Introduction

Both endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are treatment options for gastric neoplastic lesions and intervention of choice in Asia for superficial gastric cancer, yet comparative studies between the two approaches in the Western world remain sparse. Prior Western studies, mainly meta-analyses, primarily focused on the differences in en bloc resection rate, curative resection rate, and other clinical outcomes. However, little is known regarding the depth of resection by EMR versus ESD, which may critically determine the efficacy of resection.

Aims & Methods

This retrospective study aims to systemically evaluate the depth of resection following EMR and ESD procedures by histological measurement. The standardized and reproducible assessment provides important insights that may be valuable for future research and clinical practice. Ultimately, the findings from this study will contribute to a better understanding of the most effective yet less traumatic treatment modalities for gastric lesions. Gastric EMR and ESD specimens from 20 patients in the past 5 years were analyzed microscopically for pathology. Tissue sections with intact inked deep resection margins were selected for measurement. The maximum and average depth of resection were recorded and calculated for each patient, defined as depth from muscular mucosa to inked resection margin. The normality of the data for each group was assessed using the Shapiro-Wilk test. An unpaired t-test was then performed to compare the resection depths between the two groups. Other clinical and pathological features were compared between the two groups.

Results

The mean maximum resection depth is 4.53 mm for ESD and 2.33 mm for EMR (p=0.0049). The difference in average resection depth between the 2 groups is not statistically significant (p=0.132). However, ESD resulted in a higher en bloc resection rate (85.7%) as compared to EMR (69.2%). As could be expected, a larger proportion of ESD specimens (42.8%) were for malignant lesions as compared to EMR cases (15.3%). In addition, the lesion size is significantly larger in the ESD group than in the EMR group (p=0.0031), with a mean lesion size of 41.86 mm for ESD cases and 16.89 mm for EMR cases. There were no significant differences in age or gender between the 2 groups.

Conclusion

Our study provides a detailed and objective evaluation of the depth of resection achieved by ESD and EMR techniques for gastric neoplasms in a Western population. We have shown a significantly higher en bloc resection rate and greater maximum resection depth achieved with ESD. Thus, ESD may be the preferred technique for lesions requiring a greater resection depth and those with a larger size. Furthermore, ESD allows for accurate assessment of the T stage of the gastric neoplasm and evaluation of the resection margins, which is crucial in ensuring the curative resection of the lesion. However, the decision to choose between ESD and EMR should be made on a case-by-case basis, considering the individual patient and lesion characteristics and the expertise of the endoscopist. In conclusion, our findings suggest that ESD provides a deeper and more complete resection of gastric lesions as compared to EMR, similar to the results obtained in Asia.

Introduction

Intestinal ultrasound (IUS) is a non-invasive method that is increasingly used to monitor disease activity in patients with inflammatory bowel disease.¹ There is currently no consensus on the appropriate implementation of IUS to assess post-surgical recurrence in Crohn’s disease (CD). ​

Aims & Methods

The aim of this study was to determine appropriate parameters for evaluating postoperative recurrence of CD using IUS after surgery. The modified RAND-University of California Los Angeles appropriateness method (RAM)² was implemented using an international panel of 16 experts, including gastroenterologists, surgeons, radiologists, and methodologists, to evaluate the appropriateness of statements related to using IUS for assessing postoperative recurrence of CD. This exercise specifically focused on assessing the anastomosis, neoterminal ileum after ileocecal resection, and primary anastomosis in CD. To inform statement generation for the RAM, a systematic review was performed to identify parameters described in the literature for the sonographic evaluation of postoperative disease recurrence in patients with CD. Statements were developed focusing on when, where, and how sonographic parameters should be assessed after surgery. Panellists voted anonymously in 2 rounds of surveys containing up to 122 statements, rating each statement for appropriateness on a 9-point Likert scale (1=highly inappropriate; 5=uncertain; 9=highly appropriate). Median appropriateness ratings were summarised, and interquartile ranges were calculated. The statement list and survey results were discussed in moderated videoconferences prior to voting. The panellists met in person to discuss the results and ratify the final statements.

Results

After 2 rounds of voting, 80% of the statements were rated as appropriate with agreement. IUS findings in the neoterminal ileum and the inlet of the neoterminal ileum were considered likely to reflect clinically meaningful disease. Recognising that immediate postoperative changes related to surgical healing may mimic CD, IUS should not be performed within 4 weeks of resection in the context of evaluating postoperative recurrence. Defining the entire component of the anastomosis as consisting of colonic blind side, ileal blind side, neoterminal inlet, and neoterminal ileum, if any were visible/present, was considered appropriate by the panellists. However, there was uncertainty with describing and measuring thickening within the blind loops and whether those segments represent postoperative recurrence. Use of bowel wall thickness, bowel wall stratification, bowel wall vascularity on Doppler, mesenteric inflammatory fat, lymphadenopathy, submucosal layer thickness, muscularis propria layer thickness, small bowel peristalsis, free fluid, abscess, inflammatory mass, fistula/sinus tract, anastomotic or neoterminal ileal stricture, luminal narrowing, pre-stenotic dilation, and stricture length were considered appropriate to assess postoperative CD recurrence, and parameters for each component were identified.

Conclusion

This first set of internationally guided recommendations (Table) for using IUS to assess postoperative recurrence of CD has been developed to facilitate standardisation of a non-invasive method of monitoring patients following surgical bowel resection.

References

¹ Dolinger MT, Kayal M. Intestinal ultrasound as a non-invasive tool to monitor inflammatory bowel disease activity and guide clinical decision making. World J Gastroenterol. 2023;29(15):2272-2282. Doi: 10.3748/wjg.v29.i15.2272
² Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation, 2001.

Disclosure

KLN has received consulting fees from AbbVie, Bristol Myers Squibb, Celltrion, Ferring, Fresenius Kabi, Janssen, McKesson, Pendopharm, Pfizer, and Takeda, with speaker's fees from AbbVie, Fresenius Kabi, Janssen, Pfizer and Takeda; and research support from Pfizer, and the Helmsley Trust.
SA has received speaker/honoraria fees from AbbVie, Fresenius Kabi, Janssen, Pfizer, and Takeda; and received research grants from A.I Vali and ATGen.
MA received consulting fee from Nikkiso Europe, Mundipharma, Janssen, AbbVie, Ferring, Galapagos, Alfasigma, Lilly, Sandoz, and Pfizer.
AdBvO has received speaker fees from Amgen, Takeda, and Janssen Pharmaceuticals.
PGK is a speaker and consultant for AbbVie, Celltrion, Johnson & Johnson, Pfizer and Takeda. He received scientific grants from Pfizer and Takeda, and is involved in clinical research for Ventyx, Roche, and Takeda.
CL has received advisory/consulting fees from AbbVie, Agomab, Celltrion, JnJ, Lilly, Pfizer, Takeda, Fresenius Kabi, Pendopharm, and Ferring.
CM received lecture and/or consulting fee from AbbVie, Alfasigma, Biocon Biologics, Bristol Myers Squibb, Ferring, Galapagos, Gilead, Lilly, J&J, Pfizer, and Takeda.
GM has received lectures or consulting fees from AbbVie, Janssen, Samsung, Galapagos, and Fresenius-Kabi.
RP reports being a Consultant for Abbott, AbbVie, Abbivax, Alimentiv Inc. (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Prometheus Biosciences, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, Ventyx, and UCB; reports Speaker’s Fees for: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, and Takeda Pharmaceuticals; and reports Advisory Boards for: AbbVie, Alimentiv Inc. (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, and Ventyx.
MR reports receiving consulting/advisory fees from AbbVie, Janssen, UCB, Takeda, Pfizer, BMS, Organon, Amgen, Genentech, Gilead, Salix, Prometheus, Lilly, Celgene, Boehringer Ingelheim Pharmaceuticals Inc. (BIPI), Celltrion, and Roche.
JR has received lectures fees from AbbVie and Takeda; is or has been advisor for Gilead, Takeda, Agomab, Janssen, Boehringer Ingelheim, Lumen, Ferring, and Bracco; and has received consultant fees from Alimentiv Inc. He received scientific grants from Takeda and AbbVie.
AS has received consulting fees from Stryker and Johnson and Johnson.
SAT reports grant support from Takeda; consultancy with AstraZeneca; and shareholder of Motilent.
RW reports speaker or consultancy fees by Alimentiv Inc, Pfizer, Takeda, J&J, and Nautilus Scientific.
WAB reports no competing interests.
NKC reports being a Consultant for Samsung and Speaker for Bristol-Myers Squibb.
KBG has received grants from AbbVie, Pfizer Inc., Celltrion and Galapagos; consultancy fees from AbbVie, Eli Lilly, Galapagos, Gilead, Janssen Pharmaceuticals, Pfizer Inc., Samsung Bioepis, and Takeda; and speaker’s honoraria from AbbVie, Celltrion, Eli Lilly, Ferring, Janssen Pharmaceuticals, Pfizer Inc, Takeda, and Tillotts.
SA, SK, and LJC are employees of Alimentiv Inc.
CM has received consulting fees from AbbVie, Alimentiv Inc., Amgen, AVIR Pharma Inc, Bristol Myers Squibb, Celltrion, Ferring, Fresenius Kabi, Janssen, McKesson, Mylan, Pendopharm, Pfizer, Prometheus Biosciences Inc., Roche, Sanofi, Takeda, and Tillotts Pharma; speaker's fees from AbbVie, Amgen, AVIR Pharma Inc, Alimentiv Inc., Bristol Myers Squibb, Ferring, Fresenius Kabi, Janssen, Organon, Pendopharm, Pfizer, Sanofi, and Takeda; royalties from Springer Publishing; and research support from AbbVie, Ferring, and Pfizer.

Clinical Case Summary

A 47-year-old female with a one-year history of ulcerative colitis (UC) presented with painful red skin lesions on her wrists and anterior tibiae, which progressed to necrotic ulcers (1). Initial treatment for her UC was mesalamine; however, she experienced three steroid-dependent flares. Prior to the initiation of infliximab for luminal disease activity, these progressive necrotic ulcers developed. Physical examination revealed deep, irregularly bordered, necrotic-based ulcerative lesions with erythematous rims. Bilateral pulses were palpable, and mucous membranes were normal. There was no history of animal exposure or recent travel. Elevated C-reactive protein (9 mg/L, ref: 0-5 mg/L) and negative procalcitonin were noted; other tests, including rheumatoid factor, antinuclear antibody, antineutrophil cytoplasmic antibody, viral serology, and deep tissue cultures for microorganisms, were unremarkable. A skin biopsy demonstrated a necrotic epidermis and neutrophilic infiltrates, consistent with suspected pyoderma gangrenosum, which was supported by a colonoscopy showing Mayo 3 active UC. The tuberculin skin test was negative. Infliximab was initiated, resulting in an intestinal response but only a partial response of the skin lesions (2). Topical tacrolimus ointment was added. Following the infliximab induction regimen, limited improvement in the skin lesions prompted the addition of systemic corticosteroids. After two weeks, a partial response persisted, and prednisolone was tapered. Infliximab was discontinued, and ustekinumab therapy combined with hyperbaric oxygen therapy was initiated, leading to significant regression of the skin lesions starting from the tenth day (3). This case illustrates refractory pyoderma gangrenosum in ulcerative colitis with a limited response to initial anti-tumor necrosis factor therapy, highlighting the potential of interleukin-23 pathway inhibition for managing this extra-intestinal manifestation.

References

References of illustrative material:
1. Clinical Photograph of Initial Wrist Lesions: Demonstrates the early presentation of pyoderma gangrenosum as erythematous and painful lesions on the patient's wrists upon initial presentation.
2. Clinical Photograph of Refractory Tibial Ulcers: Shows the characteristic deep, necrotic, and irregularly bordered ulcers on the patient's anterior tibiae, highlighting the severity and refractory nature of the pyoderma gangrenosum despite initial treatment.
3. Clinical Photograph of Post-Treatment Improvement: Illustrates the significant regression of the skin ulcers on the patient's tibiae following the initiation of ustekinumab and hyperbaric oxygen therapy, demonstrating the positive outcome of the alternative treatment strategy.

Introduction

Volatile organic compounds (VOC) in stool samples may reflect functional activity of gut microbiome. Previous studies showed that gut flora may influence transient relaxations of lower esophageal sphincter through short-chain fatty acids production and thus - participate in pathogenesis of gastroesophageal reflux disease (GERD). However, the role of VOC in pathogenesis of GERD is poorly studied yet.

Aims & Methods

The aim of this study (FGMF-2025-0003) was to perform correlation analysis between concentrations of VOC in stool samples and GERD-Q score.
We enrolled willing to participate patients referred to perform multichannel 24-h pH-impedance recording (Ohmega, Laborie). According to the Lyon 2.0 criteria patients were allocated to the GERD or the control group. GERD-Q questionnaire was filled in by the participants on the same day as stool samples were collected. Thermo TSQ 8000 triple quadrupole mass-spectrometer (GC/MS) was used for the measurement of VOCs in stool samples were analyzed with. Correlation analysis (Spearman rank R) was performed between values of 80 VOCs in stool samples and the results of GERD-Q questionnaire.

Results

Data of 76 patients were eligible: 42 with GERD and 34 - of the control group. Participants in the GERD group were older (54.7±12.2 y.o. vs 46±14.9 y.o., P<0.05) and their BMI was greater (30.9±5.2 vs 27.2±6.5 kg/m², P<0.05). GERD-Q score was logically greater in GERD group (11.0±2.5 vs 5.2±1.2, p<0.01). Correlation analysis revealed significant correlations between GERD-Q score and concentrations of 2-methylbutyric acid (Spearman R =-0.31), caproic acid (0.34) and enantiic acid (0.396) in stool samples.

Conclusion

GERD-Q score positively correlates with concentrations of Caproic acid (0.34) and Enantiic acid (0.396) in stool samples and negatively – with 2-Methylbutyric acid. The data of this pilot study may serve as a basis for further research on the role of functional activity of gut microbiome in pathogenesis of GERD.

Introduction

Low-volume polyethylene glycol plus ascorbic acid (PEG-Asc) reduces the dosage of colonoscopic bowel preparation (BP) solution, but is still poorly tolerated. Recent studies reported that adding laxatives to the BP solution reduced the volume of fluid required, without affecting the quality. Senna, one of the anthraquinone stimulant laxatives commonly used for chronic constipation, is reported to be useful as a BP adjunctive agent. However, the appropriate dose and combination of senna and BP solutions are unclear.

Aims & Methods

This study aimed to compare 1-L PEG-Asc plus 24 mg senna (1L-PEG/AS) and conventional 2-L PEG-Asc (2L-PEG/A) regimens on BP quality and patient tolerability. A single-center, randomized, investigator-blinded, non-inferiority trial was performed between June and August 2022. Outpatients scheduled for colonoscopy were randomized (1:1) to the 1L-PEG/AS or 2L-PEG/A group. Boston Bowel Preparation Scale (BBPS) was used to evaluate the quality of BP, and adequate BP was defined as a total score ≥6 and each segmental score ≥2. The rate of adequate BP was assumed as 90% in both groups with a noninferiority margin of 10%. Compliance, adverse events and tolerability were surveyed using questionnaires. Exploratory subgroup analyses were conducted based on the potential predictor of inadequate BP (with Bonferroni correction to adjust for multiple comparisons, P<0.05/20=0.0025 was considered significant).

Results

Overall, 344 patients received either 1L-PEG/AS or 2L-PEG/A regimens. The baseline characteristics of the two groups were comparable. The 1L-PEG/AS group showed non-inferior adequate BP rates compared with the 2L-PEG/A group (88% vs. 89%, P=1.00); the overall BBPS was 7.1±1.5 and 7.2±1.5, respectively (P=0.39). More patients in the 2L-PEG/A group took <80% of solution compared to those in the 1L-PEG/AS group (17% vs. 3%, P<0.01). Nausea, vomiting, abdominal pain and discomfort, and quality of sleep, were comparable between the two groups. Higher willingness to repeat the BP was observed in the 1L-PEG/AS group (85% vs. 62%, P<0.01), and more patients in the 2L-PEG/A were unwilling to repeat BP than those in the 1L-PEG/AS group due to larger volumes of PEG-Asc consumed (49% vs. 18%, P<0.01). Exploratory subgroup analyses for adequate BP found no significant difference between the two regimens for all subgroups.

Conclusion

The 1L-PEG/AS regimen was comparable to the 2L-PEG/A regimen in terms of BP adequacy, requiring lesser BP solution volumes, with better patient tolerance. Thus, it may be a suitable alternative to the conventional BP solution for colonoscopy.

Disclosure

Nothing to disclose.

Introduction

Clostridioides difficile infection (CDI) is among of the most common causes of nosocomial diarrhea with high morbidity and mortality. Recurrent and refractory disease courses in particular represent a special challenge in the management of these patients. The identification of patients at risk for recurrent courses could improve management, e.g. through the use of new and effective therapies in patients with CDI.

Aims & Methods

The aim of this study was to investigate the relationship between the presence of different comorbidities and the course of CDI.
In a retrospective, monocentric cohort study of a tertiary centre over a period of 10 years, patients with CDI-related hospitalizations were examined. The study included 336 patients with available information on comorbidities (diverticulosis, biliary diseases (cholecysto-, docholithiasis, cholecystitis, cholangitis or cholangiectasis) inflammatory bowel diseases (IBD), liver cirrhosis and malignancies) and the diagnosis of the recurrent CDI (rCDI) vs. non-recurrent course of CDI (nrCDI). Patients on dialysis or immunosuppressed patients were also considered as comorbid.

Results

Among 336 patients included in the study, 227 (67.6%) presented with at least one comorbidity. The most common were malignancy (30.4%), biliary diseases (19.4%), diverticulosis (15.8%), liver cirrhosis (14.3%), and inflammatory bowel disease (IBD, 8.9%). rCDI occurred more frequently in patients with diverticulosis and biliary disease. Diverticulosis was present in 24.4% of rCDI cases vs. 12.6% in nrCDI cases (OR 2.24, 95% CI 1.22–4.17). Biliary diseases were observed in 26.7% of rCDI vs. 16.7% of nrCDI patients (OR 1.82, 95% CI 1.01–3.26). No significant associations with rCDI were found for IBD (OR 0.66, 95% CI 0.27–1.65), malignancy (OR 1.13, 95% CI 0.67–1.88), or liver cirrhosis (OR 0.79, 95% CI 0.38–1.61).

Conclusion

These findings suggest diverticulosis and biliary disease may be independent risk factors for rCDI, whereas other common comorbidities are not significantly associated with recurrence. Structured assessment of risk conditions may help to select patients for tailored management to prevent rCDI disease course.