Introduction

This study aims to compare the diagnostic efficacy and variables of standardized high definition white light endoscopy with image-enhancement versus non-standardized routine white light endoscopy) in detecting upper gastrointestinal mucosal lesions.

Aims & Methods

A prospective analysis was conducted on 270 patients undergoing Upper Gastrointestinal Endoscopy at Advanced Gastroenterology Institute: AGI the GASTROCITI, Ludhiana located in Punjab region of North India between December 2023 and March 2024. Patients were randomly assigned (135 each) to undergo assessment using standardized versus non standardized format. Endoscopic findings were recorded and later analyzed by experienced gastroenterologists blinded to the endoscopic modality used.

Results

In the standardized group, the mean age was 47 years, with 63 % males and 37 % females. In the nonstandardized group, the mean age was 45 years, with 58 % males and 42 % females. The most common indications for endoscopy in both groups were dyspepsia and heartburn. Due to use of premedication preparation (Surfactant Simethicone + Mucolytic N acetyl-cysteine solution), the mucosal visibility score in the standardized group was significantly better at 76% versus 32% in the nonstandardized group. Also, the time taken to examine the complete mucosa (8 minutes versus 5 minutes) and corresponding Propofol anesthetic requirement dose (140 mg versus 120 mg) along with the lesion detection rate (68% versus 53%) was higher in the standardized group. Among the 135 patients, 43 were normal in the standardized group versus 64 in the nonstandardized group. The diagnostic yield of standardized high-definition white light endoscopy with image enhancement was 68.1% versus 52.5 % in nonstandardized WLE. Specific lesions with higher rates of detection were Grade A Esophagitis, early short segment Barrett’s Esophagus, gastric atrophy, and intestinal metaplasia. The relative risk and odds ratio to find an abnormality while doing a standardized procedure was 1.3 and 1.93 respectively which showed very high statistical significance (p Value 0.009).

Conclusion

Standardized (High Definition White Light Endoscopy with Image-Enhancement) demonstrates superior diagnostic efficacy compared to non standardized routine white light endoscopy in detecting upper gastrointestinal mucosal lesions. Further large-scale studies are warranted to validate these findings and determine the optimal use of standardized (High Definition White Light Endoscopy with Image-Enhancement) in clinical practice.

Clinical Case Summary

A 28-year-old patient presented with recurrent episodes of overt gastrointestinal bleeding, requiring multiple blood transfusions over the past two months (5 units of packed red blood cells). Despite undergoing UGI endoscopy and colonoscopy twice at other medical centers, no abnormalities were detected. CT enterography with CT angiography yielded normal results. To further investigate, the patient underwent antegrade and retrograde power spiral enteroscopy, revealing gross active bleeding from a site of hookworm bite in the jejunum. Following the procedure, the patient was discharged with antihelminthic therapy. However, a week later, he experienced abdominal pain, difficulty passing stools, intermittent rectal bleeding again, and low-grade fever. A relook sigmoidoscopy revealed a large hematoma with intraluminal compression in the sigmoid colon. CT scan confirmed a localized sealed-off perforation along with the hematoma. Management included percutaneous aspiration of the hematoma, intravenous antibiotics, and repeat blood transfusion. Anti-helminthic therapy continued, and the patient recovered completely after approximately four weeks which was confirmed by sigmoidoscopy. The mechanism of this sigmoid colon hematoma involves potential mechanical injury by the overtube's spiral tip during insertion or manipulation. Although the localized perforation was sealed off in this case, the preceding bleeding and drop in hemoglobin complicated the initial treatment plan. Considering such technical challenges, the equipment and technology have now been withdrawn globally by the manufacturer. Close monitoring of patient symptoms, and vital signs, and prompt discontinuation of the procedure in case of discomfort or pain are crucial in preventing such complications. As advanced endoscopic techniques become more prevalent, maintaining a cautious approach towards technology and addressing complications promptly is essential for ensuring patient safety and effective care

Introduction

Post-esophageal variceal ligation (EVL) ulcer bleeding poses a significant challenge in clinical practice, with various management modalities employed. However, there is a lack of established guidelines for effective management. This study aims to evaluate the effectiveness and safety of self-expandable metal SX-DANIS-ELLA (DE) stents in controlling post-EVL ulcer bleeding.

Aims & Methods

This retrospective audit focused on cirrhotic patients who underwent SEMS placement for post-EVL ulcer bleed. The study assessed bleeding control rates within 48 hours post-treatment and mortality rates within 6 weeks post-treatment

Results

Among 1025 endoscopic procedures for variceal ligation over 40 months, 1.4% (15 patients) presented with post-EVL ulcer bleed, all managed with DE stents. SEMS successfully controlled bleeding in 100% of cases at 48 hours post-procedure without the need for alternative rescue strategies. Median SEMS placement duration was eight days, with complete ulcer healing observed in 14 patients upon stent removal. However, one patient passed away within 72 hours due to decompensation. Early rebleeding within 6 weeks occurred in two ( 13.3%) patients which was managed with EVL. The 6-week mortality rate was notable at 20%(3 out of 15 patients). Adverse events included superficial esophageal ulcers at upper end of stent mesh in 9 patients out of 15(60%), SEMS dislocations in 3 out of 15 patients (20%) and one very deep esophageal tear with ulcer at the upper end of the stent mesh (6.6%). Two patients also had aspiration pneumonitis post procedure which was managed conservatively

Conclusion

SX-ELLA esophageal stents effectively controlled post-EVL ulcer bleeding. Despite successful bleeding control, the high mortality rate underscores the need for further strategies. SEMS dislocations highlight the complexity of this intervention and the importance of expertise in stent placement. Future research should explore the role of early transplant referral in reducing mortality following SEMS placement and improving patient outcomes

Introduction

Artificial intelligence (AI) has recently made remarkable progress, and computer-aided detection (CAD) system for gastrointestinal endoscopy is rapidly evolving. The development of AI software that provides real-time information displayed directly on an endoscopic screen is expected to aid in the detection of neoplastic lesions. Furthermore, the integration of AI with virtual chromoendoscopy such as blue laser/light imaging (BLI) or linked color imaging (LCI) is expected to improve the accuracy of detecting early stage cancer lesions. Based on this background, Fujifilm recently developed a CAD system (CAD EYE, Fujifilm, Tokyo, Japan) for the detection of gastrointestinal neoplasms using white-light imaging (WLI) and image-enhanced endoscopy (IEE).

Aims & Methods

This study aimed to validate the performance of CAD in identifying esophageal squamous cell carcinoma (ESCC) and gastric neoplasm (GN). This multicenter retrospective study utilized image datasets comprising 15 consecutive video frames captured using WLI, BLI, and LCI. The sensitivity and specificity of CAD for successful detection were calculated using the gold standard, which consists of image datasets of neoplastic lesions annotated by experienced endoscopists.

Results

A total of 620, 679, and 682 ESCC datasets were analyzed in the WLI, BLI, and LCI groups, respectively. The sensitivity and specificity of ESCC detection were 85.9% (176/205) and 93.3% (387/415) in the WLI group, 97.6% (206/211) and 92.9% (435/468) in the BLI group, and 96.6% (201/208) and 93.2% (442/474) in the LCI group. The detection rates for pT1a ESCC were 85.3% (145/170), 97.3% (181/186), and 97.2% (172/177) in the WLI, BLI, and LCI, respectively. For GN, 846 WLI and 885 LCI datasets were analyzed. The sensitivity and specificity of GN detection were 95.5% (231/242) and 85.4% (516/604) in the WLI group, and 93.9% (263/280) and 93.9% (568/605) in the LCI group, respectively. The detection rates for pT1a early gastric cancer were 93.8% (152/162) and 92.4% (182/197) in the WLI and LCI groups, respectively.

Conclusion

The CAD system demonstrated high sensitivity in detecting ESCC and GN, highlighting its potential as a promising tool for clinical applications.

Disclosure

Seiichiro Abe: Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
Yoshiyasu Kitagawa: Endoscopy Division, Chiba Cancer Center, Chiba, Japan
Waku Hatta: Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
Takao Maekita: Second Department of Internal Medicine Wakayama Medical University, Wakayama, Japan
Motohiko Kato: Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
Akihito Nagahara and Hiroya Ueyama: Department of Gastroenterology, Juntendo University Faculty of Medicine, Tokyo, Japan
Hiroyuki Osawa: Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
Osamu Dohi: Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
Hirotaka Nakashima: Department of Gastroenterology, Foundation for detection of early gastric carcinoma, Tokyo, Japan
Cancer screening center, Cancer institute hospital of Japanese foundation for cancer research, Tokyo, Japan
Kazuhiro Furukawa: Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
Shiro Oka: Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
Tomoko Yokoyama: FUJIFILM Nishiazabu endoscopy clinic, Tokyo, Japan
Toru Ito: Department of Gastroenterological Endoscopy, Kanazawa Medical University Hospital, Ishikawa, Japan
Ichiro Oda: Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
Department of Internal Medicine, Kawasaki Rinko General Hospital, Kanagawa, Japan

Introduction

​Accurate photodocumentation is crucial for ensuring the reliability and effectiveness of upper gastrointestinal endoscopy [1]. To support proper photodocumentation during screening exams, a new AI function called the Landmark Photo Checker (LMPC) has been implemented in CAD EYE^TM (FUJIFILM. Co, Tokyo). This endoscopic AI function facilitates endoscopic photodocumentation by providing a visual indication of completion when appropriate still images of seven anatomical landmarks in the stomach (including the oesophagogastric junction, cardia and fundus, cardia near field view, body greater curvature forward view, body lesser curvature retroflex view, angulus, and pylorus near field view) are captured during the exam.

Aims & Methods

This prospective pilot study aimed to evaluate the sensitivity of LMPC for these seven landmarks as the primary endpoint, with specificity and accuracy rate as secondary endpoints. Endoscopic examinations were conducted by expert endoscopists using linked color imaging (LCI) for endoscopic observation. The study involved 95 participants, with an average age of 54.9 years, of whom 54 (56.8%) were male. The participants were randomly assigned to two groups: the sensitivity verification group (n=49) and the specificity verification group (n=46). In the sensitivity verification group, the endoscopists captured appropriate still images of the seven landmarks during the examination. Conversely, in the specificity verification group, the endoscopists intentionally captured inappropriate images of the seven landmarks. Sensitivity was defined as the proportion of images marked as "good" by LMPC in the sensitivity verification group, while specificity was defined as the proportion of images not marked as "good" by LMPC in the specificity verification group. In the specificity verification group, appropriate images of the landmarks were additionally captured using white light imaging before the endoscope was removed.

Results

A total of 633 judgments made by the LMPC during upper gastrointestinal endoscopy using LCI observation light were analyzed statistically. The sensitivity of the landmark, set as the primary endpoint for evaluation of the LMPC, was 87.3%. The secondary endpoints, specificity and accuracy rate, were 75.5% and 81.5%, respectively. The individual sensitivities (%) and specificities (%) for the seven landmarks are as follows: the esophagogastric junction (90.7 and 90.2), the cardia and fundus (77.6 and 38.6), the cardia near field view (81.6 and 60.0), the body greater curvature forward view (89.8 and 88.9), the body lesser curvature retroflex view (93.2 and 75.6), the angulus (84.4 and 86.7), and the pylorus near field view (93.2 and 88.9). The mean examination time for all 95 cases was 8 minutes 10 seconds.

Conclusion

Although there is no established standard for evaluating the accuracy of upper gastrointestinal endoscopy, systematic and appropriate photodocumentation during the endoscopic procedure is expected to improve its accuracy. The LMPC demonstrated high sensitivity to anatomical landmarks within the stomach and was found to be effective in supporting the capture of appropriate endoscopic images using the image-enhanced endoscopy technique LCI.

References

Bisschops R, Areia M, Coron E, et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy. 2016 Sep;48(9):843-64.

Disclosure

Author H. Nakashima was supported by joint research expenses from FUJIFILM Co. The other authors have no COI to disclose.

Introduction

The increasing accessibility of upper gastrointestinal endoscopy has led to a rise in its prescription. However, its overuse and inappropriate indications result in environmental and economic costs, potential iatrogenesis, and a paradoxical reduction in access. This study aims to assess the indications for elective diagnostic upper gastrointestinal endoscopy (UGE) requested in the hospital setting.

Aims & Methods

A retrospective analysis was conducted on elective diagnostic UGE requests from both outpatient and inpatient settings. The appropriateness of the requests was classified according to the recommendations of the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy.

Results

A total of 314 requests were analyzed over a three-month period: 90.8% (n=285) from outpatient consultations and 7.6% (n=24) from inpatient settings. A previous UGE had been performed in 53.8% (n=169) of patients, with an average interval of 27.13 ± 2.12 months between requests. Overall, 59.6% (n=187) of the requests were deemed appropriate, with the most frequent indications being the need for biopsies (15%, n=28), gastrointestinal bleeding or anemia (14.4%, n=27), and post-endoscopic intervention surveillance (10.7%, n=20).
Clinical information indicated the presence of alarm symptoms in 27.7% (n=87) cases, the most frequent being gastrointestinal bleeding or anemia (33.3%, n=29), age >50 years with new-onset symptoms or suspected structural disease (21.8%, n=19), and progressive dysphagia (17.2%, n=15). Conversely, 40.4% (n=127) of requests were considered inappropriate, mainly due to non-compliance with guidelines and surveillance intervals. The most common inappropriate indications included symptoms attributed to disorders of the gut-brain axis (20.5%, n=26), surveillance of atrophic gastritis, fundic gland polyps, hyperplastic polyps, and gastric intestinal metaplasia (11.8%, n=15), as well as post-gastric surgery surveillance for benign conditions in asymptomatic patients (8.7%, n=11). Additionally, 39 (28.3%) UGEs were requested for gastric cancer screening.

Conclusion

This study identified a significant proportion of UGE requests lacking appropriate and timely indications. These findings emphasize the need for well-defined criteria to ensure the rational and optimized use of this resource.

Introduction

As around 10% of upper gastrointestinal (UGI) cancers are missed in endoscopies, quality standards for UGI endoscopy have been formulated by the European Society of Gastrointestinal Endoscopy (ESGE). So far, compliance to these standards in clinical practice is largely unknown.

Aims & Methods

We aimed to assess the adherence to and the impact of implementation of the ESGE quality standards for UGI endoscopy in a multicenter prospective cohort study. Endoscopists of three centers underwent a 1-hour training on procedural quality standards, including inspection time (≥7 minutes), photodocumentation (≥ 10 anatomical landmarks + abnormalities), use of standardized terminology (e.g. Los Angeles classification) and compliance to biopsy protocols (e.g. Seattle protocol). Quality score of diagnostic UGI endoscopies performed in adult patients before (control group) and after (intervention group) the training were compared. Primary endpoint was the overall quality score, defined as percentage of the maximum score (per item: 2 points for full compliance, 1 point for partial compliance and 0 points for no compliance).

Results

Of 1,733 consecutive UGI endoscopies, 570 were eligible for inclusion: 285 in the control group and 285 in the intervention group. Median patient age was 63 y/o (IQR 51-71) with 47% males. The overall quality score increased from 58% to 65% after the training intervention (p<0.001). When comparing control group vs. intervention group, inspection time of ≥7 minutes was achieved in 19% vs. 26%, photodocumentation was complete in 33% vs. 60%, standardized terminology was correctly used in 85% vs. 90% and biopsy sampling compliance was 41% vs. 41%, respectively.

Conclusion

Adherence to the ESGE quality standards for UGI endoscopy increased after a 1-hour training. This suggests that a simple training intervention improves quality of UGI endoscopy and potentially could prevent missing lesions.