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Introduction

Functional lumen imaging probe (FLIP) is an adjunctive test indicated in the evaluation of the esophagogastric junction and esophageal motility, especially in those with an inconclusive diagnosis during esophageal high-resolution manometry (HRM) such as esophagogastric junction outflow obstruction (EGJOO) or absent contractility per Chicago Classification v4.0 (CCv4.0), and in patients that are unable to perform a HRM.

Aims & Methods

Our study aimed to evaluate the efficacy of the FLIP procedure in establishing diagnosis in a cohort of patients who underwent assessment due to dysphagia, who were either diagnosed with EGJOO or absent contractility according to CCv4.0, or were unable to perform HRM.
Our study population consisted of patients who were evaluated by FLIP due to dysphagia between March 2023 and April 2024. All patients had completed an upper gastrointestinal endoscopy and HRM per CCv.4.0. Additionally, most patients underwent further evaluation with a timed barium esophagram (TBE).

Results

We included 58 patients (52% female, median age 62.5 years) in the study cohort. Most patients (67.24%) referred to the FLIP procedure had a prior failed attempt to perform a HRM or had an inadequate test. 46.5 % of all patients had an abnormal FLIP procedure. Of those, 15 patients had EGJOO with absent contractile response compatible with achalasia (55.5 %) and another 5 patients had a confirmed diagnosis of EGJOO on FLIP (18.5 %). Of those patients who had a FLIP procedure performed due to abnormal esophageal manometry findings per CCv4.0 (n=19), 8 patients were diagnosed with EGJOO (42.1%), 5 had absent contractility (26.3 %), 4 had a hypercontractile esophagus (21 %) and 2 had ineffective esophageal motility (10.5 %). 60 % of the patients diagnosed with EGJOO by FLIP were offered an achalasia-targeted treatment (pneumatic dilation (6), POEM (4), Heller myotomy (1) and Botox injection (1)), while the rest were treated conservatively. Additionally, TBE was performed in 55% of patients with an abnormal FLIP procedure and the result was pathological in about half of them. Furthermore, in 70% of patients the diagnosis of EGJOO during FLIP was correlated to a delayed esophageal clearance on TBE.

Conclusion

FLIP is a useful tool in the assessment of dysphagia in patients who have an inconclusive diagnosis per CCv4.0, either EGJOO or absent contractility, as well as in patients who are unable to perform a HRM.

Disclosure

NO CONFLICT OF INTEREST

THE EFFICACY OF THE FUNCTIONAL LUMEN IMAGING PROBE (FLIP) PROCEDURE IN A COHORT OF PATIENTS WITH DYSPHAGIA

Carla Maradey-Romero 1, Ahmad Albshesh 1, Olga Saukhat 2, Dan Carter 1

1 Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel|||School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv, Israel

2 School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv, Israel|||Department of Radiology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel

Conference

UEG Week Vienna 2024

Topics

Oesophagus

Submission format

Abstract

Session

OESOPHAGEAL, GASTRIC AND DUODENAL (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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TRANSFORMING RADIATION PROCTOPATHY MANAGEMENT: REAL-WORLD EVIDENCE ON PURASTAT FROM A UK TEACHING HOSPITAL

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Introduction

Radiation proctopathy (RP) is a common late complication of pelvic radiotherapy, affecting up to 20% of patients treated for pelvic malignancies. It manifests as rectal bleeding, anaemia, urgency, and diarrhoea, significantly reducing quality of life. Argon Plasma Coagulation (APC) remains the standard endoscopic therapy but has notable limitations, including high recurrence rates, the need for multiple sessions, and risks such as ulceration and perforation.
PuraStat, a synthetic self-assembling peptide hydrogel, offers an innovative alternative by creating a transparent matrix that promotes haemostasis and mucosal healing without thermal injury. While small series have shown benefit, robust real-world evidence is lacking.

Aims & Methods

We assessed real-world outcomes of PuraStat in RP at a UK tertiary centre (2023–2024). Consecutive patients with chronic radiation-induced rectal bleeding were included and treated by a single endoscopist. Patients were stratified into two cohorts:
1. De novo PuraStat – no prior APC (n=50)
2. APC→PuraStat – persistent or recurrent symptoms despite APC (n=50)
PuraStat was applied during flexible sigmoidoscopy, either as monotherapy or following APC. The primary outcome was resolution or improvement of rectal bleeding. Secondary outcomes included the number of repeat endoscopic interventions within 6 months and treatment-related adverse events.

Results

A total of 100 patients were included (median age: 74 years, range 64–85; 52% male). Most had prostate or gynaecological cancer treated with pelvic radiotherapy.
- De novo PuraStat (n=50): All achieved symptomatic relief, with marked bleeding reduction and endoscopic improvement. Follow-up sigmoidoscopy showed mucosal healing or mild residual proctitis in 92%. Mean repeat sessions: 1.3 (range 0–3) over 6 months.
- APC→PuraStat (n=50): These patients had undergone a median of 3 APC sessions with limited success. PuraStat led to complete symptom control in all cases, reducing the need for frequent interventions (mean: 1.5 sessions over 6 months).
No adverse events (e.g., perforation, infection, severe pain) were reported in either group. Patients with severe radiation-associated vascular ectasia (RAVE) and refractory bleeding demonstrated excellent response to PuraStat.

Conclusion

This large real-world series demonstrates that PuraStat is a safe, effective, and well-tolerated therapy for radiation proctopathy, whether used as first-line treatment or following APC failure. It provided rapid and sustained bleeding control, significantly reduced the need for repeat endoscopic interventions, and promoted mucosal healing without the risks associated with thermal therapies. Importantly, PuraStat showed consistent efficacy even in patients with severe radiation-associated vascular ectasia (RAVE) and those refractory to conventional modalities, highlighting its role as both a frontline and salvage option. These findings position PuraStat as a valuable addition to the therapeutic armamentarium for radiation-induced rectal bleeding. Larger prospective, multicentre studies and cost-effectiveness analyses are warranted to validate these results and define its optimal place in treatment algorithms.

Table 1: Treatment Outcomes by Group

Group	n	Symptom Relief	Mean Repeat Sessions
De novo PuraStat	50	100%	1.3
APC→PuraStat	50	100%	1.5

References

1- White K, Henson CC. Endoscopically delivered PuraStat for the treatment of severe haemorrhagic radiation proctopathy: Service evaluation of a new endoscopic treatment for a challenging condition. Frontline Gastroenterol. 2021;12(1):37–42. doi:10.1136/flgastro-2020-101735
2-Van de Wetering FT, Verleye L, Andreyev HJN, Maher J, Vlayen J, Pieters BR, et al. Non-surgical interventions for late rectal problems (proctopathy) of radiotherapy in people who have received radiotherapy to the pelvis. Cochrane Database Syst Rev. 2016;(4):CD003455. doi:10.1002/14651858.CD003455.pub2
3-Andreyev HJN, Davidson SE, Gillespie C, Allum WH, Swarbrick E. Practice guidance on the management of acute and chronic gastrointestinal problems arising as result of treatment for cancer. Gut. 2012;61:179–192. doi:10.1136/gutjnl-2011-300563
4-Dahiya DS, Kichloo A, Tuma F, Albosta M, Wani F. Radiation proctitis and management strategies. Clin Endosc. 2022;55(1):22–32. doi:10.5946/ce.2020.288
5-Rustagi T, Mashimo H. Endoscopic management of chronic radiation proctopathy. World J Gastroenterol. 2011;17(41):4554–4562. doi:10.3748/wjg.v17.i41.4554
6-Lenz L, Rohr R, Nakao F, Libera E, Ferrari A. Chronic radiation proctopathy: A practical review of endoscopic treatment. World J Gastrointest Surg. 2016;8(2):151–158. doi:10.4240/wjgs.v8.i2.151

TRANSFORMING RADIATION PROCTOPATHY MANAGEMENT: REAL-WORLD EVIDENCE ON PURASTAT FROM A UK TEACHING HOSPITAL

MUHAMMAD HUSNAIN KHIZAR 1, Sergio Coda 1, Vinoth Nadesalingam Vinoth Nadesalingam 1

1 Barking, Havering And Redbridge University Hospitals NHS Trust, London, United Kingdom

Event

UEG Week Berlin 2025

Topics

Colorectal Digestive Oncology Endoscopy Histopathology

Submission format

Late-Breaking Abstract

Session

Colorectal ESD: The better way?

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Introduction

The development of peroral endoscopic myotomy (POEM) has led to a paradigm shift in the treatment of esophageal motility disorders^1-5. Hiatal hernia (HH) has been reported in approximately 4-20% of patients with achalasia^6-8. Due to the altered position of the proximal stomach entering thoracic cavity, careful anatomical inspection at the completion of myotomy is essential to minimize the risk of adverse events⁷. Although two observational studies suggested that the presence of HH did not significantly affect clinical outcomes^9-10, these studies were limited by small sample sizes from single centers, with 13 and 56 cases of HH, respectively. Further study involving larger cohorts is needed to enable meaningful comparisons and to elucidate the impact of HH on POEM outcomes.

Aims & Methods

We hypothesized that the coexistence of a HH may be associated with adverse events, such as mediastinitis and esophageal perforation, or incomplete myotomy due to the technical challenges of approaching the esophagogastric junction^6-7. This retrospective cohort study aimed to compare outcomes between patients with and without HH undergoing POEM. Using the Nationwide Inpatient Sample in the United States from 2016 through 2022, we identified 6572 patients undergoing POEM for achalasia or non-achalasia spastic disorders. One-to-one propensity score matching was performed to compare adverse events, defined as any adverse event associated with an extended length of stay (>3 days), reintervention, 30-day mortality, and length of stay between the groups.

Results

	HH (n=1276)	Non-HH (n=1276)	P value
Adverse events	107 (8.4)	80 (6.3)	0.04
Infection (peritonitis, mediastinitis, sepsis)	62 (4.9)	42 (3.3)	0.04
Bleeding (gastrointestinal bleeding, hematoma)	32 (2.3)	26 (2.0)	0.49
Perforation (esophageal perforation, laceration)	9 (0.7)	8 (0.6)	0.52
Trauma (pneumothorax, injuries to other organs)	14 (1.1)	5 (0.4)	0.03
Reintervention	92 (7.2)	67 (5.3)	0.04
Pneumatic dilatation	88 (6.9)	67 (5.3)	0.08
Laparoscopic Heller myotomy	18 (1.4)	6 (0.5)	0.01
Second POEM	0 (0)	4 (0.3)	0.05

In the propensity score-matched analysis involving 1276 pairs, the HH group had significantly higher rates of adverse events (8.4% vs 6.3%; p = 0.04) and reintervention (7.2% vs 5.3%; p = 0.04) compared to the non-HH group (Table). The most common adverse events were infections, such as peritonitis and mediastinitis (4.9% vs 3.3%; p = 0.04). A longer length of stay (median: 4 vs 3 days; p < 0.01) was observed in the HH group. No significant difference in 30-day mortality was noted between the groups. On logistic regression analysis, HH (OR 1.33; 95% CI, 1.06–1.68) and achalasia (vs. non-achalasia spastic disorders; OR 1.54; 95% CI, 1.17–2.02) were associated with adverse events.

Conclusion

The risk of adverse events and reintervention were higher in the HH group. These findings highlight the need for tailored management in POEM for HH cases.

References

[1] Inoue H, et al. POEM for esophageal achalasia. Endoscopy. 2010;42:265-71.
[2] Ramchandani M, et al. Recent Advancements and Future Perspectives of POEM. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2024;22:1983-96.e2.
[3] Inoue H, et al. Statement for GERD after POEM from an international multicenter experience. Esophagus. 2020;17:3-10.
[4] Ponds FA, et al. Effect of POEM vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. Jama. 2019;322:134-44.
[5] Inoue H, et al. Clinical practice guidelines for POEM. Digestive endoscopy. 2018;30:563-79.
[6] Ushimaru Y, et al. Occult Hiatal Hernia in Achalasia Patients: Its Incidence and Treatment Options. Dig Surg. 2019;36:418-25.
[7] Fletcher PR. Acute hiatal hernia with oesophageal perforation following Heller's operation. Br J Surg. 1978;65:486-8.
[8] Sanei-Moghaddam A, et al. Cricopharyngeal myotomy for cricopharyngeus stricture in an inclusion body myositis patient with hiatus hernia: a learning experience. BMJ case reports. 2013;2013.
[9] Xu P, et al. Peroral endoscopic myotomy is an effective treatment for achalasia combined with hiatal hernia. Surgical endoscopy. 2024;38:4543-9.
[10] Tutuian G, et al. Achalasia and Hiatal Hernia: A Rare Association and a Therapeutic Challenge. J Neurogastroenterol Motil. 2023;29:455-9.

Disclosure

No disclosures for this study

IMPACT OF HIATAL HERNIA ON PERORAL ENDOSCOPIC MYOTOMY OUTCOMES: A NATIONWIDE COHORT ANALYSIS

Yasutoshi Shiratori 1, Neha Sharma 2, Aaron Tokayer 2, Susan Hutfless 3, Anthony Kalloo 3

1 Maimonides Medical Center, New York, United States|||State University of New York Downstate, New York, United States

2 Maimonides Medical Center, New York, United States

3 Johns Hopkins University, Baltimore, United States

Conference

UEG Week Berlin 2025

Topics

Oesophagus

Submission format

Abstract

Session

Oesophageal endoscopy and motility (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Symptomatic gallstones

Philip de Reuver 1

1 Radboudumc, Nijmegen, Netherlands

Event

UEG Week Berlin 2025

Topics

Colorectal Hepatobiliary Primary Care

Session

Cross-cutting: Management changes in high prevalence problems

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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ESGE Live Endoscopy III (Complete Session)

Event

UEG Week Berlin 2025

Topics

Endoscopy Nurses

Session

ESGE Live Endoscopy III

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

UEG Presentation

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POTENTIAL FOR EXPANDING INDICATIONS AND CURABILITY CRITERIA OF ENDOSCOPIC RESECTION FOR EARLY GASTRIC CANCER IN ELDERLY PATIENTS: RESULTS FROM A JAPANESE LARGE-SCALE MULTICENTER PROSPECTIVE COHORT STUDY

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Introduction

Endoscopic resection (ER) is expected to play a major role in elderly patients with early gastric cancer (EGC) because it is less invasive than gastrectomy. However, data on ER for elderly patients and the consideration of expanding indications and curability criteria are insufficient.

Aims & Methods

We evaluated the clinical outcomes and prognosis of elderly EGC patients treated by ER using data from a Japanese multicenter prospective cohort study using a web registry system (“J-WEB/EGC”)¹ and assessed the potential for expanding ER indications and curability criteria for elderly patients. Patients aged ≥75 years with primary EGC treated with ER at 41 institutions were included. Short- and long-term outcomes (all-cause and gastric cancer deaths) were examined. ER indications and curability criteria were based on the Japanese Gastric Cancer Treatment Guidelines.² Regarding ER curability, we divided “eCuraC-2” (previously known as “noncurative resection,” for which surgical gastrectomy following ER is recommended) into two new subgroups based on previous data on metastatic risk from EGC examined using surgically resected cases³: “elderly-high (EL-H)” (>10% estimated metastatic risk) and “elderly-low (EL-L)” (≤10% risk). Cases with positive lymphovasuclar invasion, positive/unclear vertical cut margin, or >3 cm undifferentiated-type pT1b cancer were classified as “EL-H.”

Results

A total of 3,371 patients (median age: 79.0 years) with 3,821 EGCs were included. Among them, 3,586 EGCs (group A) met the guidelines’ ER indications and 235 (group B) did not. In group A, endoscopic submucosal dissection (ESD) was selected in 99.5% patients, and the proportions of en bloc resection, R0 resection, delayed bleeding, and perforation were 98.9%, 94.4%, 3.7%, and 0.8%, respectively. In group B, ESD was selected in all cases, and the corresponding proportions were 99.5%, 85.4%, 6.5%, and 5.9%, respectively, for 185 lesions diagnosed ≤3 cm, and 96.0%, 64.0%, 14.0%, and 18.0%, respectively, for 50 lesions diagnosed >3 cm. Regarding ER curability, “eCuraA/B” (previously known as “curative resection”) and “EL-L” were observed in 83.6% and 6.2% patients, respectively, in group A, and in 40.4% and 20.0% patients, respectively, in group B. The 5-year follow-up rate was 91.9%, and all-cause and gastric cancer deaths within 5 years were observed in 615 (18.2%) and 24 (0.7%) patients, respectively. Among various patient and lesion factors, relatively high adjusted hazard ratio (aHR) for all-cause death was seen for Eastern Cooperative Oncology Group performance status ≥2 (aHR 3.2 [95% confidence interval (CI) 2.2–4.5]) and body mass index <18.5 kg/m² (aHR 2.8 [2.1–3.8]). Following eCuraA/B (2,652 patients), most (99.7%) were followed without any treatment and the 5-year cumulative gastric cancer death rate was 0.3% (95% CI 0.1–0.6). While the rate was 3.5% (2.0–5.7) following EL-H (386 patients), the rate was lower (0.9% [0.2–3.5]) following EL-L even without treatment (224 patients).

Conclusion

ER for elderly patients with EGCs meeting the Japanese guidelines’ indications safely provided highly favorable curability. Even for EGCs not meeting the guidelines’ indications, ESD was relatively safe for lesions diagnosed ≤3 cm and provided eCura A/B or EL-L, which led to few gastric cancer deaths without treatment, in >60% of cases. Expansion of ER indications and curability criteria may be possible in elderly patients. Assessing the general physical conditions is crucial in deciding treatment for such elderly patients as the findings of factors influencing all-cause mortality indicated.

References

1. Suzuki H, Ono H, Hirasawa T, et al; J-WEB/EGC group. Long-term Survival After Endoscopic Resection For Gastric Cancer: Real-world Evidence From a Multicenter Prospective Cohort. Clin Gastroenterol Hepatol. 2023; 21: 307-18.
2. Japanese Gastric Cancer Association. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer. 2023; 26: 1-25.
3. Sekiguchi M, Oda I, Taniguchi H, et al. Risk stratification and predictive risk-scoring model for lymph node metastasis in early gastric cancer. J Gastroenterol. 2016; 51: 961-70.