Introduction

Obesity remains a major public health issue in developed countries. While bariatric procedures such as Roux-en-Y gastric bypass (RYGB) are effective, up to 20% of patients experience long-term weight regain. Dilation of the gastrojejunal anastomosis (GJA) may contribute to this, possibly due to faster gastric emptying. Argon plasma coagulation (APC) has been shown to reduce GJA diameter, potentially restoring satiety and promoting weight loss.

Aims & Methods

This study aimed to evaluate APC efficacy in reducing GJA diameter in patients with post-RYGB weight regain and to identify potential predictors of total weight loss (TWL).
A retrospective, single-center study included 36 RYGB patients treated with APC from 2018–2023. The primary outcome was %TWL. Secondary endpoints included reduction in anastomosis diameter (RAD), comorbidities, and adverse events (AEs). Patients were followed at 3, 6, and 12 months and categorized by TWL (≥5%, ≥10%, ≥15%). Responders were defined as those achieving ≥5% TWL at 3 months. Associations between TWL, responders to APC and demographic or clinical variables were analyzed.

Results

Total Weight Loss
Initially, all patients experienced some degree of weight loss after the APC intervention. The mean absolute TWL of 8.3%, 8%, and 8.2% at 3, 6, and 12 months.
Regarding categorical TWL, over 60% achieved ≥5% TWL throughout follow-up (Figure 1), with 61.1% at 3 months, 66.7% at 6 months, and 63.9% at 12 months. Though ≥10% and ≥15% rates were lower. No clinically significant associations were found between pre-treatment patients factors and comorbidities; and subsequent weight loss.
TWL was significantly higher in responders (14.9%, 11.7%, 11.1%) vs. non-responders (Figure 2), but no predictive baseline factors were identified (Table 1).
At 12 months (Figure 3), over 80% maintained ≥5% TWL, and more than 50% reached ≥10% . Though ≥15% was sustained in only 13.9%–16.7%, highlighting obesity’s chronic nature and APC’s limited long-term effect.
Furthermore, at 12 months, mean BMI in responders was significicantly lower (31.7kg/m²), and over a quarter (27.3%) of responders achieved a BMI <30, no longer meeting obesity criteria, which may be considered a significant clinical success.
GJA diameter
Patients presented with notably enlarged GJA diameters, with a mean pre-APC GJA of 26.61 ± 5.41 mm, and 16.4 ± 5.0 mm post-APC (p < 0.001). A small final GJA diameter (<18 mm) was achieved in 72%. The mean RAD was 10.22 ± 6.4 mm, representing a 36.9 ± 19.3% decrease. However, neither RAD nor final GJA diameter were predictive of TWL. These findings align with the hypothesis proposed by some authors, suggesting that patients with persistently larger GJA diameters (>18 mm) may benefit from alternative interventions, such as endoscopic suturing.

Conclusion

APC is a safe, non-invasive and effective option for managing weight regain after RYGB at least in the short and medium term, in 60% of patients. Despite efforts, no predictors of TWL were identified. Larger studies and a multidisciplinary approach may further improve outcomes.

References

Thompson CC, Slattery J, Bundga ME. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Surg Endosc. 2006;20(11):1744-8.
Baretta GA, Alhinho HC, Matias JE. Argon plasma coagulation of gastrojejunal anastomosis for weight regain after gastric bypass. Obes Surg. 2015;25(1):72-9.
Moon, R.C., Texeira, A.F, Neto, M.G. Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study. 2018;28(9):2737-44.

Szvarca D, Jirapinyo P. Endoscopic Management of Weight Regain After Bariatric Surgery. Gastrointest Endosc Clin N Am. octubre de 2024;34(4):639-54.

Jirapinyo, P, Moura D, Dong W. Dose response for argon plasma coagulation in the treatment of weight regain after Roux-en-Y gastric bypass. Gastrointest Endosc. 2020;91(5):1078-84.

Introduction

H.pylori infection is widespread in the world and affects about 41% of the world's population. H. pylori causes chronic gastritis. However, the development of atrophic gastritis is associated both with the duration of the disease and, possibly, with the presence of virulence factors of H.pylori. CagA is one of the most significant virulence factors of H.pylori.

Aims & Methods

The aim of the study is to determine the influence of the presence antibodies to CagA virulence factor of H. pylori on the development of atrophic gastritis according to the OLGA system.
Methods: 221 H. pylori-positive patients (69 men and 152 women) were examined in A.S. Loginov Moscow Clinical Scientific Center as part of the study on the prevalence of H. pylori in Moscow (Grant of the Moscow Center for Innovative Technologies in Healthcare, 0903-1/22). The mean age of the patients was 49.80 ± 13.66 years (from 20 to 73 years). The presence of H.pylori infection was confirmed by a ¹³C-urea breath test. All patients underwent endoscopy with morphological examination by the OLGA system and serological determination of total antibodies to CagA antigen («Vector-Best», Russia, the normal level is < 0.41 conventional unit (c.u.)). All patients were divided into 5 groups based on the OLGA system gastritis stage (from stage 0 to IV stage). The mean age of patients in the groups was 43.33, 46.52, 53.87, 56.76, and 56.86 years respectively.

Results

Results are presented in Table 1. Total antibodies to CagA virulence factor were detected in 57.47% of patients (127 of 221 patients). The proportion of CagA-positive patients was higher in groups with atrophic gastritis and was rising with increasing stage of atrophy (maximum at stage IV - 85.7%) [Kendall’s correlation coefficient (K.c.c.) is 0.247 (p<0.01)]. The trend is noted that the mean age of patients increases in groups from 0 to IV stage of atrophy according to OLGA system, the K.c.c. is 0.282 (p<0.01). Groups with II, III and IV stages of atrophy were comparable in age, but proportion of CagA-positive patients reached a maximum at stage IV of atrophy - 85.7%.

Table 1: Frequency of detection CagA-positive patients and mean age of patients in groups with different stage of atrophic gastritis according to the OLGA system

Conclusion

We found positive relationship between the presence of antibodies to CagA antigen and the atrophy stage of the OLGA system in H. pylori gastritis patients.

Disclosure

This study is part of the study on the prevalence of H. pylori in Moscow (Grant of the Moscow Center for Innovative Technologies in Healthcare, 0903-1/22).

Introduction

After an initial attempt to eradicate Helicobacter pylori (Hp), around 20% of patients remain infected. As treatment failures accumulate, the effectiveness of subsequent Hp therapies tends to decrease. Therefore, current clinical guidelines discourage repeated use of the same treatment regimen following an initial failure.

Aims & Methods

To evaluate the use and effectiveness of the triple therapy with amoxicillin-clarithromycin and of the bismuth quadruple therapy (either classical and as single-capsule format) when empirically prescribed as retreatment, despite previous eradication failure with the same regimen.
All patients registered at e-CRF AEG-REDCap as part of the European Registry on Hp management (Hp-EuReg) from 2013-2024, who had received triple therapy with amoxicillin-clarithromycin or bismuth quadruple therapy (either classical or as single-capsule) in at least 2 different treatment lines (not necessarily consecutive), were analysed separately.

Results

Triple therapy with amoxicillin-clarithromycin: Out of 518 patients treated with triple therapy from 2^nd to 6^th rescue treatment line, 230 cases received the same therapy at least in 2 different treatment lines: 199 re-treatments in 2^nd line having previously failed in 1^st line with this therapy; 19 re-treatments in 3^rd line (of which 9 had previously received the same therapy only in the 1^st line and 10 had received the same therapy in both 1^st and 2^nd line); 4 in 4^th line; 5 in 5^th line; and further 3 in 6^th line. The overall effectiveness of triple therapy with amoxicillin-clarithromycin when empirically prescribed repeatedly in 2^nd line was 74%. When the effectiveness was subanalysed by treatment length, there were increasing efficacy rates according to it: 50% with 7 days, 72% with 10 days, and 82% with 14 days. The cases retreated in 3^rd line had an overall effectiveness of 56%.
Bismuth quadruple classical therapy: Out of 672 patients treated with bismuth quadruple classical therapy from 2^nd to 6^th rescue treatment line, 13 cases received the same therapy at least in 2 different treatment lines: 6 re-treatments in 2^nd line, having previously failed in 1^st line; 2 re-treatments in 3^rd line, both had previously received the same therapy in 2^nd line; 2 in 4^th line; 1 in 5^th line; and further 2 in 6^th line. The effectiveness of bismuth quadruple classical therapy when empirically prescribed repeatedly in the 2^nd line was 69%, although the number of patients in this cohort was limited.
Bismuth quadruple therapy as single-capsule: Out of 2,579 patients treated with the single-capsule from 2^nd to 6^th rescue treatment line, 101 cases received the same therapy at least in 2 different treatment lines: 67 re-treatments in 2^nd line having previously failed in 1^st line with the single-capsule; 16 re-treatments in 3^rd line, of which 12 had previously received this same therapy in 2^nd line; 11 in 4^th line; 4 in 5^th line; and further 3 in 6^th line. The effectiveness of bismuth quadruple therapy as single-capsule when empirically prescribed repeatedly in 2^nd line was over 90%, and achieved almost 80% in all cases retreated in the 3^rd line.

Conclusion

Repeated use of triple therapy with amoxicillin-clarithromycin in patients with prior eradication failures with the same regimen demonstrated notable success rates, particularly in 2^nd line re-treatments lasting 14 days (>80%). On the other hand, bismuth quadruple therapy as single-capsule, when prescribed as re-treatment in 2^nd line after previous failure with the same therapy, achieved optimal effectiveness (>90%).

References

1. Malfertheiner P, Megraud F, Rokkas T, Gisbert JP, Liou JM, Schulz C, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022;71(9):1724–62.
2. Nyssen OP, Vaira D, Pérez Aísa Á, Rodrigo L, Castro-Fernandez M, Jonaitis L, et al. Empirical Second-Line Therapy in 5000 Patients of the European Registry on Helicobacter pylori Management (Hp-EuReg). Clin Gastroenterol Hepatol. 2022;20(10):2243–57.

Disclosure

Olga P. Nyssen has served as a speaker or has received research funding from Allergan, Mayoly Spindler, Richen, Biocodex and Juvisé.
Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé, Biocodex.
The remaining authors declare no conflicts of interest.

Introduction

After a first eradication attempt, a relevant proportion of patients fail to cure Helicobacter pylori infection.

Aims & Methods

To evaluate the effectiveness of second-line empirical treatment.
A systematic, prospective, registry of the clinical practice of European gastroenterologists (38 countries) on H. pylori management was established (Hp-EuReg, Hp-WorldReg’s partner). All infected adult patients were systematically registered at AEG-REDCap e-CRF until January 2025. Modified intention-to-treat (mITT) and per-protocol (PP) analyses were performed.

Results

Overall, 8,901 patients received a second-line empirical therapy. Mean age was 51 years, 67% were women, and 4.7% had penicillin allergy. Most frequent treatment indications were dyspepsia (74%) and gastroduodenal ulcer (13%). Overall effectiveness was 82% (both by mITT and PP). Overall, 96.5% of patients were compliant. Adverse events were reported in 19% of the cases, most of them mild. The overall effectiveness of most frequent empirical second-line treatments is shown in Table 1, showing that uniquely bismuth quadruple therapies, either with metronidazole-tetracycline or clarithromycin-amoxicillin, when prescribed for 14 days and with high-dose PPIs provided over 90% success rates. After failure of first-line clarithromycin-containing therapy, the most effective second-line treatments were triple therapy with amoxicillin and either rifabutin or levofloxacin providing 85% and 80% effectiveness, respectively. Additionally, bismuth quadruple therapy with regimens containing tetracycline-metronidazole in single-capsule and classical formulation, with clarithromycin-amoxicillin and with levofloxacin-amoxicillin achieved 87%, 84%, 88% and 85% cure rates, respectively. Within the same subgroup but in patients receiving optimised therapy —defined as a 14-day course with standard or high-dose PPIs at >40mg omeprazole equivalent twice daily —, certain regimens yielded even higher cure rates. Among these, triple therapy with amoxicillin-levofloxacin obtained 87% success rate, while non-bismuth concomitant therapy with amoxicillin-clarithromycin-metronidazole reached 86%. Bismuth quadruple therapy with either tetracycline-metronidazole (administered either as a single capsule or in the classical prescription) reported 89% success; but with amoxicillin-metronidazole or clarithromycin-amoxicillin highest effectiveness was reported, that is, 91% and 92%, respectively. After failure of bismuth quadruple therapy either in the classical format or when prescribed as the single-capsule, bismuth quadruple therapy with clarithromycin-amoxicillin achieved 95.5% and 95% cure rates, respectively; whereas, the single capsule obtained 93% and 89%, respectively.

Conclusion

In Europe, empirical second-line treatment overall effectiveness is generally suboptimal (<90%); however, successful results were obtained with bismuth quadruple therapies, either with tetracycline-metronidazole or clarithromycin-amoxicillin, when prescribed for 14 days and with high-dose PPIs. Optimization of regimen selection, treatment duration, and PPI dosing is necessary after first-line therapy failure.

Disclosure

Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from: Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé and Biocodex.
Olga P. Nyssen received research funding from: Mayoly, Allergan/Abbvie, Richen, Juvisé and Biocodex.