Introduction

Data evaluating the utility of Blue light Imaging (BLI) and Linked Color Imaging (LCI) in the diagnosis of gastric intestinal metaplasia (IM) and atrophic gastritis (AG) is limited.

Aims & Methods

We aimed to evaluate and compare the diagnostic accuracy of BLI and LCI without magnification for the detection of IM and AG.
Single centre prospective study involving consecutive patients aged ≥18 years undergoing diagnostic upper gastrointestinal endoscopy (UGIE), endoscopic follow-up of intestinal metaplasia or gastric cancer screening. Exclusion criteria: previous gastrectomy, contraindication to UGIE due to comorbidities, no gastric mucosal biopsies, refusal of consent. Endoscopy was initially performed with white light image (WLI), followed by BLI and LCI. Standardized photodocumentation of stomach was performed with WLI, BLI and LCI. Imaging features suggestive of IM: lavender color sign and whitish flat elevation with LCI, and light blue crest and white opaque substance with BLI. EGGIM and Kimura-Takamoto Classification (KTC) were applied when IM and AG were suspected. Systematic random biopsies of the antrum, incisura angularis and corpus along with targeted biopsies of suspicious gastric mucosal lesions were obtained. Histology was considered gold standard. Performance of endoscopic imaging in the detection of IM, AG and EGC was evaluated.
Initially, 134 patients were evaluated and 64 were excluded: previous gastrectomy-22, pending histology-20, non-BLI imaging-15, intolerance to UGIE-3, refusal of consent-1, esophageal stenosis-1 and contra-indication to biopsies-2. Final sample included 70 patients.
Qualitative data expressed as percentage were compared with Chi-square test. A p value of <0.05 was considered significant.

Results

Median age was 56 (19-86), with 49 (63%) female. There was family history of gastric cancer in 12(15%) and history of smoking in 35 (44%).
Histological AG was found in 15 (19%) and IM in 20 (26%) patients. WLI was suggestive of IM in 14(20%), confirmed histologically in 9 (64%). IM was suspected by LCI and BLI in 24 (34%) and 23 (32%) cases, confirmed by histology in 16 (67%) and 17 (74%), respectively.
WLI classified 56 (71%) as EGGIM 0 and after LCI and BLI, 10 (18%) and 8 (15%) of these cases had EGGIM 1 or 2. In 10 patients, EGGIM 1-2 with WLI, only 1 was upgraded to EGGIM 3-4 with LCI and BLI. In 3 (4%) EGGIM 3-4 with WLI, after LCI and BLI,1 had extensive IM (EGGIM 6). Among 19(24%) patients EGGIM 1-2 with LCI, 3(16%) had EGGIM 0 with BLI.
Atrophy was suspected by WLI and LCI in 9(12%) and 15(21%) patients, confirmed by histology in 6(67%) and 8(53%) cases, respectively. According to KTC, 5 (6%) were classified as C1, 2 (3%) as C2 and 4 (5%) as O3 with WLI. With LCI images, 8 (10%) were classified as C1, 3(4%) as C2 and 4(5%) as O3. The sensitivity (Sens), specificity (Spec), accuracy, positive predictive value (PPV), negative predictive value (NPV) of WLI, BLI and LCI in detecting AG and IM are shown in table 1.


Table 1. Sens, Spec, accuracy, PPV and NPV in detecting AG and IM with WLI, LCI and BLI.

Conclusion

Both BLI and LCI are promising advanced endoscopic imaging techniques with BLI having higher accuracy than LCI in detection of IM.

References

1. Chen H, Liu Y, Lu Y, Lin X, Wu Q, Sun J, et al. Ability of blue laser imaging with magnifying endoscopy for the diagnosis of gastric intestinal metaplasia. Lasers Med Sci. 2018 Nov 1;33(8):1757–62.
2. Ono S, Abiko S, Kato M. Linked color imaging enhances gastric cancer in gastric intestinal metaplasia. Vol. 29, Digestive Endoscopy. Blackwell Publishing; 2017. p. 230–1.
3. Ono S, Kato M, Tsuda M, Miyamoto S, Abiko S, Shimizu Y, et al. Lavender Color in Linked Color Imaging Enables Noninvasive Detection of Gastric Intestinal Metaplasia. Digestion. 2018 Nov 1;98(4):222–30.
4. Zhang G, Zheng J, Zheng L, Yu S, Jiang C, Lin W, et al. Gastric intestinal metaplasia assessment between linked color imaging based on endoscopy and pathology. Scand J Gastroenterol. 2021;56(1):103–10.
5. Shu X, Wu G, Zhang Y, Wang Y, Zheng Y, Guo Q, et al. Diagnostic value of linked color imaging based on endoscopy for gastric intestinal metaplasia: a systematic review and meta-analysis. Ann Transl Med. 2021 Mar;9(6):506–506.
6. Esposito G, Pimentel-Nunes P, Angeletti S, Castro R, Libânio D, Galli G, et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): A multicenter validation study. Endoscopy. 2019;51(6):515–21.

Introduction

Although endoscopic submucosal dissection (ESD) is established as first-choice treatment for early esophageal squamous cell carcinoma (ESCC) worldwide, most data on outcomes are derived from Asian studies. Therefore, we aimed to evaluate the short- and long-term outcomes of ESD for patients with early ESCC in a Western cohort.

Aims & Methods

In this retrospective cohort study, patients with early ESCC amendable for ESD were included in four tertiary referral hospitals in the Netherlands between 2012 and 2017. All procedures were performed by experienced endoscopists who were specifically trained in ESD. The decision for and choice of additional treatment following ESD was made on a per-patient basis. For this study, dedicated research fellows collected all relevant data by reviewing the electronic patients files. Data concerning long-term outcomes were checked with general practitioners or referral hospitals, when applicable. Outcomes included technical success, R0 resection (i.e. tumor-free lateral and vertical margins), curative resection (i.e. en-bloc radical resection with histology no more advanced than T1sm1, good differentiation and absence of lymphovascular invasion) and recurrence rates, as well as ESCC-specific and overall survival.

Results

We included 68 patients (34 males; mean age 69) with a median tumor size of 3cm (range 1-12) and circumferential extent of 50% (range 10-100), in whom ESD was technically successful in 66/68 patients (97%). While en-bloc resection was achieved in 64/66 technically successful ESDs (97%), R0 resection was accomplished in 54/66 patients (82%). Overall, a curative resection was achieved in only 34/66 patients (52%). Among the patients with a non-curative resection, 16/32 (50%) underwent additional treatment receiving either argon plasma coagulation for tumor-positive resection margins (n=1), selective lymph node dissection (n=1), definite chemoradiation therapy (n=4) or esophagectomy ± neoadjuvant chemoradiation therapy (n=10). Endoscopic surveillance was preferred in the other half of patients with a non-curative resection (16/32; 50%) based on significant comorbidities or patient choice. During a median follow-up of 66 months (p25-p75 43-88), 12/66 patients (18%) developed a local recurrence which could be treated endoscopically in most cases (10/12; 83%). Locoregional lymph node metastasis and distant metastasis were observed in 6 (6/66; 9%) and 3 (3/66; 5%) patients, respectively. A total of 30 patients (30/66; 45%) died during follow-up, of which the minority (7/30; 23%) was ESCC-related deaths. The 5-year overall and ESCC-specific survival probability were 64% (95% CI 53-76%) and 88% (95% CI 79-97%), respectively. More importantly, overall survival did not significantly differ between patients with and without curative resections (p = 0.69). In addition, no significant difference was seen for ESCC-specific survival between patients with or without additional treatment after a non-curative resection (p = 0.07).

Conclusion

In this Western cohort with long-term follow-up, the efficacy and safety of ESD for early ESCC was confirmed although the rate of non-curative resections was substantial. Irrespective of non-curative or curative resection, the long-term prognosis of these patients was limited mainly due to competing mortality. Considering additional treatment after a non-curative resection did not influence survival, the potential benefit of adjuvant therapy should be carefully balanced against the risk of dying from another cause than esophageal cancer on an individual basis.

Disclosure

C.N. Frederiks has received speaker's fee from Pentax Medical.
R.E. Pouw is a consultant for MicroTech, and has received speaker’s fee from Medtronic.
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.
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.

Clinical Case Summary

A 56-year-old male presented with postprandial vomiting and weight loss beginning three weeks after laparoscopic ulcerorraphy of a perforated pyloric ulcer. An abdominal CT showed marked gastric distension and upper GI endoscopy revealed gastric stasis and a fibrotic stenosis in the duodenal bulb in close relation with a suture stitch, only transposable with an ultra-slim gastroscope. Two sessions of balloon dilation (BD) until 20mm were performed one month apart with poor clinical/endoscopic improvement. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) was proposed to avoid surgical reintervention.
Using a standard gastroscope a 0.035´´guidewire was passed into the proximal jejunum allowing insertion of a 7-french nasobiliary drain. Jejunal distension was achieved through saline, iodate contrast and methylene blue infusion. The linear echoendoscope was used to identify a distended loop adjacent to the gastric wall and EUS-guided puncture with a 19G needle was accomplished. A 20x10mm lumen-apposing metal stent (LAMS) was deployed in distal gastric body. The flow of blue mixture to the lumen confirmed successful gastroenterostomy creation. The patient was hospitalized overnight and resumed oral feeding the day after the procedure. No symptom recurrence was observed and the gastroenterostomy remained patent during the 6 months of follow-up.
Gastric outlet obstruction (GOO) may result from several malignant and benign causes. Surgical gastroenterostomy, self-expandable metal stents (SEMS) and BD are standard therapeutic options. EUS-GE is emerging as an effective and minimally invasive alternative. EUS-GE presents high technical and clinical success with lower rates of adverse events and reduced need of reintervention when compared to surgery and other endoscopic therapies. In benign GOO, SEMS seems less adequate and BD often results in suboptimal outcomes. The authors exemplify the effectiveness of EUS-GE in a case of GOO associated with a benign condition.

References

Illustrative material:
- Endoscopic and fluoroscopic images of guidewire and nasobiliary drain passed into the proximal jejunum
- EUS image of jejunal distension previous to LAMS placement
- EUS image of LAMS placement
- Endoscopic and fluoroscopic images of LAMS in situ
- Endoscopic image of 6 months follow-up

Introduction

Dietary and lifestyle recommendations are the cornerstones of the treatment of GERD. However, the evidence of the efficacy of those recommendations is lacking. We performed a retrospective analysis of the GISTAR study¹ participants evaluating the symptoms of GERD and dietary and lifestyle parameters developing a tool for predicting GERD symptoms based on the aforementioned criteria.

Aims & Methods

The aim of the study was to analyse the factors pointing to GERD symptoms through the use of data mining and decision tree classifier.
Methods: GERD diagnosis was evaluated using a self-assessment questionnaire ². Dietary, demographic and lifestyle data were collected within the GISTAR study protocol¹. 3340 40-64 year old participants from the GISTAR study were included in the analysis. 1670 of them did not have GERD symptoms. 41 attributes describing demographic, lifestyle, and dietary habits were used for these respondents to induce a decision tree classification model using Orange Data Mining software³.

Results

Fried potatoes including French fries were the most predictive factor of GERD symptoms (65.3% with symptoms; 1516 from 2321), especially for females (82.6%; 1048/1228). This was more pronounced in the group who consumed sweets once per week (87.2%, 950/1090). In males, who consumed fried potatoes, the next most important factor was the consumption of sweets (46.3%, 431/930).
For participants who didn’t consume fried potatoes (14.6%; 147/1008), 1-3 cups of green tea (37.9%; 66/174) and male gender (71.4 % 20/28) were predictors of GERD symptoms.
The accuracy of the decision tree model was: sensitivity (74.8%), precision (75.6%), specificity (75.9%) and AUC (0.841%).

Conclusion

Fried potatoes, female gender and consumption of sweets are the risk factors predicting the diagnosis of GERD. None of the lifestyle factors were displayed as significant.

References

1. Leja M, Park JY, Murillo R, et al. Multicentric randomised study of Helicobacter pylori eradication and pepsinogen testing for prevention of gastric cancer mortality: the GISTAR study. BMJ Open 2017;7:e016999. doi: 10.1136/bmjopen-2017-016999
2. Jones R, Junghard O, Dent J, Vakil N, Halling K, Wernersson B, Lind T. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther. 2009 Nov 15;30(10):1030-8. doi: 10.1111/j.1365-2036.2009.04142.x. Epub 2009 Sep 8. PMID: 19737151.
3. Demsar J, Curk T, Erjavec A, Gorup C, Hocevar T, Milutinovic M, Mozina M, Polajnar M, Toplak M, Staric A, Stajdohar M, Umek L, Zagar L, Zbontar J, Zitnik M, Zupan B (2013) Orange: Data Mining Toolbox in Python, Journal of Machine Learning Research 14(Aug): 2349−2353.

Introduction

The Kimura-Takemoto's (KT) classification, the endoscopic assessment for the extent of gastric atrophy, has been recommended to useful risk marker of gastric cancer (GC) in Japan. In Western countries, recent studies suggest the endoscopic findings with narrow band imaging (NBI) according to the classification of endoscopic grading of gastric intestinal metaplasia (EGGIM) are useful markers for GC risk. However we reported that both KT and EGGIM are useful stratification method for the GC in Japanese, the association between KT and EGGIM is unknown.

Aims & Methods

This study is a post-hoc analysis of a multicenter prospective study for a histological and endoscopic risk for GC in 10 Japanese facilities (UMIN00027023). We assessed the KT classification with white-light endoscopy and EGGIM score with NBI endoscopy in all subjects. We also evaluated the histological findings using biopsy specimens according to the operative link for gastritis assessment (OLGA) and the operative link for gastric intestinal metaplasia (OLGIM). The biopsy specimens were taken randomly according to the updated Sydney system, not guided target biopsy with NBI. We evaluated the association between KT and EGGIM. We also analyzed the diagnostic ability for histological findings (OLGA/OLGIM) using receiver operating characteristic (ROC) analysis. In OLGA, OLGIM and EGGIM analysis, We assessed four points (lesser and greater curvatures of antrum and corpus), not included angularis because of a questionable diagnostic benefit.

Results

The 380 subjects (115 GC and 265 non-GC) were analyzed. The white-light endoscopy revealed that 99 patients were non to mild atrophy (C-0, C-1; low risk for GC), 104 were moderate atrophy (C-2,C-3; moderate risk) and 177 were extent atrophy (O-1, O-2, O-3; high risk) in KT classification. The NBI findings showed that 109 were low risk (score 0), 158 were moderate risk (score 1 to 4), 113 were high risk (score 5-8) in EGGIM score. The high risk group in KT classification had significant association with that of EGGIM score (odds ratio (OR) 4.3 [95% confidence interval (CI) 2.6-6.8]). The high risk group in KT classification showed significant relationship not only high risk group of histological atrophy (OLGA stage III/IV) with OR 5.5 [3.4-8.8], and also that of histological IM (OGIM stage III/IV) with OR 8.5 [4.5-16.0]. The area under the ROC curve of diagnostic ability for OLGA III/IV were 0.786 in KT and 0.769 in EGGIM. Also those of OLGIM IIII/IV were 0.761in KT and 0.734 in EGGIM.

Conclusion

Endoscopic assessments according to the Japanese traditional method (KT) and Western method (EGGIM) showed significant association. The KT classification associated with not only extent of histological atrophy but also extent of histological IM.

References

1. Kawamura M, Uedo N, Koike T,et al : Kyoto classification risk scoring system and endoscopic grading of gastric intestinal metaplasia for gastric cancer: Multicenter observation study in Japan. Dig Endosc 2022; 34: 508-516.
2. Kimura K, Takemoto T. An endoscopic recognition of the atrophic border and its significance in chronic gastritis. Endoscopy 1969; 1: 87–97.
3. Pimentel-Nunes P, Libânio D, Lage J et al. A multicenter prospective study of the real-time use of narrow-band imaging in the diagnosis of premalignant gastric conditions and lesions. Endoscopy 2016; 48 :723-730.
4. Esposito G, Pimentel-Nunes P, Angeletti S et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): a multicenter validation study. Endoscopy 2019; 51: 515-521.
5. Marcos, P.; Brito-Gonçalves, G.; Libânio, D.; Pita, I.; Castro, R.; Sá, I.; Dinis-Ribeiro, M.; Pimentel-Nunes, P. Endoscopic grading of gastric intestinal metaplasia on risk assessment for early gastric neoplasia: Can we replace histology assessment also in the West? Gut 2020; 69: 1762–1768.

Disclosure

All authors disclose no financial relationships relevant to this study