Endoscopic Submucosal Dissection in the Upper Gastrointestinal Tract and the Need for Rescue Surgery-A Multicenter Analysis

Endoscopic submucosal dissection (ESD) has become the standard treatment for early malignant lesions in the upper gastrointestinal (GI) tract. Its clinical results have been reported to be as good as surgery. The outcomes of rescue surgery after non-curative ESD have been reported to be as good as first-line surgery. The aim of this study was to evaluate the outcomes of ESD in the upper GI tract and the outcomes of rescue surgery after non-curative ESD performed in Linz, Austria, between 2009 and January 2023. A total of 193 ESDs were included and divided into 104 esophageal ESD and 89 gastric ESD procedures. The criteria for curative ESD were in line with established guidelines' recommendations. For esophageal lesions, the mean lesion size was 40.3 mm and the rate of curative ESD was 56.7%. In the non-curative ESD, the rate of technical failure as the reason for non-curative ESD was 13.3% and the oncological failure rate was 86.7%. Only 48.7% of indicated rescue surgeries were performed. The main reason for not performing surgery was interdisciplinary consensus due to comorbidity. Perioperative complications Dindo-Clavien ≥ 3 occurred in 22.2% of cases with an in-hospital mortality rate of 0. In gastric lesions, the mean size was 39 mm and the rate of curative ESD was 69.7%. The rate of technical failure as a reason for non-curative ESD was 25.9% and the oncological failure rate was 74.1% for non-curative ESD. Rescue surgery was performed in 48.2% of indicated cases. The perioperative rate for major complications was 0. The outcome of ESD in the upper GI tract is in line with the published literature, and non-curative ESD does not worsen surgical outcomes. The available follow-up data are in line with the international published literature, showing a low rate of residual malignancy in surgical resection specimens. Therefore, the indication of rescue surgery for oncological failure remains challenging. Furthermore, the learning curve of ESD has shown a trend towards improving outcomes over time.

Management of suspected and known eosinophilic esophagitis-a nationwide survey in Austria

INTRODUCTION

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus with increasing incidence and dysphagia as the main symptom. The management of suspected or known EoE by Austrian endoscopists has not been investigated yet.

METHODS

A web-based survey with 13 questions about the management of EoE was sent to endoscopists via the Austrian Society of Gastroenterology and Hepatology (ÖGGH).

RESULTS

A total of 222 endoscopists (74% gastroenterologists, 23% surgeons, and 2% pediatricians; 68% working in a hospital) from all 9 states participated. In patients with dysphagia but a normal appearing esophagus, 85% of respondents reported always taking biopsies; however, surgeons were less likely to obtain biopsies compared to gastroenterologists ("always" 69% vs. 90%, "sometimes" 29% vs. 10%, "never" 2% vs. 0%, p < 0.001). The approved budesonide orodispersible tablet is the preferred first-line drug used in EoE, ahead of proton pump inhibitors (PPI). Only 65% of participants monitor the patients by endoscopy and histology after 12 weeks of induction therapy, 26% do not continue maintenance therapy, and 22% monitor patients only when symptomatic.

CONCLUSION

The vast majority of Austrian endoscopists adhere to the European and US guidelines in cases of suspected EoE. In contrast, despite the chronic disease course, a significant percentage of providers indicate not to use maintenance therapy and monitor the patients routinely.

Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV)

The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.

Biodegradable biliopancreatic stents could help conserve health care resources during the COVID-19 pandemic: An observational multicenter study

BACKGROUND

Considering limited resources for follow-up due to COVID-19, we used biodegradable stents (BPBS) for a range of biliopancreatic diseases.

AIMS

This observational multicenter study aimed to evaluate technical safety and give first insights into clinical utility.

METHODS

Technical success, clinical success, and necessity of follow-up visits for BPBS placed at three Austrian tertiary care hospitals between April 2020 and January 2021 were retrospectively analyzed.

RESULTS

63 stents were deployed in 60 patients. Main indications were prophylaxis of post-ERCP pancreatitis (PEP; n = 30/63; 48%) and bridging of prolonged waiting times to cholecystectomy (n = 21/63; 33%). Median time to surgery was 47 days (range: 136 days). The technical success rate was 94% (n = 59/63; 95% CI [0.84, 0.98]). Technical difficulties primarily arose with dislocations. Clinical success was achieved in 90% (n = 57/63; 95% CI [0.80, 0.96]). Clinical failure despite successful deployment was caused by papillary bleeding (1 patient) and cholestasis (1 patient). Both required reinterventions. No follow-up visits were needed in 97% of cases (n = 57/59; 95% CI [0.88, 1.00]).

CONCLUSION

Biodegradable stents could help conserve health care resources without compromising treatment standards for PEP prophylaxis, which is particularly valuable in times of restricted resources. First insights into feasibility as bridging to cholecystectomy indicate a favorable safety profile.

New method for real-time visualization and quantitative characterization of early colorectal cancer in endoscopy: a pilot study

Background and study aims  Endoscopic optical diagnosis is crucial to the therapeutic strategy for early gastrointestinal cancer. It accurately (> 85 %) predicts pT category based on microsurface (SP) and vascular patterns (VP). However, interobserver variability is a major problem. We have visualized and digitalized the graded irregularities based on bioinformatically enhanced quantitative endoscopic image analysis (BEE) of high-definition white-light images. Methods  In a pilot study of 26 large colorectal lesions (LCLs, mean diameter 39 mm), we retrospectively compared BEE variables with corresponding histopathology of the resected LCLs. Results  We included 10 adenomas with low-grade intraepithelial neoplasia (LGIN), nine with high-grade intraepithelial neoplasia (HGIN) and early adenocarcinoma (EAC), and seven deeply submucosal invasive carcinomas. Quantified density (d) and nonuniformity (C _U ) of vascular and surface structures correlated with histology (r _s d VP: -0.77, r _s C _U VP: 0.13, r _s d SP: -0.76, and r _s C _U SP: 0.45, respectively). A computed BEE score showed a sensitivity and specificity of 90 % and 100 % in the group with LGINs, 89 % and 41 % in the group with HGINs and EACs, and 100 % and 95 % in the group with deeply invasive carcinoma, respectively. Conclusions  In this pilot study, BEE showed promise as a tool for endoscopic characterization of LCLs during routine endoscopy. Prospective clinical studies are needed.

Flexible diverticulotomy for Zenker's diverticulum - a bicentric study

INTRODUCTION

Flexible diverticulotomy is an established procedure for the treatment of Zenker's diverticulum. In a bicentric study, we investigated the development of the procedure since its introduction at the Ordensklinikum Linz Barmherzige Schwestern and Elisabethinen in 2010.

METHODS

All flexible diverticulotomies performed between January 2010 and December 2019 at the above-mentioned clinics were evaluated retrospectively. Patients were divided into two 5-year periods (2010-2014 and 2015-2019) and statistical tests were performed for comparison of data.

RESULTS

In all, 69 flexible diverticulotomies were performed. The procedure was technically successful in 93.5% of cases. No lethal outcome was encountered. Only 2 (2.9%) interventions led to serious complications which had to be treated in the intensive care unit. Mild complications occurred in 14.5% of cases. 54 patients were evaluated in the follow-up period; 11 (20.3%) patients experienced relapses of dysphagia. The primary intervention resulted in a significant improvement over the observation period. Patients in the second intervention group had shorter average hospital stays and longer recurrence-free intervals.

CONCLUSION

Flexible diverticulotomy is a safe and effective procedure for the treatment of Zenker's diverticulum. However, as the success rate appears to depend on the expertise and experience of the department, flexible diverticulotomy should be performed at centers with high caseloads.

Decline in acute upper gastrointestinal bleeding during COVID-19 pandemic after initiation of lockdown in Austria

BACKGROUND

COVID-19 has spread rapidly around the world. The Austrian government implemented a lockdown on 16 March to contain further spread of the disease. We investigated the effects of lockdown on acute upper gastrointestinal (GI) bleeding in Austria.

METHODS

We contacted 98 Austrian hospitals performing emergency endoscopies. The hospitals were asked to report upper GI endoscopies performed for recent hematemesis, melena, or both, and exhibiting endoscopically visible signs of bleeding. The study period was from 3 weeks before (calendar Week 9) to 3 weeks after (Week 14) initiation of the lockdown.

RESULTS

61 % of Austrian hospitals, and importantly all major state hospitals, responded. A total of 575 upper GI bleedings occurred during the 3 weeks before and 341 during the 3 weeks after initiation of lockdown (40.7 % reduction). There was a 54.6 % decline in nonvariceal bleeding events at Week 14 compared with Week 9 (89 vs. 196), whereas rates of variceal hemorrhage did not change (15 vs. 17).

CONCLUSIONS

National lockdown resulted in a dramatic decrease in upper GI bleeding events in Austrian hospitals.

Small colorectal polyps

Small (<10 mm) and diminutive (<6 mm) polyps harbour high-grade dysplasia or cancer in 0.3-5% of cases. The potential to grow and develop advanced histology is low. Traditional guidelines still recommend the removal of all polyps. Visual characterisation with modern endoscopic technology could enable us to leave diminutive hyperplastic polyps in situ and remove but discard small polyps. In expert hands, high-definition white-light endoscopy and virtual chromoendoscopy can reach an accuracy of more than 90% in distinguishing between hyperplastic and adenomatous pathology. For less experienced endoscopists the values are lower and therefore the concept is not yet fit for routine use. Polyps can be removed completely with snares but not with forceps. The cold snaring technique in particular has proved safe and effective for small polyps. With more experience in the future a 'cut and discard' strategy for small polyps and a 'do not resect' strategy for diminutive polyps will save money and time to deal with more advanced lesions.

Antiviral treatment of chronic hepatitis C in clinical routine

OBJECTIVE

Pegylated interferon plus ribavirin is the standard treatment for chronic hepatitis C. Sustained virological response (SVR) rates of up to 60% are reported in randomized controlled trials, but it is unclear whether the results from such trials are reproducible in the clinical routine setting. We investigated consecutive treatment-naïve chronic hepatitis C patients at our center to examine the efficacy of treatment with pegylated interferon plus ribavirin in clinical routine.

MATERIALS AND METHODS

Between 2000 and 2006 we treated a total of 219 patients with pegylated interferon alpha (2a or 2b) and ribavirin (800-1200 mg/d). Among them, 34.8% of patients infected with HCV genotypes 1/4/6 and 18.4% of those with genotypes 2/3 had advanced fibrosis or cirrhosis (F3-F4). For analysis of outcome we subdivided our series into two groups of patients: those who fulfilled standard inclusion criteria in randomized controlled trials and those who did not.

RESULTS

The overall SVR rate was 44.3%. In patients with F0-F2 an SVR was achieved in 52.5%; in those with F3-F4 the SVR rate was 20.8%. In patients infected with genotypes 1/4/6 the SVR rate was 35.4% (SVR: F0-F2 47.7%; F3-F4 19.6%); in those with genotypes 2/3 the rate was 67.8%. The SVR rate in patients with unfavorable baseline factors was significantly lower (32.4% vs. 50%; P = 0.017) and they were more likely to be non-responders (30.9% vs. 13.8%).

CONCLUSION

In everyday clinical practice, up to one-third of patients show unfavorable baseline factors for antiviral therapy, resulting in worse therapeutic outcome. Differences in therapeutic outcome are influenced by patient selection and by the proportion and severity of the underlying liver disease.

Chronic hepatitis C in Austria, 1992–2006: genotype distribution and demographic factors

Chronic hepatitis C is a leading cause of end-stage liver disease and, with a worldwide prevalence of up to 3%, is a pandemic infectious disease. Austria, like most western European countries can be considered as a low prevalence country. This analysis aimed to assess the distribution of hepatitis C virus (HCV) genotypes in patients with chronic HCV infection in Upper Austria. Between September 1992 and December 2006, we identified 1,318 consecutive patients who tested positive for HCV RNA. Genotyping was routinely performed in 1,239 of the 1,318 patients, and in a subgroup of 617 patients data on the source of transmission were collected. Additionally we obtained data on liver histology and body mass index in a subsample of 273 of the 617 patients. Hepatitis C genotypes 1, 2, 3, 4, 6 and co-infections were found in 80.4%, 4.5%, 12.3%, 2.7%, 0.1% and 0.2% of the patients, respectively. There was a highly significant age difference in relation to gender at the time of diagnosis of chronic hepatitis C, with women being older than men (men: 45.0 years; women: 49.3 years; p<0.0001). The number of new cases of chronic hepatitis C decreased substantially over the last decade, but although risk factors for obtaining HCV are well established, we did not find a decrease in the age of first diagnosis. Besides consistent screening in defined risk groups it is important to raise awareness for risk factors for HCV acquisition and liver disease progression.

Multicenter retrospective evaluation of capsule endoscopy in clinical routine

BACKGROUND AND STUDY AIMS

The small bowel is anatomically difficult to examine; disease conditions are rarely located in it, but can be serious. Neither conventional radiography nor push enteroscopy has sufficient sensitivity and specificity to detect distinct lesions. Wireless capsule endoscopy can theoretically allow imaging of the entire small bowel, with only minimal discomfort for the patient.

PATIENTS AND METHODS

Between November 2001 and May 2003, 191 patients received 195 capsules. Data were collected retrospectively from consecutive patients in three centers. The indications for capsule endoscopy were obscure or occult bleeding, suspected Crohn's disease, or other reasons in 151, 25, and 15 patients, respectively. The clinical outcome after 6 months was evaluated on the basis of interviews with patients or relatives.

RESULTS

Visualization of the entire small bowel was adequate in 78.4 % of the examinations. The colon was not reached in 16.9 % of cases, and there were minor technical problems in 4.6 %. Relevant pathological findings were identified in 56.2 % of 151 patients with obscure bleeding or iron-deficiency anemia (64 % of whom received blood transfusions). The most common findings were angiodysplasia in 39.7 % of cases and ulcers of the small bowel in 7.3 %. In addition, individual cases of tumors and parasitic worms were detected. Seven of the 25 patients with suspected Crohn's disease (28 %) had the disease confirmed. Three of five patients with polyposis syndrome of the colon were found to have polyps in the small bowel.

CONCLUSIONS

Wireless capsule endoscopy can be recommended as part of the routine work-up in patients with obscure bleeding or iron-deficiency anemia. In patients with Crohn's disease, the method may be helpful in establishing or ruling out the diagnosis.