Endoscopic submucosal dissection: a country dissemination experience and outcomes.

OBJECTIVE: An increasing use of endoscopic submucosal dissection (ESD) has been reported in Western countries, although some differences in training schemes and outcomes have been described. We aimed to report the training model, implementation, and outcomes of ESD in Portugal. METHODS: All endoscopists trained at our center from our country (n = 9) were invited to a survey regarding: (a) training period; (b) ESD outcomes and (c) implementation of ESD in each respective center. RESULTS: All endoscopists completed the survey. Learning ESD was centered on human ESD assistance in a high-volume center during a median time of 6 months and complemented mainly by hands-on courses (89%). During the surveyed period, a total of 1229 ESD were performed, mostly in gastric locations (74%). Median complete R0 and curative resection rate were 92% (IQR, 81-96.8) and 87% (IQR, 74-93.3), respectively, and median perforation rate was 0.89% (IQR, 0.25-6.22). The main limitations encountered during the implementation of ESD were related to the lack of initial mentoring or insufficient expertise to progress to more difficult lesions. CONCLUSION: Learning ESD through participation in hands-on courses and visiting high-volume centers seems to be adequate to achieve a good competence at the initial stage of ESD, which in fact is in consonance with the European Society of Gastrointestinal Endoscopy recommendations. However, mentoring is essential for technical progression, and this represents the fundamental barrier during the adoption of ESD, which may be overcome by increasing hands-on training in animal or artificial simulators, but preferably with the implementation of a structured training program.

Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.

Background and study aims Previous studies have suggested a high prevalence of musculoskeletal injuries (MI) in endoscopists. Little evidence has come from European countries. Our main aim was to evaluate the prevalence, type, and impact of MI among Portuguese endoscopists. We also sought to identify risk factors for the development, severity and number of endoscopy-related MI. Material and methods A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG - CEREGA. Results The survey was completed by 171 endoscopists (response rate of 24.3 %), 55.0 % female with a median age of 36 years (range 26-78). The prevalence of at least one MI related to endoscopy was 69.6 % (n = 119), the most frequent being neck pain (30.4 %) and thumb pain (29.2 %). The median time for MI development was 6 years (range 2 months-30 years). Severe pain was reported by 19.3 %. Change in endoscopic technique was undertaken by 61.3 % and reduction in endoscopic caseload was undertaken by 22.7 %. Missing work was reported by 10.1 %, with the median time off from work being 30 days (range 1-90). Female gender and ≥ 15 years in practice were independently associated with MI and severe pain. Years in practice, weekly-time performing endoscopy, and gender were significant predictors of the number of MI. Conclusions Prevalence of MI was significant among Portuguese endoscopists and had a relevant impact on regular and professional activities.

Prospective comparative study of endoscopic submucosal dissection and gastrectomy for early neoplastic lesions including patients' perspectives.

BACKGROUND: There are no prospective studies comparing endoscopic submucosal dissection (ESD) and gastrectomy, especially evaluating patient-reported outcomes. Our aim was to compare the safety and impact on quality of life (QoL) of ESD and gastrectomy in patients with early gastric neoplasia. METHODS: This prospective study included consecutive patients presenting with early gastric neoplasia in a tertiary center from January 2015 to August 2016. Data collection included curative resection, adverse events (AEs), and patient-reported outcomes (questionnaires: EORTC QLQ-C30, EORTC STO-22, EQ-5D-5 L, and Assessment of Survivor Concerns) before and after interventions (after 1 month, 3 - 6 months, and 1 year). RESULTS: 254 patients with early lesions were included: 153 managed by ESD and 101 by gastrectomy, the former being significantly older and with less advanced lesions. Mean procedural time and length of stay were significantly higher in the surgery group (164 vs. 72 minutes and 16.3 vs. 3.5 days; P < 0.001). Complete resection was higher in the surgical group (99 % vs. 90 %; P = 0.02); ESD was curative in 79 % of patients. Severe AEs and surgical re-intervention were significantly more frequent in the gastrectomy group (21.8 % vs. 7.8 % and 11 % vs. 1 %, respectively). Endoscopic treatment was associated with a positive impact on global health-related QoL at 1 year (net difference + 9.9; P = 0.006), role function and symptom scales (fatigue, pain, appetite, eating restrictions, dysphagia, and body image). Concerns about recurrence did not differ between the groups. CONCLUSIONS: In patients with early gastric neoplasia, ESD is safer and is associated with a positive impact on health-related QoL when compared with gastrectomy, without increasing fear of recurrence and new lesions.

Surveillance of patients with gastric precancerous conditions.

Intestinal-type gastric adenocarcinoma arises from a multistep process starting with Helicobacter pylori infection followed by gastric atrophy, gastric intestinal metaplasia and dysplasia. Indeed, patients with gastric precancerous conditions or lesions (GPC) are at increased risk to develop gastric cancer even in regions with low incidence. Thus, the identification and surveillance of a high risk subgroup could lead to the diagnosis of cancer at early stage and improve survival. However, both endoscopic and histological accuracy and interobserver agreement in the diagnosis of GPC are still far from optimal. Also, there are conceptual differences between the West and the East in the diagnosis and surveillance of patients. In the former, multiple gastric biopsies are still recommended but Eastern gastroenterologists select patients to surveillance according to the results of endoscopy or serology. In this literature review we describe the cascade of GPC and we highlight the differences between eastern and western clinical practice.

A multicenter prospective study of the real-time use of narrow-band imaging in the diagnosis of premalignant gastric conditions and lesions.

BACKGROUND AND AIM: Some studies suggest that narrow-band imaging (NBI) can be more accurate at diagnosing gastric intestinal metaplasia and dysplasia than white-light endoscopy (WLE) alone. We aimed to assess the real-time diagnostic validity of high resolution endoscopy with and without NBI in the diagnosis of gastric premalignant conditions and to derive a classification for endoscopic grading of gastric intestinal metaplasia (EGGIM). METHODS: A multicenter prospective study (five centers: Portugal, Italy, Romania, UK, USA) was performed involving the systematic use of high resolution gastroscopes with image registry with and without NBI in a centralized informatics platform (available online). All users used the same NBI classification. Histologic result was considered the diagnostic gold standard. RESULTS: A total of 238 patients and 1123 endoscopic biopsies were included. NBI globally increased diagnostic accuracy by 11 percentage points (NBI 94 % vs. WLE 83 %; P < 0.001) with no difference in the identification of Helicobacter pylori gastritis (73 % vs. 74 %). NBI increased sensitivity for the diagnosis of intestinal metaplasia significantly (87 % vs. 53 %; P < 0.001) and for the diagnosis of dysplasia (92 % vs. 74 %). The added benefit of NBI in terms of diagnostic accuracy was greater in OLGIM III/IV than in OLGIM I/II (25 percentage points vs. 15 percentage points, respectively; P < 0.001). The area under the curve (AUC) of the receiver operating characteristic (ROC) curve for EGGIM in the identification of extensive metaplasia was 0.98. CONCLUSIONS: In a real-time scenario, NBI demonstrates a high concordance with gastric histology, superior to WLE. Diagnostic accuracy higher than 90 % suggests that routine use of NBI allows targeted instead of random biopsy samples. EGGIM also permits immediate grading of intestinal metaplasia without biopsies and merits further investigation.

Light-NBI to identify high-risk phenotypes for gastric adenocarcinoma: do we still need biopsies?

OBJECTIVE: Early diagnosis of gastric cancer may be achieved through surveillance of patients with extensive gastric intestinal metaplasia (eGIM). However, diagnosis of eGIM generally implies histology. We aimed at determining the accuracy of high-resolution endoscopy with light-narrow band imaging (NBI) to assess the presence of eGIM on a per-patient basis. MATERIAL AND METHODS: Prospective cohort of 60 patients divided into two groups: derivation cohort (n = 25) to evaluate the reliability and validity, and a real-time validation group (n = 35). In the derivation group, six endoscopists with two levels of expertise were asked to estimate the grade of GIM based in endoscopic images (white light endoscopy, light-NBI and amplification/near focus). In the real-time validation set, experienced endoscopists were asked to similarly record their real-time optical diagnosis. Histology was then considered as the gold standard. RESULTS: In the derivation group diagnosis accuracy was 60% with WLE (non-expert 59% vs. 61% experts), increasing to 73% after NBI magnification (non-expert 63% vs. 83% expert, p < 0.05). Moreover, proportion of agreement with histology was 83%, with a correct diagnosis of eGIM in 87% for experienced observers. In the real-time group experts obtained 89% global diagnostic accuracy correctly identifying 91% of the eGIM. The sensitivity, specificity, LR + and LR- of real-time endoscopic diagnosis of eGIM was 0.92 (CI95%:0.67-0.99), 0.96 (0.79-0.99), 21.1 (3.08-144) and 0.09 (0.013-0.57). CONCLUSION: For the first time the reliability of high-resolution endoscopy with light-NBI for extension of GIM is described. Our results suggest that more than 90% of individuals at risk could be identified without the need for biopsies, simplifying the current recommendations.

Management of Patients with Hereditary Colorectal Cancer Syndromes.

Colorectal cancer (CRC) is one of the most important causes of death in the world. Hereditary CRC is found in 5-10% of CRC patients. In this review, we will focus on the major forms of hereditary CRC and their management according to the most recent literature available.

O cancro coloretal (CCR) é uma das mais importantes causas de morte ao nível mundial. O cancro coloretal hereditário está associado a cerca de 5 a 10% de todos os casos de CCR. Neste artigo faz-se uma revisão da abordagem dos principais síndromas hereditários associados a CCR de acordo com a literatura mais recente.