Introduction

Pathological esophageal acid exposure may persist in patients with Barrett’s esophagus (BE) despite standard proton pump inhibitor (PPI) therapy and symptom control, although current guidelines recommend at least standard-dose PPI for all patients with BE.¹

Aims & Methods

Aim was to evaluate the role of esophageal function testing in assessing acid exposure in BE patients on PPI therapy and in predicting neoplastic progression. We conducted a multicenter retrospective study including asymptomatic BE patients (defined by GerdQ total score <8 and a score of 0 on the first GerdQ item) who underwent high-resolution manometry and 24-hour pH impedance monitoring while on various PPI regimens. Maximal PPI therapy included esomeprazole 40 mg, pantoprazole 40 mg, rabeprazole 20 mg, or lansoprazole 30 mg, all administered twice daily. All other regimens were considered standard dosing. Index upper endoscopy with biopsies was performed under the same therapeutic regimen. Histologically, presence and degree of neoplasia (all confirmed by a second pathologist) was recorded. Acid exposure time (AET) <4% was defined as adequate acid control; AET >6% as pathological reflux. Predictors of pathological reflux and neoplasia were assessed using logistic regression analysis.

Results

A total of 135 patients (2016-2025) were included (mean age 58 ± 15 years; 73% male). Median BE length was C1 (range 0–3 cm) and M2 (range 1–5 cm), with 41% (n=56) classified as having long-segment BE. Sixty-seven patients (50%) were on standard-dose PPI. Pathological reflux was identified in 37 patients (27%), of whom 25 (67%) were on standard-dose therapy. Fourteen patients (10%) had borderline AET values (4–6%). Among the 84 patients (62%) with adequate acid control, 33 (39%) were taking standard-dose PPI. On multivariable analysis, standard-dose PPI (OR 3.04; 95% CI 1.34–6.89; p=0.008) and type III esophagogastric junction morphology (OR 2.52; 95% CI 1.01–5.01; p=0.047), consistent with manometric hiatal hernia, were independently associated with pathological reflux. Non-dysplastic BE was found in 112 patients, while 13 (10%) had neoplasia at index endoscopy (8 low-grade dysplasia, 3 high-grade dysplasia, 2 intramucosal adenocarcinoma). Pathological reflux was the only independent predictor of neoplasia (OR 10.41; 95% CI 2.65–41.26; p<0.001).

Table 1. Logistic regression analysis for factors associated with neoplasia on index endoscopy.

	Univariable analysis		Multivariable analysis
	OR (95% CI)	p-value	OR (95% CI)	p-value
Age, years	1.01 (0.96-1.05)	0.695	-	-
BMI, kg/m2	0.95 (0.83-1-10)	0.957	-	-
Male gender	0.71 (0.19-2.54)	0.783	-	-
PPI standard dose vs maximal	0.85 (0.27-2.69)	0.792	-	-
Long-segment BE vs short	1.70 (0.53-5.52)	0.371	-	-
Ineffective/absent contractility vs normal	0.96 (0.30-3.03)	0.939	-	-
EGJ type III morphology vs I/II	3.98 (1.16-13.71)	0.028	3.18 (0.86-11.78)	0.082
AET >6% vs <6%	11.72 (3.01-45.65)	0.001	10.41 (2.65-41.26)	<0.001

Conclusion

Nearly one-third of asymptomatic BE patients exhibit pathological reflux on pH-monitoring despite PPI treatment, predominantly among those on standard-dose and with manometric hiatal hernia. Nonetheless, adequate acid control is achieved in over one-third of patients on standard PPI therapy. Pathological reflux is associated with a 10-fold increased risk of neoplasia.

References

1. Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022;117(4):559-587.

Introduction

Endoscopic submucosal dissection (ESD) is an effective treatment for superficial esophageal cancer, but postoperative stenosis remains a significant concern. Particularly, probability of the stenosis is less investigated in cases with a 50%-75% circumferential mucosal defect.

Aims & Methods

This study aimed to identify influential factors for postoperative stenosis after the moderate circumferential resection in esophageal ESD. This multi-center retrospective observational study analyzed data from 513 patients across 19 institutions who underwent esophageal ESD from April 2018 to March 2022 and showed 50% to 75% of the circumferential mucosal defect. We firstly overviewed the current status on the postoperative stenosis, the steroid use, and postoperative adverse events in these patients. Subsequently, we identified influential factors for postoperative stenosis. Patients were categorized into stenosis and no stenosis groups, and univariate and multivariate analyses were performed for each parameter. We further investigated influential factors of stenosis in two cohorts: steroid and no steroid groups. Finally, the parameters were compared between the steroid and no steroid groups to assess the tendency of the steroid use in general practice.

Results

Postoperative stenosis was observed in 28 cases (5%). Univariate analysis comparing the stenosis group (n = 28) and no stenosis group (n = 485) revealed significant differences in the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), defect circumference (p =0.01), and procedure duration (p = 0.02). There was no significant difference in the steroid use between two groups. Multivariate analyses identified history of prior endoscopic treatment close to the lesion (p = 0.01, odds ratio [OR], 5.10), cervical esophageal lesions (p = 0.03, OR, 3.97), large circumferential defect (p <0.01, OR, 3.78), and longer procedure duration (p <0.01, OR, 3.83) as independent risk factors for stenosis formation. Among the steroid group, significant associations of the postoperative stenosis were revealed with the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), and >5/8 of defect circumference (p = 0.02). In the no steroid group, only the procedure duration (p = 0.01) showed a significant difference between the stenosis and non-stenosis groups. Comparison between the steroid (n = 223) and no steroid groups (n = 290) revealed significant differences in the prior endoscopic treatment near the lesion (p <0.01), cervical esophageal lesions (p <0.01), and resected specimen dimensions (p <0.01). The stenosis rates were 7% in the steroid group and 4% in the no steroid group, without a significant difference. No significant difference in adverse events was observed between the two groups.

Conclusion

In esophageal ESD with a 50%-75% circumferential mucosal defect, the steroid was used in over 40% of patients, and postoperative stenosis still occurred in 5%. Because wider circumference, location of the cervical esophagus, prior endoscopic treatment close to the lesion, and prolonged operative time were identified as independent risk factors on the stenosis, steroid therapy should be preferred in these cases. Particularly, lesions with a history of endoscopic treatment, on cervical esophagus, and with >5/8 of defect circumference should require more aggressive countermeasures than currently applied.

Introduction

The ORALEV randomized controlled trial demonstrated that preoperative oral antibiotics (OA) before colon surgery reduces surgical-site infections. However, concerns were raised about the potential risk of antibiotic resistance.

Aims & Methods

This study aimed to assess if OA in the ORALEV trial led to increased long-term infection-related complications due to antibiotic resistance.
This is a retrospective analysis of 3-year follow-up data from 529 patients in the ORALEV trial. Primary outcome: risk of infectious complications and antibiotic resistance in patients with vs without OA. Secondary: long-term complications, effect on COVID-19 risk.

Results

	[ALL]	Experimental	Control	p
	N=529	N=264	N=265
Hospital admission due to infection	14 (2.65%)	7 (2.65%)	7 (2.64%)	1.000
Need for antibiotic treatment	8 (1.51%)	3 (1.14%)	5 (1.89%)	0.715
COVID-19	5 (0.95%)	4 (1.52%)	1 (0.38%)	0.218
Long-term complication	16 (3.02%)	4 (1.52%)	12 (4.53%)	0.077
Long-term unplanned surgery	11 (2.08%)	1 (0.38%)	10 (3.77%)	0.015
Any type of hospital readmission	62 (11.7%)	33 (12.5%)	29 (10.9%)	0.674
3-year mortality	47 (8.88%)	24 (9.09%)	23 (8.68%)	0.989
Overall Survival (3-year)	90.6 (95%CI 88.1; 93.2)	90.4 (95%CI 86.8; 94.1)	90.9 (95%CI 87.4; 94.5)	0.819

536 patients from the ORALEV trial were assessed for eligibility, of whom 529 were included (265 no OA vs 264 OA). The incidence of infective complications resulting in hospital admissions (n=7, 2.6% vs n=7, 2.6%, no OA vs OA), antibiotic treatment (n=5, 1.9% vs n=3, 1.1%. p=0.715), and COVID-19 (n=1, 0.4% vs n=4, 1.5% p=0.22) did not differ. Two patients in each group required treatment with carbapenems. No differences were observed between the groups regarding readmissions for any complication (n=29, 10.9% vs n=33, 12.5%, p=0.67). After removing COVID-19 admissions, COPD was associated with need for antibiotic treatment in the long-term (HR 5.13, 95%CI 1.28-20.54) irrespective of OA administration. The rates of postoperative hernia (n=11, 4.1% vs n=4, 1.5% p=0.11) and indication for hernia repair (9/11, 81.8% vs 1/4, 25%, p=0.08) were higher in non-OA group, but not statistically different.

Conclusion

OA do not increase the risk of long-term infective complications and need for advanced antimicrobial treatment. COPD increased the risk of subsequent need for antibiotic treatment. Hernia rates and need for surgical repair might be higher in those patients who did not receive OA.

References

Espin Basany E, Solís-Peña A, Pellino G, Kreisler E, Fraccalvieri D, Muinelo-Lorenzo M, et al. Preoperative oral antibiotics and surgical-site infections in colon surgery (ORALEV): a multicentre, single-blind, pragmatic, randomised controlled trial. lancet Gastroenterol Hepatol. 2020 Aug;5(8):729–38.