Introduction

Endoscopic submucosal dissection (ESD) is widely implemented in Asia. Experience from the western world is still limited, so the evidence on the description of a learning curve (LC) is sparse.

Aims & Methods

The aim of this study is to evaluate the LC for ESD of gastric lesions using accepted proficiency benchmarks (PB).
Retrospective analysis with a prospectively maintained database of all patients undergoing ESD at a Western tertiary center from June 2016 to December 2022.
Inclusion criteria: ESD of gastric lesions performed by a single operator.
Primary endpoint: a LC to estimate the number of ESDs required to achieve PB (>90% for en bloc resection, >80% for histologic margin-negative (R0) resection and resection speeds (RS) >9cm2/hr), using the CUSUM method.

Results

Of 477 ESD performed, a total of 235 ESD met the inclusion criteria.
The en bloc resection rate was 100%. The R0 resection rate was 97% so no statistically significant differences were found, since it was always within PB.
Using the CUSUM method, the LC was divided into learning periods [Phase I - learning phase (cases 1-48); Phase II - adaptation phase (49-72), Phase III - consolidation (from case 73 on).
Globally, after reaching the level of 9cm2/h and after resection 73, the cumulative moving average remains above this speed for all following resections.
Several locations reach moving average proficiency levels at different number of interventions (antrum: from the beginning, body: 134th).

Conclusion

The PB regarding the en bloc and R0 resection were achieved from the beginning.
The PB regarding de RS was achieved from the beginning for the antrum.
The PB regarding de RS, globally, has a clinically significant first learning inflection at ESD number 49 and at ESD number 73 achieved sustained PB for RS.

Disclosure

There are no conflict of interest.

Introduction

Hemorrhoidal disease affects 2-7% of patients with inflammatory bowel disease (IBD) (1,2), but treatment recommendations are limited due to apparent higher morbidity in this subset of patients (3,4). Currently, there is limited data about hemorrhoidal disease treatment in IBD, there is even less information regarding non-surgical treatment.

Aims & Methods

The authors aim to evaluate the safety and efficacy of office-based procedures in hemorrhoidal disease in patients with IBD. This is a retrospective and Portuguese multicenter study (7 centers) that included patients with IBD who underwent office-based procedures for hemorrhoidal disease between July 2013 and July 2021. Data relating to IBD and hemorrhoidal disease were analyzed namely success, relapse, and complications. Success was defined as a significant improvement in symptoms after office-based procedures, without the need for additional treatment. Relapse was defined as a worsening of symptoms, requiring new office-based procedures/surgery.

Results

129 patients were included, 70% with ulcerative colitis; in Crohn's disease, 5.4% had a history of perianal disease. Only 62% of patients had endoscopic remission and 18% were on biologics. Regarding Goligher's classification, the majority had grade II (48%). 77 patients underwent rubber band ligation (RBL), 44 patients underwent polidocanol injection and 8 patients underwent both techniques, in a total of 304 procedures (median of 2(2) sessions/patient). The treatment was effective in 88% of patients, of which 14% relapsed, with an average follow-up time of 55.3±34.5 months. Of 304 procedures, 17 (5.6%) procedures were complicated, in a total of 16 patients (12.4%), 2 (0.65%) required invasive treatment, without cases of pelvic sepsis. Success, relapse, and complications were not associated with IBD (type, medication, or remission at the time of treatment) (p>0.05). Success was greater in patients with Goligher grades I and II (p=0.037). Complications were higher in patients undergoing RBL (p=0.030) and in patients with Goligher grade III (p=0.031).

Conclusion

This is the first study about office-based procedures for hemorrhoidal disease in IBD, showing similar efficacy to the general population, with a low rate of complications, and should therefore be recommended in these patients.

References

1. Eglinton TW, Barclay ML, Gearry RB, Frizelle FA. The spectrum of perianal Crohn's disease in a population-based cohort. Dis Colon Rectum. 2012 Jul;55(7):773-7.
2. Choi YS, Kim DS, Lee DH, Lee JB, Lee EJ, Lee SD, et al. Clinical Characteristics and Incidence of Perianal Diseases in Patients With Ulcerative Colitis. Ann Coloproctol. 2018 Jun;34(3):138-143.
3. Jeffery PJ, Parks AG, Ritchie JK. Treatment of haemorrhoids in patients with inflammatory bowel disease. Lancet. 1977 May 21;1(8021):1084-5.
4. D'Ugo S, Franceschilli L, Cadeddu F, Leccesi L, Blanco Gdel V, Calabrese E, et al. Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal. BMC Gastroenterol. 2013 Mar 11;13:47