Introduction

There is a widespread agreement that age is a significant predictor of impaired response to nutritional support. For the same amount of protein and energy provided, the increase in weight and fat-free mass is significantly lower in older persons. This is generally attributed to anabolic resistance, and impaired absorption is usually considered non-existent/irrelevant. Nevertheless, in older rats gradual changes of the intestinal mucosa were observed, including reductions in villus height/width and density, which reduce absorption. Despite this, the aging influence on human intestinal mucosa is a matter of debate, and the lack of knowledge is partially explained by the exclusion criteria of older patients from most research protocols.

Aims & Methods

We aimed to evaluate potential histological and ultrastructural changes associated with aging that may reflect reduced absorption in older people.
The present single-center study is observational and prospective. Younger (18-45 years) and older (≥70 years) adults referred for upper endoscopy for reasons unrelated with intestinal alterations were included and underwent duodenal biopsies. Those biopsies were analyzed for histological, histomorphometric and ultrastructural changes. Histologic analysis was performed using optical microscopy with hematoxylin–eosin staining observed by two pathologists, including one expert gastrointestinal pathologist. All samples were analyzed for the presence of mucosal atrophy according to the adapted Marsh–Oberhuber classification and histomorphometric evaluation of duodenal villi length in micrometers, with at least two villi being measured through the use of an automatic scale. For transmission electron microscopy, duodenal fragments were fixed in 3% glutaraldehyde in cacodylate buffer (0.1 M, pH 7.4) overnight at 4 °C. The fixed fragments were rinsed and post-fixed in 1.0% osmium tetroxide for 1 h in the same buffer and dehydrated in graded ethanol passages. The fragments were embedded in a mixture of Epon and Araldite after two 15-min passages in propylene oxide. Thin sections, cut on a ultramicrotome with a diamond knife, were stained on the grid with uranyl acetate and lead citrate and examined with a electron microscope.

Results

A total of 84 patients were included (38 men/46 women), 33 with 18-45 years and 50 with ≥70 years. There were no duodenal endoscopic or microscopic changes apart from mucosal atrophy that was evident in one older adult. The median villi length was 0.35 mm (0.23-0.43 mm) in older persons, lower than in younger adults (0.65 mm; 0.37-0.79 mm) (p<0.01). On ultrastructural evaluation, the enterocytes of older group showed several changes suggesting compromise of the normal cell physiology. These changes were not observed in younger adults, who displayed normal cell architecture with regular microvilli structure and normal organelles.

Variables		18-45 years (n=34)	≥ 70 years (n=50)
Age		34.8 ± 8.2 years	76.2 ± 4.1 years
Gender	Male	16 (47.1%)	22 (44.0%)
	Female	18 (52.9%)	28 (56.0%)
Indication for upper endoscopy		Dyspepsia: 16 (47.1%) Gastroesophageal reflux disease 4 (12.1%) Peptic ulcer disease: 6 (18.2%) Dysphagia: 3 (9.1%) Radiological findings: 3 (9.1%) Iron deficiency anemia: 2 (6.1%)	Dyspepsia: 13 (26.0%) Gastroesophageal reflux disease: 11 (22.0%) Peptic ulcer disease: 10 (20.0%) Dysphagia: 4 (8.0%) Gastric antral vascular ectasia: 6 (12.0%) Gastric polyp: 4 (8.0%) Iron deficiency anemia: 1 (2%) Radiological findings: 1 (2%)
Duodenal histology	Normal	34 (100%)	49 (98.0%)
	Marsh 3A	0 (0.0%)	1 (2%)
Duodenal villi length		0.57 ± 0.1 mm	0.35 ± 0.06 mm

Conclusion

Aging is associated with histological, histomorphometric and ultrastructural changes in the intestinal mucosa that can be linked with reduced absorptive capacity. Besides anabolic resistance, this could be a reason for the reduced response to nutritional support found in older citizens.

References

1. Soenen S, Rayner CK, Jones KL, et al. The ageing gastrointestinal tract. Curr Opin Clin Nutr Metab Care. 2016 Jan;19(1):12-8.
2. Patel BA, Patel N, Fidalgo S, et al. Impaired colonic motility and reduction in tachykinin signalling in the aged mouse. Exp Gerontol 2014; 53:24 – 30.
3. Saffrey MJ. Aging of the mammalian gastrointestinal tract: a complex organ system. Age 2014; 36:9603.
4. Ren WY, Wu KF, Li X, et al. Age-related changes in small intestinal mucosa epithelium architecture and epithelial tight junction in rat models. Aging Clin Exp Res 2014; 26:183 – 191.
5. Thomson AB. Small intestinal disorders in the elderly. Best Pract Res Clin Gastroenterol. 2009;23(6):861-74.
6. Nalapareddy K, Zheng Y, Geiger H. Aging of intestinal stem cells. Stem Cell Reports. 2022 Apr 12;17(4):734-740.

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.

Introduction

Prospective evidence of the long-term efficacy of endoscopic submucosal dissection (ESD) for T1 colorectal cancer (CRC) is insufficient.

Aims & Methods

We aimed to evaluate long-term ESD outcomes for T1 CRC, focusing on the risk stratification criteria and necessity of additional surgery.
This large-scale, multicenter, prospective cohort study was conducted by Hiroshima GI Endoscopy Research Group. All consecutive patients who underwent colorectal ESD between January 2014 and December 2018 were included, and those with pathologically confirmed T1 CRC were analyzed. Patients were classified into low-risk and high-risk groups based on histopathological risk factors for lymph node metastasis in JSCCR guidelines. High-risk patients were categorized into those who underwent additional surgery (surgery group) and those who were followed up without surgery (follow-up group).

Results

Among 2357 patients who underwent ESD for 2478 early colorectal neoplasms, 431 were diagnosed with T1 CRC. Ten recurrences (2.6%) and five T1 CRC-associated deaths (1.3%) occurred in the high-risk group, with none in the low-risk group. Five-year cumulative overall and local recurrence rates were significantly higher in the follow-up versus surgery group (7.7% and 1.9%; P=0.019 versus 6.4% and 0%; P<0.001), with no local recurrence in the surgery group. Five-year overall survival was significantly worse in the follow-up group (79.5% and 95.2%; P<0.001), while no significant difference was found in 5-y disease-specific survival (98.5% and 98.5%; P=0.447).

Characteristics	Total (n=383)	Low-risk (n=102)	High-risk (n=281)	P value	High-risk (n=281)		P value
					Follow-up (n=74)	Surgery (n=207)
Followed-up period, mean± SD, months	65.6±15.3	64.3±14.6	66.1±15.5	0.328	63.8±21.8	66.9±12.5	0.139
Mortality, n (%)	46 (12.0)	11 (10.8)	35 (12.5)	0.657	21 (28.4)	14 (6.8)	<0.001
Mortality associated with T1 CRC, n (%)	5 (1.3)	0 (0)	5 (1.8)	0.175	2 (2.7)	3 (1.5)	0.484
Recurrence, n (%)	10 (2.6)	0 (0)	10 (3.6)	0.012	6 (8.1)	4 (1.9)	0.014
Local recurrence	5 (1.3)	0 (0)	5 (1.8)	0.175	5 (6.8)	0 (0)	<0.001
Distant recurrence	6 (1.6)	0 (0)	6 (2.1)	0.137	2 (2.7)	4 (1.9)	0.694
5-year OS, %	91.1	91.2	91.1	0.854	79.7	95.2	<0.001
5-year DSS, %	98.9	100	98.5	0.177	98.4	98.5	0.42

Conclusion

No recurrence or mortality occurred in the low-risk group, suggesting that intensive surveillance may be unnecessary for these patients after curative ESD. Additional surgery could prevent local recurrence for high-risk T1 CRC, supporting a risk-based treatment approach.

Introduction

The vacuum-assisted closure stent (VAC-stent) is a novel approach for managing esophageal defects, combining endoscopic vacuum therapy (EVT) and metal stent support to promote effective tissue healing [1].
We present a case of esophageal perforation following circumferential Endoscopic Submucosal Dissection (ESD), successfully managed with a VAC-Stent (video 1).

Aims & Methods

We report a case of a 59-year-old man with a 40mm lesion involving 75% of the esophageal circumference (Paris 0-IIa + Is), arising in Barrett’s esophagus (Prague C4M5) and consistent with adenocarcinoma, who was referred to our unit. CT scans excluded metastatic disease, and after multidisciplinary consultation, ESD was planned.

Results

Circumferential ESD was performed using a triple-tunnel approach. After the resection, muscular tears were closed with through-the-scope (TTS) clips, and pre-emptive Endoscopic Vacuum Therapy (EVT) was applied to enhance granulation and healing.
Due to rising inflammatory markers and fever onset, an esophagogastroduodenoscopy (EGD) was performed on the 3rd Post-Operative Day (POD). The EGD revealed two <5mm perforations 4cm apart, and a VAC-stent was placed to bridge the defects. At the follow-up EGD on the 9th POD, a single defect remained, and a new VAC-Stent was placed. The patient showed progressive clinical improvement and successfully resumed a liquid diet. By the 15th POD, the perforations had healed.
The patient was discharged in good clinical condition on the 18th POD.
At the EGD on the 30th POD, homogeneous healing tissue was observed, with no stricture detected at the resection site.
Histological analysis of the ESD specimen revealed moderately differentiated adenocarcinoma with submucosal invasion: pT1b (sm1) pNX G2, with R0 resection achieved and no high-risk pathological features. An oncological and endoscopic follow-up was planned.

Conclusion

Our case demonstrates that the VAC-Stent is a safe and effective method for treating perforations following esophageal ESD. In cases of circumferential ESD, VAC-stent use may also help prevent strictures.

References

[1]. Dell’Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New “Kid on the Block” Who Marries the Best of Old Techniques—A Review. Journal of Clinical Medicine 2024; 13: 3805. doi:10.3390/jcm13133805