Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

This Technical and Technology Review from the European Society of Gastrointestinal Endoscopy (ESGE) represents an update of the previous document on the technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including the available types of needle, technical aspects of tissue sampling, new devices, and specimen handling and processing. Among the most important new recommendations are:ESGE recommends end-cutting fine-needle biopsy (FNB) needles over reverse-bevel FNB or fine-needle aspiration (FNA) needles for tissue sampling of solid pancreatic lesions; FNA may still have a role when rapid on-site evaluation (ROSE) is available.ESGE recommends EUS-FNB or mucosal incision-assisted biopsy (MIAB) equally for tissue sampling of subepithelial lesions ≥20 mm in size. MIAB could represent the first choice for smaller lesions (<20 mm) if proper expertise is available.ESGE does not recommend the use of antibiotic prophylaxis before EUS-guided tissue sampling of solid masses and EUS-FNA of pancreatic cystic lesions.

Examination of endoscopic intracanal observation with an ultrafine-diameter scope

OBJECTIVES

The endoscopic channel can be damaged by instruments during use and cleaning, leading to contamination, infection, and increased repair costs. However, few devices are available to observe the inside of the endoscopic channel. This study employed an ultrafine-diameter scope to examine damage in the endoscopic channel.

METHODS

Fifty-eight endoscopes used at our institution were examined for scratches, discoloration, or deformation in the endoscopic channel using an ultrafine-diameter scope.

RESULTS

Damage was observed in seven of the 24 observation endoscopes and 27 of the 34 therapeutic endoscopes, with damage being more common in the therapeutic endoscopes. Scratches were observed in nine of the 25 upper gastrointestinal endoscopes, 23 of the 24 colonoscopes, and one of the two echoendoscopes. Additionally, two colonoscopes, one echoendoscope, and one double-balloon endoscope showed indentation or narrowing near the curvature.

CONCLUSIONS

The use of an ultrafine-diameter scope enabled the detection of minute damage and deformations in the channel. Periodic observation with the ultrafine-diameter scope may promote the long-term use of the scopes.

Risk factors for biliary tract events during elective cholecystectomy waiting time after endoscopic retrograde cholangiopancreatography for choledocholithiasis

Objectives

Endoscopic lithotripsy and elective cholecystectomy, followed by endoscopic retrograde cholangiopancreatography, are the first-line treatments for patients with common bile duct (CBD) stones (CBDS) and gallstones. However, this approach entails acute cholecystitis and recurrent cholangitis risk while patients await surgery. We aimed to identify acute cholecystitis and cholangitis risk factors during the waiting time for elective cholecystectomy.

Methods

This study comprised 151 patients with CBDS combined with gallstones who underwent cholecystectomy within 90 days of the first endoscopic retrograde cholangiopancreatography at two tertiary care centers between January 2019 and October 2021.

Results

The incidence of biliary tract events (acute cholecystitis, acute cholangitis, or any complications requiring unplanned cholangiopancreatography) was 28% (43 cases). In univariate and multivariate analyses, plastic stent placement as a bridge to surgery for the first treatment of CBDS was an independent risk factor for biliary tract events during the waiting time for surgery (odds ratio 4.25, p = 0.002). A subgroup analysis among those with plastic stent placement revealed a CBD diameter of ≤ 10 mm as an independent risk factor for acute cholecystitis (odds ratio 4.32; p = 0.027); a CBD diameter ≥ 11 mm was an independent risk factor for acute cholangitis and unplanned re-endoscopic retrograde cholangiopancreatography (odds ratio 5.66; p = 0.01).

Conclusions

Plastic stent placement for CBDS before elective cholecystectomy increases the risk of acute cholecystitis or acute cholangitis during the waiting time for elective cholecystectomy.

Barrett's Oesophagus Surveillance Versus Endoscopy at Need Study (BOSS): A Randomized Controlled Trial

BACKGROUND & AIMS

Barrett's esophagus (BE) is a precursor lesion for esophageal adenocarcinoma (EAC). Surveillance endoscopy aims to detect early malignant progression; although widely practiced, it has not previously been tested in a randomized trial.

METHODS

BOSS (Barrett's Oesophagus Surveillance Versus Endoscopy at Need Study) was a randomized controlled trial at 109 centers in the United Kingdom. Patients with BE were randomized to 2-yearly surveillance endoscopy or "at-need" endoscopy, offered for symptoms only. Follow-up was a minimum of 10 years. The primary outcome was overall survival in the intention-to-treat population. Secondary outcomes included cancer-specific survival, time to diagnosis of EAC, stage of EAC at diagnosis, frequency of endoscopy, and serious adverse events related to interventions.

RESULTS

There were 3453 patients recruited; 1733 patients were randomized to surveillance and 1719 to at-need endoscopy. Median follow-up time was 12.8 years for the primary outcome. There was no evidence of a difference in overall survival between the surveillance arm (333 deaths among 1733 patients) and the at-need arm (356 deaths among 1719 patients; hazard ratio, 0.95; 95% CI, 0.82-1.10; stratified log-rank P = .503). There was no evidence of a difference for surveillance vs at-need endoscopy in cancer-specific survival (108 vs 106 deaths from any cancer; hazard ratio, 1.01; 95% CI, 0.77-1.33; P = .926), time to diagnosis of EAC (40 vs 31 patients had a diagnosis of EAC; hazard ratio, 1.32; 95% CI, 0.82-2.11; P = .254), or cancer stage at diagnosis. Eight surveillance patients (0.46%) and 7 at-need patients (0.41%) reported serious adverse events.

CONCLUSIONS

Surveillance did not improve overall survival or cancer-specific survival. At-need endoscopy may be a safe alternative for low-risk patients. (ClinicalTrials.gov, Number: NCT00987857.).

Rectal arterial embolization for hemostasis of acute hemorrhagic rectal ulcers: A case series

Acute hemorrhagic rectal ulcer (AHRU), though a relatively rare etiology of lower gastrointestinal bleeding, represents a critical clinical emergency characterized by sudden onset, painless, massive, and fresh rectal bleeding. While endoscopic hemostasis remains prominent therapy, its efficacy is limited in emergency settings by poor bowel preparation and obscured visualization. Rectal arterial embolization (RAE) offers a viable alternative, however, detailed descriptions of its application for AHRU in literature are lacking. Thus, we report a single-center experience of RAE in six patients with massive AHRU-related bleeding. Technical success was achieved in 83% (5/6) of cases, with clinical success was achieved in 100% cases (6/6). Rebleeding after initial RAE procedure occurred in 33% (2/6) of cases, one of which ultimately achieving hemostasis through transanal suturing after initial embolization failure. No major embolism-related complications were observed during follow-up. Moreover, complete embolization of rectal supplies demonstrated potential to reduce rebleeding risk, and empiric embolization may hold promise for managing refractory AHRU hemorrhage. These findings advocate for RAE as an effective alternative for AHRU hemorrhage, though further validation in larger cohorts is essential.

Comparison of Propofol and Sevoflurane as Anesthesia Maintenance Agents in Relation to Postoperative Pain, Nausea and Vomiting During Endoscopic Retrograde Cholangio-Pancreatography: A Prospective, Single-Center, Randomized, Single-Blind Pilot Study

Introduction Halogen gas anesthesia is considered to be more conducive to postoperative nausea and vomiting (PONV) than total intravenous anesthesia. This difference has been demonstrated in surgery, but there have been no studies on postoperative pain (POP), nausea and vomiting based on anesthesia in the specific environment of endoscopy, to the best of our knowledge. Our aim was therefore to carry out a preliminary study to investigate a trend in POP, nausea and vomiting during endoscopic retrograde cholangio-pancreatography (ERCP), depending on the type of the maintenance anesthetic agent used. Methods This single-center, prospective, randomized, single-blind pilot study included 42 adult patients (American Society of Anesthesiologists classification score, ASA ≤ 3) benefiting from ERCP. They were randomized into two groups depending on the type of maintenance anesthetic used: the "sevoflurane" group and the "propofol" group (target-controlled infusion, Schnider model). Moreover, in both groups, all patients received balanced anesthesia based on alfentanil and rocuronium. The principal aim of our study was to investigate pain, nausea and vomiting during the first 48 hours postoperatively based on the anesthesia maintenance agent chosen. During the first 48 hours, PONV episodes were counted, pain was measured using the visual analogue scale and all analgesics and antiemetics administered were recorded. Results The two groups studied showed no statistically significant difference. The incidence of PONV was 36.4% in the sevoflurane group and 30% in the propofol group. Statistical analysis showed no significant difference in the occurrence of PONV or in the number of emetic episodes at 48 h postoperatively. There was no significant difference between the two groups in terms of the analgesics used to assess postoperative pain. Finally, there were no differences in the types of analgesics used postoperatively. Conclusion There appeared to be no difference in terms of postoperative pain, nausea and vomiting after ERCP in adults, based on the choice of maintenance anesthetic agent (sevoflurane versus propofol). However, the results of this pilot study should be confirmed in a larger sample.

Endoscopic Papillary Balloon Dilation Versus Small Endoscopic Sphincterotomy for Endoscopic Retrograde Cholangiopancreatography-Related Adverse Events in Patients With Non-Dilated Distal Bile Duct

OBJECTIVE

Endoscopic papillary balloon dilation (EPBD), small endoscopic sphincterotomy (EST), and small EST plus EPBD are commonly used as rescue techniques to remove bile duct stones. However, we often encountered challenging cases with non-dilated distal bile ducts, especially in those undergoing EPBD. We aimed to explore the reasons by assessing whether patients without the dilated bile duct had a higher risk of early complications and whether it was impacted by the rescue techniques.

METHODS

We performed a retrospective cohort study by frequency matching design in patients diagnosed with stones in non-dilated distal bile duct who received rescue techniques from July 2016 to June 2022. Besides, patients with stones and without dilatation of the distal bile duct (DDBD) were divided into 3 subgroups according to the rescue technique received. Outcomes were compared between the subgroups.

RESULTS

The non-DDBD group was more likely to develop post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and hyperamylasemia (HP) than the DDBD group ( P < 0.05). Some cases had mild or moderate pancreatitis, but no one in either group developed severe pancreatitis. For subgroup analysis, each technique resulted in complete stone removal; the EPBD group had a higher HP rate than the other subgroups and reached statistical significance: the EPBD group versus the small EST group ( P = 0.013) and the EPBD group versus the EPBD plus small EST group ( P = 0.008). Although there was no statistical significance, PEP incidence in the EPBD group was 13.7% higher than in other subgroups ( P > 0.05/3).

CONCLUSION

Non-DDBD patients have a higher risk for endoscopic retrograde cholangiopancreatography-related pancreatic inflammation. EPBD should be used cautiously due to the significant association with increased rates of PEP and HP. Conversely, small EST and combination therapy are suitable for non-dilated bile duct stones because of their high safety profile and efficacy.

APAGE Position Statements on Green and Sustainability in Gastroenterology, Hepatology, and Gastrointestinal Endoscopy

BACKGROUND AND AIM

The APAGE Position Statements aimed to provide guidance to healthcare practitioners on clinical practices aligned with climate sustainability.

METHODS

A taskforce convened by APAGE proposed provisional statements. Twenty-two gastroenterologists from the Asian Pacific region participated in online voting and consensus was assessed through an anonymized and iterative Delphi process.

RESULTS

There were five sections that addressed the rationale for climate action, the importance of adopting principles of waste management, clinical practice, gastrointestinal endoscopy, and issues related to advocacy and research. Sixteen statements achieved consensus and included the following: 1. APAGE recommends adopting prompt measures to reduce the carbon footprint of clinical practice due to the importance of climate action and its health cobenefits. 5. APAGE recommends adherence to professional clinical guidelines to optimize clinical care delivery in gastroenterology and hepatology to avoid the environmental impact of unnecessary procedures and tests. 8. APAGE recommends an emphasis on health promotion, disease prevention, and appropriate screening and surveillance, when resources are available, to reduce the environmental impact of managing more advanced diseases that require more intensive resources. 12. APAGE recommends that technological advances in endoscopic imaging and artificial intelligence, when available, be used to improve the precision of endoscopic diagnosis to reduce the risk of missed lesions and need for unnecessary biopsies. 13. APAGE recommends against the routine use of single-use endoscopes.

CONCLUSION

The position statements provide guidance to healthcare practitioners on clinical practices in gastroenterology, hepatology, and endoscopy that promote climate sustainability.

All-in-one sphincterotome with high rotation performance and freely bendable blade for endoscopic sphincterotomy in patients with surgically altered anatomy (a case series with video)

A new type of sphincterotome released to the market recently has high rotation performance and a freely bendable blade. It is devised to be singly capable of accommodating not only normal anatomy but also cases with surgically altered anatomy. This study was undertaken for clinical evaluation of the usefulness of this new sphincterotome. Eight cases in a reconstructed intestine for which cannulation or endoscopic sphincterotomy (EST) had been performed were extracted from 32 cases for which endoscopic retrograde cholangiopancreatography-related procedures were performed using the sphincterotome developed during November 2023 through February 2024. The cases were investigated retrospectively. Among these, EST was applied to six cases. Cannulation was performed using the developed sphincterotome in the native papilla in four cases. The primary endpoints were the success rate of cannulation in surgically altered anatomy and the success rate of EST. Secondary endpoints were complications and usability for operators. Usability for operators was evaluated by questionnaire for several items on a 5-point scale. EST was conducted successfully in all six cases subjected to EST. Mild hemorrhage was observed in one case (17%) as an adverse event after EST. Deep cannulation to the native papilla with the developed sphincterotome was conducted successfully in three cases (75.0%). Evaluation results by operators were 4.4 ± 0.55 for rotation performance, 4.00 ± 0.63 for incision performance, 4.29 ± 0.49 for deep cannulation performance, and 4.07 ± 0.19 for overall evaluation. In conclusion, this developed sphincterotome might be very useful for EST and cannulation in cases with surgically altered anatomy.

Current status and issues for prediction and prevention of postendoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis, which sometimes results in mortality, is a significant complication of endoscopic retrograde cholangiopancreatography (ERCP). Many studies have been conducted to predict and prevent post-ERCP pancreatitis (PEP), and meta-analyses have been reported that summarized these studies. However, many issues remain unresolved. Many risk factors for PEP have been reported, and it is rare for patients undergoing ERCP to have only one risk factor. The use of artificial intelligence may be important for analyzing complex and diverse risk factors. It is desirable to develop an alternative test for pancreatic enzymes that can predict the onset of PEP within 1 h after ERCP. The effectiveness of low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are controversial. Nitrate and tacrolimus are considered medications that have additional effects on NSAIDs and may be used for the prevention of PEP. Pancreatic stent placement with deliberate placement of the guidewire into the pancreatic duct may be more effective in preventing PEP. A comparison between transpancreatic sphincterotomy with deliberate guidewire placement into the pancreatic duct and needle-knife precut sphincterotomy is necessary. Early precutting is thought to be effective for the prevention of PEP, and the effectiveness of primary precut has been reported. However, the optimal timing of precut for the prevention of PEP has not been sufficiently discussed. Further research on prediction and prevention must be conducted to eliminate the mortality caused by PEP.

Safety of cold snare resection techniques for removal of polyps in the small colon in patients taking clopidogrel and aspirin: a Korean Association for the Study of Intestinal Diseases prospective multicenter study

BACKGROUND AND AIMS

Polypectomy is a procedure associated with a high risk of bleeding. Guidelines recommend uninterrupted aspirin use during polypectomy, whereas cessation of clopidogrel 5 to 7 days before polypectomy is recommended. The cold snare resection (CSR) technique, with or without submucosal injection, is considered safer than conventional polypectomy using electrocoagulation for postpolypectomy bleeding. In this study, we compared the bleeding adverse events associated with CSR between clopidogrel and aspirin users.

METHODS

This multicenter prospective cohort study was conducted in 5 academic hospitals in Korea and included clopidogrel and aspirin users who underwent polypectomy. Antiplatelet agents were used without interruption, with ≤3 days of interruption defined as continuous use. The primary endpoint was delayed bleeding, which was defined as bleeding occurring several hours after polypectomy, whereas immediate bleeding was defined as bleeding requiring hemostasis 2 minutes after polypectomy. Risk factors for immediate bleeding were investigated for each polyp.

RESULTS

Finally, 263 patients (509 polyps) were included, including those receiving clopidogrel (n=129) and aspirin (n=134). The rates of delayed bleeding per patient in the clopidogrel and aspirin groups were .8% and .7%, respectively, meeting noninferiority (rate difference, .03%; 95% confidence interval, -2.07 to 2.13). A total of 100 cases of hemostasis (19.8%) were performed in 68 patients after polypectomy. Immediate bleeding risk factors were female sex, end-stage renal disease, submucosal injection before resection, and polyp size ≥5 mm.

CONCLUSIONS

This multicenter prospective study demonstrated the safety of CSR in patients treated with uninterrupted clopidogrel and aspirin. (Clinical trial registration number: NCT04328987.).

Genetic polymorphisms impacting clinical pharmacology of drugs used to treat inflammatory bowel disease: a precursor to multi-omics approach to precision medicine

INTRODUCTION

Inflammatory bowel diseases (IBDs), comprised of ulcerative colitis (UC) and Crohn's disease (CD), are chronic inflammatory diseases of the gastrointestinal tract. Clinicians and patients must vigilantly manage these complex diseases over the course of the patient's lifetime to mitigate risks of the disease, surgical complications, progression to neoplasia, and complications from medical or surgical therapies. Over the past several decades, the armamentarium of IBD therapeutics has expanded; now with biologics and advanced small molecules complementing conventional drugs such as aminosalicylates, corticosteroids and thiopurines. Significant attention has been paid to the potential of precision medicine to assist clinicians in tailoring therapeutics based on patients' genetic signatures to maximize therapeutic benefit while minimizing adverse effects.

AREAS COVERED

In this paper, we review the published literature on genetic polymorphisms relevant to each class of IBD therapeutics.

EXPERT OPINION

Finally, we envision a paradigm shift in IBD research toward an omics-based network analysis approach. Through global collaboration, organization and goal setting, we predict the next decade of IBD research will revolutionize existing disease frameworks by developing precise molecular diagnoses, validated biomarkers, predictive models and novel molecularly targeted therapeutics.

The Role of Endoscopic Ultrasound in Assessing Portal Hypertension: A State-of-the-Art Literature Review and Evolving Perspectives

BACKGROUND

Portal hypertension (PH) is a critical complication in patients with hepatic diseases. Its accurate evaluation is essential for early diagnosis, risk stratification, and management. Endoscopic ultrasound (EUS) has emerged as a promising diagnostic tool, offering high-resolution imaging of the portal venous system, hepatic vasculature, and surrounding structures.

AIMS

This review aims at providing an overview of the evolving role of EUS in PH evaluation in patients with liver disease.

MATERIALS AND METHODS

A systematic search was conducted in PubMed and Google Scholar until 31 May 2024. Relevant studies were identified using keywords related to EUS and PH. Additional references were included based on expert knowledge and citation analysis. Only full-length papers and abstracts in English were considered.

RESULTS

EUS demonstrates significant utility in PH assessment, offering high-resolution imaging and advanced tools like contrast enhancement (CE) and shear-wave elastography (SWE) for evaluating liver stiffness and correlating it with PH severity. EUS-guided portal pressure gradient (PPG) measurement provides a less invasive method for evaluating PH, potentially offering a safer alternative to conventional techniques.

DISCUSSION

EUS offers unique advantages in PH assessment, enabling comprehensive evaluation in a single session. Despite its potential, limitations such as invasiveness, sedation-related variability, and restricted availability persist. Emerging techniques require further validation in larger cohorts and standardised training.

CONCLUSION

EUS is a valuable diagnostic tool for PH evaluation, with the potential to improve outcomes through earlier diagnosis and better stratification. Addressing its limitations through further research and standardised protocols is critical to optimize its clinical utility.

TRIAL REGISTRATION

NCT04115046, NCT05728697, NCT05097963 and NCT03155282.

Diffusion-weighted imaging to predict longer-term response in Crohn's disease patients commencing biological therapy: results from the MOTILITY trial

OBJECTIVES

Predicting longer-term response to biological therapy for small bowel Crohn's disease (SBCD) is an unmet clinical need. Diffusion-weighted magnetic resonance (MR) imaging (DWI) may indicate disease activity, but its predictive ability, if any, is unknown. We investigated the prognostic value of DWI for 1 year response or remission (RoR) in SBCD patients commencing biologic therapy, including incremental value over C-reactive protein (CRP) and faecal calprotectin (FC).

METHODS

A subset of participants in a prospective, multicentre study investigating the predictive ability of motility MRI for 1-year RoR in patients starting biologic therapy for active SBCD, underwent additional DWI at baseline and post-induction (12-30 weeks). CRP and FC were collected in a subgroup. RoR at 1 year was evaluated using clinical and morphological MR enterography (MRE) parameters. We calculated sensitivity and specificity to predict RoR and quality of life (QoL) at 1 year, comparing apparent diffusion coefficient (ADC) value, Clermont score, and CRP using multivariable logistic regression.

RESULTS

A total of 25 participants were included (mean 36.9 years, 32% female). ADC changes and Clermont score had poor sensitivity (30.0% [95% CI, 6.7-65.2] and 40.0% [95% CI, 12.2-73.8], respectively) and poor-to-modest specificity (50.0 [95% CI, 27.2-72.8] and 65.0% [95% CI, 40.8-84.6]) for RoR. None of Clermont score, CRP, or FC predicted QoL.

CONCLUSIONS

DWI has inadequate sensitivity and specificity for RoR at 1 year. There is no significant incremental prognostic value of DWI over CRP and FC to predict RoR and/or QoL at 1 year.

ADVANCES IN KNOWLEDGE

Early post-induction DWI has no prognostic value for RoR at 1 year.

Maintenance-phase serum anti-TNF levels are not associated with mucosal healing in pediatric Crohn's disease

OBJECTIVES

Mucosal healing (MH) is a key therapeutic target in Crohn's disease (CD) and is associated with improved outcomes. While adult studies indicate a positive correlation between serum anti-tumor necrosis factor (TNF) levels and MH, data in pediatric patients is limited. We aimed to define the association of serum anti-TNF levels with MH in pediatric patients with CD during maintenance therapy.

METHODS

Retrospective data (2014-2023) was collected from pediatric CD patients treated with infliximab or adalimumab who performed an ileocolonoscopy at least 26 weeks after initiating therapy. Serum anti-TNF levels around endoscopic time were compared with endoscopic findings. MH was defined as complete absence of inflammatory or ulcerative lesions across all segments of the gastrointestinal tract. Univariable and multivariable logistic regression analysis was conducted to identify factors associated with MH.

RESULTS

Data were obtained from 107 patients (41 infliximab and 66 adalimumab), with a median age at diagnosis of 12.6 (9.9-14.0) years. Median time until ileocolonoscopy following anti-TNF initiation was 89.0 (56.3-152.3) weeks. MH was identified in 31 (29.0%) patients. Anti-TNF serum levels were comparable in the MH and non-MH groups (9.5 [4.9-13.9] vs. 9.3 [6.4-15.7] µg/mL; p = 0.73), without differences in patients treated with infliximab or adalimumab. In multivariable analysis, diagnosis weight Z-score (odds ratio [OR] = 2.860, 95% confidence interval [CI] = 1.005-8.138; p = 0.049), along with C-reactive protein (OR = 0.037, 95% CI = 0.002-0.687; p = 0.027) and fecal calprotectin (OR = 0.995, 95% CI = 0.990-1.000; p = 0.037) at time of ileocolonoscopy were significantly associated with MH.

CONCLUSIONS

In our cohort, anti-TNF levels during maintenance were not associated with MH in pediatric CD.

The Durability of Anti-TNF Therapy for Crohn's Disease Is Higher in Anti-TNF Naïve Patients and Increases With Proactive Therapeutic Drug Monitoring

Background

Antitumor necrosis factor (TNF) dose escalation is performed to improve therapeutic response and optimize outcomes in patients with Crohn's disease (CD). We aimed to describe the durability of anti-TNF therapy in patients with CD receiving escalated anti-TNF therapy, along with the overall durability of anti-TNF treatment between patients managed with a proactive versus reactive therapeutic drug monitoring (TDM) approach.

Methods

We undertook a retrospective multicentre cohort study. One center practiced proactive TDM with a weekly virtual TDM clinic, while the other practiced reactive TDM. Patients receiving escalated infliximab or adalimumab therapy for CD from January 2015 to April 2022 were included. Durability was defined as the time from biologic start to cessation for treatment failure.

Results

About 239 patients (45% female, median age 39) meeting criteria for inclusion were identified. About 165 patients were included in the proactive TDM cohort and 74 in the reactive TDM cohort.Anti-TNF naïve patients had significantly higher durability of therapy when compared with the anti-TNF exposed patients for both overall durability (P = .045) and durability postescalation (P = .017). The proactive TDM cohort had significantly higher durability when compared with the reactive cohort for both overall durability (P = .001) and durability postescalation (P = .002).

Conclusions

This multicentre, retrospective cohort study illustrates the importance of dose escalation as a therapeutic strategy in IBD care. The durability of anti-TNF therapy is superior in anti-TNF naïve compared to exposed patients and can be improved further by proactive TDM to guide dose optimization.

Effect of periampullary diverticulum morphology on ERCP cannulation and clinical results

AIM

Periampullary diverticulum (PAD) is a common anatomical variant that can potentially impact the technical difficulty and outcomes of endoscopic retrograde cholangiopancreatography (ERCP), necessitating a comprehensive understanding of its effects on the procedure. To evaluate the effect of PAD subtypes and diameter on ERCP cannulation success and clinical outcomes.

MATERIALS AND METHODS

The study included patients with PAD and papilla-naïve patients undergoing ERCP for suspected common bile duct stones or distal benign strictures (due to PAD compression). PAD subtyping was based on Lobo and Li-Tanaka classifications. Diverticulum size was categorized as small (<1 cm), medium (1-2 cm), and giant (≥2 cm).

RESULTS

Of the 907 patients analyzed, 164 (18%) had PAD with a median age of 63 years. PAD patients were significantly older than non-PAD patients and had more comorbidities. The most frequent PAD type was 2B (34.1%) based on the Li-Tanaka classification. Subgroup analysis of PAD types 1, 2, 3, and 4 showed no statistically significant differences in cannulation time, success, total procedure time, or adverse events (AEs). Overall cannulation success rates were similar between PAD and non-PAD groups (99.4% vs 99.6%). Analysis based on diverticulum size revealed higher probabilities of giant stones and procedure-related AEs in giant diverticula. The risk of post-ERCP pancreatitis was notably low at 1.8% in the PAD group.

CONCLUSION

Diverticulum size, rather than PAD subtype, may be more closely associated with cannulation success and procedure-related AEs in ERCP. Individualized management considering diverticulum size may improve outcomes in PAD patients undergoing ERCP.

Patient Safety and Care After Outpatient Endoscopic Retrograde Cholangiopancreatography (ERCP): A Single-Center Experience in Germany

The current goal of adapting care structures in the German healthcare system is to increase the provision of interventional treatments in outpatient settings. Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures were traditionally performed in an inpatient setting until 2022. However, with the introduction of a new Ambulatory Surgery Contract (according to Section 115b, Paragraph 1 of the Social Code, Book V) on January 1, 2023, these procedures are now intended to be carried out more strictly on an outpatient basis, meaning that hospitalization will no longer be reimbursed in most cases.Between June 1, 2023, and December 31, 2023 all ERCP procedures performed in an outpatient setting were included in this study. This cohort had standard ERCP indications and a low comorbidity burden according to the §115b specifications. Using propensity score matching (nearest-neighbor), these cases were matched with patients who underwent ERCP procedures in an inpatient setting between June 1, 2022, and December 31, 2022.Propensity-score matching identified a cohort of 166 patients (83 outpatients and 83 inpatients) with similar baseline characteristics. The most common indications for ERCP were choledocholithiasis and biliary strictures. Reported complications comprised pancreatitis, bleeding and cholangitis and were rare in both groups, occurring in 7% of inpatient procedures and in 6% of outpatient procedures. The latter cases required inpatient admission after self-presenting to the emergency department. No serious adverse events were reported.Outpatient ERCP is a safe procedure for selected patients with a low risk profile. Complications occurred rarely and could be adequately managed.

Sequential rescue therapy with JAK inhibitors in corticosteroid and infliximab-refractory acute severe ulcerative colitis: a case series

Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency affecting over 20% of patients with ulcerative colitis (UC). Up to 40% of patients are refractory to intravenous corticosteroids (IVCS) and require rescue medical therapy or immediate colectomy. The potent Janus kinase (JAK) inhibitors, upadacitinib and tofacitinib, have proven efficacy in a randomised control trial setting for moderate-to-severe UC, but not ASUC. We describe a case series of sequential rescue therapy with JAK inhibitors following the failure of dose-intensified infliximab in corticosteroid-refractory ASUC. Six adult (>16 years old) patients received sequential rescue therapy with a JAK inhibitor (upadacitinib n = 5, tofacitinib n = 1) following failure of IVCS and dose-intensified infliximab at the Royal Brisbane and Women's Hospital (QLD, Australia) between October 2023 and April 2024. All patients met the Truelove and Witts criteria for ASUC on admission. Data were captured during admission and at 90-days post-discharge. Co-primary outcomes were 90-day colectomy-free survival and inpatient clinical response (<4 non-bloody stools per day) 72 h after JAK-inhibitor initiation. Secondary outcomes included 90-day clinical (PRO-2 score < 1) and biochemical (faecal calprotectin (FCP) < 150 µg/g and C-reactive protein (CRP) < 5 mg/L) corticosteroid-free remission and adverse events. Median CRP on admission was 100 mg/L (interquartile range (IQR) 58-105), median FCP 3400 µg/g (IQR 910-4950) and median Mayo Endoscopic Score 3. Four out of six patients had a clinical response within 72 h of sequential JAK-inhibitor rescue therapy. Two patients underwent emergent inpatient colectomy for refractory disease - one of whom developed post-operative sepsis. Among the four JAK-responders at 90 days, all achieved corticosteroid-free clinical remission and three achieved biochemical remission. No other adverse events were recorded. There is a promising role for JAK inhibitors as sequential rescue therapy following the failure of dose-intensified infliximab in select patients with corticosteroid-refractory ASUC.

The Future of Minimally Invasive GI and Capsule Diagnostics (REFLECT), October 2024

The fifth annual REFLECT (The futuRE oF MinimalLy InvasivE GI and Capsule diagnosTics) symposium, held in October 2024 in Nyborg, Denmark, focused on advancements in minimally invasive gastrointestinal (GI) diagnostics, particularly capsule endoscopy (CE) technologies. Key discussions included clinical updates, innovations in hardware and software, and the growing role of colon CE (CCE) in colorectal cancer screening. The event provided a platform for clinicians, engineers, industry representatives, and scientists to exchange knowledge and present the latest advancements in the field. Discussions covered clinical studies, future research protocols, and technological innovations, with also a notable focus on commercial solutions and expansion of the implementation of capsule endoscopy. The symposium also highlighted the significance of predictive models for patient selection and developments in panenteric CE. Innovative technologies presented included robotics for drug delivery and magnetic endoscopic guidance systems. AI advancements were discussed for their potential to reduce diagnostic fatigue and standardize image interpretation, but ethical concerns and the need for transparent algorithms remain. The importance of multidisciplinary collaboration was emphasized to bridge innovation and clinical practice. Home-based CCE delivery emerged as a promising model, despite mixed results from environmental impact assessments. Overall, REFLECT 2024 reinforced the clinical utility and challenges of capsule-based diagnostics, advocating for ongoing interdisciplinary research to support safe and effective integration into healthcare systems.

The Clinical Utility of Precision-Guided Dosing for Adalimumab Therapy Optimization in Inflammatory Bowel Disease: A Clinical Experience Program

Background/Objectives: This study aimed to establish the clinical utility of a therapeutic drug monitoring (TDM)-supported, model-informed precision dosing (MIPD) approach (precision-guided dosing [PGD]) by assessing the impact of pharmacokinetic (clearance [CL]) and clinical laboratory parameters on adalimumab (ADA) dosage adjustments during maintenance therapy for inflammatory bowel disease (IBD). Methods: In the EMPOWER study, blood was collected at any time post-ADA injection. Pharmacokinetic (PK) testing was conducted in an accredited lab. Inputs for the PGD test included ADA concentrations, antibodies to ADA, albumin levels, and the current dosing regimen. CL was calculated using nonlinear mixed-effect models. Results were reported to health care providers (HCPs) within 3 days. HCPs' treatment decisions were recorded and classified as treatment reduction, continuation, intensification, or ADA discontinuation. The physician global assessment (PGA) of disease activity was collected. Relationships between drug concentrations, CL, disease activity, and physician decision-making were assessed using logistic regression. Results: A total of 213 cases were assessed by 21 HCPs. ADA treatment was intensified in 24% and discontinued in 13% of cases. An ADA concentration ≤ 10 μg/mL was associated with a 23.7-fold and 3.0-fold higher likelihood of therapy intensification and PGA > 0, respectively, compared to concentrations > 10 μg/mL. An ADA concentration < 5 μg/mL was associated with a 3.3-fold higher likelihood of treatment discontinuation. CL ≥ 0.318 L/day was associated with a 10.4-fold higher likelihood of therapy intensification. Higher CL (>0.8 L/day) was associated with a 3.5-fold and 4.2-fold higher likelihood of treatment discontinuation and PGA > 0, respectively. Conclusions: PGD enables earlier and precise optimization of ADA dosing by predicting trough levels at any time during the therapy cycle. Optimized dosing to achieve target ADA concentrations and low clearance is crucial to mitigate therapy discontinuation and active disease in IBD patients.

Measurement of Anti-TNF Biologics in Serum Samples of Pediatric Patients: Comparison of Enzyme-Linked Immunosorbent Assay (ELISA) with a Rapid and Automated Fluorescence-Based Lateral Flow Immunoassay

Background: Therapeutic drug monitoring (TDM) of infliximab (IFX) and adalimumab (ADL) mainly relies on the use of enzyme-linked immunosorbent assays (ELISA). More recently, rapid assays have been developed and validated to reduce turnaround time (TAT). Here, we compared IFX and ADL concentrations measured with both ELISA and a new fluorescence-based lateral flow immunoassay (AFIAS). Methods: In serum samples from pediatric patients, IFX and ADL drug levels, and total anti-IFX antibodies were measured using clinically validated ELISA kits (Immundiagnostik AG). Samples were further analyzed using a new rapid assay (AFIAS, Boditech Med Inc.) to measure drug levels and total anti-IFX antibodies. Results: Spearman's correlation coefficients (rho) were 0.98 [95% confidence interval (CI) 0.97 to 0.99] for IFX (p < 0.001) and 0.83 (95% CI 0.72 to 0.90) for ADL (p < 0.001). Calculated % bias was -14.09 (95% Limits of agreement, LoA, -52.83 to 24.66) for IFX and 15.79 (LoA -37.14 to 68.73) for ADL. For the evaluation of total anti-IFX antibodies, we did not collect sufficient data to establish a statistically significant correlation between AFIAS and ELISA. The inter-rater agreement showed a "substantial" and a "moderate" agreement for IFX and ADL, respectively. Conclusions: Our results show that the AFIAS assay has an accuracy and analytical performance comparable to that of the ELISA method used for TDM of IFX and ADL. Therefore, the introduction of this device into routine clinical practice could provide results more quickly and with similar accuracy as ELISA, allowing clinicians to rapidly formulate clinical decisions.

Clinical Practice Guidelines for post-ERCP pancreatitis 2023

The Clinical Practice Guidelines for post-ERCP pancreatitis (PEP) 2023 provide updated recommendations for the prevention, diagnosis, and management of PEP. Endoscopic retrograde cholangiopancreatography (ERCP), a valuable procedure for diagnosing and treating pancreatobiliary diseases, can result in PEP as the most common adverse event. Since the first guidelines were published in 2015, advances in techniques and new research findings have necessitated this revision. The guidelines developed using the GRADE methodology target adult patients undergoing ERCP. They offer a comprehensive framework for clinicians to minimize the risk of PEP. For high-risk patients, endoscopic ultrasound before ERCP is recommended to avoid unnecessary procedures. The guidelines also discuss procedural and patient-related risk factors for PEP, highlighting that operator experience does not significantly affect PEP rates if performed under the supervision of skilled endoscopists. The diagnostic criteria include monitoring serum pancreatic enzyme levels postprocedure, and early computed tomography is advised in suspected cases. For treatment, the guidelines recommend following acute pancreatitis protocols. Key preventive measures include the use of temporary pancreatic duct stents and rectal nonsteroidal anti-inflammatory drugs, both of which are supported by strong evidence for reducing the incidence of PEP. Overall, these guidelines aim to enhance clinical outcomes by reducing PEP incidence and improving its management through evidence-based practices.

Hereditary Colorectal Cancer Syndromes: Small Bowel Cancer Risk and Endoscopic Surveillance Strategies

Background: Hereditary colorectal cancer syndromes, including familial adenomatous polyposis (FAP), Lynch syndrome (LS), and Peutz-Jeghers syndrome (PJS), are associated with an increased risk of small bowel cancer (SBC). Due to the low incidence and non-specific presentation of SBC, effective surveillance strategies are essential for early detection and management. This review aims to evaluate and compare current endoscopic techniques for small bowel surveillance in these patients. Methods: A comprehensive review was conducted using peer-reviewed studies sourced from PubMed. Various endoscopic modalities, including capsule endoscopy (CE), device-assisted enteroscopy (DAE), and intraoperative enteroscopy (IOE), were assessed for their diagnostic yield, safety, and clinical utility. Surveillance recommendations of the different syndromes were also examined. Results: CE offers high sensitivity but lacks histological sampling capability. DAE, including double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE), enables direct visualization, biopsy, and therapeutic interventions, albeit with greater procedural complexity. In FAP, duodenal surveillance follows the Spigelman classification to stratify cancer risk, while jejunal and ileal polyps remain less studied. LS patients have an increased SBC risk, warranting tailored endoscopic approaches. In PJS, surveillance aims to mitigate intussusception risks and allow early malignancy detection. Conclusions: Optimized surveillance strategies in hereditary colorectal cancer syndromes require a multimodal approach, integrating advanced endoscopic techniques with genetic risk stratification. Centralized care in tertiary centers improves outcomes by ensuring standardized surveillance protocols and enhancing early cancer detection. Artificial intelligence (AI) applied to CE and DAE is shaping promising prospects for the future surveillance of small bowel polyps by enhancing diagnostic accuracy and reducing the duration of the diagnostic process. Further research should investigate AI-assisted imaging and molecular biomarkers to optimize screening strategies.

Endoscopic Management of Recurrent Acute Pancreatitis

This review aims to summarize the role of endoscopic therapy in the management and outcomes of recurrent acute pancreatitis (RAP). RAP is a clinical entity characterized by repeated episodes of acute pancreatitis in the setting of a normal gland or chronic pancreatitis (CP). The aetiology of RAP can be identified in about 70% of cases; for the remaining cases, the term "idiopathic" (IRAP) is used. However, advanced diagnostic techniques may reduce the percentage of IRAP to 10%. Recognized causes of RAP are gallstone disease, including microlithiasis and biliary sludge, sphincter of Oddi dysfunction (SOD), pancreatic ductal abnormalities (either congenital or acquired) interfering with pancreatic juice or bile outflow, genetic mutations, and alcohol consumption. SOD, as a clinical entity, was recently revised in the Rome IV consensus, which only recognized type 1 dysfunction as a true pathological condition, while type 2 SOD was defined as a suspected functional biliary sphincter disorder requiring the documentation of elevated basal sphincter pressure to be considered a true clinical entity and type 3 was abandoned as a diagnosis and considered functional pain. Endoscopic therapy by retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) has been proven effective when a mechanical obstruction is found and can be removed. If an obstruction is not documented, few treatment options are available to prevent the recurrence of pancreatitis and progression toward chronic disease. In gallstone disease, endoscopic biliary sphincterotomy (EBS) is effective when a dilated common bile duct or biliary sludge/microlithiasis is documented. In type 1 SOD, biliary or dual sphincterotomy is generally successful, while in type 2 SOD, endotherapy should be reserved for patients with documented sphincter dysfunction. However, in recent years, doubts have been expressed about the real efficacy of sphincterotomy in this setting. When sphincter dysfunction is not confirmed, endotherapy should be discouraged. In pancreas divisum (PD), minor papilla sphincterotomy is effective when there is a dilated dorsal duct, and the success rate is the highest in RAP patients. In the presence of obstructive conditions of the main pancreatic duct, pancreatic endotherapy is generally successful if RAP depends on intraductal hypertension. However, despite the efficacy of endotherapy, progression toward CP has been shown in some of these patients, mainly in the presence of PD, very likely depending on underlying genetic mutations. In patients with IRAP, the real utility of endotherapy still remains unclear; this is because several unknown factors may play a role in the disease, and data on outcomes are few, frequently contradictory or uncontrolled, and, in general, limited to a short period of time.

The first WHO reference panel for Infliximab anti-drug antibodies: a step towards harmonizing therapeutic drug monitoring

Immunogenicity testing for anti-drug antibodies (ADA) is mandatory for regulatory approval of a biotherapeutic and can, in some instances, continue post-licensure. Typical examples are TNF inhibitors where biotherapeutic and ADA levels are relevant in clinical decision-making for optimal patient therapy. However, challenges with non-comparability of results due to plethora of bioanalytical techniques and the lack of standardization has hindered ADA monitoring in clinical practice. Two human anti-infliximab monoclonal antibodies (A, B) with defined characteristics were therefore lyophilized and assessed for suitability as a reference panel for ADA assays in an international study. Binding assays included the simple ELISA and common electrochemiluminescence (ECL) to the rare antigen binding test and lateral flow assays. For neutralisation, competitive ligand binding and reporter-gene assays were employed. Sample testing (e.g., antibodies, sera) showed differential reactivity depending on the assay and sample. Estimates for ADA levels using in-house standards varied substantially among assays/laboratories. In contrast, using antibody A for quantitating ADA levels reduced the interlaboratory variability and provided largely consistent estimates. The degree of harmonization was dependent on the assay, sample and the laboratory. Importantly, antibody A allowed ADA detection when missed using in-house standards. Recognition of sample B varied, possibly due to its fast dissociation. Overall, the panel comprising A (coded 19/234) and B (coded 19/232) was suitable and established by the WHO Expert Committee on Biological Standardization in October 2022 as the WHO international reference panel for infliximab ADA assays. Sample A (coded 19/234) with an arbitrarily assigned unitage of 50,000IU/ampoule for binding activity and 50,000 IU/ampoule for neutralising activity is intended as a 'common standard' for assay characterization and where possible for calibration of anti-infliximab preparations to facilitate comparison and harmonization of results across infliximab ADA assays. Sample B (19/232) with its unique characteristics and variable detection but no assigned unitage is intended for assessing the suitability of the assay for detecting ADAs with fast dissociation. It is anticipated that this panel would help towards selecting and characterizing suitable assays, benchmarking of in-house standards where feasible and in harmonizing ADA assays used in clinical practice for better patient outcome globally.

Genetic factors that predict response and failure of biologic therapy in inflammatory bowel disease

Inflammatory bowel disease (IBD) represents a significant disease burden marked by chronic inflammation and complications that adversely affect patients' quality of life. Effective diagnostic strategies involve clinical assessments, endoscopic evaluations, imaging studies, and biomarker testing, where early diagnosis is essential for effective management and prevention of long-term complications, highlighting the need for continual advancements in diagnostic methods. The intricate interplay between genetic factors and the outcomes of biological therapy is of critical importance. Unraveling the genetic determinants that influence responses and failures to biological therapy holds significant promise for optimizing treatment strategies for patients with IBD on biologics. Through an in-depth examination of current literature, this review article synthesizes critical genetic markers associated with therapeutic efficacy and resistance in IBD. Understanding these genetic actors paves the way for personalized approaches, informing clinicians on predicting, tailoring, and enhancing the effectiveness of biological therapies for improved outcomes in patients with IBD.

Latest Advances in Pancreatobiliary Endoscopy

The field of biliopancreatic endoscopy has witnessed transformative advancements, driven by technological innovations, novel techniques, and an evolving understanding of disease processes [...].

Endoscopic Sustainability PrimAry Reporting Essentials (E-SPARE): European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

A growing number of studies aim to evaluate gastrointestinal (GI) endoscopy services from the perspective of their environmental impact. However, there are currently no guidelines or frameworks which provide specifically for the reporting of endoscopy sustainability studies, and a variety of metrics and assessment tools have been employed in the literature. To improve the clarity, transparency, and quality of reporting, the European Society of Gastrointestinal Endoscopy (ESGE) has developed a reporting framework for the community of researchers interested in conducting studies on sustainable GI endoscopy.

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Association of early therapeutic drug monitoring of adalimumab with biologic remission and drug survival in Crohn's Disease

Background

Therapeutic drug monitoring of adalimumab (ADA) is still controversial.

Objectives

To study the association between ADA trough levels in the early stages of treatment with biological remission (BR) and drug survival in Crohn's disease (CD).

Design

Retrospective cohort study.

Methods

Patients treated with ADA with available trough levels at weeks 2 and 6 (after the first induction and maintenance dose, respectively) were included. Fecal calprotectin (Fcal) and C-reactive protein (CRP) were registered at baseline, week 24, and week 52. BR was defined as Fcal <200 µg/g and CRP <5 mg/dl. Treatment survival and the need for dose escalation were assessed at week 52. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic accuracy of ADA cutoff levels for BR. Quartile-specific comparisons were performed to evaluate differences in the proportion of patients achieving BR at weeks 24 and 52, drug survival, and dose escalation.

Results

In all, 112 patients were included. ADA trough levels at week 6 were higher in patients achieving BR at week 24 (12.32 μg/ml vs 10.3 μg/ml, p = 0.0008), week 52 (12.3 μg/ml vs 10.8 μg/ml, p = 0.035), and in patients with 1-year treatment persistence (12.17 μg/ml vs 9.7 μg/ml, p = 0.03), but lower in patients requiring maintenance intensification (9.7 μg/ml vs 12.2 µg/ml, p < 0.0001). ADA week 6 trough levels >12.27 μg/ml predicted BR at week 24 with 79.7% specificity and 79.5% positive predictive value. Patients in the third quartile (Q3) and fourth quartile (Q4) of ADA levels at week 6 exhibited higher rates of BR at week 24, BR at week 52, 1-year drug survival, and less need for dose escalation (all p-values <0.05). In logistic regression, Q3 and Q4 of week 6 levels were significantly associated with BR at week 24 (p = 0.02 and p = 0.001); and week 6 Q4 with BR at week 52 (p = 0.02), treatment persistence (p = 0.03), and lower dose escalation (p = 0.004). ADA trough levels at week 2 did not show similar associations.

Conclusion

ADA trough levels at week 6 are associated with BR at weeks 24 and 52, drug survival, and need for dose escalation in CD. However, ADA concentrations at week 2 failed to yield similar results.

Persistence and Efficacy of Ustekinumab in Crohn's Disease After Anti-TNF Failure: An Observational Study

BACKGROUND

Anti-TNF treatment failure in Crohn's disease is common, and the literature on the selection of subsequent treatment is scant. Ustekinumab may be associated with high persistence rates and it appears to be effective in perianal disease.

AIMS

Primary objective: persistence, clinical, and biologic remission with ustekinumab.

SECONDARY OBJECTIVES

Persistence of the first biologic therapy, reasons for change of treatment, need for dose optimization, surgery, hospitalizations, and adverse events with ustekinumab.

METHODS

Retrospective, observational, single-center study from a prospective database of Crohn's disease adult patients receiving ustekinumab after failure of anti-TNF or vedolizumab. A sub-analysis was performed to evaluate ustekinumab persistence after the approval of risankizumab and upadacitinib.

RESULTS

Mean duration with ustekinumab was 27.65 months (SD 18.27) and persistence was 86.76%. Clinical remission was 40.63% at week 4, 54.35% at week 8, 54.9% at year 1, 76.92% at year 4, and 100% at year 5. Persistence with ustekinumab was longer than with anti-TNF: year 1, 93.2 vs 72.06%; year 2, 89.4 vs 45.59%; and year 3, 86.1 vs 30.88%. Just over one-third (36.76%) of patients required dose optimization. Nine (13.24%) patients stopped treatment due to primary non-response [1 (1.47%)], loss of response [5(7.35%)], and adverse events [3 (4.41%)]. Eleven (16.18%) patients needed surgery and hospitalization. After the approval of upadacitinib and risankizumab, ustekinumab persistence was 80.88%. Seven (70%) of the patients with perianal disease achieved clinical remission and 4 (40%) completed fistula healing.

CONCLUSIONS

Ustekinumab may have better persistence as a second-line treatment compared to anti-TNF and may be effective in perianal disease.

Incidence, Risk Factors, and Prevention Strategies for Post-ERCP Pancreatitis in Patients with Biliopancreatic Disorders and Acute Cholangitis: A Study from a Romanian Tertiary Hospital

Background/Objectives: Pancreatitis is the most frequent and serious complication of endoscopic retrograde cholangiopancreatography (ERCP), with an incidence between 2 and 10% and a mortality rate of 1 in 500 patients. Etiopathogenesis remains poorly understood. The aim of this study was to analyze the incidence of post-ERCP pancreatitis (PEP) and to identify potential patient- and procedure-related risk factors (RF) in a cohort of patients from a tertiary referral center in Romania. Methods: We conducted a retrospective, observational, single-center study in which we analyzed ERCP procedures performed in the Gastroenterology Department of Colentina Clinical Hospital, Bucharest, Romania, between January 2019 and September 2024. All patients received intrarectal diclofenac before the ERCP and were hydrated with at least 1500 mL of Ringer's solution after the procedure in the absence of contraindications, according to the latest international recommendations. Results: In total, 2743 ERCPs were performed in the given time period, while 2350 procedures were analyzed in the study. PEP occurred in 350 cases (14.9%). Of these, 191 (54.6%) occurred in males with a mean age of 66.5 years. Procedural RF with adjusted odds ratios (OR) were as follows: difficult cannulation of the common bile duct, OR = 3.734, p < 0.001, main pancreatic duct catheterization, OR = 1.454, p = 0.022, and endoscopic papillary balloon dilatation, with an OR of 3.258, p < 0.001. Pancreatic duct stent placement was shown to prevent PEP in this study group (p < 0.001). Conclusions: PEP remains a serious complication of ERCP, associated with significant morbidity and occasional mortality. While some proven risk factors, such as age, gender, or comorbidities, are unmodifiable, avoiding Wirsung duct cannulation and pancreatography, or prophylactic pancreatic duct stent placement, could play a significant role in PEP prevention.

Therapeutic Drug Monitoring of Biologics: Current Practice, Challenges and Opportunities - a Workshop Report

Therapeutic drug monitoring (TDM) for dose modification of biologics has the potential to improve patient outcomes. The US Food and Drug Administration (FDA) and the American Association of Pharmaceutical Scientists (AAPS) hosted the first US-based public workshop on TDM of biologics with contributions from a broad array of interested parties including healthcare providers, clinical pharmacologists, test developers, bioanalysis and immunogenicity scientists, health economics and outcomes research (HEOR) experts and regulators. The key insight was that despite a body of evidence to support TDM in certain therapeutic areas, there remain substantial challenges to widespread clinical implementation. There is a lack of consensus regarding the integration of TDM in clinical guidelines, and a lack of consensus on the cost-effectiveness of TDM; both factors contribute to the difficulty that healthcare providers face in obtaining reimbursement for TDM (both coverage of testing itself, and coverage of potential dosing modifications). The HEOR experts outlined alternative routes to obtaining reimbursement and suggested advocating for changes in coverage policies to promote TDM use in the clinic. Reaching alignment across policy makers, patients and advocacy groups, payers, and healthcare providers, on specific treatment settings where TDM will be clearly beneficial, was identified as an important step to advancing TDM implementation for the benefit of patients.

Feasibility of cholecystectomy in patients with silent common bile duct stones cohort prospective single arm multicentre study

BACKGROUND

The management of patients with concomitant gallbladder stones with silent CBDS still involves a wide range of debates, and there is little evidence regarding the recommendation of CBD clearance either before cholecystectomy or in the same session. In this study, we aimed to discuss the feasibility of performing LC with a wait-and-see strategy for patients with silent CBS.

METHOD

Patients with silent CBDS identified during preoperative examinations for gallbladder stones were studied for the feasibility of performing LC with a wait-and-see strategy for silent CBS.

RESULTS

Sixty patients who presented with gallbladder stones with silent CBDS underwent LC between February 2023 and July 2023. Seventeen patients (28.3%) underwent laparoscopic acute cholecystectomy, and 43 (71.7%) patients underwent laparoscopic elective cholecystectomy; all of these procedures were completed laparoscopically. Two patients (3.3%) developed symptomatic CBDS, both of whom were treated medically without intervention. Sixteen patients (26.7%) experienced spontaneous CBDS during the follow-up period.

CONCLUSION

Patients who present with symptomatic gall bladder stones either acutely or electively with asymptomatic CBDS can undergo laparoscopic cholecystectomy without suffering from CBDS with acceptable short-term outcomes.

TRIAL REGISTRATION

This study was registered at Suez med - IRB office under trial registration no. 6 and registered at clinicaltrials.gov (NCT06349876) in 31/3/2024.

The Role of Human Leukocyte Antigen Alleles and Maternal Microchimerism in Very-Early-Onset Ulcerative Colitis in Japanese Children

BACKGROUND

Very-early-onset ulcerative colitis (VEO-UC) is a severe form of inflammatory bowel disease that manifests before the age of 6 years. Compared to typical pediatric UC, it is characterized by distinct genetic and immunological factors. This study aimed to investigate the roles of specific human leukocyte antigen (HLA) alleles and maternal microchimerism (MMc) in the pathogenesis of VEO-UC in a Japanese population.

METHODS

This study included 27 VEO-UC patients, including 4 patients treated with colorectal resection. HLA typing was performed by polymerase chain reaction-sequence-specific oligonucleotide probing (PCR-SSOP) and compared with the Japanese general population. Immunohistochemistry and fluorescence in situ hybridization were used to evaluate MMc in intestinal tissues. Statistical comparisons of HLA were performed against data from the general Japanese population, with Bonferroni corrections applied to handle multiple comparisons.

RESULTS

HLA-B52 and HLA-DR15 were more prevalent in cases of VEO-UC than in the general Japanese population, although the statistical significance decreased after the Bonferroni correction. MMc was found in the intestinal tissues of three VEO-UC cases, whereas it was absent in the control UC cases. Maternal HLA concordance with specific alleles associated with VEO-UC was noted in several cases, suggesting maternal immune involvement in the pathogenesis of the disease.

CONCLUSIONS

VEO-UC seems to share genetic traits with adult UC, such as an association with HLA-B52 and HLA-DR15, and is also affected by maternal immune contributions, as shown by the presence of MMc in the affected tissues. These findings highlight the complex interaction between genetic and immunological factors in the pathogenesis of VEO-UC and underscore the need for further research to develop targeted therapeutic strategies that address these mechanisms.

Management of gastrointestinal bleed in the intensive care setting, an updated literature review

Gastrointestinal (GI) bleeding is a critical and potentially life-threatening condition frequently observed in the intensive care unit (ICU). This literature review consolidates current insights on the epidemiology, etiology, management, and outcomes of GI bleeding in critically ill patients. GI bleeding remains a significant concern, especially among patients with underlying risk factors such as coagulopathy, mechanical ventilation, and renal failure. Managing GI bleeding in the ICU requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures. Even with enhanced management strategies, GI bleeding in the ICU is associated with considerable morbidity and mortality, particularly when complicated by multi-organ failure. This review reiterates the need for adequate resuscitation and interventions in managing GI bleeding in critically ill patients, aiming to enhance survival rates and improve the quality of care within the ICU setting.

Biologics in the management of pediatric inflammatory bowel disease: When and what to choose

Pediatric inflammatory bowel disease (PIBD) is a chronic inflammatory disorder of the gastrointestinal tract, with rising global incidence and prevalence. Over the past two decades, biologics have added to the therapeutic armamentarium and revolutionized the approach to treatment of inflammatory bowel disease. The available biologics include monoclonal antibodies which target inflammatory cytokines (anti-tumor necrosis factor alpha, anti-interleukin 12/23) or recruitment of leucocytes to the gastrointestinal tract (anti-alpha4beta7 integrin) and small molecules (Janus kinase inhibitors, sphingosine 1-phosphate-inhibitors) which modify the proinflammatory signaling. Considering their potential disease-modifying ability, recent pediatric guidelines from the West have advocated upfront use of biologics in appropriate clinical scenarios as a top-down approach rather than the conventional step-up approach. Although real-world studies are available regarding the clinical efficacy of biologics in PIBD, there is paucity of long-term outcome and safety data in children. Also, little information is available about the best approach in the newly industrialized - developing countries where PIBD is rising but at the same time, infections are prevalent and resources are limited. In this review, we summarize the efficacy and safety profile of biologics and small molecule drugs and discuss the challenges in the management of PIBD, especially in the developing world, and future directions.

Small Bowel Motility Quantified by Cine MRI to Predict Longer-Term Response in Patients with Crohn's Disease Commencing Biological Therapy: The Motility Study

BACKGROUND

Small bowel Crohn's disease (SBCD) is increasingly treated with biological therapies. Predicting response or remission (RoR) for individual patients is difficult and complicates treatment strategy. We aimed to determine if motility magnetic resonance imaging (mMRI) is superior to CRP and fecal calprotectin (FC) for the prediction of RoR at 1 year in patients commencing biologics for SBCD.

METHODS

Prospective, multicenter (n = 13) cohort study of patients with active non-stricturing SBCD requiring anti-TNFα or anti-IL-12/23 treatment. We measured mMRI and CRP at baseline and post-induction (visit 2: 12-30 weeks), and FC in a subset. RoR was assessed at 1 year using clinical and structural magnetic resonance enterography parameters. We compared sensitivity, specificity, and area under the receiver operating characteristic curve (ROC-AUC) of changes in mMRI and CRP to predict RoR at 1 year. Secondary outcomes compared mMRI with FC, and prediction of improved quality of life (QoL).

RESULTS

Eighty-six participants completed all assessments. Stable or improved mMRI at visit 2 was more sensitive than normalization of CRP for RoR (mMRI:71.0%, 95%CI 52.0-85.8; CRP:45.2%, 95%CI 27.3-64.0%, P = .008) but less specific (mMRI:30.9%, 95%CI 19.1-44.8; CRP:67.3%, 95%CI 53.3-79.3%, P < .001). There was no significant difference in ROC-AUC (mMRI:0.48; CRP:0.53, P = .65). Similar results were obtained for FC. None of mMRI, CRP, or FC predicted patient QoL at 1 year.

CONCLUSIONS

Although improved mMRI is more sensitive than CRP and FC to predict RoR at 1 year, it is less specific. No factor predicted patient QoL. Motility MRI remains a marker of disease activity at given timepoints.

Machine Learning Models With Prognostic Implications for Predicting Gastrointestinal Bleeding After Coronary Artery Bypass Grafting and Guiding Personalized Medicine: Multicenter Cohort Study

BACKGROUND

Gastrointestinal bleeding is a serious adverse event of coronary artery bypass grafting and lacks tailored risk assessment tools for personalized prevention.

OBJECTIVE

This study aims to develop and validate predictive models to assess the risk of gastrointestinal bleeding after coronary artery bypass grafting (GIBCG) and to guide personalized prevention.

METHODS

Participants were recruited from 4 medical centers, including a prospective cohort and the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. From an initial cohort of 18,938 patients, 16,440 were included in the final analysis after applying the exclusion criteria. Thirty combinations of machine learning algorithms were compared, and the optimal model was selected based on integrated performance metrics, including the area under the receiver operating characteristic curve (AUROC) and the Brier score. This model was then developed into a web-based risk prediction calculator. The Shapley Additive Explanations method was used to provide both global and local explanations for the predictions.

RESULTS

The model was developed using data from 3 centers and a prospective cohort (n=13,399) and validated on the Drum Tower cohort (n=2745) and the MIMIC cohort (n=296). The optimal model, based on 15 easily accessible admission features, demonstrated an AUROC of 0.8482 (95% CI 0.8328-0.8618) in the derivation cohort. In external validation, the AUROC was 0.8513 (95% CI 0.8221-0.8782) for the Drum Tower cohort and 0.7811 (95% CI 0.7275-0.8343) for the MIMIC cohort. The analysis indicated that high-risk patients identified by the model had a significantly increased mortality risk (odds ratio 2.98, 95% CI 1.784-4.978; P<.001). For these high-risk populations, preoperative use of proton pump inhibitors was an independent protective factor against the occurrence of GIBCG. By contrast, dual antiplatelet therapy and oral anticoagulants were identified as independent risk factors. However, in low-risk populations, the use of proton pump inhibitors (χ21=0.13, P=.72), dual antiplatelet therapy (χ21=0.38, P=.54), and oral anticoagulants (χ21=0.15, P=.69) were not significantly associated with the occurrence of GIBCG.

CONCLUSIONS

Our machine learning model accurately identified patients at high risk of GIBCG, who had a poor prognosis. This approach can aid in early risk stratification and personalized prevention.

TRIAL REGISTRATION

Chinese Clinical Registry Center ChiCTR2400086050; http://www.chictr.org.cn/showproj.html?proj=226129.

The development and ex vivo evaluation of a computer-aided quality control system for Barrett's esophagus endoscopy

BACKGROUND : Timely detection of neoplasia in Barrett's esophagus (BE) remains challenging. While computer-aided detection (CADe) systems have been developed to assist endoscopists, their effectiveness depends heavily on the quality of the endoscopic procedure. This study introduces a novel computer-aided quality (CAQ) system for BE, evaluating its stand-alone performance and integration with a CADe system. METHOD : The CAQ system was developed using 7,463 images from 359 BE patients. It assesses objective quality parameters (e. g., blurriness, illumination) and subjective parameters (mucosal cleanliness, esophageal expansion) and can exclude low-quality images when integrated with a CADe system.To evaluate CAQ stand-alone performance, the Endoscopic Image Quality test set, consisting of 647 images from 51 BE patients across 8 hospitals, was labeled for objective and subjective quality. To assess the benefit of the CAQ system as a preprocessing filter of a CADe system, the Barrett CADe test set was developed. It consisted of 956 video frames from 62 neoplastic patients and 557 frames from 35 non-dysplastic patients, in 12 Barrett referral centers. RESULTS : As stand-alone tool, the CAQ system achieved Cohen's Kappa scores of 0.73, 0.91, and 0.89 for objective quality, mucosal cleanliness, and esophageal expansion, comparable to inter-annotator scores of 0.73, 0.93, and 0.83. As preprocessing filter, the CAQ system improved CADe sensitivity from 82 % to 90 % and AUC from 87 % to 91 %, while maintaining specificity at 75 %. CONCLUSION : This study presents the first CAQ system for automated quality control in BE. The system effectively distinguishes poorly from well-visualized mucosa and enhances neoplasia detection when integrated with CADe.

Delayed bleeding after endoscopic sphincterotomy in patients receiving anticoagulants

Delayed bleeding after endoscopic sphincterotomy (EST) constitutes a significant adverse event, occurring in ~0.5-5% of patients. The number of patients receiving anticoagulants to prevent cardiovascular and cerebrovascular disease has increased with the aging society worldwide; however, anticoagulants (direct oral anticoagulants [DOACs] and warfarin) are one of the most major risk factors for postprocedure bleeding. This review investigated post-EST bleeding in anticoagulant users, focusing on risk factors, clinical guidelines, pharmacological characteristics, and the future of post-EST bleeding. Several clinical guidelines for antithrombotic drug users have been established to prevent postprocedure bleeding; nevertheless, the risk of bleeding is believed to be several times higher than for nondrug users, regardless of clinical guideline compliance. The major problem in this field is that patients who experience delayed bleeding are often receiving multiple antithrombotic drugs, and no parameters that can accurately monitor the anticoagulant effect of DOACs have been identified. Therefore, identifying patients with a generally high-risk of postprocedure bleeding is crucial. Recently, the plasma level and antifactor Xa activity of factor Xa inhibitors have been investigated in relation to the risk of major bleeding in users. Similar to the prothrombin time-international normalized ratio for warfarin, plasma levels, and antifactor Xa activity may be useful parameters for monitoring the anticoagulant effect and identifying DOAC users at higher risk of postprocedure bleeding, including post-EST bleeding. Future studies should stratify the risk of post-EST delayed bleeding based on a scoring system to prevent this complication.

Crohn's Disease and Ulcerative Colitis Share 2 Molecular Subtypes With Different Mechanisms and Drug Responses

BACKGROUND AND AIMS

Several therapies have been approved to treat Crohn's disease (CD) and ulcerative colitis (UC), indicating that both diseases may share the same molecular subtypes. The aim of this study is to identify shared patient subtypes with common molecular drivers of disease.

METHODS

Five public datasets with 406 CD and 421 UC samples were integrated to identify molecular subtypes. Then, the patient labels from 6 independent datasets and 8 treatment datasets were predicted for validating subtypes and identifying the relationship with response status of corticosteroids, infliximab, vedolizumab, and ustekinumab.

RESULTS

Two molecular subtypes were identified from the training datasets, in which CD and UC patients were relatively evenly represented in each subtype. We found 6 S1-specific gene modules related to innate/adaptive immune responses and tissue remodeling and 9 S1-specific cell types (cycling T cells, Tregs, CD8+ lamina propria, follicular B cells, cycling B cells, plasma cells, inflammatory monocytes, inflammatory fibroblasts, and postcapillary venules). Subtype S2 was associated with 3 modules related to metabolism functions and 4 cell types (immature enterocytes, transit amplifying cells, immature goblet cells, and WNT5B+ cells). The subtypes can be replicated in 6 independent datasets based on a 20-gene classifier. Furthermore, response rates to 4 treatments in subtype S2 were significantly higher than those in subtype S1.

CONCLUSIONS

This study discovered and validated a robust transcriptome-based molecular classification shared by CD and UC and built a 20-gene classifier. Because 2 subtypes have different molecular mechanisms and drug response, our classification may aid interpretation of heterogeneous molecular and clinical information in inflammatory bowel disease patients.

Endoscopic En Bloc Vs Piecemeal Resection of Large Colonic Adenomas: Carbon Footprint Post Hoc Analysis of a Randomized Trial

BACKGROUND AND AIMS

Endoscopy makes a significant contribution to the carbon footprint of healthcare. A randomized trial (RESECT-COLON) demonstrated that endoscopic submucosal dissection (ESD) decreases the recurrence rate of large adenomas (>25 mm) vs piecemeal endoscopic mucosal resection (P-EMR), reducing the need for follow-up colonoscopy. We aimed to compare the carbon footprint of those 2 strategies.

METHODS

Devices used for both procedures were collected prospectively for each of the 359 patients. P-EMR and ESD were assessed using the life cycle assessment, evaluating 4 parameters: endoscopes and disposable medical products, electricity consumption, anesthetic products, and patient transport. The carbon footprint of the follow-up was simulated in both arms with different scenarios. We performed a post hoc analysis of the carbon footprint of these 2 strategies over 18 months.

RESULTS

Carbon footprint of a single P-EMR procedure was 63.5 kg carbon dioxide equivalent (CO2e) vs 73.2 kg CO2e for ESD (half for patient transport). Including follow-up in local centers, P-EMR generates 93.5 kg CO2e and ESD 76.3 kg CO2e, corresponding to an absolute reduction of 17 kg CO2e (18%) per procedure for ESD. Simulating a strategy of P-EMR resection and follow-up both performed in local centers, the global impact with 18 months follow-up would be 67.3 kg CO2e, favoring P-EMR over ESD.

CONCLUSIONS

ESD strategy for lesions over 25 mm could reduce the environmental impact by reducing the associated follow-up colonoscopies and transports of patients. If P-EMR could be performed in local centers with similar quality, results would be in favor of local P-EMR.

Intravenous lidocaine decreased the incidence of SRAEs for ERCP procedures in elderly frailty patients, a randomized controlled trial

OBJECTIVES

Elderly frailty patients are at particular risk of sedation-related adverse events (SRAEs) during sedation. This study aimed to assess whether intravenous lidocaine could reduce the incidence of SRAEs in elderly frailty patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 210 elderly frailty patients scheduled for ERCP were randomly divided into two groups: lidocaine and control. Patients in the lidocaine group received intravenous lidocaine (1.0 mg/kg) before anesthesia induction, followed by continuous intravenous infusion (2.0 mg/kg/h) during ERCP. The control group received an equal volume of saline solution. The primary endpoint was the composite incidence of SRAEs during ERCP. Secondary endpoints were propofol consumption, VAS score, endoscopists' and patients' satisfaction scores and lidocaine-related adverse events and so on.

RESULTS

The composite incidence of SRAEs in the lidocaine group was significantly lower than in the control group (41.05% vs. 21.86%, p < 0.05). The propofol requirement (436.11 ± 118.90, 388.54 ± 149.65. p < 0.001) and VAS score of patients (3.02 ± 1.07, 2.54 ± 1.10. p < 0.05) in the lidocaine group were significantly lower than those in the control group. The endoscopists' satisfaction scores (7.77 ± 1.12, 8.23 ± 1.10. p < 0.05) and patients' satisfaction scores (8.53 ± 0.95, 8.98 ± 0.86. p < 0.05) in lidocaine group were significantly higher than those in the control group.

CONCLUSIONS

Intravenous lidocaine can significantly decrease the incidence of SRAEs for ERCP procedures in elderly frailty patients, with no increase in lidocaine or other related adverse events.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Trial ID: ChiCTR2300067796, https://www.chictr.org.cn/showproj.html?proj=185763 ).

Evolving trends in interventions and outcomes for acute biliary pancreatitis during pregnancy: A two-decade analysis

BACKGROUND/OBJECTIVES

Cholelithiasis is the most common cause of acute pancreatitis in pregnancy. We analyzed trends in acute biliary pancreatitis (ABP) among pregnant women over the past two decades to evaluate changes in outcomes, including the incidence of severe acute pancreatitis, mortality rates, and hospital length of stay.

METHODS

Using the National Inpatient Sample, we identified adult women of childbearing age (age 18-50 years) with hospitalization for ABP from 2002 to 2020. Trends were analyzed using Cochran-Armitage and F-tests. Multivariable binary logistic regression was used to evaluate the outcome of severe acute pancreatitis (SAP).

RESULTS

45,064 pregnant and 212,009 non-pregnant women were hospitalized for ABP (2002-2020), with a significant increase in ABP during pregnancy (14.1 %→17.8 %; p < 0.001). Trend analyses in the pregnant cohort revealed increasing age (mean 27  →  28.1 years; p < 0.001), Class-III obesity (0.7 %→7.8 %; p < 0.001), comorbidities (Elixhauser index ≥3) (2.9 %→11.2 %; p < 0.001), and SAP (2.2 %→5.0 %; p < 0.001). Mortality remained very low (<0.01 %). Performance of ERCP (22.2 %→26.5 %; p < 0.001) and cholecystectomy (41.0 %→54.1 %; p < 0.001) increased while duration of hospitalization decreased (Mean 4.9  →  3.6 days; p < 0.001). Multivariable analysis revealed that the development of SAP was associated with Black race (OR 1.70, 95 % CI: 1.10-2.63) and comorbidities (OR 5.10, 95 % CI 3.64-7.14).

CONCLUSIONS

Pregnant women represent a significant portion of hospitalized ABP cases, paralleling increases in age, comorbidities, and obesity rates. Racial disparities are linked to higher odds of SAP, though comorbidities have a dominant effect. There has been an increase in guideline-recommended procedures (ERCP and cholecystectomy); however, further research is needed to address the implementation gap, considering the increased complexity of pregnant women with ABP.

Can optical evaluation distinguish between T1a and T1b esophageal adenocarcinoma: an international expert interobserver agreement study

BACKGROUND

 Piecemeal endoscopic mucosal resection (EMR) is an acceptable technique for T1a esophageal adenocarcinoma, but en bloc R0 excision is advocated for T1b disease as it may offer a potential cure and mitigate recurrence. Thus, distinguishing between T1a and T1b disease is imperative under current treatment paradigms. We investigated whether expert Barrett's endoscopists could make this distinction based on optical evaluation.

METHODS

 Endoscopic images of histologically confirmed high grade dysplasia (HGD), T1a, and T1b disease (20 sets for each) were compiled from consecutive patients at a single institution. Each set contained four images including an overview, a close-up in high definition white light, a near-focus magnification image, and a narrow-band image. Experts predicted the histology for each set.

RESULTS

 19 experts from 8 countries (Australia, USA, Italy, Netherlands, Germany, Canada, Belgium, and Portugal) participated. The majority had been practicing for > 20 years, with a median (interquartile range) annual case volume of 50 (18-75) for Barrett's EMR and 25 (10-45) for Barrett's endoscopic submucosal dissection. Esophageal adenocarcinoma (T1a/b) could be distinguished from HGD with a pooled sensitivity of 89.1 % (95 %CI 84.7-93.4). T1b adenocarcinoma could be predicted with a pooled sensitivity of 43.8 % (95 %CI 29.9-57.7). Fleiss' kappa was 0.421 (95 %CI 0.399-0.442; P < 0.001), indicating fair-to-moderate agreement.

CONCLUSIONS

 Expert Barrett's endoscopists could reliably differentiate T1a/T1b esophageal adenocarcinoma from HGD. Despite fair-to-moderate agreement for T staging, T1b disease could not be reliably distinguished from T1a disease. This may impact clinical decision making and selection of endoscopic techniques.