Introduction

Anastomotic leak remains one of the most critical complication after Ivor-Lewis esophagectomy [1][2]. While intra-cavitary approach for Endoscopic Vacuum Therapy (EVT) has been proved effective for the treatment of large dehiscences [3], no data exist comparing intraluminal EVT and Self-expanding Metal Stent (SEMS) in the management of non-large (<3 cm) anastomotic dehiscences.

Aims & Methods

In this matched-at-enrollment case-control study (1:1), we included patients who received EVT and SEMS for non-large (<3 cm) anastomotic dehiscences after oncologic Ivor-Lewis esophagectomy between May 2014 and July 2022. The primary outcome was successful closure of the leak. Exclusion criteria were: anastomotic dehiscences > 3 cm, early (≤ 2 days) and late (4 weeks) diagnosis after surgery, severe gastric conduit necrosis, sepsis/septic shock at diagnosis.

Results

Overall, 22 patients treated with EVT and 22 treated with SEMS, were matched by age (p=0.070), sex (p=0.262), BMI (0,247), American Society of Anesthesiologists (ASA) score (p=0.386), neoadiuvant radio/chemotherapy (p=0.15), dehiscence diagnosis modality (0.761), defect type (leak or fistula) (p=1.00), PCR values (p=0.103) surgical re-intervention before endoscopic treatment (p=0.472) and leak size (p=0.931). EVT and SEMS revealed no difference in leak resolution (90.9% vs 72.7%, respectively; p=0.21), whereas EVT group was associated with higher number of procedures (4.41 vs 2.18, p= 0.05, respectively). Concerning adverse events (AE’s), both EVT and SEMS showed no statistical difference in AE’s rates (p=0.61). Overall outcomes of endoscopic procedures are shown in Table 1.

Conclusion

EVT and SEMS has shown similar efficacy outcomes in the treatment of non-large (< 3 cm) anastomotic defects after Ivor-Lewis esophagectomy. Prospective comparison data are needed to validated these findings.

References

1. Seesing MFJ, Gisbertz SS, Goense L, van Hillegersberg R, Kroon HM, Lagarde SM, Ruurda JP, Slaman AE, van Berge Henegouwen MI, Wijnhoven BPL (2017) A Propensity Score Matched Analysis of Open Versus Minimally Invasive Transthoracic Esophagectomy in the Netherlands. Ann Surg 266: 839–846
2. Kassis ES, Kosinski AS, Ross P Jr, Koppes KE, Donahue JM, Daniel VC (2013) Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg 96: 1919–1926
3. Zhang CC, Liesenfeld L, Klotz R, Koschny R, Rupp C, Schmidt T, Diener MK, Müller-Stich BP, Hackert T, Sauer P, Büchler MW, Schaible A (2021) Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection. BMC Gastroenterol 21:72

Disclosure

Prof. Silvio Danese has served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millenium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor. The other authors declare no conflict of interests. Dr Francesco Vito Mandarino, Dr Alberto Barchi, Dr Lorenzo Leone, Dr Lorella Fanti, Dr Francesco Azzolini, Dr Edi Viale, Dr Dario Esposito, Dr Noemi Salmeri, Dr Francesco Puccetti, Dr Lavinia Barbieri, Dr Andrea Cossu, Dr Elio Treppiedi, Dr Ugo Elmore and Prof Riccardo Rosati have no conflict of interest to disclose.

Introduction

Propofol administration managed directly by the gastroenterologist is a sedation regimen, which is broadly spreading, in clinical practice in Endoscopy Units (EU) all over the world [1]. This is primarily due to a very high patient and endoscopist satisfaction. Moreover, fears associated with propofol use by non-anesthesia providers are based on sound theoretical principles. Non-anesthesiologist-administered-propofol (NAAPS) managed by the gastroenterologist is an issue still controversial for many anesthesiologist societies.

Aims & Methods

This study aims to analyze safety outcomes between NAAPS sedation and anesthesiologist-assisted deep sedation during endoscopic procedures for low-risk patients. We retrospectively assessed data from low anesthesiologist risk-patients (American Society of Anesthesiologists I-II), undergone esophagogastroduodenoscopies (EGDs) and colonoscopies under NAAPS sedation, and assisted anesthesiologist-deep sedation, between May 2019 and October 2021, in a tertiary center. Primary outcome was to compare sedation related-adverse events rates between NAAPS and deep sedation. Propensity score matching analysis was performed using sex, age, Body Mass Index (BMI), smoking, comorbidities and time examination in order to standardize baseline variables.

Results

Overall, in colonoscopies subset, 2491 patients were managed under NAAPS and 257 patients under deep sedation, whereas in EGDs subset, 2439 patients were managed under NAAPS and 282 patients under deep sedation. In unmatched analysis, no difference was shown in terms of adverse events rates between NAAPS and deep sedation, both in EGDs and colonoscopies subsets (1.8% vs 3.5%; p=0.202 and 1 vs 0,4%, p=0.815, respectively). After matching, EGDs subset analysis comprised 282 procedures in NAAPS group versus 188 in deep sedation group, whereas colonoscopies subset included 256 patients in NAAPS group and 174 in deep sedation group. Matched analysis revealed non-different adverse events rate between moderate and deep sedation groups (colonoscopies 3.5% vs 0.6%, p=0.249 and EGD 0.4% vs 1%, p=0.452, respectively).

Conclusion

NAAPS during endoscopy represents a safe sedation modality, comparable with safety outcomes of anesthesiologist-assisted deep sedation. Cost-efficacy analyses are needed, in order to highlight economic advantages of non-anesthesiologist management of propofol during endoscopy.

References

[1] Gouda B, Gouda G, Borle A, Singh A, Sinha A, Singh PM. Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis. Saudi J Gastroenterol. 2017;23(3):133-143. doi:10.4103/sjg.SJG_501_16

Disclosure

Prof.Silvio Danese has served as a speaker, consultant, and advisory board member for Schering-Plough, AbbVie, Actelion, Alphawasserman, AstraZeneca, Cellerix, Cosmo Pharmaceuticals, Ferring, Genentech, Grunenthal, Johnson and Johnson, Millenium Takeda, MSD, Nikkiso Europe GmbH, Novo Nordisk, Nycomed, Pfizer, Pharmacosmos, UCB Pharma and Vifor. The other authors declare no conflict of interests.

Introduction

The latest ESGE technical review guideline advocates real-time monitoring in the first hour of small bowel capsule endoscopy (SBCE) to ensure entire small bowel visualization. However, a survey demonstrated poor adherence to this statement in clinical practice, and supporting data are scarce.

Aims & Methods

We aimed to evaluate predictive factors of incomplete SBCE and to ascertain the importance and cost-effectiveness of real-time monitoring.
We retrospectively included consecutive patients who ingested SBCE (PillCam SB3) at our tertiary referral center from 2013 to 2020. Clinical and endoscopic characteristics were analyzed. Real-time monitoring was not applied according to local protocol. Prolonged gastric transit time (GTT) was defined when the capsule crossed the pylorus > 2 hours from ingestion, and prolonged small bowel transit time (SBTT) when cecum was reached > 6 hours from pylorus crossing. A logistic regression analysis was done to find significative risk factors associated with incomplete SBCE. Exclusion criteria included: capsule retention, endoscopic delivery of capsule, and major technical issues (i.e., eating within a standard gastric transit time of the capsule or major recording issues).

Results

A total of 859 SBCE were analyzed, with a completion rate of 94.5%. A prolonged GTT and a prolonged SBTT were found in respectively 46 (5.4%) and 152 (17.6%) procedures. At multivariate analysis, one modifiable (prolonged GTT[p=0.02]) and two unmodifiable risk factors (inpatient status [p<0.01] and history of incomplete SBCE [p=0.02]) were associated with a higher rate of incomplete SBCE, with increased odds ratio of 3.0 (CI95%= 1.2-7.4), 2.3 (CI95%= 1.2–4.2), and 3.7 (CI95%= 1.2-11.9), respectively. Pretest probability of SBCE completion rate was 90.5% and 95.7% in patients with and without unmodifiable risk factors (p=0.01).
Considering the rates of prolonged GTT, the number of patients to be monitored with real-time viewer to identify and treat one patient with prolonged GTT is 14.5 in patients with unmodifiable risk factors for incomplete SBCE and 20.3 in patients without risk factors for incomplete SBCE (p=0.27).
Direct cost for 1-hour real-time monitoring and intervention in case of prolonged GTT (i.e., dedicated room, nurse, +/- metoclopramide and IV access) are equal to circa 35 €. If all patients of our cohort would undergo real-time monitoring, the expense would be equal to 30065 €. Given that in our cohort 6 patients had an incomplete SBCE, the cost of RTM to prevent one incomplete SBCE would be equal to 5010 €. If RTM would be limited to patients with unmodifiable risk factors for incomplete SBCE, the total cost would be equal to 6615 €. In this sub-group only 2 patients had an incomplete SBCE, therefore, to prevent one incomplete SBCE, the total expense would be 3307 €.

Conclusion

The inpatient status, a prolonged GTT and a previous incomplete SBCE are risk factors for incomplete SBCE. According to our direct costs analysis, the number needed to treat one prolonged GTT to decrease the rate of incomplete SBCE appears to be cost-effective in patients with unmodifiable risk factors (i.e., inpatient status and history of incomplete SBCE).

Introduction

Inflammatory bowel disease (IBD) is a growing cause for concern and often missed or not thought of among pediatric population in developing economies. It is reported that about 25% of IBDs present before the age of 20.
Growing plethora of investigations have not been able to replace the role of direct visualisation of intestinal mucosa in various colorectal issues. Macroscopic findings may or may not help in clinching the diagnosis of IBD, hence “Biopsy” remains the Elixir of diagnosis. In this article, we review and attempt to correlate colonoscopic(macroscopy) and histological (microscopy) findings of colonoscopies in pediatric population, done over a period of 1 year.

Aims & Methods

Aim and objectives: To compare macroscopic findings versus histopathology findings of colonoscopies in pediatric population in suspected IBD.
To study the correlation of macroscopic findings with histopathologic findings of colonoscopies in pediatric population and to assess the frequency and pattern of microscopic impressions of colonoscopies in our cohort.
Material and methods: A prospective observational study carried out in a tertiary referral centre in children who underwent colonoscopies, aged 1 month to 17 years over a period of 12 months.
All children whose parents consented were included in the study. Inclusion and Exclusion criteria were formulated. Informed consent was obtained from the parents. Clinical details, colonoscopy findings and histopathology reports were. A total of 135 cases were enrolled during our study period. Results were collated using Microsoft Excel ™.
© Ethical clearance was obtained from the institutional ethical committee.

Results

We found that the diagnosis of IBD was much more specific than expected with good sensitivity when data was matched between Macroscopy and Microscopy

Conclusion

• It is our standard practice to do colonoscopic biopsies from 7 areas (terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum) of the colon to exclude microscopic colitis which may be missed by the endoscopist or marked as ‘normal’.
• Microscopic findings are considered as ‘Gold standard’ in the diagnosis of IBD and we envisage that it will remain the gold standard in the many next decades to come
• Our data of sensitivity and sensitivity of the microscopic findings inclined the relevance of colonic mucosal biopsies in children with a normal-appearing mucosa and also the need to analyse every segment of the colon to diagnose IBD that may masquerade as “normal” in children which will add burden to the family, society and health care system and more importantly to the child’s quality of life.

References

1. Manfredi, Michael A et al. “Good agreement between endoscopic findings and biopsy reports supports limited tissue sampling during pediatric colonoscopy.” Journal of pediatric gastroenterology and nutrition vol. 58,6 (2014): 773-8.
2. Altamimi, Eyad & Odeh, Yousef & Al-Quraan, Tuka & Mohamed, Elmi & Rawabdeh, Naif. (2022). Diagnostic and therapeutic outcomes of pediatric colonoscopies in Jordanian children. Journal of Pediatric and Neonatal Individualized Medicine. 11.

Introduction

Collagenous colitis (CC) is a debilitating, non-destructive inflammatory bowel disease (IBD) that causes intense watery, non-bloody diarrhoea. The abnormal immune response is thought to be initiated by deficient tolerance to commensal gut microbiota, and fecal sample analyses indicate similarities with classic IBD forms as ulcerative colitis and Crohn’s disease. Yet, the exact members of the microbiome that might trigger and maintain the disease remain unknown.

Aims & Methods

To identify primary microbial triggers of CC pathogenesis that could directly interact with intestinal epithelial and submucosal cells, we isolated subepithelial mucosa from CC and healthy control (Hc) formalin-fixed paraffin-embedded samples (n=7-10) by using a laser microdissection microscope (PALM MicroBeam LCM, Zeiss, Germany). Isolated nucleic acids were sequenced using shotgun metagenomics in a NovaSeq 6000 platform (Illumina, USA). Microbial communities were identified using MetaPhlan3/4, and microbial metabolic and molecular function pathways using Humann3.2 algorithms.

Results

Bray-Curtis and Jaccard similarity coefficients showed that CC subepithelial microbiome was similar to that from Hc samples. Still, further analyses indicated that microbial metabolic pathways and molecular functions could differ. Microbiota that was associated with CC included Anoxybacillus and Barnesiella, whereas microbiota associated with Hc comprised Bacteroides, Leuconostoc and Lactobacillus.

Conclusion

Mucosa-associated microbiota in CC did not significantly differ from healthy microbiota. However, our results point to a relation of CC with bacteria that form biofilms (Anoxybacillus) and affect the variability of colitis development (Barnesiella). Thus, validation and further follow-up of these results could help us identify CC triggers in the future.

References

Carstens A. The Gut Microbiota in Collagenous Colitis Shares Characteristics With Inflammatory Bowel Disease-Associated Dysbiosis. Clin Transl Gastroenterol. 2019 Jul;10(7):e00065

Disclosure

AM has received salary for consultancies from Tillotts Pharma AG, Ferring, Vifor and Dr Falk Pharma; speaker’s honoraria from Tillotts Pharma AG and Vifor. The remaining authors declare no conflicts of interest.

Introduction

Collagenous colitis (CC) is a form of microscopic colitis (MC), the others being lymphocytic colitis (LC), incomplete CC and incomplete LC (1). It is an inflammatory disease of the large bowel that causes chronic watery diarrhoea, abdominal pain, faecal incontinence, nightly defecation, and weight loss, resulting in significantly impaired quality of life (2). Incidence of MC has increased significantly during the past decades in some countries and the main reason for this increase is thought to be an enhanced disease recognition (3). The diagnosis of MC is challenging as it can only be diagnosed upon histological examination of colonic biopsies taken from normal or near normal appearing mucosa (1). Histological interpretation of biopsies involves subjective evaluation leading to inter-rater variability discrepancies in diagnosis and treatment plan. Deep learning-based assistance system can objectivise diagnostic key feature selection leading to minimisation of inter-rater variability and improvement of diagnostic accuracy.

Aims & Methods

The aim of this pilot study was to develop an algorithm for robust segmentation of light microscopy images of histological specimen slides (tissue slides) emphasizing key diagnostic features of CC.
Histological specimens were fixed with formalin, embedded in paraffin, cut into 3 µm sections, and stained with haematoxylin and eosin (H&E) for histological examination. Images were taken using OLYMPUS IX71 light microscope (x20 magnification) equipped with Q IMAGING EXI aqua camera at (1392 x 1040 pix.) resolution and 24-bit pixel encoding. Registered image pixel values were normalized in RGB colour space by histogram alignment using empty tissue-less areas using an algorithm described previously (4). Superpixel technique using Simple Linear Iterative Clustering algorithm (5) was used for initial segmentation of the images. All 1000 superpixels defined in each image were annotated by the expert, indicating ones containing thickened subepithelial collagen layer as the sought class among the others containing the rest of the tissue indicated as normal class. The feed – forward neural network (implemented in MatLab environment) was trained to classify superpixels using their normalized histogram bin-counts of the pixel values as a feature. Due to significant inequality in the data set, where the number of sought class superpixels was significantly smaller than the number of the remaining ones, the training set was formed by equalising it to the lowest class case’s value (18761). Only randomly selected cases of the bigger class were included in the training set.

Results

The proposed algorithm was tested on images from 5 treatment-naive patients with newly diagnosed CC. Patients' histological specimens were rated by an expert pathologist and 50 images were chosen (with changes characteristic of CC and without). The classification training process with extracted data set took 0.13 seconds on personal computer with an AMD Ryzen Threadripper 3970X 32-Core, 3.70 GHz processor and 128GB of RAM memory, epochs for training was set to 30 (after tests the model was not improving after 30 epochs) and data shuffling was set to every-epoch. The algorithm showed 0.807 accuracy, 0.801 sensitivity and 0.813 specificity.

Conclusion

The shown ability of deep learning algorithm to classify histology image segments can assist the diagnostic process of CC emphasizing thickened subepithelial collagen layer – the essential diagnostic feature.

References

1. Miehlke S, Guagnozzi D, Zabana Y, Tontini GE, Fiehn AMK, Wildt S, et al. European guidelines on microscopic colitis: United European Gastroenterology (UEG) and European Microscopic Colitis Group (EMCG) statements and recommendations. United European Gastroenterol J. 2020;
2. Verhaegh BPM, Münch A, Guagnozzi D, Wildt S, Cebula W, Diac AR, et al. Course of Disease in Patients with Microscopic Colitis: A European Prospective Incident Cohort Study. J Crohns Colitis. 2021;15(7):1174–83.
3. Weimers P, Ankersen DV, Lophaven S, Bonderup OK, Münch A, Løkkegaard ECL, et al. Incidence and Prevalence of Microscopic Colitis between 2001 and 2016: A Danish Nationwide Cohort Study. J Crohns Colitis. 2021;14(12):1717–23.
4. Petrolis R., Čižas P., Borutaitė V., Kriščiukaitis A. Method of fluorescence imaging for evaluation of membrane potential in cultured neurons using transmembrane voltage sensitive dye. Biomedical engineering 2011: Proceedings of International Conference. 14:16-19, 2011.

5. Achanta R, Shaji A, Smith K, Lucchi A, Fua P, Susstrunk S. SLIC Superpixels Compared to State-of-the-art Superpixel Methods. IEEE Transactions on Pattern Analysis and Machine Intelligence, Volume 34, Issue 11, pp. 2274-2282, May 2012