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OBJECTIVE: During the last decade, the management of gastric intestinal metaplasia (GIM) has been addressed by several distinct international evidence-based guidelines. In this review, we aimed to synthesise these guidelines and provide clinicians with a global perspective of the current recommendations for managing patients with GIM, as well as highlight evidence gaps that need to be addressed with future research. DESIGN: We conducted a systematic review of the literature for guidelines and consensus statements published between January 2010 and February 2023 that address the diagnosis and management of GIM. RESULTS: From 426 manuscripts identified, 15 guidelines were assessed. There was consistency across guidelines regarding the purpose of endoscopic surveillance of GIM, which is to identify prevalent neoplastic lesions and stage gastric preneoplastic conditions. The guidelines also agreed that only patients with high-risk GIM phenotypes (eg, corpus-extended GIM, OLGIM stages III/IV, incomplete GIM subtype), persistent refractory Helicobacter pylori infection or first-degree family history of gastric cancer should undergo regular-interval endoscopic surveillance. In contrast, low-risk phenotypes, which comprise most patients with GIM, do not require surveillance. Not all guidelines are aligned on histological staging systems. If surveillance is indicated, most guidelines recommend a 3-year interval, but there is some variability. All guidelines recommend H. pylori eradication as the only non-endoscopic intervention for gastric cancer prevention, while some offer additional recommendations regarding lifestyle modifications. While most guidelines allude to the importance of high-quality endoscopy for endoscopic surveillance, few detail important metrics apart from stating that a systematic gastric biopsy protocol should be followed. Notably, most guidelines comment on the role of endoscopy for gastric cancer screening and detection of gastric precancerous conditions, but with high heterogeneity, limited guidance regarding implementation, and lack of robust evidence. CONCLUSION: Despite heterogeneous populations and practices, international guidelines are generally aligned on the importance of GIM as a precancerous condition and the need for a risk-stratified approach to endoscopic surveillance, as well as H. pylori eradication when present. There is room for harmonisation of guidelines regarding (1) which populations merit index endoscopic screening for gastric cancer and GIM detection/staging; (2) objective metrics for high-quality endoscopy; (3) consensus on the need for histological staging and (4) non-endoscopic interventions for gastric cancer prevention apart from H. pylori eradication alone. Robust studies, ideally in the form of randomised trials, are needed to bridge the ample evidence gaps that exist.
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INTRODUCTION: This study aims to evaluate the effectiveness of ChatGPT (Chat Generative Pretrained Transformer) in answering patients' questions about colorectal cancer (CRC) screening, with the ultimate goal of enhancing patients' awareness and adherence to national screening programs. METHODS: 15 questions on CRC screening were posed to ChatGPT4. The answers were rated by 20 gastroenterology experts and 20 non-experts in three domains (accuracy, completeness, and comprehensibility), and by 100 patients in three dichotomic domains (completeness, comprehensibility and trustability). RESULTS: According to expert rating, the mean accuracy score was 4.8±1.1 on a scale ranging from 1 to 6. Men completeness score was 2.1±0.7 and mean comprehensibility score was 2.8±0.4 on a scale ranging from 1 to 3. Overall, accuracy (4.8±1.1 vs 5.6±0.7, P<0.001) and completeness (2.1±0.7 vs 2.7±0.4, P<0.001) scores were significantly lower for expert compared to non-expert, while comprehensibility was comparable among the two groups (2.7±0.4 vs 2.8±0.3, P=0.546). Patients rated all questions as complete, comprehensible and trustable in 97 to 100% of cases. CONCLUSIONS: ChatGPT shows good performance with the potential to enhance awareness about CRC and improve screening outcomes. Generative language systems may be further improved after proper training in accordance with scientific evidence and current guidelines.
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BACKGROUND: Early gastric cancer is treated endoscopically, but patients require surveillance due to the risk of metachronous gastric lesions (MGLs). Epigenetic alterations, particularly aberrant DNA methylation in genes, such as MIR124-3, MIR34b/c, NKX6-1, EMX1, MOS and CDO1, have been identified as promising biomarkers for MGL in Asian populations. We aimed to determine whether these changes could predict MGL risk in intermediate-risk Caucasian patients. METHODS: This case-cohort study included 36 patients who developed MGL matched to 48 patients without evidence of MGL in the same time frame (controls). Multiplex quantitative methylation-specific PCR was performed using DNA extracted from the normal mucosa adjacent to the primary lesion. The overall risk of progression to MGL was assessed using Kaplan-Meier and Cox proportional hazards model analyses. RESULTS: MIR124-3, MIR34b/c and NKX6-1 were successfully analyzed in 77 samples. MIR124-3 hypermethylation was detected in individuals who developed MGL (relative quantification 78.8 vs 50.5 in controls, p = 0.014), particularly in females and Helicobacter pylori-negative patients (p = 0.021 and p = 0.0079, respectively). This finding was further associated with a significantly greater risk for MGL development (aHR = 2.31, 95% CI 1.03-5.17, p = 0.042). Similarly, NKX6-1 was found to be hypermethylated in patients with synchronous lesions (relative quantification 7.9 vs 0.0 in controls, p = 0.0026). A molecular-based methylation model incorporating both genes was significantly associated with a threefold increased risk for MGL development (aHR = 3.10, 95% CI 1.07-8.95, p = 0.037). CONCLUSIONS: This preliminary study revealed an association between MIR124-3 and NKX6-1 hypermethylation and the development of MGL in a Western population. These findings may represent a burden reduction and a greener approach to patient care.
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Metilação de DNA , Proteínas de Homeodomínio , MicroRNAs , Neoplasias Gástricas , Humanos , Feminino , Masculino , MicroRNAs/genética , Neoplasias Gástricas/genética , Metilação de DNA/genética , Pessoa de Meia-Idade , Idoso , Proteínas de Homeodomínio/genética , População Branca/genética , Estudos de Casos e Controles , Segunda Neoplasia Primária/genética , Epigênese Genética/genética , Biomarcadores Tumorais/genéticaRESUMO
INTRODUCTION: While piecemeal endoscopic mucosal resection (EMR) for T1a oesophageal adenocarcinoma is acceptable, enbloc-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 sought to ascertain whether expert Barrett's endoscopists were able to make this distinction based on optical evaluation. METHODS: Sixty sets of endoscopic images of histologically confirmed high grade dysplasia (HGD), T1a and T1b disease (n=20 for each) were compiled from consecutive patients at a single institution. Each set contained four images, and were standardized to include an overview, a close-up in high-definition white light, a near-focus magnification image, and a narrow-band image. Experts were invited to predict 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 annual case volume for Barrett's EMR of 50 (IQR 18-75), and Barrett's ESD of 25 (IQR 10-45). Oesophageal adenocarcinoma (T1a/b) could be distinguished from HGD, with a pooled sensitivity of 89.1% (95% CI:84.7-93.4. When predicting T-stage for T1b adenocarcinoma cases, pooled sensitivity was 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 can reliably differentiate T1a/T1b oesophageal adenocarcinoma from HGD. Although there is fair-to-moderate agreement for T-staging, T1b disease cannot be reliably distinguished from T1a disease. This may have implications on clinical decision making and selection of endoscopic treatment methods.
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INTRODUCTION: The incidence of local recurrence following gastric endoscopic submucosal dissection (ESD) remains a clinical concern. We aimed to evaluate the impact of narrow safety margin (< 1 mm) on the recurrence rate. METHODS: A retrospective cohort study was conducted across two centers. Cases of R0-ESD with subsequent recurrence were compared to matched controls in a 1:2 ratio in a case-cohort analysis. RESULTS: Over a median period of 25 months (IQR 14-43), a recurrence rate of 3% (95%CI 1.7-4.3) was observed, predominantly (13/21) following R0 resections with favourable histology. Endoscopic retreatment was feasible in 18 of 21 recurrences. The proportion of R0-cases where the safety margin in both horizontal (HM) and vertical (VM) margin exceeded 1 mm was similarly distributed in the recurrence and non-recurrence group, representing nearly 20% of cases. However, cases with HM less than 1 mm, despite VM greater than 1 mm, nearly doubled in the recurrence group (7.7% vs. 3.9%), and tripled when both margins were under 1 mm (23.1% vs. 7.7%). Despite this trend, statistical significance was not achieved (p = 0.05). In the overall cohort, the only independent risk factor significantly associated with local recurrence was the presence of residual tumor at the HM (HM1) or not assessable HM (HMx) (OR 16.5 (95%CI 4.4-61.7), and OR 11.7 (95%CI 1.1-124.1), respectively). CONCLUSIONS: While not common or typically challenging to manage, recurrence post-ESD warrants attention and justifies rigorous post-procedural surveillance, especially in patients with HM1, HMx, and probably also in those with R0 resections but narrow safety margin.
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Ressecção Endoscópica de Mucosa , Margens de Excisão , Recidiva Local de Neoplasia , Neoplasias Gástricas , Humanos , Ressecção Endoscópica de Mucosa/métodos , Ressecção Endoscópica de Mucosa/efeitos adversos , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/patologia , Recidiva Local de Neoplasia/cirurgia , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Fatores de Risco , Mucosa Gástrica/cirurgia , Mucosa Gástrica/patologia , Estudos de Casos e Controles , Gastroscopia/métodos , Modelos LogísticosRESUMO
Introduction/Aim: Gastric neuroendocrine tumors (GNETs) frequently have an indolent clinical course, despite their metastatic potential. The aim of the study was to identify prognostic factors associated with overall survival and risk of metastases and to evaluate the impact of serial measurements of chromogranin A (CgA). Methods: The authors performed a retrospective cohort study including consecutive patients with GNET diagnosed between 2010 and 2019, with a minimum follow-up of 1 year. Univariate and multivariate analyses were performed. Results: We included 132 patients with GNET (type I, 113 patients; type II, 1 patient; type III, 14 patients; type IV, 2 patients; not classifiable, 2 patients), with 61% being female and a mean age at diagnosis of 66 years. During the follow-up period (median 66 months), 3 (2.3%) patients died due to metastatic disease (1 patient with type III and 2 patients with type IV). Male gender (p = 0.030), type III/IV (p < 0.001), Ki-67 index >20% (p < 0.001), grade 2/3 (p < 0.001), invasion beyond the submucosa (p < 0.001), and presence of metastases (p < 0.001) were identified as risk factors for mortality in the univariate analysis. Metastasis developed in 7 patients (5.3%). Multivariable analysis revealed that Ki-67 >20% (p = 0.016) was an independent risk factor for metastasis. Overall, CgA showed a sensitivity of 20% for detection of recurrence and a specificity of 79% (sensitivity of 8% and specificity of 71% in type I GNETs). Conclusion: Identification of risk factors for the presence of metastases and for mortality in these groups of patients can help in individualizing the therapeutic strategy. CgA seems to be a weak marker for monitoring patients with GNET.
Introdução/Objetivo: Os tumores neuroendócrinos gástricos (TNEs-G) têm frequentemente um curso indolente, apesar do seu potencial metastático. O objetivo deste trabalho foi identificar fatores de prognóstico associados à sobrevida global e à metastização nos doentes com TNEs-G e avaliar o impacto da análise seriada de cromogranina A (CgA). Methods: Estudo retrospectivo incluindo doentes consecutivos admitidos por TNE-G entre 2010 e 2019, com um follow-up mínimo de 1 ano. Foi realizada análise univariada e multivariada. Results: Foram incluídos 132 doentes com TNE-G (Tipo I, 113 doentes; Tipo II, 1 doente; Tipo III, 14 doentes; Tipo IV, 2 doentes; Não classificável, 2 doentes), sendo 61% mulheres, com idade média de 66 anos. Durante o periodo de follow-up (mediana 66 meses), 3 (2.3%) doentes faleceram por doença metastática (1 doente com Tipo III e 2 com Tipo IV). O sexo masculino (p = 0,030), tipo III/IV (p < 0,001), Ki-67 index >20% (p < 0,001), Grau 2/3 (p < 0,001), invasão além da submucosa (p < 0,001) e presença de metástases (p < 0,001) foram identificados como fatores de risco para mortalidade na análise univariada. Sete doentes desenvolveram metástases (5,3%). A análise multivariáda revelou que o Ki-67 >20% (p = 0,016) era um factor de risco independente para metastização.Globalmente, a CgA mostrou uma sensibilidade de detecção de recorrência de 20% e uma especificidade de 79% (sensibilidade de 8% e especificidade de 71% em em TNEs-G do Tipo I). Conclusão: A identificação dos fatores de risco para a presença de metástases e para a mortalidade neste grupo de pacientes pode ajudar a individualizar a estratégia terapêutica. A CgA parece ser um marcador fraco para a monitorização de doentes com TNEs-G.
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INTRODUCTION: Endoscopic Submucosal Dissection (ESD) has been reported as a feasible and effective treatment for Rectal Neuroendocrine Tumours (R-NETs). However, most of the experience on the topic comes from retrospective tertiary centre from Eastern Asia. Data on ESD for R-NETs in Western centres are lacking. MATERIALS AND METHODS: This is a retrospective study, including patients who underwent endoscopic resection of R-NETS by ESD between 2015 and 2020 in Western Centres. Important clinical variables such as demographic, size of R-NETs, histological type, presence of lymphovascular invasion or distant metastasis, completeness of the endoscopic resection, recurrence, and procedure related complications were recorded. RESULTS: 40 ESD procedure on R-NETs from 39 patients from 8 centres were included. Mean R-NETs size was 10.3 mm (SD 4.01). Endoscopic en-bloc resection was achieved in 39/40 ESD (97.5 %), R0 margin resection was obtained in 87.5 % (35/40) of the procedures, one patient was referred to surgery for lymphovascular invasion, two procedures (5 %) reported significant episodes of bleeding, whereas a perforation occurred in one case (1/40, 2.5 %) managed endoscopically. Recurrence occurred in 1 patient (2.5 %). CONCLUSION: ESD is an effective and safe treatment for R-NETs in western centres.
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1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2âmm) surrounding the polyp, for the removal of diminutive polyps (≤â5âmm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2âmm) surrounding the polyp, for the removal of small polyps (6-9âmm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19âmm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥â20âmm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥â20âmm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.
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Pólipos do Colo , Ressecção Endoscópica de Mucosa , Humanos , Ressecção Endoscópica de Mucosa/métodos , Ressecção Endoscópica de Mucosa/normas , Pólipos do Colo/cirurgia , Colonoscopia/normas , Colonoscopia/métodos , Colonoscopia/instrumentação , Neoplasias Colorretais/cirurgia , Margens de Excisão , Pólipos Adenomatosos/cirurgia , Pólipos Adenomatosos/patologia , Europa (Continente) , Sociedades Médicas/normasRESUMO
Colorectal cancer (CRC) screening relies primarily on stool analysis to identify occult blood. However, its sensitivity for detecting precancerous lesions is limited, requiring the development of new tools to improve CRC screening. Carcinogenesis involves significant alterations in mucosal epithelium glycocalyx that decisively contribute to disease progression. Building on this knowledge, we examined patient series comprehending premalignant lesions, colorectal tumors, and healthy controls for the T-antigen-a short-chain O-glycosylation of proteins considered a surrogate marker of malignancy in multiple solid cancers. We found the T-antigen in the secretions of dysplastic lesions as well as in cancer. In CRC, T-antigen expression was associated with the presence of distant metastases. In parallel, we analyzed a broad number of stools from individuals who underwent colonoscopy, which showed high T expressions in high-grade dysplasia and carcinomas. Employing mass spectrometry-based lectin-affinity enrichment, we identified a total of 262 proteins, 67% of which potentially exhibited altered glycosylation patterns associated with cancer and advanced pre-cancerous lesions. Also, we found that the stool (glyco)proteome of pre-cancerous lesions is enriched for protein species involved in key biological processes linked to humoral and innate immune responses. This study offers a thorough analysis of the stool glycoproteome, laying the groundwork for harnessing glycosylation alterations to improve non-invasive cancer detection.
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Neoplasias Colorretais , Lesões Pré-Cancerosas , Humanos , Neoplasias Colorretais/diagnóstico , Hiperplasia , Carcinogênese , Antígenos Virais de TumoresRESUMO
At the end of the last century, a far-sighted 'working party' held in Sydney, Australia addressed the clinicopathological issues related to gastric inflammatory diseases. A few years later, an international conference held in Houston, Texas, USA critically updated the seminal Sydney classification. In line with these initiatives, Kyoto Global Consensus Report, flanked by the Maastricht-Florence conferences, added new clinical evidence to the gastritis clinicopathological puzzle.The most relevant topics related to the gastric inflammatory diseases have been addressed by the Real-world Gastritis Initiative (RE.GA.IN.), from disease definitions to the clinical diagnosis and prognosis. This paper reports the conclusions of the RE.GA.IN. consensus process, which culminated in Venice in November 2022 after more than 8 months of intense global scientific deliberations. A forum of gastritis scholars from five continents participated in the multidisciplinary RE.GA.IN. consensus. After lively debates on the most controversial aspects of the gastritis spectrum, the RE.GA.IN. Faculty amalgamated complementary knowledge to distil patient-centred, evidence-based statements to assist health professionals in their real-world clinical practice. The sections of this report focus on: the epidemiology of gastritis; Helicobacter pylori as dominant aetiology of environmental gastritis and as the most important determinant of the gastric oncogenetic field; the evolving knowledge on gastric autoimmunity; the clinicopathological relevance of gastric microbiota; the new diagnostic horizons of endoscopy; and the clinical priority of histologically reporting gastritis in terms of staging. The ultimate goal of RE.GA.IN. was and remains the promotion of further improvement in the clinical management of patients with gastritis.
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Gastrite , Infecções por Helicobacter , Helicobacter pylori , Neoplasias Gástricas , Humanos , Infecções por Helicobacter/complicações , Infecções por Helicobacter/diagnóstico , Infecções por Helicobacter/patologia , Gastrite/diagnóstico , Gastrite/epidemiologia , Gastrite/patologia , Endoscopia , Neoplasias Gástricas/patologia , Mucosa Gástrica/patologiaRESUMO
BACKGROUND: Pan-intestinal capsule endoscopy (PCE) evaluates the small bowel and colon noninvasively. This study evaluated diagnostic accuracy and safety of PCE vs. colonoscopy as first-line examination in suspected mid-lower gastrointestinal bleeding (MLGIB). METHODS: In this prospective, single-center, single-blinded cohort study, consecutive patients with suspected MLGIB underwent PCE followed by same-day colonoscopy. Diagnostic accuracy for potentially hemorrhagic lesions (PHLs; combined diagnosis by PCE + colonoscopy) and incidence of adverse events were assessed. RESULTS: 100 patients were included (median age 70 [range 18-92] years; 65% female). PHLs were diagnosed in 46 patients, including small-bowel and/or colon angioectasias in 32. PCE correctly identified 54 individuals without PHLs, and 95.7% (44/46) of those with PHLs vs. 50.0% (23/46) for colonoscopy (P<0.01). PHLs were detected by PCE alone in 65.2% (30/46), both examinations in 28.3% (13/46), and colonoscopy alone in 6.5% (3/46). PHLs were diagnosed at the ileocolonic region in 28% of patients, with PCE diagnosing 25/28 cases (89.3%) and colonoscopy diagnosing 23/28 (82.1%; P=0.13). Interventional procedures were performed at colonoscopy in 13/81 patients with iron-deficiency anemia (16.0%) vs. 6/19 patients with overt bleeding (31.6%; P<0.01). No significant adverse events occurred with PCE vs. 2% with colonoscopy. CONCLUSIONS: In patients with MLGIB, PCE avoided further invasive procedures in >50% of patients. PCE was safe and more effective than colonoscopy in identifying PHL both in the small bowel and colon. These results support the potential use of PCE as first-line examination in patients with suspected MLGIB.
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Endoscopia por Cápsula , Colonoscopia , Hemorragia Gastrointestinal , Humanos , Endoscopia por Cápsula/métodos , Feminino , Masculino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Idoso , Pessoa de Meia-Idade , Colonoscopia/métodos , Colonoscopia/efeitos adversos , Adulto , Estudos Prospectivos , Idoso de 80 Anos ou mais , Adolescente , Método Simples-Cego , Adulto Jovem , Intestino Delgado/diagnóstico por imagemRESUMO
BACKGROUND: Gastrointestinal (GI) endoscopy is one of healthcare's main contributors to climate change. We aimed to assess healthcare professionals' attitudes and the perceived barriers to implementation of sustainable GI endoscopy. METHODS: The LEAFGREEN web-based survey was a cross-sectional study conducted by the European Society of Gastrointestinal Endoscopy (ESGE) Green Endoscopy Working Group. The questionnaire comprised 39 questions divided into five sections (respondent demographics; climate change and sustainability beliefs; waste and resource management; single-use endoscopes and accessories; education and research). The survey was available via email to all active members of the ESGE and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) in March 2023. RESULTS: 407 respondents participated in the survey (11% response rate). Most participants (86%) agreed climate change is real and anthropogenic, but one-third did not consider GI endoscopy to be a significant contributor to climate change. Improvement in the appropriateness of endoscopic procedures (41%) and reduction in single-use accessories (34%) were considered the most important strategies to reduce the environmental impact of GI endoscopy. Respondents deemed lack of institutional support and knowledge from staff to be the main barriers to sustainable endoscopy. Strategies to reduce unnecessary GI endoscopic procedures and comparative studies of single-use versus reusable accessories were identified as research priorities. CONCLUSIONS: In this survey, ESGE and ESGENA members acknowledge climate change as a major threat to humanity. Further improvement in sustainability beliefs and professional attitudes, reduction in inappropriate GI endoscopy, and rational use of single-use accessories and endoscopes are critically required.
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Atitude do Pessoal de Saúde , Endoscopia Gastrointestinal , Humanos , Estudos Transversais , Feminino , Masculino , Inquéritos e Questionários , Adulto , Mudança Climática , Pessoa de Meia-Idade , Conhecimentos, Atitudes e Prática em Saúde , Endoscópios GastrointestinaisRESUMO
BACKGROUND AND AIMS: Ampullary lesions (ALs) of the minor duodenal papilla are extremely rare. Endoscopic papillectomy (EP) is a routinely used treatment for AL of the major duodenal papilla, but the role of EP for minor AL has not been accurately studied. METHODS: We identified 20 patients with ALs of minor duodenal papilla in the multicentric database from the Endoscopic Papillectomy vs Surgical Ampullectomy vs Pancreatitcoduodenectomy for Ampullary Neoplasm study, which included 1422 EPs. We used propensity score matching (nearest-neighbor method) to match these cases with ALs of the major duodenal papilla based on age, sex, histologic subtype, and size of the lesion in a 1:2 ratio. Cohorts were compared by means of chi-square or Fisher exact test as well as Mann-Whitney U test. RESULTS: Propensity score-based matching identified a cohort of 60 (minor papilla 20, major papilla 40) patients with similar baseline characteristics. The most common histologic subtype of lesions of minor papilla was an ampullary adenoma in 12 patients (3 low-grade dysplasia and 9 high-grade dysplasia). Five patients revealed nonneoplastic lesions. Invasive cancer (T1a), adenomyoma, and neuroendocrine neoplasia were each found in 1 case. The rate of complete resection, en-bloc resection, and recurrences were similar between the groups. There were no severe adverse events after EP of lesions of minor papilla. One patient had delayed bleeding that could be treated by endoscopic hemostasis, and 2 patients showed a recurrence in surveillance endoscopy after a median follow-up of 21 months (interquartile range, 12-50 months). CONCLUSIONS: EP is safe and effective in ALs of the minor duodenal papilla. Such lesions could be managed according to guidelines for EP of major duodenal papilla.
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Ampola Hepatopancreática , Neoplasias do Ducto Colédoco , Neoplasias Duodenais , Neoplasias Pancreáticas , Humanos , Resultado do Tratamento , Ampola Hepatopancreática/cirurgia , Ampola Hepatopancreática/patologia , Endoscopia Gastrointestinal , Ductos Pancreáticos/patologia , Neoplasias Pancreáticas/patologia , Neoplasias Duodenais/patologia , Neoplasias do Ducto Colédoco/cirurgia , Neoplasias do Ducto Colédoco/patologia , Estudos RetrospectivosRESUMO
BACKGROUND AND AIMS: Circumferential endoscopic submucosal dissection (cESD) in the esophagus has been reported to be feasible in small Eastern case series. We assessed the outcomes of cESD in the treatment of early esophageal squamous cell carcinoma (ESCC) in Western countries. METHODS: We conducted an international study at 25 referral centers in Europe and Australia using prospective databases. We included all patients with ESCC treated with cESD before November 2022. Our main outcomes were curative resection according to European guidelines and adverse events. RESULTS: A total of 171 cESDs were performed on 165 patients. En bloc and R0 resections rates were 98.2% (95% confidence interval [CI], 95.0-99.4) and 69.6% (95% CI, 62.3-76.0), respectively. Curative resection was achieved in 49.1% (95% CI, 41.7-56.6) of the lesions. The most common reason for noncurative resection was deep submucosal invasion (21.6%). The risk of stricture requiring 6 or more dilations or additional techniques (incisional therapy/stent) was high (71%), despite the use of prophylactic measures in 93% of the procedures. The rates of intraprocedural perforation, delayed bleeding, and adverse cardiorespiratory events were 4.1%, 0.6%, and 4.7%, respectively. Two patients died (1.2%) of a cESD-related adverse event. Overall and disease-free survival rates at 2 years were 91% and 79%. CONCLUSIONS: In Western referral centers, cESD for ESCC is curative in approximately half of the lesions. It can be considered a feasible treatment in selected patients. Our results suggest the need to improve patient selection and to develop more effective therapies to prevent esophageal strictures.
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Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Carcinoma de Células Escamosas do Esôfago , Humanos , Carcinoma de Células Escamosas do Esôfago/cirurgia , Neoplasias Esofágicas/patologia , Ressecção Endoscópica de Mucosa/métodos , Esofagoscopia/métodos , Resultado do Tratamento , Estudos RetrospectivosRESUMO
This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1: ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2: ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤â10âmm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3: ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4: Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5: ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7: ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9: ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10: ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.
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Gastroenterologia , Humanos , Endoscopia Gastrointestinal/métodos , Endoscópios Gastrointestinais , Sociedades MédicasRESUMO
BACKGROUND/AIMS: Endoscopic screening for gastric cancer (GC) is not recommended in low-intermediate incidence countries. Artificial intelligence (AI) has high accuracy in GC detection and might increase the cost-effectiveness of screening strategies. We aimed to assess the cost-effectiveness of AI for GC detection in settings with different GC incidence and different accuracies of AI systems. METHODS: Cost-effectiveness analysis (using Markov model) comparing different screening strategies (no screening versus single esophagogastroduodenoscopy (EGD) at 50 years versus stand-alone EGD every 5/10 years versus combined EGD and screening colonoscopy once or twice per decade in Netherlands, Italy and Portugal) with variable AI accuracy settings. The primary outcome was the incremental cost-effectiveness ratio of the different strategies versus no screening. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: Without AI, one single EGD at 50 years (Netherlands, Italy, Portugal), EGD combined with screening colonoscopy once per decade (Italy and Portugal) and EGD combined with screening colonoscopy twice per decade (Portugal) are cost-effective when compared with no screening. If AI increases the accuracy of EGD by at least 1% in comparison to the accuracy of white-light endoscopy accuracy (89%), combined screening twice per decade also becomes cost-effective in Italy. If AI accuracy reaches at least 96%, combined screening once per decade is also cost-effective in the Netherlands. DISCUSSION: In European countries, AI-assisted EGD may improve the cost-effectiveness of GC screening with combined EGD and screening colonoscopy. The actual effect of AI on cost-effectiveness may vary dependent on the accuracy and costs of the AI system.
Assuntos
Neoplasias Colorretais , Neoplasias Gástricas , Humanos , Análise Custo-Benefício , Análise de Custo-Efetividade , Inteligência Artificial , Detecção Precoce de Câncer , Colonoscopia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/prevenção & controle , Europa (Continente) , Programas de Rastreamento , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiologiaRESUMO
BACKGROUND AND AIMS: Colorectal cancer (CRC) screening is recommended worldwide, while gastric cancer (GC) screening may also be defendable in some settings. However, adherence rates and factors influencing participation are not well characterized. This study aimed to validate a tool to determine risk perception of CRC and GC and also of endoscopy-related complications. METHODS: A questionnaire in CRC risk perception based on the Health Belief Model was used. Forward/backward translation (English-Portuguese) and cultural adaptation were performed. After revision by a panel of experts, the questionnaire was adapted to target GC risk perception and perceptions towards endoscopy-related complications. The final version of the questionnaire (PERCEPT-PREVENT tool) was applied to 44 individuals, through telephonic interview, at enrolment and at intervals ≤3 weeks. Test-retest reliability and agreement were assessed. RESULTS: Almost perfect reliability between test and retest was obtained for CRC symptom knowledge score (ICC = 0.88), risk factor knowledge score (ICC = 0.89), and perceived severity (ICC = 0.84). At least moderate agreement between test and retest was obtained for GC symptom knowledge score (ICC = 0.94), risk factor knowledge score (ICC = 0.92), and perceived severity (ICC = 0.58). Test-retest reliability was assessed for barrier domains [faecal occult blood test ICC = 0.63; colonoscopy ICC = 0.79; upper GI endoscopy (UGIE) ICC = 0.83]. A total of 91% and 98% of participants gave the same answer in the test and retest for preferred method of CRC screening and intention to undergo UGIE for GC screening combined with a screening colonoscopy, respectively. DISCUSSION: PERCEPT-PREVENT is a valid and reliable tool for CRC and GC risk perception evaluation.
Assuntos
Neoplasias Colorretais , Detecção Precoce de Câncer , Humanos , Detecção Precoce de Câncer/métodos , Reprodutibilidade dos Testes , Fatores de Risco , Colonoscopia , Inquéritos e Questionários , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/prevenção & controle , PercepçãoRESUMO
Gastric Intestinal Metaplasia (GIM) is one of the precancerous conditions in the gastric carcinogenesis cascade and its optical diagnosis during endoscopic screening is challenging even for seasoned endoscopists. Several solutions leveraging pre-trained deep neural networks (DNNs) have been recently proposed in order to assist human diagnosis. In this paper, we present a comparative study of these architectures in a new dataset containing GIM and non-GIM Narrow-band imaging still frames. We find that the surveyed DNNs perform remarkably well on average, but still measure sizeable inter-fold variability during cross-validation. An additional ad-hoc analysis suggests that these baseline architectures may not perform equally well at all scales when diagnosing GIM.Clinical relevance- Enhanching a clinician's ability to detect and localize intestinal metaplasia can be a crucial tool for gastric cancer management policies.
Assuntos
Aprendizado Profundo , Lesões Pré-Cancerosas , Humanos , Gastroscopia/métodos , Estômago/diagnóstico por imagem , Metaplasia , Lesões Pré-Cancerosas/diagnósticoRESUMO
MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥â1âcm and <â3âcm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥â3âcm and <â10âcm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥â10âcm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of <â1âcm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i.âe. submucosal invasion depth ≤â500âµm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion >â500âµm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.