Ancestral Diversity in Pharmacogenomics Affects Treatment for Hispanic/Latine Populations With Inflammatory Bowel Disease

BACKGROUND AND AIMS

The prevalence of inflammatory bowel disease among Hispanic/Latine communities is increasing. Pharmacogenomic studies reveal genetic markers that influence treatment decisions. The aim of our study was to examine the frequency and impact of genetic polymorphisms on thiopurine-associated leukopenia (NUDT15, TPMT) and anti-tumor necrosis factor (TNF) immunogenicity (HLA-DQA1∗05) in a cohort of Hispanic patients of diverse ancestral backgrounds.

METHODS

We performed a multicenter, retrospective cohort study comprising 2225 Hispanic participants. We measured the frequency of variation affecting drug response in NUDT15, TPMT, and HLA-DQA1∗05; their ancestral origin (European, African, or Amerindian); and the rate of development of myelosuppression and immunogenicity to thiopurines and anti-TNFs, in exposed patients.

RESULTS

NUDT15 and TPMT variants were rare, except for rs116855232 in NUDT15, which was common only in alleles of Amerindian origin. All NUDT15 variant alleles were inherited on an Amerindian haplotype, and among the Amerindian allele subset, the variant frequency of NUDT15∗4 (rs147390019) was a remarkable 23% in patients with leukopenia but only 3% in patients without leukopenia. HLA-DQA1∗05 and its European tagging variant rs2097432 were common in alleles from all ancestral origins and demonstrated association with immunogenicity to anti-TNFs. However, rs2097432 was only correlated with HLA-DQA1∗05 in the European allele subset.

CONCLUSIONS

These findings indicate that NUDT15 testing should become standard clinical practice before prescribing thiopurines in individuals with Amerindian/Alaska Native ancestry, including Hispanic individuals. Additionally, rs2097432 should not be used as a surrogate for HLA-DQA1∗05 testing for diverse populations. Ultimately, incorporating ancestry in personalized therapeutic approaches is important for treatment of Hispanic patients with inflammatory bowel disease.

Guidelines for endoscopic management of nonvariceal upper gastrointestinal bleeding (second edition)

The Japan Gastroenterological Endoscopy Society has prepared Guidelines for Endoscopic Practice in Nonvariceal Upper Gastrointestinal Bleeding as part of the initiative to develop evidence-based endoscopic practice guidelines. Hemorrhagic gastroduodenal (peptic) ulcers are the primary cause of nonvariceal upper gastrointestinal bleeding. With the advent of a super-aged society, the cases caused by Helicobacter pylori are on the decline, whereas those caused by drugs (e.g. aspirin) have been increasing. Endoscopic hemostasis is currently the first-line treatment for nonvariceal upper gastrointestinal bleeding, and various methods have been devised for this purpose. It is recommended to stabilize the vital signs of the patient before and after endoscopic hemostasis with appropriate management based on an assessment of the severity of illness, in addition to the administration of acid secretion inhibitors. These guidelines describe the evaluation and initial treatment of nonvariceal upper gastrointestinal bleeding, as well as the selection of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding and its management after endoscopic hemostasis. This is achieved by classifying nonvariceal upper gastrointestinal bleeding into two main categories, namely, peptic ulcer and other types of gastrointestinal bleeding. We prepared statements for any available literature with supporting evidence, including the levels of evidence and recommendations. New evidence has been pooled since the publication of the first edition in this area; however, the levels of evidence and recommendations mostly remain low.

Body weight-range based initial dosing of ustekinumab in Crohn's disease: Is it an ideal approach?

BACKGROUND & AIMS

The initial intravenous dose of ustekinumab (UST) for treating Crohn's disease (CD) is recommended based on body weight ranges for clinical convenience. However, patients whose body weight nears the upper threshold may receive a relatively lower dose (<6 mg/kg) based on current dosage calculations. We aimed to investigate whether the body weight-range based dosing calculation method for UST may lead to suboptimal therapeutic doses and then impact effectiveness, particularly in patients with borderline weight.

METHODS

A multi-center, observational, real-world cohort study was conducted in four centers. Patients with CD who received UST based on body weight-range dosing calculation were retrospectively enrolled. Participants were classified into two groups according to the initial induction dosage: the relatively higher dose (RHD) induction group (≥6 mg/kg) and the relatively lower dose (RLD) induction group (<6 mg/kg). Steroid-free remission, clinical remission, specific objective response and remission at week 24 were compared in the two groups using propensity score weighting. UST drug concentration was measured at week 24±4.

RESULTS

A total of 438 patients were included, with 176 patients in the RHD group and 262 patients in the RLD group. The RHD group demonstrated superior outcomes compared to the RLD group in achieving steroid-free remission (66.2 % vs. 54.9 %, P = 0.020, OR = 1.605, 95 % CI 1.082-2.395), clinical remission (66.7 % vs. 56.4 %, P = 0.032, OR = 1.546, 95 % CI 1.041-2.311) at week 24. In objective evaluation, the RHD group showed higher rates in ultrasound response (64.9 % vs. 52.1 %, P = 0.041, OR = 1.700, 95 % CI 1.027-2.844) and radiologic remission (25.1 % vs. 13.4 %, P = 0.022, OR = 2.163, 95 % CI 1.117-4.205). The drug concentration was significantly higher in the RHD group compared to the RLD group at week 24 [2.06 (1.36-3.17) µg/ml vs. 1.12 (0.25-1.52) µg/ml, P < 0.001]. Additionally, the RHD group required fewer treatment optimizations than the RLD group, but with no statistical difference (20.6 % vs. 24.9 %, P = 0.291, OR = 0.780, 95 % CI 0.488-1.231). The rate of adverse events was similar between the two groups (4.0 % vs 3.4 %, P = 0.767).

CONCLUSIONS

This study suggested that the current dose calculation method may result in inadequate induction doses of UST for CD patients whose body weight is close to the upper threshold, potentially impacting the effectiveness of induction.

LAY SUMMARY

A multi-center study suggests that the current body weight-range based dosing of ustekinumab for Crohn's disease may lead to insufficient induction doses for patients near the upper weight threshold, negatively impacting treatment effectiveness.

Validation of the GPAT - the Global Polypectomy Assessment Tool: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

BACKGROUND : Colorectal polypectomy is operator dependent, with variable rates of complete resection. The currently available assessment tools do not provide specific competency-based evaluation of provider technique. We aimed to validate the Global Polypectomy Assessment Tool (GPAT), a novel competency assessment tool for colorectal polypectomy. METHODS : GPAT was derived from the ESGE Curriculum for Training in endoscopic mucosal resection in the colon. Members of the curriculum taskforce plus three invited trainees and three medical students (collectively: the assessors) anonymously assessed nine endoscopic-view only polypectomy videos. The primary end point was the correlation of the assessors' GPAT scores with a consensus-derived reference GPAT score per video. Secondary end points were the assessors' subjective impression versus their GPAT score and interobserver agreement among assessors' GPAT scores. RESULTS : 171 GPAT assessments by 19 assessors (consultant gastroenterologists [n = 10], trainee gastroenterologists [n = 4], consultant surgeons [n = 2], and medical students [n = 3]) were analyzed. Reference GPAT scores did not differ significantly from those of the assessors (73.1 % [95 %CI 64.6 %-81.6 %] vs. 69.3 % [95 %CI 64.9 %-81.2 %]; P = 0.47). There was moderate IOA in GPAT scores among gastroenterologists (intraclass correlation coefficient [ICC], 0.52 [moderate]) but not among nongastroenterologists (ICC 0.32 [poor]). GPAT correlated with assessors' subjective impression of polypectomy quality (correlation coefficient 0.98 [95 %CI 0.90-1.00]; P < 0.001). Overall assessors' qualitative usability scoring of GPAT was positive. CONCLUSIONS : GPAT allows standardized scoring of polypectomies, with moderate IOA among gastroenterologists and correlation with subjective impressions of polypectomy quality. GPAT could standardize assessment of trainee polypectomy competency offering structured feedback on performance.

First step to environmentally sustainable endoscopy practice: a prospective study of minimizing multiple device use during screening colonoscopy at a large tertiary center

The healthcare sector generates 8% of greenhouse gas emissions in the USA, of which gastrointestinal (GI) endoscopy is the third largest contributor. Single-use tools are a major contributor to modifiable waste generation during GI endoscopy. Through a quality improvement initiative, we aimed to reduce endoscopy waste by urging gastroenterologists to be mindful of tools used during polypectomies by avoiding using multiple tools.We discussed green endoscopy initiatives in monthly journal club and business meetings. Over 14 weeks, 210 patients were included in the pre-intervention group and 112 in the post-intervention group.At baseline, 34% of colonoscopies required no intervention, 32% required one tool (either biopsy forceps or a snare), and 33% required multiple tools. After the intervention, the use of just one tool increased (17 percentage point increase; P=0.003) and the use of multiple tools decreased significantly (16 percentage point decrease; P=0.002). The odds ratio for use of a single tool compared with multiple tools after the intervention was 3.0 (95%CI 1.6 to 5.5; P=0.005).This single-center quality improvement study noted a significant change in practice patterns favoring the use of a single tool over multiple tools during colonoscopies after an environmentally conscious practice intervention was applied. This intervention can be readily applied to reduce endoscopy-related waste.

HLA DQA1*05 and Risk of Antitumor Necrosis Factor Treatment Failure and Anti-Drug Antibody Development in Children With Crohn's Disease

INTRODUCTION

Human leukocyte antigen (HLA) DQA1*05 has been associated with the development of anti-drug antibodies (ADA) to tumor necrosis factor antagonists (anti-TNFα) and treatment failure among adults with Crohn's disease (CD). However, findings from other studies have been inconsistent with limited pediatric data.

METHODS

We analyzed banked serum from patients with CD aged <21 years enrolled in clinical outcomes of Methotrexate Binary Therapy in practice, a multicenter, prospective randomized trial of anti-TNFα monotherapy vs combination with methotrexate. The primary outcome was a composite of factors indicative of treatment failure. The secondary outcome was ADA development.

RESULTS

A trend toward increased treatment failure among HLA DQA1*05-positive participants was not significant (hazard ratio 1.58, 95% confidence interval [CI] 0.95-2.62; P = 0.08). After stratification by HLA DQA1*05 and by methotrexate vs placebo, patients who were HLA DQA1*05 negative and assigned to methotrexate experienced less treatment failures than HLA DQA1*05-positive patients on placebo (hazard ratio 0.31, 95% CI 0.13-0.70; P = 0.005). A trend toward increased ADA development among HLA DQA1*05-positive participants was not significant (odds ratio 1.96, 95% CI 0.90-4.31, P = 0.09). After further stratification, HLA DQA1*05-negative participants assigned to methotrexate were less likely to develop ADA relative to HLA DQA1*05-positive patients on placebo (odds ratio 0.12, 95% CI 0.03-0.55; P = 0.008).

DISCUSSION

In a randomized trial of children with CD initiating anti-TNFα, 40% were HLA DQ-A1*05 positive, which was associated with a trend toward increased risk of both treatment failure and ADA. These risks were mitigated, but not eliminated, by adding oral methotrexate. HLA DQ-A1*05 is an important biomarker for prognosis and risk stratification.

Artificial Intelligence-Assisted Capsule Endoscopy Versus Conventional Capsule Endoscopy for Detection of Small Bowel Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Capsule endoscopy (CE) is a valuable tool used in the diagnosis of small intestinal lesions. The study aims to systematically review the literature and provide a meta-analysis of the diagnostic accuracy, specificity, sensitivity, and negative and positive predictive values of AI-assisted CE in the diagnosis of small bowel lesions in comparison to CE.

METHODS

Literature searches were performed through PubMed, SCOPUS, and EMBASE to identify studies eligible for inclusion. All publications up to 24 November 2024 were included. Original articles (including observational studies and randomized control trials), systematic reviews, meta-analyses, and case series reporting outcomes on AI-assisted CE in the diagnosis of small bowel lesions were included. The extracted data were pooled, and a meta-analysis was performed for the appropriate variables, considering the clinical and methodological heterogeneity among the included studies. Comprehensive Meta-Analysis v4.0 (Biostat Inc.) was used for the analysis of the data.

RESULTS

A total of 14 studies were included in the present study. The mean age of participants across the studies was 54.3 years (SD 17.7), with 55.4% men and 44.6% women. The pooled accuracy for conventional CE was 0.966 (95% CI: 0.925-0.988), whereas for AI-assisted CE, it was 0.9185 (95% CI: 0.9138-0.9233). Conventional CE exhibited a pooled sensitivity of 0.860 (95% CI: 0.786-0.934) compared with AI-assisted CE at 0.9239 (95% CI: 0.8648-0.9870). The positive predictive value for conventional CE was 0.982 (95% CI: 0.976-0.987), whereas AI-assisted CE had a PPV of 0.8928 (95% CI: 0.7554-0.999). The pooled specificity for conventional CE was 0.998 (95% CI: 0.996-0.999) compared with 0.5367 (95% CI: 0.5244-0.5492) for AI-assisted CE. Negative predictive values were higher in AI-assisted CE at 0.9425 (95% CI: 0.9389-0.9462) versus 0.760 (95% CI: 0.577-0.943) for conventional CE.

CONCLUSION

AI-assisted CE displays superior diagnostic accuracy, sensitivity, and positive predictive values albeit the lower pooled specificity in comparison with conventional CE. Its use would ensure accurate detection of small bowel lesions and further enhance their management.

Low risk, high cost: challenging the role of gastric cancer screening in low-prevalence countries

Gastric cancer is the second commonest gastrointestinal (GI) neoplasm, with a high mortality rate and highly variable regional incidence data associated with factors such as diet, genetics, and infection with Helicobacter pylori. In high-risk countries as Japan and South Korea endoscopic screening has shown its potential to reduce this cancer's mortality. However, in low-risk countries such as Spain, where population screening is not cost-effective, a selective approach is advised focused on high-risk groups, including patients with a family history of gastric cancer, or in the form of opportunistic screening during gastroscopy for other clinical indications. High-quality gastroscopy is key for the identification of early lesions. This includes using high-definition endoscopes with chromoendoscopy, pursuing optimal mucosal visibility with washes or premedication, systematically inspecting all of the mucosa, investing adequate observation times, and using risk stratification tools such as EGGIM or OLGIM. Endoscopic surveillance is particularly advisable for high-risk precursor lesions, with intervals adjusted for patient profile. Further research is crucial for optimizing these interventions and reducing the condition's mortality rate.

Overcoming the challenges of overtreating and undertreating inflammatory bowel disease

Several therapeutic advances have been achieved over the past two decades for inflammatory bowel disease (IBD). The expanding therapeutic armamentarium and the increasingly ambitious treatment targets have led to an increased use of advanced therapies and better outcomes. Nevertheless, many patients remain suboptimally treated and are at risk of disease progression, hospital admission, and surgery, even when advanced therapies are cycled, escalated, or combined. Conversely, IBD can also be characterised by an indolent disease course. Top-down and treat-to-target strategies, although beneficial in a substantial proportion of patients, might not be advantageous in patients with mild disease and might risk overtreatment. Identifying patients with mild activity and a benign disease trajectory in the long-term is important; unnecessary exposure to advanced therapies increases the risk of adverse events and increases financial costs and health-care resource utilisation. This Review details the importance of adopting clinical strategies to avoid the pitfalls of undertreating and overtreating IBD.

Mechanistic Implications of the Mediterranean Diet in Patients With Newly Diagnosed Crohn's Disease: Multiomic Results From a Prospective Cohort

BACKGROUND & AIMS

To decipher the mechanisms underlying the protective role of the Mediterranean diet (MED) in Crohn's disease (CD), we explored the implications of adherence to MED on CD course, inflammatory markers, and microbial and metabolite composition.

METHODS

Patients with newly diagnosed CD were recruited and followed prospectively. MED adherence was assessed by repeated food frequency questionnaires (FFQs) using a predefined inflammatory bowel disease Mediterranean diet score (IBDMED score), alongside validated MED adherence screeners. Crohn's disease activity index (CDAI), C-reactive protein, fecal calprotectin, and microbial composition (16S-ribosomal RNA sequencing) were assessed each visit. Baseline serum and fecal samples were analyzed for targeted quantitative metabolomics.

RESULTS

Consecutive patients: 271 (52% men, average age 31 ± 12 years, B1 phenotype 75%). FFQs collected: 636 (range 1-5 FFQs per patient). Adherence to MED was associated with a noncomplicated CD course, and inversely correlated with CDAI, fecal calprotectin, C-reactive protein, and microbial dysbiosis index (all P < .05). Increasing adherence to MED over time correlated with reduced CDAI and inflammatory markers (P < .05). Adherence to MED correlated with a microbial cluster of commensals and short-chain fatty acid producers including Faecalibacterium, and with plant metabolites, vitamin derivatives, and amino acids. Conversely, adherence to MED inversely correlated with a cluster of oral genera, Escherichia coli and Ruminococcus gnavus, known CD-associated species, and with tryptophan metabolites, ceramides, and primary bile acids (false discovery rate < 0.2).

CONCLUSION

Adherence to MED is associated with beneficial clinical outcomes and decreased inflammatory markers. These may be driven by lower levels of primary bile acids and microbial dysbiosis and a beneficial microbial and metabolite composition. Randomized controlled trials are needed to evaluate the role of MED in CD management.

Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

Identification of risk factors associated with post-ERCP pancreatitis in patients with easy cannulation: a prospective multicenter observational study (with videos)

BACKGROUND AND AIMS

Difficult biliary cannulation is an independent risk factor for post-ERCP pancreatitis (PEP); however, there is a noticeable lack of studies focusing on the incidence and risk factors of PEP among patients undergoing easy cannulation. Therefore, we systematically investigated the risk factors for PEP in patients who underwent easy cannulation.

METHODS

We prospectively enrolled patients with naive major papillae who underwent diagnostic or therapeutic ERCP between June 2018 and June 2023. The primary endpoint was to determine the incidence of PEP in patients with easy cannulation; secondary endpoints were identifying PEP risk factors and evaluating procedure-related adverse events (AEs).

RESULTS

Overall, 1930 patients were included, with 1061 (54.9%) undergoing easy cannulation. Within this cohort, PEP incidence was 3.0%, whereas 2.9% experienced procedure-related AEs, excluding PEP. A history of acute pancreatitis (odds ratio [OR], 6.75; 95% confidence interval [CI], 1.83-20.14; P = .001) and acute cholangitis on admission (OR, 2.25; 95% CI, 1.07-5.08; P = .039) were identified as independent risk factors for PEP in patients with easy cannulation. Endoscopic sphincterotomy and biliary stent placement were independent factors for procedure-related AEs.

CONCLUSIONS

Our findings underscore the importance of assessing patient- and procedure-related factors to mitigate the risk of PEP in patients undergoing easy cannulation. Despite the low incidence of PEP, the potential for the occurrence of severe cases emphasizes the need for cautious intervention, particularly in patients with a history of acute pancreatitis and acute cholangitis on admission. (Clinical trial registration number: KCT0005950.).

Trans-arterial embolization for treatment of acute lower gastrointestinal bleeding-a multicenter analysis

PURPOSE

To assess the technical feasibility, safety, and clinical success rate of trans-arterial embolization (TAE) as an emergency treatment for acute lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

Consecutive patients who received urgent TAE due to active LGIB at five academic centers in Germany were retrospectively analyzed. LGIB was confirmed and localized using contrast-enhanced computed tomography (CT) or endoscopy. Outcome parameters including technical and clinical success rates as well as ischemia-related adverse events were analyzed. Furthermore, treatment-related variables that may affect technical and clinical success were analyzed using a regression model.

RESULTS

One hundred and forty-one patients were included. TAE was performed in 91% (128/141) of patients. In 81% (114/141) of patients, TAE was performed due to active bleeding visible at angiography, the remaining 10% (14/141) underwent empiric embolization based on pre-interventional imaging. In 9% (13/141) of patients, no TAE was performed. Microcoils were the most used embolic 48.5% (62/128), followed by glue 23.5% (30/128) and Microparticles (8%; 10/128). In the case of bleeding visible in angiography, the technical success rate was 100% (114/114); the clinical success rate was 93.6% (120/128). Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% (18/128) of all patients after embolization. Thirty-day mortality was 14% (21/141). Regression analysis revealed no significant correlations but a statistical trend toward a higher incidence of bowel resection when glue was used (p = 0.090) and toward a higher 30-day mortality when an unselective embolization was performed (p = 0.057).

CONCLUSION

TAE for LGIB has a high technical and clinical success rate. Severe ischemia-related adverse events necessitating bowel surgery occurred in 14% of patients without identifying a significant correlation to the embolization technique or an embolic.

KEY POINTS

Question Is trans-arterial embolization (TAE) viable as an emergency treatment for acute lower gastrointestinal bleeding (LGIB)? Findings TAE demonstrated a 100% technical and 93.6% clinical success rate in treating acute LGIB, with severe ischemia-related adverse events occurring in 14% of patients. Clinical relevance TAE is highly effective and has an acceptable complication rate in treating lower gastrointestinal bleeding, emphasizing the need for a direct head-to-head comparison between endovascular and endoscopic therapy.

Predictors of Immunogenicity and Loss of Response to ANTI-TNFα Therapy in Crohn Disease-A Systematic Review

BACKGROUND

As the use of anti-tumor necrosis factor-α (TNFα) therapies in Crohn disease (CD) is spread, the loss-of-response (LOR) to it is increasingly encountered. Discovering a pathological pathway and biomarkers that can predict LOR would assist in the management of patients with CD. In this article, we provide a comprehensive systematic review of studies assessing predictors of immunogenicity and loss-of-response to anti-TNFα drugs in patients with CD.

DATA SOURCES

We performed a systematic review of PubMed to identify citations pertaining to predictors of immunogenicity and loss-of-response to anti-TNFα drugs in patients with CD through April 27, 2024, using a predefined string of keywords. Data extraction and quality assessment were performed independently by 2 reviewers.

RESULTS

A total of 18 eligible studies were included in the review. Four major groups of studies were identified: genetic factors, factors linked with colonic inflammation, serum and anthropological markers, and prevention of LOR. Promising predictors of LOR to infliximab or adalimumab include the carriage of HLA-DQA1*05, visceral adiposity, intestinal abundant presence of CD96, IL-17, and IL-23. Substantial heterogeneity was observed, and none of the markers had undergone formal validation. Specific limitations to acceptance of these factors included failure to use a standardized definition of LOR to anti-TNFα treatment, lack of specificity, and insufficient relevance to the pathogenesis of LOR.

CONCLUSIONS

This review underlines the lack of well-defined studies and controlled trials investigating predictors of LOR to anti-TNFα therapies in CD. A research priority is the development of reliable and accurate biomarkers that can shed light on the pathogenesis of the implied LOR. These biomarkers, along with genetic factors, have the potential to enhance clinical management by aiding in patient stratification and monitoring.

A national survey on gastroenterology and hepatology training reveals dissimilar perceptions between trainees and trainers and an important need for improvement in training programs

OBJECTIVE

We aimed to collect data on gastroenterology and hepatology training from the viewpoint of trainees and trainers.

METHODS

A national online survey was distributed among trainees and specialists at certified training institutions between February and May 2024.

RESULTS

Overall, 226 respondents - 98 trainees, 78 trainers, 50 program directors, and department heads responded, with a national coverage of 70% of trainees and 85% of specialty-department heads. A training curriculum was reported by 56% of trainees and 84% of curriculum organizers, regular feedback and training progress meetings by 11% of trainees (57% if considered without assessment of training progress), but 88% of curriculum organizers. Training was rated as very good or good by 65% of trainees, 79% of trainers, and 100% of department heads. Quality of functional diagnostics, endoscopy, and ultrasound training was rated as very good or good by trainees in 16, 61, and 54%, by trainers in 27, 79, and 58%, and by department heads in 74, 89, and 85%. Much agreement was found concerning the wish for external rotations (trainees 65%, trainers 70%, and department heads 89%) and a new postcertification advanced-endoscopy training and accreditation.

CONCLUSION

Department heads seem to overestimate the quality of their training programs. Consequently, we found large discrepancies in the perception of specialty training that should stimulate efforts to standardize training and boost necessary train-the-trainer programs. Diagnosis of functional gastrointestinal disorders and abdominal ultrasound skills are areas with the largest room for improvement. Increased flexibility of hospital providers will be crucial for significant improvement of external training possibilities.

A Bottom-Up Liquid Chromatography-Tandem Mass Spectrometry Method for Therapeutic Drug Monitoring of Infliximab: Method Development, Comparison With 2 Enzyme-Linked Immunosorbent Assay Methods, and Evaluation of Anti-Drug Antibody Interference

CONTEXT.—

Therapeutic drug monitoring is recommended to optimize infliximab use and improve outcome in chronic inflammatory disorders.

OBJECTIVE.—

To describe a simple and affordable liquid chromatography-tandem mass spectrometry (LC-MS/MS) method to measure infliximab in serum.

DESIGN.—

Infliximab was measured using winged stable isotope-labeled peptides as internal standards. Linearity, lower limit of measuring interval, limit of detection, precision, accuracy, carryover, and ion suppression were evaluated. Method comparison against 2 enzyme-linked immunosorbent assay (ELISA) methods (Remsima Monitor and IDKmonitor Infliximab) and anti-drug antibody (ADA) interference were evaluated using clinical specimens from inflammatory bowel disease patients (N = 237).

RESULTS.—

Analytical run time and sample preparation time were 5 minutes per sample and 3 hours per batch, respectively. Analytical measurement interval and limit of detection were 0.50 to 50.0 μg/mL (R2 = 0.998) and 0.25 μg/mL, respectively. The intraday and interday imprecision percentage coefficients of variation were less than 6.1%. Accuracy was 94.2% to 98.7%. No significant ion suppression or carryover was observed. Infliximab concentrations measured by LC-MS/MS showed good agreement with those measured by Remsima Monitor (mean percentage difference, 5.7%; 95% CI, -1.2% to 12.6%) but were markedly lower than those measured by IDKmonitor (-32.6%; -35.8% to -29.4%), demonstrating significant bias between ELISAs. Although a good agreement between LC-MS/MS and ELISA was observed for ADA-negative samples (-3.5%; -12.8% to 5.9%), a significant bias was observed for ADA-positive samples (13.6%; 1.7% to 25.6%).

CONCLUSIONS.—

This simple, fast, and affordable LC-MS/MS method for infliximab quantitation could improve standardization of infliximab quantitation and optimization of infliximab use in patients with high-titer ADA.

Comparing Outcomes With Subcutaneous Infliximab (CT-P13 SC) by Baseline Immunosuppressant Use: A Post Hoc Analysis of the LIBERTY-CD and LIBERTY-UC Studies

BACKGROUND

Superior efficacy of subcutaneous infliximab (CT-P13 SC) over placebo for maintenance therapy in patients with Crohn's disease (CD) and ulcerative colitis (UC) was demonstrated in the randomized LIBERTY-CD and LIBERTY-UC studies. The current post hoc analysis compared outcomes with CT-P13 SC by baseline immunosuppressant use.

METHODS

Patients with moderately to severely active CD or UC randomized to the CT-P13 SC maintenance arm of the 54-week LIBERTY trials at week 10 and who were treated in the open-label extension (weeks 56-102) were included. Pharmacokinetic, efficacy, biomarker, safety, and immunogenicity endpoints were evaluated by baseline immunosuppressant use (monotherapy vs combination therapy).

RESULTS

A total of 192 patients with CD (monotherapy, n = 126; combination therapy, n = 66) and 237 patients with UC (monotherapy, n = 180; combination therapy, n = 57) were included. In both studies, efficacy outcomes were generally comparable between monotherapy and combination therapy at week 54 or week 102. Serum concentrations were generally higher, and antidrug antibody-positive conversion rates were lower, with combination therapy relative to monotherapy. In combined analyses of CD and UC, comparable safety profiles were observed between monotherapy and combination therapy.

CONCLUSIONS

Despite some differences in pharmacokinetics and immunogenicity between CT-P13 SC received alone or in combination with immunosuppressants in patients with CD or UC, efficacy outcomes at week 54 or week 102 were generally comparable. The overall safety profile and incidence of systemic injection reactions were also comparable between monotherapy and combination therapy.

Repurposing Anthelmintic Drugs for COVID-19 Treatment: A Comprehensive Meta-Analysis of Randomized Clinical Trials on Ivermectin and Mebendazole

Background: The COVID-19 pandemic necessitated the urgent exploration of therapeutic options, including drug repurposing. Anthelmintic drugs such as ivermectin and mebendazole have garnered interest due to their potential antiviral and immunomodulatory properties. However, conflicting evidence from randomized clinical trials (RCTs) necessitates a comprehensive meta-analysis to determine their efficacy and safety in COVID-19 management. Objective: This meta-analysis evaluates the clinical efficacy of ivermectin and mebendazole in treating COVID-19 by analyzing their impact on viral clearance, symptom resolution, hospitalization duration, and safety profiles. Methods: A systematic search of Scopus, PubMed, Embase, and the Cochrane Library was conducted following PRISMA guidelines to identify RCTs published up to February 2025. Eligible studies included adult patients with confirmed COVID-19 who received ivermectin or mebendazole compared with a placebo or standard of care. Data extraction and risk of bias assessment were performed using the Cochrane Risk of Bias Tool. Statistical heterogeneity was evaluated using the I2 statistic, and pooled effect sizes were calculated for primary clinical outcomes. Results: Twenty-three RCTs (n = 12,345) were included, with twenty-one studies on ivermectin and two on mebendazole. The pooled analysis suggested no statistically significant improvement in viral clearance (p = 0.39), hospitalization duration (p = 0.15), or symptom resolution (p = 0.08) with ivermectin or mebendazole. However, individual studies indicated potential benefits, particularly for mebendazole, in reducing viral load and inflammation. Both drugs exhibited favorable safety profiles, with no significant increase in adverse events. Conclusions: The promising propensities observed in selected studies underscore the potential of ivermectin and mebendazole as adjunct therapies for COVID-19. With well-established safety profiles, immunomodulatory effects, and affordability, these drugs present strong candidates for further exploration. Advancing research through well-designed, large-scale RCTs will help unlock their full therapeutic potential and expand treatment options in the fight against COVID-19.

Endoscopic Therapy for Anastomotic Bleeding in Inflammatory Bowel Disease

Lower gastrointestinal (GI) anastomotic bleeding in patients with inflammatory bowel disease (IBD) is rare but can be detrimental. Time and effective management is critical to prevent morbidity. Endoscopy has emerged as a minimally invasive and highly effective treatment modality for the management of this complication. However, endoscopic treatment for anastomotic bleeding faces challenges such as recurrent bleeding, complication of the procedure, and need for interdisciplinary collaboration. In this study, we focus on the techniques, efficacy, and safety of endoscopic interventions for the treatment of lower GI anastomotic bleeding in patients with IBD.

The impact of COVID-19 on inflammatory bowel disease surgery: a systematic review

INTRODUCTION

The COVID-19 pandemic caused a significant disruption to the delivery of surgical services. Guidance prioritising life-saving and cancer surgery was issued. Inflammatory bowel disease (IBD) often requires considered, timely surgery, which may have not been feasible under the conditions imposed by the pandemic. This systematic review aims to quantify the impact of COVID-19 on IBD surgery and assess the safety of performing such surgery.

METHODS

A systematic review of MEDLINE, Embase and Web of Science was performed. Studies that included a prepandemic and a pandemic cohort for comparison and reported on numbers of IBD surgeries or postoperative outcomes following IBD surgery were included. Heterogeneity of included studies precluded any meta-analyses.

FINDINGS

In total, 1,220 titles were screened and 13 were included in the final review. All were cohort studies other than one case-control study. A total of 1,673,282 and 1,445,971 patients were included in the prepandemic and pandemic cohorts, respectively. Rates of elective surgery during the pandemic varied from a 66% reduction to a 9.66% increase and emergency surgery varied from no difference to an 18% reduction. Urgent surgery in IBD inpatients appears to be unaffected. Postoperative outcomes were not shown to be negatively impacted by resource limitations.

CONCLUSIONS

The COVID-19 pandemic affected IBD surgical services considerably; however, those who did undergo surgery during this period do not appear to have been at an increased risk of adverse outcomes. Further work is required to describe the long-term impacts of these cancellations on IBD services and patient morbidity.

Complete closure utilizing titanium clips minimizes delayed postpolypectomy bleeding after colorectal endoscopic mucosal resection: a retrospective analysis

Background

Delayed postpolypectomy bleeding (DPPB) constitutes one of the most prevalent complications following endoscopic mucosal resection (EMR) for colonic polyps and can be life-threatening. It has been affirmed that prophylactic clip closure can effectively diminish the risk of DPPB for colonic polyps exceeding 20 mm in the right half of the colon after EMR. Nevertheless, there remains controversy regarding whether prophylactic clip closure can prevent postoperative bleeding for polyps measuring less than 20 mm. To date, no literature has reported whether the complete closure of titanium clips following EMR for colorectal polyps ⩽20 mm can effectively prevent delayed bleeding.

Objectives

The aim of this study is to determine whether complete closure can prevent delayed postoperative bleeding and analyze the related factors that might influence delayed postoperative bleeding.

Design

In this retrospective study, a total of 1259 colorectal polyps detected in 1025 patients between January 2020 and October 2024 were evaluated for EMR.

Methods

Univariate and logistic regression analyses were conducted to assess patient-related, polyp-related, and procedure-related factors.

Results

DPPB was observed in 37 patients, representing an incidence rate of 3.6%. Logistic regression analysis indicated that male (odds ratio, 3.870; 95% confidence interval (CI), 1.594-9.396; p = 0.003), presence of large polyps (OR, 1.158; 95% CI, 1.044-1.285; p = 0.006), and partial closure (OR, 5.447; 95% CI, 2.250-13.186; p < 0.001) are significant risk factors for the development of DPPB.

Conclusion

Male, polyp size, and partial closure have been identified as potential risk factors for the development of DPPB. While gender and polyp size are immutable factors, partial closure is particularly associated with an increased risk of DPPB. Therefore, it is imperative to ensure complete closure of the wound following EMR to minimize the occurrence of DPPB.

Delphi consensus statement for the management of delayed post-polypectomy bleeding

Background

Delayed post-polypectomy bleeding (DPPB) is the most common adverse event following colonic polypectomy, yet its management remains highly heterogeneous and lacks standardization. A considerable number of colonoscopies performed for DPPB may be unnecessary and do not result in hemostatic intervention.

Objectives

To develop evidence-based statements to guide clinical decision-making in DPPB.

Design

Multidisciplinary Delphi consensus statement.

Methods

A panel of 29 experts in gastroenterology, hematology, radiology, and surgery was assembled. Through a systematic review of the literature and a modified Delphi process, consensus statements were developed through iterative rounds of anonymous voting. Statements were revised following anonymous voting and feedback at each round. Those achieving 80% agreement were accepted.

Results

The expert panel reached a consensus on 36 statements, covering areas such as antithrombotic management, bowel preparation, colonoscopy indications, and therapeutic hemostatic modalities. Key recommendations include guidance for managing self-limited bleeding and risk stratification to reduce the rate of unnecessary colonoscopies, as well as recommendations for hemodynamically unstable patients who may require primary angioembolization. A practical clinical algorithm is proposed.

Conclusion

This document provides a consensus-based framework for managing DPPB. These recommendations aim to improve patient outcomes and optimize healthcare resources while fostering a standardized approach to this common adverse event.

Transarterial embolization for acute lower gastrointestinal bleeding: a retrospective bicentric study

Transcatheter arterial embolization (TAE) represents an effective treatment option for acute lower gastrointestinal bleeding (LGIB). This retrospective, bicentric study evaluated the safety and efficacy of TAE in 77 patients with LGIB. The mean patient age was 68.39 ± 17.54 years, and the mean pre-procedural hemoglobin was 7.87 ± 1.89 g/dL. The most common cause of LGIB was angiodysplasia (36.2%). Pre-procedural computed tomography angiography (CTA) detected active bleeding in 83% of cases. Technical success was achieved in 98.7% of patients, and 30-day clinical success was achieved in 87%. The rebleeding rate was 13%, and the ischemic complication rate was 11.7%. There were no significant associations between clinical success and sex, age, coagulopathy, first-line management, active bleeding signs, culprit vessel, superior mesenteric artery, or time between CTA and digital subtraction angiography. TAE is a safe and effective procedure for LGIB, with high technical and acceptable clinical success rates. It should be considered a standard procedure in select patients, especially when endoscopic treatment is contraindicated or not feasible.

Endoscopists and endoscopic assistants' qualifications, but not their biopsy rates, improve gastric precancerous lesions detection rate

BACKGROUND

Detecting gastric precancerous lesions (GPLs) is critical for the early diagnosis and treatment of gastric cancer. Endoscopy combined with tissue examination is an important method for detecting GPLs. However, negative biopsy results often increase patients' risks, economic burdens, and lead to additional healthcare costs. Improving the detection rate of GPLs and reducing the rate of negative biopsies is currently a key focus in endoscopic quality control.

AIM

To explore the relationships between the endoscopist biopsy rate (EBR), qualifications of endoscopists and endoscopic assistants, and detection rate of GPLs.

METHODS

EBR, endoscopists, and endoscopic assistants were divided into four groups: Low, moderate, high, and very high levels. Multivariable logistic regression analysis was used to analyze the relationships between EBR and the qualifications of endoscopists with respect to the detection rate of positive lesions. Pearson and Spearman correlation analyses were used to evaluate the correlation between EBR, endoscopist or endoscopic assistant qualifications, and the detection rate of positive lesions.

RESULTS

Compared with those in the low EBR group, the odds ratio (OR) values for detecting positive lesions in the moderate, high, and very high EBR groups were 1.12 [95% confidence interval (CI): 1.06-1.19, P < 0.001], 1.22 (95%CI: 1.14-1.31, P < 0.001), and 1.38 (95%CI: 1.29-1.47, P < 0.001), respectively. EBR was positively correlated with the detection rate of gastric precancerous conditions (atrophic gastritis/intestinal metaplasia) (ρ = 0.465, P = 0.004). In contrast, the qualifications of the endoscopists were positively correlated with GPLs detection (ρ = 0.448, P = 0.005). Compared to endoscopists with low qualification levels, those with moderate, high, and very high qualification levels endoscopists demonstrated increased detection rates of GPLs by 13% (OR = 1.13, 95%CI: 0.98-1.31), 20% (OR = 1.20, 95%CI: 1.03-1.39), and 32% (OR = 1.32, 95%CI: 1.15-1.52), respectively. Further analysis revealed that the qualifications of endoscopists were positively correlated with the detection rates of GPLs in the cardia (ρ = 0.350, P = 0.034), angularis (ρ = 0.396, P = 0.015) and gastric body (ρ = 0.453, P = 0.005) but not in the antrum (ρ = 0.292, P = 0.079). Moreover, the experience of endoscopic assistants was positively correlated with the detection rate of precancerous lesions by endoscopists with low or moderate qualifications (ρ = 0.427, P = 0.015).

CONCLUSION

Endoscopists and endoscopic assistants with high/very high qualifications, but not EBR, can improve the detection rate of GPLs. These results provide reliable evidence for the development of gastroscopic quality control indicators.

Endoscopic resection of gastrointestinal tumors: Training levels and professional roles explored

In this editorial, we provide commentary on a recently published study by Zhao et al in the World Journal of Gastrointestinal Oncology. The study discusses the clinical characteristics of patients undergoing endoscopic resection for gastric cancers. We feel it is important to engage our endoscopy community in a discussion on the current evidence in the literature on the necessary number of cases for training in endoluminal surgery techniques, particularly endoscopic submucosal dissection. This includes the latest recommendations from the European Society of Gastrointestinal Endoscopy, as well as a summary of key studies on the learning curve for these techniques. Additionally, we explore the impact of an endoscopist's specialty on endoscopy outcomes, drawing from current evidence in the literature to shape our perspective in this evolving field.

The Role of ETS2 in Macrophage Inflammation

Autoimmune and inflammatory diseases are rising globally yet widely effective therapies remain elusive. Most treatments have limited efficacy, significant potential side effects, or eventually lose response, underscoring the urgent need for new therapeutic approaches. We recently discovered that ETS2, a transcription factor, functions as a master regulator of macrophage-driven inflammation-and is causally linked to the pathogenesis of multiple inflammatory diseases via human genetics. The pleotropic inflammatory effects of ETS2 included upregulation of many cytokines that are individually targeted by current disease therapies, including TNFα, IL-23, IL1β, and TNF-like ligand 1A signaling. With the move toward combination treatment-to maximize efficacy-targeting ETS2 presents a unique opportunity to potentially induce a broad therapeutic effect. However, there will be multiple challenges to overcome since direct ETS2 inhibition is unlikely to be feasible. Here, we discuss these challenges and other unanswered questions about the central role that ETS2 plays in macrophage inflammation.

Partial ampullary endoscopic mucosal resection in patients with difficult biliary cannulation: a prospective cohort study

The rescue techniques available for cannulation failure are few in number and have severe limitations. We recently described partial ampullary endoscopic mucosal resection (PA-EMR) as a novel technique for difficult biliary cannulation. We aimed to demonstrate the efficacy and safety of PA-EMR for patients with difficult biliary cannulation in a larger cohort.We conducted a prospective cohort study at our tertiary care referral hospital. We recorded demographic factors, procedure-related characteristics, and adverse event rates in patients with difficult biliary cannulation who underwent PA-EMR.Between June 2021 and June 2022, we performed 1073 consecutive endoscopic retrograde cholangiopancreatography procedures on 962 patients; 40 patients (12 male, 28 female, with a mean age of 68.1 [SD 4] years) had difficult biliary cannulation and underwent PA-EMR. Technical success was 100%, and none of the patients required a second session. None of the patients had an adverse event, and we encountered no 30-day mortality. The most typical indication was bile duct stones (60%; n = 24), followed by periampullary tumors (15%; n = 6). The total procedure time was 923 (range 392-1224) seconds.PA-EMR was an effective and safe rescue technique in patients with difficult biliary cannulation.

Diagnosis and management of gastrointestinal hemorrhage: What you need to know

ABSTRACT

Acute gastrointestinal (GI) hemorrhage is a common cause for hospital admission that requires prompt diagnosis and multidisciplinary management to optimize clinical outcomes. Acute gastrointestinal bleeding (GIB) includes both upper and lower GI tract sources with an extensive list of differential pathologies. This review provides a systematic approach to both upper and lower GIB management, emphasizing initial resuscitation, stabilization, diagnostic evaluation to identify the source, and treatment modalities. Endoscopy remains the cornerstone for diagnostic and interventional purposes, significantly reducing the need for surgical procedures. However, lower GIB and severe or refractory cases may necessitate additional imaging and interventions, including surgical management. Integrating clinical guidelines, evidence-based strategies, and individualized care, this review delineates what you need to know to diagnose and manage acute GI hemorrhage.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

HLA-DQA1*05 Allele Carriage and Anti-TNF Therapy Persistence in Inflammatory Bowel Disease

INTRODUCTION

Carriage of the HLA-DQA1*05 allele is associated with development of antidrug antibodies (ADAs) to antitumor necrosis factor (anti-TNF) therapy in patients with Crohn's disease. However, ADA is not uniformly associated with treatment failure. We aimed to determine the impact of carriage of HLA-DQA1*05 allele on outcome of biologic therapy evaluated by drug persistence.

METHODS

A multicenter, retrospective study of 877 patients with inflammatory bowel disease (IBD) treated with anti-TNF therapy with HLA-DQA1*05 genotypes were generated by imputation from whole genome sequence using the HIBAG package, in R. Primary end point was anti-TNF therapy persistence, (time to therapy failure), segregated by HLA-DQA1*05 allele genotype and development of a risk score to predict anti-TNF therapy failure, incorporating HLA-DQA1*05 allele genotype status (LORisk score).

RESULTS

In all, 877 patients receiving anti-TNF therapy were included in our study; 543 (62%) had no copy, 281 (32%) one copy, and 53 (6%) 2 copies of HLA-DQA1*05 allele. Mean time to anti-TNF therapy failure in patients with 2 copies of HLA-DQA1*05 allele was significantly shorter compared with patients with 0 or 1 copy at 700 days' follow-up: 418 vs 541 vs 513 days, respectively (P = .012). Factors independently associated with time to anti-TNF therapy failure included carriage of HLA-DQA1*05 allele (hazard ratio [HR], 1.2, P = .02; female gender HR, 1.6, P < .001; UC phenotype HR, 1.4, P = .009; and anti-TNF therapy type [infliximab], HR, 1.5, P = .002). The LORisk score was significantly associated with shorter time to anti-TNF therapy failure (P < .001).

CONCLUSIONS

Carriage of 2 HLA-DQA1*05 alleles is associated with less favorable outcomes for patients receiving anti-TNF therapy with shorter time to therapy failure. HLA-DQA1*05 genotype status in conjunction with clinical factors may aid in therapy selection in patients with IBD.

Exploring the genetic components and multi-omics sources of inflammatory bowel disease from the perspective of autoimmune disorders

BACKGROUND

Inflammatory bowel disease (IBD) and autoimmune disorders result from immune system dysregulation. However, the genetic overlap between them remains unclear. Our study aimed to investigate the genetic mechanisms and structure of IBD from the perspective of autoimmune disorders.

METHODS

The genetic correlation (rg) between traits can provide valuable information about the shared underlying biological mechanisms. Utilizing summary statistics from genome-wide association studies, we delved into the genetic correlation, shared inheritance, and potential causality of IBD (N = 34,652) with autoimmune disorders (N = 1,755,610). We performed transcriptomics at the gene level, multi-marker analyses of genome annotations, and enrichment analyses of biological pathways to highlight shared and diverse perspectives.

RESULTS

There were significant genetic correlations between IBD and ankylosing spondylitis (rg = 0.327), rheumatoid arthritis (rg = 0.242), type 1 diabetes (rg = - 0.061), psoriasis (rg = 0.246), and ankylosing spondylitis (rg = 0.308). We identified 110 unique regions (including 5p33.3, 10q25.3, and 22q13.31) after a consistent study at the gene levels. By implementing transcriptomics techniques, we discovered potential common biological mechanisms in several tissues, including blood, spleen, thyroid, and pancreas, revealing potential common biological mechanisms involving lincRNA, protein-coding, and pseudogenes.

CONCLUSION

Our study demonstrated hypothesized pleiotropic genomic regions that provide important clues to delve into the genetic basis of IBD and autoimmune disorders on the basis of multi-omics. Moreover, we have identified shared pathogenic processes and potential common therapeutic targets among these diseases. Key Points • The finding provides a new perspective on the genetic basis of inflammatory bowel disease and autoimmune disease across multi-omics platforms. • Fine mapping of functional summary-based imputation and causal genomes has identified hypothesized pleiotropic genomic regions. • The identified genes and pathways may offer innovative targets for the prevention of immune-related diseases.

Development of 3D training models for the identification and classification of colorectal polyps

Colorectal cancers develop from pre-malignant polyps that can be removed during colonoscopy. Detection, assessment, and removal of polyps has a major role in bowel cancer prevention and is an important part of bowel cancer screening programmes. Trainee colonoscopists must acquire skills to recognise and classify colorectal polyps. Accurate classification is based on morphology, surface pit and capillary patterns. It is difficult to teach assessment skills because static polyp images are often of poor quality and cannot show all areas of interest. Based on anonymised, endoscopic reference images, 3D polyp models were created in ZBrush, demonstrating a variety of morphological forms. The models had detailed pit patterns to show the capillary structure, a key predictor of pathology. The models were subsequently uploaded to the online 3D repository and model viewer, Sketchfab, to create an interactive training resource for trainee colonoscopists. The digital models were evaluated by a panel of expert colonoscopists who scored them for realism and potential as aids for training. There was agreement that the digital polyp models would be useful for teaching. Polyp morphology was rated as realistic however representation of pit patterns received a mixed response, highlighting areas for further development.

Curriculum for training in peroral endoscopic myotomy (POEM) in Europe (Part I): European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure that has become a first-line treatment for esophageal achalasia and other esophageal spastic disorders. Structured training is essential to optimize the outcomes of this technique. The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in POEM. This Position Statement presents the results of a systematic review of the literature and a formal Delphi process, providing recommendations for an optimal training program in POEM that aims to produce endoscopists competent in this procedure. In a separate document (POEM curriculum Part II), we provide technical guidance on how to perform the POEM procedure based on the best available evidence. 1: POEM trainees should acquire a comprehensive theoretical knowledge of achalasia and other esophageal motility disorders that encompasses pathophysiology, diagnostic tool proficiency, clinical outcome assessment, potential adverse events, and periprocedural management. 2: Experience in advanced endoscopic procedures (endoscopic mucosal resection and/or endoscopic submucosal dissection [ESD]) is encouraged as a beneficial prerequisite for POEM training. 3: ESGE suggests that POEM trainees without ESD experience should perform an indicative minimum number of 20 cases on ex vivo or animal models before advancing to human POEM cases with an experienced trainer. 4: ESGE recommends that the trainee should observe an indicative minimum number of 20 live cases at expert centers before starting to perform POEM in humans. 5: The trainee should undertake an indicative minimum number of 10 cases under expert supervision for the initial human POEM procedures, ensuring that trainees can complete all POEM steps independently. 6: ESGE recommends avoiding complex POEM cases during the early training phase. 7: POEM competence should reflect the technical success rate, both the short- and long-term clinical success rates, and the rate of true adverse events. 8: A POEM center should maintain a prospective registry of all procedures performed, including patient work-up and outcomes, procedural techniques, and adverse events.

Neurogastroenterology: The Cinderella among the ecological niches of gastroenterology?

Neurogastroenterology (NGE) refers to a specific sub-specialty of gastroenterology that investigates the pathophysiology, diagnostics and therapeutic approaches to the "disorders of gut-brain interaction" (DGBIs), frequently encountered in clinical practice and often associated with poor quality of life and high healthcare costs. Two recent national surveys, focused on common DGBIs, highlighted two main issues. Despite the high incidence of DGBIs there is a lack of awareness and appropriate training to effectively treat these conditions and a lack of specific referral centers in each region. Indeed, specific training and a multidisciplinary approach are required to properly manage these patients, but these are not always available. As a result, NGE lacks attractiveness for many young gastroenterologists. We believe that NGE has great potential to emerge among the various sub-branches of gastroenterology. However, its growth is limited by lack of specific training, knowledge, accessibility, diagnostic capabilities, multidisciplinary integration, and financial investments in research. To bridge this gap, it would be helpful to overcome these limits through an increase in specific training concerning DGBIs among students, residents, physicians and general practitioners. This, coupled with improved access to advanced diagnostic tests, innovative therapies, and a better multidisciplinary approach, could help expand the knowledge in this still niche area and achieve better treatment outcomes for patients.

Utilisation of Deep Neural Networks for Estimation of Cajal Cells in the Anal Canal Wall of Patients with Advanced Haemorrhoidal Disease Treated by LigaSure Surgery

Interstitial cells of Cajal (ICCs) play a key role in gastrointestinal smooth muscle contractions, but their relationship with anal canal function in advanced haemorrhoidal disease (HD) remains poorly understood. This study uses deep neural network (DNN) models to estimate ICC presence and quantity in anal canal tissues affected by HD. Haemorrhoidectomy specimens were collected from patients undergoing surgery with the LigaSure device. A YOLOv11-based machine learning model, trained on 376 immunohistochemical images, automated ICC detection using the CD117 marker, achieving a mean average precision (mAP50) of 92%, with a recall of 86% and precision of 88%. The DNN model accurately identified ICCs in whole-slide images, revealing that one-third of grade III HD patients and 60% of grade IV HD patients had a high ICC density. Preoperatively, pain was reported in 35% of grade III HD patients and 41% of grade IV patients, with a significant reduction following surgery. A significant decrease in bleeding (p < 0.0001) was also noted postoperatively. Notably, patients with postoperative bleeding, diagnosed with stage IV HD, had high ICC density in their anorectal tissues (p = 0.0041), suggesting a potential link between ICC density and HD severity. This AI-driven model, alongside clinical data, may enhance outcome prediction and provide insights into HD pathophysiology.

Epidemiology, pathogenesis, diagnosis, and treatment of inflammatory bowel disease: Insights from the past two years

ABSTRACT

Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease, is a chronic inflammation of the gastrointestinal tract with unknown etiology. The cause of IBD is widely considered multifactorial, with prevailing hypotheses suggesting that the microbiome and various environmental factors contribute to inappropriate activation of the mucosal immune system in genetically susceptible individuals. Although the incidence of IBD has stabilized in Western countries, it is rapidly increasing in newly industrialized countries, particularly China, making IBD a global disease. Significant changes in multiple biomarkers before IBD diagnosis during the preclinical phase provide opportunities for earlier diagnosis and intervention. Advances in technology have driven the development of telemonitoring tools, such as home-testing kits for fecal calprotectin, serum cytokines, and therapeutic drug concentrations, as well as wearable devices for testing sweat cytokines and heart rate variability. These tools enable real-time disease activity assessment and timely treatment strategy adjustments. A wide range of novel drugs for IBD, including interleukin-23 inhibitors (mirikizumab, risankizumab, and guselkumab) and small-molecule drugs (etrasimod and upadacitinib), have been introduced in the past few years. Despite these advancements, approximately one-third of patients remain primary non-responders to the initial treatment, and half eventually lose response over time. Precision medicine integrating multi-omics data, advanced combination therapy, and complementary approaches, including stem cell transplantation, psychological therapies, neuromodulation, and gut microbiome modulation therapy, may offer solutions to break through the therapeutic ceiling.

Optimal timing for discontinuation of ERCP in cases of difficult selective biliary cannulation

Background and study aims

Prolonged cannulation during endoscopic retrograde cholangiopancreatography (ERCP) increases risk of complications, particularly post-ERCP pancreatitis (PEP). This study aimed to determine optimal timing to discontinue ERCP when selective biliary cannulation (SBC) cannot be easily achieved.

Patients and methods

Patients with naïve papilla who underwent ERCP between January 2021 and December 2021 were analyzed. The primary outcome was to determine optimal timing for discontinuing ERCP based on cannulation success rate and complication rate.

Results

A total of 272 patients with naïve papilla underwent ERCP. Trainees did not participate in any of the procedures. Median age was 71 years, and 152 patients (55.9%) were male. The most common indication for ERCP was choledocholithiasis (60.7%), followed by malignant obstruction (24.3%) and benign stricture (4.8%). SBC was achieved in 249 patients (91.5%). After excluding patients with pre-procedure amylase elevation or preexisting pancreatitis, 232 patients were analyzed for complications. Eighteen patients (6.7%) experienced complications, with PEP occurring in 15 patients (5.5%). SBC success was achieved in 50% of cases at 3.3 minutes and in 90% at 12.1 minutes. In contrast, the PEP rate reached 10% after 7.9 minutes and 14.5% after 12.1 minutes. Multivariate analysis identified distal biliary stricture and age over 70 as significant predictors of difficult SBC.

Conclusions

In cases of difficult SBC, discontinuing attempts at around 8 minutes may minimize risk of PEP. However, extending attempts up to 12 minutes can be justified to achieve higher success rates. Beyond 12 minutes, likelihood of successful SBC diminishes significantly.

In-hospital mortality in patients with lower gastrointestinal bleeding: development and validation of a prediction score

BACKGROUND

 Lower gastrointestinal bleeding (LGIB) is a common condition linked to increased morbidity, healthcare costs, and mortality. Currently, no prospectively validated prognostic model exists to predict mortality in patients with LGIB. Our aim was to develop and validate a risk score that could accurately predict in-hospital mortality of patients admitted for LGIB.

METHODS

 Patient data from a nationwide cohort study in 15 centers in Italy (2019-2020) were used to derive the risk score, the Acute Lower gastrointestinal Bleeding and In-hospital mortality (ALIBI) score; the model was then externally validated in a cohort of consecutive patients hospitalized for LGIB in 12 centers from six countries (Italy, Spain, France, Greece, Iran, and Brazil) from 2022 to 2024. The main outcome was in-hospital mortality; we also reported rebleeding rates and the in-hospital mortality rate stratified by risk score and timing of colonoscopy. RESULTS : Among 1198 patients in the derivation cohort, 105 (8.8%) re-bled and 41 (3.4%) died. Age, Charlson Co-morbidity Index, in-hospital onset, hemodynamic instability, and creatinine level were independent predictors of in-hospital mortality. The model demonstrated excellent discrimination (area under the receiver operating curve [AUROC] 0.81, 95%CI 0.75-0.87) and calibration. In the validation cohort (n = 752 patients), the model's good discrimination (AUROC 0.79, 95%CI 0.72-0.86) and calibration were confirmed. Patients were categorized as low (0-4 points; 1% mortality), intermediate (5-9 points; 4.6% mortality), or high risk (10-13 points; 19.1% mortality). CONCLUSION : A new validated score effectively predicts in-hospital mortality in patients with LGIB, aiding in their risk stratification and management.

Clinical evaluation of a novel single-use therapeutic gastroscope: a pilot feasibility study

The trend toward disposable products in gastrointestinal endoscopy, including single-use endoscopes, remains undeterred, even though crucial questions of sustainability and performance have not been sufficiently studied. The first single-use therapeutic gastroscope was recently approved in Europe, but clinical data to support its use are currently lacking. We aimed to evaluate the performance of this novel device in routine procedures requiring a large working channel.Between January and May 2024, consecutive patients with an indication for therapeutic gastroscopy were included prospectively. The primary outcome was intraprocedural technical success rate.Eight gastrointestinal bleedings, two pancreatic necrosectomies, four foreign body removals, four stent placements, and two cryo-balloon ablations were performed. The technical success rate was 84% (16/19 patients). Crossover to a standard endoscope was required in three procedures. Clinical success was achieved in all cases with technical success. Overall user experience was 3.2 on a Likert scale of 1-5. No adverse events were reported.The single-use therapeutic gastroscope demonstrated feasibility in various therapeutic procedures; however, a 16% crossover rate and fair user assessment score suggest that further technical improvements to the device are necessary.

Successful management by laparoscopic total gastrectomy following embolization for gastric cancer with overt bleeding: two case reports

Gastric cancer (GC) bleeding is typically silent and chronic. However, active bleeding from GC can lead to life-threatening conditions. Endoscopic haemostasis is sometimes difficult and emergency surgery is associated with high postoperative complication rates. We encountered two cases of life-threatening GC haemorrhage. The patients were successfully treated with transcatheter arterial embolization and subsequent elective laparoscopic total gastrectomy. Preoperative embolization is effective for subsequent minimally invasive elective surgery in patients with severe bleeding from GC.

Massive Lower Gastrointestinal Bleeding From Colonic Submucosal Lipoma and Diverticular Disease: A Rare Case Requiring Surgical Interventions and Postoperative Management Challenges

Massive lower gastrointestinal (GI) bleeding (LGIB) is a life-threatening condition requiring prompt diagnosis and management. While diverticular disease is a common cause, rare entities such as colonic submucosal lipomas may complicate the presentation. This case highlights the diagnostic and therapeutic challenges in managing such a scenario, particularly with recurrent bleeding and postoperative complications. A 61-year-old patient presented with recurrent episodes of massive LGIB over a five-day period. Initial evaluations, including CT angiography and nuclear medicine imaging, identified diverticular disease but failed to localize the bleeding source definitively. Despite receiving 15 units of blood transfusions, the patient experienced persistent bleeding, ultimately necessitating emergency surgery. A right hemicolectomy revealed a submucosal lipoma and diverticular disease in the ascending colon with significant intraluminal hemorrhage. Postoperative management was complicated by pulmonary embolism, requiring therapeutic anticoagulation. This case emphasizes the importance of integrating multiple diagnostic modalities when evaluating massive LGIB, especially in patients with uncommon etiologies. It also highlights the complexities of managing massive transfusion protocols and postoperative thromboembolic events in high-risk patients. This report underscores the need for timely surgical intervention in unresolved cases of massive LGIB and the importance of vigilant postoperative care to prevent complications. Enhanced strategies for early mobilization and hydration are critical for improving outcomes in these patients.

Environmental and Clinical Factors Concerning Gastrointestinal Bleeding: An Umbrella Review of Meta-Analyses

OBJECTIVES

Gastrointestinal bleeding, an emergency and critical disease, is affected by multiple factors. This study aims to systematically summarize and appraise various factors associated with gastrointestinal bleeding.

DESIGN

Umbrella review.

SETTING AND PARTICIPANTS

Meta-analyses that evaluated environmental and clinical factors concerning gastrointestinal bleeding.

METHODS

We conducted a systematic search to identify eligible meta-analyses. For each included study, the risk estimates, heterogeneity estimates, small-study effects, excess significance tests, and publication biases were recalculated and appraised. Furthermore, we considered the methodologic quality and classified the evidence.

RESULTS

In this study, 51 beneficial and 44 harmful associations were found. This study found that preemptive transjugular intrahepatic portosystemic shunt was the most reliable treatment to reduce gastroesophageal variceal bleeding and mortality risk, followed by antibiotics. For gastroduodenal ulcer bleeding, Yunnan Baiyao and proton pump inhibitors (PPIs) were relatively dependable treatment drugs, and the comparatively reliable prophylactic drugs comprised PPIs and H2-receptor antagonists. Patients with hemodynamic instability and larger ulcers had a higher risk of rebleeding. Both weekend admissions and the combination of selective serotonin reuptake inhibitors and nonsteroidal anti-inflammatory drugs were high-risk factors for upper gastrointestinal bleeding and mortality. We also found that tranexamic acid was a credible drug for overall gastrointestinal bleeding. Meanwhile, aspirin, warfarin, diabetes, and renal failure were all high-risk factors.

CONCLUSIONS AND IMPLICATIONS

Altogether, many factors can substantially influence gastrointestinal bleeding. Therefore, in daily life and clinical practice, we should not only remain cautious in prescribing and taking some drugs but also pay attention to the management of lifestyle and underlying diseases. If necessary, protective drugs should be properly supplemented.

Efficacy of e-learning using video content in improving trainees' biliary cannulation skills and understanding (with video)

Objectives

E-learning with video content was created to improve trainees' biliary cannulation techniques; this study aimed to evaluate its educational effect prospectively.

Methods

E-learning program was conducted using videos demonstrating biliary cannulation for 24 papillae, targeting trainees with 2-6 years of experience in endoscopic retrograde cholangiopancreatography. Ten consecutive cases of biliary cannulation for native papillae performed by trainees were prospectively assessed before and after the e-learning, respectively. The primary outcome was the difficult biliary cannulation rate; the secondary outcomes included a comprehension score assigned by the trainer for each biliary cannulation (maximum of 6 points), trainee failure rate, and adverse events incidence.

Results

Eleven trainees participated in the e-learning program. The overall and per-trainee analyses showed no significant differences in the difficult biliary cannulation rate, trainee failure rate, and adverse event incidence before and after e-learning. However, the overall analysis showed a significant increase in comprehension scores after e-learning (median 4 vs. 5, p < 0.01) and the per-trainee analysis revealed that the rate of comprehension score ≥5 increased significantly after e-learning (p = 0.02). Comprehension score <5 (odds ratio: 4.31, p < 0.01) and endoscopic retrograde cholangiopancreatography experience <3 years (odds ratio: 2.15, p = 0.01) were independent risk factors for difficult biliary cannulation. Additionally, the difficult biliary cannulation incidence showed a negative correlation with the comprehension score (p < 0.01).

Conclusions

E-learning using video content did not result in a reduction in the difficult biliary cannulation rate. However, it significantly enhanced procedural understanding, indicating its potential to support future acquisition of biliary cannulation skills.

Automatic endoscopic gastroplasty for the treatment of obesity: results from a prospective multicenter study (with video)

BACKGROUND AND AIMS

EndoZip (Nitinotes Ltd, Cesarea, Israel) is a fully automated, operator-independent robotic endoscopic suturing device developed for gastric volume reduction and treatment of obesity. We aim to assess the efficacy and safety of EndoZip to treat patients with obesity.

METHODS

We conducted a prospective multicenter study and recruited 45 patients with a body mass index of 30 to 40 kg/m2. Our primary outcome was to assess the percentage of total body weight loss (%TBWL) at 12 months. The secondary outcome was to determine the safety and change in quality of life using the Influence of Weight on the Quality of Life questionnaire at 1 year.

RESULTS

The mean ± standard deviation age was 44.2 ± 8.8 years, and the mean ± standard deviation body mass index was 34.5 ± 2.9 kg/m2. A majority (90.7%) of patients were female. The procedure was technically successful in all patients (100%). A median of 4 (range, 3-5) full-thickness sutures were placed, and the mean procedure time was 30.8 ± 15.8 minutes. At 12 months, the mean %TBWL was 13.21 (95% confidence interval, 10.11-16.31), and 76.6% of patients achieved ≥5% TBWL. We observed significant reduction in waist circumference, glycated hemoglobin, and alanine aminotransferase levels at 12 months (P < .001). We found a significant improvement in quality of life at 12 months (51.28 ± 16.22 vs 35.8 ± 11.9, P < .001). Serious adverse events occurred in 2 patients (4.4%). The average length of stay was 1 day.

CONCLUSIONS

Our first-in-human study showed that the EndoZip device is safe and effective in treating obesity. The weight loss led to changes in comorbidities and improvement in quality of life. (Clinical trial registration number: NCT04773795.).

The efficacy, safety, and persistence of vedolizumab versus adalimumab in patients with inflammatory bowel disease: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis compared the efficacy, safety, and treatment persistence of vedolizumab and adalimumab in patients with inflammatory bowel disease (IBD).

METHODS

Through a comprehensive search of three databases up to September 2024, we calculated pooled effect estimates for binary outcomes using risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity was evaluated using Cochran's I2 and Q statistics, with a random-effects model applied when I2 exceeded 50%, and a fixed-effects model used otherwise. For randomized trials, the Cochrane Risk of Bias Tool was applied; the Newcastle-Ottawa Scale assessed nonrandomized trials.

RESULTS

We analyzed 12 studies involving 4095 patients. The findings showed that vedolizumab had higher clinical remission and response rates compared to adalimumab (RR: 1.24, 95% CI 1.14-1.34, P < 0.01; RR: 1.11, 95% CI 1.01-1.22, P = 0.03). However, no significant differences were observed in endoscopic remission between the two treatments (RR: 0.74, 95% CI 0.47-1.18, P = 0.21). Safety outcomes, based on adverse and serious adverse event rates, have no significant differences (RR: 0.67, 95% CI 0.41-1.12, P = 0.13; RR: 0.78, 95% CI 0.36-1.68, P = 0.53). Treatment persistence also showed no significant difference between vedolizumab and adalimumab (RR: 0.78, 95% CI 0.55-1.12, P = 0.19).

CONCLUSIONS

Our study suggests that vedolizumab may be more effective than adalimumab in alleviating symptoms and achieving clinical response. Importantly, this effectiveness is achieved without an increase in adverse events. No significant difference was found in treatment persistence. However, high heterogeneity may weaken the evidence, requiring further randomized trials for confirmation.

Micro-bacterial assessment of disposable gowns with a focus on green endoscopy in gastrointestinal endoscopy procedures: A Japanese pilot study for healthcare waste reduction

Objective

This study aimed to implement green endoscopy through the microbiological assessment of gowning techniques during endoscopy to reduce carbon emissions and separate medical waste.

Methods

Twenty-five patients who performed esophagogastroduodenoscopy from March to May 2024 were included in this study. Four sections of the isolation gowns (anterior, posterior, right, and left) were cut into 2 cm2 after endoscopy, and the rate of microbial contamination was examined using the stamp method.

Results

The endoscopic examination time was 8 min (6-12), and endoscopy was performed by 10 expert endoscopists, six endoscopists, and nine residents. The overall isolation gown contamination rate was 56%, with 25%, 20.8%, 20.8%, and 33.3% in the front, back, as well as right and left arms, respectively. The rates of isolation gown contamination rates in the expert endoscopists, endoscopists, and residents groups were 30%, 50%, and 77.8%, respectively, with a higher rate in the residents group. Regardless of the physician's performance, bacterial detection was consistently higher in the left arm (42.9% vs. 40% vs. 25%; p = 0.093). The detected bacteria comprised 58% Gram-positive and 42% Gram-negative organisms, including those from tap water used for endoscopy bacteria and obtained from the participant's skin or mouth. No pathogenic organisms were detected.

Conclusions

The bacteria detected in disposable gowns after gastrointestinal endoscopy were non-pathogenic. Thus, our findings suggest that changing all personal protective equipment of respective endoscopes might not be essential. We advocate for green endoscopy to achieve sustainable development goals and reduce medical waste.