Introduction

Gastroenterology is a medical specialty that includes several areas of study. Endoscopy occupies a central role in professional practice, whether in hospitals or in the private sector. The quality of initial training and the different needs of trainees are key to the quality of care delivered to the population. This study aims to assess endoscopic training experience during fellowship.

Aims & Methods

This is a cross-sectional, multicenter study conducted on gastroenterology residents practicing endoscopy and in the final phase of their curriculum (6th, 7th and 8th semesters). Postgraduated doctors have been excluded from the study. An electronic survey made by Google Forms and was sent nationwide on January 9, 2024. The survey consisted of 42 questions divided into 3 parts: The first part focused on the participants' socio-demographic data and their endoscopic experience, the second part focused on the quality of training of core endoscopic skills (cognitive and motor skills) during fellowship where a 5-point Likert scale was used to express residents' satisfaction with their skills, ranging from 1="very dissatisfied", 2="dissatisfied", 3="neither satisfied nor dissatisfied", 4="satisfied" and 5="very satisfied". The third part included questions in which participants expressed their needs and expectations for improving their training in endoscopy. A statistical analysis using the Student-t test and the Fisher’s exact test were performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

We were able to collect data from 56 respondents. Most were female residents n=40 (71.4) with a mean age of 29.2 ± 2.5 years. The majority of fellows started practicing EGD in their 4th semester (91.1%), and colonoscopy in their 6th semester (57%). On average, the fellows are supervised by 5 senior doctors, including 2 who practice interventional endoscopy. Furthermore, 37.5% of participants report performing approximately more than 100 EGDs, 14.2% more than 100 colonoscopies, 80.4% report that they have performed less than 20 endoscopic variceal ligation and 14.3% have performed more than 10 polypectomies. An average rating score of 3.34 (1= very dissatisfied; 5= very satisfied) concerning the quality of training and feedback on cognitive aspects of endoscopy was found and we reported greatest emphasis for Procedure indication/contraindication and least on Capsule endoscopy interpretation.
The quality of training in technical aspects of endoscopy was rated higher (average rating score of 3.5). We reported greatest emphasis for Withdrawal/mucosal inspection and least on Esophageal dilation.
A significant association between motor skills and cognitive skills was found with a p<0.001.
Finally, to improve their training, 87.5% of respondents considered simulation to be important/very important, 98.2% of respondents intend to complete their endoscopy training at the end of their curriculum, and 87.5% are prepared to finance such a project (median: 1000 USD [1000;3000]).

Conclusion

Despite a significant improvement in training sites and technical facilities, training in endoscopy in healthcare institutions does not yet provide all the cognitive and technical skills required to enable fellows to be fully autonomous. With the development of endoscopic procedures, it seems essential for fellows to be able to perform more standard endoscopic procedures such as polypectomy and mucosectomy by the end of their curriculum. This may involve introducing regular endoscopy conferences and simulation training as a part of the curriculum.

Introduction

Among the diagnostic methods for EHCC, cell brush is the conventional method for EHCC diagnosis, but the sensitivity of cell brush and routine biopsy is low. The sensitivity and accuracy of EHCC diagnosis can be improved by single oral choledochoscopy. Radiofrequency ablation is a common and effective treatment for unresectable EHCC, providing local tumor control. Single oral choledochoscopy combined with radiofrequency ablation can improve the positive rate of pathological diagnosis.

Aims & Methods

To investigate the feasibility and safety of treating nonresectable extrahepatic cholangiocarcinoma (EHCC) with single resection combined with radiofrequency ablation (RFA).
A total of 149 patients with suspected extrahepatic cholangiocarcinoma treated in Hangzhou First People's Hospital from January 2013 to January 2023 were reviewed. According to the treatment process, 114 patients were eventually included and divided into two groups (n=48 cases) : Single oral choledochoscopy was performed by ERCP and the lesion tissue was biopsied under direct vision. Intraoperative rapid pathologic examination was performed on the same stage RFA for the patients who were pathologically identified as malignant tumors. Regular times group (n = 66) : first by endoscopic retrograde pancreatic angiography (endoscopic retrograde cholangiopancreatography, ERCP) + cells brush or a single biopsy samples by mouth choledochoscope examination, pathological results to obtain positive line of ERCP + RFA again; The operation success rate, postoperative liver function recovery, average ERCP number, postoperative adverse event incidence, length of hospitalization and cost were compared between the two groups.

Results

1. Patients in both groups successfully completed the RFA, the operation success rate was 100% (114/114).
2. There was no significant difference in the overall incidence of postoperative adverse events between the two groups [39.58% (19/48) vs. 39.40% (26/66),χ2=0.00, P=0.984].
3. There was no significant difference in the proportion of patients with total bilirubin improvement between the two groups [41.67% (20/48) vs. 42.42% (28/66), χ2= 0.32, P=0.750].
4. The average number of ERCP in the same group was significantly lower than that in the conventional group, and the difference was statistically significant (1.00±0.00 times/person vs. 2.64±0.49 times/person, t=0.77, P<0.001).
5. The average length of hospital stay in the same group was significantly longer than that in the conventional group, with statistical significance (8.40±3.63 days vs. 17.47±9.82 days, t=6.21, P<0.001).
6. The average hospitalization cost in the same group was significantly higher than that in the conventional group, and the difference was statistically significant (27718.31±9142.02 yuan versus 49112.76±16153.14 yuan, t=7.38, P<0.001).

Conclusion

Single oral choledochoscopy combined with biopsy and RFA in the diagnosis and treatment of unresectable EHCC can reduce the number of operations and does not increase the incidence of postoperative adverse events, which is a safe and effective method with a high cost-benefit ratio.

References

[1] Le V H, O'Connor V V, Li D, et al. Outcomes of Neoadjuvant Therapy for Cholangiocarcinoma: A Review of Existing Evidence Assessing Treatment Response and R0 Resection Rate [J]. J Surg Oncol, 2021, 123(1): 164-71.
[2] Chen R, Zheng D, Li Q, et al. Immunotherapy of Cholangiocarcinoma: Therapeutic Strategies and Predictive Biomarkers [J]. Cancer Lett, 2022, 546: 215853.
[3] Rizzo A, Ricci A D, Brandi G. Durvalumab: An Investigational Anti-Pd-L1 Antibody for the Treatment of Biliary Tract Cancer [J]. Expert Opin Investig Drugs, 2021, 30(4): 343-50.
[4] Sadeghi S. Infigratinib for Cholangiocarcinoma [J]. Drugs Today (Barc), 2022, 58(7): 327-34.
[5] Vignone A, Biancaniello F, Casadio M, et al. Emerging Therapies for Advanced Cholangiocarcinoma: An Updated Literature Review [J]. J Clin Med, 2021, 10(21).
[6] Jang D K, Kim J, Paik C N, et al. Endoscopic Retrograde Cholangiopancreatography-Related Adverse Events in Korea: A Nationwide Assessment [J]. United European Gastroenterol J, 2022, 10(1): 73-9.
[7] Hollenbach M, Hoffmeister A. Adverse Events in Endoscopic Retrograde Cholangiopancreaticography (Ercp): Focus on Post-Ercp-Pancreatitis [J]. United European Gastroenterol J, 2022, 10(1): 10-1.

Disclosure

The authors declare that there are no conflicts of interest.

Introduction

Endoscopic submucosal dissection (ESD) is a highly effective and safe technique for the resection of superficial colorectal neoplasms, but it can still be technically challenging for lesions in contact with or invading the appendiceal orifice. Until recently, appendicular lesions were considered unresectable or difficult to resect by endoscopy because of the high risk of incomplete resection, perforation or acute appendicitis. Small studies have reported ESD feasibility and efficacy in this particular context, including for lesions deeply invading the appendix. However, strong data about these more complex resections is lacking and the best management strategy for this kind of lesion remains a matter of debate, with upfront surgery still being the first-choice treatment in most western countries.

Aims & Methods

With the present study, we aimed to assess and report the outcomes of ESD for the treatment of lesions in contact with or invading the appendiceal orifice. We prospectively collected data of ESD procedures for appendiceal neoplasia in a multicenter prospective register. En Bloc R0 resection rate was the primary outcome. Morbidity and additional surgery were also reported.

Results

A total of 112 patients were included, comprising 47 (42%) with previous appendectomy. Fifty-six lesions (50%) were type 3 according to Toyonaga classification (15 (13.4%) post-appendectomy). En-bloc and R0 resection rates were 86.6% and 80.4%, with no significant difference associated with different grades of appendiceal invasion (p=0.9 and p=0.4, respectively) or history of previous appendectomy (p=0.3 for both). Curative resection rate was 78.6%. Additional surgery was performed in 16 (14.3%) cases, with 10/16 (62.5%) corresponding to Toyonaga type 3 lesions (p=0.04). This included the treatment of 5 (4.5%) cases of delayed perforation and 1 acute appendicitis. A second case of acute appendicitis and 1 of delayed hemorrhage also observed, both treated conservatively.

Conclusion

To our knowledge, this is the largest reported series of ESDs for the treatment of appendicular lesions. Our results show that ESD is safe and effective in this context, and should thus be considered as a valuable treatment option. New traction strategies and devices should make it progressively less technically challenging and more widely accessible.

Clinical Case Summary

A 68-year-old woman presented after 24 hours of painless jaundice, preceded by 48 hours of dark urine and pale stools without pruritis. No history of weight loss, recent foreign travel, or high risk behaviours. She denied any illicit drug or alcohol abuse. Her co-morbidities included pre-diabetes, and obesity and only took over-the-counter vitamin supplementation with no new or regular prescribed therapies. On clinical examination, she was fully alert with jaundice with no stigmata of chronic liver disease and haemodynamic stable.

Liver tests at presentation (normal in 2020) were ALT 766 U/L, AST 984 U/L, bilirubin 463, ALP 314 U/L. PT 35.3s, APTT 45.5s, TT 26.2s and albumin was 33 g/L. Haemoglobin (139 g/L), platelet count (158 x109/L), and normal eosinophil count (0.89 x109/L). Renal function was unremarkable. Arterial blood gas demonstrated a pH 7.4, Lactate 1.8, glucose 6. CT scan demonstrated moderate volume ascites and a grossly dilated gallbladder. No intra- or extra-hepatic duct dilatation and patent vasculature. Homogenous ANA 1:400, strongly positive SMA, polyclonal gammopathy (IgG 18.8, IgM 5.5, IgA 4.2) and negative AMA/ LKM. Viral hepatitis screen was negative. Given the severity of hepatic failure, she was referred for consideration of transplantation.

This lady presented with an acute hepatocellular pattern of liver injury with hepatic failure. It came to light that her injury was a consequence of exposure to ashwagandha. Although her exposure was in 2021, a latency period prior to drug-related injury is not unusual. Previous case series have shown similar patterns of injury with ashwagandha but no hepatic failure.

1. How do we overcome the challenges distinguishing drug-induced liver injury as a cause of acute hepatic failure, particularly when markers of alternative aetiology are present?
2. What is the role of steroids in patients ?
2. What is the relationship between DILI from herbal/ dietary supplementation and acute liver failure?

References

1. Katarey D, Verma S. Drug-induced liver injury. Clin Med. 2016;16(Suppl 6):s104-s109. doi:10.7861/clinmedicine.16-6-s104
2. Chalasani N, Bonkovsky HL, Fontana R, et al. Features and Outcomes of 899 Patients With Drug-Induced Liver Injury: The DILIN Prospective Study. Gastroenterology. 2015;148(7):1340-52.e7. doi:10.1053/j.gastro.2015.03.006
3. Paul S, Chakraborty S, Anand U, et al. Withania somnifera (L.) Dunal (Ashwagandha): A comprehensive review on ethnopharmacology, pharmacotherapeutics, biomedicinal and toxicological aspects. Biomed Pharmacother. 2021;143:112175. doi:10.1016/j.biopha.2021.112175
4. Mandlik Ingawale DS, Namdeo AG. Pharmacological evaluation of Ashwagandha highlighting its healthcare claims, safety, and toxicity aspects. J Diet Suppl. 2021;18(2):183-226. doi:10.1080/19390211.2020.1741484
5. Björnsson HK, Björnsson ES, Avula B, et al. Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network. Liver Int. 2020;40(4):825-829. doi:10.1111/liv.14393

Introduction

The introduction of biological drugs has led to great expectations and growing optimism in the possibility that this new therapeutic strategy could favourably change the natural history of Inflammatory Bowel Disease (IBD) and in particular that it could lead to a significant reduction in surgery in the short and long term. The evaluation of the incidence of intestinal resection after the introduction of biological therapy is very complex and subject to several potential bias, the most prominent being the shift in IBD management over the last few decades.

Aims & Methods

This study aims to assess the impact of biological versus conventional therapy on surgery-free survival time (from the diagnosis to the first bowel resection) and on the overall risk of surgery in patients with Crohn’s disease (CD) who were never with the surgical option.
This is a retrospective, double-arm study including CD patients treated with either biological or conventional therapy (mesalamine, immunomodulators, antibiotics, or steroids). All CD patients admitted at the GI Unit of the S. Salvatore Hospital (L’Aquila, Italy) and treated with biological therapy since 1998 were included in the biological arm. Data concerning the CD patients receiving a conventional therapy were retrospectively collected from our database. These patients were divided into a pre-1998 and post-1998 group (pre and post biologic era, respectively). Our primary outcome was the evaluation of the surgery-free survival since CD diagnosis to the first bowel resection. Surgery-free time and event incidence rates were calculated and compared among all groups, both in the original population and in the propensity-matched population.

Results

203 CD patients (49 biological, 93 conventional post-1998, 61 conventional pre-1998) were included in the study. Kaplan-Mayer survivorship estimate shows that patients in the biological arm had a longer surgery-free survival compared to those in the conventional arm (p=0.03). However, after propensity matching analysis, no significant difference was found in surgery-free survival (p=0.3). A sub-group analysis showed shorter surgery-free survival in patients on conventional therapy in the pre-biologic era only (p=0.02) while no significative difference was found between the biologic and conventional post-biologic groups (p=0.15).

Conclusion

This study shows that the introduction of biological therapy had only a slight impact on the occurrence of surgery in CD patients over a long observation period. Despite the milder disease, patients in the conventional group in the biologic era had the same surgery-free survival compared to patients in biological therapy. Nevertheless, biological therapy appears to delay the first intestinal resection. However, the cumulative incidence of first intestinal resection between patients who underwent biological or conventional therapy ends up being similar considering a very long period.

Disclosure

None