Introduction

In contrast to mucosal rectal T1 adeno-CA with an R0 rate of up to 92% at centers, the R0 RR in studies drops to 62-64% in case of deep sm infiltration.[1,2] Traditionally total mesorectal excision (TME) follows as completion surgery. Deep sm infiltration as isolated risk factor excluding L+, V+, G3 and Bd2-3 seems associated with a low risk of LN metastases of only 2.6%. [3] MRI and even EUS often lead to a significant T and N overstaging.[4] A min.-invasive diagn.-ther. resection procedure providing a clear histo-pathologic staging without potentially destroying parts of the meso-rectum as it has been reported for full thickness resection techniques would be desirable for potential later surgical resection (TME).[5] Endoscopic Intermuscular Dissection (EID), similar to PAEM uses a new flexible endoscopic dissection technique with separation of the circumferential and longitudinal muscular layer providing a specimen ideally including the entire mucosa, submucosa and the inner circumferential muscle layer.[6,7] The new technique achieved in a first prospective MC study including 67 patients a technical success rate of 96% and a histologic R0 resection rate of 85%.[5] In the following we report on our first experiences using EID as referral center for ESD.

Aims & Methods

To evaluate EID in lesions with biopsy proven ADC of the rectum without endoscopic, EUS or clinical signs of local infiltration. Rectal polyps with biopsy proven HGIEN and/or suspicious for local malignant infiltration. Additionally 2 patients were included who had undergone neo-adjuvant RT/Ch therapy 24 and 26 months before refusing definitive surgery (TME). Both presented with local flat polyps with histopathologically SSA (1) / hyperplastic polyp with focal LGIEN adenoma (2) for diagn.-therapeutic resection. After endoscopic, EUS, MRI, abd/th CT-staging and rectal digital examination without suspicion of local malignant infiltration pts were offered to prospectively undergo EID after extensive informed consent within a prospective protocol. All procedures were carried out under gen. anesthesia by an exp. interv. endoscopist with >1000 ESDs. Post-Op all pts. were hospitalized and closely monitored.

Results

From 11-2023 to 4-2024, 8 EIDs in 8 pts (3 f/ 5 m) were carried out (mean 63 y; 34-83y). 6/8 lesions lower rectum, 1/8 middle, 1/8 upper rectum. 'En bloc' resection was achieved in 100%. Histopathology showed 3x ADC G2, 3 x HGIEN and in both cases with neodajuvant RT/Ch LGIEN adenoma. R0 resection was achieved in 2 of the 3 ADCs, with deep sm T1 infiltration in both but without any other risk factors. Tumor board recommendation was close clinical & imaging FU. In the 3rd ADC tumor infiltration reached the inner muscular layer (T2) and the pat. underwent uneventful TME 10 d after EID. All other cases were follow clinically. Mean length of hosp. stay was 7.1 days. Serious major complications did not occur. All pts. are closely followed with uneventful FU.

Conclusion

EID seems a new perspective for the endosc. resection of T1 ADC and high-risk polyps in the rectum. Two cases after potentially curative neo-adjuvant treatment for rectal cancer and refusal of TME show EID as potential diagnostic tool but have to be regard with caution due to a remaining risk of scattered tumor cells in the mesorectum with TME remaining the gold standard. More experience in multicenter prospective studies with matched pair analysis or a comparison to surgical local procedures (TAMIS etc.) is necessary for the final assessment of EID as new promising endoscopic technique.

References

1. Watanabe D, Toyonaga T, Ooi M et al. Clinical outcomes of deep invasive submucosal colorectal cancer after ESD. Surg Endosc 2018; 32: 2123-30
2. Yamada M, Saito Y, Takamaru H et al. Long-term clinical outcomes of en- doscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017;49: 233-42
3. Zwager LW, Bastiaansen BAJ, Montazeri NSM et al. Deep Submucosal Invasion Is Not an Independent Risk Factor for Lymph Node Metastasis in T1 Colorectal Cancer: A Meta-Analysis. Gastroenterology 2022;163:174-89
4. Detering R, van Oostendorp SE et al. MRI cT1-2 rectal cancer staging accuracy: a population-based study. Br J Surg 2020;107:1372-82
5. Eid Y, Alves A et al. Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature. J Visc Surg 2018; 155: 445–52
6. Moons LMG, Bastiaansen BAJ, Richir MC et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new en- doscopic approach. Endoscopy 2022;54: 993-8
7. Toyonaga T, Ohara Y et al. Peranal endoscopic myectomy (PAEM) for rectal lesions with severe fibrosis and exhibiting the muscle-retracting sign. Endoscopy 2018; 50: 813–7

Introduction

Helicobacter pylori (Hp) infection is one of the major causes of gastric cancer and represents a significant global public health challenge. In Japan, where the incidence of gastric cancer is high, reducing the risk through the eradication of Hp is deemed crucial. While enhancing awareness about Hp is thought to encourage testing and contribute to treatment, there is a lack of evaluation regarding the Japanese population's awareness of Hp.

Aims & Methods

In this cross-sectional study, we aim to assess baseline knowledge and attitude tuwards Hp among Japanese population. Participants were recruited through an online survey platform (Macromill, Inc), with ages ranging from 20 to 69, reflecting the age demographic composition of Japan equally across genders. Referencing the existing surveys on Hp^1-3, we assessed knowledge on five key aspects related to Hp: risk of infection (scored out of 7), diseases caused by Hp (scored out of 7), methods of testing (scored out of 5), benefits and side effects of Hp eradication (scored out of 8), and knowledge of gastric cancer prevention (scored out of 10). Attributes of participants, socioeconomic factors, and health literacy (HLS-14)⁴ were also evaluated to study their correlation with knowledge about Hp.

Results

A total of 3,095 individuals participated. Of these, 56.3% reported having some knowledge about Hp. 865 participants (28.0%) had undergone Hp testing, 354 (11.4%) confirmed Hp infection, and 283 (9.1%) had received treatment for Hp. About 55.6% (1,722 participants) consider that the treatment for Hp posed a significant financial burden. The average correct response rate across all knowledge items was 45.6% (SD: 19.0%). The individual correct response rates were 57.3% for risk of Hp infection, 50.9% for diseases caused by Hp, 24.5% for methods of testing, 45.6% for benefits and side effects of Hp eradication, and 44.4% for knowledge of gastric cancer prevention. Higher scores were significantly associated with having an income over 4 million yen, a family history of Hp, personal Hp testing history, Hp treatment history, and higher health literacy. Over 80% of respondents acknowledged that understanding the relationship between Hp and stomach symptoms, recognizing Hp as a gastric cancer risk, and knowing that Hp eradication reduces future gastric cancer risk influenced their decision on the need for eradication. Similarly, the same proportion reported that believing that the harshness of the treatment exceeds the current symptoms and the high costs of testing and treatment influenced their decisions for eradication.

Conclusion

The level of understanding of Hp among the Japanese population is moderate and influenced by income level, health literacy, and personal experience with the Hp infection. Many consider testing and treatment burdensome. Enhancing correct understanding of Hp could potentially increase testing and treatment rates, contributing to the future reduction of gastric cancer in Japan.

References

1. Kimberly S Bailey, et al., Helicobacter pylori treatment knowledge, access and barriers: a cross-sectional study. Helicobacter 2023;28(2):e12954.
2. You Wu, et al., Awareness and attitudes regarding Helicobacter pylori infection in Chinese physicians and public population: A national cross-sectional survey.Helicobacter 2020;25(4):e12705
3. Thomas Zheng Jie Teng, et al., Helicobacter pylori knowledge and perception among multi-ethnic Asians.Helicobacter 2021;26(3):e12794.
4. Machi Suka, et al.,The 14-item health literacy scale for Japanese adults (HLS-14). Environ Health Prev Med. 2013;18(5):407-15.

Introduction

Focal cryoballoon ablation (FCBA) is a relatively new ablation modality for the treatment of Barrett’s esophagus (BE) related neoplasia. This prospective, European multicenter study (Euro-Coldplay, NTR NL7253) aimed to evaluate the efficacy and safety of FCBA for the treatment of limited BE.

Aims & Methods

In eight European Barrett referral centers, patients with C≤2M≤5 BE with an indication for ablation therapy were eligible for inclusion. Before entry, any visible lesion had to be removed by endoscopic resection (max. 2cm in length and 50% of circumference). FCBA was performed by experienced and trained endoscopists at 3 month intervals until complete endoscopic eradication of BE (max. 5 sessions). During every session, the esophagogastric junction was treated circumferentially followed by all visible BE using side-by-side ablations with a dose of 8 seconds per ablation. After at least two FCBA sessions, add-on treatment was allowed with either argon plasma coagulation (APC) for BE lesions of <5mm (max. 2 sessions) or a single endoscopic mucosal resection for lesions of >5mm. Outcomes included complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D), and adverse event rate.

Results

107 patients (91 males; mean age 65) with a median BE length of C0M2 were included, containing low-grade dysplasia (32%), high-grade dysplasia (32%) or early cancer (39%) as worst baseline histology. Currently, 5/107 patients are still under treatment and therefore excluded from further analysis. Of the remaining patients, 97 (97/102; 95%) patients have finished the treatment phase per protocol, while four (4/102; 4%) patients left the study prematurely. Only one (1/102; 1%) patient could not be treated with FCBA due to a device malfunction requiring a switch to radiofrequency ablation. Overall, 65/102 (64%) patients underwent endoscopic resection at entry followed by a median of 2 (IQR 2-2) FCBA treatments with a median of 7 (IQR 5-9) ablations per treatment session. During the treatment phase, 3/102 (3%) patients developed a new visible, neoplastic lesion amenable for endoscopic resection (high-grade dysplasia n = 2, low-risk T1 cancer n = 1). Add-on treatment after at least two FCBA sessions was performed in 38/102 (37%) patients, of whom the most were treated with APC for small remaining Barrett islands (37/38; 97%). CE-D was achieved in 95% (97/102) and CE-IM in 91% (93/102), per intention-to-treat analysis. Per-protocol analysis, CE-D and CE-IM were achieved in 100% (97/97) and 96% (93/97), respectively. Esophageal stricture was the most common adverse event in 13/102 (13%) patients, which resolved after a median of 2 (IQR 1-4) dilations. Only three (3/102; 3%) patients suffered a severe stricture requiring >3 dilations. No perforation or bleeding were observed, while buried BE glands were seen in 1/102 (1%).

Conclusion

In expert hands, endoscopic eradication therapy with FCBA seems to be highly effective with an acceptable safety profile for patients with limited BE. Long-term follow-up is warranted to evaluate the durability of the treatment response.

Disclosure

C.N. Frederiks have received speaker's fee and reimbursement of study-related travel costs from Pentax Medical. A. Overwater has received reimbursement of study-related travel costs from Pentax Medical. J.J.G.H.M. Bergman is a consultant for Medtronic, Cook Medical, and Boston Scientific, and has received research funding from Pentax Medical, C2 Therapeutics, Medtronic, Aqua Medical, Olympus Endoscopy, and Fuji-film. R.E. Pouw is a consultant for MicroTech, and has received speaker’s fee from Medtronic. R. Bisschops is a consultant for Pentax Medical, Medtronic, and Erbe Medical, and has received research funding and speaker’s fees from Pentax Medical, Medtronic, and Erbe Medical. T. Beyna is consultant for Medtronic, Erbe Medical, Microtech Endoscopy, Olympus Endoscopy, and Boston Scientific. B.L.A.M. Weusten has received research funding from Pentax Medical, C2 Therapeutics, and Aqua Medical. The remaining authors declare to have no disclosures relevant to this manuscript.

Introduction

Gastroparesis (GP) is defined as symptomatic delayed gastric emptying. The most frequent etiologies are diabetes mellitus, after esophageal or gastric surgery and about a third of patients have idiopathic GP. The gastric emptying study by using a scintigraphy scintigraphy (GES) is considered as a principal diagnostic method. Endoscopic pyloromyotomy (G-POEM) is a method improving symptoms in about 60-70% of patients with GP. Its effect on gastric emptying remains controversial.

Aims & Methods

We performed a retrospective single-center analysis to assess the clinical efficicacy of G-POEM based on GES parameters. Between 2016 – 2024, a total of 72 patients with GP (confirmed by scintigraphy) underwent G-POEM and were later invited for clinical as well as scintigraphic assessment after 3, 12 and 36 months. Of these patients, 4 were excluded for missing data, incomplete follow-up data or non-standard testing meal. GES was always performed using the standardized 4 hours protocol with the standard testing meal mixed with 99Tc-DTPA. For this study, all GES were reanalyzed and the following parameters were established : residual activity after 2 hours, residual activity after 4 hours, biological halftimes of ingested activity and proximal-to-distal count ratio for time 0 (PDCR0).

Results

Mean value of GCSI before G-POEM was 3.1 and decreased to 1.6, 1.0 and 0.7 after 3, 12 and 36 months. Median value of GES after 2 hours was 60.2% before G-POEM and 38%, 32.6% and 24.2% after 3, 12 and 36 months. Median value of GES after 4 hours was 21.9% before G-POEM and 7.8%, 6.5% and 3.9% after 3, 12 and 36 months. Correlation index was weakly positive for GCSI and GES after 4 hours only for the first follow-up visit and negative for all remaining visits.
The residual activity after 2 hours and residual activity after 4 hours decreased after G-POEM during all follow-up visits (p<0,001). Mean decrease of residual activity after 4 hours was 12.89%, 15.13% and 6.7% after 3, 12 and 36 months.
Biological halftime also decreased after the procedure with statistically significant results with the mean halftime before G-POEM being 150 min and 86 min, 78.4 min and 65.8 min after 3, 12 and 36 months.
There was a difference between the diabetic and non-diabetic groups, with higher residual activity after 2 hours [median 29.6% before G-POEM, 9.0% after 3 months (p<0.001) and 11.0% after 12 months (p=0.005)] and 4 hours [median 64.8% before G-POEM, 39.4% after 3 months (p<0.001) and 37.7% after 12 months (p=0.012)] respectively in patients with diabetes.
The predictive value of PDCR0 for treatment success after G-POEM was only calculated for the first follow-up visit but was not statistically proved (p=0,712).

Conclusion

In our group of patients there is a weak correlation between the decrease of GCSI and GES early after G-POEM. The decrease in GES parameters tends to be lower in patients with diabetes compared to non-diabetic patients. Based on our data, predicting clinical success of G-POEM using PDCR0 cannot be recommended.