Endoscopic resection for early gastric cancer is recommended when the risk of lymph node metastasis is negligible and should be performed through submucosal dissection due to well‐established short‐ ...and long‐term results. To overcome technical difficulties and decrease adverse events some techniques have been studied. This review outlines current strategies for improving patient selection and highlights innovative techniques that help minimize adverse events. Moreover, we discuss how to improve management after curative and noncurative resections.
Main Recommendations
1
ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least six biopsies should be taken, two to four biopsies from the distal esophagus and two to ...four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities. Distal and proximal biopsies should be placed in separate containers.
Strong recommendation, low quality of evidence.
2
ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis.
Strong recommendation, low quality of evidence.
3
ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal cancer and suspected advanced gastric cancer.
Strong recommendation, moderate quality of evidence.
4
ESGE recommends taking only one to two targeted biopsies for lesions in the esophagus or stomach that are potentially amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm the diagnosis and not compromise subsequent endoscopic resection.
Strong recommendation, low quality of evidence.
5
ESGE recommends obtaining two biopsies from the antrum and two from the corpus in patients with suspected
Helicobacter pylori
infection and for gastritis staging.
Strong recommendation, low quality of evidence.
6
ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric adenomas.
Strong recommendation, moderate quality of evidence.
7
ESGE recommends fine-needle aspiration (FNA) and fine-needle biopsy (FNB) needles equally for sampling of solid pancreatic masses.
Strong recommendation, high quality evidence.
8
ESGE suggests performing peroral cholangioscopy (POC) and/or endoscopic ultrasound (EUS)-guided tissue acquisition in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred, with POC where this is not diagnostic.
Weak recommendation, low quality evidence.
9
ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected malignant lesions to prevent intraluminal spread of malignant disease.
Weak recommendation, low quality of evidence.
10
ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending on local experience.
Weak recommendation, low quality evidence.
Background
Portugal presents both a high prevalence of Helicobacter pylori (Hp) infection and a high prevalence of antibiotic resistance. However, conclusive data on its magnitude are lacking. We ...aimed at summarizing the existing data.
Materials and Methods
A systematic review was conducted after searching in two databases (PubMed and SciELO). Meta‐analysis was performed, and comparison of resistance rates between children and adults and by type of resistance (primary and secondary) was made.
Results
Eight cross‐sectional studies assessing Hp resistance to antibiotics were included. Overall resistance rates were as follows: clarithromycin (CLA) 42% (95% CI: 30‐54), metronidazole (MTZ) 25% (95% CI: 15‐38), ciprofloxacin (CIP) 9% (95% CI: 3‐18), levofloxacin (LVX) 18% (95% CI: 2‐42), tetracycline (TTC) 0.2% (95% CI: 0‐1), and amoxicillin (AMX) 0.1% (95% CI: 0‐0.2). Multidrug resistance was also an important problem, with the following global resistance rates: CLA plus MTZ of 10% (adults 20% (95% CI: 15‐26) vs children 6% (95% CI: 4‐9)) and CLA plus CIP of 2% (primary resistance in children's group). High secondary resistance rates were found for all antibiotics. Resistance was higher among adults for all antibiotics, except CLA that had high resistance levels both among adults and children (42% 95% CI: 14‐71 and 40% 95% CI: 33‐47).
Conclusions
Hp resistance to the most widely used antibiotics is high in Portugal. Accordingly, our results suggest that the best therapeutic strategy for Hp in Portugal may be quadruple therapy with bismuth for adults and triple therapy including AMX plus MTZ or bismuth‐based therapy for children.
Background
Cost‐effectiveness studies are highly dependent on the models, settings, and variables used and should be based on systematic reviews. We systematically reviewed cost‐effectiveness studies ...that address screening for gastric cancer and/or surveillance of precancerous conditions and lesions.
Materials and Methods
A systematic review of cost‐effectiveness studies was performed by conducting a sensitive search in seven databases (PubMed, Scopus, Web of Science, Current Contents Connect, Centre for Reviews and Dissemination, Academic Search Complete, and CINAHL Plus), independently evaluated by two investigators. Articles were evaluated for type of study, perspective, model, intervention, incremental cost‐effectiveness ratio, clinical or cost variables, and quality, according to published guidelines.
Results
From 2395 s, 23 articles were included: 19 concerning population screening and 4 on following up premalignant lesions. Studies on Helicobacter pylori screening concluded that serology was cost‐effective, depending on cancer incidence and endoscopy cost (incremental cost‐effectiveness ratio: 6264–25,881), and eradication after endoscopic resection was also cost‐effective (dominant) based on one study. Studies on imaging screening concluded that endoscopy was more cost‐effective than no screening (incremental cost‐effectiveness ratio: 3376–26,836). Articles on follow‐up of premalignant lesions reported conflicting results (incremental cost‐effectiveness ratio: 1868–72,519 for intestinal metaplasia; 18,600–39,800 for dysplasia). Quality assessment revealed a unanimous lack of a detailed systematic review and fulfillment of a median number of 23 items (20–26) of 35 possible ones.
Conclusions
The available evidence shows that Helicobacter pylori serology or endoscopic population screening is cost‐effective, while endoscopic surveillance of premalignant gastric lesions presents conflicting results. Better implementation of published guidelines and accomplishment of systematic detailed reviews are needed.
Background: Current evidence supports the use of virtual reality (VR) simulation-based training for novice endoscopists. However, there is still a need for a standardized induction programme which ...ensures sufficient preparation, with knowledge and basic skills, before their approach to patient-based training. We designed a structured progressive programme in upper endoscopy and colonoscopy and aimed to determine its impact on cognitive and technical performance. Methods: Prospective, multicentre study, focused on “Endoscopy I, 2018,” a course with a theoretical and a hands-on module (20 h) in the GI Mentor II®. Gastroenterology residents of the 1st year were enrolled. A pre-test and test were applied to evaluate the cognitive component, and a pre-training and post-training esophagogastroduodenoscopy (EGD) and colonoscopy VR cases were used to evaluate the technical component. The hands-on training included psychomotor exercises (Navigation I, Endobubble I), 4 EGD, and 4 colonoscopy VR cases. The metrics applied for technical skills evaluation were time to reach the second portion of duodenum (D2)/cecum (seconds), efficiency of screening (%), and time the patient was in pain (%). Results: Twenty-three participants were included, majority female (67%), 26 ± 0.7 years old. Comparing the pre-test versus test, the cognitive score significantly improved (11/15 vs. 14/15; p < 0.001). Considering the technical assessment after training: in EGD, the time to D2 was significantly lower (193 vs. 63 s; p < 0.001), and the efficiency of screening significantly better (64 vs. 91%; p < 0.001); in colonoscopy, the time to reach the cecum was significantly lower (599 vs. 294 s; p = 0.001), the time the patient was in pain was significantly lower (27 vs. 10%; p = 0.005), and the efficiency of screening had a tendency towards improvement (50 vs. 68%; p = 0.062). Conclusion: The proposed training curriculum in basic endoscopy for novices is aligned with international recommendations and demonstrated a significant impact on cognitive and technical skills learning achievements.
Background
Progression of extensive gastric premalignant conditions to cancer might warrant surveillance programms. Recent guidelines suggest a 3‐yearly endoscopic follow‐up for these patients. Our ...aim was to determine the cost utility of endoscopic surveillance of patients with extensive gastric premalignant conditions such as extensive atrophy or intestinal metaplasia.
Materials and Methods
A cost‐utility economic analysis was performed from a societal perspective in Portugal using a Markov model to compare two strategies: surveillance versus no surveillance. Clinical data were collected from a systematic review of the literature, costs from published national data, and community utilities derived from a population study by the EuroQol questionnaire in terms of quality‐adjusted life years (QALY). Population started at age 50, for a time horizon of 25 years and an annual discount rate of 3% was used for cost and effectiveness. Primary outcome was the incremental cost‐effectiveness ratio (ICER) of a 3‐yearly endoscopic surveillance versus no surveillance for a base case scenario and in deterministic and probabilistic sensitivity analysis. Secondary outcomes were ICER of 5‐ and 10‐yearly endoscopic surveillance versus no surveillance.
Results
Endoscopic surveillance every 3 years provided an ICER of € 18,336, below the adopted threshold of € 36,575 which corresponds to the proposed guideline limit of USD 50,000 and this strategy dominated surveillance every 5 or 10 years. Utilities for endoscopic treatment were relevant in deterministic analysis, while probabilistic analysis showed that in 78% of cases the model was cost‐effective.
Conclusions
Endoscopic surveillance every 3 years of patients with premalignant conditions is cost‐effective.
Abstract
European Society of Gastrointestinal Endoscopy recommends needle-knife fistulotomy (NKF) as the preferred precut technique. However, there is little information on whether NKF performed at ...different times is associated with different success and adverse event rates. We compared the outcomes of 3 different timings of NKF. This was an observational study conducted at 4 institutions and this was a retrospective analysis of prospectively collected data. We included 330 consecutive patients submitted to NKF attempt for biliary access. Patients were divided into three groups: NKF as an initial procedure for biliary access (group A, n = 121); early NKF defined as after 5 min, 5 attempts, or 2 pancreatic passages (group B, n = 99); and late NKF: after at least 10 min of unsuccessful standard biliary cannulation (group C, n = 110). We assessed the success rate of biliary cannulation at initial ERCP, time to perform NKF until biliary cannulation, overall biliary cannulation rate (second ERCP when initial failure), adverse event rate, and predictors of post-ERCP pancreatitis (PEP). The initial cannulation rate was 98%, 91% and 94% for groups A, B and C respectively,
p
= 0.08, whereas overall biliary cannulation rate was 100%, 95% and 98%,
p
= 0.115. The adverse event rate/PEP was 4.1%/2.5%, 7.1%/4% and 10.9%/8.2%, for groups A, B and C respectively, (
p
= 0.197 and
p
= 0.190). Median time for creating the fistula was A = 4.0 min, B = 3.2 min, and C = 5.6 min,
p
< 000.1. Each additional minute spent attempting cannulation increased the odds ratio (OR) for PEP by 1.072, and patients with 3 or more risk factors for pancreatitis had a higher chance of PEP. In conclusion, the timing of NFK does not appear to influence success rates but late NFK is associated with a higher time to create a fistula and an increased risk of pancreatitis. Primary NFK is associated with a high rate of success and a low rate of PEP and deserves additional investigation.
Endoscopic examination revealed a 20-mm 0-IIa type lesion in the great curvature of the proximal corpus with a hyperplastic appearance and a dark coloration area in one of the edges (Fig. 1, 2). ...Endoscopic biopsies were repeated, and pathological evaluation revealed diffuse involvement of the lamina propria by a malignant neoplasm, composed of cells with nuclear pleomorphism and high mitotic rate, entrapping benign gastric glands. Conflict of Interest Statement The authors have no conflicts of interest to declare.
Background
Determining the prevalence of Barrett’s esophagus is important for defining screening strategies. We aimed to synthesize the available data, determine Barrett’s esophagus prevalence, and ...assess variability.
Methods
Three databases were searched. Subgroup, sensitivity, and meta-regression analyses were conducted and pooled prevalence was computed.
Results
Of 3510 studies, 103 were included. In the general population, we estimated a prevalence for endoscopic suspicion of Barrett’s esophagus of (a) any length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.85–1.07), (b) ≥1 cm of length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.75–1.18) and (c) for any length with histologic confirmation of columnar metaplasia as 3.89% (95% confidence interval: 2.25–5.54) . By excluding studies with high-risk of bias, the prevalence decreased to: (a) 0.70% (95% confidence interval: 0.61–0.79) and (b) 0.82% (95% confidence interval: 0.63–1.01). In gastroesophageal reflux disease patients, we estimated the prevalence with afore-mentioned criteria to be: (a) 7.21% (95% confidence interval: 5.61–8.81) (b) 6.72% (95% confidence interval: 3.61–9.83) and (c) 7.80% (95% confidence interval: 4.26–11.34). The Barrett’s esophagus prevalence was significantly influenced by time period, region, Barrett’s esophagus definition, Seattle protocol, and study design. There was a significant gradient East-West and North-South. There were minimal to no data available for several countries. Moreover, there was significant heterogeneity between studies.
Conclusion
There is a need to reassess the true prevalence of Barrett’s esophagus using the current guidelines in most regions. Having knowledge about the precise Barrett’s esophagus prevalence, diverse attitudes from educational to screening programs could be taken.
Background and Aims Postprocedural bleeding (PPB) is the most common adverse event associated with endoscopic resection. Several studies have tried to identify risk factors for PPB after gastric EMR ...and endoscopic submucosal dissection (ESD), with controversial results. This systematic review and meta-analysis aimed to identify significant risk factors for PPB after gastric EMR and ESD. Methods Three online databases were searched. Pooled odds ratio (OR) was computed for each risk factor using a random-effects model, and heterogeneity was assessed by Cochran’s Q test and I2. Results Seventy-four articles were included. Pooled PPB rate was 5.1% (95% confidence interval, 4.5%-5.7%), which did not vary according to different study designs. Male sex (OR, 1.25), cardiopathy (OR, 1.54), antithrombotic drugs (OR, 1.63), cirrhosis (OR, 1.76), chronic kidney disease (OR, 3.38), tumor size > 20 mm (OR, 2.70), resected specimen size > 30 mm (OR, 2.85), localization in the lesser curvature (OR, 1.74), flat/depressed morphology (OR, 1.43), carcinoma histology (OR, 1.46), and ulceration (OR, 1.64) were identified as significant risk factors for PPB, whereas age, hypertension, submucosal invasion, fibrosis, and localization (upper, middle, or lower third) were not. Procedure duration > 60 minutes (OR, 2.05) and the use of histamine-2 receptor antagonists instead of proton pump inhibitors (OR, 2.13) were the procedural factors associated with PPB, whereas endoscopist experience and preprocedural proton pump inhibitors were not. Second-look endoscopy was not associated with decreased PPB (OR, 1.34; 95% confidence interval, .85-2.12). Conclusions Risk factors for PPB were identified that can help to guide management after gastric ESD, namely adjusting further management. Second-look endoscopy is not associated with decreased PPB.
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