Introduction

Laser therapy is a relatively recent technique that allows the treatment of anal fistulas (FIstula-tract LAser Closure: FilaC®), and anal fissure (Laser anal fissure: LSL) with the FilaC fibre, pilonidal sinuses with the SiLaC® fibre (Sinus Pilonidalis treatment), and haemorrhoids with the Laser Hemorrhoido Plasty fibre (LHP®).

Aims & Methods

Our study aims to report the preliminary results of a prospective bicentric study including all patients treated with laser therapy in two private hospitals.​
​This prospective descriptive study includes 141 patients treated with laser therapy for proctological pathology (anal fistulas, pilonidal sinuses, anal fissures, and hemorrhoids) performed in two proctology units. The majority of these procedures were performed under spinal anesthesia. Data were collected directly from the patients using an evaluation form. We studied their clinical data and the immediate and medium-term postoperative follow-up

Results

141 patients were included. The mean age was 44 years (18-76 years). 78% were male and 22% female (sex ratio = 3.5). The anal fistula was the main indication for laser therapy, with FilaC® performed in 105 patients (74.5%), followed by SiLaC® in 16 patients (11.3%), LHP® in 7 patients (5%) and 4 cases of LSL (2.8%). 9 patients benefited from combined treatment: 5 LHP®+ LSL patients (3.5%), 2 FilaC®+ LSL patients (1.4%), 1 FilaC®+ SiLaC® patient (0.7%), and 1 FilaC®+ LHP® case (0.7%). 79 patients (73.2%) benefited from initial drainage of the fistula with a loose seton for 1 to 5 months before FilaC®, while 29 patients (26.8%) with a short direct extrasphincteric fistula benefited from laser therapy.18 patients were lost to follow-up (12,8%). 104 patients (84,5%), all pathologies combined, progressed well with 19 cases of failure (15,5%) with a follow-up time of 1 to 50 months. Fistulas healed in 74 patients (80%). There were 18 confirmed failures. 15 of these were treated surgically with 4 FilaC. Failure was diagnosed within an average of 6 months and was manifested by persistent leakage with no healing of the external orifice. There were no continence problems after the procedure. 16 patients were lost to follow-up. In patients with LHP, 2 patients (15,4%) experienced early post-operative bleeding requiring surgical suturing. All patients treated with SiLaC® had a favorable outcome. The 4 patients treated for anal fissures were satisfied with the procedure.

Conclusion

Laser proctology is a minimally invasive conservative procedure with significant postoperative pain reduction. In the literature, the success rate of this technique ranges from 65 to 80%. Our hospitals were the first in Morocco to introduce this procedure. Preliminary results from our pilot study showed satisfying healing in 84.5% of patients. However, long-term confirmation is required.

References

1- Adegbola SO, Sahnan K, Tozer P, Warusavitarne J. Emerging Data on Fistula Laser Closure (FiLaC) for the Treatment of Perianal Fistulas; Patient Selection and Outcomes. Clin Exp Gastroenterol. 2021 Dec 6;14:467-475. doi: 10.2147/CEG.S269464. PMID: 34908858; PMCID: PMC8664604.

Introduction

Colorectal neuroendocrine tumors (NETs) and polyps have similar endoscopic manifestations and are easily misidentified. Due to the low incidence of NETs, it is difficult to obtain adequate images to fit deep-learning models. This study introduced a few-shot learning (FSL) model for the ternary classification of NETs and polyps on endoscopic images.

Aims & Methods

Three classes of endoscopic images (56 serrated lesions and polyps [SLPs], 86 traditional adenomas and 53 NETs) were collected from three datasets. First, three images from each class were randomly selected for Support Set (SS), while others for Query Set (QS). Second, ResNet50 V2 was pretrained based on ImageNet and then on esophageal endoscopic images Third, imaging eigenvectors were extracted based on a dual-pretrained model. Fourth, the Euclidean distances to the nine SS images were calculated for each QS image. Finally, a k-nearest neighbor classifier was used for classification based on Euclidean distances. The proposed FSL model was tested in three rounds.

Results

The performance of the FSL model (macro-area under the curve [AUC], 0.731; macro F1-score, 0.674; Matthews Correlation Coefficient [MCC], 0.526; Kappa, 0.523) was better than that of the traditional ResNet50 V2, junior endoscopist, and senior endoscopist. When identifying NETs, the proposed FSL model achieved the highest accuracy 0.823, sensitivity 0.653, precision 0.673 and F1-score 0.659, whereas the senior endoscopist achieved the highest specificity 0.904.

Conclusion

This study presented a FSL method based on transfer learning and metric learning to distinguish between SLPs, adenoma, and NETs on endoscopic images. This suggests that FSL might be an effective method for computer-aided diagnosis of rare diseases.

Introduction

The treatment of symptomatic hemorrhoidal disease (HD) in patients with bleeding disorders (BD) is challenging. This vulnerable group benefits the most from less invasive office-based procedures associated with low bleeding complications, namely polidocanol foam sclerotherapy (PFS).

Aims & Methods

The present study aimed to compare the efficacy and safety of polidocanol foam sclerotherapy (PFS) in the treatment of hemorrhoidal disease (HD) in patients with and without bleeding disorders (BD).
This was a prospective, multicentric, cohort study that enrolled patients with symptomatic internal HD grades I-III with BD (group B) and without BD (group A) following a 18-months period. HD baseline severity was assessed using the Goligher classification, the hemorrhoidal disease bleeding grade (HDBG) and the Sodergren hemorrhoid symptom severity (SHSS) scoring system. Both groups were treated with PFS prepared according to the Tessari´s technique. Patients with congenital BD did not perform prior bleeding prophylaxis and patients with acquired BD due to antithrombotic drugs did not discontinue therapy. The efficacy outcomes included therapeutic success (defined by an improvement of HDBG and SHSS score over baseline) and recurrence of HD (defined by HDBG and SHSS score greater than at the end of the intervention period) during a 12-months follow-up period. The safety outcomes comprised the rate and severity of complications related to PFS.

Results

The study included 228 patients (Group A: 155; Group B: 73). At baseline, the group B presented higher HDBG (p<0.001) and SHSS (p=0.019). The overall therapeutic success rate was 93.4% with an average number of sessions of 1.51±0.74, significantly higher for group B (1.68±0.86 vs 1.43±0.65, p=0.013). A 11.4% complications rate was reported, the majority were mild (96.2%); bleeding complications occurred in 4.8% of the patients. No significant differences were reported between the two groups concerning therapeutic success, recurrence rate, and complications rate.

Conclusion

Patients with BD may present with more symptomatic HD at baseline. Nevertheless, PFS decreased hemorrhoidal bleeding and symptom severity with low incidence of complications in these patients, demonstrating similar effectiveness and safety comparing to patients without BD. Notably, performing PFS did not expose patients with BD to an increased thrombotic risk.

Introduction

Gastric adenoma is recognized as a premalignant lesion.¹Much of the literature lumps all adenomas together with different classifications. These are few western reports regarding the prevalence, associated risk factors and outcomes of endoscopic management of different subtypes of gastric adenoma.

Aims & Methods

Aims: The aim of this study is to determine the prevalence, potential predictors, and outcomes of endoscopic management of the different subtypes of gastric adenoma.
Methods: Of 162 consecutive patients who underwent endoscopic resection for gastric lesions between 2017 and 2022 at our center, 79 patients were enrolled. All the hyperplastic polyps (n=37) and subepithelial lesions (n=46) were excluded. The patient clinical characteristics, endoscopic and histopathological features of gastric lesions were retrospectively collected. Patients were divided according to the histological types of gastric adenoma into 4 groups: intestinal group (n= 49), foveolar group (n= 23),pyloric group (n= 6) and oxyntic group (n=1). We statistically compared the clinical and endoscopic features of the three groups. In addition to the analysis of the outcomes of endoscopic resection of gastric adenomas.

Results

Of the 79 patients with a mean follow-up of 2622 months, 51 patients were males (65 %) and 28 patients were females (35%). Forty-nine patients (49/79,62%) had intestinal adenoma, 23 patients (29%) showed foveolar adenoma, 6 patients (8%) developed pyloric adenoma and only 1 patient (1%) had oxyntic adenoma. The mean age was significantly older in the intestinal group (71 ± 13 years vs. 64 ± 16 years vs. 58 ± 18 years, p = 0.03). Intestinal adenomas were significantly associated with family history of gastric adenocarcinoma (14% vs. 4% vs. 0%, p = 0.01) and history of statin intake (39% vs. 26% vs. 0%, p = 0.04).Foveolar adenomas were significantly associated with multiple lesions (≥3 lesions) (p < 0.001) and 0-IIa+IIc Paris classification (6/23, 26%). the size of largest polyp was significantly higher among pyloric group (28 ±15, p= 0.00). Among intestinal group, 33/49 patients (67%) had atrophic gastritis. 82% of the adenomas were resected by ESD with histologically complete resection (R0) in 72/79 patients (91%). Although the difference was not statistically significant (p = 0.4), adenocarcinoma was most frequently encountered among the intestinal adenoma group (17/49, 35%). The post endoscopic resection outcome was comparable among 3 groups with overall recurrence rate (group1:8% vs. group 2:17% vs group 3:17%, P = 0.07) with a comparable mean time to recurrence among three groups (21 ± 17 months vs. 20±17months vs. 14 months, p=0.8). Family history of gastric adenocarcinoma (HR=1.33, p< 0.001) and active helicobacter pylori infection (HR=1.14, p < 0.001) were identified as independent predictors of recurrence after endoscopic resection of different gastric adenoma. Among baseline endoscopic characteristics, polyp size ³ 30mm(HR= 2.04, p< 0.001), more than 3 polyps (HR=1.51, p<0.001), lesser curvature as lesion location (HR=1.72, p< 0.001) and morphology as Paris classification IIc are potential predictors of post resection recurrence. In addition to specimen size ³ 15mm (HR=2.19, p< 0.001) and T1b as lesion histology (HR=2.07, p< 0.001), in the histopathological examination.

Conclusion

The present study clarifies the endoscopic and histopathological characteristics of different gastric adenomas, in addition to the potential predictive factors for each subtype. Potential predictors of recurrence after endoscopic resection emphazie the importance of endoscopic follow up.

References

1. Fujiwara, Y. et al. Diagnosis of borderline adenomas of the stomach by endoscopic mucosal resection. Endoscopy 28, 425–430 (1996).

Introduction

Endoscopic ultrasound (EUS) is an important tool for the evaluation of patients with common bile duct (CBD) dilation without obvious identified aetiology after ultrasonography (US), computed tomography (CT) and/or magnetic resonance cholangiopancreatography (MRCP).

Aims & Methods

The aim of this study was to evaluate the diagnostic performance of EUS for CBD dilation in patients with a negative initial study.
Retrospective, unicentric and cohort study including patients who underwent EUS for CBD dilation (diameter ≥7mm if intact anatomy or ≥10mm if prior cholecystectomy) in the absence of obvious pathology on prior imaging, including US, CT and/or MRCP, from January 2016 until June 2022. All EUS procedures were performed with a linear echoendoscope.

Results

Totally, 109 patients were included, 50 patients without symptoms or altered liver biochemistry (45.9%). Among the 41 patients with positive EUS, 33 patients had choledocholithiasis (30.3%), 6 chronic pancreatitis (5.5%) and 2 had ampullary cancer (1.8%). Older age was associated with positive EUS (median 79 vs 71 years, p=0.030). Patients with jaundice, cholelithiasis and altered liver biochemistry were 16.2 (p=0.002), 3.1 (p=0.024) and 2.9 (p=0.009) times more likely to have positive EUS, respectively.
A total of 53 patients underwent MRCP with a negative result (48.6%). In this group, 12 patients had a positive EUS, 10 had choledocholithiasis (18.9%) and 2 had chronic pancreatitis (3.8%). Of those, patients with abdominal pain and jaundice were 15.4 (p<0.001) and 20.0 (p=0.007) times more likely to have positive EUS, respectively. CBD diameter in MRCP was not associated with finding a causative lesion (p=0.473).
Considering only asymptomatic patients without altered liver biochemistry, CBD diameter ≥8.5mm, evaluated by CT, had a sensibility of 100% and specificity of 75% in predicting a positive EUS (AUC 0.734, p=0.048).

Conclusion

EUS is a useful diagnostic method for patients with unexplained CBD dilation, with a higher yield, even in patients with negative MRCP, and especially in patients with older age, symptoms such as abdominal pain and jaundice, cholelithiasis and/or altered liver biochemistry. CBD diameter evaluated by CT had a moderate discriminative ability in predicting a positive EUS in asymptomatic patients without altered liver biochemistry.

Introduction

The current gold standard for diagnosis of Inflammatory bowel disease (IBD) is based on clinical and endoscopic evaluation as well as histologic and radiologic evaluation. However, endoscopic evaluation can be uncomfortable and carry some risks, especially in the pediatric population that requires general anesthesia in order to perform the procedure.

Aims & Methods

Our aim was to investigate whether serum biomarkers can differentiate between pediatric patients with and without IBD. Secondary aims were to determine whether there are biomarkers that can differentiate between Crohn's disease (CD) and Ulcerative colitis (UC), and whether we can predict progression to biologic treatment within one year from diagnosis using these biomarkers.
Pediatric patients undergoing a first diagnostic colonoscopy at British Columbia Children's Hospital (BCCH) between December 2019 and June 2022 were invited to participate in the study. A 2 ml blood sample was taken from each participant at the time of colonoscopy. Demographic and clinical data were collected from each patient. Blood samples were analyzed using the Legendplex^TM flow cytometry kits investigating which included 50 different inflammatory cytokines and chemokines associated with IBD. A prediction model was built via a supervised learning method to determine how well we can predict the different groups.

Results

One hundred pediatric patients participated in the initial study. Five were excluded from the analysis due to uncertain diagnosis. Median age was 13.36 years, 39 were females (41%) and 54 (56.84%) were diagnosed with IBD, with 35 (64.81%) diagnosed with Crohn's disease. On a univariate analysis and Volcano plot 6 biomarkers were found to be strongly associated with the diagnosis of IBD: IL22, IL8, TARC, GROA, MIG, and IL18. The cross-validated AUROC was 0.70. Using SPLS-DA the classification accuracy was improved to 0.84, and MIG was found to be the key biomarker to discriminate between pediatric IBD patients and non-IBD patients.
On a univariate analysis only TSLP was found statistically significant as a predictor of CD, and RANTES and TARC were found as negative predictors for initiating biologic treatment within one year of diagnosis. However, the prediction model did not predict well the subclasses nor progression to biologic treatment.

Conclusion

Using serum biomarkers can predict the diagnosis of Pediatric IBD. MIG was found to be the key biomarker in the prediction model.

Introduction

Radiofrequency ablation is considered the standard therapy for flat dysplastic BE. Hybrid APC is a newer under evaluation, less expensive technique, but with the need of a special injection device and catheter. Aim of the study: To evaluate the efficacy of a standard APC catheter after submucosal injection for BE ablation.

Aims & Methods

To evaluate the efficacy of a standard APC catheter after submucosal injection for BE ablation. Naïve or after previous treatments patients with BE and low - grade dysplasia (LGD) were prospectively evaluated. Sodium chloride solution 0.9% was injected submucosally with a 23 G needle followed by APC application with a standard catheter (ERBE APC 300, 45Watts) on the created cushion. The same procedure was repeated for most of BE surface to be cauterized, with special attention not to ablate large circumferential areas. Patients were under high dose PPIs. Biopsies were taken according to the Seattle protocol during the follow-up.

Results

31 patients, 28 males (90.3%), 56.7±12.5 years old. Their initial diagnosis was: 19 patients with LGD (61.3%), 7 with high grade dysplasia (22.6%), and 5 with intramucosal cancer (16.1%). Eleven patients (35.5%) had previous endoscopic mucosal resection (EMR) while 7 (22.6%) had received radiofrequency ablation (RFA). Median BE length with LGD at the beginning of APC was 4cm (25th-75th:2-7, min-max:1-10). Median follow-up:10.1(1-108) months. In total 20 (64.5%) patients completely eradicated BE. For the remaining 11 patients APC led to a substantial reduction of BE length [Initial Median: C3M6 (Min: C0M1, Max: C6M8) to a final median: C0M2 (Min:C0M1, Max:C2M5] but the study is ongoing. Initial BE length was correlated to APC sessions needed (r= 0.54, p<0.01) but was not a limiting factor for complete BE eradication. Instead, smoking was an aggravating factor for BE complete eradication (HR=3.12, 95%CI.: 1.2-8.12, p=0.02). No death, hospitalization, severe hemorrhage, or perforation were observed. In 7 patients moderate pain requiring paracetamol, resolved after a few hours of in hospital supervision while 11 patients had mild dysphagia the following days without permanent stenosis.

Conclusion

Conclusions: 1) Standard APC after submucosal injection is safe and tolerable for BE ablation. 2) It may be applied in naïve patients or if other techniques were previously used. 3) Length increases the number of sessions needed but does not seem to be a limiting factor for APC application.