Introduction

Recent research from the Netherlands, the United States, and Korea suggests that individuals who receive a positive result on the fecal immunochemical test (FIT) may be at a higher risk of developing gastroesophageal cancer (GEC) within the following 36 months. However, the associations reported in these studies may be biased due to differences in age and sex between the FIT-positive and FIT-negative groups and other confounding factors.

Aims & Methods

We aimed to evaluate the association between FIT results and the risk of GEC in a matched cohort by age and sex. Additionally, we assessed the cost-effectiveness of a one-time Esophago-Gastro-Duodenoscopy (EGD) for individuals with positive FIT results.. We created a matched cohort of individuals aged 50 to 75 who underwent FIT testing at Clalit Health in Israel between June 2016 and June 2019. For each FIT-positive individual, we matched three FIT-negative individuals based on age, sex, and H. pylori status. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were utilized to evaluate the association between a positive FIT result and the risk of GEC within 36 months. We calculated the incremental cost-effectiveness ratio (ICER) for a one-time EGD at $400 in individuals who tested positive for FIT. Screening is considered cost-effective if the ICER is below $50,000.

Results

The primary cohort included 483,710 individuals, while the matched cohort comprised 151,500 individuals (47.6% female, median age 62.5 years). During the follow-up period, 202 cases of GEC occurred: 0.2% (64/38,575) among FIT-positive individuals and 0.1% (138/112,925) among FIT-negative individuals, adjusted HR 1.39 (95% CI 1.03-1.87). Age, male sex, H. pylori exposure, country of birth, proton-pump inhibitor usage, smoking status, and anemia were all significantly associated with an increased risk of gastric cancer. A one-time EGD has been determined to be a cost-effective option in a range of ages and rates of localized disease at the time of EGD.

Conclusion

This matched cohort study suggests that individuals with a positive FIT may have an increased risk of GEC, which occurs at an overall rate of 0.2% within 36 months. A one-time EGD priced at $400 can be cost-effective in many scenarios.

Disclosure

NONE

Introduction

Lynch syndrome (LS) is a hereditary condition associated with an increased risk of early colorectal cancer (CRC), due to mutations in DNA mismatch repair (MMR) genes, accounting for 3-5% of all CRC. High-definition screening colonoscopies in specialized centers reduce CRC mortality in this setting.

Aims & Methods

We conducted a clinical audit in a large cohort of these patients, ultimately to enhance the quality of care provided. We performed a retrospective evaluation of the clinical characteristics and risk factors of LS patients under surveillance at our reference center. CRC surveillance program includes colonoscopy every 2 years, starting at ages 20–25 for MLH1/MSH2 carriers and 30–35 for MSH6/PMS2 carriers. We further analyzed compliance to surveillance protocol and its clinical outcomes – our primary endpoint was mortality rate due to CRC and secondary endpoints were time to first advanced colorectal lesion and CRC staging at diagnosis.

Results

A total of 508 patients were included (44% MSH2, 23% MLH1, 20% MSH6, and 13% PMS2). The mean age at surveillance initiation was 44.4 years, with 35.6% starting after the diagnosis of a Lynch syndrome-associated neoplasia. The mean surveillance duration was 5.6 years. Each patient underwent an average of four colonoscopies, with 50% performed within the recommended surveillance intervals.
During the follow-up period, 35 patients were diagnosed with CRC, with a mean time to first advanced colorectal polyp of 3.7 years and for the first CRC diagnosis of 4.8 years. Having any colonoscopy outside the established interval was not associated with higher CRC incidence (p = 0,647). CRC cases diagnosed prior to surveillance initiation (n=143) were more advanced (58.1% stage ≥ II) and were treated with segmental colectomy in 80% of cases. In contrast, CRC cases diagnosed during surveillance (n=48) were detected at earlier stages (64.6% Tis/T1) and managed with endoscopic resection (29%) or total colectomy (56%) (p < 0.001).
The incidence of CRC was higher in MLH1/MSH2 carriers compared to MSH6/PMS2 carriers (36% vs. 22%, p = 0.0020). The mean age at first CRC diagnosis was 45.6 years for MLH1/MSH2 carriers and 49.9 years for MSH6/PMS2 carriers (p = 0.053). The CRC-related mortality rate was 0.6% (n=3), all cases diagnosed before surveillance initiation.

Conclusion

Although adherence to the CRC surveillance program in LS patients can be optimized, our findings underscore its importance in specialized reference centers. Surveillance was associated with earlier CRC detection, less invasive therapeutic approaches, and reduced CRC-related mortality. Our results also show a lower incidence of CRC and an higher age at first CCR diagnosis in MSH6/PMS2 carriers, strengthening the personalized surveillance recommendations dependent on gene specificities.

References

Castillo-Iturra, J., Sánchez, A. and Balaguer, F. (2024) ‘Colonoscopic surveillance in Lynch Syndrome: Guidelines in perspective’, Familial Cancer [Preprint]
del Carmen, G. et al. (2023) ‘Colorectal surveillance outcomes from an institutional longitudinalcohort of Lynch syndrome carriers’, Frontiers in Oncology, 13
Kastrinos, F. et al. (2021) ‘Gene-specific variation in colorectal cancer surveillance strategies for Lynch syndrome’, Gastroenterology, 161(2)

Introduction

Colorectal cancer surveillance recommendations for individuals with Lynch Syndrome (LS) differ between professional associations and the data on interval colorectal cancer (I-CRC) and interval advanced polyps (I-AP) are limited. We aimed to measure the rate of I-CRC and I-AP within a surveillance program.

Aims & Methods

Retrospective study involved individuals with LS who participated in CRC surveillance program at Clalit Health hospitals, Israel. The main outcomes were the rates of I-CRC and I-AP ≤36 months, categorized by 12-month intervals. Included only colonoscopies with adequate preparation. I-CRC and I-AP (≥10 mm or containing high-grade dysplasia or villous histology) were defined as interval advanced neoplasia (I-AN).

Results

The cohort included 342 individuals, 52.3% females, with a median age at data analysis of 49.0 (IQR 37.7-64). At interval ≤ 12 months, there were 7 cases of I-CRC [6/142 (4.2%) of MSH2; 1/46 (2.2%) of MLH1] and 13 cases of I-AP (10/142 (7.0%) of MSH2, 2/46 (4.3%) of MLH1, 1/136 (0.7%) of MSH6]. At 12-24 months, there were 3 cases of I-CRC [2/142 (1.4%) of MSH2, 1/136 (0.7%) of MSH6] and 10 cases of I-AP [8 /142 (5.6%) of MSH2, 1/46 (2.2%) of MLH1, 1/136 (0.7%) of MSH6]. At 24-36 months, there were 3 cases of I-CRC [2/142 (1.4%) of MSH2, 1/18 (5.6%) of PMS2] and 4 cases of I-AP [1 /142 (0.7%) of MSH2, 3/136 (2.2%) of MSH6]. Of all I-CRC, four were diagnosed at stage 3 [4/342 (1.2%)], all at interval ≤24months [3-MSH2, 1-MSH6]. Increasing age and path_MSH2 were significantly associated with I-AN.

Conclusion

Extending surveillance colonoscopy intervals could result in significant rates of I-CRC and I-AP. Diagnosis of I-CRC at advance stage can occur at interval less than 24 months.

Clinical Case Summary

Aim: Abdominal Cocoon syndrome is the complete or partial wrapping of the abdominal organs with a membrane structure. Diagnosis can be made by laparoscopy. Patients mostly present with acute abdomen symptoms due to intestinal obstruction.
Case: 27-year-old male patient had recurrent abdominal pain for 12 years and was diagnosed with Behçet's disease and started on treatment. The patient’s abdominal pain increased in the last 6 months. He was followed up 4 months ago with suspected ileus, recovered with symptomatic treatments. A colonoscopy was performed and aphthous ulcers were detected in the terminal ileum and linear ulcers in the sigmoid colon. Tuberculosis,vasculitis and amyloid was excluded in the biopsies .With the preliminary diagnosis of Crohn's disease, 5-ASA and Azathioprine were started, and when no clinical response was obtained, Adalimumab was switched. The patient, who had no history of alcohol, cigarette use or any surgery, stopped all of her medications because she had not had symptomatic improvement for a long time, and was relieved by vomiting voluntarily. Her family history included rheumatoid arthritis in her sister and ulcerative colitis in her cousin. In the physical examination, there was no pathology other than widespread tenderness in the abdomen. In the ultrasonography; the small intestine walls were seem to be slightly edematous and retracted. Enteroscopy was completely normal. In the CT-Enterography, it was thought that it could be an "abdominal cocoon", so a laparotomy was performed and the diagnosis. The small intestines were freed from the fibrotic bands. The patient did not develop any post-operative complications, and her abdominal pain completely resolved after the operation.
Conclusion: Abdominal cocoon syndrome should be kept in mind as a very rare disease that can cause diagnostic confusion, remain undiagnosed for a long time, and cause unnecessary treatments, and can be fixed totally with surgical treatment.

Introduction

​Post-ERCP pancreatitis (PEP) is still the most common major complication of ERCP despite technical advancements and meticulous patient selection. The efficacy of the existing techniques is conflicting.

Aims & Methods

We aimed to compare the efficacy of peripapillary epinephrine injection in combination with rectal diclofenac for the prevention of PEP in high-risk patients .
Methods Between January 2023 and August 2023, a total of 378 patients were enrolled. We calculated that 189 patients in each group (rectal diclofenac – Group A and peripapillary epinephrine injection plus rectal indomethacin – Group B) would suffice based on a previous study by our group (α:0.05, 80% power). Patients with a non-naive papillae, ampulla of Vater cancer, biliary pancreatitis, altered anatomy, pregnancy, and pancreatic diseases such as chronic pancreatitis were excluded. Patients were assigned in a 1:1 simple randomized fashion. The primary outcome was the rate of PEP. Secondary outcomes were the rate of hyperamylasemia and rates of other adverse events.

Results

​Demographic characteristics, indications, and procedure-related risk factors were similar between the groups. The overall success rate of selective cannulation was 99.2% in Group A and 99.3% in Group B (p=0.997). PEP occurred in 9 of the 189 (4.8%) patients in Group A and 2 of the 189 (0.5%) patients in Group B. All cases were mild and managed conservatively. The rate of post-procedure 4th-hour hyperamylasemia was significantly higher in Group A (19% vs 5%, p<0.001). Postsphincterotomy-related bleeding developed in 5 patients in Group A (2.64%) but none of the patients had bleeding in Group B. Stapfer type-II perforation occurred in two patients in each group. No major cardiac adverse events-related to epinephrine injection were detected in Group B.

Conclusion

Compared to rectal diclofenac, peripapillary epinephrine injection significantly reduced the incidence of PEP, post-procedure hyperamylasemia, and sphincterotomy-related bleeding.