Introduction

There is limited data on the impact of sedation on cardio-cerebrovascular disease (CCD) adverse events after esophagogastroduodenoscopy (EGD) in patients with gastric cancer. We investigated the incidence rate, risk factors and the impact of sedation on CCD adverse events after surveillance EGD in patients with gastric cancer.

Aims & Methods

We performed a nationwide population-based cohort study using Health Insurance Review and Assessment Service databases from January 1, 2018 to December 31, 2020. Using a propensity score-matched analysis, the patients with gastric cancer were divided into two groups: sedative agent users and non-users for surveillance EGD. We compared the occurrence of 14-day CCD adverse events between the two groups.

Results

Of 103,463 patients with gastric cancer, newly diagnosed CCD adverse events occurred in 2.57% within 14 days after surveillance EGD. Sedative agent was used in 41.3% during the EGD. The incidence rate of CCD adverse events with non-sedation and sedation are 315.4/10,000 and 173.6/10,000, respectively. Propensity score matching based on confounding variables yielded 56,016 matched patients (28,008 pairs). Between sedative agent users and non-users, there were not significantly difference in the occurrence of 14-day CCD adverse events, cardiac adverse events, cerebral adverse events, and other vascular adverse events, respectively. (2.28% vs. 2.22%, P = 0.69; 0.86% vs. 0.93%, P = 0.42; 1.44% vs. 1.31%, P = 0.23; 0.74% vs. 0.84%, P = 0.20).

Conclusion

In a population-based, matched cohort study, sedation during surveillance EGD was not associated with CCD adverse events in patients with gastric cancer. These findings suggest that use of sedative agent may be considered in patients with gastric cancer during surveillance EGD without excessive concerns for CCD adverse events.

Introduction

Gastric cancer (GC) incidence based on the endoscopic Kyoto classification of gastritis has not been systematically investigated using time-to-event analysis. Therefore, we examined GC incidence in an endoscopic surveillance cohort.

Aims & Methods

This study was retrospectively conducted at the Toyoshima Endoscopy Clinic. Patients who underwent two or more esophagogastroduodenoscopies (EGDs) were enrolled. GC incidence was based on Kyoto classification scores, such as atrophy, intestinal metaplasia (IM), enlarged folds (EF), nodularity, diffuse redness (DR), and total Kyoto scores. Atrophy was classified using the Kimura-Takemoto classification. Non-atrophy and Closed I, Closed II and III, and Open I to III were scored as atrophy scores of 0, 1, and 2, respectively. IM scores of 0, 1, and 2 were defined as the absence of IM, IM limited to the antrum, and IM extending into the corpus, respectively. The absence and presence of EF were scored as 0 and 1, respectively. The absence and presence of nodularity were scored 0 and 1, respectively. DR scores of 0, 1, and 2 were defined as the absence of DR, mild DR and/or DR with partial regular arrangement of collecting venules (RAC), and severe DR without RAC, respectively. The endoscopists diagnosed the Kyoto classification scores on-site during the index EGD. Hazard ratios [HRs] adjusted for age and sex were calculated using a Cox hazard model. This study was approved by the institutional review board of the Yoyogi Mental Clinic (approval no. RKK227).

Results

A total of 6718 patients were enrolled (mean age 55.0 years; men 44.2%). Of them, 3754, 2264, 700 patients were in H. pylori uninfected, eradicated, and currently infected status, respectively. Patients were followed up for up to 5.02 years. The mean Kyoto classification scores for atrophy, IM, EF, nodularity, DR, and total Kyoto were 0.585, 0.284, 0.039, 0.026, 0.312, and 1.247, respectively. During the follow-up period, 37 GCs occurred in 34 patients. All GCs were superficial and within the submucosal depth. Lauren’s intestinal type made up 89.1% of GCs. The annual incidence rates of GC were 0.04%, 0.17%, and 0.73% for atrophy scores of 0, 1, and 2; 0.07%, 0.25%, and 1.10% for IM scores of 0, 1, and 2; 0.17% and 0.92% for EF scores of 0 and 1; and 0.06%, 0.55%, and 0.74% for DR scores of 0, 1, and 2, respectively. The annual incidence rate of GC was 0.19%. The GC incidence rates were 0.05, 0.07, 0.47, and 1.27%/year for the total Kyoto scores of 0-1, 2-3, 4, and 5-8, respectively. Multivariate analysis showed that Kyoto atrophy scores 1 (HR with score 0 as reference: 3.66, 95% confidence interval [CI]: 1.06-12.61), 2 (11.60, 3.82-35.27), IM score 2 (9.92, 4.37-22.54), EF score 1 (4.03, 1.63-9.96), DR scores 1 (6.22, 2.65-14.56), and 2 (10.01, 3.73-26.86) were associated with GC incidence, whereas nodularity scores were not. The total Kyoto scores of 4 (HR with total Kyoto scores 0-1 as reference: 6.23, 95% CI: 1.93-20.13) and 5-8 (16.45, 6.29-43.03) were more likely to develop GC, whereas the total Kyoto scores 2-3 were not, as shown in table. The HR of the total Kyoto score for developing GC per 1 rank was 1.75 (95% CI: 1.46-2.09, P<0.001).

Total Kyoto score	Gastric cancer patients, no.	Non-gastric cancer patients, no.	Hazard ratio	95% confidence interval	P value
0-1	6	4615	Reference
2-3	2	1008	1.12	0.22-5.63	0.887
4	6	473	6.23	1.93-20.13	0.002
5-8	20	588	16.45	6.29-43.03	<0.001

Conclusion

A high total Kyoto score (≥ 4) was associated with GC incidence. The endoscopy-based diagnosis of gastritis can stratify GC risk.

Disclosure

All authors disclosed no personal conflicts of interest.

Introduction

Eosinophilic esophagitis (EoE) is a chronic, allergic inflammatory disease of the esophagus. Major adverse cardiovascular events (MACE) have been associated with diseases of chronic inflammation. Data on MACE from large population-based cohorts of biopsy-proven EoE are lacking.

Aims & Methods

The aim of this study was to investigate the association between EoE and MACE. It included all Swedish adults with EoE (1990-2017) without a record of previous cardiovascular disease (CVD) (n=1,546, with follow-up until 2019). EoE was defined from prospectively recorded esophageal histopathology reports from all Swedish pathology departments (n=28) in the Epidemiology Strengthened by Histopathology Reports in Sweden (ESPRESSO) cohort. Individuals with EoE were matched with up to five general population reference individuals (n=7,281) for age, sex, calendar year and county without EoE or CVD. Multivariable-adjusted hazard ratios (aHRs) for MACEs (any of ischemic heart disease, congestive heart failure, stroke and cardiovascular mortality) were calculated using Cox proportional hazards models. In secondary analyses, individuals with EoE were compared to their siblings to account for residual confounding.

Results

The majority of individuals with EoE were male (75%), and the median age at EoE diagnosis was 37 years (IQR 19-51). Over a median of 6.0 (IQR 4.6-8.0) years of follow-up, 65 (4.2%) MACE events were observed in patients with EoE and 225 (3.1%) in reference individuals, corresponding to 6.4 vs. 4.7 events per 1,000 person-years (incidence rate difference: 1.7, 95%CI=0.0-3.4), respectively. No significantly higher overall risk (aHR=1.14, 95%CI=0.86-1.51) of MACE outcomes. No significant differences between age, sex and follow-up time were observed. When adjusting for relevant CVD medication and sibling comparison, results were similar.

Table 1 Incidence Rates, Absolute Rate Differences and Hazard Ratios for incident Major Adverse Cardiovascular Events in patients with Eosinophilic Esophagitis compared to general population reference individuals 1990-2019
		Reference individuals	EoE
		N=7 281	N=1 546
	MACE outcomes*
	Incident events (%)	226	65
	Incidence rate per 1000 py (95%CI)	4.7 (4.1-5.4)	6.4 (4.9-8.1)
	Absolute rate difference per 1000 py (95%CI)	0 (ref.)	1.7 (0-3.4)
	Unadjusted HR# (95%CI)	1 (ref.)	1.37 (1.04-1.80)
	Adjusted HR (95%CI)	1 (ref.)	1.14 (0.86-1.51)

CI, confidence interval; EoE, eosinophilic esophagitis; HR, hazard ratio; MACE, major adverse cardiovascular events; py, person-years

^*Includes ischemic heart disease, congestive heart failure, stroke and cardiovascular mortality.
^#Adjusted for age, sex, calendar year, county of residence at index date, country of birth (Nordic country or other), educational level (compulsory school, upper secondary school or college/university), ≥1 metabolic disease (diabetes, obesity, hypertension or dyslipidemia), chronic kidney disease, atopic dermatitis, celiac disease and chronic respiratory disease (chronic obstructive pulmonary disease or asthma) diagnosis.

Conclusion

Individuals with biopsy-proven EoE had no increased risk of MACE outcomes compared to general population or sibling comparators. The absence of any association with MACEs in our study may be reassuring for patients with EoE.

Disclosure

Dr. Forss has served as a speaker and advisory board member for Janssen corporation. Dr. Uchida is a medical advisor for Sanofi-Regeneron and AstraZeneca. Dr. Roelstraete has no conflicts of interest. Dr. Ebrahimi has served as advisory board member for Boehringer Ingelheim. Dr. Garber do not have any conflicts of interest to declare related to this study. Dr. Sundström reports stock ownership in Anagram kommunikation AB and Symptoms Europe AB outside the submitted work. JFL has coordinated an unrelated study on behalf of the Swedish IBD quality register (SWIBREG). This study received funding from Janssen corporation. JFL has also received financial support from MSD to develop a paper reviewing national healthcare registers in China, and has ongoing discussions with Takeda about a celiac disease project.

Introduction

Early gastric cancers (EGC) are confined to the gastric mucosa and submucosa irrespective of lymph node metastases. The proportion of gastric cancers diagnosed at an early stage varies considerably between Western countries but is low compared to countries with a screening program for gastric cancer. The majority of EGC patients have been treated with surgical resection including standard lymphadenectomy in Western countries. In contrast, Asian countries have treated larger proportions of EGC with endoscopic submucosal dissection (ESD) followed by estimation of risk of lymph node metastases based on histopathological characteristics. The aim of the present study was to characterize EGCs in Central Norway before ESD was an available treatment option. Furthermore, we aimed to assess histopathological characteristics associated with lymph node metastases and long-term survival in our cohort of EGC patients.

Aims & Methods

The study was a retrospective population-based study using patients identified from the Norwegian Cancer Registry and Norwegian Patient Registry (NPR). The annual number of gastroscopies was retrieved from NPR. 1205 patients were diagnosed with gastric cancer from 2001 to 2016, a period when gastrectomy with a modified D2 resection was standard treatment. In accordance with Western diagnostic criteria, patients with carcinoma in situ were not included. Patients who received neoadjuvant chemotherapy and histologically ypT0 or ypT1 were excluded to study only chemo naïve (true) EGC. Histopathological specimens were re-examined and eCura score risk stratification was calculated. Finally, long-term survival and cause of death were assessed.

Results

Of the 1205 patients with gastric cancer 88 (7.3%) had EGC. The number of gastric cancers declined (p=0.010), but the relative proportion of EGC was unchanged during the study period despite a doubling of annual gastroscopies at a national level during the study period. Patients with EGC had median age 77 (43-91) years vs. 74 (21-99) years for non-EGC controls. EGCs were more often of the Lauren intestinal type (p<0.001) and were more often localized in the antrum or corpus. Eighty-three patients underwent surgical resection and eight (9.0%) of these had N+ disease. An eCura score could be calculated for 79 EGCs. A significant proportion (9.4%, n=5) of the patients with a low risk eCura had lymph node metastases, whereas further exclusion of tumours with histological ulceration or SM2 invasion in a post-hoc analysis identified a N0 cohort (n=36). Recurrence of cancer was diagnosed in seven (8.1%) patients after a median time of 29 (14-124) months from the EGC diagnosis. Fifty-five (62.5%) EGC patients died during follow-up, whereof 43 (78.2%) deaths were unrelated to EGC, seven (12.7%) died of cancer recurrence and five (9.1%) died from postoperative complications. Median survival for EGC patients was 117.1 months (95% CI 99.8-134.3) and 5-year overall survival 75%. Approximately half of deaths related to cancer recurrence (3 of 7) occurred more than five years after the EGC diagnosis.

Conclusion

EGCs constituted a minor but constant proportion of gastric cancers despite a considerable increase in gastroscopies. In this historic cohort with formal gastric resection for EGC, 9.0% had pN+ disease. Low risk eCura score alone was insufficient to predict pN0 disease whereas additional exclusion of patients with histological ulceration or SM2 infiltration identified a pN0 cohort. Long-term follow-up of more than five years is needed to assess EGC related mortality.

Introduction

Although an effective and relatively safe procedure, bleeding complications often occur after gastric endoscopic submucosal dissection (ESD). We aimed to comprehensively evaluate the risk factors of post-procedural bleeding following gastric ESD.

Aims & Methods

This study was designed as a nationwide, population-based, retrospective study utilizing the Korean National Health Insurance Service database, comprising patients who underwent gastric ESD for gastric cancer or adenoma from November 2011 to December 2022. Operational definitions were created to identify the target population and post-procedural bleeding using the diagnosis and procedure code, which underwent validation. We established operational definitions to identify the target population and post-procedural bleeding by utilizing diagnosis and procedure codes, which underwent validation. The risk factors analyzed included age, sex, hospital volume, socioeconomic status (SES), histology, lesion numbers, comorbidities, and medication usage.

Results

During the study period, there were 191,932 procedures conducted on 175,779 patients, resulting in 9921 cases of bleeding events. Several factors were associated with increased post-ESD bleeding risk. Following multiple logistic regression, relevant factors with adjusted odds ratios (aORs) were identified. These factors included young age (aOR: 0.990, 95% CI 0.987-0.992), male sex (aOR: 1.377, 95% CI 1.311-1.448), low-volume center compared to high-volume center (aOR: 1.289, 95% CI 1.022-1.621), medical aid compared to the top 25% SES (aOR: 1.307, 95% CI 1.188-1.440), higher Charlson comorbidity index (aOR: 1.040, 95% CI 1.026-1.054), gastric cancer (aOR: 1.369, 95% CI 1.307-1.434), and multiple lesions (aOR: 1.144, 95% CI 1.032-1.267). Furthermore, bleeding risk was significantly higher in groups with several comorbidities and antithrombotic agent users, particularly showing Notably high aORs in groups with renal failure (aOR: 2.086, 95% CI 1.909-2.278), warfarin (aOR: 2.641, 95% CI 2.219-3.143), direct oral anticoagulants (aOR: 2.519, 95% CI 2.220-2.859), and antiplatelet combinations (aOR: 2.073, 95% CI 1.783-2.410).

Conclusion

This study revealed various factors associated with increased bleeding risk after gastric ESD using a large cohort, which could be an important issue in terms of risk stratification and personalized treatment.

Introduction

Helicobacter pylori (H. pylori) infection is the primary risk factor for gastric cancer (GC), and although the risk decreases after H. pylori eradication (HPE), it remains elevated. Understanding the impact of lifestyle factors on post-HPE GC risk is crucial for prevention strategies.

Aims & Methods

The aim of this study is to clarify the effect of lifestyle on GC risk after HPE.
Using the Korean National Health Insurance Services (NHIS) database, adult individuals who claimed HPE between 2010 and 2016 were analyzed. The adjusted hazard ratios (aHR) for GC were analyzed according to the lifestyle status including smoking (never; light [<10PY]; moderate [10-20PY]; heavy [≥20PY]), drinking (non; mild [<30g/day]; heavy [≥30g/day]), and abdominal obesity (yes; no) were evaluated by using Cox proportional hazard model under control with potentially related factors.

Results

During a median follow-up of 6.7 years, 9,754 individuals were diagnosed with GC. Moderate (aHR 1.12, 95% confidence interval [CI] 1.04–1.20) and heavy smokers (aHR 1.34, 95% CI 1.27–1.42) had a greater risk of GC, with a dose-response relationship. Heavy drinkers had an increased risk (aHR 1.23, 95% CI 1.15–1.32), and those with abdominal obesity had a slightly elevated risk (aHR 1.11, 95% CI 1.06–1.15). Subgroup analyses showed that individuals aged ≥ 55 years were more affected by unhealthy lifestyles, and males had a stronger association between smoking and GC risk compared to females (p-for-interaction 0.02).

Conclusion

Unhealthy lifestyle factors, such as smoking, alcohol consumption, and abdominal obesity, are major risk factors for post-HPE GC. These findings underscore the importance of addressing lifestyle factors during the post-eradication period to reduce GC risk.

Disclosure

The authors disclose that they have nothing to disclose.

Introduction

For gastric neoplasms, endoscopic submucosal dissection (ESD) is a well-known therapeutic option. Our study aimed to investigate the influence of procedural volume on the outcome of gastric ESD.

Aims & Methods

Patients who received ESD for gastric cancer or adenoma from November 2011 to December 2017 were identified using the Korean National Health Insurance Service database. The diagnostic and procedure codes were combined to develop operational definitions, which were validated using individual hospital medical record data. Outcomes included bleeding, perforation, pneumonia, 30-day mortality, composite outcome comprising all these adverse outcomes, and additional resection. Hospital volume was categorized into four groups: very high-, high-, low-, very low-volume hospitals (VHVH, HVH, LVH, VLVH). The outcomes of ESD were compared in relation to hospital volume.

Results

A total of 89,780 patients underwent 95,411 procedures during the research period. There were 5,607 composite events, which included 5,098 bleeding, 601 perforation, and 712 pneumonia cases, respectively. Additional resection occurred within 180days in 7,900 cases. There were significant differences in ESD-related adverse outcomes among the four hospital volume categories. Multiple logistic regression revealed that VHVH, HVH, and LVH were associated with lower risk of a composite outcome, when compared to VLVH (OR, 0.627, 95% CI, 0.445-0.885, p=0.008; OR, 0.542, 95% CI, 0.406-0.722, p<0.001; OR, 0.697, 95% CI, 0.548-0.886, p=0.003). Similar tendencies were also shown for bleeding, perforation, and pneumonia, although this was not evident in additional resection.

Conclusion

The procedural volume at an institutional level was closely associated with clinical outcomes, such as bleeding, perforation, pneumonia, and a composite outcome, in patients with ESD for gastric cancer or adenoma. The outcomes of gastric ESD should be closely and systemically monitored in a nationwide level, to ensure the quality of procedures and the safety of patients.