Alanna Ebigbo

Endoscopic submucosal dissection for early rectal neoplasia: experience from a European center.

Background and study aims Endoscopic resection is a curative treatment option for large nonpedunculated colorectal polyps (LNPCPs). Endoscopic submucosal dissection (ESD) allows en bloc resection but ESD experience is still limited outside Asia. The aim of our study was to evaluate the role of ESD in the treatment of early rectal neoplasia in a European center. Patients and methods 330 patients referred for endoscopic resection of rectal LNPCPs were included prospectively. Results ESD was performed for 302 LNPCPs (median diameter 40 mm). Submucosal invasive cancer (SMIC) was present in 17.2 % (n = 52). SMIC was associated with Paris type (54.5 % among type 0-Is lesions, 100 % of 0-Is-IIc type, 0 % of 0-IIa, 14.9 % of 0-IIa-Is, and 59.3 % of 0-IIa-IIc type; P < 0.001) and with surface pattern (71.4 % among nongranular plus mixed surface lesions, 17.9 % of lesions with granular surface and nodule ≥ 10 mm). For SMICs, resection rates were en bloc 81.4 %, R0 65.1 %, and curative 30.2 %. Curative resection rate improved from 13.6 % to 47.6 % over the study period (P = 0.036). The reason for 83.3 % (25/30) of noncurative resections was submucosal invasion exceeding 1000 µm. For benign lesions (n = 250, 82.8 %), the R0 resection increased from 55.2 % to 84.8 % over the study period (P < 0.001). Recurrence rate was 4.8 %, bleeding rate 5.2 %, and perforation rate 0.8 % (all complications managed conservatively). Median follow-up was 35 months. Conclusions The majority of rectal LNPCPs are benign lesions. ESD offers high R0 resection and low recurrence rates but EMR may be appropriate. In lesions with a risk for SMIC, ESD should be offered to achieve R0 resection. Despite high rates of R0 resection the curative resection rate of ESD for rectal SMIC is < 50 %. Pretherapeutic lesion selection needs improvement.

Endoscopic submucosal dissection for early gastric cancer: are expanded resection criteria safe for Western patients?

Background and study aims Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric cancer (EGC) fulfilling guideline resection criteria or the expanded resection criteria in Asia. It is unclear whether the expanded criteria can be transferred to European patients, and long-term follow-up data are lacking. The aim of this study was to evaluate long-term follow-up data after ESD of EGCs in Europe. Patients and methods Patients with EGC who underwent ESD were included in this single-center study at a German referral center. Patient and lesion characteristics, procedure characteristics, and follow-up data were recorded prospectively. Results A total of 179 patients with 191 EGCs were included over a period of 141 months, with 29.6 % of lesions meeting guideline criteria and 48.6 % meeting expanded criteria. The en bloc resection rate was 98.4 % for guideline criteria and 89.0 % for expanded criteria lesions (P = 0.09), and the R0 resection rate was 90.2 % and 73.6 %, respectively (P = 0.02). The main reason for the expanded criteria was a lesion diameter > 20 mm (81.6 %). COMPLICATIONS perforation 1 %, delayed bleeding 6.3 %, stricture 2.1 %, procedure-related mortality 1.1 %. Local recurrence rate was 0 % for guideline criteria and 4.8 % for expanded criteria lesions (P = 0.06), and the rate of metachronous neoplasia was 15.1 % and 7.1 %, respectively (median follow-up 51 and 56 months, respectively); 92.9 % of metachronous neoplasia were treated curatively with repeat ESD. One patient developed lymph node metastasis after ESD of a submucosal invasive expanded criteria lesion. Long-term-survival was comparable between the two criteria (P = 0.58). No gastric cancer-related death was observed in either group. Conclusions ESD can achieve high rates of long-term curative treatment using the expanded criteria in EGCs in Western countries. We recommend ESD as treatment of choice not only for guideline criteria EGCs but also for intramucosal nonulcerated EGCs regardless of their diameter.

Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique

BACKGROUND AND STUDY AIM Relief from dysphagia and regurgitation are the main goals of therapy in symptomatic Zenkers diverticulum. Flexible endoscopic treatment has proved to be an effective and safe method in control of these symptoms. The aim of our study was to further improve the resection of the cricopharyngeal muscle using a new technique, the double incision and snare resection (DISR) procedure, to reduce the recurrence rate. PATIENTS AND METHODS From February 2016 to April 2017, 16 patients were treated with 18 DISR procedures at our institution. The symptoms of the patients were recorded by a seven-item questionnaire prior to treatment, and re-evaluation was scheduled at 1 and 6 months after treatment. RESULTS The median age was 70 years (range 55 - 85), and 10 patients were men (62 %). The median size of the diverticulum was 20 mm (range 5 - 40 mm), and the DISR procedure was performed in 28 minutes (range 20 - 47 minutes), with no major postinterventional complications. All patients re-started oral nutrition on the day after the intervention; a gastric tube was not required. The median follow-up was 3 months (range 1 - 15 months). Two patients received a planned second-step procedure, one because of a very large cricopharyngeal muscle and one because of a cyst inside the Zenkers bridge. Although one patient suffered from mild recurrence of symptoms, she refused a second treatment. All other patients were free of symptoms after treatment. CONCLUSIONS The DISR procedure is a new endoscopic treatment technique that safely and reproducibly offers relief from symptomatic Zenkers diverticulum.

Partnership with African Countries: European Society of Gastrointestinal Endoscopy (ESGE) – Position Statement

Recommendations A new objective for the European Society of Gastrointestinal Endoscopy (ESGE) is to develop long-term partnerships with African countries. For this, an International Affairs Working Group (IAWG) was formed. In conjunction with the World Endoscopy Organization (WEO), ESGE conducted a survey of gastrointestinal (GI) endoscopy in Africa. Survey results showed that many African countries have few GI endoscopy centers with adequate resources. Barriers to the development of endoscopy services include a shortage of endoscopists who have undergone advanced endoscopy training, and a lack of equipment and basic infrastructure. Diseases related to infectious etiology are more prevalent than neoplastic diseases in Africa. Any development of endoscopy services needs to consider the local prevalence of diseases for which GI endoscopy is required, as well as the availability of resources. The IAWG will initiate a cascade approach to identify and adapt ESGE guidelines for local use. The guidelines will consider the level of resources available for each intervention, as well as cost, infrastructure, and training, and will be approved by consensus of local experts who are representative of different African areas. Suitable centers in African countries will be identified, and in future will be developed into WEO/ESGE training centers, to provide local training in both basic and advanced endoscopy according to the needs of the area.

Endoscopic treatment of early colorectal cancer – just a competition with surgery?

Abstract The endoscopic treatment of cancerous and precancerous lesions in the gastrointestinal (GI) tract has experienced major breakthroughs in the past years. Endoscopic mucosal resection (EMR) is a simple and efficient method for the treatment of most benign lesions in the GI tract. However, with the introduction of endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR), the scope of lesions eligible for endoscopic treatment has been widened significantly even in the colon. These methods are now being used routinely not just for the treatment of benign lesions but also in the curative en bloc resection of early colorectal cancers. The quick, efficient, and noninvasive character of these endoscopic procedures make them not just an alternative to surgery but, in many cases, the methods of choice for the treatment of most early colon cancers and some rectal cancers.

Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline

In order to address the status of gastrointestinal (GI) endoscopy in Africa, a European Society of Gastrointestinal Endoscopy (ESGE) International Affairs Working Group (IAWG) was established with participation from the World Endoscopy Organization (WEO) 1 . A previous survey conducted by the IAWG on the main indications of GI endoscopy in African countries showed nonvariceal upper GI hemorrhage (NVUGIH) to be among the top three indications 1 . This indication may reflect the very high prevalence of Helicobacter pylori infection, which is well known to be associated with gastroduodenal peptic ulcers and their complications, such as bleeding. In addition, the increased use of aspirin as prevention and treatment of cardiovascular disease, and the increase in life expectancy, may also, at least in part, account for the NVUGIH indication 2 3 4 . The management of NVUGIH requires a multi-step approach, involving endoscopic factors such as emergency endoscopy with different hemostatic devices, and clinical factors such as hospitalization, blood transfusion, and drugs. Such an approach is clearly sensitive to organizational, medical, pharmaceutical, and technological resources. However, the lack of structural endoscopic and clinical health resources in some underserved African areas is likely to affect the clinical outcome of patients with NVUGIH. In this regard, the previous IAWG survey revealed several critical needs in training, education, and technology that may represent a barrier to adequate NVUGIH management 1 . Most of the respondents from the African countries participating in the IAWG survey reported a lack of national guidelines for GI endoscopy; however, there was interest in the international guidelines, pending adaptation to reflect the endoscopic resources available in their regions. For this reason, the IAWG decided to apply the cascade methodology to adapt ESGE guidelines to resource-sensitive settings in partnership with African experts 1 . Cascade guidelines are resource oriented and provide hierarchical recommendations based on the resources available to the medical care provider 5 6 . In detail, four levels of resource availability – basic, limited, enhanced, and maximal levels – are identified, with most of the interest being in the basic and limited levels. We aimed to standardize the management of NVUGIH in low-resources setting. Here, we report the cascade adaptation of the ESGE guideline on the diagnosis and management of NVUGIH 7 .

Step-up training for colorectal and gastric ESD and the challenge of ESD training in the proximal colon: results from a German Center

Background and study aims The endoscopic submucosal dissection (ESD) of cancerous and precancerous lesions in the gastrointestinal (GI) tract is an effective but difficult-to-learn procedure, especially for Western endoscopists. We developed a step-up training protocol and evaluated its outcome on a single endoscopist using specific performance measures. Patients and methods The training protocol included a 12-month period of 50 observational and supervised ESD cases as well as 24 animal procedures. After completion of the protocol, ESD competency was evaluated in the first 30 independent ESD cases. Majority of lesions were located in the stomach and rectum. Performance measures included R0-resection rate, complication rate and resection speed. Results R0 resection rate was 93 %, complication rate was 7 % and median resection speed was 6,77 cm 2 /h. 1 case of delayed perforation with subsequent hemicolectomy occurred in the descending colon. Conclusion The ESD step-up training protocol used in this study on a single endoscopist showed excellent outcomes for lesions in the rectum and stomach. However, ESD training in the upper colon remains a challenge.

A survey on Barrett's esophagus analysis using machine learning

This work presents a systematic review concerning recent studies and technologies of machine learning for Barretts esophagus (BE) diagnosis and treatment. The use of artificial intelligence is a brand new and promising way to evaluate such disease. We compile some works published at some well-established databases, such as Science Direct, IEEEXplore, PubMed, Plos One, Multidisciplinary Digital Publishing Institute (MDPI), Association for Computing Machinery (ACM), Springer, and Hindawi Publishing Corporation. Each selected work has been analyzed to present its objective, methodology, and results. The BE progression to dysplasia or adenocarcinoma shows a complex pattern to be detected during endoscopic surveillance. Therefore, it is valuable to assist its diagnosis and automatic identification using computer analysis. The evaluation of the BE dysplasia can be performed through manual or automated segmentation through machine learning techniques. Finally, in this survey, we reviewed recent studies focused on the automatic detection of the neoplastic region for classification purposes using machine learning methods.

Barrett’s Esophagus Analysis Using Convolutional Neural Networks

We propose an automatic approach for early detection of adenocarcinoma in the esophagus. High-definition endoscopic images (50 cancer, 50 Barrett) are partitioned into a dataset containing approximately equal amounts of patches showing cancerous and non-cancerous regions. A deep convolutional neural network is adapted to the data using a transfer learning approach. The final classification of an image is determined by at least one patch, for which the probability being a cancer patch exceeds a given threshold. The model was evaluated with leave one patient out cross-validation. With sensitivity and specificity of 0.94 and 0.88, respectively, our findings improve recently published results on the same image data base considerably. Furthermore, the visualization of the class probabilities of each individual patch indicates, that our approach might be extensible to the segmentation domain.