Introduction

Musculoskeletal disorders (MSDs) are a major cause of occupational health issues. These conditions, often painful or chronic, affect muscles, tendons, and nerves. The medical profession, due to its demanding nature, involves long working hours, prolonged procedures, and awkward postures—all contributing factors to the development of MSDs among healthcare professionals, particularly in digestive endoscopy. Knowledge and training in endoscopic ergonomics may serve as effective preventive measures. Therefore, implementing a structured ergonomics training program is essential to mitigate the risks associated with endoscopy. Although ergonomic guidelines exist to prevent MSDs, their awareness and application remain uncertain. The aim of this study was to evaluate gastroenterology residents’ knowledge of ergonomic recommendations in endoscopy.

Aims & Methods

Eighty-five gastroenterologists fellows were recruited from four university hospitals to participate in the study. All participants provided informed consent. Data were collected using an online questionnaire. The questionnaire comprised 45 questions, organized into four sections: (1) general information, (2) level of ergonomic knowledge in endoscopy (one point per correct answer), (3) ergonomic practices during procedures, and (4) presence of pain and impact on professional activity. Participants completed the questionnaire individually, without time constraints. After this questionnaire, all the students had information on endoscopy ergonomics through a dedicated learning program.

Results

A total of 85 responses were analyzed. The majority of respondents were women (58%) with a median age of 27 years (interquartile range [IQR]: 26–29). Nearly half (49.4%) were in their first or second year of gastroenterology fellowship, and 47% had completed at least one semester in a dedicated endoscopy unit. Notably, 99% had not received any formal ergonomics training during their fellowship. Only 22.5% were aware of the risk of developing musculoskeletal disorders (MSDs) related to endoscopy practice.
Knowledge scores were generally low: 20% of participants scored below 25% correct answers, and 64% scored between 25% and 50%. Despite limited theoretical knowledge, some ergonomic practices were nonetheless implemented: 91.7% of fellows reported regularly adjusting bed height, 83.5% adjusted screen position, and 75.3% adjusted screen height during procedures. A large majority (89.4%) believed that ergonomic adaptations could help reduce the risk of MSDs. Additionally, 96.5% expressed interest in receiving formal ergonomics training. ​The evaluation results of the dedicated ergonomics program are currently under analysis.

Conclusion

This study highlights a significant lack of ergonomics knowledge among gastroenterology fellows, despite the high prevalence of MSDs associated with endoscopic practice. The absence of structured training contributes to this knowledge gap. However, the widespread adoption of some ergonomic behaviors and the strong interest in formal education underscore a clear opportunity to implement targeted ergonomics training programs within gastroenterology fellowships.

Introduction

Eosinophilic esophagitis (EoE) is an inmune-mediated inflammatory chronic disease, which may require topical swallowed corticosteroids for its treatment, despite concerns about its safety (1). Corticosteroids side effects are well known, with adrenal insufficiency (AI) and decalcification as the most feared ones. Swallowed formulations appear to be less harmful, due to its less absorption into the bloodstream. All EoE studies based in budesonide have ruled out AI by measuring basal cortisol levels, a high specific test, instead of using other tests with more sensitivity (2). This is the first study ad hoc conducted in adults to examine the effects of this treatment in the hypothalamic-pituitary-adrenal axis and in bone resorption.

Aims & Methods

We conducted a prospective study with 20 patients with confirmed diagnosis of EoE, with no previous response to proton pump inhibitors (PPI) and no previous treatment with corticosteroids. They were given orodispersable budesonide (JorvezaⓇ) 1 mg twice a day for 14 weeks. They were carried out physical exams, blood tests to rule out decalcification as well as other side effects, and an ACTH stimulation test (also known as SynacthenⓇ test) before and after the treatment.

Results

	Before treatment with JorvezaⓇ	Week 14 after treatment with JorvezaⓇ
N	20	20
Baseline cortisol	13.04 +/- 3.45	12.13 +/- 3.59	p-value 0.131
Cortisol 60 minutes after administration of SynacthenⓇ	22.93 +/- 2.37	20.63 +/- 2.42	p-value 0.183
Osteocalcin	32.16 +/- 16.91	24.18 +/- 9.76	p-value 0.006

Differences in SynacthenⓇ test before and after treatment with JorvezaⓇ were not statistically significant, with only 3 patients below the baseline of 18 mcg/dl of cortisol 60 minutes after the administration of SynacthenⓇ in the second visit (2 of them with cortisol value above 17 mcg/dl, and the other one with a cortisol value of 16.6 mcg/dl; with these results being considered as variants of normality). A statistically significant decrease in seric osteocalcin was found (24.18 +/- 9.76 ng/mL in week 14 vs 32.16 +/- 16.91 ng/mL baseline with p=0.006), whilst other bone resorption values remained unchanged after the treatment.

Conclusion

This study endorses, for the first time in adults, that patients with EoE in treatment with orodispersable budesonide at this dose have no risk of acute or chronic AI, which might simplify their management and follow-up as there is no need of progressive decline of the dose or switching to another corticoid after induction treatment with JorvezaⓇ. On the other hand, osteocalcin decrease could reveal some corticoids systemic absorption, which may not have any consequence in terms of fracture risk given the short period of treatment, but this needs to be addressed with further study.

References

1. Lucendo, A.J. et al. (2017) ‘Guidelines on eosinophilic esophagitis: Evidence‐based statements and recommendations for diagnosis and management in children and adults’, United European Gastroenterology Journal, 5(3), pp. 335–358. doi:10.1177/2050640616689525.
2. Woods, C.P. et al. (2015) ‘Adrenal suppression in patients taking inhaled glucocorticoids is highly prevalent and management can be guided by morning cortisol’, European Journal of Endocrinology, 173(5), pp. 633–642. doi:10.1530/eje-15-0608.

Introduction

Eosinophilic esophagitis (EoE) is a chronic disease characterized by eosinophil-predominant inflammation of the esophagus. Due to his progressive condition, it may evolve to fibrostenotic disease if a treatment is not prescribed. When stricture is already present, the standard therapeutic strategy is represented by endoscopic dilatation, but the use of topical steroids as a first-line approach is gradually being considered.

Aims & Methods

The aim of the study is to evaluate endoscopic modification of esophageal stenosis after induction therapy with budesonide orodispersible tablets (BOT). To date, these data have not been studied yet. A retrospective study was conducted to include all EoE patients in BOT therapy followed in our center. Data on demographics, clinical characteristics, prevalence and endoscopic features of stenosis before BOT medication were evaluated. After induction BOT treatment (1 mg twice a day), endoscopic and histological findings were studied, with attention to modification, intended by total remission, improvement (stricture passed by standard gastroscope) or stability of stenosis. Concomitant treatment with proton-pump inhibitors (PPI) was reviewed.

Results

A total of 93 EoE patients in BOT therapy were evaluated. 22 patients (24%) presented esophageal stenosis localized in 7 patients (32%) in cervical esophagus, in 4 patients (18%) in mid esophagus and in 11 patients (50%) in distal esophagus. After induction treatment, 8 patients (36%) reported total remission of stenosis, 7 patients (32%) improvement and 2 patients (9%) stability, 5 patients (23%) have not already performed gastroscopy at time of analysis. All patients (100%) with fibrostenotic disease reached total histologic remission (0 eosinophil/HPF) on gastroscopy after BOT induction therapy. Concomitant treatment with PPI was reported in 6 patients (28%), while 15 patients (72%) were not taking this medication.

Conclusion

Esophageal strictures in EoE are a well-known complication of disease. Our results show that stenosis may be modified by BOT induction therapy with a total remission or improvement in diameter in most of patients. This data could be explained by the inflammatory component of some stenosis, which respond to medical therapy with budesonide. Consistent with the already established efficacy of BOT, all patients achieved total histologic remission. On the contrary, concomitant treatment with PPI didn’t show an additional role in ameliorating fibrostenotic picture, but further studies are needed.

Introduction

A growing proportion of the general population is affected by Metabolic dysfunction-associated steatotic liver disease (MASLD). The relationship between MASLD and breast cancer is not sufficiently understood. The question, whether MASLD is a risk factor for breast cancer has become of great interest. The other way round, the question to what extent breast cancer therapy with tamoxifen leads to MASLD needs to be addressed.

Aims & Methods

In order to investigate the relationship between MASLD and breast cancer, we analyzed data from the liver Magnetic Resonance Imaging (MRI) subset of the United Kingdom Biobank (UK Biobank) (20,601 women, 3,817 MASLD and 1,048 breast cancer cases) and data from the Mayo Clinic Biobank and Tapestry studies (7,943 women, 1,976 MASLD and 634 breast cancer cases). MRI data were used to differentiate between MASLD and controls in the UK Biobank cohort. In the Mayo Clinic cohort, International Classification of Diseases (ICD) 9 and 10 codes, natural language processing and chart review were used. In the UK Biobank cohort we adjusted the analysis for age and Body Mass Index (BMI) by multivariable logistic regression, whereas in the Mayo Clinic cohort the controls were matched by age and BMI.

Results

We found an association between MASLD and breast cancer among lean women in both cohorts independent of age and BMI (both p<0.001). Most women with breast cancer and MASLD were diagnosed with breast cancer before they were diagnosed with MASLD. Significantly more women used tamoxifen in the MASLD group compared to the control group in the UK Biobank cohort (p=0.002) and the Mayo Clinic cohort (p=0.008) independent of age and BMI. In a subgroup analysis of the women, who were diagnosed with breast cancer after the study MRI of the liver in the UK Biobank, there was no significant association of MASLD and breast cancer independent of age and BMI (p=0.219). This was also not the case among lean or overweight women.

Conclusion

In this study we observed an association between MASLD and breast cancer among lean women. The use of tamoxifen in breast cancer therapy offers a possible explanation for the association. This study raises awareness that the development of hepatic steatosis through breast cancer therapy with tamoxifen might also be relevant for lean women.

Disclosure

financial support:
C.V.S. is supported by a grant from the Interdisciplinary Centre for Clinical Research within the faculty of Medicine at the RWTH Aachen University (PTD 1-13/IA 532313), the Junior Principal Investigator Fellowship program of RWTH Aachen Excellence strategy and the NRW Rueckkehr Programme of the Ministry of Culture and Science of the German State of North Rhine-Westphalia. K.M.S. is supported by the Federal Ministry of Education and Research (BMBF) and the Ministry of Culture and Science of the German State of North Rhine-Westphalia under the Excellence strategy of the federal government and the Laender as well as the NRW Rueckkehr Programme of the Ministry of Culture and Science of the German State of North Rhine-Westphalia. C.D., C.V.S. and K.M.S. are supported by the CRC 1382 project A11 and B09 funded by Deutsche Forschungsgesellschaft (DFG, German Research Foundation) – Project-ID 403224013 – SFB 1382. K.J.W. is supported by the U.S. National Cancer Institute through grant R37CA259201 and the Mayo Clinic Hepatobiliary SPORE (P50 CA210964).

Introduction

Self-expandable metallic stent (SEMS) placement is a palliative treatment for inoperable esophageal malignancies to improve the quality of life. Traditional methods rely on fluoroscopy and endoscopy, but anatomical landmarks can simplify the procedure.

Aims & Methods

To evaluate the technical success, safety and reproducibility of using vertebral column and diaphragm landmarks for SEMS placement.
This retrospective observational study included 801 patients with inoperable esophageal malignancies undergoing SEMS placement for dysphagia due to malignant esophageal strictures, by using vertebral column and diaphragm as landmarks, from 1^st January 2006 to 31^st December 2024. The primary endpoint was to assess the technical success, safety and reproducibility of this unique technique for SEMS placement.
Methodology for Stent Placement in Esophageal Tumors:
1. For Proximal or Mid-Esophageal Tumor, following algorithm was followed: Step 1: Identify key anatomical landmarks using fluoroscopy. Step 2: With the scope in place, under fluoroscopic guidance, identify the vertebra in line with the distal extent of the tumor using the diaphragm as a reference, followed by identification of vertebra at the proximal extent of the tumor. Count the vertebrae between the distal and proximal extent of the tumor. Assign a length of 2.5 cm per vertebral body. Ascertain the desired size of SEMS by calculating the total length of the stricture by counting the vertebrae, adding one vertebral body above and below the tumor for proper stent placement. Step 3: Using fluoroscopy, position the stent. Place the distal end of the stent at the distal vertebral marker. Position the proximal end of the stent at the proximal vertebral marker. Release the stent at the appropriate position to ensure full coverage of the stricture.
2. For Tumor Extending Beyond the Gastro-Esophageal Junction (GEJ), following algorithm was followed: Step 1: Identify the proximal extent of the tumor. Align the proximal extent of the tumor with the vertebra, using the diaphragm as a reference for precise alignment. Measure the distance from the proximal end of the tumor to the proximal stomach using the scope to decide the required size of the stent. Step 2: Place the stent under fluoroscopic guidance. Position the upper end of the stent at the identified vertebra. Extend the distal end of the stent into the stomach, past the GE junction to ensure proper coverage. Release the stent.

Results

408 (50.9%) patients were females. The age range was 18-95 years (mean50±Standard deviation15). Predominant presenting complaint was dysphagia (85.39%). Average duration of dysphagia was 3.84 months. 594 (74.16%) patients had squamous cell carcinoma, whereas 207 (25.84%) patients were diagnosed with adenocarcinoma on histopathology. 365 (45.57%) patients had tumor confined to the lower one-third of esophagus. Major cause of inoperability was distant metastasis (52.81%). 240 (30%) patients had involvement of GEJ. Average length of malignant stricture was 8.4 cm. 139 (17.40%) patients required dilatation by using savary gilliard dilators before SEMS placement. TEF was present in 48 (6%) patients. Range of length of SEMS was 8-18 cm (12.5±2.26). Technical success was achieved in 100% cases. No major immediate complications occurred. Minor complications were rare.

Conclusion

Using vertebral column and diaphragm landmarks is a reliable, safe, simplified and reproducible approach for SEMS placement in patients with inoperable esopahgeal malignancies.

References

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