The role of endoscopy in the management of gastroesophageal reflux disease

Effect of sex on the outcomes of peroral endoscopic myotomy for the treatment of achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) has emerged as the first-line therapy for achalasia. However, large-scale studies which examine sex-related differences in symptoms and outcomes remain limited.

AIM

To evaluate the impact of sex on achalasia symptoms, diagnostic findings, and postoperative improvement following POEM.

METHODS

We conducted a retrospective review of achalasia patients who underwent POEM at a large center between 2010 and 2020, analyzing demographics and variables collected before, during, and after the procedure for both female and male cases.

RESULTS

Our study included 526 cases in total, with the female group experiencing more severe chest pain (P = 0.008). After stratifying age, we found that women aged 40 to 60 showed higher chest pain scores compared to their male counterparts. In female cases, the severity of dysphagia before POEM was lowest among those aged 60 and older (P = 0.033). Preoperatively, the integrated relaxation pressure (IRP) and resting lower esophageal sphincter pressure (LESP) were higher in the female group compared to the male group (P < 0.001 and P = 0.001, respectively). However, no differences in postoperative IRP and LESP were observed between two groups. The overall efficiency of POEM was 96.52%, with a significant improvement in chest pain scores noted in female cases (P = 0.043).

CONCLUSION

Sex may influence the severity and frequency of chest pain, with female cases exhibiting higher LESP and IRP compared to male cases. POEM is proven to be a safe and effective procedure for both sexes, with female cases potentially experiencing greater benefits.

Prevalence and Risk Factors of Gastroesophageal Reflux Disease in Patients with Dyspeptic and Reflux Symptoms: An Endoscopy-Based Prospective Study from Al Khobar, Saudi Arabia

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) in Saudi Arabia has only been reported using questionnaires, which have low sensitivity and specificity compared with endoscopy. This study aimed to determine the prevalence and associated factors of GERD among dyspeptic adult patients undergoing upper gastrointestinal (GI) endoscopy at a tertiary hospital in Saudi Arabia.

PATIENTS AND METHODS

In this prospective observational study, we included all adult patients (aged ≥ 18 years) with persistent dyspeptic and reflux symptoms who were scheduled for upper GI endoscopy at a tertiary academic hospital in Al Khobar, Saudi Arabia, between August 2019 and August 2023. GERD was defined according to the Los Angeles Classification (Grades A-D), while non-erosive reflux disease (NERD) was defined according to the Montreal International Consensus.

RESULTS

We included 303 patients in the study (mean age: 44.1 years; female: 57.8%). Endoscopic findings revealed hiatal hernia (51.9%) and esophagitis (31.4%) as the most common esophageal abnormalities, while gastritis (83.5%) and duodenitis (73.7%) were the most common findings in the stomach and duodenum, respectively. The prevalence of GERD was 20.1%, while NERD was the most frequent diagnosis (28.1%). The prevalence of GERD was significantly higher in males (P < 0.001) and among patients with regurgitation (P = 0.033), abnormal esophageal findings (P < 0.001), esophagitis or incompetent cardia (P < 0.001), and gastric ulcers (P = 0.041). Independent predictors of GERD were male gender (OR: 2.77; 95% CI: 1.53-5.01; P = 0.001) and the presence of "other" comorbidities (OR: 2.55; 95% CI: 1.11-5.83; P = 0.027).

CONCLUSION

This prospective study found that about one-fifth of the patients undergoing upper GI endoscopy for dyspeptic and reflux symptoms at a tertiary hospital in Al Khobar, Saudi Arabia, had GERD, and more than one-fourth had NERD.

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease: A systematic review and meta-analysis

Background and study aims Gastroesophageal reflux disease (GERD) is a widespread chronic gastrointestinal condition with an increasing worldwide prevalence. This research was a systematic review and meta-analysis evaluating the efficacy, safety, and long-term outcomes of endoscopic full-thickness plication (EFTP) for the treatment of GERD. Methods A comprehensive search of databases was conducted for studies published up to April 2023. We included randomized controlled trials (RCTs) and prospective observational studies that examined the use of EFTP in treating GERD among adult patients. We calculated pooled effect estimates using a random-effects model. Results EFTP significantly improved GERD Health-Related Quality of Life (GERD-HRQL) scores at 3-, 6-, and 12-month follow-up intervals. A considerable proportion of patients discontinued proton pump inhibitors, with cessation rates of 59% (95% confidence interval [CI]: 0.47-0.71), 68% (95% CI: 0.58-0.78), and 67% (95% CI: 0.46-0.89,) at 3, 6, and 12 months, respectively. At 3 and 6 months, 61% (95% CI: 0.54-0.68) and 66% (95% CI: 0.56-0.76) of patients experienced ≥50% improvement in GERD-HRQL scores. EFTP demonstrated a favorable safety profile, with a low rate of severe adverse events. We observed a 6.76% reduction (95% CI: -14.53-1.02) in the percentage of time with esophageal pH <4, a decrease in DeMeester scores, and fewer total reflux episodes. The average procedure time was 22.75 minutes (95% CI: 22.03-23.48). Subgroup analyses suggest that both the GERDx system and the NDO Plicator are effective and safe in treating GERD. Conclusions The findings from our study reveal that EFTP is a safe and effective treatment for GERD patients who have not responded adequately to conventional therapies. Given its minimally invasive nature, effectiveness, and limited adverse effects, EFTP emerges as a compelling alternative to conventional surgical procedures.

Uncertainty-aware network for fine-grained and imbalanced reflux esophagitis grading

Computer-aided diagnosis (CAD) assists endoscopists in analyzing endoscopic images, reducing misdiagnosis rates and enabling timely treatment. A few studies have focused on CAD for gastroesophageal reflux disease, but CAD studies on reflux esophagitis (RE) are still inadequate. This paper presents a CAD study on RE using a dataset collected from hospital, comprising over 3000 images. We propose an uncertainty-aware network with handcrafted features, utilizing representation and classifier decoupling with metric learning to address class imbalance and achieve fine-grained RE classification. To enhance interpretability, the network estimates uncertainty through test time augmentation. The experimental results demonstrate that the proposed network surpasses previous methods, achieving an accuracy of 90.2% and an F1 score of 90.1%.

Application of artificial intelligence in gastrointestinal endoscopy in Vietnam: a narrative review

The utilization of artificial intelligence (AI) in gastrointestinal (GI) endoscopy has witnessed significant progress and promising results in recent years worldwide. From 2019 to 2023, the European Society of Gastrointestinal Endoscopy has released multiple guidelines/consensus with recommendations on integrating AI for detecting and classifying lesions in practical endoscopy. In Vietnam, since 2019, several preliminary studies have been conducted to develop AI algorithms for GI endoscopy, focusing on lesion detection. These studies have yielded high accuracy results ranging from 86% to 92%. For upper GI endoscopy, ongoing research directions comprise image quality assessment, detection of anatomical landmarks, simulating image-enhanced endoscopy, and semi-automated tools supporting the delineation of GI lesions on endoscopic images. For lower GI endoscopy, most studies focus on developing AI algorithms for colorectal polyps' detection and classification based on the risk of malignancy. In conclusion, the application of AI in this field represents a promising research direction, presenting challenges and opportunities for real-world implementation within the Vietnamese healthcare context.

Role of endoscopy in gastroesophageal reflux disease

In general, gastroesophageal reflux disease (GERD) is diagnosed clinically based on typical symptoms and/or response to proton pump inhibitor treatment. Upper gastrointestinal endoscopy is reserved for patients presenting with alarm symptoms, such as dysphagia, odynophagia, significant weight loss, gastrointestinal bleeding, or anorexia; those who meet the criteria for Barrett's esophagus screening; those who report a lack or partial response to proton pump inhibitor treatment; and those with prior endoscopic or surgical anti-reflux interventions. Newer endoscopic techniques are primarily used to increase diagnostic yield and provide an alternative to medical or surgical treatment for GERD. The available endoscopic modalities for the diagnosis of GERD include conventional endoscopy with white-light imaging, high-resolution and high-magnification endoscopy, chromoendoscopy, image-enhanced endoscopy (narrow-band imaging, I- SCAN, flexible spectral imaging color enhancement, blue laser imaging, and linked color imaging), and confocal laser endomicroscopy. Endoscopic techniques for treating GERD include esophageal radiofrequency energy delivery/Stretta procedure, transoral incisionless fundoplication, and endoscopic full-thickness plication. Other novel techniques include anti-reflux mucosectomy, peroral endoscopic cardiac constriction, endoscopic submucosal dissection, and endoscopic band ligation. Currently, many of the new endoscopic techniques are not widely available, and their use is limited to centers of excellence.

Frontiers in Endoscopic Treatment for Gastroesophageal Reflux Disease

BACKGROUND

The 3rd edition of the evidence-based clinical practice guidelines for gastroesophageal reflux disease (GERD) 2021 from the Japanese Society of Gastroenterology states that the treatment strategy for potassium-competitive acid blocker (PCAB)-refractory GERD remains unclear. Furthermore, even if GERD improves with the administration of an acid secretion inhibitor, it is feared that GERD may flare up after discontinuation of the drug, resulting in some cases in which patients are forced to take vonoprazan semipermanently (the so-called PCAB-dependent cases). From a global perspective, PCAB is not yet used in all countries and regions, and measures that can be taken now for cases in which a conventional proton pump inhibitor (PPI) is inadequately effective need to be devised.

SUMMARY

Endoscopic treatment for GERD may be effective in cases where conventional proton pump inhibitors are ineffective; however, there are insufficient long-term studies to corroborate this, and its cost effectiveness is unknown. Other treatment options for PCAB or PPI-refractory GERD include surgical procedures (Nissen and Toupet operations), which have a longer history than endoscopic treatment for GERD. However, their long-term results are not as good as those of acid secretion inhibitors, and they are not cost effective. Endoscopic treatment for GERD may fill gaps in inadequate surgical treatment. In April 2022, endoscopic anti-reflux mucosal resections (ARMS [anti-reflux mucosectomy] and ESD-G [endoscopic submucosal dissection for GERD]) were approved for reimbursement, making endoscopic treatment of GERD possible throughout Japan.

KEY MESSAGES

It is important to identify the background factors in cases in which endoscopic treatments are effective.

Using deep learning and explainable artificial intelligence to assess the severity of gastroesophageal reflux disease according to the Los Angeles Classification System

OBJECTIVES

Gastroesophageal reflux disease (GERD) is a complex disease with a high worldwide prevalence. The Los Angeles classification (LA-grade) system is meaningful for assessing the endoscopic severity of GERD. Deep learning (DL) methods have been widely used in the field of endoscopy. However, few DL-assisted researches have concentrated on the diagnosis of GERD. This study is the first to develop a five-category classification DL model based on the LA-grade using explainable artificial intelligence (XAI).

MATERIALS AND METHODS

A total of 2081 endoscopic images were used for the development of a DL model, and the classification accuracy of the models and endoscopists with different levels of experience was compared.

RESULTS

Some mainstream DL models were utilized, of which DenseNet-121 outperformed. The area under the curve (AUC) of the DenseNet-121 was 0.968, and its classification accuracy (86.7%) was significantly higher than that of junior (71.5%) and experienced (77.4%) endoscopists. An XAI evaluation was also performed to explore the perception consistency between the DL model and endoscopists, which showed meaningful results for real-world applications.

CONCLUSIONS

The DL model showed a potential in improving the accuracy of endoscopists in LA-grading of GERD, and it has noticeable clinical application prospects and is worthy of further promotion.