Endoscopic Submucosal Dissection in the Upper Gastrointestinal Tract and the Need for Rescue Surgery-A Multicenter Analysis.

Endoscopic submucosal dissection (ESD) has become the standard treatment for early malignant lesions in the upper gastrointestinal (GI) tract. Its clinical results have been reported to be as good as surgery. The outcomes of rescue surgery after non-curative ESD have been reported to be as good as first-line surgery. The aim of this study was to evaluate the outcomes of ESD in the upper GI tract and the outcomes of rescue surgery after non-curative ESD performed in Linz, Austria, between 2009 and January 2023. A total of 193 ESDs were included and divided into 104 esophageal ESD and 89 gastric ESD procedures. The criteria for curative ESD were in line with established guidelines' recommendations. For esophageal lesions, the mean lesion size was 40.3 mm and the rate of curative ESD was 56.7%. In the non-curative ESD, the rate of technical failure as the reason for non-curative ESD was 13.3% and the oncological failure rate was 86.7%. Only 48.7% of indicated rescue surgeries were performed. The main reason for not performing surgery was interdisciplinary consensus due to comorbidity. Perioperative complications Dindo-Clavien ≥ 3 occurred in 22.2% of cases with an in-hospital mortality rate of 0. In gastric lesions, the mean size was 39 mm and the rate of curative ESD was 69.7%. The rate of technical failure as a reason for non-curative ESD was 25.9% and the oncological failure rate was 74.1% for non-curative ESD. Rescue surgery was performed in 48.2% of indicated cases. The perioperative rate for major complications was 0. The outcome of ESD in the upper GI tract is in line with the published literature, and non-curative ESD does not worsen surgical outcomes. The available follow-up data are in line with the international published literature, showing a low rate of residual malignancy in surgical resection specimens. Therefore, the indication of rescue surgery for oncological failure remains challenging. Furthermore, the learning curve of ESD has shown a trend towards improving outcomes over time.

Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV).

The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.

Management of suspected and known eosinophilic esophagitis-a nationwide survey in Austria.

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus with increasing incidence and dysphagia as the main symptom. The management of suspected or known EoE by Austrian endoscopists has not been investigated yet. METHODS: A web-based survey with 13 questions about the management of EoE was sent to endoscopists via the Austrian Society of Gastroenterology and Hepatology (ÖGGH). RESULTS: A total of 222 endoscopists (74% gastroenterologists, 23% surgeons, and 2% pediatricians; 68% working in a hospital) from all 9 states participated. In patients with dysphagia but a normal appearing esophagus, 85% of respondents reported always taking biopsies; however, surgeons were less likely to obtain biopsies compared to gastroenterologists ("always" 69% vs. 90%, "sometimes" 29% vs. 10%, "never" 2% vs. 0%, p < 0.001). The approved budesonide orodispersible tablet is the preferred first-line drug used in EoE, ahead of proton pump inhibitors (PPI). Only 65% of participants monitor the patients by endoscopy and histology after 12 weeks of induction therapy, 26% do not continue maintenance therapy, and 22% monitor patients only when symptomatic. CONCLUSION: The vast majority of Austrian endoscopists adhere to the European and US guidelines in cases of suspected EoE. In contrast, despite the chronic disease course, a significant percentage of providers indicate not to use maintenance therapy and monitor the patients routinely.

Biodegradable biliopancreatic stents could help conserve health care resources during the COVID-19 pandemic: An observational multicenter study.

BACKGROUND: Considering limited resources for follow-up due to COVID-19, we used biodegradable stents (BPBS) for a range of biliopancreatic diseases. AIMS: This observational multicenter study aimed to evaluate technical safety and give first insights into clinical utility. METHODS: Technical success, clinical success, and necessity of follow-up visits for BPBS placed at three Austrian tertiary care hospitals between April 2020 and January 2021 were retrospectively analyzed. RESULTS: 63 stents were deployed in 60 patients. Main indications were prophylaxis of post-ERCP pancreatitis (PEP; n = 30/63; 48%) and bridging of prolonged waiting times to cholecystectomy (n = 21/63; 33%). Median time to surgery was 47 days (range: 136 days). The technical success rate was 94% (n = 59/63; 95% CI [0.84, 0.98]). Technical difficulties primarily arose with dislocations. Clinical success was achieved in 90% (n = 57/63; 95% CI [0.80, 0.96]). Clinical failure despite successful deployment was caused by papillary bleeding (1 patient) and cholestasis (1 patient). Both required reinterventions. No follow-up visits were needed in 97% of cases (n = 57/59; 95% CI [0.88, 1.00]). CONCLUSION: Biodegradable stents could help conserve health care resources without compromising treatment standards for PEP prophylaxis, which is particularly valuable in times of restricted resources. First insights into feasibility as bridging to cholecystectomy indicate a favorable safety profile.

New method for real-time visualization and quantitative characterization of early colorectal cancer in endoscopy: a pilot study.

Background and study aims Endoscopic optical diagnosis is crucial to the therapeutic strategy for early gastrointestinal cancer. It accurately (> 85 %) predicts pT category based on microsurface (SP) and vascular patterns (VP). However, interobserver variability is a major problem. We have visualized and digitalized the graded irregularities based on bioinformatically enhanced quantitative endoscopic image analysis (BEE) of high-definition white-light images. Methods In a pilot study of 26 large colorectal lesions (LCLs, mean diameter 39 mm), we retrospectively compared BEE variables with corresponding histopathology of the resected LCLs. Results We included 10 adenomas with low-grade intraepithelial neoplasia (LGIN), nine with high-grade intraepithelial neoplasia (HGIN) and early adenocarcinoma (EAC), and seven deeply submucosal invasive carcinomas. Quantified density (d) and nonuniformity (C U ) of vascular and surface structures correlated with histology (r s d VP: -0.77, r s C U VP: 0.13, r s d SP: -0.76, and r s C U SP: 0.45, respectively). A computed BEE score showed a sensitivity and specificity of 90 % and 100 % in the group with LGINs, 89 % and 41 % in the group with HGINs and EACs, and 100 % and 95 % in the group with deeply invasive carcinoma, respectively. Conclusions In this pilot study, BEE showed promise as a tool for endoscopic characterization of LCLs during routine endoscopy. Prospective clinical studies are needed.

Flexible diverticulotomy for Zenker's diverticulum - a bicentric study.

INTRODUCTION: Flexible diverticulotomy is an established procedure for the treatment of Zenker's diverticulum. In a bicentric study, we investigated the development of the procedure since its introduction at the Ordensklinikum Linz Barmherzige Schwestern and Elisabethinen in 2010. METHODS: All flexible diverticulotomies performed between January 2010 and December 2019 at the above-mentioned clinics were evaluated retrospectively. Patients were divided into two 5-year periods (2010-2014 and 2015-2019) and statistical tests were performed for comparison of data. RESULTS: In all, 69 flexible diverticulotomies were performed. The procedure was technically successful in 93.5% of cases. No lethal outcome was encountered. Only 2 (2.9%) interventions led to serious complications which had to be treated in the intensive care unit. Mild complications occurred in 14.5% of cases. 54 patients were evaluated in the follow-up period; 11 (20.3%) patients experienced relapses of dysphagia. The primary intervention resulted in a significant improvement over the observation period. Patients in the second intervention group had shorter average hospital stays and longer recurrence-free intervals. CONCLUSION: Flexible diverticulotomy is a safe and effective procedure for the treatment of Zenker's diverticulum. However, as the success rate appears to depend on the expertise and experience of the department, flexible diverticulotomy should be performed at centers with high caseloads.

Decline in acute upper gastrointestinal bleeding during COVID-19 pandemic after initiation of lockdown in Austria.

BACKGROUND: COVID-19 has spread rapidly around the world. The Austrian government implemented a lockdown on 16 March to contain further spread of the disease. We investigated the effects of lockdown on acute upper gastrointestinal (GI) bleeding in Austria. METHODS: We contacted 98 Austrian hospitals performing emergency endoscopies. The hospitals were asked to report upper GI endoscopies performed for recent hematemesis, melena, or both, and exhibiting endoscopically visible signs of bleeding. The study period was from 3 weeks before (calendar Week 9) to 3 weeks after (Week 14) initiation of the lockdown. RESULTS: 61 % of Austrian hospitals, and importantly all major state hospitals, responded. A total of 575 upper GI bleedings occurred during the 3 weeks before and 341 during the 3 weeks after initiation of lockdown (40.7 % reduction). There was a 54.6 % decline in nonvariceal bleeding events at Week 14 compared with Week 9 (89 vs. 196), whereas rates of variceal hemorrhage did not change (15 vs. 17). CONCLUSIONS: National lockdown resulted in a dramatic decrease in upper GI bleeding events in Austrian hospitals.

The VITRO Score (Von Willebrand Factor Antigen/Thrombocyte Ratio) as a New Marker for Clinically Significant Portal Hypertension in Comparison to Other Non-Invasive Parameters of Fibrosis Including ELF Test.

BACKGROUND: Clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥10 mmHg, causes major complications. HVPG is not always available, so a non-invasive tool to diagnose CSPH would be useful. VWF-Ag can be used to diagnose. Using the VITRO score (the VWF-Ag/platelet ratio) instead of VWF-Ag itself improves the diagnostic accuracy of detecting cirrhosis/ fibrosis in HCV patients. AIM: This study tested the diagnostic accuracy of VITRO score detecting CSPH compared to HVPG measurement. METHODS: All patients underwent HVPG testing and were categorised as CSPH or no CSPH. The following patient data were determined: CPS, D'Amico stage, VITRO score, APRI and transient elastography (TE). RESULTS: The analysis included 236 patients; 170 (72%) were male, and the median age was 57.9 (35.2-76.3; 95% CI). Disease aetiology included ALD (39.4%), HCV (23.4%), NASH (12.3%), other (8.1%) and unknown (11.9%). The CPS showed 140 patients (59.3%) with CPS A; 56 (23.7%) with CPS B; and 18 (7.6%) with CPS C. 136 patients (57.6%) had compensated and 100 (42.4%) had decompensated cirrhosis; 83.9% had HVPG ≥10 mmHg. The VWF-Ag and the VITRO score increased significantly with worsening HVPG categories (P<0.0001). ROC analysis was performed for the detection of CSPH and showed AUC values of 0.92 for TE, 0.86 for VITRO score, 0.79 for VWF-Ag, 0.68 for ELF and 0.62 for APRI. CONCLUSION: The VITRO score is an easy way to diagnose CSPH independently of CPS in routine clinical work and may improve the management of patients with cirrhosis.

Small colorectal polyps.

Small (<10 mm) and diminutive (<6 mm) polyps harbour high-grade dysplasia or cancer in 0.3-5% of cases. The potential to grow and develop advanced histology is low. Traditional guidelines still recommend the removal of all polyps. Visual characterisation with modern endoscopic technology could enable us to leave diminutive hyperplastic polyps in situ and remove but discard small polyps. In expert hands, high-definition white-light endoscopy and virtual chromoendoscopy can reach an accuracy of more than 90% in distinguishing between hyperplastic and adenomatous pathology. For less experienced endoscopists the values are lower and therefore the concept is not yet fit for routine use. Polyps can be removed completely with snares but not with forceps. The cold snaring technique in particular has proved safe and effective for small polyps. With more experience in the future a 'cut and discard' strategy for small polyps and a 'do not resect' strategy for diminutive polyps will save money and time to deal with more advanced lesions.

A case of obstructive jaundice due to autoimmune pancreatitis and a review of the literature.

A 33-year-old man presented with jaundice, mild pancreatitis, and some weight loss. Laboratory tests showed cholestatic icterus. Imaging revealed distal bile duct obstruction and a mass in the head of the pancreas suspicious for cancer. Besides the enlargement of the head, the whole pancreatic parenchyma was altered. Therefore, autoimmune pancreatitis was considered. Endoscopic ultrasound biopsy found pancreatic tissue with lymphoplasmacytic inflammation and fibrosis. IgG4 serum concentration was within normal range. Due to the benign histology, a therapeutic attempt with prednisolone was initiated. The radiologic changes improved within 2 weeks, which supported the diagnosis of autoimmune pancreatitis. Bile duct obstruction and radiologic abnormalities of the pancreas completely resolved after a 4-month course of steroid treatment. Within 10 months, no relapse occurred. In context with this case, the recent literature was reviewed and the international consensus diagnostic criteria for autoimmune pancreatitis are summarized.

Endoscopic radiofrequency ablation for malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications.

BACKGROUND: Biliary radiofrequency ablation (RFA) using the Habib™ EndoHBP catheter is a new endoscopic palliation therapy for malignant biliary obstruction. The aim of this study was to assess the feasibility and safety of this technique. METHODS: In this nationwide retrospective study of prospectively collected clinical data, all patients treated by biliary RFA in Austria between November 2010 and December 2012 were included. Procedure-related complications, adverse events within 30 days post-intervention, stent patency, and mortality rates were investigated. RESULTS: A total of 58 patients (31 male, 27 female, median age 75 years) underwent 84 RFA procedures at 11 Austrian referral centers for biliary endoscopy. The predominant underlying condition was Klatskin tumor (45 of 58 cases). All 84 RFA procedures were feasible without technical problems. A partial liver infarction was induced by RFA in a 49-year-old Klatskin tumor patient. During 30 days after each RFA procedure, five cases of cholangitis, three cases of hemobilia, two cases of cholangiosepsis, and one case each of gallbladder empyema, hepatic coma, and newly diagnosed left bundle branch block occurred. Median stent patency after last electively performed RFA was 170 days (95 % CI 63-277) and was almost significantly different between metal and plastic stenting (218 vs. 115 days; p = 0.051). Median survival was 10.6 months (95 % CI 6.9-14.4) from the time of the first RFA in each patient and 17.9 months (95 % CI 10.3-25.6) from the time of initial diagnosis. CONCLUSIONS: Except for one severe interventional complication (hepatic infarct), RFA presented as a technically feasible and safe therapeutic option for the palliative treatment of malignant biliary obstruction. The good results of stent patency and survival in this study should be proven in prospective (controlled) trials to further quantify the efficacy of this promising new technique.

Antiviral treatment of chronic hepatitis C in clinical routine.

OBJECTIVE: Pegylated interferon plus ribavirin is the standard treatment for chronic hepatitis C. Sustained virological response (SVR) rates of up to 60% are reported in randomized controlled trials, but it is unclear whether the results from such trials are reproducible in the clinical routine setting. We investigated consecutive treatment-naïve chronic hepatitis C patients at our center to examine the efficacy of treatment with pegylated interferon plus ribavirin in clinical routine. MATERIALS AND METHODS: Between 2000 and 2006 we treated a total of 219 patients with pegylated interferon alpha (2a or 2b) and ribavirin (800-1200 mg/d). Among them, 34.8% of patients infected with HCV genotypes 1/4/6 and 18.4% of those with genotypes 2/3 had advanced fibrosis or cirrhosis (F3-F4). For analysis of outcome we subdivided our series into two groups of patients: those who fulfilled standard inclusion criteria in randomized controlled trials and those who did not. RESULTS: The overall SVR rate was 44.3%. In patients with F0-F2 an SVR was achieved in 52.5%; in those with F3-F4 the SVR rate was 20.8%. In patients infected with genotypes 1/4/6 the SVR rate was 35.4% (SVR: F0-F2 47.7%; F3-F4 19.6%); in those with genotypes 2/3 the rate was 67.8%. The SVR rate in patients with unfavorable baseline factors was significantly lower (32.4% vs. 50%; P = 0.017) and they were more likely to be non-responders (30.9% vs. 13.8%). CONCLUSION: In everyday clinical practice, up to one-third of patients show unfavorable baseline factors for antiviral therapy, resulting in worse therapeutic outcome. Differences in therapeutic outcome are influenced by patient selection and by the proportion and severity of the underlying liver disease.