Below are the abstracts and references alluded to in the Podcast! 

1
IMPROVING ALL-CAUSE INPATIENT MORTALITY AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY.
SOURCE Digestive Diseases & Sciences. 66(5):1593-1599, 2021 May.
AUTHORS Stein DJ; Moore MB; Hoffman G; Feuerstein JD
INSTITUTION Stein, Daniel J. Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, 110 Francis St 8e Gastroenterology, Boston, MA, 02215, USA.
BACKGROUND AND AIMS: Percutaneous gastrostomy (PEG) is a common inpatient procedure. Prior data from National Inpatient Sample (NIS) in 2006 reported a mortality rate of 10.8% and recommended more careful selection of PEG candidates. This study assessed for improvement in the last 10 years in mortality rate and complications for hospitalized patients.
METHODS: A retrospective cohort analysis of all adult inpatients in the NIS from 2006 to 2016 undergoing PEG placement compared demographics and indication for PEG placement per ICD coding. Survey-based means and proportions were compared to 2006, and rates of change in mortality and complication rates were trended from 2006 through 2016 and compared with linear regression. Multivariable survey-adjusted logistic regression was used to determine predictors of mortality and complications in the 2016 sample.
RESULTS: A total of 155,550 patients underwent PEG placement in 2016, compared with 174,228 in 2006. Mortality decreased from 10.8 to 6.6% without decreased comorbidities (p < 0.001). This trend was gradual and persistent over 10 years in contrast to a stable overall inpatient mortality rate (p = 0.113). Stroke remained the most common indication (29.7%). The majority of patients (64.6%) had Medicare. Indications for placement were stable. Complication rates were stable from 2006 (4.4%) to 2016 (5.1%) (p = 0.201).
CONCLUSIONS: Inpatient PEG placement remains common. Despite similar patient characteristics, mortality has decreased by approximately 40% over the last 10 years without a decrease in complications likely reflecting improved patient selection.


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Rizzo SM et.al.  Enteral nutrition via nasogastric tube for refeeding patients with anorexia nervosa: A systematic review. Nutr Clin Pract 2019; 34: 359–370


ABSTRACT Weight restoration is an important first step in treating patients with anorexia nervosa, because it is essential for medical stabilization and reversal of long‐term complications. Tube feeding may help facilitate weight restoration, but its role in treatment remains unclear. This study aimed to review the literature describing the efficacy, safety, tolerance, and long‐term effects of nasogastric refeeding for patients with anorexia nervosa. Four electronic databases were systematically searched through in May 2018.  10 studies were included: 8 retrospective chart reviews, 1 prospective cohort, and 1 randomized controlled trial. 9 studies were performed in‐hospital. In 8 studies, nasal feeding resulted in an average rate of weight gain exceeding 1 kg/wk. In 4 of 5 studies including an oral‐only control group, mean weekly weight gain and caloric intake were significantly higher in tube‐fed patients.  3 studies considered psychological outcomes, and 4 assessed patients post discharge. NG feeding was not associated with an increased risk for adverse outcomes and NG nutrition was considered safe and well tolerated, and increased caloric intake and rate of weight gain in patients with AN. However, results are limited by weaknesses in study designs]
·       The problem with nasogastric feeding in that it is uncomfortable for the patient, unsightly and prone to becoming displaced or blocked, requiring frequent exchanges which is traumatic for the patient and diverts endoscopy capacity away from finding cancers in symptomatic patients.
·       Do patients with eating disorders have a better quality of life or survival after placement of nasal feeding tubes compared to those eating normally?  What does having a nasal feeding tube do for relationships, career prospects and chance of remission ?


2
ESGE GUIDELINE ON THE ENTERAL FEEDING TUBES IN ADULTS – PART 2: PERI- AND POST-PROCEDURAL MANAGEMENT.Gkolfakis Paraskevas et al. Endoscopy 2021; 53: 178–195
When placing a jejunal extension, clips may secure the distal end of the tube to reduce the risk of retrograde migration. The PEG site should be placed near the antrum, to create a better angle of insertion.  Finally, a nonrandomized, comparative study in 104 patients (56 patients with percutaneously placed PEJ and 49 with a PEG extention) concluded that the percutaneous jejunal feeding tubes were better than PEG extensions as they lasted longer and there were fewer endoscopic re-interventions when the tube coiled back into the stomach.
Risk factors for bleeding include anticoagulation and previous anatomic alteration  [Gastroenterology 2011; 141: 742–765].   Regarding the management of anticoagulant or antiplatelet therapy, insertion of a NGT/NJT is a low-risk procedure [Endoscopy 2016; 48: 385–402] and there is no need to stop antiplatelet therapies or anticoagulant therapies.
PEG placements carry a risk of bleeding. Immediate gastric bleeding after PEG placement is very rare (0.3 %) and is usually caused by injury of the left gastric or gastroepiploic arteries or one of their branches. Severe intraperitoneal bleeding can also occur because of liver laceration and this presents as severe postprocedural hypotension with or without peritonitis.  Cutaneous bleeding is treated with external pressure. 
For PEG feeding, clopidogrel should be stopped whilst aspirin may be continued [62]. Warfarin should be discontinued from 2 - 5 days before the procedure and the INR should be below 1.5 [62]. DOAC’s should be stopped 48 - 72 hours before the procedure.  Aspirin should be continued, particularly in at-risk patients.   If there is a high thrombotic risk, warfarin should be substituted with heparin [62]. Antiplatelet/anticoagulant therapy should be resumed up to 48 hours after the procedure depending on the perceived individual bleeding/thrombotic risks, respectively [62]. 
After the PEG placement, external fixator should be placed tightly at 0.5 cm above the skin, to prevent leakage during the first 3 to 5 days [146].  After 7 to 10 days the tube should be gently moved from 2 to 5 cm inward and outward in order to prevent future adhesion and buried bumper [146]. After this manoeuvre, the tube should be returned to and fixed in its initial position.
Removal is by cutting the tube at the skin level and then pushing the internal bumper into the stomach with a blunt stylet (“cut and push” technique).  Endoscopic retrieval of the bumper is recommended only in cases with previous bowel surgery and for patients at risk of strictures or ileus.


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3
CLINICAL IMPACT OF ENDOSCOPIC ULTRASOUND-GUIDED THROUGH-THE-NEEDLE MICROBIOPSY IN PATIENTS WITH PANCREATIC CYSTS.
SOURCE Endoscopy. 53(1):44-52, 2021 Jan.
AUTHORS Kovacevic B; Klausen P; Rift CV; Toxvaerd A; Grossjohann H; Karstensen JG; Brink L; Hassan H; Kalaitzakis E; Storkholm J; Hansen CP; Hasselby JP; Vilmann P
INSTITUTION Kovacevic, Bojan. Gastroenterology Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark.  
BACKGROUND: The limited data on the utility of endoscopic ultrasound (EUS)-guided through-the-needle biopsies (TTNBs) in patients with pancreatic cystic lesions (PCLs) originate mainly from retrospective studies. Our aim was to determine the clinical impact of TTNBs, their added diagnostic value, and the adverse event rate in a prospective setting.
METHODS: This was a prospective, single-center, open-label controlled study. Between February 2018 and August 2019, consecutive patients presenting with a PCL of 15 mm or more and referred for EUS were included. Primary outcome was a change in clinical management of PCLs following TTNB compared with cross-sectional imaging and cytology. Adverse events were defined according to the ASGE lexicon.
RESULTS: 101 patients were included. needle biopsy led to a change in the management in 11.9 % of cases (n = 12). Of these, 10 had serous cysts and surveillance was discontinued, while one of the remaining two cases underwent surgery following diagnosis of a mucinous cystic neoplasm. The diagnostic yield of needle biopsies for a specific cyst diagnosis was higher compared with FNA cytology (69.3 % vs. 20.8 %, respectively; P < 0.001). The adverse event rate was 9.9 % (n = 10; 95 % confidence interval 5.4 % - 17.3 %), 9 out 10 complications was acute pancreatitis (n = 9). Four of the observed adverse events were severe, including one fatal outcome.
CONCLUSIONS: Needle biopsy resulted in a change of management in about 1 in 10 patients and 1: 10 patients suffered a potentially serious adverse event.   The risk of an adverse event was substantial. Further studies are warranted to elucidate in which subgroups of patients the clinical benefit outweighs the risks.


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4
OVER-THE-SCOPE CLIP SYSTEM AS A FIRST-LINE THERAPY FOR HIGH-RISK BLEEDING PEPTIC ULCERS: A RETROSPECTIVE STUDY.
SOURCE Surgical Endoscopy. 35(5):2198-2205, 2021 May.
AUTHORS Robles-Medranda C; Oleas R; Alcivar-Vasquez J; Puga-Tejada M; Baquerizo-Burgos J; Pitanga-Lukashok H  - None of these have declared any conflict of interests with the German company OVESCO
INSTITUTION Guayaquil, Ecuador.
BACKGROUND: Effective hemostasis is essential to prevent rebleeding. We evaluated the efficacy and feasibility of the Over-The-Scope Clip (OTSC) system compared to combined therapy (through-the-scope clips with epinephrine injection) as a first-line endoscopic treatment for high-risk bleeding peptic ulcers.
METHODS: We retrospectively analyzed data of 95 patients from a single, tertiary center and underwent either OTSC (n = 46) or combined therapy (n = 49). Twenty-three patients in the cohort were taking oral anticoagulants at the time of presentation; 12 in the OTSC group and 13 in the combined therapy group . 
RESULTS: All patients achieved hemostasis within the procedure; 2 patients in the OVESCO group and 4 patients in the combined therapy group developed rebleeding (p = 0.444).
There were no perforations.   OTSC had a shorter median procedure time than combined therapy (11 min versus 20 min; p < 0.001).  The procedure cost was superior for OTSC compared to combined therapy ($102,000 versus $101,000; p < 0.001).  We found no significant difference in the rebleeding prevention rate (95.6% versus 91.8%, p = 0.678), hospitalization days (3 days versus 4 days; p = 0.215), and hospitalization costs ($108,000 versus $240,000, p = 0.215) of the OTSC group compared to the combined therapy group.
CONCLUSION: OTSC treatment is an effective and feasible first-line therapy for high-risk bleeding peptic ulcers. OTSC confers comparable costs and patient outcomes as combined treatments, with a shorter procedure time.
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At the recent BSG Campus Prof Jan Tack from Leuven in Belgium mentioned G-POEM for gastroparesis.  He pointed out that several studies have all confirmed that there is NO relationship between symptom severity or weight loss and delay in gastric emptying!!   Furthermore, drug interventions which accelerate gastric emptying didn’t make any difference to symptoms!!!  It’s actually even worse because a study by Pasricha et al [Gastroenterology 2015;149(7):1762-74] showed that it was patients with the slowest gastric emptying who were the most likely to feel better after 48 weeks.  Therefore, the idea that improving gastric emptying by a G-POEM will actually improve symptoms appears to be optimistic!!!   We need a RCT of sham G-POEM vs real G-POEM!  

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5
One-year results of gastric peroral endoscopic myotomy for refractory gastroparesis: a French multicenter study.
SOURCE Endoscopy. 53(5):480-490, 2021 May.
AUTHORS Ragi O; Jacques J; Branche J; Leblanc S; Vanbiervliet G; Legros R; Pioche M; Rivory J; Chaussade S; Barret M; Wallenhorst T; Barthet M; Kerever S; Gonzalez JM
INSTITUTION Limoges, Lille, Paris, Nice, Lyon, Rennes, Marseille.
BACKGROUND: Data on the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis are lacking. We report the results of a large multicenter long-term follow-up study of G-POEM for refractory gastroparesis.
METHODS: This was a retrospective multicenter study of all G-POEM operations performed in seven expert French centers for refractory gastroparesis with at least 1 year of follow-up. The primary endpoint was the 1-year clinical success rate, defined as at least a 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI);  
1)      Bloating or nausea (none, mild, moderate, severe or very severe)
2)      Early satiety
3)      Post prandial fullness
4)      Epigastric pain
5)      Vomiting (1 point per daily vomit up to a maximum of 4)
the maximum total symptom score could be (5 symptoms * maximum score 4 divided by 5); hence, the maximum score is 20/5=4.
RESULTS: 76 patients were included (60.5 % women; age 56 years). The median symptom duration was 48 months. The median gastric retention at 4 hours (H4) before G-POEM was 45 % (interquartile range [IQR] 29 % - 67 %). The median GCSI before G-POEM was 3.6 (IQR 2.8 - 4.0). Clinical success was achieved in 65.8 % of the patients at 1 year, with a median rate of reduction in the GCSI score of 41 %. In logistic regression analysis, only a high preoperative GCSI satiety subscale score was predictive of clinical success (odds ratio [OR] 3.41, 95 % confidence interval [CI] 1.01 - 11.54; P = 0.048), while a high rate of gastric retention at H4 was significantly associated with clinical failure (OR 0.97, 95 %CI 0.95 - 1.00; P = 0.03).
CONCLUSIONS: The results confirm the efficacy of G-POEM for the treatment of refractory gastroparesis, as evidenced by a 65.8 % clinical success rate at 1 year. Although G-POEM is promising, prospective sham-controlled trials are urgently needed to confirm its efficacy and identify the patient populations who will benefit most from this procedure.

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6
SPATIAL DISTRIBUTION OF DYSPLASIA IN BARRETT'S ESOPHAGUS SEGMENTS BEFORE AND AFTER ENDOSCOPIC ABLATION THERAPY: A META-ANALYSIS.
SOURCE Endoscopy. 53(1):6-14, 2021 Jan.
AUTHORS Garg S; Xie J; Inamdar S; Thomas SL; Trindade AJ
INSTITUTION Arkansas, New York, USA.
BACKGROUND: Dysplasia in Barrett's esophagus (BE) is focal and difficult to locate. The aim of this meta-analysis was to understand the spatial distribution of dysplasia in BE before and after endoscopic ablation therapy.
METHODS: A systematic search was performed of multiple databases to July 2019. The location of dysplasia prior to ablation was determined using a clock-face orientation (right or left half of the esophagus). The location of the dysplasia post-ablation was classified as within the tubular esophagus or at the top of the gastric folds (TGF).
RESULTS: 13 studies with 2234 patients were analyzed. Pooled analysis from six studies (819 lesions in 802 patients) showed that before ablation, dysplasia was more commonly located in the right half versus the left half (odds ratio [OR] 4.3; 95 % confidence interval [CI] 2.33 - 7.93; P < 0.001). Pooled analysis from seven studies showed that dysplasia recurred in 101 /1432 patients (7.05 %; 95 %CI 5.7 % - 8.4 %). In 2/3, recurrence of dysplasia was at the top of the gastric folds (n = 68) rather than in the neo-squamous covered oesophagus (n = 34; OR 5.33; 95 %CI 1.75 - 16.21; P = 0.003). Of the esophageal lesions, 90 % (27 /30) of lesions were visible within the oesophagus, compared with 46 % (23 /50) of the recurrent dysplasia at the GOJ (P < 0.001).
CONCLUSION: Before ablation, dysplasia in BE is found more frequently in the right half of the esophagus versus the left. Post-ablation recurrence is more commonly found in the TGF and is non-visible, compared with the tubular esophagus, which is mainly visible. Copyright Thieme. All rights reserved.


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7
Double-balloon endoscopy facilitates efficient endoscopic resection of duodenal and jejunal polyps in patients with familial adenomatous polyposis.
SOURCE Endoscopy. 53(5):517-521, 2021 May.
AUTHORS Sekiya M; Sakamoto H; Yano T; Miyahara S; Nagayama M; Kobayashi Y; Shinozaki S; Sunada K; Lefor AK; Yamamoto H
INSTITUTION Shimotsuke, Japan.
BACKGROUND : Many patients with familial adenomatous polyposis (FAP) have adenomatous polyps of the duodenum and the jejunum. We aimed to elucidate the long-term outcomes after double-balloon endoscopy (DBE)-assisted endoscopic resection of duodenal and jejunal polyps in patients with FAP.
METHODS : We retrospectively reviewed patients who underwent more than two sessions of endoscopic resection using DBE from August 2004 to July 2018.
RESULTS : A total of 72 DBEs were performed in eight patients (median age 30 years, range 12-53; 1.4 DBE procedures/patient-year) during the study period, and 1237 polyps were resected. The median observation period was 77.5 months (range 8-167). There were 11 adverse events, including seven delayed bleeds and four episodes of acute pancreatitis. No delayed bleeding occurred after cold polypectomy. Although, in one patient, one endoscopically resected duodenal polyp was diagnosed as being intramucosal carcinoma, none of the patients developed an advanced duodenal or jejunal cancer during the study period.
CONCLUSIONS : Endoscopic resection of duodenal and jejunal polyposis using DBE in patients with FAP can be performed safely, efficiently, and effectively. Copyright Thieme. All rights reserved.


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8
Hemostatic spray powder TC-325 in the primary endoscopic treatment of peptic ulcer-related bleeding: multicenter international registry.
SOURCE Endoscopy. 53(1):36-43, 2021 Jan.
AUTHORS Hussein M; Alzoubaidi D; Lopez MF; Weaver M; Ortiz-Fernandez-Sordo J; Bassett P; Rey JW; Hayee BH; Despott E; Murino A; Moreea S; Boger P; Dunn J; Mainie I; Graham D; Mullady DK; Early DS; Ragunath K; Anderson JT; Bhandari P; Goetz M; Kiesslich R; Coron E; Lovat LB; Haidry R
INSTITUTION University College London, Nottingham, Amersham, United Kingdom, Kings College Hospital, London, The Royal Free Hospital, London, Bradford, Southampton, Gloucestershire Hospitals, Portsmouth, Tubingen, Germany, Wiesbaden, Germany, Nantes, France, St. Louis, Missouri and Osnabruck, Germany.
BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % - 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy.
METHODS: Data were collected prospectively over 3 years (January 2016 - March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist's discretion.
RESULTS: 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P < 0.05) compared with monotherapy or rescue therapy. There were high immediate hemostasis rates across all peptic ulcer disease Forrest classifications.
CONCLUSIONS: This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers. Copyright Thieme. All rights reserved.


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9
UNRESECTABLE POLYP MANAGEMENT UTILIZING ADVANCED ENDOSCOPIC TECHNIQUES RESULTS IN HIGH RATE OF COLON PRESERVATION.
SOURCE Surgical Endoscopy.  2021 Apr 22.
AUTHORS Wickham CJ; Wang J; Mirza KL; Noren ER; Shin J; Lee SW; Cologne KG
INSTITUTION California.
PURPOSE: "Endoscopically unresectable" benign polyps identified during screening colonoscopy are often referred for segmental colectomy. Application of advanced endoscopic techniques can increase endoscopic polyp resection, sparing patients the morbidity of colectomy. This retrospective case-control study aimed to evaluate the success of colon preserving resection of "endoscopically unresectable" benign polyps using advanced endoscopic techniques including endoscopic mucosal resection, endoscopic submucosal dissection, endoluminal surgical intervention, full-thickness laparo-endoscopic excision, and combined endo-laparoscopic resection.
METHODS: A prospectively maintained institutional database identified 95 patients referred for "endoscopically unresectable" benign polyps from 2015 to 2018. Cases were compared to 190 propensity score matched controls from the same database undergoing elective laparoscopic colectomy for other reasons. Primary outcome was rate of complete endoscopic polyp removal. Secondary outcomes included length of stay, unplanned 30-day readmission and reoperation, 30-day mortality, and post-procedural complications.
RESULTS: Advanced endoscopic techniques achieved complete polyp removal without colectomy in 66 patients (70% success rate). Failure was most commonly associated with previously attempted endoscopic resection and occult malignancy. Compared with matched colectomy controls, endoscopic polyp resection resulted in significantly shorter hospital stay (1.13 +/- 2.41 vs 3.89 +/- 4.57 days; p < 0.001), lower number of emergency readmissions (1.1% vs 7.7%; p < 0.05), and fewer complications (4.2% vs 33.9%; p < 0.001). Unplanned 30-day reoperation (2.1% vs 4.4%; p = 0.34) and 30-day mortality (0% vs 0.6%; p = 0.75) trended lower.
CONCLUSIONS: Endoscopic resection of complex polyps can be highly successful, and it is associated with favorable outcomes and decreased morbidity when compared with segmental colon resection. Attempting colon preservation using these techniques is warranted.

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10
The yield of upper gastrointestinal endoscopy in patients below 60 years and without alarm symptoms presenting with dyspepsia.
SOURCE Scandinavian Journal of Gastroenterology. 1-7, 2021 Apr 20.
AUTHORS Theunissen F; Lantinga MA; Borg PCJT; Ouwendijk RJT; Bruno MJ; Siersema PD; Trans IT Foundation Study Group
INSTITUTION Rotterdam, Nijmegen, Goes in the Netherlands.
BACKGROUND AND AIMS: Upper gastrointestinal (GI) endoscopy is frequently performed in patients with upper abdominal symptoms. Although guidelines recommend withholding an endoscopy in the absence of alarm symptoms, dyspeptic symptoms remain a predominant indication for endoscopy. We aimed to investigate the yield of upper GI endoscopy in patients with low-risk dyspeptic symptoms.
METHODS: We conducted an analysis in a prospectively maintained endoscopy reporting database. We collected the results of all upper GI endoscopy procedures between 2015 and 2019 that was performed in adult patients aged <60 years with dyspeptic symptoms. Patients with documented alarm symptoms were excluded. We categorized endoscopic findings into major and minor endoscopic findings.
RESULTS: We identified 26,440 patients with dyspeptic symptoms who underwent upper GI endoscopy. A total of 13,978 patients were considered low-risk and included for analysis (median age 46 years, interquartile range (IQR) [36-53], 62% female). In 11,353 patients (81.2%), no endoscopic abnormalities were detected. Major endoscopic findings were seen in 513 patients (3.7%) and minor endoscopic findings in 2178 patients (15.6%). Cancer was found in 47 patients (0.3%), including 16 (0.1%) oesophageal, 28 (0.2%) gastric and 5 (0.04%) duodenal lesions. Despite an initial unremarkable endoscopy result, 1015 of 11,353 patients (8.9%) underwent a follow-up endoscopy after a median of 428 days [IQR 158-819]. This did not lead to the additional identification of malignancy.
CONCLUSIONS: The yield of upper GI endoscopy in low-risk (<60 years, no alarm symptoms) patients with dyspepsia is very limited. This study further supports a restrictive use of upper GI endoscopy in these patients.

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11
DIAGNOSTIC YIELD OF COLONOSCOPY IN PATIENTS WITH SYMPTOMS COMPATIBLE WITH ROME IV FUNCTIONAL BOWEL DISORDERS.
SOURCE Clinical Gastroenterology & Hepatology.  2020 Aug 31.
AUTHORS Asghar Z; Thoufeeq M; Kurien M; Ball AJ; Rej A; David Tai FW; Afify S; Aziz I
INSTITUTION Sheffield.
BACKGROUND & AIMS: There is little data on the diagnostic yield of colonoscopy in patients with symptoms compatible with functional bowel disorders (FBDs). Previous studies have only focused on diagnostic outcomes of colonoscopy in those with suspected irritable bowel syndrome using historic Rome I-III criteria, whilst having partially assessed for alarm features and shown markedly conflicting results. There is also no colonoscopy outcome data for other FBDs, such as functional constipation or functional diarrhea. Using the contemporaneous Rome IV criteria we determined the diagnostic yield of colonoscopy in patients with symptoms compatible with a FBD, stratified diligently according to the presence or absence of alarm features.
METHODS: Basic demographics, alarm features, and bowel symptoms using the Rome IV diagnostic questionnaire were collected prospectively from adults attending out-patient colonoscopy in 2019. Endoscopists were blinded to the questionnaire data. Organic disease was defined as the presence of inflammatory bowel disease, colorectal cancer, or microscopic colitis.
RESULTS: 646 patients fulfilled symptom-based criteria for the following Rome IV FBDs: IBS (56%), functional diarrhea (27%) and functional constipation (17%). Almost all had alarm features (98%). The combined prevalence of organic disease was 12%, being lowest for functional constipation and IBS-constipation (~6% each), followed by IBS-mixed (~9%), and highest amongst functional diarrhea and IBS-diarrhea (~17% each); p = .005. The increased prevalence of organic disease in diarrheal versus constipation disorders was accounted for by microscopic colitis (5.7% vs. 0%, p < .001) but not inflammatory bowel disease (7.2% vs. 4.0%, p = .2) or colorectal cancer (4.2% vs. 2.3%, p = .2). However, 1-in-4 chronic diarrhea patients - conceivably at risk for microscopic colitis - did not have colonic biopsies taken. Finally, only 11 of 646 (2%) patients were without alarm features, in whom colonoscopy was normal.
CONCLUSIONS: Most patients with symptoms of FBDs who are referred for colonoscopy have alarm features. The presence of organic disease is significantly higher in diarrheal versus constipation disorders, with microscopic colitis largely accounting for the difference whilst also being a missed diagnostic opportunity. In those patients without alarm features, the diagnostic yield of colonoscopy was nil.

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12
Comparative study of treatment options and construction nomograms to predict survival for early-stage esophageal cancer: a population-based study.
SOURCE Scandinavian Journal of Gastroenterology. 1-12, 2021 Apr 19.
AUTHORS Jia R; Xiao W; Zhang H; Yu Z
INSTITUTION Tianjin, PeKing, Shenzhen, China.
BACKGROUND: The aim of this study was to investigate the impact of several common treatment options on the long-term survival of patients with early-stage esophageal cancer and to construct nomograms for survival prediction.
METHOD: This study was performed using the Surveillance, Epidemiology and End Results (SEER) database (2004-2015) on patients with early-stage (pT1N0M0) esophageal cancer who underwent endoscopic local therapy (ET), radiotherapy (RT), esophagectomy (ES) or neoadjuvant therapy (NT). Multivariate Cox regression was used to explore which factors influenced patient survival, and these factors were then incorporated into propensity sore matching (PSM) and the construction of nomogram plots. Kaplan-Meier analysis was used to compare whether there was a difference in long-term survival between the other three treatments and esophagectomy.
RESULT: Data from 4184 patients were included in this study. Multivariate Cox regression analysis showed that age, grade, marital status, and treatment method were independent factors affecting survival. After matching, Kaplan-Meier analysis showed that the EMR group had better cause specific survival than the surgical group, but no difference in overall survival, while patients treated with neoadjuvant therapy or radiotherapy had a worse survival than the EMR group. In the nomogram prediction model, the c-indexes of the training and validation cohorts were 0.805 and 0.794, respectively. Additionally the ROC curve (5-year AUC = 0.877) and DCA curve showed that the model had a good predictive effect.
CONCLUSION: For early-stage esophageal cancer, the results of this study showed that endoscopic resection was not inferior to a surgical resection. Based on the independent factors affecting prognosis identified in the study, we constructed and validated a predictive model for predicting long-term survival in patients with early-stage esophageal cancer.

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13
Recurrence pattern and surveillance strategy for rectal neuroendocrine tumors after endoscopic resection.
SOURCE Journal of Gastroenterology & Hepatology. 36(4):968-973, 2021 Apr.
AUTHORS Chung HG; Goh MJ; Kim ER; Hong SN; Kim TJ; Chang DK; Kim YH
INSTITUTION Seoul, South Korea.
BACKGROUND: Endoscopic resection is highly effective treatment option for rectal neuroendocrine tumors (NETs) as they usually present as small localized tumors. However, there are no well-established surveillance strategies following endoscopic resection. We established our own protocol for the surveillance of rectal NETs after endoscopic resection since 2013. This study aimed to assess the outcome and to optimize the surveillance strategies after endoscopic resection.
METHODS: We retrospectively analyzed the data of patients with endoscopically treated rectal NETs between January 2013 and April 2018 at Samsung Medical Center. We analyzed 337 patients with a median follow-up duration of 35.0 months (min-max: 12.0-88.3).
RESULTS: A total of 329 (97.6%) patients had tumors <= 1 cm in size, and eight (2.4%) patients had tumors > 1 cm in diameter. Synchronous rectal NETs were diagnosed in nine (2.7%) patients. Thirteen (3.9%) patients were identified as having positive resection margins. Regardless of the salvage treatment, none of these patients developed recurrence. Metachronous rectal NETs developed in nine (2.7%) patients.  Patients who developed Metachronous lesions were more likely to have more than one rectal NET at the index examination (P < 0.001, hazard ratio = 1.75, 95% confidence interval = 1.38-2.23). Extracolonic metastasis was not detected in this study.
CONCLUSION: Although initial screening for detecting metastatic lesions using computed tomography is recommended, repeated imaging for detecting extracolonic recurrence was not necessary for small non-metastatic rectal NETs. However, regular endoscopic follow-up seems reasonable, especially in case of synchronous rectal NETs, for detecting metachronous rectal NETs.

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14

ACCURACY OF ENDOSCOPIC SIZE MEASUREMENTS OF EARLY GASTRIC SIGNET RING CELL CARCINOMA.
SOURCE Surgical Endoscopy. 35(5):2324-2331, 2021 May.
AUTHORS Kim JS; Kang SH; Moon HS; Lee ES; Kim SH; Sung JK; Lee BS; Jeong HY
INSTITUTION Daejeon, South Korea.
BACKGROUND AND AIMS: Indications for endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) are expanding, but signet ring cell carcinoma (SRC) is still unclear because of its unclear boundaries. The purpose of this study was to compare pathologic size and endoscopic size in SRC-type EGC and to find risk factors associated with tumor size underestimation.
METHODS: Medical records of 137 patients diagnosed with SRC-type EGC between January 2009 and December 2016 at our tertiary hospital were reviewed. According to pathologic and endoscopic tumor sizes, they were classified into correct estimation, underestimation, and overestimation groups, and risk factors related to underestimation were analyzed.
RESULTS: Among 137 patients with SRC-type EGC, 77 patients (56.2%) had undergone correct estimation, 43 patients (31.4%) had undergone underestimation, and 17 patients (12.4%) had undergone overestimation. Mean pathologic size (SD) was 20.1 (13.8) mm and mean endoscopic size (SD) was 17.9 (10.1) mm, the correlation coefficients were 0.919 (p < 0.001) , and there was no significant difference between the two groups. Multivariate analysis showed that tumor size more than 20 mm (OR 3.419; 95% CI 1.271-9.194; p = 0.015) and atrophy (OR 6.011; 95% CI 2.311-15.633; p = 0.001) were risk factors for tumor size underestimation.
CONCLUSION: There was no significant difference in pathologic and endoscopic size in SRC-type EGC. Therefore, ESD may be considered as a therapeutic option if the size of the tumor is less than 20 mm and atrophy is not present in the surrounding mucosa.