Introduction

Operator dexterity is recognised as a critical determinant of outcomes after surgery (1-2). No such recognition exists for the quality of endoscope tip manipulation (tip-control) and no objective measurement scale exists.

Aims & Methods

The aim of this study was to develop and validate a score for tip-control in an ex-vivo setting.
A web application containing a timed-score with clickable buttons to indicate correct and incorrect application of snare tip soft coagulation (STSC) was developed. The score was tested on a training model containing 4 shapes constructed from 1-4 identical circles (radius 1.4cm) connected at their mid-points drawn onto a single piece of cooked ham.
Endoscopists with varied profiles consented to video recording of their timed complete application of STSC (hits) to sequential circles using a gastroscope. Correct application was defined as any visualised diathermy application touching the marked lines. Median correct-hits/incorrect-hits (accuracy) and correct hits/second (speed) were determined by a single rater over the 4 recordings and stratified by shape and endoscopist demographics.

Results

22 endoscopists (8[36.4%] trainees, 6[27.3%] non-interventional consultant gastroenterologists and 8[36.4%] interventional endoscopists) participated.
Participant median accuracy was 82.0% (IQR17.5, 95%CI 77.0-85.0) and correct hits/second 0.141 (IQR0.095, 95%CI 0.120-0.160). Accuracy strongly correlated with blinded rater opinion of the macroscopic ham appearance (correlation coefficient=0.78, P<.001).
A scatter plot of endoscopist accuracy versus correct hits/second categorized endoscopists into 4 groups (combinations of accurate/inaccurate, fast/slow)(Figure 1). Interventional endoscopists were commonly fast and accurate (accuracy 88.0%[P=.001], correct hits 0.191/s[P=.04]) versus other participants. Non-interventional consultants had the lowest accuracy numerically and statistically similar tip-control to other participants (accuracy 69.0%[P=.15], correct hits 0.135/s[P=.97])(inaccurate). Trainees had similar accuracy to non-trainees but lower correct hits/second (accuracy 73.6%[P=.25], correct hits 0.153/s [P=.03])(slow). Endoscopists with >5 years experience did not have better tip-control (accuracy 88.0%[P=.07], correct hits 0.132/s[P=.36]) when compared to the rest of the participants (table 1).

Conclusion

This is the first demonstration of an ex-vivo objective tool to assess the quality of endoscopic tip manipulation. Tip-control reliably stratifies endoscopists by important demographics including interventional profile, number of polypectomies performed and those performing difficult polypectomy but does not correlate with years of endoscopy experience.
If tip-control can be linked to established performance indicators it may provide an objective benchmark for endoscopy and interventional procedures allowing tracking of progress over time.

References

1. Fecso AB, Szasz P, Kerezov G, Grantcharov TP. The Effect of Technical Performance on Patient Outcomes in Surgery: A Systematic Review. Ann Surg. 2017 Mar;265(3):492-501. doi: 10.1097/SLA.0000000000001959. PMID: 27537534.
2. Goldenberg MG, Garbens A, Szasz P, Hauer T, Grantcharov TP. Systematic review to establish absolute standards for technical performance in surgery. Br J Surg. 2017 Jan;104(1):13-21. doi: 10.1002/bjs.10313. Epub 2016 Sep 30. PMID: 27686465.

Disclosure

David James Tate consulting fees and research support from Olympus Medical. The remaining authors have no competing interests to disclose.

Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Introduction

Until a few years ago, there existed only off-label medical treatment options for eosinophilic esophagitis (EoE) such as proton pump inhibitors (PPI) or swallowed topical corticosteroids (STC) with various formulations and ingredients. Since the approval of a budesonide orodispersible tablet (BOT), the first biological agent (Dupilumab) has been approved by the EMA and FDA, and another budesonide oral suspension has been received approval by the FDA recently. Currently, many phase 3 trials with different drugs are running, resulting in various treatment options in the next years. However, data about patients’ perspectives are lacking. We therefore aimed to assess patients’ awareness, beliefs and restrictions to medical treatment options in EoE

Aims & Methods

We developed a web-based survey using SurveyMonkey and sent a questionnaire comprised of 47 questions about patients’ preferences regarding medical treatment options to patients with established EoE in Switzerland, Austria and Germany.

Results

A total of 56 patients (64% male, 66% with other atopic diseases) from Switzerland (64%), Austria (34%) and Germany (2%) answered the questionnaire. A swallowed topical therapy was ranked first (71% of patients) in terms of patient’s preference followed by a subcutaneous therapy every 4 weeks (21.4%) and by an oral therapy with systemic effect (7%). Although one third do not have reservations against long-term medical therapy, nearly half of patients (42%) are skeptical about long-term treatment and 65% are afraid of adverse events. However, a third of patients are not aware that STC are locally effective medications with nearly no systemic effect. Furthermore, 48% of patients believe that physicians underemphasize adverse events of medication. Nearly all patients understand the importance of not only treating symptoms but also inflammation (85%).

Conclusion

Patients with EoE prefer topical agents over other available routes of administration. Patient education should be carried out to address reservations about long-term treatment.

Disclosure

Falk Pharma, Sanofi (both consultency meetings)

Introduction

Focal cryoballoon ablation (FCBA) is a relatively new ablation modality for the treatment of Barrett’s esophagus (BE) related neoplasia. This prospective, European multicenter study (Euro-Coldplay, NTR NL7253) aimed to evaluate the efficacy and safety of FCBA for the treatment of limited BE.

Aims & Methods

In eight European Barrett referral centers, patients with C≤2M≤5 BE with an indication for ablation therapy were eligible for inclusion. Before entry, any visible lesion had to be removed by endoscopic resection (max. 2cm in length and 50% of circumference). FCBA was performed by experienced and trained endoscopists at 3 month intervals until complete endoscopic eradication of BE (max. 5 sessions). During every session, the esophagogastric junction was treated circumferentially followed by all visible BE using side-by-side ablations with a dose of 8 seconds per ablation. After at least two FCBA sessions, add-on treatment was allowed with either argon plasma coagulation (APC) for BE lesions of <5mm (max. 2 sessions) or a single endoscopic mucosal resection for lesions of >5mm. Outcomes included complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D), and adverse event rate.

Results

107 patients (91 males; mean age 65) with a median BE length of C0M2 were included, containing low-grade dysplasia (32%), high-grade dysplasia (32%) or early cancer (39%) as worst baseline histology. Currently, 5/107 patients are still under treatment and therefore excluded from further analysis. Of the remaining patients, 97 (97/102; 95%) patients have finished the treatment phase per protocol, while four (4/102; 4%) patients left the study prematurely. Only one (1/102; 1%) patient could not be treated with FCBA due to a device malfunction requiring a switch to radiofrequency ablation. Overall, 65/102 (64%) patients underwent endoscopic resection at entry followed by a median of 2 (IQR 2-2) FCBA treatments with a median of 7 (IQR 5-9) ablations per treatment session. During the treatment phase, 3/102 (3%) patients developed a new visible, neoplastic lesion amenable for endoscopic resection (high-grade dysplasia n = 2, low-risk T1 cancer n = 1). Add-on treatment after at least two FCBA sessions was performed in 38/102 (37%) patients, of whom the most were treated with APC for small remaining Barrett islands (37/38; 97%). CE-D was achieved in 95% (97/102) and CE-IM in 91% (93/102), per intention-to-treat analysis. Per-protocol analysis, CE-D and CE-IM were achieved in 100% (97/97) and 96% (93/97), respectively. Esophageal stricture was the most common adverse event in 13/102 (13%) patients, which resolved after a median of 2 (IQR 1-4) dilations. Only three (3/102; 3%) patients suffered a severe stricture requiring >3 dilations. No perforation or bleeding were observed, while buried BE glands were seen in 1/102 (1%).

Conclusion

In expert hands, endoscopic eradication therapy with FCBA seems to be highly effective with an acceptable safety profile for patients with limited BE. Long-term follow-up is warranted to evaluate the durability of the treatment response.

Disclosure

C.N. Frederiks have received speaker's fee and reimbursement of study-related travel costs from Pentax Medical. A. Overwater has received reimbursement of study-related travel costs from Pentax Medical. J.J.G.H.M. Bergman is a consultant for Medtronic, Cook Medical, and Boston Scientific, and has received research funding from Pentax Medical, C2 Therapeutics, Medtronic, Aqua Medical, Olympus Endoscopy, and Fuji-film. R.E. Pouw is a consultant for MicroTech, and has received speaker’s fee from Medtronic. R. Bisschops is a consultant for Pentax Medical, Medtronic, and Erbe Medical, and has received research funding and speaker’s fees from Pentax Medical, Medtronic, and Erbe Medical. T. Beyna is consultant for Medtronic, Erbe Medical, Microtech Endoscopy, Olympus Endoscopy, and Boston Scientific. B.L.A.M. Weusten has received research funding from Pentax Medical, C2 Therapeutics, and Aqua Medical. The remaining authors declare to have no disclosures relevant to this manuscript.

Introduction

Helicobacter pylori (Hp) infection is one of the major causes of gastric cancer and represents a significant global public health challenge. In Japan, where the incidence of gastric cancer is high, reducing the risk through the eradication of Hp is deemed crucial. While enhancing awareness about Hp is thought to encourage testing and contribute to treatment, there is a lack of evaluation regarding the Japanese population's awareness of Hp.

Aims & Methods

In this cross-sectional study, we aim to assess baseline knowledge and attitude tuwards Hp among Japanese population. Participants were recruited through an online survey platform (Macromill, Inc), with ages ranging from 20 to 69, reflecting the age demographic composition of Japan equally across genders. Referencing the existing surveys on Hp^1-3, we assessed knowledge on five key aspects related to Hp: risk of infection (scored out of 7), diseases caused by Hp (scored out of 7), methods of testing (scored out of 5), benefits and side effects of Hp eradication (scored out of 8), and knowledge of gastric cancer prevention (scored out of 10). Attributes of participants, socioeconomic factors, and health literacy (HLS-14)⁴ were also evaluated to study their correlation with knowledge about Hp.

Results

A total of 3,095 individuals participated. Of these, 56.3% reported having some knowledge about Hp. 865 participants (28.0%) had undergone Hp testing, 354 (11.4%) confirmed Hp infection, and 283 (9.1%) had received treatment for Hp. About 55.6% (1,722 participants) consider that the treatment for Hp posed a significant financial burden. The average correct response rate across all knowledge items was 45.6% (SD: 19.0%). The individual correct response rates were 57.3% for risk of Hp infection, 50.9% for diseases caused by Hp, 24.5% for methods of testing, 45.6% for benefits and side effects of Hp eradication, and 44.4% for knowledge of gastric cancer prevention. Higher scores were significantly associated with having an income over 4 million yen, a family history of Hp, personal Hp testing history, Hp treatment history, and higher health literacy. Over 80% of respondents acknowledged that understanding the relationship between Hp and stomach symptoms, recognizing Hp as a gastric cancer risk, and knowing that Hp eradication reduces future gastric cancer risk influenced their decision on the need for eradication. Similarly, the same proportion reported that believing that the harshness of the treatment exceeds the current symptoms and the high costs of testing and treatment influenced their decisions for eradication.

Conclusion

The level of understanding of Hp among the Japanese population is moderate and influenced by income level, health literacy, and personal experience with the Hp infection. Many consider testing and treatment burdensome. Enhancing correct understanding of Hp could potentially increase testing and treatment rates, contributing to the future reduction of gastric cancer in Japan.

References

1. Kimberly S Bailey, et al., Helicobacter pylori treatment knowledge, access and barriers: a cross-sectional study. Helicobacter 2023;28(2):e12954.
2. You Wu, et al., Awareness and attitudes regarding Helicobacter pylori infection in Chinese physicians and public population: A national cross-sectional survey.Helicobacter 2020;25(4):e12705
3. Thomas Zheng Jie Teng, et al., Helicobacter pylori knowledge and perception among multi-ethnic Asians.Helicobacter 2021;26(3):e12794.
4. Machi Suka, et al.,The 14-item health literacy scale for Japanese adults (HLS-14). Environ Health Prev Med. 2013;18(5):407-15.

Introduction

Although endoscopic submucosal dissection (ESD) is established as first-choice treatment for early esophageal squamous cell carcinoma (ESCC) worldwide, most data on outcomes are derived from Asian studies. Therefore, we aimed to evaluate the short- and long-term outcomes of ESD for patients with early ESCC in a Western cohort.

Aims & Methods

In this retrospective cohort study, patients with early ESCC amendable for ESD were included in four tertiary referral hospitals in the Netherlands between 2012 and 2017. All procedures were performed by experienced endoscopists who were specifically trained in ESD. The decision for and choice of additional treatment following ESD was made on a per-patient basis. For this study, dedicated research fellows collected all relevant data by reviewing the electronic patients files. Data concerning long-term outcomes were checked with general practitioners or referral hospitals, when applicable. Outcomes included technical success, R0 resection (i.e. tumor-free lateral and vertical margins), curative resection (i.e. en-bloc radical resection with histology no more advanced than T1sm1, good differentiation and absence of lymphovascular invasion) and recurrence rates, as well as ESCC-specific and overall survival.

Results

We included 68 patients (34 males; mean age 69) with a median tumor size of 3cm (range 1-12) and circumferential extent of 50% (range 10-100), in whom ESD was technically successful in 66/68 patients (97%). While en-bloc resection was achieved in 64/66 technically successful ESDs (97%), R0 resection was accomplished in 54/66 patients (82%). Overall, a curative resection was achieved in only 34/66 patients (52%). Among the patients with a non-curative resection, 16/32 (50%) underwent additional treatment receiving either argon plasma coagulation for tumor-positive resection margins (n=1), selective lymph node dissection (n=1), definite chemoradiation therapy (n=4) or esophagectomy ± neoadjuvant chemoradiation therapy (n=10). Endoscopic surveillance was preferred in the other half of patients with a non-curative resection (16/32; 50%) based on significant comorbidities or patient choice. During a median follow-up of 66 months (p25-p75 43-88), 12/66 patients (18%) developed a local recurrence which could be treated endoscopically in most cases (10/12; 83%). Locoregional lymph node metastasis and distant metastasis were observed in 6 (6/66; 9%) and 3 (3/66; 5%) patients, respectively. A total of 30 patients (30/66; 45%) died during follow-up, of which the minority (7/30; 23%) was ESCC-related deaths. The 5-year overall and ESCC-specific survival probability were 64% (95% CI 53-76%) and 88% (95% CI 79-97%), respectively. More importantly, overall survival did not significantly differ between patients with and without curative resections (p = 0.69). In addition, no significant difference was seen for ESCC-specific survival between patients with or without additional treatment after a non-curative resection (p = 0.07).

Conclusion

In this Western cohort with long-term follow-up, the efficacy and safety of ESD for early ESCC was confirmed although the rate of non-curative resections was substantial. Irrespective of non-curative or curative resection, the long-term prognosis of these patients was limited mainly due to competing mortality. Considering additional treatment after a non-curative resection did not influence survival, the potential benefit of adjuvant therapy should be carefully balanced against the risk of dying from another cause than esophageal cancer on an individual basis.

Disclosure

C.N. Frederiks has received speaker's fee from Pentax Medical.
R.E. Pouw is a consultant for MicroTech, and has received speaker’s fee from Medtronic.
J.J.G.H.M. Bergman is a consultant for Medtronic, Cook Medical, and Boston Scientific, and has received research funding from Pentax Medical, C2 Therapeutics, Medtronic, Aqua Medical, Olympus Endoscopy, and Fuji-film.
B.L.A.M. Weusten has received research funding from Pentax Medical, C2 Therapeutics, and Aqua Medical. The remaining authors declare to have no disclosures relevant to this manuscript.