Introduction

Esophagogastric junction contractile integral (EGJ-CI) is a metric of EGJ barrier function on high-resolution manometry (HRM), which may be limited by measurement discrepancies and unclear clinical utility. Mean EGJ basal pressure is a novel, simple HRM metric assessing barrier function. We compared their performance to predict conclusive gastroesophageal reflux disease (GERD).

Aims & Methods

Consecutive patients (Nov 2022-Oct 2023) undergoing combined HRM and 24 hour pH-impedance testing OFF antisecretory therapy (except for Barrett's patients) for known or suspected GERD were eligible, all with prior upper endoscopy. Mean (between end-expiration and end-inspiration) basal EGJ pressure, referenced to mean intragastric pressure, was calculated manually using the isobaric contour tool. EGJ-CI was calculated using the smart box tool, with the isobaric contour set 2 mmHg above intragastric pressure, over three respiratory cycles and normalized for its duration. On pH-impedance testing, Lyon classification 2.0 was applied. Conclusive GERD was defined as acid exposure time (AET) >6% or histologically confirmed Barrett’s. Mann-Whitney U and Kruskal-Wallis test, with Bonferroni correction, were used. ROC curves were plotted.

Results

125 patients were included (mean age 51.6 ± 16.5 years, 60% males). Upon applying Lyon 2.0 classification, 45 (36%) patients had conclusive GERD (25 Barrett’s), 7 (6%) borderline GERD, 16 (13%) reflux hypersensitivity (RH), while 57 (45%) had functional symptoms. Patients with conclusive GERD, on HRM, had a significantly lower mean basal EGJ pressure (11.0 vs 18.5 mmHg; p<0.001) than patients without conclusive GERD, while EGJ-CI was not statistically different (26.1 vs 35.1 mmHg∙cm; p=0.101). Mean basal EGJ pressure was significantly different across Lyon v2.0 subgroups (median values in GERD: 11, borderline GERD: 16, RH: 19, FH: 20 mmHg; p<0.001), while EGJ-CI did not differ (p=0.283). Mean basal EGJ pressure (AUROC: 0.73, 95%CI 0.64-0.82) showed greater predictive performance of conclusive GERD than EGJ-CI (AUROC: 0.59, 95%CI 0.49-0.69). The optimal cut-off of 13 mmHg had 72% sensitivity and 62% specificity; a cut-off of 9.5 mmHg had 86% sensitivity, while a cut-off of 23.5 mmHg had 91% specificity.

Conclusion

Mean EGJ basal pressure is a simple HRM metric to predict conclusive GERD, well differentiating GERD phenotypes, with greater performance than EGJ-CI. This metric could be preferred over EGJ-CI as a useful adjunctive measure to support GERD diagnosis.

Introduction

In cirrhosis, several prognostic scores have been developed to predict overall and complication-free survival. The MELD (Model for End-Stage Liver Disease), MELD-Na and MELD3.0 scores have been proposed as a criteria for allocating organs.

Aims & Methods

The aim of our study was to assess the performance of these 3 scores for the prediction of overall and complication-free survival in decompensated Tunisian cirrhotic patients.
Methods: We conducted an observational, retrospective study involving all patients with decompensated cirrhosis managed in Gastroenterology department of Taher Maamouri hospital during the period from January 2010 to December 2021. Mortality was assessed using the Kaplan Meier model. The performance of the scores was assessed using the AUROC (Area under the Receiver Operating Characteristic curve).

Results

One hundred and fifty-two patients were included with an average age of 61 years. Viral liver cirrhosis was the most common (65.13%). The mean value of the MELD-Na and MELD3.0 scores was 17.74 and 19.4, respectively. The mean follow-up time was 17.1 months. The rate of complications and short-term mortality was 33.6% and 18.4% respectively.
The AUROC of the MELD3.0 score in predicting of the occurrence of further decompensation was the highest (0.775) compared to those of the MELD and MELD-Na score (0.743 and 0.756 respectively). The cut-off value of the MELD3.0 score in predicting further decompensation was 20 (sensitivity 60.7%, specificity 73.3%).
In the prediction of 3-month mortality, the AUROCs of the MELD, MELD-Na and MELD3.0 scores were 0.786; 0.841 and 0.850 respectively. The cut-off value of the MELD3.0 score was 24 (sensitivity 68%, specificity 88%). A statistically significant correlation was noted between the MELD3.0 score ≥24 and 3-month mortality (p=0.04).

Conclusion

The MELD3.0 score had the best predictive value for the occurrence of further decompensation and short-term mortality in decompensated cirrhotic patients. Those with a MELD 3.0 score ≥24 should be prioritized on waiting lists.

Introduction

Piecemeal endoscopic mucosal resection (EMR) vs endoscopic submucosal dissection (ESD) has been a long standing debate in the endoscopic community worldwide with multiple studies done to evaluate the preferred method to manage large colorectal neoplasms. Piecemeal EMR with thermal ablation of the margin has been strongly advocated and reported by certain groups to be a simple, inexpensive and effective technique and this has been preferred widely due to its perceived ease of performance and shorter learning curve.¹ However, close, repeated surveillance colonoscopy is recommended even when the lesion is thought to have been completely resected² as residual tumors can cause interval cancers.³ Some groups, mainly from east Asian countries, have recommended en bloc resection by ESD due to significantly lower risk of local recurrence and precise pathological diagnosis.⁴ But its usage is limited due to concerns about risk of serious adverse events. With improvement in training and devices, colorectal ESD is now being performed by various centers globally. This study aims to report the outcomes of an international, multicenter study on colorectal ESD.

Aims & Methods

Patients who underwent colorectal ESD for lesions greater than 20mm between January 2022 to April 2024 from centers in USA, Japan, and India respectively were included in this study. Recurrent lesions after endoscopic therapy, neoplasms identified in patients with ulcerative colitis, and non-epithelial lesions were included. Primary outcomes were en bloc and R0 resection rate, delayed adverse events (bleeding/perforation), and local recurrence rate. Secondary outcomes were procedure time, lesion size, and pathology. Univariate and multivariate analysis were done to identify the risk factors for primary outcomes.

Results

309 patients (median size, 40(27.5-60)mm; location rectum 52.4%, left colon 26.2%, right colon 21.4%) were involved in this study. The en bloc resection rate was 96.1% and R0 resection rate was 90.3%. 3 patients experienced delayed bleeding which was managed endoscopically. 2 patients underwent surgery for delayed perforation. 6 patients had a local recurrence. 67(23%) patients had intramucosal carcinoma on pathology. Univariate analysis showed lesser procedure time (median(IQR) 145(80-236.25) vs 270(180-300) minutes, P= 0.005) and smaller lesion size (median(IQR) 40(26-56.25) vs 60(40-90) mm, P= 0.004) were significant factors for successful en bloc resection. However, lesser procedure time (median(IQR) 74(29.5-97.5) vs 150(82.5-240) minutes, P= 0.034) led to an increased delayed adverse event rate. Multivariate analysis using Cox regression showed en bloc resection (odds ratio 0.038; 95% confidence interval 0.003-0.421; P= 0.008) was an independent factor preventing local recurrence.

Conclusion

This international, multicenter study with data from three countries shows favorable outcomes for colorectal ESD for large lesions. The high en bloc and R0 resection rate, and low adverse event rate show increased global adaptation to this procedure. Reduced local recurrence is an added benefit. Data from a more centers globally will be valuable to establish ESD as the standard for large colorectal neoplasms.

References

1. Sidhu M, Shahidi N, Gupta S et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology. 2021 Jul 1;161(1):163-70.
2. Gupta S, Lieberman D, Anderson JC et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020;91:463-485.e5.
3. Rutter MD, Beintaris I, Valori R et al. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology 2018;155:909-925.e3.
4. Ohata K, Kobayashi N, Sakai E et al. Long-term outcomes after endoscopic submucosal dissection for large colorectal epithelial neoplasms: a prospective, multicenter, cohort trial from Japan. Gastroenterology. 2022 Nov 1;163(5):1423-34.

Introduction

Suspected foreign body ingestion and food bolus impaction are common indications for urgent esophagogastroduodenoscopy. Nevertheless, most of the ingested foreign bodies (80 to 90%) pass spontaneously throughout the gastrointestinal tract. In 2022, the Decision-To-Scope (DTS) Score was developed, revealing an excellent accuracy in predicting foreign bodies in the esophagus.

Aims & Methods

Our aim was to prospectively evaluate the diagnostic accuracy of the DTS-Score.
We have prospectively included consecutive patients admitted for suspected foreign body in the upper gastrointestinal tract, for a 6-month period. Previously to endoscopic evaluation, the DTS-score - time since ingestion < 6 hours (+1pt); absence of any meal since the suspected ingestion (+2pts); dysphagia (+3pts); odynophagia (+1pt) and drooling (+4pts) - was applied in each patient. The maximal possible value was 11 points, with a DTS-Score ≥5 being considered to assign a high probability of endoscopic confirmation of the foreign body.

Results

Final sample included 47 patients, from which 26 (55.3%) were females, with a mean age of 60±16 years. From these, most (n=42; 91.5%) were evaluated for accidental ingestion of food-related foreign bodies (fish or chicken bones) or suspected food bolus impaction. A DTS-Score ≥5 was calculated in 11 (23.4%) of the patients, with an esophageal foreign body being confirmed in 12 (25.5%) of them. DTS-score presented an excellent accuracy in predicting the endoscopic confirmation of a foreign body in the esophagus (AUC=0.94; 95%CI 0.85-1.00; p<0.001). The originally defined cut-off (DTS-Score ≥5) presented a specificity of 97.1%, a sensitivity of 83.3%, a positive predictive value of 90.9% and a negative predictive value of 94.4%.

Conclusion

When prospectively applied, the DTS-score demonstrated an excellent acuity in stratifying the probability of endoscopic confirmation of a suspected foreign body in the esophagus. This tool may be included in future clinical algorithms for suspected foreign bodies ingestion.

Introduction

The clinical value of combined resection of important hepatic vessels in hilar cholangiocarcinoma remains controversial. We aimed to compare the short-term and long-term outcome of combined versus non-combined major vessel resection in patients undergoing radical resection for hilar cholangiocarcinoma.

Aims & Methods

This single centre retrospective cohort study of patients with hilar cholangiocarcinoma was conduct from January 2007 to December 2018. Patients who underwent radical re-resection were enrolled. The short-term and long-term clinical outcomes of the groups were compared after propensity score matching.

Results

A total of 310 patients were included. There was no statistically significant difference in perioperative clinical outcomes between VR group (PVR and AVR) and non-VR group after 1:2 PSM. Patients who received PVR had significantly longer OS (p=0.023) and DFS (p=0.010) compared to those in the non-PVR group. AVR group was associated with improved OS (p=0.036) and DFS (p=0.029) compared with non-AVR group following the curative-intent resection. The postoperative complications of combined VR would not worsen long-term survival for patients (OS: p=0.159; DFS: p=0.112).

Conclusion

Combined vascular resection (VR) would improve the long-term survival for patients with hilar cholangiocarcinoma. The postoperative complications of combined VR would not worsen long-term survival. Therefore, radical surgical resection should be actively performed in these patients.

Disclosure

The authors declare that they have no competing interests.

Introduction

Non-alcoholic steatohepatitis (NASH) is a chronic liver disease characterized by liver steatosis and inflammation which abnormal immune responses involved in pathogenesis, and there is no approved therapeutic drug. Rhein, one of the main bioactive components of Rheum palmatum, has exerted anti-inflammatory properties. However, the mechanism by which Rhein exerts beneficial effects against NASH is far from elucidated. Here, our study aimed to investigate the therapeutic effects of Rhein on liver steatosis and inflammation and elucidate the related mechanisms of immunoregulation.

Aims & Methods

Male C57BL/6 mice were given high-fat diet for 10 weeks to induce NASH, followed by Rhein suspension administration at a dose of 100mg/kg and 200mg/kg for 4 weeks. The therapeutic effect of NASH was estimated by body weight, liver weight, LW/BW, food intake, the liver appearance and the histological analysis of liver section stained with hematoxylin and eosin. The proportion of lymphocyte cells in the mesenteric lymph nodes (MLNs) was detected by flow cytometry.

Results

Our findings demonstrated that high-fat diet treatment resulted in severe liver inflammation and severe steatosis, while Rhein appreciably reverse these phenomenon, as evidenced by the reduction of body weight, liver wet weight, LW/BW, and liver size in mice. Histological analysis of liver section revealed that administration of Rhein exhibited improvement of severe steatosis, elimination of inflammatory cells and resolution of balloon-like changes when compared to mice in the HFD group. Interestingly, there were no significant differences in food intake among groups of mice, suggesting that the protective effect of Rhein is not achieved by inhibiting appetite. Mechanistically, flow cytometry analysis showed that higher Th1 and Th17 polarized response were detected in the MLN compartments in HFD-induced mice, evidenced by the detection of increased numbers of Th1 cells (CD3+CD4+IFN-γ+) and Th17 cells (CD3+CD4+IL-17+), and Rhein intervention showed significant decrease numbers of Th1 and Th17 in MLNs. In contrast, Rhein treatment significantly increased the numbers of Treg cells (CD3+CD4+Foxp3+) with anti-inflammatory effects in the MLN of NASH mice.

Conclusion

Our results provide novel insights into the protective role of Rhein in modulating the liver steatosis and inflammation, with therapeutic potential for immunology-targeted strategy in the treatment of NASH.

References

[1] Cheng L, Chen Q, Pi R, Chen J. A research update on the therapeutic potential of rhein and its derivatives. Eur J Pharmacol. 2021,899:173908. doi:10.1016/j.ejphar.2021.173908.
[2] Gebru YA, Gupta H, Kim HS, et al. T Cell Subsets and Natural Killer Cells in the Pathogenesis of Nonalcoholic Fatty Liver Disease. Int J Mol Sci. 2021,22(22):12190. doi:10.3390/ijms222212190

Disclosure

The authors declare that there are no conflicts of interest regarding the publication of this paper.