Introduction

Two years after the Delphi consensus-proposed revolution in the nomenclature and diagnosis of Steatotic Liver Disease (SLD), the potential benefits of adopting Metabolic dysfunction-associated steatotic liver disease (MASLD) rather than Metabolic dysfunction-associated fatty liver disease (MAFLD) diagnostic criteria in defining the disease progression risk of SLD patients have never been systematically and longitudinally evaluated in real-life.

Aims & Methods

The present study aimed to compare MASLD and MAFLD criteria in estimating the 3-year risk of advanced fibrosis (AF) progression and Acute Cardiovascular Event (ACE) occurrence in not-lean (NL) and lean (L) SLD patients.
For this purpose, we retrospectively analyzed the anthropometrical, biochemical, clinical, and Liver Stiffness Measurement (LSM - FibroScan) data stored in the University Hospital (UH)-official Health Documents Digitization Archive of 931 SLD patients admitted to UH “Luigi Vanvitelli” (between January 2016 and May 2021), and followed up for 3 years. Based on baseline Body Mass Index (BMI), patients were subdivided into “L” (BMI <25 kg/m2) (n:134) and “NL” (n:797) and, subsequently, by applying MAFLD and MASLD criteria, in NL-MASLD (n:206), NL-MASLD/MAFLD (n:481), NL-MAFLD (n:110), and L-MASLD (n:39), L-MASLD/MAFLD (n:68), L-MAFLD (n:27). The following validated LSM cut-offs were used to identify the different liver fibrosis stages according to the Metavir score: (a) F0-F2 ≤ 9.6 kPa; (b) F3: 9.7 - 13.5 kPa; (c) F4 ≥ 13.6 kPa. AF (F3-F4) was defined by LSM values > 9.7 kPa. The transition from F0-F2 to F3-F4 defined AF progression. Retrospectively collected and documented ACEs were: (1) Acute Myocardial Infarction (IMA), (2) Acute Coronary Syndrome (ACS), (3) Ictus cerebri (IC), and (4) Transient Ischemic Attack (TIA).

Results

MASLD and MAFLD criteria similarly estimated [MASLD: OR: 2.334, C.I.95%: 1.878 - 3.028, MAFLD: OR: 2.469, C.I.95%: 1.892 - 3.668, p < 0.0001; positive predictive value (PPV), MASLD: 0.800, C.I. 95%: 0.641-0.89 vs MAFLD: 0.785, C.I. 95%: 0.604-0.897, p: 0.076)] the overall 3-year risk of AF progression in NL-SLD, whereas in L-SLD, MAFLD criteria better estimated the overall 3-year risk of AF progression [PPV, MASLD: 0.571, C.I. 95%: 0.405-0.841 vs MAFLD: 0.714, C.I. 95%: 0.558-0.794, p: 0.006].
Compared to MASLD, MAFLD diagnostic criteria better estimated the 3-year risk of ACEs occurrence in NL [HR: 1.104, C.I..95%: 0.024-1.293, p:0.025], and not in L [HR: 1.260, C.I..95%: 0.665-2.101, p:0.071] patients. Multivariate competing risk analysis (adjusted for sex, age, diabetes, steatosis, and fibrosis severity) revealed diabetes (aHR: 2.113, C.I. 95%: 1.981-2.434, p:0.001), high-sensitivity-C-reactive protein (aHR: 1.441; C.I. 95%: 1.232-1.775; p:0.02) and Homeostatic-model-assessment-for-insulin-resistance (aHR: 1.228; C.I. 95%: 1.152-1.893; p:0.03) as associated with ACE occurrence in NL-MAFLD patients.

Conclusion

MAFLD criteria better estimate the 3-year AF progression and the ACE occurrence risk in L-SLD and NL-SLD patients, respectively.

References

1. Rinella ME, and NAFLD Nomenclature consensus group. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol. 2023 Dec;79(6):1542-1556. doi: 10.1016/j.jhep.2023.06.003. Epub 2023 Jun 24. PMID: 37364790.
2. Ramírez-Mejía MM, Jiménez-Gutiérrez C, Eslam M, George J, Méndez-Sánchez N. Breaking new ground: MASLD vs. MAFLD-which holds the key for risk stratification? Hepatol Int. 2024 Feb;18(1):168-178. doi: 10.1007/s12072-023-10620-y. Epub 2023 Dec 21. PMID: 38127259.
3. Alboraie M, Butt AS, Piscoya A, Dao Viet H, Hotayt B, Al Awadhi S, Bahcecioglu IH, Alkhalidi N, Al Mahtab M, Méndez-Sánchez N. Why MASLD Lags Behind MAFLD: A Critical Analysis of Diagnostic Criteria Evolution in Metabolic Dysfunction-Associated Liver Diseases. Med Sci Monit. 2024 Jul 30;30:e945198. doi: 10.12659/MSM.945198. PMID: 39075772; PMCID: PMC11299466.
4. De A, Bhagat N, Mehta M, Taneja S, Duseja A. Metabolic dysfunction-associated steatotic liver disease (MASLD) definition is better than MAFLD criteria for lean patients with NAFLD. J Hepatol. 2024 Feb;80(2):e61-e62. doi: 10.1016/j.jhep.2023.07.031. Epub 2023 Aug 7. PMID: 37558135.

Introduction

While the clinical trial (JCOG1009/1010) evaluating the efficacy and safety of endoscopic submucosal dissection (ESD) for intramucosal (T1a(M)) undifferentiated early gastric cancer (UD-EGC) of the predominant type measuring <2 cm not associated with ulceration showed a favorable 5-year survival outcome (99.3% (95% confidence interval: 97.1-99.8 )), the 10-year prognosis is still uncertain. We have followed the patients for 10 years.

Aims & Methods

Main eligibility criteria were endoscopically diagnosed cT1a/N0/M0, single primary lesion, size ≤2 cm, no ulceration, and histological components of undifferentiated adenocarcinoma in biopsy. Based on the histologic findings after ESD, additional gastrectomy was indicated if the histopathologic examination did not meet the criteria for curative resection. The primary endpoint was 5-year overall survival (OS) of the undifferentiated-predominant type group, and 10-years follow-up of patients was planned.

Results

Of a total of 346 patients enrolled between February 2011 and May 2013 from 49 institutions, 337 were eligible and all eligible patients underwent ESD. Histopathologic findings of the resected specimens showed undifferentiated predominant cancer in 275 patients while one patient could not be evaluated due to emergent surgery for a perforation during ESD. Of the 275 patients, 195 whose ESD was judged to result in a curative resection were followed up without additional treatment, and 73 of the remaining 79 patients whose ESD was judged to result in a non-curative resection received additional gastrectomy. Among the 275 patients with UD-EGC, one patient experienced a metastatic recurrence 3,034 days after ESD. The 10-year OS and relapse-free survival (RFS) of patients with undifferentiated-predominant type were 96.2% (95% confidence interval: 93.1-97.9) and 95.7% (95% confidence interval: 92.4-97.6), respectively, while the 10-year OS and RFS for all 346 enrolled patients were 95.1 % and 94.7 %, respectively.

Conclusion

ESD for UD-EGC with tumor size of 2 cm or less is the standard treatment, with excellent 10-year survival results as well as in the 5-year period.

Introduction

Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is performed to treat pathology within the biliary system. Patients undergoing this may be on systemic anticoagulation. ERCP is classed as a high-risk bleeding procedure within BSG guidelines. This would necessitate anticoagulation interruption to prevent bleeding. It is recognised however, that resumption of antiplatelets and anticoagulants is associated with improved survival and reduced incidence of thrombotic complications. Thus, all patients should have a clear anticoagulation plan.

Aims & Methods

Attendances for ERCP over a 6-month period were analysed. Of the 132 patients, 33 (25%) were taking either an antiplatelet, warfarin or a Direct Oral Anticoagulant (DOAC). Medical records were reviewed in relation to pre-procedure management of these medications, advice from the endoscopist regarding resumption and whether these medicines were managed appropriately thereafter.
Several interventions were then made; a change to the reporting software led to a prompt relating to antiplatelet/anticoagulant medications, an education campaign for post graduate doctors in training and medication guidance summaries visible in the endoscopy department.
A second 6-month review was then undertaken to evaluate if there had been any improvement in outcomes. In this time frame, 143 patients underwent ERCP of whom 27 (16.7%) were taking antithrombotic therapy.

Results

Results are in Table 1:

	Pre-Intervention	Post Intervention
Pre-procedure appropriate management	48.5%	70.9%
Documented advice on endoscopy report	10%	30%
Post procedure appropriate prescribing	36.3%	70%

One common error was holding of anticoagulation/antiplatelet medication from admission in anticipation of ERCP. This led to long periods off anticoagulation whilst awaiting ERCP.
Documented advice was given more frequently on Endoscopy reports in cases where the patient required further procedure.
It was challenging to analyse post procedural management for inpatients, as the quality of ward round documentation and discharge letters was variable.

Conclusion

Further education to junior staff around utility of BSG anticoagulation guidelines greatly improved pre and post procedure management and thus forms a cornerstone to improve care. Further education to more senior staff may also improve decision rationale and medication advice in ward round documentation and discharge paperwork. Human factors also need to be considered; limited advice is likely related to high endoscopy workload pressures, with sub analysis showing that advice is improved when further intervention is required or in higher risk settings, illustrating that antithrombotic decisions are considered by the endoscopist. Improved documentation at procedure with the support of upgrades to reporting software will enhance post procedure care and consequently reduce demands on the service.​

References

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline updateVeitch AM, Radaelli F, Alikhan R, et al. Gut 2021;70:1611–1628
UEG poster: Improving documented advice regarding anticoagulants and antiplatelets in acute upper gastrointestinal bleeds. Authors: Dr Emily Creed, Dr Vanessa Theis, Dr Katie Clark, Dr Sweekriti Gurung, Dr Abdullah Motam and Dr Gregor Farrell Bins.

Introduction

Colorectal cancer is the third most common cancer worldwide and the second leading cause of cancer-related death. Most colorectal cancers arise from benign polyps, especially dysplastic adenomas. Colonoscopy with polypectomy is the gold standard for preventing cancer by interrupting the adenoma-carcinoma sequence. This has led to the development of various techniques and devices for improved prevention and treatment. Hot snare endoscopic mucosal resection (HS-EMR), which combines submucosal injections with electrocautery, is commonly used for excising various colorectal polyps. However, it carries risks of diathermy-related complications, such as perforation, and bleeding. To address these issues, cold snare endoscopic mucosal resection (CS-EMR) has been proposed as an alternative. Concerns about residual adenoma/recurrence have been raised with CS-EMR. Therefore, we conducted this meta-analysis to compare the two techniques.

Aims & Methods

We searched electronic databases, including MEDLINE via PubMed, Scopus, Web of Science, and Cochrane, without restrictions on publication date or language. We included RCTs comparing CS-EMR and HS-EMR for colorectal polyp resection. Primary outcomes included the incidence of delayed bleeding and residual/recurrent adenoma (RRA).

Results

On Nov 5, 2024, our literature search across electronic databases retrieved a total of 1,888 records. Following a meticulous screening process, six studies met the eligibility criteria encompassing 1,449 patients and 1,947 polyps. Regarding safety, the overall effect estimates regarding delayed bleeding showed statistically significant results favoring CS-EMR group [OR 0.31, 95 % CI (0.12–0.76), P = 0.01] with no heterogeneity (P = 0.40; I² = 0 %). However, statistical superiority for CS-EMR could not be detected regarding early bleeding [OR 0.78, 95 % CI (0.31–1.97), P = 0.60]. Only two studies reported data on delayed perforation, showing a numerical difference favoring CS-EMR; however, statistical significance could not be obtained [OR 0.26, 95 % CI (0.03–2.41), P = 0.24]. Regarding efficacy, the overall effect estimates regarding complete resection and RRA did not favor either of the groups [OR 0.62, 95 % CI (0.25–1.53), P = 0.30], [OR 2.81, 95 % CI (0.43–18.47), P = 0.28] respectively.

Conclusion

Evidence obtained from this meta-analysis suggests that CS-EMR offers superior safety compared to HS-EMR for colorectal polyp resection. Current evidence remains limited due to the small number of studies included. Therefore, further high-quality randomized controlled trials with larger sample sizes are needed.

References

• Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.

• Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med. 1993;329(27):1977–81.

• Facciorusso A, Del Prete V, Antonino M, Buccino VR, Muscatiello N. Efficacy of endoscopic polypectomy techniques for colorectal polyps: a systematic review and network meta-analysis. Gastrointest Endosc. 2020;91(4):733–745.e9.

• Pohl H, Srivastava A, Bensen SP, Anderson P, Rothstein RI, Gordon SR, et al. Incomplete polyp resection during colonoscopy—results of the complete adenoma resection (CARE) study. Gastroenterology. 2013;144(1):74–80.e1.

• Tutticci N, Hewett DG. Cold snare polypectomy: A safe, effective technique for sessile polyps. Gastrointest Endosc Clin N Am. 2015;25(2):291–301.

• Kawamura T, Takeuchi Y, Asawa S, Yokota I, Matsuno T, Omori T, et al. A comparison of cold and hot snare polypectomy for small colorectal polyps: a randomized controlled trial. Am J Gastroenterol. 2018;113(3):403–411.

Introduction

The safety and efficacy of endoscopic haemostasis in patients with upper gastrointestinal (UGI) bleeding has been widely assessed over the years. However, to date no study addressed the management of UGI bleeding specifically in the setting of patients with surgically altered anatomy.

Aims & Methods

Our study is focused on the evaluation of the endoscopic management of UGI bleeding in these patients with specific concern about the techniques used to achieve haemostasis, the management of technical failure and the rate of adverse events. We conducted a multicentre retrospective- prospective observational study in 13 endoscopy units in Italy. All consecutive patients with UGI bleeding and surgically altered anatomy managed endoscopically were collected from January 2023 to November 2024.

Results

We enrolled 162 patients (73% males) with a mean age of 69 years. 45% of patients had history of oncologic surgery while 20% underwent bariatric surgery. The most common clinical manifestations were melena (59%) followed by hematemesis (22%). At bleeding event patients were taking anticoagulants and antiplatelet in 32% and 16% of cases, respectively. In 43% of cases from 1 to 4 blood units were needed, in 15% more than 4 blood units, while in 42% of patients no transfusions ware required. 42% of endoscopic procedures were performed with anesthesiologist assistance. Bleeding was located at anastomotic site in 70% of cases and ulcer was the most common source of bleeding (54% of patients). The most frequently used treatments were adrenaline combined with TTSC (40 %) and TTSC alone (24%). Haemostatic powder or gel and adrenaline combined with thermal treatment were used only in 6 and 4% of cases respectively while OTSC was used in 1 patient alone after failure of adrenaline combined with TTSC. Bleeding control during endoscopy was achieved in 94% of patients. In 12 patients rebleeding occurred, which was managed with surgery in 2 patients, interventional radiology in 1 case and with new endoscopic treatment in 4 cases. No serious adverse events linked to endoscopy were reported.

Conclusion

Our preliminary results showed that patients with altered anatomy often had severe bleeding requiring a large amount of blood transfusions. The standard endoscopic homeostatic techniques seemed to be effective for the management of bleeding, although a not negligible rate of patients needed additional treatments. However, further data are needed to better assess clinical outcomes in this setting and to better define possible predictive predictors of clinical success and therefore which technique should be preferred to achieve haemostasis.

References

1. S. G. Lim et al., “Endoscopic Approach for Postoperative Complications Following Laparoscopic-Assisted Gastrectomy in Early Gastric Cancer: Literature Review,” Hepatogastroenterology., vol. 59, pp. 1308–1312, 2012.
2. J.-H. Park et al., “Safety and efficacy of post-anastomotic intraoperative endoscopy to avoid early anastomotic complications during gastrectomy for gastric cancer.,” Surg. Endosc., vol. 34, no. 12, pp. 5312–5319, Dec. 2020.
3. K.-H. Kim, M.-C. Kim, G.-J. Jung, J.-S. Jang, and S.-R. Choi, “Endoscopic treatment and risk factors of postoperative anastomotic bleeding after gastrectomy for gastric cancer.,” Int. J. Surg., vol. 10, no. 10, pp. 593–597, 2012.
4. Shen, Y.; Xiao, M.; Weng, J.; Yang, L.; Feng, Y.; Ye, Y.; Zheng, P. Diagnosis and treatment of postoperative bleeding in patients after gastrectomy: A retrospective case series study. J. Gastrointest. Oncol. 2023, 14, 110–118.
5. Wichmann, D.; Fusco, S.; Werner, C.R.; Voesch, S.; Duckworth-Mothes, B.; Schweizer, U.; Stüker, D.; Königsrainer, A.; Thiel, K.; Quante, M. Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers 2022, 14, 980.