Publications by authors named "Cesare Hassan"

538 Publications

Detection of High-Risk Sessile Serrated Lesions: Multi-Target Stool DNA Versus CT Colonography.

AJR Am J Roentgenol 2021 Nov 10. Epub 2021 Nov 10.

Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, Wisconsin 53705.

The serrated pathway for colorectal cancer (CRC) development is increasingly recognized. Patients with sessile serrated lesions (SSLs) that are large (≥10 mm) and/or have dysplasia (i.e., high-risk SSLs) are at higher risk of progression to CRC. Detection of SSLs is challenging given their predominantly flat and right-sided location. The yield of non-invasive screening tests for detection of high-risk SSLs is unclear. The aim of this study was to compare non-invasive screen detection of high-risk SSLs between the multi-target stool DNA test (mt-sDNA; Cologuard) and CT colonography (CTC). This retrospective study included 7974 asymptomatic adults (4705 women, 3269 men; mean age 60.0 years) who underwent CRC screening at a single center by mt-sDNA (Cologuard) from 2014-2019 (n=3987) or by CTC from 2009-2019 (n=3987). Clinical interpretations of CTC examinations were recorded. Subsequent colonoscopy findings and histology of resected polyps were also recorded. Chi-square or two-sample t tests were used to compare results between mt-sDNA and CTC using 6-mm and 10-mm thresholds for test positivity. The overall colonoscopy referral rate for a positive screening test was 13.1% (522/3987) for mt-sDNA versus 12.2% (487/3987; p=.23) and 6.5% (260/3987; p<.001) for CTC at 6-mm and 10-mm thresholds, respectively. The PPV for high-risk SSLs was 5.5% (26/476) for mt-sDNA, versus 14.4% (66/457; p<.001) and 25.9% (63/243; p<.001) for CTC at 6-mm and 10-mm thresholds, respectively. The overall screening yield of high-risk SSLs was 0.7% (26/3987) for mt-sDNA versus 1.7% (66/3987; p<.001) and 1.6% (63/3987; p<.001) for CTC at 6-mm and 10-mm thresholds, respectively. CTC at 6-mm and 10-mm thresholds had significantly higher yield and PPV for high-risk SSLs compared with mt-sDNA. The significantly higher detection of high-risk SSLs by CTC than by mt-sDNA should be included in discussions with patients who decline colonoscopy and opt for noninvasive screening.
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http://dx.doi.org/10.2214/AJR.21.26719DOI Listing
November 2021

Stay on Top: COVID-19 As an Opportunity to Improve the GI Scientific Career - The Impact on Papers and Literature.

Tech Innov Gastrointest Endosc 2021 5;23(2):212-214. Epub 2020 Dec 5.

Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy.

The main barrier for a young researcher in the field of endoscopy is that too much is known about virtually every aspect not only of the natural history, but also of the efficacy and safety of different Gastrointestinal (GI) techniques. The main fuel for research remains uncertainty, and this has been the primary characteristic of COVID-19. The unprecedented visibility of the main papers on the natural history and medical management of COVID-19 on all the main worldwide medical Journals has had an effect of drainage on the reports of COVID-19 in GI endoscopy, suddenly opening up the interest of main GI journals to this topic. Furthermore, given the nature and the urgency of the topic, these high-ranking journals have accepted study designs outside rigorous randomized controlled trials and/or systematic reviews and meta-analysis, what used to be the "conditio sine qua non" for being considered for publication. Suddenly, rigorous guidelines have been replaced by expert-derived suggestions on the basis that the best possible guidance is better than no guidance. This situation has been a great occasion for young researchers to gain visibility even without having access to the complex means and long time-spans needed to finalize a randomized trial.
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http://dx.doi.org/10.1016/j.tige.2020.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8528487PMC
December 2020

A prospective study on quality in endoscopic retrograde cholangiopancreatography (ERCP): trend in Italy from the REQUEST study.

Endosc Int Open 2021 Oct 16;9(10):E1563-E1571. Epub 2021 Sep 16.

Department of Gastroenterology, Nuovo Regina Margherita Hospital, Roma, Italy.

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure with a relatively high rate of adverse events. Data on training of operators and fulfillment of quality indicators in Italy are scarce. The goal of this study was to assess the overall quality of ERCP in Italy compared to international standards. This was a prospective, observational study from different Italian centers performing ERCP. Operators answered a questionnaire, then recorded data on ERCPs over a 1-to 3-month period. Nineteen Italian centers participated in the study. The most common concern of operators about training was the lack of structured programs. Seven/19 centers routinely used conscious sedation for ERCP. Forty-one experienced operators and 21 trainees performed 766 ERCPs: a successful deep biliary cannulation in native-papilla patients was achieved in 95.1 % of cases; the post-ERCP pancreatitis (PEP) rate was 5.4 % in native-papilla patients; cholangitis rate was 1.0 %; bleeding and perforation occurred in 2.7 % and 0.4 % of the patients, respectively. This study revealed that, overall, ERCP is performed in the participating Italian centers meeting good quality standards, but structured training and sedation practice are still subpar. The bleeding and perforation rate slightly exceeded the American Society of Gastrointestinal Endoscopy indicator targets but they are comparable to the reported rates from other international surveys.
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http://dx.doi.org/10.1055/a-1531-4691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445684PMC
October 2021

Colonoscopy quality across Europe: a report of the European Colonoscopy Quality Investigation (ECQI) Group.

Endosc Int Open 2021 Oct 16;9(10):E1456-E1462. Epub 2021 Sep 16.

Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Bologna, Italy.

The European Colonoscopy Quality Investigation (ECQI) Group comprises expert colonoscopists and investigators with the aim of raising colonoscopy standards. We assessed the levels of monitoring and achievement of European Society of Gastrointestinal Endoscopy (ESGE) performance measures (PMs) across Europe using responses to the ECQI questionnaires. The questionnaire comprises three forms: institution and practitioner questionnaires are completed once; a procedure questionnaire is completed on multiple occasions for individual total colonoscopies. ESGE PMs were approximated as closely as possible from the data collected via the procedure questionnaire. Procedure data could provide rate of adequate bowel preparation, cecal intubation rate (CIR), withdrawal time, polyp detection rate (PDR), and tattooing resection sites. We evaluated ECQI questionnaire data collected between June 2016 and April 2018, comprising 91 practitioner and 52 institution questionnaires. A total of 6445 completed procedure forms were received. Institution and practitioner responses indicate that routine recording of PMs is not widespread: adenoma detection rate (ADR) is routinely recorded in 29 % of institutions and by 34 % of practitioners; PDR by 42 % and 47 %, CIR by 62 % and 64 %, bowel preparation quality by 56 % and 76 %, respectively. Procedure data showed a rate of adequate bowel preparation of 84.2 %, CIR 73.4 %, PDR 40.5 %, mean withdrawal time 7.8 minutes and 12.2 % of procedures with possible removal of a non-pedunculated lesion ≥ 20 mm reporting tattooing. Our findings clearly show areas in need of quality improvement and the importance of promoting quality monitoring throughout the colonoscopy procedure.
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http://dx.doi.org/10.1055/a-1486-6729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445680PMC
October 2021

Computer-aided detection versus advanced imaging for detection of colorectal neoplasia: a systematic review and network meta-analysis.

Lancet Gastroenterol Hepatol 2021 10 5;6(10):793-802. Epub 2021 Aug 5.

Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, Rozzano, Milan, Italy.

Background: Computer-aided detection (CADe) techniques based on artificial intelligence algorithms can assist endoscopists in detecting colorectal neoplasia. CADe has been associated with an increased adenoma detection rate, a key quality indicator, but the utility of CADe compared with existing advanced imaging techniques and distal attachment devices is unclear.

Methods: For this systematic review and network meta-analysis, we did a comprehensive search of PubMed/Medline, Embase, and Scopus databases from inception to Nov 30, 2020, for randomised controlled trials investigating the effectiveness of the following endoscopic techniques in detecting colorectal neoplasia: CADe, high definition (HD) white-light endoscopy, chromoendoscopy, or add-on devices (ie, systems that increase mucosal visualisation, such as full spectrum endoscopy [FUSE] or G-EYE balloon endoscopy). We collected data on adenoma detection rates, sessile serrated lesion detection rates, the proportion of large adenomas detected per colonoscopy, and withdrawal times. A frequentist framework, random-effects network meta-analysis was done to compare artificial intelligence with chromoendoscopy, increased mucosal visualisation systems, and HD white-light endoscopy (the control group). We estimated odds ratios (ORs) for the adenoma detection rate, sessile serrated lesion detection rate, and proportion of large adenomas detected per colonoscopy, and calculated mean differences for withdrawal time, with 95% CIs. Risk of bias and certainty of evidence were assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Findings: 50 randomised controlled trials, comprising 34 445 participants, were included in our main analysis (six trials of CADe, 18 of chromoendoscopy, and 26 of increased mucosal visualisation systems). HD white-light endoscopy was the control technique in all 50 studies. Compared with the control technique, the adenoma detection rate was 7·4% higher with CADe (OR 1·78 [95% CI 1·44-2·18]), 4·4% higher with chromoendoscopy (1·22 [1·08-1·39]), and 4·1% higher with increased mucosal visualisation systems (1·16 [1·04-1·28]). CADe ranked as the superior technique for adenoma detection (with moderate confidence in hierarchical ranking); cross-comparisons of CADe with other imaging techniques showed a significant increase in the adenoma detection rate with CADe versus increased mucosal visualisation systems (OR 1·54 [95% CI 1·22-1·94]; low certainty of evidence) and with CADe versus chromoendoscopy (1·45 [1·14-1·85]; moderate certainty of evidence). When focusing on large adenomas (≥10 mm) there was a significant increase in the detection of large adenomas only with CADe (OR 1·69 [95% CI 1·10-2·60], moderate certainty of evidence) when compared to HD white-light endoscopy; CADe ranked as the superior strategy for detection of large adenomas. CADe also seemed to be the superior strategy for detection of sessile serrated lesions (with moderate confidence in hierarchical ranking), although no significant increase in the sessile serrated lesion detection rate was shown (OR 1·37 [95% CI 0·65-2·88]). No significant difference in withdrawal time was reported for CADe compared with the other techniques.

Interpretation: Based on the published literature, detection rates of colorectal neoplasia are higher with CADe than with other techniques such as chromoendoscopy or tools that increase mucosal visualisation, supporting wider incorporation of CADe strategies into community endoscopy services.

Funding: None.
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http://dx.doi.org/10.1016/S2468-1253(21)00215-6DOI Listing
October 2021

EUS-guided biopsy confocal laser endomicroscopy in patients with pancreatic cystic lesions: A systematic review and meta-analysis.

Endosc Ultrasound 2021 Jul-Aug;10(4):270-279

Gastro Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre; Department of Clinical Medicine, University of Copenhagen, København, Denmark.

Background And Objectives: Pancreatic cystic lesions (PCLs) are frequent incidental findings on cross-sectional imaging and represent a diagnostic challenge as different kinds of PCLs harbor a dissimilar risk of malignancy. Two diagnostic tools have recently been developed and introduced: through-the-needle biopsy (TTNB) and needle-based confocal laser endomicroscopy (nCLE). The aim of this meta-analysis was to compare the diagnostic yield and performance, as well as the safety profile of the two methods.

Methods: This meta-analysis was performed in accordance with the PRISMA statement. Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies with five or more patients undergoing either endoscopic ultrasound (EUS)-TTNB or EUS-nCLE for a PCL. Reviews, case reports, editorials, conference abstracts, and studies on exclusively solid pancreatic lesions were excluded. Outcomes of interest were diagnostic yield and performance, safety, and technical success.

Results: Twenty studies with 1023 patients were included in the meta-analysis. Pooled diagnostic yield of EUS-nCLE was higher compared to EUS-TTNB (85% vs. 74%, P < 0.0001), while diagnostic performance was high and comparable for both methods (pooled sensitivity: 80% vs. 86% and pooled specificity: 80% vs. 83% for TTNB and nCLE, respectively, P > 0.05). Pooled estimate of total adverse event (AE) rate was 5% in the TTNB group and 3% in the nCLE group, P = 0.302. Technical success rates were high and comparable (94% and 99% for EUS-TTNB and nCLE, respectively; P = 0.07).

Conclusion: EUS-TTNB and EUS-nCLE have a similar safety profile with a relatively low number of AEs. Technical success, sensitivity, and specificity are comparable; however, EUS-nCLE seems to have a slightly higher diagnostic yield.
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http://dx.doi.org/10.4103/EUS-D-20-00172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411554PMC
July 2021

Colorectal Screening Program in Northern Portugal: First Findings.

Acta Med Port 2021 Jul 20. Epub 2021 Jul 20.

Departamento de Gastroenterologia. Instituto Português de Oncologia do Porto. Porto. Portugal.

Introduction: In Portugal, a colorectal cancer screening program based on faecal immunochemical test followed by colonoscopy was shown to be cost-effective for individuals between 50 and 74 years old. We report the first findings of the implementation of a population-based program In Northern Portugal.

Material And Methods: In the pilot phase, eligible subjects were allocated either to a direct mailing invitation or to primary care centers. In the first year of program implementation, we assessed the uptake rate, the faecal immunochemical test -positivity rate, the diagnostic yield of advanced neoplasia, and the quality parameters for post-faecal immunochemical test + colonoscopy.

Results: We invited 100 501 eligible subjects (49% male with a median age of 55 years). Of these, 5228 participated in the pilot phase and 95 273 participated in the first year of the program. In the first year of the program, the adherence was 29%, with a positivity rate of 5% and a 60% compliance to colonoscopy. The faecal immunochemical test-detection rate of advanced neoplasia was 0.35/1000 subjects, and the positive predictive value at post- faecal immunochemical test + colonoscopy was 44% and 2% for advanced adenoma and invasive cancer, respectively. No major adverse events were reported after colonoscopy.

Discussion: The suboptimal adherence to faecal immunochemical test and post-faecal immunochemical test + colonoscopy remains the most urgent step to be addressed.

Conclusion: A centralized invitation system based on direct mailing was feasible and both colonoscopy quality and diagnostic yield were adequate antecipating the success of the programme.
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http://dx.doi.org/10.20344/amp.15904DOI Listing
July 2021

Safety and efficacy of multiband mucosectomy for Barrett's esophagus: a systematic review with pooled analysis.

Ann Gastroenterol 2021 Jul-Aug;34(4):487-492. Epub 2021 Apr 2.

Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici).

Background: According to guidelines, all visible lesions in Barrett's esophagus (BE) should be endoscopically resected. Available methods of endoscopic resection include the cap-assisted technique and, more recently, multiband mucosectomy (MBM). Data on the efficacy and safety of MBM have yet to be systematically reviewed. We performed the first systematic review with pooled analysis to evaluate the outcomes of MBM in patients with BE.

Methods: Electronic databases (Medline, Scopus, EMBASE) were searched up to August 2019. Studies including patients with BE who underwent MBM were eligible. The primary outcome was the adverse events rate. Secondary outcomes were the proportions of complete resections and R0 resections. Outcomes were assessed by pooling data using a random or fixed-effect model, according to the degree of heterogeneity, to obtain a proportion with a 95% confidence interval.

Results: Fourteen studies were eligible (1334 procedures, 986 patients). The adverse event rate was 5.3%. Immediate and post-procedural bleeding, perforations and strictures occurred in 0.2%, 0.7%, 0.3% and 3.9% of procedures, respectively. Focal lesions were resected at a complete rate of 97.6% with an R0 resection rate of 94.1%.

Conclusion: MBM is a safe and effective technique for treating visible lesions in BE.
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http://dx.doi.org/10.20524/aog.2021.0620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276358PMC
April 2021

Promotion of gastrointestinal endoscopy in Sub-Saharan Africa: What is needed, and how can ESGE and WEO help?

Endosc Int Open 2021 Jul 17;9(7):E1001-E1003. Epub 2021 Jun 17.

Department of Transplantation Medicine, Faculty of Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway. Co-chair of the Committee of Activities to Reach Africa - World Endoscopy Organization.

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http://dx.doi.org/10.1055/a-1495-5215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211488PMC
July 2021

Artificial intelligence and colonoscopy experience: lessons from two randomised trials.

Gut 2021 Jun 29. Epub 2021 Jun 29.

Gastroenterology and Digestive Endoscopy Unit, Ospedale Nuovo Regina Margherita, Roma, Italy.

Background And Aims: Artificial intelligence has been shown to increase adenoma detection rate (ADR) as the main surrogate outcome parameter of colonoscopy quality. To which extent this effect may be related to physician experience is not known. We performed a randomised trial with colonoscopists in their qualification period (AID-2) and compared these data with a previously published randomised trial in expert endoscopists (AID-1).

Methods: In this prospective, randomised controlled non-inferiority trial (AID-2), 10 non-expert endoscopists (<2000 colonoscopies) performed screening/surveillance/diagnostic colonoscopies in consecutive 40-80 year-old subjects using high-definition colonoscopy with or without a real-time deep-learning computer-aided detection (CADe) (GI Genius, Medtronic). The primary outcome was ADR in both groups with histology of resected lesions as reference. In a post-hoc analysis, data from this randomised controlled trial (RCT) were compared with data from the previous AID-1 RCT involving six experienced endoscopists in an otherwise similar setting.

Results: In 660 patients (62.3±10 years; men/women: 330/330) with equal distribution of study parameters, overall ADR was higher in the CADe than in the control group (53.3% vs 44.5%; relative risk (RR): 1.22; 95% CI: 1.04 to 1.40; p<0.01 for non-inferiority and p=0.02 for superiority). Similar increases were seen in adenoma numbers per colonoscopy and in small and distal lesions. No differences were observed with regards to detection of non-neoplastic lesions. When pooling these data with those from the AID-1 study, use of CADe (RR 1.29; 95% CI: 1.16 to 1.42) and colonoscopy indication, but not the level of examiner experience (RR 1.02; 95% CI: 0.89 to 1.16) were associated with ADR differences in a multivariate analysis.

Conclusions: In less experienced examiners, CADe assistance during colonoscopy increased ADR and a number of related polyp parameters as compared with the control group. Experience appears to play a minor role as determining factor for ADR.

Trial Registration Number: NCT:04260321.
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http://dx.doi.org/10.1136/gutjnl-2021-324471DOI Listing
June 2021

Artificial Intelligence for gastrointestinal endoscopy: When technology meets our needs!

Best Pract Res Clin Gastroenterol 2021 Jun-Aug;52-53:101725. Epub 2021 Jan 31.

III Medizinische Klinik, Universitatsklinikum Augsburg, Augsburg, Germany.

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http://dx.doi.org/10.1016/j.bpg.2021.101725DOI Listing
January 2021

Impact of artificial intelligence on colorectal polyp detection.

Best Pract Res Clin Gastroenterol 2021 Jun-Aug;52-53:101713. Epub 2020 Dec 4.

Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Rozzano, 20089, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.

Since colonoscopy and polypectomy were introduced, Colorectal Cancer (CRC) incidence and mortality decreased significantly. Although we have entered the era of quality measurement and improvement, literature shows that a considerable amount of colorectal neoplasia is still missed by colonoscopists up to 25%, leading to an high rate of interval colorectal cancer that account for nearly 10% of all diagnosed CRC. Two main reasons have been recognised: recognition failure and mucosal exposure. For this purpose, Artificial Intelligence (AI) systems have been recently developed that identify a "hot" area during the endoscopic examination. In retrospective studies, where the systems are tested with a batch of unknown images, deep learning systems have shown very good performances, with high levels of accuracy. Of course, this setting may not reflect actual clinical practice where different pitfalls can occur, like suboptimal bowel preparation or poor examination technique. For this reason, a number of randomised clinical trials have recently been published where AI was tested in real time during endoscopic examinations. We present here an overview on recent literature addressing the performance of Computer Assisted Detection (CADe) of colorectal polyps in colonoscopy.
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http://dx.doi.org/10.1016/j.bpg.2020.101713DOI Listing
July 2021

Systematic review with meta-analysis: the long-term efficacy of Barrett's endoscopic therapy-stringent selection criteria and a proposal for definitions.

Aliment Pharmacol Ther 2021 08 24;54(3):222-233. Epub 2021 Jun 24.

Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA.

Background: Barrett's endoscopic therapy (BET) is well established for neoplasia in Barrett's oesophagus using a concept of complete eradication of all Barrett's. However, long-term efficacy is not known.

Aims: To perform a systematic review and meta-analysis to examine long-term efficacy of BET for Barrett's neoplasia.

Methods: Electronic databases were searched for studies meeting stringent criteria: (a) subjects with high-grade dysplasia and/or superficial adenocarcinoma who underwent BET (ablation ± endoscopic mucosal resection); (b) BET completion by confirmation of complete eradication of neoplasia (CE-N) and intestinal metaplasia (CE-IM) with systematic sampling and (c) clearly defined follow-up (endoscopy and biopsy) protocol of ≥2 years thereafter for detection of recurrence. Pooled estimates of CE-N and CE-IM after BET completion and follow-up were analysed.

Results: Eight studies met the stringent criteria (n = 794, males 89%, age 64.6 years). Despite high efficacy of BET at therapy completion (CE-N: 95.9 [91.7-98.7]%; CE-IM: 90.9 [83-96.6]%), this declined (CE-N: 89 [73.4-98.2]%; CE-IM: 77.8 [65.6-88]%) over 3.4 years of follow-up. There was considerable heterogeneity. Only two studies reported a post-BET follow-up of >5 years (CE-IM 50 [41.5%-58.5]%). Higher person years of follow-up seem to correlate with decrease in BET efficacy.

Conclusion: Using stringent criteria for appropriate study selection with sufficient follow-up, a lack of high-quality controlled intervention trials becomes evident for assessment of long-term durable remission rates of BET despite initial high success rates. We plea for a uniform documentation of study details which could be used in future trials.
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http://dx.doi.org/10.1111/apt.16473DOI Listing
August 2021

Erratum: Updating the recommendations on bowel preparation for acute lower gastro-intestinal bleeding: The time has come!

Endosc Int Open 2021 Jun 16;9(6):C7. Epub 2021 Jun 16.

Gastroenterology and Digestive Endoscopy Unit, Azienda USL Modena, Italy.

[This corrects the article DOI: 10.1055/a-1372-4051.].
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http://dx.doi.org/10.1055/a-1525-7686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8208838PMC
June 2021

Single-dose versus short-course prophylactic antibiotics for peroral endoscopic myotomy: a randomized controlled trial.

Gastrointest Endosc 2021 11 11;94(5):922-929. Epub 2021 Jun 11.

Department of Biomedical Sciences, Humanitas University, Milan, Italy; Digestive Endoscopy Unit, Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy.

Background And Aims: Peroral endoscopic myotomy (POEM) has been recommended for achalasia treatment. To prevent the potential of infective risk, antibiotic prophylaxis is usually administered, whereas the additional need of antibiotic therapy after POEM is uncertain. The primary endpoint was to determine whether prophylaxis versus prophylaxis plus short therapy was needed after POEM.

Methods: Consecutive patients scheduled for POEM were randomly assigned (1:1) to group A (prophylactic cefazolin 2 g IV) or group B (prophylaxis + cefazolin 2 g IV × 3 followed by oral amoxicillin/clavulanate 3 g/day). Infective risk was assessed by means of host response, namely body temperature and serum levels of white blood cells and C-reactive protein; immune response (the cytokines interleukin [IL]-6, IL-1β, and tumor necrosis factor-α and microbial translocation mediators lipopolysaccharide binding protein and soluble CD14); and blood cultures at time points before (t0) and after (t1, t2) POEM.

Results: After POEM, none of the 124 enrolled patients (54.6 ± 12.6 years old; 64 men) developed any fever (body temperature: t0, 36.56± .49°C; t1, 36.53± .52°C; t2, 36.48± .41°C), without any differences between groups at any time point. Regarding systemic inflammation, no difference was reported between groups in serum levels of C-reactive protein and white blood cells. Considering microbial translocation mediated response, lipopolysaccharide binding protein (group A: t0, 1539 ± 168.6 pg/mL; t1, 1321 ± 149.1 pg/mL; t2, 2492 ± 283.2 pg/mL; group B: t0, 1318 ± 115.9 pg/mL; t1, 1492 ± 163.8 pg/mL; t2, 2600 ± 328.2 pg/mL) and soluble CD14 (group A: t0, 2.16 ± .15 μg/mL; t1, 1.89 ± .15 μg/mL; t2, 2.2 ± .15 μg/mL; group B: t0, 2.1 ± .13 μg/mL; t1, 2 ± .13 μg/mL; t2, 2.5 ± .2 μg/mL) were similar between the 2 groups; the immune response cytokines IL-6, IL-1β, and tumor necrosis factor-α also were similar in the 2 groups. In relation to blood cultures, at t1 the group B bacteremia rate was 3.2% (2/62) and group A was 1.6% (1/62) with no difference (P = .6). All subsequent blood cultures were negative at t2.

Conclusions: According to our study, postprophylactic short-term antimicrobial therapy after POEM is not required because of a very low residual infective risk. (Clinical trial registration number: NCT03587337.).
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http://dx.doi.org/10.1016/j.gie.2021.05.045DOI Listing
November 2021

Live endoscopy events (LEEs): European Society of Gastrointestinal Endoscopy Position Statement - Update 2021.

Endoscopy 2021 08 10;53(8):842-849. Epub 2021 Jun 10.

Serviço de Gastrenterologia, Instituto Português de Oncologia, Porto, Portugal.

The European Society of Gastrointestinal Endoscopy (ESGE) is dedicated to improving the quality of gastrointestinal endoscopy, including through educational activities such as live endoscopy events (LEEs). The primary goal of LEEs should be to facilitate the improvement of endoscopic patient care through the acquisition of best endoscopic practice. Patients should not expect additional benefit from being treated during a LEE compared to a routine setting. There is limited available evidence on LEE safety but to date there is no indication that patients are at increased risk from participation. Pre-recorded cases with live facilitation can also be used to fulfill learning outcomes. Establishing an endoscopic curriculum with clear learning outcomes is important to structure attendees' learning, assess course outcomes, and allow appropriate targeting of courses to learner experience. Increasingly, LEEs are streamed online and therefore the necessary measures should be taken to ensure that patients have given appropriate consent and that their anonymity has been safeguarded. ESGE recommends that an endoscopist who is not participating in the live demonstrations is named as patient advocate, and that patient safety should must be prioritized throughout. In all ESGE-organized LEEs the intended learning outcomes, procedural indications and descriptions, attendee feedback, and adverse events should be recorded and submitted in a post-event report to ESGE.
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http://dx.doi.org/10.1055/a-1511-1657DOI Listing
August 2021

What gastroenterologists should know about SARS-CoV 2 vaccine: World Endoscopy Organization perspective.

United European Gastroenterol J 2021 Jun 8. Epub 2021 Jun 8.

Department of Biomedical Sciences, Humanitas University, Rozzano, Italy.

Background: The novel Coronavirus (SARS-CoV-2) has caused almost 2 million deaths worldwide. Both Food and Drug Administration and European Medicines Agency have recently approved the first COVID-19 vaccines, and a few more are going to be approved soon.

Methods: Several different approaches have been used to stimulate the immune system in mounting a humoral response. As more traditional approaches are under investigation (inactivated virus vaccines, protein subunit vaccines, recombinant virus vaccines), more recent and innovative strategies have been tried (non-replicating viral vector vaccines, RNA based vaccines, DNA based vaccines).

Results: Since vaccinations campaigns started in December 2020 in both the US and Europe, gastroenterologists will be one of the main sources of information regarding SARS-CoV 2 vaccination for patients in their practice, including vulnerable patients such as those with Inflammatory Bowel Disease (IBD), patients with chronic liver disease, and GI cancer patients.

Conclusions: Thus, we must ourselves be well educated and updated in order to provide unambiguous counseling to these categories of vulnerable patients. In this commentary, we aim to provide a comprehensive review of both approved COVID-19 vaccines and the ones still under development, and explore potential risks, benefits and prioritization of vaccination.
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http://dx.doi.org/10.1002/ueg2.12103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8242672PMC
June 2021

Second-generation thrombopoietin receptor agonists: New players in the management of cirrhotic patients undergoing therapeutic endoscopy?

Dig Liver Dis 2021 Oct 2;53(10):1362-1363. Epub 2021 Jun 2.

Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

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http://dx.doi.org/10.1016/j.dld.2021.05.007DOI Listing
October 2021

Higher rate of en bloc resection with underwater than conventional endoscopic mucosal resection: A meta-analysis.

Dig Liver Dis 2021 Aug 29;53(8):958-964. Epub 2021 May 29.

Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany.

Objectives: Previous meta-analysis including nonrandomized studies showed marginal benefit of underwater endoscopic mucosal resection(U-EMR) compared to conventional EMR(C-EMR) in terms of polypectomy outcomes. We evaluated U-EMR compared to C-EMR in the treatment of colorectal polyps with respect to effectiveness and safety by analyzing only randomized controlled trials(RCTs).

Material And Methods: PubMed and Cochrane Library databases were searched for RCTs published until 11/2020, evaluating U-EMR vs. C-EMR regarding en bloc resection, post-endoscopic resection adenoma recurrence, complete resection, adverse events rates and difference in resection time. Abstracts from Digestive Disease Week, United European Gastroenterology Week and ESGE Days meetings were also searched. Effect size on outcomes is presented as risk ratio(RR; 95% confidence interval[CI]) or mean difference(MD; 95%CI). The I test was used for quantifying heterogeneity, while Grading of Recommendations Assessment, Development and Evaluation(GRADE) was used to assess strength of evidence.

Results: Six RCTs analyzing outcomes from 1157 colorectal polypectomies(U-EMR589;C-EMR,568) were included. U-EMR associated with significant higher rate of en bloc resection compared to C-EMR [RR(95%CI):1.26(1.01-1.58); Chi² for heterogeneity=30.43, P<0.0001; I²=84%, GRADE: Very low]. This effect was more prominent regarding resection of polyps sized ≥20 mm compared to polyps <20 mm [RR(95%CI):1.64(1.22-2.20) vs. 1.10(0.98-1.23)]. Post-resection recurrence [RR(95%CI):0.52(0.28-0.94);GRADE:Low] was lower significantly in U-EMR group. In contrast, no significant difference was detected between U-EMR and C-EMR regarding complete resection [RR(95%CI): 1.06(0.91-1.24) GRADE:Very low] and adverse events occurrence[RR(95%CI):1.00 (0.72-1.39); GRADE:Low].

Conclusion: Meta-analysis of RCTs supports that U-EMR resection achieves higher rate of en bloc resection compared to conventional EMR. This effect is driven when resecting large(≥20 mm) polyps.
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http://dx.doi.org/10.1016/j.dld.2021.05.001DOI Listing
August 2021

Colon cancer survival differs from right side to left side and lymph node harvest number matter.

BMC Public Health 2021 05 12;21(1):906. Epub 2021 May 12.

Epidemiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, 42122, Reggio Emilia, MD, Italy.

Background: Right-sided colorectal cancer (CRC) has worse survival than does left-sided CRC. The objective of this study was to further assess the impact of right-side location on survival and the role of the extent of lymphadenectomy.

Methods: All CRCs diagnosed between 2000 and 2012 in Emilia-Romagna Region, Italy, were included. Data for stage, grade, histology, screening history, and number of removed lymph nodes (LN) were collected. Multivariable Cox regression models were used to estimate hazard ratios (HR), with relative 95% confidence intervals (95%CI), of right vs. left colon and of removing < 12, 12-21 or > 21 lymph nodes by cancer site.

Results: During the study period, 29,358 patients were registered (8828 right colon, 18,852 left colon, 1678 transverse). Patients with right cancer were more often older, females, with advanced stage and high grade, and higher number of removed LNs. Five-year survival was lower in the right than in the left colon (55.2% vs 59.7%). In multivariable analysis, right colon showed a lower survival when adjusting for age, sex, and screening status (HR 1.12, 95%CI 1.04-1.21). Stratification by number of lymph nodes removed (12-21 or > 21) was associated with better survival in right colon (HR 0.54, 95%CI 0.40-0.72 and HR 0.40, 95%CI 0.30-0.55, respectively) compared to left colon (HR 0.89, 95%CI 0.76-1.06 and HR 0.83, 95%CI 0.69-1.01, respectively).

Conclusions: This study confirms that right CRC has worse survival; the association is not due to screening status. An adequate removal of lymph nodes is associated with better survival, although the direction of the association in terms of causal links is not clear.
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http://dx.doi.org/10.1186/s12889-021-10746-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117551PMC
May 2021

Endoscopists' diagnostic accuracy in detecting upper gastrointestinal neoplasia in the framework of artificial intelligence studies.

Endoscopy 2021 May 5. Epub 2021 May 5.

Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.

Background:  Estimates on miss rates for upper gastrointestinal neoplasia (UGIN) rely on registry data or old studies. Quality assurance programs for upper GI endoscopy are not fully established owing to the lack of infrastructure to measure endoscopists' competence. We aimed to assess endoscopists' accuracy for the recognition of UGIN exploiting the framework of artificial intelligence (AI) validation studies.

Methods:  Literature searches of databases (PubMed/MEDLINE, EMBASE, Scopus) up to August 2020 were performed to identify articles evaluating the accuracy of individual endoscopists for the recognition of UGIN within studies validating AI against a histologically verified expert-annotated ground-truth. The main outcomes were endoscopists' pooled sensitivity, specificity, positive and negative predictive value (PPV/NPV), and area under the curve (AUC) for all UGIN, for esophageal squamous cell neoplasia (ESCN), Barrett esophagus-related neoplasia (BERN), and gastric adenocarcinoma (GAC).

Results:  Seven studies (2 ESCN, 3 BERN, 1 GAC, 1 UGIN overall) with 122 endoscopists were included. The pooled endoscopists' sensitivity and specificity for UGIN were 82 % (95 % confidence interval [CI] 80 %-84 %) and 79 % (95 %CI 76 %-81 %), respectively. Endoscopists' accuracy was higher for GAC detection (AUC 0.95 [95 %CI 0.93-0.98]) than for ESCN (AUC 0.90 [95 %CI 0.88-0.92]) and BERN detection (AUC 0.86 [95 %CI 0.84-0.88]). Sensitivity was higher for Eastern vs. Western endoscopists (87 % [95 %CI 84 %-89 %] vs. 75 % [95 %CI 72 %-78 %]), and for expert vs. non-expert endoscopists (85 % [95 %CI 83 %-87 %] vs. 71 % [95 %CI 67 %-75 %]).

Conclusion:  We show suboptimal accuracy of endoscopists for the recognition of UGIN even within a framework that included a higher prevalence and disease awareness. Future AI validation studies represent a framework to assess endoscopist competence.
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http://dx.doi.org/10.1055/a-1500-3730DOI Listing
May 2021

Novel 1-L polyethylene glycol + ascorbate versus high-volume polyethylene glycol regimen for colonoscopy cleansing: a multicenter, randomized, phase IV study.

Gastrointest Endosc 2021 Oct 30;94(4):823-831.e9. Epub 2021 Apr 30.

Digestive Endoscopy Unit, Carpi-Mirandola Hospitals, Azienda USL Modena.

Background And Aims: Adequate bowel cleansing is critical to ensure quality and safety of a colonoscopy. A novel 1-L polyethylene glycol plus ascorbate (1L-PEG+ASC) regimen was previously validated against low-volume regimens but was never compared with high-volume regimens.

Methods: In a phase IV study, patients undergoing colonoscopy were randomized 1:1 to receive split-dose 1L PEG+ASC or a split-dose 4-L PEG-based regimen (4L-PEG) in 5 Italian centers. Preparation was assessed with the Boston Bowel Preparation Scale (BBPS) by local endoscopists and centralized reading, both blinded to the randomization arm. The primary endpoint was noninferiority of 1L-PEG+ASC in colon cleansing. Secondary endpoints were superiority of 1L-PEG+ASC, patient compliance, segmental colon cleansing, adenoma detection rate, tolerability, and safety.

Results: Three hundred eighty-eight patients (median age, 59.8 years) were randomized between January 2019 and October 2019: 195 to 1L-PEG+ASC and 193 to 4L-PEG. Noninferiority of 1L-PEG+ASC was demonstrated for cleansing in both the entire colon (BBPS ≥ 6: 97.9% vs 93%; relative risk [RR], 1.03; 95% confidence interval [CI], 1.001-1.04; P superiority = .027) and in the right-sided colon segment (98.4% vs 96.0%; RR, 1.02; 95% CI, .99-1.02; P noninferiority = .013). Compliance was higher with 1L-PEG+ASC than with 4L-PEG (178/192 [92.7%] vs 154/190 patients [81.1%]; RR, 1.10; 95% CI, 1.05-1.12), whereas no difference was found regarding safety (moderate/severe side effects: 20.8% vs 25.8%; P = .253). No difference in adenoma detection rate (38.8% vs 43.0%) was found.

Conclusions: One-liter PEG+ASC showed noninferiority compared with 4L-PEG in achieving adequate colon cleansing and provided a higher patient compliance. No differences in tolerability and safety were detected. (Clinical trial registration number: NCT03742232.).
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http://dx.doi.org/10.1016/j.gie.2021.04.020DOI Listing
October 2021

Overutilization of surgery for the resection of benign colorectal lesions: the hidden reasons for inappropriate referral!

Endosc Int Open 2021 May 22;9(5):E713-E715. Epub 2021 Apr 22.

Department of gastroenterology and endoscopy, Nuovo Regina Margherita Hospital Rome, Italy.

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http://dx.doi.org/10.1055/a-1373-5176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062238PMC
May 2021

Training methods in optical diagnosis and characterization of colorectal polyps: a systematic review and meta-analysis.

Endosc Int Open 2021 May 22;9(5):E716-E726. Epub 2021 Apr 22.

Institute of Translational Medicine and Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom.

Correct optical diagnosis of colorectal polyps is crucial to implement a resect and discard strategy. Training methods have been proposed to reach recommended optical diagnosis thresholds. The aim of our study was to present a systematic review and meta-analysis on optical diagnosis training. PubMed/Medline and Cochrane databases were searched between 1980 and October 2019 for studies reporting outcomes on optical diagnosis training of colorectal polyps. The primary outcome was optical diagnosis accuracy compared to histological analysis pre-training and post-training intervention. Subgroup analyses of experienced/trainee endoscopists, training methods, and small/diminutive polyps were included. Overall, 16 studies met inclusion criteria, analyzing the impact of training on 179 endoscopists. Pre-training accuracy was 70.3 % (6416/9131 correct diagnoses) whereas post-training accuracy was 81.6 % (7416/9213 correct diagnoses) (risk ratio [RR] 1.17; 95 % confidence interval [CI]: 1.09-1.24,  < 0.001). In experienced endoscopists, accuracy improved from 69.8 % (3771/5403 correct diagnoses) to 82.4 % (4521/5485 correct diagnoses) (RR 1.20; 95 % CI: 1.11-1.29,  < 0.001). Among trainees, accuracy improved from 69.6 % (2645/3803 correct diagnoses) to 78.8 % (2995/3803 correct diagnoses) (RR 1.14; 95 % CI 1.06-1.24,  < 0.001). In the small/diminutive polyp subgroup, accuracy improved from 68.1 % (3549/5214 correct diagnoses) to 77.1 % (4022/5214 correct diagnoses) in (RR 1.16 95 % CI 1.08-1.24  < 0.001). On meta-regression analysis, the improvement in accuracy did not differ between computerized vs. didactic training approaches for experienced (  = 0.792) and trainee endoscopists (  = 0.312). Optical diagnosis training is effective in improving accuracy of histology prediction in colorectal polyps. Didactic and computer-based training show comparable effectiveness in improving diagnostic accuracy.
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http://dx.doi.org/10.1055/a-1381-7181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062231PMC
May 2021

Prioritizing an oncologic approach to endoscopic resection of pedunculated colorectal polyps.

Gastrointest Endosc 2021 07 27;94(1):155-159. Epub 2021 Apr 27.

Nuovo Regina Margherita Hospital, Rome, Italy.

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http://dx.doi.org/10.1016/j.gie.2021.03.003DOI Listing
July 2021

AI everywhere in endoscopy, not only for detection and characterization.

Endosc Int Open 2021 Apr 14;9(4):E627-E628. Epub 2021 Apr 14.

Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.

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http://dx.doi.org/10.1055/a-1373-4799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046591PMC
April 2021

Sessile serrated lesion detection rates during average risk screening colonoscopy: A systematic review and meta-analysis of the published literature.

Endosc Int Open 2021 Apr 13;9(4):E610-E620. Epub 2021 Apr 13.

Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, United States.

 Sessile serrated lesion (SSL) detection rate has been variably reported and unlike adenoma detection rate (ADR) is not currently a quality indicator for screening colonoscopy. Composite detection rates of SSL in patients undergoing average risk screening colonoscopy are not available.  Electronic database search (Medline, Embase and Cochrane) was conducted for studies reporting detection rates of serrated polyps (SSL, Hyperplastic polyp, traditional serrated adenoma) among average risk subjects undergoing screening colonoscopy. Primary outcomes were pooled SDR (SSL detection rate) and proximal serrated polyp detection rate (PSPDR). Pooled proportion rates were calculated with 95 %CI with assessment of heterogeneity (I ). Publication bias, regression test and 95 %prediction interval were calculated. A total of 280,370 screening colonoscopies among average risk subjects that were eligible with 48.9 % males and an average age of 58.7 years (± 3.2). The pooled SDR was available from 16 studies: 2.5 % (1.8 %-3.4 %) with significant heterogeneity (I  = 98.66 %) and the 95 % prediction interval ranging from 0.6 % to 9.89 %. When analysis was restricted to large (n > 1000) and prospective studies (n = 4), SDR was 2 % (1.1 %-3.3 %). Pooled PSPDR was 10 % (8.5 %-11.8 %; 12 studies). There was evidence of publication bias (  < 0.01).  Definitions of SSL have been varying over years and there exists significant heterogeneity in prevalence reporting of serrated polyps during screening colonoscopy. Prevalence rate of 2 % for SSL and 10 % for proximal serrated polyps could serve as targets while robust high-quality data is awaited to find a future benchmark showing reduction in colorectal cancer arising from serrated pathway.
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http://dx.doi.org/10.1055/a-1352-4095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043815PMC
April 2021

Correction: Artificial intelligence for colonoscopy: the new Silk Road.

Endoscopy 2021 Mar 16;53(3):C6. Epub 2021 Apr 16.

Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.

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http://dx.doi.org/10.1055/a-1480-4809DOI Listing
March 2021
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