Introduction

Endoscopic characterization aims to predict the histology of a lesion and thus the risk of cancer. This characterization step is essential, especially in the case of large superficial colorectal lesions, as the choice of resection technique directly depends on it. The JNET (Japan NBI Expert Team) classification is the classification proposed by European and Japanese guidelines to select the optimal therapeutic approach between EMR (endoscopic mucosal resection), ESD (endoscopic submucosal dissection), or surgery, but has not been evaluated in large laterally spreading lesions (LSTs) (>20 mm). We therefore evaluated the diagnostic performance of the JNET classification for predicting the risk of submucosal invasive cancer (SMIC) in LSTs >20 mm.

Aims & Methods

Single-center, prospective, observational study including all patients referred for endoscopic resection of lesions >20 mm, between 2017 and 2022. All LST samples with SMIC underwent a secondary pathological examination to establish the correlation between "covert" carcinoma (SMICs categorized as JNET 2A) and "buried" carcinoma (existence of SMICs more than 0.5 mm from the surface). The primary outcome was the diagnostic accuracy of the JNET classification for histological prediction of LSTs >20 mm. The secondary objective was to assess the combined performance of the JNET classification and pejorative macroscopic (macronodule >1 cm, Paris 0-IIc area, JNET 2B area, Non-Granular LST) criteria also called the CONECCT classification. We also attempted to determine the characteristics and risk factors of LSTs with covert or buried carcinoma, and to identify potential associations between the two.

Results

972 lesions were removed by en-bloc ESD, of which 110 (11.3%) of these lesions contained SMIC. The median lesion size was 57 mm. Of the 110 submucosal cancers, 33 had covert carcinoma and 35 were classified as buried carcinoma. The sensitivity and specificity for predicting high-grade dysplasia (HGD) to SMIC were 46% and 75% for JNET 2B and 87% and 38% for CONECCT IIC, respectively; and for predicting superficial SMIC were 67% and 67% for JNET 2B and 94% and 27% for CONECCT IIC, respectively. The false negative rates (FNR) (probability of missing SMIC) of JNET 2B and CONECCT IIC were 31% (31/100) and 3% (3/100) for predicting SMIC, respectively; and 33% (16/48) and 6% (3/48) for predicting superficial SMIC, respectively. JNET 2B exhibited significantly higher specificity than CONECCT IIC for predicting HGD to superficial SMIC (75% vs. 38%; p< 0.001) and for predicting isolated superficial cancer (67% vs. 27%; p< 0.0001). And CONECCT IIC was significantly more sensitive than JNET 2B for predicting HGD to superficial SMIC (46% vs. 87%; p< 0.001) and for predicting isolated superficial cancer (67% vs. 97%; p< 0.0001). No association was found between covert carcinoma and buried carcinoma (p 0.889).

Conclusion

The JNET classification has low diagnostic accuracy for predicting the risk of submucosal cancer for large superficial colorectal lesions and for making decisions on en bloc endoscopic treatment using ESD. If a selective ESD and piecemeal EMR strategy is used based on the submucosal cancer risk, the CONECCT classification is preferred to prevent under-treatment of SMIC.

Disclosure

Nothing to declare.

Introduction

Eosinophilic esophagitis (EoE) presents with varying histologic extents, yet the impact of comorbidities on eosinophilic distribution and the implications on disease progression and treatment response remains poorly understood.^1,2 This study aimed to investigate the prevalence of different EoE extents and their impact on disease progression and treatment response within a multicenter cohort.

Aims & Methods

Clinical, endoscopic, and histologic data from adult EoE patients actively followed up at four Italian referral centers from October 2022 to October 2023 were retrospectively collected. The primary endpoint was to assess the prevalence of different EoE histologic extents (proximal, distal, diffuse) based on the presence of a pathological eosinophilic infiltrate (³15 Eo/HPF) and evaluate their association with comorbidities (atopic diseases, gastroesophageal reflux disease), clinical characteristics, endoscopic features. The secondary objective was to compare treatment responses among different histologic extents of EoE.

Results

149 patients were included (median age: 37 years [IQR 25-51], 38.2% males). Proximal EoE was observed in 8.1% (12/149), distal EoE in 27.5% (41/149), and diffuse EoE in 64.4% (96/149) of patients. In proximal-EoE, male patients were significantly more prevalent (91.7% vs. 68.3% distal-EoE vs. 55.5% diffuse-EoE, P=0.03). No significant differences were found in the rate of autoimmune comorbidities (8.3%, 14.6% distal-EoE, 10.4% diffuse-EoE; P=0.8). Only allergic rhinitis was significantly more prevalent in the distal and diffuse-EoE groups compared to the proximal group (33.3% vs. 72.5% vs. 61.5%, P=0.049). The prevalence of asthma, atopic dermatitis, oral allergy syndrome, and gastroesophageal reflux disease was similar among the three EoE extent groups. Endoscopic inflammatory features at diagnosis were significantly more prevalent in the proximal-EoE group, compared to the distal and diffuse-EoE groups (91.7% vs 53.8% vs 66%; P=0.05). Endoscopic fibrotic features at diagnosis were similar between all the groups (proximal-EoE 50%, distal 42.5%, and diffuse-EoE 51.1%; P=0.6) The clinical response after first-line therapy was comparable in all groups (75.0%, 70.7%, and 69.8%, P=0.93) and proton pump inhibitors were the most frequently prescribed therapy (77.8%). The endoscopic fibrotic remission rate after first-line therapy was higher in the proximal-EoE compared to the distal and diffuse-EoE groups (100.0% vs. 35.7% vs. 13.8%, P=0.0001).

Conclusion

In adult patients with EoE, an increasing proximal-to-distal gradient of esophageal eosinophilic infiltrate was observed. There was no clear correlation between the histologic extent of EoE and comorbidities, development of fibrosis, and response to treatment.

References

1. Ghoz H, Stancampiano FF, Valery JR, et al. Extent of eosinophilic esophagitis predicts response to treatment. Endosc Int Open 2021;9:E1234-e1242.
2. Godat A, Mueller R, Schenker D, et al. Eosinophil Distribution in Eosinophilic Esophagitis and its Impact on Disease Activity and Response to Treatment. Clin Gastroenterol Hepatol 2023.

Introduction

Device-assisted enteroscopy (DAE) is the only exam capable of a panendoscopic diagnostic and therapeutic intervention in gastrointestinal tract. Despite the limited data, DAE appears to be a safe procedure in pediatric population. In fact, a few studies demonstrate ​the feasibility and safetiness of DAE in several clinical contexts, namely small ​bowel ​bleeding, polyposis syndromes or inflammatory bowel disease.

Aims & Methods

With this study, the authors aim to describe DAE experience, specifically balloon assisted enteroscopy, in a pediatric population of a tertiary center.
A unicentric retrospective study was performed in patients up to 18 years old undergoing DAE (either by anterograde or retrograde pathway), between January 2011 and February 2024.

Results

A total of 23 DAE exams from 16 patients were included in the study, 56% from the male gender. The study population had a medium age of 13 years (ranging from 4 to 18 years old). DAE was performed due to polyposis syndromes in 8 cases (6 cases of Peutz-Jeghers syndrome and 2 cases of juvenile polyposis) and in suspicious cases of middle gastrointestinal bleeding in 8 patients (5 with melena and 3 with ferropenic anemia). There was a total of 17 anterograde DAE, 5 retrograde DAE and 1 intraoperatory enteroscopy. 35% of the procedures were performed in an inpatient setting.
DAE had a diagnostic yield of 95%, identifying polyps in the small bowel or other locations, ulcers, small bowel stenosis and foreign body. A therapeutic procedure was performed in 56% of the cases, namely polypectomy, argon plasma coagulation and foreign body removal. A self-limited bleeding was observed in the first 24 hours after an anterograde DAE, solved without the need of an additional endoscopic or surgical procedure. DAE led to a modification in the clinical outcome in over 90% of the patients.

Conclusion

The present study confirms the safety profile of DAE in the pediatric population. In a cohort from a tertiary referral center, DAE led to therapeutic procedure in the majority of patients, without significant procedure related complications.

References

1. Pennazio, Marco et al. “Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.” Endoscopy vol. 55,1 (2023): 58-95.
2. Di Nardo, Giovanni et al. “Enteroscopy in children.” United European gastroenterology journal vol. 6,7 (2018): 961-969.

Disclosure

1. Pennazio, Marco et al. “Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.” Endoscopy vol. 55,1 (2023): 58-95.
2. Di Nardo, Giovanni et al. “Enteroscopy in children.” United European gastroenterology journal vol. 6,7 (2018): 961-969.