Introduction

Endoscopic resection is the therapeutic standard for localized rectal neuroendocrine tumors (NETs), yet the innovative endoscopic intermuscular dissection (EID) technique remains under-examined. This study endeavors to assess the clinical outcomes and efficacy of EID in the management of rectal NETs.

Aims & Methods

This retrospective analysis compiled patient data from three esteemed institutions: South China Hospital of Shenzhen University, Shenzhen Hospital of Southern Medical University, and Ningbo Medical Center Lihuili Hospital. Subjects with rectal NETs treated via EID from November 2017 to November 2023 were evaluated. Primary endpoints included technical and clinical success rates, while secondary endpoints involved procedural duration, postoperative hospital stay, adverse event occurrence, and longitudinal follow-up outcomes.

Results

A total of 18 patients (mean age 46.0; 72.2% male), with an average lesion size of 9.1 mm (SD 2.8), were enrolled, and 44.44% presented lesions over 10 mm in diameter. All patients (100%) reported technical and clinical success. Median operative time was 55 minutes (IQR: 43-67 minutes). Complete resection, validated by histopathological examination indicating G1 classification with clear margins, was accomplished universally. Median postoperative hospitalization was 5.6±1.0 days, devoid of complications such as hemorrhage, perforation, infection, or pain. Over an average of 28.8 months of follow-up (SD 22.9 months), there was no evidence of residual or recurrent disease, nor distant metastasis.

Conclusion

EID is substantiated as a viable and effective technique for rectal NET management. The observed outcomes suggest that EID could be a significant addition to the therapeutic modalities for rectal NETs, meriting further scrutiny in future research.

References

• [1] Liao Suhuan, Li Bo, Huang Longbin et al. Endoscopic intermuscular dissection in the management of a rectal neuroendocrine tumor. Endoscopy 2023; 55: E977-E979.
• [2] Kim J, Kim JH, Lee JY, et al. Clinical outcomes of endoscopic mucosal resection for rectal neuroendocrine tumor. BMC Gastroenterol 2018; 18: 77.
• [1] chaefer Marion, Albouys Jérémie, Geyl Sophie, et al. Endoscopic intermuscular dissection of a residual rectal neuroendocrine tumor with high-pressure injection and double-clip traction. Endoscopy 2023; 55: E1126–E1127.
• [2] Ichita Chikamasa, Sasaki Akiko, Kawachi Jun, et al. Endoscopic intermuscular dissection for a lower rectal gastrointestinal stromal tumor. Endoscopy 2023; 55: E258-E259.
• [3] De Cristofaro Elena, Rivory Jérôme, Jean Masgnaux Louis, et al. Repeat endoscopic intermuscular dissection of the visible scar after noncurative endoscopic intermuscular dissection of a rectal neuroendocrine tumor. Endoscopy 2024; 56: E205-E206.
• [4] Edward J Despott, Laura A Lucaciu, Alberto Murino et al. First report of gastric endoscopic intermuscular dissection. Endoscopy. 2024, 56: E132-E133.
• [5] Masgnaux Louis-Jean, Yzet Clara, Rivory Jérôme, et al. Endoscopic intermuscular dissection of rectal T1 cancer with adaptive traction: use of additional loops to improve traction directly on the circular muscular layer. Endoscopy 2023; 55: E410-E411.

Disclosure

There is no potential conflict of interest for all authors

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

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

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

In contrast to mucosal rectal T1 adeno-CA with an R0 rate of up to 92% at centers, the R0 RR in studies drops to 62-64% in case of deep sm infiltration.[1,2] Traditionally total mesorectal excision (TME) follows as completion surgery. Deep sm infiltration as isolated risk factor excluding L+, V+, G3 and Bd2-3 seems associated with a low risk of LN metastases of only 2.6%. [3] MRI and even EUS often lead to a significant T and N overstaging.[4] A min.-invasive diagn.-ther. resection procedure providing a clear histo-pathologic staging without potentially destroying parts of the meso-rectum as it has been reported for full thickness resection techniques would be desirable for potential later surgical resection (TME).[5] Endoscopic Intermuscular Dissection (EID), similar to PAEM uses a new flexible endoscopic dissection technique with separation of the circumferential and longitudinal muscular layer providing a specimen ideally including the entire mucosa, submucosa and the inner circumferential muscle layer.[6,7] The new technique achieved in a first prospective MC study including 67 patients a technical success rate of 96% and a histologic R0 resection rate of 85%.[5] In the following we report on our first experiences using EID as referral center for ESD.

Aims & Methods

To evaluate EID in lesions with biopsy proven ADC of the rectum without endoscopic, EUS or clinical signs of local infiltration. Rectal polyps with biopsy proven HGIEN and/or suspicious for local malignant infiltration. Additionally 2 patients were included who had undergone neo-adjuvant RT/Ch therapy 24 and 26 months before refusing definitive surgery (TME). Both presented with local flat polyps with histopathologically SSA (1) / hyperplastic polyp with focal LGIEN adenoma (2) for diagn.-therapeutic resection. After endoscopic, EUS, MRI, abd/th CT-staging and rectal digital examination without suspicion of local malignant infiltration pts were offered to prospectively undergo EID after extensive informed consent within a prospective protocol. All procedures were carried out under gen. anesthesia by an exp. interv. endoscopist with >1000 ESDs. Post-Op all pts. were hospitalized and closely monitored.

Results

From 11-2023 to 4-2024, 8 EIDs in 8 pts (3 f/ 5 m) were carried out (mean 63 y; 34-83y). 6/8 lesions lower rectum, 1/8 middle, 1/8 upper rectum. 'En bloc' resection was achieved in 100%. Histopathology showed 3x ADC G2, 3 x HGIEN and in both cases with neodajuvant RT/Ch LGIEN adenoma. R0 resection was achieved in 2 of the 3 ADCs, with deep sm T1 infiltration in both but without any other risk factors. Tumor board recommendation was close clinical & imaging FU. In the 3rd ADC tumor infiltration reached the inner muscular layer (T2) and the pat. underwent uneventful TME 10 d after EID. All other cases were follow clinically. Mean length of hosp. stay was 7.1 days. Serious major complications did not occur. All pts. are closely followed with uneventful FU.

Conclusion

EID seems a new perspective for the endosc. resection of T1 ADC and high-risk polyps in the rectum. Two cases after potentially curative neo-adjuvant treatment for rectal cancer and refusal of TME show EID as potential diagnostic tool but have to be regard with caution due to a remaining risk of scattered tumor cells in the mesorectum with TME remaining the gold standard. More experience in multicenter prospective studies with matched pair analysis or a comparison to surgical local procedures (TAMIS etc.) is necessary for the final assessment of EID as new promising endoscopic technique.

References

1. Watanabe D, Toyonaga T, Ooi M et al. Clinical outcomes of deep invasive submucosal colorectal cancer after ESD. Surg Endosc 2018; 32: 2123-30
2. Yamada M, Saito Y, Takamaru H et al. Long-term clinical outcomes of en- doscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017;49: 233-42
3. Zwager LW, Bastiaansen BAJ, Montazeri NSM et al. Deep Submucosal Invasion Is Not an Independent Risk Factor for Lymph Node Metastasis in T1 Colorectal Cancer: A Meta-Analysis. Gastroenterology 2022;163:174-89
4. Detering R, van Oostendorp SE et al. MRI cT1-2 rectal cancer staging accuracy: a population-based study. Br J Surg 2020;107:1372-82
5. Eid Y, Alves A et al. Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature. J Visc Surg 2018; 155: 445–52
6. Moons LMG, Bastiaansen BAJ, Richir MC et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new en- doscopic approach. Endoscopy 2022;54: 993-8
7. Toyonaga T, Ohara Y et al. Peranal endoscopic myectomy (PAEM) for rectal lesions with severe fibrosis and exhibiting the muscle-retracting sign. Endoscopy 2018; 50: 813–7

Introduction

Endoscopic ultrasound-guided fine needles biopsy (EUS-FNB) is nowadays considered mandatory for the assessment of solid pancreatic lesions (SPLs) in the neoadjuvant era. Even if most recent guidelines suggest that not less than 3 passes are sufficient to obtain adequate histological characterization, the right number of needle passes with the newest generation of FNB needles remains a topic of debate. In our study we aim to evaluate if less than 3 passes are enough to ensure high rates of confirmed histological diagnosis with the newest generation of FNB cutting needles.

Aims & Methods

Consecutive patients with SPLs requiring tissue sampling through EUS-FNB were enrolled in our study between October 2022 and March 2023. Tissue sampling was performed by the same expert endoscopist through a new 22G needle with asymmetric three-prong tip with the slow-pull technique and fanning when possible. The number of needle passes was determined by the macroscopic onsite evaluation (MOSE), and samples, coming from different passes, were divided into different test tubes. Our endpoints were diagnostic accuracy, positive core procurement yield and sample quality considering each test tube separetely.

Results

53 lesions (of which 75% pancreatic ductal adenocarcinoma) were sampled with an average size of 31 mm (SD=12mm). Sampling was performed with 2 or 3 passes, according to MOSE. Regarding the first needle pass, diagnostic accuracy was 97% (51 confirmed histological diagnosis) which reached 98% considering the second needle pass. Sample adequacy reached approximately 99%. Positive core procurement and tissue quality were >95% in all test tubes. No major adverse events were detected.

Conclusion

In patients with SPLs, the newest generation of histology needles for EUS-FNB could ensure a high diagnostic accuracy with only one needle pass, becoming extremely relevant in terms of time-saving, cost-effectiveness and safety, especially in high volume centers. Due to the limited number of patients additional data are needed.

Introduction

Intubation of the terminal ileum (TI) is the gold standard for completion of colonoscopy.
Our aim was to assess if this objective was achieved in our centre between endoscopists using various bowel preparations.
Poly ethylene glycol 4000 Vs Magnesium sulphate combined with potassium and sodium sulphates were the two commonly used bowel preparations. Magnesium containing preparations must be used with caution and avoided in patients with renal insufficiency, cardiac disease or pre-existing electrolyte abnormality and patients on diuretic therapy.
The Boston Bowel Preparation Scale was developed to limit inter-observer variability in the rating of bowel preparation quality, while preserving the ability to distinguish various degrees of bowel cleanliness and is mainly designed for adults. There is no dedicated bowel preparation score available for paediatric colonoscopies, BBPS is being used for critical comparison in our prospective cohort.

Aims & Methods

Objectives: To compare the intubation rate of TI between two endoscopists with quality of bowel preparation of colonoscopies in a tertiary health care centre and to assess the quality of bowel preparation of individual colonoscopies performed vis-a-vis, Boston bowel preparation scale as a prospective study over a period of 1 year.
Material and methods: A prospective study in a tertiary referral centre in children who underwent colonoscopies, aged 1 month to 17 years over a period of 1 year.
All children whose parents consented were included in the study. Results were collated using Microsoft Excel ™.A total of 135 cases were enrolled during our study period.

Results

1. TI intubation rate in PEG-4000 + bisacodyl based laxative formula is 87%
2. TI intubation rate in Magnesium/sodium/potassium based saline laxative formula is 79%
3. No side effects were encountered/ observed in either of the cohort.

Conclusion

In our study albeit the fact that our endoscopist chose different bowel preparations based on their anecdotal evidence based experience, we found that the bowel preparation was adequate.
There was no standardised paediatric bowel preparation globally and we note that every hospital or department or clinician have devised their own bowel preparation based either on personal experience or current available scientific literature.
We also note that we do not have a BBPS for paediatrics which will of immense value for research evaluation and revalidation of bowel preps.

References

1. Hien PT, Thoi VH, Ha NT, Kalach N. Efficacy of Two Regimens for Colon Cleansing Using Polyethylene Glycol 4000: A Randomized Open Label Trial. Indian Pediatr. 2021 Dec 15;58(12):1119-1123. Epub 2021 May 28.
2. Goodman and Gilman’s The pharmacological basis of therapeutics., 13^th edition
3. Mamula, Petar, and Noor Nema. “Bowel Preparation for Pediatric Colonoscopy.” Frontiers in pediatrics vol. 9 705624. 1 Sep. 2021
4. Barraclough H, Gillett P, Basude D, et al OC68 A multicentre assessment of adequacy of bowel preparation for paediatric ileocolonoscopy using the Boston bowel preparation scale (BBPS) Frontline Gastroenterology 2023;14:A42.