Introduction

Considering the impaired platelet function in uremic patients, the risk of post-polypectomy bleeding may increase in patients with end-stage renal disease undergoing colonoscopic polypectomy. Nevertheless, little is known about the risk factors of bleeding after colonoscopic polypectomy in these patients. This study investigated the incidence and risk factors of post-polypectomy bleeding, including immediate and delayed bleeding, in patients with end-stage renal disease (ESRD).

Aims & Methods

Ninety-two patients with ESRD who underwent colonoscopic polypectomy between September 2005 and June 2020 at a single tertiary referral center were included. The patients’ medical records were retrospectively reviewed. Patient- and polyp-related factors associated with immediate PPB (IPPB) were analyzed using logistic regression analysis. Additionally, the optimal cutoff polyp size related to a significant increase in the risk of IPPB was determined by performing receiver operating characteristic (ROC) analysis and calculating the area under the ROC curve (AUC).

Results

In total, 286 polyps were removed. IPPB occurred in 24 (26.1%) patients and 46 (16.1%) polyps, and delayed post-polypectomy bleeding occurred in 2 (2.2%) patients. Regarding the hemostasis method for IPPB, clipping was used in 31 (67.4%) cases and a combined method with clipping and coagulation was used in 15 (32.6%) cases. According to multivariate analysis, the polyp size (> 7 mm) (odds ratio=5.259, 95% confidence interval [CI]: 2.367–11.684), old age (>70) (odds ratio=4.186, 95% CI: 2.012–8.708), and endoscopic mucosal resection (EMR) as the polypectomy method (EMR versus non-EMR: odds ratio=3.339, 95% CI: 1.440–7.743) were found to be independent risk factors for IPPB. According to the Youden index method, the optimal cutoff polyp size to identify high-risk polyps for IPPB was 7 mm (AUC=0.755; sensitivity, 76.1%; specificity, 69.6%).

Conclusion

Colonoscopic polypectomy should be performed with caution in patients with ESRD, especially in those with the following risk factors: advanced age (>70 years), polyp size >7 mm, and EMR as the polypectomy method.

Introduction

Colonoscopy is a well-established screening tool for detection of colorectal lesions. Colonoscopy waiting lists can last for months, however, the rates of unperformed procedures due to patients' absence ('no-show') are 8-15% globally.

Aims & Methods

The aim of this study was to evaluate whether a personalized digital platform would reduce 'no-show' rates for ambulatory colonoscopies.
We retrospectively analyzed prospectively collected data regarding scheduled ambulatory colonoscopies. The GistMD digital platform includes a patient-tailored animated video, individualized according to age, gender, comorbidities and language. It also includes links to written instruction forms and consent forms, and a set of reminders. During 01/2022-06/2022, a link to the GistMD system was randomly sent to patients before a scheduled colonoscopy. The study group ('GM-Link') included all patients that were sent the link by SMS. The control group received standard written instructions by email.

Results

During the study period, a total of 2114 colonoscopies were included. The GistMD link was randomly sent to 1621 (76.7%) patients ('GM-Link') and standard written prepration instructions to 493 (23.3%) controls ('No link').
The 'no-show' rates were reduced by half among the 'GM-Link' group compared to controls [190 (11.7%) vs. 114 (23.1%), respectively, p<0.001]. This significant 'no-show' rate reduction in the 'GM-Link' group compared to the 'No Link' group was consistent among males and females subgroups analysis (11.8% vs. 27.5%, p<0.001 and 11.7% vs. 19.3%, p=0.003, respectively) and among all age groups (p<0.05, for all groups). Furthermore, the 'GM-Link' group was divided according to usability: 1. 'No video' - Video was not watched at all, 757/1621 (46.7%), 2. 'Min users' - Watched<75% of the video,77/1621 (4.8%) and 3. 'Max users' - Watched >75% of video, 787/1621 (48.6%). There was a "dose-dependent" trend between usability groups and 'no-show' rates: 'No link' - 23.1%, 'No video'-17.4%, 'Min users' -10.4%, 'Max users'- 6.4% (P<0.001).
In two multivariate logistic regression adjusted for age, sex and morning vs. afternoon colonoscopy, 'GM-Link' receivers and 'Max users' were each independently associated with 51% and 76% 'no show' rate reduction compared to 'No link' controls (OR 0.491, P<0.001 and OR 0.242, p<0.001, respectively). According to number needed to treat analysis, the number of sent links required for prevention of one 'no show' was 8 links. In terms of economical calculations, using the digital platform will reduce the monthly income loss due to 'no-show' by ~70,000 ILS (~17,550 euro) and the yearly income loss by ~840,000 ILS (~210,500 euro), considering 400 colonoscopies/month of which 35% include polypectomy.

Conclusion

Implementation of a digital platform significantly reduced 'no show' rates for ambulatory colonoscopy. This reduction can result in increased efficiency and reduced financial losses as well as shorter waiting times in gastroenterology units.

Introduction

Endoscopic submucosal dissection (ESD) has been routinely used for en-bloc resection of superficial lower GI neoplasms as it provides precise information on the histology, margins and invasion (lateral and deep). The meta-analysis by Fuccio et al (2017, pp 74) compared the outcomes of the Asian countries with the non-Asian countries and concluded that there was a high disparity between the two groups. There were higher R0 resections rates and lower postoperative complications, and recurrences at 12 months in the Asian setting, suggesting that the possible factors could be the low number of ESD procedures and reduced expertise in this field in the West.

Aims & Methods

We analysed the key performance indicators of Colorectal ESDs at a teaching hospital in the UK from 2017 to 2022. The procedures were performed by a single operator, who was trained in the West and has had no prior exposure to the Eastern training framework and guidelines. All procedures done between the above years were included starting from 2017 when ESD service was newly introduced in hospitals. Data was collected on R0 resections rates(deep and lateral margins free of neoplasia), post-operative bleeding and perforation rates, and recurrences/residual lesions at 6-12 months post-resection. We then compared the data with the results of the meta-analysis previously published. We then theorised the probable reasons for the disparity, based on potential contributing factors.

Results

Parameters/Setup	Our Outcomes in Percentages (2017-2022)	Asian - Fuccio et al (2017, pp 74)	Non-Asian- Fuccio et al (2017, pp 74)
R0 resection	83.1%	85.6%	71.3%
Delayed Bleeding	1.3%	2.4%	4.2%
Perforation	1.2%	4.5%	8.6%
Recurrence at 6-12 months	0%	1.1%	5.2%

The data presented in the table suggests that comparable outcomes to the Standard ESD technique in Asian countries can also be achieved in Western countries. The study analyzed data from 82 patients for R0 resection, 82 patients for delayed bleeding, 84 patients for perforation, and 38 patients for recurrence at 12 months. The discrepancy in the number of patients between the primary procedure and post-resection surveillance is attributed to various factors, including patient preferences, the need for further management of malignant lesions, and patients awaiting their follow-up appointment.

Conclusion

Our data indicate that the Eastern standards can be met in the West with regard to key performance indicators for lower GI ESD. The reasons for underperformance can't be attributed to training and exposure. The above table and analysis indicate a need for the exploration of other probable factors and an updated review of Eastern and Western standards.

References

Fuccio, L., Hassan, C., Ponchon, T., Mandolesi, D., Farioli, A., Cucchetti, A., Frazzoni, L., Bhandari, P., Bellisario, C., Bazzoli, F. and Repici, A., 2017. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointestinal endoscopy, 86(1), pp.74-86. (Accessed: 31^st March 2023)

Introduction

Colorectal carcinoma (CRC) is one of the most important indications for colorectal surgery despite the availability of screening measures. Anastomotic leakage is among the most common potentially life-threatening complications. Increasing evidence suggests a causal role of the gut microbiota in the pathogenesis of anastomotic leakage.

Aims & Methods

The aim of the study was to evaluate the dynamics of microbiome changes in patients with colorectal carcinoma before, during and after surgical intervention in relation to anastomotic insufficiency. From a total of 18 patients recruited, the records of 16 patients were systematically analysed according to inclusion/exclusion criteria and sequencing quality. Biopsies were taken from the 3 sites (proximal to the tumour, tumour region, distal to the tumour) before, during and after surgery. All patients received preoperative Metronidazole and Paromomycin for intraluminal bowel decontamination and a single intravenous dose of Ertapenem during surgery. DNA extraction was followed by amplification of the V1-V2 region of the 16S rRNA gene and Illumina sequencing.

Results

Phocaeicola, Prevotella and Enterococcus were the most abundant of the 259 different genera found in the cohort. Hierarchical clustering showed that samples from the same patient at the same time point generally had high similarity (66%), and in 6 cases all samples from more than one time point formed a cluster. These results were corroborated by comparing the Bray-Curtis similarity of sample sites and time points. Periinterventional procedures were associated with a significant decrease in diversity in samples collected during or after surgery. Samples with anastomotic leakage had a different microbial structure at all time points, with Prevotella being more abundant in the anastomotic leakage group (p<0.0001), whereas Phocaeicola was more abundant in the sufficient anastomosis group (p=0.04). Systematic longitudinal analysis revealed an increasing abundance of bacterial species, particularly Enterococcus and Escherichia/Shigella, at subsequent sampling times.

Conclusion

The mucosal microbiota is substantially altered by colorectal surgery, and the microbiome of patients with anastomotic leakage differs from that of patients with sufficient anastomoses. Further studies are needed to unravel the molecular and functional interactions between the microbiota and mucosal tissue.

Introduction

Sarcopenia is a syndrome characterized by the progressive and generalized loss of skeletal muscle mass. Primary sarcopenia is associated with the aging process, while the secondary one is caused by several factors including inflammatory conditions, such as inflammatory bowel disease (IBD). Since there is a complex interaction between inflammation, intestinal dysbiosis and malnutrition which lead to muscle degeneration in IBD patients, it is referred to as the gut-muscle axis. In particular, the high level of cytokines and the gut dysbiosis which characterizes IBD is responsible for the activation of pathways that cause an imbalance in muscle protein synthesis. However, the involvement of molecular and microbial mechanisms of sarcopenia, at present, has not been extensively studied in IBD.

Aims & Methods

In order to identify the mechanisms that are potentially involved in the onset of sarcopenia, a DSS-induced colitis mouse model has been created. To ensure that the model developed sarcopenia, we performed physical performance assessment at rotarod. On this well-characterized model, we studied the muscle by immunohistochemistry, by fiber count per field and by Cross Sectional Area. Next, we evaluated the gut microbiota and serum LPS detection. In vitro, with the aim to create a situation of intestinal inflammation and to assess the activation of pathways of muscle atrophy, we used the immortalized murine myoblast cell line C2C12 at different time points, 30'-2h-6h. Treatments performed included pro-inflammatory cytokines (TNF-α, IFN-γ, IL-6), LPS and drugs (Infliximab, Upadacitinib, Tofacitinib) in order to assess cellular response to the most promising drugs used in the treatment of IBD.

Results

The mouse model showed a reduction in body weight and muscle performance, probably associated with quantitative and qualitative alterations in muscle fibers. In addition, increased expression of markers of muscle atrophy (myostatin and Murf-1) was found in colitic mouse muscle. Also we observed increasing expression of the pathway STAT3-pSTAT3 involved in muscle wasting and decreasing pAKT, which is associated with muscle growth. Most relevant, a condition of dysbiosis was found in the colitic model, as well as increased LPS in the serum of mice.
In vitro, Upadacitinib and Tofacitinib in the presence of inflammatory cytokines decrease the expression of muscle atrophy-associated pathways (STAT3, its active form pSTAT3, and the transcriptional factor NFkB) and increase the expression of pAKT, a protein associated with muscle synthesis. When cells were treated with LPS, NFkB expression did not decrease with drug addition, suggesting that LPS is able to activate NFkB independently of the JAK/STAT pathway.

Conclusion

These data open new scenario for the gut-muscle axis as a promising area of research for the management of sarcopenia in IBD. Therefore, we might also consider the role of microbiota and LPS in addition to inflammatory cytokines in the pathogenesis of sarcopenia in IBD, since LPS-induced signaling is only partially controlled by drugs.

Introduction

Liver transplant is the only definitive treatment for chronic liver disease (CLD). Referral to a hepatologist for consideration for liver transplant should be made when a patient with CLD experiences a hepatic decompensation or has a MELD score ≥ 15. Failure to refer in a timely manner can result needing a liver transplant evaluation (LTE) in the inpatient setting while a patient is experiencing acute decompensation.

Aims & Methods

We aimed to compare the clinical presentation of patients undergoing LTE in the inpatient setting versus the outpatient setting to identify potential risk factors for requiring urgent evaluation. A list of all LTEs performed at our institution between 10/2017-8/2021 was obtained. Medical records were preliminarily reviewed for evaluation setting (Inpatient vs. Outpatients); evaluations for re-transplantation and acute liver failure were excluded. After all Inpatients (n=159) were identified, Outpatients (n=159) were selected at random to create a sample matched for age, gender, race, and ethnicity (n=318). Data were collected using our institutions electronic medical record and outside health records as obtained during LTE process. “Prior decompensations” refers to the number of the following clinical decompensations experienced prior to the time of LTE: ascites, hepatic encephalopathy (HE), variceal/acute UGIB, SBP and HRS. Categorical variables and continuous were compared between using Fisher’s Exact test, and student’s T test, respectively.

Results

Alcohol was the most common CLD etiology (42.1% Inpatient, 48.4% Outpatient). Inpatients tended to live further from our center than Outpatients (p=0.079). Inpatients had significantly higher MELD-Na scores (27.1 ± 8 vs. 13.3 ± 6; p<0.0001). Malnutrition was more common in 5.6 times more common in inpatients than outpatients (OR 5.6, 95% CI 2.9-10.8, p<0.001).. A similar proportion of patients had 1 hospitalization. But inpatients were 3 times as likely to have had ≥ 1 liver-related hospital admission prior to LTE (p<0.0001). Inpatients had significantly more prior decompensations than Outpatients prior to inpatient LTE (3.2 ± 1.4 vs. 1.8 ± 1.1, p<0.001), with the greatest differences in SBP and HRS.

Variable		Outpatient	Inpatient	p
Nutritional status (%)	Malnutrition	8.2	33.5	<0.0001
Previous hospital admissions (%)	0 admissions	23.9	11.4	<0.0001
	1 admissions	36.5	22.8
	>1 admissions	39.6	65.8
History of Decompensation (%)	Ascites	71.1	91.8	<0.0001
	HE	50.3	71.1	0.0002
	UGIB	23.3	32.1	0.1029
	SBP	3.8	22.0	<0.0001
	HRS	3.8	32.7	<0.0001

Conclusion

Multiple liver-related hospitalizations and malnutrition may be considered a risk factor for ultimately needing inpatient LTE and should be taken seriously by health care providers caring for patients with CLD. Episodes of SBP and HRS should prompt providers to consider immediate or urgent LTE referral regardless of other factors.

References

Multiple liver-related hospitalizations may be considered a risk factor for ultimately needing inpatient LTE and should be taken seriously by health care providers caring for patients with CLD. Episodes of SBP and HRS should prompt providers to consider immediate or urgent LTE referral regardless of other factors.

Disclosure

D Devuni has received grant funding from Sequana Medical and receives grant support from the NIAAA (AA017986-11), both for research unrelated to this work.