British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

The Role of Screening and Early Detection in Upper Gastrointestinal Cancers

Upper gastrointestinal cancers are among the leading causes of cancer deaths worldwide with exceptionally poor prognosis, which is largely attributable to frequently delayed diagnosis. Although effective screening is critical for early detection, the highly variable incidence of upper gastrointestinal cancers presents challenges, rendering universal screening programs suboptimal in most populations globally. Optimal strategies in regions of modest incidence, such as the United States, require a targeted approach, focused on high-risk individuals based on demographic, familial, and clinicopathologic risk factors. Assessment of underlying precancerous lesions has key implications for risk stratification and informing clinical decisions to improve patient outcomes.

The durability of previous examinations for cancer: Danish nationwide cohort study

OBJECTIVE

Patients previously examined for cancer with a negative result may present in general practice with ongoing or new symptoms or signs suggestive of cancer. This paper explores the potential existence of a relatively safe period for cancer occurrence after receiving negative examination results for specific types of cancer, including lung (CT thorax), upper gastrointestinal (gastroscopy), colorectal (colonoscopy), bladder (cystoscopy), and breast (clinical mammography).

DESIGN

Register-based time-to-event analyses.

SETTING

Denmark.

SUBJECTS

All 3.3 million citizens aged 30-85 years who on January first, 2017, had not previously been diagnosed with the specific type of cancer were categorized based on the time since their most recent examination.

MAIN OUTCOME MEASURES

Using 1-year follow-up, we calculated the age- and sex-adjusted hazard ratios of being diagnosed with the related cancer, with non-examined individuals as reference. Negative examination results were defined as the absence of a cancer diagnosis within 6 months following the examination.

RESULTS

Previous negative examination results were common, also among those diagnosed with cancer during follow-up. For 10 years after a negative colonoscopy the risk of diagnosing a colorectal cancer was nearly halved. However, already 1 year after a clinical mammography and 2 years after a CT thorax the risk of diagnosing the related cancers was significantly higher among those with a previous negative result compared to non-examined individuals.

CONCLUSION

This study did not identify a post-examination period in which the cancer risk, compared to non-examined individuals, was sufficiently low to confidently rule out any of the investigated cancers.

Causal inference between pernicious anemia and cancers: a bidirectional two-sample mendelian randomization analysis

BACKGROUND

Observational study investigated the association between pernicious anemia (PA) and cancers. However, with the exception of gastric cancer, the results are mostly contradictory. The purpose of this study was to investigate the potential causal relationship between PA and cancers through bidirectional two-sample Mendelian randomized (MR) analysis.

METHODS

The European sample FinnGen project provided the genetic summary data for PA and 20 site-specific cancers. This bidirectional two-sample MR design mainly used the inverse variance weighting (IVW) method to evaluate the causal relationship between PA and cancer risk. Benjamini-Hochberg correction was performed to reduce the bias caused by multiple tests.

RESULTS

Our study shows that there was a causal relationship between PA and gastric cancer, prostate cancer, testicular cancer and malignant melanoma of skin, and there was a reverse causal relationship between prostate cancer or gastric cancer and PA (P < 0.05). After Benjamini-Hochberg correction test, there was still a causal correlation between PA and gastric or prostate cancer (P' < 0.05), while there was only an implied causal association between PA and testicular cancer and malignant melanoma of skin (P'> 0.05). There was still a reverse causal relationship between gastric cancer and PA (P'< 0.05), while prostate cancer shows an implied reverse causal relationship(P'> 0.05). In addition, MR-Egger and MR-PRESSO tests showed no significant horizontal pleiotropy.

CONCLUSIONS

PA may be genetically associated with testicular cancer, prostate cancer, gastric cancer, and malignant melanoma of skin.

Endoscopic and histological risk stratification for gastric cancer using gastric intestinal metaplasia

BACKGROUND AND AIM

Intestinal metaplasia (IM) of the gastric mucosa is strongly associated with the risk of gastric cancer (GC). This study was performed to investigate the usefulness of endoscopic and histological risk stratification for GC using IM.

METHODS

This was a post-hoc analysis of a multicenter prospective study involving 10 Japanese facilities (UMINCTR000027023). The ridge/tubulovillous pattern, light blue crest (LBC), white opaque substance (WOS), endoscopic grading of gastric IM (EGGIM) score using non-magnifying image-enhanced endoscopy, and operative link on gastric IM assessment (OLGIM) were evaluated for their associations with GC risk in all patients.

RESULTS

In total, 380 patients (115 with GC and 265 without GC) were analyzed. The presence of an LBC (limited to antrum: odds ratio [OR] 2.4 [95% confidence interval 1.1-5.0], extended to corpus: OR 3.6 [2.1-6.3]), the presence of WOS (limited to antrum: OR 3.0 [1.7-5.3], extended to corpus: OR 4.2 [2.1-8.2]), and histological IM (limited to antrum: OR 3.2 [1.4-7.4], extended to corpus: OR 8.5 [4.5-16.0]) were significantly associated with GC risk. Additionally, the EGGIM score (5-8 points: OR 8.8 [4.4-16.0]) and OLGIM (stage III/IV: OR 12.5 [6.1-25.8]) were useful for stratification of GC risk. The area under the receiver operating characteristic curve value for GC risk was 0.740 for OLGIM and 0.706 for EGGIM.

CONCLUSIONS

The LBC, WOS, EGGIM, and OLGIM were strongly associated with GC risk in Japanese patients. This finding can be useful for GC risk assessment in daily clinical practice.

The diagnostic value of image-enhanced endoscopy system in sinonasal inverted papilloma

PURPOSE

This study aimed to evaluate the diagnostic value of image-enhanced endoscopy (IEE) in detecting sinonasal inverted papilloma (SNIP).

METHODS

Overall, 86 patients with unilateral nasal papillary or lobulated neoplasms were included between July 2018 and June 2019. All patients underwent IEE examinations, and the diagnosis of all neoplasms was confirmed through postoperative pathology. Logistic regression analysis was conducted to screen for independent predictors of various types of vascular patterns of SNIP. Furthermore, a prognostic nomogram was constructed using the independent predictors screened by logistic regression analysis to evaluate its usefulness in distinguishing SNIP from nasal polyp (NP) and papillary mucosa folds (PMF).

RESULTS

In total, 86 consecutive cases were observed, including 37 with SNIP, 40 with NP, and 9 with PMF. Logistic regression analysis showed that spot, corkscrew, and multilayered vascular patterns were independent predictors of SNIP diagnosis. Furthermore, a nomogram comprising the three independent risk factors was constructed with scores of 5, 2, and 3. The area under the receiver operating characteristic curve for predicting SNIP was 0.954, 0.66, 0.71, and 0.76 for the nomogram model, spot vascular pattern, corkscrew vascular pattern, and multilayered vascular pattern, respectively.

CONCLUSION

The nomogram model based on spot, corkscrew, and multilayered vascular patterns in SNIP observed using IEE can be a useful diagnostic tool for predicting and distinguishing between NP and PMF.

Comprehensive analysis of T-cell regulatory factors and tumor immune microenvironment in stomach adenocarcinoma

BACKGROUND

Gastric cancer (GC) is one of the most prevalent malignant tumors worldwide and is associated with high morbidity and mortality rates. However, the specific biomarkers used to predict the postoperative prognosis of patients with gastric cancer remain unknown. Recent research has shown that the tumor microenvironment (TME) has an increasingly positive effect on anti-tumor activity. This study aims to build signatures to study the effect of certain genes on gastric cancer.

METHODS

Expression profiles of 37 T cell-related genes and their TME characteristics were comprehensively analyzed. A risk signature was constructed and validated based on the screened T cell-related genes, and the roles of hub genes in GC were experimentally validated.

RESULTS

A novel T cell-related gene signature was constructed based on CD5, ABCA8, SERPINE2, ESM1, SERPINA5, and NMU. The high-risk group indicated lower overall survival (OS), poorer immune efficacy, and higher drug resistance, with SERPINE2 promoting GC cell proliferation, according to experiments. SERPINE2 and CXCL12 were significantly correlated, indicating poor OS via the Youjiang cohort.

CONCLUSIONS

This study identified T cell-related genes in patients with stomach adenocarcinoma (STAD) for prognosis estimation and proposed potential immunotherapeutic targets for STAD.

Enhancing endoscopic measurement: validating a quantitative method for polyp size and location estimation in upper gastrointestinal endoscopy

BACKGROUND

Accurate measurement of polyps size is crucial in predicting malignancy, planning relevant intervention strategies and surveillance schedules. Endoscopists' visual estimations can lack precision. This study builds on our prior research, with the aim to evaluate a recently developed quantitative method to measure the polyp size and location accurately during a simulated endoscopy session.

METHODS

The quantitative method merges information about endoscopic positions obtained from an electromagnetic tracking sensor, with corresponding points on the images of the segmented polyp border. This yields real-scale 3D coordinates of the border of the polyp. By utilising the sensor, positions of any anatomical landmarks are attainable, enabling the estimation of a polyp's location relative to them. To verify the method's reliability and accuracy, simulated endoscopies were conducted in pig stomachs, where polyps were artificially created and assessed in a test-retest manner. The polyp measurements were subsequently compared against clipper measurements.

RESULTS

The average size of the fifteen polyps evaluated was approximately 12 ± 4.3 mm, ranging from 5 to 20 mm. The test-retest reliability, measured by the Intraclass Correlation Coefficient (ICC) for polyp size estimation, demonstrated an absolute agreement of 0.991 (95% CI 0.973-0.997, p < 0.05). Bland & Altman analysis revealed a mean estimation difference of - 0.17 mm (- 2.03%) for polyp size and, a mean difference of - 0.4 mm (- 0.21%) for polyp location. Both differences were statistically non-significant (p > 0.05). When comparing the proposed method with calliper measurements, the Bland & Altman plots showed 95% of size estimation differences between - 1.4 and 1.8 mm (- 13 to 17.4%) which was not significant (p > 0.05).

CONCLUSIONS

The proposed method of measurements of polyp size and location was found to be highly accurate, offering great potential for clinical implementation to improve polyp assessment. This level of performance represents a notable improvement over visual estimation technique used in clinical practice.

Is there any difference between Eastern and Western clinical practice guidelines in management of gastric cancer?

BACKGROUND AND RECENT FINDINGS

Gastric cancer (GC) has been known as one of the most common causes of cancer mortality both in Western and Eastern countries. However, there might be differences between how it is managed in different countries. Thus, we aimed to investigate these differences.

MATERIALS AND METHODS

The most well-known clinical guidelines in field of GC management including Korean GC Association (KGCA), Japanese GC Association (JGCA), National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), British Society of Gastroenterology (BSG), and National Institute for health and Care Excellence (NICE) have been reviewed.

RESULTS

The contents of these guidelines were categorized under eight headings including (1) genetic predisposition, (2) prevention, (3) management of gastric polyp, atrophy, dysplasia and metaplasia, (4) diagnosis, (5) pathology and molecular biology, (6) treatment, (7) supportive and palliative care, and (8) follow up. Difference in each section was discussed.

CONCLUSION

Considering KGCA and JGCA as Eastern and NCCN, ESMO, BSG, and NICE as Western guidelines, it is revealed that both sets of guidelines share common practices such as prioritizing comprehensive diagnostic evaluations, personalizing treatment plans, and palliative care. However, main differences can be seen in treatment regimens, the adoption of newer therapies like immunotherapy, and the utilization of emerging techniques such as HIPEC. These differences reflect the diverse clinical landscapes, research focuses, and healthcare systems within these regions.

Mapping network connection and direction among symptoms of depression and anxiety in patients with chronic gastritis

Regarding neurophysiological and developmental findings, anxiety and depression are usual comorbidities of gastritis patients. However, research related to anxiety and depression among chronic gastritis patients was conducted on the disease level while ignoring symptoms. Hence, we rendered the network approach to reveal the symptoms of anxiety and depression among chronic gastritis patients. Three hundred and sixty-nine chronic gastritis patients (female = 139, Mage = 55.87 years) were asked to complete the Self-Rating Anxiety Scale and Self-Rating Depression Scale. Three symptom networks and one directed acyclic graph (DAG) network were formed. First, in the anxiety network of chronic gastritis patients, dizziness was the most influential symptom. In the depression network of chronic gastritis patients, depressed affect and psychomotor retardation were the influential symptoms. Second, panic, easy fatiguability, weakness, palpitation, depressed affect, tachycardia, fatigue, and psychomotor agitation bridged the anxiety-depression network of chronic gastritis patients. Third, DAG networks showed that anxiousness and hopelessness could trigger other symptoms in the anxiety-depression networks of chronic gastritis patients. The current study provided insightful information on patients with chronic gastritis by examining the structures of symptoms.

Influence of Procedural Volume on the Outcome of Gastric Endoscopic Submucosal Dissection: A Nationwide Population-Based Study Using Administrative Data

BACKGROUND & AIMS

Endoscopic submucosal dissection (ESD) is a well-established treatment modality for gastric neoplasms. We aimed to investigate the effect of procedural volume on the outcome of ESD for gastric cancer or adenoma.

METHODS

In this population-based cohort study, patients who underwent ESD for gastric cancer or adenoma from November 2011 to December 2017 were identified using the Korean National Health Insurance Service database. Operational definitions to identify the target population and post-procedural complications were created using diagnosis and procedure codes and were validated using hospital medical record data. Outcomes included hemorrhage, perforation, pneumonia, 30-day mortality, a composite outcome comprising all of these adverse outcomes, and additional resection. Hospital volume was categorized into 3 groups based on the results of the threshold analysis: high-, medium-, low-volume centers (HVCs, MVCs, and LVCs, respectively). Inverse probability of treatment weighting analysis was applied to enhance comparability across the volume groups.

RESULTS

There were 94,246 procedures performed in 88,687 patients during the study period. There were 5886 composite events including 4925 hemorrhage, 447 perforation, and 703 pneumonia cases. There were significant differences in ESD-related adverse outcomes among the 3 hospital volume categories, showing that HVCs and MVCs were associated with a lower risk of a composite outcome than LVCs (inverse probability of treatment-weighted odds ratio [OR], 0.651; 95% CI, 0.521-0.814; inverse probability of treatment-weighted OR, 0.641; 95% CI, 0.534-0.769). Similar tendencies were also shown for hemorrhage, perforation, and pneumonia; however, these were not evident for additional resection.

CONCLUSIONS

Procedural volume was closely associated with clinical outcome in patients undergoing ESD for gastric cancer or adenoma.

Impact of endoscopic surveillance on the early diagnosis and endoscopic resection likelihood of gastric cancer

BACKGROUND

Endoscopy could help detect early gastric cancer (EGC) and improve the prognosis of patients. The aim of this study was to analyze the impact of endoscopy and endoscopic surveillance on the early detection of gastric cancer (GC), GC staging, and treatment selection.

METHODS

Patients with GC diagnosed at our center from 2010 to 2022 were retrospectively analyzed and allocated to the short-interval group (had received endoscopy within 3 years before diagnosis), the long-interval group (had received endoscopy more than 3 years before diagnosis), and the unchecked group (had not received endoscopy before diagnosis). The differences in GC staging and treatment modalities among the three groups were analyzed, and the differences in the clinical and pathological features of EGC were further analyzed.

RESULTS

One thousand and twenty-five GC patients were included, with 395 cases of EGC and 630 cases of advanced GC. The proportions of EGC in the short-interval, long-interval, and unchecked groups were 98.0%, 84.2%, and 29.8%, respectively (p < 0.001). Among the 387 lesions of 367 EGC patients were resected by endoscopic submucosal dissection (ESD), 341 (88.1%) exhibited curative resection, and 46 (11.9%) involved noncurative resections. Lesions of EGC differed significantly in diameter, depth of invasion, and curative resection rate (p = 0.033, 0.019, and 0.005, respectively). In the short-interval group, 87.8% of the lesions were ≤ 2 cm, 95.6% of the invasion depths were confined to the mucosal layer, and 96.7% of the eCura scores were A or B. Compared with the unchecked group, they had smaller diameters (RR = 0.419, 95% CI 0.234-0.752), shallower invasion depths (RR = 0.286, 95% CI 0.105-0.777), and a higher curative resection rate (RR = 0.215, 95% CI 0.068-0.676).

CONCLUSION

Endoscopic surveillance at 3-year intervals can help detect EGC, and the EGC lesions found have smaller diameters and shallower depths of invasion, helping improve the curative resection rate of ESD.

Analysis of endoscopic and pathological features of 6961 cases of gastric cancer

Gastric cancer (GC) stage and tissue differentiation affect treatment efficacy and prognosis, highlighting the importance of understanding the risk factors that affect these parameters. Therefore, this study analyzed risk factors affecting the GC stage and differentiation and the relationships between the cancer site and the sex and age of the patient. We collected clinical data from 6961 patients with GC, including sex, age, endoscopic lesion location, and pathological differentiation. Patients were grouped based on GC stage (early or advanced), differentiation (well or poorly differentiated), and lesion site (upper stomach [cardia and fundus], middle stomach [gastric body], and lower stomach [gastric antrum]). Differences in sex, age, location, stage, and degree of differentiation were assessed based on these groupings. Univariate analysis revealed that the disease location and differentiation significantly differed based on the GC stage (P < 0.05), whereas sex, age, site, and stage significantly differed based on GC differentiation (P < 0.05). A multivariate analysis confirmed these factors as independent risk factors affecting GC. Moreover, lesion sites significantly differed between sexes (P < 0.05) and among age groups (P < 0.05). Although the effects of family history, lifestyle, and Helicobacter pylori infection status of the patients were not considered, this single-center retrospective study established independent risk factors for GC.Trial registration ChiCTR2200061989.

Practice Trends among US Gastroenterologists following the 2020 American Gastroenterological Association Guidelines on Gastric Intestinal Metaplasia: Data from a Tertiary Care Center

BACKGROUND AND AIMS

Studies show variability in gastroenterologists' management of gastric intestinal metaplasia (GIM) in the United States. In 2020, the American Gastroenterological Association published GIM guidelines, recommending physician-patient shared decision-making on GIM surveillance based on risk factors. We compared gastroenterologists' communication trends of a GIM finding and surveillance recommendations before and after 2020 and evaluated patient and provider factors associated with a surveillance recommendation.

METHODS

A sample of patients diagnosed with GIM on biopsies from upper endoscopies performed in 2018 (cohort A) and 2021 (cohort B) were included. Logistic regression analysis assessed the association between patient/provider characteristics and surveillance recommendations in the overall cohort and over time.

MATERIALS

In all, 347 patients were included: 175 in cohort A and 172 in B. Median age was 65.7 (56.0, 73.4), and 54.5% were females. Communication to patients about GIM findings and surveillance recommendations increased from 24.6% <2020 to 50% >2020 (P<0.001) and 20% <2020 to 41.3% >2020 (P<0.001), respectively. Overall, endoscopy >2020, family history of gastric cancer, autoimmune gastritis, female providers, and gastroenterologists with 10 to 20 years of experience were associated with a surveillance recommendation. The effect of family history of gastric cancer and the effect of the patient's female sex on surveillance was significantly different between both cohorts [Odds ratio (OR): 0.13, 95% (Confidence interval) CI: 0.02, 0.97 and OR 3.39, 95% CI: 1.12, 10.2, respectively).

CONCLUSIONS

Despite a 2-fold increase in surveillance recommendations after 2020, there was no meaningful effect of any of the patients' factors on a recommendation for surveillance over time, which raises the question as to whether surveillance is being offered to both average and high-risk patients without thorough risk stratification.

Combining systemic inflammatory response index and albumin fibrinogen ratio to predict early serious complications and prognosis after resectable gastric cancer

BACKGROUND

Gastric cancer has a high incidence and fatality rate, and surgery is the preferred course of treatment. Nonetheless, patient survival rates are still low, and the incidence of major postoperative complications cannot be disregarded. The systemic inflammatory response, nutritional level, and coagulation status are key factors affecting the postoperative recovery and prognosis of gastric cancer patients. The systemic inflammatory response index (SIRI) and the albumin fibrinogen ratio (AFR) are two valuable comprehensive indicators of the severity and prognosis of systemic inflammation in various medical conditions.

AIM

To assess the clinical importance and prognostic significance of the SIRI scores and the AFR on early postoperative outcomes in patients undergoing radical gastric cancer surgery.

METHODS

We conducted a retrospective analysis of the clinicopathological characteristics and relevant laboratory indices of 568 gastric cancer patients from January 2018 to December 2019. We calculated and compared two indicators of inflammation and then examined the diagnostic ability of combined SIRI and AFR values for serious early postoperative complications. We scored the patients and categorized them into three groups based on their SIRI and AFR levels. COX analysis was used to compare the three groups of patients the prognostic value of various preoperative SIRI-AFR scores for 5-year overall survival (OS) and disease-free survival (DFS).

RESULTS

SIRI-AFR scores were an independent risk factor for prognosis [OS: P = 0.004; hazards ratio (HR) = 3.134; DFS: P < 0.001; HR = 3.543] and had the highest diagnostic power (area under the curve: 0.779; 95% confidence interval: 0.737-0.820) for early serious complications in patients with gastric cancer. The tumor-node-metastasis stage (P = 0.001), perioperative transfusion (P = 0.044), positive carcinoembryonic antigen (P = 0.014) findings, and major postoperative complications (P = 0.011) were factors associated with prognosis.

CONCLUSION

Preoperative SIRI and AFR values were significantly associated with early postoperative survival and the occurrence of severe complications in gastric cancer patients.

The Effect of Nationwide Organized Cancer Screening Programs on Gastric Cancer Mortality: A Synthetic Control Study

BACKGROUND & AIMS

Nationwide organized gastric cancer (GC) screening programs have been running for decades in South Korea and Japan. This study conducted a quasi-experimental analysis to assess the population impact of these programs on GC mortality.

METHODS

We used the flexible synthetic control method (SCM) to estimate the effect of the screening programs on age-standardized GC mortality and other upper gastrointestinal (UGI) diseases (esophageal cancer and peptic ulcer) among people aged ≥40 years. World Health Organization mortality data and country-level covariates from the World Bank and the Global Burden of Diseases study were used for the analyses. We compared postintervention trends in outcome with the counterfactual trend of the synthetic control and estimated average postintervention rate ratios (RRs) with associated 95% confidence intervals (CIs). A series of sensitivity analyses were conducted.

RESULTS

The preintervention fits were acceptable for the analyses of South Korea and Japan's GC mortality but poor for Japan's other UGI disease mortality. The average postintervention RRs were 0.83 (95% CI, 0.71-0.96) for GC mortality and 0.72 (95% CI, 0.57-0.90) for other UGI disease mortality in South Korea. The RR reached 0.59 by the 15th year after the initiation of nationwide screening. For Japan, the average RRs were 0.97 (95% CI, 0.88-1.07) for GC mortality and 0.93 (95% CI, 0.68-1.28) for other UGI disease mortality. Sensitivity analysis reveals the result for Japan may potentially be biased.

CONCLUSIONS

South Korea's nationwide GC screening has apparent benefits, whereas the Japanese program's effectiveness is uncertain. The experiences of South Korea and Japan could serve as a reference for other countries.

Diagnosing and grading gastric atrophy and intestinal metaplasia using semi-supervised deep learning on pathological images: development and validation study

OBJECTIVE

Patients with gastric atrophy and intestinal metaplasia (IM) were at risk for gastric cancer, necessitating an accurate risk assessment. We aimed to establish and validate a diagnostic approach for gastric biopsy specimens using deep learning and OLGA/OLGIM for individual gastric cancer risk classification.

METHODS

In this study, we prospectively enrolled 545 patients suspected of atrophic gastritis during endoscopy from 13 tertiary hospitals between December 22, 2017, to September 25, 2020, with a total of 2725 whole-slide images (WSIs). Patients were randomly divided into a training set (n = 349), an internal validation set (n = 87), and an external validation set (n = 109). Sixty patients from the external validation set were randomly selected and divided into two groups for an observer study, one with the assistance of algorithm results and the other without. We proposed a semi-supervised deep learning algorithm to diagnose and grade IM and atrophy, and we compared it with the assessments of 10 pathologists. The model's performance was evaluated based on the area under the curve (AUC), sensitivity, specificity, and weighted kappa value.

RESULTS

The algorithm, named GasMIL, was established and demonstrated encouraging performance in diagnosing IM (AUC 0.884, 95% CI 0.862-0.902) and atrophy (AUC 0.877, 95% CI 0.855-0.897) in the external test set. In the observer study, GasMIL achieved an 80% sensitivity, 85% specificity, a weighted kappa value of 0.61, and an AUC of 0.953, surpassing the performance of all ten pathologists in diagnosing atrophy. Among the 10 pathologists, GasMIL's AUC ranked second in OLGA (0.729, 95% CI 0.625-0.833) and fifth in OLGIM (0.792, 95% CI 0.688-0.896). With the assistance of GasMIL, pathologists demonstrated improved AUC (p = 0.013), sensitivity (p = 0.014), and weighted kappa (p = 0.016) in diagnosing IM, and improved specificity (p = 0.007) in diagnosing atrophy compared to pathologists working alone.

CONCLUSION

GasMIL shows the best overall performance in diagnosing IM and atrophy when compared to pathologists, significantly enhancing their diagnostic capabilities.

Performance of a single-use gastroscope for esophagogastroduodenoscopy: Prospective evaluation

Background and study aims Reprocessing reusable endoscopes is challenging due to their non-sterilizable nature. Disinfection has been shown to have a significant risk of failure with serious consequences. Single-use endoscopes can eliminate contamination risk and reduce workflow delays caused by reprocessing. This study evaluated the clinical performance of single-use gastroscopes in patients undergoing esophagogastroduodenoscopy (EGD). Patients and methods In this case series, 60 patients underwent EGD using single-use gastroscopes, with 34 procedures in the endoscopy department and 26 in the intensive care unit. The primary outcome was successful completion of the intended EGD objective. Furthermore, certified endoscopists assessed device performance on a five-point Likert scale (ranging from 1-"much worse" to 5-"much better"), considering their experience with a reusable gastroscope. Results Successful completion of EGDs using only the single-use gastroscope was achieved in 58 of 60 cases (96.7%). In two cases, crossover to an ultra-slim endoscope was necessary to either reach the esophageal stenosis or to transverse the stenosis. Overall satisfaction was rated as comparable to reusable scopes in 51 of 56 cases (91.1%) and inferior in five cases (8.9%). The lower weight of the single-use gastroscope was rated as superior in 42 of 60 cases (70.0%). Drawbacks included reduced image quality (23 of 45 cases; 51.1%). Feedback included the absence of a freeze button, lens cleaning issues, and small image size. Conclusions Single-use gastroscopes exhibited a high EGD completion rate and effectiveness for various indications. Further research should focus on evaluating the implementation of single-use gastroscopes in a comprehensive context, considering clinical effectiveness, costs, and environmental impact.

Pathology and Clinical Relevance of Gastric Epithelial Dysplasia

Gastric dysplasia is defined as an unequivocally neoplastic epithelium. Dysplastic lesions are characterized by cellular atypia reflective of abnormal differentiation and disorganized glandular architecture. The last few years have been marked by a refinement of the prognosis and risk of progression of gastric dysplasia and the recognition of novel morphologic patterns of dysplasia. Determination of the correct diagnosis and grade of dysplasia are critical steps since it will be predicting the risk of malignant transformation and help tailor appropriate surveillance strategy. This review describes the morphologic characteristics of conventional dysplasia and nonconventional gastric dysplasia that have been more recently characterized.

The effect of incorporating domain knowledge with deep learning in identifying benign and malignant gastric whitish lesions: A retrospective study

BACKGROUND AND AIM

Early whitish gastric neoplasms can be easily misdiagnosed; differential diagnosis of gastric whitish lesions remains a challenge. We aim to build a deep learning (DL) model to diagnose whitish gastric neoplasms and explore the effect of adding domain knowledge in model construction.

METHODS

We collected 4558 images from two institutions to train and test models. We first developed two sole DL models (1 and 2) using supervised and semi-supervised algorithms. Then we selected diagnosis-related features through literature research and developed feature-extraction models to determine features including boundary, surface, roundness, depression, and location. Then predictions of the five feature-extraction models and sole DL model were combined and inputted into seven machine-learning (ML) based fitting-diagnosis models. The optimal model was selected as ENDOANGEL-WD (whitish-diagnosis) and compared with endoscopists.

RESULTS

Sole DL 2 had higher sensitivity (83.12% vs 68.67%, Bonferroni adjusted P = 0.024) than sole DL 1. Adding domain knowledge, the decision tree performed best among the seven ML models, achieving higher specificity than DL 1 (84.38% vs 72.27%, Bonferroni adjusted P < 0.05) and higher accuracy than DL 2 (80.47%, Bonferroni adjusted P < 0.001) and was selected as ENDOANGEL-WD. ENDOANGEL-WD showed better accuracy compared with 10 endoscopists (75.70%, P < 0.001).

CONCLUSIONS

We developed a novel system ENDOANGEL-WD combining domain knowledge and traditional DL to detect gastric whitish neoplasms. Adding domain knowledge improved the performance of traditional DL, which provided a novel solution for establishing diagnostic models for other rare diseases potentially.

Gastric cancer screening in Western countries: A call to action

Gastric cancer is a major cause of cancer-related death worldwide, despite the reduction in its incidence. The disease is still burdened with a poor prognosis, particularly in Western countries. The main risk factor is the infection by Helicobacter pylori, classified as a class I carcinogen by the IARC, and It is well-known that primary prevention of gastric cancer can be achieved with the eradication of the infection. Moreover, non-invasive measurement of pepsinogens (PGI and PGI/PGII ratio) allows the identification of patients that should undergo upper gastrointestinal (GI) endoscopy. Gastric non-cardia adenocarcinoma is indeed preceded by a well-defined precancerous process that involves consecutive stages, described for the first time by Correa et al. more than 40 years ago, and patients with advance stages of gastric atrophy/intestinal metaplasia and with dysplastic changes should be followed-up periodically with upper GI endoscopies. Despite these effective screening and surveillance methods, national-level screening campaigns have been adopted only in few countries in eastern Asia (Japan and South Korea). In this review, we describe primary and secondary preventive measures for gastric cancer, discussing the need to introduce screening also in Western countries. Moreover, we propose a simple algorithm for screening that could be easily applied in clinical practice.

A deep learning model based on magnifying endoscopy with narrow-band imaging to evaluate intestinal metaplasia grading and OLGIM staging: A multicenter study

BACKGROUND AND PURPOSE

Patients with stage III or IV of operative link for gastric intestinal metaplasia assessment (OLGIM) are at a higher risk of gastric cancer (GC). We aimed to construct a deep learning (DL) model based on magnifying endoscopy with narrow-band imaging (ME-NBI) to evaluate OLGIM staging.

METHODS

This study included 4473 ME-NBI images obtained from 803 patients at three endoscopy centres. The endoscopic expert marked intestinal metaplasia (IM) regions on endoscopic images of the target biopsy sites. Faster Region-Convolutional Neural Network model was used to grade IM lesions and predict OLGIM staging.

RESULTS

The diagnostic performance of the model for IM grading in internal and external validation sets, as measured by the area under the curve (AUC), was 0.872 and 0.803, respectively. The accuracy of this model in predicting the high-risk stage of OLGIM was 84.0%, which was not statistically different from that of three junior (71.3%, p = 0.148) and three senior endoscopists (75.3%, p = 0.317) specially trained in endoscopic images corresponding to pathological IM grade, but higher than that of three untrained junior endoscopists (64.0%, p = 0.023).

CONCLUSION

This DL model can assist endoscopists in predicting OLGIM staging using ME-NBI without biopsy, thereby facilitating screening high-risk patients for GC.

RE.GA.IN.: the Real-world Gastritis Initiative-updating the updates

At the end of the last century, a far-sighted 'working party' held in Sydney, Australia addressed the clinicopathological issues related to gastric inflammatory diseases. A few years later, an international conference held in Houston, Texas, USA critically updated the seminal Sydney classification. In line with these initiatives, Kyoto Global Consensus Report, flanked by the Maastricht-Florence conferences, added new clinical evidence to the gastritis clinicopathological puzzle.The most relevant topics related to the gastric inflammatory diseases have been addressed by the Real-world Gastritis Initiative (RE.GA.IN.), from disease definitions to the clinical diagnosis and prognosis. This paper reports the conclusions of the RE.GA.IN. consensus process, which culminated in Venice in November 2022 after more than 8 months of intense global scientific deliberations. A forum of gastritis scholars from five continents participated in the multidisciplinary RE.GA.IN. consensus. After lively debates on the most controversial aspects of the gastritis spectrum, the RE.GA.IN. Faculty amalgamated complementary knowledge to distil patient-centred, evidence-based statements to assist health professionals in their real-world clinical practice. The sections of this report focus on: the epidemiology of gastritis; Helicobacter pylori as dominant aetiology of environmental gastritis and as the most important determinant of the gastric oncogenetic field; the evolving knowledge on gastric autoimmunity; the clinicopathological relevance of gastric microbiota; the new diagnostic horizons of endoscopy; and the clinical priority of histologically reporting gastritis in terms of staging. The ultimate goal of RE.GA.IN. was and remains the promotion of further improvement in the clinical management of patients with gastritis.

Streptococcus anginosus promotes gastric inflammation, atrophy, and tumorigenesis in mice

Streptococcus anginosus (S. anginosus) was enriched in the gastric mucosa of patients with gastric cancer (GC). Here, we show that S. anginosus colonized the mouse stomach and induced acute gastritis. S. anginosus infection spontaneously induced progressive chronic gastritis, parietal cell atrophy, mucinous metaplasia, and dysplasia in conventional mice, and the findings were confirmed in germ-free mice. In addition, S. anginosus accelerated GC progression in carcinogen-induced gastric tumorigenesis and YTN16 GC cell allografts. Consistently, S. anginosus disrupted gastric barrier function, promoted cell proliferation, and inhibited apoptosis. Mechanistically, we identified an S. anginosus surface protein, TMPC, that interacts with Annexin A2 (ANXA2) receptor on gastric epithelial cells. Interaction of TMPC with ANXA2 mediated attachment and colonization of S. anginosus and induced mitogen-activated protein kinase (MAPK) activation. ANXA2 knockout abrogated the induction of MAPK by S. anginosus. Thus, this study reveals S. anginosus as a pathogen that promotes gastric tumorigenesis via direct interactions with gastric epithelial cells in the TMPC-ANXA2-MAPK axis.

Helicobacter pylori Treatment and Gastric Cancer Risk After Endoscopic Resection of Dysplasia: A Nationwide Cohort Study

BACKGROUND & AIMS

The study investigated the association between Helicobacter pylori treatment and the risk of gastric cancer after endoscopic resection of gastric dysplasia.

METHODS

Patients who received endoscopic resection for gastric dysplasia between 2010 and 2020 from Korean nationwide insurance data were included. We verified the occurrence of new-onset gastric cancer and metachronous gastric neoplasm, which encompasses both cancer and dysplasia, >1 year after the index endoscopic resection. Newly diagnosed gastric cancer ≥3 years and ≥5 years was regarded as late-onset gastric cancer. A multivariable Cox regression model with H pylori treatment status as a time-dependent covariate was used to determine the risk of gastric cancer and metachronous gastric neoplasms.

RESULTS

Gastric dysplasia in 69,722 patients was treated with endoscopy, and 49.5% were administered H pylori therapy. During the median 5.6 years of follow-up, gastric cancer developed in 2406 patients and metachronous gastric neoplasms developed in 3342 patients. Receiving H pylori therapy was closely related to lower gastric cancer risk (adjusted hazard ratio [aHR], 0.88; 95% confidence interval [CI], 0.80-0.96). H pylori treatment also significantly decreased metachronous gastric neoplasm development (aHR, 0.76; 95% CI, 0.70-0.82). Furthermore, H pylori therapy showed a prominent protective effect for late-onset gastric cancer development at ≥3 years (aHR, 0.84; 95% CI, 0.75-0.94) and ≥5 years (aHR, 0.80; 95% CI, 0.68-0.95).

CONCLUSIONS

In this nationwide cohort, H pylori therapy after endoscopic resection of gastric dysplasia was associated with a reduced risk of gastric cancer and metachronous gastric neoplasm occurrence.

Evolving Concepts in Helicobacter pylori Management

Helicobacter pylori is the most common chronic bacterial infection worldwide and the most significant risk factor for gastric cancer, which remains a leading cause of cancer-related death globally. H pylori and gastric cancer continue to disproportionately impact racial and ethnic minority and immigrant groups in the United States. The approach to H pylori case-finding thus far has relied on opportunistic testing based on symptoms or high-risk indicators, such as racial or ethnic background and family history. However, this approach misses a substantial proportion of individuals infected with H pylori who remain at risk for gastric cancer because most infections remain clinically silent. Moreover, individuals with chronic H pylori infection are at risk for gastric preneoplastic lesions, which are also asymptomatic and only reliably diagnosed using endoscopy and biopsy. Thus, to make a significant impact in gastric cancer prevention, a systematic approach is needed to better identify individuals at highest risk of both H pylori infection and its complications, including gastric preneoplasia and cancer. The approach to H pylori eradication must also be optimized given sharply decreasing rates of successful eradication with commonly used therapies and increasing antimicrobial resistance. With growing acceptance that H pylori should be managed as an infectious disease and the increasing availability of susceptibility testing, we now have the momentum to abandon empirical therapies demonstrated to have inadequate eradication rates. Molecular-based susceptibility profiling facilitates selection of a personalized eradication regimen without necessitating an invasive procedure. An improved approach to H pylori eradication coupled with population-level programs for screening and treatment could be an effective and efficient strategy to prevent gastric cancer, especially in minority and potentially marginalized populations that bear the heaviest burden of H pylori infection and its complications.

Endoscopic measurement of the size of gastrointestinal polyps using an electromagnetic tracking system and computer vision-based algorithm

PURPOSE

Polyp size is an important factor that may influence diagnosis and clinical management decision, but estimation by visual inspection during endoscopy is often difficult and subject to error. The purpose of this study is to develop a quantitative approach that enables an accurate and objective measurement of polyp size and to study the feasibility of the method.

METHODS

We attempted to estimate polyp size and location relative to the gastro-oesophageal junction by integrating data from an electromagnetic tracking sensor and endoscopic images. This method is based on estimation of the three-dimensional coordinates of the borders of the polyp by combining the endoscope camera position and the corresponding points along the polyp border in endoscopic images using a computer vision-based algorithm. We evaluated the proposed method using a simulated upper gastrointestinal endoscopy model.

RESULTS

The difference between the mean of ten measurements of one artificial polyp and its actual size (10 mm in diameter) was 0.86 mm. Similarly, the difference between the mean of ten measurements of the polyp distance from the gastroesophageal junction and its actual distance (~ 22 cm) was 1.28 mm. Our results show that the changes in camera positions in which the images were taken and the quality of the polyp segmentation have the most impact on the accuracy of polyp size estimation.

CONCLUSION

This study demonstrated an innovative approach to endoscopic measurements using motion tracking technologies and computer vision and demonstrated its accuracy in determining the size and location of the polyp. The observed magnitude of error is clinically acceptable, and the measurements are available immediately after the images captured. To enhance accuracy, it is recommended to avoid identical images and instead utilise control wheels on the endoscope for capturing different views. Future work should further evaluate this innovative method during clinical endoscopic procedures.

Latest Advances in Endoscopic Detection of Oesophageal and Gastric Neoplasia

Endoscopy is the gold standard for the diagnosis of cancers and cancer precursors in the oesophagus and stomach. Early detection of upper GI cancers requires high-quality endoscopy and awareness of the subtle features these lesions carry. Endoscopists performing surveillance of high-risk patients including those with Barrett's oesophagus, previous squamous neoplasia or chronic atrophic gastritis should be familiar with endoscopic features, classification systems and sampling techniques to maximise the detection of early cancer. In this article, we review the current approach to diagnosis of these conditions and the latest advanced imaging and diagnostic techniques.

A study on the improvement in the ability of endoscopists to diagnose gastric neoplasms using an artificial intelligence system

Background

Artificial intelligence-assisted gastroscopy (AIAG) based on deep learning has been validated in various scenarios, but there is a lack of studies regarding diagnosing neoplasms under white light endoscopy. This study explored the potential role of AIAG systems in enhancing the ability of endoscopists to diagnose gastric tumor lesions under white light.

Methods

A total of 251 patients with complete pathological information regarding electronic gastroscopy, biopsy, or ESD surgery in Xi'an Gaoxin Hospital were retrospectively collected and comprised 64 patients with neoplasm lesions (excluding advanced cancer) and 187 patients with non-neoplasm lesions. The diagnosis competence of endoscopists with intermediate experience and experts was compared for gastric neoplasms with or without the assistance of AIAG, which was developed based on ResNet-50.

Results

For the 251 patients with difficult clinical diagnoses included in the study, compared with endoscopists with intermediate experience, AIAG's diagnostic competence was much higher, with a sensitivity of 79.69% (79.69% vs. 72.50%, p = 0.012) and a specificity of 73.26% (73.26% vs. 52.62%, p < 0.001). With the help of AIAG, the endoscopists with intermediate experience (<8 years) demonstrated a relatively higher specificity (59.79% vs. 52.62%, p < 0.001). Experts (≥8 years) had similar results with or without AI assistance (with AI vs. without AI; sensitivities, 70.31% vs. 67.81%, p = 0.358; specificities, 83.85% vs. 85.88%, p = 0.116).

Conclusion

With the assistance of artificial intelligence (AI) systems, the ability of endoscopists with intermediate experience to diagnose gastric neoplasms is significantly improved, but AI systems have little effect on experts.

Simultaneous detection of Helicobacter pylori infection comparing between white light and image-enhanced endoscopy

BACKGROUND

Helicobacter pylori (H. pylori) is associated with gastric cancer. Early and accurate diagnosis of H. pylori infection can reduce risk of gastric cancer. Conventional white light imaging (WLI) and image-enhanced endoscopic (IEE) techniques such as narrow-band imaging (NBI), linked color imaging (LCI) and blue laser imaging (BLI) plays pivotal role in H. pylori diagnosis. This study aimed to determine diagnostic performance of real-time endoscopy between WLI and other IEE techniques for diagnosis of H. pylori infection.

METHODS

This prospective study compared endoscopic images by gastroscopy using WLI and IEE techniques (LCI, Magnifying-BLI, and Magnifying-NBI) at Thammasat University Hospital, Thailand between January 2020, and July 2021. All participants underwent gastroscopy. Three biopsies at gastric antrum and two biopsies at body were obtained for H.pylori diagnosis. H. pylori infection was defined as a positive test of either one of the following tests: rapid urease test, histopathology, H. pylori culture.

RESULTS

Of 167 dyspeptic patients undergoing gastroscopy, 100 were enrolled in this study. Overall H. pylori infection was 40%. Patients had the mean age of 59.1 years and 53% were males. Enlarged gastric folds and antral nodularity can predict H. pylori infection with 100% PPV, while fundic gland polyps and red streak provided 100% PPV for exclusion of H. pylori infection on WLI. Sensitivity, specificity, PPV, NPV and accuracy for diagnosis of H. pylori infection for WLI were 80%, 71.7%, 65.3%, 84.3% and 75% respectively, while those for LCI were 90%, 70%, 66.7%, 91.3% and 78% respectively. M-NBI and M-BLI endoscopy demonstrated elongated pits in H. pylori-positive patients. Sensitivity, specificity, PPV, NPV and accuracy for M-BLI were 95%, 80%, 76%, 96% and 86% respectively, whereas those for M-NBI were 92.5%, 86.7%, 82.2%, 94.6% and 89% respectively. Sensitivity of M-BLI was better than WLI, while sensitivities of LCI and M-NBI were also numerically higher than WLI without statistical difference (M-BLI 95%vs.WLI 80%, p = 0.03; M-NBI 92.5%vs.WLI 80%, p = 0.13; LCI 90%vs.WLI 80%, p = 0.22). Sensitivities of all IEE modes were not different from one another (LCI 90%vs.M-BLI 95%, p = 0.50; LCI 90%vs.M-NBI 92.5%, p = 1.00, M-BLI 95%vs.M-NBI 92.5%, p = 1.00).

CONCLUSIONS

M-BLI significantly improved sensitivity of real-time endoscopic diagnosis of H. pylori infection compared with WLI. Enlarged gastric folds and antral nodularity could be reliable predictors for H. pylori infection, while fundic gland polyps and red streak could be important endoscopic findings for H. pylori-negative mucosa.

An artificial intelligence system for chronic atrophic gastritis diagnosis and risk stratification under white light endoscopy

BACKGROUND AND AIMS

The diagnosis and stratification of gastric atrophy (GA) predict patients' gastric cancer progression risk and determine endoscopy surveillance interval. We aimed to construct an artificial intelligence (AI) system for GA endoscopic identification and risk stratification based on the Kimura-Takemoto classification.

METHODS

We constructed the system using two trained models and verified its performance. First, we retrospectively collected 869 images and 119 videos to compare its performance with that of endoscopists in identifying GA. Then, we included original image cases of 102 patients to validate the system for stratifying GA and comparing it with endoscopists with different experiences.

RESULTS

The sensitivity of model 1 was higher than that of endoscopists (92.72% vs. 76.85 %) at image level and also higher than that of experts (94.87% vs. 85.90 %) at video level. The system outperformed experts in stratifying GA (overall accuracy: 81.37 %, 73.04 %, p = 0.045). The accuracy of this system in classifying non-GA, mild GA, moderate GA, and severe GA was 80.00 %, 77.42 %, 83.33 %, and 85.71 %, comparable to that of experts and better than that of seniors and novices.

CONCLUSIONS

We established an expert-level system for GA endoscopic identification and risk stratification. It has great potential for endoscopic assessment and surveillance determinations.

Lesion size affects the risk of technical difficulty in gastric endoscopic submucosal dissection

Current evidence shows an inter-country inconsistency in the effect of lesion size on the technical difficulty of gastric endoscopic submucosal dissection (ESD). We aimed to evaluate the specific correlation and quantify the ensuing risks. This retrospective study consisted of 405 ESD cases with gastric single lesion from April 2015 to April 2023. The correlation and risk prediction of lesion size with technical difficulty was explored to provide further clinical evidence. An additive generalized model and recursive algorithm were used to describe the non-linear association, and a linear two-piece regression was constructed to analyze the inflection point. Subgroup analysis and interaction were used to explore intergroup characteristics. Overall, difficult cases had larger lesion sizes, and the more significant the increase, the higher the risk of technical difficulty. In the full model, after adjusting for all covariates, each 1 mm, 3 mm, 5 mm, 7 mm, and one standard increase in lesion size increased the risk of technical difficulty by 8%, 26%, 42%, 72%, and 125%, respectively. There is a nonlinear positive correlation between lesion size and risk of technical difficulty, and the premeditated inflection point was 40 (mm) via two-piecewise linear regression and recursive algorithm. Subgroup analysis showed a stronger correlation between lesion size and difficult ESD in the upper site and submucosal fibrosis groups. Available evidence suggests that lesion size as a risk signal nonlinearly increases the technical difficulty of gastric ESD procedure, especially in cases of upper site and submucosal fibrosis, which deserves further investigation.

Endoscopic surveillance for familial intestinal gastric cancer in low-incidence areas: An effective strategy

While clinical practice guidelines for hereditary diffuse gastric cancer are well established, there is no consensus on the approach for familial intestinal gastric cancer (FIGC). In low-incidence gastric cancer (GC) areas such as the United States or most European countries, there are no evidence-based recommendations on endoscopic assessment in FIGC families. We aim to describe the yield of GC surveillance in these families, and to identify epidemiological risk factors for the development of GC and its precursor lesions. This is a multicenter observational study involving nine tertiary Spanish hospitals, in which all individuals fulfilling FIGC criteria who underwent endoscopic surveillance were included between 1991 and 2020. Forty-one healthy individuals of 31 families were recruited. The median number of upper gastrointestinal endoscopies per individual was 3 (interquartile range, IQR, 1-4). The median interval time between tests was 2 years (IQR 1.5-2.5), and the median follow-up was 9 years (IQR 3-14.5). In 18 (43.9%) subjects, a precursor lesion of GC was found during follow-up, and in 2 (4.9%), an early GC was identified, in which curative treatment was offered. Helicobacter pylori (Hp) infection proved to be independently associated with an increased risk of developing precursor lesions or GC, adjusted by age, gender and follow-up, with an Odds Ratio of 6.443 (1.36-30.6, P value .019). We present the first outcomes that support endoscopic surveillance with biopsies and detection of Hp in FIGC families, although the periodicity has yet to be defined.

Gastric dysplasia in random biopsies: the influence of Helicobacter pylori infection and alcohol consumption in the presence of a lesion

BACKGROUND

Gastric dysplasia in the absence of an endoscopically defined lesion is rare, usually either a false positive diagnosis or a previously unidentified precancerous lesion during esophagogastroduodenoscopy (EGD).

AIMS

Evaluate factors associated with the presence of an endoscopically visible lesion during follow-up in patients with histologic diagnosis of gastric dysplasia in random biopsies.

METHODS

Retrospective cohort study including patients referred to our institution for gastric dysplasia in random biopsies during Index EGD. Endoscopic evaluation was performed with a high-definition endoscope using narrow band imaging (HD EGD-0). If no lesion was detected, endoscopic surveillance (HD EGD-FU) was conducted within 6 months for high grade dysplasia (HGD) or 12 months for low grade (LGD) or indefinite for dysplasia (IFD).

RESULTS

From a total sample of 96 patients, 5 (5.2%) presented with an endoscopically visible lesion during HD EGD-0, while 10 lesions (10.4%) were identified during HD EGD-FU. Patients with Helicobacter pylori infection at Index EDG and with regular alcohol consumption (≥25 g/day) were 8 and 4 times more likely to have an endoscopically visible lesion on HD EGD-FU (p = 0.012 and p = 0.047). In binary logistic regression, both factors were independent predictors of the presence of gastric lesion on HD EGD-FU (OR 9.284, p = 0.009 and OR 5.025, p = 0.033).

CONCLUSIONS

The presence of an endoscopically visible lesion after the histologic diagnosis of gastric dysplasia in random biopsies was more frequent during HD EGD-FU. H. pylori infection at Index EGD and regular alcohol consumption were significant predictors of the presence of gastric lesion on HD EGD-FU.

The Clinical Impact and Cost-Effectiveness of Surveillance of Incidentally Detected Gastric Intestinal Metaplasia: A Microsimulation Analysis

BACKGROUND & AIMS

Gastric intestinal metaplasia (GIM) is associated with a higher risk of noncardia intestinal gastric adenocarcinoma (GA). The aim of this study was to estimate lifetime benefits, complications, and cost-effectiveness of GIM surveillance using esophagogastroduodenoscopy (EGD).

METHODS

We developed a semi-Markov microsimulation model of patients with incidentally detected GIM, to compare the effectiveness of EGD surveillance with no surveillance at 10-year, 5-year, 3-year, 2-year, and 1-year intervals. We modeled a simulated cohort of 1,000,000 US individuals aged 50 with incidental GIM. Outcome measures were lifetime GA incidence, mortality, number of EGDs, complications, undiscounted life-years gained, and incremental cost-effectiveness ratio with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY).

RESULTS

In the absence of surveillance, the model simulated 32.0 lifetime GA cases and 23.0 lifetime GA deaths per 1000 individuals with GIM, respectively. Among surveilled individuals, simulated lifetime GA incidence (per 1000) decreased with shorter surveillance intervals (10-year to 1-year, 11.2-6.1) as did GA mortality (7.4-3.6). Compared with no surveillance, all modeled surveillance intervals yielded greater life expectancy (87-190 undiscounted life-years gained per 1000); 5-year surveillance provided the greatest number of life-years gained per EGD performed and was the cost-effective strategy ($40,706/QALY). In individuals with risk factors of family history of GA or anatomically extensive, incomplete-type GIM intensified 3-year surveillance was cost-effective (incremental cost-effectiveness ratio $28,156/QALY and $87,020/QALY, respectively).

CONCLUSIONS

Using microsimulation modeling, surveillance of incidentally detected GIM every 5 years is associated with reduced GA incidence/mortality and is cost-effective from a health care sector perspective. Real-world studies evaluating the impact of GIM surveillance on GA incidence and mortality in the United States are needed.

Precision endoscopy in the era of climate change and sustainability

Global warming caused by increased greenhouse gas (GHG) emissions has a direct impact on human health. Gastrointestinal (GI) endoscopy contributes significantly to GHG emissions due to energy consumption, reprocessing of endoscopes and accessories, production of equipment, safe disposal of biohazardous waste, and travel by patients. Moreover, GHGs are also generated in histopathology through tissue processing and the production of biopsy specimen bottles. The reduction in unnecessary surveillance endoscopies and biopsies is a practical approach to decrease GHG emissions without affecting disease outcomes. This narrative review explores the role of precision medicine in GI endoscopy, such as image-enhanced endoscopy and artificial intelligence, with a focus on decreasing unnecessary endoscopic procedures and biopsies in the surveillance and diagnosis of premalignant lesions in the esophagus, stomach, and colon. This review offers strategies to minimize unnecessary endoscopic procedures and biopsies, decrease GHG emissions, and maintain high-quality patient care, thereby contributing to sustainable healthcare practices.

Advances in Endoscopic Diagnosis and Treatment of Gastric Neuroendocrine Neoplasms

Gastric neuroendocrine neoplasms refer to a group of diseases that are relatively rare. They can be classified into three subtypes based on their clinical and histopathological features, and there are significant differences in diagnosis, treatment, and prognosis among the different subtypes. The incidence of gastric neuroendocrine neoplasms has been increasing globally in recent years with the localized disease being particularly evident. Gastrointestinal endoscopy is of irreplaceable importance for the diagnosis and management of g-NENs. Endoscopy with biopsy is the gold standard for the diagnosis of g-NENs. Ultrasound endoscopy can assess the depth of tumor invasion and the presence of lymphatic metastases, which is important for the development of treatment strategies. Meanwhile, for some small and low-risk lesions, endoscopic surveillance or endoscopic resection has satisfactory therapeutic results and prognosis. This means that even though the incidence has increased, advances in endoscopic techniques have allowed more patients to adopt a relatively conservative treatment strategy. However, the criteria for patients suitable for endoscopic surveillance or endoscopic resection remain controversial.

Can Gastric Juice Analysis with EndoFaster® Reduce the Environmental Impact of Upper Endoscopy?

Gastrointestinal (GI) endoscopy services are in third place as major contributors to CO2 emissions among healthcare facilities, especially due to their massive waste production. One of the measures suggested to reduce this environmental impact is a reduction in histological examinations performed on biopsy specimens taken during endoscopy. A reliable candidate to reduce the rate of biopsies and, consequently, the impact of CO2 emissions could be EndoFaster®, an innovative medical device that allows one to suspect or rule out both H. pylori infection and precancerous lesions on the gastric mucosa by analyzing a small amount of gastric juice aspirated during endoscopy in real time. In the present study, we investigated the ability of EndoFaster® to reduce the environmental impact of upper endoscopy, comparing the CO2 production of standard biopsy sampling as suggested in guidelines and biopsies guided by real-time EndoFaster® results during endoscopy. By estimating an overall 90% rate of biopsies according to standard guidelines and a reduction of 50% of gastric biopsies based on EndoFaster® results, we calculated a 44% overall reduction in CO2 emissions, demonstrating that by using this tool, it is possible to distinctly reduce the contribution of upper endoscopy to global warming.

Gastric Intestinal Metaplasia: Real Culprit or Innocent Bystander as a Precancerous Condition for Gastric Cancer?

Gastric intestinal metaplasia (GIM), which denotes conversion of gastric mucosa into an intestinal phenotype, can occur in all regions of the stomach, including cardiac, fundic, and pyloric mucosa. Since the earliest description of GIM, its association with gastric cancer of the differentiated (intestinal) type has been a well-recognized concern. Many epidemiologic studies have confirmed GIM to be significantly associated with subsequent gastric cancer development. Helicobacter pylori, the principal etiologic factor for gastric cancer, plays the most important role in predisposing to GIM. Although the role of GIM in the stepwise progression model of gastric carcinogenesis (the so-called "Correa cascade") has come into question recently, we review the scientific evidence that strongly supports this long-standing model and propose a new progression model that builds on the Correa cascade. Eradication of H pylori is the most important method for preventing gastric cancer globally, but the effect of eradication on established GIM, is limited, if any. Endoscopic surveillance for GIM may, therefore, be necessary, especially when there is extensive corpus GIM. Recent advances in image-enhanced endoscopy with integrated artificial intelligence have facilitated the identification of GIM and neoplastic lesions, which will impact preventive strategies in the near future.

A descriptive analysis of gastric cancer with an immunohistochemical Study of Ki67 and p53 as prognostic factors.: Bahrain experience

OBJECTIVES

To describe the increasing number of gastric cancer cases at Bahrain Defense Force Hospital with implementation of immunohistochemistry markers as prognostic factors.

METHODS

This study included histologically confirmed malignant gastric tumors diagnosed at Bahrain Defense Force Hospital from January 2009 to June 2019. Various epidemiological and pathological data were abstracted and recorded with immunohistochemical analysis of the proliferation marker Ki67 and cell-cycle regulator p53 as prognostic factors.

RESULTS

A total of 53 patients with gastric cancer were included in the study, with mean age of 59.75 ± 12.9 years. The typical histological types were signet ring cell adenocarcinoma (68%) and intestinal type adenocarcinoma (17%). Helicobacter pylori and intestinal metaplasia were significantly associated with gastric cancer (p<0.01). The studied population's mortality was 39 (74%). The Ki67 proliferation index showed a mean and standard deviation of 67.09 ± 16.338, with a higher mortality rate in patients with low Ki67 but no difference in survival time. No statistically significant association was found between clinicopathological findings with p53 immunostaining positivity.

CONCLUSION

The common gastric cancers are signet ring cell adenocarcinoma and intestinal type adenocarcinoma, affecting a wide range of age groups (33-91 years), with those over 60 years at greater risk. Interestingly, low Ki67 is associated with a higher mortality rate, whereas p53 has no prognostic significance. Expression of both Ki67 and p53 showed no association with survival time.

The prediction model of operative link on gastric intestinal metaplasia stage III-IV: A multicenter study

Purpose

Intestinal metaplasia plays a crucial role in the risk stratification of gastric cancer development. The objective of the study was to develop a prediction model for Operative Link on Gastric Intestinal Metaplasia (OLGIM) Stage III-IV.

Methods

We analyzed 7945 high-risk gastric cancer individuals from 115 hospitals who underwent questionnaires and gastroscope. The participants were assigned to either the development or validation cohort randomly. Demographics and clinical characteristics were obtained. The outcome measurement was OLGIM III-IV. Univariate logistic regression was used for feature selection and multivariate logistic analysis was performed to develop the nomogram. Area under the curves, calibration plots, decision curve and clinical impact analysis were used to assess the performance of the nomogram.

Results

4600 individuals and 3345 individuals were included in the development and validation cohort, of which 124 and 86 individuals were diagnosed with OLGIM III-IV, respectively. Parameters in the training validation cohort matched well and there was no significant difference between two cohorts. A nomogram model for predicting OLGIM Stage III-IV consisted of 4 significantly associated variables, including age, gender, PG I and G-17 (AUC 0.723 and 0.700 for the 2 cohorts). The nomogram demonstrated excellent performance in the calibration curve. Decision curve and clinical impact analysis suggested clinical benefit of the prediction model.

Conclusions

This reliable individualized nomogram might contribute to more accurate management for patients with OLGIM III-IV. Therefore, we suggest that this study be used as an incentive to promote the application.

Risk stratification of gastric cancer screening in community population based on oral contrast-enhanced ultrasonography examination: A 3-year follow-up analysis report

Objective

This study aimed to retrospectively investigate the use of oral contrast-enhanced ultrasonography (O-CEUS) in assessing the thickness of the gastric wall for gastric cancer (GC) screening and to establish screening strategies for GC with different risk stratifications based on the gastric wall thickness.

Methods

From January 2015 to March 2020, people who underwent O-CEUS at the Physical Examination Center of our hospital with at least three years of follow-up were included in this study. The thickness of the gastric wall measured by O-CEUS was divided into three groups using 6 mm and 9 mm as cutoff values. The occurrence of GC in each group was observed. The imaging and clinical information of these populations were recorded and analyzed. Kaplan-Meier survival analysis and Cox's proportional hazards regression were performed to calculate the risk of GC occurrence.

Results

A total of 4,047 people were finally included in this study. During the follow-up period, GC occurred in 7 individuals (incidence rate 0.17%). Among them, according to the thickness of the gastric wall, one case occurred in Group A (< 6 mm), two cases occurred in Group B (6-9 mm), and four cases occurred in Group C (>9mm). Based on Kaplan-Meier survival analysis, the curves of the three groups were significantly different (P < 0.01). The risk of GC occurrence in Group C and Group B were higher than that in Group A (4.76E+2-fold and 1.50E+2-fold).

Conclusion

O-CEUS is a convenient, economical, safe, and noninvasive screening method for GC. Measuring the thickness of the gastric wall is helpful to predict the risk of GC occurrence according to our stratification screening system.

Comprehensive analysis of disulfidptosis related genes and prognosis of gastric cancer

BACKGROUND

Gastric cancer (GC) is a common malignant tumor of the digestive system. Disulfidptosis is a new programmed cell death mechanism, although its specific mechanism in GC is incompletely understood.

AIM

In this study, we used bioinformatics analysis to explore a disulfidptosis-based predictive model related to GC prognosis and to identify potential therapeutic targets and sensitive drugs for GC.

METHODS

We extracted GC-related data from The Cancer Genome Atlas and Gene Expression Omnibus databases. R software (version 4.2.1) was used for correlation analysis.

RESULTS

Through the above analysis, we found that the disulfidptosis related gene may be related to the prognosis of GC. Six genes, namely, PLS3, GRP, APOD, SGCE, COL8A1, and VAMP7, were found to constitute a predictive model for GC prognosis. APOD is a potential therapeutic target for treating GC. Bosutinib and other drugs are sensitive for the treatment of GC.

CONCLUSION

The results of this study indicate that disulfidptosis is related to the prognosis and treatment of GC, while APOD represents a potential therapeutic target for GC.

Diagnostic and therapeutic recommendations on Helicobacter pylori infection. Recommendations of the Working Group of the Polish Society of Gastroenterology

Helicobacter pylori remains a major health problem worldwide, causing considerable morbidity and mortality due to peptic ulcer disease and gastric cancer. These guidelines constitute an update of the previous "Recommendations on the diagnosis and management of Helicobacter pylori infection" issued in 2014. They have been developed by a Task Force organized by the Governing Board of the Polish Society of Gastroenterology. They discuss, with particular emphasis on new scientific data covering papers published since 2014: the epidemiology, clinical presentation, diagnostic principles and criteria for the diagnosis, and recommendations for the treatment of H. pylori infection. The guidelines in particular determine which patients need to be tested and treated for infection. The Task Force also discussed recommended treatment algorithms. Accordingly, a combination of available evidence and consensus-based expert opinion were used to develop these best practice advice statements. It is worth noting that guidelines are not mandatory to implement but they offer advice for pragmatic, relevant and achievable diagnostic and treatment pathways based on established key treatment principles and using local knowledge and available resources to guide regional practice.

Risk factors associated with recurrence of gastric hyperplastic polyps: a single-center, long-term, retrospective cohort study

BACKGROUND

The likelihood of recurrence of gastric hyperplastic polyps (GHPs) following endoscopic resection and the need for long-term follow-up remain unknown. We, therefore, aimed to investigate the factors associated with the recurrence and cumulative incidence of GHPs over a 10-year period.

METHODS

Between May 1995 and December 2020, 1,018 GHPs > 1 cm were endoscopically resected from 869 patients. Medical records of these patients were retrospectively reviewed and their clinical features and outcomes were assessed. Groups of GHPs with recurrence and those without recurrence group were compared, and univariate and multivariable analyses were performed to identify the potential risk factors for GHP recurrence.

RESULTS

A total of 104 (12.0%) patients who underwent endoscopic removal of GHPs experienced recurrence. Compared to patients without recurrent GHPs, those with recurrent GHPs showed considerably larger median polyp size (28 mm vs. 14 mm, P < 0.001), a higher proportion of multiple polyps (41.3% vs. 29.3%, P = 0.020), polyps with lobulation (63.5% vs. 40.3%, P = 0.001), and exudate (63.5% vs. 46.8%, P = 0.001). Compared to the local recurrence (n = 52) group, the metachronous recurrence (n = 52) group had larger median polyp size (20 mm vs. 16 mm, P = 0.006) as well as higher rates of polyp lobulation (86.5% vs. 40.4%, P < 0.001) and exudate (82.7% vs. 44.4%, P = 0.001). After primary GHP excision, the cumulative incidence of recurrence was 7.2%, 12.7%, and 19.6% at 2 years, 5 years, and 10 years, respectively.

CONCLUSION

The incidence of GHP recurrence following endoscopic excision increased as the follow-up period increased, especially in patients whose GHPs were large-sized, multiple, or characterized by surface exudates/lobulations.

Exploring the challenge of early gastric cancer diagnostic AI system face in multiple centers and its potential solutions

BACKGROUND

Artificial intelligence (AI) performed variously among test sets with different diversity due to sample selection bias, which can be stumbling block for AI applications. We previously tested AI named ENDOANGEL, diagnosing early gastric cancer (EGC) on single-center videos in man-machine competition. We aimed to re-test ENDOANGEL on multi-center videos to explore challenges applying AI in multiple centers, then upgrade ENDOANGEL and explore solutions to the challenge.

METHODS

ENDOANGEL was re-tested on multi-center videos retrospectively collected from 12 institutions and compared with performance in previously reported single-center videos. We then upgraded ENDOANGEL to ENDOANGEL-2022 with more training samples and novel algorithms and conducted competition between ENDOANGEL-2022 and endoscopists. ENDOANGEL-2022 was then tested on single-center videos and compared with performance in multi-center videos; the two AI systems were also compared with each other and endoscopists.

RESULTS

Forty-six EGCs and 54 non-cancers were included in multi-center video cohort. On diagnosing EGCs, compared with single-center videos, ENDOANGEL showed stable sensitivity (97.83% vs. 100.00%) while sharply decreased specificity (61.11% vs. 82.54%); ENDOANGEL-2022 showed similar tendency while achieving significantly higher specificity (79.63%, p < 0.01) making fewer mistakes on typical lesions than ENDOANGEL. On detecting gastric neoplasms, both AI showed stable sensitivity while sharply decreased specificity. Nevertheless, both AI outperformed endoscopists in the two competitions.

CONCLUSIONS

Great increase of false positives is a prominent challenge for applying EGC diagnostic AI in multiple centers due to high heterogeneity of negative cases. Optimizing AI by adding samples and using novel algorithms is promising to overcome this challenge.