Endoscopic grading of gastric intestinal metaplasia (EGGIM): a multicenter validation study

BACKGROUND

Random biopsies are recommended to identify individuals at risk of gastric adenocarcinoma. Cumulative evidence suggests that narrow-band imaging (NBI) can be used to grade gastric intestinal metaplasia (GIM). We aimed to externally validate a classification of endoscopic grading of gastric intestinal metaplasia (EGGIM).

METHODS

Consecutive patients in two centers were submitted to high resolution white-light gastroscopy followed by NBI to estimate EGGIM - a score (0 - 10) resulting from the sum of endoscopic assessments of GIM, scored as 0, 1, or 2 for no GIM, ≤ 30 %, or > 30 % of the mucosa, respectively, in five areas (lesser and greater curvature of both antrum and corpus, and incisura). If GIM was endoscopically suspected, targeted biopsies were performed; if GIM was not noticeable, random biopsies were performed according to the Sydney system to estimate the operative link on gastric intestinal metaplasia (OLGIM; the gold standard).

RESULTS

250 patients (62 % female; median age 55 years) were included. GIM was staged as OLGIM 0, I, II, III, IV in 136 (54 %), 15 (6 %), 52 (21 %), 34 (14 %), and 13 (5 %) patients, respectively. All patients with GIM except three were identifiable with targeted biopsies. For the diagnosis of OLGIM III/IV, the area under the ROC curve was 0.96 (95 % confidence interval [CI] 0.93 - 0.98) and by using the cutoff > 4, sensitivity, specificity, and positive likelihood ratio were 89 %, 95 %, and 16.5, respectively; results were similar (91 %, 95 %, and 18.1) when excluding patients with foveolar hyperplasia.

CONCLUSIONS

For the first time, an endoscopic approach was externally validated to determine the risk of gastric cancer without the need for biopsies. This can be used to simplify and individualize the management of patients with gastric precancerous conditions.

Comparison of Endoscopic Techniques in the Management of Type I Gastric Neuroendocrine Neoplasia: A Systematic Review

Background. Endoscopic resection is considered the treatment of choice for type I gastric neuroendocrine neoplasia (gNEN) given its indolent behaviour; however, the favoured endoscopic technique to remove these tumours is not well established. Aims. This systematic review is aimed at investigating the best endoscopic management for type I gNEN. Methods. PubMed Central/Medline and Scopus were systematically searched for records up to August 31, 2020. Results. After screening the 675 retrieved records, 6 studies were selected for the final analysis. The main endoscopic resection techniques described were endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Overall, 112 gNENs were removed by EMR and 77 by ESD. Both techniques showed similar results for complete and en bloc resection (97.4% and 98.7%; 92.3% and 96.3% with ESD and EMR, respectively). ESD was associated with a higher rate of complications than EMR (11.7% vs. 5.4%), but this difference was not statistically significant ( $p=0.17$ ). The rates of recurrence during follow-up were 18.2% and 11.5% for EMR and ESD, respectively. Conclusions. To date, there are no sufficient data showing superiority of a given endoscopic technique over others. Both ESD and EMR seem to be effective in the management of type I gNEN, with a relatively low rate of recurrence.

Endoscopic Submucosal Dissection of Gastric Neoplastic Lesions: An Italian, Multicenter Study

Endoscopic submucosal dissection (ESD) allows removing neoplastic lesions on gastric mucosa, including early gastric cancer (EGC) and dysplasia. Data on ESD from Western countries are still scanty. We report results of ESD procedures performed in Italy. Data of consecutive patients who underwent ESD for gastric neoplastic removal were analyzed. The en bloc resection rate and the R0 resection rates for all neoplastic lesions were calculated, as well as the curative rate (i.e., no need for surgical treatment) for EGC. The incidence of complications, the one-month mortality, and the recurrence rate at one-year follow-up were computed. A total of 296 patients with 299 gastric lesions (80 EGC) were treated. The en bloc resection was successful for 292 (97.6%) and the R0 was achieved in 266 (89%) out of all lesions. In the EGC group, the ESD was eventually curative in 72.5% (58/80) following procedure. A complication occurred in 30 (10.1%) patients. Endoscopic treatment was successful in all 3 perforations, whereas it failed in 2 out of 27 bleeding patients who were treated with radiological embolization (1 case) or surgery (1 case). No procedure-related deaths at one-month follow-up were observed. Lesion recurrence occurred in 16 (6.2%) patients (6 EGC and 10 dysplasia). In conclusion, the rate of both en bloc and R0 gastric lesions removal was very high in Italy. However, the curative rate for EGC needs to be improved. Complications were acceptably low and amenable at endoscopy.

Narrow band imaging characteristics of gastric polypoid lesions: a single-center prospective pilot study

INTRODUCTION

Gastric polypoid lesions (GPL) are endoscopic findings whose histological nature is difficult to determine with white-light endoscopy. Hyperplastic polyps (HP), type-1 gastric carcinoids (T1-GC) and adenomas are the most frequent GPL needing different management. Narrow-band imaging (NBI) has high accuracy for gastric malignant lesions but few studies assessed whether GPL display specific NBI characteristics. We aimed to investigate the endoscopic NBI appearances of GPL.

MATERIALS AND METHODS

During gastroscopies, images of GPL were recorded, and lesions were removed for histological evaluation. Two endoscopists blindly reviewed the digital images and registered the endoscopic NBI appearances on a specific check-list. GPL were categorized in HP, adenomas and T1-GC using histology as gold standard.

RESULTS

Overall 52 GPL, observed in 40 patients [F55%; age 63 (36-85) years], were included: 29 (55.8%) HP; 18 (34.6%) T1-GC; 5 (9.6%) adenomas. The median size was seven (2-35) mm. A regular circular mucosal pattern was more frequently observed in HP and T1-GC compared to adenomas (P < 0.001). T1-GC showed a central erosion in 77.8% (P < 0.001 versus HP) with a clear demarcation line in 33.3%. Adenomas had tubule-villous mucosal pattern in 80% (P = 0.01 versus other lesions).

CONCLUSION

NBI analysis of the mucosal pattern seems to be effective to endoscopically discriminate between adenomas and HP while the main characteristic of T1-GC seems to be the presence of a central erosion, sometimes with demarcation line. The endoscopic NBI characterization of GPL may contribute to optimize the management of these lesions.

Enteroscopy in children and adults with inflammatory bowel disease

Inflammatory bowel disease (IBD) includes Crohn's disease (CD), ulcerative colitis and unclassified entities. CD commonly involves the terminal ileum and colon but at the time of diagnosis it can be confined to the small bowel (SB) in about 30% of the patients, especially in the young ones. Management of isolated SB-CD can be challenging and objective evaluation of the SB mucosa is essential in differentiating CD from other enteropathies to achieve therapeutic decisions and to plan the follow-up. The introduction of cross-sectional imaging techniques and capsule endoscopy (CE) have significantly expanded the ability to diagnose SB diseases providing a non-invasive test for the visualization of the entire SB mucosa. The main CE limitations are the low specificity, the lack of therapeutic capabilities and the impossibility to take biopsies. Device assisted enteroscopy (DAE) enables histological confirmation when traditional endoscopy, capsule endoscopy and cross-sectional imaging are inconclusive and also allows therapeutic interventions such as balloon stricture dilation, intralesional steroid injection, capsule retrieval and more recently stent insertion. In the current review we will discuss technical aspect, indications and safety profile of DAE in children and adults with IBD.

Occurrence of Acute Oesophageal Necrosis (Black Oesophagus) in a Single Tertiary Centre

Acute oesophageal necrosis (AON) is a rare condition characterised by the endoscopic finding of diffuse, circumferential, black mucosal pigmentation of the oesophagus, which typically stops at the gastro-oesophageal junction. This observational study aimed to assess the occurrence, clinical characteristics and outcomes of AON in a consecutive endoscopic cohort in a single tertiary university centre. A retrospective analysis of endoscopic data of upper gastrointestinal endoscopy (UGE) was carried out from 2008 to 2018. Out of 25,970 UGE, 16 patients (0.06%) had AON; 75.0% were men with a median age of 75 years. Almost all patients underwent diagnosis during emergency UGE performed for gastrointestinal bleeding, but one patient was diagnosed during elective UGE for persistent vomiting and diarrhoea. All patients reported one or more pre-existing comorbidities and concomitant acute events. Two patients had AON as the first presentation of Zollinger-Ellison syndrome (ZES). One patient developed an oesophageal stenosis, and another patient presented a relapse of AON. Mortality was 50%, but no patient died as a direct consequence of AON. AON is a rare cause of gastrointestinal bleeding diagnosed mainly during emergency UGE. Our study showed that ZES might manifest with this critical presentation, and endoscopists must be aware of this evidence.