Introduction

Green tea polyphenols (GTPs) and aspirin were demonstrated to be novel candidates for cancer chemoprevention.

Aims & Methods

This study aimed to investigate the effects of GTPs and aspirin on esophageal diseases. This prospective cohort study recruited participants who self-reported long-term GTPs intake, aspirin intake and no medicine use in the questionnaire and underwent gastroscopy with biopsies if needed. The outcomes were the regression rates of esophageal precursor lesions after a one-year follow-up and side effects of GTPs and aspirin intake.

Results

A total of 159, 151,160 participants self-reported long-term GTPs, aspirin intake, and no medication at baseline. After one year, 78, 81, and 83 participants received the follow-up endoscopy in the GTPs, aspirin, and control groups, respectively. The average age of participants was 50.11 ± 5.62 years old, consisting of 42 (17%) female and 200 (83%) male. The regression rates of esophageal precursor diseases were 67.90%, 55.13%, and 48.19% in the GTPs, aspirin, and control groups, respectively (P = 0.036). Analyzing the esophagitis subgroup, the regression rate of GTPs group (43/69, 62.32%) was significantly higher than aspirin group (32/67, 47.76%) and control group (27/70, 38.57%) (P = 0.019). The incidences of nausea were 0.63% in GTPs group (1/159) and 0.66% of participants in aspirin group (1/151) suffered gastrointestinal bleeding, respectively.

Conclusion

GTPs, rather than aspirin, could improve the outcomes of esophagitis compared with the control group. The protective effects of GTPs on esophageal precursor diseases make it a promising health supplement.

Introduction

Recent insights in polyp molecular biology have suggested that hyperplastic polyps (HP) are closely related to sessile serrated lesions (SSL). Their hallmark serrated crypts closely resemble those found in SSL. Furthermore, similar to SSL, specific subtypes of HP can harbor BRAFV600E-mutations. These findings, amongst others, have raised the hypothesis that some HP may have an intrinsic malignant potential through the serrated neoplasia pathway. However, in everyday clinical practice, no routine HP subdifferentiation is performed. Therefore, we aimed to develop a deep learning algorithm to classify molecular subclasses of HP, namely microvesicular hyperplastic polyps (MVHP) and goblet cell-rich hyperplastic polyps (GCHP), based on their endoscopic features.

Aims & Methods

In this single-center trial 238 hyperplastic polyps from 159 patients were retrospectively selected. All polyps had high quality endoscopic video in white light endoscopy and virtual chromoendoscopy (i-scan) using Pentax EC38-i20c and EC34-i10 endoscopes. All histological slides were reviewed by an expert pathologist, updating diagnoses to MVHP, GCHP or mixed HP. We selected the polyps without mixed constitution for development of a deep learning algorithm. These polyps were randomly split into 70% for training, 10% for validation and 20% for testing. Sequences of still images of the polyps were manually annotated and subsequently used to train a deep learning algorithm, with dataset imbalance addressed by randomly oversampling the MVHP.

Results

The 238 HPs were reclassified as 152 GCHP, 59 MVHP and 27 mixed HPs after expert histological review. We subsequently trained a convolutional neural network on the 211 HPs without mixed constitution. This resulted in a model with an AUC of 0.817, corresponding to a sensitivity of 80.0% for predicting MVHP and 78.4% for predicting GCHP. However, due to the low prevalence of MVHP (28%) the positive predictive value for MVHP is only 33.3%, whilst the positive predictive value for GCHP is 96.7%.

Conclusion

We successfully developed a deep learning algorithm capable of differentiating between molecular subclasses of hyperplastic polyps (MVHP vs GCHP) based on their endoscopic features. This model demonstrated a robust AUC of 81.7% with a sensitivity of 80.0% and 78.4% for predicting MVHP and GCHP respectively. However, the low prevalence of MVHP (28%) limited its positive predictive value (33.3%) for predicting MVHP. Despite these challenges, this pilot study serves as a proof of concept that artificial intelligence is capable of predicting hyperplastic polyp subclasses based on endoscopic appearance. Furthermore, it highlights the potential of artificial intelligence to enhance the diagnostic precision, which could contribute to more tailored surveillance and management strategies in the future.

Disclosure

The authors declare no conflicts of interest.

Introduction

Chronic viral hepatitis is among the principal public health problems and a leading cause of morbidity and mortality. The advent of direct-acting antiviral agents (DAAs) impressively changed the management of chronic Hepatitis C virus (HCV) infection. In parallel, WHO's global hepatitis strategy aims to reduce new hepatitis infections by 90% and deaths by 65% from 2016 to 2030 and to identify undiagnosed individuals with chronic hepatitis infection before clinical progression. Currently, a free screening for HCV infection is offered in Italy to subjects born between 1969 and 1989 and also to subjects under the care of addiction services (SerD) and those in detention. In line with national screening plans, the Tuscany Region activated free screening among these subjects.

Aims & Methods

This study aimed to define the prevalence of chronic HCV infection in patients over 55, specifically those not included in free HCV screening programs, aligning with global, regional, and national plans for HCV elimination. Additionally, the study provides a linkage to the care of those infected, evaluates the hepatitis B virus (HBV) prevalence in a subgroup of patients, and describes the clinical features of this study population. Patients born before 1969 hospitalized to the Internal Medicine and Gastroenterology Divisions at Santa Maria alle Scotte Hospital in Siena prospectively underwent screening for HCV antibodies. The gastroenterology cohort was evaluated for HBV infection. All enrolled patients were assessed for comorbidities, treatment and transaminase levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]).

Results

A total of 207 subjects, of whom 169 resided in Siena, were divided into three cohorts based on the department where they were admitted and underwent HCV screening. Patients present a high prevalence of comorbidities (88.4%), among them common were cardiovascular diseases (68.1%), cancer (35.3%), liver and hepatobiliary diseases (28%), and diabetes (22.2%). In the entire study population, 15.5% of patients received immunomodulating drugs. Overall, 63 patients (30.4%) showed the presence of elevated transaminase levels, 8 patients (3.9%) were anti-HCV positive, and 2 were HCV RNA positive (0.9%). Of 96 patients in the gastroenterology cohort, 9 (9.4%) had HBV infection, of whom 8.4% had HBsAg-negative infection.

Conclusion

An active HCV infection prevalence of 0.9% was found in hospitalized patients (> 55 years old). A substantial proportion of people in the gastroenterology cohort residing in South-Eastern Tuscany carried occult HBV infection (8.4%). The increase in transaminase levels can be linked to the combined presence of liver and hepatobiliary diseases and the administration of immunomodulatory drugs. This study confirms that an opportunistic screening can contribute to identifying the submerged people affected by viral hepatitis.

References

1. World Health Organization. Global health sector strategy on viral hepatitis 2016–2021. Accessed June 2016. http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdf
2. Ministero della Salute. DECRETO 14 Maggio 2021. Esecuzione dello Screening Nazionale per L’eliminazione del Virus dell’HCV. (21A04075) (GU Serie Generale n.162 del 08-07-2021). https://www.gazzettaufficiale.it/eli/id/2021/07/08/21A04075/sg (accessed on 8 July 2021).
3. REGIONE TOSCANA. Avvio di un Programma di Screening Gratuito per Prevenire, Eliminare ed Eradicare il Virus Dell’epatite C, in Attuazione Dell’art. 25-Sexies del D.L.n. 162/2019. http://www301.regione.toscana.it/bancadati/atti/Contenuto.xml?id=5355950&nomeFile=Delibera_n.1538_del_27-12-2022 (accessed on 31 December 2022)

Disclosure

Prof. Brillanti reports grants and personal fees from Gilead Sciences.

Introduction

Endoscopic depth diagnosis is essential for the treatment decision of Barrett's esophageal adenocarcinoma (BEA). However, it is sometimes difficult to diagnose due to the anatomy of the esophagogastric junction, such as the difficulty of luminal distension. For inconclusive cT1a or cT1b lesions, we introduced staging ESD, allowing for histologic diagnosis for depth invasion. However, the clinical feasibility and significance of staging ESD remain unclear.

Aims & Methods

In this study, we evaluated the performance of endoscopic depth diagnosis of cT1 BEA and the appropriate treatment strategy.
This study included cT1N0M0 BEA treated with ESD or surgery from January 2015 to June 2024. The cases with poorly differentiated component on target biopsy were excluded. Endoscopic depth diagnosis was based on macroscopic appearance (such as the following findings suggestive of cT1b: polypoid, mixed macroscopic type, thickness, hardness, severe redness, and ulceration). EUS was added at the discretion of the endoscopist. We made the treatment decision based on our multidisciplinary conference, and the final diagnosis was classified as conclusive cT1a or cT1b, and inconclusive cT1a or cT1b. We performed ESD for conclusive cT1a, and surgery for conclusive cT1b. And we performed staging ESD for inconclusive cT1a or cT1b. Curative resection was defined as pT1a with R0 resection, and without lymphovascular invasion or poorly differentiated component.

Results

This study included 54 lesions in 52 patients. The median age was 66 years (43-92). There were 42 male patients. Siewert type [type I/type II] were 12 and 42, respectively. Background Barrett’s esophagus [SSBE/LSBE] were 36 and 16, respectively. The median size was 20mm (5-50). Major macroscopic appearances [0-I/0-IIa/0-IIb/0-IIc] were 11, 19, 1, and 23, respectively. Histology on targeted biopsy [tub1/tub2] were 41, 13, respectively. 39 lesions were diagnosed by white light endoscopy alone, and 15 lesions were comprehensively diagnosed by additional EUS. 41 lesions were diagnosed as cT1a and 13 lesions were diagnosed as cT1b. ESD and surgery were performed for 47 and 7 lesions, respectively. Pathologic depths [T1a/T1b/T2] were 42, 11, and 1, respectively. The sensitivity, specificity, and positive predictive value of endoscopic diagnosis of T1b were 25.0%, 76.2%, and 23.1%, respectively. 10 of 54 (18.5%) T1a lesions were overdiagnosed. Staging ESD was performed for 20 lesions, and all of them achieved en bloc resection without adverse events. R0 resection was achieved in 13 of 14 (92.9%) cT1a and 5 of 6 (83.3%) cT1b, respectively. Curative resection was achieved in 8 of 14 (57.1%) cT1a and 4 of 6 (60.0%) cT1b, respectively. 3 of 54 (5.6%) T1a were diagnosed as conclusive cT1b, and underwent surgery, leading to overtreatment.

Conclusion

The diagnostic performance of endoscopic depth diagnosis is insufficient, leading to overdiagnosis. Staging ESD for inconclusive cT1 BEA is technically feasible and can be an option to avoid overtreatment.

Introduction

Anorectal dysfunction affects approximately 8% of the global population.¹ Whilst conservative management can manage mild symptoms, surgery is often indicated in patients with structural abnormalities and severe symptoms. A Magnetic Resonance Imaging Defecating Proctogram (MRDP) forms a key part of patients’ pre-surgical investigations, visualising the anterior, middle and posterior compartments of the pelvis, and provides a dynamic image of the pelvic floor during defecation. It has been criticised as it is often performed in the supine position, which does not reflect normal physiological positioning for defecation.² However, little is known about how patients themselves feel about how this test reflects their usual defecatory process.

Aims & Methods

As part of a service evaluation, between September 2024 and April 2025, all patients who underwent an MRDP at Imperial College Healthcare NHS Trust in London, United Kingdom, were asked to complete a 21-item questionnaire exploring their experiences, prior to, during and after their MRDP. Five-point Likert Scales (1 - Strongly Disagree, 5 - Strongly Agree) were used for each question, except two concluding questions on overall experience, which were answered using free-text boxes. Patients with insufficient cognitive function or comprehension of English to complete the questionnaires were excluded.

Results

Thirty-eight patients responded to the questionnaire, and after excluding those with missing data, 35 completed questionnaires were included in the analyses (30[86%] female, 28[80%] 50-79 age category). Reasons for referral to MRDP included FI (15/35 [43%]) and/or constipation (13/35 [37%]) and/or POP (9/35 [26%]). Although 32(91%) strongly agreed that their privacy was respected, and none strongly agreed they felt embarrassed, just 12(34%) strongly agreed that they felt ‘comfortable during the test’. Less than a third of patients (10[29%]) agreed that they were able to ‘defecate as they do at home’ and only a quarter (9[26%]) felt that defecating lying supine was easy. Whilst 16(46%) patients felt that the contrast mixture inserted gave them a ‘normal urge to open their bowels’, only 4(12%) reported that the contrast mixture was ‘similar to their own stool’. Nevertheless, 23(66%) patients agreed that the experience matched what they would expect, and most patients (29[83%]) would have the test again if it were necessary. Patients aged 70-79 were associated with disagreeing with the statement that they could ‘defecate as they would at home’ (neutral/disagree/strongly disagree vs. agree/strong agree: 8/8[100%] vs 0.0[0%], p = 0.011).

Conclusion

Whilst patients reported being able to tolerate the MRDP, the large majority reported that defecating during the investigation did not reflect their usual defecatory process. Contrary to expectation, it appears that patients’ main complaints were not due to embarrassment, but rather patient position and environment. Whilst patient experiences are highly institution and staff dependent, understanding patients’ perspectives during an MRDP is useful for optimisation of pre-investigation counselling and expectation setting. Implementing post-MRDP questionnaires, or pro-active clinician exploration of the extent to which patients felt able to replicate their symptoms could facilitate clinical interpretation of MRDP results. Moving towards evacuation testing that aligns more closely with a patient's normal defecatory habits is likely to yield results that better reflect symptom profiles and therefore provide better insights into specific surgical targets responsible for symptom generation.

References

1. Jaafari H, Houghton LA, West RM, et al. The national prevalence of disorders of gut brain interaction in the United Kingdom in comparison to their worldwide prevalence: Results from the Rome foundation global epidemiology study. Neurogastroenterology & Motility. 2023; 35:e14574. doi:10.1111/nmo.14574
2. Pilkington, S.A., Nugent, K.P., Brenner, J., Harris, S., Clarke, A., Lamparelli, M., Thomas, C. and Tarver, D. (2012), Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study. Colorectal Disease, 14: 1224-1230. https://doi.org/10.1111/j.1463-1318.2012.02945.x

Introduction

A grey zone known as the borderline resectable (BR) category, which lies between resectable and unresectable, has been proposed for perihilar cholangiocarcinoma; however, there is no international consensus on this classification. BR can be considered from various perspectives, including local tumor factors, surgical risk, long-term prognosis, liver reserve capacity, and systemic condition.

Aims & Methods

The study's aim is to define the borderline resectable (BR) of perihilar cholangiocarcinoma based on surgical procedure and preoperative liver function. We examined 1) the comparison of surgical outcomes between extended surgery and standard surgery and 2) the risk of postoperative mortality from liver failure in patients who underwent portal vein embolization.
Study 1) Surgical cases from January 2011 to December 2023 were divided into two groups: the Extended surgery group: left or right trisectionectomy(L3/R3), concomitant hepatic artery resection (AR), hepatopancreaticoduodenectomy (HPD), and the other standard surgery groups. Study 2) The risk of postoperative liver failure in patients who underwent resection after portal vein embolization (PVE) between January 2001 and December 2022 (including HPD) was evaluated

Results

Study 1) A total of 181 patients (59 in the extended surgery group and 122 in the standard surgery group) were included in the study. There were significant differences in operation time (median 798/700 minutes, p<0.01) and blood loss (2000 ml/1295 ml, p<0.01) in the extended surgery group compared to the standard surgery group, but no significant differences in postoperative complication rate (Clavien Dindo 3a or higher: 79%/67%) or in-hospital mortality rate (5%/5%). The 5-year overall survival rate was 34% in the extended surgery group and 50% in the standard surgery group, which was not significantly different by the log-rank test. Study 2: The incidence of liver failure (%) and mortality (%) by surgical technique were R (37/5.7), L3 (30/5), and R3 (54/7.7). ICGK x proportion of remnant liver volume（ICGKF）<0.05 before PVE, operation time >660 minutes, and blood loss >1900 ml were identified as risk factors in univariate and multivariate analyses, and the mortality rate for patients with these three factors was high at 25%.

Conclusion

Patients who required extended surgery with poor pre-PVE liver function (ICGKF<0.05) should be considered BR in perihilar cholangiocarcinoma.

References

1: Nooijen LE, de Boer MT, Braat AE, Dewulf M, den Dulk M, Hagendoorn J, Hoogwater FJH, Lam HD, Molenaar Q, Neumann U, Porte RJ, Swijnenburg RJ, Zonderhuis B, Kazemier G, Klümpen HJ, van Gulik T, Groot Koerkamp B, Erdmann JI.
National consensus on a new resectability classification for perihilar cholangiocarcinoma - A modified Delphi method. Eur J Surg Oncol. 2025 Feb;51(2):107117. PMID: 37880001.
2: Kuriyama N, Usui M, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Kato H, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Mizuno S, Isaji S.
Neoadjuvant chemotherapy followed by curative-intent surgery for perihilar cholangiocarcinoma based on its anatomical resectability classification and lymph node status. BMC Cancer. 2020 May 11;20(1):405. doi: PMID: 32393197;.
3: Matsuyama R, Mori R, Ota Y, Homma Y, Yabusita Y, Hiratani S, Murakami T, Sawada Y, Miyake K, Shimizu Y, Kumamoto T, Endo I.
Impact of Gemcitabine Plus S1 Neoadjuvant Chemotherapy on Borderline Resectable Perihilar Cholangiocarcinoma.
Ann Surg Oncol. 2022 Apr;29(4):2393-2405. doi: 10.1245/s10434-021-11206-4. Epub
2022 Jan 7. PMID: 34994885.

Introduction

In laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC) is recommended to clarify biliary anatomy, detect choledocholithiasis and identify complications. IOC interpretation may be performed by either surgeons or radiologists, but it remains unclear which approach is preferable. This study investigates how the type of medical specialist interpreting the IOC affects surgical outcomes and operating time.

Aims & Methods

All LCs registered in the Swedish Registry of Gallstone surgery and Endoscopic retrograde Cholangiopancreatography (GallRik) between January 1, 2009, and December 31, 2020, were included. A complementary survey was distributed to all participating surgical clinics to determine local IOC interpretation practices. Registry and survey data were linked and outcomes were analysed using mixed model analysis and logistic regression.

Results

A total of 118.556 procedures from 61 surgical units were included. Operating time was longer when radiologists assessed the IOC (mean differences 11.3 minutes; 95% CI 1.60-20.89). Intraoperative complications were more common with radiologist interpretation (2.6% vs 1.5%; OR 0.58, 95% CI 0.52-0.63), while postoperative complications were slightly higher with surgeon-led interpretation (8.2% vs 7.3%; OR 1.14, 95% CI 1.08-1.20). Bile duct injury rates (0.3%; OR 1.0, 95% CI 0.79-1.27) and detection of choledocholithiasis (12.4% vs 12.6%; OR 1.02, 95% CI 0.90-0.99) were similar between groups.

Conclusion

Surgeon-led IOC interpretation is associated with shorter operating times and fewer intraoperative complications, without increasing the risk of bile duct injury or missed choledocholithiasis. Routine radiologist involvement may be unnecessary and an inefficient use of resources.