorectal cancer represents a challenging subset of CRC, which has a different clinical and tumour phenotype to classical-onset CRC. Our study reflects the reported incidence rates of YOCRC of 11%, although the true epidemiology and frequency of YOCRC remains to be clarified. Haematochezia was the commonest presentation, while thrombocytosis and tumour budding were higher in the YOCRC group, suggesting a more advanced disease at diagnosis. Although the overall survival rates were similar between groups, further research would benefit from larger prospective studies with subdivision of YOCRC cases by age as poorer survival have been suggested in patients aged <30 years. There is a need to elucidate the respective aetiologies, environmental risk factors and pathogenesis of YOCRC, to allow early targeted treatment of such cases.

Table 1: Clinical presentation of YOCRC and COCRC

Clinical presentation n (%)	YOCRC (n=34)	COCRC (n=273)	p
Positive FIT	8 (23.5)	102 (37.4)	0.113
Anaemia	6 (17.6)	78 (28.6)	0.178
Change in bowel habit	7 (20.6)	70 (25.6)	0.522
Haematochezia	12 (35.3)	53 (19.4)	0.033*
Abdominal pain	6 (17.6)	34 (12.5)	0.396
Weight loss	5 (14.7)	30 (11.0)	0.520

*p<0.05

References

Mauri G, Sartore-Bianchi A, Russo AG, Marsoni S, Bardelli A, Siena S. Early-onset colorectal cancer in young individuals. Mol Oncol. 2019;13(2):109-131.

Introduction

The ergonomics has been considered important in practicing surgical laparoscopy, and prior studies have shown significance of relevant factors e.g. operating room setup and design of surgical devices. However, little has been known in flexible endoscopy; How do endoscopists control flexible endoscopes? Which muscles are loaded during endoscopy? The deeper understanding of ergonomic aspects in flexible endoscopy is indispensable, since the number of endoscopies performed and its complexity are rapidly increasing.

Aims & Methods

We aimed to identify the differences of ergonomics between diagnostic endoscopy (EGD) and therapeutic endoscopy (ESD), by 1) multiple motion capture technology, and 2) wireless surface electromyography (EMG), in pre-clinical setting.
1) The multiple motion capture assessment
The control section of standard flexible endoscope (GIF-Q260J; Olympus, Tokyo, Japan), from the boot to the angulation knobs, was marked with 6 optical reflective markers. These markers were traced using a motion capture system (OptiTrack Flex13; NaturalPoint, OR) and the data were processed to generate 3-D coordinate data (The sternum manubrium of the endoscopist was setup as the coordinate origin; X: left-right axis, Y: cranio-caudal axis, Z: antero-posterior axis). EGD and ESD were performed with this motion capture system using live porcine models. For each endoscopist, mean±2SD for plotted coordinates from the origin was calculated in the three axes and described as a range of his/her arm/hand movement. The data were compared between EGD and ESD.
2) EMG assessment
Muscle activation of the left biceps brachii muscle, trapezius muscle, extensor carpi ulnaris muscle, flexor carpi radialis muscle, pronator teres muscle, thenar muscle, back neck muscle, and erector spinae muscle were recorded during endoscopic procedures using wireless surface EMG (BioLog DL-5500, DL-510A; S&ME, Tokyo, Japan). The maximal voluntary contraction (MVC) was obtained to normalize root-mean-square muscle activation as %MVC. We compared differences in muscle activity between EGD and ESD using %MVC.

Results

1) The motion capture was performed on 15 board-certified endoscopists conducting EGD (n=13) and ESD (n=12). The movement range of endoscopist’s left hand/arm holding endoscope is shown in the Table. On all three axes, the range of movement was significantly narrower during ESD than during EGD (X, p<0.001; Y, p=0.015; Z, p<0.001).

	EGD			ESD
	X axis	Y axis	Z axis	X axis	Y axis	Z axis
Mean ± 2SD (cm)	-0.32±14.2	-24.3±11.0	12.8±11.6	-1.3±9.9	-22.8±9.8	7.9±8.9

2) The EMG was recorded during 15 EGDs and 8 ESDs. The %MVC was higher during ESD than EGD in an analysis including all muscles (LS-mean±SE; EGD, 28.9±1.5%; ESD, 34.1±2.6%; p=0.078). The comparison by each specific muscle showed that the extensor carpi ulnaris muscle (EGD, 34.6±3.5%; ESD, 47.8±5.8%; p=0.093) and the pronator teres muscle (EGD, 42.8±6.6%; ESD, 67.6±10.9%; p=0.092) had significantly larger %MVC during ESD (p<0.1 was considered statistically significant).

Conclusion

Our study has first shown that the range of endoscopis’s movement was significantly narrower in therapeutic endoscopy than in diagnostic endoscopy. Furthermore, it was demonstrated that muscle activity, especially in left forearm muscles, was larger during therapeutic endoscopy. These data may help understanding the ergonomics in flexible endoscopy, and potentially contribute to optimize its working environment and further development of relevant medical devices.