Introduction

The segmentation of patients in homogeneous groups, according to their clinical variables and treatments, could help to improve the effectiveness of current eradication therapies.

Aims & Methods

1) To determine the most important characteristics of the treatments used in the European Registry on H. pylori management (Hp-EuReg), using machine learning techniques.
2) To evaluate the effectiveness of the treatments according to the year of the visit and the country using a cluster decomposition.
Sub-study of the Hp-EuReg, a systematic, prospective, registry of the routine clinical practice of European gastroenterologists on the management of H. pylori infection. All cases with a first-line empirical eradication treatment registered from June 2013 to December 2022, were included in the current analysis. Boruta, a random-forest-like method was used to determine the following ‘most important’ variables: compliance, duration of treatment, PPI dosage, patient’s country, and treatment scheme.

Results

In total, 35,852 European patients were analysed. Table 1 shows the increasing trend in the effectiveness of treatments, from an average 87% in 2013 to 93% in 2022 (more than 100 patients/clusters). The cluster 3 in 2016 (lowest effectiveness) was composed of 97.5% triple therapy with clarithromycin-amoxicillin/metronidazole, mainly in Slovenia (54%), with a majority (85%) of 7-day prescriptions, and 99% compliance. The highest effectiveness was obtained in cluster #1 in 2022, with 81% of Spanish cases, 32% of concomitant therapy with clarithromycin-amoxicillin-metronidazole/tinidazole and 63% of bismuth quadruple therapy with tetracycline-metronidazole (prescribed as single capsule), 69% of 10 days prescriptions, and 32% of 14 days treatment length.

Conclusion

Cluster analysis allowed both to identify patients with homogeneous treatment groups, as well as to assess the effectiveness of the different first-line treatments, its compliance, the region where it was administered, and the prescription year.

Disclosure

Olga P. Nyssen received research funding from Mayoly and Allergan.
Javier P. Gisbert served as speaker, consultant, and advisory member for or received research funding from Mayoly, Allergan, Diasorin, Gebro Pharma, and Richen.

Introduction

Recently, the number of ESD cases of early gastric cancer detected after Helicobacter pylori eradication (GCAE) has been increasing. As the number of years since eradication increases, the management of metachronous carcinomas after ESD for GCAE has also become an issue. Serum gastrin level has been reported to be useful in identifying groups at high-risk of developing gastric cancer. In this study, we investigated the clinicopathological characteristics of patients with early-stage GCAE who underwent ESD at our department. Furthermore, we determined the risk of metachronous GCAE after ESD and the correlation between serum gastrin level and metachronous GCAE.

Aims & Methods

We retrospectively analyzed a total of 300 lesions in 245 patients who underwent ESD for GCAE with known period after eradication at Hiroshima University Hospital between April 2010 and December 2019 and examined their clinicopathology. We divided 220 lesions in 194 patients with initial GCAE who had no history of gastric endoscopic resection before successful eradication into the " metachronous gastric cancer (MGC) groups " and " no metachronous gastric cancer (NGC) groups ". Then, we examined the clinicopathological characteristics of metachronous gastric cancer cases. We classified 74 lesions in 63 patients of male and differentiated type cancers who have not been using PPIs into two groups: 37 lesions in 32 patients with gastrin level of less than 80 pg/ml and 37 lesions in 31 patients with gastrin level higher than 80 pg/ml.

Results

At a median follow-up of 4.0 years, 16 patients (8.2%) developed metachronous gastric cancers. Males were more predominant in the MGC group than in the NGC group (male / female; 16/0 vs. 223/74，p=0.02), which included increased cases of severe atrophy of the background gastric mucosa (mild to moderate / severe; 3/13 vs. 94/84, p=0.01), more lesions in the U and M regions of stomach (U･M / L; 19/4 vs 121/76, p=0.05), and a higher proportion of synchronous multiple lesions (synchronous tumor/ no synchronous tumor; 11/12 vs. 160/37, p=0.01). The relationship between gastrin levels and metachronous gastric cancer was examined, revealing that gastrin levels were higher in the MGC group. The group with a gastrin level of 80 pg/ml or higher had a significantly higher incidence of metachronous lesions than the group with that of less than 80 pg/ml (OR 6.88; 95% CI, 1.61–29.3; p=0.01).

Conclusion

These results that male patient with severe atrophy, the rates of localization to the U and M regions of stomach and the incidence of synchronous multiple lesions before ESD indicate should be noted and surveyed more strictly for metachronous gastric cancers developing after ESD of GCAE. Patients with gastrin 80 pg/ml or higher had increased risk of MGC, indicating that gastrin level may be a serological marker for MGC.

Introduction

Gastroscopy is the gold standard for screening for gastric cancer(GC) and precancerous lesions. However, the high miss rate of conventional gastroscopy on detection of early GC and High-grade intraepithelial neoplasia has been reported. In our previous studies, a deep learning-based system (named intelligent and real-time gastroscopy analytical device, IREAD) was proposed and validated, which has shown its great potential for improving early detection of gastric neoplasms.

Aims & Methods

The aim of this study was to evaluate the cost-effectiveness of implementing IREAD-assisted gastroscopy screening for GC. We constructed a decision-analytic Markov model for a cohort of individuals aged 40 years and older for high-risk individuals in China with a total of 40 1-year cycles. We calculated the cost-effectiveness of three screening strategies (non-screening, conventional screening and AI-assisted screening) from a societal perspective (including direct and indirect costs). Screening frequencies and compliance were considered. The sensitivity and specificity of IREAD-assisted and conventional screening were obtained from our previous clinical trials. Prevalence rates, transitional probabilities, costs, and utilities were obtained from published literatures and public data sources. We calculated incremental cost-effectiveness ratios (ICER) using quality-adjusted life-years (QALY). One-way deterministic and simulated probabilistic sensitivity analyses were used to assess the robustness of the main outcomes.

Results

The average cost per patient was $3177,$3530 and $3482 while the average effectiveness was 16.03 QALY,16.04 QALY and 16.05 QALY per individual in non-screening, conventional screening and IREAD-assisted screening, respectively. Compared to the non-screening strategy, the ICERs for conventional screening and IREAD-assisted screening strategy were $20846.66/QALY and $14932.12/QALY, respectively, which were both cost-effective at the predetermined Willingness-to-pay threshold of $25,704/QALY. At the national level, replacement of conventional screening by IREAD-assisted screening could prevent 3372 GC cases and 917 GC deaths per year, and result in a cost savings of $1.75 billion. When setting the screening interval as 2 years according to the current recommendation, we found ICER increased as screening uptake rates decrease. By conducting further comparisons of the screening intervals from 1 to 3 years at 100% uptake, more frequent screening would be associated with a gain of more QALY but with higher costs for both conventional gastroscopy screening and IREAD assisted gastroscopy screening. In all the interval scenarios, the IREAD was cost saving compared to conventional screening and was cost effective compared to non-screening.

Conclusion

The implementation of IREAD-assisted screening was both cost-saving and effective compared to conventional screening. IERAD-assisted screening has potential to further prevent GC incidence and mortality.

Introduction

Postoperative ileus, is one of the most common causes of prolonged hospital stays after abdominal surgery which cause from physiologic hypomotility of the gastrointestinal tract occurring immediately after abdominal surgery. Multi-modal approach to the resolution of postoperative ileus includes ERAS protocol such as opioid minimization, early ambulation, intake of prokinetic drug. Mosapride citrate (mosapride) is known to promote gastrointestinal motility. The objective of this study is to evaluate the effects of mosapride on postoperative ileus and postoperative gastrointestinal motility in patients undergoing elective open and laparoscopic colorectal surgery.

Aims & Methods

The study was approved by ethics committee of the Faculty of Medicine Ramathibodi Hospital Mahidol University (Ref. Number COA.MURA2021/328,ClinicalTrials.gov Identifier: NCT04905147). Forty-four colorectal cancer patients, undergoing open and laparoscopic colorectal surgery in Ramathibodi Hospital during July 2021-August 2022, were randomly assigned to a mosapride group or control group. The mosapride group received 15 mg of mosapride by enteric route with 50 ml of water three times a day, starting on postoperative day 1. The control group received 15 mg of placebo drug with 50 ml of water at the same time. Postoperative time to the first passage of flatus and the first bowel movement were evaluated by one investigator with triple blind study. Time to step diet, length of postoperative hospital stays, and adverse effects were also evaluated in secondary outcomes.

Results

All forty four patients were include, twenty-three in control group and twenty-one in mosapride group. There were no statistically significance differences between mean age and type of surgery (laparoscopic or open) in two group (P>0.05). Time to first bowel movement and time to passage of flatus after operation were significantly shorter in the mosapride group than the control group (26 vs 50 hours, P=0.004 and 40 vs 70 hours, P=0.003, respectively). Time to step diet (soft diet) was also shorter in the mosapride group (90 vs 132 hours, P=0.004). Time to defecate was less in mosapride group than control group (80 vs 120 hours, P <0.001). Length of hospital stay was significantly shorter in patients receiving mosapride (7 vs 10 days, P=0.004).

Conclusion

This study demonstrated the efficacy of mosapride when administered to patients who underwent elective colorectal surgery. Mosapride significantly enhance recovery of gastrointestinal motility and shorter length of hospital stay with no significant adverse effects.

References

1. Collins TC, Daley J, Henderson WH, Khuri SF. Risk factors for prolonged length of stay after major elective surgery. Ann Surg 1999;230:251–9
2. Vather R, O'Grady G, Bissett IP, Dinning PG. Postoperative ileus: mechanisms and future directions for research. Clin Exp Pharmacol Physiol. 2014;41(5):358-370.
3. Goldstein JL, Matuszewski KA, Delaney C, Senagore A, Chiao E, Shah M, et al. Inpatient economic burden of postoperative ileus associated with abdominal surgery in the United States. P AND T.2007;32(2):82.
4. Venara A, Neunlist M, Slim K, Barbieux J, Colas PA, Hamy A, et al. Postoperative ileus: Pathophysiology, incidence, and prevention. J Visc Surg 2016;153:439-46.
5. Luckey A, Livingston E, Taché Y. Mechanisms and Treatment of Postoperative Ileus. Arch Surg. 2003;138(2):206–214.
6. Georgiadis, G & Markantonis, Sophia & Triantafillidis, John. (2000). Prokinetic agents: Current aspects with focus on cisapride. Annals of Gastroenterology. 13.
7. Reynolds, J.C. & Putman, P.E. (1992) Prokinetic Agents, Gastroenterol Clin of North Am, Vol.21, pp.567-596.
8. Taniyama, K., Makimoto, N., Furuichi, A. et al. Functions of peripheral 5-hydroxytryptamine receptors, especially 5-hydroxytryptamine₄ receptor, in gastrointestinal motility. J Gastroenterol 35, 575–582 (2000).

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

Endoscopic full thickness resection (EFTR) is emerging as an effective modality for mucosal and submucosal lesions in colorectum.

Aims & Methods

In this systematic review and meta-analysis, we aimed to analyze the success and safety of device assisted EFTR in colon and rectum. A literature search was performed in Embase, PubMed, Medline databases for studies evaluating device assisted EFTR between inception to October-2022. The primary outcome of the study was clinical success (R0 resection) with EFTR. Secondary outcomes included technical success and adverse events.

Results

29 studies with 3467 patients [2045(59%) males] with 3492 lesions were included in the analysis. The lesions were located in right colon in 1660 (47.5%), left colon in 990 (28.6%) and rectum 840 (24.3%). EFTR was performed for sub-epithelial lesions in 252 (7.2%) patients. Pooled mean size of the lesions was 16.6 mm (95% CI 14.9 – 18.2, I ² 98%). Technical success was achieved in 87.1% (95% CI 85.1%-88.9%, I²39%) procedures. The pooled rate of en bloc resection was 87.9% (95% CI 85.1%-88.9%, I²50%) and R0 resection was 81.6% (95% CI 78.8% to 84.2%, I²57%). In sub-epithelial lesions, pooled rate of R0 resection was 94.3% (95% CI 89.7% to 96.9%, I² 0%). Pooled rate of adverse events was 12.1%(95% CI 10.3%-14.1%, I²44%) and major adverse events requiring surgery was 2.5% (95% CI 2.0%-3.1%, I²0%).

Conclusion

Device assisted EFTR is a safe and effective treatment modality in cases with adenomatous and sub-epithelial colorectal lesions. Comparative studies are required with conventional resection techniques including endoscopic mucosal resection and submucosal dissection.

Introduction

Rigid surgical instruments used for conventional laparoscopic surgery provide limited movement, and it is difficult to perform skillful surgery due to their long, jointless straight features. Articulated instruments could have the same advantages seen in robotic surgery, such as excellent control in smaller spaces, restoration of more intuitive and ergonomic movements, and the ability to overcome obstacles on a direct visual line. The aim of this study was to evaluate the surgical performance and clinical outcomes of patients following laparoscopic colorectal surgery with multijoint laparoscopic instruments, ArtiSential® (LivsMed, Seongnam, Korea), compared with those using conventional instruments.

Aims & Methods

Patients aged 19–80 years undergoing elective laparoscopic surgery for colorectal disease between December 2021 and November 2022, were consecutively enrolled. The first 20 cases underwent conventional laparoscopic surgery, and the latter 50 cases underwent laparoscopic surgery using ArtiSential®. Unedited operative videos were submitted to the Crowd-Sourced Assessment of Technical Skills (C-SATS) platform for evaluation using the Global Operative Assessment of Laparoscopic Skills (GOALS), which is a validated tool for technical proficiency. Each of GOALS’ four domains (bimanual dexterity, depth perception, efficiency, and tissue handling) was scored on a Likert scale between 1 and 5, scoring anchor, with a total score ranging from 4 to 20. The learning curve analysis was performed using the cumulative sum control chart (CUSUM) for GOALS grades (Registration number: KCT0006798).

Results

There was no significant difference between group with regards to type of operation, hospital stay, and 30-day postoperative complication. The GOALS’ grades were similar between the two groups (15.7 ± 0.7 vs. 15.9 ± 0.5, P = 0.190), but the scores in two domains (depth perception and tissue handling) were significantly higher in the ArtiSential® group (3.9 ± 0.3 vs. 4.0 ± 0.2, P = 0.014 and 3.9 ± 0.2 vs. 4.1 ± 0.2, P = 0.048, respectively) compared with those in the conventional group. In addition, patients in the ArtiSential® group experienced a shorter operation time (122.3 ± 58.9 vs. 88.1 ± 35.1, P = 0.022) and less intraoperative blood loss (56.5 ± 69.9 vs. 29.8 ± 1.4, P = 0.002) than those in the conventional group. According to the CUSUM learning curve analysis, the first 10 cases using ArtiSential® were in the inexperienced phase, and the remaining 40 cases were in the experienced phase. The GOALS’ score in the experienced phase of ArtiSential® was improved compared with that in the conventional group (16.0 ± 0.5 vs. 15.7 ± 0.7, P = 0.037).

Conclusion

A plateau in the learning curve of laparoscopic colorectal surgery performed with an articulated instrument was observed in approximately 10 cases, and it can be expected that surgical proficiency in the experienced phase increases without deterioration of clinical outcome as compared to that in conventional surgery.

References

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Disclosure

This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grantnumber: HI20C2092).